Routine preoperative screening computed tomography of the thorax for cardiac surgery.

Introduction: This study aimed to evaluate the role of screening computed tomography (CT) of the thorax in cardiac surgery by analysing the presence of CT aortic calcifications in association with changes in operative strategy and postoperative stroke, and the CT features of emphysema with development of pneumonia. Methods: All patients who underwent cardiac surgery from January 2013 to October 2017 by a single surgeon were retrospectively studied. Patients who underwent screening CT thorax before cardiac surgery (CT group) were compared to those who did not (no CT group). Multivariate subgroup analyses were performed to determine significant association with postoperative outcomes. Results: A total of 392 patients were included, of which 156 patients underwent preoperative screening CT thorax. Patients in the CT group were older (63.9 vs. 59.0 years, P = 0.001), had fewer recent myocardial infarctions preoperatively (41% vs. 56.4%, P = 0.003) and had better ejection fraction (>30%; P = 0.02). Operative strategy was changed in 4.3% of patients, and 4.9% of patients suffered stroke postoperatively. The presence of CT aortic calcifications was significantly associated with change in operative strategy (P = 0.016) but not with postoperative stroke (P = 0.33). Age was an independent risk factor for change in operative strategy among patients with CT thorax (P = 0.02). Multivariate age-adjusted analysis showed only palpable plaque to be significantly associated with change in operative strategy (P < 0.001). None of the patients with CT emphysema features developed pneumonia. Conclusion: The results of this study do not support routine use of preoperative screening CT thorax. Contrasted CT may be advisable in older patients and for other operative planning purposes.

Helicopter Air Transport of a Patient Using High Flow Nasal Cannula: A Case Report.

The classic out-of-hospital approach to a patient with severe acute respiratory failure involves both orotracheal intubation and invasive mechanical ventilation. The use of non-invasive methods for respiratory support has been shown to be beneficial in managing both acute and chronic respiratory failure. However, its use had not been previously considered for air medical transport due to concerns related to airway safety during flight, limited oxygen availability, and limited experience in this setting. We describe the successful inter-hospital helicopter transport of a patient with end-stage lung disease to a transplantation unit while utilizing a high-flow oxygen cannula, which was performed without significant complications. Our successful case report raises the possibility that high-flow nasal cannulas may be safely employed in the management of respiratory failure in specific patient populations during air medical transport.

Non-surgical treatment of tetanus infection associated with breast cancer skin ulcer: a case report and literature review.

BACKGROUND: Previous studies have reported poor prognosis in cases of tetanus that develops after bacteria enters via breast cancer-related skin ulcers that are not treated with surgical debridement. Herein, we review the literature concerning this presentation and report the first case of complete remission from tetanus without surgical debridement of the skin ulcer. CASE PRESENTATION: An Asian woman aged over 60 years had a history of skin ulcer caused by breast cancer. She was diagnosed with tetanus due to trismus and opisthotonus. Based on the suspicion that the skin ulcer was the portal of entry for tetanus bacteria, we considered several debridement and thoracic surgical options for tetanus treatment. However, debridement was not performed as the surgery was considered high risk and the patient did not consent to it. The patient received treatment with anti-tetanus globulin and metronidazole; sound insulation and shielding were also performed in a dark room. Subsequently, the patient's symptoms improved, and sound insulation and deep sedation management were completed on 19th day of hospitalization. With no symptom recurrence, the patient was discharged on Day 54. To date, over 3 years after treatment, no evidence of tetanus recurrence has been observed. The case was characterized by a lack of autonomic hyperactivity. The tetanus severity was likely representative of the low amount of toxin that the patient was exposed to. CONCLUSION: This case involved moderate severity tetanus originating from a chronic skin ulcer related to breast cancer. The patient survived without undergoing extensive debridement. No evidence of tetanus relapse was observed during the follow-up period, likely due to vaccination that might have restored the patient's active immunity. Debridement is not always necessary for tetanus complicated by breast cancer skin ulcers. Furthermore, appropriate toxoid vaccination is critical for preventing the onset and recurrence of tetanus in these patients.

Evaluation of Autologously Derived Biomaterials and Stem Cells for Bone Tissue Engineering.

Despite progress, clinical translation of tissue engineering (TE) products/technologies is limited. A significant effort is underway to develop biomaterials and cells through a minimally modified process for clinical translation of TE products. Recently, bone marrow aspirate (BMA) was identified as an autologous source of cells for TE applications and is currently being tested in clinical therapies, but the isolation methods need improvement to avoid potential for contamination and increase progenitor cell yield. To address these issues, we reproducibly processed human peripheral blood (PB) and BMA to develop autologously derived biomaterials and cells. We demonstrated PB-derived biomaterial/gel cross-linking and fibrin gel formation with varied gelation times as well as biocompatibility through support of human bone marrow-derived stem cell survival and growth in vitro. Next, we established a plastic culture-free process that concentrates and increases the yield of CD146+/CD271+ early mesenchymal progenitor cells in BMA (concentrated BMA [cBMA]). cBMA exhibited increased colony formation and multipotency (including chondrogenic differentiation) in vitro compared with standard BMA. PB-derived gels encapsulated with cBMA also demonstrated increased cell proliferation and enhanced mineralization when assessed for bone TE in vitro. This strategy can potentially be developed for use in any tissue regeneration application; however, bone regeneration was used as a test bed for this study.

Gallbladder Cancer: Managing the Incidental Diagnosis.

Managing patients with incidental gallbladder cancer requires stratifying patients risk for recurrence and an appreciation for the recurrence patterns characterizing this malignancy. Although standard management includes reresection to remove sites at risk of harboring residual disease and to achieve negative resection margin status, the decision to perform surgery is tempered by an early and frequent distant recurrence, the most common cause of surgical failure. High-risk patients may benefit from neoadjuvant chemotherapy before reresection. The goal of curative-intent reresection is achieving R0 margin status and optimal staging while limiting morbidity and mortality.

Superficial Temporal Artery to Anterior Cerebral Artery Hemi-bonnet Bypass Using Radial Artery Graft for Prevention of Complications after Surgical Treatment of Partially Thrombosed Large/Giant Anterior Cerebral Artery Aneurysm.

BACKGROUND: Partially thrombosed large/giant aneurysm of the anterior cerebral artery is still challenging because this complex aneurysm requires arterial revascularization in the deep operation field. Therefore, direct neck clipping is often impossible. We describe our experiences with extracranial-intracranial bypass as an insurance bypass prior to clipping of partially thrombosed anterior cerebral artery aneurysms, and discuss the microsurgical technique and strategy. CLINICAL PRESENTATION: Consecutive, single-surgeon experience with the surgical treatment of partially thrombosed anterior cerebral artery aneurysms was retrospectively reviewed. Three cases of partially thrombosed anterior cerebral artery aneurysms, 2 anterior communicating artery aneurysms, and 1 postcommunicating artery (A2 segment of the anterior cerebral artery) aneurysm, presented as mass effect symptoms from giant aneurysms in 2 patients and incidentally discovered aneurysm in one patient. Superficial temporal artery-radial artery graft-anterior cerebral artery hemi-bonnet bypass was performed as an insurance bypass prior to clipping of the partially thrombosed anterior cerebral artery aneurysms. Complete aneurysm obliteration and bypass patency were demonstrated in all 3 patients. No neurological sequelae occurred. CONCLUSIONS: Superficial temporal artery-radial artery graft-anterior cerebral artery hemi-bonnet bypass prior to aneurysm dissection can avoid ischemic complication during temporary occlusion and secures permanent revascularization after complete obliteration of partially thrombosed large/giant anterior cerebral artery aneurysm.

Does near-infrared (NIR) fluorescence angiography modify operative strategy during emergency procedures?

INTRODUCTION: Bowel viability can be difficult to evaluate during emergency surgery. Near-infrared (NIR) fluorescence angiography allows an intraoperative assessment of organ perfusion during elective surgery and might help to evaluate intestinal perfusion during emergency procedures. The aim of this study was to assess if NIR modified operative strategy during emergency surgery. MATERIALS AND METHODS: From July 2014 to December 2015, we prospectively evaluated all consecutive patients, who had NIR assessment during emergency surgery. Primary endpoint was the modification of operative strategy after the assessment with NIR. Secondary endpoints were general post-operative outcomes, including reoperation rate. RESULTS: Fifty-six patients were included in the study. Mean age was 64 ± 17 years. An exploratory laparoscopy was performed in 39% (n = 22) and an open surgery in 61% of cases (n = 34). Conversion rate to open surgery was 41% (n = 9). 32 patients had a bowel resection. In 32% of the cases (n = 18), the result of the NIR test led to a modification of the operative strategy. Among them, 33% (n = 6) had a larger resection or a resection, which was initially not planned. The other 12 patients (67%) had finally no resection, which was initially thought to be performed. Importantly, none of those patients needed a reoperation for ischemia. Mean time for performing NIR test was 167 s (± 121). Overall reoperation rate was 16.1% (n = 9). Two patients had an anastomotic leak. Eight patients (14.3%) died within the first 30 post-operative days; however, none of them presented a bowel ischemia or an anastomotic leak. CONCLUSION: NIR is an easy and short procedure, which can be performed during emergency surgery to assess bowel perfusion. It may help the surgeon to preserve intestinal length or to define the exact limits of resection. Overall, we report a modification of operative strategy in up to one-third of evaluated patients.

Changes in operative strategy for patients enrolled in the International Registry of Acute Aortic Dissection interventional cohort program.

OBJECTIVE: Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time. METHODS: One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016). RESULTS: Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P < .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P < .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values < .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P < .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017). CONCLUSIONS: There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan.

Unique Technique for Open Surgical Repair after Failed Endovascular Aneurysm Repair with Proximal Anastomoses.

Endovascular aortic aneurysm repair (EVAR) has revolutionized the management of abdominal aortic aneurysms (AAAs), with lower perioperative morbidity and mortality compared to conventional surgical repair. However, late secondary re-interventions after EVAR are still needed before aneurysm rupture in many cases. A patient with impending rupture of an AAA associated with a type I endoleak 7 years after EVAR who was successfully treated with a unique technique of fixation of the proximal aortic neck taking into account the structure of the stent graft is reported. This technique offers a safe solution to late open conversion after failed EVAR.