Pulmonary fibrosis combined with lung cancer following lung transplantation: should we do more?

Currently, lung transplantation is the standard of care for patients with end-stage lung disease, with interstitial lung disease (ILD) being the most common reason in the recent years In the other hand, in cases where stage II and III lung cancer have been identified following lung transplantation, long-term survival outcomes are poor when compared to lung cancer patients that have not received a lung transplant because the use of immunosuppressant and the problem of rejection and infection and the treatment of recurrence and so on. However, there is no statistical difference observed in stage I (pT1N0M0) patients. In this paper we report about a patient with ILD receiving left lung transplantation in the early time. A lesion of the right lung which was considered the normal ILD tissue and without enough attention. Post-transplant it showed progress and finally the whole right lung (native lung) was occupied by the tumor. Some ground glass changes could also be found in the transplanted lung several months later. A secondary lung transplant was performed for this patient, and there has been no postoperative recurrence thus far. For lung transplant patients with high-risk factors, effective surveillance methods are required for the early detection of lung cancer.

Extrapericardial Tamponade After Blunt Trauma.

Cardiac tamponade results from compression of the heart and great vessels. Mediastinal hematoma has been reported in association with cardiac tamponade in multiple settings, including nonaortic mediastinal hemorrhage from cervical spine fractures, aortic and carotid aneurysmal rupture, mediastinal penetrating trauma, and cardiac penetrating trauma. A few cases of blunt trauma to the anterior chest wall resulting in tamponade formation have been reported. We present a patient with an anterior mediastinal hematoma resulting from blunt chest trauma that caused extrapericardial cardiac tamponade due to bleeding from a branch of the left internal mammary artery after a motor vehicle collision.

Is Internal Mammary to the Anterior Descending Always the Best Option?

The left internal mammary artery (LIMA) is the gold standard conduit used to revascularize the left anterior descending artery and has consistently been shown to be associated with better survival, graft patency, and freedom from cardiac events compared with other used conduits. Evaluation of LIMA flow and anatomy is not routinely done by the interventional cardiologist while performing the left heart catheterization. We present a case where the LIMA was found to be the major blood supply to the left leg, which might have led to leg ischemia if the LIMA had been used as graft.

Pulmonary Artery Systolic Pressure Measured Intraoperatively by Right Heart Catheterization Is a Predictor of Kidney Transplant Recipient Survival.

BACKGROUND The effect of pulmonary artery systolic pressure (PASP) measured by Swan-Ganz right heart catheter (SG-RHC) on kidney transplant recipient survival has not been previously studied. The objective of this study was to assess the relationships between PASP measured via SG-RHC, done intraoperatively at the time of initiating anesthesia at the beginning of kidney transplant surgery, and patient survival. Multiple comorbidities, time on dialysis before the transplantation, and graft function were also analyzed in our study. MATERIAL AND METHODS This was a retrospective cohort study using data from all consecutive patients undergoing kidney transplant between January 1, 2005 and December 31, 2009 at Tampa General Hospital. Kidney transplant recipients were divided into 2 groups: Group 1 with PASP <35 mmHg and group 2 with PASP ≥35 mmHg. Patients and graft survival data, time on dialysis before transplant, and comorbidities were compared between the 2 groups. RESULTS Only 363 patients were found to have a documented PASP measurement at the time of anesthesia induction for the transplant surgery, and were included in the specific analysis of our study. Patients with PASP ≥35 mmHg showed a significant decrease in survival in comparison to patients having PASP values <35 mmHg (HR 1.88; 95% CI 1.012 to 3.47, P=0.04). There was a significant positive correlation between time on dialysis and PASP (rho 0.20; 95% CI 0.09 to 0.30, p<0.001), as well as a significant difference in median time on dialysis between PASP <35 vs. PASP ≥35 (22 vs. 29 months, p=0.004). There were no significant differences in graft failure between the 2 PASP groups (HR 0.34; 95% CI 0.12 to 1.01, P=0.05). CONCLUSIONS Patients with PASP ≥35 mmHg, measured intraoperatively by SG-RHC, showed significantly shorter survival in comparison to patients having PASP values <35 mmHg. This result suggests the need for a randomized controlled trial to address the importance of post-transplant pulmonary hypertension management in patient survival.

Surgical Thoracic Transplant Training: Super Fellowship-Is It Super?

OBJECTIVE: The quality of training provided to thoracic transplant fellows is a critical step in the care of complex patients undergoing transplant. The training varies since it is not an accreditation council for graduate medical education accredited fellowship. METHOD: A total of 104 heart or lung transplant program directors throughout the United States were sent a survey of 24 questions focusing on key aspects of training, fellowship training content and thoracic transplant job satisfaction. Out of the 104 programs surveyed 45 surveys (43%) were returned. RESULTS: In total, 26 programs offering a transplant fellowship were included in the survey. Among these programs 69% currently have fellows of which 56% are American Board of Thoracic Surgery board eligible. According to the United Network for Organ Sharing (UNOS) requirements, 46% of the programs do not meet the requirements to be qualified as a primary heart transplant surgeon. A total of 23% of lung transplant programs also perform less than the UNOS minimum requirements. Only 24% have extra-surgical curriculum. Out of the participating programs, only 38% of fellows secured a job in a hospital setting for performing transplants. An astounding 77% of replies site an unpredictable work schedule as the main reason that makes thoracic transplant a less than favorable profession among new graduates. Long hours were also a complaint of 69% of graduates who agreed that their personal life is affected by excessive work hours. CONCLUSION: Annually, almost half of all thoracic transplant programs perform fewer than the UNOS requirements to be a primary thoracic surgeon. This results in a majority of transplant fellows not finding a suitable transplant career. The current and future needs for highly qualified thoracic transplant surgeons will not be met through our existing training mechanisms.

Successful Delivery in a Patient With Left Ventricular Assist Device and Unplanned Pregnancy.

We report the case of a woman supported by a left ventricular assist device (LVAD) who presented at 20 weeks of gestation and decided against recommendations to continue with her pregnancy. This was managed with well-developed plan for a multidisciplinary team approach. With close and regular follow-up and regular adjustment of the patient's medications and LVAD parameters, successful delivery and outcome for both the mother and the newborn were achieved.

Tuberculous Empyema Post Bilateral Lung Transplant.

Tuberculous empyema in lung transplantation recipients is a rare entity, with only a handful of cases reported in the English-language literature. We are reporting a case of tuberculous empyema 3 months after uncomplicated bilateral lung transplantation. The recipient underwent video-assisted thoracic surgery for diagnosis and decortication. Both the recipient and donor lacked a history of tuberculosis or tuberculosis exposure.

Use of extracorporeal membranous oxygenator in transcatheter aortic valve replacement.

The superiority of transcatheter aortic valve replacement (TAVR) compared with medical therapy for patients with aortic stenosis (AS) who are not suitable candidates for surgery had been proven. Cardiopulmonary bypass (CPB) is rarely used in TAVR. Reports of early use of extracorporeal membranous oxygenator (ECMO) have promising outcomes. ECMO offers the option of cardiac support rescue in case of intraoperative hemodynamic instability and can be instituted in advance when hemodynamic instability is expected. Here we review the English literature about the use of ECMO in TAVR procedures, and discuss the indications and rationale for its use as well as its advantages.

Primary extraskeletal pleural osteosarcoma: a rare pleural identity.

A 69-year-old female with a history of a heart transplant 16 years prior, presented with a large left chest mass identified on fluoroscopy in the cardiac catheterization lab. The patient noted a 40 pound weight loss in one year. A chest X-ray (CXR) and chest computed tomography (CT) demonstrated a large complex cystic mass in the left chest. A CT guided aspiration was performed, and the cytology for the cyst fluid was negative for malignancy. The patient continued to have worsening shortness of breath, a repeat chest CT scan and magnetic resonance imaging (MRI) three months later, demonstrated a recurrence of the left pleural mass. Further, work-up was negative for tumor. A left video assisted thoracotomy exploration was performed and left thoracotomy was needed for the mass resection. The final pathology demonstrated a high grade osteosarcoma. The post-operative course was unremarkable.

A successful percutaneous mechanical vegetation debulking used as a bridge to surgery in acute tricuspid valve endocarditis.

Timing of surgical management of acute infective endocarditis is a major challenge, with respect to surgical complications, risks of recurrences and optimal valve repair or replacement. We present a case of a 24-year-old male with a history of intravenous drug abuse, who was referred to our center after 10 days of medical management of acute infective endocarditis. Upon arrival he was in septic shock, multi-organ failure, and mobile vegetations on the tricuspid valve with severe tricuspid regurgitation. He also had bilateral pulmonary infarcts and an ischemic stroke in the right parietal lobe. A successful percutaneous transcatheter mechanical vegetation debulking was performed followed by surgical valve replacement seven days later. This case introduces a new option in the management of right-sided endocarditis in critically ill patient, and demonstrates the technical feasibility of a debulking procedure in this setting, which led subsequently to a significant improvement in patient's condition, and he was ultimately able to undergo definitive surgery.

Successful Resection of Giant Mediastinal Lipofibroadenoma of the Thymus by Video-Assisted Thoracoscopic Surgery.

We report the case of a 20-year-old man who presented with a large heterogeneous mass incidentally found on a chest roentgenogram performed in the context of acute onset of fever and cough. A chest computed tomography scan showed a large heterogenous mass in the anterior mediastinum. The patient underwent surgical resection by a right video-assisted thoracoscopic approach. The resected mass was completely encapsulated and was histologically determined to be a lipofibroadenoma. Complete resection is curative. This is the sixth reported case of lipofibroadenoma of the thymus in the English literature and the first reported case of video-assisted thoracoscopic resection of a lipofibroadenoma.

Acute Aortic Dissection Extending Into the Lung.

The radiologic manifestations of ruptured acute aortic dissection, Stanford type A aortic dissection, DeBakey type 1 can present in different radiographic scenarios with devastating outcomes. Here, we present a rare case of a 70-year-old man who presented to the emergency department with chest pain radiating to the back. A chest computed tomography scan showed a Stanford type A, DeBakey type 1, acute aortic dissection ruptured into the aortopulmonary window and stenosing the pulmonary trunk, both main pulmonary arteries, and dissecting the bronchovascular sheaths and flow into the pulmonary interstitium, causing pulmonary interstitial hemorrhage. The patient underwent emergent ascending aorta replacement with hemiarch replacement with circulatory arrest. The postoperative course was unremarkable.

Pulmonary Artery Agenesis Associated With Emphysema and Multiple Invasive Non-Small Cell Lung Cancers.

Pulmonary artery (PA) agenesis in the absence of associated cardiac abnormalities is a rare congenital abnormality. It may remain undiagnosed until adulthood when patients present with respiratory symptoms such as hemoptysis, dyspnea, repeated respiratory infections, or pulmonary hypertension. Herein we present a case of a 50-year-old woman who was found to have multiple, morphologically distinct non-small cell lung cancers in association with agenesis of the PA. This instance represents the fourth reported case of such association in the English literature.

Awake cardiopulmonary bypass to prevent hemodynamic collapse and loss of airway in a severely symptomatic patient with a mediastinal mass.

Management of a large mediastinal mass causing respiratory and hemodynamic compromise represents a major challenge during induction of anesthesia and surgical resection. The hemodynamic changes associated with anesthetic induction and initiation of positive-pressure ventilation can lead to acute hemodynamic collapse or inability to ventilate, or both. Initiation of cardiopulmonary bypass before anesthetic induction represents a safe alternative. We present a 37-year-old woman who underwent successful resection of a large anterior mediastinal mass through sternotomy. Cardiopulmonary bypass was instituted using the right femoral vessels under local analgesia to allow safe anesthetic induction. Her postoperative course was uneventful. This represents an example of a team approach to the management of a complex patient to achieve a successful outcome.

Laparoscopic repair for failed antireflux procedures.

BACKGROUND: Minimally invasive procedures have become common, and more reoperations for failed antireflux procedures are performed laparoscopically. We wanted to study the outcomes of laparoscopic reoperations for reflux. METHODS: Medical records of all patients who underwent reoperation without esophageal resection after previous antireflux procedures between January 2000 and October 2012 were reviewed. RESULTS: Seventy-five patients were included in this report: 56 (77%) women and 19 (23%) men. Median age was 58 years. The previous operation was laparoscopic antireflux procedures in 65 (87%) patients. The median interval between the last antireflux procedure and laparoscopic reoperation was 42 months. The median body mass index (BMI) was 28.7. All patients were symptomatic. Intraoperative findings included recurrent hiatal hernia in 47 (63%) patients, incompetent fundoplication in 14 (19%) patients, tight fundoplication in 8 (11%) patients, and tight crura in 2 (3%) patients. Laparoscopic Nissen fundoplication was performed in 57 (76%) patients, partial posterior fundoplication was performed in 12 (16%) patients, partial anterior fundoplication was performed in 3 (4%) patients, removal of crural stitches was performed in 2 patients, and a combination of partial posterior fundoplication and removal of crural stiches was performed in 1 patient. Complications occurred in 13 (15%) patients. Improvement in symptoms was observed in 70 (93%) patients in early postoperative follow-up and in 59 (78%) patients in long-term follow-up. Functional results were classified as excellent in 59 (78%) patients, good in 6 (7%) patients, fair in 7 (8%) patients, and poor in 3 (4%) patients. CONCLUSIONS: Laparoscopic reoperation for failed antireflux operations is a complex procedure, but it is safe and effective in selected patients. Reoperation after a failed antireflux repair results in excellent or good functional status in a majority of patients, but these results may deteriorate over time.

How we select our residents--a survey of selection criteria in general surgery residents.

INTRODUCTION: The future of general surgery depends on the quality of the resident trainees, and successful resident selection is a factor that is important in the process of high-quality surgical education. METHODS: A 36-question survey regarding resident selection and the interview process was sent to surgical program directors, department chairs, and associate program directors across the United States and Canada. RESULTS: In all, 262 valid replies were received (65%), of which 83% were program directors. University hospital programs accounted for 49% of the completed surveys. The mean yearly applicant number per residency program was 571. Most programs indicated that they strictly adhere to their selection criteria (82%). The screening selection is made by the program director in 62%. Only 31% of programs show their selection criteria on their web page. United States Medical Licensing Examination (USMLE) Step 1 is the single most important factor in screening criteria (37%), followed by USLME Step 2 (24%). A total of 96% of all programs have female residents, 66% have non-Liaison Committee on Medical Education graduates, and 38% have Doctor of Osteopathy (DO) residents. Final selection is made by the program director in 49%. Although research experience is considered in selection criteria (80%), only 46% of programs offer research opportunities to their residents and only 13% require 1-year of research. On a Likert 5-point scale, the interview is by far the most important factor (4.69), followed by Step 1 score (4.21), and letters of recommendation (4.02). CONCLUSIONS: Even though all general surgery programs have a wide range of screening/selection criteria, USLME Step 1 is the single most important factor for preliminary screening, and the interview is the most important factor in determining the final selection. The final selection is relatively subjective and based on a combination of interview, USLME scores, research experience, and personal judgment.

Lymphomas and chylous ascites: review of the literature.

Chylous ascites is a rare and challenging clinical condition that occurs as a result of disruption of the abdominal lymphatics. We include a review of the literature describing the etiology, diagnosis, and therapy of chylous ascites.