Evaluation of Postoperative Pain After Cardiothoracic Surgery in Patients With and Without Significant Preoperative Anxiety: A Prospective Observational Study.

BACKGROUND AND AIMS: Anxiety plays a distressing role in cardiothoracic operations. It may trigger hemodynamic instability, increased morbidity, and very crucially, postoperative pain and analgesic use. Our aim is to look at the association between anxiety, postoperative pain, and analgesic use. MATERIALS AND METHODS: One hundred and twenty-two patients scheduled for cardiothoracic surgeries were asked questions according to the Amsterdam Preoperative Anxiety and Information Scale (APAIS), the evening prior to the surgery. Different factors that could affect anxiety perioperatively were recorded through the patient's hospital records. The visual analog score (VAS) was recorded at arrival in the ICU after surgery. Paracetamol (1 g) and Inj Tramadol (1 mg/kg) were administered as postoperative analgesia. Additional fentanyl boluses (1 mcg/kg) were administered whenever the VAS exceeded 4. Analgesic doses were documented. All the data were then analyzed statistically. RESULTS: Preoperative anxiety was recorded in 63.9% of the 122 subjects included in the study, with younger patients and patients with very low socioeconomic status being the majority. VAS, at 20 and 24 hrs of assessment, was higher in both groups, and there was a statistically significant difference, with patients that were preoperatively anxious, recording higher VAS scores. Postoperative analgesic doses were also significantly higher for patients with anxiety. CONCLUSIONS: This clinical trial demonstrated that greater than 60% of the participants presented with preoperative anxiety, the majority being young participants. Lower socioeconomic status is also a risk factor for preoperative anxiety. Patients who suffered from preoperative anxiety are more likely to have greater pain scores and analgesic needs during postsurgical assessment.

Congenital bilio-bronchial fistula in an adult: a review of literature and video demonstration of laparoscopic fistula tract excision.

This article presents a review of the literature on congenital bilio-bronchial fistula (BBF), a rare anomaly characterized by abnormal communication between the bile duct and respiratory tract. Congenital BBF often presents with bilioptysis in early neonates and infants; however, patients with no overt symptoms may occasionally present in adulthood. Our literature search in Medline from 1850 to 2023 revealed 42 reported cases of congenital BBF, primarily managed with thoracotomy and excision of the fistula tract. About one-third of these cases required multiple surgeries due to associated biliary anomalies. The review underscores the importance of diagnostic imaging, including bronchoscopy, in identifying and delineating the extent of the fistula. It also highlights the evolving surgical management, with recent cases showing the efficacy of minimally invasive approaches such as laparoscopy and thoracoscopy. In addition to the literature review, we report a young female patient with a history of recurrent respiratory infections presenting with bilioptysis and extensive left lung damage. Initial management included bronchoscopy-guided glue instillation, left thoracotomy, and pneumonectomy. Following the recurrence of symptoms, the patient was successfully treated with laparoscopic excision of the fistula tract. In recent times, minimally invasive approaches such as laparoscopy and thoracoscopy, with excision of the fistula tract are gaining popularity and have shown good results. We suggest biliary communication being the high-pressure end, tackling it transabdominal may prevent recurrent problems.

Relationship between difference of preoperative and cardiopulmonary bypass mean arterial pressure, and acute kidney injury in cardiac surgical patients undergoing valve surgery.

BACKGROUND: Modifiable and non-modifiable factors contribute to development and progression of acute kidney injury (AKI) during cardiac surgery. We hypothesized that, the difference between preoperative mean arterial pressure (MAP) and the average mean arterial pressure maintained on cardiopulmonary bypass (CPB) would be strongly predictive of AKI. We also measured plasma Neutrophil gelatinase-associated lipocalin (NGAL), to establish its association with cardiac surgery associated-AKI (CSA-AKI). METHODS: One hundred and twelve high-risk patients undergoing valve, and valve plus coronary artery bypass grafting (CABG) surgery under cardiopulmonary bypass (CPB) were included in this study. Delta mean arterial pressure (MAP) was calculated as the difference between the average of pre-operative and on-bypass MAP, and blood was sampled for NGAL levels, at baseline, and 6-h after CPB. Detailed data collection was done, tabulating most of the factors which might influence development of post-operative cardiac surgery associated-AKI (CSA-AKI). To define CSA-AKI within the first 24-h post-operatively, the Kidney Disease Improving Global Outcomes (KDIGO) classification was used. RESULTS: Out of 112 patients, 44 (39.3%) developed CSA-AKI postoperatively. With an ROC analysis cut-off of delta MAP of more than 25.67 mmHg, 46.4% patients developed post-operative AKI, and the average CPB flows which were 1.8 ± 0.2 were not contributory to the development of early CSA-AKI. In our study, ELISA test for human NGAL was performed on serum samples, and the estimated cut-off value of 1661 ng/mL was found to be significantly associated with early CSA-AKI. CONCLUSIONS: Delta MAP and CPB flows are not related to early post-surgical CSA-AKI in cases with prior high-risk elements. However, baseline serum NGAL, as well as its percent change during the early post-surgical period independently predicted the development of CSA-AKI. This implies that, there may be patients with a higher pre-operative preponderance to develop this complication, which could actually be delineated by the use of serum NGAL estimations at baseline.

Primary Ewings Sarcoma of the Inferior Vena Cava.

INTRODUCTION: Sarcomas of vascular origin are rare. A case of Ewings sarcoma of Inferior Vena Cava [IVC] is reported here. REPORT: A 36-year-old lady presented with a 6-month history of bilateral pitting lower limb swelling and 1-month history of vaginal bleeding. Contrast-enhanced computed tomography of the thorax and abdomen revealed a soft tissue lesion extending from the cavoatrial junction to the junction of the middle hepatic vein with IVC. She underwent IVC resection (suprahepatic) and left lateral hepatectomy with dacron graft reconstruction. The pathology was suggestive of Ewings sarcoma and she received adjuvant chemotherapy. CONCLUSION: Preoperative tissue diagnosis can be considered in vascular tumors to sequence the various treatment modalities for improved outcomes.

Guillain-Barre Syndrome-A Rare Cause of Quadriparesis after the Bentall Procedure for Type A Aortic Dissection.

Neurological complications following aortic surgery are most often cerebrovascular accidents due to embolism, or spinal infarcts resulting in hemiparesis or hemiplegia. Guillain-Barre syndrome is a rare cause of quadriparesis. Here, we report a 49-year old male who presented with acute aortic dissection and underwent the Bentall procedure following which he developed quadriparesis, subsequently diagnosed to be a case of Guillain-Barre syndrome. He was successfully treated with intravenous immunoglobulin.

A Giant Right Atrial Hemangioma- Case Report.

A primary cardiac tumor is sporadic. Most cardiac tumors are benign, with cardiac myxoma being the most common tumor. The incidence of cardiac hemangioma is extremely low. We report a 55-year-old female patient admitted for chest pain and breathlessness and, on evaluation by Echocardiography and Computed tomography, was diagnosed with a right atrial mass. The patient was taken up for surgery. The excised right atrial mass was confirmed as atrial hemangioma by postoperative histopathology. Cardiac hemangioma should be suspected when imaging shows a homogenous mass with vascularity. We present this case as the tumor is sporadic and illustrate the technical difficulties we encountered during the surgery.

Giant Celiac Artery Pseudoaneurysm in a Case of Chronic Pancreatitis: A Rare Case Report With Literature Review.

Pancreatic pseudoaneurysms though uncommon can result in life-threatening spontaneous acute gastrointestinal or intraperitoneal hemorrhage. Celiac artery pseudoaneurysm in a background of chronic pancreatitis is a very rare event. Digital Subtraction Angiography is an important adjunct in the diagnosis and follow-up with the advantage of providing therapeutic options along with giving other details regarding the site, size, and flow characteristics. It has replaced emergency surgical procedures with the added advantage of fewer postoperative complications and lower morbidity and mortality. An urgent surgical intervention remains the only option when such endovascular management fails, not feasible, or is unavailable. Surgical options include proximal arterial ligation or a pancreatic resection, depending on the location of the pseudoaneurysm. We report a case of a 35-year-old gentleman, a known patient of chronic pancreatitis, who presented to our emergency with clinical features of hypovolemic shock and was diagnosed to have celiac artery pseudoaneurysm. Following a failed endovascular coiling, he was successfully managed with operative celiac artery ligation.

Thoracic mucormycosis in immunocompetent patients.

BACKGROUND: Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes. METHODS: We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm. RESULTS: The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment. CONCLUSION: Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

Leiomyosarcoma of the inferior vena cava posing as an adrenal incidentaloma.

Adrenal incidentalomas are incidentally detected adrenal lesions on imaging, which have a variety of differential diagnoses, the most common being a non-functioning adenoma. Surgical intervention for these lesions is needed when there is hypersecretion, for lesions larger than 4 cm and smaller lesions with suspicious characteristics. Here we present a young woman who was incidentally found to have a right suprarenal mass with loss of fat planes with the inferior vena cava (IVC). She underwent resection of the tumour along with the posterior wall of IVC, which was primarily repaired. Her postoperative biopsy was suggestive of leiomyosarcoma arising from the IVC. In the absence of distant metastasis, the sole prognostic factor for this tumour is achieving negative margins through radical resection of the tumour with IVC resection. Retroperitoneal leiomyosarcomas should be considered as a differential diagnosis for larger lesions, especially those more than 10 cm.

Tracheo-innominate Artery Fistula in a Complicated Penetrating Neck Trauma: A Successfully Managed Rare Complication of Low Tracheotomy.

Tracheo-innominate artery fistula is a rare complication of tracheotomy with very high mortality rate. Only a few patients survive this complication as reported in the literature. Here we report the case of a 54-year-old gentleman who presented to the emergency department with a history of penetrating neck trauma following a road traffic accident. Neck exploration and tracheotomy were done to secure the airway. After two weeks, the patient had an episode of massive stomal bleed for which he was taken to the operating room and re-explored. A tracheo-innominate artery fistula was detected, and right side aorto-carotid and right side aorto-subclavian anastomoses were done using reversed saphenous vein graft with interruption of flow. Following a successful surgery, the patient was decannulated later, and now lives a healthy normal life. Early diagnosis and immediate intervention are the key in managing this complication. Bedside management also plays a vital role.

Left Ventricular Pseudoaneurysms in Children-A Case Series.

Left ventricular pseudoaneurysms are very rare in children. In children, left ventricular pseudoaneurysms can occur following infection, trauma, ischemia, or cardiac surgery. The authors report a series of three cases treated at our hospital with two of the cases having a history of extrapulmonary tuberculosis and one patient with a history of varicella zoster infection.

Growing teratoma syndrome in primary mediastinal germ cell tumor: our experience.

BACKGROUND: Growing teratoma syndrome is a rare phenomenon seen in nonseminomatous germ cell tumors after chemotherapy, where the tumor grows paradoxically despite normalization of tumor markers. It has been found in various locations, most commonly, the retroperitoneum in association with metastatic disease. The occurrence of growing teratoma syndrome in a mediastinal primary is very rare and there are only a few reports in the literature. METHODS: In a retrospective review, out of 12 patients with mediastinal involvement by a germ cell tumor, 5 had a primary from the mediastinum. We present a series of 3 cases of primary germ cell tumor of the mediastinum, which after chemotherapy, fulfilled the criteria for growing teratoma syndrome and were managed with surgical excision. CONCLUSION: Development of growing teratoma syndrome in a primary mediastinal germ cell tumor is extremely rare. Its awareness and early detection can lead to successful surgical excision and long-term cure.

Spectrum of morphological abnormalities and treatment outcomes in ostium secundum type of atrial septal defects: Single center experience in >500 cases.

BACKGROUND: Transcatheter closure (TCC) has emerged as the first line treatment option for secundum type of atrial septal defects (ASD). Outcomes of TCC depend upon proper delineation of defect anatomy by transesophageal echocardiography (TEE). Stability and proper placement of the device mandates adequate rims and proper alignment to the septum. Failed or unfavorable morphology for TCC requires referral for surgical repair. METHODS: We prospectively analyzed the ASD patients who were referred for treatment. The morphological features of the defect were evaluated and the outcomes of TCC studied. Patients who undergo TCC and surgical repair were followed for immediate and long-term outcome comparison. RESULTS: Of the 512 patients who underwent treatment, TCC was attempted in 430/512 (83.2%) patients. It was successful in 393/430 (91.3%) patients. The remaining 119 patients underwent surgical patch closure. Twenty patients had failure of device alignment and device embolization occurred in 17 patients. Very large defect size ≥35 mm, absent or deficient posterior rim, absent/deficient inferior naval rim showed high chances for failure and formed major reasons for surgical referral. The surgical group had higher success (100%) across all anatomic variables. However, they had longer intensive care unit (ICU) and hospital stay (p < 0.001). CONCLUSION: TCC offered a success rate of 91% in complex defects after TEE selection. Very large size and deficient inferior, posterior rims predicted failure of TCC. Surgery offered 100% success and it involved a longer hospital and ICU stay. The long-term clinical results were identical with both treatment modalities.

Acute severe mitral regurgitation with cardiogenic shock following balloon mitral valvuloplasty: echocardiographic findings and outcomes following surgery.

Acute severe mitral regurgitation (MR) is the commonest indication for emergency surgery following a balloon mitral valvuloplasty (BMV). It results in hemodynamic compromise with cardiogenic shock and or acute pulmonary edema. These patients deteriorate fast and often require respiratory and critical care support, followed by urgent mitral valve replacement (MVR). We analyzed the data of 1224 BMV procedures done over the 18-year period. We had 85 patients (6.9%) with acute severe MR and cardiogenic shock. The clinical profile, echocardiographic features and operative findings were studied. The echocardiography scores were compared for association with occurrence of MR. The immediate and long-term clinical outcomes of these acutely sick patients were studied. Of the 85 patients, 84 underwent MVR. Anterior mitral leaflet tear was observed in 65 (75%) cases, para-commissural with annular tear in 8 (9.4%), Chordal injury in 7 (8%) and torn posterior leaflet in 5 (5.8%). We documented severe MR in 88 patients (7.1%), with 85 (6.9%) among them developing features of cardiogenic shock. None of the echocardiographic scoring systems were predictive of the occurrence of MR. The 30-day mortality was 4.7%. The mean clinical follow-up period after discharge was 9.3 ± 0.9 years (range 2.2-17.8) with no late mortality. Acute severe MR had an incidence of 7% in this study. Injury to the anterior mitral leaflet was the commonest cause. The long-term outcomes were good with timely intervention and valve replacement surgery despite the fact that the majority (96%) presented with cardiogenic shock. None of the present valve scoring systems could predict the occurrence of severe MR.