RESUMO
BACKGROUND: Crescent cannula adhesion in the setting of COVID-19 respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support is a novel complication. The objective of this case presentation is to highlight this rare complication and to explore potential predisposing factors and our management strategies. CASE PRESENTATION: We present the case of a 25 y.o. patient with COVID-19 respiratory failure requiring ECMO support for 16-days in which a 32 Fr crescent cannula became adherent to the SVC and proximal jugular vein. Attempts to remove the cannula at the bedside failed due to immobility of the cannula. Ultrasound of the right neck was unremarkable, so he was taken to the hybrid OR where both TEE and fluoroscopy were unrevealing. An upper sternotomy was performed, and the superior vena cava and proximal jugular vein were dissected revealing a 2 cm segment of the distal SVC and proximal jugular vein that was densely sclerosed and adherent to the cannula. The vessel was opened across the adherent area at the level of the innominate vein and the cannula was then able to be withdrawn. The patient suffered no ill effects and had an unremarkable recovery to discharge. CONCLUSIONS: To date, there have been no reports of crescent cannula adhesion related complications. In patients with COVID-19 respiratory failure requiring ECMO, clinicians should be aware of widespread hypercoagulability and the potential of unprovoked, localized venous sclerosis and cannula adhesion. We report our technique of decannulation in the setting of cannula adhesion and hope that presentation will shed further light on this complication allowing clinicians to optimize patient care.
Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Síndrome do Desconforto Respiratório , Insuficiência Respiratória , COVID-19/terapia , Cânula , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Masculino , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Veia Cava SuperiorRESUMO
Acute type A aortic dissections starting at the arch pose a challenge for cardiac surgeons. Open surgical repair requires deep hypothermic circulatory arrest for arch reconstruction and is associated with significant morbidity and mortality. Hybrid aortic repair techniques, with open arch debranching and thoracic endovascular aortic repair, have been employed in high-risk cases and challenging aortic pathology. Herein, we present a case of a 33-year-old African American male with a history of open thoracoabdominal aortic reconstruction and femoral-femoral artery bypass for a type B dissection who subsequently presented with new-onset chest pain and was found to have a retrograde type A dissection of a bovine arch with multiple dissection flaps and possible contrast extravasation on chest computed tomography. Endovascular reconstruction of the aortic arch using a hybrid technique was utilized and proved to be feasible and further should be considered when complex anatomy limits traditional surgical options.
Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Doença Aguda , Adulto , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/fisiopatologia , Aorta Torácica/anormalidades , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/fisiopatologia , Aortografia/métodos , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada , Procedimentos Endovasculares/instrumentação , Hemodinâmica , Humanos , Masculino , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
The optimal technique for complex ventral hernia repair (VHR) remains controversial. Component separation (CS) reinforced with porcine acellular dermal matrix (PADM) has shown favorable results compared with series of conventional bridged VHR, but few comparative studies exist. We conducted a retrospective cohort study comparing 40 randomly selected patients who underwent CS/PADM reinforcement against an identical number of patients who underwent conventional open VHR with mesh at our institution. Patient characteristics, operative findings, outcomes, complications, reoperations, and recurrences were obtained by chart review. Fisher's exact/t test compared outcomes between the two cohorts. Statistical significance was set as P < 0.05. Mean follow-up was 33.1 months. Patient groups did not differ significantly in race (P = 1.00), age (P = 0.82), body mass index (P = 0.14), or comorbid conditions (smoking, chronic obstructive pulmonary disease, obesity, steroid use; P values 0.60, 0.29, 0.08, and 0.56, respectively). Defect size was greater in the CS/PADM group (mean, 372.5 vs 283.7 cm(2), P = 0.01) as was the percentage Ventral Hernia Working Group Grade III/IV hernias (65.0 vs 30.0%, P = 0.03). Recurrences were lower in the CS/PADM group (13.2 vs 37.5%, P = 0.02). Mesh infection was lower in the CS/PADM group (0 vs 23% in the bridged group, P = 0.002), all of which occurred with synthetic mesh. Indications for reoperation (recurrence or complications requiring reoperation) were also lower in the CS/PADM group (17.5 vs 52.5%, P = 0.002). Superior results are achieved with CS/PADM reinforcement over traditional bridged VHR. This is evidenced by lower recurrence rates and overall complications requiring reoperation, particularly mesh infection. This is despite the greater use of CS in larger defects and contaminated hernias (VHWG Grade III and IV). CS/PADM reinforcement should be strongly considered for the repair of significant midline ventral hernia defects.
Assuntos
Derme Acelular , Hérnia Ventral/cirurgia , Herniorrafia/instrumentação , Telas Cirúrgicas , Animais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/cirurgia , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Suínos , Resultado do TratamentoRESUMO
The benign category of the Bethesda System for reporting thyroid cytopathology (BSRTC) predicts an incidence of malignancy from zero to three per cent. However, recent series report higher rates of malignancy ranging from eight to 14 per cent. Surgery is often performed for reasons other than their fine needle aspiration biopsy (FNAB) such as symptoms, nodule enlargement, or worrisome imaging. We hypothesized that an analysis of patients who underwent thyroidectomy despite a benign FNAB would identify predictors of malignancy, an area not currently addressed by American Thyroid Association guidelines. We performed a retrospective analysis of patients with benign FNAB results who underwent thyroidectomy from October 2007 to October 2012. Data collected included symptoms, imaging findings, FNAB results, and operative and histopathology results, all of which were obtained by chart review. Findings were compared between patients with and without a diagnosis of malignancy. Statistical significance was set as P < 0.05. Of 3839 FNABs, 2838 were benign. Of these, 180 underwent surgery for indications other than the FNAB category. Twenty-four (13.4%) malignancies were identified: 12 (6.7%) incidental microcarcinomas and 12 (6.7%) significant cancers (papillary greater than 1.0 cm, any nonpapillary histology). No patient's symptoms or signs reached significance as a predictor of malignancy. Suspicious ultrasound appearance was significantly associated with an underlying carcinoma (P = 0.004). The false-negative result with benign FNAB is higher in surgical series than suggested by the BSRTC. Patients with tolerable symptoms may be observed in the face of a benign FNAB. Additionally, despite a benign FNAB, recommendations for closer follow-up or surgical intervention are warranted if the ultrasound appearance is suspicious.
Assuntos
Neoplasias da Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/patologia , Tireoidectomia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha Fina , Citodiagnóstico , Reações Falso-Negativas , Feminino , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Neoplasias da Glândula Tireoide/cirurgia , Nódulo da Glândula Tireoide/cirurgiaAssuntos
Tumores Neuroectodérmicos Primitivos Periféricos/diagnóstico , Tumores Neuroectodérmicos Primitivos Periféricos/cirurgia , Sarcoma de Ewing/diagnóstico , Sarcoma de Ewing/tratamento farmacológico , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Biópsia , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tumores Neuroectodérmicos Primitivos Periféricos/tratamento farmacológicoRESUMO
This pilot study examined symptom relief and quality of life in pediatric patients who received laparoscopic cholecystectomy surgery at our institution for biliary dyskinesia. We used two validated questionnaires: the Child Health Questionnaire (CHQ-PF28), to assess general well-being, and the Gastrointestinal Quality of Life Index (GIQLI), to measure gastrointestinal-related health. After Institutional Review Board approval, all patients under the age of 18 years who underwent laparoscopic cholecystectomy for biliary dyskinesia between November 2006 and May 2010 received mailed questionnaires. Preoperative and postoperative data were retrospectively collected from respondents and included age, race, symptoms, gallbladder ejection fraction values, pathologic findings, and clinical course. Of 89 patients meeting inclusion criteria, 21 responded. Mean age at surgery was 13.08 years (range, 8 to 17 years). The most common preoperative symptoms consisted of nausea (100%), postprandial pain (90.5%), right upper quadrant pain (81.0%), and vomiting (66.7%). Mean long-term follow-up interval was 18.9 months (range, 7 to 40 months; SD 10.37). Patients with long-term symptom relief reported significantly higher GIQLI scores than those with enduring symptoms. Examination of the results from the CHQ-PF28 revealed significantly lower scores than a general U.S. pediatric sample in both the Physical and Psychosocial Summary Measures (P < 0.05). Children experiencing long-term symptom cessation after laparoscopic cholecystectomy reported higher quality of life than those who had incomplete or only short-term relief. However, regardless of the degree of symptom relief, the degree of quality of life experienced by our study sample of patients with biliary dyskinesia is lower than that of a comparable U.S. pediatric sample.