Middle lobe torsion following lobectomy. / Midtlappstorsjon etter lobektomi.

BACKGROUND: Pulmonary torsion is a rare complication following thoracic surgery. CASE PRESENTATION: A man in his seventies was diagnosed with stage IIIA lung cancer occupying the right upper lobe, and lobectomy was performed through posterolateral thoracotomy. Postoperative chest X-rays revealed extensive, progressive middle lobe opacities on postoperative day 0 and 1, with no corresponding clinical or bronchoscopic findings. Contrast-enhanced computed tomography raised suspicion of middle lobe torsion, and exploratory surgery confirmed the finding of a necrotic middle lobe with 180 degrees of torsion. The middle lobe was resected and the patient recovered well. INTERPRETATION: Pulmonary lobar torsion is a rare but potentially life-threatening complication following thoracic surgery that should not be overlooked even in the absence of symptoms that raise concern. Bronchoscopy and radiological imaging may suggest the condition, but the final diagnosis is made surgically.

Rib fractures in trauma patients: does operative fixation improve outcome?

PURPOSE OF REVIEW: Renewed interest in surgical fixation of rib fractures has emerged. However, conservative treatment is still preferred at most surgical departments. We wanted to evaluate whether operative treatment of rib fractures may benefit severely injured patients. RECENT FINDINGS: Several studies report a reduction in mechanical ventilation time, ICU length of stay (LOS), hospital LOS, pneumonia, need for tracheostomy, pain and costs in operatively treated patients with multiple rib fractures compared with patients treated nonoperatively. Although patient selection and timing of the operation seem crucial for successful outcome, no consensus exists. Mortality reduction has only been shown in a few studies. Most studies are retrospective cohort and case-control studies. Only four randomized control trials exist. SUMMARY: Conservative treatment, consisting of respiratory assistance and pain control, is still the treatment of choice in the vast majority of patients with multiple rib fractures. In selected patients, operative fixation of fractured ribs within 72 h postinjury may lead to better outcome. More randomized control trials are needed to further determine who benefits from surgical fixation of rib fractures.

Endothelin-1 in the human myocardium and circulating plasma: evaluation before, during and after correction of aortic stenosis with aortic valve replacement.

OBJECTIVES: Due to the pathological effects of endothelin-1 (ET-1) on cardiomyocytes and the extracellular matrix, ET-1 levels may impact on the prognosis of aortic stenosis (AS) patients operated with aortic valve replacement (AVR). We examined ET-1 levels in AS patients throughout the whole AVR process, thus exposing potential therapeutic windows of opportunity. METHODS: Plasma ET-1 levels were measured before and 2 days, 6 and 12 months after AVR in 22 patients with AS. Myocardial ET-1 was measured in biopsies from 7 patients undergoing AVR. Peroperatively, plasma ET-1 was analyzed in the coronary sinus and radial artery before aortic cross-clamp and at 5 and 20 min of reperfusion, in a second group of 30 patients. RESULTS: Circulating ET-1 levels were transiently increased 2.6-fold 2 days following AVR. Myocardial ET-1 protein was 2.1-fold higher in patients with AS compared to controls. Plasma levels of ET-1 correlated to echocardiographic markers of diastolic dysfunction postoperatively. There was no increase in plasma ET-1 during early reperfusion, but veno-arterial differences indicated potential cardiac ET-1 extraction. CONCLUSIONS: Plasma ET-1 increases 2 days following AVR and myocardial ET-1 protein levels are increased in patients with AS before AVR. Peroperatively, no plasma ET-1 augmentation or release from the heart was observed in AS patients.

GDF-15 is increased during early reperfusion following aortic valve replacement.

OBJECTIVES: To examine the circulating levels of Growth differentiation factor 15 (GDF-15) and Interleukin 18 (IL-18) in relation to ischemia and early reperfusion, and cardioplegia type during isolated aortic valve replacement (AVR). DESIGN: Thirty consecutive patients operated for aortic stenosis with AVR at Oslo University Hospital, Ullevål, were included in the study. The patients were randomized into two groups, receiving either cold blood or crystalloid cardioplegia. Samples from both the radial artery and coronary sinus were analyzed before cardiac ischemia, and after 5 and 20 minutes of reperfusion. RESULTS: Radial artery and coronary sinus plasma GDF-15 were significantly elevated after 5 and 20 minutes of reperfusion in both cardioplegia groups. In the total group of thirty patients, this represented an increase of 31% and 55% in the radial artery and an increase of 27% and 40% in the coronary sinus after 5 and 20 minutes of reperfusion respectively. IL-18 increased after 20 minutes of reperfusion in the crystalloid cardioplegia group only. No veno-arterial differences were detected during reperfusion. CONCLUSIONS: Plasma levels of GDF-15 were significantly elevated after 5 and 20 minutes of myocardial reperfusion during AVR. Plasma levels of IL-18 were elevated after 20 minutes, but only when using crystalloid cardioplegia.

Catamenial pneumothorax, clinical manifestations--a multidisciplinary challenge.

INTRODUCTION: Pleural endometriosis is a rare condition. Spontaneous, recurring pneumothorax occurring during menstruation, referred to as catamenial pneumothorax, is associated with pleural endometriosis. A multidisciplinary approach is needed for a successful result. MATERIAL AND METHODS: During the last five years (2005-2010), we have treated six patients with menstruation related pneumothorax at Oslo University Hospital. The surgical treatment was performed by the thoracic surgery department but the medical follow-up was carried out by the gynecological and pulmonary medicine departments. RESULTS: We report three of the patients treated. All three patients were premenopausal, aged 19-36, and had recurring, menstruation related, spontaneous pneumothorax, predominantly on the right side. The condition was treated by various surgical approaches, including chest tube drainage, video assisted thoracic surgery, chemical pleurodeses and thoracotomy. CONCLUSION: Spontaneous, recurring pneumothorax in women with no previous history of endometriosis can be the first manifestation of pleural endometriosis. The disorder requires surgical intervention, but early diagnosis and postoperative hormonal therapy are just as important for a successful outcome.

Plasma IL-18 and IL-18BP are altered differently in reverse remodeling following aortic valve replacement.

OBJECTIVES: Patients with aortic stenosis (AS) develop left ventricular remodeling characterized by changes in extracellular matrix (ECM) and cardiomyocyte-hypertrophy. Aortic valve replacement (AVR) reverses this process (reverse remodeling). We examined plasma levels of interleukin-18 (IL-18) and its binding protein (IL-18BP) before and after AVR for AS since these mediators have been shown experimentally to exert effects on myocardial remodeling. DESIGN: Plasma levels of IL-18 and IL-18BP were analyzed in 22 patients with AS undergoing AVR, preoperatively, two days, six and 12 months postoperatively. Echocardiography and functional testing were performed. RESULTS: IL-18BP was significantly increased by 28% and 15% at two days and six months after AVR, compared to preoperative values. In contrast, IL-18 showed a later peak (increased by 24% at 12 months postoperatively) when IL-18BP was normalized. IL-18 correlated positively with deceleration time (R = 0.44) at this time-point which might indicate an association with diastolic function. CONCLUSIONS: We report for the first time that plasma IL-18 and IL-18BP are differentially regulated after AVR for AS with an early increase in IL-18BP postoperatively followed by a later peak in IL-18 at 12 months. Given the known effects of these mediators on myocardial remodeling and function, they might play a role in the reverse and remodeling process associated with AVR.

Access site complications after transfemoral aortic valve implantation - a comparison of Manta and ProGlide.

BACKGROUND: Despite decreasing sheath diameter, access site bleeding and vascular complications are still a major concern in transfemoral aortic valve implantation (TAVI), and may increase morbidity and even increase mortality. The aim was to compare safety of arterial closure in transfemoral TAVI with two different principles, pre-suture with ProGlide and collagen plug closure with Manta. RESULTS: Seventy-six patients treated with ProGlide and 75 with Manta were analysed. The endpoints were 1: access site vascular complications and 2: non-planned vascular or endovascular surgery at the puncture site. Complications occurred in 2 (2.7%) ProGlide and in 8 (10.7%) Manta cases, p = 0.047. During the learning phase there were no significant differences. In the established phase there was one event (2%) in the ProGlide group, compared to 6 endpoints (12.0%), p = 0.047, in the Manta group.Unplanned surgery or intervention was seen in two (2.7%) ProGlide and in 7 (9.3%) Manta patients, p = ns. There were no significant differences during the learning phase. In established use, endpoints occurred more frequently in patients treated with the Manta device (12%), than in patients treated with the ProGlide (2%), p = 0.047. CONCLUSION: The ProGlide presuture closure device was associated with significantly lower rates of vascular complications and lower rates of surgery and interventions compared to the collagen plug Manta system. TRIAL REGISTRATION: The data were collected from Internal quality control registry on treatment of patients with valvular heart disease with or without coronary artery disease, No 2014/17280, Oslo University Hospital, Ullevål.