Combined Minimal Invasive Transdiaphragmatic Resections of Peripheral Colorectal Lung Metastases in Patients Undergoing Laparoscopic Liver Resections.

BACKGROUND: The management of patients with simultaneously diagnosed colorectal liver and lung metastases (SLLM) remains controversial. A recent study based on an analysis of the LiverMetSurvey demonstrated that patients with SLLM suitable for resection of all metastases have a survival similar to that of patients who undergo removal of isolated liver metastases.1 Simultaneous transdiaphragmatic resection of peripheral lung lesions and liver resection by laparotomy has been described previously.2 To the authors' knowledge, no previous reports on a similar minimally invasive approach have been published. In April 2015, the authors started performing combined minimally invasive transdiaphragmatic resections of peripheral colorectal lung metastases in patients undergoing laparoscopic liver resections. This video aims to demonstrate the authors' first experience with this minimally invasive approach. METHODS: This report describes a combined minimally invasive transdiaphragmatic resection of peripheral colorectal lung metastasis in a patient undergoing a laparoscopic liver resection. General anesthesia was induced with placement of a double-lumen endotracheal tube to achieve single-lung ventilation. Once laparoscopic liver resection was completed, the left lung containing the metastatic lesion was deflated. The left hemidiaphragm was carefully divided using a 10-cm incision around the central tendon to avoid damage to the phrenic nerve. The lung metastasis was localized using intraoperative ultrasound, and the lesion was resected using endoscopic 60-mm vascular staplers. A thoracic tube was placed, and the diaphragm was closed with a running nonabsorbable suture. RESULTS: The operative time was 180 min, and the blood loss was 100 ml. The postoperative course was uneventful. The patient was discharged on postoperative day 4. Pathology confirmed two colorectal metastases. Tumor-free margins of 5 mm for the liver and 7 mm for the lung were achieved. CONCLUSIONS: Simultaneous transdiaphragmatic resection of peripheral lung lesions is feasible for patients undergoing laparoscopic liver resection. The low invasiveness of the described technique could facilitate an aggressive operative approach to SLLM.

Nonintubated versus intubated thoracoscopic bullectomy for primary spontaneous pneumothorax: A multicenter propensity-matched analysis.

BACKGROUND: We aimed at comparing in a multicenter propensity-matched analysis, results of nonintubated versus intubated video-assisted thoracic surgery (VATS) bullectomy/blebectomy for primary spontaneous pneumothorax (PSP). METHODS: Eleven Institutions participated in the study. A total of 208 patients underwent VATS bullectomy by intubated (IVATS) (N = 138) or nonintubated (NIVATS) (N = 70) anesthesia during 60 months. After propensity matching, 70 pairs of patients were compared. Anesthesia in NIVATS included intercostal (N = 61), paravertebral (N = 5) or thoracic epidural (N = 4) block and sedation with (N = 24) or without (N = 46) laryngeal mask under spontaneous ventilation. In the IVATS group, all patients underwent double-lumen-intubation and mechanical ventilation. Primary outcomes were morbidity and recurrence rates. RESULTS: There was no difference in age (26.7 ± 8 vs 27.4 ± 9 years), body mass index (19.7 ± 2.6 vs 20.6 ± 2.5), and American Society of Anesthesiology score (2 vs 2). Main results show no difference both in morbidity (11.4% vs 12.8%; p = 0.79) and recurrence free rates (92.3% vs 91.4%; p = 0.49) between NIVATS and IVATS, respectively, whereas a difference favoring the NIVATS group was found in anesthesia time (p < 0.0001) and operative time (p < 0.0001), drainage time (p = 0.001), and hospital stay (p < 0.0001). There was no conversion to thoracotomy and no hospital mortality. One patient in the NIVATS group needed reoperation due to chest wall bleeding. CONCLUSION: Results of this multicenter propensity-matched study have shown no intergroup difference in morbidity and recurrence rates whereas shorter operation room time and hospital stay favored the NIVATS group, suggesting a potential increase in the role of NIVATS in surgical management of PSP. Further prospective studies are warranted.

Long-term results after endovascular abdominal aortic aneurysm repair using the Cook Zenith endograft.

OBJECTIVE: This study assessed the long-term outcome of patients with abdominal aortic and aortoiliac aneurysms treated with the Cook Zenith endovascular graft (Cook Inc, Bloomington, Ind). METHODS: Between September 1998 and October 2003, 143 patients underwent elective endovascular aneurysm repair (EVAR) using the Cook Zenith endograft. Data from these patients were reviewed from a prospective database in October 2008. Primary outcome measures were overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary outcome measures were early and late postoperative complications, including endoleaks. RESULTS: Mean follow-up was 66.4 months (range, 1.9-121.0 months). Overall survival was 72.1% at the 5-year follow-up and 50.9% at the 8-year follow-up. Intervention-free survival was 77.1% at 5 years and 63.8% at 8 years. There were no reintervention-related deaths. Six patients had a late aneurysm rupture, which was fatal in three. Freedom from aneurysm rupture was 98.1% at 5 years and 91.0% at 8 years. Late complications occurred throughout the follow-up period, with a tendency for aneurysm rupture and surgical conversion to occur at a later stage in the follow-up period. Aneurysm sac enlargement during follow-up was associated with late aneurysm rupture and with the need for reintervention. CONCLUSION: Elective EVAR using the Cook Zenith endograft provides excellent results through a mean follow-up of >5 years. There is a low aneurysm-related mortality and an acceptable rate of postoperative complications and reinterventions. The occurrence of late complications throughout the follow-up period stresses the need for continued postoperative surveillance in EVAR patients.

Esophageal necrosis after endoprosthesis for ruptured thoracoabdominal aneurysm type I: can long-segment stent grafting of the thoracoabdominal aorta induce transmural necrosis?

BACKGROUND: To study the pathophysiology of esophageal necrosis after endoprosthesis was performed for a ruptured aneurysm and to define preventive measures and possible treatment options. METHOD: A 72-year-old man with thoracoabdominal aneurysm type I and dysphagia underwent an emergent carotico-carotid bypass in combination with thoracic endovascular aortic aneurysm repair starting at a point distal to the brachiocephalic trunk and ending proximal to the superior mesenteric artery. On day 12, a decortication was performed for treating an infection in the remaining hematoma. However, further deterioration occurred as a result of mediastinitis secondary to the transmural necrosis of the middle third of the esophagus combined with accompanying mediastinitis. The patient's family refused to give consent for further treatment by esophagectomy. He died 24 days after the initial operation. CONCLUSION: Dysphagia aortica, mucosal abnormalities on esophagogastroscopy, and mediastinal compression by hematoma at the time of rupture draws our attention toward ischemia of the esophagus after thoracic endovascular aortic aneurysm repair. Repeated esophagoscopy can provide us with the opportunity to act before full thickness necrosis and mediastinitis occur.

Recurrent laryngeal nerve paralysis by compression from a tracheal diverticulum.

Tracheal diverticulum is a rarely encountered entity, located usually on the right side of the trachea as an outpouching of the wall. Based on mainly histologic features, it can be classified in a congenital or an acquired form. It is usually an incidental finding in an asymptomatic patient. When symptoms are present, they are mostly nonspecific such as chronic cough, dyspnea, or pulmonary infections. We describe a case of dysphonia due to right recurrent laryngeal nerve compression from a tracheal diverticulum. Computed tomography scanning and bronchoscopy revealed the lesion and surgical resection resolved the symptom.

Endovascular treatment of acute traumatic thoracic aortic injuries: a retrospective analysis of 20 cases.

OBJECTIVE: We report our 10-year experience in the endovascular treatment of acute traumatic thoracic aorta rupture at the Hospital Clinic. METHODS: We reviewed 20 patients with an acute traumatic thoracic aorta lesion treated with a thoracic endograft between August 1997 and July 2007. All patients had multi-trauma resulting from high-velocity accidents or accidents with great impact. The diagnosis of aortic injury was made on a clinical basis and conventional imaging, confirmed by computed tomographic angiography. The following parameters were studied: age, sex, type and site of the lesion, type of endovascular graft, endovascular operation time, length of stay in the intensive care unit, length of stay in the hospital, immediate and perioperative complications, and mortality. Follow-up data were recorded, consisting of clinical visits, computed tomographic angiography, and plain chest radiographs at regular intervals (3, 6, and 12 months and every subsequent year). The mean follow-up was 58 months. RESULTS: All endovascular procedures were technically successful, and the mean operating time for the endovascular procedure was 74 minutes (range, 55-130 minutes). We recorded an external iliac lesion during the procedure as an unique immediate complication, and it was corrected by an iliofemoral bypass. The only perioperative death (perioperative mortality rate of 5%) was unrelated to the aortic rupture or stent placement. There was no intervention-related mortality during the follow-up. Postoperative data showed no severe endovascular graft- or procedure-related morbidity. We recorded 2 cases of stent fracture, diagnosed by chest radiograph and computed tomographic angiography, without clinical impact or signs of endoleak. CONCLUSION: The short- and mid-term results of immediate endovascular repair of traumatic aortic injuries are promising, especially when compared with open surgical treatment, indicating that endovascular therapy is preferable in patients with multi-trauma and traumatic ruptures of the thoracic aorta. Nevertheless, long-term follow-up data are necessary to assess the overall durability of this procedure, considering the young age of these patients. The long-term follow-up results will determine whether endovascular treatment should replace open surgery as first-line therapy in thoracic aortic injuries.