Intraoperative Extracorporeal Membrane Oxygenation in Thoracic Surgery.

Evidence supporting the utilization of extracorporeal membrane oxygenation (ECMO) outside the intensive care unit is limited. We present 3 clinical situations where intraoperative ECMO was beneficial. Peripheral venovenous cannulation was used to augment tracheal surgery in 2 patients, and in 1 patient who did not tolerate lung isolation. After surgery, all patients were de-cannulated and there were no complications observed due to ECMO. Use of this technology can greatly facilitate thoracic surgical procedures with low risk. ECMO should be considered when performing tracheal surgery and in situations of poor tolerance to lung isolation.

Transthoracic Paraesophageal Hernia Repair.

The transthoracic approach to PEH repair has been displaced by the laparoscopic methods of repair for valuable reasons. Despite the pressures of performing minimally invasive surgery, the experienced esophageal surgeon will appreciate the benefits of the transthoracic repair in select circumstances as outlined in this article. In this writing, we discussed our indications, the salient anatomy and important steps in performing a successful transthoracic PEH repair.

Serum Monitoring and Phenotype Identification of Stage I Non-Small Cell Lung Cancer Patients.

A stage I non-small cell lung cancer (NSCLC) serum profiling platform is presented which is highly efficient and accurate. Test sensitivity (0.95) for stage I NSCLC is the highest reported so far. Test metrics are reported for discriminating stage I adenocarcinoma vs squamous cell carcinoma subtypes. Blinded analysis identified 23 out of 24 stage I NSCLC and control serum samples. Group-discriminating mass peaks were targeted for tandem mass spectrometry peptide/protein identification, and yielded a lung cancer phenotype. Bioinformatic analysis revealed a novel lymphocyte adhesion pathway involved with early-stage lung cancer.

Ultrasound-Guided Needle Biopsy of Neck Lymph Nodes in Patients With Suspected Lung Cancer: Are the Specimens Sufficient for Complete Pathologic Evaluation to Guide Patient Management?

BACKGROUND: The purpose of this study is to determine the ability of ultrasound guided needle biopsy of a neck lymph node to provide adequate tissue for complete pathologic evaluation of suspected metastatic lung cancer, including molecular testing for epidermal growth factor receptor gene mutations by pyrosequencing and anaplastic lymphoma kinase gene rearrangement by fluorescence in situ hybridization. METHODS: Institutional review board approval was obtained and the requirement for informed consent was waived. All ultrasound guided neck biopsies performed July 1, 2011, to June 30, 2015, were retrospectively reviewed, and all biopsies performed for suspected lung cancer metastatic to supraclavicular and cervical lymph nodes were included. RESULTS: Forty patients with suspected lung cancer underwent ultrasound-guided needle biopsy of an abnormal appearing neck lymph node identified on preprocedure computed tomography or positron emission tomography/computed tomography. Thirty-seven patients were subsequently diagnosed with lung cancer and 3 were diagnosed with lymphoma. A definitive pathologic diagnosis was rendered in 95% of neck node biopsies (38/40; 95% confidence interval, 84%-99%). Of the 36 specimens diagnostic for lung cancer, 16 were considered for further molecular testing and the specimen was adequate for molecular testing in 15 (94%; 73%-100%) cases. Therefore, the neck node biopsy specimens were adequate for complete pathologic workup in 93% (37/40; 81%-98%). No complications related to the biopsies were observed. CONCLUSIONS: In patients presenting with suspected lung cancer and suspicious neck lymph nodes, ultrasound-guided needle biopsy frequently provides adequate tissue for complete pathologic evaluation and eliminates the need for more invasive procedures.

Discriminating patients with early-stage pancreatic cancer or chronic pancreatitis using serum electrospray mass profiling.

Blood tests are needed to aid in the early detection of pancreatic ductal adenocarcinoma (PDAC), and monitoring pancreatitis development into malignancy especially in high risk patients. This study exhibits efforts and progress toward developing such blood tests, using electrospray-mass spectrometry (MS) serum profiling to distinguish patients with early-stage PDAC or pancreatitis from each other and from controls. Identification of significant serum mass peak differences between these individuals was performed using t tests and "leave one out" cross validation. Serum mass peak distributions of control individuals were distinguished from those of patients with chronic pancreatitis or early-stage PDAC with P values <10(-15), and patients with chronic pancreatitis were distinguished from those of patients with early-stage PDAC with a P value <10(-12). Sera from 12 out of 12 patients with PDAC stages I, IIA and IIB were blindly validated from controls. Tandem MS/MS identified a cancer phenotype with elements of PDAC involved in early-stage PDAC/control discrimination. These studies indicate electrospray-MS mass profiling can detect serum changes in patients with pancreatitis or early-stage pancreatic cancer. Such technology has the potential to aid in early detection of pancreatic cancer, biomarker development, and in monitoring development of pancreatitis into PDAC.

Distinguishing patients with stage I lung cancer versus control individuals using serum mass profiling.

Serum mass profiling can discern physiological changes associated with specific disease states and their progression. Sera (86 total) from control individuals and patients with stage I nonsmall cell lung cancer or benign small pulmonary nodules were discriminated retrospectively by serum changes discerned by mass profiling. Control individuals were distinguished from patients with Stage I lung cancer or benign nodules with test sensitivities of 89% and 83%. Lung cancer patients versus those with benign nodules were distinguished with 80% sensitivity. This study exhibits progress toward a minimally-invasive aid in early detection of lung cancer and monitoring small pulmonary nodules for malignancy.

Massive right-sided Bochdalek hernia with two unusual findings: a case report.

INTRODUCTION: In this report, the case of an adult patient with a massive right-sided Bochdalek hernia with multiple displaced abdominal organs, including the liver and gallbladder, is described. This patient presented with acute cholecystitis of the malpositioned gallbladder. During surgery, nodular regenerative hyperplasia of the liver was also found. To the best of this author's knowledge, these two entities have never been reported in association with this rare condition. CASE PRESENTATION: A 54-year-old Caucasian man presented with nausea and epigastric pain. He had a known history of right-sided Bochdalek hernia which was being managed expectantly. A computerized tomogram revealed the massive hernia with displaced stomach, liver, intestine and omentum into his right thorax. It was believed that our patient had bowel incarceration and he was therefore taken to surgery, where acute cholecystitis and a macronodular liver was identified. A thoracoabdominal approach was used to remove his gallbladder, reduce the herniated viscera and reconstruct his diaphragm. A liver biopsy identified nodular regenerative hyperplasia of the ectopic liver. There were no postoperative complications and at 12 month follow-up, our patient continues to do well. CONCLUSION: This case report describes two unusual findings associated with a congenital Bochdalek diaphragmatic hernia that have never been reported. In addition, unique caveats to the surgical management of this complex rare condition are discussed.

Giant Posterior Mediastinal Ancient Schwannoma Requiring Thoracoabdominal Resection: A Case Report and Literature Review.

Posterior mediastinal schwannomas are benign, slow growing nerve sheath tumors and rarely cause symptoms. We present a case of a 47-year-old man who presents with severe mid-back pain and dyspnea on exertion. Chest radiograph and computed topography revealed a large posterior mediastinum mass. Surgical resection required en bloc resection of a portion of the diaphragm, and wedge resection of the left lower lobe of the lung via left thoracoabdominal approach. Pathology was consistent with ancient schwannoma. This case is unique due to the location and size of the mass and the surgical approach required for complete resection.

Cardiac surgery in kidney and liver transplant recipients.

OBJECTIVE: To evaluate operative management, outcome, and long-term survival in patients with functioning renal and hepatic allografts who underwent cardiac surgery. PATIENTS AND METHODS: We studied all patients who had previously undergone either renal or hepatic transplantation and who subsequently (1986-2001) underwent cardiac surgery at our institution. Data were obtained by retrospective medical record analysis. RESULTS: The study comprised 47 patients with renal (n=34) and hepatic (n=13) functioning allografts. Median time to cardiac surgery from transplantation was 79 months. The most common procedures were as follows: coronary artery bypass grafting, 22 (47%); aortic valve procedures, 11 (23%); and mitral valve procedures, 5 (11%). One patient (2%) died within 30 days of surgery. Renal allograft dysfunction was noted in 5 renal patients (15%) immediately after surgery. Two patients required dialysis postoperatively, 1 of whom required continued dialysis on dismissal. Transient allograft dysfunction, as determined by elevated liver enzyme levels, occurred in 6 hepatic patients (46%). However, all hepatic patients had functional allografts on dismissal. Two patients (4%) developed leg wound infections, and 9 (19%) had respiratory complications. No sternal or mediastinal infection occurred. One- and 5-year survival rates (mean +/- SEM) for all patients were 93%+/-4% and 76%+/-8%, respectively. Of the renal patients, 1- and 5-year survival rates (mean +/- SEM) were 97%+/-3% and 82%+/-8%, respectively. One- and 5-year survival rates (mean +/- SEM) for hepatic patients were 77%+/-12% and 69%+/-13%, respectively. CONCLUSION: Cardiac surgery can be performed safely in kidney and liver transplant recipients, with low early mortality and excellent medium-term survival. In almost all instances, allograft function is well preserved.

Idiopathic pulmonary artery aneurysm.

A case of idiopathic pulmonary artery aneurysm is presented along with a review of our experience of this rare condition. These entities may have an association with cystic medial degeneration of the arterial wall and are subject to the same complications as aortic aneurysms.

Pulmonary carcinoid tumors with Cushing's syndrome: an aggressive variant or not?

BACKGROUND: Adrenocorticotropic hormone (ACTH)-secreting pulmonary carcinoid is considered an aggressive variant of carcinoid tumors. Current knowledge is based upon a limited number of reports with few patients. METHODS: All patients with Cushing's syndrome (CS) resulting from pulmonary carcinoid (PC) who underwent pulmonary resection at our institution from November 1966 through April 1998 were reviewed. RESULTS: The group studied consisted of 10 males and 13 females. The median age was 39 years (range: 14-71). Pulmonary symptoms were present in 4 patients. Chest radiographs identified an abnormality in 13 patients (57%) and chest computerized tomography (CT) identified an abnormality in all 20 patients examined. Before pulmonary resection, hypophysectomy and bilateral adrenalectomy were performed in 7 patients (30%) each. Median time interval from presentation to pulmonary resection was 17 months (range: 1-228). Lobectomy was performed in 16 patients, segmentectomy was performed in 4 patients, and bilobectomy, pneumonectomy, and wedge excision was performed in 1 patient each. There were no operative deaths. Typical carcinoid was identified in 21 patients (91%) and atypical carcinoid was identified in 2 patients (9%). The median tumor diameter was 1.3 cm (range: 0.3-10). Nineteen patients (83%) underwent mediastinal lymphadenectomy and lymph node metastasis was found in 6 patients (32%) (N1 in 4 patients, N2 in 2 patients). The median follow-up was 78 months (range: 1-432). CS resolved in all of the patients. CS with PC recurred in 4 patients and CS alone recurred in 1 patient. Two patients underwent curative re-resection. Two patients, one with disseminated PC, died at last follow-up. CONCLUSIONS: Despite long delays in surgical therapy, pulmonary resection for ACTH-secreting PCs results in a favorable prognosis. Anatomic resection with complete mediastinal lymphadenectomy decreases local recurrence. Although rare these tumors do not seem to be as aggressive a variant of typical carcinoid tumors as previously reported.

Septal myectomy results in regression of left ventricular hypertrophy in patients with hypertrophic obstructive cardiomyopathy.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is a genetic disorder characterized by ventricular hypertrophy that occurs in the absence of predisposing cardiovascular stimuli; approximately one quarter of patients with HCM will have left ventricular (LV) outflow tract obstruction. Transaortic septal myectomy relieves outflow gradients and improves symptoms, but the effect of operation on ventricular hypertrophy is not well defined. METHODS: We reviewed 60 patients who underwent septal myectomy for obstructive HCM; all had complete two-dimensional and Doppler studies including calculation of LV mass and LV mass index before operation and after dismissal. RESULTS: Before myectomy the mean LV outflow gradient was 67 +/- 44 mm Hg, and at dismissal the mean LV outflow gradient was 12 +/- 13 mm Hg (p < 0.004). We found a significant decrease in the LV mass and LV mass index that occurred early after operation and persisted beyond 2 years follow-up. The early decrease in LV mass was greatest in patients younger than 50 years, but patients of all ages benefited from extended septal myectomy with decrease in LV hypertrophy. CONCLUSIONS: Transaortic septal myectomy results in significant decreases in LV mass and LV mass index. This favorable remodeling occurs early after operation and persists beyond 2 years. Whether the regression of LV mass continues to decrease or stabilize over time is unclear.