Primary Intrapulmonary Thymoma Appearing as a Solitary Pulmonary Nodule: The "Master of Disguise" of Lung Tumors?: Case Report.

Primary intrapulmonary thymomas (PITs) are defined as thymomas arising in intrapulmonary locations, without an associated mediastinal component. They are rare lesions, the diagnosis of which can be very difficult. We present a case of PIT in an asymptomatic 74-year-old woman in whom pulmonary nodules were found on pulmonary angiography performed for an episode of pulmonary embolism. She underwent wedge resection and the pathology report revealed a PIT. We also summarize this patient's clinicopathological features and discuss the diagnosis, pathogenesis, and treatment of PIT.

Outpatient treatment of pulmonary embolism.

Over the past decade there has been an increasing trend to manage many conditions traditionally treated during a hospital admission as outpatients. Evidence is increasing to support this approach in patients with pulmonary embolism (PE). In this article, we review the current status of outpatient management of confirmed PE and present a pragmatic approach for clinical healthcare settings.

Acute dyspnoea due to an unusual giant thymic cyst.

Does a percutaneous needle aspiration of thymic cyst should be considered? In case when a surgical excision is contradicted, the percutaneous needle aspiration should be performed. Surgical resection can be performed with a thoracotomy or a videothoracoscopic procedure, but sometimes, a median sternotomy is unavoidable.

Unilateral pulmonary hypoplasia in an adult patient.

Pulmonary hypoplasia (PH) is a developmental anomaly of the lung parenchyma, characterized by a decrease in the number and size of airways, alveoli and vessels. We present a case of a 31-year-old patient with a history of chronic productive cough and frequent respiratory infections, who was referred for investigation of abnormal chest x-ray. The combination of chest computed tomography (CT) and bronchoscopy set the diagnosis of left pulmonary hypoplasia and the patient was treated surgically with a left pneumonectomy. PH is usually diagnosed immediately after birth, causing severe respiratory failure with high mortality. The less severe, unilateral forms can possibly survive by causing compensatory hyperinflation of the other lung and remain undiagnosed until adulthood, presenting either asymptomatic or with symptoms of chronic bronchitis and recurrent respiratory infections. Chest CT is considered the imaging technique of choice for the diagnosis and for the differential diagnosis from other congenital or acquired conditions. The treatment is usually conservative, although surgical resection is indicated in cases of severe cystic changes and intense symptomatology.

Benign emptying of the post-pneumonectomy space: recognizing this rare complication retrospectively.

Patients presenting with a sudden drop in the pleural fluid level after a pneumonectomy in the absence of a recognizable bronchopleural fistula (BPF) have been classified as cases of benign emptying of the post-pneumonectomy space (BEPS). A retrospective study of 1378 pneumonectomies identified 4 cases of BEPS (0.29%). The patients were men; median age 64 years and all had undergone a right pneumonectomy. The median time at diagnosis was 31 days postoperatively and the median follow-up time was 31 months. None of the patients experienced a documented BPF or empyema. Although BEPS is an extremely rare complication, early recognition and close patient monitoring will prevent unnecessary interventional strategies.

Left thoracotomy utilizing splenectomy in blunt thoracic injury: An alternative surgical approach.

INTRODUCTION: Posterolateral thoracotomy could be an alternative surgical approach in selected cases coexistence of abdominal injuries with ipsilateral thoracic injury. PRESENTATION OF CASE: A 65-year-old male with left sided chest injury was initially admitted to a regional health center after a crawler overthrow accident. He underwent chest tube drainage of left hemithorax and he was transferred immediately to our hospital. A CT scan showed a large spleen which was injured by a wedged splint of the 10th rib into its parenchyma. Lung parenchyma was also lacerated by chest tube misplacement with associated hemothorax. He underwent a lower left lateral thoracotomy. Splenectomy was performed via a phrenotomy and subsequently the injured lung was repaired. His postoperative course was uneventful. DISCUSSION: Incisions in the diaphragm are commonly made to provide adequate exposure during a variety of thoracic and abdominal operations. Thoracic approach could potentially be advantageous for thoracic and abdominal injuries. CONCLUSION: Thoracic approach is a safe alternative, providing excellent exposure of upper abdominal organs, and should be considered in selected cases of abdominal trauma, especially when an ipsilateral thoracic injury coexists.

The role of intercostal cryoanalgesia in post-thoracotomy analgesia.

OBJECTIVES: Patients undergoing thoracotomy were studied to compare the effects of cryoanalgesia, combined with intravenous patient-controlled analgesia (IVPCA), against IVPCA alone during the four days following surgery. METHODS: Fifty patients were randomized into two groups: an IVPCA group (n = 25) and an IVPCA-cryo group (n = 25). Subjective pain intensity was assessed on a verbal analogue scale at rest and during coughing. The intensity and the incidence of post-thoracotomy pain, numbness, epigastric distension and/or back pain, the analgesic requirements, as well as the blood gas values and respiratory function tests were evaluated up to the second postoperative (postop) month. Haemodynamic data and episodes of nausea and/or vomiting were recorded over the four postop days. RESULTS: In the cryo group there was a statistically significant improvement in postop pain scores (P = 10(-4)), reduction in consumption of morphine (P = 10(-4)) and other analgesics (P = 10(-4)), optimization (less acidosis) of the pH values of blood gases (P < 0.015 over 72 hours postop and P < 0.03 on the first and second postop months), increase in systolic blood pressure (P < 0.05 over 96 hours postop), reduction in heart rate (P < 0.05 over 96 hours postop), increase in values of FEV1 (P < 0.02) and FVC (P < 0.05) at the first and second postop months, reduction in the incidence of nausea (0.05 < P < 0.1 over 18 hours postop), numbness, epigastric distension and back pain (P < 0.05 at days 5, 6, 7, 14, 30 and 60 following surgery). CONCLUSIONS: We suggest that cryoanalgesia be considered as a simple, safe, inexpensive, long-term form of post-thoracotomy pain relief. Cryoanalgesia effectively restores FEV1 values at the second postop month.

Chylothorax complicating thoracic surgery: conservative or early surgical management?

Postoperative chylothorax is a rare complication in thoracic surgery. There is considerable controversy concerning the management of chylothorax with some physicians favoring conservative treatment while others favor a surgical one. Considering the current surgical experience with VATS and by reviewing the problems and outcome of conservative management, the guidelines regarding timing of surgery in patients with chylous leak need to be revised.

Chylothorax complicating thoracic aortic surgery.

OBJECTIVE: Chylothorax is a very rare complication of patients undergoing thoracic aortic aneurysm repair. Possible mechanisms of this condition during thoracic aorta operations and current therapeutic strategies are analyzed according to our experience and thorough search of the English literature. METHODS: Current experience with chylothorax occurring during thoracic aortic surgery is analyzed in this review by collecting data retrieved from English literature research. RESULTS: Significant risk factors for postoperative chylothorax development after thoracic aorta surgical procedures are thoracic aortic reoperations and descending thoracic repairs. Various treatment modalities from conservative to operative intervention have been proposed. CONCLUSION: Currently, the morbidity and mortality have improved due to prompt management. Surgical intervention is needed when response to conservative treatment has failed.

Thoracoabdominal aneurysm repair using a four-branched thoracoabdominal graft: a case series.

Revascularization of the visceral arteries during thoracoabdominal aneurysm repair is usually performed sequentially by an anastomosis between a prosthetic graft and an aortic patch. There are immediate operative risks such as bleeding and distortion. In the longer term, aneurysm, pseudo-aneurysm and rupture may occur. These require reoperation and are associated with significant morbidity and mortality.We present our experience with Crawford IV thoracoabdominal aneurysm repair in four patients, using a prefabricated four-branched graft (Coselli graft). At two years there were no deaths, no complications and no vessel abnormalities on computed tomography. We recommend its use as the graft of choice in young patients with an aortic tissue disorder requiring total resection of the aortic wall at the level of the visceral vessels.

Prophylactic preoperative levosimendan administration in heart failure patients undergoing elective non-cardiac surgery: a preliminary report.

INTRODUCTION: Preoperative optimization of cardiac failure (CF) patients undergoing non-cardiac surgery is of utmost importance. Levosimendan is a promising adjunct in our therapeutic repertoire for the treatment of CF; however, it has not been evaluated in CF patients undergoing non-cardiac surgery. Our objective was to evaluate the safety and efficacy of prophylactic preoperative levosimendan administration in these patients. METHODS: CF patients with ejection fraction <35% undergoing elective non-cardiac (abdominal) surgery during a 6-month-period were included in this prospective study. All patients, admitted to the Surgical Intensive Care Unit (SICU) one day preoperatively for levosimendan administration, received a bolus infusion (2.4 Ig/kg) for 10 min followed by a 24-hour continuous infusion (0.1 Ig/kg/min) at the end of which they were operated. Patients were under continuous hemodynamic monitoring in the SICU during levosimendan infusion and for 24 h post-infusion. Hemodynamic parameters, including heart rate, arterial pressure and pulmonary artery catheter data, were recorded before treatment, 10 min after drug initiation, and at 3-hour intervals to 24 h post-infusion. Echocardiography was performed before infusion and on the 7th post-infusion day. RESULTS: Nine patients were enrolled. Cardiac index (0-48 h, 95% CI: -2.790-0.432, p<0.001) and stroke volume index (0-48 h, 95% CI: -32.53-0.91, p=0.01) increased significantly at 24 h after drug initiation and remained increased for 24 h post-infusion. Systemic vascular resistance index decreased at 10 min and remained reduced during the whole observation period (0-48 h, 95% CI: 875.64-2378.14, p<0.001). Ejection fraction was significantly increased on the 7th post-infusion day (32.65 +/- 7.32 vs. 20.89 +/- 6.24, p<0.05). No adverse reactions, complications or deaths occurred during 30 days' follow up. CONCLUSION: Prophylactic preoperative levosimendan treatment may be safe and efficient for the perioperative optimization of heart failure patients undergoing non-cardiac surgery.

Paroxysmal atrial fibrillation due to left atrial appendage herniation and review of the literature.

The incidence of the isolated form of partial absence of the pericardium is a rare finding. The authors present a case of an isolated left sided pericardial defect with intrathoracic protrusion of the left atrial appendage found during a left upper lobectomy for lung cancer, unrecognized after serial echocardiographs and computed tomography scan of the thorax. The patient suffered from episodes of atrial fibrillation which disappeared after pericardial defect repair without antiarrhythmic medication.

The significance of one-station N2 disease in the prognosis of patients with nonsmall-cell lung cancer.

BACKGROUND: A retrospective study was conducted to define the characteristics and the prognosis of N2 disease subgroups according to their patterns of spread. METHODS: From January 1993 to December 2004, 1,329 patients underwent lung resection for bronchogenic carcinoma The records of all patients with positive mediastinal lymph nodes at the surgical specimen (pIIIA/N2) after radical resection were analyzed, and the pattern of mediastinal lymphatic spread was classified according to regional spread, to skip metastasis, and to one or two or more lymph node stations, in relation to primary tumor location. Age, sex, type of resection, right or left lesion, T status, primary tumor location, tumor size, tumor central or peripheral location, histology, and survival were recorded and analyzed. Survival was analyzed according to regional spread or not, number of mediastinal lymph node stations involved, and skip metastasis status. RESULTS: Among 302 cases (22.7%) with positive mediastinal lymph nodes pIIIA/N2, 66 (22%) were skip metastases, 72 (24%) had a nonregional mode of spread, and 199 (66%) included two or more stations of mediastinal lymph node invasion. Cox regression analysis of all cases disclosed malignant invasion in only one mediastinal lymph node station as the only favorable factor of survival (p < 0.001, odds ratio 0.57, 95% confidence interval: 0.42 to 0.78). CONCLUSIONS: The presence of one-station mediastinal lymph node metastasis in patients with nonsmall-cell lung cancer who underwent major lung resection with complete mediastinal lymph node dissection proved to be a good prognostic factor that should be taken into account in the future.

The hybrid stent-graft technique: a solution to complex aortic problems and lessons learned.

OBJECTIVE: The frozen elephant trunk technique has been recently presented in the literature and has been considered as a novel surgical option for single-stage repair of complex aortic pathology such as combined arch and descending thoracic aortic aneurysms. PATIENTS AND METHODS: The first patient, a 74-year-old male, was admitted severely symptomatic (interscapular pain), with aortic distal arch and proximal descending thoracic aortic aneurysm with a diameter of 6 cm. The second patient, a 72-year-old male, underwent descending aortic aneurysm stent grafting one year ago and was admitted gravely symptomatic (interscapular pain), with aortic arch aneurysm (diameter of 5.7 cm) and type I endoleak at the proximal end of the stent. RESULTS: The first patient developed paraplegia after the operation and died three months after the operation due to pneumonia while he was on a rehabilitation program. The second patient's recovery was uneventful and was discharged on postoperative day nine. CONCLUSION: This report summarizes our preliminary experience with this technique emphasizing two points: first, it offers the opportunity to manage efficiently complex aortic problems, and second, there is a potential risk of serious complications related to the limited stent sizes available of the device to match the patient's anatomical characteristics and pathology.

Malignant conversion of a solitary papilloma in the distal trachea: report of a case.

A solitary papilloma versus the usual multiple lesions of papillomatosis is extremely rare. Even more infrequent is a solitary papilloma of the trachea in an adult patient. In the present report, a case of a solitary papilloma in the distal trachea is presented. After two unsuccessful sessions of laser ablation, resection of the lower one-third of the trachea was performed through a right posterolateral thoracotomy. Postoperative histology results disclosed a malignant degeneration into squamous cell carcinoma. The patient had an excellent outcome after resection of the affected portion of the trachea. There was no evidence of recurrence after 20 months of follow-up.