Circulatory effects of dexmedetomidine in early sepsis: a randomised controlled experimental study.

We designed this experimental study with a view to evaluate the effects of dexmedetomidine (DEX) on cardiac performance and systemic and peripheral hemodynamics in healthy and early-stage endotoxemia swine models. Our study hypothesis was that DEX can ensure hemodynamic stability during the course of endotoxemia. Thirty-two male pigs (25-27 kg) were assigned into four groups: (1) no intervention (group A), (2) DEX 0.8 µg/kg was administered in non-septic animals (group B), (3) sepsis induced by intravenous Escherichia coli endotoxin (group C) and (4) DEX 0.8 µg/kg was administered in septic animals (group D). Hemodynamic parameters such as heart rate, mean blood pressure, central venous pressure, pulmonary artery pressures, pulmonary artery occlusion pressure, pulmonary vascular resistance and cardiac output were continuously recorded. Central venous oxygen saturation was also measured in order to obtain a complete evaluation of cardiovascular response to sepsis. Heart rate was decreased, whilst mean arterial pressure decrease was alleviated after DEX administration in septic animals. In addition, central venous pressure was stable in animals with sepsis after DEX infusion. Sepsis dramatically elevated pulmonary function indicators but DEX succeeded in ameliorating this effect. The important decrease measured in central venous oxygen saturation in both sepsis groups reflected the decreased perfusion of tissues that takes place at the end of early sepsis. Our findings support the hypothesis that DEX has beneficial effects on heart rate and pulmonary artery pressure, whilst reduction in systemic blood pressure occurs at acceptable levels.

Chest wall lipoblastoma in a 3 year-old boy.

BACKGROUND: Lipoblastoma is a rare, benign, fatty tissue tumor that occurs in infancy and early childhood. The most common tumor locations are the extremities and the torso. The location of this tumor in the chest wall and an intrathoracic extension is uncommon. CASE REPORT: We present a case of a 3-year-old boy with anterior chest wall lipoblastoma with an intrathoracic extension. Computed tomography was suggestive of lipoblastoma. The mass was completely excised through a right posterolateral thoracotomy. The histologic examination of the lesion confirmed the diagnosis of lipoblastoma. CONCLUSION: Although extremely rare, chest wall lipoblastoma should be included in the differential diagnosis of thoracic mass in childhood.

Successful treatment of familial congenital chylothorax by ligation of the thoracic duct: A case report.

A full term boy was admitted with respiratory distress in the fourth week of his life due to spontaneous chylothorax in his right hemithorax. Spontaneous chylothorax occurred previously in a first cousin of the neonate establishing that way the final diagnosis of familial idiopathic congenital pneumothorax. Failure of the conservative treatment consisting of chest tube drainage, discontinuation of oral diet and administration of total parenteral nutrition in combination with octreotide for one month was followed by the successful ligation of the thoracic duct through a right thoracotomy. The boy still remains free of symptoms and without recurrence of the chylothorax two years later.

Massive chest wall resection and reconstruction for malignant disease.

OBJECTIVE: Malignant chest wall tumors are rare neoplasms. Resection with wide-free margins is an important prognostic factor, and massive chest wall resection and reconstruction are often necessary. A recent case series of 20 consecutive patients is reported in order to find any possible correlation between tumor histology, extent of resection, type of reconstruction, and adjuvant treatment with short- and long-term outcomes. METHODS: Twenty patients were submitted to chest wall resection and reconstruction for malignant chest wall neoplasms between 2006 and 2014. The mean age (ten males) was 59±4 years. The size and histology of the tumor, the technique of reconstruction, and the short- and long-term follow-up records were noted. RESULTS: The median maximum diameter of tumors was 10 cm (5.4-32 cm). Subtotal sternal resection was performed in nine cases, and the resection of multiple ribs was performed in eleven cases. The median area of chest wall defect was 108 cm(2) (60-340 cm(2)). Histology revealed soft tissue, bone, and cartilage sarcomas in 16 cases (80%), most of them chondrosarcomas. The rest of the tumors was metastatic tumors in two cases and localized malignant pleural mesothelioma and non-Hodgkin lymphoma in one case. The chest wall defect was reconstructed by using the "sandwich technique" (propylene mesh/methyl methacrylate/propylene mesh) in nine cases of large anterior defects or by using a 2 mm polytetrafluoroethylene (e-PTFE) mesh in nine cases of lateral or posterior defects. Support from a plastic surgeon was necessary to cover the full-thickness chest wall defects in seven cases. Adjuvant oncologic treatment was administered in 13 patients. Local recurrences were observed in five cases where surgical reintervention was finally necessary in two cases. Recurrences were associated with larger tumors, histology of malignant fibrous histiocytoma, and initial incomplete resection or misdiagnosis made by nonthoracic surgeons. Three patients died during the study period because of recurrent disease or complications of treatment for recurrent disease. CONCLUSION: Chest wall tumors are in their majority mesenchymal neoplasms, which often require major chest wall resection for their eradication. Long-term survival is expected in low-grade tumors where a radical resection is achieved, while big tumors and histology of malignant fibrous histiocytoma are connected with the increase rate of recurrence.

Repair of post-intubation tracheoesophageal fistulae through the left pre-sternocleidomastoid approach: a recent case series of 13 patients.

OBJECTIVE: Post-intubation tracheoesophageal fistula (TEF) is a late complication of tracheotomy, while membranous trachea laceration during percutaneous dilational tracheostomy is implicated in the generation of early post-tracheotomy TEF. Surgical repair is the only viable option for these patients and the technique of repair depends on a variety of factors. METHODS: Totally 13 patients (mean age: 54.1±12.6 years; male: 8) with post-intubation TEF were managed between 2007 and 2013. The diagnosis was always made through esophagoscopy followed by endoscopic gastrostomy and bronchoscopy for repositioning of the tracheal tube just above the carina. Repair of the fistula was made in all patients through a left pre-sternocleidomastoid incision followed by dissection of the fistulous tract, suturing of esophagus and trachea and interposition of the whole pedicled left sternocleidomastoid muscle (SCMM) between the two suture lines. RESULTS: Five out of the 13 procedures were performed in mechanically ventilated patients; 3 of them died from septic complications during the postoperative period while fistula recurred in 1 of those 3 patients due to extensive inflammation of the tracheal wall. The rest 8 patients underwent fistula repair after weaning from mechanical ventilation and the results of repair were excellent. The additional procedure of temporary T-tube insertion was obviated in one patient to manage extensive tracheomalacia. CONCLUSIONS: The left pre-sternocleidomastoid incision is an excellent access for the repair of a post-intubation TEF without tracheal resection. The interposition of the whole left pedicled SCMM between the suture lines of trachea and esophagus avoids fistula recurrence and offers the best chance for cure.

Magnetic connectors for coronary surgery: what do we know a decade later?

In 2001, a novel sutureless magnetic anastomotic device (MVP) for coronary anastomosis was introduced in Europe for both on-pump and off-pump procedures. The device has been implanted in more than 150 patients with encouraging short-term but less favorable mid-term results. However, to date long-term patency outcomes of those recipients have not been investigated. This is the first report on an excellent angiographic performance of this automated magnetic device ten years after left internal thoracic artery to left anterior descending grafting in a man who underwent coronary angiography prior to thymectomy.

Early reoperation performed for the management of complications in patients undergoing general thoracic surgical procedures.

OBJECTIVE: To detect the rate and predisposing factors for the development of postoperative complications requiring re-operation for their control in the immediate postoperative period. METHODS: During the time period 2009-2012, 719 patients (male: 71.62%, mean age: 54±19 years) who underwent a wide range of general thoracic surgery procedures, were retrospectively collected. Data of patients who underwent early re-operation for the management of postoperative complications were assessed for identification of the responsible causative factors. RESULTS: Overall, 33/719 patients (4.6%) underwent early re-operation to control postoperative complications. Early re-operation was obviated by the need to control bleeding or to drain clotted hemothoraces in nine cases (27.3%), to manage a prolonged air leak in six cases (18.2%), to drain a post-thoracotomy empyema in five cases (15.2%), to revise the thoracotomy incision or an ischemic musculocutaneous flap in five cases (15.2%), to manage a bronchopleural fistula in four cases (12.1%), to manage persistent atelectasis of the remaining lung in two cases (6.1%), to cease a chyle leak in one case (3%) and to plicate the right hemidiaphragm in another one case (3%). The factors responsible for the development of complications requiring reopening of the chest for their management were technical in 17 cases (51.5%), initial surgery for lung or pleural infections in 9 (27.3%), the recent antiplatelet drug administration in 4 (12.1%) and advanced lung emphysema in 3 (9.1%). Mortality of re-operations was 6.1% (2/33) and it was associated with the need to proceed with completion pneumonectomy in the two cases with persistent atelectasis of the remaining lung and permanent parenchymal damage. The majority of complications requiring reoperation were observed after lung parenchyma resection (17 out of the 228 procedures/7.4%) or pleurectomy (7 out of the 106 procedures/6.5%). Reoperations after video-assisted thoracic surgery (VATS) were uncommon (2 out of the 99 procedures/2%). CONCLUSIONS: The rate of complications requiring reoperation after general thoracic surgery procedures is low and it is mainly related to technical issues from the initial surgery, the recent administration of antiplatelet drugs, the presence of advanced emphysema and surgery for infectious diseases. The need to proceed with completion pneumonectomy has serious risk for fatal outcome.

Treatment of infected thoracic aortic prosthetic grafts with the in situ preservation strategy: a review of its history, surgical technique, and results.

For cardiothoracic surgeons prosthetic graft infection still represents a difficult diagnostic and treatment problem to manage. An aggressive surgical strategy involving removal and in situ replacement of all the prosthetic material combined with extensive removal of the surrounding mediastinal tissue remains technically challenging in any case. Mortality and morbidity rates following such a major and risky surgical procedure are high due to the nature of the aggressive surgical approach and multi-organ failure typically caused by sepsis. However, removal of the infected prosthetic graft in patients who had an operation to reconstruct the ascending aorta and/or the aortic arch is not always possible or necessary for selected patients according to current alternative treatment options. Rather than following the traditional surgical concept of aggressive graft replacement nowadays a more conservative surgical approach with in situ preservation and coverage of the prosthetic graft by vascular tissue flaps can result in a good outcome. In this article, we review the relevant literature on this specific topic, particularly in terms of graft-sparing surgery for infected ascending/arch prosthetic grafts with special emphasis on staged treatment and the use of omentum transposition.

Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment.

Pancoast tumors account for less than 5% of all bronchogenic carcinomas. These tumors are located in the apex of the lung and involve through tissue contiguity the apical chest wall and/or the structures of the thoracic inlet. The tumors become clinically evident with the characteristic symptoms of the "Pancoast-Tobias syndrome" which includes Claude-Bernard-Horner syndrome, severe pain in the shoulder radiating toward the axilla and/or scapula and along the ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein resulting in edema of the upper arm. The diagnosis will be made by the combination of the characteristic clinical symptoms with the radiographic findings of a mass or opacity in the apex of the lung infiltrating the 1(st) and/or 2(nd) ribs. A tissue diagnosis of the tumor via CT-guided FNA/B should always be available before the initiation of treatment. Bronchoscopy, thoracoscopy and biopsy of palpable supraclavicular nodes are alternative ways to obtain a tissue diagnosis. Adenocarcinomas account for 2/3 of all Pancoast tumors, while the rest of the tumors are squamous cell and large cell carcinomas. Magnetic resonance imaging of the thoracic inlet is always recommended to define the exact extent of tumor invasion within the thoracic inlet before surgical intervention. Pancoast tumors are by definition T3 or T4 tumors. Induction chemo-radiotherapy is the standard of care for any potentially resectable Pancoast tumor followed by an attempt to achieve a complete tumor resection. Resection can be made through a variety of anterior and posterior approaches to the thoracic inlet. The choice of the approach depends on the location of the tumor (posterior - middle - anterior compartment of the thoracic inlet) and the depth/extent of invasion. Prognosis depends mainly on T stage of tumor, response to preoperative chemo-radiotherapy and completeness of resection. Resection of the invaded strictures of the thoracic inlet should me made en bloc with pulmonary parenchyma resection, preferably an upper lobectomy. Invasion of the vertebral column is not a contraindication for surgery which, however, should be performed in oncologic centers with experience in spinal surgery. Surgery for Pancoast tumors is associated with 5% mortality rate and the complication rate varies from 7-38%. The overall 2-year survival rate after induction chemo-radiotherapy and resection varies from 55% to 70%, while the 5-year survival for R0 resections is quite good (54-77%). The main pattern of recurrence is that of distant metastases, especially in the brain.

Advanced bronchoscopic techniques in diagnosis and staging of lung cancer.

The role of advanced brochoscopic diagnostic techniques in detection and staging of lung cancer has steeply increased in recent years. Bronchoscopic imaging techniques became widely available and easy to use. Technical improvement led to merging in technologies making autofluorescence or narrow band imaging incorporated into one bronchoscope. New tools, such as autofluorescence imagining (AFI), narrow band imaging (NBI) or fuji intelligent chromo endoscopy (FICE), found their place in respiratory endoscopy suites. Development of endobronchial ultrasound (EBUS) improved minimally invasive mediastinal staging and diagnosis of peripheral lung lesions. Linear EBUS proven to be complementary to mediastinoscopy. This technique is now available in almost all high volume centers performing bronchoscopy. Radial EBUS with mini-probes and guiding sheaths provides accurate diagnosis of peripheral pulmonary lesions. Combining EBUS guided procedures with rapid on site cytology (ROSE) increases diagnostic yield even more. Electromagnetic navigation technology (EMN) is also widely used for diagnosis of peripheral lesions. Future development will certainly lead to new improvements in technology and creation of new sophisticated tools for research in respiratory endoscopy. Broncho-microscopy, alveoloscopy, optical coherence tomography are some of the new research techniques emerging for rapid technological development.

Adjuvant chemotherapy and radiotherapy in the treatment of non-small cell lung cancer (NSCLC).

Lung cancer is one of the most common human malignancies and remains the leading cause of cancer related deaths worldwide. Many recent technological advances led to improved diagnostics and staging of lung cancer. With development of new treatment options such as targeted therapies there might be improvement in progression free survival of patients with advanced stage non-small cell lung cancer (NSCLC). Improvement in overall survival is still reserved for selected patients and selected treatments. One of the mostly investigated therapeutic options is adjuvant treatment. There are many open issues in selection of patients and administration of appropriate adjuvant treatment.

Pericardial patch tracheoplasty for the repair of a long, multisegmental postintubation tracheal damage.

A 64-year-old man was admitted with a postintubation, multisegmental tracheal damage comprising of two stenotic lesions, below and above a tracheotomy. The patient underwent resection of the damaged anterolateral tracheal wall through a combined collar-cuff and median sternotomy incision and tracheoplasty with autologous pericardium around a Silastic T-tube that was fixed to the cricoid cartilage, healthy distal trachea, and the remaining membranous wall. The postoperative period was complicated with a deep sternal wound infection that was successfully treated with vacuum-assisted closure for 2 weeks. Removal of the T-tube 9 months later resulted in a patent and well-functioning airway. Pericardial patch tracheoplasty and T-tube stenting of the repair for several months is a good alternative to extended tracheal resection for the treatment of the rare long, postintubation multisegmental tracheal damage. The pericardial patch is highly resistant to infection and allows the formation of a neotrachea.

A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study.

BACKGROUND: Currently, most thoracic surgeons perform surgical pleurodesis for recurrent spontaneous pneumothorax (RSP) by video-assisted thoracic surgery (VATS). However, the superiority of VATS over axillary minithoracotomy is not been established in prospective studies to date. A modified two-port VATS technique and axillary minithoracotomy were prospectively evaluated for possible differences in the short- and long-term outcome for patients. METHODS: In this study, 66 consecutive patients underwent surgical pleurodesis for RSP through either a modified two-port VATS procedure (group A, 33 patients) or axillary minithoracotomy (group B, 33 patients). According to the study design (NCT01192217), the patients were randomly assigned to the two groups, which were similar in terms of age and body mass index. One-lung ventilation time, histology of the available lung parenchyma specimens, early postoperative complications, length of chest tube drainage and hospital stay, recurrence rate, and a score for patient satisfaction with treatment based on the sum of postoperative pain, dependent-arm mobilization, and return to full activity subscores were evaluated. The follow-up period varied from 3 to 53 months (median, 30 months). RESULTS: The one-lung ventilation and operating times were significantly longer (p < 0.001) in group A than in group B. The overall detection of blebs, bulla, or both was 51.5% in group A and 63.8% in group B. The recurrence rate, complication rate, postoperative chest tube drainage duration, postoperative hospital stay, and incidence of chronic pain did not differ between the two groups. The score for patient satisfaction with treatment was significantly higher in group A than in group B (p < 0.001) according the subscores for better dependent-arm mobilization and return to full activity. CONCLUSIONS: Axillary minithoracotomy and VATS are equally effective for the treatment of RSP, although the rate for resection of blebs, bulla, or both is higher with the axillary minithoracotomy procedure. Although VATS is more time consuming, it offers to the patient more satisfaction with treatment.

The management of post-intubation tracheal stenoses with self-expandable stents: early and long-term results in 11 cases.

OBJECTIVE: The optimal management of post-intubation tracheal stenoses is surgical reconstruction of the airway. Stenting of the trachea using silastic T-tubes or one of the various types of tracheal stents are the alternative ways to surgical reconstruction for the management of post-intubation tracheal stenoses. The early and long-term results of 11 patients with post-intubation tracheal stenosis, who underwent tracheal stenting with self-expandable metallic stents (SEMSs), are presented. METHODS: Twelve patients (10 men, mean age: 47.8±20.4 years) with post-intubation tracheal stenosis were referred for tracheal stenting with SEMS (2000-2004). In three cases, the upper tracheal stenosis extended within the subglottic larynx. Stenting was successful in 11 patients, while, in one patient with involvement of the subglottic larynx, the attempt to insert the stent failed. Follow-up time varied from 6 to 96 months, and it was made with virtual and fiberoptic bronchoscopy. RESULTS: Immediate relief of obstructive symptoms was observed in all the 11 patients, where an SEMS was successfully inserted. Stent dislodgement occurred shortly after the procedure in two patients, and it was treated with insertion of a new stent in the first case and a stent-on-stent insertion in the second. Good patency of the stent was observed in three patients for 60-96 months. Three patients with good patency of the stent died from other reasons 24-48 months after stent insertion. Four patients developed obstructive granulation tissue at the ends of the stent after 12-43 months, requiring further treatment with thermal lasers and/or tracheostomy. One patient underwent stent removal and successful laryngotracheal reconstruction 6 months after stent insertion. CONCLUSIONS: The application of SEMS in post-intubation tracheal stenoses results in immediate improvement of obstructive symptoms without significant perioperative complications. SEMSs have the potential risks of migration and of granulation tissue formation at the end of the stent. SEMS should be applied only in strictly selected patients with post-intubation tracheal stenosis, who are considered unfit for surgery and/or with limited life expectancy.

Intraoperative infusion of S(+)-ketamine enhances post-thoracotomy pain control compared with perioperative parecoxib when used in conjunction with thoracic paravertebral ropivacaine infusion.

OBJECTIVE: The authors explored the use of continuous postoperative subpleural paravertebral ropivacaine alone combined with intraoperative S(+)-ketamine or perioperative parecoxib as a new approach to pain control after major thoracotomy. DESIGN: A randomized study. SETTINGS: A single university hospital. PARTICIPANTS: Eighty patients underwent elective thoracotomy under general anesthesia. METHODS: Study patients were assigned to 1 of 3 groups: group K (n = 27) received intraoperative S(+)-ketamine (0.5 mg/kg as a preincisional bolus followed by a continuous infusion 400 µg/kg/h), group P (n = 27) received perioperative parexocib (40 mg before extubation and 12 hours postoperatively), and group C (n = 26) served as the control group. At the end of surgery, all patients received a subpleural paravertebal infusion of ropivacaine. MEASUREMENTS AND MAIN RESULTS: Pain was assessed by visual analog scores and supplemental morphine consumption with PCA up to 48 hours postoperatively. The duration of stay and postoperative functional parameters also were collected. Compared with ropivacaine alone, S(+)-ketamine significantly reduced pain scores at rest and during movement at 4, 12, 24, and 48 hours postoperatively. Moreover, at 24 and 48 hours, pain was less after S(+)-ketamine compared with parexocib. S(+)-ketamine also reduced morphine needs in comparison to placebo at 4, 12, 24, and 48 hours and in comparison to parexocib at 48 hours after thoracotomy. There were no differences in parameters for lung or bowel function, mobilization time, or ICU and hospital stay. CONCLUSIONS: In patients with thoracotomy, postoperative paravertebral ropivacaine combined with intraoperative S(+)-ketamine provided better early postoperative pain relief than ropivacaine and perioperative parexocib or ropivacaine alone.

Prenatal interventional and postnatal surgical therapy of extralobar pulmonary sequestration.

Extralobar sequestration, a discrete developmental mass of pulmonary parenchyma which is enclosed within a separate pleural envelope and has its own vascular supply, is recently diagnosed prenatally by ultrasonography. We report two male newborn babies, 10 days old, who prenatally underwent amnioperitoneal shunt, pleural drainage and laser ablation of the feeding artery. Both babies underwent thoracotomy on their 10th day of life, removal of the sequestration, ligation of the feeding vessel which remained patent despite laser treatment in the first case and drainage of a large pleural effusion in the second case. Both babies had an uncomplicated course and are well 80 and 48 months after surgery, respectively. Extralobar sequestration should undergo operation as early as possible after birth, even after prenatal laser ablation of the feeding artery, since mortality and morbidity of surgery are extremely low, while newborns are protected from future infections.