RESUMEN
Bicuspid aortic valve (BAV) disease remains the most common congenital cardiac disease and is associated with an increased risk of potentially fatal aortopathy including aortic aneurysm and dissection. Mutations in the NOTCH1 gene are one of only a few genetic anomalies identified in BAV disease; however evidence for defective NOTCH signaling, and its involvement in the characteristic histological changes of VSMC apoptosis and differentiation in ascending aortae of BAV patients is lacking. This review scrutinizes the evidence for the interactions of NOTCH signaling, cellular differentiation and apoptosis in the context of aortic VSMCs and provides focus for future research efforts in the diagnosis of BAV aortopathy and prevention of catastrophic complications through NOTCH signaling manipulation.
Asunto(s)
Enfermedades de la Aorta/metabolismo , Válvula Aórtica/anomalías , Apoptosis , Diferenciación Celular , Enfermedades de las Válvulas Cardíacas/metabolismo , Músculo Liso Vascular/metabolismo , Miocitos del Músculo Liso/metabolismo , Receptor Notch1/metabolismo , Vasoconstricción , Animales , Aorta/metabolismo , Aorta/patología , Aorta/fisiopatología , Enfermedades de la Aorta/genética , Enfermedades de la Aorta/patología , Enfermedades de la Aorta/fisiopatología , Válvula Aórtica/metabolismo , Válvula Aórtica/patología , Válvula Aórtica/fisiopatología , Enfermedad de la Válvula Aórtica Bicúspide , Progresión de la Enfermedad , Predisposición Genética a la Enfermedad , Enfermedades de las Válvulas Cardíacas/genética , Enfermedades de las Válvulas Cardíacas/patología , Enfermedades de las Válvulas Cardíacas/fisiopatología , Humanos , Músculo Liso Vascular/patología , Músculo Liso Vascular/fisiopatología , Mutación , Miocitos del Músculo Liso/patología , Fenotipo , Pronóstico , Receptor Notch1/genética , Transducción de SeñalRESUMEN
AIM: As resective surgery for oesophageal carcinoma is only appropriate for a selected cohort of patients, preoperative staging plays an important role in the management of these patients. This study assessed the accuracy of endoscopic ultrasound (EUS) staging in comparison with computerised tomography (CT) staging and the impact of EUS in management of patients with oesophageal carcinoma undergoing gastro-esophagectomy. METHODS: Ninety-six consecutive patients with oesophageal carcinoma underwent preoperative staging with multislice CT and EUS. Of these, 50 patients underwent gastro-esophagectomy, allowing preoperative staging data from these imaging modalities to be compared to postoperative histopathological staging, classified according to the TNM system. Management plans for these patients made without use of EUS were then compared to those following EUS staging. RESULTS: The overall accuracy rate of EUS for T staging was 64%, showing good agreement with postoperative histopathological staging of the resected specimen (weighted k=0.42, 95%CI= 0.32-0.52). In terms of clinical decision making, the T stage accuracy rose to 90% when differentiating T1 from T2/3 lesions. In terms of N staging, the overall accuracy was 72% (weighted k=0.44, 95% CI=0.34-0.54). In comparison, N staging by CT was significantly less accurate (62% vs 72%, P<0.01, chi squared) and showed poor agreement with postoperative histopathological nodal staging (weighted k=0.24, 95%CI =0.11-0.37). Importantly, in 56% of patients, staging information obtained from EUS instigated change in management compared to that configured without EUS. CONCLUSION: EUS enhances preoperative staging of oesophageal cancer and is important in preoperative clinical decision making process, especially with increasing use of neoadjuvant chemotherapy.
Asunto(s)
Carcinoma/diagnóstico por imagen , Endosonografía , Neoplasias Esofágicas/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma/diagnóstico , Carcinoma/terapia , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/terapia , Esofagectomía , Femenino , Gastrectomía , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante/métodos , Estadificación de Neoplasias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Synchronous tumours of the thymus and lung are rare. We describe the case of a 57-year-old gentleman, who presented with a large type AB thymoma in the superior anterior mediastinum and a primary bronchogenic adenocarcinoma in the right upper lobe. In view of this, he underwent surgical resection of the thymoma directly through amedian sternotomy and right upper lobectomy via the median sternotomy with video assisted thoracoscopic guidance.
Asunto(s)
Adenocarcinoma/cirugía , Neoplasias Pulmonares/cirugía , Neoplasias Primarias Múltiples/cirugía , Cirugía Torácica Asistida por Video , Timoma/cirugía , Neoplasias del Timo/cirugía , Humanos , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Neoplasias Primarias Múltiples/patología , Timoma/patología , Neoplasias del Timo/patologíaAsunto(s)
Fibroma/complicaciones , Neoplasias Cardíacas/complicaciones , Obstrucción del Flujo Ventricular Externo/etiología , Anciano , Ecocardiografía , Fibroma/diagnóstico por imagen , Neoplasias Cardíacas/diagnóstico por imagen , Humanos , Masculino , Obstrucción del Flujo Ventricular Externo/diagnóstico por imagenRESUMEN
Adult cardiac surgery in patients with malrotation of the heart is rare. A 60 year-old lady, with known cardiac dextroversion, presented with dyspnoea and pre-syncopal attacks. Echocardiographical and radiological investigation confirmed the dextroversion, with clockwise rotation of the heart through its longitudinal axis. This resulted in the right ventricular outflow tract and pulmonary artery being wrapped anteriorly around the aorta, with posterior displacement of the right atrium. The presence of a heavily calcified, bicuspid aortic valve and dilated ascending aorta was also demonstrated. At surgery, venous cannulation was established by rotating the heart anticlockwise and access to the aortic valve gained with a more superior oblique aortotomy. In the presence of a dilated ascending aorta with a calcified, bicuspid aortic valve, the aortic root was replaced with a valved conduit. To the authors' knowledge, this is the first report of an aortic root replacement in a patient with cardiac dextroversion.
Asunto(s)
Enfermedades de la Aorta/cirugía , Válvula Aórtica , Calcinosis/cirugía , Dextrocardia/complicaciones , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Procedimientos Quirúrgicos Vasculares/métodos , Aorta Torácica , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico por imagen , Calcinosis/complicaciones , Calcinosis/diagnóstico por imagen , Dextrocardia/diagnóstico por imagen , Dilatación Patológica , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Humanos , Persona de Mediana Edad , Tomografía Computarizada por Rayos XAsunto(s)
Neoplasias Cardíacas/complicaciones , Hipertensión Pulmonar/etiología , Mixoma/complicaciones , Ecocardiografía Doppler/métodos , Atrios Cardíacos , Neoplasias Cardíacas/diagnóstico , Humanos , Angiografía por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Mixoma/diagnósticoRESUMEN
AIM: The aim of this study was to analyse the outcomes of patients admitted to the intensive care unit (ICU) following initial recovery after elective thoracic surgery. METHODS: The case notes of all patients who underwent elective thoracic surgery over a one-year period were reviewed. Patients who were admitted to ICU following an initial recovery on the ward were identified and their postoperative course analysed. The clinical and demographic characteristics of these patients were recorded and their outcomes analysed. RESULTS: A total of 20 patients were admitted to ICU of whom 13 (65%) were admitted for respiratory complication, 5 with sepsis and 2 with cardiovascular instability. Sixteen (80%) patients required CPAP or BIPAP, of whom only 7 (35%) required mechanical ventilation. Renal support was required in 7 patients, with 2 (10%) requiring haemofiltration. ICU survival was 15 patients (75%), whilst overall three-month survival post ICU admission was 65%. Requirement for renal support was the only predictor of mortality on univariate and multivariate analysis. CONCLUSIONS: Salvage ICU admission following elective thoracic surgery is associated with significant mortality, however the outcome is far from hopeless. The majority of patients can be managed without recourse to mechanical ventilation or haemofiltration. The need for renal support is, however, a significant adverse prognostic indicator.
Asunto(s)
Cuidados Críticos , Procedimientos Quirúrgicos Electivos , Servicios Médicos de Urgencia , Procedimientos Quirúrgicos Torácicos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Phaeochromocytomas of the heart are very rare. This report describes the case of a 69 year old woman presenting with persistent hypertension and a left atrial phaeochromocytoma diagnosed by 131I-metaiodobenzylguanidine scintigraphy scanning. She was successfully treated by surgical excision with the aid of cardiopulmonary bypass and perioperative alpha and beta adrenergic blockade.
Asunto(s)
Neoplasias Cardíacas/cirugía , Feocromocitoma/cirugía , 3-Yodobencilguanidina , Anciano , Puente Cardiopulmonar/métodos , Femenino , Atrios Cardíacos , Neoplasias Cardíacas/diagnóstico por imagen , Humanos , Feocromocitoma/diagnóstico por imagen , Cintigrafía , RadiofármacosAsunto(s)
Enfermedades Linfáticas/complicaciones , Derrame Pleural/cirugía , Implantación de Prótesis/métodos , Anciano , Anastomosis Quirúrgica , Femenino , Humanos , Derrame Pleural/etiología , Implantación de Prótesis/efectos adversos , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/cirugía , Reoperación , Síndrome , Resultado del TratamientoRESUMEN
We describe successful replacement of the iliac vein using a descending aortic homograft. The ilio femoral system was avulsed after recannulation of the femoral vein during a third cardiac reoperation.
Asunto(s)
Aorta Torácica/trasplante , Vena Ilíaca/cirugía , Adulto , Cateterismo Periférico/efectos adversos , Vena Femoral , Humanos , Vena Ilíaca/lesiones , Masculino , Trasplante HomólogoRESUMEN
OBJECTIVE: The choice of analgesia in the management of post-thoracotomy pain remains controversial. Although several alternative forms of post-thoracotomy analgesia exist, all have their disadvantages. Cryoanalgesia, localized freezing of intercostal nerves, has been reported to have variable effectiveness and an incidence of long-term cutaneous sensory changes. We carried out an animal study to assess the reversibility of histological changes induced by cryoanalgesia and a prospective randomized trial to compare the effectiveness of cryoanalgesia with conventional analgesia (parenteral opiates). METHODS: In six anaesthetized dogs, intercostal nerves were exposed to a varying duration of cryo-application (30, 60, 90 and 120 s). The nerves were biopsied and examined histologically at regular intervals over the following 6 months. In the clinical study, 200 consecutive patients undergoing thoracotomy were randomized to cryoanalgesia and conventional (parenteral opiates) analgesia groups. Postoperative pain scores, respiratory function tests and use of opiate analgesia were measured for the two groups. RESULTS: Following application of the cryoprobe, degeneration and fragmentation of the axons was evident with associated inflammatory changes. As the endoneurium remained intact, axonal regeneration took place after the resolution of axonal swelling. Over the course of weeks, recovery of the intercostal nerve occurred and was complete after 1 month for the 30 and 60 s groups. For nerves exposed to longer durations of cryoanalgesia, the time taken for complete recovery was proportionally increased. Clinically, there was a statistically significant (P<0.05) improvement in postoperative pain scores and use of opiate analgesia and an improvement (P>0.05) in respiratory function tests for patients in the cryoanalgesia group. The previously suggested cutaneous sensory changes resolved within 6 months with complete restoration of function. CONCLUSIONS: We suggest that cryoanalgesia be considered as a simple, inexpensive, long-term form of post-thoracotomy pain relief, which does not cause any long-term histological damage to intercostal nerves.
Asunto(s)
Hipotermia Inducida , Nervios Intercostales/patología , Dolor Postoperatorio/prevención & control , Toracotomía , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Animales , Axones/patología , Perros , Femenino , Humanos , Hipotermia Inducida/efectos adversos , Nervios Intercostales/fisiopatología , Masculino , Meperidina/uso terapéutico , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Estudios ProspectivosRESUMEN
Septic complications are rare following laparoscopic cholecystectomy if prophylactic antibiotics are given, as demonstrated in previous studies. Antibiotic treatment may be unnecessary and, therefore, undesirable, so we compared two forms of prophylaxis: a cephalosporin antibiotic and bag extraction of the dissected gallbladder. A total of 76 patients undergoing laparoscopic cholecystectomy were randomised to either receive an antibiotic or to have their gallbladder removed from the abdomen in a plastic bag. Complicated cases were excluded. There was a total of 6 wound infections (7.9%), 3 in each of the study groups. All these were associated with skin commensals. There were no other septic complications. Bacteriological studies grouped the organisms isolated from the bile and the wound as potential pathogens and likely commensals. A total of 10 potential pathogens were isolated, 9 of which were found in the group receiving antibiotics. We conclude that septic sequelae of uncomplicated laparoscopic cholecystectomy are uncommon, but clearly not entirely prevented by antibiotic or mechanical prophylaxis. Prophylactic antibiotics may not be required in uncomplicated laparoscopic cholecystectomy. Further study is warranted.
Asunto(s)
Profilaxis Antibiótica , Cefuroxima/uso terapéutico , Cefalosporinas/uso terapéutico , Colecistectomía Laparoscópica/métodos , Infección de la Herida Quirúrgica/prevención & control , Bacterias/aislamiento & purificación , Femenino , Vesícula Biliar/microbiología , Humanos , Masculino , Estudios Prospectivos , Infección de la Herida Quirúrgica/microbiología , Ombligo/microbiologíaRESUMEN
BACKGROUND: Postoperative mediastinal false aneurysm is associated with a substantial morbidity and mortality. Surgical treatment is mandatory, although the individual approach varies according to the type of pathologic process, infection status, and site of origin of the aneurysm. METHODS: Between April 1993 and February 1999, we treated 10 patients, aged 25 to 73 years, with anastomotic mediastinal false aneurysm originating from the proximal thoracic aorta. Nine had undergone prior operations on the ascending aorta (7, type A dissection repair; 1, aortitis; 1, root abscess) with a Dacron conduit (n = 5) or valved conduit (n = 4). The last patient had undergone valve replacement for excavating aortic root sepsis. False aneurysms were detected from 2 to 70 months after the most recent operation. Three patients had positive tissue cultures. The surgical procedure was direct suture repair of the disrupted anastomosis in 5, root or ascending aortic replacement with an aortic homograft in 4, and Dacron graft interposition in 1. Hypothermic low-flow perfusion with or without circulatory arrest was used in all patients. RESULTS: There was one hospital death caused by staphylococcal mediastinitis. A false aneurysm recurred after direct suture repair in 2 patients with underlying type A dissection or aortitis. This resulted in one late death. One patient experienced a neurologic event during removal of an infected vascular graft. All 8 surviving patients are alive and well after a mean follow-up of 2 years. Three patients with mycotic false aneurysms remain free from infection after aortic homograft replacement. CONCLUSIONS: Mediastinal false aneurysms are surgically taxing. Low-flow hypothermic perfusion with or without circulatory arrest allows safe reentry. Radical surgery provides a satisfactory outcome in infected patients. Local repair of suture dehiscence in pathologic tissues may predispose to recurrence. We suspect that excessive use of formalin in gelatin-resorcin-formol glue may predispose to tissue necrosis.
Asunto(s)
Aneurisma Falso/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Adulto , Anciano , Anastomosis Quirúrgica , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/etiología , Aneurisma de la Aorta Torácica/etiología , Femenino , Paro Cardíaco Inducido , Humanos , Masculino , Mediastino , Persona de Mediana Edad , Complicaciones Posoperatorias , Técnicas de Sutura , Tomografía Computarizada por Rayos XRESUMEN
Sural nerve injury is a complication of Achilles Tendon (TA) rupture. We dissected 30 cadaveric lower limbs to describe the course of the sural nerve in relation to the TA. At the level of insertion of the TA into the calcaneum, the sural nerve was a mean 18.8 mm from the lateral border of the TA. The proximal course of the nerve was towards the midline such that it crossed the lateral border of the TA at a mean distance of 9.8 cm from the calcaneum. The significant individual variation in the position of the sural nerve in relation to the achilles tendon should be borne in mind when placing sutures in the proximal part of the achilles tendon. Percutaneous sutures should not be placed in the lateral half of the TA.