Primary Infected Left Ventricular Pseudoaneurysm and the Use of Omental Flap.

A 55-year-old man with autoimmune deficiency syndrome presented with an infected left ventricular pseudoaneurysm and sepsis. The aneurysmectomy consisted of a Dor-style pericardial patch plus debridement of the abscess cavities. The infected pseudoaneurysm recurred, much larger, within five months due to persistent infected abscess cavities. The second repair was done without a Dor-style patch and with an omental flap. No recurrence has occurred one year after the second repair, but the patient has asymptomatic, partial gastric herniation inside the pericardium. This is the first description of a primary infected left ventricular pseudoaneurysm. The omental flap contributed to the successful treatment.

Minimally invasive esophagectomy is safe in patients with previous gastric bypass.

BACKGROUND: The prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE). METHODS: Retrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012. RESULTS: Five patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up. CONCLUSIONS: Minimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett's esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery.

Pre-therapy laparoscopic feeding jejunostomy is safe and effective in patients undergoing minimally invasive esophagectomy for cancer.

OBJECTIVE: Laparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients. DESIGN: This research is a retrospective case series. SETTING: This study was conducted in a university tertiary care center. PATIENTS: Between August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy. MAIN OUTCOME MEASURES: The outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients. RESULTS: One hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection. CONCLUSION: A laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.

Candida albicans necrotizing soft tissue infection: a case report and literature review of fungal necrotizing soft tissue infections.

BACKGROUND: Necrotizing fasciitis (NF) most often is caused by bacterial infection while a fungal source has been reported in immunosuppressed patients. Early wide surgical resection remains the mainstay of treatment. Split thickness skin grafts are both versatile and easy to harvest, thus making them a long-established option for soft tissue reconstruction. CASE REPORT: A 55-year-old man was admitted for gunshot wounds. Purulence was noted at the central catheter site. Cultures grew Candida albicans. Antifungal therapy was initiated and debridement for NF of the neck and upper chest was performed. The patient underwent reconstruction using a split thickness skin graft obtained from the anterolateral thigh. CONCLUSIONS: Necrotizing fasciitis secondary to Candida species infection is exceedingly rare. We report an unusual case of candidal NF in a patient with no past medical history of immunocompromise. Patients with this type of infection can be successfully treated with aggressive surgical debridement and intravenous anidulafungin.

Esophagectomy in the state of Florida: is regionalization of care warranted?

Centralization of cancer care needs to be based on evidence that regionalization will improve outcomes in a given region. We analyzed outcomes for esophagectomy performed in Florida using the Agency for Health Care Administration database. We determined the risk-adjusted mortality rate for the procedure in low-volume and high-volume centers. From 1997 to 2006, 991 esophagectomies were performed in Florida. The incidence of esophagectomy significantly increased from 1997 to 2001 compared with 2002 to 2006, and the postoperative mortality decreased in the latter time period (odds ratio [OR], 1.87; confidence interval [CI], 1.16-3.03). The risk-adjusted postoperative mortality was significantly lower (OR, 0.54; CI, 0.32-0.92) in high-volume centers (5.1 vs 10.4%). The anastomotic leak rates were 8.2 per cent in both high- and low-volume centers. In the largest population-based study for esophagectomy in Florida, outcomes are better in high-volume centers. These data support the regionalization of esophagectomy to high-volume locations in Florida to reduce procedure-related mortality.

A regionalised strategy for improving motor vehicle-related highway driver deaths using a weighted averages method.

OBJECTIVE: The state of Florida has some of the most dangerous highways in the USA. In 2006, Florida averaged 1.65 fatalities per 100 million vehicle miles travelled (VMT) compared with the national average of 1.42. A study was undertaken to find a method of identifying counties that contributed to the most driver fatalities after a motor vehicle collision (MVC). By regionalising interventions unique to this subset of counties, the use of resources would have the greatest potential of improving statewide driver death. METHODS: The Florida Highway Safety Motor Vehicle database 2000-2006 was used to calculate driver VMT-weighted deaths by county. A total of 3,468,326 motor vehicle crashes were evaluated. Counties that had driver death rates higher than the state average were sorted by a weighted averages method. Multivariate regression was used to calculate the likelihood of death for various risk factors. RESULTS: VMT-weighted death rates identified 12 out of 67 counties that contributed up to 50% of overall driver fatalities. These counties were primarily clustered in central and south Florida. The strongest independent risk factors for driver death attributable to MVC in these high-risk counties were alcohol/drug use, rural roads, speed limit ≥45 mph, adverse weather conditions, divided highways, vehicle type, vehicle defects and roadway location. CONCLUSIONS: Using the weighted averages method, a small subset of counties contributing to the majority of statewide driver fatalities was identified. Regionalised interventions on specific risk factors in these counties may have the greatest impact on reducing driver-related MVC fatalities.

Esophageal cancer--the five year survivors.

BACKGROUND: Esophageal cancer in the United States carries a poor prognosis with overall 5 year survival rate of approximately 10%. Due to this dismal outcome, data analyzing factors predictive of survival for greater than 5 years are not available. METHODS: Single institution retrospective review of esophageal resection for curative intent from 1984 to 2004. We identified 50 actual 5 year survivors (long term survivors, LTS) out of 266 patients (19%) with invasive esophageal cancer and, using multivariate logistic regression, compared characteristics between the LTS, and short-term (<5 year) survivors (STS). RESULTS: There was no significant difference in clinical T stage or N stage by EUS (P = 0.81) or in the utilization of neoadjuvant therapy in the LTS versus STS (58% vs. 62%, respectively, P = 0.36). The LTS group was significantly more likely to have pathologic complete response (69% vs. 41%, P < 0.001), lower pathologic T stage, i.e., pT0, pTis, or pT1 (83% vs. 45%, P < 0.001), pN0 stage (97% vs. 68%, P < 0.001), favorable tumor differentiation (well or well to moderate, 39% vs. 13%, P < 0.001), and absence of angiolymphatic (88% vs. 69%, P < 0.01) or perineural invasion (95% vs. 83%, P = 0.04). In comparing the factors predictive of outcome in LTS versus the STS with increasing relative risk, absence of perineural invasion (RR 0.41 (0.27, 0.61)), negative margins (RR 0.41 (0.29, 0.57)), absence of angiolymphatic invasion (RR 0.39 (0.30, 0.51)), pN0 stage (RR 1.37 (1.23, 1.52)), pT0 or pT1 (RR 1.85 (1.64, 2.07)), pathologic complete response (RR 2.02 (1.76, 2.31)), and favorable tumor grade (RR 3.00 (2.49, 3.61)) were associated with improved survival. CONCLUSION: Tumor biological factors including favorable tumor grade may be the most important influence on 5 year actual survival in esophageal cancer.

Epidermoid cyst of round ligament: case report and review of literature.

Round ligament tumors are rare, and when found are typically leiomyomas. Herein is described a case of an epidermoid cyst of the round ligament, previously reported only once in the literature. Epidermoid cysts are similar to dermoid tumors but have only an epidermis-lined structure filled with keratin. Management included laparoscopic removal of the tumor. The patient's recovery was uneventful.

Early blood biomarkers predict organ injury and resource utilization following complex cardiac surgery.

BACKGROUND: Patients undergoing complex cardiac surgery (thoracic aorta and valve) are at risk for organ failure and increased resource utilization. Neutrophil gelatinase-associated lipocalin (NGAL) has been found to be an early biomarker for renal injury. Multiplex cytokine immunoassays allow the evaluation of the early inflammatory response. We examined the relationship between early biomarker appearance (NGAL and multiplex cytokines) and organ injury and resource utilization. MATERIALS AND METHODS: NGAL and multiplex cytokine immunoassays were performed at baseline, 1, 6, and 24 h following surgery on 38 patients undergoing thoracic aorta and valve operations. The mean age was 65 y with 26 males and 12 females. Acute kidney injury (AKIN definition), pulmonary failure (>24 h ventilation), and intensive care unit and hospital stays were examined. RESULTS: One hour following complex cardiac surgery, the quartile of patients with the greatest IL-6 response had higher serum NGAL levels compared with the lowest quartile (347 versus 145 ng/mL, P=0.002), and 70% of these patients progressed to clinical kidney injury. Six hours following surgery, the quartile of patients with the greatest IL-10 response had higher serum NGAL compared with the lowest quartile (271 versus 160, P =0.04), more pulmonary failure (60% versus 10%, P =0.01), and longer ICU and hospital stays (P =0.001). CONCLUSIONS: Patients with early elevated biomarkers of inflammation exhibited higher NGAL, more pulmonary failure, and greater resource utilization. Earlier identification of patients at risk for organ injury may allow for earlier intervention and reduce resource utilization.

Brain natriuretic peptide is not reno-protective during renal ischemia-reperfusion injury in the rat.

BACKGROUND: Acute kidney injury (AKI) occurs in 30% of patients undergoing complex cardiovascular surgery, and renal ischemia-reperfusion (I/R) injury is often a contributing factor. A recent meta-analysis observed that perioperative natriuretic peptide administration was associated with a reduction in AKI requiring dialysis in cardiovascular surgery patients. This study was designed to further clarify the potential reno-protective effect of brain natriuretic peptide (BNP) using an established rat model of renal I/R injury. METHODS: The study comprised three groups (n = 10 kidneys each): (1) control (no injury); (2) I/R injury (45 min of bilateral renal ischemia followed by 3 h of reperfusion); and (3) BNP (I/R injury plus rat-BNP pretreatment at 0.01 µg/kg/min). Glomerular filtration rate (GFR) and a biomarker of AKI, urinary neutrophil gelatinase-associated lipocalin (uNGAL), were measured at baseline and at 30 minute intervals post-ischemia. Groups were compared using two-way repeated measures analysis of variance (mean ± SD, significance P < 0.05). RESULTS: Baseline GFR measurements for control, I/R, and BNP groups were 1.07 ± 0.55, 0.88 ± 0.51, and 1.03 ± 0.59 mL/min (P = 0.90), respectively. Post-ischemia, GFR was significantly lower in I/R and BNP compared with controls at 30 min, 1.29 ± 0.97, 0.08 ± 0.04, and 0.06 ± 0.05 mL/min (P < 0.01), and remained lower through 3 h, 1.79 ± 0.44, 0.30 ± 0.17, and 0.32 ± 0.12 mL/min (P < 0.01). Comparing I/R to BNP groups, GFR did not differ significantly at any time point. There was no significant difference in uNGAL levels at 1 h (552 ± 358 versus 516 ± 259 ng/mL, P = 0.87) or 2 h (1073 ± 589 versus 989 ± 218 ng/mL, P = 0.79) between I/R and BNP. CONCLUSIONS: BNP does not reduce the renal injury biomarker, urinary NGAL, or preserve GFR in acute renal ischemia-reperfusion injury.

Recurrent retroperitoneal sarcoma: impact of biology and therapy on outcomes.

BACKGROUND: Local recurrence remains the major cause of death in patients with retroperitoneal sarcoma (RPS). There is no consensus regarding management of patients with recurrent RPS. STUDY DESIGN: We performed a retrospective review of patients with recurrent RPS managed at 2 tertiary care centers between 1983 and 2008. Presentation, treatments, and outcomes were analyzed. RESULTS: Seventy-eight patients were identified and analyzed. Sixteen patients (22%) presented with concurrent metastatic disease; survival in this subset of patients was poor (median 12 months). Forty-eight patients underwent resection of the first local recurrence of RPS. Palliation of tumor-related symptoms was achieved in 79% with operation. Survival was significantly better in patients having complete (p = 0.001) and incomplete resection (p = 0.02) compared with patients having biopsy only. Among patients with first local recurrence, high grade tumor (p = 0.0001) and no resection (p = 0.007) were significantly associated with reduced survival. On multivariate analysis, radiation therapy, multifocality, histologic subtype, and time to local recurrence did not significantly correlate with survival. Second and third local recurrences occurred at shorter intervals compared with first local recurrence and were less likely to be completely resectable. Patients undergoing resection of second and third local recurrences had survival similar to that in patients undergoing resection of first local recurrence. CONCLUSIONS: Tumor biology (high grade) is a significant prognostic factor for patients with recurrent RPS. Resection should be considered in patients with first and subsequent local recurrences (even if multifocal) of RPS because it is associated with improved survival. Operation should also be considered for palliation of symptoms in patients in whom resection is not possible.

Uric acid: a novel risk factor for acute kidney injury in high-risk cardiac surgery patients?

BACKGROUND: Uric acid has been reported to be a risk factor for the development of chronic kidney disease; however, no study has examined whether uric acid may confer a risk for acute kidney injury. METHODS: We investigated the relation between serum uric acid and the incidence of postoperative acute kidney injury in patients undergoing high-risk cardiovascular surgery (cardiac valve and aneurysm surgery). RESULTS: Following cardiovascular surgery, 18 of 58 patients (31%) developed acute kidney injury, with 11 of 24 (45.8%) in the elevated uric acid group (defined as >6 mg/dl) and 7 of 34 (20.5%) in the normal uric acid group (p = 0.05). After controlling for baseline renal function, left ventricular ejection fraction, use of nesiritide, type of surgery, and history of previous surgery, an elevated preoperative uric acid conferred a 4-fold risk for acute kidney injury (OR: 3.98, CI: 1.10-14.33, p = 0.035) and longer hospital stay (36.35 vs. 24.66 days, p = 0.009). CONCLUSION: This preliminary study suggests that uric acid may be a novel risk factor for acute kidney injury in patients undergoing high-risk cardiovascular surgery.

Evolution in the management of the total thoracic aorta.

OBJECTIVES: Extensive aneurysms of the ascending, arch, and descending thoracic aorta traditionally have been managed with a 2-stage "elephant trunk" procedure. Single-stage transmediastinal repairs have also been used, because in some patients the entire repair is not completed owing to either complications during first-stage repair or magnitude of the second-stage operation. Since 2006, second-stage elephant trunks have been preferentially completed with endovascular stent grafts in anatomically appropriate patients. This study compares outcomes of 2-stage elephant trunk, single-stage, and hybrid endovascular repairs of extensive thoracic aortic aneurysms. METHODS: This is a single-institution retrospective cohort study of 103 patients (1992-2007) with extensive thoracic aortic aneurysms undergoing 2-stage elephant trunk repair with either surgical (OPEN) or endovascular (TEVAR) completion versus single-stage transmediastinal replacement (SS). Outcomes were analyzed with Statistica 8.0 software (Tulsa, Okla). RESULTS: Of 103 patients, 74 had elephant trunk procedures, 24 TEVAR-eligible and 50 OPEN, and 29 had SS. Completion rates were higher with TEVAR than OPEN (78% vs 47%; P = .01). Seven of 18 TEVARs were performed during the index hospitalization. TEVAR patients had shorter second-stage hospital stay (5.5 vs 16.5 days [P < .01]), required fewer transfusions (P < .01), and had less acute kidney injury (P = .04). There were no differences in mortality, paraplegia, or stroke. Six-month Kaplan-Meier survival estimates for OPEN, TEVAR, and SS were 64%, 78%, and 64% (P = .08). CONCLUSION: More patients complete the second stage when TEVAR is used after elephant trunk repair, with fewer hospital days and transfusions. TEVAR is feasible and safe in the hybrid management of extensive thoracic aortic aneurysms.

Isolated lymphoplasmacytic sclerosing pancreatitis involving the pancreatic tail.

We present an interesting case of a 62-year-old woman with a 3-month history of vague, left-sided abdominal pain. CT imaging revealed a hypodense lesion in the tail of the pancreas. The patient had no history of pancreatitis or autoimmune diseases. Laboratory testing revealed a normal CA19-9 (33 U/mL) and an elevated IgG4 (133 mg/dL). Due to concerns of pancreatic malignancy, she underwent operation. We found a dense, inflammatory mass in the tail of the pancreas, which was removed via an open distal pancreatectomy with splenectomy. Histologic analysis revealed a pancreas with sclerotic ducts and surrounding lymphoplasmacytic inflammation most consistent with lymphoplasmacytic sclerosing pancreatitis (LPSP). LPSP, also termed autoimmune pancreatitis, is a benign disease of the pancreas, which can mimic pancreatic adenocarcinoma. It is the most common benign finding diagnosed on pathology after pancreatic resection for presumed malignancy. LPSP most commonly involves the head and, more uncommonly, the tail of the pancreas. It can be successfully treated with steroids obviating the need for resection. IgG4 levels may assist in recognition of this disease. As our experience with utilization of IgG4 testing and knowledge of the systemic nature of LPSP increase, patients with this disease may be spared unnecessary resection.

Autoimmune pancreatitis and concurrent small lymphocytic lymphoma: not just a coincidence?

CASE: A 76-year-old gentleman presented with painless jaundice, weight loss, and anorexia. Computed tomography imaging revealed fullness of the pancreatic head and multiple enlarged retroperitoneal lymph nodes. Cholangiogram revealed a distal common bile duct stricture. Due to concerns of malignancy, the patient underwent operative exploration. Several enlarged lymph nodes in the aortocaval region and a firm hard mass in the pancreatic head were found. Frozen section from one of the lymph nodes was suspicious for low-grade lymphoma. A pancreaticoduodenectomy was performed. Histologic analysis of the pancreatic head revealed a lymphoplasmacytic infiltrate with stromal fibrosis consistent with autoimmune pancreatitis. The retroperitoneal lymph nodes were involved by small lymphocytic lymphoma. DISCUSSION: Autoimmune pancreatitis is the most common benign diagnosis after pancreatic resection for presumed malignancy. It has a well-documented association with autoimmune conditions, such as Sjögren's syndrome, inflammatory bowel disease, and sclerosing cholangitis. Additionally, chronic lymphocytic leukemia-small lymphocytic lymphoma is often associated with autoimmune phenomena, most notably autoimmune hemolytic anemia. However, an association between autoimmune pancreatitis and small lymphocytic lymphoma has not been previously described. To our knowledge, this is the first reported case of a patient with concurrent autoimmune pancreatitis and small lymphocytic lymphoma.

Primary presacral neuroendocrine tumor associated with imperforate anus.

BACKGROUND: Presacral masses are unusual growths that have a limited differential diagnosis, typically not including neuroendocrine tumors (NETs). Classically, NETs are well-differentiated gastroenteropancreatic tumors of probable benign behavior. These tumors are associated with a typical morphologic pattern and involve the distal colon, rectum, and genitourinary tract; they are considered less aggressive, frequently asymptomatic, and rarely cause carcinoid syndrome, even when metastatic. Neuroendocrine tumors of the presacral region are extremely rare and few have been described in the literature. They have not been previously reported as being associated with imperforate anus. CASE PRESENTATION: We present an interesting case of a woman with a history of imperforate anus that was found to have a primary neuroendocrine tumor of the presacral region with no rectal wall involvement. CONCLUSION: We argue that this is a primary gastroenteropancreatic neuroendocrine tumor which likely originated from cells of hindgut origin that underwent an abnormal migration during embryonic development.