Detection of inadvertent passage of guide wire into the false lumen during thoracic endovascular aortic repair of Type B aortic dissection by transesophageal echocardiography.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has become a widely accepted treatment strategy for patients with thoracic aortic pathologies. We present a case of TEVAR where transesophageal echocardiography (TEE) played a crucial role for adequate placement of an endovascular stent graft. CASE PRESENTATION: A 71-year-old male received TEVAR for type B aortic dissection. TEE detected both true/false lumens with an intimal tear. A guidewire was inserted into the descending aorta via the left femoral artery; however, angiography failed to identify the precise location of the tip of the guidewire. TEE detected the guide wire passing through the intimal tear into the false lumen, promoted the surgeon to manipulate and advance it to the true lumen, followed by placement of a stent graft. The patient was hemodynamically stable through the whole procedure. CONCLUSION: TEE was crucially important for detecting the precise location of the guidewire and preventing complications during TEVAR.

Postoperative Diaphragmatic Liver Herniation Diagnosed by Point-of-Care Ultrasound.

Point-of-care ultrasound (PoCUS) is a sensitive and specific tool in early identification of malignant pathologies in unstable patients leading to improved outcomes. Postoperative diaphragmatic rupture is rare, can be life-threatening, and is difficult to diagnose. This report describes a 62-year-old women undergoing thoracoscopic right hemidiaphragm plication with acute postoperative hemodynamic instability. Bedside PoCUS identified hepatic herniation into the thorax causing cardiac compression and lateral displacement, which lead to expedited imaging and surgical reexploration.

Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery.

BACKGROUND: Atelectasis occurs regularly after induction of general anesthesia, persists postoperatively, and may contribute to significant postoperative morbidity and additional health care costs. Laparoscopic surgery has been reported to be associated with an increased incidence of postoperative atelectasis. It has been shown that during general anesthesia, obese patients have a greater risk of atelectasis than nonobese patients. Preventing atelectasis is important for all patients but is especially important when caring for obese patients. METHODS: We randomly allocated 66 adult obese patients with a body mass index between 30 and 50 kg/m(2) scheduled to undergo laparoscopic bariatric surgery into 3 groups. According to the recruitment maneuver used, the zero end-expiratory pressure (ZEEP) group (n = 22) received the vital capacity maneuver (VCM) maintained for 7-8 s applied immediately after intubation plus ZEEP; the positive end-expiratory pressure (PEEP) 5 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 5 cm H(2)O of PEEP; and the PEEP 10 group (n = 22) received the VCM maintained for 7-8 s applied immediately after intubation plus 10 cm H(2)O of PEEP. All other variables (e.g., anesthetic and surgical techniques) were the same for all patients. Heart rate, noninvasive mean arterial blood pressure, arterial oxygen saturation, and alveolar-arterial Pao(2) gradient (A-a Pao(2)) were measured intraoperatively and postoperatively in the postanesthesia care unit (PACU). Length of stay in the PACU and the use of a nonrebreathing O(2) mask (100% Fio(2)) or reintubation were also recorded. A computed tomographic scan of the chest was performed preoperatively and postoperatively after discharge from the PACU to evaluate lung atelectasis. RESULTS: Patients in the PEEP 10 group had better oxygenation both intraoperatively and postoperatively in the PACU, lower atelectasis score on chest computed tomographic scan, and less postoperative pulmonary complications than the ZEEP and PEEP 5 groups. There was no evidence of barotrauma in any patient in the 3 study groups. CONCLUSIONS: Intraoperative alveolar recruitment with a VCM followed by PEEP 10 cm H(2)O is effective at preventing lung atelectasis and is associated with better oxygenation, shorter PACU stay, and fewer pulmonary complications in the postoperative period in obese patients undergoing laparoscopic bariatric surgery.