Surgical management of pleuro-peritoneal fistula in chronic renal failure patient-safety and effectiveness.

BACKGROUND: Pleuro-peritoneal fistula (PPF) is a known complication arising in patients receiving continuous ambulatory peritoneal dialysis (CAPD) as a form of renal replacement therapy with an incidence of approximately 2% (1). Previous literature has shown that the recurrence rate of non-operative management of PPF to be ~45%. Video-assisted thoracoscopic surgery (VATS) has been shown to be an effective and safe means of treating patients with PPF. However, to the author's knowledge, there is currently no sizeable case series that discuss the various intra-operative findings, operative techniques employed, post-operative complications, duration of peritoneal dialysis suspension and fistula recurrence in this particular patient group. METHODS: From January 2009 to January 2019, patients who underwent VATS for the repair of PPF at The Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Hong Kong were retrieved from the Clinical Data Analysis and Reporting System (CDARS). Patient's epidemiological data, comorbidities and surgical data were analyzed. RESULTS: There were 35 patients who underwent VATS PPF repair in our series. The mean age was 60.8 years (44 to 82 years), the (54.3%), mean operative time was 60.8 minutes (15-224 minutes). There were 8 patients (25.8%) who suffered from recurrence of pleural effusion after re-initiation of CAPD. Concomitant use of mechanical and talc pleurodesis was statistically significant in preventing PPF recurrence with an odds ratio of 0.1201 when compared to non-operative techniques. One patient suffered from hemothorax requiring re-operation on post-operative day one. There were no 30-day mortalities. CONCLUSIONS: VATS appears to be a safe and effective surgical treatment to prevent recurrence of continuous peritoneal dialysis associated PPF. Concomitant mechanical and talc pleurodesis appears to have additional benefit.

Concurrent transcatheter transfemoral tricuspid valve-in-valve and aortic valve implantation using a 3D printed model for pre-OT planning.

Re-operation of a tricuspid bioprosthesis carries high morbidity and mortality, especially when carried out with other concomitant valvular heart surgery. Concurrent transcatheter valve implantation has evolved as an alternative option. Here we report on a 77-year-old lady who suffered from symptomatic severe recurrent stenosis of a tricuspid bioprosthesis (Sorin Pericarbon More, 27) and moderate to severe aortic stenosis (AS) who was declined for redo open heart surgery as it was deemed very high risk. We used a 3D customised printed right heart model for pre-OT rehearsal. Percutaneous V-in-V TVR using a 26 mm Edwards SAPIEN 3 was performed under general anaesthesia via the right femoral vein and showed a satisfactory result in one single attempt. We also evaluated the necessity of aortic valve intervention in detail before and after V-in-V TVR. After confirmation of severe AS, a 26 mm Medtronic CoreValve Evolut R was deployed in the non-calcified rheumatic aortic valve without any predilatation or post-dilatation via the right femoral artery. No significant gradient or leakage was seen. This case shows the feasibility and safety of concurrent transfemoral V-in-V TVR and TAVI. Rehearsal using a 3D printed model helped to increase the accuracy and success rate of the procedure. The transcatheter approach allows detailed haemodynamic assessment after each valvular intervention in the case of multiple valve interventions.

Diffuse large B-cell lymphoma associated with chronic inflammation as an incidental finding and new clinical scenarios.

Diffuse large B-cell lymphoma that develops in the setting of long-standing chronic inflammation is typically associated with Epstein-Barr virus, and usually presents as tumor mass involving body cavities, as in pyothorax-associated lymphoma. It is listed as a distinct entity in the latest World Health Organization lymphoma classification. We report four cases that were incidentally discovered on histologic examination, one each in a splenic false cyst, a long-standing hydrocele, an atrial myxoma, and metallic-implant wear debris. Microscopic foci of atypical (neoplastic) large lymphoid cells were found within the contents of the cysts or curettage material, or within the stroma of the atrial myxoma. Despite the diverse clinical scenarios, all cases showed a homogeneous phenotype: positivity for B-lineage markers (CD20+, CD79a+, PAX5+), non-germinal center immunophenotype (CD10-, BCL6-/+, MUM-1+), and positivity for Epstein-Barr virus with type III latency (LMP1+, EBNA2+). The last feature supports the hypothesis that the lymphoma has arisen in a setting of 'local immunodeficiency' as a result of long-standing chronic inflammation in an enclosed space, a characteristic pathogenetic mechanism of diffuse large B-cell lymphoma associated with chronic inflammation. These cases therefore expand the spectrum of this entity to include new clinical scenarios for the development of this lymphoma type.