Chest wall tumor following intravesical BCG instillation for non-muscle invasive bladder cancer.

Mycobacterium bovis bacille Calmette-Guérin (BCG) is the most effective intravesical immunotherapy for non-muscle invasive bladder cancer (NMIBC), administered after its transurethral resection. Although its instillation is generally well tolerated, BCG-related infectious complications may occur in up to 5% of patients. Clinical manifestations may arise in conjunction with initial BCG instillation or develop months or years after the last BCG instillation. The range of presentations and potential severity pose an imminent challenge for clinicians. We present a case of an isolated subcutaneous chest wall abscess in an immunocompetent 52-year-old patient nearly two years after intravesical BCG instillation for NMIBC, an absolute rarity. As the enlarging chest wall tumor may be misinterpreted as malignancy, its expedient diagnosis and prompt treatment are of critical importance.

Portrayal of video-assisted mediastinoscopic lymphadenectomy's range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective.

BACKGROUND: Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious - at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 - to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure. CASE PRESENTATION: We present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up. CONCLUSION: Presenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA's important role as a diagnostic and therapeutic tool.

Pyopericardium and extensive mediastinal abscess following EBUS-TBNA for mediastinal staging of NSCLC: a case report.

Background: Based on the algorithm on preoperative mediastinal staging in patients with non-small cell lung cancer (NSCLC), endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is indicated in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. It represents both a safe minimal invasive procedure with complication rates of less than 1.5% and a valid tool with a high sensitivity defining mediastinal nodal disease. However, infectious complications like mediastinitis or pyopericardium are most feared. Case Description: A 54-year-old woman was admitted to our hospital for further investigation of a suspected NSCLC of the right upper lobe. EBUS-TBNA was performed to receive both diagnosis and samples of the mediastinal lymph nodes. Two weeks after EBUS-TBNA, the patient presented with symptoms of cardiogenic/septic shock: hypotension, tachycardia, chest pain and fever. Prompt diagnosis of concomitant infectious mediastinitis and extensive pyopericardium in consequence of EBUS-TBNA was obvious. Besides systemic antibiotics, bilateral thoracoscopic interventions finally made the breakthrough. The patient could be discharged roughly three weeks after emergent re-admittance. As being finally diagnosed with NSCLC (stage IIIA squamous cell carcinoma), the patient underwent-subsequent to induction chemotherapy-a definitive sequential chemoradiotherapy. Twelve-month follow-up confirmed stable disease. Conclusions: It is to be expected that with increasing application of EBUS-TBNA as mediastinal staging tool, the number of serious infection-related complications will rise accordingly. The efficacy of antibiotic prophylaxis after EBUS-TBNA has not yet been proved and is therefore not included in any guideline. Our case gives an impression on the severity of delayed infectious complications after EBUS-TBNA and outlines up-front surgery as primary objective to broadly debride all contagious abscess-/empyema sites. With increased use of EBUS-TBNA as mediastinal staging tool, clinicians should be aware of this rare but highly critical peri-interventional complication in order to closely monitor endangered patients.

Association of early-onset myasthenia gravis and primary Sjögren's syndrome: a case-based narrative review.

Coexistent myasthenia gravis (MG) and primary Sjögren's syndrome (pSS) is an absolute rarity. That is kind of a surprise as both entities seem to share the same corresponding immunologic mechanisms. We hereby report the case of a 41-year-old woman with coincident early-onset MG (EOMG) and pSS. Because EOMG was the leading clinical feature, she was primarily treated by innovative non-intubated uniportal subxiphoid video-assisted thoracoscopic surgery (VATS) thymectomy. As the association of EOMG and pSS is so unusual, we contextualize our findings with the relevant literature. Particular relevance is an anti-nuclear antibody screening throughout the clinical course of MG and-in reverse-a screening for MG variables when pSS patients complain either muscle fatigability or fatigable ptosis. As pSS patients do not develop any serious morbidity, supervising MG progress in patients with both diseases is of utmost importance. Apart from conscientious pSS diagnosis, prompt adjusting of EOMG progress is the essential aspect of targeted treatment. In this context, it is relevant that therapeutic decisions are made in a multidisciplinary approach. Due to its rarity, multicenter prospective studies of larger sample sizes are indispensably needed to obtain a better understanding of this unusual link.

Non-intubated Uniportal Subxiphoid Video-Assisted Thoracoscopic Surgery for Extended Thymectomy in Myasthenia Gravis Patients: A Case Series.

Minimally invasive strategies are increasingly popular in patients with myasthenia gravis (MG)-associated thymomas. Within the context of video-assisted thoracoscopic surgery (VATS) as a widely known minimally invasive option, the most recent achievement is uniportal subxiphoid VATS. In MG patients, it is mandatory (1) to minimize perioperative interference with administered anesthetics to avoid complications and (2) to achieve a complete surgical resection, as the prognosis essentially depends on radical tumor resection. In order to fulfill these criteria, we merged this surgical technique with its anesthesiologic counterpart: regional anesthesia with the maintenance of spontaneous ventilation via a laryngeal mask. Non-intubated uniportal subxiphoid VATS for extended thymectomy allowed radical thymectomy in all MG patients with both rapid symptom control and fast recovery.

Technique for ectopic intrathymic parathyroid adenoma: the uniportal subxiphoid approach.

Parathyroid adenomas (PAs) are the main cause for primary hyperparathyroidism with almost a quarter of them being ectopic, most likely located in the superior mediastinum within the thymus. Besides the challenge of their prompt and correct diagnosis, utmost care should be taken during surgical resection as leaving behind parathyroid tissue may result in metastasis and recurrence of hyperparathyroidism. With tumor excision via median sternotomy or thoracotomy being the conventional approaches for a long period, video-assisted thoracoscopic surgery (VATS) is of gaining popularity. As the lateral thoracic approach lacks in clarity on the contralateral mediastinum, the newest evolution in VATS-the supxiphoid approach-closes the gap to the insufficient intraoperative visibility and hence optimizes postoperative outcome. We hereby present the practicality of the uniportal subxiphoid resection of an ectopic mediastinal PA.

Relocation of an infected tracheostoma: anterior mediastinal tracheostomy as Mission:Impossible.

Infected tracheostomas are frequently associated with high morbidity and mortality rates-especially in patients after neck-oncological surgery with subsequent radiochemotherapy. A 59-year-old male patient with a history of hypopharynx carcinoma, successive laryngectomy and adjuvant radiochemotherapy developed an oesophagotracheal fistula with massive inflammation and periodical bleedings, uncontrollable by regular stent alternations. In a multidisciplinary setting, the decision was made to treat the patient with an anterior mediastinal tracheostomy. Extending usual anterior mediastinal tracheostomy indications, we present an ultimate treatment option for infected tracheostomas and highly advocate this interdisciplinary venture, as it significantly improves quality of life.

Thoracoabdominal actinomycosis - Chameleon through kaleidoscope.

Actinomyces is a gram-positive anaerobic bacterium that generally inhabits the human commensal flora of the bronchial system, the gastrointestinal and urogenital tract. In the rare case of becoming invasive under certain circumstances, the resulting Actinomycosis affects most commonly cervicofacial, thoracic, abdominal and pelvic regions. Due to its rarity and presenting with nonspecific clinical symptoms, thoracic and/or abdominal Actinomycosis in particular are highly intriguing clinical conditions that can easily be mistaken for other diseases including malignancies. Astute considerations are therefore necessary whenever we are challenged diagnostically to allow early diagnosis and thus avoiding gratuitous invasive surgery. In order to highlight different issues of this ultimate chronic disease we report a particular case of thoracoabdominal Actinomycosis.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) for staging & treatment of non-small cell lung cancer (NSCLC).

Precise preoperative staging and restaging of mediastinal lymph nodes in patients with potentially resectable non-small cell lung cancer (NSCLC) is of supreme importance. Over the last years, algorithms on preoperative mediastinal staging incorporating imaging, endoscopic and surgical techniques have been widely published, offering more evidence concerning different mediastinal staging techniques. Current guidelines well define when and how to receive tissue confirmation in case of computed tomography (CT)-enlarged or positron emission tomography (PET)-positive mediastinal lymph nodes. Endosonography [(endoscopic bronchial ultrasonography/oesophageal ultrasonography (EBUS/EUS)] with fine needle aspiration still is the first choice (when accessible) since it is minimally invasive and has a high sensitivity to confirm mediastinal nodal disease. If negative, surgical staging with nodal dissection or biopsy is indicated. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) and transcervical extended mediastinal lymphadenectomy (TEMLA) are preferred over conventional mediastinoscopy if a mediastinal R0-resection can be achieved. The mutual use of endoscopic and surgical staging effects highest accuracy. Straight surgical resection of tumors ≤3 cm (located within the external third of the lung) with systematic nodal dissection is justified as soon as there are no enlarged lymph nodes on CT-scan and once there is no nodal uptake on PET-CT. In case of central tumors and enlarged or FDG avid nodes regardless of cytological result, preoperative invasive mediastinal staging is indicated to rule out mediastinal nodal spread. However, accuracy needed in preoperative nodal staging has been under continuous debate ever since and with the advent of immunotherapy is right now intensely revived. During the last two decades VAMLA has been growing up from being a merely staging tool to an expert-recognized therapeutic tool in the context of minimal invasive lung cancer resection.

Glomus tumor of the trachea - Synopsis of histology & methodology of treatment.

Glomus tumors are neoplasms arising from modified smooth muscle cells surrounding arteriovenous anastomosis in the dermis and subcutaneous tissues, which are contributing to blood flow regulation and temperature control on the skin surface. Glomus cells are sparse or absent in visceral organs, making extracutaneous presentation of glomus tumors an extremely rare finding. We briefly report histological considerations on glomus tumors of the trachea and sum the multidisciplinary aspects of their staged endoscopic and surgical management using the example of a rare case presentation.

Cross-clamping a porcelain aorta: an alternative technique for high-risk patients.

BACKGROUND: Aortic cross-clamping in patients with porcelain aorta is associated with high mortality and morbidity rates. The aim is to establish a new approach to improve the outcome in this high-risk population. METHODS: Between September 2007 and November 2012, 42 patients with an aortic (N.=33; 81.3±6.4 years) or mitral valve disease (N.=9; 80.3±5.7) combined with a porcelain aorta underwent aortic (AVR) or mitral valve replacement (MVR). After arterial cannulation via distal aortic arch or femoral artery, longitudinal aortotomy under total cardiopulmonary bypass (CPB) was performed. The aorta was slowly clamped, thus mobilized atherosclerotic material could leave the aorta through the open incision. Subsequent to the actual operation, the aorta was gradually unclamped. Again, plaques were flushed out via the still open aortotomy ("open proximal ascending aorta"). RESULTS: Intraoperatively, no technical no problems occurred. Mean CPB time was 92.2±27.9 min (AVR) and 92.3±36.3 min (MVR); cardiac ischemia time was 74.3±26.7 min (AVR) and 77.1±31.6 min (MVR). Surgical revision was necessary in three patients (7.1%) due to major bleedings. Two AVR-patients suffered from minor stroke and one MVR-patient from major stroke (neurological deficit rate =7.1%). Transient ischemic attacks occurred in three patients (7.1%), another three patients (7.1%) required temporary hemofiltration. Neither gastrointestinal disorders nor respiratory failure or valve-related problems were noted. 30-day mortality was 6.9%. CONCLUSIONS: Cross-clamping with "open proximal ascending aorta" is effective and the incidence of stroke and systemic embolization in patients with porcelain aorta is low compared to literature.

Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†.

Ischaemic spinal cord injury (SCI) remains the Achilles heel of open and endovascular descending thoracic and thoracoabdominal repair. Neurological outcomes have improved coincidentially with the introduction of neuroprotective measures. However, SCI (paraplegia and paraparesis) remains the most devastating complication. The aim of this position paper is to provide physicians with broad information regarding spinal cord blood supply, to share strategies for shortening intraprocedural spinal cord ischaemia and to increase spinal cord tolerance to transitory ischaemia through detection of ischaemia and augmentation of spinal cord blood perfusion. This study is meant to support physicians caring for patients in need of any kind of thoracic or thoracoabdominal aortic repair in decision-making algorithms in order to understand, prevent or reverse ischaemic SCI. Information has been extracted from focused publications available in the PubMed database, which are cohort studies, experimental research reports, case reports, reviews, short series and meta-analyses. Individual chapters of this position paper were assigned and after delivery harmonized by Christian D. Etz, Ernst Weigang and Martin Czerny. Consequently, further writing assignments were distributed within the group and delivered in August 2014. The final version was submitted to the EJCTS for review in September 2014.

Lung transplantation: a treatment option in end-stage lung disease.

BACKGROUND: Lung transplantation is the final treatment option in the end stage of certain lung diseases, once all possible conservative treatments have been exhausted. Depending on the indication for which lung transplantation is performed, it can improve the patient's quality of life (e.g., in emphysema) and/ or prolong life expectancy (e.g., in cystic fibrosis, pulmonary fibrosis, and pulmonary arterial hypertension). The main selection criteria for transplant candidates, aside from the underlying pulmonary or cardiopulmonary disease, are age, degree of mobility, nutritional and muscular condition, and concurrent extrapulmonary disease. The pool of willing organ donors is shrinking, and every sixth candidate for lung transplantation now dies while on the waiting list. METHOD: We reviewed pertinent articles (up to October 2013) retrieved by a selective search in Medline and other German and international databases, including those of the International Society for Heart and Lung Transplantation (ISHLT), Eurotransplant, the German Institute for Applied Quality Promotion and Research in Health-Care (Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen, AQUA-Institut), and the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO). RESULTS: The short- and long-term results have markedly improved in recent years: the 1-year survival rate has risen from 70.9% to 82.9%, and the 5-year survival rate from 46.9% to 59.6%. The 90-day mortality is 10.0%. The postoperative complications include acute (3.4%) and chronic (29.0%) transplant rejection, infections (38.0%), transplant failure (24.7%), airway complications (15.0%), malignant tumors (15.0%), cardiovascular events (10.9%), and other secondary extrapulmonary diseases (29.8%). Bilateral lung transplantation is superior to unilateral transplantation (5-year survival rate 57.3% versus 47.4%). CONCLUSION: Seamless integration of the various components of treatment will be essential for further improvements in outcome. In particular, the follow-up care of transplant recipients should always be provided in close cooperation with the transplant center.

Impact of previous cardiovascular surgery on postoperative morbidity and mortality after major pulmonary resection for non-small cell lung cancer.

PURPOSE: The aim of this study was to evaluate the impact of previous cardiovascular surgery on the postoperative morbidity and mortality following major pulmonary resection for non-small cell lung cancer (NSCLC). METHODS: Medical records of 227 patients, who underwent major pulmonary resection for NSCLC from 2003 to 2012 at our department, were reviewed retrospectively. Thirty-one patients with a mean age of 65.8 years had previous cardiovascular surgery (group A) including coronary artery revascularization in 11 patients, peripheral arterial revascularization in 6 patients, carotis endarterectomy in 9 patients, and combined coronary artery revascularization and carotis endarterectomy in 5 patients, whereas 167 patients (mean age = 62.0 years) had no cardiovascular comorbidity (group B). Twenty-nine patients with nonsurgically treated cardiovascular comorbidity were excluded from this study. RESULTS: There were no significant differences in overall postoperative morbidity (22.6 % in group A vs. 19.2 % in group B) and mortality (no mortality in group A vs. 2.4 % in group B) between both groups. CONCLUSIONS: Major pulmonary resections for NSCLC can be performed safely in patients with previous cardiovascular surgical history who are fulfilling the common cardiopulmonary criteria of operability. Operative risk in this subpopulation is comparable to that in patients without cardiovascular comorbidity.

Mid-term results of a modified arterial switch operation using the direct reconstruction technique of the pulmonary artery.

BACKGROUND: There is ongoing discussion as to whether it is beneficial to avoid pulmonary sinus augmentation in the arterial switch operation. We report a single-surgeon series of mid-term results for direct pulmonary artery anastomosis during switch operation for transposition of the great arteries (TGA). METHODS: This retrospective study includes 17 patients with TGA, combined with an atrial septal defect, patent foramen ovale or ventricular septal defect. Patient data was analyzed from hospital charts, including operative reports, post-operative course, and regular follow-up investigations. The protocol included cardiological examination by a single pediatric cardiologist. Echocardiographic examinations were performed immediately after arrival on the intensive unit, before discharge, and then after three, six, and 12 months, followed by yearly intervals. Pulmonary artery stenosis (PAS) was categorized into three groups according to the Doppler-measured pulmonary gradient: grade I (trivial stenosis) = increased pulmonary flow with a gradient below 25 mm Hg; grade II (moderate stenosis) = a gradient ranging from 25 to 49 mm Hg; and grade III (severe stenosis) = a gradient above 50 mm Hg. Follow-up data was available for all patients. The length of follow-up ranged from 1.2 to 9.7 years, median: 7.5 years (mean 6.1 years ± 14 months). RESULTS: During follow-up, 12 patients (70.6%) had no (or only trivial) PAS, five patients (29.4%) had moderate stenosis without progress, and no patient had severe PAS. Cardiac catheterization after arterial switch operation was performed in 11 patients (64.7%) and showed a good correlation with echocardiographic findings. During follow-up there was no reintervention for PAS. CONCLUSIONS: Direct reconstruction of the neo-pulmonary artery is a good option in TGA with antero-posterior position of the great vessels, with very satisfactory mid-term results.

Minimum cause--maximum effect: the travelogue of a bullet.

This case report involves a 57-year-old male, accidentally shot in the chest with a small bore firearm. The bullet entered the left hemithorax, disrupting the left internal mammarian artery. It then penetrated the anterior wall of the right ventricle causing a pericardial tamponade. After leaving the base of the right heart it perforated the diaphragm, the liver, the spleen and the pancreas. Finally, it penetrated the abdominal aorta 3 cm proximally to the coeliac trunk and reached its final position paravertebrally. This case report illustrates that the management of even minimum gunshot wounds requires a maximum variety of surgical skills.

A follicular dendritic cell sarcoma of the mediastinum with immature T cells and association with myasthenia gravis.

Follicular dendritic cell (FDC) sarcoma is a very rare neoplasm showing morphologic and phenotypic features of FDCs. It occurs primarily in lymph nodes but also in extranodal sites. So far, there have been no reports on FDC sarcoma associated with myasthenia gravis. In the following we will present a case of an FDC tumor of the mediastinum associated with paraneoplastic myasthenia gravis in a 39-year-old man. The tumor contained a major proportion of immature T cells, which may be connected to this patient's very unusual clinical presentation with autoimmune phenomena. Extranodal FDC sarcomas still seem hardly noticed, and their clinical and pathologic characteristics remain to be better defined.

Surgical treatment of aortic coarctation in adults: Beneficial effect on arterial hypertension.

BACKGROUND: The aim of this study was to determine the outcome after surgical repair of aortic coarctation in adults, analysing its effect on arterial blood pressure. METHODS: Twenty-five adults (9 women, 16 men), mean age 43.4 years (19 to 70 years), underwent aortic coarctation surgical repair. All patients suffered from preoperative hypertension. Mean blood pressure was 182/97 mm Hg. Sixteen (64%) patients demonstrated reduced load capacity. Operative technique was resection and end-to-end anastomosis for 5 patients (20%), interposition of a Dacron-tube graft for 3 patients (12%), Dacron-patch dilatation was performed in 7 (28%) patients, and in 10 (40%) patients we performed an extra-anatomical bypass graft. RESULTS: Early mortality occurred in 1 patient (4%). The mean blood pressure was reduced [systolic 182 mm Hg vs. 139 mm Hg (p < 0.001), diastolic 97 mm Hg vs. 83 mm Hg (p < 0.001)] in all patients. In 12 patients, blood pressure normalized immediately after surgery, in 7 patients it remained slightly elevated (systolic blood pressure between 140-160 mm Hg), and 1 patient suffered from prolonged arterial hypertension. Preoperatively, all patients were treated with antihypertensive drugs. Eleven of 20 patients received long-term medication during follow- up. In the remaining 4 patients, medication lists were unobtainable in retrospect. The mean follow-up was 7.1 years (min. 1.0 years; max. 16.6 years). One patient (5%) died from cardiac failure 12.4 years after the operation. On average, the New York Heart Association (NYHA) class was improved by 0.92. CONCLUSIONS: The surgical repair of aortic coarctation in adults can be performed with low surgical risk. Surgery reduces hypertension and permits more effective medical treatment.