Early and mid-term outcomes of trans-sternal and video-assisted thoracoscopic surgery for thymoma.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) for thymoma has uncertain safety and effectiveness in comparison with trans-sternal resection. This feasibility study compared short- and mid-term outcomes for patients undergoing these two procedures, highlights weaknesses in current research and makes recommendations for long-term technological evaluations in this field. METHODS: Consecutive thymoma cases between 2004 and 2010 were identified. Patients were divided into two groups according to surgical approach (Group I trans-sternal; Group II VATS) and comparisons were made between groups. The primary outcome was overall survival. Secondary outcomes included operative morbidity and mortality, hospital stay, recurrence rate and disease-free survival. RESULTS: Thirty-nine patients were included (Group I: n = 22 vs Group II: n = 17). There were no differences between groups at baseline for all measured covariates. No deaths occurred within 30 days of surgery. More patients in Group I developed complications (Group I: n = 10 vs Group II: n = 3; P = 0.093), while hospital stay was shorter in Group II (Group I: 6.4 ± 4.6 days vs Group II: 4.4 ± 1.8 days; P = 0.030). Five-year overall survival (Group I: 93.8 ± 6.1% vs Group II: 83.3 ± 11.2%; P = 0.425), 5-year disease-free survival (Group I: 71.0 ± 15.3% vs Group II: 83.3 ± 11.2%; P = 0.827) and recurrence rates at final follow-up (Group I: n = 2 vs Group II: n = 1; P = 0.363) were similar between the groups. CONCLUSION: VATS thymectomy for thymoma is feasible, safe and has comparable mid-term oncological outcomes to trans-sternal thymectomy. Future research is required to evaluate long-term oncological outcomes of VATS thymectomy for thymoma in national registries and randomized, controlled trials.

A rare complication of pneumonectomy: hiatal hernia associated with gastric volvulus.

A rare case of intrathoracic gastric herniation resulting in intermittent gastric volvulus was observed in a 69-year-old female patient five months after left pneumonectomy for lung cancer. The mechanism of post-pneumonectomy intermittent gastric volvulus and the techniques of surgical repair are discussed.

Video-assisted mediastinoscopy (VAM) for surgical resection of ectopic parathyroid adenoma.

BACKGROUND: Ectopic mediastinal parathyroid adenomas or hyperplasia account for up to 25% of primary hyperparathyroidism (HPT). Two percent of them are not accessible by standard cervical surgical approaches. Surgical resection has traditionally been performed via median sternotomy or thoracotomy and more recently, via video assisted thoracoscopic surgery (VATS). We present our experience with the novel use of Video-Assisted Mediastinoscopy (VAM) for resection of ectopic mediastinal parathyroid glands. CASE PRESENTATION: 4 patients underwent VAM for removal of an ectopic intramediastinal parathyroid gland. All of them had at least one previous unsuccessful neck exploration.In all cases histology confirmed complete resection of ectopic parathyroid glands (3 parathyroid adenomas and one parathyroid hyperplasia). Two of the patients required a partial sternal split to facilitate exploration. CONCLUSION: The cervical approach for resection of ectopic parathyroid adenomas is frequently unsuccessful. Previously, the standard surgical approach in such cases was sternotomy and exploration of the mediastinum. Recently, a number of less invasive modalities have been introduced. We found that VAM has several advantages. It has a short theatre time does not require a complex anaesthetic and is performed with the patient in classic supine position utilising often a previous cervical scar with good cosmetic results. It offers a short hospital stay; it is cost effective with minimal use of fancy and pricy consumables with a comfortable incision and no violation of the pleural space. Additionally the use of digital Video imaging has increased the sensitivity of the mediastinoscopy and has added safety and confidence in performing a detailed mediastinal exploration with an additional great training value as well.

Atypical presentation of Boerhaave's syndrome as Enterococcal bacterial pericardial effusion.

Boerhaave's perforation is a serious condition describing spontaneous transmural perforation of the oesophagus. The classical presentation of this condition is vomiting, lower thoracic pain and subcutaneous emphysema. However, the condition often presents atypically and it is important to reach the correct diagnosis quickly. We present the case of a 54-year-old woman with a Boerhaave's perforation that presented as Enterococcal bacterial pericardial effusion.

Photodynamic therapy (PDT) in Barrett's esophagus with dysplasia or early cancer.

OBJECTIVE: Esophagectomy is the standard treatment for high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC) arising within Barrett's esophagus. Results of photodynamic therapy (PDT) were retrospectively studied to evaluate the effectiveness of PDT in ablating HGD and/or IMC complicating Barrett's esophagus. METHODS: Thirty-one patients unfit for or refusing esophagectomy (male: 20, mean age: 73.4+/-9.3 years) underwent Porfimer sodium PDT ablation of their HGD (15 patients), HGD plus IMC (10 patients) or submucosal/limited T2 adenocarcinoma (6 patients). The mean Barrett's length was 5.8+/-2.2 cm. Pre-PDT endoscopic mucosal resection or Nd:YAG laser ablation of mucosal nodularity within Barrett's segment was offered in six patients. RESULTS: The main PDT complications were esophagitis (16.1%), photoreactions (12.9%) and stricture requiring dilatation (6.25%). The median post-PDT follow-up was 14 months. The long-term results were (a) for HGD/IMC: initial complete response (endoscopic and histologic absence of HGD-IMC) to PDT was observed in 80.95% of patients, partial response (no endoscopic abnormality, residual IMC-HGD on biopsy) in 9.52%, no response in 9.52% (the recurrence rate after an initial complete response was 17.64%) and (b) for T1b/limited T2 tumors: two patients died from cancer after 24 and 46 months, no evidence of tumor was found in two patients after 12 and 19 months and tumor recurrence was seen in two after 15 and 17 months. The mean survival was 22.1+/-12.3 months. CONCLUSIONS: PDT is effective in ablating HGD/IMC complicating Barrett's esophagus in the majority of cases, while it also seems to be quite effective in treating T1b/limited T2 carcinomas.

Successful treatment of a posttraumatic pulmonary artery pseudoaneurysm with coil embolization.

A 29-year-old man presented to the emergency department after having been stabbed in the posterior right hemithorax twice. He underwent thoracotomy for hemodynamic instability and continuous bleeding. His postoperative recovery was complicated by the incidental finding of a posttraumatic pseudoaneurysm of the pulmonary artery. We describe successful coil embolization of the aneurysmal sac avoiding any further surgical intervention.

Spontaneous haematoma of the oesophagus.

Haematoma of the oesophagus is a rare occurrence and is usually in response to trauma, retching or vomiting. We report a case of spontaneous haematoma of the oesophagus that presented with only bruising over the chest. It resolved completely with conservative management. We review the literature, common causes, the differential diagnosis and the management of oesophageal haematoma.

Staged pulmonary and hepatic metastasectomy in colorectal cancer--is it worth it?

OBJECTIVES: Resection of isolated pulmonary and hepatic metastases from colorectal cancer can offer potential cure. However, little data is available to determine the results of staged hepatic and pulmonary resections in the same patient. METHODS: We retrospectively reviewed all patients who underwent staged hepatic and pulmonary metastasectomy for colorectal cancer in our institute from September 1998 to May 2002. Probability of survival was estimated by the Kaplan-Meier method. RESULTS: Thirty-three metastasectomies (seven redo) were carried out in 26 patients. There were 19 male and 7 female patients with a mean age of 61 years (range 34-76 years). The mean disease-free interval for hepatic and pulmonary resection was 21.8 and 23.9 months, respectively. Sternotomy, thoracotomy and video assisted thoracoscopic approach were used in 3.03, 72.7 and 24.2% of patients, respectively. Wedge excision, lobectomy and pneumonectomy were carried out in 87.87, 9.09 and 3.03% of cases, respectively. There was one hospital death following acute respiratory failure after pneumonectomy. Mean follow-up was 23.3 months (range 2-71 months). The mean survival after last pulmonary resection was 34.7 months (SE 3.03 and 95% CI of 28.8-40.6). CONCLUSIONS: Our results support aggressive surgical management of pulmonary and hepatic metastases in colorectal cancer.

Video-assisted thoracoscopic surgical excision of paravertebral neurogenic tumour manifesting with unilateral facial and upper limb anhydrosis.

A 21-year-old man presented with a recent onset history of tingling and numbness of his left upper limb. He also had a 3 year history of anhydrosis affecting the left half of his face and left upper limb. Clinical and Doppler assessment did not reveal any vascular cause for his symptoms. However, a chest roentgenogram revealed a smooth mediastinal-based shadow in the left upper zone. Further imaging revealed a well-rounded left upper paravertebral tumour with cystic areas. There was no evidence of intraspinal extension. He underwent a video-assisted thoracoscopic surgical (VATS) excision of the tumour. Following this, he made an uneventful recovery.

Recurrence of stage I thymoma in sternum, 13 years after "complete" excision.

Recurrence after complete excision of non-invasive thymoma is infrequent. We report a case of recurrent thymoma in the sternum in a 76-year-old man 13 years after complete surgical resection of stage I thymoma.

Swallow syncope associated with paroxysmal atrial fibrillation.

Swallow or deglutition syncope is a very unusual potentially lethal but treatable disorder. We report the case of a 26-year-old woman, who presented with a history of recurrent, multiple fainting episodes precipitated by swallowing. Twenty-four-hour manometry and pH recording together with continuous 24-h ECG monitoring revealed multiple episodes of symptomatic and asymptomatic paroxysmal atrial fibrillation, and significant gastro-oesophageal reflux associated with swallowing. Oesophageal function tests and continuous electrocardiographic evaluation is important in the diagnosis of this rare condition.