Infected port-a-cath leading to subpectoral and sterno-manubrial abscess.

Sterno-manubrium and subpectoral abscess have been rarely reported in literature. If the diagnosis and treatment are not properly performed, a soft tissue abscess can cause serious complications such as sepsis or even death. Therefore, awareness of such conditions is essential for early diagnosis and prompt treatment. Here, we report a case of sterno-manubrial and subpectoral abscess with significant destruction of cartilage due to extension from an infected subclavian porta-a-cath. Our management started with intravenous antibiotic therapy initially; however, due to lack of clinical resolution, incision and drainage followed by serial debridements were performed, highlighting importance of awareness of uncommon presentation.

Surgical management of locally invasive basaloid carcinoma of thymic gland.

Thymic basaloid carcinoma is an extremely rare thymic tumor variant, and the most common presentations have been an incidental finding on a routine chest X-ray and dyspnea on exertion. Given its rarity, no treatment modalities have been demonstrated to improve survival. This rare case describes a patient with locally advanced thymic basaloid carcinoma treated by en bloc resection of phrenic nerve and left upper lobe with the tumor followed by adjuvant radiation therapy. Patient had no respiratory complaints at 10 months follow-up, and 10-month post-operative surveillance radiological study showed no objective sign of tumor recurrence.

External iliac artery dissection secondary to endofibrosis in a cyclist.

Endofibrosis of the external iliac artery is an uncommon disease affecting primarily young, otherwise healthy, endurance athletes. Thigh pain during maximal exercise with quick resolution postexercise is characteristic of the so-called cyclist's iliac syndrome. We report an unusual case in which the typical endofibrotic plaque was accompanied by dissection of the external iliac artery. The patient was treated surgically with excision of the affected artery segment and placement of an interposition graft. This case highlights an unusual finding in association with external iliac artery endofibrosis and provides an opportunity to briefly review the literature on the subject.

Isolated Left Lower Lobe Pleuroparenchymal Fibroelastosis Presenting as Hemothorax.

Characterized by pleural and subpleural fibrosis with alveolar septal elastosis, pleuroparenchymal fibroelastosis is a rare restrictive lung disease. Symptoms are often subtle, including dyspnea, cough, and weight loss; while acute presentations of spontaneous pneumothorax have been recorded. We report a patient who developed a spontaneous hemothorax, who upon evacuation of the chest was found to have a hemorrhagic lower lobe mass consistent with pleuroparenchymal fibroelastosis. Various conditions are associated with pleuroparenchymal fibroelastosis, suggesting chronic lung injury as a factor in pathogenesis. Hemothorax of this magnitude with relatively no known inciting risk factors, represents an exceptionally rare case presentation.

Predictors of electrocardiographic change, cardiac troponin elevation, and survival after major vascular surgery: a community hospital experience.

Cardiovascular disease is the leading cause of perioperative morbidity and mortality after vascular surgery. The purpose of this study was to identify risk factors for myocardial ischemia after vascular surgery and to investigate a potential association of ischemia with mortality in a community hospital setting. A retrospective review was conducted after 190 major vascular procedures. Electrocardiogram (ECG) results and troponin I levels were obtained serially during the first 24 postoperative hours. Outcomes analyzed were ischemic ECG changes, troponin I level more than 2 ng/mL, 6-month mortality, and overall survival. The authors investigated any association of these outcomes with each other and the type of operation, history of coronary artery disease, diabetes, recent coronary intervention, age older than 70 years, or postoperative symptoms. Twenty-seven (14%) patients experienced ischemic ECG changes. Twenty-one (11%) patients experienced troponin I elevation. Univariate analysis revealed a history of coronary artery disease, diabetes, concerning symptoms, and troponin elevation to be predictive of ECG change (P < 0.05). ECG change and symptoms were predictive of troponin elevation (P < 0.01). Cox multivariate analysis revealed only infrainguinal bypass to predict 6-month mortality (odds ratio = 2.92, P = 0.02). Diabetes was the sole predictor of overall mortality (odds ratio = 1.94, P = 0.001). Nonsustained ischemic postoperative ECG changes during the first 24 postoperative hours do not independently influence 6-month or overall mortality after major vascular surgery. Postoperative troponin elevation likely conveys a mortality risk in the subsequent 6 months. In the community hospital setting, midterm survival rates after vascular surgery equivalent to those in higher volume centers can be achieved. Patients undergoing infrainguinal bypass and diabetics continue to be the most moribund vasculopaths.

Intrathoracic gallstones: a case report and literature review.

BACKGROUND: Laparoscopic cholecystectomy is one of the most commonly performed procedures in general surgery. There have been very few reported thoracic complications from this surgical procedure. METHODS: We report the case of a patient who underwent a laparoscopic cholecystectomy with gallstone spillage 34 months before presenting to the thoracic surgery service. The patient first complained of streaks of hemoptysis at 6 months from the time of the original procedure. A lower lobe infiltrate was noted and treated successfully with oral antibiotics. Over the next 2 years, the patient's symptoms waxed and waned. RESULTS: Due to the chronic infiltrate in his lung, a thoracotomy was performed that revealed erosion of the stone through the right diaphragm with formation of a lung abscess. CONCLUSION: A high index of suspicion for a gallstone-related problem should be entertained by the practitioner when presented with a patient who has a right lung infiltrate and a history of open or laparoscopic cholecystectomy.

Aberrant right hepatic artery in laparoscopic cholecystectomy.

INTRODUCTION: Presented herein is a case in which an aberrant right hepatic artery (RHA) passes anterior to the infundibulum and fundus of the gallbladder and courses to an unusually anterior hepatic entry. CASE REPORT: A 54-year-old female with a history of biliary colic was scheduled for laparoscopic cholecystectomy. Laparoscopic dissection revealed an aberrant right hepatic artery (RHA) anterior to the infundibulum and fundus of the gallbladder. Further dissection revealed the cystic artery to branch laterally off this RHA over the gallbladder fundus anteriorly. The cystic artery then wrapped posterolaterally on the gallbladder's surface to its neck. After the gallbladder was removed, the aberrant RHA was readily visible traveling across the gallbladder bed and entering the liver at an unusually anterior location. Intraoperative images are included. The procedure was completed laparoscopically without complication. DISCUSSION: The origins and paths of both the cystic and right hepatic arteries have several documented anomalies. We are unaware of any reports of an RHA that transverses the entire neck and fundus of the gallbladder before such an anterior hepatic entry. CONCLUSION: This case serves as a striking reminder of the variations in extrahepatic biliary and vascular anatomy. Ligation of this uniquely located aberrant RHA could have led to intraoperative hemorrhage or potential hepatic ischemia.

A novel technique for creation of adjustable pneumoperitoneum.

Creation of a pneumoperitoneum has been demonstrated to be a useful maneuver to help eliminate postresection spaces and air leaks. However, a single instillation of air intraoperatively may not be adequate, and postoperative transabdominal administration of air is uncomfortable and potentially hazardous to the patient. We describe a simple technique that allows repeated administration of pneumoperitoneum and even provides the ability to adjust the amount of air within the abdomen. Our technique is performed at the time of the initial pulmonary resection and enables easy postoperative management of an adjustable pneumoperitoneum.

Anterior access to the lumbar spine: laparoscopic versus open.

The purpose of this study is to investigate the potential advantages and complications of a minimally invasive laparoscopic approach for anterior spinal exposure as compared with the open technique and to quantify differences in operative time, blood loss, transfusion requirements, analgesia, and morbidity. A retrospective review was performed on all patients undergoing access for anterior spinal procedures. Demographics, operation-related variables, complications, and estimated cost were analyzed. Categorical data were analyzed using the Fisher's exact test and continuous variables were analyzed with the Mann-Whitney U test. We performed a total of 65 anterior spinal access procedures between February 1997 and April 2001 at our institution. Forty-five operations were performed at the L5-S1 level: 31 using transperitoneal laparoscopic techniques and 14 using an open minilaparotomy. Mean follow-up was 12 months (range 1-50). No significant differences between the groups were found when comparing analgesia requirements, time to resumption of oral intake, length of hospitalization, and complication rates. Statistical analysis showed that laparoscopic procedures were associated with shorter operating room times (P = 0.08) and less intraoperative blood loss (P = 0.029). The laparoscopic approach was estimated to cost $1,374 more than the open technique. Transperitoneal laparoscopic techniques for anterior spinal exposure are comparable to the standard open approach and offer no substantive advantages. The overall cost of laparoscopic spinal surgery is higher compared with conventional open procedures.

Percutaneous biopsy in evaluation of lung nodules.

Management of an indeterminate pulmonary nodule is a diagnostic challenge that commonly confronts primary care physicians and specialists. Patients often present with this radiographic finding in the course of an unrelated medical evaluation. We examined our institution's experience with percutaneous biopsy of lung nodules to determine the impact of this procedure on overall patient care. Although significant complications are uncommon, the expedience of percutaneous lung biopsy often supplants a surgical opinion prior to initiation of therapy without added diagnostic benefit or cost-savings. Hence, we caution practitioners to use this technique as an adjunct to diagnosis and not a substitute for multidisciplinary care.

Cardiac morphology in lung volume reduction surgery for endstage emphysema.

Lung volume reduction surgery for endstage emphysema produces significant improvements in various pulmonary parameters, but its effects on cardiac morphology and function have not been clearly defined. Ten patients scheduled for lung volume reduction surgery underwent pulmonary function testing, right-heart catheterization, and electron beam computed tomography of the heart. These studies were repeated 12-16 weeks after the procedure. Quantitative assessments of right and left ventricular function and left ventricular muscle mass were obtained. Postoperatively, all patients showed significant improvements in forced expiratory volume at one minute compared to the preoperative value (1.57 +/- 0.24 L versus 1.10 +/- 0.21 L), predicted residual lung volume (115% +/- 15% versus 205% +/- 15%), and 6-minute walk test (318 +/- 17 m versus 267 +/- 24 m). There were no significant differences between postoperative and preoperative right ventricular end-diastolic volumes (167.3 +/- 21.2 mL versus 169.2 +/- 17.3 mL) or left ventricular end-diastolic volumes (112.5 +/- 10.2 mL versus 119.2 +/- 9.7 mL).

Thoracoscopic transillumination in chest wall resection.

Determining the extent of chest wall resection during en bloc lung cancer operations is often difficult secondary to the location of these tumors. We describe a hybrid technique that employs video-thoracoscopy and chest wall transillumination to determine the appropriate margin of resection.

Morcellized Omental Transfer for Severe HIV Facial Wasting.

BACKGROUND: A novel surgical technique to reconstruct facial wasting was developed for patients with severe human immunodeficiency virus lipoatrophy and no source of subcutaneous fat for donor material. Fourteen patients underwent endoscopic harvest of omentum, extracorporeal morcellation, and autologous transfer to the face. METHODS: Omental fat was harvested using a standard 3-port laparoscopic technique. A mechanical tissue processor created morsels suitable for transfer. Gold-plated, multi-holed catheters delivered living particulate fat to the subcutaneous planes of the buccal, malar, lateral cheek, and temporal regions. Results were evaluated using standardized pre- and postoperative photographs for specific anatomic criteria found along the typical progression of the disease process. RESULTS: Electron microscopy confirmed that morcellized fat retained intact cell walls and was appropriate for autologous transfer. Complications were minor and transient. Patients were discharged home within 24 hours. No patient required open laparotomy. Survival of the adipose grafts was deemed good to excellent in 13 of the 14 cases. CONCLUSIONS: Mechanically morcellized omental fat transfer provides a safe option to restore facial volume in those unusual patients with severe wasting and no available subcutaneous tissue for transfer. Consistent anatomic progression of facial wasting permits preoperative classification, counseling of patients, and postoperative evaluation of surgical improvement.

Unusual metastatic patterns of invasive lobular carcinoma of the breast.

Invasive lobular carcinoma of the breast has similar patterns of metastatic disease when compared to invasive ductal carcinoma; however, lobular carcinoma metastasizes to unusual sites more frequently. We present a 65-year-old female with a history of invasive lobular breast carcinoma (T3N3M0) treated with modified radical mastectomy and aromatase-inhibitor therapy who underwent a surveillance PET scan, which showed possible sigmoid cancer. Colonoscopy with biopsy revealed a 3 cm sigmoid adenocarcinoma. The patient underwent a lower anterior resection. Pathology showed an ulcerated, invasive moderately differentiated adenocarcinoma extending into but not through the muscularis propria. However, six of seventeen paracolonic lymph nodes were positive for metastatic breast carcinoma (ER+/PR+), consistent with her lobular primary breast carcinoma; there was no evidence of metastatic colon cancer. This case highlights the unusual metastatic patterns of lobular carcinoma.

In situ aortic thrombosis secondary to intra-abdominal abscess.

BACKGROUND: Abdominal aortic mural thrombus is uncommon in the absence of aneurysm or atherosclerosis. CASE REPORT: We report the case of a 46-year-old man who presented to our institution with perforated appendicitis for which he initially declined surgery. Four days after admission he ultimately consented to appendectomy and abdominal washout. Follow-up imaging to evaluate for intra-abdominal abscess revealed mural thrombus of the infra-renal abdominal aorta extending into the left iliac artery. This thrombus was not present on the admission CT scan. The patient had no clinical signs of limb ischemia. Conservative treatment with therapeutic anticoagulation resulted in resolution of the thrombus. CONCLUSIONS: While portal, mesenteric, and major retroperitoneal venous thrombosis are well associated with major intra-abdominal infection and inflammatory bowel disease, aorto-iliac arterial thrombus formation in the absence of associated aneurysm, atherosclerosis or embolic source is exceedingly rare. We are unaware of other reports of in-situ aorto-iliac arterial thrombus formation secondary to perforated appendicitis.

Spontaneous rupture of a saccular intrahepatic artery aneurysm.

Hepatic artery aneurysms are the second most common visceral aneurysm but are still relatively uncommon. Over the last century, methods for treating these lesions have evolved substantially. The presented case covers the presentation, diagnosis, and treatment of a 65-year-old woman with an aneurysm of the intrahepatic portion of the hepatic artery. This case demonstrates the variety of techniques available for managing these lesions and the importance of both a thorough knowledge of the available treatments and the flexibility to switch among them when necessary.