Annals of thoracic surgery short reports最新文献

Background

Bronchopleural fistula (BPF) is a rare and often difficult postoperative complication to manage. This case series describes a bronchoscopic technique using a bone plug for closure of BPFs.

Methods

Six patients at Henry Ford Hospital from 2014 to 2021, who had a postoperative BPF after lung resection with curative intent for non-small cell lung cancer, underwent bronchoscopic placement of a customized bone plug.

Results

All 6 patients experienced initial resolution of the BPF after bone plug placement. Four of the 6 (66.7%) patients were inpatients, with severe pleural space infections requiring chest tube drainage; all patients clinically improved with resolution of persistent air leaks resulting in chest tube removal. Two of the 6 (33.3%) patients had BPF recurrence within 2 months, and 2 of the /6 (33.3%) patients also eventually required additional surgical repair.

Conclusions

Endobronchial placement of a customized bone plug is an option for the management of postoperative BPF.

Video-assisted thoracoscopy surgical diaphragmatic plication is the standard of care for diaphragmatic eventration. However, it is associated with complications like injuries to the bowel, liver, spleen, and lung parenchyma. We report life-threatening cardiac tamponade after Video-assisted thoracoscopy surgical diaphragmatic plication. The mechanisms contributing to the injury are described as well.

Background

Cardiac surgery patients are at increased risk for venous thromboembolism (VTE). Prevention is the most critical strategy to reduce VTE-associated morbidity and death. However, there is a lack of data on the optimal approach to VTE prophylaxis in this population of high-risk patients. This study aimed to assess whether the standard dose of enoxaparin, the subcutaneous injection of 40 mg of enoxaparin daily, achieves adequate anti–factor Xa (aFXa) levels for VTE prophylaxis in patients after open heart surgery.

Methods

All patients with open heart surgery with cardiopulmonary bypass from August to December 2022 who received at least 3 consecutive doses of subcutaneously administered enoxaparin were included in the study. Patients receiving therapeutic anticoagulation, patients who underwent cardiac transplantation or placement of ventricular assist device, and patients with renal insufficiency were excluded. Serum aFXa was measured 0.5 to 1 hour before the fourth dose to attain the steady-state trough levels.

Results

Data were completed for 44 patients. The target aFXa level was between 0.10 and 0.20 IU/mL for the avoidance of both underanticoagulation (≤0.10 IU/mL) and overanticoagulation (>0.20 IU/mL). The mean was 0.049 IU/mL with SD of 0.026 IU/mL, which was statistically significantly lower than the lower end of the target aFXa values (0.10 IU/mL; t₄₃ = −13; P < .001; d = −1.9; 99% CI, −0.059 to −0.043).

Conclusions

The daily subcutaneous administration of 40 mg of enoxaparin leads to subprophylactic aFXa levels for most patients who undergo cardiac surgery. Further studies on the clinical relevance are warranted.

Background

Intraoperative molecular imaging (IMI) uses a cancer-targeted fluorescent agent injected into patients to localize tumor nodules. Pafolacianine is a folate receptor (FR)–targeted near-infrared fluorescent probe. Almost 10% of patients have false negative fluorescence findings intraoperatively. We hypothesized that tumor histology explains why lung cancer may not fluoresce.

Methods

Adenocarcinoma (AC) (A549, LKR) and squamous cell carcinoma (SCC) (H127, H1264) cell lines were stained with pafolacianine. Near-infrared fluorescent microscopy was used to quantify mean fluorescence intensity. Tissue microarray slides of patients with AC and SCC were evaluated by immunohistochemistry for FR alpha (FRα) and beta (FRβ) expression. Finally, we retrospectively analyzed IMI data from clinical trials of patients with AC and SCC receiving pafolacianine.

Results

AC (intensity 30.31) cell lines have a higher fluorescence intensity than SCC cell lines (intensity 5.4) (P < .001). On slide analysis, 93.8% of ACs expressed FRα compared with 44.4% of SCCs (P = .002). Finally, there were 326 patients enrolled in clinical trials: 211 had lesions localized in vivo, and 134 of these patients had pure AC or SCC. All 9 patients with SCC have a positive smoking history and a mean pack-year of 60.2 (SD 3,6), whereas 76% of patients with AC have a history of smoking and a mean pack-year of 29.3 (P = .02). The odds ratio for fluorescence of (AC/SCC) was 2.05 (P = .004) and 2.01 (P = .02) on univariate and multivariate logistic regression, respectively.

Conclusions

During IMI with pafolacianine, a nonfluorescent nodule is more likely to be SCC than AC. AC has a high probability of fluorescing because of higher expression of FRα or FRβ, or both.

Background

The study focuses on vascular compression of the main bronchus in the aortopulmonary space, examining potential contributors within the same axial plane. Its goal is to uncover mechanisms of bronchial compression in patients with intracardiac anomalies and review surgical outcomes, aiming to enhance future results.

Methods

The morphology and topology of structures within the axial plane of the aortopulmonary space were objectively analyzed, including the sternum, ascending aorta, heart, pulmonary artery, descending aorta, and other relevant elements. Identified deviations from the normal configuration were systematically identified. Operative procedures included mobilizing and removing the compressing vessel, followed by suspending the airway wall to a rigid prosthesis (external stenting), vertebra, or ascending aorta.

Results

Computed tomography revealed potential factors contributing to bronchial stenosis, including anteriorly deviated descending aorta (20 patients), dilated pulmonary artery (6), cardiomegaly (12), flat chest (7), funnel chest (3), posteriorly deviated ascending aorta after arterial switch operation (3), low aortic arch (3), and aberrant subclavian artery (2). Kaplan-Meier analysis demonstrated operative survival rates of 96% at 1 year, 87% at 5 years, and 80% at 8-15 years. Ten-year follow-up computed tomography after external stenting procedure revealed the narrowest diameter of the stented bronchus as 94.4% of the reference.

Conclusions

Consistent long-term airway patency was observed post-surgery. While the pulmonary artery and descending aorta exert direct compressive effects in most cases, various other potential mechanisms may contribute to bronchial compression. Identifying and addressing these factors through a multidisciplinary approach is crucial for sustaining bronchial patency and preventing complications.

Background

This study aimed to investigate the diagnostic performance of combined computed tomography (CT) and fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) for predicting histologic invasiveness of pure ground-glass nodules (pGGNs).

Methods

The study analyzed 91 patients who underwent resection of pGGNs and examined the correlation of pathologic invasiveness with preoperative CT and FDG PET findings.

Results

Overall, 24, 36, and 31 patients had adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), and invasive adenocarcinoma (IAD), respectively. Compared with AIS and MIA, IAD was significantly correlated with larger CT size (P = .001), maximum CT value (P = .026), and high maximum standardized uptake value (SUVmax; P < .001). Multivariable logistic analyses revealed that CT size (odds ratio [OR], 3.848; P = .019) and SUVmax (OR, 4.968; P = .009) were independent predictors of histologic invasiveness. Receiver operating characteristic curve analysis revealed that a cutoff CT size value of 18 mm predicted histologic invasiveness with a sensitivity and specificity of 65% and 80%, respectively; similarly, a cutoff SUVmax value of 1.5 predicted histologic invasiveness with a sensitivity and specificity of 61% and 90%, respectively. Of 20 lesions with CT size ≥18 mm and SUVmax ≥1.5, 16 (80%) were IAD. Of 54 lesions with CT size <18 mm and SUVmax <1.5, 46 (85%) were non-IAD lesions. Furthermore, all pGGNs with SUVmax ≥2.5 were IAD.

Conclusions

CT size and SUVmax were significantly correlated with the histologic invasiveness of pGGNs. These factors may aid in determining optimal surgical procedures.

Esophageal carcinoma cuniculatum is a rare histology and can be difficult to diagnose prior to resection. To date, there have been 28 cases of resected esophageal carcinoma cuniculatum reported. Herein we describe a case found in the stomach of a patient who previously underwent a Roux-en-Y gastric bypass surgery. We report the preoperative, intraoperative, and postprocedural care. We review gross and histologic pathology.

Background

Continuous retrograde flow across the aortic valve from left ventricular assist device (LVAD) therapy can result in cusp damage and progressive aortic regurgitation, potentially triggering recurrent heart and multiorgan failure. The management of aortic regurgitation after LVAD implantation has not been well defined.

Methods

This study retrospectively reviewed the investigators’ experience with the management of de novo aortic regurgitation requiring intervention in patients with continuous-flow LVAD.

Results

Six patients who had undergone LVAD implantation and who required intervention were identified. Two patients underwent redo sternotomy with bioprosthetic aortic valve replacement, and 4 patients underwent percutaneous management, including Amplatzer device (Abbott) placement and transcatheter aortic valve replacement. All patients had resolution of aortic regurgitation with improved hemodynamics and relief from heart failure. One early and 2 late deaths occurred. Valve function was intact, with all valves opening intermittently without greater than trivial aortic regurgitation.

Conclusions

Multiple treatment modalities exist for LVAD-induced aortic valve regurgitation, including open surgical and percutaneous strategies. With a tailored risk-adjusted approach, acceptable results may be achieved.

Pleural extension of pseudomyxoma peritonei is rare, and treatment demands multidisciplinary care. Perioperative management during cytoreductive surgery and hyperthermic intrathoracic chemotherapy challenges anesthesiology and surgical teams in unique ways. Hemodynamic, arrhythmogenic, ventilatory, fluid balance, acid-base, and nephroprotection issues are important considerations. The use of cytoreductive surgery and hyperthermic intrathoracic chemotherapy for extraperitoneal pseudomyxoma peritonei is an innovative and potentially curative approach. Here, we describe our approach to managing these patients.

Among repairs for ventriculoarterial discordance, ventricular septal defect, and pulmonary stenosis, aortic root translocation (Nikaidoh operation) offers the most anatomic result. With a diminutive pulmonary annulus or hypoplastic left ventricular outflow tract, the distance gained posteriorly with aortic translocation is negligible. We developed the “hemi-Nikaidoh” procedure as an alternative. Geometric shift is achieved by mobilizing the anterior two-thirds of the aortic root, and posterior aortic translocation is performed by plicating the left ventricular outflow tract without dividing the conus. The right ventricular outflow tract is reconstructed with an orthotopic conduit. Herein, we describe the hemi-Nikaidoh operation.