Primary melanotic schwannoma with typical histology

We present a case of a 17-year male with a soft tissue density spreading from the neural foramina [T3] of the spinal cord and involving the right upper thoracic cavity. We managed the patient through surgical intervention and resected the complete tumor. Gross definition and microscopic findings of the resected tissue revealed the definitive diagnosis of melanotic schwannoma. The histological characteristics in this case were very specific and harbour an important diagnostic clue for this rare disease. Malignant melanoma was ruled out on the basis of histological findings. The patient recovered completely and was healthy on one-year follow-up

Simultaneous off-pump coronary artery bypass grafting [CABG] and right upper lobectomy for critical left anterior descending artery [LAD] stenosis and aspergilloma

58 years old man with a history of ischemic heart disease presented with massive hemoptysis. On evaluation with CT chest, he was found to have a large aspergilloma in the left upper lobe. Coronary angiogram was also performed for increasing episodes of angina which showed critical 100% ostial left anterior descending [LAD] stenosis. In view of aspergilloma and hemoptysis, patient could not have conventional open heart surgery and heparinization. Therefore, coronary artery bypass grafting [CABG] was performed on beating heart and this was followed by left upper lobectomy at the same time. Patient had an uneventful post-operative course

Delayed presentation of forgotten thyroid goiter - 25 years after thyroidectomy

Forgotten goiter is a rare occurrence [2 - 16% of retrosternal thyroid cases] that depicts recurrence of retrosternal thyroid mass due to growth of remnant thyroid tissue overlooked during an initial thyroidectomy. The patient is a 59-year female who presented with dyspnea and stridor 25 years after total thyroidectomy. She was diagnosed as having a mediastinal mass on radiographic imaging. There were only localized pressure symptoms due to mass effect. The mass was excised employing an extra-cervical approach and using a partial sternotomy. The profuse extension of thyroid tissue, adherent to vital structures in the thorax and the extra-cervical thyroidectomy was a novel experience. The mass was completely excised and the patients symptoms alleviated after the surgery. The patient recovered without any complications and there was no recurrence at 1 year of follow-up

Mitral valve replacement in systemic lupus erythematosus associated Libman-Sacks endocarditis

Libman-Sacks endocarditis, first discovered in 1924, is a cardiac manifestation of systemic lupus erythematosus [SLE]. Valvular involvement has been associated with SLE and antiphospholipid syndrome [APS]. Mitral valve, especially its posterior leaflet, is most commonly involved. We report a case of a 34 year old woman with antiphospholipid antibody syndrome and SLE, who presented with mitral valve regurgitation. The patient underwent a prosthetic mitral valve replacement, with no followup complications. We suggest mechanical valve replacement employment in the management of mitral regurgitation in Libman- Sacks endocarditis, in view of the recent medical literature and our own case report

Outcomes of surgical management of tracheobronchial injuries---a case series from a developing country / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>Tracheobronchial injuries are defined as injuries involving the trachea and/or bronchi from the level of the cricoid cartilage extending up to the division of the bronchi. We present a case series with most of the tracheobronchial injuries found to be sustained after penetrating trauma.</p><p><b>METHODS</b>A retrospective review was performed at the Aga Khan University, Karachi, Pakistan. From January 2004 to December 2009, 168 patients with thoracic trauma were treated, of whom 15 were recognized to have major tracheobronchial and pulmonary injuries.</p><p><b>RESULTS</b>The average age was 31 years with most of the patients being male (14:1). Among them,11 patients had penetrating trauma as the main cause of injury, 3 patients had blunt trauma from road traffic accidents, only 1 patient had combined trauma (blunt and penetrating trauma). Eight patients were diagnosed based on radiological findings. All the patients were treated surgically. Lobectomy was the most common intervention performed in 7 patients. The mortality rate was 7% (1 patient). Most patients survived with no sequelae (10 patients) while 5 survived with disability. We found that penetrating trauma was the leading cause of injury in our series. The severity of injury depends upon the weapon causing the trauma. Patients in our series had multiple injuries and required surgical management.</p><p><b>CONCLUSIONS</b>Tracheobronchial injuries are rare but potentially life threatening. They require quick diagnosis and management. Diagnosis tends to be difficult since there are no specialised diagnostic modalities available at present.</p>

Cardiac surgery in octogenarians

In Europe and North America, cardiac surgery can be done successfully on octogenarians, but differences in patient selection, surgical and bypass techniques prevent us from concluding similarly in Pakistan. This study investigated the short and long-term outcomes of cardiac surgery in octogenarians operated over a 5 years period at The Aga Khan University Hospital, from January 2001 to December 2006. Seventeen octogenarians, [mean age 81.7 +/- 2.3] underwent coronary artery bypass graft [CABG]. Thirty-days hospital mortality was reported in only 1 patient. Surgical complication of any kind was reported in 13 [76.5%] patients with pleural effusion being the commonest in hospital complication seen in 11 [64.7%] patients. About 13 [92.9%] patients were satisfied with the results of the surgery and reported post-surgery improvement in quality of their life. Cardiac surgery has an important role in the management of elderly patients with medically refractory cardiac symptoms, but the implications of widespread cardiac surgery in the elderly need to be addressed

Acute traumatic subclavian artery thrombosis and its successful repair via resection and end-to-end anastomosis / 中华创伤杂志(英文版)

Subclavian artery thrombosis is a rare complication of clavicle fractures. We reported a 20-year-old man who was admitted to the emergency room after a road traffic accident. He was a pedestrian who was initially hit by a bus and after he fell down on the road, he was run over by a car. On evaluation, he was found to have multiple facial and rib fractures, distal right humerus and right clavicle fracture. Significantly, right radial pulse was absent. After further evaluation including Doppler studies and an angiography which revealed complete obstruction of right subclavian artery just distal to its 1st portion, the patient was urgently taken to the operation room. A midclavicular fracture was adjacent to the injured vessel. We established proximal and distal control, removed damaged part. After mobilizing the subclavian artery, an end-to-end anastomosis was made. Then open reduction and internal fixation of right distal humerus was performed. The rest of the postoperative course was unremarkable. To prevent complications of subclavian artery thrombosis, different treatment modalities can be used, including anticoagulation therapy, angioplasty, stenting and bypass procedures.

Dilemma in the diagnosis of mediastinal adenopathy in the south Asian population-role of CT guided biopsy, mediastinoscopy and video-assisted thoracoscopy [VATS]

The diagnosis of mediastinal adenopathy is a dilemma amongst treating physicians especially in South Asia. This is because although tuberculosis is endemic in this region, many a times lymphoma and sarcoidosis cannot be excluded. Often patients are being treated with medications without a confirmed diagnosis. The Video-assisted thoracoscopy [VATS] has revolutionized the way mediastinal adenopathy is diagnosed and managed in this part of the world

Successful treatment of early postinfarction massive ventricular septal rupture and cardiogenic shock

A 65 years old woman presented to the ER with vomiting and severe retro-sternal chest pain for twelve hours. She was extremely dyspneic with a respiratory rate of 32/min, heart rate of 120/min, blood pressure of 70/50 mmHg and 02 saturations of 91% on 15 liters by face mask. She had bilateral crepitations upto mid lung zones bilaterally and had pan systolic murmur and had cool extremities with no pedal pulses. ECG showed massive anterior ST elevation myocardial infarction. An emergent echocardiography showed dilated right ventricle, and a large ventricular septal rupture anteriorly with severely reduced LV function. Patient was intubated, taken to the cardiac catheterization lab. An IABP was placed and on angiography large ventricular septal rupture was identified along with complete LAD occlusion. Median sternotomy was performed and patient was placed on cardiopulmonary bypass. The anterior infracted portion was excised and large anterior VSD was identified. The edges were debrided and then a large 7.5 cm defect in the anterior interventricular septum was identified. A Dacron patch was sewn along the edges of the VSD with interrupted plegeteted ethibond sutures and then the free wall of the LV and RV were brought together with plegeted prolene sutures; thus sandwitching the patch and closing the ventricular free wall also. LAD was grafted with a vein graft. IABP was removed after 48 hours and the patient was extubated. The rest of the hospital stay was unremarkable and patient was discharged home in 10 days

Tracheal injury due to blunt chest trauma: a rare surgical emergency

Tracheal injury is a rare complication of blunt chest trauma. The patients usually present with signs of respiratory distress. Primary repair is the treatment of choice in case of large defects, while small tears can be managed conservatively. Immediate operation is recommended to improve deteriorating pulmonary function. The decrease in mortality and long-term morbidity depends on early diagnosis. We report a case of tracheal injury due to non-penetrating thoracic trauma which was successfully managed with surgery

Solitary pulmonary nodule

The management of solitary pulmonary nodules varies greatly among physicians. The goal of the evaluation and management of the solitary pulmonary nodule is straightforward and two- fold: to identify a solitary pulmonary nodule which is malignant so that it can be removed surgically and to avoid thoracotomy in patients with a benign nodule