High Output Chylous Fistula Post First Rib Resection.

We present a patient who developed high output chyle leak post left first-rib resection for neurogenic thoracic outlet syndrome. The persistent high output chylorrhea was refractory to 3 surgical reexplorations attempting to ligate leaking branches, bed rest, nonfat diet, parenteral nutrition, octreotide administration, and vacuum-assisted closure (VAC) therapy. In addition, she developed hypovolemia, hyponatremia, and hypoalbuminemia. Control of the chylous fistula was achieved by reattaching the sternocleidomastoid muscle laterally to protect the phrenic nerve and brachial plexus in order to redirect chyle to the medial portion of the neck incision site. This was supported by the application of fibrin sealants in combination with VAC therapy. The patient was discharged after a 27-day hospital stay with complete resolution of her chylous fistula prior to discharge.

Single-session catheter-directed lysis using adjunctive power-pulse spray with AngioJet for the treatment of acute massive and submassive pulmonary embolism.

OBJECTIVE: An alternative single-session catheter-directed thrombolysis (CDT) method using adjunctive power-pulse spray (PPS) technique (with the AngioJet system; Boston Scientific, Fremont, Calif) was investigated to evaluate its safety and effectiveness in the treatment of acute massive and submassive high-risk pulmonary embolism (PE). METHODS: Between May 2016 and July 2018, patients diagnosed with extensive massive or submassive PE who triggered intensive care unit involvement and were considered for escalation of treatment were offered CDT with adjunctive PPS technique, provided they met the clinical inclusion criteria. Clinical success was defined as stabilization of hemodynamic parameters, resolution of hypoxia, and survival to discharge. In addition, reversal of right ventricular (RV) failure and pulmonary artery hypertension was evaluated after 24 to 48 hours using echocardiography. After 4 weeks, echocardiography was repeated to check for reversal of RV failure and pulmonary artery hypertension. In addition, computed tomography pulmonary angiography was performed to check for residual thrombus. Functional capacity was also re-evaluated at the follow-up consultation. RESULTS: During the study period, 575 inpatients were diagnosed with PE at The Wollongong Hospital. Of these patients, 32 (5.6%) were referred for escalation of treatment, met the inclusion criteria, and received treatment with the CDT and PPS technique. These patients were classified as having massive (23 [71.9%]) or submassive (9 [28.1%]) PE. Technical success was achieved in all 32 patients, and 31 patients survived to discharge (96.9%). There were no major or minor adverse events and no procedure-related complications. Improvement of RV strain and pulmonary hypertension was achieved in all survivors within 48 hours of the intervention. Furthermore, all echocardiograms completed at 4 weeks after discharge were reported normal. Results from computed tomography pulmonary angiography 4 weeks after discharge demonstrated complete resolution of thrombus in 79.3% of patients, and the remaining 20.7% had only minor residual thrombus reported. In addition, 82.8% of patients reported a return to premorbid exercise tolerance by the time of postoperative consultation with the treating physician (mean follow-up, 6.7 weeks). CONCLUSIONS: This initial series indicates that single-session CDT with adjunctive PPS technique using the AngioJet system is safe and effective in treating massive and submassive acute PE. It appears to offer several potential advantages compared with current options, allowing safer and faster thrombus resolution. Multicenter prospective trials are required to validate these findings.

The effect of guanylate cyclase inhibitors on non-adrenergic and non-cholinergic neurogenic relaxations of the South American opossum lower esophageal sphincter.

South American (SA) opossum lower esophageal sphincter (LES) circular smooth muscle relaxes by activation of enteric nerves elicited by EFS (electrical field stimulation, 0.5 ms, 48 V, 0.5-8 Hz for 10 s). The identity of the mediator released and the cellular mechanism, however, remain to be fully elucidated. The purpose of this study was to determine the effect of the enzyme soluble guanylate cyclase (cGC) inhibitors, cystamine (100 microM), methylene blue (30 microM), LY 83583 (6-anilino-5,8 quinoledione, 10 microM) and ODQ (H-[1,2,4]oxadiazolo[4,3]quinoxalin-1-one, 1 microM) on the relaxations induced by EFS and by exogenous NO (nitric oxide, 0.5 mM) or NO-donors on SA opossum LES smooth muscle strips. EFS caused frequency-dependent relaxations, which were inhibited by NO-synthase inhibitors and abolished by tetrodotoxin. Cystamine did not affect relaxations caused by EFS and NO or NO-donor. Methylene blue also failed to affect EFS-caused relaxations, although it was capable of inhibiting relaxation induced by NO. LY 83583 inhibited relaxations induced by NO, but did not affect those induced by EFS or by SNAP and HXA. ODQ abolished relaxations caused by EFS at lower frequencies and by HXA (hydroxylamine, 10 microM) and SNAP (S-nitroso-N-acetyl penicillamine, 10 microM). Relaxations at higher frequencies of EFS and induced by SNP (sodium nitroprusside, 30 microM) and NO were only reduced by ODQ. These findings indicate that activation of the cGC can be involved in relaxations induced by EFS at lower frequencies, but other mechanisms can be involved at higher frequencies of EFS and caused by SNP or NO.