R0 resection and reconstruction for a large, rapidly progressive chest wall sarcoma.

BACKGROUND: Chest wall sarcomas are a rare group of soft tissue malignancies with variable presentations. Here we describe the definitive management of a large, rapidly progressing chest wall sarcoma arising from the pectoralis major muscle. CASE REPORT: An obese 42-year-old African American male with multiple medical comorbidities presented with new onset right-sided chest pain and a palpable right chest mass. Initial CT chest demonstrated a 9x9x9cm necrotic mass arising from the pectoralis major. CT-guided core biopsy was positive for high-grade spindle cell neoplasm (positive for smooth muscle actin, desmin, S100, and CD31; negative for CD34, PAX8, and beta-catenin). Staging imaging 2 months later demonstrated growth of the mass to 21.4 × 17.8 × 13.7 cm. The patient underwent neoadjuvant chemoradiation with surveillance CT imaging demonstrating a stable tumor. Then he underwent wide local excision of the mass followed by delayed local myocutaneous flap reconstruction and skin grafting. Final pathology was R0 resection, 38x20x18 cm tumor with 70% gross necrosis. Microscopic examination confirmed high-grade sarcoma with smooth muscle differentiation. Final pathologic staging was Stage III G3 pT2bNxMx. CONCLUSIONS: This patient presented with a rare, rapidly enlarging high-grade leiomyosarcoma of the chest wall without metastases or violation of the thorax. We describe the definitive management including a multidisciplinary team to manage a complex and rapidly progressive sarcoma of the chest wall.

A 33-Year-Old Woman With a Fluorodeoxyglucose-Avid Left Lower Lobe Mass.

A 33-year-old woman of Latin American origin was referred to our department by her primary care physician for a left lower lobe mass, which was incidentally found on a CT scan of her abdomen. The patient had complaints of abdominal pain for which she underwent imaging of her abdomen. Review of systems was negative for any respiratory complaints, and she denied any history of cigarette smoking or recreational drug use.

Operative Intercostal Nerve Blocks With Long-Acting Bupivacaine Liposome for Pain Control After Thoracotomy.

BACKGROUND: Postthoracotomy pain is quite intense. Epidural analgesia (EPI) has long been the gold standard but is often associated with hypotension and urinary retention. The recent availability of liposomal bupivacaine formulation (Exparel) stimulated us to use it for multilevel intercostal nerve blocks (IB) injected during open thoracotomy. METHODS: We reviewed the records of 85 patients who had open thoracotomies for lung, pleural, or mediastinal pathologies between March 2010 and December 2013. Clinical variables; pain score; supplemental narcotic utilization on day 1, 2, and 3; postoperative pulmonary complications; and hospital length of stay were compared in the 2 groups. RESULTS: In all, 53 patients in the IB group had similar clinical data compared to 32 in the EPI group. There were statistically significant lower mean pain scores on days 1 and 3, but no significant difference in pain score on day 2. Supplemental narcotic utilization was not different between the 2 groups. There was a significant decrease in pulmonary complications in the IB group (4 of 53) compared to the EPI group (8 of 32).The total length of hospital stay was 7.4 days in the IB group versus 9.3 days in EPI group (p < 0.05). CONCLUSIONS: It appears that intraoperative IB with bupivacaine liposome at 6 levels during thoracotomy provided significantly better pain control in postoperative days 1 and 3, compared to EPI in this retrospective study. This technique is simple, safe, and reproducible. It does not require epidural space invasion, infusion pumps, or another service to comanage the postoperative pain therapy.

Integrated cerebral perfusion for hypothermic circulatory arrest during transverse aortic arch repairs.

OBJECTIVES: Antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) for ascending/transverse arch repair is used for cerebral protection. This study evaluates ACP in combination with retrograde cerebral perfusion (RCP) during extended HCA and compares it to RCP-only. METHODS: Between January 2005 and April 2007, we performed 64 consecutive arch repairs requiring extended HCA (>40 min). RCP-only was used with 34 patients and ACP with brief RCP ('integrated') was used with 30 patients. Mean HCA time was 51 + or - 13 min. Mean RCP-only time was 47 + or - 9.6 min; in the integrated group, mean ACP time was 42 + or - 14.4 min with an added RCP time of 10.8 + or - 7.6 min. For the entire cohort, 95% (61/64) underwent total arch repair, and 67% (43/64) had elephant trunk reconstruction. Variables predictive of mortality and neurological outcomes were analysed prospectively, but technique selection was non-randomised. RESULTS: Preoperative and operative variables did not differ between the RCP-only and the integrated groups except for aortic valve replacement, which was more frequently performed in the integrated group (33% (10/30) vs 12% (4/34), P=0.05), and preoperative renal dysfunction, which was more frequent in the RCP group (26% (9/34) vs 7% (2/30), P=0.04). No significant difference was observed in outcomes between the groups; however, the integrated group had higher mortality, stroke and temporary neurological deficit than RCP-only. CONCLUSIONS: The observed trends in actual outcomes were a cause for concern. ACP combined with a short period of RCP did not provide better outcomes than RCP-only. The use of RCP remains warranted in our experience.

Repair of retrograde type a aortic dissection after thoracic endovascular aortic aneurysm repair using the modified elephant trunk technique.

We present a case of retrograde type A aortic dissection after thoracic endovascular stenting for acute type B aortic dissection. We describe the specifics of our surgical technique and provide a brief review of the literature.

Analysis of ascending and transverse aortic arch repair in octogenarians.

BACKGROUND: Increasing numbers of older patients are requiring complex thoracic aortic surgery. This retrospective study analyzed early and late outcomes after ascending and transverse arch surgery using hypothermic circulatory arrest (HCA). METHODS: Between January 1991 and December 2006, 779 patients requiring HCA were treated. Outcomes are reported by age group: group 1, 80 years or more (37, 4.8%); and group 2, less than 80 years (742, 95.2%). Univariate and multivariate analyses were used to identify risk factors for morbidity and mortality. RESULTS: Early mortality and stroke did not differ between groups. Thirty-day mortality was13.5% (5 of 37) in group 1 and 10% (78 of 742) in group 2 (p = 0.57). Stroke occurred in 8% (3 of 37) of group 1 patients and 2.7% (20 of 742) of group 2 patients (p = 0.09). Predictors of stroke were prior stroke (p = 0.003) and pump time (p = 0.02). Predictors of early mortality were low glomerular filtration rate (p = 0.0001), long cardiopulmonary bypass time (p = 0.0001), and emergent repair (p = 0.0009). Retrograde cerebral perfusion was protective against stroke (p = 0.0001) and reduced early mortality (p = 0.02). Age was not a predictor of stroke (p = 0.12) or early mortality (p = 0.39). Survival in group 1 compared with the age-matched US population at 1 year was 56% versus 86% (p = 0.02); at 2 years, 48% versus 76% (p = 0.03); at 5 years, 36% versus 48% (not significant); and at 10 years, 20% versus 20%. CONCLUSIONS: Ascending and aortic arch surgery in octogenarians involving profound HCA resulted in reasonable morbidity and short- and long-term mortality rates. The use of profound HCA for aortic surgery remains warranted in octogenarians.

Biatrial myxoma: a case report and review of the literature.

BACKGROUND: In surgical series, a majority of benign cardiac tumors are myxomas. Of these, only about 2.5% are biatrial. Only 10 cases have been reported in the last 10 years. We present here a successful case in a 51-year-old man. A brief review of the literature is presented to place this case in context. METHODS: The tumor was removed surgically via a midline sternotomy using cardiopulmonary bypass. Both left and right atrial extensions of the tumor mass were removed. The resection involved the entire septum, with a bovine patch used to reconstruct the atrial septum. RESULTS: Patient recovered uneventfully. We advised follow-up evaluation using transthoracic echocardiography annually. CONCLUSIONS: Biatrial myxoma is a very rare condition, with diagnostic challenges, but is amenable to modern surgical approaches.

Outcomes of delayed sternal closure after complex aortic surgery.

OBJECTIVE: Open chest management during complex proximal aortic surgery may sometimes be necessary. Infectious complications such as mediastinitis and late aortic graft infection remain a concern. The objective of this study was to report our experience with open chest management and delayed sternal closure after complex proximal aortic surgery. METHODS: Between 1991 and 2007, 12 patients (1.2%, 12/1011) required open chest management and delayed sternal closure. Eight patients were men (67%), with a mean age of 56 years (range 28-83 years). Four cases involved redo-median sternotomy (33%) and seven cases (58%) involved acute dissection. All procedures were performed using total cardiopulmonary bypass with profound hypothermic circulatory arrest. Reasons for open chest management included hemodynamic instability, mediastinal edema, bleeding, and respiratory compromise. RESULTS: In-hospital mortality was 16.7% (2/12). Delayed sternal closure was achieved in 92% of patients (11/12). Mean time to closure was 3 days (range 1-9 days). Five patients (42%) required one or more mediastinal explorations prior to final closure. Mean length of stay was 51 days (range 1-186 days). Significant predictors of open chest management were pump time (p<0.0001) and intra-operative blood transfusions (p<0.002). Mean follow-up was 60 months (range 8-106 months). No patients developed mediastinitis or aortic graft infection during postoperative follow-up. CONCLUSIONS: Open chest management with delayed sternal closure after complex aortic repairs may be performed with acceptable mortality. Open chest management does not appear to increase the risk of infectious complications (mediastinitis or graft infections) during complex proximal aortic replacement.