Acquired tracheo-esophageal fistula in adult-a classical case of 'what not to do'.

Acquired tracheo-esophageal fistulas (TEFs) are challenging. The most common causes are prolonged intubation, malignancy, and trauma whereas granulomatous infections like tuberculosis are rare. Endoscopic intervention with esophageal or tracheal stenting or clipping is of unproven benefit in the management of such lesions, where surgical repair is almost invariably required. We report a case of a 32-year-old man, with a case of multidrug-resistant pulmonary tuberculosis. He had no history of malignancy or trauma. The patient developed spontaneous TEF probably due to mediastinal lymph node necrosis. Multiple attempts were made using staplers, clips, and atrial septal defect (ASD) device closure but were unsuccessful. The nuanced complication leads to very individualized course of treatment which was optimal for this patient.

Technique of lung retraction during internal mammary artery harvesting.

We describe a novel technique for lung retraction during dissection of the internal mammary artery for its use in coronary artery bypass grafting. The lung is retracted using the blades of the Octopus (Medtronic Inc, Minneapolis, MN) suction stabilizer, without the suction connected. This technique can be used when the internal mammary artery is harvested by widely opening the pleura or by the extrapleural approach. This technique makes mammary artery dissection easy, and it can be used for harvesting internal mammary arteries bilaterally. The method described is simple, causes no impairment in gas exchange, and offers no additional expense, because the same stabilizer would be used later for the off-pump coronary artery bypass surgery.