Asymptomatic fatal post-lobectomy hemopericardium.

We report a case of an asymptomatic post-lobectomy hemopericardium in a female who died suddenly at day two post surgery. Autopsy revealed no pathologic findings, but 250 ml of blood and clots in the pericardium and a non-significant injury to the epicardial fat overlying the circumflex artery territory.

Primary pulmonary melanoma diagnosis: the role of immunohistochemistry and immunocytochemistry.

We report a rare case of a primary melanoma of the lung initially presenting with haemoptysis, which was diagnosed using 2 new immunohistochemistry markers and cytology with immunocytochemistry. A 67-year-old male underwent repeated major lung resections and died because of early recurrences of a primary pulmonary melanoma as detailed study excluded other primary foci. The diagnosis of the patient's last recurrence was achieved on a fine needle aspiration (FNA) specimen with immunocytochemistry. To the best of our knowledge this is the first case of primary pulmonary melanoma diagnosed by immunocytochemistry on FNA material.

Evaluation of a wireless ingestible temperature probe in cardiac surgery.

OBJECTIVES: CorTemp is a wireless intestinal temperature monitoring system in the form of an ingestible pill and an external receiver. The aim of the study was to evaluate the system's accuracy and practicality during cardiac surgery. METHODS: A repeat measures design using simultaneous temperature readings from the pulmonary artery (T (pa)), a nasopharyngeal thermometer (T (np)), skin thermometers (T (sk)) and the CorTemp system (T (in)), was conducted in 15 patients undergoing elective cardiac surgery under hypothermic conditions. RESULTS: Only 67 % of patients' data was analysed and the statistical analysis of a total of 264 sets of readings showed a clinically significant temperature difference of T (in) compared to the other thermometers with limits of agreement between T (in) and T (pa), T (np) and T (sk) (+/- 0.35 to +/- 1.53 degrees C), (+/- 0.72 to +/- 1.63 degrees C) (+/- 0.40 to +/- 1.84 degrees C), respectively. The T (in) bias was significantly different from that of T (pa) ( P = 0.0023), T (np) ( P = 0.018) and T (sk) ( P = 0.0005) during rewarming. The T (in) rate of temperature change was also found to be significantly slower during the rewarming period. CONCLUSIONS: The significant temperature differences detected during rewarming urge caution regarding CorTemp use as an accurate estimator of brain temperature in cardiac surgery. Further studies are required to assess its potentially useful role as a body core and intestinal temperature monitoring system and as a useful adjunct in investigating bowel ischaemia aetiology in cardiac surgery.

Are the perioperative changes of serum magnesium in lung surgery arrhythmiogenic?

PURPOSE: To prospectively study the perioperative changes in serum magnesium (sMg) after major lung resections and their effect to the generation of cardiac dysrhythmias, and to present a brief review of the literature surrounding this phenomenon. PATIENTS AND METHODS: We studied 33 patients with non small cell lung cancer (NSCLC), scheduled for major pulmonary resection. Three patients were excluded from the study due to preoperative medication with beta-blocker and calcium (Ca) antagonists. Pneumonectomy was performed in 10 patients and lobectomy in 20. Heparinized arterial blood samples for the assessment of sMg, potassium (K) and Ca concentration were obtained before surgery, on arrival to the High Dependency Unit (HDU), and on the morning of the first and the second postoperative day. No patient had evidence of cardiac disease. RESULTS: Atrial fibrillation occurred in 3 (10%) patients. There was no statistically significant association between sMg and dysrhythmias. A statistically significant difference after adjusting for age was found between sMg concentration, just after the operation and the first post-operative day and the baseline measurement (before the operation). The type of surgical procedure was not found to be associated with the sMg concentration or the appearance of dysrhythmia. The serum K and Ca concentration for all samples was within normal range. CONCLUSION: Serum concentration of Mg decreases significantly within the first 24 hours of major lung resection. Although our study didn't demonstrate a relationship between decreases in sMg and the generation of arrhythmias, this link is well established in other fields and thus we support the prophylactic MgSO(4) administration in their prevention in such cases whilst we await further larger studies.

The prevalence of congenital bronchial atresia in males.

BACKGROUND: Congenital bronchial atresia is a rare anomaly, which usually occurs in adulthood as an incidental finding on routine chest radiograph. METHODS: The purpose of the study was to retrospectively evaluate the cases that were diagnosed in our hospital, from January 1995 to March 2003, to estimate the prevalence of this disorder and to determine the diagnostic studies of choice, according to the existing literature. Since the main portion of the male population of our country is referred to our hospital for screening soon after their enrollment in the army, epidemiological data can be easily estimated for many congenital anomalies occuring in adulthood, such as bronchial atresia. RESULTS: We found seven patients with Congenital Bronchial Atresia and the prevalence of this disorder was estimated at 1.2 cases per 100,000 in males. The chosen diagnostic procedure is computed tomography of the chest with high-resolution scans. Bronchoscopy would only exclude serious alternative diagnosis and prevent unnecessary surgical interventions. CONCLUSIONS: Congenital bronchial atresia is a rare anomaly, with a mild clinical course. The diagnosis is made radiologically, the HRCT of the chest being the procedure of choice. Bronchoscopy should be performed to exclude any endobronchial lesion due to a different disease entity and to prevent unnecessary surgical intervention in an otherwise asymptomatic individual.

Diagnostic mini-video assisted thoracic surgery. Effectiveness and accuracy of new generation 2.0 mm instruments.

OBJECTIVE: Recently 2.0 mm mini-VATS has aroused much interest among surgeons involved with endoscopic surgery. We report our initial experience with the first first 54 patients who underwent this procedure. The aim of this study is to evaluate the effectiveness and accuracy of mini-VATS. METHODS: 54 patients were undertaken to mini-VATS for diagnostic purposes. Patients were randomly selected and the indication for operation was set by the classic VATS criteria. 35 (65%) patients were treated under general anesthesia, while 19 (35%) patients were treated under local anesthesia. RESULTS: The average length of hospital stay was 1.8 +/- 0.9 days. The days of requirement for narcotic analgesia were 1.9 +/- 1.0. Diagnostic accuracy was 100%; morbidity and mortality rates were 0%. CONCLUSIONS: The high diagnostic accuracy and low operative danger, combined with less postoperative pain, due to minor surgical trauma and faster patient recovery, has established mini-VATS as a dynamic competitor to the classic VATS procedure. Since high technology is a strong partner in endoscopic surgery, a strong potentiality for evolution exists.

The role of mediastinoscopy in postresection lung cancer patients.

PURPOSE: To emphasize the role of mediastinoscopy in the evaluation of mediastinal lymphadenopathy in postresection lung cancer patients. PATIENTS AND METHODS: During the period 1997-1999, 11 patients who had a previous lobectomy or bilobectomy and mediastinal lymph node dissection for primary lung cancer underwent cervical mediastinoscopy for the evaluation and tissue diagnosis of mediastinal lymphadenopathy, discovered at planned, part of the follow-up,computed tomography (CT) of the chest. Five patients had received postoperative adjuvant radiation therapy and/or chemotherapy. RESULTS: Nodal metastasis was histologically confirmed in 9 patients who subsequently received a combination of chemotherapy and radiation therapy, with a mean survival of 8.1 months. Two patients had no evidence of lymph node metastasis and remain alive and disease-free 21 and 27 months after mediastinoscopy, without any additional therapy. CONCLUSION: Cervical mediastinoscopy, after a previously performed mediastinal lymph node dissection, is a special condition. However, it is the method of choice for the evaluation of the nature of mediastinal lymphadenopathy in postresection lung cancer patients. The alternative way of repeat thoracic CT at frequent intervals and the lymph node size enlargement criterion should be preserved for patients with a previous pneumonectomy or those who cannot tolerate additional radiation therapy or chemotherapy.

Wedge resection of the bronchus: an alternative bronchoplastic technique for preservation of lung tissue.

OBJECTIVES: We present a modified wedge resection of the bronchus, as an alternative bronchoplastic technique for lung resection, in cases of patients with or without adequate pulmonary reserve to undergo a pneumonectomy, in order to preserve lung tissue. METHODS: Seventeen patients underwent a major lung resection with wedge resection of the bronchus for non-small cell lung cancer (NSCLC) in our department, from March 1995 to October 1999. A right-sided NSCLC were diagnosed in 17 males, with a mean age 62.5+/-6.6 (range 51-72) years. Further workup was free of metastatic disease. All patients underwent a right posterolateral thoracotomy, under general anesthesia with a double lumen endotracheal tube. Twelve right upper lobectomies, four right upper and middle lobectomies and one carinal resection were performed. The wedge resection of the bronchus carried out longitudinally, along the bronchial tree, and the bronchial defect was reapproximated transversely, in a single-layer, with interrupted non-absorbable suture. The frozen section of the distal margin of the resected bronchus was negative for malignancy in all patients. Extended mediastinal lymph node dissection followed each lung resection. RESULTS: The pathology report showed 12 squamous-cell carcinomas, three adenocarcinomas, one adenosquamous carcinoma and one neuroendocrine carcinoma. The differentiation of the carcinomas was well in two cases, moderate in ten and poor in five. The pTNM stage was IB in four patients (23.5%), IIA in one (5.9%), IIB in eight (47.1%) and IIIA in four (23.5%). The median disease-free distal margin of the bronchus was 5 mm (range 2-15 mm). The average postoperative hospital stay was 15 days (range 12-28 days). The morbidity and mortality rate was 11.8 and 5.9%, respectively. Postoperative follow-up was every 6 months. The average survival is 20.0+/-15.2 months (range 1-54 months). There are 12 patients alive, and their follow-up is negative for locoregional recurrence or distant metastasis. The survival study showed no significantly statistic relation to the histologic type, cancer differentiation, pTNM stage, and disease-free distal margin of resection larger or less than 0.5 cm (Kaplan-Meier study log rank method). CONCLUSIONS: The wedge resection of the bronchus as a bronchoplastic procedure is an easy, fast and safe technique of reparation of the bronchial tree. It presents not only a low rate of morbidity and mortality, but also a satisfactory survival.

Prognostic significance of pleural lavage cytology after resection for non-small cell lung cancer.

OBJECTIVE: In the staging of lung cancer, pleural effusion that is malignant on cytologic examination is regarded as T4 disease, and curative resection cannot be performed. We conducted this study to determine whether cancer cells can be present in the pleural cavity with no pleural effusion, to investigate the factors contributing to that occurrence, and to evaluate its prognostic significance. METHODS: Eighty-five patients (77 males, eight females) with a median age 60.1-+/--7.9 years (31--74 years) underwent a major lung resection, due to lung cancer in our department. From January 1998 to December 1999, 30 pneumonectomies, seven bilobectomies, 46 lobectomies and two wedge-resections were performed. Chest wall resection was performed in four patients. After performing a posterolateral thoracotomy and lung resection with extended mediastinal lymph node dissection, the pleural cavity was filled with 1 l physiologic saline solution (PSS) and the fluid was shaken. The lavage fluid was suctioned off (S1). Immediately after the lavage, the pleural cavity was refilled with 3 l PSS. The surgeon washed out the pleural cavity by hand for 1 min and the fluid was suctioned off. Finally, the pleural cavity was refilled with 1 l PSS and a new lavage fluid was suctioned off (S2). A cytologic examination was carried out for each sample. RESULTS: The pathology report showed 39 adenocarcinomas, 33 squamous-cell, two adenosquamous, four large-cell, two neuroendocrine and five undifferentiated carcinomas. S1 was positive in eight patients (9.4%), while S2 was positive in four patients (4.7%). The correlation of positive pleural lavage and infiltrated lymph nodes demonstrated a statistically significant relation between presence of N2 disease and positive S2 sample (P = 0.049). No significant correlation existed between positive lavage sample (S1 or S2) and TNM stage, level of T, extent of tumor invasion, kind of operation, histological type or differentiation of the cancer (Chi square test). The mean follow-up is 11.3 +/- 6.2 months (4--22 months). There are 78 patients alive. A significance difference in survival was identified in-patients with positive S1 (P = 0.0081), and positive S2 (P = 0.0251) (Kaplan--Meier). CONCLUSION: The cytologic results of lavage were positive for malignant cells in eight of 85 patients (9.4%). The existence of cancer cells in the pleural cavity can be the result of their exfoliation or surgical manipulations. The mechanical irrigation subdivides the percentage of positive samples. Our study supports that the positive findings on pleural lavage cytology is an essential prognostic factor.

Acute pulmonary embolism due to multiple hydatid cysts.

A case of acute pulmonary embolism due to multiple hydatid cysts is reported. Chest X-ray, echocardiography, spiral CT scan and MR-angiography were performed for the diagnostic evaluation. The patient underwent a left anterior thoracotomy and a left pulmonary arteriotomy in order to remove the hydatid cysts, without using extracorporeal circulation. The post-operative recovery was uneventful and the patient, 42 months later, has a normal life.

Secondary achalasia due to a mesenchymal tumour of the oesophagus.

A rare case of a secondary achalasia or pseudoachalasia due to a mesenchymal tumour of the oesophagus is presented. A 67-year-old Caucasian man had symptoms including dysphagia, odynophagia, and weight loss for 8 months. Radiological examination revealed no signs of neoplasia but an exploratory laparotomy revealed the presence of a mesenchymal tumour of the oesophagus. Tucker's criteria constitute an important tool in the differential diagnosis of secondary achalasia from primary achalasia with clinical value, but in this case, exploratory laparotomy rather than non-invasive diagnostic procedures provided the final and definite diagnosis.

Congenital bronchoesophageal fistula in the adult.

Congenital bronchoesophageal fistulas, when not associated with esophageal atresia, are compatible with life and may persist until adulthood before diagnosis has been established. We report such a rare case of a 55-year-old Caucasian female with a history of repeated pulmonary infections, suffering from cough during the last 12 months due to a mass in the right lung. A bronchoesophageal fistula (type III according to Braimbridge and Keith classification) was incidentally discovered during thoracotomy which was resected and end-sutured. Following that, a right lower lobectomy was performed. The patient had an uneventful recovery. The final diagnosis of congenital bronchoesophageal fistula was established excluding all the reasons that lead to the acquired disease. The diagnostic and therapeutic procedures are analyzed and the relevant literature is reviewed.

Huge non-functioning pancreatic cystic neuroendocrine tumour: a case report.

A case of an 18-cm large cystic, non-functioning endocrine (islet cell) tumour located at the tail of the pancreas in a 29-year-old Caucasian female is reported here. Pre-operative radioimmunoassays for pancreatic peptides were negative, while immunohistochemistry confirmed the neuroendocrine nature of the tumour. This is the largest cystic non-functioning islet-cell tumour so far described.