Left innominate vein wrapping with Dacron sheath after thymectomy.

BACKGROUND: Any type of radical thymectomy, open or thoracoscopic, always results in a skeletonized left innominate vein (LIV), which is highly expected to form adhesions to the posterior surface of the sternum. Therefore, in case of future sternotomy, the LIV remains highly exposed to trauma. METHODS: We describe a surgical technique that is expected to protect the innominate vein in case of future sternotomy. RESULTS: Our technique is not technically demanding, is easily reproducible, can be applied in both open and thoracoscopic procedures and does not significantly prolong the overall duration or cost of the procedure. CONCLUSIONS: Our alternative is the only protective measure for the left innominate vein that can be applied in the first operation and in our opinion should be a standard part of the procedure.

Surgical Management of Non-small Cell Lung Cancer with Solitary Hematogenous Metastases.

BACKGROUND/AIM: The treatment of patients with solitary hematogenous metastases from non-small cell lung cancer (NSCLC) remains controversial, although numerous retrospective studies have reported favorable results for patients offered combined surgical therapy. Our aim was to determine the role of surgical resection in the management of NSCLC with solitary extrapulmonary metastases and to investigate for possible prognostic factors. PATIENTS AND METHODS: Between January 2004 and December 2012, 12 patients with NSCLC, from two Institutions, underwent metastasectomy for their solitary metastatic lesion. Sites of metastases included brain (n=3), adrenal gland (n=6), thoracic wall (n=2) and diaphragm (n=1). All patients had undergone pulmonary resections for their primary NSCLC. RESULTS: Median survival for the entire cohort was 24.1 months, whereas 1- and 5-year survival rates were 73% and 39%, respectively. Patients with stage III intrathoracic disease had significantly worse survival than those with lower tumor stage. A tendency for adenocarcinomatous histology to positively affect survival was recognized, although it was proven not to be statistically significant. CONCLUSION: Despite the retrospective nature of our study and the small cohort size, it is emerging that combined surgical resection might offer patients with NSCLC with solitary hematogenous metastases a survival benefit. Limited intrathoracic disease and adenocarcinomatous histology might be associated with better outcomes.

Stage-II thymoma and emergency coronary artery bypass. To irradiate or not to irradiate to avoid radiation induced vascular injury? Case report and literature review.

PURPOSE: The purpose of this study was to present the controversial role of adjuvant radiotherapy to a 72-year-old male patient with Masaoka stage II thymoma and coronary artery bypass and to review the relevant literature. METHODS: The data were collected by relevant studies on PubMed and EMBASE. Articles up to March 2017 were included. RESULTS: Although the radiation-induced vascular injury to the internal thoracic artery and its suitability for grafting in a patient who is candidate for coronary artery bypass is documented, the possible catastrophic effect of adjuvant radiotherapy to existing grafts in a patient with prior bypass surgery has not been fully investigated. CONCLUSION: The application of radiotherapy in a patient with R0 stage II thymoma is currently considered of 2B level of evidence but its potential occlusive effect to an underlying coronary graft may dramatically affect the survival of the patient and accordingly drop the level of evidence of its use.

Sternotomy following minimally invasive thoracoscopic procedures: a word of caution.

An increasing number of patients with previous minimally invasive thoracic procedures for anterior mediastinal tumors are now requiring cardiac surgery. This paper highlights the potential damage that can occur when standard sternal splitting techniques are used in these patients.

"Directed" cardioplegia: a new approach in myocardial protection in left main coronary artery disease.

"Directed cardioplegia" is a novel approach in myocardial protection in which a certain volume of cardioplegic solution is diverted into a severely diseased coronary artery after surgical occlusion of the other main branches that can be accessed by the surgeon. In this way, the surgeon is able to eliminate the cardioplegic steal from a severely stenosed vessel through other less severely diseased and/or patent arteries during the nonselective antegrade administration of cardioplegia and to protect myocardial regions, which are poorly perfused. We performed this new technique in 2 patients with severe left main coronary artery disease with excellent results.

WITHDRAWN: Tropical plant needle: cause of unknown recurrent tamponade.

This article has been withdrawn consistent with Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). The Publisher apologizes for any inconvenience this may cause.

Heparin induced thrombocytopenia diagnosis in cardiac surgery: is there a role for thromboelastography?

The aim of the present protocol is to investigate the potency of thromboelastography (TEG) to screen postcardiac heparin induced thrombocytopenia (HIT) patients suspicious for HIT type II, and to differentiate which of them are subject to suffer thrombotic complications from those who will suffer hemorrhagic complications.

Can thromboelastography predict which patients with heparin-induced thrombocytopenia may suffer thrombotic complications of type II?

Despite the existence of several sensitive functional and antigen assays used for the diagnosis of heparin-induced thrombocytopenia (HIT), an additional assessment of the patient's hemostatic status, in order to predict the thrombotic complications of the malevolent HIT type II, has become necessary. Herein below, we present the findings of thromboelastography (TEG) in a post-cardiac-surgery patient with the clinical diagnosis of HIT type II and false negative tests for heparin antibodies. We have reached the conclusion that TEG may prove to be a useful supplementary method to predict those HIT patients who may suffer complications of HIT type II.

Retrograde cardioplegia in CABG: is it really useful? The microcirculation and a capillary unit model.

Most surgeons, ourselves including, use retrograde cardioplegia in numerable operations in cardiac surgery. It is believed to be not only supplementary to antegrade, but also a unique alternative in special complicated cases. Regarding CABGs (coronary artery bypass grafts), many authors advocate its routine use together with antegrade, while others do not suggest it for standard practice. The existing disagreement on this special item is consequential to the different results among various protocols which have studied the effect of antegrade and retrograde perfusion. In these studies, fundamental variations in design, materials, and methods have resulted in an inability to compare results. Additionally, most of the published protocols studying cardioplegic arrest offer only a gross estimation of the microcirculatory perfusion, which is the basis of myocardial protection. Our present review is an attempt to elucidate the differences, explain the necessity of comparing retrograde cardioplegia alone with antegrade in CABGs for the reproduction of safe results, clarify the role of Thebesian veins and venovenous connections during retroperfusion, consider the critical anatomic differences between human hearts and those of animals which may result in serious study bias, and, finally, offer an explanation of what may really be going on in the microcirculation during antegrade and retrograde perfusion using a human capillary model.

A huge posteromedial mediastinal cyst complicated with vertebral dislodgment.

BACKGROUND: Mediastinal cysts compromise almost 20% of all mediastinal masses with bronchogenic subtype accounting for 60% of all cystic lesions. Although compression of adjoining soft tissues is usual, spinal complications and neurological symptoms are outmost rare and tend to characterize almost exclusively the neuroenteric cysts. CASE PRESENTATION: A young patient with intermittent, dull pain in his back and free medical history presented in the orthopaedic department of our hospital. There, the initial clinical and radiologic evaluation revealed a mediastinal mass and the patient was referred to the thoracic surgery department for further exploration. The following computed tomography (CT) and magnetic resonance imaging (MRI) shown a huge mediastinal cyst compressing the T4-T6 vertebral bodies. The neurological symptoms of the patient were attributed to this specific pathology due to the complete agreement between the location of the cyst and the nervous rule area of the compressed thoracic vertebrae. Despite our strongly suggestions for surgery the patient denied any treatment. CONCLUSION: In controversy with the common faith that the spine plays the role of the natural barrier to the further expansion of cystic lesions, our case clearly indicates that, exceptionally, mediastinal cysts may cause severe vertebral complications. Therefore, early excision should be considered especially in young patients or where close follow up is uncertain.

Spontaneous rupture of the colon sigmoid following spontaneous recurrent pneumothorax in a patient with Marfan syndrome.

BACKGROUND: Spontaneous ruptures of the colon and rectum are very rare clinical entities and always require laparotomy. In such cases, despite meticulous exploration an underlying pathology cannot be revealed and most reports in the world literature relate spontaneous colon ruptures with unusual connective tissue disorders such as Marfan or Ehlers-Danlos syndrome. Connective tissue diseases affect the structure and the synthesis of elastin and type III collagen, resulting in various systemic disorders. Among the several pulmonary manifestations, spontaneous pneumothorax is observed in about 5% of patients expressing one of the above syndromes. CASE REPORT: In the following report we present a unique case of spontaneous rupture of the sigmoid colon secondary to spontaneous recurrent contralateral pneumothorax. CONCLUSIONS: The aim of this presentation is to raise the level of suspicion in every surgeon and gastroenterologist to include connective tissue disorders in their differential diagnosis in any case of spontaneous colon rupture and, if found, to follow further diagnostic procedures in anticipation of any other visceral complications.

Sigmoid schwannoma: a rare case.

Schwannomas are rare tumors derived from the cells of Schwann that form the neural sheath. When located in the gastrointestinal tract, they constitute together with leiomyoma, leiomyoblastoma, and leiomyosarcoma, the gastrointestinal stromal tumors (GIST). Peripheral nerve sheath tumors represent 2-6% GIST with most common location, the stomach and the small intestine. Schwannomas of the colon and rectum are extremely rare and radical excision with wide margins is mandatory, due to their tendency to recur locally and become malignant, if left untreated. In the present study, we report a rare case of a sigmoid schwannoma, which was successfully treated in our department and reviewed the literature.

Treatment of iatrogenic injury of membranous trachea with intercostal muscle flap.

Iatrogenic injuries of the membranous trachea are rare but potentially lethal, and most commonly require surgical treatment. Such injuries occur intraoperatively during specific thoracic surgery procedures or are associated with endotracheal anesthesia. Special technical difficulties in managing them surgically are encountered when lacerations are in proximity to the rigid rings of the trachea because of the lack of membranous tissue distal to the tear. We describe our technique used in a patient with such an iatrogenic tracheal injury during resection of invasive lung carcinoma.

The effect of nitric oxide synthases inhibitors on inflammatory bowel disease in a rat model.

BACKGROUND/AIMS: Overexpression of nitric oxide (NO) has been implicated in the pathogenesis of experimental and clinical inflammatory bowel disease (IBD). NO is produced by two types of enzymes: constitutively expressed and inducible NO synthases (NOS). This study assessed N(W)-nitro-L-arginine methyl ester (L-NAME) and aminoguanidine (AMG), the most studied inhibitors of nitric oxide synthases, with regard to their effectiveness as modulators of inflammation in trinitrobenzene sulfonic acid (TNBS)-induced colitis in the rat. MATERIALS AND METHODS: Colitis was induced in Wistar rats. The colitis was treated everyday for 10 days with L-NAME and AMG. To assess the severity of the colitis, clinical (body weight), hematological (hematocrit and erythrocytes sedimentation rate-ESR) and morphological (gross and microscopic) criteria were used. RESULTS: The administration of both nitric oxide synthases inhibitors L-NAME and AMG proved to be beneficial in all the examined parameters compared with the control group. A statistically significant difference between the L-NAME and the AMG groups was observed only in macroscopic and histological grading. CONCLUSION: NOS inhibitors may be promising agents in preventing the onset, or mediating the symptoms, of inflammatory bowel disease.