Surgical treatment of primary aortojejunal fistula.

INTRODUCTION: Primary aortoenteric fistula is a rare clinical situation with a high mortality rate. One should suspect that condition when an abdominal aortic aneurysm is known to be present. We describe the case of a 60 year old man who presented with upper gastrointestinal bleeding as the first and sole manifestation of an abdominal aortic aneurysm, due to the rupture of the aneurysm in the jejunum. PRESENTATION OF CASE: The patient was admitted with hematemesis and melena. He reported no abdominal pain. Upper gastrointestinal endoscopy disclosed no bleeding or lesions of the stomach and duodenum. Bleeding stopped the following day, only to recur 4 days later. The patient was then subjected to abdominal CT scan, which revealed the presence of a subrenal aortic aneurysm, with fistulization to the small intestine. At laparotomy the aortic aneurysm was adherent to the first centimeters of jejunum. The diseased aorta was excised and replaced with a Dacron Y graft in situ. DISCUSSION: Primary aortojejunal fistulas are only rarely encountered. They usually are the result of a nonspecific aneurysm of the abdominal aorta. They usually manifest with premonitory bleeding, followed by catastrophic hemorrhage few days later. Even with surgery the mortality rate is high. CONCLUSION: Diagnosis of primary aortoenteric fistula requires a high index of suspicion in cases of upper gastrointestinal bleeding, especially when endoscopy is negative and there is no knowledge of the existence of an abdominal aortic aneurysm. CT scan and prompt surgery are crucial to the survival of these patients.

Pericardial window procedures: Implications on left ventricular function.

INTRODUCTION: Pericardial window procedures are generally designed to relieve pericardial fluid pressure on the heart, in cases of cardiac tamponade, and to restore the hemodynamic stability of the patient. Rarely, however, may acute left ventricular failure develop after creation of a pericardial window. PRESENTATION OF CASE: We describe a patient in whom that complication developed. We are trying to give an insight to the pathophysiology, existence of potential predisposing factors, as well as to propose therapeutic measures. DISCUSSION: Acute heart failure, developing after pericardiocentesis or surgical creation of a pericardial window is an unusual complication, with several theories developed to explain that paradox. CONCLUSION: Treatment is supportive, but that complication of pericardial window procedures may carry a high mortality rate.

"Near total" pneumonectomy: Is it feasible?

INTRODUCTION: There are various procedures for treating lung cancer. Segmentectomy, wedge excision, lobectomy (including bilobectomy) and pneumonectomy are the operations used to resect malignant lung tumors. We describe an operation of near total pneumonectomy for the first time in the literature. PRESENTATION OF CASE: A 55 year old man with borderline respiratory function was subjected to a right upper and middle lobectomy and stapled excision of the superior segment of the right lower lobe for a right upper lobe mass invading the major fissure. DISCUSSION: When operating on patients with borderline respiratory function one should always consider conservation of as much lung tissue as possible without compromising cancer clearance. CONCLUSION: From the case we present, it is obvious that the remaining lung basilar segments, combined with creation of an apical pleural tent, may well function properly and add benefit to the respiratory function of such compromised patients. We believe that this operation of near total pneumonectomy may have a role in lung cancer surgery.

A rare case of a giant cavernous lymphangioma of the chest wall and axilla in an adult patient.

INTRODUCTION: Lymphangiomas are benign lesions that are most commonly encountered in the neck of small infants, but are quite uncommon in the adult population. Their removal can be quite difficult, when they reach enormous dimensions or they develop in critical locations. Complete resection is curative, but incomplete resections entail the risk of relapse. Lymphangiomas of the chest wall are quite rare. PRESENTATION OF CASE: We report a case of a 35-year old man with a giant cavernous lymphangioma of the right lateral chest wall extending into the axilla, which was removed en bloc. DISCUSSION: These tumors of lymphatic origin tend to grow, as is the case in our patient, but they also tend to recur if not resected completely. Clinical examination and chest CT scan may provide a clue to the diagnosis. CONCLUSION: Lymphangiomas of the thoracic wall are extremely rare lesions and wide resection is recommended due to the high recurrence rate of these benign lesions.

Successful pleurodesis for refractory chylothorax due to chronic lymphocytic leukemia.

INTRODUCTION: Chylothorax is a very rare complication of chronic lymphocytic leukemia. PRESENTATION OF CASE: We describe the case of an 83-year old woman with chronic lymphocytic leukemia, complicated by recurrent chylothorax and ultimately treated by pleurodesis with bleomycin. DISCUSSION: There are several options for management of patients presenting with chylothorax due to chronic lymphocytic leukemia. CONCLUSION: Pleurodesis is a reasonable and effective treatment modality for patients with refractory chylothorax.

Left main bronchus foreign body masquerading as diaphragmatic hernia in an adult patient.

OBJECTIVE: Foreign body aspiration is quite uncommon in the adults. It can be a life-threatening situation and it often requires a high index of suspicion, because the diagnosis can be obscure. PRESENTATION OF CASE: We present a case of food aspiration by a 31-year old female patient, masquerading as diaphragmatic hernia, for the first time in the literature. DISCUSSION: Foreign body aspiration may escape diagnosis, especially if there is no recollection of the episode. CONCLUSION: The thoracic surgeon may be suspicious of this condition, even if the patient history and imaging obscure the clinical picture.

Simultaneous bilateral carotid endarterectomy under local anesthesia.

A 75-year-old man with bilateral carotid stenosis and severe coronary artery disease underwent successful simultaneous bilateral carotid endarterectomy under local anesthesia. A few days later, coronary artery bypass grafting was performed with no complications.