Case report on the approach to surgical management for a large chest wall chondrosarcoma.

INTRODUCTION AND IMPORTANCE: Primary chest wall tumours are uncommon. Challenges arise in management due to delays in diagnosis and timing of treatment. The mainstay of treatment remains complete resection as adjuvant therapy has a limited role. Choice of repair and materials for chest wall reconstruction vary depending on the size and location of the defect. There are no published reports on management of chondrosarcomas arising from the rib in the Caribbean. CASE PRESENTATION: A 61-year-old female was referred from a rural clinic with a 10-month history of a progressively enlarging, painless right anterior chest wall lump. Computed Tomography (CT) shows features of a conventional chondrosarcoma arising from the ribs and including surrounding soft tissue, muscle and pleura. Surgical specimen confirms a grade 2 chondrosarcoma. CLINICAL DISCUSSION: This case illustrates the importance of a multidisciplinary team discussion. Differentiating a chondrosarcoma from a benign cartilaginous tumour requires consideration of clinical features, radiological characteristics and histological features. Chest wall reconstruction aims to preserve functional and structural integrity with adequate soft tissue coverage. The patient had good cosmesis as well as pulmonary function postoperatively and no recurrence at the 3 year follow up. CONCLUSION: This case highlights that the MDT is essential to a good outcome for the surgical management of a chest wall chondrosarcoma. Wide en-bloc resection followed by reconstruction using polypropylene mesh and a latissimus dorsi flap as a one-stage procedure can be successful.

Evolution of Video Assisted Thoracoscopic Surgery in the Caribbean.

Video Assisted Thoracoscopic Surgery (VATS) has become the mainstay of thoracic procedures in developed countries. The benefits of VATS over a thoracotomy, and its equivalency in oncologic resections has been clearly established. The introduction of this minimally invasive approach to thoracic surgery to the Caribbean has been a slow progression. The main restrictions to the full implantation of VATS in the resource poor Caribbean setting has been obtaining material resources, developing the necessary human resources, and the small case loads. Each territory has adopted its own innovative approach to getting VATS programmes started. We review the current status of VATS in the English speaking Caribbean.

Practical and effective stomal sphincter creation: evaluation in pigs.

PURPOSE: Stoma creation frequently presents complications for which there is no satisfactory surgical solution. We reexamined the feasibility of managing stoma continence with an artificial sphincter, addressing the outstanding issues of geometry, electrode disposition, and fatigue resistance. METHODS: In 6 pigs, 1 rectus abdominis muscle was preconditioned with electric stimulation for 4 weeks by an implanted stimulator. A sphincter was then constructed and tested for its ability to provide continence against saline at a typical intestinal pressure. The result was compared with a sphincter fashioned from the unconditioned contralateral (control) muscle. In each case, stimulation was applied alternately to longitudinal segments. RESULTS: A 2-layered wrap was required to achieve continence. Sphincters created from the preconditioned muscles could sustain continence continuously for at least 90 minutes. CONCLUSION: This study establishes a practical approach to the creation of a sphincter from the rectus abdominis muscle in stoma patients. Continence can be achieved only with a double-layered wrap. Fatigue during long-term operation can be avoided by a combination of preconditioning and segmental stimulation of intramuscular nerve branches.

Cardiac surgery take-away kit.

BACKGROUND: Trauma to the heart is usually rapidly fatal, but survival can be improved with timely and appropriate surgical management. However, certain injuries require specialist cardiothoracic surgical intervention. METHODS: Three patients with coronary artery lacerations treated by cardiac surgeons at remote hospitals are presented. The recent literature, the current treatment options available and suggestions on techniques to improve survival are reviewed. CONCLUSIONS: Laceration of the coronary arteries is difficult to manage, especially in the absence of specialty equipment. Appropriate protocols should be established to provide this service in order to optimise the management of patients with complicated trauma. A cardiac surgical take-away kit could facilitate the management of these difficult patients in a setting remote from the cardiac operating room.

Adaptive conditioning of skeletal muscle in a large animal model (Sus domesticus).

Recognition of the adaptive capacity of mammalian skeletal muscle has opened the way to a number of clinical applications. For most of these, the fast, fatigue-susceptible fibres need to be transformed stably to fast, fatigue-resistant fibres that express the 2A myosin heavy chain isoform. The thresholds for activity-induced change are size-dependent, so although the requisite patterns of electrical stimulation are known for the rabbit, in humans these same patterns would produce type 1 fibre characteristics, with an undesirable loss of contractile speed and power. We have used histochemistry, immunohistochemistry and electrophoretic separations to evaluate a possible conditioning regime in a large animal model. Stimulation of the porcine latissimus dorsi muscle with a phasic 30-Hz pattern for up to 41 days converted all type 2X and 2A/2X fibres to 2A with only a small increase in the type 1 population, from 17% to 22%. Stimulation for longer periods increased the proportion of type 1 fibres to 52%. Based on this model, stimulation regimes designed to achieve a stable 2A phenotype in humans should deliver fewer stimulating impulses, possibly by a factor of 2, than the pattern assessed here. Any such pattern needs to be tested for at least 8 weeks.

Autologous blood transfusion for cardiopulmonary bypass: effects of storage conditions on platelet function.

OBJECTIVES: Cardiopulmonary bypass impairs formation of large stable platelet aggregates (macroaggregation), although formation of small aggregates (microaggregation) is preserved. A factor in the uncertain benefits of intraoperative autologous blood transfusion may be the effects of storage on platelet function. The effects of citrate preservative and heparinization before storage on platelet function was therefore assessed. METHODS: Twenty-seven patients undergoing elective coronary artery bypass grafting were randomly allocated to have 450 to 1,000 mL of blood taken into CPDA anticoagulant bags either before (n = 14) or after heparinization (n = 13). Samples from the patients and stored blood were anticoagulated with rhirudin, 200 U/mL. The macroaggregatory response to submaximal collagen was measured by impedance aggregometry and microaggregation by single platelet counting. RESULTS: During macroaggregation, before cardiopulmonary bypass, the ex vivo median (interquartile range) response was 16.3 (12.4-18.7) Omega. This decreased 10 minutes after heparin to 8.9 (3.3-11.0) Omega (p < 0.0001). In the blood bags (in vitro), the initial response for nonheparinized blood was 4.8 (0.1-7.5) Omega (p < 0.002 v ex vivo) and at end-cardiopulmonary bypass was 2.4 (1.6-8.2) Omega. During microaggregation, in vivo heparinization decreased microaggregation both ex vivo and in vitro in CPDA blood; the in vitro response of nonheparinized blood at end-cardiopulmonary bypass was greater than that seen after in vivo heparinization (p < 0.007). No difference in bleeding or transfusion requirements was seen. CONCLUSIONS: Collecting blood into CPDA anticoagulant caused a marked deterioration in platelet function. This was worse after in vivo heparinization and included depression of microaggregation.

Counterpulsation from the skeletal muscle ventricle and the intraaortic balloon pump in the normal and failing circulations.

BACKGROUND: The intra-aortic balloon pump (IABP) is the device that is in most common use to provide cardiovascular support. A skeletal muscle ventricle (SMV) was configured to produce counterpulsation in the thoracic aorta similar to that obtained with an IABP. The hemodynamic effects of an IABP and a SMV in the same animal and in both normal and failing circulations were assessed. METHODS AND RESULTS: SMVs were connected to and IABPs were placed in the thoracic aorta of 12 anesthetized pigs. Hemodynamic parameters during the IABP- or the SMV-assisted beat were compared with those during the preassist beat. Acute heart failure was induced in 6 of the pigs by snaring the left anterior descending coronary artery (LAD). The hemodynamic effects of the IABP and the SMV were then reassessed. In the assisted cycles, SMV activation increased the mean aortic diastolic pressure (MADP) by 26.5+/-3.5%, the mean diastolic LAD flow by 48.4+/-7.2%, and endocardial viability ratio (EVR) by 31.6+/-3.8% (P<0.0001). In the same animals, IABP assist increased MADP by 19.8+/-2.3%, mean diastolic LAD flow by 37.2+/-3.9%, and EVR by 21.4+/-3.0% (P<0.0001). Under acute heart failure conditions, both SMV and IABP assist significantly increased MADP, mean diastolic LAD flow, and EVR. CONCLUSIONS: In both the normal and failing circulations, the SMV was an effective counterpulsator, providing cardiac assist that was at least equal to that available from an IABP. The SMV may therefore provide the proven benefits of an IABP in ambulant patients.

The effect of chronic steroid therapy on outcomes following cardiac surgery: a propensity-matched analysis.

OBJECTIVE: Steroids are beneficial in reducing the inflammatory response accompanying surgery with cardiopulmonary bypass. However, chronic steroid therapy has been implicated as a risk factor for abdominal complications and mortality following surgery. We assessed the impact of chronic steroid therapy had on outcome following cardiac surgery. METHODS: During the period January 1999 to March 2003 there were 98 patients on chronic steroid therapy (Group S) who underwent cardiac surgery at our institution. These patients were matched with a control group of 98 patients who were not on steroids (Group C). A propensity score was used to perform the matching. The C statistic for this model was 0.72. RESULTS: Ninety (93.7%) of the 98 patients in Group S had been on oral prednisolone for a median of 9.5 years (25th and 75th percentile of 5 and 12 years) with a median dose of 5mg (25th and 75th percentile of 4 and 8.75 mg). Preoperative characteristics were well matched between both groups. There was no difference in the post-operative outcome between the two groups with respect to mortality, stroke, renal failure, abdominal complications, wound infections, requirement for inotropic support and myocardial infarction. Patients in Group S were more likely to develop atrial arrhythmias and to require prolonged ventilation, although this did not reach statistical significance. CONCLUSIONS: Chronic steroid therapy was not associated with increased mortality or overall morbidity following cardiac surgery. However, patients on chronic steroids may be at greater risk of developing atrial arrhythmias or of requiring prolonged ventilation.

Timing of intra-aortic balloon pump support and 1-year survival.

OBJECTIVE: The relationship between the timing of intra-aortic balloon pump (IABP) support and surgical outcome remains a subject of debate. Peri-operative mechanical circulatory support is commenced either prophylactically or after increasing inotropic support has proved inadequate. This study evaluates the effect timing of IABP support on the 1-year survival of patients undergoing cardiac surgery. METHODS: From April 1997 to September 2002, 7698 consecutive cardiac surgical procedures were performed. This included 5678 isolated coronary artery bypasses (CABGs), 1245 isolated valve procedures and 775 simultaneous CABG and valve procedures. IABP support was required in 237 patients (3.1%). Twenty-seven patients (0.35%) were classed as high-risk and received preoperative IABP support, 25 patients (0.32%) were haemodynamically compromised and required preoperative IABP support, 120 patients (1.56%) required intra-operative IABP support, and 65 patients (0.84%) required post-operative IABP support. Multiple variables were offered to a Cox proportional hazards model and significant predictors of 1-year survival were identified. These were used to risk adjust Kaplan-Meier survival curves. RESULTS: 1-year follow-up was complete and 450 deaths (5.8%) were recorded. The significant independent predictors of increased mortality at 1-year (P<0.05, HR=hazard ratio) were post-operative renal failure (HR=3.5), increasing EuroSCORE (HR=1.2), post-operative myocardial infarction (HR=3.7), post-operative IABP (HR=4.1) intra-operative IABP (HR=2.8), post-operative stroke (HR=2.5), increasing number of valves (HR=1.6), ejection fraction <30% (HR=1.3) and triple-vessel disease (HR=1.3). After risk-adjustment, 1-year survival for patients who required intra-operative IABP support was significantly greater than for those patients who required IABP support in the post-operative period. CONCLUSIONS: Patients who warrant IABP support in the post-operative setting have a significantly increased mortality at 1-year when compared to any other group. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome.

Recurrent coarctation in a patient with Alagille syndrome.

A boy presented with Alagille syndrome and recurrent coarctation of the descending thoracic aorta. Initially, he underwent resection of the coarctation segment and end-to-end anastomosis. Following recurrent coarctation an extra-anatomic bypass procedure (a conduit was interposed between the ascending and descending thoracic aorta) was performed. He recently presented with stenosis at the anastomosic site between the extra-anatomic conduit and ascending aorta. Tissue overgrowth at the anastomotic site was responsible for the 'recoarctation'. This was surgically relieved. Patients with Alagille syndrome have vascular lesions affecting multiple organs. The management of these patients is developing. We highlight the need to tailor-make treatment to the requirements of the individual, the need for close follow-up, and the importance of long-term management of these patients.

Spontaneous haematoma of the oesophagus.

Haematoma of the oesophagus is a rare occurrence and is usually in response to trauma, retching or vomiting. We report a case of spontaneous haematoma of the oesophagus that presented with only bruising over the chest. It resolved completely with conservative management. We review the literature, common causes, the differential diagnosis and the management of oesophageal haematoma.

Spinal injury in South Trinidad - rationale for a spinal unit - Pster abstract

OBJECTIVE: To determine the quantum and patterns of serious spinal injury in a population of half a million persons in South Trinidad and to determine if there is a need for a spinal unit. DESIGN and METHOD: Charts of all cases of serious spinal injury from January 1991 to December 1995 were reviewed and data collected on demographic and injury details, neurologic deficit, admitting and managing units, management, complications, duration of stay and outcome. RESULTS: There were 160 cases mainly in the third to fifth decades, male:female 3:1. Labourers outnumbered sedentary workers 2:1 and more than 1/3 fell from heights. Injuries were in the lumbo-sacral spine (50 percent), cervical (33 percent) and thoracic (25 percent) areas. Neurologic deficit was present in 38 cases and 16 other had potentially disabling injuries. The majority (112) were admitted to orthopaedics; 26 to general surgery and 37 cases were referred to neurosurgery and 32 cases were managed jointly by orthopaedics and neurosurgery. Management was by cervical collars, calipers 5, Minerva jackets 10, plaster jackets 88 and surgical treatment 17. Complication were mainly pressure sores and urinary tract infections. Mortality was 5, all quadriplegic. Hospital stay averaged 21.5 days. CONCLUSIONS: In South Trinadad from 1991-1995 a total of 54 cases of spinal injury had neurological deficit or potentially disabling injury and might have benefited from a spinal unit with joints management by specialists in several disciplines including nurses, technicians and social workers. A unit of 4-6 beds may be appropriate. (Au)