Two-staged surgical management for complicated Boerhaave syndrome with esophagectomy and deferred gastroplasty: A case report.

INTRODUCTION AND IMPORTANCE: Boerhaave syndrome is a rare, challenging entity with high morbimortality rates. Therefore, early diagnosis and prompt treatment are needed. However, a standardized technique has not been developed, especially in large esophageal ruptures. PRESENTATION OF CASE: A female patient of 69 years with an acute thoracic syndrome consistent with severe retrosternal pain of sudden onset, radiating to the left hemithorax, vomiting, and dyspnea that began after food intake associated with subcutaneous emphysema, hypotension, and tachycardia. An A-CT was performed, revealing an esophageal perforation, and Boerhaave syndrome was diagnosed. The patient was taken to esophagectomy and gastroplasty. 2,5 years after the procedure, the patient was without long-term complications, and only dysphagia was present. CLINICAL DISCUSSION: The differential diagnoses of acute thoracic syndromes are needed to be ruled out; however, it usually delays the diagnosis of Boerhaave syndrome. Therefore, early diagnosis (<24 h) may impact this patient's outcomes. On the other hand, esophagectomy can be feasible to control the acute condition and permit a digestive tract reconstruction. CONCLUSION: In patients with large esophageal ruptures and concomitant septic shock, an esophagectomy is an option to control the source of infection and to permit early digestive tract reconstruction.

Intentional Lung Transplantation Due to ABO Incompatibility: A Case Report.

We present a case of a 16-year-old adolescent female with blood group O+ who was diagnosed with cystic fibrosis (CF). The patient had to be hospitalized due to septic shock and respiratory failure, and extracorporeal membrane oxygenation and mechanical ventilation were applied. Faced with high urgency, she was promptly enlisted for a lung transplant, ultimately receiving a blood group A1 deceased donor lung through rescue allocation. Bilateral incompatible lung transplantation, with parental consent, was successfully performed. The postoperative course was favorable, marked by the administration of rabbit anti-thymocyte globulin, plasmapheresis, and immunosuppression (mycophenolate, steroids, and tacrolimus) as per the prescribed protocol. Notably, the patient experienced a smooth recovery without infectious complications or humoral rejection. This case highlights the viability of lung transplantation in cases of ABO incompatibility, particularly for patients in urgent need on the transplant waiting list.

Cardiac sympathetic denervation for intractable ventricular arrhythmias in Chagas disease.

BACKGROUND: Autonomic modulation is a valuable therapeutic option for the management of ventricular arrhythmias. Bilateral cardiac sympathetic denervation (BCSD) has shown promising results in the acute, intermediate, and long-term management of polymorphic and monomorphic ventricular tachycardia (VT) in patients with structural heart disease. Cardiomyopathy (CM) due to Chagas disease (CD), and associated VT, is thought to be in part due to autonomic neuronal destruction and dysfunction. OBJECTIVE: The purpose of this study was to assess whether BCSD is a safe and effective treatment modality in patients with CD and VT storm or refractory VT. METHODS: A retrospective analysis of data from patients with chagasic CM who underwent BCSD between 2009 and 2015 at 2 international centers was performed. RESULTS: Of 75 patients who underwent BCSD for VT storm or refractory VT in the setting of CM, 7 (9.3%) patients had CD as the etiology of CM. All patients had monomorphic VT. Median follow-up was 7 months (range 1-46 months). All patients either underwent previous unsuccessful catheter ablation or were not candidates for ablation. The median number of implantable cardioverter-defibrillator (ICD) shocks 1 month before BCSD was 4 (range 2-30) and decreased to 0 (range 0-2) during available follow-up after BCSD. When antitachycardia pacing therapies were included in the analysis, the median number of ICD therapies (shocks + antitachycardia pacing) still decreased to 1 (range 0-3). CONCLUSION: In patients with chagasic CM presenting with refractory monomorphic VT, early evidence suggests that BCSD reduces appropriate ICD therapy and may represent a valuable treatment option.

Comparison of two protective lung ventilatory regimes on oxygenation during one-lung ventilation: a randomized controlled trial.

BACKGROUND: The efficacy of protective ventilation in acute lung injury has validated its use in the operating room for patients undergoing thoracic surgery with one-lung ventilation (OLV). The purpose of this study was to investigate the effects of two different modes of ventilation using low tidal volumes: pressure controlled ventilation (PCV) vs. volume controlled ventilation (VCV) on oxygenation and airway pressures during OLV. METHODS: We studied 41 patients scheduled for thoracoscopy surgery. After initial two-lung ventilation with VCV patients were randomly assigned to one of two groups. In one group OLV was started with VCV (tidal volume 6 mL/kg, PEEP 5) and after 30 minutes ventilation was switched to PCV (inspiratory pressure to provide a tidal volume of 6 mL/kg, PEEP 5) for the same time period. In the second group, ventilation modes were performed in reverse order. Airway pressures and blood gases were obtained at the end of each ventilatory mode. RESULTS: PaO2, PaCO2 and alveolar-arterial oxygen difference did not differ between PCV and VCV. Peak airway pressure was significantly lower in PCV compared with VCV (19.9 ± 3.8 cmH2O vs 23.1 ± 4.3 cmH2O; p < 0.001) without any significant differences in mean and plateau pressures. CONCLUSIONS: In patients with good preoperative pulmonary function undergoing thoracoscopy surgery, the use of a protective lung ventilation strategy with VCV or PCV does not affect the oxygenation. PCV was associated with lower peak airway pressures.