Abdominal aortic aneurysm rupture into a retro-aortic left renal vein.

We present a case of an abdominal aortic aneurysm ruptured into a retroaortic left renal vein. The patient presented with left flank pain, left-sided varicocoele and haematuria. Imaging showed a juxtarenal AAA associated with a retroaortic left renal vein and simultaneous contrast captation of the aneurysm, the vena cava, the left renal vein and the left vena testicularis. After opening of the aneurysm sac, the defect was controlled by digital pressure and closed by suture. The patient underwent a successful abdominal aorto bi-iliac replacement. We discuss prevalence, clinical features and treatment options of this rare condition.

Post-traumatic severe fat embolism syndrome with uncommon CT findings.

Although the diagnosis of fat embolism syndrome is usually based on clinical findings, we describe ill-defined centrilobular and subpleural nodules in addition to ground-glass opacities and consolidation on a computed tomography scan of the chest in a trauma patient with fat embolism syndrome. The nodules presumably represent alveolar oedema, microhaemorrhage and an inflammatory response secondary to ischaemia and cytotoxic emboli in fat embolism syndrome. The literature of computed tomography findings in patients with fat embolism syndrome is reviewed and summarized.

Aortic graft infection from appendicitis. A case report.

Fifteen years after aortobifemoral bypass and five years after left femoropopliteal bypass, a 73-year old man presented with a vague abdominal pain syndrome. After an extensive work-up, aortobifemoral graft infection was suspected; an appendiceal abscess infiltrating the prosthesis was discovered during exploratory laparotomy. Appendectomy was performed followed by removal of the vascular graft, the latter being replaced by a bilateral axillofemoral prosthesis. Aortic graft infection from appendicitis is an extremely rare condition; a review of similar cases is presented.

Asymptomatic aneurysm of the hepatic artery. Management options.

Hepatic aneurysms are rare. The majority of patients present acutely with aneurysm rupture, with an attended high mortality. Diagnosis is difficult and often delayed, owing to the non-specific symptoms and lack of clinical findings. We present three cases of hepatic artery aneurysm diagnosed in a pauci- or asymptomatic stage, illustrating the different therapeutic options described when these aneurysms are diagnosed in this stage: expectant management, embolization, or surgery.

Current outcome in patients with lung cancer and positive mediastinoscopy.

PURPOSE: A retrospective study was undertaken to determine the contemporary treatment and outcome of patients with lung cancer and positive lymph nodes proven at mediastinoscopy. MATERIAL AND METHODS: From 1994 to 1999 a cervical mediastinoscopy was performed in 361 patients. Metastatic lymph nodes from a bronchogenic carcinoma were present in 81 patients; 71 were men. Mean age was 61.7 years. Squamous cell carcinoma and adenocarcinoma were present in 26 patients each (32.1%), large cell carcinoma in 19 patients (23.4%), small cell carcinoma in six patients (7.4%) and other histologies in four patients (5%). Stage IIIA was found in 51 patients (69.9%), IIIB in 17 (23.3%) and IV in 5 (6.8%). Of eight patients no precise stage could be determined (9.9%). These patients were retrospectively reviewed. Survival time was analyzed according to the Kaplan-Meier method. A multivariate Cox analysis was performed to determine significant factors in relation to survival. RESULTS: Forty-four patients (54.3%) were treated by induction chemotherapy, of which 15 were operated on, 11 patients (13.6%) had chemotherapy only, 11 (13.6%) radiotherapy only, 3 (3.7%) combined chemo- and radiotherapy, 1 patient (1.2%) had an operation only, and 11 (13.6%) received palliative treatment. Follow-up was complete; 16 patients (19.8%) are alive and 65 (80.2%) died, mostly of local recurrence and metastases. Median survival time (MST) for all 81 patients was 12 months [95% confidence interval (CI) 10-14 months.]. MST for the 15 patients treated by induction chemotherapy + surgery was 27 months [95% CI 18-36 months] and for the 15 patients treated by induction chemotherapy + radiotherapy 15 months [95% CI 12-18 months]. The difference between these two subgroups was significant (p = 0.03). For the 11 patients who had palliative treatment MST was 6 months [95% CI 4-8 months]. The other subgroups had a MST of 10 months or less. In a multivariate Cox analysis only specific treatment (p = 0.0002) and stage (p = 0.02) were found to be significant. CONCLUSIONS: Outcome of patients with lung cancer and positive mediastinoscopy remains poor. In this retrospective study best results were obtained by induction chemotherapy + surgery. An effort should be made to include as many of these patients as possible in neoadjuvant trials.

Thoracic trauma: an analysis of 187 patients.

A retrospective analysis of 187 cases of thoracic trauma seen between January 1, 1994 and June 30, 1999 is presented. The majority of the patients were male (male-female ratio 2.9:1) and the average age at admission was 41.1 years. Blunt trauma, especially motor vehicle accidents (72.2%) and falls (17.1%), were the most frequent causes of chest injury (95.8%). We used the injury severity score (ISS) to assess the severity of trauma. The average ISS for the total group was 27.8 (ranges: 4-75). In only 17.6% of the patients an isolated thoracic trauma was present. Rib fractures (n = 133), pulmonary contusion (n = 110), pneumothorax (n = 78) and haemothorax (n = 65) were the most frequent lesions. Most patients (97.9%) were admitted to the intensive care department. A minority of the patients required thoracotomy (n = 19, 10.2%). Main indications for thoracotomy were pulmonary laceration (n = 5), aortic rupture (n = 3) and rupture of the diaphragm (n = 3). For the majority of cases, observation and/or tube thoracostomy (52.4%) and/or mechanical ventilation (61.0%) were sufficient. Pneumonia and adult respiratory distress syndrome were the most common complications (38.0 and 7.0% respectively). The overall mortality rate was 16.6%. Main causes of death were intracranial hypertension, sepsis combined with multiple organ failure, and hypovolaemic shock. For patients who did not survive the average ISS was 40.3. In a survival analysis the ISS was found to be the most significant determining survival (p < 0.0001), followed by neurotrauma (p = 0.05). Mortality after thoracic trauma remains relatively high, especially in case of associated neurotrauma. The ISS is a valuable score for assessing the severity of trauma and predicting outcome.

Pulmonary metastasectomy in a patient with malignant melanoma after a disease-free interval of 15 years.

Prognosis in melanoma patients after resection of pulmonary metastases is poor. Little information is available about the relationship between long-term disease-free interval and survival rate after pulmonary metastasectomy. We report a patient treated for malignant melanoma of the forehead who developed a pulmonary metastasis after a disease-free interval of 15 years. Lobectomy was performed, but unfortunately 12 months later the patient died of brain metastases.

Operative staging of lung cancer.

For earlier stage non-small cell lung cancer, surgical resection remains the most effective therapy. Complete resection of the primary tumour and lymph nodes should be the final aim in order to obtain the best long-term prognosis. Resectability depends on the tumour stage, and precise pre- and peroperative staging are of the utmost importance. In some cases, lung-sparing or extended operations are indicated. Despite modern scanning techniques, invasive staging by mediastinoscopy or thoracoscopy often remains necessary for determining resectability or deciding on a specific treatment. During thoracotomy, precise evaluation of the tumour and node factor is imperative for determining the extent of resection and achieving a complete tumour clearance. A systematic nodal dissection during thoracotomy is advised. Lung resection after induction therapy remains a technical challenge, especially after combined chemoradiotherapy. Peroperative staging is often difficult as distinction between viable tumour and fibrotic reaction is not easily made. Although combined modality treatment has an overall increased morbidity and mortality rate, it improves survival in selected cases of locally advanced non-small cell lung cancer.

Lamellar bone formation in an atherosclerotic plaque of the carotid artery, with a review of histogenesis--a case report.

Longer existing atherosclerotic lesions may contain calcifications; lamellar bone rarely develops within them. A 59-year-old man was referred with a progressive stroke. A high-grade stenosis of the left common carotid artery, formed by an ulcerating atherosclerotic plaque with a free-floating thrombus, was detected on angiography. An urgent endarterectomy was performed. Surprisingly this plaque contained pieces of lamellar bone, proved by histologic examination.

Left middle lobe resection for bronchiectasis in Kartagener's syndrome.

We report the case of a young girl with Kartagener's syndrome who suffered from severe bronchiectasis confined to the left middle lobe. Due to chronic abscedation which failed to respond to medical therapy, resection of the left middle lobe was performed. Although there was an initial clinical benefit, afterwards she had to be treated again for recurrent infectious exacerbations.

Improved ventilatory function after combined operation for pulmonary emphysema and lung cancer.

BACKGROUND: Smoking is the leading cause of both lung cancer and emphysema. Therefore, some patients with stage I and II disease will present with contra-indications to resection including a predicted postoperative FEV1 of less than 0.81 or a VO2max of less than 10 ml/kg/min. Recently, lung volume reduction surgery (LVRS) has re-emerged in the management of emphysema with excellent results. METHODS AND PATIENTS: 2 patients are reported with lung cancer in the left lower lobe and emphysematous destruction in both upper lobes. They, respectively, had a predicted postoperative FEV1 of 0.9211 and 0.6851. No metastases were present. Pre-operatively, a COPD index of 0.9 and 0.7 was calculated. A left lower lobectomy together with volume reduction of the left upper lobe was performed through a standard posterolateral thoracotomy. RESULTS: Pathological examination showed, respectively, stage IIb and stage Ib disease. The postoperative course was uneventful and 3 months later a FEV1 of 1.441 for patient 1 and 1.041 for patient 2 were recorded. CONCLUSION: These findings suggest that pulmonary function criteria for pulmonary resection have to be revised when patients can undergo simultaneous lung cancer resection and LVRS. The pre-operatively calculated COPD index can be used to predict which patients may not have a decrease in ventilatory function.

Repeat mediastinoscopy in the staging of lung cancer.

OBJECTIVE: Despite technical difficulties due to mediastinal fibrosis, repeat mediastinoscopy can be a valuable tool in the restaging of lung cancer. It provides essential pathological information on mediastinal invasion when selecting patients for surgical resection after induction chemotherapy in stage IIIa disease. The aim of our study was to evaluate the feasibility, sensitivity and accuracy of repeat mediastinoscopy. METHODS: From 1994 to 1997 we performed a repeat mediastinoscopy in 15 patients (13 men, two women) with bronchogenic carcinoma. Their age ranged from 49 to 75 years. (mean 64.7). Seven patients had induction chemotherapy for a non-small cell bronchogenic carcinoma with positive N2 nodes on mediastinoscopy. Four patients had a second primary contralateral lung cancer, one had a locoregional recurrence of bronchogenic carcinoma. The other three had a first mediastinoscopy for other reasons than lung cancer, repeat mediastinoscopy being performed for staging of malignant disease. RESULTS: In all 15 patients it was possible to perform a complete repeat mediastinoscopy. In one patient repeat mediastinoscopy turned out to be false negative, so, in our series, sensitivity was 87.5%, specificity 100% and accuracy 93.7%. CONCLUSION: Previous mediastinoscopy is no contraindication for a repeat one. Repeat mediastinoscopy offers valuable pathological information in restaging of lung cancer.

Chylothorax complicating left lower sleeve lobectomy.

Postoperative chylothorax is an infrequent but potential life-threatening complication and has most often been described following oesophageal resection. Its incidence after pulmonary resection is low, but has increased to 0.3-0.5%, probably due to more extensive types of resections and radical lymph node dissections. We report a case of chylothorax after a left sleeve lobectomy for a primary bronchogenic carcinoma, that was treated conservatively with chest tube drainage and a diet of medium chain triglycerides. Five additional case reports in English and French literature confirmed chylothorax after bronchoplastic procedures to be extremely rare. More frequent use of bronchial sleeve resection as alternative to pneumonectomy to save functional lung tissue, can increase the incidence of chylothorax after bronchoplastic procedures.

Chronic herniation of the lung in a patient with chronic obstructive pulmonary disease. Case report and review of the literature.

Lung herniation is a rare condition and can be classified by both anatomical site and etiology. A 70-year-old man was referred with dyspnea, productive cough, and right-sided chest pain. Radiological investigation showed healed rib fractures and a lung herniation between ribs 8 and 9. Two years after surgical repair the patient is free of complaints. Treatment can be conservative or surgical, but as experience is limited no long-term results have been reported.

The current role of invasive staging in lung cancer.

Precise mediastinal lymph node staging in otherwise operable non-small cell lung cancer (NSCLC) is imperative as it determines subsequent treatment and prognosis. For mediastinal staging, even present-day computed tomography (CT) scanners have a low accuracy, and routine cervical mediastinoscopy is advised for precise lymph node assessment, certainly when considering a neoadjuvant protocol. Cervical mediastinoscopy remains the gold standard, and sampling of subcarinal nodes is essential. The role of remediastinoscopy after induction chemo- or radiotherapy remains to be determined. Extended mediastinoscopy is indicated to take biopsies of scalene lymph nodes or aorto-pulmonary nodes, which can also be reached by anterior mediastinoscopy. Video-assisted thoracic surgery (VATS) does not replace cervical mediastinoscopy but is a valid alternative to anterior or extended mediastinoscopy. A more complete exploration of the ipsilateral hemithorax is possible, with biopsies of aortopulmonary and inferior mediastinal nodes and judgment about resectability of the primary tumour.

Lung volume reduction surgery as an emergency and life-saving procedure.

Lung volume reduction surgery (LVRS) is emerging as a promising and unique therapeutic option for rigorously selected patients with severe debilitating emphysema. A 51 yr old man with generalized emphysema developed bilateral pneumothoraces during his first holiday abroad. Due to respiratory insufficiency, intubation and mechanical ventilation were necessary. In total, six chest tubes were inserted but massive air leak persisted and his respiratory condition deteriorated due to bronchopneumonia and sepsis. The patient was transferred to Belgium. As a last resort, bilateral LVRS was performed through a median sternotomy. The most diseased areas of the upper lobes containing the air leak were resected bilaterally and a pleurectomy was associated. Three months after operation, there was a remarkable improvement in spirometric values with an increase in forced expiratory volume in one second of almost 100%. The results were sustained after a follow-up of 18 months. In this dramatic case, lung volume reduction surgery proved to be effective, and was even a life saving procedure.

Intraoperative identification of parathyroids by means of methylene blue.

In 134 cervical explorations for hyperparathyroidism, methylene blue was administered intraoperatively to stain parathyroid glands. Seventy-seven out of 79 adenomas (97.5%) and 199 out of 204 hyperplastic glands (97.6%) were clearly stained. The only recurrences were observed in patients undergoing surgery for hyperplasia of the parathyroid glands. The recurrences (12%) were mainly due either to initial wrong diagnosis of parathyroid adenoma, or they were graft dependent. Methylene blue is an effective, safe and easy way to localize and identify abnormal parathyroid glands, thereby improving the results and shortening the operating time.

Chylothorax after blunt chest trauma.

An unusual patient with chylothorax following blunt chest trauma is presented. Diagnosis was, in this acute case, clear after thoracostomy. In our patient conservative therapy with total parenteral nutrition failed and he was cured with a surgical closure of the duct leak. Chylothorax can be the cause of important morbidity and mortality, and straightforward diagnosis and therapy are mandatory.