Primary Laryngotracheal Amyloidosis With Bilateral Vocal Cord Involvement and Associated Bronchiectasis.

Localized tracheobronchial amyloidosis is a rare disease that results from submucosal deposition of insoluble amyloid proteins in the large airways. Amyloidosis affecting the larynx and subglottic space typically results in unilateral, nodular vocal cord infiltration. It rarely can present with bilateral vocal cord involvement and can progress to lifethreatening respiratory failure due to upper airway obstruction. In these patients, typical treatment modalities such as CO2 laser ablation are often ineffectual. Bronchiectasis is a predisposing risk factor associated with the secondary (AA) form of disease. We present a patient with the primary (AL) form of localized laryngotracheal amyloidosis with pre-existing bronchiectasis, and also review the existing literature on this disease.

Use of Dual, Tubularized Supraclavicular Artery Island Flaps in Series to Restore Gastrointestinal Continuity After a Failed Ileocolic Esophageal Reconstruction.

The supraclavicular artery island flap (SCAIF) is a versatile pedicled flap that can be an excellent alternative to free flap reconstruction in complex head and neck defects. We use the SCAIF routinely as a first-line option for many of our soft tissue head and neck reconstructions. Here we describe a novel application of dual SCAIFs used in series for proximal esophageal reconstruction. This followed esophagectomy for neoplastic disease and failed gastric pull-up and colonic interposition procedures.

Biopsy trauma dislodges thymocytes from a thymoma to fill regional lymph node sinusoids.

We present a case of an incisional thymoma biopsy causing dissemination of thymocytes to a regional lymph node. Lymphatic seeding from circulating tumor cells is a distinct mechanism of tumor spread. We review the literature relevant to operative trauma as a cause of tumor cell migration to nearby lymph nodes. Summarized are case reports wherein metastasis of benign tumors has been related to operative trauma.

Penetrating cardiac injury and the significance of chest computed tomography findings.

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.

Versatility of a mini-trapdoor incision in upper mediastinal exposure.

Exposure of the upper mediastinum and thoracic outlet can pose major surgical challenges. We report our application of a previously described mini-trapdoor incision to a variety of surgical problems involving the upper mediastinum and thoracic outlet, including subclavian vein thrombosis, penetrating subclavian artery injury, debridement of subjacent chest wall infection, lymph node excision, and Pancoast tumor resection. This versatile approach provides excellent structural visualization while obviating clavicular resection or sternoclavicular joint disruption, or both.

The use of human acellular dermal matrix for chest wall reconstruction.

BACKGROUND: Reconstruction of chest wall defects has evolved, but challenges remain. This is particularly true when defects are large or contamination is present. Although numerous materials are available for reconstruction, acellular dermal matrix has the advantage of becoming vascularized and incorporated autologously. By its resistance to infection and lack of adhesion formation, it is a promising although expensive alternative to synthetic materials in some circumstances. This report examines our experience with human acellular dermal matrix (HADM) in reconstruction of major chest wall and diaphragmatic defects. METHODS: A retrospective study was conducted of all patients who underwent thoracic reconstruction using HADM between March 2007 and March 2010 at Harbor-University of California-Los Angeles Medical Center. Data acquisition included demographics, surgical indications, operative details, complications, and follow-up evaluation. RESULTS: Ten patients were identified. Indications included thoracic tumor resection in 5, Clagett procedure modification for postpneumonectomy empyema in 2, resection of chest wall osteomyelitis in 2, and pneumonectomy for multiple aspergillomata in 1. Complications occurred in 4 patients and included respiratory failure, pneumonia, and wound seromas. All wounds healed without need to remove or revise the HADM, and sound chest wall closure was achieved in every case. CONCLUSIONS: HADM is an effective but expensive alternative to synthetic mesh in reconstruction of chest wall and diaphragmatic defects. It is particularly attractive for use under conditions of potential or overt contamination.

Damage control: cavoatrial anastomosis during a catastrophic right intrapericardial pneumonectomy.

While undergoing an intrapericardial pneumonectomy for a massive right pulmonary inflammatory pseudotumor that had invaded the mediastinum, an 18-year-old woman experienced a nearly fatal iatrogenic complication. Dense scarring adjacent to the pseudotumor had drawn in the superior vena cava posterolaterally and fused the right main pulmonary artery to the right superior pulmonary vein within the pericardium. The failure of a linear stapler to secure the pulmonary vessels led to torrential hemorrhage. Attempts to control the bleeding resulted in inadvertent superior vena cava occlusion and central venous pressure elevation. Because cardiopulmonary bypass might not have been reliably established in time to avoid irreversible cerebral ischemia, we borrowed a technique from congenital heart surgery and rapidly fashioned a cavoatrial connection. The patient survived the operation without negative neurologic or cardiac sequelae, recovered fully, and had no recurrence of the pseudotumor. Herein, we describe the intraoperative decisions that were made under intense time pressure to avert catastrophe.

Thoracoscopic thoracic duct ligation for persistent cervical chyle leak: utility of immediate pathologic confirmation.

OBJECTIVE: Chylous fistulas can occur after neck surgery. Both nonoperative measures and direct fistula ligation may lead to fistula resolution. However, a refractory fistula requires upstream thoracic duct ligation. This can be accomplished minimally invasively. Success depends on lymphatic flow interruption where the duct enters the thorax. We report on the utility of frozen section confirmation in achieving this goal. METHODS: Persistent chylous fistulas occurred in 2 patients after left cervical operations. In the first patient, attempted direct fistula ligation and sclerosant application failed. Fasting, parenteral nutrition, and somatostatin-analog provided no benefit. For the second patient, nonoperative treatment was also ineffective. Prior radiation therapy and multiple cervical operations militated against attempted direct fistula ligation. Both patients underwent thoracoscopic thoracic duct interruption. RESULTS: In both cases, a duct candidate was identified between the aorta and azygos vein. Frozen section analysis of tissue resected between endoclips verified it as thoracic duct. Fistula resolution ensued promptly in both instances. CONCLUSIONS: This report lends further credence to the efficacy of minimally invasive thoracic duct ligation in treating postoperative cervical chylous fistulas. Frozen section confirmation of thoracic duct tissue is useful. It allows one facile with thoracoscopy, but less familiar with thoracic duct ligation, to confidently terminate the operation.

Hilar control in penetrating chest trauma: a simplified approach to an underutilized maneuver.

BACKGROUND: In both urban and military settings, penetrating thoracic injuries remain a significant source of trauma-related mortality, and many patients require resuscitative thoracotomy. Existing literature emphasizes relief of pericardial tamponade and aortic clamp application as the key therapeutic maneuvers. The purpose of this report is to revisit pulmonary hilar clamping and highlight its application for hemorrhage control, air embolism prevention, and other benefits in the setting of massive hemothorax. METHODS: Records from an urban, American College of Surgeons verified level I trauma center were evaluated over a six-month period. Patients who underwent early pulmonary hilar clamping were identified. RESULTS: Twenty-four patients with trauma presented during the study period required thoracotomy. Of these, three (13%) underwent early pulmonary hilar clamping for massive hemothorax. Trauma mechanism was penetrating in each instance. Injuries included pulmonary lobe destruction, subclavian artery disruption, and internal thoracic artery transection. These cases illustrate the utility of early pulmonary hilar clamping for hemorrhage control, prevention of air embolization, and improved exposure. CONCLUSION: To decrease morbidity and mortality at our institution, a method of pulmonary hilar control has evolved using an organized, "hand-over-hand" approach that controls hemorrhage, prevents fatal air embolism, protects against blood spillage into contralateral airways, and facilitates pulmonary surgery. Several features distinguish our approach from those previously reported.

Benign esophagobronchial fistula with and without esophageal obstruction: two ends of the surgical spectrum.

Acquired esophagobronchial fistula (EBF) is uncommon and its surgical remediation is challenging. Management depends on the cause, degree of pulmonary involvement, and existence of esophageal obstruction. We report management of two EBF cases representing extremes of the surgical spectrum. One patient with EBF secondary to mediastinal fungal infection underwent pulmonary resection and esophageal repair. Another, who was positive for human immunodeficiency virus, required esophageal resection and fistula closure, but no pulmonary resection. Successful outcome was achieved in both patients.

Comparison of fungal culture versus surgical pathology examination in the detection of Histoplasma in surgically excised pulmonary granulomas.

CONTEXT: Granulomatous pulmonary nodules are common in areas endemic for Histoplasma infection, and may require surgical excision to exclude neoplasia. Surgeons may elect to routinely send material directly to the clinical microbiology laboratory for fungal and mycobacterial cultures. OBJECTIVE: To determine if tissue from surgically excised pulmonary granulomatous nodules removed from patients in a geographic area endemic for Histoplasma infection should be routinely submitted for fungal culture. DESIGN: Retrospective review and comparison of surgical pathology histochemical findings and clinical microbiology results of 30 surgical (wedge) lung excisions that demonstrated granulomatous nodule at the time of frozen section. RESULTS: Twenty cases demonstrated fungal organisms consistent with Histoplasma species via histochemical fungal stains. Of these 20 cases, 17 were tested in the microbiology laboratory using direct smear examination and fungal culture; Histoplasma was detected in 1 case (1/17). Eight cases revealed no organisms by surgical pathology. Of these, 6 were tested in the microbiology laboratory, and all 6 were negative by culture and direct smear (0/6). The remaining 2 cases demonstrated organisms other than Histoplasma by surgical pathology examination. CONCLUSIONS: Surgical pathology examination of granulomatous pulmonary nodules detected Histoplasma organisms with greater sensitivity than culture and direct smear. There were no false-negative surgical pathology diagnoses when compared with microbiological results. These findings suggest that it is not necessary to routinely send material from solitary pulmonary granulomas for fungal culture when the material is removed from immunocompetent patients in a geographic area endemic for histoplasmosis.

Closure of a bronchopleural fistula using bronchoscopic placement of an endobronchial valve designed for the treatment of emphysema.

Pneumothoraces are sometimes complicated by a persistent air leak or bronchopleural fistula requiring prolonged chest tube drainage. Non-surgical treatment of persistent bronchopleural fistulas is often performed in patients who are poor surgical candidates, but the ideal method of closure is not known. Here we report closure of a persistent distal bronchopleural fistula using a one-way endobronchial valve designed for the treatment of emphysema.

Devices for lung isolation used by anesthesiologists with limited thoracic experience: comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker.

BACKGROUND: Lung isolation is accomplished with a double-lumen tube or a bronchial blocker. Previous studies comparing lung isolation methods were performed by experienced anesthesiologists in thoracic anesthesia. Therefore, the results of these studies may not be relevant to the anesthesiologist with limited experience. This study compared the success rates of lung isolation devices among anesthesiologists with limited experience in thoracic anesthesia. METHODS: A prospective, randomized trial was designed to determine the success and time required for proper placement of the left-sided double-lumen tube (n = 22), the Univent tube (Vitaid Ltd., Lewiston, NY; n = 22), and the Arndt Blocker (Cook Critical Care, Bloomington, IN; n = 22). Anesthesiologists with less than two lung isolation cases per month were included (faculty n = 17 and senior residents n = 11). Variables recorded included (1) successful placement (as determined by an independent observer), (2) time of placement, and (3) the number of times the fiberoptic bronchoscope was used. RESULTS: Participants failed to place or position their assigned device in 25 of 66 patients (failure was 39% among faculty and 36% among senior residents). The failure rate did not differ among the three devices (P = 0.65). The median (25th-75th percentile) times to complete the placement procedures were as follows: (1) double-lumen tube: 6.1 min (4.6-9.5 min), (2) Univent tube: 6.7 min (4.9-8.8 min), and (3) Arndt Blocker: 8.6 min (5.8-17.5 min) (P = 0.45 comparing all devices). After device malposition was identified, it took 1 min or less for the investigating anesthesiologist to achieve optimal position. CONCLUSIONS: Anesthesiologists with limited experience in thoracic anesthesia frequently fail to successfully place lung isolation devices. Rapid successful device placement by an experienced anesthesiologist excluded any contribution of uniquely difficult anatomy. The nature of the malpositions suggests that the most critical factor in successful placement was the anesthesiologist's knowledge of endoscopic bronchial anatomy.

Hyperbaric oxygen treatment of hemorrhagic radiation-induced gastritis after esophagectomy.

My colleagues and I present 2 cases of hemorrhagic postesophagectomy gastritis after chemoradiotherapy for esophageal cancer. On the basis of the location of the gastritis (lesser curve and midstomach) and the classic radiation injury appearance, radiation damage was believed to be the cause. In both patients, hyperbaric oxygen therapy rapidly arrested bleeding. This is the first description in which hyperbaric oxygen therapy was used to treat hemorrhagic postesophagectomy gastritis.

Ontogeny of vascular growth factors in perinatal sheep myocardium.

OBJECTIVE: To examine developmental changes in myocardial gene expression of previously identified regulators of vascular growth. METHODS: Ovine left (LV) and right ventricle (RV) samples were obtained at four time points: 95 days' and 140 days' gestation (term = 145 days) and 7 days and 8 weeks postnatally. mRNA and protein levels of vascular endothelial growth factor (VEGF), its respective receptors (Flk-1 and Flt-1), basic fibroblast growth factor (bFGF), transforming growth factor-beta1 (TGF-beta1), and endothelial nitric oxide synthase (eNOS) were measured at these different time points. RESULTS: RV but not LV VEGF mRNA levels decreased postnatally, although VEGF protein expression remained unchanged after birth. Flt-1 mRNA expression was divergent between ventricles, although the protein expression pattern was similar in RV and LV, decreasing with maturation. RV and LV Flk-1 mRNA decreased between 95 days and 140 days, remaining stable thereafter, while protein levels only decreased after birth. bFGF protein levels were highest in the LV at 140 days, and decreased after birth but remained unchanged in the RV throughout the period examined. TGF-beta1 and eNOS levels were highest early in gestation, decreasing with maturation in both ventricles. CONCLUSION: Developmentally regulated ventricle-specific expression of VEGF, Flt-1, Flk-1, TGF-beta1, bFGF, and eNOS was demonstrated in the ovine myocardium. These findings suggest these proteins may participate in coronary vascular remodeling during the perinatal period and underscore the importance of studying the relationships among transcription factors, target genes, and anatomic/physiologic changes in the whole animal.