Stewart R. Craig

Potential complications of vascular stapling in thoracoscopic pulmonary resection

In a series of 57 patients undergoing thoracoscopic pulmonary lobectomy, 2 required expeditious conversion to open thoracotomy when a stapling device (Endo-GIA 30 V3; Autosuture, Ascot, UK) used on the main right lower pulmonary artery in 1 case and on the left superior pulmonary vein in the other cut but failed to staple the vessel involved. In both instances the vessel was successfully controlled while a thoracotomy was performed and the involved vessel was oversewn. Both patients made an uncomplicated postoperative recovery. As the number of thoracoscopic pulmonary resections increases, it is likely that similar episodes will occur in the future. These cases strongly emphasize the fact that patients undergoing this procedure should do so in a center specializing in thoracic surgery where there is the necessary surgical expertise and equipment to deal with such potentially life-threatening vascular complications.

Esophagectomy for carcinoma in the octogenarian

BACKGROUND Esophageal carcinoma is predominantly a disease of the elderly, a group often only considered for palliative therapies. METHODS A case note review identified 31 octogenarians undergoing resection for carcinoma of the esophagus or gastric cardia over a 12-year period ending December 1994. RESULTS Nineteen patients made either an uncomplicated postoperative recovery (n = 12) or suffered minor complications (n = 7). Of the 12 patients who suffered moderate or severe complications, 5 died (in-hospital mortality, 16%). The deaths included 2 of 3 patients who underwent emergency operation for esophageal perforation and 3 of 28 patients who underwent elective esophagectomy (elective mortality rate, 10.7%). Nineteen of the 26 survivors (73%) experienced no further dysphagia. The 5-year survival rate was 17%. CONCLUSIONS Elective esophageal resection can be performed safety in selected octogenarians who have no or few coexisting medical problems and present with a localized carcinoma that is technically easy to resect. Patients undergoing emergency operations or in whom moderate or severe postoperative complications develop often have poor physiologic reserve and are therefore at risk of early postoperative death.

Effect of blood transfusion on survival after esophagogastrectomy for carcinoma.

BACKGROUND There is growing evidence that blood transfusion is associated with clinical factors that can lead to transfusion-induced immunosuppression. This effect can be beneficial or deleterious. METHODS The effect of perioperative allogeneic blood transfusion on survival was studied retrospectively in 524 patients who were discharged from the hospital after esophagogastrectomy for carcinoma performed in a single unit over a 10-year period. RESULTS The median operative blood loss for the series was 500 mL (range, 50 to 3,750 mL). Three hundred thirty-five patients (64%) received a perioperative allogeneic blood transfusion related to esophagogastrectomy, and 189 (36%) did not. The median perioperative blood transfusion administered was 900 mL (range, 300 to 12,950 mL). Perioperative allogeneic blood transfusion was associated with reduced survival for patients in stage III (p < 0.05) at 1 year, but no significant difference was found in this stage at 3 or 5 years after resection. Stage III disease accounted for 250 (48%) of the 524 patients discharged. CONCLUSIONS Although perioperative allogeneic blood transfusion does not affect long-term survival after esophagogastrectomy for carcinoma, it does have a significant association with short-term survival in a group whose overall survival is often limited after resection. Attention should be directed toward minimizing operative blood loss and transfusing only for factors known to be clinically important, such as oxygen delivery and hemodynamics, not arbitrary hemoglobin levels.

Video-Assisted Thoracoscopic Pneumonectomy for Bronchial Carcinoid Tumor in a 14-Year-Old Girl

A 14-year-old girl with a carcinoid tumor of the proximal right bronchus intermedius underwent a video-assisted thoracoscopic pneumonectomy. She was fully ambulant within 48 hours of surgery, had less pain than that normally associated with standard thoracotomy, and was discharged on the 7th postoperative day.

Spontaneous rupture of the right hemidiaphragm after video-assisted lung volume reduction operation

Lung volume reduction operation is an important therapeutic option in patients with advanced emphysema. We report a case of spontaneous rupture of the right diaphragm after a video-assisted thoracoscopic surgical procedure for emphysema. The pathophysiology of this complication is also discussed, along with practical points for perioperative management of emphysematous patients.

Life-threatening haemoptysis due to tracheal varices secondary to pulmonary vein obstruction

A 30-year-old man with a 3 day history of increasing breathlessness and frank haemoptysis was suspected of having pulmonary embolism and anticoagulated with heparin. Haemoptysis worsened so anticoagulation was reversed and he was transferred to our institution. Pulmonary and bronchial angiography revealed a small right pulmonary artery and a prominent right intercostobronchial trunk which was embolised. However, haemoptysis recurred and a contrast enhanced ECG-gated CT scan confirmed a hypoplastic right pulmonary artery and showed thrombosed right pulmonary veins that had no communication to the left atrium, a ‘bulky’ right hilum and thickened bronchial walls with smooth mucosal indentations into the airway lumen …

Ventricular Assist Devices as Rescue Therapy in Cardiogenic Shock After Subarachnoid Hemorrhage

We review the journey to myocardial and neurologic recovery of a 42-year-old mother with severe acute cardiogenic shock and multiorgan failure after extensive subarachnoid hemorrhage, who was salvaged successfully using a CentriMag short-term biventricular assist device.

Heartport endoclamp for complex cardiac repairs with total circulatory arrest.

A method of performing redo cardiac operations using port-access technology and total circulatory arrest is described. The technique was useful in 2 cases requiring re-intervention within 4 months of the primary procedure. The indications were repair of an infected ventricular aneurysm and recurrence of a postinfarction ventricular septal defect. Dense mediastinal adhesions were avoided by approaching the site of pathology directly via a left anterior thoracotomy.

The “Annular Sandwich”: A Simple Method of Reinforcing a Friable Mitral Valve Annulus

In 6 patients undergoing prosthetic mitral valve replacement a ring of Teflon felt, instead of conventional Teflon pledgets, was used because of concern about seating a new prosthesis in a disrupted friable mitral valve annulus. The technique avoided the potential risk of pledget loss in the event of suture breakage and, in these patients, prevented postoperative paraprosthetic mitral valve regurgitation.

A Pedunculated Intraluminal Foregut Reduplication Cyst of the Proximal Esophagus

A 66-year-old woman with a 3-month history of progressive dysphagia underwent transoral excision of a pedunculated cyst arising in the proximal esophagus. Histologic examination confirmed a pedunculated intraluminal foregut reduplication cyst. She remains well 1 year after excision with no recurrence of dysphagia.