Aortogenic embolic stroke after sleeve pneumonectomy with median sternotomy for lung cancer: a case report

Background The median sternotomy approach in sleeve pneumonectomy enables diseased lung ventilation in selected cases, which may reduce the difficulty in achieving anastomosis under intubation of the left main bronchus. However, with median sternotomy, the ascending aorta requires repeated mobilization to expose the operative field for anastomosis, which can cause an aortogenic embolic stroke. Case presentation A 70-year-old Asian man presenting 6 months after developing hemoptysis was diagnosed with right upper lobe lung cancer (stage T4N0M0), invading the lower trachea and basal bronchus. Preoperative computed tomography revealed ascending aorta calcification. Right sleeve pneumonectomy was performed using median sternotomy with diseased lung ventilation. The ascending aorta was repeatedly mobilized to adequately expose the tracheobronchial bifurcation. Surgery was uneventful, but he did not recover complete consciousness even after termination of anesthesia. Mild paralysis of both upper extremities was observed. Head magnetic resonance imaging on postoperative day 1 revealed multiple small acute infarctions in the brain, possibly caused by mobilization of the aorta. He received anticoagulation therapy and rehabilitation and was discharged on postoperative day 30. Conclusion The median sternotomy approach in sleeve pneumonectomy enables diseased lung ventilation. However, the possibility of aortogenic embolic stroke should be considered when calcification of the ascending aorta is observed on preoperative computed tomography.

Montgomery T-Tube Insertion Under ECMO in a Patient With Complete Subglottic Stenosis and Severe Lower Tracheal Collapse

The treatment of complete subglottic stenosis (SGS) remains a challenge due to anatomic and technological limitations. Placement of the Montgomery T-tube is an effective treatment option. For complete SGS patient combined with lower trachea collapse, the ventilation management during the T-tube insertion process is more complicated. Here, we report a case with complete SGS combined with severe lower trachea collapse, which was successfully managed with T-tube insertion under extracorporeal membrane oxygenation.

Thoracic aortic aneurysms exerting high extrinsic pressure on the airway

Background Thoracic aortic aneurysms, although mostly asymptomatic, are life threatening owing to the risk of rupture. Moreover, the extrinsic pressure of a ruptured aneurysm may encroach the mediastinum. Case presentation A 74-year-old woman diagnosed with ruptured descending thoracic aortic aneurysm compressing the lower trachea and both main bronchi underwent thoracic endovascular aortic repair; however, the extrinsic pressure on the airway persisted. Following failing of endobronchial silicon stents insertion, extracorporeal membrane oxygenation support was required, and endobronchial metallic stents were inserted. The patients’ hypoventilation resolved, and the patient was withdrawn from the ventilator. Conclusions Technological improvement in endovascular or endobronchial procedures has provided more options for managing complex cases. However, we must be aware of how high the extrinsic pressure might be before management and take steps to minimize complications.

Pulmonary Artery Sling Presenting as Pneumonia and Inhalation of a Foreign Body

Pulmonary artery sling is a rare cause of respiratory distress created by compression of the lower trachea and right mainstem bronchus due to an aberrant origin of the left pulmonary artery. The condition is frequently associated with recurrent respiratory infections and other congenital malformations including tracheal rings. We present the case of an infant presenting with pulmonary distress and a history of recurrent respiratory infection. The infant underwent surgery to remove a foreign object; however, the symptoms did not resolve. Bronchoscopy revealed bronchus stenosis, and subsequent echocardiogram and CT scans revealed the presence of a pulmonary artery sling. We prescribed infection prophylaxis with the immunomodulator OM-85 to mitigate the risk of further infections prior to surgery. PAS and bronchus stenosis were corrected successfully by surgical intervention leading to resolution of symptoms of respiratory distress and a reduction in the incidence of respiratory infection.

Ingredients derived from the slaughter of bovines in dog food

ABSTRACT: This study evaluated the nutritional levels, apparent digestibility coefficients, and faecal characteristics of dogs fed with four by-products from bovine slaughter: testicles, residue sirloin steak, trachea, and liver. Ingredients were processed and packed in tins for heat treatment in autoclaves. For the digestibility and faeces quality, ingredients were mixed with a reference diet (commercial food) in the proportion of 30g kg-1 test ingredient and 70g kg-1 reference diet (as dry matter). Ten adult dogs were distributed in double Latin block squares (5x5) with five treatments and five periods, totalling ten repetitions per treatment. The residue sirloin steak presented the highest levels of essential (414.2g kg-1 of dry matter) and non-essential (399.0g kg-1 of dry matter) amino acids in tested ingredients. No differences (P>0.05) were observed in apparent digestibility coefficients of dry matter - ADCDM (907g kg-1), ADCOM (930g kg-1), ADCCP (841g kg-1), ADCAEE (954g kg-1) values, and DE (5069kcal kg-1) and ME (4781kcal kg-1) values between testicle, residue sirloin steak, and liver. The trachea presented lower digestibility and energy values (digestible and metabolizable) than the other ingredients. This lower trachea digestibility resulted in higher faecal volume for natural and dry matter (P<0.05). There was no difference (P>0.05) in faecal score between ingredients. Ingredients tested in this study can be used in feeds for adult dogs; however, their nutritional levels and digestibility values should be considered for correct diet balance.