Lung Retraction for Exposure of Lateral Wall Vessels in Off-Pump Bypass Grafting

One of the major challenges in off-pump coronary artery bypass grafting (OPCAB) is ensuring adequate exposure of the lateral wall vessels. In most cases when the left pleura is opened during harvesting of the left internal thoracic artery , the lung frequently obscures the view. Reducing the tidal volume is practised by certain surgeons, which however in the presence of a single lumen tube affects both lungs and is best avoided in OPCAB. We describe a technique that allows adequate exposure of the circumflex artery and its branches without compromising the tidal volume.

Pancreatico-Pleural Fistula – from Diagnosis to Management. A Case Report

Pancreatic pseudocysts are frequent complications of both acute and chronic pancreatitis. By contrast, pancreatico-pleural fistula is rare. Here we report a case of massive pleural effusion secondary to a fistula in the left hemi-diaphragm, between a pancreatic pseudocyst and the left pleura, in a patient with a right kidney tumor and bilateral massive pulmonary thromboembolism. This fistula developed after several episodes of un-investigated acute pancreatitis. The pleural effusion was treated by three thoracocenteses, without recurrence.

Simulation study of volumetric modulated arc therapy for thoracic esophageal cancer using automated-radiotherapy planning software.

158 Background: To prevent cardiac toxicity after chemoradiotherapy for esophageal cancer (EC), decrease of high irradiation dose to the heart without expanding the volume of lung irradiated low dose is needed, but this is not easy under the conventional techniques. Purpose of this study is to investigate the utility of volumetric modulated arc therapy using automated-radiotherapy planning software (auto-VMAT) to solve this issue. Methods: In this simulation study, data of 12 patients with stage I-III ECs previously treated by 3D-conformal radiotherapy (3DCRT) was used. We performed auto-VMAT planning using commercially available ‘Pinnacle3 Auto-Planning’ software. Targets for gross tumor (PTV1) and elective nodal region (PTV2), and organs at risk (OARs: lung, heart, left ventricle, epicardium, left pleura, liver and spinal cord) were delineated. Multi-portal beams were used for 3DCRT and dose description was 40 Gy in 20 fractions for PTV1+2 and 20 Gy in 10 fractions-boost for PTV1. We used the simultaneous integrated boost method for auto-VMAT with a dose description of 60 Gy for PTV1 and 48 Gy for PTV2 in 30 fractions. We performed planning in consideration with decrease of volumes irradiated middle to high dose in left ventricle and achievement of volume irradiated 5 Gy (V5) in lung < 50% as high-priority dose constraints. Results: Prescribed dose coverage of PTVs was equivalent between 3DCRT and auto-VMAT, while auto-VMAT showed better dose-conformity. Auto-VMAT showed a significant decrease of mean dose and V20-V60 in heart, left ventricle and epicardium and significant decrease of V50-V60 in lung and left pleura. V5 in lung was equivalent between 3DCRT and auto-VMAT (46.6±9.6% vs 45.6±4.7%; p = 0.72). Auto-VMAT achieved the V5 in lung < 50% in 10 among 12 patients and the max V5 in lung was 52.5%. Conclusions: Auto-VMAT for ECs achieved better dose conformity of targets, decrease of middle-high dose in heart, left ventricle and epicardium, and equivalent low dose volumes in lung. Auto-VMAT planning brings high quality dose distribution, uniformity of quality of planning, laborsaving and timesaving in treatment planning.

Symptomatic isolated thoracic splenosis 11 years after abdominal trauma: Case report

Introduction. Thoracic splenosis is defined as the autotransplantation of splenic tissue into thorax. It occurs due to splenic rupture in association with a diaphragmatic tear on the left side after a traumatic event. It is a rare disease that most commonly remains undiscovered as it is usually asymptomatic. Case Outline. We present a symptomatic case of thoracic splenosis in a 53-year-old smoker male patient with a medical history of abdominal surgery and splenectomy for a thoracoabdominal gunshot. Three years before the medical examination he was suffering from dyspnea, frequent coughing, left pleuritic chest pain and complained about faster fatigue. A chest radiograph obtained during a medical checkup showed a multinodular left pleura-based mass in the upper lobe. Established histopathological diagnosis after surgical removal of the nodule was splenosis. No evidence of malignancy was observed. Conclusion. Splenosis should be considered as a differential diagnosis by the undertaken workup of left pulmonary nodules or masses in patients with a history of trauma.

Case 13.8

62-year-old man with shortness of breath and an abnormal chest CT Axial 3D SPGR postgadolinium images (Figure 13.8.1) demonstrate diffuse thickening and enhancement of the left pleura, with a few minimally enhancing, focal right-sided pleural plaques. Malignant pleural mesothelioma Malignant pleural mesothelioma is a rare neoplasm that originates from the mesothelial cells lining the visceral and parietal pleura. The incidence of malignant pleural mesothelioma in the United States is 15 cases per million; there is a strong correlation with asbestos exposure. Malignant pleural mesothelioma is divided into 3 histologic subtypes: epithelial (55%-65%), sarcomatoid (10%-15%), and mixed (20%-35%). Patients with epithelial malignant pleural mesothelioma have the best prognosis, and among those with limited disease who undergo extrapleural pneumonectomy (removal of the pleura, lung, hemidiaphragm, and part of the pericardium), survival is longer (5-year survival, 39%) than among all patients (median survival, 8-18 months after diagnosis)....

Cervical necrotizing fasciitis with thoracic extension after total laryngectomy

Cervical necrotizing fasciitis (CNF) with thoracic extension is rare. It has never been reported in laryngectomized patients. A case of fatal CNF in a laryngectomized patient equipped with a voice prosthesis is presented. Diagnosis and treatment are discussed. CNF with thoracic extension was diagnosed on clinical picture, computed tomography (CT) and biopsies were taken just above the tracheostoma. Antibiotic treatment was started and extensive debridement of the affected tissues performed. A minor extension to the left pleura was considered irresectable. Irradical debridement and the impossibility of administering hyperbaric oxygen therapy caused death within two day after presentation. CNF is a rare disease and to our knowledge, has never been reported after total laryngectomy. This case emphasizes the need for early antibiotic treatment and radical surgical resection of the affected tissues.

The case of surplus lung

During the preparation at the Anatomical Institute of the Corpse Vessels, one of the interesting deviations from the norm in the respiratory system was noticed, namely: on the opening of cavum thoracis in an infant of the second month of life, in the cavity of the left pleura, when the left diaphragmatic cost sinus was retracted to the right , to the left and posterior to the lower part of the aorta thoracalis, a special formation was seen, somewhat resembling the adrenal gland in shape, of uneven thickness, color and consistency of the lung tissue.