Severe haemoptysis due to subclavian arteritis

Severe haemoptysis due to infective subclavian arteritis has, to our knowledge, never been documented. We report a case of subclavian arterial vasculitis that eroded into the left lung apex, causing a large intraparenchymal mycotic pseudoaneurysm. The patient presented with high fever and blood expectoration. An emergent left lateral thoracotomy was performed. The inflamed segment of the subclavian artery was resected and continuity was restored with a reversed saphenous vein graft. The postoperative course was uneventful and the patient was discharged on the 10th postoperative day.     

Non‐transplant surgical approach to liver‐based hereditary haemorrhagic telangiectasia: a first report

A 55‐year‐old woman with hereditary haemorrhagic telangiectasia (HHT) underwent a left lateral liver bisegmentectomy (removal of segments 2 and 3) for hepatic‐based arteriovenous malformations. This lesion determined a progressive fatigue and invalidating effort dyspnoea. The postoperative course was uneventful and the patient is currently doing well at 4 years after surgery. To our knowledge, this is the first case of hepatic‐based HHT treated with liver resection. This anecdotal report should promote the evaluation of this approach in order to define its role in the treatment of liver involvement in this rare disease.     

Systematic laparoscopic left lateral segmentectomy of the liver for hepatocellular carcinoma

A systematic technique for the resection of hepatocellular carcinoma (HCC) prevents the dissemination of cancer cells through the portal vein of the remnant liver. We successfully performed a systematic laparoscopic left lateral segmentectomy in a 62-year-old man with HCC. The tumor was located in the left lateral segment of the liver, and measured approximately 4 cm in diameter. Since no other tumors were detected in the liver or in any distant organs, the patient was considered to be a candidate for surgery. A laparoscopic hepatic resection was selected as the procedure of choice. Prior to dissection of the liver parenchyma, the arteries and branches of the portal vein feeding the left lateral segment were divided and dissected, together with the branches of the biliary tree in the umbilical portion of the left pedicle of Glisson's capsule. The liver parenchyma was then dissected and the left hepatic vein divided and dissected, and transection of the left lateral segment was completed. The patient's postoperative course was uneventful and he was discharged on postoperative days 14. No evidence of recurrence has been noted in the 22 months after surgery (the time of this report). This less invasive surgery, taking into consideration the pathogenesis of HCC, may be a useful new approach in selected patients with this tumor.     

Lesional tachycardias related to mitral valve surgery

OBJECTIVES: The purpose of this study was to define the anatomic distribution of electrically abnormal atrial tissue and mechanisms of atrial tachycardia (AT) after mitral valve (MV) surgery. BACKGROUND: Atrial tachycardia is a well-recognized long-term complication of MV surgery. Because atrial incisions from repair of congenital heart defects provide a substrate for re-entrant arrhythmias in the late postoperative setting, we hypothesized that atriotomies or cannulation sites during MV surgery also contributed to postoperative arrhythmias. METHODS: In 10 patients with prior MV surgery, electroanatomic maps were constructed of 11 tachycardias (6 right atrium [RA], 4 left atrium [LA] and 1 biatrial). Activation and voltage maps were used to identify areas of low voltage, double potentials and conduction block. RESULTS: Lesions were present in the lateral wall of the RA (six of seven maps) and in the LA along the septum adjacent to the right pulmonary veins (four of five maps). In 8 of 10 patients, these findings corresponded to atrial incisions or cannulation sites. Arrhythmia mechanisms were identified for 9 of 11 tachycardias. A macro-re-entrant circuit was mapped in six cases, three involving lesions in the lateral wall of the RA and three involving the LA septum and right pulmonary veins. In three of these cases figure-of-eight re-entry was demonstrated, and in the other three a single macro-re-entrant circuit was observed. In three other cases, a focal origin was identified adjacent to abnormal tissue in the RA (two cases) or within a pulmonary vein (one case). CONCLUSIONS: Surgical incisions for MV surgery provide a substrate for atrial arrhythmias. Both macro-re-entrant and focal mechanisms contribute to AT after MV surgery.     

Inflammatory pseudotumour of the liver: a diagnostic dilemma.

Inflammatory pseudotumour is a rare, focal, benign inflammatory lesion of the liver parenchyma. It is largely a self-limiting entity and has favorable prognosis; it is thus important to preoperatively distinguish this lesion from malignancy, which it closely imitates. Inflammatory pseudotumour may present variously. We present the case of a 54-year old gentleman who presented with a three-month history of low-grade intermittent fever. Ultrasonography and computed tomography revealed a mass in the left lobe of the liver and the erythrocyte sedimentation rate was raised with coincident hypergammaglobulinaemia. A diagnostic laparotomy with left lateral hepatectomy was performed and histopathological evaluation of the specimen along with special staining and tissue culture revealed an inflammatory pseudotumour. On the second day post-operative the fever subsided and following an uneventful five days the patient was discharged and remains well at one-year follow up with no recurrence or relapse.     

Spontaneous external biliary fistula: a rare complication of cholangiocarcinoma

A 68-year-old woman presented with yellowish discharge oozing from a fistula opening in the upper epigastric area that had persisted for one month prior to her visit. The patient had undergone a left lateral segmentectomy of the liver ten years prior for treatment of intrahepatic duct (IHD) stones. An abdominal computed tomography (CT) scan showed focal stricture and proximal dilatation of remnant IHD and a 1 cm-sized rim-enhancing lesion located under the surgical bed of the abdominal wall surrounding the dilated remnant IHD. Despite conservative management including nasobiliary drainage, no further improvement was anticipated. Partial hepatectomy and fistulectomy were performed for pathologic diagnosis and treatment of the enhancing lesion. Histopathology revealed adenocarcinoma. In this case, cholangiocarcinoma might have arisen in association with IHD stones and then developed a choledocho-cutaneous fistula as a clinical manifestation.     

Implantation metastasis along the percutaneous transhepatic biliary drainage sinus tract

We describe herein the case of a 75-year-old man with metastatic tumor seeding at the percutaneous transhepatic biliary drainage tract that occurred following a pylorus-preserving pancreatoduodenectomy for carcinoma of the distal common bile duct. On postoperative day 30, the catheter was removed and ethanol was injected into the percutaneous transhepatic biliary drainage sinus tract to prevent cancer implantation. One year and 3 months after the initial operation, abdominal computed tomography showed dilation of the left lateral segmental bile ducts and a 2-cm mass. The location of this mass corresponded to the puncture point from the previously performed percutaneous transhepatic biliary drainage. Implantation of the bile duct carcinoma at the percutaneous transhepatic biliary drainage sinus tract was diagnosed, and the recurrent tumor was successfully resected by performing a left hepatic lobectomy. Currently, 1 year after the second operation, the patient is in good health without any signs of recurrence. This case report demonstrates the importance of resecting the percutaneous transhepatic biliary drainage sinus tract during the initial surgery. If left in place, careful follow-up and awareness of this mode of tumor recurrence may lead to a timely resection, with preservation of a good quality of life and long-term survival.     

Malignant fibrous histiocytoma of the liver--a case report.

A case of surgically confirmed primary malignant fibrous histiocytoma of the liver is presented. A 35-year-old man was admitted to hospital with an epigastric mass. No abnormal laboratory findings, including tumor markers, were detected. Ultrasound and computed tomography showed the main tumor in the left lateral segment and a daughter nodule in the posterior segment of the liver. Arteriography demonstrated a slightly hypervascular mass in the left lateral segment. Histological examination of the resected tumor showed bundles of spindle cells with a focal storiform pattern, which were intermingled with bizarre giant cells, therefore a diagnosis of malignant fibrous histiocytoma was made.     

Catheter Ablation of Subepicardial Ventricular Tachycardia Using Electroanatomic Mapping

BACKGROUND: In patients with left ventricular tachycardia (VT) and failed endocardial ablation, a subepicardial substrate may be considered. PATIENTS AND METHODS: Seven patients with drug-refractory VT of right bundle branch block morphology were investigated to identify the arrhythmogenic substrate using three-dimensional (3-D) electroanatomic endocardial and epicardial mapping. RESULTS: In three patients with repetitive monomorphic VT, endocardial and epicardial mapping during tachycardia showed a focal pattern with an earliest activation preceding the onset of the QRS complex by 20 and 28 ms in the lateral aspect of the epicardial outflow tract in two patients and by 24 ms near the posterolateral mitral annulus in one patient; in two patients with sustained VT, endocardial mapping during tachycardia displayed a focal pattern with a wide breakthrough, and epicardial mapping showed a macroreentrant VT with an isthmus located in the left anterior wall in one patient and in the left inferolateral wall in the other. In the remaining two patients, endocardial and epicardial mapping were performed during sinus rhythm. An area with fragmented and late potentials as well as low amplitude was only identified in the epicardial left inferolateral wall. During tachycardia, a diastolic potential was only recorded on the epicardium and coincided with the late potential during sinus rhythm in the same area. A focal or linear epicardial irrigated lesion terminated the VT and resulted in noninducibility in all seven patients. During a median follow-up of 16 months, VT recurred in two patients without antiarrhythmic drugs. The recurrent VT was successfully reablated in one patient and treated with oral amiodarone in the other. CONCLUSION: Subepicardial left focal and macroreentrant VT may present as focal origin on endocardial mapping and can only be abolished by radiofrequency (RF) applications in the epicardial space.     

Three origins of focal atrial tachycardia in the lateral mitral isthmus

Multiple origins of focal atrial tachycardia (AT) located at the left lateral isthmus is a rare case. We present a case of a 31-year-old female with incessant AT. During radiofrequency ablation, 3 origins of AT located in the lateral mitral ishtmus from a lower to a higher position were identified with changes of the ECG morphology and earliest activation on 3D mapping. Ablation of the AT origins can terminate the tachycardia.     

Repeat hepatectomy for colonic liver metastasis presenting intrabiliary growth--application of percutaneous transhepatic portal vein embolization for impaired liver

A 77-year-old man, whose past history included hepatitis C viral infection, transverse colectomy for transverse colon carcinoma, and right hepatectomy for colonic liver metastasis with intrabiliary growth, demonstrated left lateral sectional bile duct dilatation by computed tomography (CT). Percutaneous transhepatic cholangioscopy following percutaneous transhepatic biliary drainage demonstrated a papillary tumor compatible with recurrent liver metastasis presenting with intrabiliary growth. The recurrent tumor extended both into the left lateral inferior (B2) and superior (B3) bile duct branches. Percutaneous transhepatic portal vein embolization (PTPE) of the left lateral sectional branches was performed selectively to enhance the safety of hepatectomy in patients with impaired liver. Expected liver resection volume decreased from 48% to 36% by CT volumetry before and 5 weeks after PTPE. Left lateral sectionectomy was performed without serious postoperative complications. Resected specimen showed a solid tumor measuring 30x25mm and intraluminal tumor extension in B3 and B2. All surgical margins including the bile duct stump were free from carcinoma invasion. The patient survived for 4 years and 5 months postoperatively and died of other causes. An aggressive surgical strategy and PTPE provided significant palliation in this selected patient.     

Malignant fibrous histiocytoma of the liver-A case report

A case of surgically confirmed primary malignant fibrous histiocytoma of the liver is presented. A 35-year-old man was admitted to hospital with an epigastric mass. No abnormal laboratory findings, including tumor markers, were detected. Ultrasound and computed tomography showed the main tumor in the left lateral segment and a daughter nodule in the posterior segment of the liver. Arteriography demonstrated a slightly hypervascuIar mass in the left lateral segment. Histological examination of the resected tumor showed bundles of spindle cells with a focal storiform pattern, which were intermingled with bizarre giant cells, therefore a diagnosis of malignant fibrous histocytoma was made.     

Postoperative left ventricle-right auricle fistula: a case report

We present a case of a postoperative left ventricular--right atrial shunt in a 46 year-old patient operated for aortic valvulopathy. Through two-dimensional echocardiography and hemodynamic studies a communication between the left ventricle and the right atrium was observed. We review the literature about this rare anomaly.     

Thoracoscopic esophagectomy in the prone position

Thoracoscopic esophagectomy performed with the patient in the left lateral position has been occasionally reported since the 1990s, but it has not been established as a standard procedure. This may be because the success of this procedure largely depends on the technical competence of an assistant to secure an adequate field of view during the procedure. Thoracoscopic esophagectomy with the patient in the prone position has recently been introduced and has been consistently shown to be useful. Compared with left lateral thoracoscopic esophagectomy, prone thoracoscopic esophagectomy requires less assistance in exposing the operative field and it is relatively easy to obtain a satisfactory field of view. We performed prone thoracoscopic esophagectomy on 20 patients and were successful in achieving a wide field of view. The postoperative course was remarkably favorable in all patients and the procedure is considered promising for standard thoracoscopic esophagectomy. There are few detailed reports of this procedure; herein, we describe the procedure of prone thoracoscopic esophagectomy employed at our hospital.     

Left ventricular apical hypertrophy emerged from the fourth-year post heart transplantation: Case report and literature review

Apical hypertrophic cardiomyopathy (AHCM) is a relatively rare phenotype of hypertrophic cardiomyopathy, which is characterized by focal thickening of the left ventricular (LV) apical myocardium, showing a spade-shaped shadow on the left ventricle. We present the case of a 59-year-old man who was found to have AHCM, is an asymptomatic orthotopic heart transplantation (HTx) patient. This rare and progressive case of LV apical hypertrophy emerged from the fourth year post surgery. We analyzed the etiology of this case and summarized the clinical manifestations and prognosis of AHCM following HTx by reviewing our case and the literature.     

Case report of pure single-port robotic left lateral sectionectomy using the da Vinci SP system

Introduction:Since its first appearance in the early 1990s, laparoscopic hepatic resection has become increasingly accepted and recognized as safe as laparotomy. The recent introduction of robotic surgery systems has brought new innovations to the field of minimally invasive surgery, such as laparoscopic surgery. The da Vinci line of surgical systems has recently released a true single-port platform called the da Vinci SP system, which has 3 fully wristed and elbowed instruments and a flexible camera in a single 2.5 cm cannula. We present the first case of robotic liver resection using the da Vinci SP system and demonstrate the technical feasibility of this platform.Patient concerns and diagnosis:A 63-year-old woman presented with elevated liver function test results and abdominal pain. Computed tomography (CT) and magnetic resonance cholangiopancreatography showed multiple intrahepatic duct stones in the left lateral section and distal common bile duct stones near the ampulla of Vater.Interventions:The docking time was 8 minute. The patient underwent successful da Vinci SP with a total operation time of 135 minute. The estimated blood loss was 50.0 ml. No significant intraoperative events were observed.Outcomes:The numerical pain intensity score was 3/10 in the immediate postoperative period and 1/10 on postoperative day 2. The patient was discharged on postoperative day 5 after verifying that the CT scan did not show any surgical complications.Conclusion:We report a technique of left lateral sectionectomy, without the use of an additional port, via the da Vinci SP system. The present case suggests that minor hepatic resection is technically feasible and safe with the new da Vinci SP system in select patients. For the active application of the da Vinci SP system in hepatobiliary surgery, further device development and research are needed.     

Focal atherosclerotic abdominal aortic stenosis

We report a case of a 54-year-old woman presenting a symptomatic focal atherosclerotic abdominal aortic stenosis. Computed tomographic angiography allowed to study the lesion, the abdominal aorta and its main branches. The patient was treated via an endovascular approach using a covered stent. The postoperative course was uneventful and the patient was asymptomatic with a patent reconstruction after 18 months. Improvement in endovascular technology has totally modified the treatment of focal atherosclerotic abdominal aortic stenosis. However, many technical points remain to be determined including the necessity of systematic stenting, the type of stent to use, and the steps of the procedure.     

Periarteritis nodosa complicated by intrapancreatic vascular rupture

Clinical pancreatic manifestations are unusual in polyarteritis nodosa. A case of intrapancreatic hemorrhage due to vascular rupture occurring during the course of histologically proven polyarteritis nodosa is described. The patient presented with massive hemoperitoneum requiring emergency laparotomy. Splenopancreatectomy was performed to control bleeding. Steroid therapy was continued during the postoperative course, with favorable outcome. The mechanism of vascular rupture is not clear, but is probably related to focal arteritis with consequent infarction. No ruptured microaneurysm was found in this case.     

Reversible posterior leukoencephalopathy in a patient with non-Hodgkin's lymphoma after treatment with CHOP

Reversible posterior leukoencephalopathy syndrome is a newly characterised and increasingly recognized clinico-radiologic syndrome. Underlying conditions that reportedly trigger this syndrome include hypertensive encephalopathy, eclampsia, renal failure, and immunosuppressive drug therapy with cyclosporine, tacrolimus and interferon alpha. We describe a 51-year-old woman with non-Hodgkin's lymphoma treated with conventional CHOP chemotherapy. Eight days after this treatment she developed severe headache, bilateral visual loss and focal seizures with secondary generalization. Neurologic examination showed confusion, cortical blindness, and left hemiparesis with hyperreflexia and sensory loss. A cranial T2-weighted magnetic resonance imaging revealed increased signal intensity in the occipital and frontal lobes in both hemispheres and right parietal lobe. A diagnosis of reversible posterior leukoencephalopathy was made. She presented a favourable outcome with conservative treatment with mannitol and phenytoin. A new cranial scanning showed nearly complete resolution of the abnormalities. To the best of our knowledge, this is the first case of reversible posterior leukoencephalopathy in a patient treated with standard-dose CHOP. In this patient, we confirm the theoretical pathophysiologic mechanisms suggested explaining how these drugs can cause the syndrome.     

Patient with positional wheezing due to endobronchial lipomatous hamartoma

Endobronchial hamartoma is a rare form of pulmonary hamartoma, and endobronchial lipomatous hamartomas are even rarer. We describe the case of a 39-year-old man who presented with a two-year history of dyspnea on exertion and wheezing over the left chest only while lying on his left side. The patient was diagnosed with endobronchial lipomatous hamartoma occluding the left main bronchus. He underwent a superior segmentectomy of the left lower lobe, which promptly relieved the dyspnea and positional wheezing. To our knowledge, fewer than 10 such cases are cited in the English literature, none of which presented with positional wheezing. This patient represents the first case of focal and positional wheezing resulting from endobronchial lipomatous hamartoma.