Stroke of a cardiac myxoma origin

Objective

The clinical features of cardiac myxoma stroke have not been sufficiently described. Debates remain concerning the options and timing of treatment and the clinical outcomes are unknown. This article aims to highlight the pertinent aspects of this rare condition.

Methods

Data source of the present study came from a comprehensive literature collection of cardiac myxoma stroke in PubMed, Google search engine and Highwire Press for the year range 2000-2014.

Results

Young adults, female predominance, single cerebral vessel (mostly the middle cerebral artery), multiple territory involvements and solitary left atrial myxoma constituted the outstanding characteristics of this patient setting. The most common affected cerebral vessel (the middle cerebral artery) and areas (the basal ganglion, cerebellum and parietal and temporal regions) corresponded well to the common manifestations of this patient setting, such as conscious alteration, ataxia, hemiparesis and hemiplegia, aphasia and dysarthria. Initial computed tomography scan carried a higher false negative rate for the diagnosis of cerebral infarction than magnetic resonance imaging did. A delayed surgical resection of cardiac myxoma was associated with an increased risk of potential consequences in particular otherwise arterial embolism. The mortality rate of this patient population was 15.3%.

Conclusion

Cardiac myxoma stroke is rare. Often does it affect young females. For an improved diagnostic accuracy, magnetic resonance imaging of the brain and echocardiography are imperative for young stroke patients in identifying the cerebral infarct and determining the stroke of a cardiac origin. Immediate thrombolytic therapy may completely resolve the cerebral stroke and improve the neurologic function of the patients. An early surgical resection of cardiac myxoma is recommended in patients with not large territory cerebral infarct.     

Infected Cardiac Myxoma: an Updated Review

OBJECTIVE

This study aims to present an updated clinical picture of the infected cardiac myxoma. Revankar & Clark made a systematic review of infected cardiac myxoma based on the literature before 1998. Since then, there has not been any updated information describing its recent changing trends.

METHODS

A comprehensive literature search of infected cardiac myxoma was conducted on MEDLINE, Highwire Press and Google between 1998 and 2014.

RESULTS

In comparison with Revankar & Clark''s series, the present series disclosed a significantly decreased overall mortality. It is believed that refinement of the prompt diagnosis and timely management (use of sensitive antibiotics and surgical resection of the infected myxoma) have resulted in better outcomes of such patients.

CONCLUSION

The present series of infected cardiac myxoma illustrated some aggravated clinical manifestations (relative more occasions of high-grade fever, multiple embolic events and the presence of refractory microorganisms), which should draw enough attention to careful diagnosis and treatment. In general, the prognosis of infected cardiac myxoma is relatively benign and the long-term survival is always promising.     

Right ventricular myxoma in a patient with tetralogy of Fallot

INTRODUCTION

Cardiac myxoma is the most common primary cardiac tumour in adulthood and may present in the context of Carney''s complex.

PRESENTATION OF CASE

A 32-year-old male with a history of repaired tetralogy of Fallot in childhood was admitted with severe pulmonary valve regurgitation and a mobile mass in the right ventricle. The patient underwent pulmonary valve replacement and mass excision. Pathology examination showed myxoma.

DISCUSSION

In the majority of cases myxomas originate in the atria, nevertheless they can also be found in a ventricular cavity. Myxoma is a prevalent feature of Carney''s complex, an inherited, autosomal disease, characterised by multiple tumours in several organs. Tetralogy of Fallot has also been described in association with Carney''s complex.

CONCLUSION

Coexistence of tetralogy of Fallot with a cardiac ventricular myxoma in a patient not affected from Carney''s complex or other familial syndrome.     

Comparison of Ovulation Induction Protocols After Endometrioma Resection

Background and Objectives:

The aim of this study was to compare the in vitro fertilization (IVF) outcomes of long gonadotropin-releasing hormone agonist (GnRH-a) and GnRH-antagonist (GnRH-ant) protocols in endometriosis patients who have undergone laparoscopic endometrioma resection surgery. To our knowledge, there is no study in the current literature that compares the effectiveness of long GnRH-a and GnRH-ant protocols in management of IVF cycles in endometriosis patients who underwent laparoscopic endometrioma resection surgery.

Methods:

Eighty-six patients with stage III to IV endometriosis who had undergone laparoscopic resection surgery for endometrioma were divided into 2 groups: those who had ovarian stimulation with a long GnRH-a protocol (n = 44), and those who had ovarian stimulation with a GnRH-ant protocol (n = 42).

Results:

The number of follicles on human chorionic gonadotropin injection day, duration of hyperstimulation, number of retrieved metaphase II oocytes, and total number of grade 1 embryos were statically significantly higher in the long GnRH-a protocol. There were no significant differences in positive β-human chorionic gonadotropin pregnancy rates (25% vs 21.4%; P = .269) and ongoing pregnancy rates per patient (20.5% vs 19.1%; P = .302) between the 2 protocols.

Conclusions:

Long GnRH-a and GnRH-ant protocols both present similar IVF outcomes in patients with endometriosis who have undergone laparoscopic endometrioma resection surgery. A long GnRH-a protocol may lead to a higher number of embryos that can be cryopreserved, providing the possibility of additional embryo transfers without having to go through the process of ovarian stimulation again.     

Chronic stress and coping among cardiac surgeons: a single center study

Introduction

Cardiac surgeons stress may impair their quality of life and professional practice.

Objective

To assess perceived chronic stress and coping strategies among cardiac surgeons.

Methods

Twenty-two cardiac surgeons answered two self-assessment questionnaires, the Trier Inventory for Chronic Stress and the German SGV for coping strategies.

Results

Participants mean age was 40±14.1 years and 13 were male; eight were senior physicians and 14 were residents. Mean values for the Trier Inventory for Chronic Stress were within the normal range. Unexperienced physicians had significantly higher levels of dissatisfaction at work, lack of social recognition, and isolation (P<0.05). Coping strategies such as play down, distraction from situation, and substitutional satisfaction were also significantly more frequent among unexperienced surgeons. "Negative" stress-coping strategies occur more often in experienced than in younger colleagues (P=0.029). Female surgeons felt more exposed to overwork (P=0.04) and social stress (P=0.03).

Conclusion

Cardiac surgeons show a tendency to high perception of chronic stress phenomena and vulnerability for negative coping strategies.     

Small-bowel resection for metastatic melanoma

Objective

To determine whether complete resection of small-bowel metastases from melanoma improves patient survival.

Design

A computer-aided chart review.

Setting

Hospitals associated with McGill University.

Patients

Twenty patients (17 men, 3 women), identified from 1524 patients with melanoma, who underwent surgery to the small bowel for metastases. Patient age and clinical presentation, tumour site and stage were recorded.

Intervention

Exploratory laparotomy with complete or partial resection of involved small bowel.

Main Outcome Measures

Operative morbidity, mortality and length of survival related to the extent of small-bowel resection.

Results

Eleven patients had complete resection, 8 patients had partial resection and 1 patient had a palliative bypass only. Long-term survival (ranging from 2 to 10 years) was 36% in those who had complete resection and 0% in those who had partial resection; operative morbidity and mortality were 20% and 15% respectively.

Conclusion

Complete resection of small-bowel metastases in patients with metastatic melanoma can result in long-term survival.     

A giant right atrial villous myxoma with simultaneous pulmonary embolism

INTRODUCTION

Primary cardiac tumors are rare and approximately three quarters of them are benign and up to half of the benign tumors are myxomas. Right atrial villous myxoma with pulmonary embolism is an unusual apparition.

PRESENTATION OF CASE

A 29 year-old male was admitted to our outpatient clinic with progressive exertional dyspnea, chest pain and intermittent feeling faint. A giant right atrial villous mobile mass was detected by means of transthoracic echocardiography. To exclude possible pulmonary embolism, chest computed tomography scan was performed and showed filling defects in the branch of the pulmonary artery. The mass was totally resected.

DISCUSSION

RA villous myxoma is a rare subtype in an unusual location with high potential of pulmonary embolism. Early surgery for villous myxoma has a great importance in order to reduce the risk of pulmonary embolism.

CONCLUSION

3D TEE should be a sufficient technique for diagnosis and evoluation of shape, size and origin of the cardiac mass an adequate guide to surgical treatment.     

Gastric cancer surgery--a balance of risk and radicality

INTRODUCTION

The aim of this study was to determine whether tailoring the extent of resection would allow radical gastric cancer surgery to be performed safely in a UK population.

PATIENTS AND METHODS

A total of 180 consecutive patients (median age 70 years; male:female ratio 2:1) undergoing resection for gastric adenocarcinoma with curative intent were studied. Extent of lymphadenectomy was based upon pre-operative and intra-operative staging, and balanced against the patient''s age and fitness.

RESULTS

In the study group, 83 patients underwent subtotal or distal partial gastrectomy and 97 patients underwent total or proximal partial gastrectomy. Operative procedures were: D1 lymphadenectomy (n = 62); modified (spleen and pancreas preserving) D2 lymphadenectomy (n = 73); D2 lymphadenectomy (n = 42); and extended resection (n = 3). TNM classification was: stage 1 (n = 45); stage 2 (n = 37); stage 3 (n = 61); and stage 4 (n = 37). Of the patients, 48 developed postoperative complications including 17 patients with a major surgical complication. The in-hospital mortality was 1.7% (3 of 180). Predicted mortality according to POSSUM and P-POSSUM was 21.4% and 7.8%, respectively. Disease-specific 5-year survival according to stage was 85.4%, 64.2%, 33.3%, and 6.9%.

CONCLUSIONS

By tailoring the extent of resection and balancing risk and radicality, gastric cancer surgery can be performed with low mortality in Western patients.     

Cardiac resynchronization therapy in patients with chronic Chagas cardiomyopathy: long-term follow up

Introduction

Chagas disease is a major cause of cardiomyopathy and sudden death in our country. It has a high mortality when their patients develop New York Heart Association (NYHA) class IV.

Objective

The objective of this study is to analyze the clinical outcome of patients with Chagas'' cardiomyopathy with congestive heart failure with optimized pharmacological therapy, undergoing cardiac resynchronization therapy.

Methods

Between January 2004 and February 2009, 72 patients with Chagas'' cardiomyopathy in NYHA class III and IV underwent cardiac resynchronization therapy and were monitored to assess their clinical evolution. We used the t test or the Wilcoxon test to compare the same variable in two different times. A P value < 0.05 was established as statistically significant.

Results

The average clinical follow-up was 46.6 months (range 4-79 months). At the end of the evaluation, 87.4% of patients were in NYHA class I or II (P<0.001). There was response to therapy in 65.3% of patients (P<0.001), with an overall mortality of 34.7%.

Conclusion

In patients with chronic Chagas cardiomyopathy undergoing cardiac resynchronization therapy, we found the following statistically significant changes: improvement in NYHA class and increase of left ventricle ejection fraction, a decrease of the systolic final diameter and systolic final left ventricle volume and improvement of patient survival.     

Non-Gynecologic Laparoscopy in Second and Third Trimester Pregnancy: Obstetric Implications

Purpose:

To review the effect of non-gynecologic laparoscopic procedures performed during the second and third trimesters of pregnancy on pregnancy outcome.

Materials and Methods:

A review of the patient log for the antenatal obstetrical unit was used to identify the patients in this series from January 1, 1997 to December 31, 1997. Medical records were then analyzed to identify estimated gestational age at surgery and delivery, type of delivery, use of tocolysis, and complications from surgery.

Results:

Nine patients were identified as having non-gynecologic laparoscopic surgery (without conversion to laparotomy) during the second or third trimester of pregnancy. The median estimated gestational age at surgery was 25 weeks (mean 24 weeks). The most common procedure performed was laparoscopic cholecystectomy (6 patients). Five patients received tocolysis after the initial procedure. All patients delivered at greater than or equal to 37 weeks estimated gestational age (median 38 weeks). No infants were admitted to the neonatal intensive care unit.

Conclusions:

Laparoscopic procedures appear safe in second and third trimester pregnancy. In this study, laparoscopic cholecystectomies were performed as late as 34 weeks estimated gestational age without any adverse effects on pregnancy outcome.     

Simultaneous liver resection and double cardiac valve replacement. A case report

INTRODUCTION

We present a rare case in which both a double cardiac valve replacement was performed as well as a hepatic resection.

PRESENTATION OF CASE

We report the case of a 36 year old patient who presented with intra abdominal bleeding thought to have been caused by a liver haemangioma she also had severe autoimmune cardiac valve disease. She underwent a simultaneous right hepatectomy with cardiac valve replacement.

DISCUSSION

Management of this challenging case is discussed.

CONCLUSION

We advocate the possibility of performing combined operations where both valve replacement and hepatic resection is required.     

Surgical management of symptomatic hydatid liver disease: experience from a Western centre

Background

Hydatid liver cysts are rare in North America. The objective of this study was to determine the optimal surgical management for hydatid liver cysts treated outside endemic areas.

Methods

We reviewed the cases of consecutive patients who underwent management of hydatid liver cysts. Radical liver resections were compared with other types of procedures. Clinical presentation, investigations, perioperative outcomes and long-term follow-up were evaluated. We evaluated disease recurrence using the Kaplan–Meier method.

Results

Forty patients underwent surgery for hydatid liver cysts. Most patients had single (68%) right-sided (46%) cysts with a median size of 10 cm. Most (83%) underwent liver resection with or without drainage/marsupialization. Radical liver resection was carried out in 60% (19 major, 5 minor). Additional procedures were required in 50% (biliary fistulization 30%, diaphragmatic fistulization 20% or paracaval location/ fusion 8%). Postoperative complications occurred in 48%. The median follow-up was 39 months. The 3-year recurrence-free survival was significantly different between patients who had radical resection and those who had other procedures (100% v. 71%, p = 0.002).

Conclusion

The surgical management of hydatid liver cysts in North America remains rare and challenging and is frequently associated with fistulizing complications. Excellent long-term outcomes are best achieved using principles of radical liver resection that are familiar to North American surgeons.     

The value of intraoperative ultrasound and preoperative imaging, individually and in combination, in liver resection for metastatic colorectal cancer

INTRODUCTION

Liver resection is proved to offer potential long-term survival for colorectal liver metastases (CRLM). Accurate radiological assessment is vital to enable an appropriate surgical approach. The role of intraoperative ultrasound (IOUS) has been controversial. This study was designed to analyse the accuracy of IOUS compared with that of preoperative imaging (POI) in these patients.

MATERIALS AND METHODS

A prospective analysis of 51 consecutive patients who underwent liver resection for CRLM was undertaken. The accuracy of POI and IOUS were correlated and compared with histopathological analysis. Statistical analyses included t-tests, to compare continuous variables, and chi-square and Fisher’s exact tests to compare categorical variables. p<0.05 was considered significant

RESULTS

POI correlated with histology in 35 patients (68.6%). The sensitivity and specificity were 82.4% and 86.3% respectively. IOUS correlated with histology in 31 (60.8%) patients. The sensitivity and specificity were 84.3% and 76.5% respectively. There was no difference in accuracy between modalities. The accuracy of POI combined with IOUS correlated with histology in 40 patients (78.4%). The sensitivity and specificity were 88.2% and 84.3% respectively. The accuracy of combined modalities was significantly greater than IOUS or POI alone.

CONCLUSIONS

POI combined with IOUS may significantly increase the diagnostic accuracy of patients undergoing liver resection for CRLM.     

Is prophylactic resection valid as an indication for elective surgery in diverticular disease?

Objective

To determine whether interval resection in asymptomatic patients after 1 or 2 episodes of acute diverticulitis (prophylactic resection) is justified as a means of preventing late inflammatory complications of diverticular disease.

Design

A retrospective analysis.

Setting

A university-affiliated tertiary care hospital.

Patients

Those requiring hospitalization from 1987 to 1995 for treatment of acquired diverticular disease of the colon. Twenty-eight patients underwent elective resection and 154 were treated for inflammatory complications (perforation, fistula, complete large-bowel obstruction).

Interventions

Standard surgical management for diverticular disease, but only 3 prophylactic resections were undertaken during this period.

Outcome measures

Type of operation, stoma creation and closure, hospital death. In those treated for complicated disease, the effects on outcome of all previous outpatient treatment and hospitalizations.

Results

Only 10% of those presenting with complications had been treated conservatively for acute diverticulitis and only 5% had been hospitalized for this reason.

Conclusions

Prophylactic resection is unlikely to prevent late major complications of diverticular disease; therefore, as an elective indication for surgery in this disease its use is questionable.     

Early and late outcomes after cardiac retransplantation

Background

Cardiac retransplantation remains the most viable option for patients with allograft heart failure; however, careful patient selection is paramount considering limited allograft resources. We analyzed clinical outcomes following retransplantation in an academic, tertiary care institution.

Methods

Between 1981 and 2011, 593 heart transplantations, including 22 retransplantations were performed at our institution. We analyzed the preoperative demographic characteristics, cause of allograft loss, short- and long-term surgical outcomes and cause of death among patients who had cardiac retransplantations.

Results

Twenty-two patients underwent retransplantation: 10 for graft vascular disease, 7 for acute rejection and 5 for primary graft failure. Mean age at retransplantation was 43 (standard deviation [SD] 15) years; 6 patients were women. Thirteen patients were critically ill preoperatively, requiring inotropes and/or mechanical support. The median interval between primary and retransplantation was 2.2 (range 0–16) years. Thirty-day mortality was 31.8%, and conditional (> 30 d) 1-, 5- and 10-year survival after retransplantation were 93%, 79% and 59%, respectively. A diagnosis of allograft vasculopathy (p = 0.008) and an interval between primary and retransplantation greater than 1 year (p = 0.016) had a significantly favourable impact on 30-day mortality. The median and mean survival after retransplantation were 3.3 and 5 (SD 6, range 0–18) years, respectively; graft vascular disease and multiorgan failure were the most common causes of death.

Conclusion

Long-term outcomes for primary and retransplantation are similar if patients survive the 30-day postoperative period. Retransplantation within 1 year of the primary transplantation resulted in a high perioperative mortality and thus may be a contraindication to retransplantation.     

Comparison of 5-, 10-, and 15-Point Laparoscopic Ovarian Electrocauterization in Patients With Polycystic Ovarian Disease: a Prospective, Randomized Study

Objective:

We compared 12-month pregnancy and live birth rates in patients with polycystic ovarian disease undergoing 5-, 10-, and 15-point laparoscopic ovarian electrocauterization.

Methods:

This was a prospective, randomized study performed at the Dabirashrafi Fertility and Endoscopy Research Center, Tehran, Iran. The study included 187 patients with polycystic ovarian disease who were randomly assigned to 3 groups. Group I comprised 67 patients whose ovaries received 5-point electrocauterization. Group II comprised 57 patients whose ovaries received 10-point electrocauterization. Group III comprised 63 patients whose ovaries received 15-point electocauterization.Laparoscopic ovarian electrocauterization with a unipolar current was used. The main outcome measures were 12-month pregnancy and live birth rates.

Results:

Patients were homogeneous for age, body mass index, and type and duration of infertility. Twenty pregnancies resulted in Group I, with a pregnancy rate of 29.9% (20/67) and a live birth rate of 20.9% (14/57). Eighteen pregnancies resulted in Group II, with a pregnancy rate of 31.6% (18/57), and a live birth rate of 28.1% (16/57).Thirty-three pregnancies resulted in group III, with a pregnancy rate of 52.4% (33/63), and a live birth rate of 47.6% (30/63). Comparison of Group III with Groups I and II revealed a statistically significant increase in pregnancies (P=0.016) and live birth rates (P=0.004).

Conclusion:

We recommend 15-point electrocauterization of ovaries in patients with polycystic ovarian disease.     

Complications of Liver Resection: Laparoscopic Versus Open Procedures

Background and Objective:

Minimally invasive surgery for liver resection remains controversial. This study was designed to compare open versus laparoscopic surgical approaches to liver resection.

Methods:

We performed a single-center retrospective chart review.

Results:

We compared 45 laparoscopic liver resections with 17 open cases having equivalent resections based on anatomy and diagnosis. The overall complication rate was 25.8%. More open resection patients had complications (52.9% vs 15.5%, P < .008). The conversion rate was 11.1%. The mean blood loss was 667.1 ± 1450 mL in open cases versus 47.8 ± 89 mL in laparoscopic cases (P < .0001). Measures of intravenous narcotic use, intensive care unit length of stay, and hospital length of stay all favored the laparoscopic group. Patients were more likely to have complications or morbidity in the open resection group than in the laparoscopic group for both the anterolateral (P < .085) and posterosuperior (P < .002) resection subgroups.

Conclusion:

In this series comparing laparoscopic and open liver resections, there were fewer complications, more rapid recovery, and lower morbidity in the laparoscopic group, even for those resections involving the posterosuperior segments of the liver.     

Size of metastatic deposits affects prognosis in patients undergoing pulmonary metastectomy for colorectal cancer

INTRODUCTION

Pulmonary metastectomy for colorectal cancer (CRC) is a well accepted procedure although data regarding indications and prognostic outcomes are inconsistent. This study aimed to analyse our experience with resection of pulmonary CRC metastases to evaluate clinically relevant prognostic factors affecting survival.

METHODS

A retrospective analysis was undertaken of the records of all patients with pulmonary metastases from CRC who underwent a thoracotomy between 2004 and 2010 at a single surgical centre.

RESULTS

Sixty-six patients with pulmonary metastases from the colon (n=34) and the rectum (n=32) were identified. The 30-day hospital mortality rate was 0%, with 63 patients undergoing a R0 resection and 3 having a R1 resection. The median survival was 45 months and the cumulative 3-year survival rate was 61%. Size of pulmonary metastasis and ASA (American Society of Anesthesiologists) grade were statistically significant prognostic factors (p=0.047 and p=0.009 respectively) with lesions over 20mm associated with a worse prognosis. Sex, age, site, disease free interval (cut-off 36 months), primary tumour stage, hepatic metastases, number of metastases (solitary vs multiple), type of operation (wedge vs lobe resection), hilar lymph node involvement and administration of adjuvant chemotherapy were not found to be statistically significant prognostic factors.

CONCLUSIONS

Pulmonary metastectomy has a potential survival benefit for patients with metastatic CRC. Improved survival even in the presence of hepatic metastases or multiple pulmonary lesions justifies aggressive surgical management in carefully selected patients. In our cohort, size of metastatic deposit was a statistically significant poor prognostic factor.