New Trends in Skeletal Reconstruction after Resection of Chest Wall Tumors

Involvement of the chest wall in malignant tumors, either primary or resulting from contiguous or metastatic spread, occurs in less than 5% of thoracic malignancies. From 1963 through 1978, 155 patients had chest wall resection in continuity with the tumor. Eighty-five tumors were carcinomas, and 70 were sarcomas.Since 1973 reconstruction of chest wall defects in 12 patients has included the use of a composite of Marlex mesh and methyl methacrylate. It provides an excellent replacement both physiologically and esthetically. Such a reconstructed chest wall has obviated the need for postoperative respiratory support.The overall mortality was 4.5% (7 out of 155). The 5-year survival in this varied group of patients is 20%. We believe excellent palliation can be achieved even in patients who are not potentially curable.     

Regional right ventricular function and timing of contraction in healthy volunteers evaluated by strain‐encoded MRI

Purpose

To prospectively determine the feasibility and accuracy of strain‐encoded (SENC) magnetic resonance imaging (MRI) for the characterization of the right ventricular free wall (RVFW) strain and timing of contraction at 3.0 Tesla (3T) MRI.

Materials and Methods

In 12 healthy volunteers the RVFW was divided into three segments (anterior, lateral, and inferior) in each of three short‐axis (SA) slices (apical, mid, and basal) and into three segments (apical, mid, and basal) in a four‐chamber view. The study was repeated on a different day and interobserver and interstudy agreements were evaluated.

Results

Maximal systolic longitudinal strain values were highest at the apex and base, with a pronounced decrease in the medial segments (apex: –19.1% ± 1.4; mid: –17.4% ± 2; base: –19.4% ± 2.4, P < 0.001), and maximal systolic circumferential strain showed the highest values at the apex (apex: –18.1% ± 1.7; mid: –17.6% ± 1.2; base: –16.6% ± 0.9, P < 0.001). Peak systolic longitudinal and circumferential shortening occurred earliest at the apex compared to the mid‐ventricle and base. Excellent interobserver and interstudy correlation and agreement were observed.

Conclusion

The use of SENC MRI for the assessment of normal RV contraction pattern is feasible and accurate in 3T MRI. J. Magn. Reson. Imaging 2008;28:1379–1385. © 2008 Wiley‐Liss, Inc.     

On-table Endoscopy Following Laparoscopic Fundoplication

Background Laparoscopic fundoplication represents the gold standard in the surgical management of gastro-esophageal reflux disease (GERD). The achievement of long-lasting symptomatic and physiological control of reflux is the goal of therapy, as well as the minimization of troubling sequelae, in particular, dysphagia. On-table endoscopy after fundoplication was introduced in this Unit as a quality initiative in an attempt to minimize dysphagia and technical errors, and the aim of this study is to report the experience to date, and compare outcomes with the previous 100 cases performed by an experienced team. Methods Eighty patients who underwent laparoscopic Rosetti-Nissen fundoplication and on-table endoscopy (group 2) were compared with 100 consecutive prior cases (group 1). Patients were prospectively evaluated and had pre- and postoperative symptom scoring and analysis of complications (all patients), and manometry and 24-h pH testing in 120 patients (60 in each group). Results Both groups were similar with respect to demographics, esophagitis, pH score, and dysmotility. No bougie was used in either group. On-table endoscopy resulted in technical modifications in 4 (5%) patients. Early grade 2 or 3 dysphagia was evident in 4 (5%) patients in group 2, compared with 15 (15%) in group 1 (p < 0.001). Late dysphagia was evident in one patient (1.5%) in group 2 compared with 7 (7%) in group 1 (p < 0.05). Dilatation was performed in four patients (5%) in group 2, compared with 11 (11%) in group 1 (p < 0.05). Conclusions These data suggest that on-table endoscopy may be a useful quality assurance adjunct in laparoscopic anti-reflux surgery, in particular, reducing the incidence of dysphagia and reinterventions.     

Short-term and long-term outcome in low body mass index patients undergoing cardiac surgery

Objective  We sought to assess the effect of low body mass index (BMI) on short- and long-term outcomes following cardiac surgery. Methods  This is a retrospective review of a prospectively collected departmental database over a 6-year period. Patients were eligible for the study if the BMI was <25 kg/m². All morbidities, length of hospital stay, and short- and long-term mortality were reviewed. Results  There were 704 patients divided into low (n = 71) and normal (n = 633) BMI. Postoperative pulmonary complications were higher in the low BMI group compared to the normal BMI group (24% vs. 11%, P < 0.001) with a higher incidence of in-hospital mortality (10% vs. 5%). Using multiple logistic regression, low BMI was an independent risk factor for in-hospital mortality. The 1-, 3-, and 5-year survivals for the low group were 90%, 78%, and 70% compared to 94%, 86%, and 81% in the normal BMI group. Conclusion  Low BMI is associated with increased morbidity and mortality following cardiac surgery. Risk scoring systems should utilize the BMI in the preoperative risk assessment with special attention to low BMI. This study was presented in poster form at the 7th international congress on coronary artery disease, Venice, Italy, October 2007.     

Thromboembolic Events Following Splenectomy: Risk Factors,Prevention, Management and Outcomes

Background

Thromboembolic events following splenectomy are not uncommon. However, the role of thromboprophylaxis and risk factors for thrombosis, as well as the clinical course and outcomes, are not well characterized.

Methods

A retrospective review of individuals who underwent splenectomy between January 2006 and December 2015 in two university hospitals.

Results

Overall, 297 patients underwent splenectomy [open splenectomy (n = 199), laparoscopic splenectomy (n = 98)]. Mechanical (thigh-length pneumatic compression stockings) and pharmacologic thromboprophylaxis (40 mg enoxaparin daily, starting 12 h after surgery until discharge) was provided for all patients. One hundred and sixteen patients (39%) also received an extended thromboprophylaxis course of enoxaparin for 2–4 weeks after discharge. Twenty-three patients (7.7%) experienced thrombotic complications following splenectomy, including 16 cases (5.4%) of portal-splenic mesenteric venous thrombosis (PSMVT), 5 (1.7%) pulmonary embolism and 2 (0.7%) deep vein thrombosis. Longer operative time (mean operative time of 405 vs. 273 min, P = 0.03) was independently associated with PSMVT. Post-splenectomy thrombocytosis was not associated with thrombosis (P = 0.41). The overall thrombosis rate was significantly lower in patients who received an extended thromboprophylaxis course following splenectomy (3.4 vs. 10.5%, P = 0.02). Complete resolution of thrombosis was observed in most cases (n = 20, 87.0%), with no recurrent thrombosis during a mean follow-up of 38 ± 25 months.

Conclusions

Thromboembolic complications, mainly PSMVT, are common following splenectomy. Longer operative time was associated with thrombosis. Significantly lower rates of thrombosis were found in patients who received an extended thromboprophylaxis course.