Haemodynamic complications after pneumonectomy: atrial inflow obstruction and reopening of the foramen ovale.

BACKGROUND: Haemodynamic impairments after pneumonectomy are rare complications and present in different forms. Due to a low awareness of these potential complications their diagnosis is difficult and often established late. The most important forms are: firstly reopening of a previously closed foramen ovale (PFO) caused by a combination of changed anatomic position of the left atrium and elevated pulmonary artery pressure leading to a significant right-left shunt; secondly diaphragmatic relaxation can lead to a dislocation of the liver into the right hemithorax, compressing the right atrium with subsequent inflow obstruction. METHODS: We retrospectively analysed our patient cohort from 1997 to 2006 for occurrence of haemodynamic complications requiring surgical intervention after pneumonectomy. RESULTS: Five hundred and forty-six pneumonectomies were performed in our centre during the observation period. Five patients (1 female, 4 male, age 59+/-9 years) with haemodynamic complications were identified. Two of those patients were referred with haemodynamic complications after pneumonectomy was performed in a peripheral centre. All patients had undergone right pneumonectomy for NSCLC (n=4) or atypical carcinoid (n=1). Two patients were readmitted 3 months and 2 years postoperatively due to increasing platypnoea and orthodeoxia. After closure of the reopened foramen ovale, which was found as the underlying pathological mechanism, respiratory symptoms were resolved. One patient required reintubation 2h postoperatively; after surgical closure of a PFO the respiratory situation significantly improved. One patient was readmitted due to right atrial inflow obstruction 17 months after right pneumonectomy. Underlying cause was a severe diaphragmatic relaxation with compression of the atrium by the liver. After diaphragmatic plication all symptoms resolved. However 1 year thereafter reoperation for recurrence of diaphragmatic elevation was required. One patient was readmitted 3 months after pneumonectomy and partial atrial resection for cyanosis and dyspnoea. Diagnostics revealed a PFO and a massive raise of the right diaphragm with compression of the right atrium. After surgical correction of the contorted foramen ovale and diaphragmatic plication, symptoms vanished. CONCLUSION: Haemodynamic alterations due to a reopened foramen ovale or right atrial inflow obstruction are rare, however they are severe complications after pneumonectomy. They occur at variable points in time after pneumonectomy. Diagnostic efforts are often made at a late stage due to a low awareness of the problem. Closure of the PFO either surgical or interventional and/or plication of the elevated diaphragm are mandatory. In our experience these complications occur only after right pneumonectomy.     

Intestinale Angiodysplasie als Ursache schwerer Dünndarmblutungen — Bericht über vier Fälle

Summary Angiodysplasia of the small intestine alone cannot be differentiated histologically from hereditary hemorrhagic telangiectasia (Morbus Rendu-Osler-Weber). Isolated localisation in the small intestine is rare and requires surgery in the event of massive bleeding. Four cases of bleeding from angiodysplasias of the small intestine in patients having undergone surgery at our institution over a ten-year period are presented. In three patients the particular intestine was resected. Two of these patients had an uneventful follow-up of even and ten years, one patient relapsed and was rehospitalized for surgical treatment. The fourth patient, who showed angiodysplasias scattered over the entire small intestine, had no further bleeding over a three-year period after transmural ligations of the lesions found by intraoperative endoscopical diaphany.

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Perforated Diverticulitis with Generalized Peritonitis: Low Stoma Rate Using a “Damage Control Strategy”

Purpose

Optimal surgical management of perforated diverticulitis of the sigmoid colon has yet to be clearly defined. The purpose of this study was to evaluate efficacy of a “Damage Control Strategy” (DCS).

Materials and methods

Patients with perforated diverticulitis of the sigmoid colon complicated by generalized peritonitis (Hinchey III and IV) surgically treated according to a damage control strategy between May 2011 and February 2017 were enrolled in the present multicenter retrospective cohort study. Data were collected at three surgical centers. DCS comprises a two-stage concept: [1] limited resection of the perforated colon segment with oral and aboral blind closure during the emergency procedure and [2] definitive reconstruction at scheduled second laparotomy (anastomosis???loop ileostomy or a Hartmann’s procedure) after 24–48?h.

Results

Fifty-eight patients were included into the analysis [W:M 28:30, median age 70.1 years (30–92)]. Eleven patients (19%) initially presented with fecal peritonitis (Hinchey IV) and 47 patients with purulent peritonitis (Hinchey III). An anastomosis could be created during the second procedure in 48 patients (83%), 14 of those received an additional loop ileostomy. In the remaining ten patients (n?=?17%), an end colostomy was created at second laparotomy. A fecal diversion was performed in five patients to treat anastomotic complications. Thus, altogether, 29 patients (50%) had stoma at the end of the hospital stay. The postoperative mortality was 9% (n?=?5), and median postoperative hospital stay was 18.5 days (3–66). At the end of the follow-up, 44 of 53 surviving patients were stoma free (83%).

Conclusion

The use of the Damage Control strategy leads to a comparatively low stoma rate in patients suffering from perforated diverticulitis with generalized peritonitis.

     

Paroxetine decreases platelet serotonin storage and platelet function in human beings

BACKGROUND: Serotonin is a platelet agonist and potent vasoconstrictor that has recently received attention concerning its potential role in acute coronary artery thrombosis. Selective serotonin-reuptake inhibitors, such as paroxetine, are widely used antidepressant agents. We sought to characterize the potential inhibitory effect of paroxetine on platelet function. METHODS: Healthy male volunteers received 20 mg/d paroxetine for 2 weeks in a randomized, double-blind, placebo-controlled, two-way cross-over trial. RESULTS: Paroxetine decreased intraplatelet serotonin concentrations by -83% (P < .01). This inhibited platelet plug formation as reflected by a 31% prolongation of closure time measured with the platelet function analyzer-100 (P < .05). Furthermore, paroxetine lowered expression of the platelet activation marker CD63 in response to two different concentrations of thrombin receptor-activating peptide (P < .01). Plasma concentrations of prothrombin fragment, von Willebrand factor antigen, and circulating P-selectin remained unchanged in either period, indicating that paroxetine does not increase activation of coagulation, endothelium, or platelets in vivo, underlining a favorable safety profile. CONCLUSIONS: Paroxetine substantially decreases intraplatelet serotonin content and thereby reduces platelet plug formation under shear stress, and responsiveness to thrombin receptor activating peptide-induced platelet activation. Further studies will reveal whether these pharmacodynamic effects can be exploited for treatment of thrombotic artery disease.     

Isoprostanes as Markers of Oxidative Stress-Induced Cell Damage in Porcine Islet Cell Isolation

Introduction

Mechanical stress and reagents used during the isolation and purification process as well as digestion time and temperature can alter the success of porcine islet cell (PIC) isolation. This study aimed to characterize the occurrence of isoprostanes during PIC isolation using a modified automated Ricordi method and to evaluate their influence on PIC isolation outcome.

Methods

Porcine pancreatic tissue was harvested at the local slaughter house, and 10 PIC isolations were performed using a modified automated Ricordi method. As positive controls for tissue damage-associated oxidative stress, six consecutive PIC isolations were performed in the presence of 1 μg lipopolysaccharide (LPS). PIC were purified by density gradient centrifugation using the Lymphoprep density gradient. Isoprostane measurement was performed using enzyme-linked immunosorbent assay.

Results

The final yield of viable and pure PICs in the experimental group was 3479 ± 542 IEQ/g pancreas, and the LPS group yielded lower cell numbers compared to the experimental group. Isoprostane levels were significantly elevated in the LPS group as compared to the experimental group at all time points during the isolation from the beginning of the digestion process.

Discussion

PIC isolation and purification results significantly differed in the two experimental groups, underlining the negative effects of oxidative stress on PIC viability and purity, which impact negatively on PIC transplantation success.     

Die Nora-Läsion

Nora’s lesion, also known as “bizarre parosteal osteochondromatous proliferation” (BPOP), was first described in 1983 by the pathologist Nora. This lesion is defined as a proliferation of the bone. In most cases the lesion emanates from the intact cortical substance of short bones. It used to be assigned to reactive, heterotopic ossifications. More recent publications described constant genetic alterations supposing a tumorous genesis. Nora lesions are mostly found in the third or fourth decade of life; a preference of sexes is not described in the literature. They are characterized by a typical appearance in radiological diagnostics, but the diagnosis is ultimately determined by histopathological examination. Surgical resection is the therapy of choice. We report the case of a 29-year-old patient with an undetermined proliferation of the proximal ulna. The diagnosis of a Nora’s lesion was made. The therapeutic approach, differential diagnosis and corresponding literature are presented and discussed.