Primary Laryngotracheal Amyloidosis With Bilateral Vocal Cord Involvement and Associated Bronchiectasis.

Localized tracheobronchial amyloidosis is a rare disease that results from submucosal deposition of insoluble amyloid proteins in the large airways. Amyloidosis affecting the larynx and subglottic space typically results in unilateral, nodular vocal cord infiltration. It rarely can present with bilateral vocal cord involvement and can progress to lifethreatening respiratory failure due to upper airway obstruction.

Biopsy trauma dislodges thymocytes from a thymoma to fill regional lymph node sinusoids.

We present a case of an incisional thymoma biopsy causing dissemination of thymocytes to a regional lymph node. Lymphatic seeding from circulating tumor cells is a distinct mechanism of tumor spread. We review the literature relevant to operative trauma as a cause of tumor cell migration to nearby lymph nodes.

Use of Dual, Tubularized Supraclavicular Artery Island Flaps in Series to Restore Gastrointestinal Continuity After a Failed Ileocolic Esophageal Reconstruction.

The supraclavicular artery island flap (SCAIF) is a versatile pedicled flap that can be an excellent alternative to free flap reconstruction in complex head and neck defects. We use the SCAIF routinely as a first-line option for many of our soft tissue head and neck reconstructions. Here we describe a novel application of dual SCAIFs used in series for proximal esophageal reconstruction.

Penetrating cardiac injury and the significance of chest computed tomography findings.

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed.

Versatility of a mini-trapdoor incision in upper mediastinal exposure.

Exposure of the upper mediastinum and thoracic outlet can pose major surgical challenges. We report our application of a previously described mini-trapdoor incision to a variety of surgical problems involving the upper mediastinum and thoracic outlet, including subclavian vein thrombosis, penetrating subclavian artery injury, debridement of subjacent chest wall infection, lymph node excision, and Pancoast tumor resection. This versatile approach provides excellent structural visualization while obviating clavicular resection or sternoclavicular joint disruption, or both.

The use of human acellular dermal matrix for chest wall reconstruction.

Background: Reconstruction of chest wall defects has evolved, but challenges remain. This is particularly true when defects are large or contamination is present. Although numerous materials are available for reconstruction, acellular dermal matrix has the advantage of becoming vascularized and incorporated autologously.

Damage control: cavoatrial anastomosis during a catastrophic right intrapericardial pneumonectomy.

While undergoing an intrapericardial pneumonectomy for a massive right pulmonary inflammatory pseudotumor that had invaded the mediastinum, an 18-year-old woman experienced a nearly fatal iatrogenic complication. Dense scarring adjacent to the pseudotumor had drawn in the superior vena cava posterolaterally and fused the right main pulmonary artery to the right superior pulmonary vein within the pericardium. The failure of a linear stapler to secure the pulmonary vessels led to torrential hemorrhage.

Thoracoscopic thoracic duct ligation for persistent cervical chyle leak: utility of immediate pathologic confirmation.

Objective: Chylous fistulas can occur after neck surgery. Both nonoperative measures and direct fistula ligation may lead to fistula resolution. However, a refractory fistula requires upstream thoracic duct ligation.

Hilar control in penetrating chest trauma: a simplified approach to an underutilized maneuver.

Background: In both urban and military settings, penetrating thoracic injuries remain a significant source of trauma-related mortality, and many patients require resuscitative thoracotomy. Existing literature emphasizes relief of pericardial tamponade and aortic clamp application as the key therapeutic maneuvers. The purpose of this report is to revisit pulmonary hilar clamping and highlight its application for hemorrhage control, air embolism prevention, and other benefits in the setting of massive hemothorax.

Benign esophagobronchial fistula with and without esophageal obstruction: two ends of the surgical spectrum.

Acquired esophagobronchial fistula (EBF) is uncommon and its surgical remediation is challenging. Management depends on the cause, degree of pulmonary involvement, and existence of esophageal obstruction. We report management of two EBF cases representing extremes of the surgical spectrum.

Comparison of fungal culture versus surgical pathology examination in the detection of Histoplasma in surgically excised pulmonary granulomas.

Context: Granulomatous pulmonary nodules are common in areas endemic for Histoplasma infection, and may require surgical excision to exclude neoplasia. Surgeons may elect to routinely send material directly to the clinical microbiology laboratory for fungal and mycobacterial cultures.

Objective: To determine if tissue from surgically excised pulmonary granulomatous nodules removed from patients in a geographic area endemic for Histoplasma infection should be routinely submitted for fungal culture.

Closure of a bronchopleural fistula using bronchoscopic placement of an endobronchial valve designed for the treatment of emphysema.

Pneumothoraces are sometimes complicated by a persistent air leak or bronchopleural fistula requiring prolonged chest tube drainage. Non-surgical treatment of persistent bronchopleural fistulas is often performed in patients who are poor surgical candidates, but the ideal method of closure is not known. Here we report closure of a persistent distal bronchopleural fistula using a one-way endobronchial valve designed for the treatment of emphysema.

Devices for lung isolation used by anesthesiologists with limited thoracic experience: comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker.

Background: Lung isolation is accomplished with a double-lumen tube or a bronchial blocker. Previous studies comparing lung isolation methods were performed by experienced anesthesiologists in thoracic anesthesia. Therefore, the results of these studies may not be relevant to the anesthesiologist with limited experience.

Hyperbaric oxygen treatment of hemorrhagic radiation-induced gastritis after esophagectomy.

My colleagues and I present 2 cases of hemorrhagic postesophagectomy gastritis after chemoradiotherapy for esophageal cancer. On the basis of the location of the gastritis (lesser curve and midstomach) and the classic radiation injury appearance, radiation damage was believed to be the cause. In both patients, hyperbaric oxygen therapy rapidly arrested bleeding.

Ontogeny of vascular growth factors in perinatal sheep myocardium.

Objective: To examine developmental changes in myocardial gene expression of previously identified regulators of vascular growth.

Methods: Ovine left (LV) and right ventricle (RV) samples were obtained at four time points: 95 days' and 140 days' gestation (term = 145 days) and 7 days and 8 weeks postnatally. mRNA and protein levels of vascular endothelial growth factor (VEGF), its respective receptors (Flk-1 and Flt-1), basic fibroblast growth factor (bFGF), transforming growth factor-beta1 (TGF-beta1), and endothelial nitric oxide synthase (eNOS) were measured at these different time points.

Myocardial apoptosis after cardioplegic arrest in the neonatal lamb.

Objective: Myocardial apoptosis is observed after various cardiac injuries and is also a normal part of fetal cardiac development and early postnatal maturation. Cardioplegic arrest and reperfusion result in ischemic injury and oxidative stress, known triggers of apoptosis. Because the neonatal heart is in a proapoptotic state, we hypothesize that apoptosis is triggered after cardioplegic arrest in neonatal myocardium.

The modified Konno procedure for complex left ventricular outflow tract obstruction.

Background: Complex left ventricular outflow tract (LVOT) obstruction with normal aortic valve function requires aggressive resection in the subaortic region and preservation of the aortic valve. The modified Konno procedure allows generous exposure of the LVOT from the left ventricular apex to the inter leaflet trigones of the aortic valve. Widespread use of this procedure has been limited by concern over injury to the aortic valve, the conduction system, and possibility of residual ventricular septal defect (VSD).

Metabolic adaptation of the fetal and postnatal ovine heart: regulatory role of hypoxia-inducible factors and nuclear respiratory factor-1.

Numerous metabolic adaptations occur in the heart after birth. Important transcription factors that regulate expression of the glycolytic and mitochondrial oxidative genes are hypoxia-inducible factors (HIF-1alpha and -2alpha) and nuclear respiratory factor-1 (NRF-1). The goal of this study was to examine expression of HIF-1alpha, HIF-2alpha, and NRF-1 and the genes they regulate in pre- and postnatal myocardium.

Effects of fetal ovine adrenalectomy on sympathetic and baroreflex responses at birth.

Studies were performed to test the hypothesis that the absence of adrenal glucocorticoids late in gestation alters sympathetic and baroreflex responses before and immediately after birth. Fetal sheep at 130-131 days gestation (term 145 days) were subjected to bilateral adrenalectomy before the normal prepartum increase in plasma cortisol levels. One group of fetuses (n = 5) received physiological cortisol replacement with a continuous infusion of hydrocortisone (2 mg x day(-1) x kg(-1) for 10 days), whereas the other group received 0.