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Aim of the study is the description of the successful management of gastroepiploic artery pseudoaneurysm with preservation of parent vessels using flow-diversion technology. The present report describes the application of a flow-diversion Pipeline™ Flex device for occlusion of a sidewall bleeding pseudoaneurysm on a patient who was status-post sub-total pancreatectomy and remote esophagectomy with a gastric conduit. The pseudoaneurysm was on the solitary vessel supplying the patient's conduit. Use of flow diversion technology excluded the sidewall pseudoaneurysm while maintaining gastric conduit perfusion. In our case, the application of flow diversion technology allowed the preservation of patency of the main arterial supply to the gastric conduit on a post-esophagectomy patient; loss of the right gastroepiploic artery in that case would had been otherwise catastrophic. Flow-diversion technology can be considered for the treatment of pseudoaneurysms post-pancreatic resections, especially when there is no other surgical or endovascular treatment option.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare variant of hepatocellular carcinoma, usually presenting in the younger population (

OBJECTIVES: Patients with pectus excavatum (PE) after prior sternotomy for cardiac surgery present unique challenges for repair of PE. Open repairs have been recommended because of concerns about sternal adhesions and cardiac injury. We report a multi-institutional experience with repair utilizing substernal Nuss bars in this patient population.METHODS: Surgeons from the Chest Wall International Group were queried for experience and retrospective data on PE repair using sub-sternal Nuss bars in patients with a history of median sternotomy for cardiac surgery (November 2000 to August 2015). A descriptive analysis was performed.RESULTS: Data for 75 patients were available from 14 centres. The median age at PE repair was 9.5 years (interquartile range 10.9), and the median Haller index was 3.9 (interquartile range 1.43); 56% of the patients were men. The median time to PE repair was 6.4 years (interquartile range 7.886) after prior cardiac surgery. Twelve patients (16%) required resternotomy before support bar placement: 7 pre-emptively and 5 emergently. Sternal elevation before bar placement was used in 34 patients (45%) and thoracoscopy in 67 patients (89%). Standby with cardiopulmonary bypass was available at 9 centres (64%). Inadvertent cardiac injury occurred in 5 cases (7%) without mortality.CONCLUSIONS: Over a broad range of institutions, substernal Nuss bars were used in PE repair for patients with a history of sternotomy for cardiac surgery. Several technique modifications were reported and may have facilitated repair. Cardiac injury occurred in 7% of cases, and appropriate resources should be available in the event of complications. Prophylactic resternotomy was reported at a minority of centres.

BACKGROUND Recurrence of pectus excavatum (PE) is not an uncommon problem after open repair using the Ravitch technique. The optimal approach for redo surgery is still under debate, especially in adults with less chest wall pliability. Aim of this study was to investigate the usefulness and efficacy of the minimally invasive Nuss technique for repair of recurrent PE after conventional open repair. METHODS We performed a retrospective multicentre review of 20 adult patients from University Hospital Bern (n=6) and the US Mayo Clinic (n=14) who underwent minimally invasive repair of recurrent PE after unsuccessful prior Ravitch procedure. RESULTS Mean patient age at primary open correction was 21 years, with recurrence being evident after a mean duration of 10.5 years (range, 0.25-47 years). Mean age at redo surgery using the Nuss technique was 31 years, with a mean Haller index of 4.7 before and 2.5 after final correction. Main reason for redo surgery was recurrent or persistent deformity (100%), followed by chest pain (75%) and exercise intolerance (75%). No major intraoperative or postoperative complications occurred and successful correction was possible in all patients. CONCLUSIONS Although the procedure itself is more challenging, the minimally invasive Nuss technique can be safely and successfully used for repair of recurrent PE after failed open surgery. In our series final results were good to excellent in the majority of patients without major complications or recurrence.

Introduction Constrictive pericarditis is a heterogeneous disease with many causes. Traumatic hemopericardium is an uncommon initiating cause. We report the case of a man developing constrictive pericarditis after blunt chest trauma, in order to highlight an approach to diagnosing the condition and to raise awareness of the possibility of this condition developing after blunt trauma. Case presentation A 72-year-old Caucasian man presented initially to our outpatient clinic with a one-year history of progressively worsening dyspnea, and recent onset of edema of the legs. He was later taken to the emergency department and admitted to hospital. He had previously received unsuccessful treatment from his local primary physicians for suspected respiratory disorder and cellulitis of his legs. Echocardiography showed evidence of pericardial constriction, and computed tomography revealed nodular, lobulated thickening of the pericardium and pleura bilaterally. Interventional biopsies were taken, but gave inconclusive results. Thus, as pericarditis and/or advanced malignancy were suspected, diagnostic video-assisted thoracoscopic surgery was performed to take biopsies from the abnormal lung and pericardial tissue. Examination of these supported the diagnosis of pericarditis, as acute and chronic inflammation and fibrous thickening were found, with no evidence of malignancy. Our patient underwent cardiac catheterization, which revealed three-vessel coronary artery disease. Emergency total pericardiectomy and coronary bypass were performed. Having excluded other common initiating factors, we considered that a blunt trauma that our patient had previously sustained to his chest was the potential cause of the constrictive pericarditis. Conclusion This was an interesting case of blunt chest trauma followed by progressive pericardial and pleural thickening. Subsequent development of chronic constrictive pericarditis occurred, requiring treatment by surgical pericardiectomy, as the clinical course of constrictive pericarditis is usually progressive without surgical intervention. Diagnosis of constrictive pericarditis remains challenging. Although uncommon, blunt trauma should be considered as a possible initiating cause. Delayed presentation of constrictive pericarditis should also be considered as a possible morbidity in a patient who has sustained blunt chest trauma. Our case also highlights the importance of performing echocardiography promptly in patients experiencing ongoing symptoms of congestive heart failure to allow earlier diagnosis of constrictive pericarditis or other cardiac disorders, and avoid unnecessary treatments.

Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to diagnose and treat. Interest in AMR of cardiac allografts has increased over the last decade as it has become apparent that untreated humoral rejection threatens graft and patient survival. An international and multidisciplinary consensus group has formulated guidelines for the diagnosis and treatment of AMR and established that identification of circulating or donor-specific antibodies is not required and that asymptomatic AMR, that is, biopsy-proven AMR without cardiac dysfunction is a real entity with worsened prognosis. Strict criteria for the diagnosis of cardiac AMR have not been firmly established, although the diagnosis relies heavily on tissue pathological findings. Therapy remains largely empirical. We review an unfortunate experience with one of our patients and summarize recommended criteria for the diagnosis of AMR and potential treatment schemes with a focus on current limitations and the need for future research and innovation.

Large posterior mediastinal goiters are extremely rare. Progressive enlargement and possible compression of adjacent structures, as well as malignant potential necessitate that these goiters should be surgically excised. A review of mediastinal tumors, specifically intra-thoracic goiters is presented along with a case report of acute respiratory compromise secondary to tracheal compression by a large posterior goiter.

Lung hernias are rare, occurring most commonly after trauma or surgery. Spontaneous lung hernias are even rarer and have only been reported as occurring anteriorly. We present a 72-year-old male who developed a spontaneous posterior lung hernia after a severe coughing episode. We describe the evaluation and surgical management of this unusual condition and provide a brief review of the literature.

Objective Recent literature has questioned the efficacy of routine detailed preoperative cardiac ischemia testing and preoperative cardiac intervention before noncardiac surgical procedures. Methods We performed a retrospective review of patients undergoing thoracotomy (n = 294) between January of 1999 and January of 2005. Results The median age was 62 years. Detailed preoperative cardiac testing was performed on 184 patients (63%) and went beyond a thorough history, physical examination, and electrocardiogram to include at least one of the following: dobutamine stress echo (n = 116), nuclear stress test (n = 66), treadmill test (n = 8), and coronary angiogram (n = 40). Evidence for coronary disease was detected in 43% of tests (99/230) performed. Revascularization was performed in 10% of all patients (4/40) who underwent coronary angiography. Postoperative myocardial infarction occurred in 7 patients (2.4%) with 4 myocardial infarction-related mortalities. No significant difference was found in the incidence of myocardial infarction in patients with (n = 184) or without (n = 110) detailed preoperative cardiac testing (3.3% vs 0.9%, P = .29). Of the 4 patients (1.4%) who underwent revascularization to treat coronary lesions identified during prethoracotomy workup, 2 had a myocardial infarction, 1 of which was caused by thrombosis of a coronary stent. In the subset of patients who underwent lobectomy (n = 149), detailed cardiac testing was performed on 107 patients (72%). The incidence of myocardial infarction was similar in tested and untested patients (2.8% vs 2.4% respectively, P = 1.0). Conclusion Selective use of detailed preoperative cardiac testing refines risk stratification and identifies patients for corrective cardiac interventions; however, it did not prove fully protective against myocardial infarction after thoracotomy in our study.

IntroductionThe Nuss procedure for pectus excavatum (PE) repair has been successfully performed in Marfan syndrome (MFS) patients however there is concern for future risk of aortic dilation/rupture and need for emergent access with support bars in place.Case presentationWe present a 45 year-old male with MFS that required descending aortic replacement shortly after modified Nuss repair.DiscussionThe majority of MFS patients have severe PE and repair with the Nuss procedure is not uncommon. The risk for life threatening aortic dilation, dissection, or rupture in such patients is a concern when utilizing this technique. Our work has been reported in line with the CARE criteria.ConclusionNuss repair should be considered in MFS patients with technique modifications and careful consideration of future risk of aortic dilation and rupture.