Thoracoabdominal duplication with hematochezia as an onset symptom in a baby:A case report

BACKGROUND Alimentary tract duplication is a rare congenital disease that may occur in any part of the alimentary tract,whereas thoracoabdominal duplications only account for approximately 2%of all alimentary tract duplication cases.Many symptoms,including abdominal pain,abdominal distension,vomiting,gastrointestinal bleeding,chest discomfort,chest pain,and shortness of breath,may be present in patients with abdominal or thoracic duplication.CASE SUMMARY A 10-mo-old infant,with a free previous medical history,was admitted to our hospital with melena three times in 6 d.Enhanced magnetic resonance imaging of the thoracic vertebrae revealed multiple cervicothoracic vertebral deformities,spina bifida,meningomyelocele towards the posterior mediastinum,and possible concurrent infection.Upper gastroenterography indicated intestinal malrotation.A laparoscopic abdominal examination was performed,and the operation was intraoperatively converted to laparotomy.This case was diagnosed intraoperatively as thoracoabdominal intestinal duplication.The intestinal duplications in the abdomen and large part of the thorax were excised.The results of postoperative pathological examination confirmed that this case was alimentary tract duplication and that part of the duplication contained gastric mucosa.The infant recovered well and was discharged 1 wk after the surgery.A follow-up computed tomography scan 3 mo after operation showed myelomeningocele while the posterior mediastinal cyst was significantly reduced.CONCLUSION Thoracoabdominal duplication should be considered if a child has suspected abdominal intestinal duplication with hematochezia as an onset symptom.

Right trisegmentectomy with thoracoabdominal approach after transarterial embolization for giant hepatic hemangioma

Hepatic hemangiomas need to be treated surgically in cases where they are accompanied with symptoms, have a risk of rupture, or are hardly distinguishable from malignancy. The present authors conducted embolization of the right hepatic artery one day before an operation for a huge hemangioma accompanied with symptoms and confirmed a decrease in its size. The authors performed a right trisegmentectomy through a J-shape incision, using a thoracoabdominal approach, and safely removed a giant hemangioma of 32.0 cm × 26.5 cm × 8.0 cm in size and 2300 g in weight. Even for inexperienced surgeons, a J-shape incision with a thoracoabdominal approach is considered a safe and useful method when right-side hepatectomy is required for a large mass in the right liver.

Thoracoabdominal pseudocyst of pancreas: An rare location, managed by retrocolic retrogastric Roux-en-Y cystojejunostomy

Pseudocyst formation is a common complication of acute and chronic pancreatitis. Most common site of pseudocyst is lesser sac; mediastinal extension of pseudocyst is rare. Other possibilities of posterior mediastinal cyst must be considered. This patient presented with computed tomography abdomen with thorax showing a large thoraco-abdominal pseudocyst with right sided pleural effusion. It was confirmed to be pancreatic pseudocyst by analyzing fluid for amylase and lipase during surgery. In our patient, the pseudocyst was accessible transabdominaly. Cystogastrostomy was not possible as it was causing twisting of cardio-esophageal junction; we did retrocolic and retrogastric Roux-en-Y cystojejunostomy. Only two such cases were reported in literature.

Extensive complex thoracoabdominal aortic aneurysm salvaged by surgical graft providing landing zone for endovascular graft:A case report

BACKGROUND Surgical repair of complex abdominal aortic aneurysm is associated with a higher perioperative mortality and morbidity.The advent of endovascular aortic repair(EVAR)has reduced perioperative complications,although the utilization of such techniques is limited by lesion characteristics,such as involvement of the visceral or renal arteries(RA)and/or presence of a sealing zone.CASE SUMMARY A 60-year-old male presented with a Crawford type IV complex thoracoabdominal aortic aneurysm(CAAA)starting directly distal to the diaphragm extending to both common iliac arteries(CIAs).The CAAA consist of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level.Due to the poor performance of the patient and the expansive disease,we planned a stepwise-combined surgery and EVAR to minimize invasiveness.A branched graft was implanted after surgical debranching of the visceral and RA.Since the patient had renal and liver injury after surgery,the second stage EVAR was performed 10 mo later.The stent graft was implanted from the distal portion of surgical branched graft to both CIAs during EVAR.The patient has been uneventful for 5-years after discharge and is being followed in the outpatient clinic.CONCLUSION The current case demonstrates that the surgical graft can provide a landing zone for second stage EVAR to avoid aggressive surgery in patients with poor performance with a long hostile CAAA.

Surgical repair of thoracoabdominal aortic aneurysms using the critical artery reattachment technique

In the study, we sought to retrospectively analyze the effectiveness and safety of surgical repair of thoracoab-dominal aortic aneurysm using the critical artery reattachment technique. Twenty-three consecutive thoracoab-dominal aortic aneurysm patients were treated using the technique of sequential aortic clamping and critical artery reattachment. The entire procedure was technically successful in all patients. One died of renal failure and the overall hospital mortality was 4.35%. The total incidence of complications was 21.74%. At a median follow-up of 33 months, all patients were alive. We found that the application of critical artery reattachment technique in the management of thoracoabdominal aortic aneurysm provides excellent short- and mid-term results in most patients. It could markedly increase the curing rate and reduce the morbidity of postoperative complications including par-aplegia, ischemia of abdominal viscera, and renal failure.

Maintenance of High Blood Pressure and Early Establishment of Pulsatile Blood Flow to the Spinal Cord during Thoracoabdominal Aortic Repair

Objectives: Despite continuous advancements in the surgical treatments for thoracoabdominal aortic aneurysms (TAAA), paraplegia remains a devastating treatment-related complication. We aimed to summarize our experience with a novel surgical strategy involving maintenance of high blood pressure and early establishment of pulsatile blood flow to the spinal cord. Materials and Methods: Between August 2011 and October 2017, 29 patients (age, 67 ± 12 years) underwent open surgery for TAAA. According to the Crawford classification, two aneurysms were type I, eight were type II, 12 were type III, and seven were type IV. We used partial cardiopulmonary bypass under mild hypothermia in all patients except one. By maintaining distal aortic perfusion pressure at 60 - 80 mmHg and creating the distal aortic anastomosis before visceral branch reconstruction, we established early perfusion of the hypogastric arteries with native pulsatile flow. Intraoperative spinal monitoring and cerebrospinal fluid drainage were performed in 26 (90%) and 23 (79%) patients, respectively. Nineteen patients (66%) underwent reconstruction of the intercostal arteries. During perioperative management, the mean arterial pressure was kept >80 mmHg. Results: No in-hospital deaths or acute neurological complications occurred. One patient (3.4%) experienced delayed temporal paraplegia. During follow-up, aorta-related death occurred in only one patient, who developed prosthetic vascular graft infection but did not undergo repeat graft replacement. The 3-year freedom from aortic-related death was 95%. Conclusion: Our surgical strategy involving maintenance of high blood pressure and early establishment of pulsatile flow to the spinal cord was effective in preventing spinal cord injury following open surgery for TAAA.

Repeated Surgery for Recurrent Pseudoaneurysms after Thoracoabdominal Aortic Replacement

Aneurysm or pseudoaneurysm formation in the aortic patch containing the intercostal or visceral arteries is an unusual late complication after thoracoabdominal aortic surgery. We report the case of a 58-year-old woman who had previously undergone thoracoabdominal aortic replacement (Crawford extent II) for dissecting aneurysm. About 12 months after the operation repeated pseudoaneurysmal degenerations occurred at the intercostal or visceral artery reattachment site. They were repaired with open surgery or endovascular stent-graft. The patient recovered without major complications, and computed tomographic scans showed no recurrence of aneurysm or pseudoaneurysm at the sites of repair 1 year after the procedure.

Multi-slice computed tomography for diagnosis of combined thoracoabdominal injury

Purpose： To investigate the diagnostic value of multi-slice computed tomography （MSCT） for combined thoracoabdominal injury. Methods： A retrospective study was conducted to analyze the clinical data and MSCT images of 68 patients who sustained a combined thoracoabdominal injury associated with diaphragm rupture, and 18 patients without diaphragm rupture. All the patients were admitted and treated in the Chongqing Emergency Medical Center （a level I trauma center） between July 2005 and February 2014. There were 71 males and 15 females with a mean age of 39.1 years （range 13-88 years）. Among the 86 patients, 40 patients suffered a penetrating injury, 46 suffered a blunt injury as a result of road traffic accident in 21 cases, fall from a height in 16, and crushing injury in 9. The MSCT images were retrospectively reviewed by two radiologists. The results of CT diagnosis were compared with surgical findings and/or follow-up results. Results： Among the 86 cases, diaphragm discontinuity was found in 29 cases, segmental nonrecognition of the diaphragm in 14, diaphragmatic hernia in 21, collar sign in 14, dependent viscera sign in 18, elevated abdominal organs in 21, bowel wall thickening and/or hematoma in 6, and pneumoperitoneum in 8. CT diagnostic accuracy for diaphragm rupture was 88.4% in the right side and 90.7% in the left side. CT diagnostic accuracy for hemopneumothorax, pulmonary contusion, mediastinal hemorrhage, kidney and adrenal gland injuries was 100%, while for liver, spleen and pancreas injuries was 96.5%, 96.5g, 94.2% respectively. Conclusion： To reach an early diagnosis of combined thoracoabdominal injury, surgeons and radiologists should be familiar with all kinds of images which might show signs of diaphragm rupture, such as diaphragm discontinuity, segmental nonrecognition of the diaphragm, dangling diaphragm sign, diaphragm herniation, collar sign, dependent viscera sign, and elevated abdominal organs.

Clinical experience with multiple stents in complex thoracoabdominal aortic aneurysms

The unfavorable vessel anatomy is still a major challenge in the endovascular aneurysm repair,with usually insufficient or even no proximal/distal landing zone for the stent-graft.During recent years,several articles have been published concerning the new approach of multiple stents to the treatment of aneurysm by reducing the stent porosity to encourage laminar flow,preserving branch patency,and promoting thrombus formation in the aneurysm.1,2 We herein report the use of multiple overlapping stents in the treatment of thoracoabdominal aortic aneurysms.

Total endovascular repair of an intraoperative stent-graft deployed in the false lumen of Stanford type A aortic dissection: A case report

BACKGROUND A 46-year-old male underwent ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection in 2016.However,an intraoperative stent-graft was deployed in the false lumen inadvertently.This caused severe iatrogenic thoracic and abdominal aortic dissection,and the dissection involved many visceral arteries.CASE SUMMARY The patient had pain in the chest and back for 1 mo.A computed tomography scan showed that the patient had secondary thoracic and abdominal aortic dissection.The ascending aortic replacement,total arch replacement,and descending aortic stent implantation for Stanford type A aortic dissection were performed 2 years prior.An intraoperative stent-graft was deployed in the false lumen.Endovascular aneurysm repair was performed to address this intractable situation.An occluder was used to occlude the proximal end of the true lumen,and a covered stent was used to direct blood flow back to the true lumen.A three-dimensional printing technique was used in this operation to guide prefenestration.The computed tomography scan at the 1stmo after surgery showed that the thoracic and abdominal aortic dissection was repaired,with all visceral arteries remaining patent.The patient did not develop renal failure or neurological complications after surgery.CONCLUSION The total endovascular repair for false lumen stent-graft implantation was feasible and minimally invasive.Our procedures provided a new solution for stent-graft deployed in the false lumen,and other departments may be inspired by this case when they need to rescue a disastrous stent implantation.

Chest, pericardium, abdomen, and thigh penetrating injury by a steel rebar: A case report

BACKGROUND Combined penetrating trauma involving the chest, pericardium, abdomen, and thigh is rare and lethal. It is difficult to quickly rescue patients with penetrating injuries from long steel bars.CASE SUMMARY A previously healthy 56-year-old male worker presented with a length of rebar that penetrated the chest-abdomen-pelvic cavity and was palpable on the anterior side of the neck and thigh. On radiological imaging, the left chest wall-left chest cavity-mediastinum-abdominal cavity-right groin area-right thigh demonstrated a strip-like density shadow, about 1.5 cm thick, with the heart, stomach wall, and part of the intestine involved. There was a left-sided pleural effusion, left lung compression of about 50%-60%, and a small amount of left pleural effusion/blood accumulation;possible perforation of hollow organs;and double multiple ribs fractures on the side. An emergency green channel was opened to provide a rescue process for smooth and timely diagnostic and treatment to save the patient's life. The patient was followed at 4 mo after discharge and showed good recovery.CONCLUSION For pre-hospital emergency treatment in locations that are not fully prepared for surgery, we do not recommend cutting the steel bars outside the body. We advocate pulling out foreign bodies intact to reduce secondary injuries.

Laparoscopic reduction and repair of acute traumatic diaphragmatic hernia:A video review

Traumatic diaphragmatic hernia is one of the sequela of thoraco-abdominal injury,occurring in about 0.5%-5% of patients presenting post major trauma.Motor vehicle collision is the leading blunt trauma etiology.A high level of suspicion is essential to discover such injuries,as a majority of the patients can be asymptomatic.A case of a successful trans-abdominal laparoscopic reduction and repair of a large acute traumatic diaphragmatic hernia is presented as a video demonstration.We were able to evacuate all intrathoracic air,obliviating the need for a chest tube.Post operatively the patient did well with no complications.If expertise is available,laparoscopic intervention is a feasible option even for large traumatic diaphragmatic hernia preventing the need for a large midline laparotomy incision.

品管圈活动在胸腹联合伤患者院前急救护理中的应用

目的 探讨品管圈活动在胸腹联合伤患者院前急救护理中的应用效果。方法 2016年8月我院成立"救生圈"品管圈,将其用于严重胸腹联合伤患者院前急救护理中。分别从品管圈成立、选定主题、现状把握及分析、要因确认、护理对策及实施、效果确认、标准化急救流程等方面进行干预处理,分析品管圈活动在胸腹联合伤患者院前急救护理中的有形成果和无形成果。结果 品管圈活动后抢救成功率高于活动前(P <0. 05);品管圈活动后残疾率、植物生存率及死亡率均低于活动前(P <0. 05);品管圈活动后全体成员发现并解决问题能力、凝聚力、学习新事物、合作能力、拓展思维及沟通能力均高于活动前(P <0. 05)。结论 品管圈活动用于胸腹联合伤患者院前急救护理中,有助于改善急救结局,降低临床死亡率,提高全体圈员综合能力,值得临床推广应用。

胸腹部外伤导致延迟性脾破裂临床分析

目的提高对胸腹外伤致脾脏延迟性破裂的早期诊断及治疗。方法分析患者受伤及诊疗经过,通过详细的体检及必要的辅助检查,对患者作出及时正确诊断与治疗。结果患者经抗休克及手术治疗2周后痊愈出院。结论对闭合性胸腹外伤患者在就诊时要查体仔细,早期正确诊断及处理,并做好观察随访工作。

Nursing experience of digestive function maintenance in 25 patients after thoracic and abdominal aortic eplacement

Objective: To explore the nursing experience of digestive function after thoracic and abdominal aortic replacement in order to promote the better recovery. Methods: 25 patients undergoing thoracic and abdominal aortic replacement were managed after operation. First, the fluid volume and blood pressure were controlled, and the use of vasoactive drugs was strictly regulated to ensure the perfusion of abdominal organs. And the enteral nutrition is carried out as early as possible to accelerate the recovery of gastrointestinal function of patients;And multimode analgesia is adopted to promote patients to get out of bed as early as possible to recover gastrointestinal peristalsis;At the same time, anticoagulation management is strengthened to prevent microthrombosis. Results: 23 of 25 patients after thoracic and abdominal aortic replacement recovered well and discharged smoothly. 2 Cases died,1 case died of hemorrhagic shock due to rupture of abdominal great vessels, and 1 case died of multiple organ failure due to septic shock. Conclusion: To strengthen the maintenance of digestive function, ensure the blood perfusion of gastrointestinal tract, get out of bed early, promote the gastrointestinal peristalsis and implement enteral nutrition as early as possible, can promote the recovery of gastrointestinal function, accelerate the rehabilitation process and shorten the hospitalization time.