THE CHOICE OF SURGICAL TACTICS FOR BOERHAAVE SYNDROME IN COMBINATION WITH BILATERAL PLEURAL EMPYEMA (CLINICAL CASE)

Introduction. Boerhaave syndrome is a rare, difficult to diagnose and formidable disease with a high mortality rate. For the treatment of this pathology, many variants of interventions have been proposed. Some surgeons prefer to use a thoracotomic access, others – a laparotomic transhiatal one. In the domestic literature there are scant observations of usement of minimally invasive technologies.Clinical observation. The patient was admitted to the surgical department for emergency indications. In the admission department spontaneous left side hydropneumothorax was diagnosted. Drainage of the left pleural cavity was performed. On the second day, a spontaneous rupture of the esophagus was diagnosed. Video-laparotranschiatal drainage of the posterior mediastinum, drainage of the left subhepatic space, Maydl jejunostomy was performed. In the postoperative period, intensive conservative therapy was carried out, massive lavage of the mediastinum and the left pleural cavity with antiseptic solutions. For a long time, there was a large drainage debit. Because of treatment the dynamics were positive. On the 45th day the drainage of the pleural cavity was removed. By the 66th day complete healing of the esophageal defect and removal of the mediastinal drainage.Discussion. Due to the difficulties in diagnosis, a spontaneous rupture of the esophagus was detected a day later. The applied surgical access and technique allowed to provide adequate drainage and sanitation of the posterior mediastinum and left pleural cavity. The subsequent tactics of managing the patient ensured his recovery. The trauma of the video-laparotranschiatal access is less, in comparison with open surgical interventions. We consider the experience of using video endoscopic technologies for Boerhaave syndrome positive and promising.

Effectiveness of posterior pericardiotomy in preventing cardiac tamponade and effusion pericarditis in the early period after interventions on the thoracic aorta

<p><strong>Background.</strong> Interventions on the thoracic aorta involving prolonged artificial circulation, clamping of the aorta and extensive dissection of the mediastinal structures are associated with a higher incidence of pericardial effusion and cardiac tamponade compared to other interventions. We suggest that routine implementation of posterior pericardiotomy may significantly affect the incidence of postoperative pericardial effusion syndrome and cardiac tamponade after interventions on the thoracic aorta.</p><p><strong>Aim.</strong> Evaluation of the effectiveness of posterior pericardiotomy regarding the development of cardiac tamponade, effusion pericarditis and the postoperative course of patients in the early period after interventions on the thoracic aorta.</p><p><strong>Methods.</strong> We conducted a retro- and prospective study that included 100 patients with thoracic aorta pathologies who were operated on in the cardiac surgery department of clinic from 2017 to 2020. All subjects were divided into two groups: a treatment group of 40 patients who underwent routine posterior pericardiotomy, and a control group of 60 patients without posterior pericardiotomy but with standard installation of postoperative drains. Assessment of the effect of posterior pericardiotomy on pericardial effusion, cardiac tamponade and the early postoperative period was conducted on the basis of transthoracic echocardiography that was performed daily during hospitalisation (the maximum amount of effusion during the observation period was taken as the control point), as well as up to one month after discharge from hospital.</p><p><strong>Results.</strong> The study groups did not differ regarding parameters such as time of artificial circulation (p = 0.39), time of myocardial ischaemia (p = 0.42), length of intensive care unit stay (p = 0.79) and length of hospitalisation (p = 0.21). Evaluation of pericardial effusion of varying severity during hospital follow-up revealed its presence in 15 (37.5%) patients in the PPt group and in 54 (90%) in the control group (p = 0.0001). Early postoperative cardiac tamponade developed in 4 (6.7%) patients in the control group, but was not observed in the PPt group (p = 0.09). At the same time, 5 (8.3%) patients without pericardiotomy required pericardiocentesis; however, this procedure was not performed in the PPt group (p = 0.06). Additionally, we did not find a statistically significant difference between the groups in relation to the frequency of puncture of the left pleural cavity (37.5% in the PPt group versus 43.3% in the control group, p = 0.56). According to the results of control echocardiography after one month, effusion of varying severity was found in 21 (35%) patients in the control group versus 1 (2.5%) in the PPt group (p = 0.0001).</p><p><strong>Conclusion.</strong> Posterior pericardiotomy is an affordable, applicable, safe and effective method for preventing postoperative pericardial effusion and cardiac tamponade after thoracic aortic surgery. This manipulation did not significantly affect the length of hospitalisation or the incidence of postoperative atrial fibrillation in this cohort of patients. Posterior pericardiotomy is not associated with a more frequent need for puncture of the left pleural cavity.</p><p>Received 13 October 2020. Revised 10 December 2020. Accepted 11 December 2020.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p>

Delayed gastropleural fistula: a rare cause of a persistent pleural effusion after blunt force trauma

A gastropleural fistula (GPF) is a rare pathological connection between the stomach and pleural cavity. Diagnosis and treatment are frequently delayed due to the lack of specific clinical, laboratory and radiological findings. We describe a case of a 53-year-old gentleman who presented to our institution with respiratory sepsis and a massive haemopneumothorax on imaging. Uniquely, he was discharged a week prior after a splenectomy for a traumatic fall. Gut flora in the pleural fluid and a subsequent positive dye test suggested an aero-digestive connection. Repeat imaging revealed a fistula between stomach and the left pleural cavity through a ruptured diaphragm. He underwent an open sleeve gastrectomy and primary repair of the diaphragm. This is the first GPF in literature presenting in such a fashion. Although rare, a persistent effusion with a history of blunt thoracoabdominal trauma may herald a GPF, which, if not diagnosed promptly, may result in significant morbidity.

CONGENITALABSENCE OF LEFT PERICARDIUM AND MEDIASTINAL PLEURA: A RARE INCIDENTAL FINDING DURING OPEN HEART SURGERY.

9 Year old male child planned for elective Atrial Septal Defect closure Surgery.He had a incidental Intra Operative finding of Partial pericardial defect on left side with Pericardial Herniation in left pleural cavity.

Chylothorax After Cardiac Surgery

In the following article we present a case of postoperative chylothorax as rare and severe complication after cardiac surgery. We present a case of 56-year-old man after double-valve replacement procedure and aorto-coronary artery bypass grafting, including pedicled left internal mammary artery towards left anterior descending artery. By the tenth postoperative day the total amount of drained milky white fluid from the left pleural cavity reached the colossal volume of 13 040 ml, despite the conservative therapy with intravenous Sandostatin (Octreotide) and parenteral feeding with a solution rich in medium chain triglycerides and amino acids – OliClínomel. The results of the biochemical analysis confirmed the diagnosis chylothorax. On the tenth postoperative day, a revision of the left pleural cavity through left thoracotomy was performed and lesion of the thoracic duct was identified. The lesion was sutured and secured with fibrin tissue glue – Tissucol for definitive treatment of the lymphorrhagia. The combined therapeutic and surgical approach concerning this serious complication turned out to be effective, and the patient was discharged on the thirty-second postoperative day with significant clinical improvement without ultra-sound and x-ray data for left pleural effusion.

Unexpected finding of an ablation catheter during thoracoscopic exploration for a spontaneous hemothorax – case report

Varicose veins of lower extremities represent a common medical condition with minimally invasive percutaneous endovenous ablation techniques as a treatment of choice. A very rare complication is a catheter migration in the deep venous system. In the literature only 7 cases have been published so far, with only 2 cases with migration to the systemic circulation and heart involvement. In this paper we present an interesting case report from the perspective of a thoracic surgeon with the finding of a laser ablation catheter remnant in the left pleural cavity during thoracoscopic exploration for a spontaneous hemothorax in a 47-year old male patient after collapse. A similar complication affecting the pleural cavity has not been published before. In this paper we discuss possible routes of the cathether migration into the left pleural cavity, impending complications when a part of the catheter is left behind in the body and the means of prevention of these serious potentially fatal complications even after many years following the initial treatment.

IMMEDIATE AND LONGTERM RESULTS OF ENDOVASCULAR STENT-GRAFTING IN DISSECTIONS AND ATHEROSCLEROTIC ANEURYSMS OF THORACIC AORTA

Objective: to analyze the results of endovascular stent-graftingin dissections and atherosclerotic aneurysms of descending part of thoracic aorta.Material and method: in this analysis includes 28 patients with dissections and atherosclerotic aneurysms of descending part of thoracic aorta. Acute aortic dissection type 3 was occurred in 10 patients and two of them were complicated with rupture into the left pleural cavity. 10 patients with chronic aortic dissection type bunderwent operations and one of them was complicated with rupture into the left pleural cavity. Among 8 operated patients due to chronic aneurysms of descending part of thoracic aorta, 4 patients were manifested with symptoms of hemothorax. In 3 patients with aortic dissection type 1 in long-term period, endovascular stent-grafting was performed concerning with the dilatation of descending thoracic aorta and patent false lumen. During in-hospital and long-term periods immediate clinical results, serious clinical complications and long-term survival were compared.Results: technical success of endovascular stent-grafting was achieved in 100 % of cases. In-hospital mortality was 4 (14,2 %) and 30-day mortality was 3 (10,7 %). Events of paraplegia, TIA (Transient Ischemic Attack), prosthetic infection were not found in our research. Two clinical occurrences of vascular approach site complication were found; one case of endoleak type 1 and stent-graft dislocation which required repeated endovascular stent-grafting and one case of endoleak type 2 which was performed subclaviancarotid bypass and ligation of left subclavian artery. Prolong intubation was needed in 5 patients (18,5 %).conclusion: Endovascular stent-grafting in dissections and atherosclerotic aneurysms of descending part of thoracic aorta contributes good immediate clinical results associating with less quantity of serious complications.

PS01.067: SHLYAKHOVSKIY I.A., ERMOLOVA I.V., SELINA I. E., P. O., BURCHULADZE/PERFORATED APPENDICITES IN DIAPHRAGMAL HERNIA

Background We present a clinical case of a patient with acute perforated appendicitis complicated by empyema in a false left-sided diaphragmatic hernia. Methods Patient K. 21 L. taken by ambulance to the intensive care unit. X-ray conclusion—the rupture of the left dome of the diaphragm to the infringement of the colon. The patient urgently operated. The defect of the diaphragm size 10,0х6,5cm. There is a lack in the abdominal cavity of small and large intestine, and spleen. The diagnosis—gangrenous perforated appendicitis in the left pleural cavity, empyema. Performed appendectomy, diaphragm was sutured. 5 days after surgery performed videothoracoscopy Results The patient is in satisfactory condition was discharged from hospital 32 days after admission. Conclusion Polypositional x-ray examination of the chest and abdominal cavity and active surgical tactics has allowed to establish the correct diagnosis and resulted in a favorable outcome. Disclosure All authors have declared no conflicts of interest.