The modified transmanubrial approach in thyroid malignant tumors: an optimal and less invasive surgical option.

- We retrospectively evaluated a large series of patients (n: 15) underwent a modified transmanubrial approach for wide mediastinal resection in case of malignance thyroid mass - In fourteen cases, also with thyroid tumor involving the middle line. A bilateral mTMA was necessary to perform a cava vein resection. - No major postoperative and cutaneous/sternum complications were detected. - mTMA allows an optimal exposure of the upper thoracic inlet achieving a complete radical oncological resection of the tumor/lymph-node and a safety vascular/tracheal control. - As a limitation, the modified mTMA is anatomically more demanding and not familiar for most surgeons in comparison to sternotomy

Incoercible Vomiting in a Polycystic (ADPKD) Patient on Peritoneal Dialysis

Although gastrointestinal symptoms are not uncommon in PD patients due to several causes, such as infusion volume with early satiety, constipation, or peritonitis, sometimes the differential diagnosis is more challenging for nephrologists. We present the case of a woman with end-stage renal disease due to autosomal dominant polycystic kidney disease on PD who presented with swollen legs and incoercible vomiting. After ruling out constipation and infection, an abdominal CT was done, revealing extrinsic compression of the intrahepatic inferior cava vein (ICV) and massive venous thrombosis from ICV to bilateral iliofemoral deep veins. In addition, CT also showed displacement and extrinsic compression of the stomach, pylorus, and duodenum due to an enlarged liver cyst. Percutaneous drainage and sclerosis of the cyst compressing the stomach was performed, anticoagulation was started, and the patient clinically improved with complete resolution of symptoms.

Major Hepatectomy En Bloc with Cava Vein Resection for Locally Invasive Caudate Lobe Hepatocarcinoma

Background/Aim: Locally advanced liver tumours with vascular invasion have been considered for a long period of time as unresectable lesions, so the patient was further deferred to oncology services for palliation. However, improvement of the surgical techniques and the results reported so far came to demonstrate that extended hepatic and vascular resections might be safely performed in such cases and might significantly improve the long-term outcomes. Materials and Methods: A 61-year-old patient was diagnosed with a caudate lobe tumour invading the inferior cava vein and the right hepatic pedicle. Results: The patient was successfully submitted to surgery, and an extended right hepatectomy en bloc with cava vein resection was performed; the continuity of the cava vein was re-established by the placement of a synthetic graft. The postoperative outcome was uneventful. Conclusions: Although initially considered as a formal contraindication for resection, vascular invasion of the greater vessels should not preclude surgery if complete resection is achievable.

DEEP VEINS THROMBOSIS MIMICKING AN INFECTION IN A POSTPARTUM WOMAN

Ovarian Vein Thrombosis (OVT) is a rare, yet a serious complication, especially if it extends to an inferior cava vein. OVT can occur at any stage, but it mostly occurs during the postpartum period. Diagnosis is not often immediately apparent, and many other diseases can mimic this condition. Exclusion of any infectious etiologic cause in a postpartum patient with fever is the first step in establishing an OVT diagnosis. It can be accurately diagnosed by appropriate non-invasive investigations to enable early therapy with anticoagulants and intravenous antibiotics, which are the mainstay of treatment. We present a case of a 38-year-old female in the postpartum period who was diagnosed with right OVT reaching the inferior vein cava after a vaginal delivery. She was treated with intravenous antibiotic and anticoagulant therapy and had a successful recovery after repeated image six months after, showing complete resolution of thrombus.

The Tumoral Etiology of the Superior Cava Vein Syndrome Presenting as Exsudative Pericarditis in a Young Patient

We present the case of a 36-year-old patient admitted with dyspnea, subjective sensation of edema of the cervical region, and precordial pain with sudden onset. Pathological antecedents revealed a respiratory intercourse three weeks ago. Laboratory findings indicated an inflammatory syndrome accompanied by hypoproteinemia. We performed an echocardiographic examination which revealed important pericardial effusion and swinging heart aspect with diastolic collapse of the right atrium and ventricle. According to the existing guidelines pericardiocentesis was immediately required. The hemorrhagic pericardial effusion had an intense positive Rivalta reaction with frequent macrophages and malignant atypical cells. The next step was a full-body computer tomography scan, which revealed an expansive mediastinal mass, invading the upper cava vein and pericardium, with mediastinal adenopathy. A biopsy was performed and the pathology examination concluded there was a classical Hodgkin’s lymphoma nodular sclerosis type. Finally the patient was directed to oncology department.

Congenital Extrahepatic Portosystemic Deviation in a Mixed-Breed Dog

Background: Portosystemic deviation (PSD) is a congenital or acquired vascular anomaly that allows an abnormal blood flow from the portal vein directly to the systemic circulation. This liver by-pass avoids hepatic metabolism of several toxins. Congenital PSDs are usually solitary and extra-hepatic, with a high incidence in pure-breed dogs. Acquired PSDs are usually multiple and occur as a consequence of portal hypertension. Surgery is the definitive treatment. Clinicians and surgeons may present difficulties in the propaedeutic of animals with PSD. This paper aims at reporting a successful surgical treatment of a solitary extra-hepatic congenital PSD in a mixed-breed dog.Case: A 7-month-old mixed-breed dog, female, spayed, weighing 8 kg, was presented with a history of sudden syncope after feeding. Complementary exams revealed normocytic hypochromic anaemia, hypoalbuminemia and increased alanine aminotransferase and alkaline phosphatase. Abdominal ultrasound revealed an anomalous vessel inserted in the caudal cava vein, compatible with a congenital extra-hepatic PSD. Computed tomography revealed the anomalous vessel, with 1,1 cm of diameter, originated from the cranial mesenteric vein and it inserted in the cranial margin of the caudal cava vein. A medical support was started with hydration, metronidazole, lactulose, probiotic and Hepatic diet. After 15 days the dog was submitted to surgery and a 5 mm ameroid constrictor ring was placed to gradually close the anomalous vessel. The dog recovered well and an abdominal ultrasound was repeated after 30 days, showing the ameroid constrictor ring ring in the left cranial abdominal region, occluding the PSD close to its insertion in the caudal cava vein. The patient was followed up for more than three years, gained weight and presented a healthy normal life.Discussion: Although PSD is more often diagnosed in pure-breed dogs, this paper reports a case in a mixed-breed dog. However clinical signs and the age of onset were compatible with this pathology. Dogs with PSD may present neurological, gastrointestinal and urinary disorders, related to failure of the detoxification process and toxin by-pass to the systemic circulation. Young dogs are usually presented overdue underdevelopment, reduced body height or weight loss as described in this report. Hepatic encephalopathy is a result of the production of ammonia and several other toxins, which escapes hepatic metabolism, and once they remain liposoluble, they are able to cross-pass the blood-brain barrier and produce the neurological signs, which might be more pronounced after feeding, as in the reported case, although this dog presented only mild neurological signs. The haematological and biochemical findings in the dog of this report were also compatible with PSD. Hypoglycemia, hypocholesterolemia, increased of bile acids and serum ammonia may also be present but they were not demonstrated in this case. Abdominal ultrasound was able to identify the anomalous extra-hepatic vessel which was precisely described by computed tomography, which allower surgical planning. Medical support is recommended for the patient´s clinical estabilization, as performed in this case. Surgery is the treatment of choice for congenital solitary PSD, as in the reported case, and placement of the ameroid constrictor is the most employed technique, as performed. Patient´s improvement starts in the day after surgery and it is completed within a couple months. The patient of this report did not present any complications in the postoperative period and for more than three years, showing total remission of the clinical signs and good life´s quality.

Intracardiac Metastasis from a Large Cell Neuroendocrine Lung Carcinoma

Primary malignant tumors of the heart are rare; the biggest group is sarcomas. Cardiac metastases make up the biggest group of secondary cardiac tumors. We present a rare case of cardiac metastasis (3.1 × 3.2 × 2.8 cm) localized in the right atrium, originating from a large cell neuroendocrine lung carcinoma, with close contact to the tricuspid valve and inferior cava vein.