Mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO) are increasingly used to bridge patients to lung transplantation. We investigated the impact of using MV, with or without ECMO, before lung transplantation on survival after transplantation by performing a retrospective analysis of 826 patients who underwent transplantation at our high-volume center. Recipient characteristics and posttransplant outcomes were analyzed. Most lung transplant recipients (729 patients) did not require bridging; 194 of these patients were propensity matched with patients who were bridged using MV alone (48 patients) or MV and ECMO (49 patients). There was no difference in overall survival between the MV and MV+ECMO groups (p = 0.07). The MV+ECMO group had significantly higher survival conditioned on surviving to 1 year (median 1,811 days ([MV] vs. not reached ([MV+ECMO], p = 0.01). Recipients in the MV+ECMO group, however, were more likely to require ECMO after lung transplantation (16.7% MV vs. 57.1% MV+ECMO, p < 0.001). There were no differences in duration of postoperative MV, hospital stay, graft survival, or the incidence of acute rejection, renal failure, bleeding requiring reoperation, or airway complications. In this contemporary series, the combination of MV and ECMO was a viable bridging strategy to lung transplantation that led to acceptable patient outcomes.

In his 1890 description of operative repair of complete rectal prolapse, Caddy used the following words to describe the physical appearance of his patient's rectal prolapse: "A complete prolapse of the rectum, six inches in length, and eleven inches in circumference. The mucous membrane, which was in numerous circular folds, was covered with slimy mucus, and was bleeding slightly at several small points." 1 With that description, it is easy to see that rectal prolapse, or rectal procidentia, is a morbid condition characterized by protrusion of the rectal wall through the anus. 2 Definition and AssociationsTrue rectal prolapse is the protrusion of all rectal layers through the anal sphincters. 3 The prolapse is classified by the degree of severity. The categories in order of decreasing severity include complete full-thickness rectal prolapse, mucosal prolapse, and internal or occult prolapse. 4 The leading clinical sign is the protrusion itself, with additional symptoms including constipation, sensation of incomplete evacuation, rectal bleeding, rectal pain, incontinence, urgency, and tenesmus. 5 Multiple associated findings on history and physical exam are seen in patients with rectal prolapse. A history of obstetric trauma or previous anorectal surgery is often present. Other associated abnormalities include spina bifida, prior back injury or surgery, psychiatric illness, old age, and female gender. Symptoms of fecal incontinence and constipation are reported in up to 75% and 25-50%, respectively, of patients with prolapse. 3 Patients often have other pelvic floor derangements including rectocele, cystocele, enterocele, and uterine prolapse, and a complete evaluation of constipation and prolapse should be performed. 6 Solitary rectal ulcer syndrome is directly related to rectal prolapse and is caused by injury and ischemia of the mucosa after internal prolapse of the rectal wall. 7 EtiologyThe cause of rectal prolapse is not completely understood and, like many poorly understood diseases, many procedures (more than 100) have been described for its treatment. The two accepted theories regarding the etiology of rectal prolapse involve either a sliding hernia that protrudes through a defect in the pelvic floor 7 or a circumferential intussusception of the upper rectum and rectosigmoid colon. 6 These theories are based on the anatomic defects associated with rectal prolapse: diastasis of the levator ani muscles, deep pouch Keywords ► rectal prolapse ► rectopexy ► mesh repair ► laparoscopy AbstractRectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient-most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or im...

No abstract

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Thoracic malignancies are associated with high mortality rates. Conventional therapy for many of the patients with thoracic malignancies is obviated by a high incidence of locoregional recurrence and distant metastasis. Fortunately, developments in immunotherapy provide effective strategies for both local and systemic treatments that have rapidly advanced during the last decade. One promising approach to cancer immunotherapy is to use oncolytic viruses, which have the advantages of relatively high tumor specificity, selective replication-mediated oncolysis, enhanced antigen presentation, and potential for delivery of immunogenic payloads such as cytokines, with subsequent elicitation of effective antitumor immunity. Several oncolytic viruses including adenovirus, coxsackievirus B3, herpes virus, measles virus, reovirus, and vaccinia virus have been developed and applied to thoracic cancers in preclinical murine studies and clinical trials. This review discusses the current state of oncolytic virotherapy in lung cancer, esophageal cancer, and metastatic malignant pleural effusions and considers its potential as an emergent therapeutic for these patients.

Occupational lung diseases (OLD) including silicosis, asbestosis, and pneumoconiosis progress to end stage lung disease requiring lung transplantation (LT). Prognosis and treatment of OLDs are poorly understood and a paucity of data exists regarding LT outcomes. Additionally, transplant operative complexity for patients with OLD is high. A single center retrospective review of all single and bilateral LT recipients between May 2005 and Oct 2016 was performed. Patients were grouped by OLD, and nearest neighbor matching was performed at a ratio of 1:3 cases to controls. Thirty cases were matched to 88 controls. Seventeen patients (57%) with OLD required intraoperative support with either extra‐corporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (P = 0.02), and 5 (17%) required delayed chest closure (P = 0.05) which was more frequent than matched controls. In addition, operative time was significantly longer in patients with OLD (P = 0.03). Despite these factors, there were no significant differences in immediate post‐operative outcomes including mechanical ventilator support, post‐operative ECMO, and tracheostomy. Chronic lung allograft dysfunction and long‐term survival were also similar between cases and controls. OLDs should not preclude LT. The operation should be performed at experienced centers.

No abstract

Cardiopulmonary bypass and extracorporeal membrane oxygenation are commonly used adjuncts to lung transplantation. These techniques are not without associated morbidity and mortality, and the surgeon must be aware of the possibility of aberrant anatomy that could lead to vascular injury during cannulation. In this report, we describe a patient with congenital absence of the inferior vena cava undergoing lung transplantation who required perioperative cardiopulmonary support. A percutaneous dual lumen cannula, Protek Duo, was connected in an Oxy-RVAD configuration to provide right ventricular and oxygenation support both intraoperatively and postoperatively to this patient.