Azygos Vein Research Articles

A RARE CASE OF HISTOPLASMA CAUSING OBLITERATION OF THE SUPERIOR VENA CAVA AND SUBSEQUENT DEVELOPMENT OF COLLATERAL CIRCULATION

A RARE CASE OF HISTOPLASMA CAUSING OBLITERATION OF THE SUPERIOR VENA CAVA AND SUBSEQUENT DEVELOPMENT OF COLLATERAL CIRCULATION

Push-pull monorail technique to overcome a difficult course through the left internal jugular vein.

We assessed the outcomes of a push-pull monorail technique to overcome a difficult anatomical course through the left internal jugular vein in implantable port insertions. From December 2018 to May 2021, a total of 5326 patients were referred for implantable port insertion in our interventional unit, among which 472 cases were requested for insertion on the left side. Our monorail technique was applied only when the catheter tip entered the azygos vein instead of the superior vena cava (n = 8). The technique consists of a puncture at the distal tip of the port catheter with a 21-gauge micropuncture needle, advancing a 0.018-inch hair-wire to the guide, providing support for the pre-assembled port, and advancing the microsheath over the hair-wire to prevent extrusion of the catheter. The push-pull monorail technique was performed in eight patients, and all cases were technically successful, exhibiting a technical success rate of 100%. There were no immediate or delayed complications. The push-pull monorail technique is helpful in overcoming the difficult anatomical course through the left internal jugular vein during implantable port insertion.

379. ENLIGHTENMENT OF THE VENOUS ANATOMY OF THE ESOPHAGUS—AN ANOMALY CAPTURED UNDER MEDIASTINOSCOPY

Abstract Distant organ metastasis often occurs early in the course of esophageal cancer development and is associated with a poor prognosis. The modes of metastasis include hematological and lymphatic routes. Although in the literature the venous outflow of the esophagus is described to occur through the esophageal vein into the azygous vein, which subsequently joins the superior vena cava, the detained anatomy of the venous and lymphatic systems of the esophagus remains to be further investigated. We aimed to elucidate the regional anatomy of the venous system surrounding the esophagus via mediastinoscopic esophagectomy. Between January 2021 to January 2022, six patients with early esophageal cancer without apparent distant metastasis underwent minimally invasive esophagectomy and posterior mediastinal reconstruction with mediastinoscopy in our hospital. Detailed anatomy was captured and the spatial relationship between the esophageal vein and its draining vein was assessed intraoperatively and thoroughly reviewed postoperatively for any anomalies. A venous anomaly was seen in one out of six patients where the esophageal vein drained into the left pulmonary vein rather than into the azygous vein. This anomaly was not detectable on the preoperative CT images. Hemostasis of the esophageal vein was achieved without major hemorrhage or injury to surrounding tissues. The esophageal specimen showed a localized ulcerative lesion in the midthoracic esophagus that was consistent with moderately differentiated squamous cell carcinoma, pT3N0M0 pStage IIB, with v1 and ly1 invasion. The patient will remain under surveillance for recurrence. Direct venous drainage into the systemic circulation may attribute to its high rates of distant metastasis in esophageal cancer. This mechanism supports the higher prevalence of metastasis to the liver over the lung, and relatively high rates of bone and brain metastases. Close attention should be paid when performing esophagectomy as injuries to the esophageal vein and inadequate hemastasis may result in catastrophic bleeding when a direct connection with the systemic circulation is present.

291. A CASE OF LAPAROSCOPIC AND THORACOSCOPIC ENUCLEATION FOR GIANT CIRCUMFERENTIAL ESOPHAGEAL LEIOMYOMA

Abstract Enucleation is surgically or endoscopically performed for submucosal tumors of the esophagus, especially for esophageal leiomyoma. Enucleation for large and circumferential tumors is technically challenging given a higher risk of mucosal injury and/or tumor rupture during procedure. We present a case of giant leiomyoma with a maximal diameter of 8 cm successfully enucleated by laparoscopic and thoracoscopic approaches. A 24-year-old man was referred to our hospital with a mediastinal tumor suspected on chest X-ray. He suffered from heartburn for more than 10 years and recently dysphagia. Endoscopic examination revealed esophageal submucosal tumors located at 30 cm to 35 cm from the incisor, involving whole luminal circumference. Boring biopsies were endoscopically performed of which pathological diagnosis was esophageal leiomyoma. CT showed wall thickening in the lower esophagus with a maximal esophageal diameter of 8 cm. Giant esophageal tumor enucleation with antireflux fundoplication was performed using both laparoscopy and thoracoscopy. The tumor expanded circumferential shape with the longitudinal extent of approximately 8 cm. After tumor enucleation, the esophageal mucosa was circumferentially exposed from the level of the azygos vein to the esophagogastric junction without the muscle layer. The esophageal mucosal injury occurred in 3 places, which were repaired by primary closure using absorbable threads. The operation time was 827 minutes and the loss of blood was 230 mL. The specimen was 160 g, and the final pathological diagnosis was leiomyoma. Postoperative course was not eventful. We experienced a case of enucleation for a giant esophageal circumferential submucosal tumor. Enucleation may be considered a possible treatment strategy to avoid esophagectomy even for a giant circumferential tumor especially in young patients.

162. EXPERIENCE IN PRIMARY REPAIR OVER T TUBE IN IATROGENIC OESOPHAGEAL PERFORATION

Abstract Iatrogenic oesophageal perforation can be a devastating event following endoscopic or surgical procedures. It remains a challenge for the surgeon to intervene. The most common cause of oesophageal perforation which accounts for about 70% of the cases is iatrogenic perforation with mortality ranging from about 10 to 25%. Most of the iatrogenic perforations are from endoscopic procedures. This case report like to highlight one of the treatments for iatrogenic oesophageal perforation. A 73-year-old female presented to the ORL team with the inability to swallow and associated with choking sensation and drooling of saliva for 2 days. The patient developed intrascapular pain post-Rigid Esophagoscopy which intensified postprandially, and developed respiratory distress with excruciating pain over the centre of the chest anteriorly and intrascapular region. Examination revealed reduce air entry of the right lung with Xray revealed right pneumothorax with a collapsed lung. CT Thorax revealed mid-oesophageal injury at above the carina with extravasation of oral contrast. Oesophagogastroduodenoscopy, Right Thoracotomy, Primary Oesophageal perforation repair over T-tube, Right Thoracic Decortication, and Washout were done. Defect at mucosa anteriorly with stricture 23 cm and submucosal flap 28 cm from the incisor into the left thoracic cavity with perforation at the right lateral wall of the oesophagus 5 cm below the azygos vein crossing point. Myotomy performed and T-tube catheter inserted as control fistula. Oesophageal repair done and 2 chest tubes inserted at the site of perforation and base of thorax. Intraoperatively right lung expanded well. A contrast swallow study on day 46 shown no evidence of fistula between trachea and oesophagus or leak. The surveillance endoscope showed remarkable healing. Iatrogenic oesophageal perforation remains amongst the main causes for oesophageal emergencies which require proper planning, and prompt management. Proper selection of both non-operative and operative management are interchangeable with the time, and progression of a patient’s conditions. As these cases are rarely encountered thus such cases should be managed at a centre that is equipped with a trained, and experienced specialist unit, thus preventing misdiagnosis, undertreated treatment, and unwanted outcomes.

650. ROBOTIC ESOPHAGEAL LEIOMYOMA ENUCLEATION

Abstract Leiomyomas are rare benign esophageal neoplasms. Surgery is indicated in symptomatic patients or if malignancy is suspected. A 20-year-old female presented with dysphagia to solids. Contrast enhanced computed tomography showed a 33-mm by 30-mm by 51 mm well circumscribed lobulated mass arising from the right anterolateral wall of the upper thoracic esophagus, causing luminal narrowing and abutting the azygos vein. An esophageal ultrasound performed for confirmation showed the lesion arising from the muscularis propria. Patient was scheduled for a robotic leiomyoma excision. Patient was placed in left lateral position, lung isolation was obtained with a double lumen tube. Four standard ports were placed in the sixth intercostal space. Robotic instruments used were the monopolar scissors, Maryland bipolar forceps, fenestrated bipolar forceps for dissection and needle holder for suturing. The leiomyoma was identified, mediastinal pleura and muscle layer were incised longitudinally. The leiomyoma was dissected all around in the submuscular plane taking care not to injure the underlying mucosa. However, while delivering the deep lobulated portion, there was an inadvertent injury to the mucosa. The mucosal tear was repaired with interrupted sutures utilising 4-0 Polydiaxanone sutures and the muscle layer was closed with V-Lock sutures. A check endoscopy was performed on table along with air insufflation with saline in the pleural cavity to check for an air leak. A nasogastric tube was placed, specimen was retrieved in a bag through the assistant port. Surgery was completed in 155 minutes with 50 ml blood loss. Post-operative course was uneventful, and the patient was discharged on full diet on the fourth post-operative day. Histopathology showed a SMA and desmin-positive spindle cell neoplasm without conspicuous mitotic activity. Precise dissection in a confined space is possible due to wrist-like movements, three-dimensional view and magnification offered by the robot. Repair of the injured mucosa and myotomy closure to prevent future diverticulum formation is easily accomplished with robotic suturing. Intraoperative endoscopy is useful in evaluating the integrity of the mucosa and muscle repair. Hence a robotic approach may be superior to a thoracoscopic/open leiomyoma enucleation and can be utilised even in moderate size masses.

274. AUTOMATED SURGICAL STEP RECOGNITION FOR ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY USING ARTIFICIAL INTELLIGENCE

Abstract More robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed owing to three-dimensional field of view, image stabilization, and flexible joint function, however, both the surgeon, and surgical team require proficiency. Therefore, assessing the surgical learning curve and determining the surgical difficulty are essential for reducing complications. This study aimed to establish an artificial intelligence (AI)-based automated surgical phase recognition system for RAMIE by analyzing robotic surgical videos and evaluate the learning curve. This study enrolled 31 patients who underwent RAMIE. We annotated the videos into the following nine surgical phases, namely preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. We divided all patients into two groups, namely early period (20 patients) and late period (11 patients), after which the relationship between the surgical phase duration and learning curve was assessed. Frames were extracted from each video at a rate of one frame per second (fps), with an average of 14517 ± 4770 frames per video, which were used to train and test the AI model. Four-fold cross validation was applied to evaluate the performance of the present model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and ‘no step’ (p < 0.001) phases predicted by the AI were significant shorter in the late period than in the early period. We established an automated surgical phase recognition system for RAMIE using deep learning. Specific phase durations were significantly associated with surgeons’ learning curve, and similar tendencies were observed on phase durations predicated by the AI. Our AI-based system can be useful for not only education or OR efficiency but also evaluating surgical skill.

Simultaneous IVC/SVC Endovascular Sharp Recanalization in A Patient with Budd-Chiari Syndrome, Systemic Lupus Erythematosus and Antiphospholipid Syndrome, A Case Report

Abstract:
 Background: Budd‐Chiari syndrome (BCS) is a rare life-threatening condition and is caused by an obstruction to the hepatic venous outflow. We herein report a case of BCS complicated with inferior vena cava (IVC) and superior vena cava (SVC) stenosis that was managed by a simultaneous IVC/SVC sharp recanalization.
 Case presentation: A forty-year-old lady came to the clinic complaining of distended abdomen. She is a known case of antiphospholipid syndrome and systemic lupus erythematosus. Triphasic liver computed tomography showed a heterogeneous liver with nutmeg appearance and attenuation of hepatic veins with caudate hypertrophy. There was a severe dilatation of the azygos and hemiazygos veins with multiple posterior mediastinal and retrocrural tortuous collaterals recanalizing the IVC distally. Contrast enhanced CT of the chest showed a chronic complete occlusion of the left brachiocephalic vein with enlargement of the left superior intercostal vein, hemiazygos, and azygos veins. SVC was patent with multiple calcific foci of the wall likely related to chronic thrombosis. Through the right femoral access, inferior venacavogram was obtained, which showed suprahepatic IVC complete occlusion. Then, an upper venous access was obtained through the right internal jugular vein. Followed by a venogram which showed a complete occlusion at the right brachiocephalic vein with extensive collaterals were noted. Sharp recanalization from the jugular access of the brachiocephalic vein/SVC was performed targeting the balloon within the SVC that was advanced from the azygos vein, which followed by placing a covered stent graft. Then Multiple balloon angioplasties were made at the level of suprahepatic IVC followed by placing a non-covered stent.
 Conclusion: It was a Successful recanalization for the completely occluded suprahepatic IVC and placement of IVC stent, and a Successful recanalization for the completely occluded right brachiocephalic vein and placement of a stent.

Causes and management of intraoperative complications in robot-assisted anatomical pulmonary resection for lung cancer.

BackgroundTo perform safe robot-assisted anatomical lung resections, the details of intraoperative complications need to be shared among thoracic surgeons. However, only limited data are available.MethodsThis retrospective, single-institutional study evaluated 134 patients who underwent robot-assisted anatomical lung resection. We examined the causes, management, and outcomes of all intraoperative complications.ResultsOf the 134 eligible patients, 118 (88%) underwent lobectomy and 16 (12%) underwent segmentectomy. Intraoperative complications occurred in 17 (12.7%) patients. These complications included pulmonary artery (PA) injuries in seven patients, pulmonary vein (PV) injuries in three, azygos vein (AV) injury in one, superior vena cava (SVC) injury in one, bronchial injuries in three, and lung injuries in four. Most PA injuries were at a distal side and controlled by pressure, fibrin sealant, or stapling of the proximal side. In the three PV injuries, right upper PV was sandwiched by robotic instruments, V6 was punctured by the tip of the Maryland bipolar forceps, and the distal side of V2t was injured during tunneling of a minor interlobar fissure. These were controlled the same way as the PA injuries. The AV injury occurred during hilar lymph node (LN) dissection and was controlled by suturing. The SVC injury was caused by interference of the robotic forceps and the suction tube outside the field of view during upper mediastinal LN dissection. The injury was controlled by continuous pressure while layering polyglycolic acid sheets and fibrin glue. In the three bronchial injuries, B10 was injured during subcarinal LN dissection, right main bronchus was injured during upper bronchus dissection and the stapling failure of the bronchus occurred by strong traction. They were all repaired by suturing. All lung parenchymal injuries were caused by manipulation of robotic instruments outside the field of view. The lung injuries were repaired by suturing with pledgets. No cases were converted to thoracotomy. The 30-day mortality rate was 0.7%. The cause of mortality was pneumonia.ConclusionsIn robot-assisted anatomical pulmonary resection for lung cancer, most major intraoperative complications can be safely managed robotically without conversion to thoracotomy.

The "chicken-leg anastomosis": Low-cost tissue-realistic simulation model for esophageal atresia training in pediatric surgery.

IntroductionShifting the training from the operating room (OR) to simulation models has been proven effective in enhancing patient safety and reducing the learning time to achieve competency and increase the operative efficiency. Currently the field of pediatric surgery only offers few low-cost trainers for specialized training and these feature predominantly artificial and often unrealistic tissue. The aim of this study was to develop an easy access low-cost tissue-realistic simulation model for open training of esophageal atresia and to evaluate the acceptance in trainees and junior pediatric surgeons.Materials and methodsThe model is fashioned using reconfigured chicken skin from a chicken leg. To create a model of esophageal atresia, the chicken skin is dissected off the muscle and reconfigured around a foley catheter balloon to recreate the proximal pouch and a feeding tube to recreate the distal pouch. Surrounding structures such as the tracheo-esophageal fistula and the azygos vein can be easily added, obtaining a realistic esophageal atresia (Type C) prototype. Evaluation of model construction, usage and impact on user were performed by both a self-assessment questionnaire with pre- and post-training questions as well as observer-based variables and a revised Objective Structured Assessment of Technical Skills (OSATS) score.ResultsA total of 10 participants were constructing and using the model at two different timepoints. OSATS score for overall performance was significantly higher (p = 0.005, z = −2.78) during the second observational period [median (MD): 4,95% confidence interval CI: 3.4, 5.1] compared to the first (MD: 3, 95% CI 2.4, 4.1). Self-reported boost in confidence after model usage for performing future esophageal atresia (EA) repair and bowel anastomosis (BA) in general was significantly higher (EA: U = 1, z = −2.3, p = 0.021, BA: U = 1, z = −2.41, p = 0.016) in participants with more years in training/attending status (EA MD:5, BA MD: 5.5) compared to less experienced participants (EA MD: 1.5, BA: 1).ConclusionOur easy access low-cost simulation model represents a feasible and tissue realistic training option to increase surgical performance of pediatric surgical trainees outside the OR.

Evolution of Thoracic Duct Congestion after Portal Decompression by TIPS in Cirrhotic Patients.

To evaluate the thoracic duct (TD) diameter on CT scan in a population of cirrhotic patients before and after relief of portal hypertension by transjugular intrahepatic portosystemic shunt (TIPS) insertion. To evaluate the association between the initial TD diameters and the cirrhosis severity, the morphological signs of portal hypertension and the clinical success of TIPS. This retrospective monocentric study included 54 cirrhotic patients who underwent TIPS insertion between 2010 and 2020. Measurements of the TD were performed in CT scan at two distinct points: at the cisterna chyli (CC) and at the terminal TD near the lymphovenous junction. The mean diameter of the TD was 6.4 mm (± 2.9) at the CC and 6.9 mm (± 1.9) near the lymphovenous junction. After TIPS, the mean diameter decreased to 5.1 (± 2.1) at the CC (p < 0.001) and to 4.3 (± 1.5) at the terminal TD (p = 0.001). The initial TD diameter was associated with the presence of voluminous venous collaterals (p = 0.04 at CC and p = 0.04 junction). The initial terminal TD diameter was weakly associated with the largest axis of the spleen (r = 0.126, p = 0.03) and moderately associated with the azygos vein diameter (r = 0.511, p = 0.001). Initial TD diameter was not associated with Child-Pugh score (r = 0.276, p = 0.08 and r = 0.169, p = 0.7) or with clinical success of TIPS on ascites (p = 0.33 and 0.60) or on bleeding (p = 0.13 and 0.99). The diameter of the TD decreases after TIPS, but its initial diameter does not seem to be predictive of the clinical success of TIPS.

Modified McKeown vs. traditional McKeown minimally invasive esophagectomy in improving short-term efficacy and the quality of life of esophageal cancers: a retrospective comparative cohort study.

BackgroundTraditional McKeown minimally invasive esophagectomy (MIE-McKeown) with resection of the thoracic and abdominal branches of vagus nerve, the azygos vein and the bronchial artery, is notorious for high complications incidence and sharply decreased quality of life (QoL) postoperatively in esophageal cancer (EC). Recently, reports of preservation of azygos vein arch or the vagus nerve have shown the advantages of decreasing postoperative complication incidence. However, the modified MIE-McKeown with preservation of azygos vein arch, vagus nerve and the bronchial artery has never been investigated in EC. In the present study, we aimed to compare the short-term efficacy and postoperative QoL between modified MIE-McKeown and traditional MIE-McKeown.MethodsA total of 218 eligible patients with esophageal squamous cell carcinoma (ESCC) who met our inclusion criteria between October 2018 and January 2022 in our center were retrospectively enrolled and divided into modified MIE-McKeown group (N=48) and the control group with traditional MIE-McKeown (N=170) according to their surgical procedure. We compared the perioperative parameters (e.g., operation time and postoperative complications) between the two groups. The core quality of life questionnaire (QLQ-C30) (version 3.0) and the EC-specific QoL assessment form (QLQ-OES18) were used to evaluate the QoL in the 2 groups at 1 and 3 months after operation.ResultsThere were no significant differences in baseline characteristics between modified MIE-McKeown group and the control group. Compared with the control group, the modified MIE-McKeown group had significantly lower postoperative drainage volume (551.46±249.45 vs. 812.96±405.82; P<0.001) and a lower incidence of thoracic stomach syndrome (TSS; P=0.001). The bleeding loss in the modified MIE-McKeown group was lower than that in the control group (56.88±20.44 vs. 83.18±97.93; P=0.066), but not significantly. There were no significant differences observed in postoperative complications and other perioperative parameters between the two groups. The results of QLQ-C30 and QLQ-OES18 questionnaire revealed that the modified MIE-McKeown group was associated with better physical function, better global health status and milder symptoms of gastroesophageal reflux and cough.ConclusionsThe modified MIE-McKeown is a safe and efficient procedure and has the potential to improve postoperative health status of patients with EC.

Síndrome de vena cava superior por trombosis de catéter venoso central

Superior vena cava syndrome is a rare entity. The neoplastic etiology is the most relevant, as well as that related to invasive procedures with central venous catheter. A 32-year-old man consults the Emergency Department for sudden facial cyanosis, facial tightness, dry cough, odynophagia, dysphonia and vertigo without dyspnea. He presents colon neoplasia since 2019, with colostomy and left subclavian Port-catheter. At examination, facial and upper extremity edema, central cyanosis, multiple petechiae and nail bleeding on the hands. The angiotomography shows filling defect fort recent thrombosis in left internal jugular and brachiocephalic vein, right brachiocephalic vein, arch of the azygos vein and superior vena cava in its entire lumen. The surgical mechanical thromboaspiration allowed resection of the thrombus and restitution of circulation, with relative safety and low mortality.

Роль симпатичних стовбурів в іннервації кровоносних судин заднього середостіння у плодів людини

The purpose of the study was to establish patterns of variation of the branches of the right and left sympathetic trunks in the thoracic aorta azygos and hemiazygos veins during the fetal period of human ontogenesis. Materials and methods. An anatomical study was performed on 47 human fetuses using macromicroscopic preparation of neurovascular branches under the control of binocular magnifier, vascular injection, application contrasting of prepared vessels and nerves, making 3D reconstruction models of the posterior mediastinum structures and morphometry. Results. The anatomical variability of nodes and branches of the thoracic right and left sympathetic trunks involved in the innervation of the thoracic aorta, azygos and hemiazygos veins has been established in the human fetuses of different age groups. The segmental-metameric distribution of the visceral branches of the thoracic sympathetic trunk was revealed, as well as the preservation of the segmental sympathetic innervation of the thoracic aorta, azygos and hemiazygos veins both on the left and on the right. Despite the significant progress in the study of morphological features of innervation of posterior mediastinum organs and structures, the active development of fetal surgery in recent years raises a number of questions related to the sources of sympathetic innervation of the thoracic aorta, azygos and hemiazygos veins. Conclusion. The sources of innervation of the thoracic aorta, azygos and hemiazygos veins in human fetuses are: thoracic nodes and internodal branches of the right and left sympathetic trunks; large visceral nerves; branches of the esophageal, pulmonary and cardiac plexuses; vagosympathetic trunks; collateral trunk. The number of branches to the thoracic aorta from the left sympathetic trunk is 4-16, and from the right sympathetic trunk – 3-14. The largest number of branches that enter the wall of the thoracic aorta, from the left sympathetic trunk skeletotopically determined at the level of III-VI thoracic segments, and from the right sympathetic trunk – at the level of IV-VI thoracic segments. Different skeletotopic levels of the branches of the right and left large visceral nerves are involved in the innervation of the thoracic aorta – from V to X thoracic segments. It is noted that the right and left sympathetic trunks are almost equally involved in the innervation of the azygos and hemiazygos veins. The number of sympathetic branches to the azygos vein ranges from 4 to 7, and the number of sympathetic branches to the hemiazygos vein is usually 2-4

Artificial reconstruction for a thymoma invading superior vena cava

Artificial reconstruction for a thymoma invading superior vena cava

Automated Surgical-Phase Recognition for Robot-Assisted Minimally Invasive Esophagectomy Using Artificial Intelligence.

Although a number of robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed due to three-dimensional field of view, image stabilization, and flexible joint function, both the surgeons and surgical teams require proficiency. This study aimed to establish an artificial intelligence (AI)-based automated surgical-phase recognition system for RAMIE by analyzing robotic surgical videos. This study enrolled 31 patients who underwent RAMIE. The videos were annotated into the following nine surgical phases: preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. An additional phase ("no step") was used to indicate video sequences upon removal of the camera from the thoracic cavity. All the patients were divided into two groups, namely, early period (20 patients) and late period (11 patients), after which the relationship between the surgical-phase duration and the surgical periods was assessed. Fourfold cross validation was applied to evaluate the performance of the current model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and "no step" (p < 0.001) phases predicted by the AI were significantly shorter in the late period than in the early period. A highly accurate automated surgical-phase recognition system for RAMIE was established using deep learning. Specific phase durations were significantly associated with the surgical period at the authors' institution.

Thoracoscopic approach to the resection of idiopathic azygos vein aneurysm: a case report

BackgroundAzygos vein aneurysm (AVA) is a rare thoracic pathological entity that mimics a posterior mediastinal mass. However, the pathogenesis of primary azygos vein aneurysms is not clear and its pathology is still being discussed. Some of the AVA are asymptomatic and usually discovered accidentally by routine physical examination.Case presentationWe report the case of a 37-year-old woman who had an azygos vein arch aneurysm with no obvious clinical symptoms. With the analysis of clinical features of the case and AVA morphological characteristics, the AVA was found by a chest computed tomography. Then, enhanced chest computed tomography showed a soft-tissue mass (4.9 × 3.7 × 3.2 cm) in the right posterior mediastinum, which was connected to the superior vena cava and significantly enhanced with contrast agent stratification. The density of the tumor in the delayed stage was the same as that in the azygos vein. The patient underwent video-assisted thoracoscopic surgery. Histopathological evaluation of the surgical biopsy specimen proved to be a completely thrombosed aneurism of the azygos vein arch.ConclusionsAVA is a rare pathology that must be taken into consideration during the differential diagnosis of right posterior mediastinal masses. Thoracoscopic surgery is one of the most preferred treatment options for azygos vein aneurysm.

Therapy Effect of the Stable Gastric Pentadecapeptide BPC 157 on Acute Pancreatitis as Vascular Failure-Induced Severe Peripheral and Central Syndrome in Rats.

We revealed the therapy effect of the stable gastric pentadecapeptide BPC 157 (10 μg/kg, 10 ng/kg ig or po) with specific activation of the collateral rescuing pathways, the azygos vein, on bile duct ligation in particular, and acute pancreatitis as local disturbances (i.e., improved gross and microscopy presentation, decreased amylase level). Additionally, we revealed the therapy’s effect on the acute pancreatitis as vascular failure and multiorgan failure, both peripherally and centrally following “occlusion-like” syndrome, major intoxication (alcohol, lithium), maintained severe intra-abdominal hypertension, and myocardial infarction, or occlusion syndrome, and major vessel occlusion. The application-sacrifice periods were ligation times of 0–30 min, 0–5 h, 0–24 h (cured periods, early regimen) and 4.30 h–5 h, 5 h–24 h (cured periods, delayed regimen). Otherwise, bile duct-ligated rats commonly presented intracranial (superior sagittal sinus), portal and caval hypertension and aortal hypotension, gross brain swelling, hemorrhage and lesions, heart dysfunction, lung lesions, liver and kidney failure, gastrointestinal lesions, and severe arterial and venous thrombosis, peripherally and centrally. Unless antagonized with the key effect of BPC 157 regimens, reversal of the inferior caval and superior mesenteric vein congestion and reversal of the failed azygos vein activated azygos vein-recruited direct delivery to rescue the inferior-superior caval vein pathway; these were all antecedent to acute pancreatitis major lesions (i.e., acinar, fat necrosis, hemorrhage). These lesions appeared in the later period, but were markedly attenuated/eliminated (i.e., hemorrhage) in BPC 157-treated rats. To summarize, while the innate vicious cycle may be peripheral (bile duct ligation), or central (rapidly developed brain disturbances), or peripheral and central, BPC 157 resolved acute pancreatitis and its adjacent syndrome.

Esophageal atresia with proximal and distal fistulae in a neonate with interrupted vena cava and azygos continuation

Esophageal atresia with proximal and distal fistulae in a neonate with interrupted vena cava and azygos continuation

Thoracoscopic AF ablation in situs inversus dextrocardia with interrupted inferior vena cava continuation in azygos vein

IntroductionSitus inversus totalis, dextrocardia with interrupted inferior vena cava, and azygos vein continuation concomitant with symptomatic atrial fibrillation requiring ablation. This case was deemed not suitable for percutaneous ablation due to anatomic variations and the lack of case reports in the literature.Methods and ResultsWe performed bilateral thoracoscopic epicardial ablation and epicardial left atrial appendage exclusion. The direct vision allowed for a complete box lesion set with bipolar radiofrequency device. Patient remained in sinus rhythm at the 12‐months follow‐up.ConclusionSurgical thoracoscopic epicardial ablation is safe and effective also in congenital defects. Multidisciplinary expertise can offer minimally invasive ablation treatments.