Surgical Outcome of Renal Cell Carcinoma with Tumor Thrombus Extension into Inferior Vena Cava and Right Atrium (Beating Heart Removal of Level 4 Thrombus): A Challenging Scenario

Aim: “To evaluate oncological and surgical outcomes of different levels of tumor thrombus and tumor characteristics secondary to renal cell carcinoma (RCC)”. Materials and Methods: Retrospective review from 2013 to 2020 of 34 patients who underwent radical nephrectomy with thrombectomy for RCC with tumor thrombus extending into the inferior vena cava (IVC) and right atrium (RA) at our center. Level I and most level II tumors were removed using straight forward occluding maneuvers with control of the contralateral renal vein. None of the patients had level III tumor extensions in our study group. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for retrieval of thrombus from the right atrium. Results: “Of the 34 patients with thrombus”, 19 patients had level I, 12 patients had level II, none had level III, and three patients had level IV thrombus. Two patients required simplified CPB. Another patient with level IV thrombus CPB, was not attempted in view of refractory hypotension intraoperatively. Pathological evaluation showed clear-cell carcinoma in 67.64%, papillary carcinoma in 17.64%, chromophobe in 5.8%, and squamous cell carcinoma in 8.8% of cases. Left side thrombectomy was difficult surgically, whereas right side thrombectomy did not have any survival advantage. Mean blood loss during the procedure was 325 mL, ranging from 200 to 1000 mL, and mean operative time was 185 min, ranging from 215 to 345 min. The immediate postoperative mortality was 2.9%. Level I thrombus had better survival compared to level II thrombus. Conclusion: Radical nephrectomy with tumor thrombectomy remains the mainstay of treatment in RCC with inferior venacaval extension. The surgical approach and outcome depends on primary tumor size, location, level of thrombus, local invasion of IVC, any hepato-renal dysfunction or any associated comorbidities. The higher the level of thrombus, the greater is the need for prior optimization and the adoption of a multidisciplinary approach for a successful surgical outcome

Traumatic diaphragmatic rupture, a diagnostic dilemma in the presence of eventration: a case report

Eventration of the diaphragm is the condition where the muscle is permanently elevated, but retains its continuity and attachments to the costal margins. Traumatic diaphragmatic rupture is a recognized consequence of high velocity blunt trauma to the abdomen usually a result of motor vehicle accident. Multi-slice CT and Magnetic Resonance Imaging in the pre-operative evaluation of trauma patients, diaphragmatic rupture can be still overlooked if not evaluated with the fair degree of clinical suspicion, more so if it is associated with an eventration of diaphragm - as was in our case

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950-2019 : a comprehensive demographic analysis for the Global Burden of Disease Study 2019

Background: Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods: 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10–14 and 50–54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings: The global TFR decreased from 2·72 (95% uncertainty interval [UI] 2·66–2·79) in 2000 to 2·31 (2·17–2·46) in 2019. Global annual livebirths increased from 134·5 million (131·5–137·8) in 2000 to a peak of 139·6 million (133·0–146·9) in 2016. Global livebirths then declined to 135·3 million (127·2–144·1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2·1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27·1% (95% UI 26·4–27·8) of global livebirths. Global life expectancy at birth increased from 67·2 years (95% UI 66·8–67·6) in 2000 to 73·5 years (72·8–74·3) in 2019. The total number of deaths increased from 50·7 million (49·5–51·9) in 2000 to 56·5 million (53·7–59·2) in 2019. Under-5 deaths declined from 9·6 million (9·1–10·3) in 2000 to 5·0 million (4·3–6·0) in 2019. Global population increased by 25·7%, from 6·2 billion (6·0–6·3) in 2000 to 7·7 billion (7·5–8·0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58·6 years (56·1–60·8) in 2000 to 63·5 years (60·8–66·1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019

Single-stage bilateral minimally invasive approach for pulmonary hydatid disease: An alternative technique

AbstractJ Thorac Cardiovasc Surg 2002;124:1021-

Pattern, presentation and management of vascular injuries due to pellets and rubber bullets in a conflict zone

Background: Rubber bullets and pellet guns are considered non-lethal low-velocity weapons. They are used to disperse a mob during street protests. The present study was undertaken to analyze the pattern, presentation and management of vascular injuries caused by these weapons. Patients and Methods: This was a prospective study of patients with features of vascular injuries due to pellets and rubber bullets from June 2010 to November 2010. All patients with features of vascular injuries due to these non-lethal weapons were included in the study. Vascular injuries caused by other causes were excluded from the study. Results: A total of 35 patients who presented with features of vascular injury during this period were studied. All of them were males. The mean age was 22 years. Fifteen patients were revascularized primarily, 19 patients needed reverse saphenous vein graft and, in one, patient lateral repair was done. There were two mortalities in our series. Wound infection was the most common complication. The amputation rate was around 6%. Conclusion: Pellet and rubber bullets can cause serious life-threatening injuries. Vascular injury caused by these weapons need no different approach than other vascular injuries. Early revascularization and prompt resuscitation prevents the loss of limb or life

Spontaneous pneumothorax

Background: Spontaneous pneumothorax is classified into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP). PSP occurs without any cause, usually as a result of the rupture of subpleural blebs. SSP is related to the presence of underlying lung disease. The pathological consequences depend primarily on the site of pneumothorax and the condition of the underlying lung. Material and Methods: Data related to 84 patients with 126 episodes of pneumothorax presenting from January 1998 to December 2000 were retrospectively reviewed to assess the clinical manifestations and therapy of spontaneous pneumothorax. Results: There were 52 patients with 80 episodes of PSP and 32 patients with 46 episodes of SSP. The common causes for SSP were tuberculosis (18 patients with 29 episodes) and emphysema (7 patients with 10 episodes). The age of presentation was 27±11 years for PSP and 58.8±15.2 years for SSP (p<0.01). The commonest clinical manifestation with PSP was chest pain (86.25 %)whereas dyspnoea was the commonest manifestation with SSP (84.78%). Seventy-three (91.25%) episodes of PSP and 37 (80.43%) episodes of SSP were managed with non-operative treatment. Thoracotomy was done in 7 (8.7%) and 9 (19.5%) episodes of PSP and SSP respectively. The overall recurrence rate of PSP was 31.25% and 26.08% in SSP. No recurrence was seen with open thoracotomy in both groups of patients. Conclusions: We conclude that patients with both PSP and SSP should be managed initially with nonoperative treatment. Thoracostomy tube drainage is the mainstay of treatment. Patients with SSP are generally debilitated from the respiratory standpoint and may have other significant comorbid diseases. Effective treatment must be individualized

Right anterolateral thoracotomy a minimally invasive approach to mitral valve replacement

Background: The objectives of this study were to analyze the results of the right anterolateral thoracotomy approach for primary mitral valve replacement with reference to length of incision, surgical exposure, mean cross-clamp time, mean bypass time, intensive care unit (ICU) stay, hospital stay, overall comorbidity sepsis, dehiscence, healing cosmesis and cost-effectiveness. Materials and Methods: Thirty-three patients were operated for mitral valve disease in the Department of Cardiovascular and Thoracic Surgery at the Sher-i-Kashmir Institute of Medical Sciences from September 2009 to August 2011 and all patients underwent mitral valve replacement. Results: Of the 33 patients, 13 were male (40.6%) and 19 were female (59.4%). The length of incision was 14.8 ± 2.3 cm and, in thoracotomy, there was a significantly lesser duration of ICU stay the entire hospital stay. Scar visibility was around 25% in case of thoracotomy. Conclusion: Approach through a right anterolateral thoracotomy proved to be easy to perform while maintaining maximum security for the patients. Besides its better cosmetic result, especially in female patients, this approach proved to have several advantages. It offered a better exposure to the mitral apparatus even in patients with small left atrium, allowing mitral valve replacement to be performed easily. The shorter hospital stay and cost-effectiveness of thoracotomy approach is an additional relief to the family