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Objective: This study aims to determine if a novel imaging protocol (ultralow-dose dynamic expiratory computed tomography [CT] with repeated imaging) identifies tracheomalacia (TM) more reliably than traditional dynamic tracheal CT., Methods: We performed a retrospective evaluation of 184 consecutive ultralow-dose dynamic CTs for TM during 2017. The protocol obtains images during 1 inspiration and 2 forced expirations. Tracheal narrowing during both expirations (airway narrowing [percentage] during first dynamic expiration CT [DE1], airway narrowing [percentage] during second dynamic expiration CT [DE2]) was reported as a percentage of inspiratory area. We identified maximum narrowing of each patient's sequence (maximum narrowing [percentage] on either dynamic expiration CT [DEmax] = greatest narrowing of DE1 or DE2) and compared DE1, DE2, and DEmax in individual studies and between patients. Outcomes included frequency of TM, tracheal narrowing, and severity. Reliability was assessed by comparing tracheal area narrowing and TM grade., Results: There was significantly more airway narrowing using 2 expiratory image acquisitions. Average DEmax tracheal area was 12% narrower than DE1 alone and 21% worse than DE2 alone (both P < 0.001). Using DEmax, TM was diagnosed 35% more often than DE1 alone and 31% more often than DE2 alone ( P < 0.001). DEmax identified more severe distribution of TM compared with DE1 or DE2 alone ( P < 0.001). Reliability between DE1 and DE2 was good for tracheal narrowing and moderate for TM grade. The mean effective radiation dose was 2.41 millisievert (mSv) for routine inspiration CT and 0.07 mSv for each dynamic expiration CT (total effective radiation, 2.55 mSv)., Conclusions: Dynamic expiration CT with 2 expiratory image acquisitions enhanced evaluation of TM, minimally increased radiation dose, and should be considered as a noninvasive screening option., Competing Interests: S.L.C. and B.C.B. have received funding from Siemens Healthineers and Society of Thoracic Radiology. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. No conflicts of interest were declared for the remaining authors., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions., Summary Background Data: Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets., Methods: Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors., Results: A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007)., Conclusions: Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations., Competing Interests: A.E.A.: Consultant, Intuitive Surgical. R.J.C.: Consultant, Intuitive Surgical. M.R.D.: Consultant for Intuitive Surgical and Verb Surgical, Clinical Education Ethicon. L.J.H.: Consultant, Intuitive Surgical. K.G.J.: Consultant, Intuitive Surgical. M.S.K.: Speaker, Intuitive Surgical. R.M.R.: Consultant for Intuitive Surgical and Auris Health, Advisory Board Medtronic. P.R.: Consultant, Intuitive Surgical. I.S.S.: Consultant, Intuitive Surgical. L.Y.S.: Proctor, Intuitive Surgical. W.B.T.: Consultant, Intuitive Surgical. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The study objective was to examine pulmonary function and quality of life improvement after robotic-assisted thoracoscopic tracheobronchoplasty for patients with different degrees of obstructive airway disease., Methods: We performed a retrospective review of a prospective database of patients who underwent robotic-assisted thoracoscopic tracheobronchoplasty between 2013 and 2020., Results: A total of 118 patients underwent robotic-assisted thoracoscopic tracheobronchoplasty. Preoperative and postoperative pulmonary function tests were available for 108 patients. Postoperative pulmonary function tests at a median of 16 months demonstrated a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 76.76% predicted, postoperative: 83% predicted, P = .002). Preoperative and postoperative St George Respiratory Questionnaires were available for 64 patients with a significant decrease in postoperative score at a median of 7 months (preoperative median: 61, postoperative: 41.60, P < .001). When stratified by preoperative degree of obstruction, robotic-assisted thoracoscopic tracheobronchoplasty improved forced expiratory volume in 1 second in moderate to very severe obstruction with a statistically significant improvement in moderate (preoperative median: 63.91% predicted, postoperative median: 73% predicted, P = .001) and severe (preoperative median: 44% predicted, postoperative median: 57% predicted, P = .007) obstruction. St George Respiratory Questionnaire scores improved for all patients. Improvement for mild (preoperative median: 61.27, postoperative median: 36.71, P < .001) and moderate (preoperative median: 57.15, postoperative median: 47.52, P = .03) obstruction was statistically significant., Conclusions: Robotic-assisted thoracoscopic tracheobronchoplasty improves obstruction and symptoms. With limited follow-up, subgroup analysis showed forced expiratory volume in 1 second improved in severe preoperative obstruction and quality of life improved in moderate obstruction. Future follow-up is required to determine robotic-assisted thoracoscopic tracheobronchoplasty effects on the most severe group, but we cannot conclude that increased degree of preoperative obstruction precludes surgery., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to analyze outcomes of open lobectomy (OL), VATS, and robotic-assisted lobectomy (RL)., Summary Background Data: Robotic-assisted lobectomy has seen increasing adoption for treatment of early-stage lung cancer. Comparative data regarding these approaches is largely from single-institution case series or administrative datasets., Methods: Retrospective data was collected from 21 institutions from 2013 to 2019. All consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Neoadjuvant cases were excluded. Propensity-score matching (1:1) was based on age, sex, race, smoking-status, FEV1%, Zubrod score, American Society of Anesthesiologists score, tumor size, and clinical T and N stage., Results: A total of 2391 RL, 2174 VATS, and 1156 OL cases were included. After propensity-score matching there were 885 pairs of RL vs OL, 1,711 pairs of RL vs VATS, and 952 pairs of VATS vs OL. Operative time for RL was shorter than VATS ( P < 0.0001) and OL ( P = 0.0004). Compared to OL, RL and VATS had less overall postoperative complications, shorter hospital stay (LOS), and lower transfusion rates (all P <0.02). Compared to VATS, RL had lower conversion rate ( P <0.0001), shorter hospital stay ( P <0.0001) and a lower postoperative transfusion rate ( P =0.01). RL and VATS cohorts had comparable postoperative complication rates. In-hospital mortality was comparable between all groups., Conclusions: RL and VATS approaches were associated with favorable perioperative outcomes compared to OL. Robotic-assisted lobectomy was also associated with a reduced length of stay and decreased conversion rate when compared to VATS., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The initial description of robotic tracheobronchoplasty for the treatment of tracheobronchomalacia demonstrated feasibility, safety, and short-term symptomatic and functional improvement. The purpose of the current study was to demonstrate intermediate outcomes in postoperative pulmonary function and quality of life after robotic tracheobronchoplasty., Methods: We retrospectively reviewed prospectively collected clinical data from 42 patients who underwent robotic tracheobronchoplasty from May 2016 to December 2017. The Institutional Review Board or equivalent ethics committee of the Northwell Health approved the study protocol and publication of data. Patient written consent for the publication of the study data was waived by the Institutional Review Board., Results: A total of 42 patients underwent robotic tracheobronchoplasty during the study period. Median total follow-up is 40 months. There was 1 death since surgery from an unrelated disease. Significant decreases in St George's Respiratory Questionnaire total score (preoperative mean: 64.01, postoperative mean: 38.91, P = .002), St George's Respiratory Questionnaire symptom score (preoperative median: 82.6, postoperative median: 43.99, P < .001), and St George's Respiratory Questionnaire impact score (preoperative median: 55.78, postoperative median: 25.95, P < .001) were apparent at a median follow-up of 13 months. Comparison of preoperative and postoperative pulmonary function tests revealed a significant increase in percent predicted forced expiratory volume in 1 second (preoperative median: 74% vs postoperative median: 82%, P = .001), forced vital capacity (preoperative median: 68.5% vs postoperative median: 80.63%, P < .001), and peak expiratory flow (preoperative median: 61.5% vs postoperative median: 75%, P = .02) measured at a median follow-up of 29 months., Conclusions: Robotic tracheobronchoplasty is associated with low intermediate-term mortality. Robotic tracheobronchoplasty results in significant improvement in quality of life and postoperative pulmonary function. Longer-term follow-up is necessary to continue to elucidate the effect of robotic tracheobronchoplasty on halting pathologic progression of tracheobronchomalacia and to determine the long-term impact of tracheobronchoplasty on symptomatic and functional improvement., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Fungal prosthetic graft infections are associated with high mortality, typically requiring aggressive surgical debridement. We present an alternative, minimally invasive approach to address these challenging clinical cases., Case Presentation: A 76-year-old Caucasian male with prior aortic root and arch replacement presented with localized chest wall tenderness after being hit by a car door. Computed tomography angiogram incidentally identified fluid in the anterior mediastinum, surrounding his ascending aortic graft. Rather than undertaking a high-risk reoperative sternotomy and redo complex aortic reconstruction, we elected to proceed with a robotic-assisted, minimally invasive debridement of the aortic graft, coupled with an omental wrap, entirely within the closed chest. Microbiology was positive for Aspergillus species. The patient made an uncomplicated recovery and was discharged home on antifungal therapy, likely to continue indefinitely., Conclusions: Infected prosthetic aortic grafts can be successfully managed with debridement and pedicled omental flap coverage via a minimally invasive approach within the closed chest, obviating the morbidity of a complex reoperative open procedure., (© 2022. The Author(s).)

Case Presentation: A 54-year-old man sought treatment at the ED for a productive cough with green phlegm of approximately 6 months' duration that was accompanied by a 10-pound weight loss, night sweats, and occasional subjective fevers. He had made several prior visits to the ED for the cough and was hospitalized 4 months earlier for similar symptoms, at which time he underwent a bronchoscopy with BAL and was discharged with antibiotics for presumed pneumonia. He did not report any itching, rashes, sinus infections, joint swelling, joint pain, or GI symptoms. His long-term medications included omeprazole and amlodipine. The patient had a past medical history of grade III follicular lymphoma for which he completed six cycles of bendamustine 4 years before presentation and had been in remission since. He was a never smoker, had a recent travel history to the Dominican Republic 8 months before admission, and had no recent sick contacts., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: In the tide of robot-assisted minimally invasive surgery, few cases of robot-assisted pneumonectomy exist in the literature. This study evaluates the perioperative outcomes and risk factors for conversion to thoracotomy with an initial robotic approach to pneumonectomy for lung cancer., Methods: This study is a single-center retrospective review of all pneumonectomies for lung cancer with an initial robotic approach between 2015 and 2019. Patients were divided into 2 groups: surgeries completed robotically and surgeries converted to thoracotomy. Patient demographics, preoperative clinical data, surgical pathology, and perioperative outcomes were compared for meaningful differences between the groups., Results: Thirteen total patients underwent robotic pneumonectomy with 8 of them completed robotically and 5 converted to thoracotomy. There were no significant differences in patient characteristics between the groups. The Robotic group had a shorter operative time ( P < 0.01) and less estimated blood loss ( P = 0.02). There were more lymph nodes harvested in the Robotic group ( P = 0.08) but without statistical significance. There were 2 major complications in the Robotic group and none in the Conversion group. Neither tumor size nor stage were predictive of conversion to thoracotomy. Conversions decreased over time with a majority occurring in the first 2 years. There were no conversions for bleeding and no mortalities., Conclusions: Robotic pneumonectomy for lung cancer is a safe procedure and a reasonable alternative to thoracotomy. With meticulous technique, major bleeding can be avoided and most procedures can be completed robotically. Larger studies are needed to elucidate any advantages of a robotic versus open approach.

Objective: The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform., Methods: We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed., Results: This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS ( P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield., Conclusions: RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

Aortopulmonary paragangliomas are rare, neural crest-derived tumours that arise in the aortopulmonary window and present a significant surgical challenge due to their proximity to major vessels. In the relatively few cases reported in the study, thoracotomy and video-assisted thorascopic surgery (VATS) approaches have been utilized for the treatment of such masses. In this report, we describe the application of a totally endoscopic robotic-assisted VATS approach for the excision of an aortopulmonary paraganglioma., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The aim of this study was to determine the average effective radiation dose and feasibility of ultralow dose dynamic expiratory computed tomography (CT) for evaluation of tracheomalacia (ULD) and to evaluate factors that impact image quality., Methods: This is a retrospective study of 64 consecutive patients from September to October 2016 for the evaluation of tracheomalacia. All studies were performed with routine inspiration chest CT followed by ULD z(kilovoltage peak (kVp) 80, 100, or 120 and fixed milliamperage 10) or typical dose CT (TD) (kVp 100 or 120 with automated milliamperage) dynamic expiration CT. Image quality was considered diagnostic if the trachea area could be accurately measured for tracheomalacia assessment, and diagnostic studies were graded fair, good, or excellent. Scan length, image quality, and effective radiation dose were compared for ULD versus TD and ULD at 100 kVp versus ULD at 80 kVp. For ULD studies, patient factors were compared across image quality., Results: The ULD had a mean effective radiation dose of 0.08 mSv, with all studies of diagnostic image quality. The ULD showed 95% reduction in effective radiation dose (P < 0.001), 14% significant reduction in scan length (P = 0.029), and qualitatively decreased image quality compared w2 ith TD (P < 0.001). The ULD at 100 kVp had significantly better image quality compared with ULD at 80 kVp (P = 0.041) with higher effective radiation dose (0.09 vs 0.05 mSv) (P < 0.001). Body mass index significantly impacted image quality for all ULD studies but not for ULD at 80 or 100 kVp., Conclusion: For evaluation of tracheomalacia, ULD showed low effective radiation dose less than 0.1 mSv and maintained diagnostic image quality.

Objective: Single-surgeon cohorts assessing robotically assisted video-assisted thoracic (RA-VATS) lobectomy have reported good outcomes, but there are little data regarding multiple surgeons applying a standard technique in separate hospitals. The purpose of this study was to show how a standardized robotic technique is both safe and reproducible between surgeons and institutions., Methods: From July 1, 2012, to October 1, 2013, patients undergoing RA-VATS lobectomy for both benign and malignant disease were identified from a prospectively collected database of two thoracic surgeons from different hospitals within the same healthcare system and retrospectively analyzed. Each surgeon employed an identical "rule of 10" completely port-based approach through all 128 cases. The primary end points of the study were in-hospital and 30-day mortality. Secondary end points were differences in morbidity and perioperative outcomes between the two surgeons based on their "rule of 10" technique., Results: A total of 128 cases were performed with 121 lobectomies, 3 bilobectomies, and 4 pneumonectomies for both malignant and benign disease. Each surgeon had 64 cases without a single in-hospital or 30-day mortality. Overall morbidity was 16.4%. Each surgeon had one readmission and take back to operating room (a washout and a mechanical pleurodesis). The most common complication was prolonged air leak (38.1%, 8/21 patients). There was no statistical difference in length of stay, complications, severity of illness, and clinical staging between the two surgeons. There was a significant difference in resected lymph nodes (11.79 vs 14.45, P = 0.0086). Compared with published national meta-analysis on RA-VAT lobectomies, there was a significantly reduced length of stay (4.2 vs 6 days, P = 0.0436) and bleeding (0.8 vs 1.8%, P = 0.0003). Nodal upstaging from cN0 to pN1 was 8% and cN0 to pN2 was 2% for an overall nodal upstaging of 10% for stage I nonsmall cell lung cancer., Conclusions: By standardizing how a robotic lobectomy is performed, we were able to show that RA-VATS lobectomy is safe and may allow for the expansion of minimally invasive lobectomy to surgeons who otherwise have failed to adopt traditional VATS. When compared with the most recent national meta-analysis, we had reduced morbidity, mortality, bleeding, and length of stay. Robotic nodal upstaging for stage I nonsmall lung cancer was consistent with larger multicenter study. We hope that these results will help lead to the standardization robotic lobectomy and a larger multisurgeon/institutional study that could pave the way for greater adoption of minimally invasive lobectomy.

We describe the technique for the first robotically assisted bilateral bronchoplasty for the treatment of tracheobronchomalacia. Since 1954, this disease process has been treated with a right thoracotomy and posterior splinting of the tracheal membrane with mesh to restore the C-shape of the trachea. Traditional video-assisted thoracoscopic surgery has been of limited benefit in these cases owing to technical challenges. A robotically assisted technique offers the dual benefit of a minimally invasive port-based system while reproducing an open surgical technique.

Surgical participation in the management of fungal infections has changed since the advent of effective antimicrobials. Even so, a surgeon may be called on for a variety of reasons, depending on the specific fungal infection and the evolution of thoracic disease. Specific fungal infections are enumerated. Each organism, its clinical picture, and method of diagnosis are briefly described and the medical and surgical management of thoracic disease are discussed., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Cardiac papillary fibroelastomas (CPF) are benign endocardial papillomas commonly formed from valve endothelium. The majority of tumors are found on the left side of the heart, with only a few case reports of pulmonary valve fibroelastomas. We report here a case of pulmonary valve papillary fibroelastoma that was successfully managed with simple excision of the mass.

Background: Previous studies have reported that risk factors for elevated mortality after Roux-en-Y gastric bypass include male gender, as well as a very elevated BMI. The present study was aimed at determining whether these same risk factors applied to patients undergoing the duodenal switch (DS) operation., Materials and Methods: A retrospective chart review was performed of a cohort of 385 patients who underwent DS. The 30-day mortality of super-superobese (SSO) patients [BMI > or =60 kg/m2 (n=102)] was compared with the mortality of the super- and morbidly obese (SMO) patients [35 or =60 kg/m2.

Background: Recent data has shown that the use of warmed, humidified carbon dioxide (CO2) insufflation during laparoscopic surgery may be associated with better outcomes., Methods: We performed a randomized, doubleblind, prospective controlled clinical trial of 30 patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Patients were randomized into 2 groups. The first group (group 1, n=15) received standard (dry, room temperature) CO2 for insufflation during the surgery, while the second group (group 2, n=15) received warmed (35 degrees C) and humidified (95%) CO2. Patients received postoperative analgesia from morphine delivered via a patient-controlled analgesia (PCA) pump. Pain scores (on a scale of 0 to 10, 0 being no pain and 10 being the worst pain) were measured postoperatively at 3 h, 6 h, 1 day and 2 days. The amount of morphine that was delivered through the PCA was also measured at the same time intervals. Operating-room (OR) time, core temperature, and total hospital length of stay were documented., Results: Postoperative pain as documented by pain scores and narcotic usage were not statistically different in the 2 groups. We demonstrated a statistically significant difference (mean+/-SD) in OR time (76+/-16 min vs 101+/-34 min, P=0.02), total hospital length of stay (3.2+/-.4 days vs 4.0+/-.9 days, P=0.01) and end-of-case core temperature (36.2+/-.5 degrees C vs 35.7+/-.6 degrees C, P=0.02) in group 2 compared with group 1., Conclusion: The use of warmed, humidified CO2 insufflation in bariatric patients undergoing LRYGBP was not associated with any significant benefit with regards to postoperative pain.

Background: Severe sepsis syndrome (SSS) and septic shock have an associated mortality ranging from 31 to 60%. Drotrecogin alfa (activated), activated protein C (APC), has been shown in a recent trial to decrease mortality from 44 to 31% in patients with SSS and a high risk of death. We present 3 patients who developed SSS after bariatric surgery and were treated with APC as part of comprehensive therapy for sepsis., Methods: At our institution, patients must have SSS plus an APACHE II score >or= 25 in order to receive APC. JL is a 43-year-old man who developed SSS (APACHE II score 26) after Roux-en-Y gastric bypass. ML is a 33-year-old man who developed SSS (APACHE II=28) because of a distal obstruction 2.5 years after gastric bypass surgery. TQ was a 35-year-old man who developed SSS (APACHE II=35) in the setting of laparoscopic banding., Results: After receiving 90% of the 96-hour infusion, JL developed ecchymoses and a decrease in his platelet count; thus, the drug was stopped. ML received a full 96-hour infusion. Both patients made a full recovery from their SSS and were successfully discharged from the hospital. TQ developed septic shock and expired despite all efforts., Conclusion: Weight alone should not be considered a contraindication to the use of APC. Close coordination between the intensivist and surgeon is recommended for bariatric surgery patients with SSS, so that a rapid determination can be made as to the patient's risk of death and eligibility to receive APC.

Background: Venous thromboembolic (VTE) disease is a much-feared complication of bariatric surgery. The most common unexpected cause of death in the morbidly obese patient is pulmonary embolism (PE). Recent data supports the expanded use of systemic thrombolytics in hemodynamically stable patients with PE and echocardiographic evidence of right ventricular (RV) dysfunction., Methods: We report a morbidly obese 28-year-old female who presented with dyspnea 3 weeks following bariatric surgery. The patient developed a submassive PE, despite being on low molecular weight (LMW) heparin (dalteparin) postoperatively. The patient was admitted to the surgical intensive care unit of an urban community teaching hospital and underwent successful thrombolysis., Results: Although the patient was not hypotensive, she was tachycardic and highly symptomatic. Spiral CT scanning revealed a large saddle embolism. Transthoracic echocardiography revealed moderate-to-severe acute RV dysfunction with paradoxical septal motion. The patient was started on i.v. heparin followed by an infusion of alteplase 100 mg i.v. over 2 hours. She had no mental status changes during the infusion or evidence of hemorrhage. She had a rapid improvement of her symptoms. Repeat CT scanning revealed marked resolution of the PE. She was discharged home in excellent condition., Conclusion: To our knowledge, this is the first report of systemic thrombolysis for a submassive PE after bariatric surgery in a hemodynamically stable patient with RV dysfunction. Given the high incidence and morbidity of VTE disease in this population, and the expanding indications for thrombolytic therapy, successful cases such as these should be documented.

Background: The purpose of this study was to compare the long-term results of Dacron and polytetrafluoroethylene (PTFE) aortic bifurcation grafts in a prospective randomized manner., Methods: Sixty patients with aortoiliac occlusive disease were randomized to receive Dacron or PTFE bifurcation grafts. Preoperative risk factors, perioperative blood loss and fluid requirements, and postoperative complications were compared. A mean follow-up of 57 months was achieved., Results: The immediate postoperative morbidity and mortality rates were similar in the two groups, and the long-term complications were low in number and comparable. The cumulative patency rate for Dacron graft limbs was 86% versus 95% for PTFE graft limbs., Conclusions: No significant differences were noted between the results achieved with Dacron and PTFE aortic bifurcation grafts.

As laparoscopic hernia repair continues to evolve as an operative procedure, papers will continue to be published discussing new variations and new techniques which will better the operative procedure as a whole and quite possibly decrease its associated complications (i.e., morbidity and mortality). We present a case of laparoscopic bilateral herniorrhaphy in which after uncomplicated surgery and an immediate, uneventful postoperative course, the patient returned to our institution with both a rectus sheath hematoma and small bowel obstruction. The patient, who was initially treated conservatively, ultimately required laparotomy for persistent small bowel obstruction. Laparotomy revealed incarcerated small bowel in a cavity between the posterior rectus fascia and the rectus muscle proper. The patient did well after laparotomy and was discharged home with no further complications.