BACKGROUND Hepatocellular carcinoma(HCC)is one of the most frequent cancers and the main cause of cancer-related death worldwide.Ectopic HCC,an extremely rare type of HCC,exhibits a wide range of clinical signs and ra...BACKGROUND Hepatocellular carcinoma(HCC)is one of the most frequent cancers and the main cause of cancer-related death worldwide.Ectopic HCC,an extremely rare type of HCC,exhibits a wide range of clinical signs and radiographic features,making preoperative identification challenging.CASE SUMMARY A 47-year-old man underwent routine abdominal color ultrasonography,which identified an asymptomatic tumor in the left upper abdomen.The patient had no history of hepatitis,did not drink alcohol,and had no family history of cancer.Abdominal contrast-enhanced computed tomography(CT)revealed a heterogeneously enhanced lesion between the spleen and stomach that had invaded the diaphragm,with blood supplied by the left inferior phrenic artery.The patient underwent laparoscopic surgery,and HCC was identified by postoperative pathology.Additionally,specific immunohistochemical staining was performed to assess the molecular biological characteristics of the HCC.The patient underwent two rounds of hepatic arterial interventional chemotherapy after surgery.Abdominal plain and enhanced magnetic resonance imaging and lung CT 3 mo postoperatively revealed no signs of local recurrence or distant metastasis.CONCLUSION This asymptomatic ectopic HCC case described achieved an excellent result due to early detection,radical resection,and systematic surveillance.展开更多
BACKGROUND Bronchial Dieulafoy’s disease(BDD)is characterized by the erosion of an anomalous artery in the submucosa of the bronchus.The etiology of pediatric BDD is mainly congenital dysplasia of bronchus and pulmon...BACKGROUND Bronchial Dieulafoy’s disease(BDD)is characterized by the erosion of an anomalous artery in the submucosa of the bronchus.The etiology of pediatric BDD is mainly congenital dysplasia of bronchus and pulmonary arteries,which is different from chronic inflammatory injury of the airway in adult patients.The internal thoracic artery,subclavian artery,and intercostal artery are known to be involved in the blood supply to the BDD lesion in children.CASE SUMMARY We report a case of BDD in a 4-year-old boy with recurrent hemoptysis for one year.Selective angiography showed a dilated right bronchial artery,and anastomosis of its branches with the right lower pulmonary vascular network.Bronchoscopy showed nodular protrusion of the bronchial mucosa with a local scar.Selective embolization of the bronchial artery was performed to stop bleeding.One month after the first intervention,the symptoms of hemoptysis recurred.A computed tomography angiogram(CTA)showed another tortuous and dilated feeding artery in the right lower lung,which was an abnormal ascending branch of the inferior phrenic artery(IPA).The results of angiography were consistent with the CTA findings.The IPA was found to be another main supplying artery,which was not considered during the first intervention.Finally,the IPA was also treated by microsphere embolization combined with coil interventional closure.During the one-year follow-up,the patient never experienced hemoptysis.CONCLUSION The supplying arteries of the bleeding lesion in children with BDD may originate from multiple different aortopulmonary collateral arteries,and the IPA should be considered to reduce missed diagnosis.CTA is a noninvasive radiological examination for the screening of suspected vessels,which shows a high coincidence with angiography,and can serve as the first choice for the diagnosis of BDD.展开更多
BACKGROUND:Residual postoperative pleural spaces(RPPS) are often encountered during pulmonary resection;this could adversely affect the outcome and prolong recovery.Nerve cryotherapy reduces postoperative complication...BACKGROUND:Residual postoperative pleural spaces(RPPS) are often encountered during pulmonary resection;this could adversely affect the outcome and prolong recovery.Nerve cryotherapy reduces postoperative complications and does not affect neural regeneration.However,it remains unclear whether nerve cryotherapy reduces RPPS occurrence following pulmonary resection.OBJECTIVE:To explore pathological changes in the phrenic nerve following exposure to-50 °C for various freezing times,and to explore the feasibility and efficacy of phrenic nerve cryotherapy following pulmonary resection based on animal experiment results.DESIGN,TIME AND SETTING:A comparative animal study was conducted at the Animal Experimental Center of General Hospital of Chinese PLA from January to June 2008.Based on results from the animal study,a randomized,controlled,clinical study was initiated at the Department of Thoracic Surgery of General Hospital of Chinese PLA between July 2008 and July 2009.PARTICIPANTS:A total of 160 patients undergoing lobectomy were selected at the Department of Thoracic Surgery of General Hospital of Chinese PLA from July 2008 to July 2009.METHODS:Animal experiment:27 adult goats were randomly assigned to three groups(n = 9).The phrenic nerves were frozen at-50 °C for 30,60,and 90 seconds,respectively.Clinical study:160 patients undergoing lobectomy were randomly assigned to two groups(n = 80).In the cryoanalgesia group,patients received phrenic nerve cryotherapy;phrenic nerves were frozen above the capsula cordis for 60 seconds at-50 °C prior to chest closure.Patients in the control group did not receive cryotherapy.MAIN OUTCOME MEASURES:Pathological changes were observed at days 1,30,and 60 following phrenic nerve cryotherapy.In the clinical study,RPPS incidence rate was regularly recorded.Respiratory function tests,including measured forced vital capacity and forced expiratory volume in 1 second,were regularly conducted post-surgically.The incidence of post-surgical infection complications and the average days of chest drainage and hospital stay were observed and recorded.RESULTS:Animal study:nerve damage progressively increased with prolonged freezing time at-50 °C,and recovery time from damage gradually increased.Nerves,which were frozen for 30 and 60 seconds,recovered by 30 days,and all nerves completely recovered by 60 days.Clinical study:the RPPS incidence rate was significantly less in the cryoanalgesia group compared with the control group at 1,5,10,and 30 days following surgery(P < 0.05).Simultaneously,phrenic nerve cryotherapy decreased the incidence rate of RPPS and shortened the average days of chest drainage and hospital stay in patients undergoing lobectomy(P < 0.05).However,phrenic nerve cryotherapy did not affect forced vital capacity,forced expiratory volume in 1 second,and the incidence rate of post-surgical infection complications(P > 0.05).CONCLUSION:Following phrenic nerve cryotherapy in the goat at-50 °C,the phrenic nerve recovered to normal by 60 days.In the clinical study,phrenic nerve cryotherapy reduced the RPPS incidence rate,had no effect on pulmonary function,shortened hospital stay in patients undergoing lobectomy,and proved to be a safe,effective method.展开更多
BACKGROUND Phrenic nerve(PN)injury is one of the recognized possible complications following epicardial ablation of ventricular tachycardia(VT).High-output pacing is a widely used maneuver to establish a relationship ...BACKGROUND Phrenic nerve(PN)injury is one of the recognized possible complications following epicardial ablation of ventricular tachycardia(VT).High-output pacing is a widely used maneuver to establish a relationship between the PN and the ablation catheter tip.An absence of PN capture is usually considered an indication that it is safe to ablate,and that successful ablation may be performed at adjacent sites.However,PN capture may impact the procedural outcome.Only a few cases have been reported in the literature that avoid PN injury by using different techniques.CASE SUMMARY Three patients with a previous history of myocarditis and one patient with ischemic cardiomyopathy underwent epicardial ablation for drug-refractory VT.Before the procedure,transthoracic echocardiogram,coronary angiogram,and cardiac magnetic resonance imaging were performed on all patients.Under general anesthesia,endo/epicardial three-dimensional anatomical and substrate maps of the left ventricle were accomplished.Before radiofrequency delivery,the course of the PN was identified by provoking diaphragmatic stimulation with high-output pacing from the distal electrode of the ablation catheter.In every case,a scar region with late potentials was mapped along the PN course.After obtaining another epicardial access,a second introducer sheath was placed,and a vascular balloon catheter was inserted into the epicardial space and inflated with saline solution to separate the PN from the epicardium.Once the absence of PN capture had been proven,radiofrequency was applied to aim for complete late potential elimination and avoid VT induction.CONCLUSION PN injury can occur as one of the complications following epicardial VT ablation procedures,and may prevent successful ablation of these arrhythmias.PN displacement by using large balloon catheters into the epicardial space seems to be feasible and reproducible,avoid procedure-related morbidity,and improve ablation success when performed in selected centers and by experienced operators.展开更多
Hypoxemia after general anesthesia is not uncommon.For patients after thoracotomy,the differential diagnosis is usually difficult.Surgical,anesthetic,and patient-associated factors may contribute to postoperative hypo...Hypoxemia after general anesthesia is not uncommon.For patients after thoracotomy,the differential diagnosis is usually difficult.Surgical,anesthetic,and patient-associated factors may contribute to postoperative hypoxemia.We described two patients who underwent videassisted thoracoscopic thymectomy and developed hypoxemia immediately after extubation.Phrenic nerve injury was suspected in both patients.One case recovered spontaneously without intervention.The second case who had been demonstrated as bilateral phrenic nerve injury after the operation was continuously on ventilator after physical therapy and respiratory training for 2 months.展开更多
Phrenic nerve stimulation is a technique whereby a nerve stimulator provides electrical stimulation of the phrenic nerve to cause diaphragmatic contraction in patients with respiratory failure due to cervical spinal c...Phrenic nerve stimulation is a technique whereby a nerve stimulator provides electrical stimulation of the phrenic nerve to cause diaphragmatic contraction in patients with respiratory failure due to cervical spinal cord injury. This paper presents an eigth-channel stimulator circuit with an output stage (electrode driving circuit) that doesn’t need off-chip blocking-capacitors and is used for phrenic nerve stimulation. This stimulator circuit utilizes only 1 output stage for 8 channels. The proposed current generator circuit in this stimulator reducing to a single step the translation of the digital input bits into the stimulus current, thus minimizing silicon area and power consumption. An 8 bit implementation is utilized for this current generator circuit. The average pulse width for this eight- channel stimulator with 1 mA current, 20 Hz frequency and 8 bits resolution, is 150 - 300 μs. The average power consumption for a single-channel stimulation is 38 mW from a 1.2 V power supply. This implantable stimulator system was simulated in HSPICE using 90 nm CMOS technology.展开更多
Background: Up to one in three patients implanted with a cardiac resynchronization therapy-defibrillator (CRT-D) device experience phrenic nerve stimulation (PNS). Quadripolar leads are effective at reducing PNS, but ...Background: Up to one in three patients implanted with a cardiac resynchronization therapy-defibrillator (CRT-D) device experience phrenic nerve stimulation (PNS). Quadripolar leads are effective at reducing PNS, but compared to standard bipolar leads they have limitations related to maneuverability and high pacing thresholds. The ability of standard bipolar leads to overcome PNS is explored here. Methods: The French multicenter, observational study ORPHEE enrolled 90 CRT-D-eligible patients. Detection of PNS took place after satisfactory positioning of the LV bipolar lead (stable pacing threshold - LV ring, LV tip - RV ring and LV ring - RV coil) could prevent PNS from occurring in at least 90% of patients. Results: In 80 evaluable patients, PNS was reported in 12 patients (15%). Reprogramming overcame PNS in 10 patients: LV ring - RV coil in 8 patients;LV tip - LV ring in 1;and LV tip- RV ring in 1. As PNS was avoided in 78 of 80 patients (97.5%), the primary endpoint was significant (97.5% vs. 90%, p = 0.01). Conclusion: During CRT-D implantation, PNS occurred in 15% of patients. In most (97.5%) implanted patients, PNS could be avoided by vector reprogramming using a bipolar LV lead. For patients whose coronary sinus anatomy precludes the implantation of multi-electrode leads, bipolar leads are a suitable, reliable alternative.展开更多
Accessory renal arteries(ARAs)are common and usually originate from the abdominal aorta and the renal artery.Inferior phrenic arteries(IPAs)can also arise from the abdominal aorta or its branches.In this paper,we pres...Accessory renal arteries(ARAs)are common and usually originate from the abdominal aorta and the renal artery.Inferior phrenic arteries(IPAs)can also arise from the abdominal aorta or its branches.In this paper,we present the first case of a common trunk of the right ARA and right IPA arising from the thoracic artery at the level of T10,which was discovered by multidetector-row computed tomography in pretherapeutic evaluation and clearly confirmed by selective angiography.It is important to recognize this anatomical variation when performing cardiovascular and interventional radiological procedures.展开更多
Phrenic nerve injury can occur as a complication of lung transplantation. A 54-year-old man underwent single-lung transplantation due to interstitial pneumonia. The patient required circulatory support with venoarteri...Phrenic nerve injury can occur as a complication of lung transplantation. A 54-year-old man underwent single-lung transplantation due to interstitial pneumonia. The patient required circulatory support with venoarterial extracorporeal membrane oxygenation and was unable to be weaned from ventilatory support with nitric oxide. Although enhanced CT scanning showed stenotic anastomosis of the right pulmonary artery (PA), pulmonary angiograph findings revealed that PA flow was normal under sedation and considerably decreased with spontaneous breathing. Fluoroscopy showed that the right diaphragm moved inversely to the position of the left diaphragm, indicating that the right phrenic nerve was paralytic. We performed diaphragmatic plication 7 days after lung transplantation and weaning from ventilator support was accomplished soon thereafter. Phrenic nerve dysfunction is an important clinical problem following lung transplantation. In the present case, diaphragmatic plication was effective for treatment of circulatory failure due to phrenic nerve paralysis even in acute phase after lung transplantation.展开更多
Exogenous discharge can positively promote nerve repair. We, therefore, hypothesized that endogenous discharges may have similar effects. The phrenic nerve and intercostal nerve, controlled by the respiratory center, ...Exogenous discharge can positively promote nerve repair. We, therefore, hypothesized that endogenous discharges may have similar effects. The phrenic nerve and intercostal nerve, controlled by the respiratory center, can emit regular nerve impulses; therefore these endogenous automatically discharging nerves might promote nerve regeneration. Action potential discharge patterns were examined in the diaphragm, external intercostal and latissimus dorsi muscles of rats. The phrenic and intercostal nerves showed rhythmic clusters of discharge, which were consistent with breathing frequency. From the first to the third intercostal nerves, spontaneous discharge amplitude was gradually increased. There was no obvious rhythmic discharge in the thoracodorsal nerve. Four animal groups were performed in rats as the musculocutaneous nerve cut and repaired was bland control. The other three groups were followed by a side-to-side anastomosis with the phrenic nerve, intercostal nerve and thoracodorsal nerve. Compound muscle action potentials in the biceps muscle innervated by the musculocutaneous nerve were recorded with electrodes. The tetanic forces of ipsilateral and contralateral biceps muscles were detected by a force displacement transducer. Wet muscle weight recovery rate was measured and pathological changes were observed using hematoxylin-eosin staining. The number of nerve fibers was observed using toluidine blue staining and changes in nerve ultrastructure were observed using transmission electron microscopy. The compound muscle action potential amplitude was significantly higher at 1 month after surgery in phrenic and intercostal nerve groups compared with the thoracodorsal nerve and blank control groups. The recovery rate of tetanic tension and wet weight of the right biceps were significantly lower at 2 months after surgery in the phrenic nerve, intercostal nerve, and thoracodorsal nerve groups compared with the negative control group. The number of myelinated axons distal to the coaptation site of the musculocutaneous nerve at 1 month after surgery was significantly higher in phrenic and intercostal nerve groups than in thoracodorsal nerve and negative control groups. These results indicate that endogenous autonomic discharge from phrenic and intercostal nerves can promote nerve regeneration in early stages after brachial plexus injury.展开更多
Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Scien...Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering ‘excellent' and ‘good' muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.展开更多
BACKGROUND: Both hypoxia and carbon dioxide retention can damage phrenic nerve and muscle conduction, as well as diaphragm function. Diaphragm compound muscle action potential and phrenic nerve conduction time are rel...BACKGROUND: Both hypoxia and carbon dioxide retention can damage phrenic nerve and muscle conduction, as well as diaphragm function. Diaphragm compound muscle action potential and phrenic nerve conduction time are reliable indicators for measuring phrenic nerve and diaphragm function. OBJECTIVES: To verify the hypothesis that changes of phrenic nerve conduction time (PNCT) and diaphragm compound muscle action potential (CMAP) in obstructive sleep apnea-hypopnea syndrome (OSAHS) patients might contribute to the decline of phrenic nerve and diaphragm function. PNCT and CMAP were measured with multipair esophageal electrodes combined with unilateral magnetic stimulation. DESIGN, TIME AND SETTING: Case controlled study. The experiment was carried out in Guangzhou Institute of Respiratory Disease, Guangzhou Medical College, from June 2005 to April 2006. PARTICIPANTS: Twenty seven OSAHS patients and eight primary snoring subjects from Guangzhou Institute of Respiratory Disease, Guangzhou Medical College were recruited and all subjects were diagnosed by polysomnography (PSG). Sixteen healthy, non-snoring subjects in the hospital for medical examination during the same time period were selected as the control group. METHODS: Esophageal electrodes, made by Guangzhou Institute of Respiratory Disease, combined with unilateral magnetic stimulation, were used to measure PNCT and CMAP of all subjects. PNCT was defined as the time from stimulation artifact to the onset of CMAP and diaphragm CMAP amplitude was measured from peak to peak. Oxygen desaturation index and apnea-hypopnea index were measured using PSG, and their relevance to PNCT and CMAP were analyzed. PNCT and CMAP in five OSAHS patients were repeatedly measured after effective nasal continuous positive airway pressure treatment for more than 2 months. MAIN OUTCOME MEASURES: (1) PNCT and diaphragm CMAP of subjects in each group. (2) Relevance of oxygen desaturation index and apnea-hypopnea index to PNCT and CMAP. (3) Changes of PNCT and CMAP of OSAHS patients before and after treatment. RESULTS: All subjects were included in the analyzed results. (1) PNCT of the OSAHS group was significantly longer compared to that of the control and primary snore groups, while CMAP of the OSAHS group was significantly lower (P < 0.05). (2) PNCT and CMAP recorded from both sides correlated significantly with oxygen desaturation index and with apnea-hypopnea index (P < 0.01). (3) PNCT shortened significantly after effective nasal continuous positive airway pressure treatment for more than 2 months ( P < 0.05). CONCLUSION: Prolongation of PNCT and decrease of CMAP might contribute to the decline of phrenic nerve and diaphragm function caused by repeated nocturnal hypoxia and carbon dioxide retention. The impairment of the phrenic nerve might also decrease diaphragm function.展开更多
This study measured the vagus and phrenic nerves from 12 adult cadavers. We found that the width and thickness of the vagus and phrenic nerves were different in the chest. The distance from the point of the vagus nerv...This study measured the vagus and phrenic nerves from 12 adult cadavers. We found that the width and thickness of the vagus and phrenic nerves were different in the chest. The distance from the point of the vagus nerve and phrenic nerve on the plane of the inferior border of portal pulmonary arteries (T point) was approximately 7 cm to the diaphragm and was approximately 10 cm to the clavicle level. The number of motor fibers in the vagus nerves was 1 716 ± 362, and the number of nerve fibers was 4 473 ± 653. The number of motor fibers in the phrenic nerves ranged from 3 078 ± 684 to 4 794 ± 638, and the number of nerve fibers ranged from 3 437 ± 642 to 5 071 ± 723. No significant difference was found in the total number of nerve fibers. The results suggest that width, thickness, and total number of nerve fibers are similar between the vagus and phrenic nerves, but the number of motor fibers is different between them.展开更多
Phrenic nerve injury after cardiac surgery increases postoperative pulmonary complica- tions. The purpose of this study was to analyze the causes and effects of phrenic nerve injury after cardiac surgery. Prospectivel...Phrenic nerve injury after cardiac surgery increases postoperative pulmonary complica- tions. The purpose of this study was to analyze the causes and effects of phrenic nerve injury after cardiac surgery. Prospectively collected data on 2084 consecutive patients who underwent cardiac surgery from Jan. 1995 to Feb. 2002 were analyzed. Twenty-eight preoperative and operation related variables were subjected to logistic analysis with the end point being phrenic nerve injury. Then phrenic nerve injury and 6 perioperative morbidities were included in the analysis as variables to de- termine their independent predictive value for perioperative pulmonary morbidity. An identical ap- proach was used to identify the independent risk factors for perioperative mortality. There were 53 phrenic nerve injuries (2.5 %). There was no phrenic nerve injury in non-coronary surgery or coro- nary surgery using conduits other than the internal mammary artery. The independent risk factors for phrenic nerve injury were the use of internal mammary artery (Odds ratio (OR)=14.5) and the pres- ence of chronic obstructive pulmonary disease (OR=2.9). Phrenic nerve injury was an independent risk factor (OR=8.1) for perioperative pulmonary morbidities but not for perioperative mortality. Use of semi-skeletonized internal mammary artery harvesting technique and drawing attention to possible vascular or mechanical causes of phrenic nerve injury may reduce its occurrence. Unilateral phrenic nerve injury, although rarely life-threatening, is an independent risk factor for postoperative respira- tory complications. When harvesting internal mammary arteries, it should be kept in mind avoiding stretching, compromising, or inadvertently dissecting phrenic nerve is as important as avoiding dam- age of internal mammary artery itself.展开更多
Thoracic ultrasound has attracted much interest in detecting pleural effusion or pulmonary consolidation after cardiac surgery.In 2016,Trovato reported,in the World Journal of Cardiology,the interest of using,in addit...Thoracic ultrasound has attracted much interest in detecting pleural effusion or pulmonary consolidation after cardiac surgery.In 2016,Trovato reported,in the World Journal of Cardiology,the interest of using,in addition to echocardiography,thoracic ultrasound.In this editorial,we highlight the value of assessing diaphragm function after cardiac surgery and interventional cardiology pro-cedures.Various factors are able to impair diaphragm function after such interventions.Diaphragm motion may be decreased by chest pain secondary to sternotomy,pleural effusion or impaired muscle function.Hemidiaphragmatic paralysis may be secondary to phrenic nerve damage complicating cardiac surgery or atrial fibrillation ablation.Diagnosis may be delayed.Indeed,respi-ratory troubles induced by diaphragm dysfunction are frequently attributed to pre-existing heart disease or pulmonary complications secondary to surgery.In addition,elevated hemidiaphragm secondary to diaphragm dysfunction is sometimes not observed on chest X-ray performed in supine position in the intensive care unit.Analysis of diaphragm function by ultrasound during the recovery period appears essential.Both hemidiaphragms can be studied by two complementary ultrasound methods.The mobility of each hemidiaphragms is measured by M-mode ultrasonography.In addition,recording the percentage of inspiratory thickening provides important information about the quality of muscle function.These two approaches make it possible to detect hemidiaphragm paralysis or dysfunction.Such a diagnosis is important because persistent diaphragm dysfunction after cardiac surgery has been shown to be associated with adverse respiratory outcome.Early respiratory physio-therapy is able to improve respiratory function through strengthening of the inspiratory muscles i.e.diaphragm and accessory inspiratory muscles.展开更多
文摘BACKGROUND Hepatocellular carcinoma(HCC)is one of the most frequent cancers and the main cause of cancer-related death worldwide.Ectopic HCC,an extremely rare type of HCC,exhibits a wide range of clinical signs and radiographic features,making preoperative identification challenging.CASE SUMMARY A 47-year-old man underwent routine abdominal color ultrasonography,which identified an asymptomatic tumor in the left upper abdomen.The patient had no history of hepatitis,did not drink alcohol,and had no family history of cancer.Abdominal contrast-enhanced computed tomography(CT)revealed a heterogeneously enhanced lesion between the spleen and stomach that had invaded the diaphragm,with blood supplied by the left inferior phrenic artery.The patient underwent laparoscopic surgery,and HCC was identified by postoperative pathology.Additionally,specific immunohistochemical staining was performed to assess the molecular biological characteristics of the HCC.The patient underwent two rounds of hepatic arterial interventional chemotherapy after surgery.Abdominal plain and enhanced magnetic resonance imaging and lung CT 3 mo postoperatively revealed no signs of local recurrence or distant metastasis.CONCLUSION This asymptomatic ectopic HCC case described achieved an excellent result due to early detection,radical resection,and systematic surveillance.
基金the National Natural Science Foundation of China,No.81701888Science-Technology Support Plan Projects of Sichuan Province,No.2019YFS0239 and No.2023YFS0206.
文摘BACKGROUND Bronchial Dieulafoy’s disease(BDD)is characterized by the erosion of an anomalous artery in the submucosa of the bronchus.The etiology of pediatric BDD is mainly congenital dysplasia of bronchus and pulmonary arteries,which is different from chronic inflammatory injury of the airway in adult patients.The internal thoracic artery,subclavian artery,and intercostal artery are known to be involved in the blood supply to the BDD lesion in children.CASE SUMMARY We report a case of BDD in a 4-year-old boy with recurrent hemoptysis for one year.Selective angiography showed a dilated right bronchial artery,and anastomosis of its branches with the right lower pulmonary vascular network.Bronchoscopy showed nodular protrusion of the bronchial mucosa with a local scar.Selective embolization of the bronchial artery was performed to stop bleeding.One month after the first intervention,the symptoms of hemoptysis recurred.A computed tomography angiogram(CTA)showed another tortuous and dilated feeding artery in the right lower lung,which was an abnormal ascending branch of the inferior phrenic artery(IPA).The results of angiography were consistent with the CTA findings.The IPA was found to be another main supplying artery,which was not considered during the first intervention.Finally,the IPA was also treated by microsphere embolization combined with coil interventional closure.During the one-year follow-up,the patient never experienced hemoptysis.CONCLUSION The supplying arteries of the bleeding lesion in children with BDD may originate from multiple different aortopulmonary collateral arteries,and the IPA should be considered to reduce missed diagnosis.CTA is a noninvasive radiological examination for the screening of suspected vessels,which shows a high coincidence with angiography,and can serve as the first choice for the diagnosis of BDD.
文摘BACKGROUND:Residual postoperative pleural spaces(RPPS) are often encountered during pulmonary resection;this could adversely affect the outcome and prolong recovery.Nerve cryotherapy reduces postoperative complications and does not affect neural regeneration.However,it remains unclear whether nerve cryotherapy reduces RPPS occurrence following pulmonary resection.OBJECTIVE:To explore pathological changes in the phrenic nerve following exposure to-50 °C for various freezing times,and to explore the feasibility and efficacy of phrenic nerve cryotherapy following pulmonary resection based on animal experiment results.DESIGN,TIME AND SETTING:A comparative animal study was conducted at the Animal Experimental Center of General Hospital of Chinese PLA from January to June 2008.Based on results from the animal study,a randomized,controlled,clinical study was initiated at the Department of Thoracic Surgery of General Hospital of Chinese PLA between July 2008 and July 2009.PARTICIPANTS:A total of 160 patients undergoing lobectomy were selected at the Department of Thoracic Surgery of General Hospital of Chinese PLA from July 2008 to July 2009.METHODS:Animal experiment:27 adult goats were randomly assigned to three groups(n = 9).The phrenic nerves were frozen at-50 °C for 30,60,and 90 seconds,respectively.Clinical study:160 patients undergoing lobectomy were randomly assigned to two groups(n = 80).In the cryoanalgesia group,patients received phrenic nerve cryotherapy;phrenic nerves were frozen above the capsula cordis for 60 seconds at-50 °C prior to chest closure.Patients in the control group did not receive cryotherapy.MAIN OUTCOME MEASURES:Pathological changes were observed at days 1,30,and 60 following phrenic nerve cryotherapy.In the clinical study,RPPS incidence rate was regularly recorded.Respiratory function tests,including measured forced vital capacity and forced expiratory volume in 1 second,were regularly conducted post-surgically.The incidence of post-surgical infection complications and the average days of chest drainage and hospital stay were observed and recorded.RESULTS:Animal study:nerve damage progressively increased with prolonged freezing time at-50 °C,and recovery time from damage gradually increased.Nerves,which were frozen for 30 and 60 seconds,recovered by 30 days,and all nerves completely recovered by 60 days.Clinical study:the RPPS incidence rate was significantly less in the cryoanalgesia group compared with the control group at 1,5,10,and 30 days following surgery(P < 0.05).Simultaneously,phrenic nerve cryotherapy decreased the incidence rate of RPPS and shortened the average days of chest drainage and hospital stay in patients undergoing lobectomy(P < 0.05).However,phrenic nerve cryotherapy did not affect forced vital capacity,forced expiratory volume in 1 second,and the incidence rate of post-surgical infection complications(P > 0.05).CONCLUSION:Following phrenic nerve cryotherapy in the goat at-50 °C,the phrenic nerve recovered to normal by 60 days.In the clinical study,phrenic nerve cryotherapy reduced the RPPS incidence rate,had no effect on pulmonary function,shortened hospital stay in patients undergoing lobectomy,and proved to be a safe,effective method.
基金support to Michela Grande, BEng, Abbott, Milan, Italy
文摘BACKGROUND Phrenic nerve(PN)injury is one of the recognized possible complications following epicardial ablation of ventricular tachycardia(VT).High-output pacing is a widely used maneuver to establish a relationship between the PN and the ablation catheter tip.An absence of PN capture is usually considered an indication that it is safe to ablate,and that successful ablation may be performed at adjacent sites.However,PN capture may impact the procedural outcome.Only a few cases have been reported in the literature that avoid PN injury by using different techniques.CASE SUMMARY Three patients with a previous history of myocarditis and one patient with ischemic cardiomyopathy underwent epicardial ablation for drug-refractory VT.Before the procedure,transthoracic echocardiogram,coronary angiogram,and cardiac magnetic resonance imaging were performed on all patients.Under general anesthesia,endo/epicardial three-dimensional anatomical and substrate maps of the left ventricle were accomplished.Before radiofrequency delivery,the course of the PN was identified by provoking diaphragmatic stimulation with high-output pacing from the distal electrode of the ablation catheter.In every case,a scar region with late potentials was mapped along the PN course.After obtaining another epicardial access,a second introducer sheath was placed,and a vascular balloon catheter was inserted into the epicardial space and inflated with saline solution to separate the PN from the epicardium.Once the absence of PN capture had been proven,radiofrequency was applied to aim for complete late potential elimination and avoid VT induction.CONCLUSION PN injury can occur as one of the complications following epicardial VT ablation procedures,and may prevent successful ablation of these arrhythmias.PN displacement by using large balloon catheters into the epicardial space seems to be feasible and reproducible,avoid procedure-related morbidity,and improve ablation success when performed in selected centers and by experienced operators.
文摘Hypoxemia after general anesthesia is not uncommon.For patients after thoracotomy,the differential diagnosis is usually difficult.Surgical,anesthetic,and patient-associated factors may contribute to postoperative hypoxemia.We described two patients who underwent videassisted thoracoscopic thymectomy and developed hypoxemia immediately after extubation.Phrenic nerve injury was suspected in both patients.One case recovered spontaneously without intervention.The second case who had been demonstrated as bilateral phrenic nerve injury after the operation was continuously on ventilator after physical therapy and respiratory training for 2 months.
文摘Phrenic nerve stimulation is a technique whereby a nerve stimulator provides electrical stimulation of the phrenic nerve to cause diaphragmatic contraction in patients with respiratory failure due to cervical spinal cord injury. This paper presents an eigth-channel stimulator circuit with an output stage (electrode driving circuit) that doesn’t need off-chip blocking-capacitors and is used for phrenic nerve stimulation. This stimulator circuit utilizes only 1 output stage for 8 channels. The proposed current generator circuit in this stimulator reducing to a single step the translation of the digital input bits into the stimulus current, thus minimizing silicon area and power consumption. An 8 bit implementation is utilized for this current generator circuit. The average pulse width for this eight- channel stimulator with 1 mA current, 20 Hz frequency and 8 bits resolution, is 150 - 300 μs. The average power consumption for a single-channel stimulation is 38 mW from a 1.2 V power supply. This implantable stimulator system was simulated in HSPICE using 90 nm CMOS technology.
文摘Background: Up to one in three patients implanted with a cardiac resynchronization therapy-defibrillator (CRT-D) device experience phrenic nerve stimulation (PNS). Quadripolar leads are effective at reducing PNS, but compared to standard bipolar leads they have limitations related to maneuverability and high pacing thresholds. The ability of standard bipolar leads to overcome PNS is explored here. Methods: The French multicenter, observational study ORPHEE enrolled 90 CRT-D-eligible patients. Detection of PNS took place after satisfactory positioning of the LV bipolar lead (stable pacing threshold - LV ring, LV tip - RV ring and LV ring - RV coil) could prevent PNS from occurring in at least 90% of patients. Results: In 80 evaluable patients, PNS was reported in 12 patients (15%). Reprogramming overcame PNS in 10 patients: LV ring - RV coil in 8 patients;LV tip - LV ring in 1;and LV tip- RV ring in 1. As PNS was avoided in 78 of 80 patients (97.5%), the primary endpoint was significant (97.5% vs. 90%, p = 0.01). Conclusion: During CRT-D implantation, PNS occurred in 15% of patients. In most (97.5%) implanted patients, PNS could be avoided by vector reprogramming using a bipolar LV lead. For patients whose coronary sinus anatomy precludes the implantation of multi-electrode leads, bipolar leads are a suitable, reliable alternative.
文摘Accessory renal arteries(ARAs)are common and usually originate from the abdominal aorta and the renal artery.Inferior phrenic arteries(IPAs)can also arise from the abdominal aorta or its branches.In this paper,we present the first case of a common trunk of the right ARA and right IPA arising from the thoracic artery at the level of T10,which was discovered by multidetector-row computed tomography in pretherapeutic evaluation and clearly confirmed by selective angiography.It is important to recognize this anatomical variation when performing cardiovascular and interventional radiological procedures.
文摘Phrenic nerve injury can occur as a complication of lung transplantation. A 54-year-old man underwent single-lung transplantation due to interstitial pneumonia. The patient required circulatory support with venoarterial extracorporeal membrane oxygenation and was unable to be weaned from ventilatory support with nitric oxide. Although enhanced CT scanning showed stenotic anastomosis of the right pulmonary artery (PA), pulmonary angiograph findings revealed that PA flow was normal under sedation and considerably decreased with spontaneous breathing. Fluoroscopy showed that the right diaphragm moved inversely to the position of the left diaphragm, indicating that the right phrenic nerve was paralytic. We performed diaphragmatic plication 7 days after lung transplantation and weaning from ventilator support was accomplished soon thereafter. Phrenic nerve dysfunction is an important clinical problem following lung transplantation. In the present case, diaphragmatic plication was effective for treatment of circulatory failure due to phrenic nerve paralysis even in acute phase after lung transplantation.
基金supported by the Scientific Research Project of Huashan Hospital of Fudan University of China,No.2013QD05the National Natural Science Foundation of China,No.81501051&81572127
文摘Exogenous discharge can positively promote nerve repair. We, therefore, hypothesized that endogenous discharges may have similar effects. The phrenic nerve and intercostal nerve, controlled by the respiratory center, can emit regular nerve impulses; therefore these endogenous automatically discharging nerves might promote nerve regeneration. Action potential discharge patterns were examined in the diaphragm, external intercostal and latissimus dorsi muscles of rats. The phrenic and intercostal nerves showed rhythmic clusters of discharge, which were consistent with breathing frequency. From the first to the third intercostal nerves, spontaneous discharge amplitude was gradually increased. There was no obvious rhythmic discharge in the thoracodorsal nerve. Four animal groups were performed in rats as the musculocutaneous nerve cut and repaired was bland control. The other three groups were followed by a side-to-side anastomosis with the phrenic nerve, intercostal nerve and thoracodorsal nerve. Compound muscle action potentials in the biceps muscle innervated by the musculocutaneous nerve were recorded with electrodes. The tetanic forces of ipsilateral and contralateral biceps muscles were detected by a force displacement transducer. Wet muscle weight recovery rate was measured and pathological changes were observed using hematoxylin-eosin staining. The number of nerve fibers was observed using toluidine blue staining and changes in nerve ultrastructure were observed using transmission electron microscopy. The compound muscle action potential amplitude was significantly higher at 1 month after surgery in phrenic and intercostal nerve groups compared with the thoracodorsal nerve and blank control groups. The recovery rate of tetanic tension and wet weight of the right biceps were significantly lower at 2 months after surgery in the phrenic nerve, intercostal nerve, and thoracodorsal nerve groups compared with the negative control group. The number of myelinated axons distal to the coaptation site of the musculocutaneous nerve at 1 month after surgery was significantly higher in phrenic and intercostal nerve groups than in thoracodorsal nerve and negative control groups. These results indicate that endogenous autonomic discharge from phrenic and intercostal nerves can promote nerve regeneration in early stages after brachial plexus injury.
基金funded by the National High Technology Research and Development Program of China(863 Program),No.2008AA022400a grant from Science&Technology Department of Sichuan Province of China,No.2009JY0174
文摘Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering ‘excellent' and ‘good' muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.
文摘BACKGROUND: Both hypoxia and carbon dioxide retention can damage phrenic nerve and muscle conduction, as well as diaphragm function. Diaphragm compound muscle action potential and phrenic nerve conduction time are reliable indicators for measuring phrenic nerve and diaphragm function. OBJECTIVES: To verify the hypothesis that changes of phrenic nerve conduction time (PNCT) and diaphragm compound muscle action potential (CMAP) in obstructive sleep apnea-hypopnea syndrome (OSAHS) patients might contribute to the decline of phrenic nerve and diaphragm function. PNCT and CMAP were measured with multipair esophageal electrodes combined with unilateral magnetic stimulation. DESIGN, TIME AND SETTING: Case controlled study. The experiment was carried out in Guangzhou Institute of Respiratory Disease, Guangzhou Medical College, from June 2005 to April 2006. PARTICIPANTS: Twenty seven OSAHS patients and eight primary snoring subjects from Guangzhou Institute of Respiratory Disease, Guangzhou Medical College were recruited and all subjects were diagnosed by polysomnography (PSG). Sixteen healthy, non-snoring subjects in the hospital for medical examination during the same time period were selected as the control group. METHODS: Esophageal electrodes, made by Guangzhou Institute of Respiratory Disease, combined with unilateral magnetic stimulation, were used to measure PNCT and CMAP of all subjects. PNCT was defined as the time from stimulation artifact to the onset of CMAP and diaphragm CMAP amplitude was measured from peak to peak. Oxygen desaturation index and apnea-hypopnea index were measured using PSG, and their relevance to PNCT and CMAP were analyzed. PNCT and CMAP in five OSAHS patients were repeatedly measured after effective nasal continuous positive airway pressure treatment for more than 2 months. MAIN OUTCOME MEASURES: (1) PNCT and diaphragm CMAP of subjects in each group. (2) Relevance of oxygen desaturation index and apnea-hypopnea index to PNCT and CMAP. (3) Changes of PNCT and CMAP of OSAHS patients before and after treatment. RESULTS: All subjects were included in the analyzed results. (1) PNCT of the OSAHS group was significantly longer compared to that of the control and primary snore groups, while CMAP of the OSAHS group was significantly lower (P < 0.05). (2) PNCT and CMAP recorded from both sides correlated significantly with oxygen desaturation index and with apnea-hypopnea index (P < 0.01). (3) PNCT shortened significantly after effective nasal continuous positive airway pressure treatment for more than 2 months ( P < 0.05). CONCLUSION: Prolongation of PNCT and decrease of CMAP might contribute to the decline of phrenic nerve and diaphragm function caused by repeated nocturnal hypoxia and carbon dioxide retention. The impairment of the phrenic nerve might also decrease diaphragm function.
基金supported by the National Natural Science Foundation of China,No.30571886
文摘This study measured the vagus and phrenic nerves from 12 adult cadavers. We found that the width and thickness of the vagus and phrenic nerves were different in the chest. The distance from the point of the vagus nerve and phrenic nerve on the plane of the inferior border of portal pulmonary arteries (T point) was approximately 7 cm to the diaphragm and was approximately 10 cm to the clavicle level. The number of motor fibers in the vagus nerves was 1 716 ± 362, and the number of nerve fibers was 4 473 ± 653. The number of motor fibers in the phrenic nerves ranged from 3 078 ± 684 to 4 794 ± 638, and the number of nerve fibers ranged from 3 437 ± 642 to 5 071 ± 723. No significant difference was found in the total number of nerve fibers. The results suggest that width, thickness, and total number of nerve fibers are similar between the vagus and phrenic nerves, but the number of motor fibers is different between them.
基金This project was supported by a grant from the Shanxi Pro-vincial Foundation (No.74-2003)
文摘Phrenic nerve injury after cardiac surgery increases postoperative pulmonary complica- tions. The purpose of this study was to analyze the causes and effects of phrenic nerve injury after cardiac surgery. Prospectively collected data on 2084 consecutive patients who underwent cardiac surgery from Jan. 1995 to Feb. 2002 were analyzed. Twenty-eight preoperative and operation related variables were subjected to logistic analysis with the end point being phrenic nerve injury. Then phrenic nerve injury and 6 perioperative morbidities were included in the analysis as variables to de- termine their independent predictive value for perioperative pulmonary morbidity. An identical ap- proach was used to identify the independent risk factors for perioperative mortality. There were 53 phrenic nerve injuries (2.5 %). There was no phrenic nerve injury in non-coronary surgery or coro- nary surgery using conduits other than the internal mammary artery. The independent risk factors for phrenic nerve injury were the use of internal mammary artery (Odds ratio (OR)=14.5) and the pres- ence of chronic obstructive pulmonary disease (OR=2.9). Phrenic nerve injury was an independent risk factor (OR=8.1) for perioperative pulmonary morbidities but not for perioperative mortality. Use of semi-skeletonized internal mammary artery harvesting technique and drawing attention to possible vascular or mechanical causes of phrenic nerve injury may reduce its occurrence. Unilateral phrenic nerve injury, although rarely life-threatening, is an independent risk factor for postoperative respira- tory complications. When harvesting internal mammary arteries, it should be kept in mind avoiding stretching, compromising, or inadvertently dissecting phrenic nerve is as important as avoiding dam- age of internal mammary artery itself.
文摘Thoracic ultrasound has attracted much interest in detecting pleural effusion or pulmonary consolidation after cardiac surgery.In 2016,Trovato reported,in the World Journal of Cardiology,the interest of using,in addition to echocardiography,thoracic ultrasound.In this editorial,we highlight the value of assessing diaphragm function after cardiac surgery and interventional cardiology pro-cedures.Various factors are able to impair diaphragm function after such interventions.Diaphragm motion may be decreased by chest pain secondary to sternotomy,pleural effusion or impaired muscle function.Hemidiaphragmatic paralysis may be secondary to phrenic nerve damage complicating cardiac surgery or atrial fibrillation ablation.Diagnosis may be delayed.Indeed,respi-ratory troubles induced by diaphragm dysfunction are frequently attributed to pre-existing heart disease or pulmonary complications secondary to surgery.In addition,elevated hemidiaphragm secondary to diaphragm dysfunction is sometimes not observed on chest X-ray performed in supine position in the intensive care unit.Analysis of diaphragm function by ultrasound during the recovery period appears essential.Both hemidiaphragms can be studied by two complementary ultrasound methods.The mobility of each hemidiaphragms is measured by M-mode ultrasonography.In addition,recording the percentage of inspiratory thickening provides important information about the quality of muscle function.These two approaches make it possible to detect hemidiaphragm paralysis or dysfunction.Such a diagnosis is important because persistent diaphragm dysfunction after cardiac surgery has been shown to be associated with adverse respiratory outcome.Early respiratory physio-therapy is able to improve respiratory function through strengthening of the inspiratory muscles i.e.diaphragm and accessory inspiratory muscles.
