Case Report: COVID-19 Pneumonia Following Left Pneumonectomy for Lung Cancer Complicated by Empyema and Bronchopleural Fistula

Background: Venous and arterial thromboembolism is commonly reported in critically ill COVID-19 patients, although there are still no definitive statistical data regarding its incidence.

Case presentation: we report a case of a patient who fell ill with Covid during hospitalization for a pneumonectomy complicated by empyema and bronchopleural fistula. The patient, despite being cured of COVID, died after 14 days for pulmonary thromboembolism.

Conclusion: Our case strengthens the suggestion of adequate thromboprophylaxis in all hospitalized COVID patients and of increasing prophylaxis in critically ill patients even in the absence of randomized studies

Case Report: Mediastinal Mass in SARS-COV-2 Pandemic: A Word of Caution

Background: SARS-CoV-2 is a new disease with some manifestations not yet well-known. Sharing experiences in this topic is crucial for the optimal management of the patients.

Case Presentation: Left upper extremity deep vein thrombosis (UEDVT) due to a mediastinal mass strongly suspected of lymphoproliferative disease in a patient affected by SARS-CoV-2, disappearing at the resolution of the viral infection.

Conclusion: Before proceeding to surgical biopsy, mediastinal mass in SARS-CoV-2 patients must be revaluated after the resolution of the infection.

Primary signet-ring cell carcinoma of the lung in an HIV-positive patient

Primary lung signet-ring cell carcinomas are a rare entity and only a few cases of pure signet-ring cell carcinomas of the lung are reported in the English literature. They usually have an aggressive behavior and a poor prognosis because in most cases they are identified at an advanced stage. We present a unique case of primary signet-ring cell carcinoma of the lung because the patient was HIV positive, a heavy smoker, and also the tumor, discovered incidentally during chest x-ray, was a pure type of signet-ring cell carcinoma. Surgical therapy associated with chemoradiotherapy represents the gold standard in the care of these patients.

Incarcerated sigmoid large-cell neuroendocrine carcinoma in an inguinal hernia

Large-cell neuroendocrine carcinomas (NECs) of the colon are extremely rare aggressive tumors. A 79-year-old man presented at our hospital for muco-hematic diarrhea, weight loss and incarcerated hernia in his left groin. Colonoscopy revealed sigmoid stenosis. Computed tomography confirmed an incarcerated hernia containing sigmoid mass and massive abdominal adenopathy. In absence of colonic obstruction, the patient underwent elective palliative sigmoid resection and colostomy by laparoscopic approach, and direct hernia repair through inguinal access. Histopathological examination revealed a large cells sigmoid NEC. We report the first case of large-cell neuroendocrine colon cancer incarcerated in an inguinal hernia. Due to the advanced stage, we have performed a palliative laparoscopic resection in order to reduce surgical trauma, confirm pre-operative results and minimize post-operative complications, and direct hernia repair through inguinal access.

Case Report: Multidisciplinary Approach for a Rare Case of Thymic Vascular Malformation

We report the rare case of a 2.5 cm in size mass diagnostic for residual thymus associated with venous vascular malformation (ISSVA classification, 2008) in a 58 years old man. Diagnosis was obtained only after surgical removal that was complicated by a sudden massive bleeding (about 1,500 cc) requiring emergency conversion to median sternotomy. Difficulty in preoperative diagnosis, rarity of histologic pattern, and surgical challenges make this case very interesting for surgeons, pathologists and radiologist. Our message, dealing with mediastinal masses, is: (a) differential diagnosis between the more frequent solid antero-superior mediastinal tumors and vascular malformation should be always considered (b) preoperative angiography should always be performed in case of uncertain diagnosis (c) coil embolization should always be considered to reduce potentially fatal bleeding (d) histologic differentiation with other thymic neoplasms must be always considered.

Voluminous schwannoma type 'ancient' of the cervicothoracic district removed through a cervicotomic approach

Schwannomas are generally benign tumors, well delimited, resulting from nerve sheaths that are frequently found in the thorax, mainly in the posterior mediastinum. We report a 58-year-old patient who carried out investigations following the appearance of a large right supraclavicular cervical mass associated with anisocoria and eyelid ptosis, histologically diagnosed as ancient schwannoma, completely removed through a cervicotomic approach without opening the chest.

Unexpected thymoma in a challenging case of hyperparathyroidism

We report the case of a woman with primary hyperparathyroidism suspected of mediastinal ectopic parathyroid adenoma revealed to be a thymoma. Our aim was to focus on some possible criticisms in distinguishing between ectopic parathyroid and thymus.

Robotic vs laparoscopic right colectomy – the burden of age and comorbidity in perioperative outcomes: An observational study

BACKGROUND

Several studies have shown the safety, feasibility and oncologic adequacy of robotic right hemicolectomy (RRH). Laparoscopic right hemicolectomy (LRH) is considered technically challenging. Robotic surgery has been introduced to overcome this technical limitation, but it is related to high costs. To maximize the benefits of such surgery, only selected patients are candidates for this technique. In addition, due to progressive aging of the population, an increasing number of minimally invasive procedures are performed on elderly patients with severe comorbidities, who are usually more prone to post-operative complications.

AIM

To investigate the outcomes of RRH vs LRH with regard to age and comorbidities.

METHODS

We retrospectively analyzed 123 minimally invasive procedures (68 LRHs vs 55 RRHs) for right colon cancer or endoscopically unresectable adenoma performed in our Center from January 2014 until September 2019. The surgical procedures were performed according to standardized techniques. The primary clinical outcome of the study was the length of hospital stay (LOS) measured in days. Secondary outcomes were time to first flatus (TFF) and time to first stool evacuation. The robotic technique was considered the exposure and the laparoscopic technique was considered the control. Routine demographic variables were obtained, including age at time of surgery and gender. Body mass index and American Society of Anesthesiologists physical status were registered. The age-adjusted Charlson Comorbidity Index (ACCI) was calculated; the tumor-node-metastasis system, intra-operative variables and post-operative complications were recorded. Post-operative follow-up was 180 d.

RESULTS

LOS, TFF, and time to first stool were significantly shorter in the robotic group: Median 6 [interquartile range (IQR) 5-8] vs 7 (IQR 6-10.5) d, P = 0.028; median 2 (IQR 1-3) vs 3 (IQR 2-4) d, P < 0.001; median 4 (IQR 3-5) vs 5 (IQR 4-6.5) d, P = 0.005, respectively. Following multivariable analysis, the robotic technique was confirmed to be predictive of significantly shorter hospitalization and faster restoration of bowel function; in addition the dichotomous variables of age over 75 years and ACCI more than 7 were significant predictors of hospital stay. No outcomes were significantly associated with Clavien-Dindo grading. Sub-group analysis demonstrated that patients aged over 75 years had a longer LOS (median 6 -IQR 5-8- vs 7 -IQR 6-12- d, P = 0.013) and later TFF (median 2 -IQR 1-3- vs 3 -IQR 2-4- d, P = 0.008), while patients with ACCI more than 7 were only associated with a prolonged hospital stay (median 7 -IQR 5-8- vs 7 -IQR 6-14.5- d, P = 0.036).

CONCLUSION

RRH is related to shorter LOS when compared with the laparoscopic approach, but older age and several comorbidities tend to reduce its benefits.

Metastatic lung cancer presenting as thoracic empyema. A Case report

Increased cancer risk in patients with inflammatory and infectious diseases has been reported in many studies and lung cancer-associated empyema in <0.3% patients. We present a patient with empyema in whom the final diagnosis was metastatic lung adenocarcinoma. Purulent pleural fluid obtained by drainage or thoracentesis must always been examined because the association of malignant tumors and empyema should be taken into consideration.

Laparoscopic subtotal colectomy for synchronous colon high-grade dysplasia adenomas in intestinal malrotation: A case report and literature review

Intestinal malrotation is an embryologic anomaly rarely presenting in adults especially in association with colon cancer. Fully laparoscopic colonic resection has not yet described in literature for adenomas in malrotation. Preoperative assessment of vascular anatomy by computed tomography is considered mandatory to perform safely laparoscopic surgery.

Left colonic metastasis from primary hepatocellular carcinoma: A case report

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for 5-6% of all human cancers. Considering the extrahepatic metastasis, the main organs involved are lymphnodes, lung, bone and adrenal gland. Usually colon metastasis is very rare, especially on the left sided colon.

CASE SUMMARY

We report a case of a 70 years-old man hepatitis B carrier with HCC treated four times with trans-arterial chemoembolization, presented to our surgical department complaining of gastrointestinal bleeding. A colonoscopy revealed a mass of 4 cm of the sigmoid colon with signs of bleeding. The computed tomography showed a mass originated from the sigmoid colon of 3.5 cm, and the presence of HCC in segment VI and VII, without portal vein thrombosis. Due to the large size of the mass and the active bleeding, the patient underwent a left colectomy. The postoperative period was uneventful, and the patient was discharged in fifth post-operative day. Histological examination revealed that the neoplasm was characterized by a diffuse proliferation of epithelial cells with an hepatoid differentiation. So, the presence of a history of HCC of the liver and the histopathological features supported the diagnosis of metastasis from the liver.

CONCLUSION

Although rare, colon metastasis from an HCC can be left-sided and can present with acute bleeding.

Malignant pleural mesothelioma: Is reconstruction of the diaphragm necessary in left pleurectomy/decortication? A case report

We describe a case of complete intrathoracic stomach and intestinal herniation after pleurectomy/decortication due to diaphragm reconstruction without mesh. Is reconstruction with mesh always necessary? Can lung sparing obviate the tension on residual diaphragm? These are the questions not well described to which we try to give an answer.

Atrial fibrillation, an epiphenomenon of acute Stanford type-A aortic dissection with suspected intimo-intimal intussusception

Supraventricular arrhythmias can sometimes be "only" epiphenomena appearing during acute hypoxia, pneumonia, pulmonary embolism, and thrombosis. Indeed, atrial fibrillation is not rare in acute aortic dissection as it is estimated in about one half of patients and may be secondary to a perfusion deficit of the sinoatrial node artery.

Wirsung atraumatic rupture in patient with pancreatic pseudocysts: a case presentation

Background

Pancreatic duct disruption is a challenging condition leading to pancreatic juice leakage and consequently to pancreatic fluid collections. The manifestations of pancreatic main duct leak include pseudocysts, walled-off necrosis, pancreatic fistulas, ascites, pleural and pericardial effusions. Pseudocyst formation is the most frequent outcome of a pancreatic duct leak.

Case presentation

We describe a case of a 64-year old man with large multiple pancreatic cysts discovered for progressive jaundice and significant weight loss in the absence of a previous episode of acute pancreatitis. Computed tomography scan showed lesion with thick enhancing walls. The main cyst dislocated the stomach and the duodenum inducing intra and extrahepatic bile ducts enlargement. Magnetic resonance cholangiopancreatography revealed a communication between the main pancreatic duct and the cystic lesions due to Wirsung duct rupture. Endoscopic ultrasound guided fine needle aspiration cytology did not show neoplastic cells and cyst fluid analysis revealed high amylase concentration. Preoperative exams were suggestive but not conclusive for a benign lesion. Laparotomy was necessary to confirm the presence of large communicating pseudocysts whose drainage was performed by cystogastrostomy. Histology confirmed the inflammatory nature of the cyst wall. Subsequently, the patient had progressive jaundice resolution.

Conclusion

Pancreatic cystic masses include several pathological entities, ranging from benign to malignant lesions. Rarely pseudocysts present as complex cystic pancreatic lesions with biliary compression in absence of history of acute pancreatitis. We describe the rare case of multiple pancreatic pseudocysts due to Wirsung duct rupture in absence of previous trauma or acute pancreatitis. Magnetic resonance showed the presence of communication with the main pancreatic duct and endoscopic ultrasound fine needle aspiration suggested the benign nature of the lesion.