Pathogenesis and treatment of perioperative hiccups: a narrative review

INTRODUCTION

Hiccups affect 0.05% of general in-patients and up to 10% of patients with gastroesophageal reflux disease. Hiccups are typically self-limited. In certain cases, they can become persistent and intractable, suggesting a potentially more serious underlying pathological condition. Treatment of hiccups in the perioperative period is challenging as it is difficult to identify their causes, and the existing literature is mainly based on case studies. This review aims to comprehensively explore the aetiology, mechanisms and treatment of perioperative hiccups to provide new insights.

METHODS

A systematic search was conducted in multiple databases such as PubMed, Embase, and Web of Science, for literature published within the past three decades. Search terms included 'Hiccups, Perioperative, Pathogenesis, Treatment, Lidocaine', etc. Inclusion criteria included original research articles, review papers and case reports that provided relevant information on the topic. Exclusion criteria were non-relevant studies, duplicates and articles with insufficient data.

RESULTS

Surgical, anaesthesia- and patient-related aetiological factors and mechanisms of perioperative hiccups were systematically analysed. Management strategies across different perioperative phases were summarized, highlighting the emerging evidence of lidocaine's therapeutic efficacy. Current understanding of perioperative hiccups is limited as it mainly depends on case reports and observational studies, lacking strong evidence from controlled clinical trials. Preoperative risk stratification, intraoperative dynamic assessment, and postoperative multimodal safety protocols are clinically essential.

CONCLUSION

Research on the pathogenesis and treatment of perioperative hiccups requires further enhancement. Large-scale prospective studies are needed to validate the proposed management strategies and treatment recommendations, which will be beneficial for improving the clinical management of this condition.

Optimizing the management of anastomotic leaks after esophagectomy: a narrative review of salvage strategies and outcomes

BACKGROUND

Anastomotic leaks (ALs) after esophagectomy remain a major postoperative complication, leading to increased morbidity, prolonged hospital stays, and higher mortality. Despite advancements in surgical techniques and perioperative care, AL management lacks standardized protocols. This review aimed to evaluate current salvage strategies, including conservative, endoscopic, and surgical approaches, to optimize outcomes and reduce complications.

METHODS

A comprehensive literature search was conducted using PubMed, Scopus, Cochrane Library, and Google Scholar databases to identify studies published between 2000 and 2025 on AL management after esophagectomy. Peer-reviewed clinical trials, guidelines, and expert consensus reports were reviewed, focusing on minimally invasive and surgical interventions, patient outcomes, and emerging treatment strategies.

RESULTS

AL management strategies were classified into 3 primary approaches. Conservative management includes nutritional support, antibiotic therapy, and percutaneous drainage, particularly for contained leaks. Endoscopic interventions, such as self-expanding metal stents and endoscopic vacuum-assisted closure, have shown high success rates, with vacuum-assisted closure achieving superior closure outcomes. Hybrid techniques, including stent-over-sponge and vacuum-assisted closure-stent, are emerging as promising alternatives. Surgical interventions remain the gold standard for severe or refractory leaks with options, including primary repair, esophageal diversion, and delayed conduit reconstruction.

CONCLUSION

A multidisciplinary approach is crucial for optimizing AL management, incorporating enhanced recovery protocols, early risk assessment, and individualized treatment plans. Endoscopic techniques have reduced the need for surgical revisions, but surgical intervention remains necessary for severe cases. Future research should focus on refining treatment algorithms, integrating novel technologies, and establishing standardized guidelines to improve patient survival and quality of life.

Hepatic and extra-hepatic hydatid cysts: A case series of radiological and clinical insights

Hydatid disease, caused by Echinococcus granulosus, is a parasitic infection that primarily affects the liver but can also involve other organs, including the spleen, kidney, and peritoneum. This case series examined 9 patients with hydatid cysts, highlighting their clinical presentations, radiological findings, and management strategies. This study analyzed 9 patients diagnosed with hepatic and extrahepatic hydatid cysts. Comprehensive evaluations were performed for all patients, including clinical history and contrast-enhanced computed tomography (CT) imaging. The cases included cystic lesions in the liver (7 patients), spleen (3 patients), kidney (2 patients), and peritoneum (1 patient). Typical radiological features, such as the "double-wall sign," daughter cysts, and peripheral calcifications, were observed. The management strategies varied from surgical excision to medical therapy with albendazole. Hydatid disease presents diverse clinical and radiological features. Early diagnosis using advanced imaging techniques and a multidisciplinary approach is critical for effective management and prevention of complications.

The value of nomogram analysis in predicting pulmonary metastasis in hepatic alveolar echinococcosis

Hepatic alveolar echinococcosis (HAE) is a rare zoonotic parasitic disease that closely resembles malignant tumors in both behavior and appearance. It can cause infiltration of affected organs and chronic liver damage. In advanced stages, it may metastasize or invade surrounding organs, resembling liver cancer, and is clinically referred to as "parasitic cancer." However, the prognosis of HAE with pulmonary metastasis is poor, and no reliable method currently exists to predict lung metastasis. This study aims to investigate the efficacy of a nomogram model, based on CT and MRI imaging features in conjunction with clinical indicators, for predicting pulmonary metastasis in HAE. A retrospective analysis was conducted using imaging and clinical data from 297 patients diagnosed with HAE. Univariate and multivariate logistic regression analyses identified independent factors associated with pulmonary metastasis, including lesion size, the presence of metastasis to other organs, cavitary lesions, and enhancement characteristics. The nomogram, developed using these variables, demonstrated strong predictive performance in both the training and validation cohorts. This model provides an effective tool for predicting the risk of pulmonary metastasis, offering early insights into disease progression and assisting clinicians in formulating personalized treatment and prognostic plans.

Molecular Profiling in Non-Small-Cell Lung Cancer: A Single-Center Study on Prevalence and Prognosis

The aim of this study is to evaluate the prognostic value of molecular profiling in patients with metastatic non-small-cell lung cancer (NSCLC). This single-center study included patients diagnosed and treated between July 2020 and April 2024. The molecular profiles of patients detected by either next-generation sequencing or conventional methods were reviewed retrospectively. Survival analyses were conducted based on the targetable alterations and treatments received. Seventy patients were included, with a median age of 65 years and a median overall survival (OS) of 13 months. Of all patients, 56 (80%) had at least one molecular alteration, and the most frequent alteration was TP53 (52.9%), followed by KRAS (20%) and EGFR (8.6%). Eighteen patients (25.7%) had an alteration amenable to targeted therapy. Patients who could reach a matched targeted therapy at any treatment line exhibited a longer median OS compared to those who could not (not reached vs. 6.9 months, p = 0.042). Patients with a targetable alteration for first-line treatment demonstrated a longer progression-free survival compared to those without a targetable alteration (not reached vs. 4.9 months, p = 0.006). According to current guidelines, conducting molecular testing to identify all potential targetable alterations in NSCLC is the cornerstone of the treatment decision process. The survival analysis in this study emphasized the impact of the use of targeted therapies on the survival outcomes.

Primitive Ewing Sarcoma of Epididymis: A Case Report and Literature Review

We present the case of a 22-year-old man with a firm and tender mass in the left scrotum region. Color Doppler ultrasound and radiographic examination (CT and MRI) suggested that the mass arose from the left epididymis without tumor metastasis. The histopathological and immunohistochemical findings revealed a chrysanthemum-like arrangement of round tumor cells, along with strong positive expression of CD99, vimentin, CD117, CD56, and Ki-67 (70%), supporting the diagnosis of primary epididymal Ewing sarcoma. The patient underwent surgical excision and received 3 cycles of postoperative chemotherapy with vincristine, doxorubicin, and cyclophosphamide. The patient is recovering satisfactorily, and his follow-up treatments and condition are being monitored.

Predicting worsening risk in MGFA class I, II and III myasthenia gravis patients: development and validation of a predictive nomogram

BACKGROUND

Myasthenia gravis (MG), a neuromuscular junction autoimmune disorder, causes skeletal muscle weakness. MG worsening frequently occurs during the disease course, severely impairing quality of life and elevating myasthenic crisis risk. Existing predictive models remain scarce. This study developed a predictive model for MG worsening to facilitate early risk stratification and personalized care.

RESEARCH DESIGN & METHODS

Retrospective analysis included 437 the Myasthenia Gravis Foundation of America (MGFA) class I - III myasthenia gravis patients from December 2019 to September 2024. Sociodemographic, clinical variables and worsening status were analyzed. Predictors were identified via univariate analysis, the Least Absolute Shrinkage and Selection Operator (LASSO) regression, and multivariate logistic regression. Model performance was assessed using receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis.

RESULTS

Patients were randomized into training (n = 305) and validation (n = 132) cohorts. Worsening rates were comparable (26.52% vs. 31.15%, p = 0.331). Six predictors emerged: age, MGFA classification, thymectomy history, chills, fatigue, and emotional disturbances (ED). The nomogram demonstrated strong discrimination (AUC: 0.82 training, 0.83 validation) and calibration (Hosmer-Lemeshow p > 0.05). Decision curve analysis confirmed clinical utility at 10-70% probability thresholds.

CONCLUSION

This nomogram integrates accessible clinical variables to stratify MG worsening risk, enabling early intervention. Validation through multicenter prospective studies is warranted to optimize generalizability.

Parasitic lung diseases

PURPOSE OF REVIEW

Parasitic lung diseases occur because of transient migration of parasites in the lung or because of a subsequent immunologic reaction. The purpose of this review is to scan for any recent developments in the epidemiology, diagnostics and treatment of these exotic diseases.

RECENT FINDINGS

Disease is mostly seen in endemic countries, but with international travel, globalization and mass migration, together with their late presentations, these diseases can present worldwide, often mimicking other conditions. The expansion of immunosuppressive and chemotherapeutic agents has led to some increase in the susceptibility to parasitic infection and parasitic hyper-infection syndromes.

SUMMARY

In this review, we consider the principle pulmonary parasites of medical significance, their natural history, clinical and radiological features, and their management.

Cystic Echinococcosis in Hospitalized Children and Adults from Western Romania: 2007-2022

Cystic echinococcosis (CE) is a serious health problem in many countries worldwide, including in Romania, because of the high infection rates in both humans and animals. We retrospectively assessed the demographic and epidemiological features of CE in children and adults hospitalized in Western Romania between 2007-2022. Analyzed data were collected from the hospitals' medical records. This research involved 426 subjects (3-90 years): 60 (14.1%) children and 366 (85.9%) adults. A decreasing trend in the number of cases was noted during the analyzed period (p = 0.004). Multiple-organ involvement was reported in 16.7% of the children and in 6.3% of the adults (p = 0.005). The liver was the most commonly affected organ. The rate of lung involvement was higher in children (25%) than in adults (13.1%) (p = 0.02). Most of the patients had one hospital presentation (74.9%). Multiple hospitalizations were reported in 40% of the children and 22.7% of the adults (p = 0.004). CE is a severe zoonotic disease that impacts individuals of all ages. Despite the decline in cases, CE remains a public-health problem in Western Romania. Health programs that target risk factors and control measures should be implemented to stop the parasite's spread and maintain the trend toward reduced numbers of CE cases.

Global Landscape of Infection-Induced Pulmonary Hypertension

Introduction: Infectious diseases significantly impact pulmonary vascular disorders, particularly in developing countries where parasitic infections remain prevalent. These infections constitute a substantial yet frequently overlooked contributor to pulmonary hypertension. Discussion: This review examines the prevalence of parasitic lung diseases in regions where communicable infections are endemic and highlights their pathophysiological links to pulmonary hypertension. Schistosomiasis and HIV notably increase pulmonary hypertension risk in these areas. While other infectious diseases may also cause pulmonary vascular lesions, most remain insufficiently studied. The review addresses global epidemiological trends, diagnostic challenges, and recent advancements in understanding the multifaceted origins of pulmonary hypertension. Conclusion: The association between parasitic infections and pulmonary hypertension is significant, necessitating a high index of suspicion for pulmonary hypertension in patients with a history of parasitic diseases, especially in endemic regions. More research is needed to understand infection-related pulmonary hypertension mechanisms and reduce its global impact.

Advancing Esophageal Cancer Staging and Restaging: The Role of MRI in Precision Diagnosis

This review provides an in-depth analysis and comprehensive overview of recent advancements in MRI techniques for evaluating esophageal cancer (EC). It discusses the specific MRI acquisition protocols and parameters that enhance image quality and diagnostic accuracy. The review highlights MRI's role and performance in the initial TNM staging and its potential to refine treatment strategies by improving tumor delineation and characterization. Additionally, the paper explores MRI utility in restaging after NAT, focusing on its accuracy in assessing treatment response and detecting residual or recurrent disease. Comparisons with other imaging modalities currently used-such as endoscopic ultrasound (EUS), contrast-enhanced computed tomography (CE-CT), and 18F-fluorodeoxyglucose (FDG) positron emission tomography/CT (PET/CT)-are included to highlight the strengths and limitations of each method. Illustrated with numerous Figures, this article proposes a novel MRI-based strategy for EC staging and restaging. It aims to integrate MRI into clinical practice by leveraging its superior soft-tissue contrast and functional imaging capabilities to enhance diagnostic precision and improve patient outcomes. Through this comprehensive evaluation, the review underscores the potential of MRI to become a cornerstone in the precision diagnosis and management of EC.

Usefulness of shear-wave elastography for detection of lymph node metastasis in esophageal and gastric cancer

BACKGROUND

Tissue hardness is closely related to disease pathophysiology. Shear-wave elastography (SWE) is a simple and noninvasive ultrasound technique that has been used to evaluate the presence of lymph node metastases and differentiate between benign and malignant tumors.

AIM

To investigate SWE usefulness in measuring lymph node hardness to predict metastasis presence or absence in surgically removed lymph nodes.

METHODS

This observational study obtained data from patients who underwent surgery for esophageal or gastric cancer at Nippon Medical School Hospital. The hardness of the surgically removed lymph nodes was measured using SWE. The lymph nodes with hardness values ≥ 2.2 m/s were considered clinically positive for metastasis, whereas those with lower hardness values were considered clinically negative. The lymph nodes subsequently underwent pathological examination to determine the presence of metastasis, and the SWE results and pathological assessments were compared.

RESULTS

A total of 1077 lymph nodes were evaluated; 18 and 15 cases of esophageal and gastric cancer were identified, respectively. The optimal cutoff value for lymph node size was calculated to be 5.1 mm, and the area under the curve value was 0.74 (95% confidence interval: 0.69-0.84). When limited to a lymph node larger than the cut off value, the SWE sensitivity and specificity for metastasis identification were 0.76 and 0.82, respectively.

CONCLUSION

SWE was useful in detecting lymph node metastases in the upper gastrointestinal tract.

LncRNA gm40262 promotes liver fibrosis and parasite growth through the gm40262-miR-193b-5p-TLR4/Col1α1 axis

Alveolar echinococcosis (AE) is a severe and life-threatening parasitic disease caused by Echinococcus multilocularis. Liver fibrosis is a significant pathological feature of advanced AE, characterized by the excessive production and accumulation of extracellular matrix (ECM). However, the precise underlying mechanism remains largely unknown. In this study, we show that the long noncoding RNA gm40262, predominantly expressed in hepatic stellate cells (HSCs), is upregulated in AE. Interestingly, its knockdown leads to liver fibrosis resolution, accompanied by a substantial suppression of parasite growth. Gm40262 functions by targeting miR-193b-5p to activate HSCs and stimulate their proliferation in a TGF-β-dependent manner, thereby promoting ECM production by upregulating Col1α1. Moreover, gm40262 is also involved in inflammation through the gm40262-miR-193b-5p-TLR4 axis. Our findings suggest that gm40262 plays a pivotal role in parasite-induced liver fibrosis through multiple mechanisms, highlighting its potential as a therapeutic target for hepatic fibrosis.

IMPORTANCE

Echinococcus multilocularis is a tiny parasite with significant medical implications. The chronic parasitism of E. multilocularis in the liver generally leads to liver fibrosis, but the underlying mechanisms are poorly understood. We herein show that gm40262, a long noncoding RNA predominantly expressed in hepatic stellate cells (HSCs), is involved in hepatic fibrogenesis during infection by activating HSCs and promoting extracellular matrix production. The gm40262-orchestrating fibrogenesis occurs through the gm40262-miR-193b-5p-TLR4 and gm40262-miR-193b-5p-Col1α1 axes. The knockdown of gm40262 remarkably alleviates liver fibrosis, with decreased parasite growth. Our findings reveal a key role of gm40262 in liver fibrosis during E. multilocularis infection, rendering it a therapeutic target for hepatic fibrosis.

Progress on the HIF-1α/VEGF/VEGFR2 signal pathway in hepatic alveolar echinococcosis

Alveolar echinococcosis (AE), a lethal parasitic zoonosis mimicking malignant tumors, progresses via hepatic infiltration and metastatic spread, causing multiorgan failure. Despite its clinical resemblance to cancer, molecular drivers of its aggressiveness remain poorly defined. Recent studies highlight perilesional angiogenesis as pivotal for lesion invasiveness, mediated by VEGF-driven pathological vascularization. VEGF not only fuels parasitic proliferation by creating nutrient-rich microenvironments but also engages crosstalk with host-parasite interactions, including immune evasion by Echinococcus multilocularis, germinal layer hyperplasia, and periparasitic inflammation.Targeting the HIF-1α/VEGF/VEGFR2 axis emerges as a promising therapeutic strategy. Mechanistically, VEGF/VEGFR2 blockade may simultaneously disrupt angiogenesis-dependent parasitic expansion and survival pathways. Preclinical evidence shows that inhibiting HIF-1α (VEGF's upstream regulator) suppresses metacestode proliferation and tissue invasion by starving lesions of vascular support while modulating immune-inflammatory responses. This dual action addresses both parasitic resource acquisition and host defence subversion.This review synthesizes molecular insights into HIF-1α/VEGF-mediated pathogenesis with clinical observations, proposing anti-angiogenic therapy as a rational adjunct to current treatments. By delineating VEGF's role in sustaining parasitic metabolic demands and immune regulation, we underscore the translational potential of pathway-specific inhibitors. Such approaches could mitigate limitations of conventional therapies (e.g., benzimidazoles), particularly for advanced-stage AE with microvascular proliferation. Systematic analysis of angiogenesis signalling networks advances our understanding of AE's "parasitic cancer" paradigm while guiding development of targeted interventions to improve patient outcomes.

Spinal deformity after thoracotomy in children with pulmonary hydatid disease

BACKGROUND

Pulmonary hydatid cyst disease is a common zoonotic infection, especially in agricultural and livestock communities. Thoracotomy is an important surgical procedure in the treatment of pulmonary hydatid cysts in children. However, the development of a spinal deformity is one of the long-term musculoskeletal complications of this procedure. The aim of this study was to evaluate the incidence, risk factors and clinical outcomes of spinal deformity in pediatric patients after thoracotomy.

METHODS

Between 2008 and 2022, 116 pediatric patients who underwent thoracotomy for pulmonary hydatid disease and met the study criteria were retrospectively reviewed. Age, sex, side of surgery, pre- and postoperative spinal radiographs, presence of spinal deformity and Cobb angles were measured.

RESULTS

Spinal deformities developed in 57.8% of 116 patients after thoracotomy. The risk of spinal deformity increases with decreasing age at surgery. The side of the thoracotomy can influence the direction of the apex of the spinal deformity. However, sex had no significant effect on the development of spinal deformity.

CONCLUSIONS

Children with pulmonary hydatid cyst disease are at high risk of developing spinal deformity after thoracotomy, and this risk is greater in younger patients. This study emphasises the importance of multidisciplinary approaches in the prevention and management of spinal deformity.

An 11-month-old infant with laryngeal and pharyngeal injuries due to aspiration of an L-shaped metal fragment: A case report

Airway foreign bodies require urgent removal owing to their life-threatening risks. Symptoms such as coughing and wheezing typically appear immediately after aspiration, although symptom improvement can delay diagnosis and treatment. This report describes a rare case of aspiration of an L-shaped metal fragment that injured the larynx and pharynx. The patient was an 11-month-old girl who developed a persistent cough while eating baby food. Her primary care physician initial discharged her with mild hoarseness, but persistent hoarseness led to an emergency room visit. Although her vital signs were stable, crying revealed hoarseness and inspiratory wheezing. Suspecting an airway foreign body, a chest X-ray revealed a metal object in the neck. Computed tomography showed that the fragment's edges were in the larynx and pharynx, spanning the arytenoid cartilages. The pharyngeal end of the fragment had punctured the posterior pharyngeal wall, and submucosal free air was observed. The foreign body-a thin and 2-cm-long L-shaped metal fragment-was removed under intravenous anesthesia using video laryngoscopy. Owing to the risks of emphysema, hematoma, and edema from inflammation of the posterior pharyngeal wall, the patient was intubated for 3 days and recovered well. As demonstrated, aspiration of irregularly shaped foreign objects can cause severe injury to surrounding structures. Careful diagnostic attention is crucial, and for suspected emphysematous lesions in the pharynx or mediastinum, endotracheal intubation and ventilatory support should be considered.

Slicing Through the Options: A Systematic Review of Esophageal Leiomyoma Management

Esophageal leiomyomas are rare, benign tumors that can remain asymptomatic or cause dysphagia and chest discomfort when they grow large. Despite advancements in diagnostic and therapeutic strategies, optimal management remains debated. This systematic review evaluates current diagnostic modalities and treatment approaches, synthesizing findings from a comprehensive PubMed search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 51 studies were included, comprising six original studies, 26 case reports, nine retrospective cohort studies, nine case series, and two cross-sectional studies. Findings indicate that endoscopic ultrasonography (EUS) is the most accurate diagnostic tool (89% accuracy), while computed tomography (CT) and barium swallow studies provide complementary structural assessments. Immunohistochemical staining differentiates leiomyomas from gastrointestinal stromal tumors (GISTs), with leiomyomas expressing desmin and smooth muscle actin (SMA) but lacking CD34 and KIT. Surgical intervention is recommended for symptomatic tumors or those exceeding 5 cm. Minimally invasive techniques, including robotic-assisted thoracoscopic surgery (RATS) and submucosal tunneling endoscopic resection (STER), offer superior outcomes compared to traditional open surgery. RATS demonstrates a negligible mucosal injury rate versus 1-15% for other approaches, while STER minimizes blood loss and accelerates recovery. Postoperative outcomes are generally favorable, though transient gastroesophageal reflux disease (GERD) is the most common complication. While STER and RATS present effective alternatives with reduced morbidity, this review highlights limitations, including variability in study designs, small sample sizes, and a lack of long-term follow-up data. Further prospective studies are needed to optimize patient selection and establish long-term efficacy. This review provides insights to inform clinical practice and guide future research in the management of esophageal leiomyomas.

Treatment of Boerhaave syndrome: experience from a tertiary center

BACKGROUND

Boerhaave syndrome is a rare, life-threatening condition, characterized by spontaneous esophageal rupture. This study aims to share our 13-year experience in managing Boerhaave syndrome.

METHODS

A retrospective, observational study was conducted of consecutive patients with Boerhaave syndrome who presented at our tertiary referral center, between 2011 and 2023. Patients were categorized by time to diagnosis, to assess the impact of diagnostic delay.

RESULTS

Among 21 patients, 13 (62%) were diagnosed early (< 24 h) and 8 (38%) late (> 24 h). In the early-diagnosed group (n = 13), 6 patients (46%) received primary intervention with stent placement in combination with surgical drainage (5 with mediastinal and pleural drainage and 1 with only pleural drainage), while 5 patients (38%) were initially treated with only a stent. One patient (8%) underwent surgical pleural drainage alone and one (8%) underwent an esophagectomy. Among the 8 late-diagnosed patients, 4 (50%) were primarily treated with both stent placement and surgical drainage (2 with mediastinal drainage, 1 with pleural drainage and 1 with both), 3 (38%) with only stent placement, and one (13%) was managed conservatively. Additional interventions were required in 14 patients (67%). Additional surgical drainage was performed in 5 of 8 patients who had initially been treated with stent only (63%) and in 2 of 10 patients who had initially received both stent and surgical drainage (20%). Stent complications occurred in 7 patients (37%), including leakage (16%), migration (16%), and bleeding (5%). The median hospital stay was 32 days (IQR 15-37) and the overall 90-day mortality was 14%. Mortality was significantly higher in late-diagnosed patients (n = 3, 38%) compared to those early diagnosed (n = 0, 0%) (p = 0.042), with all 3 deceased patients either refusing or being unfit for treatment.

CONCLUSION

Based on this study, we recommend prioritizing closure of the defect combined with drainage, while considering individual patient factors, including advanced age.

Implementing sustainable practices to reduce wastage and costs in adenotonsillectomy

BACKGROUND

Surgical waste presents significant environmental and economic challenges in healthcare. Adenotonsillectomy, a common otolaryngological procedure, contributes to this issue. There is limited research on sustainability measures in adenotonsillectomy, and no studies have specifically identified waste reduction strategies for this operation in a general ENT unit. This study aimed to identify sustainable practices for waste reduction in adenotonsillectomy surgeries and quantify the extent of waste reduction in terms of weight and cost.

METHODS

The items opened and waste produced during adenotonsillectomies in a single institution were documented, including weights and costs. After reviewing the actual materials used by otolaryngologists and identifying potentially avoidable waste, a low-waste setup was designed. Waste weight and costs were evaluated post-implementation and compared with baseline values.

RESULTS

Several steps to reduce wastage in adenotonsillectomy surgeries were identified, including the elimination of surgical drapes and gowns. This resulted in a waste reduction of over 60%, with an average reduction in weight per case of 1.114 kg. The estimated reduction over 1 year for 294 cases was 327.52 kg. The mean reduction in material costs per case was $41.67, with an extrapolated annual savings of $12 250.98 for 294 cases.

CONCLUSION

Implementing sustainable practices in adenotonsillectomy surgeries can significantly reduce waste and healthcare facility cost, providing both environmental and economic benefits.

Assessing Surgical Approaches and Postoperative Complications for Thoracic Schwannomas: A Multicenter Retrospective Observational Analysis of 106 Cases

Background: Thoracic schwannomas are benign nerve sheath tumors that can cause neurological and respiratory symptoms depending on their location and extension. The optimal surgical approach remains debated, particularly regarding resection extent, complication rates, and postoperative morbidity. Methods: This retrospective multicenter study analyzed 106 patients treated between 2011 and 2024, classifying tumors according to the Eden system and comparing surgical strategies. Surgical variables, including operative time, blood loss, resection extent, recurrence rates, and complications classified by Clavien-Dindo, were analyzed. Results: Eden I and II schwannomas were treated with laminectomy (LCT) or hemilaminectomy (HLCT) and transpedicular approaches (TPD), achieving high gross total resection (GTR) rates with minimal complications. Eden III dumbbell tumors benefited from a combined neurosurgical-thoracic approach (LCT + VATS), which resulted in higher GTR rates (100% vs. 62%, p < 0.01) and lower dural complications compared to neurosurgical resection alone. Eden IV extraforaminal schwannomas were best managed with VATS, which was associated with lower intraoperative blood loss (p = 0.018), shorter surgical duration (p = 0.027), and reduced postoperative complications compared to open thoracotomy. Our findings confirm that minimally invasive techniques, particularly VATS and combined neurosurgical-thoracic approaches, optimize tumor resection while reducing morbidity. However, feasibility depends on institutional resources and multidisciplinary collaboration. Conclusions: This study provides a stratified comparison of surgical approaches tailored to Eden classification, aiming to identify the most effective and least morbid strategies for each lesion type. Future prospective studies should validate these findings, integrating preoperative functional assessments and long-term follow-up to better stratify surgical risk, personalize operative planning, and refine surgical decision making for thoracic schwannomas.

Treatment of pulmonary hydatid cysts: a single-centre analysis of 872 cases

OBJECTIVES

The objective of this study was to investigate the importance of pulmonary parenchyma preservation, the results of cystotomy and the capitonnage technique and the efficacy of postoperative albendazole treatment.

METHODS

A retrospective study was conducted at a single centre between 2000 and 2024, encompassing 872 consecutive patients with pulmonary hydatid cysts.

RESULTS

Of the cases studied, 394 (45.2%) were female and 478 (54.8%) were male, with a mean age of 26.8 ± 19.7 years (range: 2-86 years). Isolated lung involvement was observed in 553 (63.4%) cases. In general, a single hydatid cyst was detected in 665 (76.3%) patients, and 466 (53.4%) of these had isolated lung involvement. In 452 cases (51.8%), only the right lung was affected, whereas 294 (33.7%) had left lung involvement, and 126 (14.5%) had bilateral lung involvement. An operation was performed in 807 (92.5%) cases. Cystotomy and capitonnage were performed in 782 (89.7%) patients. Thoracoscopic wedge resection was performed in 13 cases (1.5%), cystotomy alone in 5 cases (0.6%), lobectomy in 5 cases (0.6%) and enucleation with capitonnage in 2 cases (0.2%). Postoperative complications included atelectasis in 45 cases (5.6%), prolonged air leak in 8 cases (1.0%), empyema in 6 cases (0.7%), wound infection in 3 cases (0.4%) and bleeding in 2 cases (0.2%). Recurrence was observed in 4 (0.5%) surgically treated cases, and 1 case (0.1%) resulted in death in the postoperative period.

CONCLUSIONS

The management of pulmonary hydatid cysts with cystotomy and capitonnage is feasible in the majority of patients and results in acceptable success and complication rates. Administration of albendazole postoperatively has been shown to be an effective method of preventing recurrence.

A Greener Vascular Surgery: A Survey of Current Green Practices

BACKGROUND

Climate change is an environmental emergency. With health care systems contributing to 5% of carbon emissions globally, environmental sustainability is an important consideration when delivering surgical services. This survey aimed to understand current green practices across vascular centers.

METHODS

A survey on routine sustainable practices and the feasibility of implementing greener practices was developed between the Vascular and Endovascular Research Network and the Vascular Society of Great Britain and Ireland. The survey was delivered using the Qualtrics online survey tool and distributed through mailing lists and social media. The survey was open to completion by all vascular health care professionals internationally. Responses were collected between June 2, 2023, and September 15, 2023.

RESULTS

A total of 115 vascular health care professionals across 14 different countries responded. Disposable theater materials were used in 85% (98/115) of respondents' centers. Most centers used electronic patient records (investigation requests [76%, 85/112], observation charts [81%; 91/112], prescriptions [74%; 83/112]). Paper recycling policies were available in 52% (58/112) of respondents' centers. All the respondents agreed that vascular surgery can be greener. 80% (92/115) of respondents reported environmental sustainability was never discussed in departmental meetings and 24% (28/115) reported their department engaged with management to implement more sustainable practices. Barriers to change included finance (77%, 89/115), competing priorities (84%, 97/115), and lack of engagement (82%, 94/115).

CONCLUSION

This survey identified areas where vascular services could be more environmentally friendly, including reducing the use of disposable materials and improving recycling. Vascular health professionals are largely supportive of implementing changes to reduce the carbon footprint.

A review of silicosis and other silica-related diseases in the engineered stone countertop processing industry

BACKGROUND

Engineered stone (ES), a material that has become widespread for its use in kitchen and bathroom countertops since the 1980s, is composed of over 90% crystalline silica by weight, significantly exceeding the silica content of natural stones such as granite (40-50%) and marble (< 10%). Workers fabricating ES are exposed to dangerously high levels of respirable crystalline silica (RCS) and other toxic chemicals, which increases the risk of developing silicosis and other lung and systemic diseases. The purpose of this review is to explore the epidemiology, occupational risks, regulatory gaps, diagnostic evaluation, and clinical challenges associated with ES dust exposure.

MAIN BODY

ES silicosis was first described in the early 2010s among ES countertop workers in Spain, Italy, and Israel. Since then, hundreds of cases have emerged worldwide, namely in China, Australia, the United States, the United Kingdom, and Belgium. Silicosis from ES dust is accelerated and diagnosed after 7-19 years of exposure, often affecting young individuals (median age 33-55 years) from marginalized or immigrant communities. Morbidity and mortality are poor, with high rates of lung transplantation and death. Industrial hygiene air sample monitoring data shows that despite engineering controls such as wet saws and exhaust ventilation, exposure to respirable crystalline silica when cutting ES frequently exceeds safe exposure levels. Diagnostic evaluation and treatment are clinically challenging due to delayed medical screening, misdiagnosis, and lack of treatment options.

CONCLUSIONS

This review underscores the urgent need for enhanced occupational safety regulations, active screening, and healthcare support to address the rising burden of ES silicosis among vulnerable worker populations globally.

Global, regional, and national assessment of foreign body aspiration (1990-2021): novel insights into incidence, mortality, and disability-adjusted life years

BACKGROUND

Foreign body aspiration (FBA) is a preventable yet underrecognized global health challenge, contributing to substantial clinical and economic burdens. Comprehensive and comparable analyses of FBA trends across diverse populations and socioeconomic contexts remain limited. Leveraging data from the 2021 Global Burden of Disease (GBD) Study, we provide an in-depth global, regional, and national analysis of FBA trends over the past three decades, including the first evaluation of disability-adjusted life years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs).

METHODS

We examined FBA incidence, mortality, and disease burden across regions, nations, ages, sexes, and Socio Demographic Index (SDI) levels from 1990 to 2021, calculating age-standardized incidence (ASIR) and death (ASDR) rates, as well as estimated annual percentage changes (EAPCs).

RESULTS

Globally, FBA incidence declined by 35.3% between 1990 and 2021 (EAPC: -2.02; 95% CI: -2.13 to -1.91), with marked reductions among children under 5 years of age. Nonetheless, total FBA-related deaths rose slightly from 99,329 (95% UI: 80,764-112,381) in 1990 to 103,915 (95% UI: 82,081-113,555) in 2021. While many regions showed improvement, countries such as Italy, Georgia, and Zimbabwe recorded increases in ASIRs. In 2021, children under 5 remained at highest risk of morbidity, while older adults (≥ 70 years), especially in high-income Asia Pacific and Western Europe, showed elevated mortality. Notably, younger children achieved substantial decreases in incidence, death, and DALYs, yet older populations faced modest rises in mortality and DALYs. Higher-SDI regions reported the greatest morbidity and mortality, and high-middle SDI regions exhibited the highest DALYs, YLLs, and YLDs, reflecting the influence of socioeconomic development on FBA burden.

CONCLUSIONS

Global FBA incidence declined from 1990 to 2021, yet the number of associated deaths continued to rise, indicating ongoing challenges in prevention and management. High- and middle-high SDI regions carried the greatest burden, with children under 5 and older adults (≥ 70 years) particularly affected. These patterns suggest that both advancing socioeconomic development and population aging influence FBA outcomes. Strengthening surveillance, improving emergency response, and implementing targeted, population-specific prevention strategies are essential for reducing the global FBA burden.

Pulmonary manifestations and clinical management of echinococcosis in a low-endemic region of Mexico: a 15-year retrospective cohort study at a tertiary hospital

BACKGROUND

Cystic echinococcosis has a low incidence even in endemic countries. It is a chronic and complex zoonosis that in many cases presents delay in diagnosis; it typically affects the liver in up to 90% of the cases, being disseminated pulmonary disease the most common in young subjects, while the rate of cases located only in the pulmonary parenchyma is low. In Mexico it is considered a disease of low endemicity.

MATERIAL AND METHODS

We retrospectively collected data from patients with suspected echinococcosis infection from the hospital discharge database.

RESULTS

Of the 70 patients in the database, 59 had a clinical history (84.3%), of whom 11 had a histopathological diagnosis of cystic echinococcosis and were included in this study, 67.6% were female, with a median age of 32 years (IQR 17-53.5). A total of 45.6% had some comorbidity, the most frequent being type II diabetes mellitus (80%); only 54.6% had lived in a rural area as a risk factor, while only 27.2% had exposure to canines. All cases were symptomatic, with a mean symptom duration of 49 days. A total of 81.8% had exclusive pulmonary disease, while the rest had simultaneous lung and liver involvement. No case presented spontaneous rupture. All cases received anthelmintic treatment and, in 9 cases, surgical resection of the pulmonary parenchyma. The only postsurgical complication was a chylothorax with adequate resolution. The median follow-up in months was 8.3 (IQR 3.7 to 10.7 months), and almost two-thirds of the cases presented dyspnea grade 2-3 (mMRC) as sequelae.

CONCLUSION

Of all the patients studied with pulmonary echinococcosis, only two presented with hepatic-pulmonary hydatid disease, and spontaneous cyst rupture was not reported. About half had exposure to cattle as a risk factor, while no specific risk factor was identified in the rest of the subjects.

Surgical approaches for thymectomy: a narrative review

Background and Objective

Thymectomy continues to be a standard treatment strategy for patients with thymic neoplasms and myasthenia gravis. The total thymectomies performed has exponentially increased by 69.8% between 2012 and 2019. Trans-sternal and minimally invasive thymectomy increased by 62.8% and 83.7%, respectively. Our objective is to provide a narrative overview of the various approaches of thymectomy. We have briefly described the indications for thymectomy, discussed important preoperative considerations and an operative description of the different techniques of the procedure. We have aimed to summarize the pros and cons of each approach and narrated the technique we have adopted at the University of Minnesota.

Methods

A literature search was conducted encompassing original full-length articles, meta-analyses, review articles and case reports up to July 2024 from the MEDLINE and Google Scholar databases.

Key Content and Findings

Complete surgical resection remains the goal to decrease the risk of recurrence for non-myasthenic thymomas and thymic carcinomas. Surgical procedures have evolved from traditional open approaches to a wide variety of minimally invasive methods. A variety of factors specific to the tumor, patient and surgeon have to be considered while planning a thymectomy.

Conclusions

As of today, there is no consensus on the best surgical technique, with each approach providing specific pros and cons. Each technique may be a viable option in the management of thymic pathologies, thus preoperative evaluation in patients is necessary to optimize prognosis and outcomes.

Threshold size criterion to suspect malignant supraclavicular lymph node < 10 mm in esophageal cancer

OBJECTIVES

To determine the threshold size for predicting metastasis of supraclavicular lymph nodes (SCLNs) < 10 mm on axial and multiplanar reconstruction CT in esophageal squamous cell carcinoma (ESCC).

METHODS

This retrospective, multicenter study received approval from three institutional review boards, which waived informed consent. Patients with ESCC had ultrasound-guided fine-needle aspiration biopsy (US-FNAB) for SCLNs, with contrast-enhanced CT performed within 2 weeks prior to US-FNAB. A CT and ultrasound radiologist jointly analyzed images to identify and mark biopsied SCLNs < 10 mm on CT, followed by two blinded radiologists who independently measured short-axis diameter (SAD), long-axis diameter (LAD), short diameter of multiplanar reconstruction (SD-MPR), long diameter of multiplanar reconstruction (LD-MPR) and the intra-class correlation coefficient (ICC) was analyzed. Center 1 included 220 SCLNs as the training set, and Centers 2 + 3 included 75 SCLNs as the validation set. The optimal cutoff value was determined using receiver operating characteristic (ROC) curves.

RESULTS

In the training and validation sets, 31.8% (70/220) and 32.0% (24/75) of SCLNs were positive. ICC for SAD was excellent (ICC = 0.847). The area under the receiver operating characteristic curve of SAD was 0.832 in the training set, higher than others, with a cutoff value of > 6 mm, resulting in sensitivity, specificity, positive predictive value, negative predictive value, accuracy of 77.1%, 80.7%, 65.0%, 88.3%, 79.1%, respectively. In the validation set, these metrics were 87.5%, 74.5%, 61.8%, 92.7%, 81.0%, respectively.

CONCLUSION

SAD on CT can suspect metastasis of SCLN < 10 mm in ESCC patients, with a threshold size of > 6 mm.

CLINICAL RELEVANCE STATEMENT

Determining the threshold size criterion on CT images may enhance the prediction of supraclavicular lymph node metastasis in esophageal squamous cell carcinoma patients, thereby benefiting diagnostic and therapeutic strategies.

KEY POINTS

Supraclavicular lymph nodes < 10 mm in esophageal carcinoma are indeterminate for malignancy. Supraclavicular lymph nodes > 6 mm are highly suspicious for malignancy. The metastasis status of supraclavicular lymph nodes is critical for staging esophageal carcinoma.

The role of ELISA IgG antibodies in diagnosis of cystic echinococosis of lung. A retrospective study of a single centre activity in Albania

BACKGROUND

Cystic Echinococcosis presents significant biological, medical, economic, and social challenges. The diagnosis of cystic echinococcosis relies on immunodiagnostic methods alongside radiological in combinations with clinical findings. In human Cystic Echinococcosis, false negative immunologic results can occur in 3-5% of patients and reach up to 35-40% in hyper endemic regions. This study aimed to assess the role of Elisa IgG CE serum antibody titres in diagnosing pulmonary Cystic Echinococcosis.

MATERIAL AND METHODS

A retrospective review of medical records for 362 CE patients diagnosed in a cohort of 20 years was conducted. Diagnosis was based on radiological and clinical data, personal and family history with confirmation by serodiagnosis or histology in surgery cases. Age, sex, cysts location, size, complications and treatment were reviewed. ELISA IgG CE was studied preoperatively in all cases with its specificity and sensitivity in all cases RESULTS: The cohort included 362 patients of whom 51.4% males and 48.6% females, with a mean age of 40 years (range 12-80). 42 % were from rural regions. Among the cases, 112 (31%) presented with intact cysts, while 250 (69%) were complicated. ELISA IgG CE serum antibody titre tests were conducted for all cases. 350 (96.7%) underwent surgical treatment, while the remainder received conservative care. ELISA IgG CE was positive in 181 patients (50%). The sensitivity was 70% (175 patients) for complicated cases, but only 18.8% (21 patients) for uncomplicated cases.

CONCLUSIONS

ELISA IgG CE has limited value in diagnosing CE. However, it may aid in identifying complicated CE. Interpretation of ELISA IgE CE results should consider clinical imaging findings. Establishing pre and postoperative surveillance protocols involving family doctors and diagnostic imaging services can enhance patient care quality.

Weighing up GnRH agonist therapy for endometriosis: outcomes and the treatment paradigm

INTRODUCTION

Endometriosis is a chronic inflammatory estrogen-dependent disease affecting 10% of women worldwide leading to chronic pelvic pain and infertility which may be treated clinically or surgically.

AREAS COVERED

Current literature was reviewed using the keywords 'gonadotropin releasing hormone agonists (GnRHa),' 'endometriosis,' 'infertility' and 'chronic pelvic pain.' Relevant papers prioritizing randomized controlled clinical trials (RCT), systematic reviews, meta-analyses, as well as international guidelines were evaluated.

EXPERT OPINION

Available options for relieving endometriosis-associated pain include GnRHa, progestagens, and combined oral contraceptives, all of which block menstruation to control symptoms without curing the disease. GnRHa administration decreases pain and symptom recurrence after surgical treatment, but side effects and costs limit its use. Published studies to test its effectiveness in easing endometriosis-associated pain are heterogeneous, consider different outcomes with no long-term results. Drug choice should be individualized considering the side-effect profile, tolerability, costs, risks, and benefits as one size does not fit all. As we wait for the development of an ideal pharmacological agents, GnRHa with an add-back regimen remains a second-line option to alleviate the painful symptoms in women with endometriosis. Endometriosis management should consider the systemic nature of the disease and the complexity involved in the pathogenesis of symptoms.

Value of Computed Tomography Scan for Detecting Lymph Node Metastasis in Early Esophageal Squamous Cell Carcinoma

BACKGROUND

The necessity of computed tomography (CT) scan for detecting potential lymph node metastasis (LNM) in early esophageal squamous cell carcinoma (ESCC) before endoscopic and surgical treatments is under debate.

METHODS

Patients with histologically proven ESCC limited to the mucosa or submucosa were examined retrospectively. Diagnostic performance of CT for detecting LNM was analyzed by comparing original CT reports with pathology reports. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

A total of 625 patients from three tertiary referral hospitals were included. The rate of pathologically confirmed LNM was 12.5%. Based on original CT reports, the sensitivity, specificity, accuracy, PPV, and NPV of CT to determine LNM in T1 ESCC were 41.0%, 83.2%, 77.9%, 25.8%, and 90.8% respectively. For mucosal cancers (T1a), these parameters were 50.0%, 81.7%, 80.9%, 6.8%, and 98.4%, respectively. For submucosal cancers (T1b), they were 40.0%, 85.0%, 75.0%, 43.0%, and 83.3%, respectively. Additionally, the diagnostic performance of CT for LNM was relatively better for ESCC in the lower esophagus. Pathologically, 69.2% of patients with LNM did not exhibit lymphovascular invasion (LVI), and the sensitivity of CT for recognizing LNM in these patients (33.3%) was lower than those with LVI (58.3%).

CONCLUSIONS

Computed tomography can detect nearly half of the LNM cases in early ESCC with high specificity. The performance of CT further improved in LNM cases with LVI. Therefore, we conclude that routine preoperative CT for the assessment of potential LNM risk in patients with early ESCC is necessary.

Environmental responsibility in resource utilization during the practice of regional anesthesia: a Canadian Anesthesiologists' Society Delphi consensus study

PURPOSE

Regional anesthesia (RA) is often perceived to be more environmentally sustainable than alternative forms of anesthesia. Nevertheless, the principles of sustainable RA remain ill-defined in the presence of variability of resource utilization within RA practice. Many infection prevention practices are based on low-level evidence, and recommendations vary internationally. We sought to conduct an evidence review and Delphi consensus study to provide guidance on aspects that lack high-quality evidence in RA practice to reconcile responsible resource stewardship and infection prevention in RA.

METHODS

We conducted a three-round modified Delphi process. After distributing an initial free-text questionnaire to all collaborators, we created structured questions, followed by two rounds of anonymized voting. We defined strong consensus as ≥ 75% agreement and weak consensus as ≥ 50% but < 75% agreement.

RESULTS

Forty-six experts agreed to take part in the study and 36 (78%) completed all the voting rounds. Regional anesthesia practice parameters with strong consensus included hand hygiene using alcohol scrub rather than soap and water, sterile gowns being unnecessary for single-injection RA techniques, only minimal equipment in the premade packs, and goal-directed use of sedation and supplemental oxygen.

DISCUSSION

We obtained consensus on the safe and environmentally responsible practice of RA for both single-injection and indwelling catheter techniques and identified areas of research focus. While more robust evidence is being generated, clinicians may use these findings as a guide to infection prevention and environmental sustainability in their anesthesia practice.

Hepato-thoracic cystic echinococcosis transit. Clinical features, postoperative complications and hospital mortality. A systematic review

BACKGROUND

Hepato-thoracic hydatid transit (HTT) is an evolutionary complication of hepatic cystic echinococcosis. This study aimed to report the available evidence regarding postoperative complications (POC) and hospital mortality (HM).

METHODS

Systematic review. Studies related to HTT were included. Searches were performed in Trip Database, SciELO, BIREME-BVS, WoS, PubMed, EMBASE and SCOPUS.

PRIMARY OUTCOMES

POC and HM.

SECONDARY OUTCOMES

publication date, origin and designs, number of patients, cyst type, hospital stance, treatments; and methodological quality (MQ) of studies applying MInCir-T and MInCir-Pr2 scales. Descriptive statistics, weighted means (WM) and their comparison using least squares logistic regression, and meta-analysis of prevalence of POC and HM were applied.

RESULTS

604 studies were retrieved (101 met selection criteria, representing 1020 patients). WM age: 42.6 years, 58.3 % male. Reports are mainly from Spain (19.8 %) and Turkey (17.8 %). With a WM of 18.3 days of hospital stance, it was verified 28.9 % of POC, 12.6 % needed re-interventions, and 9.7 % died. MQ of studies: 9.1 ± 1.9 (MInCir-T) and 13.2 ± 2.9 (MInCir-Pr2). Comparing the behavior of variables in two periods (1983-2002 vs. 2003-2024), statistically significant differences were observed in POC, HM, and reinterventions.

CONCLUSION

HTT is associated with high POC, and significant HM, despite the passage of time.

Environmental Sustainability in ICUs: A Report From the Society of Critical Care Medicine Sustainability Task Force

OBJECTIVES

The charge of the newly formed Society of Critical Care Medicine Sustainability Task Force is to describe actionable items supporting environmental stewardship for ICUs, to discuss barriers associated with sustainability initiatives and outline opportunities for future impact.

DATA SOURCES

Ovid Medline, EBSCOhost CINAHL, Elsevier Embase, and Scopus databases were searched through to March 2024 for studies reporting on environmental sustainability and critical care.

STUDY SELECTION

Systematic reviews, narrative reviews, quality improvement projects, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed.

DATA EXTRACTION

Data regarding environmental sustainability initiatives that aimed to quantify, manage, or mitigate pollution and/or carbon emissions with a focus on ICUs, barriers to change, and opportunities for development were qualitatively assessed.

DATA SYNTHESIS

ICUs are resource-intensive and as such, methods to attenuate carbon emissions and waste can play a substantial role in mitigating the sizable burden of healthcare-related pollution and greenhouse gas emissions. Several initiatives and strategies exist for clinicians and providers to engage in environmental stewardship, with specific attention to avoiding low-value care while maintaining or improving patient safety and high-quality care. Increased focus on sustainability can be met with resistance to change, including institutional, financial, and behavioral barriers. Collaboration and innovative thinking create valuable opportunities for clinicians, patients, families, and policymakers to advocate for patient and planetary health.

CONCLUSIONS

Within the healthcare system, ICUs are well positioned to lead sustainability action, policy, and practice. Critical care teams have the capability and the moral responsibility to mitigate the negative impact of critical care medicine upon our environment and become change agents promoting sustainable healthcare for the benefit of human health.

A Diagnostic Challenge for Bilateral Lung Involvement in a 13-Month-Old Saudi Child Due to Multiple Popcorn Kernel Aspirations: A Case Report

Foreign body aspiration (FBA) should be considered in the differential diagnosis of pediatric respiratory cases, particularly when symptoms are atypical and bilateral lung involvement is present. Early recognition and prompt intervention are crucial to preventing severe complications.

Anastomotic Leak After Esophagectomy: Modern Approaches to Prevention and Diagnosis

Anastomotic leak (AL) remains one of the most serious complications following esophagectomy, contributing to significant morbidity, prolonged hospital stays, and increased mortality. Despite advancements in surgical techniques and perioperative care, AL continues to challenge surgeons and negatively impact patient outcomes. Various factors contribute to its development, including patient-specific comorbidities, tumor characteristics, anastomotic technique, conduit perfusion, and perioperative management. Prevention strategies have evolved with the integration of intraoperative techniques such as fluorescence-guided perfusion assessment, omental reinforcement, and meticulous surgical handling of the gastric conduit. Emerging technologies, including endoluminal vacuum therapy (EVT) and multimodal perioperative protocols, have demonstrated potential in reducing leak incidence and improving management. Diagnosing AL remains complex due to its variable presentation, necessitating a combination of clinical evaluation, inflammatory markers, imaging studies, and endoscopic assessments. While routine postoperative imaging has shown limited sensitivity, on-demand CT and endoscopic evaluations play a crucial role in early detection and intervention. This review provides a comprehensive analysis of the risk factors, prevention strategies, and diagnostic modalities for AL after esophagectomy, incorporating recent advancements and emerging technologies.

Challenges in the Management of Pediatric Pancreatic Hydatid Disease: A Systematic Review of the Literature and Our Clinical Experience

Pancreatic hydatid disease (PHD) in children is rare compared to liver and lung involvement. The rarity and overlap with other cystic lesions often lead to challenges in the preoperative diagnosis and intraoperative surprises. Clear guidelines on the appropriate management of PHD are lacking. This review is intended to address these gaps in the literature. A systematic literature search was performed in PubMed, Scopus, Cochrane Central Registry of Controlled Trials (The Cochrane Library), and ScienceDirect databases for pediatric PHD. Observational studies such as case reports, case series, and retrospective studies were included. Letters, editorials, conference abstracts, comments, animal studies, and non-English literature studies were excluded. After sorting out 794 articles, 11 articles describing 16 patients (including our cases) were included in qualitative synthesis. The author's two cases were described separately. Preoperative diagnosis was made in only 35.71% of the patients. Both the conservative surgical (92.86%) and radical approaches (7.14%) have been described with favorable results (85.71%). One patient managed with the conservative surgical approach developed a pancreatic leak. No recurrence was reported. PHD in children is rare. Accurate preoperative diagnosis is uncommon and requires a high index of suspicion. A normal pancreas, nondilated pancreatic duct, and normal enzymes in a patient from an endemic zone should prompt consideration of PHD. Surgical management must be individualized due to the limited data. Both conservative and radical approaches can be effective, but caution is needed for potential pancreatic leaks after the conservative approach due to ductal communication.

Advances in Novel Diagnostic Techniques for Alveolar Echinococcosis

Alveolar echinococcosis (AE), caused by the larval stage of the tapeworm Echinococcus multilocularis, is a serious parasitic disease that presents significant health risks and challenges for both patients and healthcare systems. Accurate and timely diagnosis is essential for effective management and improved patient outcomes. This review summarizes the latest diagnostic methods for AE, focusing on serological tests and imaging techniques such as ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography/computed tomography (PET/CT). Each imaging modality has its strengths and limitations in detecting and characterizing AE lesions, such as their location, size, and invasiveness. US is often the first-line method due to its non-invasiveness and cost-effectiveness, but it may have limitations in assessing complex lesions. CT provides detailed anatomical information and is particularly useful for assessing bone involvement and calcification. MRI, with its excellent soft tissue contrast, is superior for delineating the extent of AE lesions and their relationship to adjacent structures. PET/CT combines functional and morphological imaging to provide insights into the metabolic activity of lesions, which is valuable for monitoring treatment response and detecting recurrence. Overall, this review emphasizes the importance of a multifaceted diagnostic approach that combines serological and imaging techniques for accurate and early AE diagnosis, which is crucial for effective management and improved patient outcomes.

Cervical cancer burden and attributable risk factors across different age and regions from 1990 to 2021 and future burden prediction: results from the global burden of disease study 2021

Background

Cervical cancer (CC) is a global public health problem. We aimed to evaluate the global and regional CC burden between 1990 and 2021, identify the attributable risk factors, and project its burden up to 2035.

Methods

Data were extracted from the Global Burden of Disease Study 2021, and the CC incidence, mortality, age-standardized incidence rate (ASIR), age-standardized death rate (ASDR), age-standardized disability-adjusted life years (DALYs), and attributable risk factors from 1990 to 2021 were analyzed. The impacts of geographical variations, different age groups, and the socio-demographic index (SDI) on CC morbidity and mortality measurements were assessed. The attributable risk factors to CC death and DALY were evaluated, and the incidence, mortality, and DALYs to 2035 were projected.

Results

Globally, the number of CC cases has increased from 409,548.49 cases in 1990 to 667,426.40 cases in 2021. However, the ASIR decreased from 18.11 to 15.32 per 100,000, with the greatest ASIR decrease in high SDI regions (estimated annual percentage change: -1.41). Between 1990 and 2021, the global ASDR decreased from 9.68 to 6.62 per 100,000, and the rate of age-standardized DALYs decreased from 330.11 to 226.28 per 100,000. However, these improvements were not consistent across different SDI regions. The CC incidence was the highest in the 55-59 age group, globally. The risk factors, which included unsafe sex and smoke, significantly varied by region. The global ASIR exhibited a downward trend from 2021 to 2035.

Conclusion

From 1990 to 2021, although the overall trend in incidence, mortality, and DALYs of CC exhibited a global and regional downward trend, there were significant disparities among areas with different socioeconomic development. More efficient targeted prevention and management strategies, easy access to health care in less developed regions, and risk factor modifications should be promoted, in order to reduce the global burden of CC.

The Impact of Deep Learning on Determining the Necessity of Bronchoscopy in Pediatric Foreign Body Aspiration: Can Negative Bronchoscopy Rates Be Reduced?

INTRODUCTION

This study aimed to evaluate the role of deep learning methods in diagnosing foreign body aspiration (FBA) to reduce the frequency of negative bronchoscopy and minimize potential complications.

METHODS

We retrospectively analysed data and radiographs from 47 pediatric patients who presented to our hospital with suspected FBA between 2019 and 2023. A control group of 63 healthy children provided a total of 110 PA CXR images, which were analysed using both convolutional neural network (CNN)-based deep learning methods and multiple logistic regression (MLR).

RESULTS

CNN-deep learning method correctly predicted 16 out of 17 bronchoscopy-positive images, while the MLR model correctly predicted 13. The CNN method misclassified one positive image as negative and two negative images as positive. The MLR model misclassified four positive images as negative and two negative images as positive. The sensitivity of the CNN predictor was 94.1 %, specificity was 97.8 %, accuracy was 97.3 %, and the F1 score was 0.914. The sensitivity of the MLR predictor was 76.5 %, specificity was 97.8 %, accuracy was 94.5 %, and the F1 score was 0.812.

CONCLUSION

The CNN-deep learning method demonstrated high accuracy in determining the necessity for bronchoscopy in children with suspected FBA, significantly reducing the rate of negative bronchoscopies. This reduction may contribute to fewer unnecessary bronchoscopy procedures and complications. However, considering the risk of missing a positive case, this method should be used in conjunction with clinical evaluations. To overcome the limitations of our study, future research with larger multi-center datasets is needed to validate and enhance the findings.

TYPE OF STUDY

Original article.

LEVEL OF EVIDENCE

III.

Exploring metabolic reprogramming in esophageal cancer: the role of key enzymes in glucose, amino acid, and nucleotide pathways and targeted therapies

Esophageal cancer (EC) is one of the most common malignancies worldwide with the character of poor prognosis and high mortality. Despite significant advancements have been achieved in elucidating the molecular mechanisms of EC, for example, in the discovery of new biomarkers and metabolic pathways, effective treatment options for patients with advanced EC are still limited. Metabolic heterogeneity in EC is a critical factor contributing to poor clinical outcomes. This heterogeneity arises from the complex interplay between the tumor microenvironment and genetic factors of tumor cells, which drives significant metabolic alterations in EC, a process known as metabolic reprogramming. Understanding the mechanisms of metabolic reprogramming is essential for developing new antitumor therapies and improving treatment outcomes. Targeting the distinct metabolic alterations in EC could enable more precise and effective therapies. In this review, we explore the complex metabolic changes in glucose, amino acid, and nucleotide metabolism during the progression of EC, and how these changes drive unique nutritional demands in cancer cells. We also evaluate potential therapies targeting key metabolic enzymes and their clinical applicability. Our work will contribute to enhancing knowledge of metabolic reprogramming in EC and provide new insights and approaches for the clinical treatment of EC.

Rapid Growth of a Hepatic Hydatid Cyst in a Pediatric Patient: A Case Report From Iran and Its Clinical Significance

Hepatic hydatid cysts in pediatric patients present unique diagnostic and therapeutic challenges due to their rapid growth and potential to mimic other pathologies. This case highlights the importance of considering hydatid disease in the differential diagnosis of hepatic cysts, especially in children from endemic regions. The unusual rapid growth rate observed in pediatric cases, influenced by age-related immune and tissue dynamics, underscores the need for heightened vigilance even when prior imaging appears normal. Timely recognition and intervention are crucial to preventing complications such as cyst rupture, secondary infection, and compression of adjacent organs. This case also illustrates the utility of serological and radiological tools in confirming the diagnosis and the role of surgical and pharmacological therapies in ensuring favorable outcomes. Clinicians must remain alert to atypical presentations, ensuring comprehensive evaluation and prompt treatment to improve prognosis and reduce the burden of complications associated with hydatid disease.

Implementation of Green Surgery Approach in Healthcare System and its Effect on Carbon Footprint Reduction in Operating Theatres

Healthcare systems, particularly operating theatres (OTs), are among the leading causes of pollution due to energy-intensive procedures, anaesthetic gases, and single-use surgical instruments. This perspective review provides actionable, evidence-based recommendations that not only minimise the environmental impact but also offer quality patient care. A wide literature search of available studies on green surgery was conducted. Searches were conducted in databases, including PubMed, Science Direct, Scopus, ProQuest, and Web of Science, from January 2013 to the present. A review of global practices highlighted the effectiveness of green surgical initiatives. Some initiatives related to the health sector report reductions in carbon emissions by reusable surgical instrument implementation in hospitals of up to 97%, energy savings of up to 50% with modifications to heating, ventilation, and air-conditioning (HVAC) systems, and waste management programmes, including the recycling and reprocessing of single-use devices, reporting waste reductions from 40% to 66%. Key strategies include shifting to renewable energy sources by promoting reusable instruments, optimising HVAC systems, and promoting comprehensive staff training for sustainability. All these factors are important for decreasing the environmental burden without compromising operational efficiency. The integration of sustainable practices in Malaysian OTs can significantly reduce carbon emissions and waste generated by hospitals while maintaining patient safety. These measures support the national goals of achieving Sustainable Development Goals (SDGs) and advancing Universal Health Coverage (UHC). Aligning with global sustainability efforts, Malaysia's health care system can reduce its carbon footprint.

Congenital diaphragmatic hernia with intrathoracic kidney: case report, review of the literature, and strategy for treatment in neonates and infants

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a rare developmental defect in the diaphragm, occurring in 2 in 10,000 births. Herniation of intraperitoneal organs through the diaphragmatic opening is always present, however few cases mention the herniation of retroperitoneal organs, such as a kidney. Due to the rarity of this condition, the optimal treatment strategy remains unclear.

METHODS

A PubMed search was conducted, gathering all published reports of CDH with intrathoracic herniation of the kidney. Cases of isolated intrathoracic kidney without CDH and cases of traumatic hernia were excluded. Patients who underwent surgical repair before the age of 5 years were included for further analysis.

RESULTS

Thirty-seven cases were found from 1970 to 2022. The approach used for surgical repair was not mentioned in 55.6% of cases. 52.9% of the remaining patients were treated through laparotomy, whereas in 23.5% a thoracoscopy was performed. A primary repair of the hernia was performed in 88.6%. A hernia sac was noted in 70%. Most patients had a normal origin of the renal vessels and reduction of the intrathoracic kidney was achieved in 78.8%. Moreover, we report a case of CDH with intrathoracic kidney treated through thoracoscopic repair.

CONCLUSION

A thoracoscopic approach is effective for the treatment of CDH with an intrathoracic kidney case with an associated intrathoracic kidney. A therapeutic strategy for CDH with intrathoracic kidney is suggested based on data from published cases.

Spontaneous Postpartum Pneumomediastinum (Hamman's Syndrome): A Case Report and Review of Chest Pain Management in the Immediate Postpartum Period

Spontaneous pneumomediastinum is a rare condition in the postpartum period, characterized by symptoms such as dyspnea, chest pain, subcutaneous neck edema, tachycardia, crepitus, dysphonia, and dysphagia. The Valsalva maneuver, commonly performed during the second stage of vaginal delivery, has been implicated as a key precipitating factor in the pathogenesis of this condition. We report the case of a 25-year-old woman (G1P1001, 39w5d), with a history of smoking, who developed postpartum dyspnea and chest pain 24 hours following an uncomplicated vaginal delivery. A comprehensive diagnostic workup, including a CT scan with intravenous contrast, confirmed severe pneumomediastinum. The patient was managed conservatively with analgesics, supplemental oxygen, and close clinical monitoring. A follow-up chest CT performed 24 hours later demonstrated interval improvement of the pneumomediastinum and an esophagogram excluded the presence of an esophageal tear or rupture. Although spontaneous pneumomediastinum is a rare obstetric complication of normal childbirth, it can present dramatically with chest pain, dyspnea, and hemodynamic instability. Diagnosis is established through a combination of history, clinical presentation, and radiographic findings. Management is conservative and includes analgesics, rest, supplemental oxygen therapy, and bronchodilators. Importantly, other potentially life-threatening causes of postpartum chest pain and dyspnea must be carefully ruled out to ensure timely and appropriate treatment.

Endoscopic vacuum therapy for the treatment of Boerhaave syndrome: a multicenter analysis

BACKGROUND AND AIMS

Boerhaave syndrome, an effort rupture of the esophagus, is a rare but serious condition. Endoscopic vacuum therapy (EVT) is a new therapeutic approach for GI perforation. We aimed to evaluate EVT for treatment of Boerhaave syndrome.

METHODS

This retrospective study was conducted at 5 tertiary hospitals in southern Germany. All patients treated for Boerhaave syndrome since 2010 were identified and included. Treatment success and outcomes were assessed and compared between the different modes of primary treatment.

RESULTS

Fifty-seven patients with Boerhaave syndrome were identified (median age, 68 years; n = 16 female). The primary treatment was EVT in 25 cases, surgery in 14, and endoscopic stenting in 15. Primary EVT was successful in 20 (80.0%) of the 25 patients. Two patients were switched to surgical treatment, 1 was switched to esophageal stenting, and 2 patients died. The mortality rate was lower (P = .160) in patients treated primarily with EVT (n = 2 [8.0%]) compared with patients in the non-EVT group (n = 8 [25.0%]). Treatment success was significantly higher (P = .007) for primary EVT (80.0%) than for non-EVT (43.8%). Primary EVT was associated with treatment success in multivariable analysis.

CONCLUSIONS

EVT showed a high success rate for treatment of Boerhaave syndrome and was associated with treatment success.

Chronic pericarditis secondary to pericardial lymphangioma. An unusual presentation of an unusual tumor: case report

Pericardial lymphangiomas are exceptionally rare and affect both children and adults. Although they are usually asymptomatic, they can cause symptoms secondary to the mass effect, from syncope or palpitations to arrhythmia or congestive heart failure. The most reliable diagnostic methods are echocardiography, computed tomography, and magnetic resonance imaging, with subsequent confirmation by histopathology. Its treatment consists of complete surgical resection. We present the case of a 2-year-old female patient with a definitive diagnosis of pericardial lymphangioma who debuted with cardiac tamponade and hemodynamic repercussions. She underwent a pleuropericardial window by lateral thoracotomy with resection of nodular masses at the posterior level of the pericardium without complications. The patient's evolution and prognosis were favorable.

Burden of Myasthenia Gravis in the Czech Republic: Analysis of the Nationwide Patient Registry

INTRODUCTION

The main goal of this study was to describe the Czech population of patients with MG in terms of demographics, disease characteristics, management approaches, and treatment trends.

METHODS

We selected all patients, both incident and prevalent, who were enrolled in the Czech MyReg registry between August 24, 2015 and November 19, 2021. For the descriptive analysis, all patients enrolled in the registry, regardless of their date of diagnosis or date of enrolment, were included. We analyzed the following disease-related endpoints: myasthenia gravis composite (MGC) score, forced vital capacity (FVC), and Myasthenia Gravis Foundation of America (MGFA) clinical classification.

RESULTS

The incidence showed a consistent increasing trend from 0.62 to 3.13. The mean MGC score was 5.0 (median 4.0, 95% CI 4.7, 5.3) representing mild form of MG. The difference in FVC from the predicted value in patients during and without myasthenic crisis was 58.93% (95% CI 37.27, 80.59) and 75.93% (95% CI 74.87, 77.00), respectively. We identified 70 patients (5.0%) with refractory MG, of whom 58.6% were female. The MGFA classifications in those with refractory vs. non-refractory disease was as follows: IIa 21.8% vs 23.2%, IIb 45.3% vs 33.6%, and IIIb 14.1% vs 4.6%, respectively.

CONCLUSION

Our analysis shows that the incidence of MG is increasing in the Czech Republic and that patients with refractory disease, of whom up to 58% are female, have a higher burden of disease than non-refractory patients.