Management of esophageal perforations

BACKGROUND

Esophageal perforations remain a life-threatening event requiring rapid diagnosis and treatment. Surgical repair and interventional endoscopic or conservative treatment are the common treatment methods.

METHODS

From 1998 to 2006, the authors retrospectively analyzed 62 patients treated for esophageal perforation. Data were evaluated for cause of perforation, symptoms, therapeutic regimen, complications, and mortality.

RESULTS

The causes of perforation were iatrogenic or suicidal (n = 33) or spontaneous (n = 29). In the first group, the causes were dilation of stenosis (n = 16), endoscopy (n = 7), transesophageal echography (n = 4), ingestion of acid or leach (n = 2), intubation (n = 2), ingestion of a foreign body (n = 1), and migration of a screw after osteosynthesis (n = 1). The spontaneous perforations were caused by tumors (n = 19), Boerhaave syndrome (n = 6), unknown origin (n = 3), and Barrett's ulcer (n = 1). The most frequent symptoms were dysphagia (n = 50), pain (n = 35), fever (n = 24), and vomiting (n = 18). At the time of perforation, 28 patients presented with cancer. Of these 28 patients, 18 had esophageal cancer. The treatment included surgery (n = 32), which consisted of double-layer suture (n = 26) or esophageal resection (n = 6). A total of 30 patients were treated interventionally with a stent (n = 21), clips (n = 1), or without further measures (n = 8). The patients in the surgery group presented with severe primary and postoperative general conditions including renal failure (25%), respiratory insufficiency (65.5%), and need for catecholamines (62.5%). This multiorgan involvement was found only occasionally in the conservative group. The overall hospital mortality rate was 14.5%, involving 9 patients (5 in the surgery group and 4 in the conservative group). Early treatment led to better survival than late treatment with a delay exceeding 24 h.

CONCLUSION

The treatment method still must be chosen on an individual basis. It appears that surgical treatment is necessary in cases of severe general conditions. The data from this study show that surgical repair and conservative treatment may be used successfully. The best outcome was obtained after immediate treatment.

MDCT findings of denim-sandblasting-induced silicosis: a cross-sectional study

BACKGROUND

Denim sandblasting is as a novel cause of silicosis in Turkey, with reports of a recent increase in cases and fatal outcomes. We aimed to describe the radiological features of patients exposed to silica during denim sandblasting and define factors related to the development of silicosis.

METHODS

Sixty consecutive men with a history of exposure to silica during denim sandblasting were recruited. All CT examinations were performed using a 64-row multi-detector CT (MDCT). The nodules were qualitatively and semi-quantitatively analyzed by grading nodular profusion (NP) on CT images.

RESULTS

Silicosis was diagnosed radiologically in 73.3% of patients (44 of 60). The latency period (the time between initial exposure and radiological imaging) and duration of silica exposure was longer in patients diagnosed with silicosis than in those without silicosis (p < 0.05). Nodules were present in all cases with centrilobular type as the commonest (63.6%). All cases of silicosis were clinically classified as accelerated and 11.4% had progressive massive fibrosis (PMF). Mild NP lesions were the most prevalent in all six zones of the lung. The NP score was significantly correlated with the duration of silica exposure, the latency period, presence of PMF, and pleural thickening. Enlarged lymphadenopathy was present in 45.5% of patients.

CONCLUSIONS

The duration of exposure and the latency period are important for development of silicosis in denim sandblasters. MDCT is a useful tool in detecting findings of silicosis in workers who has silica exposure.

A geriatric patient with diffuse idiopathic skeletal hyperostosis

The most frequent health problems seen in senility are chronic and degenerative diseases. A 75-year-old male patient with the complaints of weight loss and difficulty in swallowing was admitted to our hospital from a nursing home. Upper system fiber-optic gastrointestinal endoscopy was performed and a mass at the junction of the hypopharynx and esophagus just below recessus piriformis obstructing almost the whole of the lumen and blocking the distal passage was detected. Computed tomography revealed marked narrowing secondary to osseous hypertrophy in the air column of the hypopharynx and proximal esophagus. Diffuse idiopathic skeletal hyperostosis or Forestier’s disease is an idiopathic disease characterized by the ossification of the anterior longitudinal ligament of vertebra and some of the extraspinal ligaments. In the present case we aim to discuss an elderly patient who suffered from dysphagia and weight loss and the diagnostic stages.

Options in the management of esophageal perforation: analysis over a 12-year period

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.

Treatment of intractable hiccups with an oral agent monotherapy of baclofen -a case report-

Hiccups are an involuntarily powerful spasm of the diaphragm, followed by a sudden inspiration with a closure of the glottis. Hiccups that are caused by gastric distention, spicy foods and neural dysfunction can resolve themselves without any treatment. Some hiccups are associated with certain diseases or they occur postsurgically, and life-restricting intractable hiccups should be treated. The cause of hiccups should be quickly determined so as to administer the proper treatment. Hiccups often remit spontaneously within a short period of time, but they may also occur without remission for a prolonged period in some cases. We report here on a 36-year-old man who suffered with intractable hiccups for 5 years. We administered a single oral dose of baclofen, and then the hiccups disappeared. We conclude that a single dose of baclofen is a good treatment for intractable hiccups.

The use of the LigaSureTM in esophagectomy

This study aimed to evaluate the efficacy of the LigaSure vessel sealing system (LVSS) when used for esophagectomy. We compared 56 consecutive patients (32 male and 24 female, mean age: 56.64+/-12.61 years), who had undergone Ivor-Lewis esophagectomy for esophageal carcinoma between January 2005 and May 2009. Among them, from January 2005 to April 2007, 27 patients (group 1) were operated on with the conventional clamp-and-tie technique, whereas from April 2007 to May 2009, 29 patients (group 2) underwent total esophagectomy for esophageal cancer with the LVSS. Both groups were compared for operation duration, amount of intraoperative bleeding, postoperative hospitalization time, and intraoperative complications. In the evaluation of the patients, the two groups had similar distributions of age and gender. The duration of operation (349.44+/-46.82 min vs. 288.27+/-60.09 min, P<0.05) and the amount of intraoperative bleeding (414.82+/-137.04 ml vs. 217.41+/-111.78 ml, P<0.05) were significantly lower in LVSS group than in the conventional method group. There were no differences for hospitalization time and intraoperative complications between the groups. LVSS significantly shortens operation duration and decreases the amount of intraoperative bleeding compared with the conventional methods, but does not provide advantages for hospitalization time and/or intraoperative complications. We believe LVSS is an effective and reliable method for esophagus surgery.

Tumors of the diaphragm

Primary tumors of the diaphragm are rare. The most common benign cystic lesions of the diaphragm are bronchogenic or mesothelial cysts, while the most common benign solid lesion is a lipoma. Benign tumors of the diaphragm are resected if they are symptomatic or if there is a doubt about the diagnosis. The most common primary malignant lesion is rhabdomyosarcoma. Malignant tumors are treated based on histology and often with chemotherapy and/or radiation along with surgical resection if feasible. Endometriosis, a benign process that metastasizes to the diaphragm, is typically treated medically; surgical ablation or resection is considered only after failed conservative treatment. Surgical resection of metastatic malignant tumors, such as ovarian cancer and thymoma, as well as malignancies affecting the diaphragm by direct extension, such as mesothelioma, lung, and esophageal cancer, may provide some survival advantage.

Hydatid cyst of the rib: a new case and review of the literature

The hydatid cyst is not rare in our country, but bone lesions are less common. The disease often takes the appearance of abscess or malignant lesion. We report a case of a 35-year-old man with a hydatid cyst of the rib complicated with cutaneous fistula. The surgery allowed both diagnosis and treatment. Albendazole was then administered to prevent relapse.

A case of Poland Syndrome associated with dextroposition

Classical Poland Syndrome (PS) is characterized by unilateral, partial or complete absence of the sternocostal head of the major pectoral muscle and brachysyndactyly of fingers on the same side. We report the case of a newborn infant with dextrocardia and PS located on the left side. This association is very rare: to date only 19 cases have been described in scientific literature. In all reported cases, as in the present, the Poland defect involved the left side and was associated to rib defects, whereas most cases of PS are on the right side and few have rib defects. This case supports the view that dextrocardia follows the loss of volume of the left hemithorax caused by Poland sequence and that the combination of PS and dextrocardia is not coincidental.

Bilateral congenital Morgagni-Larrey's hernia

BACKGROUND

Congenital Morgagni-Larrey's hernia (CMLH) is rare and known to be associated with a high incidence of bilaterality and associated anomalies. This study aimed to review our patients with bilateral CMLH and evaluate their presentation, associated anomalies, diagnostic difficulties and therapy.

METHODS

From January 1989 to December 2007, we treated 8 children with bilateral CMLH at our hospital. Their medical records were retrospectively reviewed for age, sex, symptoms, associated anomalies, diagnosis, operative findings, treatment and outcome.

RESULTS

Among the 8 children, 4 were male and 4 female, with a mean age of 22.74 months (range: 0.93-108 months). Six of them sustained repeated attacks of pneumonia. In 5 children, bilaterality was diagnosed at surgery. Associated anomalies were observed in all children, including congenital heart disease in 5, Down's syndrome in 4, malrotation in 3, inguinal hernia in 2, umbilical hernia in 1, and pyloric stenosis in 1. All of these children were operated on transabdominally. All of them did well postoperatively and on follow-up ranging from 1.5 years to 5 years (mean: 3 years), one had recurrence of the hernia as well as an incisional hernia.

CONCLUSIONS

The diagnosis of bilateral CMLH may be difficult preoperatively, especially if one of the hernial sacs is empty. CT scan is valuable to diagnose bilateral hernias. To repair these hernias, we advocate a transabdominal approach, which allows easy reduction and inspection of contents, access and repair of bilateral hernias, and correction of associated malrotation if present.

Complications of metallic stent placement in malignant esophageal stricture and their management

OBJECTIVE

At the present time, covered self-expandable metallic stent placement is the palliative treatment method for inoperable esophageal cancer. However, life-threatening early and late complications are seen related to esophageal stent placement. In this study, we discuss complications of esophageal stent placement with their management and present our own experience.

METHODS

Between January 2000 and February 2009, 215 covered esophageal stent placements were performed in 174 inoperable esophageal cancer and/or esophagorespiratory fistula patients in the Department of Thoracic Surgery at the Ataturk University Hospital.

RESULTS

Major complications related to stent placement developed in 24 patients (11 bleeding, 6 aspiration pneumonia, 3 tracheal compressions, 2 perforations, and 2 esophagorespiratory fistulas). Two hundred and thirty minor complications were observed among 174 patients (165 chest pain, 29 tumoral overgrowth, 17 stent migration, 6 gastroesophageal reflux, 3 failure in stent placement, 3 hiccup, 2 foreign body sensation, 2 failure in stent expansion, 1 tumor ingrowth, 1 granulation tissue formation, and 1 food bolus obstruction). Reintervention was required in 56 (32.2%) patients who experienced complications. Stent-related mortality was seen in 4 (2.3%) patients (2 aspiration pneumonia, 1 tracheal compression, and 1 esophagorespiratory fistula). One hundred sixty-two of 174 patients died during follow up. The mean survival time was 177.3+/-59.3 days (range: 2 to 993 d).

CONCLUSIONS

The complication rate of self-expandable metallic stent placement is high in inoperable esophageal cancer patients. Although some of these complications are life threatening, many of them can be managed successfully with endoscopic reintervention.

High-risk chief complaints I: chest pain--the big three

Chest pain is one of the most frequently seen chief complaints in patients presenting to emergency departments, and is considered to be a "high-risk" chief complaint. The differential diagnosis for chest pain is broad, and potential causes range from the benign to the immediately life-threatening. Although many (if not most) emergency department patients with chest pain do not have an immediately life-threatening condition, correct diagnoses can be difficult to make, incorrect diagnoses may lead to catastrophic therapies, and failure to make a timely diagnosis may contribute to significant morbidity and mortality. Several atraumatic "high-risk" causes of chest pain are discussed in this article, including myocardial infarction and ischemia, thoracic aortic dissection, and pulmonary embolism. Also included are brief discussions of tension pneumothorax, esophageal perforation, and cardiac tamponade.

Ruptured hydatid cyst masquerading as tension pneumothorax

We report a 35-year-old man who presented to us with features suggestive of a tension pneumothorax. However insertion of a chest tube did not result in any signs of improvement. Further investigation demonstrated that he had a ruptured hydatid cyst. He underwent an emergency thoractomy and excision of the cyst. Ruptured hydatid cyst should be considered as a possibility in patients who present with sudden onset respiratory distress and hypoxia in geographical areas where the disease may be prevalent.

Mediastinal hydatid cyst

BACKGROUND

The objective of this study was to report our experience in the management of hydatid cysts of the mediastinum.

METHODS

Among 206 patients who underwent surgery in our department for intrathoracic hydatid cysts between September 2001 and September 2008, 7 patients (3.4%) aged 24 to 49 years (mean, 36.2 years) had mediastinal hydatid cysts. Imaging consisted of chest X-ray and computed tomography. Surgical approach was by posterolateral thoracotomy in all cases.

RESULTS

The cyst was located in the posterior mediastinum in 3 cases (42.8%), in the anterior mediastinum in 2 cases (28.5%) and in the middle mediastinum in 2 cases (28.5%). Two patients had cysts in other thoracic locations (diaphragm, pleural). All cysts were intact. Surgical approach was right thoracotomy in 5 patients (71.4%) and left thoracotomy in 2 patients (28.5%). In 5 cases, a small part of the cyst wall intimately adherent to vital structures was left in place. There were no postoperative complications or mortality.

CONCLUSION

Mediastinal hydatid cyst is an uncommon disease. Because of the surrounding vital structures, the cyst should be removed immediately. Surgical removal remains the treatment of choice for mediastinal echinococcosis, without extensive resection when progression of dissection is impossible or dangerous.

Surgical treatment of intrathoracic hydatid disease: a 5-year experience in an endemic region

PURPOSE

To present our recent surgical experience in treating patients with intrathoracic hydatidosis.

METHODS

This study reviewed the files of patients with pulmonary/intrathoracic extrapulmonary hydatid cysts treated surgically between 2003 and 2009. Demographic, laboratory and radiological data, clinical manifestations, site of the cyst, surgical approaches, and final outcome were noted and analyzed.

RESULTS

Forty patients underwent 42 operations (21 females, 19 males, mean age 36 years). Thirty-six patients (90%) had pulmonary (56.7% were intact/uncomplicated), three (7.5%) had intrathoracic extrapulmonary, and one (2.5%) had both pulmonary/intrathoracic extrapulmonary hydatid cysts. The right lung was involved in 64.9%. Larger pulmonary cysts ruptured more commonly (P = 0.007). Most patients (95%) were symptomatic, mostly dyspneic (72.5%). The mean forced expiratory volume in 1 s value was significantly reduced in cases with a large (P < 0.0001), or ruptured cyst (P = 0.05). The erythrocyte sedimentation rate was elevated in case of rupture (P = 0.05). A thoracotomy was performed for all patients. A cystotomy and capitonnage was performed more commonly than cystotomy without capitonnage for the pulmonary, and total excision was performed for the intrathoracic extrapulmonary hydatid cysts. The mortality was 0% and the morbidity was 17.5%. All patients received antihelminthic therapy postoperatively. There was no recurrence.

CONCLUSION

Surgery is considered to be the optimal treatment for intrathoracic hydatid disease. In addition, recurrence is very low when all such patients receive postoperative antihelminthic therapy.

Morgagni hernia: diagnosis with multidetector computed tomography and treatment

PURPOSE

We aimed to retrospectively evaluate morbidity, mortality and treatment outcomes in 12 cases of Morgagni hernia diagnosed with multidetector computed tomography (MDCT) and treated appropriately.

METHODS

This is a retrospective study and data on the demographics, presenting symptoms, MDCT images, operative approach, morbidity and mortality were collected from hospital records.

RESULTS

Of 12 patients with a mean age of 60 years, ten were female. The diagnosis was made with MDCT before surgery. All hernias were unilateral and located in the right part of the thorax. The contents of the hernias were omentum and colon in the majority of the patients, and the contents of the hernia as diagnosed with CT was confirmed at surgery. Six patients had surgery. Of these, one had emergency surgery for hernia, two laparoscopic hernia repair, three transabdominal repair and one transthoracic repair.

CONCLUSIONS

MDCT is a good imaging technique to be used before surgery in that it is fast and non-invasive, helps to make an accurate diagnosis of Morgagni hernias and provides detailed information about the contents of the hernia and accompanying complications. Modern surgical techniques, including laparoscopy, help to achieve the repair of Morgagni hernias safely with short hospital stay and with little morbidity and mortality.

Unique case of esophageal rupture after a fall from height

Background

Traumatic ruptures of the esophagus are relatively rare. This condition is associated with high morbidity and mortality. Most traumatic ruptures occur after motor vehicle accidents.

Case Presentation

We describe a unique case of a 23 year old woman that presented at our trauma resuscitation room after a fall from 8 meters. During physical examination there were no clinical signs of life-threatening injuries. She did however have a massive amount of subcutaneous emphysema of the chest and neck and pneumomediastinum. Flexible laryngoscopy revealed a lesion in the upper esophagus just below the level of the upper esophageal sphincter. Despite preventive administration of intravenous antibiotics and nutrition via a nasogastric tube, the patient developed a cervical abscess, which drained spontaneously. Normal diet was gradually resumed after 2.5 weeks and the patient was discharged in a reasonable condition 3 weeks after the accident.

Conclusions

This case report presents a high cervical esophageal rupture without associated local injuries after a fall from height.

Dextrocardia in patients with Poland syndrome: phenotypic characterization provides insight into the pathogenesis

OBJECTIVE

Poland syndrome is a rare congenital anomaly characterized by complete or partial agenesis of the pectoralis major muscle variably associated with other thoracic malformations, upper limb malformations, or both. More than 20 patients with dextrocardia and left-sided Poland syndrome have been previously described. The association between these 2 rare anomalies suggests a causal relationship, but the etiopathogenetic mechanism has not been clarified yet. We studied the clinical correlation between these 2 anomalies, and we tried to elucidate whether dextrocardia or Poland syndrome comes first.

METHODS

This is a multicentric multidisciplinary study conducted over the last 5 years. We identified 122 patients with Poland syndrome, and we investigated heart position through different imaging techniques. Logistic regression statistical analyses were carried out.

RESULTS

We observed dextrocardia in 14 (11.5%) patients, which was never associated with situs inversus. All of them presented with left-sided Poland syndrome and partial agenesis of 2 or more ribs. Conversely, all patients with Poland syndrome with partial agenesis of 2 or more ribs presented with dextrocardia, whereas dextrocardia was never associated with partial agenesis of a single rib. Three patients with dextrocardia presented with simple congenital heart defects.

CONCLUSIONS

These findings suggest that mechanical factors during embryonic life could explain the strong association between left-sided Poland syndrome and dextrocardia. According to this hypothesis, partial agenesis of 2 or more ribs is needed to displace the heart toward the right side. The peculiar features of dextrocardia when associated with Poland syndrome (neither associated with situs inversus nor complex intracardiac anomalies) support our hypothesis.

Giant primary muscular hydatid cyst with a secondary bone localization

Primary musculoskeletal hydatidosis is less frequent than hydatidosis of the parenchymal organs. This localization has been little studied and so there is little information in the literature on the subsequent disease evolution. We present a case of primary hydatidosis of the abductor muscle that came to medical attention very late. After complete surgical removal of the huge mass, a secondary bone localization developed, causing a femoral pertrochanteric pathological fracture. The case described is exceptional in view of both the localization and the great size of the primary multi-lobed muscle hydatid cyst. We underline the difficulties of diagnosis and treatment of both the primary muscle localization and the secondary bone recurrence.

PillCam ESO versus esophagogastroduodenoscopy in esophageal variceal screening: A decision analysis

OBJECTIVES

PillCam ESO has been evaluated as a possible strategy to screen patients with cirrhosis for esophageal varices, but current guidelines recommend patients undergo screening with esophagogastroduodenoscopy (EGD), as it is currently the gold standard. Although recent data have suggested that PillCam ESO may be an acceptable alternative for screening, there is limited data on its cost-effectiveness compared with other screening modalities. This study was performed to compare the cost-effectiveness of PillCam ESO versus EGD for esophageal variceal screening.

METHODS

Markov models were constructed to compare 2 screening strategies: PillCam ESO versus EGD. In each arm, patients were followed for a time horizon of 15 years in 1-year transition intervals. All variables, transition probabilities, and costs were derived from the medical literature, and sensitivity analyses were performed on the different variables in the model.

RESULTS

Base-case analysis shows that PillCam ESO is associated with an average expected cost of $22,589 and an average expected effectiveness measure of 12.81 life-years. EGD is associated with an average expected cost of $23,083 and an average expected effectiveness measure of 12.67 life-years. PillCam ESO was found to dominate EGD as a screening strategy for patients with cirrhosis. Sensitivity analyses found several variables within the model to have influential effects on the results.

CONCLUSIONS

PillCam ESO is the dominant strategy for screening patients with cirrhosis for esophageal varices. However, based on a small difference in costs and effectiveness between each strategy, the results would suggest that PillCam ESO and EGD are essentially equivalent strategies.

Usefulness of MDCT evaluation of the intraluminal surface of esophageal masses using only effervescent powder without injection of hypotonic agent

This study evaluated the inner surface of esophageal masses using multidetector computed tomography (MDCT) after esophageal distention with an ingested effervescent powder without inducing pharmacological esophageal hypotonia. From September 2004 to December 2005, 38 patients underwent MDCT after esophageal distention using only an effervescent powder that was ingested only 35 s after injecting the contrast agent and twice 50 s after the injection. Ten patients had a normal esophagus and twenty-eight patients had an esophageal mass detected by endoscopy. The degree of distention at three levels (upper, middle, and lower) and the intraluminal surface of the esophageal mass were evaluated. The surface between the normal and esophageal mass were analyzed using an ANOVA test. Esophageal distention in the upper and middle thirds was classified as either "good" or "fair" in 90.8% of cases. In the lower third, 81.6% of cases were either "good" or "fair". All esophageal cancers had an irregular surface but all normal lining and benign esophageal masses had a smooth surface. MDCT after esophageal distention using the effervescent powder ingested twice achieved good-to-fair distention in the esophagus, and is a useful diagnostic modality for identifying the intraluminal surface of esophageal masses.

Resection of thyroid cancer metastases to the sternum

The role of surgical resection in patients with metastatic thyroid cancer is not clearly defined. Reported is a case of concurrent thyroid metastases to the lungs and sternum treated with total sternectomy followed by radioiodine therapy. A comprehensive review of the literature was also performed to evaluate the characteristics of reported cases of sternal thyroid cancer metastases treated with surgical resection. Overall, we demonstrate that radical resection of sternal metastases can be performed safely even in patients with poor prognosis to achieve palliation and potentiation of radioiodine therapy for concurrent metastases.

Total occlusion of the superior vena cava due to bronchogenic cyst

Bronchogenic cysts are the most common form of congenital cystic lesions in the mediastinum. Of all cases with bronchogenic cysts, 1/3 are symptomatic. The symptoms vary depending on the location and compression of the adjacent structures of the cyst. Some mediastinal bronchogenic cysts can cause severe respiratory distress due to airway and vascular compression. We herein present a case with a bronchogenic cyst that required venoplasty to the superior vena cava (SVC) due to total occlusion of the SVC.

Parenchyma-Preserving Surgery in the Management of Pulmonary Hydatid Cysts

Pulmonary hydatid cysts remain a significant health problem in endemic regions like Turkey. Here, we present our surgical experience in patients with pulmonary hydatid cysts. Between January 1985 and January 2001, 1118 operations were performed in 1032 patients (528 males, 504 females; mean age 32.7 years; range 1-87 years) with pulmonary hydatid cysts in our department. Posterolateral thoracotomy was performed in 1015 (98.3%), two-stage thoracotomy in 34 (3.3%), and median sternotomy in 17 (1.7%) patients. We preferred conservative surgical procedures. As a surgical procedure, cystotomy and capitonnage was performed in 626 (56%), cystotomy alone in 368 (33%), wedge resection in 81 (7%), enucleation in 29 (3%), and decortication in 11 (1%) patients. None of our patients were treated with anatomic resection. During surgery, 949 patients (92%) had unruptured and 83 patients (8%) had ruptured hydatid cyst. The morbidity ratio was 6.7%. Major complications were wound infection (2.3%), prolonged air leak (1.9%), atelectasis (1.2%), pleural effusion (0.8%), postoperative hemothorax (0.6%), and empyema (0.3%). Two patients (0.2%) died within the first month postoperatively. Mean follow-up was 31.2 months. Recurrence was detected in only 35 patients (3.3%). Treatment of pulmonary hydatid cyst is primarily surgical. Medical treatment is indicated for recurrent and multiple hydatid cysts postoperatively. Cystotomy alone, or cystotomy and capitonnage, as parenchyma-preserving surgery, is preferred. Radical surgery including pneumonectomy, lobectomy, and segmentectomy should be avoided.

Do foreign bodies migrate through the body towards the heart?

Fixation of foreign bodies (FB), in the mucosa, can favor its migration, giving origin to the popular saying: “FB walk to the heart”.

Aim

describe the mechanisms involved in FB migration and how to diagnose them.

Methodology

From a sample of 3,000 foreign bodies, during 40 years, we analyzed four which had extra-lumen migration. We analyzed clinical, radiologic, endoscopic and ultrasound data collected at the medical documentation service.

Results

three clinical histories are presented, describing two fish bones and one piece of fish cartilage. FB shifting was analyzed in all of them. Migration started in the esophagus in two, one going to the aorta and the other to the neck area. In the other two, migration started in the pharynx, and the FB moved towards the prevertebral fascia and the other externalized in the submandibular region. The mechanisms and the risks posed to the patient, by FB migration, and the way to diagnose them are hereby discussed.

Conclusions

the study allows us to determine that FB can move through the body but not towards the heart. The study also serves as a warning sign: in cases of prolonged histories of FB ingestion, imaging studies are mandatory before endoscopic examination.

Giant primary posterior mediastinal hydatid cyst in a child: report of a case and review of literature

Primary posterior mediastinal cyst is an exceptionally uncommon manifestation of hydatid disease especially in pediatric age group. We herein present the account of a giant posterior mediastinal hydatid cyst in an 8-year-old boy that was peculiar due to the absence of typical clinical and radiological features of hydatid disease. The diagnosis was established perioperatively by a combination of surgical and pathological findings. The report depicts one of the myriad presentations of hydatid disease and also emphasizes the verity that it should be considered in the differential diagnoses of any mediastinal cystic lesion even in pediatric patients.

Esophageal cancer: pneumo-64-MDCT

BACKGROUND

Pre-surgical characterization and staging of esophageal cancer with only one imaging method could be useful since gastric invasion determines the scope of resection and the kind of surgery to be performed. Our aim is to demonstrate the usefulness of Pneumo-64-MDCT (PnCT64) in the presurgical characterization of esophageal neoplasms in correlation with surgical findings.

MATERIALS AND METHODS

A total of 50 patients with diagnosis of esophageal neoplasm were prospectively studied. A 14 French Foley catheter was used transorally in all patients. Air was instilled through the catheter to achieve esophageal distension. A 64-row MDCT scan was performed and the tumor was characterized according to scope, shape and anatomic location by using multiplanar 3D reconstructions and virtual endoscopy. Wall infiltration and presence of adenopathies were analyzed.

RESULTS

Adequate gastroesophageal distension was achieved in all patients. In 44/50 patients, wall thickening was observed, and in 34/50 regional adenopathies were found. In 29/50 patients the lesion was found in the lower third and in the gastroesophageal junction. The surgical correlation for wall infiltration was 85.7%.

CONCLUSIONS

PnCT64 proved to be useful and safe for identification of esophageal wall thickening and presurgical characterization. Optimal distension allowed definition of both upper and lower borders of the tumors located in the gastroesophageal junction, of utmost importance to determine the surgical approach.

PNET/Ewing's sarcoma of the rectum: a case report and review of the literature

A 34-year-old female presented with anorectal pain and rectal bleeding due to an extensive rectal tumour. A trephine loop ileostomy was fashioned and biopsies were initially reported to show a poorly differentiated cloacogenic carcinoma. CT revealed numerous liver metastases. A histological review and immunohistochemical studies subsequently favoured a primitive neuroectodermal tumour (PNET). Stem-cell supported chemoradiotherapy resulted in complete resolution of her primary tumour and liver metastases. Serial CT scanning and endoscopy revealed no recurrence after 7 years of follow-up, when she presented with a malignant anal fissure. Imaging and subsequently abdominoperineal resection revealed no evidence of metastases from either the anal cancer or the PNET tumour. Histopathology showed a T1N0R0 basaloid squamous carcinoma originating from grade III squamous intraepithelial neoplasia with no obvious wart viral infection.

[Echinococcosis of the rib with epidural extension]

Osseous hydatidosis, especially when located in the rib, is a very rare disease. Less than 50 cases of costal echinococcosis have been reported in the literature to date. The authors report a case of echinococcosis of the rib with epidural extension in a 76-year-old patient presenting paraparesis. In addition, the patient presented a large posterior and thoracic soft tissue mass measuring about 30 centimetres in diameter. A chest x-ray, a CT thoracic scan and an MRI of the dorsal spine were performed. The imaging suggested echinococcosis of the rib with epidural extension. The cyst was completely resected. Histopathology of the resected specimen confirmed the diagnosis of echinococcosis. The patient died due to postoperative complications. Accurate presurgical diagnosis allows for appropriate management and helps eradicate the disease. This also prevents the dissemination of parasites and further complications.

Case report of a primary multiloculate muscular cystic hydatidosis

Hydatidosis is a zoonosis caused by the ingestion of Echinococcus granulosus eggs, released though the feces, from infected dogs to humans. Primary localization is mostly hepatic and/or pulmonary, whereas muscular involvement is very rare, even more so in muscular striated tissue. This is the report of a case of a primary intramuscular hydatid cyst in a 79-year-old woman who presented with a 3-year history of a painful lump in her proximal medial left thigh. The authors document the exceptional giant dimensions of the cyst, which have not previously been reported in a case of striated muscular hydatid disease.