Conservative Surgical Management of a Pulmonary Hydatid Cyst in an Adolescent Having Extra-pulmonary Lesions by a Multi-disciplinary Approach

Echinococcus granulosus causes hydatid cysts, a significant zoonotic and pulmonary parasitic disease that can mimic various pathologies and is often harder to manage than the disease itself. A hydatid cyst is considered a significant health problem in India, Iran, China, and Mediterranean countries, which lack satisfactory environmental health, preventive medicine, and veterinarian services. Echinococcosis continues to be a major community health burden in several countries, and in some terrains, it constitutes an emerging and re-emerging disease. Cystic echinococcosis is the most common human disease of this genus, and it accounts for a significant number of cases worldwide. Herein, a case involving an 11-year-old presenting with fever, dry cough, and right hypochondrial pain is presented, where imaging revealed a hydatid cyst in the lung. Surgical removal of the cyst was achieved through right posterolateral thoracotomy under one-lung ventilation and anesthesia using intubation with a double-lumen endotracheal tube (DLET or DLT), highlighting surgery as the primary treatment despite the lack of consensus on surgical methods. This case underscores the effectiveness of individualized, parenchyma-preserving surgery for even large, uncomplicated cysts, indicating a positive prognosis.

A 10-year experience with anastomotic leaks in upper gastrointestinal surgery-Retrospective cohort study

BACKGROUND

Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge. We seek to identify clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries.

METHODS

592 patients underwent UGI surgeries with an anastomosis between January 2011 and January 2021. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed.

RESULTS

The overall occurrence of AL was 6.4 %. Tachycardia >120 BPM (OR 6.959, 95 % CI 1.856-26.100, p = 0.004) and leukocyte count >19 × 109/L (OR 3.327, 95 % CI 1.009-10.967, p = 0.048) were independent predictors of AL. On multivariate analysis, patients whose anastomosis was deemed high risk and had pre-emptive investigation done postoperatively to exclude a leak were less likely to require intervention and were more likely to be managed conservatively (66.7 % vs 14.3 %, p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had 50.0 %, 20.0 % and 9.1 % false negative results, while esophagogastroduodenoscopy had none. There was no misdiagnosed AL when more than 1 investigation (n = 15, 39.5 %) were performed.

CONCLUSION

Our study demonstrates that the presence of a triad including desaturation, tachycardia and leucocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed. A practice of evaluating high risk anastomosis prior to commencement of feeding decreased the need for surgical intervention and improves success of conservative treatment.

Doubling time in pulmonary and hepatic hydatid cysts

BACKGROUND

This study aims to investigate whether the concept of doubling time in hydatid cysts differs according to different parameters such as age, sex, and whether the cyst is located in the lung or liver. Background: This study aims to investigate whether the concept of doubling time in hydatid cysts differs according to different parameters such as age, sex, and whether the cyst is located in the lung or liver.

METHODS

Between January 2012 and August 2023, a total of 138 hydatid cysts were retrospectively analyzed. There were 55 pulmonary (32 males, 23 females; mean age: 25.6±23.8 years; range, 2 to 77 years) and 83 hepatic hydatid cyst patients (32 males, 51 females; mean age: 31.1±22.8 years; range, 3 to 75 years).

RESULTS

The mean doubling times for pulmonary and hepatic hydatid cysts were 73.4±41.8 and 172.6±108.8 days, respectively (p<0.001). When children (≤18 years old) and adult cases were compared for pulmonary hydatid cysts, the mean doubling times were 61.1±17.6 and 87.1±55.3 days, respectively (p=0.119), and for hepatic hydatid cysts, 110.6±48.4 and 215.6±118.3 days, respectively (p<0.001). While comparing male and female cases, the mean doubling time for pulmonary hydatid cysts was 77.6±32.2 and 67.6±52.6 days, respectively (p=0.018), while for hepatic hydatid cysts, it was 192.0±111.7 and 160.4±106.2 days, respectively (p=0.250).

CONCLUSION

The doubling time seems to be approximately 10 weeks in the lung and approximately 25 weeks in the liver. Hydatid cysts grow faster in children than adults in both the lungs and liver.

Thymic lipofibroadenoma: A case report

Lipofibroadenoma (LFA) is an epithelial tumor. It has been seen rarely in the thymus, and only a handful of cases have been reported. LFA is usually seen in the anterior mediastinum and is defined as a coalescence of epithelial thymic, adipose, and fibrotic tissue. We present a 30-year-old female who presented due to an unrelated traffic accident. An incidental mass was found in her left anterior superior mediastinum. After performing a complete excision, a histologic examination of the excised mass revealed it to be LFA of the thymus, which is extremely rare. The follow-up period was uneventful. LFA is a slow-growing benign tumor and is very similar to fibroadenoma of the breast. The etiology and clinical findings are yet to be well-defined. It was only seen in men in the prior cases. But recent cases, including this one, have also reported female patients. The tumor is mainly observed in the anterior mediastinum, which was also the case in our patient. The gold standard of diagnosis is pathologic examination. Our examination showed strands and nests of thymic parenchyma, including Hassall corpuscles, which separated fibro adipose tissue. Thymectomy is the treatment of choice. It can be performed by either video-assisted thoracic surgery or open surgery. We performed open surgery. The most important prognostic factor for this tumor is staging.

Incidental Discovery of a Morgagni Hernia in a 72-Year-Old Woman After COVID-19 Pneumonia: A Case Report

Morgagni hernia is a rare condition characterized by a congenital retrosternal defect of the diaphragm, leading to the protrusion of abdominal organs into the thoracic cavity. Here, we report the case of a 72-year-old woman with a Morgagni hernia incidentally discovered during evaluation for persistent dyspnea following COVID-19 pneumonia. The diagnosis was made by imaging, including a chest X-ray and a thoracic CT scan, which showed an ascent of the transverse colon and omentum through an anterior retrosternal defect. Surgical exploration via right posterolateral thoracotomy revealed an anterior diaphragmatic hernia with a small defect containing the greater omentum and transverse colon, which was repaired by resecting the hernia sac and closing the diaphragmatic defect by fixing the anterior rim of the diaphragm to the retrosternal fascia with interrupted silk sutures. Postoperative recovery was uneventful, and follow-up examinations revealed no abnormalities on chest X-rays obtained at one, three, and six months. This case highlights the incidental discovery and successful surgical management of a Morgagni hernia in an elderly patient through a thoracic approach.

European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.

Clinical manifestations and outcomes of otitis media with effusion in adult patients following Omicron infection in China

Within the constantly changing landscape of the coronavirus disease 2019 (COVID-19) pandemic, the emergence of new variants introduces novel clinical challenges, necessitating the acquisition of updated insights into their impacts on various health conditions. This study investigates the clinical features and therapeutic outcomes of otitis media with effusion (OME) in adults following infection with the Omicron variant of COVID-19, in the context of China ending its "Zero-COVID-19" policy. Conducted as a multicenter, retrospective analysis at two medical institutions in Eastern China from December 2022 to February 2023, the study included patients with confirmed Omicron infection who were diagnosed with OME within two months, adhering to guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF). Data on demographics, time from infection to OME manifestation, associated symptoms, and treatment outcomes were collected. Among 68 patients (73 affected ears) with OME post-Omicron infection, common symptoms included cough and nasal obstruction (69.1%). All reported ear fullness, with 86.8% experiencing hearing loss. Tympanic bullae were observed in 72.6% during otoscopy, and most tympanometry results showed a B-type tympanogram (80.0%). An integrated treatment strategy led to an 83.6% cure rate, although 8.2% experienced relapse within 2-3 months. Our findings highlight OME as a prevalent ear complication associated with COVID-19 during the Omicron pandemic, underscoring the necessity for further investigation into its complexities. While the integrated treatment approach proved effective, the 8.2% post-treatment recurrence rate underscores the importance of ongoing monitoring and signals an urgent need for more comprehensive research.

Delayed Surgical Treatment of a CE1 Lung Cyst Resulting in Pericystectomy of CE4 Cyst

Lung is the second most common locationof cystic echinococcosis (CE), after the liver. Diagnosis of lung CE is often incidental, and clinical manifestations depend on the location and size of the cyst, the most common being chest pain, shortness of breath, expectoration of fragments of endocyst, and haemoptysis. Surgery is the primary treatment, with a minor role for medical therapy. Delayed diagnosis and treatment may have important consequences. We present a case of lung CE in whichsurgical treatment was delayed due to the first wave of COVID-19. Since surgery could not be performed immediately, the patient was kept on albendazole and the cyst stage moved from CE1 to CE3a, to CE4, eventually requiring a more aggressive pericystectomy instead of the commonly performed endocystectomy. The clinical and imaging characteristics of a rare CE4 cyst of the lung are reported.

Foreign body aspiration with iatrogenic right bronchus perforation - A case report and literature review

INTRODUCTION AND IMPORTANCE

Evacuation of obstructed trachea foreign body (FB) can be challenging and may have several life-threatening complications. Iatrogenic tracheobronchial injury (TBI) is a rare and devastating complication which need prompt diagnosis and management.

CASE PRESENTATION

An 11-year-old child was brought to the emergency with a history of cough and chest discomfort for the last 15 days. Chest x-ray and computed tomography (CT) chest were done which showed the presence of a FB in the right main bronchus. After all pre-operative investigations, rigid bronchoscopy and removal of the foreign body under general anesthesia was performed. After several attempts, the foreign body couldn't be removed and there was massive surgical emphysema of the chest. Immediately bilateral chest tube was inserted. A repeat CT chest was done which revealed a ruptured of the right main bronchus with migration of the foreign body to the right pleural cavity. Right thoracotomy was performed under general anesthesia. The foreign body was removed and the bronchus ruptured was repaired. The child's vital signs were normal throughout the procedure and she was discharged on the seventh post-operative day.

CLINICAL DISCUSSION

TBI can have devastating scenarios in the absence of quick diagnosis and treatment. Around 80 % of patients with TBI due to accidents have been found to have fatal outcomes before reaching the hospital, probably due to tension pneumothorax, hypoxia, or respiratory failure.

CONCLUSION

Prompt diagnosis and management of complications with definitive repair of the injury were key elements in saving lives after TBI.

Reducing the carbon footprint of general anaesthesia: a comparison of total intravenous anaesthesia vs. a mixed anaesthetic strategy in 47,157 adult patients

Global warming is a major public health concern. Volatile anaesthetics are greenhouse gases that increase the carbon footprint of healthcare. Modelling studies indicate that total intravenous anaesthesia is less carbon intensive than volatile anaesthesia, with equivalent quality of care. In this observational study, we aimed to apply the findings of previous modelling studies to compare the carbon footprint per general anaesthetic of an exclusive TIVA strategy vs. a mixed TIVA-volatile strategy. This comparative retrospective study was conducted over 2 years in two French hospitals, one using total intravenous anaesthesia only and one using a mixed strategy including both intravenous and inhalation anaesthetic techniques. Based on pharmacy procurement records, the quantity of anaesthetic sedative drugs was converted to carbon dioxide equivalents. The primary outcome was the difference in carbon footprint of hypnotic drugs per intervention between the two strategies. From 1 January 2021 to 31 December 2022, 25,137 patients received general anaesthesia in the hospital using the total intravenous anaesthesia strategy and 22,020 in the hospital using the mixed strategy. The carbon dioxide equivalent footprint of hypnotic drugs per intervention in the hospital using the total intravenous anaesthesia strategy was 20 times lower than in the hospital using the mixed strategy (emissions of 2.42 kg vs. 48.85 kg carbon dioxide equivalent per intervention, respectively). The total intravenous anaesthesia strategy significantly reduces the carbon footprint of hypnotic drugs in general anaesthesia in adult patients compared with a mixed strategy. Further research is warranted to assess the risk-benefit ratio of the widespread adoption of total intravenous anaesthesia.

Wilderness Medical Society Clinical Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents: 2024 Update

To provide guidance to the general public, clinicians, and avalanche professionals about best practices, the Wilderness Medical Society convened an expert panel to revise the evidence-based guidelines for the prevention, rescue, and resuscitation of avalanche and nonavalanche snow burial victims. The original panel authored the Wilderness Medical Society Practice Guidelines for Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents in 2017. A second panel was convened to update these guidelines and make recommendations based on quality of supporting evidence.

Uncertainties and opportunities in delivering environmentally sustainable surgery: the surgeons' view

Surgery is a carbon-heavy activity and creates a high volume of waste. Surgical teams around the world want to deliver more environmentally sustainable surgery but are unsure what to do and how to create change. There are many interventions available, but resources and time are limited. Capital investment into healthcare and engagement of senior management are challenging. However, frontline teams can change behaviours and drive wider change. Patients have a voice here too, as they would like to ensure their surgery does not harm their local community but are concerned about the effects on them when changes are made. Environmentally sustainable surgery is at the start of its journey. Surgeons need to rapidly upskill their generic knowledge base, identify which measures they can implement locally and take part in national research programmes. Surgical teams in the NHS have the chance to create a world-leading programme that can bring change to hospitals around the world. This article provides an overview of how surgeons see the surgical team being involved in environmentally sustainable surgery.

Uniportal video-assisted thoracoscopic surgery in the prone position for esophageal bronchogenic cyst

Esophageal bronchogenic cysts are very rare. A bronchogenic cyst is a congenital malformation resulting from abnormal sprouting of primitive bronchi because of a foregut bronchopulmonary malformation. An 18-year-old patient with a cystic tumor in the left posterior mediastinum was identified. The mediastinal tumor was removed by uniportal video-assisted thoracoscopic surgery. The operation was performed in the prone position through a single 4-cm incision on the lateral scapular line in the left ninth intercostal space. After tumor resection, the dissected esophageal muscle and mediastinal pleura were sutured with two continuous barbed sutures. The operation took 80 min. A biopsy confirmed the diagnosis of esophageal bronchial cyst. Diet was started on the evening of the operation. The chest tube was removed on the 1st postoperative day, and the patient was discharged without any problems on the 2nd postoperative day.

The role of point-of-care ultrasound in the management of neonates with congenital diaphragmatic hernia

In the last few years, current evidence has supported the use of point-of-care ultrasound (POCUS) for a number of diagnostic and procedural applications. Considering the valuable information that POCUS can give, we propose a standardized protocol for the management of neonates with a congenital diaphragmatic hernia (CDH-POCUS protocol) in the neonatal intensive care unit. Indeed, POCUS could be a valid tool for the neonatologist through the evaluation of 1) cardiac function and pulmonary hypertension; 2) lung volumes, postoperative pleural effusion or pneumothorax; 3) splanchnic and renal perfusion, malrotations, and/or signs of necrotizing enterocolitis; 4) cerebral perfusion and eventual brain lesions that could contribute to neurodevelopmental impairment. In this article, we discuss the state-of-the-art in neonatal POCUS for which concerns congenital diaphragmatic hernia (CDH), and we provide suggestions to improve its use. IMPACT: This review shows how point-of-care ultrasound (POCUS) could be a valid tool for managing neonates with congenital diaphragmatic hernia (CDH) after birth. Our manuscript underscores the importance of standardized protocols in neonates with CDH. Beyond the well-known role of echocardiography, ultrasound of lungs, splanchnic organs, and brain can be useful. The use of POCUS should be encouraged to improve ventilation strategies, systemic perfusion, and enteral feeding, and to intercept any early signs related to future neurodevelopmental impairment.

Scenario analysis of the socioeconomic impacts of achieving zero-carbon energy by 2030

This study uses scenario analysis to assess the socioeconomic impacts of achieving zero-carbon energy by 2030. Three scenarios are developed: 1) business as usual; 2) accelerated deployment of renewable energy and electric vehicles; and 3) scenario 2 plus comprehensive energy efficiency improvements. Quantitative models are used to evaluate the impacts on employment, productivity, consumer costs, inequality and energy security under each scenario. The results show that scenario 3, with the most ambitious decarbonization and efficiency measures, can generate the most jobs (2.1 million more than business as usual) and the lowest consumer costs (12% reduction). However, it may also lead to a small productivity loss (1.2% lower than business as usual) due to higher costs of new technologies. Income and health inequality are projected to decrease across all scenarios due to improved energy access and reduced fuel poverty. Energy security is expected to improve significantly in scenarios 2 and 3 due to reduced oil dependence. This study provides an analytical framework to assess the integrated socioeconomic impacts of zero-carbon transitions under uncertainty. The scenarios and findings can inform policymaking by highlighting the opportunities and challenges around the low-carbon transition, enabling decision makers to maximize benefits and minimize negative consequences.

Burden of silica-attributed pneumoconiosis and tracheal, bronchus & lung cancer for global and countries in the national program for the elimination of silicosis, 1990-2019: a comparative study

BACKGROUND

In industries worldwide, crystalline silica is pervasive and poses risks of pneumoconiosis and respiratory malignancies, with the latter being a knowledge gap in disease burden research that this study aims to address. By integrating both diseases, we also seek to provide an in-depth depiction of the silica-attributed disease burden.

METHODS

Data from the Global Burden of Disease 2019 were extracted to analyze the disease burden due to silica exposure. The trends of age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) from 1990 to 2019, as well as the age-specific number and rate of deaths and disability-adjusted life years (DALYs) in 1990 and 2019, were presented using GraphPad Prism software. The average annual percentage changes (AAPCs) on ASMR and ASDR were calculated using joinpoint regression models.

RESULTS

The global trends of disease burden due to silica exposure from 1990 to 2019 showed a significant decrease, with AAPCs on ASMR and ASDR of -1.22 (-1.38, -1.06) and - 1.18 (-1.30, -1.05), respectively. Vietnam was an exception with an unprecedented climb in ASMR and ASDR in general over the years. The age-specific deaths and DALYs mainly peaked in the age group 60-64. In comparison to 1990, the number of deaths and DALYs became higher after 45 years old in 2019, while their rates stayed consistently lower in 2019. Males experienced an elevated age-specific burden than females. China's general age-standardized burden of pneumoconiosis and tracheal, bronchus & lung (TBL) cancer ranked at the forefront, along with the highest burden of pneumoconiosis in Chilean males and South African females, as well as the prominent burden of TBL cancer in Turkish males, Thai females, and overall Vietnamese. The age-specific burden of TBL cancer surpassed that of pneumoconiosis, and a delay was presented in the pneumoconiosis pinnacle burden compared to the TBL cancer. Besides, the burden of pneumoconiosis indicated a sluggish growth trend with advancing age.

CONCLUSION

Our research highlights the cruciality of continuous enhancements in occupational health legislation for countries seriously suffering from industrial silica pollution and the necessity of prioritizing preventive measures for male workers and elderly retirees.

Descending necrotizing mediastinitis with esophageal perforation and tracheal ulcer: a case report and literature review

BACKGROUND

Descending necrotizing mediastinitis (DNM) is a rare and life-threatening condition, with high morbidity and mortality. Consequently, appropriate and prompt diagnosis and treatment are necessary. Herein, we report a case of esophageal perforation and bronchial ulcer secondary to DNM, for which thoracoscopic esophagectomy was performed after the failure of conservative treatment.

CASE PRESENTATION

A 63-year-old man was diagnosed with mediastinitis affecting the posterior mediastinum after presenting with a sore throat, back pain, and dyspnea. He also had type 2 diabetes mellitus and renal failure. The patient developed septic shock the following day, and intensive treatment was initiated. The condition of the patient gradually improved; however, the laboratory data revealed that levels of C-reactive protein remained high. On day 22, the esophageal perforation was demonstrated on esophagogastroduodenoscopy. Bronchoscopy was remarkable for the ulcer on the membranous tracheal wall, though he did not go into respiratory failure. The emergency thoracoscopic esophagectomy was performed on day 27. The reconstruction surgery was performed on day 100.

CONCLUSIONS

Despite the fact that the general condition is stable with conservative treatment, DNM can develop esophageal perforation. Thus, it is essential to determine the appropriate timing of surgical intervention if levels of inflammation markers continue to be high.

Anaesthesia Management for Neurosurgery in a Patient With Congenital Lung Agenesis

Congenital lung agenesis is a rare congenital abnormality associated with an absence or under-development of either one or both lungs, and its presentation in adulthood is even rarer. We describe a 40-year-old female patient with a history of congenital agenesis of the right lung and a high-grade glioma in the frontal region of the brain presenting for craniotomy and excision of the tumor in an MRI suite. Lung protective strategies of ventilation were utilized intraoperatively. The remote location of the MRI suite made access to extra manpower support challenging. The patient was managed uneventfully and discharged stable to the high-dependency unit. Our case describes how congenital lung agenesis poses a unique set of challenges for anaesthetic management, particularly in neurosurgical patients, and provides guidance to a multidisciplinary team approach.

Efficacy and Safety of Peroral Endoscopic Myotomy in the Treatment of Zenker's Diverticulum: A Single-Center Experience

BACKGROUND/AIMS

The efficacy and safety of Zenker's peroral endoscopic myotomy (Z-POEM), a current method in the treatment of Zenker's diverticulum (ZD), have been demonstrated in a limited number of studies and case reports. This study aimed to report our experience with the Z-POEM method.

MATERIALS AND METHODS

Patients with ZD who were treated with Z-POEM between January 2019 and March 2023 and had a followup period of at least 3 months were included in the study. Our primary endpoint was clinical success. A Kothari-Haber score (KHS) of 2 or less at 1 month postoperatively was defined as clinical success. Our secondary endpoints were adverse events and recurrence rates.

RESULTS

In total, 20 patients (males, 65%; mean age, 63 ± 14.4 years) were treated with Z-POEM. The mean ZD septum length was 33.7 (±11.04) mm. The technical success rate was 100% (20/20), and the clinical success rate was 95% (19/20). In 1 case with a large ZD (septum length of 60 mm), the mucosal septum, which was thought to cause partial persistence of symptoms, was treated by endoscopic septotomy. The mean KHS decreased significantly after Z-POEM (preoperative KHS: 7.3 and postoperative KHS: 0.15, P < .0001). The median follow-up period was 10 months (interquartile range, 3-39). No recurrence was observed in any case. Intraprocedural mild subcutaneous emphysema was observed in 4 (20%) cases. Emphysema regressed spontaneously in the postoperative period without any treatment.

CONCLUSION

Zenker's peroral endoscopic myotomy is a successful and reliable method in the treatment of ZD, with low recurrence rates.

Primary Retroperitoneal Hydatid Cyst: A Diagnostic and Treatment Conundrum

Hydatid cysts are caused by accidental egg ingestion of the Echinococcus granulosus parasite. A 24-year-old female was admitted to our hospital for chronic left lumbar pain. Computed tomography (CT) and abdominal ultrasonography identified an 8/12 cm retroperitoneal cyst. The CT results coupled with enzyme-linked immunosorbent assay tests (positive IgG for Echinococcus granulosus) confirmed that the tumor was a hydatid cyst. Treatment consisted of preoperative chemotherapy with albendazole, intraoperative parasite inactivation, laparoscopic partial cystectomy, and drainage. The drain was removed after three days. Chemotherapy was maintained for two years after surgery. No relapse was observed at the six-month reevaluation. In this article, the diagnostic and therapeutic options and resources are discussed and compared with the published literature.

CT esophagogram in the emergency setting: typical findings and suggested workflow

PURPOSE

Esophageal perforation (EP) can be a diagnostic challenge. Computed tomography (CT) and CT esophagography (CTE) are often used to rule out EP in the emergency setting with promising diagnostic performance, but the standard of care remains fluoroscopic esophagography (FE). We assess the diagnostic performance of CT and CTE when interpreted by expert and generalist radiologists and created an imaging workflow guide.

METHODS

Retrospective study of patients presenting with suspected EP. Two expert radiologists independently reviewed blinded CT/CTE studies, recorded CT findings, and assigned an esophageal injury grade. We also collected initial (general radiologist) CT findings and interpretation and FE diagnoses. We assessed inter-reader reliability and diagnostic performance.

RESULTS

EP was diagnosed in 46/139 (33%) encounters. The most common CT/CTE findings in EP were esophageal wall thickening (46/46, 100%), pneumomediastinum (42/46, 91%), and mediastinal stranding (39/46, 85%). CT and CTE sensitivity for detecting EP was 89% and 89% for expert radiologists, respectively, and 79% and 82% for general radiologists, compared with 46% for FE. Inter-reader agreement for detecting EP by CT and CTE was kappa 0.35 and 0.42 (both p < .001) between expert and generalist radiologists. We present radiographic images for key CT/CTE findings and a suggested workflow for the evaluation of possible EP.

CONCLUSION

CT and CTE are more sensitive than FE for EP in the emergency setting. Due to the rarity of EP and current wide variability in imaging interpretation, an imaging workflow and injury grading system based on esophageal and mediastinal CT findings are offered to help guide management.

Rare esophageal carcinoma-primary adenoid cystic carcinoma of the esophagus: A case report

BACKGROUND

Esophageal adenoid cystic carcinoma (EACC) is an exceedingly rare malignant tumor of the esophagus, posing significant challenges in the clinic.

CASE SUMMARY

This report detailed the case of a 72-year-old male whose diagnosis of EACC was confirmed through postoperative histopathological examination. The patient underwent thoracoscopy-assisted radical resection of the esophageal tumor, coupled with lymph node dissection. Pathological findings revealed an adenoid cystic carcinoma infiltrating the entire layer of the muscularis propria, locally extending into the outer membrane of the esophageal fiber, involving the cardia and exhibiting no lymph node metastasis. The patient's condition was classified as primary EACC, T3N0M0, per the American Joint Committee on Cancer (2017; 8th edition). One month after surgery, the patient received postoperative adjuvant radiation therapy.

CONCLUSION

In addressing the rarity and high potential for biopsy misdiagnosis of EACC, this study delved into its diagnostic methods and treatment.

Cystic Echinococcosis in Hospitalized Children from Western Romania: A 25-Year Retrospective Study

Cystic echinococcosis (CE) is a cosmopolitan parasitic disease caused by Echinococcus granulosus. We aimed to assess the epidemiological aspects of the disease in hospitalized children from Western Romania, a well-known endemic area for CE. We retrospectively investigated the medical records of children hospitalized between 1998 and 2022. A total of 144 patients were included, and 58.3% were from rural areas. The number of cases increased with age, from 9% in the age group 3-5 years to 59.7% in the age group 11-17 years. The liver was more frequently affected (65.3%), and a significant association between gender and the affected organ was noted; liver cysts were more frequently diagnosed in girls, while lung cysts were recorded mostly in boys. Complications were more frequently reported in patients with pulmonary CE compared to hepatic CE (p = 0.04). Boys had more complications (16/23, 69.6%) compared to girls (7/23, 30.4%) (p = 0.03). A third of the children were hospitalized for more than 14 days, and multiple hospitalizations were recorded in 31.3% of the patients. This paper provides new insights into the epidemiologic features of cystic echinococcosis in children from Western Romania. Our findings indicate that exposure to the parasite starts in childhood, and the rate of hospitalization increases with age. Public health strategies should be implemented and permanently improved in order to lower the prevalence of CE in children.

National Multicenter Study on the Comparison of Robotic and Open Thymectomy for Thymic Neoplasms in Myasthenic Patients: Surgical, Neurological and Oncological Outcomes

Thymectomy is the gold standard in the treatment of thymic neoplasm and plays a key role in the therapeutic path of myasthenia gravis. For years, sternotomy has been the traditional approach for removing anterior mediastinal lesions, although the robotic thymectomy is now widely performed. The literature is still lacking in papers comparing the two approaches and evaluating long-term oncological and neurological outcomes. This study aims to analyze the postoperative results of open and robotic thymectomy for thymic neoplasms in myasthenic patients. Surgical, oncological and neurological data of myasthenic patients affected by thymic neoplasms and surgically treated with extended thymectomy, both with the open and the robotic approach, in six Italian Thoracic Centers between 2011 and 2021 were evaluated. A total of 213 patients were enrolled in the study: 110 (51.6%) were treated with the open approach, and 103 (48.4%) were treated with robotic surgery. The open surgery, compared with the robotic, presented a shorter operating time (p < 0.001), a higher number of postoperative complications (p = 0.038) and longer postoperative hospitalization (p = 0.006). No other differences were observed in terms of surgical, oncological or neurological outcomes. The robotic approach can be considered safe and feasible, comparable to the open technique, in terms of surgical, oncological and neurological outcomes.

Robotic surgery in the management of synchronous esophageal and gastric perforation after endoscopic dilation

Upper gastrointestinal perforation is a feared complication of diagnostic and therapeutic endoscopy, with an incidence of perforation between 0.3% and 5%. Even though is rare, the mortality rate can be as high as 40%. Currently, there is no consensus on the best therapeutic strategy and it usually depends on patient stability, the extent of perforation, time to diagnosis, surgeon experience and available resourcesWe present a case of a patient who presented to our institution to undergo an ambulatory oesophageal dilation. After dilation, the patient developed two full-thickness gastric perforations and a full-thickness oesophageal perforation without haemodynamic instability. All perforations were diagnosed and treated with a combination of intraoperative endoscopy and robotic surgery with excellent outcomes.We demonstrate that a robotic approach combined with intraoperative diagnostic endoscopy is a safe and feasible treatment option for esophageal and gastric perforations in a stable patient without large extraluminal contamination.

Transgastric drainage of the perforated esophagus: our experiences over 10 years

We first described the technique of transgastric drainage of esophageal injuries in 2008. The method establishes vacuum drainage of the lumen of the esophagus, while maintaining patency, effectively exteriorizing the perforation to allow healing. We summarize this technique and present our experiences from the largest published series of patients. Our unit has treated selected esophageal injuries with transgastric drainage for 10 years. Indications include perforations not amenable to primary repair and treatment failure following prior surgical intervention. A 36 French silastic chest drain is pulled through the abdominal and stomach wall and introduced into the esophagus so that it crosses the perforation. Gastropexy is performed. Mediastinal decontamination and drainage are performed as needed. Continuous suction of -10 cm water is applied. Leak resolution is assessed with weekly water-soluble swallows. For this retrospective observational study, we analyzed data for patients with esophageal perforation, between 2012 and 2022. Inpatient mortality and time to leak resolution were set as primary and secondary outcomes. Esophageal perforations were treated with transgastric drain in 35 patients, of whom 68% (n = 24) were men. Median age was 67 (26-84). Spontaneous perforations accounted for 60% (n = 21), 31% (n = 11) were iatrogenic and 6% (n = 2) were ischemic. Inpatient and 30-day mortality was 14% (n = 5). Among successful treatments, the median length to resolution of leak on imaging was 34.5 days (6-80). Transgastric drainage can successfully treat esophageal perforations, where primary repair is not feasible. The mortality rate of 14% and reduced morbidity compares favorably with other traditional methods of management for esophageal perforation.

Thymic epithelial tumours: histopathological classification and differential diagnosis

The epithelial and lymphoid compartments of the thymus can give rise to a wide variety of tumours, including thymomas, thymic carcinomas, lymphoreticular proliferations, germ cell tumours, and sarcomas. While some of these have close similarity to their counterparts in other organs, both in terms of histology and immunohistochemistry, as well as molecular features, others are unique to the thymus. The epithelial tumours, which can develop in the thymus, will be discussed in this review, with a particular emphasis on resolving differential diagnosis by means of morphology, immunohistochemical profiles, and molecular diagnostics.

Isolated renal hydatid cyst

INTRODUCTION AND IMPORTANCE

Hydatid disease, is a parasitic disease caused by the larval stage of the cestode Echinococcus granulosus. The Liver and lungs are the commonly affected organs but rarely kidney can be affected. Patient with primary renal hydatid may present with nonspecific symptoms or may be diagnosed incidentally. Imaging and serology are useful for diagnosis. The best therapy is surgery.

CASE PRESENTATION

This case is reported to discuss a 35-year-old female presented with complaints of left side flank pain and swelling. The abdominal US and CECT show renal cyst, which was nonspecific. She underwent an open surgical exploration and cystectomy plus partial pericystectomy done. Post-operative serology test show Echinococcus IgG positive. Postoperatively, the patient had an uneventful recovery and discharged with Albendazole therapy for 8 weeks.

CLINICAL DISCUSSION

Renal hydatid cyst is rare, accounting for less than 2 to 3 % of all hydatid disease. Renal hydatid cysts can remain asymptomatic for many years and then can be discovered incidentally. The diagnosis and staging of renal hydatid cysts rely heavily on imaging and serology. Hydatid disease is primarily treated surgically.

CONCLUSION

A high index of suspicion should be maintained, especially in endemic areas, to ensure timely and accurate diagnosis of renal hydatid cyst. Surgical excision remains the treatment of choice, with appropriate preoperative and postoperative anthelminthic therapy. Long-term follow-up is crucial to monitor for recurrence and associated complications.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a rare developmental defect of the diaphragm, characterized by the herniation of abdominal contents into the chest, resulting in varying degrees of pulmonary hypoplasia and pulmonary hypertension. Significant advances in the prenatal diagnosis and identification of prognostic factors have resulted in the continued refinement of the approach to fetal therapies for CDH. In the postnatal period, protocolized approaches to lung-protective ventilation, nutrition, prevention of infection, and early aggressive management of pulmonary hypertension have led to improved outcomes in infants with CDH. Surgical repair of CDH is not urgent in most circumstances and can be delayed until the pulmonary status of the patient has stabilized. This article provides a comprehensive review of CDH, focusing on the complex pathophysiology, advances in prenatal diagnosis, fetal interventions, and optimal postnatal management of CDH.

Solitary Langerhans cell histiocytosis of the sternum in a 21-year-old woman

Children are more likely to develop Langerhans cell histiocytosis (LCH), a rare disorder with an unknown cause. LCH often invades skeletal systems, while it has occasionally been seen in the sternum or ribs. The best course of treatment for single-site, skeletal LCH is yet unknown. We present an instance of sternal LCH with adult onset. By fusing and reconstructing chest computed tomography, it was possible to determine the extent of surrounding soft tissue invasion. Because LCH is so uncommon, it could be challenging to recall when we see a sternal lesion. Adult Patients who arrive with anterior chest discomfort and an osteolytic sternal lesion should include LCH on their differential diagnosis list.

Videothoracoscopic surgery in children

Video-assisted thoracic surgery (VATS) is now being used with increasing frequency for a wide variety of indications in pediatric patients. Although there is no high level of evidence for the advantages of VATS in the pediatric patient group, the proven benefits of this method in the adult patient group have encouraged thoracic surgeons to perform VATS in this patient population. In this study, the procedures performed in pediatric patients under 18 years of age and their results were reviewed with the help of articles obtained as a result of searches using relevant keywords in the English literature (PubMed, Web of Science, EMBASE, and Cochrane). The frequency, indications, and results of the procedures performed differed according to age groups.

Lung Hydatidosis Unveiled: A Multisystem Mirage of Pathological Rarity

Lung hydatidosis is a zoonotic infection, primarily caused by Echinococcus sp., and has a significant role in the economy and public health. Canines are the predominant hosts of these parasitic tapeworms. Lungs are the most commonly infected organ after the liver. Hepatic pulmonary blood circulation is mainly reported to transport infection to the lungs. The prevalence of hydatid disease has increased over the past decade. In addition, patients with multi-organ involvement of hydatid cysts have been reported in different parts of the world. Hydatidosis can remain asymptomatic for years after infection in some conditions, especially in cases of splenic hydatidosis. Chest radiography and computed tomography findings can be used to confirm the diagnosis of hydatid disease. Hydatid disease is, in general, managed by pharmacological therapy, but if multi-organ involvement is observed, surgery along with medical management is required. Long-term follow-up is recommended in such cases to check the recurrence of the disease.

Comparison of the Diagnostic Performance of Antigen B Purified from Sheep Hydatid Cyst Fluid (HCF) with Commercial ELISA Kit

INTRODUCTION

Cystic echinococcosis (CE) is a zoonotic parasitic disease caused by the metacestode of Echinococcus granulosus. CE is a health problem in Middle Eastern countries, such as Iran. The purpose of this study was to purify subunit 8 KDa antigen B from crude sheep hydatid cyst fluid (HCF) and compare its sensitivity and specificity with a commercial human ELISA kit (PT-Hydatid-96).

METHODS

28 sera samples were collected from hydatid cyst patients who had surgery for a hydatid cyst and had their disease confirmed by pathology after the surgery. Furthermore, 35 samples of healthy individuals with no history of hydatid cysts were collected, as were nine serum samples from parasite-infected non-CE patients. HCF was obtained from sheep fertile cysts at a Sari slaughterhouse and used as an antigen. In an indirect ELISA test, the B antigen was employed, and the results were compared to those from a commercial ELISA kit.

RESULTS

The results of this study were analyzed using the Kappa test. The commercial ELISA kit showed 17 cases (23.6%) positive, 44 cases (61.1%) negative, and 11 cases (15.3%) borderline. B antigen showed that 18 (25%), 43 (59.7 %), and 11 (15.3%) were positive, negative, and borderline, respectively. One sample (1.4% of 72 total samples) of 35 serum samples from healthy individuals was positive using B antigen-based ELISA. In addition, all nine serum samples from parasite-infected non-CE patients were negative for both tests. The sensitivity and specificity of the commercial ELISA kit have been evaluated at 60.7% and 100%, respectively. For B antigenbased ELISA, these values are 64.3 and 97.7%, respectively.

CONCLUSION

Antigen B produced from hydatid cyst fluid is a promising option for serological identification of hydatid cysts in both infected and healthy individuals. In an indirect ELISA test, hydatid fluid antigen could be used as a precise source of detection.

Incidental finding and successful management of Larrey's hernia during laparoscopic cholecystectomy: Case report

INTRODUCTION

Larrey hernias (LH) are birth defects causing abdominal viscera to protrude into the thoracic cavity. With an incidence of 2-4 %, they are exceptional in adults.

CASE PRESENTATION

A 65-year-old female patient was admitted for an elective laparoscopic cholecystectomy. During history intake, besides biliary colic, no additional symptoms were reported. Physical examination yielded normal results. Chest-X ray did not reveal any anomalies. Intraoperatively, an inspection of the diaphragm revealed a 3 cm defect in the left-sided sternocostal triangle, with the omentum protruding through the thorax. After performing cholecystectomy, the content of the LH was cautiously reduced. The hernia sac was not resected, to prevent potential injury to the neighboring anatomical structures. The defect was closed using non-resorbable interrupted sutures. The postoperative course was uneventful. No recurrence was detected during follow-up.

CLINICAL DISCUSSION

LH diagnosis is challenging due to its unspecific symptoms. Only 10 % of patients are asymptomatic. CT imaging establishes a positive diagnosis and identifies acute complications requiring emergency management.

CONCLUSION

Asymptomatic LH cases mandate surgery. Laparoscopic management is safe and efficient. The trans-abdominal approach offers easier access to hernia content. Hernia sac resection is still debatable. The selection of defect closure technique hinges on the quality and elasticity of the tissue, as well as the size of the defect, all under the unwavering banner of the tension-free principle. Literature remains conflicting on mesh use.

Esophageal perforation management: a single-center experience

BACKGROUND

Esophageal perforation is a serious medical condition where a hole or tear develops in the esophagus, the muscular tube that connects the throat to the stomach. Although rare, the condition is potentially life-threatening, as it can lead to infection and inflammation in surrounding tissues, including the mediastinum, pleura, and peritoneum.

METHODS

Between 2014 and 2022, a retrospective study was conducted on cases of esophageal rupture treated at our institution. Eighteen cases were included in the study. Patient data, including age, gender, risk factors, delay in diagnosis, diagnostic method, site of perforation, etiology of perforation, treatment approach, complications, length of hospital stay, and outcomes, were collected. The Pittsburgh Severity Score (PSS) was calculated for each patient.

RESULTS

The mean patient age was 46.33 years, with a male predominance (72.2%). Causes included iatrogenic (22.2%), foreign body (50%), and trauma (27.8%). Perforations primarily occurred in the cervical (38.9%), thoracic (33.3%), and distal esophagus (27.8%). Higher mortality was associated with elevated white blood cell count (WBC), delayed diagnosis, and contrast leakage (p<0.05). Computed tomography (CT) findings and complications significantly influenced intensive care unit (ICU) stay, with abscesses reducing and mediastinitis increasing the duration (p<0.05). Other factors, including age, length of hospitalization, gender, etiology, and treatment type, did not significantly affect Pittsburg Severity Scores (p>0.05).

CONCLUSION

Esophageal perforation remains a challenging clinical condition associated with significant morbidity and mortality. To optimize patient outcomes, rapid diagnosis, risk stratification using tools such as the PSS, and tailored management strategies are essential.

Lung function responses to cold water ingestion: A randomised controlled crossover trial

This study tested the hypothesis that cold water ingestion would reduce lung function and thereby confound its measurement in a way that is mediated by both temperature and volume. In a randomised crossover trial, 10 healthy adults performed spirometry before and 5, 10, 15, and 30-minutes after consuming one-of-four drinks: 500 mL or 1000 mL refrigerated water (∼2 °C); identical water volumes at ambient temperature (∼18 °C). Ingesting 1000 mL cold water significantly reduced forced vital capacity (FVC) for at least 10 min (mean difference =0.28 L, p < 0.05, d=1.19) and forced expiratory volume in 1 s (FEV1) for at least 15 min (0.20-0.30 L, p < 0.05, d=1.01). Ingesting 500 mL cold water reduced FEV1 for 5 min (0.09 L, p < 0.05, d=1.05). Room-temperature water had no influence on lung function. To avoid confounding the measurement of lung function, we conclude that individuals should avoid drinking cold water, especially in large volumes, immediately prior to a given test.

Lung cancer from suspicion to treatment: An indicator of healthcare access in Turkey

BACKGROUND

Lung cancer is the leading cause of cancer-related deaths worldwide. Before beginning lung cancer treatment, it is necessary to complete procedures such as suspecting lung cancer, obtaining a pathologic diagnosis, and staging. This study aimed to investigate the processes from suspicion of lung cancer to diagnosis, staging, and treatment initiation.

METHODS

The study was designed as a multicenter and cross-sectional study. Patients with lung cancer from various health institutions located in all geographic regions of Turkey were included in the study. The sociodemographic and clinical characteristics of the patients, the characteristics of the health institutions and geographic regions, and other variables of the lung cancer process were recorded. The time from suspicion of lung cancer to pathologic diagnosis, radiologic staging, and treatment initiation, as well as influencing factors, were investigated.

RESULTS

The study included 1410 patients from 29 different medical centers. The mean time from the initial suspicion of lung cancer to the pathologic diagnosis was 48.0 ± 52.6 days, 39.0 ± 52.7 days for radiologic staging, and 74.9 ± 65.5 days for treatment initiation. The residential areas with the most suspected lung cancer cases were highly developed socioeconomic zones. Primary healthcare services accounted for only 0.4% of patients with suspected lung cancer. The time to pathologic diagnosis was longer in the Marmara region, and the wait time for staging and treatment initiation was longer in Eastern and Southeastern Anatolia. Patients who presented to chest disease referral hospitals with peripheral lesions, those with early-stage disease, and those who were diagnosed surgically had significantly longer wait times.

CONCLUSION

The time between pathologic diagnosis, staging, and treatment initiation in lung cancer was longer than expected. Increasing the role of primary healthcare services and distributing socioeconomic resources more equally will contribute to shortening the time to diagnosis and improve treatment processes for lung cancer.

Echinococcoses - A Primer for Radiologists

BACKGROUND

Cystic (CE) and alveolar (AE) echinococcoses are zoonotic parasitoses that may pose diagnostic problems due to their relative rarity in Middle Europe.

METHODS

Based on a recent literature search and the observation of casuistics from a national echinococcosis treatment center, epidemiological, radiological, and therapeutic fundamentals are presented and important differences between AE and CE are discussed.

RESULTS AND CONCLUSION

AE and CE must be regarded as completely different diseases, which differ from each other in every significant aspect. This applies not only to the epidemiological background of the patients but also to the biology of the diseases and their respective imaging features.

KEY POINTS

· AE and CE are very distinct from one another and must be considered separately.. · AE is endemic in Middle Europe and is known as malignant parasitosis due to its destructive growth form.. · CE is primarily seen in Middle Europe in individuals with migration background and has a rather benign character..

CITATION FORMAT

· Weber TF, Mokry T, Stojkovic M. Die Echinokokkosen - Einblicke aus Sicht der Radiologie. Fortschr Röntgenstr 2023; 195: 1106 - 1121.

Risk factors and clinical features for pulmonary paragonimiasis-associated pneumothorax

BACKGROUND

Pulmonary paragonimiasis, a food-borne zoonotic helminthiasis, is a parasitic disease of the lung caused by infection with trematodes species of the genus Paragonimus. Although pneumothorax has been reported as occuring with paragonimiasis, to date no study has been performed concerning the clinical features and predictive risk factors for this condition.

METHODS

This retrospective study, which aims to fill this gap, was conducted at Jeonbuk National University Hospital. All patients (aged ≥19 years) were diagnosed with paragonimiasis between May 2011 and December 2021. Medical records were reviewed and information concerning age, sex, vital signs, underlying diseases, clinical signs and symptoms, laboratory findings, radiologic findings, treatment, and clinical outcomes was collected. An odds ratio (OR) for the risk factors associated with pneumothorax was calculated using the binary logistic regression model.

RESULTS

Among 179 consecutive patients diagnosed with pulmonary paragonimiasis, the postive rate of pneumothorax was 10.6% (19/179). Pneumothorax occurred mostly in the right lung (78.9%, 15/19), and intrapulmonary parenchymal lesions showed an ipsilateral relationship with pneumothorax (94.7%, 18/19). Fifteen patients (78.9%, 15/19) of pneumothorax associated with pulmonary paragonimiasis are accompanied by pleural effusion. Most of patients with pneumothorax (89.5%, 17/19) underwent chest tube insertion as a first treatment. Three patients (15.8%) showed relapses but in no case was a death recorded. Asthma (odds ratio [OR] 8.10, 95% confidence interval [CI] 1.43-45.91), chest pain (OR 8.15, 95% CI 2.70-24.58), and intrapulmonary lesions (OR 8.94, 95% CI 1.12-71.36) were independent risk factors for pulmonary paragonimiasis-associated pneumothorax.

CONCLUSIONS

Our findings suggest that clinicians should keep in mind the possibility of pneumothorax when approached by patients with pulmonary paragonimiasis complaining of chest pain, accompanied by intrapulmonary lesions or with asthma as an underlying disease.

Occupational interstitial lung diseases

Millions of workers are exposed to substances known to cause occupational interstitial lung diseases (ILDs), particularly in developing countries. However, the burden of the disease is likely to be underestimated due to under-recognition, under-reporting or both. The diagnosis of occupational ILD requires a high level of suspicion and a thorough occupational history, as occupational and non-occupational ILDs may be clinically, functionally and radiologically indistinguishable, leading to delayed diagnosis and inappropriate management. A potential occupational aetiology should always be considered in the differential diagnosis of ILD, as removal from the workplace exposure, with or without treatment, is a key therapeutic intervention and may lead to significant improvement. In this article, we provide an overview of the 'traditional' inorganic dust-related ILDs but also address idiopathic pulmonary fibrosis and the immunologically mediated chronic beryllium disease, sarcoidosis and hypersensitivity pneumonitis, with emphasis on the importance of surveillance and prevention for reducing the burden of these conditions. To this end, health-care professionals should be specifically trained about the importance of occupational exposures as a potential cause of ILD.

A rare and challenging case of intrapericardial hydatidosis

BACKGROUND

Hydatid cysts are most frequently located in the liver and lungs and very rarely can be found in the pericardium. Diagnosis and treatment are quite challenging, as the disease can present itself in many forms depending to the location and the complications that it might cause.

CASE PRESENTATION

A 22-year-old man presented to our hospital with ongoing dry cough for more than 1 month prior to admission. Other symptoms included chest pain, fatigue, low grade fever, and night sweats, which have worsened in the past 2 weeks. Physical examination revealed normal respiratory and heart function. Chest X-ray demonstrated mediastinal enlargement and left pleural effusion. Contrast-enhanced computed tomography images showed a walled cystic mass lesion measuring up to 56 × 50 mm in close proximity to the upper left atrium, ascending aorta and pulmonary artery, potentially localized in the pericardium, with a 10 mm endoatrial filling defect, findings were compatible with hydatid cyst, left pleural effusion and peripheral pulmonary upper left lobe consolidation. Cardiac involvement was excluded on magnetic resonance imaging and trans-esophageal ultrasound. The patient underwent fine needle aspiration of the affected lung and thoracocentesis. No malignancy was found, meanwhile the biopsy confirmed the presence of pulmonary infarction. In view of the imaging findings were highly suspicious of a hydatid cyst, we performed a test of antibody titers that was negative. The patient underwent left anterolateral thoracotomy, and after the opening of the pericardium, a cystic mass of 5 cm in diameter was found next to the left atrium and in close proximity with the left pulmonary veins. The content of the cyst was completely removed after the surgical area was isolated with gauze impregnated with hypertonic solution (NaCl 10%). The mass resulted to be an echinococcal cyst with multiple daughter cysts within it that did not penetrate/involve (perforate) the cardiac wall.

CONCLUSION

Pericardial echinococcosis is a very rare pathology in which a high expertise multidisciplinary approach is required. The compression mass effect caused by the cyst can lead to complications, such as in our case where the pulmonary vein was compressed, leading to pulmonary infarction. The value of radiology studies and transoesophageal ultrasound are very important in the diagnosis. Surgery in these cases is always recommended, but preferred surgical approach is questionable. In cases such as ours, we recommend anterolateral thoracotomy.

From emissions to incisions and beyond: the repercussions of climate change on surgical disease in low- and-middle-income countries

Climate change has far-reaching repercussions for surgical healthcare in low- and middle-income countries. Natural disasters cause injuries and infrastructural damage, while air pollution and global warming may increase surgical disease and predispose to worse outcomes. Socioeconomic ramifications further strain healthcare systems, highlighting the need for integrated climate and healthcare policies.

Comparing Capitonnage and Uncapitonnage Techniques for Pulmonary Hydatid Cysts: A Systematic Review and Meta-analysis

Surgery is the primary treatment for pulmonary hydatid cysts. This systematic review and meta-analysis aimed to compare the results of capitonnage and uncapitonnage techniques for the surgery of pulmonary hydatid cysts. Descriptive Boolean queries were used to search PubMed, Scopus, and Web of Science for articles published up to June 2022 to evaluate the outcomes of pulmonary hydatid cysts in terms of mortality, postoperative complications, and hospital stay. A total of 12 studies were included. An analysis of the total side effects revealed that there was a statistically significant difference between the capitonnage and uncapitonnage groups (odds ratio=3.81, 95% confidence interval=[1.75-8.31], P < .001). The results showed that more side effects were observed in the uncapitonnage group than in the capitonnage group. The risk of side effects in the uncapitonnage group is 3.81 times higher than in the capitonnage group. The results showed that more prolonged air leak was seen in uncapitonnage group than in the capitonnage group (odds ratio=4.18, 95% confidence interval=[1.64-10.64], P=.003). The results show that more empyema was observed in uncapitonnage group than in the capitonnage group (odds ratio=4.76, 95% confidence interval=[1.29-17.57], P =0.020). An analysis of atelectasis and mean hospital stay revealed that there was no statistically significant difference between the capitonnage and uncapitonnage groups. The results reveal the advantages of capitonnage in the treatment of pulmonary hydatid cysts and that the capitonnage method is quite effective in reducing complications compared to the uncapitonnage method.

Bilateral follicular thyroid carcinoma with large sternal metastasis: Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Follicular thyroid cancer (FTC) typically spreads hematogenously, with bone metastasis being worrisome, often appearing to be resistant to radioactive iodine (RAI) therapy. Metastasis to sternum is exceedingly rare.

CASE PRESENTATION

A 43-year-old Egyptian male presented with chest tightness, cough, and shortness of breath. He was initially treated as bronchial asthma. Later, he was referred to our thyroid surgery clinic as a case of goitre and palpable sternal mass. He looked clinically well, with enlarged anterior neck mass and visible sternal mass, no lymphadenopathy. Laboratory tests showed thyroid-stimulating hormone levels within normal (2.13 mIU/L), and mildly decreased FT4 (10.3 pmol/L). Neck/chest CT demonstrated multinodular goitre with retrosternal extension, expansile lytic lesion in the sternum, and bilateral lung metastases. Thyroid fine needle aspiration and cytology showed FLUS, and true cut biopsy from the sternal lesion showed invasive FTC.

DISCUSSION

Rare bilateral FTC presenting as slow-growing sternal metastasis. The patient underwent total thyroidectomy, followed by high dose RAI therapy, and concluded with sternectomy and reconstruction surgery repair using polymethyl methacrylate wrapped in proline mesh. On follow-up, he received further RAI ablation therapy and became RAI refractory. He then received systemic therapy (Lenvatinib). Most recent follow up showed that the disease was controlled (low volume cancer) and he was tolerating treatment well with no reported symptoms.

CONCLUSION

Bilateral FTC with sternal metastasis is rare, and can be treated with total thyroidectomy, sternectomy and reconstruction, followed by RAI therapy and systemic therapy where required, hence inferring real survival benefit.

The use of indocyanine green (ICYG) angiography intraoperatively to evaluate gastric conduit perfusion during esophagectomy: does it impact surgical decision-making?

BACKGROUND

Ischemia is known to be a major contributor for anastomotic leaks and indocyanine green (ICYG) fluorescence angiography has been utilized to assess perfusion. Experienced esophageal surgeons have clinically assessed the gastric conduit with acceptable outcomes for years. We sought to examine the impact of ICYG in a surgeon's decision-making during esophagectomy.

METHODS

We queried a prospectively maintained database to identify patients who underwent robotic esophagectomy. Time to initial perfusion, time to maximum perfusion, and residual ischemia were measured and used as a guide to resection of residual stomach. During esophagectomy the surgeon identified the anticipated line of ischemic demarcation (LOD) prior to ICYG injection. The distance between the surgeon's LOD and ICYG LOD was measured.

RESULTS

We identified 312 patients who underwent robotic esophagectomy, 251 without ICYG and 61 with ICGY. There were no differences in age, sex, race, body mass index, histology, stage, or neoadjuvant therapy use between groups. The incidence of anastomotic leak did not differ between groups (non-ICYG, 5.2% vs. ICYG, 6.6%), p = 0.67. The initial perfusion time was ≥ 10 s and max perfusion was > 25 s in all the patients in the ICYG that developed anastomotic leaks. All patients were noted to have at least 1 cm of residual gastric ischemia. Fifteen patients underwent independent surgeon evaluation of the ischemic LOD prior to ICYG. Differential distances were noted in 12 (80%) patients with a mean distance between surgical line of demarcation and ICYG LOD of 0.77 cm.

CONCLUSION

While the implementation of ICYG during esophagectomy demonstrates no significant improvements in anastomotic leak rates compared to historical controls, surgeon's decision-making is impacted in 80% of cases resulting in additional resection of the gastric conduit. Elevated times to initial perfusion and maximum perfusion were associated with increased gastric ischemia and anastomotic leaks.

Outcomes Associated With Esophageal Perforation Management: Results From a French Nationwide Population-based Cohort Study

OBJECTIVE

To evaluate outcomes associated with esophageal perforation (EP) management at a national level and determine predictive factors of 90-day mortality (90dM), failure-to-rescue (FTR), and major morbidity (MM, Clavien-Dindo 3-4).

BACKGROUND

EP remains a challenging clinical emergency. Previous population-based studies showed rates of 90dM up to 38.8% but were outdated or small-sized.

METHODS

Data from patients admitted to hospitals with EP were extracted from the French medico-administrative database (2012-2021). Etiology, management strategies, and short and long-term outcomes were analyzed. A cutoff value of the annual EP management caseload affecting FTR was determined using the "Chi-squared Automatic Interaction Detector" method. Random effects logistic regression model was performed to assess independent predictors of 90dM, FTR, and MM.

RESULTS

Among 4765 patients with EP, 90dM and FTR rates were 28.0% and 19.4%, respectively. Both remained stable during the study period. EP was spontaneous in 68.2%, due to esophageal cancer in 19.7%, iatrogenic postendoscopy in 7.3%, and due to foreign body ingestion in 4.7%. Primary management consisted of surgery (n = 1447,30.4%), endoscopy (n = 590,12.4%), isolated drainage (n = 336,7.0%), and conservative management (n = 2392,50.2%). After multivariate analysis, besides age and comorbidity, esophageal cancer was predictive of both 90dM and FTR. An annual threshold of ≥8 EP managed annually was associated with a reduced 90dM and FTR rate. In France, only some university hospitals fulfilled this condition. Furthermore, primary surgery was associated with a lower 90dDM and FTR rate despite an increase in MM.

CONCLUSIONS

We provide evidence for the referral of EP to high-volume centers with multidisciplinary expertise. Surgery remains an effective treatment for EP.

Spontaneous Endoscopic Esophageal Stent Fracture Post-endoscopic Placement: A Case Report

Endoscopic esophageal stent (EES) placement is an important tool for the non-operative management of esophageal pathologies. A rare and infrequently reported complication of EES placement is stent fracture and subsequent migration of the broken fragments. We report a rare case of a spontaneous EES fracture from Pakistan four weeks following its placement for esophageal perforation management, and an uneventful endoscopic retrieval of the fractured stent pieces. The recommended guidelines from available, albeit limited, research literature are also discussed as part of this case report.