Asymptomatic diaphragmatic hernia diagnosed after six years following esophagectomy: a case report

Diaphragmatic hernia, secondary to transhiatal esophagectomy, appears to be a relatively infrequent diagnosis. Patients may be asymptomatic or present with various symptoms. Diagnosis of this condition requires a high index of suspicion. The most common cause of diaphragmatic hernia is widened esophageal hiatus during surgery; therefore, narrowing the hiatus can prevent conduit herniation. Herein, we present the case of a 65-year-old man, who underwent transhiatal esophagectomy and gastric pull-up for squamous cell carcinoma six years ago. The patient was asymptomatic and diaphragmatic hernia was detected unexpectedly in the surveillance follow-up interval. In the present report, we also aimed to discuss the risk factors, as well as preventive and treatment methods

Delayed presentation of traumatic diaphragmatic hernia: the evaluation of surgical treatment results

Introduction: Diaphragmatic hernia could be caused by congenital disorders, blunt trauma or penetrating injuries. The diagnosis of traumatic diaphragmatic hernia is normally neglected during the first presentation leading to late complications and considerably increased mortality and morbidity among the patients

Materials and Methods: In this retrospective, descriptive study, we reviewed the medical records of patients presented with traumatic diaphragmatic hernia who had undergone surgical operations between 1982-2015 in Ghaem Hospital and Omid Hospital affiliated to Mashhad University of Medical Sciences, Iran. The studied variables included age, gender, clinical symptoms, location of hernia, involved organs, type of imaging modalities, surgical techniques, length of hospital stay, mortality rate and surgical complications

Results: In this study, 38 patients were diagnosed with traumatic diaphragmatic hernia consisting of 28 men and 10 women. In total, 79% and 21% of the patients suffered from penetrating trauma and blunt trauma, respectively. In addition, left-sided, right-sided and bilateral hernias were present in 33%, 4% and 1% of the patients, respectively. The most frequently herniated organ was the stomach, and the most common clinical symptoms were abdominal pain [84%] and dyspnea [53%]. Initially, chest radiographs were performed on all the patients and thoracotomy was performed to repair diaphragmatic tears in all the cases [100%]. In this study, 3 patients had previously undergone Hartmann's operation for gangrenous herniated colon, and devolvulation of gastric volvulus had also been performed on 3 patients. The main post-operative complications were reported to be pneumonia and respiratory insufficiency [2 cases], and the mean length of hospital stay was 6 days [5-8 days] which was longer [1-2 months] in patients with gangrenous bowel [3 patients]. Furthermore, no mortality was reported during the course of hospitalization in these patients

Conclusion: According to the results of this study, patients presented with blunt or penetrating traumas to the upper abdomen or lower chest require urgent attention as to immediately rule out diaphragmatic hernia in order to prevent later complications and mortality and morbidity among these patients

Role of conservative management in neck trauma: a case series study

Introduction: Given the fact that neck is a vital component of one's anatomy, injuries of this organ may be accompanied by fatal complications. In this article, we aimed to evaluate the etiology of neck trauma, simultaneous injuries of other organs, therapeutic methods for neck trauma, associated complications, length of hospital stay, at Ghaem Hospital over 10 years

Materials and Methods: In this retrospective study, we evaluated all cases of neck trauma at Ghaem hospital during 1994-2013. Patients were allocated into two groups of blunt and penetrating injuries. Trauma zone, therapeutic methods, coexisting injuries of other organs, associated complications, length of hospital stay, and mortality rate were evaluated in these two groups

Results: In this study, 75 [75%] and 25 [25%] cases were penetrating and blunt, respectively. Overall, 45% of the subjects had other simultaneous injuries and central nervous system injury accounted for the majority of cases. Zone II of the neck was involved in 89% of penetrating neck injuries and 70% of these subjects underwent surgery; conservative management was applied for 30% of the cases. Mortality rate was estimated at 3% for penetrating neck injuries and mean length of hospital stay time was 6 +/- 2 days. Moreover, 68% of blunt neck injuries were explored. The most common cause of surgery was vascular exploration [68%] and the most common surgical intervention was vein ligation [64%]. Mortality rate for blunt neck injuries was estimated at 5.2%, and mean mortality rate was 3.5% in both groups

Conclusion: Considering the severity of complications associated with neck injuries, early neck exploration is suggested for unstable cases or individuals with injuries deeper than the platysma. In addition, the role of diagnostic techniques such as helical computed tomography and interventional angiography was emphasized in the current study

Surgical resection: the mainstay of management of type II pulmonary arteriovenous malformations

Twenty percent of pulmonary arteriovenous malformations [PAVM] are type II PAVMs. This type of PAVM is characterized by less than 5 AVMs in the body and no other vascular anomalies such as AV fistulas or aneurisms. We studied seven cases of type II PAVMs in which surgical resection was the mainstay of treatment. All were free of symptoms and without relapse after the surgery. During a 26-year period, 7 subjects proven to have PAVM by imaging studies were entered in this cross-sectional study. Demographic, clinical and imaging findings along with results of catheterization and angiography were collected. All cases were operated on and followed to assess the results of surgery, complications and recurrence. Seven cases were entered in this study [five males and two females]. Seventy-one percent of our patients were in the first decade of life. Dyspnea and cough were present in 6[85%] and 5 cases [71%], respectively. Physical exam showed polycythemia in 5 [71%], clubbing in 4[57%] and arterial bruit over the chest in 2 [28%] cases. Two paradoxical emboli were seen, [one to the brain and one to the coronary artery]. Family history was negative. Chest x-rays revealed large PAVMs in 5 cases [71%]. Diagnosis was made by CT-scan, catheterization, angiography, and histopathology. Location of lesions was in the lower lobes in all cases. Surgical approach was lobectomy in 5 cases and segmentectomy in two cases. Operations were without any compilcation and the patients were symptom-free thereafter. Surgical resection of large PAVMs was completely curative without any early or late complications

Thymectomy by partial sternotomy for the treatment of non-thymomatous myasthenia gravis

Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of voluntary muscles. Thymectomy is considered an effective therapeutic option for patients with myasthenia gravis. The purpose of this study is to evaluate the efficacy of thymectomy by partial sternotomy for the treatment of non-thymomatous myasthenia gravis. From 2002 to 2006, patients with non-thymomatous myasthenia gravis who underwent thymectomy through a partial median sternotomy were studied prospectively and analyzed to evaluate the results of thymectomy performed by this technique. There were 10 patients [8 women and 2 men] and the mean age at the time of thymectomy was 25.9 years. Eight patients [80%] were in class IIA of Osserman's classification while 2 patients [20%] were in class IIB. Mean duration of symptoms before operation was 2 years. Mean follow-up was 9 +/- 3 months. Mean postoperative hospital stay was 6.1 days [5 to 10 days]. Pathology examination revealed thymus hyperplasia in all patients. There was no mortality. Complications occurred in two [20%] patients. One [10%] patient needed mechanical ventilation for 24 hours postoperatively. After 6 months of follow-up, 2 patients [20%] had complete remission of symptoms, 5 [50%] had a significant improvement, 2 [20%] had a mild improvement, whereas one patient [10%] had no improvement in his clinical symptoms. Partial median sternotomy may be a useful surgical approach to the thymus, as demonstrated by the good functional and aesthetic results, associated with low morbidity and no mortality

Gastroesophageal leiomyomatosis in a young women with vulvar leiomyomatosis and gallstone disease: report of a rare case

Gastroesophageal-vulvar leiomyomatosis is a very rare condition; it is characterized by diffuse, ill-defined proliferation of smooth muscle in the esophagus and vulva. We present an interesting case of esophageal leiomyomatosis in a woman with a history of vulvar leiomyomatosis and a gall bladder full of stones. She was I8-years old and had a 4 year history of vulvar mass and clitoromegaly, with subclinical dysphagia. This paper represents the first reported simultaneous occurrence of these three pathologic entities in the English literature. Esophago-vulvar leiomyomatosis should be considered in a young patient with vulvar mass and long-standing dysphagia in whom a smooth, tapered esophageal narrowing on barium study and circumferential esophageal wall thickening on CT scan are seen. An esophagectomy combined with a reconstruction procedure is indicated