Novel Therapy for Acquired Tracheomalacia with a Tissue-Engineered Extraluminal Tracheal Splint and Autologous Mesenchymal-Derived Chondrocytes

Abstract Introduction Acquired tracheomalacia (ATM) is characterized by a loss of structural strength of the tracheal framework, resulting in airway collapse during breathing. Near half of the patients undergoing prolonged invasive mechanical ventilation will suffer tracheal lesions. Treatment for ATM includes external splinting with rib grafts, prosthetic materials, and tracheal resection. Failure in the use of prosthetic materials has made reconsidering natural origin scaffolds and tissue engineering as a suitable alternative. Objective To restore adequate airway patency in an ovine model with surgicallyinduced ATM employing a tissue-engineered extraluminal tracheal splint (TE-ETS). Methods In the present prospective pilot study, tracheal rings were partially resected to induce airway collapse in 16 Suffolk sheep (Ovis aries). The TE-ETS was developed with autologous mesenchymal-derived chondrocytes and allogenic decellularized tracheal segments and was implanted above debilitated tracheal rings. The animals were followed-up at 8, 12, and 16 weeks and at 1-year postinsertion. Flexible tracheoscopies were performed at each stage. After sacrifice, a histopathological study of the trachea and the splint were performed. Results The TE-ETS prevented airway collapse for 16 weeks and up to 1-year postinsertion. Tracheoscopies revealed a noncollapsing airway during inspiration. Histopathological analyses showed the organization of mesenchymal-derived chondrocytes in lacunae, the proliferation of blood vessels, and recovery of epithelial tissue subjacent to the splint. Splints without autologous cells did not prevent airway collapse. Conclusion It is possible to treat acquired tracheomalacia with TE-ETS without further surgical removal since it undergoes physiological degradation. The present study supports the development of tissue-engineered tracheal substitutes for airway disease.

Manejo conservador en diverticulitis aguda perforada con aire extraluminal / Conservative management of perforated diverticulitis with extraluminal air

Resumen Introducción: El tratamiento óptimo de la diverticulitis perforada con aire extraluminal (DPA) es materia de debate. El manejo conservador es controversial; en casos seleccionados puede ofrecer menor morbimortalidad y evitar una ostomía. Objetivo: Describir las características clínicas, imagenológicas, necesidad de intervención quirúrgica y morbimortalidad de pacientes con DPA tratados con manejo conservador. Materiales y Método: Estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de DPA hemodinámicamente estables sin evidencia de peritonitis entre los años 2009 y 2015. Resultados: Se hospitalizaron 162 pacientes con diagnóstico de diverticulitis aguda (DA), el 53,1% fueron diverticulitis agudas complicadas (DC), de las cuales el 43% (37 casos) eran DPA, la edad promedio fue 59,6 años, la mayoría eran mujeres (54,1%). Las manifestaciones clínicas más comunes fueron dolor abdominal (97,3%), signos peritoneales (59,5%) y fiebre (40,5%). La tomografía axial computada de abdomen y pelvis (TC AP) mostró burbujas extracolónicas en el 78,4% y neumoperitoneo en el 21,6%. El manejo conservador fue exitoso en el 87,8%. Durante el seguimiento de 71,2 meses la recurrencia fue 28,1% y el 31,3% se realizó sigmoidectomía electiva. La falla del tratamiento médico se presentó en 5 casos (12,2%), uno de los cuales fallece. Conclusión: el manejo conservador de la DPA es una alternativa válida de tratamiento con alto porcentaje de éxito en pacientes hospitalizados seleccionados. La decisión de cirugía de urgencia y de sigmoidectomía electiva posterior a una DPA tratada médicamente debe ser individualizada.

Background: The conservative management of perforated diverticulitis with extraluminal air (PDA) is controversial. In selected hospitalized patients may offer less morbidity and mortality and avoid an ostomy. Aim: To describe its clinical and imagenologic characteristics, the need for surgical procedure and morbimortality of patients with perforated diverticulitis with extraluminal air in conservative management. Materials and Methods: Retrospective descriptive study of hemodynamically stable hospitalized patients with a PDA diagnosis without evidence of peritonitis during the years 2009 and 2015. Results: 162 patients were admitted with the diagnosis of acute diverticulitis. 53.1% of cases were acute complicated diverticulitis, 43% (37 cases) were PDA. The average age was 59.6 years and most of them women (54.1%). The most common clinical manifestations were abdominal pain (97.3%), peritoneal signs (59.5%) and fever (40.5%). The abdomen and pelvic computerized axial tomography scan showed extra-colonic bubbles in 78.4% and pneumoperitoneum in 21.6%. The conservative management was successful in 87.8% of cases. After a 71.2-month follow-up, the recurrence was 28.1% and 31.3% had an elective sigmoidectomy. 5 cases did not respond to medical treatment, one of them resulting in death. Conclusion: The conservative management of PDA is a valid treatment option with a high degree of success in the selected sample of hospitalized patients. The decision of having emergency surgery and elective sigmoidectomy post DPA should be evaluated individually.

Pneumatosis cystoides intestinalis - an incidental finding with unpredictable evolution / Pneumatose cistoide intestinal - um achado incidental com evolução imprevisível

Abstract Pneumatosis cystoides intestinalis is an uncommon disease with unknown etiology characterized by the presence of multiple gas-filled cysts within the submucosa or subserosa of the intestinal wall. Pneumoperitoneum and/or intestinal perforation are complications that may be associated with pneumatosis cystoides intestinalis. The patients are often prone to misdiagnosis or mistreatment.We are presenting a case of pneumatosis cystoides intestinalis in a 42 year-old woman affected by peritoneal free air and numerous, diffuse, bubble-like intramural gas collections into the jejunum and ileum, showed in CT-enterography images. The woman had a carcinoid tumor located in jejunum two years ago, treated with enterectomy. Recent complaints of nonspecific symptoms of abdominal discomfort and diarrhea motivated the realization of CT scan, serum chromogranin and urine 5-hidroxindolacetic acid for hypothesis of tumor carcinoid recurrence withdraw. The only change found was the presence of pneumatosis cystoides intestinalis in CT-enterography images without intestinal necrosis, bleeding or evident obstruction. For that reason no surgical procedure was realized and the patient stayed on surveillance. Actually, the patient complaints are sporadic abdominal discomfort, without pneumatosis cystoides intestinalis clinical evidence. Conclusion: The treatment plan of patient with PCI depends on underlying cause and clinical condition severity. When conservative treatment is adopted the clinical evolution of pneumatosis cystoides intestinalis is unpredictable and can even disappear in an indeterminate number of patients.

Resumo A pneumatose cistoide intestinal é uma doença incomum, de etiologia desconhecida, caracterizada pela presença de múltiplos cistos preenchidos com gás na submucosa ou subserosa da parede intestinal. O pneumoperitoneu e/ou a perfuração intestinal são complicações que podem estar associadas à pneumatose cistoide intestinal. Os pacientes geralmente estão sujeitos a erros de diagnóstico ou de tratamento.Apresentamos um caso de pneumatose cistoide intestinal em paciente do sexo feminino, 42 anos de idade, com ar livre peritoneal e numerosas coleções gasosas intramurais, difusas e semelhantes a bolhas no jejuno e íleo, visualizados em imagens de enterografia por tomografia computadorizada (TC). Há dois anos, a paciente teve um tumor carcinoide localizado no jejuno que foi tratado com enterectomia. As queixas recentes de sintomas inespecíficos, desconforto abdominal e diarreia motivaram a realização da TC e exame de cromogranina sérica e ácido 5-hidroxindolacético na urina para excluir a hipótese de recorrência do tumor carcinoide. A única alteração encontrada foi a presença de pneumatose cistoide intestinal em imagens de enterografia por TC sem necrose intestinal, sangramento ou obstrução evidente. Por esse motivo, nenhum procedimento cirúrgico foi realizado, e a paciente permaneceu em observação. Atualmente, a queixa da paciente é de desconforto abdominal esporádico, sem evidência clínica de pneumatose cistoide intestinal. Conclusão: O plano de tratamento de pacientes com PCI depende da causa subjacente e da gravidade da condição clínica. Quando o tratamento conservador é adotado, a evolução clínica da pneumatose cistoide intestinal é imprevisível e pode até desaparecer em alguns pacientes.

An Analysis of Role of Computed Tomography Scan Abdomen in Differentiating Perforated from Non-perforated Appendicitis Accurately and Comparing with Histopathology Reports

Background: Acute appendicitis is one of the most common abdominal surgical emergencies requiring accurate diagnosis. Itis characterized by obstruction of its lumen, leading to inflammation and finally perforation. To define its prognosis, choose anappropriate surgical procedure and to decide non-surgical treatment, the pre-operative diagnosis of perforated or non-perforatedappendicitis is very important.Aim of the Study: This study aims to analyze the diagnostic accuracy of computed tomography (CT) scan abdomen indifferentiating perforated from non-perforated appendicitis using histopathology as the final diagnosis.Materials and Methods: Aprospective, cross-sectional analytical study, wherein 85 patients diagnosed with acute appendicitisreferred to the radiological department for CT scan abdomen were included in the study. Patients aged between 15 and 70 yearswere included in the study. CT scan abdomen with and without contrast was performed on a Toshiba 64 Multislice CT scanner(Toshiba Medical Systems Corp., Tokyo, Japan) which was used for all the patients. All the CT scans were interpreted by the sameconsultant radiologists with a minimum of 5 years of experience. The radiological features for the diagnosis of non-perforatedacute appendicitis by CT were based on swollen appendix, thickened enhancing wall, and smudging of surrounding fat planes,whereas the radiological features for perforated appendicitis used were, with abscess formation, phlegmon, extraluminal air,extraluminal appendicolith, and focal defect in the appendicular wall. Histopathology of the specimen collected following surgerywas undertaken by the hospital consultant pathologist of more than 5-year experience.Observations and Results: Among the 85 patients included in this study for the analysis of CT scan abdomen features, therewere 57 (67.05%) males and 28 (32.94%) females with a male-to-female ratio of 2.03:1. The mean age of the patients was38.90 ± 6.70 years. The incidence of non-perforated appendicitis was 66/85 (77.64%) including males 44/85 (51.76%) andfemales 22/85 (25.88%). The incidence of perforated appendicitis was 19/85 (22.35%) and males were 12/85 (14.11%) and 7/85(8.23%) were female. Patients aged 15–45 years of both genders constituted to 63/85 (74.11%) of the total patients. Amongthese patients, presenting with non-perforated appendicitis was 51/85 (60%) and perforated appendicitis was 12/85 (14.11%).Conclusions: Multislice CT scan abdomen was considered as the modality of choice for acute appendicitis not only to confirmthe diagnosis but also it plays an important role in assessment of appendicular complication, particularly in the detection ofperforated appendix. Using one or more of the five radiological signs of CT scan abdomen to identify appendicular perforationraised the sensitivity significantly reaching 94.12%.

Splenic Cyst Mimicking Gastric Subepithelial Tumor Diagnosed by Endoscopic Ultrasonography

Recent research reveal that the diagnosis of gastric extraluminal compressions mimicking subepithelial tumor is increasing in numbers as esophagogastroduodenoscopy becomes widespread. Endoscopic ultrasonography is a very useful tool for differentiating extraluminal compressions from subepithelial tumors. Gastric extraluminal compressions are due to compression by either normal adjacent organs or pathologic conditions. Pathologic conditions are mainly benign, but some requires operation according to its size. We report a case of a 24-year-old female, who underwent esophagogastroduodenoscopy and was misdiagnosed with gastric subepithelial tumor. Endoscopic ultrasonographic findings showed anechoic cyst outside the gastric wall, which revealed to be a splenic cyst.

The Clinical Significance of Extraluminal Compressions According to the Site of the Stomach / 대한소화기내시경학회지

BACKGROUND/AIMS: It can be difficult to differentiate an extraluminal compression from a true submucosal tumor (SMT) in the stomach. The best method for differentiating an extraluminal compression from a true SMT is endoscopic ultrasonography (EUS). Extragastric compression is frequently observed, but its clinical significance has rarely been reported on. We evaluated the clinical findings of extraluminal compression according to the site of the stomach. METHODS: Ninety-one patients were diagnosed by EUS as having extragastric compressions from January 2006 to July 2008. Abdominal sonography or computed tomography was performed in some cases. RESULTS: The causes of normal structures (64 cases) were the vessels, spleen, intestine, gallbladder, liver, mesentery, pancreas and kidney. The causes of pathologic lesions (27 cases) were hepatic cyst, distended gallbladder with sludge, splenic cyst, hepatic hemangioma, polycystic hepatic and renal disease, pancreatic cyst, renal cyst, calcified lymph node and hepatocelluar carcinoma. The great curvature of the fundus was the most frequent site of extraluminal compressions. The lesions in the anterior wall of the body showed a higher frequency of pathologic lesions than did those lesions in other sites. CONCLUSIONS: EUS is useful for finding the causes of extragastric compression. Careful evaluation is needed because many lesions in the anterior wall of the body of the stomach were due to pathologic causes.

Extra-gastric Cyst Lesions Mimicking Gastric Submucosal Tumor

Gastric cancer remains still the most frequent type of cancer despite its declining incidence in Korea. As a result of the health promotion policy of the Korean government and increase in concern for individuals' health, screening endoscopy for detecting early gastric cancer and general physical exams have become widespread. Thereby, the incidental detection of gastric submucosal tumors (SMTs) are now occasionally diagnosed by screening endoscopy. Since endoscopic examination gives little information on SMTs, a variety of studies have been conducted to determine the etiology of SMTs and to distinguish them from extra-luminal compressive lesions. Here, we report one clinical case of cavernous hemangioma on the left lateral section of the liver and one case of omental cyst, which was preoperatively mistaken as gastric SMT.

A Case of a Myxoid Variant of a Pedunculated Extraluminal Gastrointestinal Stromal Tumor (GIST) in the Stomach / 대한소화기내시경학회지

Gastointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They are frequently identified as incidental lesions found by routine endoscopy or in resection specimens that are removed for other reasons. The macroscopic morphology of GISTs may be classified as the intraluminal type, extraluminal type, mixed type and intramural type. The extraluminal type is the second most frequent tumor encountered, but a GIST pedunculated externally from the stomach is very rare. In addition, the myxoid epithelioid variant, which is characterized by an unusually myxoid stroma and epithelioid histology, is also a rare distinct subtype of a GIST that is closely correlated with negative immunoreactivity for c-kit. We report a case of a myxoid epithelioid variant of a pedunculated extraluminal GIST in a 62-year-old man that presented with an abdominal mass.

Diagnostic Usefulness of Eedoscopic Ultrasongraphy for Extraluminal Compressions Mimicking Submucosal Tumors / 대한소화기내시경학회지

BACKGROUND/AIMS: When a submucosal lesion is discovered through an upper gastrointestinal endoscopy, it may be often difficult to differentiate an extra-gastric compression from a true submucosa1 tumor (SMT). An endoscopic ultrasonography (EUS) provides information about the relationship between a lesion and the gastric or esophageal wall. Furthermore, EUS helps in identifying the compression caused by surrounding organs. The diagnostic usefulness of EUS for extralumina1 compressed lesion was assessed. METHODS: The 261 patients who received an endoscopic diagnosis of submucosal tumors had EUS examinations performed. The results of EUS to additional diagnostic procedures such as UGI, USG, CT scan or tissue biopsy were then compared. RESULTS: Of 261 patients who received endoseopic diagnosis as SMT, extraluminal compression existed in 46 (17.6%) cases and true intramural lesion were found in 215 (82.4%) cases on EUS. The causes of extraluminal compression are lymph nodes (2 case.), the gallbladder (12 cases), the pancreas (9 cases), the spleen (6 cases), a pancreatic pseudocyst (5 cases), pancreatic cancer (2 cases), a hepatic cyst (2 cases), the left lobe of the liver (4 cases), hepatoma (1 case), a mesenteric tumor (2 caws) and a splenic vein (1 case). CONCLUSIONS: EUS is considered to be a useful diagnostic method not only for differential diagnosis of extraluminal compression from true SWT, but also for clarifying the cause of extraluminal compressed lesions.