Does prophylactic negative pressure wound therapy prevent surgical site infection in abdominal surgery?

OBJECTIVE: To determine if prophylactic negative pressure wound therapy (pNPWT) allows for the prevention of surgical site infections (SSIs) in abdominal surgery. METHOD: A non-systematic review assessing the evidence was conducted in 2020. RESULTS: Retrospectve studies comparing patients with pNPWT with patients receiving standard wound dressing after abdominal surgery showed encouragning results in favour of pNPWT for reducing the incidence of SSIs, but randomised controlled trials have so far reported mixed results. CONCLUSION: New randomised controlled trials including a sufficient number of patients at risk of SSIs are needed for confirming the results of non-interventional studies.

Implementation and validation of a competency assessment tool for laparoscopic cholecystectomy.

BACKGROUND: Achieving proficiency in a surgical procedure is a milestone in the career of a trainee. We introduced a competency assessment tool for laparoscopic cholecystectomy in our residency program. Our aim was to assess the inter-rater reliability of this tool. METHODS: We included all laparoscopic cholecystectomies performed by residents under the supervision of board certified surgeons. All residents were assessed at the end of the procedure by the supervising surgeon (live reviewer) using our competency assessment tool. Video records of the same procedure were analyzed by two independent reviewers (reviewer A and B), who were blinded to the performing trainee's. The assessment had three parts: a laparoscopic cholecystectomy-specific assessment tool (LCAT), the objective structured assessment of technical skills (OSATS) and a 5-item visual analogue scale (VAS) to address the surgeon's autonomy in each part of the cholecystectomy. We compared the assessment scores of the live supervising surgeon and the video reviewers. RESULTS: We included 15 junior residents who performed 42 laparoscopic cholecystectomies. Scoring results from live and video reviewer were comparable except for the OSATS and VAS part. The score for OSATS by the live reviewer and reviewer B were 3.68 vs. 4.26 respectively (p = 0.04) and for VAS (5.17 vs. 4.63 respectively (p = 0.03). The same difference was found between reviewers A and B with OSATS score (3.75 vs. 4.26 respectively (p = 0.001)) and VAS (5.56 vs. 4.63 respectively; p = 0.004)). CONCLUSION: Our competency assessment tool for the evaluation of surgical skills specific to laparoscopic cholecystectomy has been shown to be objective and comparable in-between raters during live procedure or on video material.

Impact of Nonalcoholic Steatohepatitis on the Outcome of Patients Undergoing Roux-en-Y Gastric Bypass Surgery: a Propensity Score-Matched Analysis.

PURPOSE: It is currently unknown whether NASH (nonalcoholic steatohepatitis), as compared to simple steatosis, is associated with impaired postoperative weight loss and metabolic outcomes after RYGB surgery. To compare the effectiveness of Roux-en-Y gastric bypass (RYGB) on patients with NASH versus those with simple nonalcoholic fatty liver (NAFL). MATERIALS AND METHODS: We retrospectively retrieved data from 515 patients undergoing RYGB surgery with concomitant liver biopsy. Clinical follow-up and metabolic assessment were performed prior to surgery and 12 months after surgery. We used multivariate analysis of variance (MANOVA) and propensity score matching and we assessed for changes in markers of hepatocellular injury and metabolic outcomes. RESULTS: There were 421 patients with simple NAFL, and 94 with NASH. Baseline alanine and aspartate aminotransferases were significantly higher in patients with NASH (p < 0.01). Twelve months after the RYGB surgery, as determined by both MANOVA and propensity score matching, patients with NASH exhibited a significantly greater reduction in alanine aminotransferase (ß-coefficient - 12 iU/l [- 22 to - 1.83], 95% CI, adjusted p = 0.021) compared to their NAFL counterparts (31 matched patients in each group with no loss to follow-up at 12 months). Excess weight loss was similar in both groups (ß-coefficient 4.54% [- 3.12 to 12.21], 95% CI, adjusted p = 0.244). Change in BMI was comparable in both groups (- 14 (- 16.6 to - 12.5) versus - 14.3 (- 17.3 to - 11.9), p = 0.784). CONCLUSION: After RYGB surgery, patients with NASH experience a greater reduction in markers for hepatocellular injury and similar weight loss compared to patients with simple steatosis.

PROphylactic MESH (PROMESH) for stoma closure: does it reduce the incidence of incisional hernia? Protocol for a triple-blinded randomised controlled trial.

INTRODUCTION: Application of a prophylactic mesh during stoma closure was shown to reduce the incidence of incisional hernia at the site of stoma closure. Our objective is to provide high quality evidence to validate this finding. METHODS AND ANALYSIS: The study will be a randomised controlled triple-blinded superiority parallel monocentric trial. Patients undergoing elective ileostomy or colostomy closure after surgery for digestive cancer will be eligible for inclusion. Patients allergic to the mesh, immunosuppressed or refusing to participate will be excluded. Randomisation will be performed based on a 1:1 allocation ratio between stoma closure with application of a non-absorbable mesh in the sublay position (intervention) and stoma closure without a mesh (control). The primary outcome will be the 1-year incidence of incisional hernia at the site of stoma closure, determined clinically and by CT. Secondary outcomes will be the 31-day incidence of surgical site infection and the modified Carolinas Comfort Scale. Patients, radiologists and investigators performing the assessment at 1 year will be blinded for the allocated study group. Analysis will be performed in intention-to-treat. The trial will include 68 patients (34 with mesh, 34 without mesh). ETHICS AND DISSEMINATION: The present randomised controlled trial was registered into clinicaltrials.gov (NCT04510558) and was accepted by the local ethic committee (Geneva, Switzerland: CCER 2021-00053). The results will be presented at national and international congresses in the fields of colorectal surgery and general surgery, and published in a peer-reviewed journal.

Prophylactic negative-pressure wound therapy for prevention of surgical site infection in abdominal surgery: a nationwide cross-sectional survey.

Our objective was to determine current practice in Switzerland regarding the use of pNPWT in abdominal surgery. An online survey was carried out to evaluate the use of pNPWT among abdominal surgeons in Switzerland. One hundred and ten participants replied to the survey from 16.12.2019 to 15.01.2020. Eleven were excluded, leaving 99 responders for analysis. Seventy participants (70.7%) were using pNPWT, 3 (3%) have stopped using it and 26 (26.3%) have never used it. pNPWT was used on midline laparotomy by 63 responders (90%), closed stoma wounds by 21 (30%), closed perineal wounds by 20 (28.6%), Pfannenstiel incisions by 18 (23.7%), groin incisions by 16 (22.9%), subcostal incisions by 13 (18.6%), Mc Burney incisions by 3 (4.3%) and other incisions by 18 (25.7%). Forty-eight participants (68.6%) used pNPWT on less than 10% of patients, 14 (20%) on 10-25% of patients, six (8.6%) on 25-50% of patients and two (2.9%) on 75-100% of patients. Suggestions for improvement to pNPWT were: better sealing, recyclable system, better adaptation to the perineum, smaller device, reduced cost and possibility to check the surgical wound through the dressing. In conclusion, pNPWT is widely used among Swiss surgeons, mostly on midline incisions. However, most of them apply pNPWT on a small proportion of patients only. Suggestions for improvement were a better sealing for complex wounds, reduced cost and possibility to check the wound during the therapy.

The Use of a Stoma Rod/Bridge to Prevent Retraction: A Systematic Review.

PURPOSE: We evaluated evidence related to the use of a rod (bridge) to prevent stoma retraction during loop ostomy construction. METHODS: We completed a systematic review of the literature. We searched MEDLINE, EMBASE, and COCHRANE databases up to December 4, 2019. We posed the following question based on a PICO format. Do adult patients undergoing ostomy surgery experience less stomal retraction when compared to patients managed without placement of a stoma rod? FINDINGS: Our initial search returned 182 articles; after reading studies in full, 5 articles were identified that collectively enrolled 1058 participants. Four studies were randomized controlled trials and one was a prospective cohort study. Meta-analysis could not be performed because of the small number of studies and the heterogeneity of outcomes measurements. The incidence of stoma retraction ranged between 0%-8% in patients managed with a rod and 0.78%-8.2% in patients with no rod. The number of reported adverse events was low. Placement of a stoma rod was associated with more adverse outcomes than in patients managed without a rod. Adverse events included local edema, stoma necrosis, skin necrosis, peristomal moisture-associated skin damage (irritant dermatitis), peristomal abscess, bleeding, and mucocutaneous separation. CONCLUSIONS: Stoma rod does not seem to reduce the risk of stoma retraction and might result in other adverse events. IMPLICATIONS: We recommend avoidance of stoma rod/bridge placement during ostomy surgery.

Gastric necrosis following a hiatal hernia: A case report.

INTRODUCTION: Gastric volvulus are rare. Complications can be life threatening, including necrosis and perforation. Assessment of mucosal viability is essential, and urgent surgical intervention is mandatory in case of vascular compromise. PRESENTATION OF CASE: An 72-year-old female known for a paraesophageal hiatal hernia was admitted at our emergency department with acute abdominal pain. Blood count demonstrated leukocytosis and increased C-reactive protein. Abdominal computed tomography showed a mesenteroaxial gastric volvulus. Urgent upper endoscopy revealed mucosal ischemia, which prompted immediate laparotomy with partial gastrectomy, cruroplasty, and Dor fundoplication. Postoperative course was uneventful. DISCUSSION: Gastric volvulus is initially treated with nasogastric tube decompression, but definitive treatment is achieved surgically. When there is an associated hernia, closing the anatomical defect and fundoplication should be performed. Complication such as necrosis is associated with a high mortality, and requires urgent surgical repair. CONCLUSION: Gastric volvulus can be life-threatening. Urgent endoscopic or surgical assessment should be conducted to assess mucosal viability.

The role of perineal application of prophylactic negative-pressure wound therapy for prevention of wound-related complications after abdomino-perineal resection: a systematic review.

BACKGROUND: Closed perineal wounds often fail to heal by primary intention after abdomino-perineal resection (APR) and are often complicated by surgical site infection (SSI) and/or wound dehiscence. Recent evidence showed encouraging results of prophylactic negative-pressure wound therapy (pNPWT) for prevention of wound-related complications in surgery. Our objective was to gather and discuss the early existing literature regarding the use of pNPWT to prevent wound-related complications on perineal wounds after APR. METHODS: Medline, Embase, and Web of Science were searched for original publications and congress abstracts reporting the use of pNPWT after APR on closed perineal wounds. RESULTS: Seven publications were included for analysis. Two publications reported significantly lower incidence of SSI in pNPWT patients than in controls with a risk reduction of about 25-30%. Two other publications described similar incidences of SSI between the two groups of patients but described SSI in pNPWT patients to be less severe. One study reported significantly lower incidence of wound dehiscence in pNPWT patients than in controls. CONCLUSION: The largest non-randomized studies investigating the effect of pNPWT on the prevention of wound-related complications after APR showed encouraging results in terms of reduction of SSI and wound dehiscence that deserve further investigation and confirmation.

Surgical resection does not avoid the risk of diverticulitis recurrence-a systematic review of risk factors.

PURPOSE: Fifteen percent of patients undergoing elective sigmoidectomy will present a diverticulitis recurrence, which is associated with significant costs and morbidity. We aimed to systematically review the risk factors associated with recurrence after elective sigmoidectomy. METHODS: PubMed/MEDLINE, Embase, Cochrane, and Web of Science were searched for studies published until May 1, 2020. Original studies were included if (i) they included patients undergoing sigmoidectomy for diverticular disease, (ii) they reported postoperative recurrent diverticulitis, and (iii) they analyzed ≥ 1 variable associated with recurrence. The primary outcome was the risk factors for recurrence of diverticulitis after sigmoidectomy. RESULTS: From the 1463 studies initially screened, six studies were included. From the 1062 patients included, 62 patients recurred (5.8%), and six variables were associated with recurrence. Two were preoperative: age (HR = 0.96, p = 0.02) and irritable bowel syndrome (33.3% with recurrence versus 12.1% without recurrence, p = 0.02). Two were operative factors: uncomplicated recurrent diverticulitis as indication for surgery (73.3% with recurrence versus 49.9% without recurrence, p = 0.049) and anastomotic level (colorectal: HR = 11.4, p = 0.02, or colosigmoid: OR = 4, p = 0.033). Two were postoperative variables: the absence of active diverticulitis on pathology (39.6% with recurrence versus 26.6% without recurrence) and persistence of postoperative pain (HR = 4.8, p < 0.01). CONCLUSION: Identification of preoperative variables that predict the occurrence of diverticulitis recurrence should help surgical decision-making for elective sigmoidectomy, while peri- and postoperative factors should be taken into account for optimal patient follow-up.

Current Surgical Strategies for the Treatment of Rectal Adenocarcinoma and the Risk of Local Recurrence.

BACKGROUND: Despite new medical and surgical strategies, 5-year local recurrence of rectal adenocarcinoma was reported in up to 25% of cases. Therefore, we aimed to review surgical strategies for the prevention of local recurrences in rectal cancer. SUMMARY: After implementation of the total mesorectal excision (TME), surgical resection of rectal adenocarcinoma with anterior resection or abdominoperineal excision (APE) allowed decrease in local recurrence (3% at 5 years). More recently, extralevator APE was described as an alternative to APE, decreasing specimen perforation and recurrence rate. Moreover, technique modifications were developed to optimize rectal resection, such as the laparoscopic or robotic approach, and transanal TME. However, the technical advantages conferred by these techniques did not translate into a decreased recurrence rate. Lateral lymph node dissection is another technique, which aimed at improving the long-term outcomes; nevertheless, there is currently no evidence to recommend its routine use. Strategies to preserve the rectum are also emerging, such as local excision, and may be beneficial for subgroups of patients. Key Messages: Rectal cancer management requires a multidisciplinary approach, and surgical strategy should be tailored to patient factors: general health, previous perineal intervention, anatomy, preference, and tumor characteristics such as stage and localization.

Prophylactic Negative-pressure Wound Therapy Prevents Surgical Site Infection in Abdominal Surgery: An Updated Systematic Review and Meta-analysis of Randomized Controlled Trials and Observational Studies.

BACKGROUND: Prevention of surgical site infection (SSI) is a public health challenge. Our objective was to determine if prophylactic negative-pressure wound therapy (pNPWT) allows preventing SSI after laparotomy. METHODS: Medline, Embase, and Web of Science were searched on 6 October 2019 for original studies reporting the incidences of SSI in patients undergoing open abdominal surgery with and without pNPWT. Risk differences (RDs) between control and pNPWT patients and risk ratios (RRs) for SSI were obtained using random-effects models. RESULTS: Twenty-one studies (2930 patients, 5 randomized controlled trials [RCTs], 16 observational studies) were retained for the analysis. Pooled RD between patients with and without pNPWT was -12% (95% confidence interval [CI], -17% to -8%; I2 = 57%; P < .00001) in favor of pNPWT. That risk difference was -12% (95% CI, -22% to -1%; I2 = 69%; P = .03) when pooling only RCTs (792 patients). pNPWT was protective against the incidence of SSI with a RR of 0.53 (95% CI, .40-.71; I2 = 56%; P < .0001). The effect on pNPWT was more pronounced in studies with an incidence of SSI ≥20% in the control arm. The preventive effect of pNPWT on SSI remained after correction for potential publication bias. However, when pooling only high-quality observational studies (642 patients) or RCTs (527 patients), significance was lost. CONCLUSIONS: Existing studies suggest that pNPWT on closed wounds is protective against the occurrence of SSI in abdominal surgery, but these findings need to be confirmed by more high-quality evidence, preferentially in subgroups of patients with an incidence of SSI ≥20% in the control arm.

Surgical management of vascular Ehlers-Danlos syndrome and its challenges: a case report.

BACKGROUND: Ehlers-Danlos syndrome (EDS) is a heterogeneous group of rare inherited diseases involving connective tissue. Vascular EDS (vEDS) is associated with abnormal type III collagen, which is an essential component of skin, hollow organs and arterial walls, and causes potentially fatal visceral and arterial complications. The surgical management of these patients is challenging and should be limited to life-saving procedures. CASE DESCRIPTION: We report a case of a 42-year-old male who presented a hemorrhagic shock due to spontaneous rupture of an ascending branch of the left colic artery. The coexisting presence of multiple abdominal vascular abnormalities suggested the diagnosis of vEDS, later confirmed by the discovery of a new missense mutation in the COL3A1 gene with pathogenic significance. The post-operative course was marked by a mechanical ileus caused by an ischemic stenosis of the descending colon. Failure of conservative management and the well-known risk of colonic perforation in these patients led to the decision to perform a diverting ileostomy. CONCLUSION: The management of these patients is difficult, and risk-benefit assessments must be made on a case-by-case basis. Less invasive procedures should be considered whenever possible.

Introduction of a specialized consultation prior to insertion of totally implantable access venous devices: Impact on cancellation rate and patient satisfaction.

OBJECTIVES: Preoperative consultation is usually not performed before insertion of a totally implantable venous access device (TIVAD). In our experience, an incomplete preoperative assessment, a predictable medical condition contraindicating surgery, or no-show patients the day of surgery led to several surgery cancellations. Therefore, we introduced a specific preoperative surgical consultation for TIVAD that took place shortly before surgery. The aim of the present study is to evaluate the patients' satisfaction and to establish the rate of cancellation after the adoption of this strategy. METHODS: Two-hundred and four patients who benefited from the preoperative consultation before TIVAD insertion from August 2014 to August 2016 were included. Satisfaction of patients and cancellation rate were documented. RESULTS: With that strategy, no TIVAD insertion was either delayed or cancelled. The overall level of satisfaction was high (91.8%); 184 patients (90.2%) judged the consultation useful in preparation for the surgery. The surgical procedure met their expectations in 92.2% of cases. Patients known for a psychiatric comorbidity were more likely to express dissatisfaction. CONCLUSIONS: The introduction of a specific preoperative surgical consultation for TIVAD insertion led to a high level of patients' satisfaction. After the preoperative consultation, no cancellation was recorded. Special approaches have to be considered for patients with a psychiatric comorbidity.

Unexpected Finding of a Small Intestinal Neuroendocrine Tumor: A Case Report and Literature Review.

BACKGROUND The incidence of neuroendocrine tumors (NETs) has increased in recent years. They can affect every area of the human body that presents cells with a secretory function. In this report, we focus on gastrointestinal NETs. The small bowel (SI) is the most affected area and SI-NETs have recently become more common than adenocarcinomas. Inside the small intestine, the appendix suffers from this pathology more than other organs. CASE REPORT Our case report deals with a 70 years-old man with extensive abdominal pain due to ingestion of an apricot kernel. A CT abdominal scan showed, around the kernel, a mechanical ileus with inflammation of the distal ileum and thickening of the intestinal wall. During the operation, we replaced laparoscopy with mini-laparotomy, performing an ileocecectomy due to suspicion of a tumor lesion. The histopathological exam revealed a well-differentiated neuroendocrine tumor (NET G1) of the distal ileum. CONCLUSIONS This case report shows that SI-NETs can be found in cases of small bowel occlusion. Depending on the size and distinction, such patients can have good survival rates.

Intussusception in an Immunocompromised Patient: A Case Report and Review of the Literature.

BACKGROUND Intussusception in adults (AI) accounts for 1% of all cases of bowel obstruction. While pediatric intussusception is well known and almost always idiopathic, an underlying cause is usually found in adults. Indication for surgical treatment and intussusception reduction before resection remain controversial in AI. Here, we present an uncommon case of an immunocompromised patient who had multiple intussusceptions. CASE REPORT A 59-year-old woman, who had received a kidney-pancreas transplant for type 1 diabetes with end-stage renal failure, was admitted to our Intensive Care Unit for septic shock of suspected pulmonary origin. A thoraco-abdominal CT scan demonstrated signs of bilateral pneumonia and multiple abdominal intussusceptions, for which she underwent surgery. Four intestinal intussusceptions were found. Manual desinvagination was performed without bowel resection. After surgery, the patient presented a new bowel obstruction, requiring a second surgery, showing recurrence of 1 intussusception. Segmental resection was indicated, but not performed because of the septic shock, requiring high-dose noradrenalin. The patient progressed toward multi-organ failure, leading to her death a few days later. An autopsy revealed that multiple adenomas were responsible for the intussusceptions. CONCLUSIONS This case confirms that AI is rarely a spontaneous disease and that the therapeutic strategy should be planned accordingly. There is currently no systematic approach for AI, and guidelines are needed to improve its management.

Anatomy of a Suicide: A Case Report.

BACKGROUND Penetrating neck injuries (PNI) have a relatively low incidence constituting just 1.6% to 3.0% of overall suicide attempts. Nonetheless, the anatomical challenges as well as the likelihood of vascular and airway lesions make it one of the most lethal injury types of all Abbreviated Injury Scale regions. Traditional PNI management which divides PNI into anatomical zones is being reconsidered in light of high numbers of negative surgical explorations, weak correlation between the area of wounds and organ injury and significantly longer hospitalizations. CASE REPORT A 52-year-old female was admitted after a self-inflicted, right para tracheal stab wound. A cervico-thoracic computed tomography (CT) scan excluded vascular and other organ lesions. A right pneumothorax was treated with a chest drain and a right exploratory cervicotomy was performed. A pharyngoscopy and an esophagoscopy showed no lesions. CONCLUSIONS Advanced Trauma Life Support (ATLS) principles determine the initial assessment of PNI. Invasive airway management was required if orotracheal intubation is unfeasible. Hemodynamically unstable patients with platysma, vascular or aerodigestive lesions require surgery. Laryngotracheal injuries require panendoscopy and bronchoscopy prior to surgical exploration. Pharyngo-esophageal injuries may be treated conservatively. Esophageal lesions require timing dependent surgery. Recently, a "no zone" approach irrespective of anatomical classification shows improved results in stable PNI. Multidetector helical CT with angiography (MDCT-A) significantly reduces negative exploratory surgery. Consensus regarding the best management of PNI is shifting, as increasing evidence suggests a "no-zone" approach is more beneficial and cost effective.

Spontaneous Hemothorax in a Patient with von Recklinghausen's Disease: A Case Report and Review of the Literature.

BACKGROUND Von Recklinghausen's disease, also known as Type 1 neurofibromatosis (NF1), is a genetic disorder characterized by skin tumors, neurofibromas of multiple organs and vascular abnormalities. Spontaneous thoracic hemorrhage is a rare but potentially fatal consequence of this disorder. After a review of the literature over the last 10 years and on the basis of a case study, the aim of this study was to report the challenges of management of this pathology. CASE REPORT We report a rare case of a 45-years-old male with a medical history of neurofibromatosis who complained of a 3-day history of progressive dyspnea. At his admission to the Emergency Department, the patient was hemodynamically stable. A chest computed tomography (CT) scan showed a large left hemothorax with mediastinal shift to the right without active bleeding. A chest tube was introduced, and conservative treatment was followed. Another CT scan performed 2 days later revealed a middle lobar pulmonary embolism on the opposite side. A full treatment of anticoagulation was administered, and the patient was released after 8 days of hospitalization. Three weeks later, a new chest CT scan indicated the absence of vascular aneurysm or source for hemothorax. CONCLUSIONS Our systematic literature review found 15 articles which were described as early as 2005. To our knowledge, endovascular treatment produces the best immediate successful result (100%) and may be used in adjunction with video-assisted thorax surgery (VATS) or thoracic drainage to optimize outcomes. In the present case, conservative treatment showed a good result despite anticoagulation for pulmonary embolism. The endovascular approach seems to be the most promising, but treatment needs to be tailored to each individual patient.

Thyroid Gland Hemorrhage in a Patient with Past Medical History of Renal Clear Cell Carcinoma: Report of a Very Rare Case.

BACKGROUND The incidence of metastasis to the thyroid gland is extremely rare, with hemorrhage being a particularly uncommon manifestation of metastatic thyroid disease. CASE REPORT A 68-year-old man who underwent a right nephrectomy for RCC 8 years ago was referred to the Emergency Department (ED) complaining of upper-chest pain radiating to the left shoulder, tachycardia, and increased dysphonia. An enhanced computed tomography (CT) scan suggested a thyroid mass originating from both thyroid lobes, with right deviation of the trachea due to active bleeding. The patient underwent an emergency total thyroidectomy. The postoperative course was uneventful. The histopathological analysis of the surgical specimen revealed metastasis of an RCC. CONCLUSIONS Active bleeding of the thyroid gland is a formal indication for emergency surgical management. In patients with a history of cancer, especially in cases of RCC, metastatic disease should be suspected, although in most cases the final diagnosis can only be made after surgery.

Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia: A Case Report and Review of the Literature.

BACKGROUND Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare pulmonary disorder that is characterized by diffuse hyperplasia of bronchiolar and bronchial pulmonary neuroendocrine cells. In this condition, when no other pathological pulmonary condition is detected, DIPNECH is considered to be an idiopathic lung disease. DIPNECH is a rare condition that can be difficult to distinguish from other forms of reactive pulmonary neuroendocrine cell hyperplasia (NECH). We present a case of DIPNECH and describe the approach to diagnosis of this rare condition. CASE REPORT A 69-year-old woman with a past medical history of successfully treated lobular carcinoma of the breast, presented to our department with a respiratory tract infection. High-resolution computed tomography (HRCT) of the chest showed a suspicious pulmonary nodule, measuring 13 mm, in the right middle pulmonary lobe. Combined positron emission tomography (PET) and computed tomography (CT), showed a solid and metabolically active nodule. A transbronchial biopsy and histopathology confirmed a diagnosis of DIPNECH. CONCLUSIONS It is possible that DIPNECH is an under-diagnosed pulmonary condition because it is rarely associated with symptoms. At this time, there are no evidence-based management guidelines. While the majority of cases have stable clinical course, some cases can progress to cause airway obstruction. This case report highlights this rare, but potentially progressive condition, and the need for evidence-based management guidelines for DIPNECH.