New hybrid method for trachea dilatation with rigid and flexible tools.

Trachea stenosis is observed either in benign or malignant situations. In cancer malignancy a tumor might obstruct the central airway in three different ways. Again granuloma tissue is usually observed after intubation or stent placement in order to manage a benign malformation of the trachea. In any case there are several tools and techniques that can be used either with surgery or endoscopically to manage such situation. We will focus on a hybrid technique in order to ventilate the patient while performing endoscopic management of granuloma tissue.

Coincidence of thymoma and breast cancer and in a 56-year-old female patient.

We present a case of a 56-year-old female, with a familial history of breast, lung and brain cancer, which revealed a breast tumor, located in the upper outer quadrant of the left breast. During the routinely staging examinations, a 15 cm intrathoracic tumor was found in the upper left mediastinum, penetrating the pericardium and a smaller tumor, in the left side of parietal pleura. Core biopsies from both lesions, revealed a lobular carcinoma of the breast classic type, grade II (e-cadherin-, ER+, PR+, Her-2-, Ki-67 10%) and a B3 thymoma (CK19+, CD5+) penetrating the pericardium and the left lung. A synchronous removal of both tumors was scheduled, including median sternotomy and left intrapericardial pneumonectomy, followed by a modified radical left mastectomy and a sentinel lymph node biopsy. The postoperative course was uneventful. This case advocates that thymoma patients appear to have a predisposition towards developing additional neoplasms, as breast carcinoma. Clinicians should be aware of the increased incidence of extrathymic cancers, occurring in thymoma patients.

Successful surgical treatment of a complicated esophageal perforation, by use of primary closure and lung parenchyma reinforcement.

Esophageal perforation (EP) is a medical condition which demands urgent confrontation with significant complications. The cause of the perforation may be common, spontaneous or iatrogenic, with conservative or surgical therapeutic strategy, which is needed in the majority of incidents, depending on the characteristics of the lesion. We report a case of a 68-year-old man, with the existence of an ulcerative lesion 31 cm approximately from the dental barrier, and a coexistent stenosis, diagnosed through esophagogastroduodenoscopy, which evolved to an extensive purulent necrotic mediastinitis, diagnosed through a thorax CT scan after the patient began to complain of asphyxiation during eating. A right posterolateral thoracotomy was performed along with intensive wide spectrum antibiotic therapy. Primary closure of the perforation as well as pulmonary tenting was used with satisfactory results. There was no evidence of leakage after a 12-month "follow-up" period. The early diagnosis of an EP combined with immediate surgical procedure and frequent "follow-up" of the patient, eliminate the risks for the patient's life and ensure a satisfactory outcome.

Percutaneous tracheostomy-beware of the thyroidea-ima artery.

Percutaneous tracheostomy is a minimally invasive operation performed in patients, in order to provide an air passage through the windpipe. A rare cause of severe bleeding during such operation is the injury of the thyroidea-ima artery. This case report presents a patient with hemorrhage after thyroidea-ima injury during percutaneous dilatational tracheostomy. Surgeons should always be aware of such anatomic variation, in order to prevent urgent sternotomy.

Thoracocentesis: from bench to bed.

Lung cancer can be diagnosed with minimal interventional procedures such as: bronchoscopy, endobronchial ultrasound (EBUS), fine needle aspiration under CT guidance and esophageal ultrasound. In our current editorial we will provide a definition and current up to date information regarding fine needle aspiration under CT guidance. We will focus on pneumothorax and treatment methods.

Pleura space anatomy.

The pleural cavity is the potential space between the two pleurae (visceral and parietal) of the lungs. The pleurae are serous membranes which fold back onto themselves to form a two-layered membranous structure. The thin space between the two pleural layers is known as the pleural cavity and normally contains a small amount of pleural fluid. There are two layers; the outer pleura (parietal pleura) is attached to the chest wall and the inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood vessels, bronchi and nerves. The parietal pleurae are highly sensitive to pain, while the visceral pleura are not, due to its lack of sensory innervation. In the current review we will present the anatomy of the pleural space.

Physiology of the pleural space.

The pleural cavity is created between the 4(th) and 7(th) week of embryologic development. These embryonic components of visceral and parietal pleurae develop different anatomic characteristics with regard to vascular, lymphatic, and nervous supply. There are two layers: a superficial mesothelial cell layer facing the pleural space and an underlying connective tissue layer. The pleura might present inflammatory response and maintenance of the pleural fluid is observed. The latter function is especially important in the mechanical coupling of the lung and chest wall. Fluid is filtered into the pleural space according to the net hydrostatic oncotic pressure gradient. It flows downward along a vertical pressure gradient, presumably determined by hydrostatic pressure and resistance to viscous flow. There also may be a net movement of fluid from the costal pleura to the mediastinal and interlobar regions. In these areas, pleural fluid is resorbed primarily through lymphatic stomata on the parietal pleural surface. In the current review we will present the physiology of the pleural space in a step by step manner.

Barotrauma and pneumothorax.

Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or in contact with the body, and the surrounding fluid. This situation typically occurs when the organism is exposed to a significant change in ambient pressure, such as when a scuba diver, a free-diver or an airplane passenger ascends or descends, or during uncontrolled decompression of a pressure vessel, but it can also happen by a shock wave. Whales and dolphins are also vulnerable to barotrauma if exposed to rapid and excessive changes in diving pressures. In the current review we will focus on barotraumas from definition to treatment.

Lung inflammatory response syndrome after cardiac-operations and treatment of lornoxicam.

The majority of patients survive after extracorporeal circulation without any clinically apparent deleterious effects. However, disturbances exist in various degrees sometimes, which indicate the harmful effects of cardiopulmonary bypass (CPB) in the body. Several factors during extracorporeal circulation either mechanical dependent (exposure of blood to non-biological area) or mechanical independent (surgical wounds, ischemia and reperfusion, alteration in body temperature, release of endotoxins) have been shown to trigger the inflammatory reaction of the body. The complement activation, the release of cytokines, the leukocyte activation and accumulation as well as the production of several "mediators" such as oxygen free radicals, metabolites of arachidonic acid, platelet activating factors (PAF), nitric acid, and endothelin. The investigation continues today on the three metabolites of lornoxicam (the hydroxylated metabolite and two other metabolites of unknown chemical composition) to search for potential new pharmacological properties and activities.

Extrapelvic endometriosis: a rare entity or an under diagnosed condition?

Endometriosis is a clinical entity characterized by the presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity. Endometriosis can be either endopelvic or extrapelvic depending on the location of endometrial tissue implantation. Despite the rarity of extrapelvic endometriosis, several cases of endometriosis of the gastrointestinal tract, the urinary tract, the upper and lower respiratory system, the diaphragm, the pleura and the pericardium, as well as abdominal scars loci have been reported in the literature. There are several theories about the pathogenesis and the pathophysiology of endometriosis. Depending on the place of endometrial tissue implantation, endometriosis can be expressed with a wide variety of symptoms. The diagnosis of this entity is neither easy nor routine. Many diagnostic methods clinical and laboratory have been used, but none of them is the golden standard. The multipotent localization of endometriosis in combination with the wide range of its clinical expression should raise the clinical suspicion in every woman with periodic symptoms of extrapelvic organs. Finally, the therapeutic approach of this clinical entity is also correlated with the bulk of endometriosis and the locum that it is found. It varies from simple observation, to surgical treatment and treatment with medication as well as a combination of those. Virtual slides: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1968087883113362.

Lymphangioleiomyomatosis: current and future.

Lymphangioleiomyomatosis is a rare slowly progressive lung disease that affects almost exclusively young women of reproductive age. It occurs sporadically or in association with Tuberous Sclerosis Complex. LAM is characterized by cystic remodeling of the lung parenchyma, due to proliferation of abnormal smooth muscle-like LAM cells and presence of extra pulmonary manifestations such as lymphadenopathy, angiomyolipomas and abdominal lymphangioleiomyomas. The most common clinical manifestations are progressive dyspnea on exertion, pneumothorax and chylous effusions. Currently there is no curative treatment for the disease, but the ongoing study of the genetic and molecular pathways implicated in the pathogenesis of the disease could lead to targeted therapy.

Abdominal wall endometrioma mimicking an incarcerated hernia: a case report.

The case of a tender, isolated abdominal wall tumor within a Pfannenstiel incision due to a seeding deposit of endometrial tissue secondary to a previous obstetric operation (caesarean section) in a 39-year-old female without previously reported pelvic endometriosis is presented. The lesion clinically mimicked the appearance of an incarcerated incisional hernia at the outer corner of the healed Pfannenstiel incision. The preoperative differential diagnosis also included that of a locally forming post-operative tender granuloma and the remote possibility of an incisional endometrioma (although no link to menstruation could be made). Local malignancy was not taken as a serious possibility. Definitive diagnosis of the excised lesion was made at histology. The pre-operative diagnostic dilemma is presented, along with a short review of the literature.

Management of sigmoid volvulus avoiding sigmoid resection.

Acute sigmoid volvulus is typically caused by an excessively mobile and redundant segment of colon with a stretched mesenteric pedicle. When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation. A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness. The patient had tympanitic percussion tones and no bowel sounds. She was diagnosed with acute sigmoid volvulus. Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression. Controversy exists on the decision of the time, the type of definitive treatment, the strategy and the most appropriate surgical technique, especially for teenagers for whom sigmoid resection can be avoided.