Gastric Pull-up: A Back-up Surgical Solution in the Treatment of Large Hiatal Hernias.

The laparoscopic treatment of the hiatal hernias is nowadays the standard procedure. However, due to the volume and the age of the affliction, there are some situations in which the classical approach is indicated. The latter is associated with specific risks. The appearance of some intra-operatory incidents or accidents could lead to changes in the tactics and the techniques, moreover the abandon of the classical procedure and the use of alternative solutions. These procedures are meant to solve the case with minimum negative effects on the patient. This article presents the case of a 62 year-old female patient, diagnosed with a large type II hiatal hernia on which the surgical team had to intervene through a median xypho-umbilical laparotomy. During the attempt to perform the Nissen procedure, the irreversible lesion of the abdominal esophagus occurred, the esophageal wall having already suffered because of the esophagitis. This led to the restoring of the gastric continuity using the gastric pull-up technique and a cervical anastomosis. The remaining esophagus was removed during the second procedure, 3 moths later. The immediate and the late evolution of the patient was excellent.

[Videomediastinoscopic transcervical approach of postpneumonectomy left main bronchial fistula]. / Abordarea cervicala video-mediastinoscopica a fistulei de bont bronsic post-pneumonectomie stânga.

Bronchopleural fistulas and empyema are the most devastating complications after lung resection. The optimal management remains a major subject of controversy for thoracic surgeons over the wide variety of therapeutic approaches, none suitable for all patients. In 1996 Azorin et al. reported the first successful mediastinoscopic reclosure by stapling of an insufficient bronchial stump after left pneumonectomy using video-assisted mediastinoscopy. The authors report the first national case of left-sided bronchopleural fistula closure using video-assisted mediastinoscopy, describing their experience with this technique. A 40 years old woman presented to our unit with left thorax empyema after having undergone left pneumonectomy for TB destructed lung with aspergillosis in another hospital. Bronchoscopy revealed a 15 mm long bronchial stump with insufficiency. Despite all advances made over the last decades in perioperative management, bronchopleural fistula after pneumonectomy remains a significant problem in thoracic surgery. Video-mediastinoscopy is an alternative to the open methods as it allows approaching the bronchial stump via the mediastinum. The dissection of the trachea through its natural route enables bronchial mobilization. Positive factors influencing our decision were the virgin mediastinum with no surgical dissection and no radiation therapy applied. The mediastinoscopic approach for bronchial stump closure after pneumonectomy is a novel option in highly selected patients. This is our choice for a long (at least 10 mm) bronchial stump because its morbidity is minimal compared with transpericardial sternotomy or a transthoracic approach. It warrants minimal surgical trauma; however, skilled surgeons with experience in mediastinoscopy have to be prepared to convert to an open technique immediately.

[Sleeve resection of right main bronchus for posttraumatic bronchial stenosis]. / Rezectie bronhoanastomoza de bronhie primitiva dreapta cu prezervare pulmonara totala pentru stenoza post-traumatica.

INTRODUCTION: Tracheobronchial disruption is one of the most severe injuries caused by blunt chest trauma. A high index of clinical suspicion and accurate interpretation of radiological findings are necessary for prompt surgical intervention with primary repair of the airway. Delays in treatment increases the risk of partial to complete bronchial stenosis. CASE REPORT: A 21 years old male was admitted to our hospital following a workplace accident. A chest radiograph showed bilateral pneumothorax, cephalic and mediastinal emphysema. Chest tubes were placed on each side, with full pulmonary expansion and remission of emphysema. Minimal lesions of the right main bronchus were found at fiberoptic bronchoscopy. Daily chest X-rays showed an uncomplicated recovery. A stenosis was suspected due to right lung pneumonia evolving under specific antibiotherapy. Right main bronchus posttraumatic stricture was diagnosed by fiberoptic bronchoscopy. He underwent a right lateral thoracotomy with sleeve resection of stenotic bronchi. Control bronchoscopy reveals main bronchus widely patent with untraceable suture line. DISCUSSION: Main bronchus rupture in blunt chest trauma is an additive effect of chest wall compression between two solid surfaces, traction on the carina and sudden increase in intraluminal pressure. Symptoms may vary: soft air leak, pneumothorax or limited mediastinal emphysema. Bronchoscopy should be performed immediately or when available. Granulation tissue leads to progressive bronchial obstruction, with distal infection and permanent parenchymal damage. Sleeve resection of the stenosed segment is the treatment of choice and restores fully the lung function. CONCLUSION: Rupture of main bronchus is a complication of blunt chest trauma. Flexible bronchoscopy is useful and reliable for early diagnosis of traumatic tracheobronchial injuries. Delayed diagnosis can lead to lung parenchyma alteration due to retrostenotic pneumonia. Resection and end-to-end anastomosis is the key of successful in these cases.