Transcervical Mediastinoscopic Closure of Left-Sided Postpneumonectomy Bronchial Stump Fistula.

INTRODUCTION: This article presents a series of patients on which the transcervical approach was used to close a left-sided postpneumonectomy fistula. MATERIALS AND METHODS: The series comprises nine patients with a left pneumonectomy performed for a tuberculosis-related suppurative disease in five cases and for lung cancer in the remaining four. This procedure can be performed under certain conditions, the most important one being the length of the bronchial stump, which should be at least 1 cm, ideally 1.5 cm. The transcervical stump closure was successfully achieved in all patients, having been more technically demanding in cancer cases with previous lymphadenectomy. The postpneumonectomy infected cavity was subsequently treated. RESULTS: The follow-up continued for at least 1 year; one individual from the cancer patients group died from an uncontrolled sepsis during the postoperative period, another one died 17 months later from metastatic cancer and two of them are alive, with no signs of neoplastic or infectious relapse 15 and 37 months, respectively, after the cervical procedure. One patient from the suppurative disease group had a relapse of the fistula 2 months after surgery, requiring additional surgical procedures to deal with this issue; all the other patients are alive, with no signs of recurrence. CONCLUSIONS: The transcervical approach is a very suitable maneuver in selected patients with a bronchial stump at least 1 cm long, ideally 1.5 cm.

Thoracic endometriosis with a long delay in diagnosis.

This paper describes a case of thoracic endometriosis in 36-year-old woman with a long delay in diagnosis. At the admission in the hospital, the patient had a medical history of persistent dysmenorrhea since the age of 13, infertility and an episode of total right pneumothorax two months ago successfully resolved by minimum pleurotomy of the right hemitorax. She came with moderate pain on right hemithorax and dyspnea, which occurred on the first day of menstruation but she did not have any other respiratory symptoms such as hemoptysis, cough. Radiological imaging (chest radiography and computer tomography) at the time of admission confirmed recurrence of the right pneumothorax. She underwent surgical treatment of the right pneumothorax using a single-port video-assisted approach. Intraoperative macroscopic lesions were found catamenial pneumothorax characteristic diagnosis and biopsy material taken (parietal pleura) for histopathology. Immuno-histochemical tests confirmed the diagnosis of thoracic endometriosis. The gonadotropin-releasing hormone analogue was received by the patient early after surgery and there was no clinical or radiological recurrence at a four months follow-up.

[Complex case with respiratory, endocrine and digestive manifestations--late complications after a colic replacement of the esophagus for lye ingestion]. / Caz complex cu tulburari respiratorii, endocrine si digestive--complicatii tardive post-esofagoplastie cu colon pentru ingestie de soda caustica.

Long term complications after colic replacement of the esophagus are well known and their managment is known as being difficult, due to multiple associated comorbidities; we present the case of a 26-year-old patient with multiple late complications after a coloesophagoplaty for lye ingestion during childhood. The patient finally died despite all the eforts of treatement during a prolonged hospitalisation. We will try to analyse the key moments on patient's evolution and discuss other possible options in this case.

Main bronchial stenosis--sequel of delayed diagnosis after posttraumatic bronchial injury.

Bronchial ruptures due to blunt chest traumas are rarely encountered injuries and frequently late diagnosed. Once the diagnostic is established by bronchoscopy surgical treatment is mandatory and usually, the results are very good. In order to conserve as much as possible lung parenchyma minimal possible resection is required. We present four cases managed in our department by means of main bronchial sleeve resection--two on the right side and two on the left side--with good outcome. We were able to save the entire lung in all four cases despite long-term atelectasis.

[Role of surgery in small cell lung cancer]. / Rolul chirurgiei în tratamentul cancerului bronhopulmonar cu celule mici.

Role of surgery in small cell lung cancer Small-cell lung cancer (SCLC) is a very aggressive neuroendocrine carcinoma that accounts for approximately 10-15% of all lung cancer cases. This histological subtype is a distinct entity with biological and oncological features differing from non-small cell lung cancer (NSCLC). Standard treatment is performed using systemic chemotherapy, and surgery in association with chemotherapy and radiotherapy may be indicated for a minor proportion of cases with limited disease. Since the results after surgical intervention in patients with very early disease are comparable to those for NSCLC, careful staging is required, especially in terms of nodal involvement- use of PET-CT EUS, EBUS and/ or mediastinoscopy is recommended. However, only two randomized control studies have examined the efficacy of surgery in SCLC, and both yielded negative results and are out of date. We review here several studies concerning surgery for SCLC and discuss the results from a practical standpoint.

[Aspects of the surgical treatment in plurivisceral echinococcosis--case report]. / Aspecte ale tratamentului chirurgical in echinococoza pluriviscerala---prezentare de caz.

Hydatid disease remains endemic in many parts of the world, most notably the Mediterranean region, Australia, New Zealand, the Middle East, and South America. Plurivisceral echinococcosis is defined as the concomitant or successive presence of hydatidosis in more than one internal organ. It has been noticed that the number of cases with multi-organ localizations and multiple cysts has increased in the last years. As the surgery of plurivisceral echinococcosis remains one of the challenges for the medical world, in this article we present our experience during 2000-2007 with this disease, followed by a case report of one of the most special cases of echinococcosis, discussing the principles of treatment, along with a new classification of this disease. Plurivisceral echinococcosis is associated with higher postoperative morbidity and mortality than uncomplicated cysts, related to organ involvement and surgical treatment. In the sequential approach we recommend resolving first surgically the complicated cysts or those at risk. In the thoracic and abdominal locations, the thoracic cysts will be approached first. The treatment methods will be as conservative as possible. Management of pulmonary and hepatic cysts (diaphragmatic side) simultaneously through the thoracic route is convenient and should be encouraged in patients because this prevents a second operation.

[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.

[Tracheal stenosis--diagnostic and therapeutic principles, results]. / Stenozele traheale--principii de diagnostic si tratament, rezultate.

Between November 2001-April 2010, 107 tracheal resections were performed in our department for different types of tracheal stenosis: iatrogenic or tumoral, benign or malignant. We present the diagnosis and treatment principles that we used, along with our results. We operated on 74 (69.15%) iatrogenic postintubation tracheal stenosis, 6 (5.6%) of them complicated with tracheo-esophageal fistula, 6 (5.6%) benign tumors, 11 (10.28%) primary malignant and 16 (14.97%) secondary malignant ones, with a 3.8% total mortality. Tracheal resection and reconstruction is the only curative treatment for all types of tracheal stenosis. Interventional endoscopy is of a major importance in the assessment and treatment of tracheal stenosis. We believe that each patient diagnosed with a tracheal stenosis should be referred to a tertiary center with multidisciplinary experience in the treatment of tracheal stenosis.

[Remediastinoscopy--current indications. A case report]. / Remediastinoscopia--indicatii actuale. Prezentare de caz.

Current indications for remediastinoscopy include an inadequate first procedure, recurrent and second primary lung cancer, lung cancer occurring after an unrelated disease such as lymphoma, and restaging after induction therapy. Nowadays, restaging is the most frequent indication for remediastinoscopy. We present the case of a 42 years old male with a mediastinoscopy performed in another surgical unit 4 months before being admitted in our department. The CT scan showed bulky mediastinal lymph node enlargement, in evolution compared with the prior one, and no other lesions in the lung parenchyma. As the histopathological examination from the first specimen was negative, a diagnosis was requested in order to allow a correct treatment. A remediastinoscopy was successfully performed and avoided a more invasive procedure.

[Complications of mediastinoscopy]. / Complicatiile mediastinoscopiei.

Mediastinoscopy is a minimum invasive investigation representing a reference in mediastinum exploration and having a major role regarding therapeutic strategies in patients with lung cancer or other mediastinal pathology. Research studies show that this surgical intervention, although having in reality low morbidity and mortality (0.6-3.7% morbidity and 0.2% mortality), is potentially dangerous in non properly trained hands. Mediastinoscopy related complications appear as a consequence of the following: (1) incision and access path; (2) surgical maneuvers and are also general complications as in any other surgical approach related to anesthesiology act or postoperative recovery course. The most frequent complications are surgical-related: hemorrhage, recurrent palsy, pneumothorax, tracheal laceration, esophageal lesions, wound dehiscence or anesthesiology-related such as: cardiac arrest and respiratory hypoxia, various arrhythmias, cerebral insufficiency, amaurosis fugax. From all the complications only 0.1-0.5% have clinical significance, the most dreadful remaining massive hemorrhage, which requires a trained team with a very well equipped operating theatre for thoracic, vascular and cardiac surgery. Frequently in cure and prevention of such disastrous events a close cooperation between radiologist, oncologist, surgeon is required (for method limits) and anesthesiologist and from a different perspective with the bronchologist, pneumologist and gastro-enterologist. In trained hands and in teaching hospitals mediastinoscopy remains the golden standard in mediastinal evaluation, a simple procedure, with low morbidity and mortality.

[Thoracoscopic sympathectomy for arterial ischemia of the upper extremities: a case report]. / Simpatectomia toracoscopica în tratamentul ischemiei arteriale a membrului superior: prezentare de caz.

INTRODUCTION: Thoracoscopic surgery reduce the morbidity of sympathectomy. Major indications of video-assisted sympathectomy (VAT) include hyperhidrosis, Raynaud's disease, causalgia, and reflex sympathetic dystrophy. Because little information is available in the national and international literature VAT sympathectomy in the treatment of upper extremities ischemia, we decided to present our first case. CLINIC CASE: The 38 years old patient was hospitalized for left upper-extremity ischemia (Raynaud's syndrome). Thoracoscopic sympathectomy was performed with resection of the main trunk proximally immediately after the stellate ganglion and distally at the level of T4 and identification and resection of 2 collateral branches of the sympathetic chain T2-T3. RESULTS: The postoperative evolution demonstrated evident clinical benefit. The thermography performed postoperative showed hyperthermia and hyper-vascularization in the left hemithorax with a difference of temperature of 2 degrees C between the two sides of the thorax. COMMENT: Before the advent of VAT, thoracic sympathectomy was performed only in highly selected patients because of its invasiveness. Now VAT sympathectomy is considered in most cases as the last resort to prevent extensive and successive amputation. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier in the natural course of this disease.