Unraveling the spectrum of inflammatory myofibroblastic tumors in the lung: A comprehensive case series highlighting endobronchial, pleural, and lung parenchymal tumors.

Objectives: Diverse cases of inflammatory myofibroblastic tumors (IMTs) in the lung (pleural, endobronchial, and parenchymal) are presented while discussing the (preoperative) diagnostic challenges and treatment modalities. Other objectives include emphasizing the significance of gene rearrangements and highlighting the multidisciplinary approach in addressing IMTs. Methods: Four cases of IMT in the lung are presented, including a young adolescent girl with an ETV6-neurotrophic tyrosine receptor kinase 3 (NTRK3) gene rearrangement, a 5-year-old boy with challenging preoperative diagnosis, and 2 middle-aged women with respectively pleural and endobronchial tumors with one peribronchial relapse. Results: The cases demonstrate the diverse clinical presentations and diagnostic complexities associated with IMT in the lung. Surgical resection remains the primary treatment modality, with complete resection leading to a cure in most patients. Unfortunately, aggressive relapse can occur, as in our last case of an endobronchial tumor. Frozen section may confirm the presence of malignant cells perioperatively and impact further treatment. The presence of gene rearrangements, such as ETV6-NTRK3, suggests potential therapeutic implications. Conclusions: Early detection and complete surgical removal of IMT are crucial for effective treatment. Identifying gene rearrangements such as ETV6-NTRK3 holds promise for targeted therapies. Diagnostic challenges, including the controversy of biopsies and preoperative evaluations, underscore the importance of a multidisciplinary approach. Anatomopathological recognition of IMT stays demanding. Close surveillance is necessary due to potential relapse, whereas frozen section perioperatively can help further treatment. This case series emphasizes the diagnostic challenges and therapeutic considerations for IMT in the lung.

Refractory chylothorax after severe vomiting and coughing in a 4-year-old child.

Chylothorax is the accumulation of lymphatic fluid in the pleural space. It is a rare condition with potentially life-threatening disorders. In children, the etiology of chylothorax can be mainly attributed to idiopathic factors, congenital, miscellaneous, trauma and malignancies. Conservative treatments can solve most chylothorax, but refractory chylothorax can be challenging to manage. We herein present the case of a 4-year-old girl with no previous medical history who was admitted to our institution after severe vomiting and right chylothorax. The etiological assessment could not identify specific causes. Initial treatment was conservative but after 14 days, the patient showed no improvement. An exploratory thoracoscopy using indocyanine green showed no active leaks. Pleurodesis was performed and, later on, ligation of the ductus thoracicus. Hereafter, the patient progressed favorably. Even though conservative treatments of chylothorax show a high success rate, the efficacy of additional therapies and the benefits between surgical procedures need further investigation.

Percutaneous tracheostomy for long-term ventilated COVID-19-patients: rationale and first clinical-safe for all-experience.

INTRODUCTION: COVID-19 infection has resulted in thousands of critically ill patients admitted to ICUs and treated with mechanical ventilation. Percutaneous tracheostomy is a well-known technique utilised as a strategy to wean critically ill patients from mechanical ventilation. Worldwide differences exist in terms of methods, operators, and settings, and questions remain regarding timing and indications. If tracheostomy is to be performed in COVID-19 patients, a safe environment is needed for optimal care. MATERIAL AND METHODS: We present a guidewire dilating forceps tracheostomy procedure in COVID-19 patients that was optimised including apnoea-moments, protective clothing, checklists, and clear protocols. We performed a retrospective analysis of the outcome after tracheostomy in COVID-19 patients between March 2020 and May 2020. RESULTS: The follow-up of the first 16 patients, median age 62 years, revealed a median intubation time until tracheostomy of 18 days and median cannulation time of 20 days. The overall perioperative complication rate and complication rate while cannulated was 19%, mainly superficial bleeding. None of the healthcare providers involved in performing the procedure developed any symptoms of the disease. CONCLUSIONS: This COVID-19-centred strategy based on flexibility, preparation, and cooperation between healthcare providers with different backgrounds facilitated percutaneous tracheostomy in COVID-19 patients without an increase in the overall complication rate or evidence of risk to healthcare providers. Our findings provide initial evidence that tracheostomy can be performed safely as a standard of care for COVID-19 patients requiring prolonged mechanical ventilation as was standard practice in ICU patients prior to the COVID-19 pandemic to promote ventilator weaning and patient recovery.

An air-containing mediastinal mass in a patient with a primary adenocarcinoma of the right lung.

Objective: The following case report elicits the treatment of a 55-year-old male who was diagnosed with a surinfected mediastinal chyloma as a complication of mediastinoscopy and radiotherapy for a primary adenocarcinoma of the right lung (cT2aN2M0). Methods: The patient was admitted to the hospital after radiographical imaging showed a surinfected mediastinal chyloma. CT-guided percutaneous drainage was performed and via gastroscopy a fistula was diagnosed for which a full covered stent was placed. Then, a right thoracotomy was performed to wash out the chylous cavity, to seal the thoracic duct and to cover the other end of the fistula with an intercostal muscle flap. Results: Postoperative imaging showed a clear reduction of the mediastinal mass with no residual air-fluid level. Realimention was possible three days after placement of the stent. The patient was discharged after 11 days. There was no recurrence of the chyloma. Fistulisation did recur after removal of the stent. Conclusion: Surinfected mediastinal chyloma due to oesopagho-mediastinal fistula is an extremely rare complication after cervical mediastinoscopy and radiotherapy. Open drainage of the chyloma and total coverage of the fistula can control infection and prevent recurrence on short term.

Air leaks localized with lung ventilation SPECT.

A 61-year-old man with severe chronic obstructive pulmonary disease presented to our hospital with recurrence of a right-sided spontaneous secondary pneumothorax. Thoracoscopic abrasion of the parietal pleura was performed, but an important air leak persisted. Presumed to originate from a bulla in the right upper lobe, bullectomy and pleural decortication were performed, but leakage remained. Lobectomy was considered, and quantitative ventilation/perfusion SPECT was performed to predict the functional outcome.Fused high-resolution CT/Tc Technegas images localized leakage not only to a bleb in the right upper lobe but also to the subcutaneous emphysema in the thoracic wall. The air leak resolved after conservative treatment.

Origin and propagation of the slow wave in the canine stomach: the outlines of a gastric conduction system.

Slow waves are known to originate orally in the stomach and to propagate toward the antrum, but the exact location of the pacemaker and the precise pattern of propagation have not yet been studied. Using assemblies of 240 extracellular electrodes, simultaneous recordings of electrical activity were made on the fundus, corpus, and antrum in open abdominal anesthetized dogs. The signals were analyzed off-line, pathways of slow wave propagation were reconstructed, and slow wave velocities and amplitudes were measured. The gastric pacemaker is located in the upper part of the fundus, along the greater curvature. Extracellularly recorded slow waves in the pacemaker area exhibited large amplitudes (1.8 +/- 1.0 mV) and rapid velocities (1.5 +/- 0.9 cm/s), whereas propagation in the remainder of the fundus and in the corpus was slow (0.5 +/- 0.2 cm/s) with low-amplitude waveforms (0.8 +/- 0.5 mV). In the antrum, slow wave propagation was fast (1.5 +/- 0.6 cm/s) with large amplitude deflections (2.0 +/- 1.3 mV). Two areas were identified where slow waves did not propagate, the first in the oral medial fundus and the second distal in the antrum. Finally, recordings from the entire ventral surface revealed the presence of three to five simultaneously propagating slow waves. High resolution mapping of the origin and propagation of the slow wave in the canine stomach revealed areas of high amplitude and rapid velocity, areas with fractionated low amplitude and low velocity, and areas with no propagation; all these components together constitute the elements of a gastric conduction system.

Septic shock in digestive surgery: a retrospective study of 89 patients.

BACKGROUND/AIMS: septic shock is the most severe systemic inflammatory response to infection. Septic shock is associated with organ dysfunction and with major circulatory failure. The aim of this work is to study the impact of septic shock in digestive surgery. This is a retrospective study. METHODOLOGY: Between January 2001 and March 2008, we selected patients hospitalized in the intensive care unit who underwent digestive surgery and who developed septic shock during the same hospitalization were selected: 89 patients were enrolled in this group which included 53 men and 36 women (sex ratio M/W 1.47), and the age average was 71.5 years. They were divided into two subgroups: preoperative septic shock (62/89) and postoperative (27/89). The majority of septic shock occurred in patients who developed an inflammatory disease and an organ perforation. Esophagogastric surgery generates the most postoperative septic shock. RESULTS: The overall mortality was 54%. The most frequent complications were digestive and pulmonary. The germ most frequently encountered is Escherichia coli. The majority of patients received a combination of two or three antibiotics. The empirical antibiotic therapy most frequently administered was a combination of piperacillin/ tazobactam and amikacin. DISCUSSION: The results observed in the present study are, for the most part, in agreement with those found in the literature. However, the question of the most effective antibiotic therapy remains open. CONCLUSION: In digestive surgery, septic shock is pathology with significant mortality (54%). The germ most frequently responsible is Escherichia coli. The most frequently administered empirical antibiotic therapy is a combination of amikacin and piperacillin.

Focal activities and re-entrant propagations as mechanisms of gastric tachyarrhythmias.

BACKGROUND & AIMS: Gastric arrhythmias occur in humans and experimental animals either spontaneously or induced by drugs or diseases. However, there is no information regarding the origin or the propagation patterns of the slow waves that underlie such arrhythmias. METHODS: To elucidate this, simultaneous recordings were made on the antrum and the distal corpus during tachygastrias in open abdominal anesthetized dogs using a 240 extracellular electrode assembly. After the recordings, the signals were analyzed, and the origin and path of slow wave propagations were reconstructed. RESULTS: Several types of arrhythmias could be distinguished, including (1) premature slow waves (25% of the arrhythmias), (2) single aberrant slow waves (4%), (3) bursts (18%), (4) regular tachygastria (11%), and (5) irregular tachygastria (10%). During regular tachygastria, rapid, regular slow waves emerged from the distal antrum or the greater curvature, whereas, during irregular tachygastria, numerous variations occurred in the direction of propagation, conduction blocks, focal activity, and re-entry. In 12 cases, the arrhythmia was initiated in the recorded area. In each case, after a normal propagating slow wave, a local premature slow wave occurred in the antrum. These premature slow waves propagated in various directions, often describing a single or a double loop that re-entered several times, thereby initiating additional slow waves. CONCLUSIONS: Gastric arrhythmias resemble those in the heart and share many common features such as focal origin, re-entry, circular propagation, conduction blocks, and fibrillation-like behavior.

Benign retroperitoneal schwannoma presenting as colitis: a case report.

We report a case of a patient presenting with clinical, radiological and endoscopic features of colitis due to a compressive left para-aortic mass. Total open surgical excision was performed, which resulted in complete resolution of colitis. Histopathology and immunohistochemistry revealed benign retroperitoneal schwannoma. These neural sheath tumors rarely occur in the retroperitoneum. They are usually asymptomatic but as they enlarge they may compress adjacent structures, which leads to a wide spectrum of non-specific symptoms, including lumbar pain, headache, secondary hypertension, abdominal pain and renal colicky pain. CT and MR findings show characteristic features, but none are specific. Schwannoma can be isolated sporadic lesions, or associated with schwannomatosis or neurofibromatosis type II (NF2). Although they vary in biological and clinical behavior, their presence is, in nearly every case, due to alterations or absence of the NF2 gene, which is involved in the growth regulation of Schwann cells. Both conditions were excluded by thorough mutation analysis. Diagnosis is based on histopathological examination and immunohistochemistry. Total excision is therapeutic and has a good prognosis. Schwannomatosis and NF2 should be excluded through clinical diagnostic criteria. Genetic testing of NF2 is probably not justified in the presence of a solitary retroperitoneal schwannoma.

Laparoscopic appendectomies: results of a monocentric prospective and non-randomized study.

BACKGROUND/AIMS: Appendicitis is one of the most frequent causes of abdominal pain in western countries. It occurs in 6 to 7% of the United States population. Despite laboratory and imagery tests, 15 to 40% appendices removed by laparotomy appear to be normal at histological examination. Thus, others pathologies beside appendicitis may be found in patients with right lower quadrant pain. This had led some to advocate laparoscopy for patients suspected to have acute appendicitis. The aim of this study is to determine the contribution of laparoscopy in patients with right lower quadrant pain and the implications of removing a macroscopic normal appendix. Rates of all pathologies and normal appendices were found at laparoscopy. Morbidity, mortality rates and length of hospital stay linked to laparoscopic appendectomy. DESIGN: Prospective non-randomized study. METHODOLOGY: Between January 1995 and September 2004, 615 patients have been approached by laparoscopy for acute, subacute or chronic abdominal right-lower-quadrant pain in our Department of Digestive and Laparoscopic Surgery. Thirteen patients have not been hold and the study involves 602 patients including 311 men and 291 women with a mean age of 33 years. All removed tools have been analyzed histologically. During the same period, only 5 patients have been approached by laparotomy. RESULTS: Five hundred and thirty patients (88%) had appendicitis, 39 patients (6.5%) had another pathology and no disease was found in 33 patients (5.5%). According to the sex, appendicitis was found in 242 women (83.2%) versus 288 men (92.6%). Thirty-four women (11.7%) versus 5 men (2%) had another pathology. The local morbidity was 4.3%, the general morbidity 1% and the mortality was 0%. The average length of postoperative hospital stay was 4 days (range: 1-27). Oral intake was assumed on average 1.5 days postoperatively (range: 0-13). There were 10 reoperations (1.6%). CONCLUSIONS: Laparoscopy is a reliable technique, safe and reproducible. It is an effective and relatively atraumatic tool to investigate abdominal cavity. This allows an accurate decision-making, which is especially advantageous in young women who have a high rate of non-appendicular pathologies. Laparoscopy also reduces the rate of unnecessary abdominal exploration while realizing a correct diagnosis of others possible pathologies. We therefore advocate laparoscopy in patients with abdominal right-lower-quadrant pain, especially women.

The effects of cholinergic stimulation and of nucleoside transport inhibition on spikes and spike patches in the canine small intestine in vivo.

Muscarinic agonists are known to enhance small intestinal contractions. A similar effect was also seen in pilot experiments with a nucleoside transport inhibitor. However, there is no information on their effects on the spatial pattern of action potential propagation. In an anesthetized, open-abdomen, canine (n=8) model, the propagation patterns of the slow wave and the ensuing action potentials (= spikes) were recorded before and during the i.v. administration of bethanechol or nucleoside transport inhibitor. Vehicle injections in 8 dogs served as controls. Electrical recordings were made using a 240-electrode array positioned on a 5-cm segment of the jejunum in situ. The incidence and the propagation of the action potentials were analyzed. Bethanechol dose-dependently increased the number of both longitudinally and circumferentially propagating spikes per slow wave. As during control, spikes in bethanechol propagated for a limited distance before terminating spontaneously, thereby exciting only a limited area (= patch). However, bethanechol did not change the size of the longitudinal spike patches (18.8+/-6.9 mm(2) at baseline and 25.0+/-18.6 mm(2) at 0.5 mg/kg) nor of the circular spike patches (90.0+/-41.2 mm(2) at baseline and 95.4+/-36.5 mm(2) at 0.5 mg/kg). The nucleoside transport inhibitor increased the occurrence of circular spikes in a step-wise fashion (>or=0.5 mg/kg). The size of the nucleoside transport inhibitor-induced circular spike patches (136.6+/-46.8 mm(2)) was larger than those during baseline or muscarinic stimulation. Muscarinic agonists stimulate small intestinal contractility by inducing more action potentials, which in turn would trigger increased calcium release from intracellular stores. On the other hand, nucleoside transport inhibition enhances contractility by increasing both the number and the size of the circular spike patches.