Extraluminal Obstruction Research Articles

Difference in the Overall Survival Between Malignant Central Airway Obstruction Patients Treated by Transbronchial Microwave Ablation and Stent Placement: A Single-institution Retrospective Study.

Transbronchial microwave ablation (MWA) can be performed safely in patients with malignant central airway obstruction (MCAO), under moderate sedation and a high fraction of inspired oxygen. We retrospectively evaluated the difference in the overall survival (OS) after transbronchial interventions (TBIs) between MCAO patients with endoluminal or mixed-type obstruction who were treated by MWA (MWA group, n=34) and those with extraluminal obstruction who were treated by stent placement (STP) (STP group, n=27). The OS was longer in the MWA group than in the STP group (10.2 months vs. 4.5 months, p=0.001). A significant difference in the OS between the two groups was observed in the patients who received post-TBI anticancer therapy (27.2 months vs. 6.0 months, p=0.002). The OS tended to be longer in the MWA group than in the STP group, among the patients who received best supportive care alone (3.8 months vs. 1.8 months, p=0.068). Nine patients (26%) of the MWA group underwent additional MWA when tumor regrowth into the airway lumen was noted (median of TBI sessions, 3). Multivariate analysis identified the adoption of MWA as the initial treatment procedure to be independently associated with a reduced risk of death in patients with MCAO (hazard ratio=0.473, p=0.031). Adoption of MWA as the initial treatment procedure is beneficial in MCAO patients with endoluminal or mixed-type obstruction, regardless of whether patients receive post-TBI anticancer therapy or not.

AN UNUSUAL CAUSE OF SECONDARY SPONTANEOUS PNEUMOTHORAX

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Secondary spontaneous pneumothorax (SSP) is defined as a non-traumatic pneumothorax in patients with underlying lung disease. They are commonly seen in patients with conditions such as chronic obstructive pulmonary disease, cystic fibrosis, infection, and cancer. While it is widely recognized that tuberculosis (TB) can cause SSP, estimates suggest less than 1% of TB cases are complicated by SSP. This case describes a rare initial presentation of TB. CASE PRESENTATION: A 41-year-old woman from Mexico presented with acute onset sharp left-sided chest pain. She had been having pneumonia symptoms (cough, chills, sputum production) for four months and took several courses of oral antibiotics with no improvement. She had no prior episodes of pneumonia, tuberculosis or other infections, and had no sick contacts. On presentation, she was afebrile, tachycardic, tachypneic and mildly hypoxic with decreased breath sounds on the left. A chest radiograph showed a large left-sided pneumothorax, and a 14-French pigtail chest tube was placed. Computed tomography of the chest showed bronchiectasis and cystic changes with large cavitation. Sputum acid-fast bacilli staining as well as mycobacterium tuberculosis (MTB) polymerase chain reaction returned positive. She was diagnosed with secondary spontaneous pneumothorax, and RIPE therapy was initiated. The chest tube was connected to suction which produced a continuous air leak which improved when the tube was connected to water seal, raising concern for a bronchopleural fistula. The air leak persisted for 14 days, and thus she was evaluated by thoracic surgery who ultimately performed a lobectomy. DISCUSSION: This case illustrates an unusual initial presentation of tuberculosis – this patient had an SSP from underlying bronchiectasis as well as a bronchopleural fistula. Mycobacterial infections (classically, non-tuberculous mycobacterium) often complicate pre-existing bronchiectasis. MTB itself can cause bronchiectasis from longstanding tuberculous bronchitis, post-obstructive damage secondary to post-tuberculous bronchial wall stenosis, and extraluminal bronchial obstruction by enlarged tuberculous lymph nodes. This patient had no symptoms of longstanding lung disease, and a basic workup for other causes of bronchiectasis returned normal, leaving MTB as the most likely reason for her abnormal lung architecture. The acute onset SSP triggered her eventual presentation to the hospital. It is estimated that SSP complicates between 0.6% and 1.5% of cases of tuberculosis. In one series, patients with SSP from MTB were safely treated with pleural drainage for an average of 13 days (ranging from 4 - 54 days). 28% of patients required surgery for persistent air leak, as did this patient. CONCLUSIONS: SSP is a potentially fatal complication of MTB that typically responds well to pleural drainage and RIPE therapy. Surgery may be needed for continuous air leaks. REFERENCE #1: Freixinet JL, Caminero JA, Marchena J, Rodríguez PM, Casimiro JA, Hussein M. Spontaneous pneumothorax and tuberculosis: long-term follow-up. Eur Respir J. 2011;38(1):126-131. doi:10.1183/09031936.00128910 REFERENCE #2: Doucette K, Cooper R. Tuberculosis. In: Grippi MA, Elias JA, Fishman JA, Kotloff RM, Pack AI, Senior RM, Siegel MD. eds. Fishman's Pulmonary Diseases and Disorders, Fifth Edition. McGraw-Hill; Accessed April 22, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=1344§ionid=81199723 REFERENCE #3: Burguete S, DeArmond DT, Soni NJ, Peters J. Pneumothorax. In: Grippi MA, Elias JA, Fishman JA, Kotloff RM, Pack AI, Senior RM, Siegel MD. eds. Fishman's Pulmonary Diseases and Disorders, Fifth Edition. McGraw-Hill; Accessed April 29, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=1344§ionid=81193412 DISCLOSURES: No relevant relationships by Ethan Loftspring, source=Web Response No relevant relationships by Dharani Kumari Narendra, source=Web Response No relevant relationships by Divya Verma, source=Web Response

Surgical Excision of Perirectal Melanoma in the Horse. 3 Cases

Equine melanoma is one of the most common skin neoplasms encountered in equine practice. Surgical excision of melanocytic tumors is a viable treatment option and is considered to be locally curative. In the literature, information regarding surgical removal and long-term outcome of perirectal melanomas is limited. A total of three cases were included in this report, all presented with large perirectal melanomas, infiltrating the retroperitoneal musculature, leading to extra-luminal obstruction of the rectum. Horses were showing signs of dyschezia and tenesmus, secondary to rectal fecal impaction. Rectal palpation and transrectal ultrasonography aided in assessing the depth and size of the masses, as well as tumor invasion into the rectal wall. Tumor biopsy by fine needle aspiration was used to confirm the diagnosis. All horses underwent surgical excision of the masses to permanently alleviate clinical signs. In one horse, complete incision and reconstruction of the rectal wall was necessary in order to excise the whole tumor. Although surgery was successful in all three horses, one of them had to be euthanized 5 days after surgery, as clinical signs persisted. The aim of this report was to extensively describe the surgical approach, pre-operative considerations and postsurgical complications associated with surgical excision of perirectal melanoma in the horse.

Extraluminal oesophageal stricture following traumatic diaphragmatic hernia repair in a cat

A one-year six-month-old male neutered domestic shorthaired cat was presented for regurgitation of increasing severity, 10 days following surgical repair of a suspected traumatic diaphragmatic hernia. Diaphragmatic hernia repair had...

Uncommon Causes of Pyloric and Duodenal Obstruction in Pediatric Population: Radiological and Surgical Correlation

Abstract Background: Duodenal and pyloric obstruction in neonates and young children have diverse causes such as atresia, volvulus, and foreign body or may be extra-luminal obstruction. Aim of Study: To assess causes of pyloric and duodenal obstruction in pediatric population (other than CHPS) and determine the causes of obstruction radiologically and compare them with surgical data. Patients and Methods: Our study included 22 patients (12 boys and 10 girls), age range from 1 day to 6 years. This study was done on cases of pyloric and duodenal obstruction in newborns, infants and young children less than 6 years in the period from 2017 through 2019. Cases of Congenital Hypertrophic Pyloric Stenosis (CHPS) were excluded from the study. The clinical, radiological data were gathered and compared to each other. Results: The spectrum of causes of pyloric and duodenal obstruction was as follow: 4 cases of pyloric atresia, 5 cases with duodenal atresia, 3 cases with duodenal stenosis by incomplete web, one case with annular pancreas, 4 cases with midgut volvulus, one case with duodenal duplication cyst, 3 cases with foreign body obstruction and one case with trichob-ezoar. All cases were treated surgically to alleviate the ob-struction. The radiological data were well correlated with surgical findings. Conclusion: Pyloric and duodenal obstruction in pediatric population has different causes. Radiological imaging could determine the cause of obstruction with good correlation with surgery.

Sugammadex Efficacy for Rapid Reversal of Rocuronium Induced Neuromuscular Blockade in Pediatric Rigid Bronchoscopy Regardless the Depth of Anesthesia

Background: Bronchoscopy may be either rigid or flexible. Rigid bronchoscopy is usually done for diagnosis and treatment of intra and/or extra luminal obstruction in the airway for adults and children, anaesthesia for bronchoscopy poses unique challenges for the anaesthesiologist. This procedure needs specific technical precision because both the anaesthesiologist and operator share the same working space, that is, the airway. Pediatric rigid bronchoscopy needs a deep level of general anesthesia with a good (profound) muscle relaxation for a short time, with the modern anesthetic muscle relaxant rocuronium Bromide and its unique rapid onset it gives chance to be used in challenging airway procedures like rigid bronchoscopy and with the its newly advent of selective reversal, sugamadex, encourage its use in pediatric rigid bronchoscopy as it is usually performed for Foreign body removal. Aim: The aim of this study is to compare the efficacy of sugammadex and neostigmine for reversal of neuromuscular blockade induced by rocuronium for facilitating interventional rigid bronchoscopy and having awake child with good adequate muscle power and good ability to protect airway reflexes. Methods: This study was done on 100 patients ASA1-11 underwent rigid bronchoscopy for foreign body aspiration, we compared the efficiency of both neostigmine and the newly selective reversal agent; sugamadex in recovery of the patients, hemodynamics, and the presence of any side effects. Results: Our results showed that no significant changes between two groups in Table 1, Table 2, Table 3 i.e. heart rate, arterial blood pressure and O2 saturation (%) during all period of study i.e. Base line, Strating study drug, 2 min, 5 min, 10 min. But in Table 4, Table 5, Table 6 i.e. Time (in min) from administration at study drug until recovery (TOF>0.9) , extubation time in min (from administration at study drug until extubation), Recovery time (from administration at study drug until Aldrete score more than 9) the time was significantly shorter in group (1) when compared with group (2) which was (3.6 ± 2.6, 3.9 ± 2.6 and 7.3 ± 1.9) in group (1) and (15.12 ± 1.85, 15.85 ± 1.85 and 19.59 ± 2.3) in group (2). In Table 7, there was no significant difference in the side effects between both groups. Conclusion: Sugammadex achieved significantly faster recovery of rocuronium-induced neuromuscular block when compared with neostigmine regardless the depth of anesthesia. Serious adverse events were less than 1% of patients in both sugammadex and neostigmine, and data showed no differences in risk of serious adverse events between groups. sugammadex was well tolerated.

The right hepatic artery syndrome – a rare cause of biliary obstruction

Various benign and malignant conditions could cause extraluminal biliary obstruction. Compression of extrahepatic bile duct by the anteriorly overriding right hepatic artery was reported as a right hepatic artery syndrome. On the best of our knowledge, only 7 cases of this entity were reported up to date. The authors present a case of the 54-yr male patient with clinical, laboratory, US and CT signs of hilar biliary obstruction, mimicking Klatskin tumor. During the surgery, right hepatic artery syndrome was confirmed by intraoperative cholangiography. Problem was solved by the careful dissection of the right hepatic artery and deliberation of the common bile duct. The patient remains symptom-free with normal clinical and laboratory data more than 5 years months after surgery.

Benign cystic teratoma of the mesosigmoid: Report of a case

Extragonadal intraperitoneal teratomas are very rare, especially those arising from mesentery and mesocolon. In the contemporary literature only 22 cases of such tumors have been published and described. We report a case of a 52-year-old woman with a benign cystic teratoma of the mesosigmoid. The patient presented with mild clinical signs of intestinal obstruction. Computerized tomography of the pelvis and abdomen showed a large 9.7 × 8.9 × 9.4 cm calcified tumor in the lower part of the left hemiabdomen. Extraluminal obstruction was verified by colonoscopy at 35 cm from the anal verge. Intraoperatively, a cystic calcified tumor of the mesosigmoid was found causing extraluminal obstruction of the left colon. The tumor was extirpated and a partial resection of the adherent great omentum was performed. The histopathological examination revealed a benign cystic teratoma. Considering the fact that mesenteric teratomas are extremely rare tumors, it is difficult to designate a general conclusion for an adequate treatment of patients suffering from them. Complete surgical excision is indicated in order to establish a correct histopathological diagnosis and to relieve the patients of symptoms.

Sequential use of cryoextraction postelectrocautery for airway recanalization using fiberoptic bronchoscopy

Airway obstruction presents with dyspnea, cough, hemoptysis, and atelectasis. Removing or decreasing the size of the obstructing lesions improves patient’s symptoms and life quality. Assessing the efficacy and safety of sequential use of cryoextraction and electrocautery in achievement of airway patency using fiberoptic bronchoscopy (FOB). This study was conducted at the Chest Medicine Department, Mansoura University, Egypt and included 22 patients with central airway obstruction (15 males and seven females) with a mean age of 50.5 ± 18.3 years. After etiologic diagnosis of airway obstruction, they were divided into two groups: group A (nonmalignant); eight patients and group B (malignant); 14 patients. All patients were subjected to sequential use of cryoextraction after electrocautery. Operable, unfit patients or patients with extraluminal obstruction were excluded. Clinical, radiological, functional, and bronchoscopic data were evaluated before and after FOB. The improvement in performance scale was highly significant in group B (P < 0.001) and significant in group A (P = 0.001). Spirometric parameters improved in both groups but were highly significant in group B (P < 0.001). Radiological improvement occurred in four out of eight of group A and in three out of 14 of group B. FOB score improved in group B (P = 0.003) and was more significant in group A. The procedure was complicated with atrial fibrillation and hemoptysis in one case and postbronchoscopy hypoxemia in two cases with no deaths. Cryoextraction after electrocautery using FOB are effective, safe, easy, and cheap in achieving airway patency. Egypt J Broncho 2015 9:269–275

Effect of Minimally Invasive Surgical Training Center on Laparoscopic Surgery: Observation from Preliminary Results for Primary Stomach GastroIntestinal Stromal Tumor in a Health Care System

Gastrointestinal stromal tumors (GISTs), are different from other mesenchymal tumors by immunohistochemistric biomarkers and are often encountered in the alimentary tract and less commonly originating from omentum, mesentery and peritoneum. They usually present as subepithelial tumors in the gastrointestinal tract or intraabdominal masses with malignant potential. The tumors might cause symptoms such as pain, intraluminal or extraluminal GI tract bleeding and obstruction but might also present as incidental findings. Gastroscopy, Ultrasonography and CT scan are employed for preoperative evaluation. The surgical principles are to excise the tumor with safe margin microscopically. Minimally invasive procedures are revolutionary innovation in surgery. Asian Institute of TeleSurgery training center is established in mid Taiwan in 2008 with the cooperation between Show Chwan Health Care System and European Institute of TeleSurgery in Strasbourg, France. We retrospectively reviewed 24 primary stomach GISTs operated at our institution in the past four years. The patients were divided into laparoscopy group (18 patients) and laparotomy group (6 patients) depending on the main surgical methods. The patients’ age, gender, hospital stay, operative time, blood loss, tumor size and complication rate were used for stastical analysis. There were significant differencesin tumor size and blood loss between the two groups with a p value of less than 0.05. In the past 4 years, 75% of primary gastric GISTs in our hospital were managed by laparoscopic surgery. Our experience showed that laparoscopic surgery is feasible for primary stomach GISTs in selective cases.

Fluoroscopic Guide Wire Manipulation of Malfunctioning Peritoneal Dialysis Catheters Initially Placed by Interventional Radiologists

PurposeTo assess the efficacy of fluoroscopic guide wire manipulation in patients with malfunctioning peritoneal dialysis (PD) catheters that were initially placed by interventional radiologists under fluoroscopic guidance. Materials and MethodsFrom January 2002 to April 2012, 52 patients (mean age, 52.8 y ± 2.10s; range, 12–79 y) with malfunctioning PD catheters in whom fluoroscopic guide wire manipulation was performed were retrospectively reviewed. Technical success, clinical success, and complications were evaluated. Technical success was defined as fluoroscopically verified, successful catheter repositioning and adequate dialysate drainage after the procedure. Clinical success was defined as maintenance of PD catheter function for at least 30 days after the manipulation. ResultsDuring the study period, 72 manipulations (68 initial manipulations and 4 remanipulations) for malfunctioning PD catheters were done. The technical success rate was 74% (50 of 68) for initial manipulations and 75% (3 of 4) for remanipulations. The overall clinical success rate was 47% (32 of 68) for initial manipulations and 0% (0 of 4) for remanipulations. The primary causes of catheter malfunction were extraluminal obstruction by omental wrapping or adhesions in 43 of 68 cases (63.2%) and catheter malposition in 25 of 68 (36.8%) cases. There were no procedure-related major complications. ConclusionsFluoroscopic guide wire manipulation in patients with malfunctioning PD catheters initially placed by interventional radiologists is a simple procedure, an effective way of prolonging PD catheter life, and a recommended procedure before invasive surgical procedures.

Would the Indwelling Internal Ureteral Stent Influence Renal Function Despite Relief of Benign Ureteral Obstruction?

To assess the effect of internal ureteral stents (IUS) on renal function (RF) and to determine factors associated with the RF changes. Between February 2009 and September 2012, 103 patients with bilateral or IUS in a solitary kidney were retrospectively analyzed. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration Equation (CKD-EPI). It was calculated from serum creatinine after adequate relief of obstruction (baseline) and at last follow-up. Deterioration of eGFR was considered if the last eGFR declined by >20% from the baseline value. Predictors of RF changes were detected using univariate and multivariate binary logistic regression analyses. The mean patients' age was 54±14 years with males constituting 71.4% of the study population. During follow-up after IUS fixation, the median eGFR has declined from 50.6 mL/min/1.73 m(2) at baseline to 25 mL/min/1.73 m(2) at time of last follow-up (p<0.0001). Fifty-two (50.5%) patients experienced decline in their RF by >20% of baseline value. On multivariate analysis, positive urine culture (odds ratio [OR]: 3; p=0.026), baseline eGFR <60 mL/min (OR: 3.6; p=0.011), and extraluminal obstruction (OR: 2.9; p=0.035) were independent predictors of RF deterioration. One half of patients with IUS lasting more than 3 months experienced RF deterioration during follow-up. This decline was significantly associated with positive urine cultures, presence of CKD, and extraluminal obstruction. All efforts should be exerted for active treatment of associated urinary tract infection and active follow-up of RF.

Successful treatment of an intra-pelvic fungal pseudomycetoma causing constipation and hypercalcaemia in a Persian cat.

This case report describes the successful treatment of a Persian cat diagnosed with intra-abdominal fungal pseudomycetoma causing hypercalcaemia and constipation due to an extra-luminal mechanical obstruction of the colon. Treatment included surgical excision, supportive care and itraconazole for 6 months.

Extraluminal bowel obstruction by endometrioid adenocarcinoma 34 years post-hysterectomy: risks of unopposed oestrogen therapy

High levels of oestrogens are a strong risk factor for endometrial adenocarcinoma. Therefore, at present, guidelines state that unopposed oestrogen hormone replacement therapy (HRT) is recommended only for patients who have had a hysterectomy.1 However in patients with endometriosis who have had a total abdominal hysterectomy and salpingo-oophorectomy (TAHBSO), unopposed oestrogens may cause a malignant change in any remaining endometrial deposits. We describe such a case presenting with bowel obstruction. As a result, we propose regular reviews for patients with endometriosis taking HRT post-TAHBSO. This will ensure that the advantages of HRT continue to outweigh the disadvantages.

Use of small bowel imaging for the diagnosis and staging of Crohn’s disease—a survey of current UK practice

This study used a postal survey to assess the current use of small bowel imaging investigations for Crohn's disease within National Health Service (NHS) radiological practice and to gauge gastroenterological referral patterns. Similar questionnaires were posted to departments of radiology (n = 240) and gastroenterology (n = 254) identified, by the databases of the Royal College of Radiologists and British Society of Gastroenterologists. Questionnaires enquired about the use of small bowel imaging in the assessment of Crohn's disease. In particular, questionnaires described clinical scenarios including first diagnosis, disease staging and assessment of suspected extraluminal complications, obstruction and disease flare. The data were stratified according to patient age. 63 (27%) departments of radiology (20 in teaching hospitals and 43 in district general hospitals (DGHs)) and 73 (29%) departments of gastroenterology replied. These departments were in 119 institutions. Of the 63 departments of radiology, 55 (90%) routinely performed barium follow-though (BaFT), 50 (80%) CT, 29 (46%) small bowel ultrasound (SbUS) and 24 (38%) small bowel MRI. BaFT was the most commonly used investigation across all age groups and indications. SbUS was used mostly for patients younger than 40 years of age with low index of clinical suspicion for Crohn's disease (in 44% of radiology departments (28/63)). MRI was most frequently used in patients under 20 years of age for staging new disease (in 27% of radiology departments (17/63)) or in whom obstruction was suspected (in 29% of radiology departments (18/63)). CT was preferred for suspected extraluminal complications or obstruction (in 73% (46/63) and 46% (29/63) of radiology departments, respectively). Gastroenterological referrals largely concurred with the imaging modalities chosen by radiologists, although gastroenterologists were less likely to request SbUS and MRI. BaFT remains the mainstay investigation for luminal small bowel Crohn's disease, with CT dominating for suspected extraluminal complications. There has been only moderate dissemination of the use of MRI and SbUS.

Interventional management of tracheobronchial strictures

Tracheobronchial balloon dilation and stent placement have been well used in the treatment of patients with benign and/or malignant diseases. Balloon dilation is the first option in the treatment of benign airway stenosis. Although balloon dilation is simple and fast, recurrence rate is high. Stent placement promptly relieves acute airway distress from malignant extraluminal and intraluminal airway obstruction. Temporary stent placement may be an alternative for benign airway strictures refractory to balloon dilation. This article reviews the indications, pre-procedure evaluation, technique, outcomes and complications of balloon dilation and stent placement with regard to benign and malignant tracheobronchial stenoses.

Flexible bronchoscopy in pediatric intensive care

To define the benefits of a flexible bronchoscopy (FB) service in a Paediatric Intensive Care Unit (PICU). Review of the first 200 FBs undertaken in a large PICU. Large cardiac and medical PICU in the United Kingdom, also providing extra-corporeal life support. 129 patients (78 males, 51 females, median age 9.9 months, median weight 4.6 kg) underwent FB from August 1990 to June 2003. Broncho-alveolar lavage (BAL) as indicated at time of bronchoscopy. Basic patient parameters were identified, including ventilation modes and diagnoses. FB findings were correlated with microbiology results. The majority of the FBs were diagnostic (161 of 200). 114 of these were undertaken to exclude underlying airway abnormalities and 47 to aid the diagnosis of pneumonia. Therapeutic procedures including bronchial stenting, directed surfactant instillation and broncho-alveolar toileting were undertaken in 39 cases. 68% of the diagnostic FBs were deemed to be abnormal. 16% had significant extra-luminal airway obstruction. 24% had new findings of airway anomalies. 14.5% of the FBs showed endo-tracheal tube misplacement. Positive microbiological results which altered or confirmed changes in patient management occurred in 46.1% children who had BAL specimens cultured. 80 of the FBs were undertaken whilst the children were receiving extra-corporeal life support. Only one FB procedure was ceased because of patient instability. There is a high yield of positive findings from undertaking FB both anatomically and microbiologically. FB should be seen as a routine diagnostic and therapeutic tool in paediatric intensive care.

Hilar traumatic neuroma after liver transplantation

Abstract We report our first case of symptomatic traumatic neuroma in the liver hilum after orthotopic liver transplantation. Compression of the hepatic artery caused extraluminal obstruction and resulted in perfusion damage to the graft. Moreover, intimal hyperplasia of the hepatic artery was present. Retransplanta-tion was necessary because the hepatic artery was not salvageable. Potential pathophysiological mechanisms for these findings are discussed.

Extrahepatic biliary tract obstruction: a retrospective study of 45 cases (1983-1993).

The medical records of 41 dogs and four cats with either surgical or postmortem confirmation of extrahepatic biliary tract obstruction were reviewed. Clinical signs of icterus, vomiting, anorexia, or a combination of these signs were exhibited by 100% of cases. Elevated serum bilirubin was documented in 37 of 41 dogs and two of four cats (86.6%). The predominant, underlying, pathological process was extraluminal obstruction of the biliary tract due to pancreatitis (19 of 45 cases; 42.2%) or neoplasia (11 of 45 cases; 24.4%). Biliary tract surgery was performed in 29 cases, of which 12 (41.3%) recovered. Animals diagnosed with extrahepatic biliary tract obstruction had a relatively good long-term prognosis, provided they were not compromised substantially due to severe necrotizing pancreatitis or neoplasia.

Streptococcus bovis endocarditis presenting with gastrointestinal bleeding

thesis. lo Tracheal narrowing by the proximal end of the tube was demonstrated in that patient by esophagram, but no further respiratory difficulty occurred after endotracheal extubation. The sequence of events in our patient suggests that prosthesis placement led to air flow obstruction of the distal trachea or right mainstem bronchus. The onset of respiratory difficulty coincided with the insertion of the prosthesis across the esophageal narrowing. Reversal of hypoxemia and high peak inspiratory flow pressures upon removal of the prosthesis further implicate the prosthesis as causing extraluminal obstruction of the trachea or right mainstem bronchus. Pulmonary flow volume curves can document fixed obstruction, but it is uncertain whether such measurements could have predicted this complication since no fixed obstruction of the trachea or right mainstem bronchus was found at autopsy. In patients with extraluminal esophageal compression secondary to pulmonary malignancy, esophageal prosthesis insertion should be approached with caution.