Left Cavity Research Articles

Eosinophilic vasculitis: an inhabitual and resistant manifestation of a vasculitis

A 55-year-old woman was referred because of diffuse pruritic erythematous lesions and an ischemic process of the third finger of her right hand. She was known to have anaemia secondary to hypermenorrhea. She presented six months before admission with a cutaneous infiltration on the left cubital cavity after a paravenous leakage of intravenous iron substitution. She then reported a progressive pruritic erythematous swelling of her left arm and lower extremities and trunk. Skin biopsy of a lesion on the right leg revealed a fibrillar, small-vessel vasculitis containing many eosinophils.Two months later she reported Raynaud symptoms in both hands, with a persistent violaceous coloration of the skin and cold sensation of her third digit of the right hand. A round 1.5 cm well-delimited swelling on the medial site of the left elbow was noted. The third digit of her right hand was cold and of violet colour. Eosinophilia (19 % of total leucocytes) was present. Doppler-duplex arterial examination of the upper extremities showed an occlusion of the cubital artery down to the palmar arcade on the right arm. Selective angiography of the right subclavian and brachial arteries showed diffuse alteration of the blood flow in the cubital artery and hand, with fine collateral circulation in the carpal region. Neither secondary causes of hypereosinophilia nor a myeloproliferative process was found. Considering the skin biopsy results and having excluded other causes of eosinophilia, we assumed the diagnosis of an eosinophilic vasculitis. Treatment with tacrolimus and high dose steroids was started, the latter tapered within 12 months and then stopped, but a dramatic flare-up of the vasculitis with Raynaud phenomenon occurred. A new immunosuppressive approach with steroids and methotrexate was then introduced. This case of aggressive eosinophilic vasculitis is difficult to classify into the usual forms of vasculitis and constitutes a therapeutic challenge given the resistance to current immunosuppressive regimens.

Role of Irrigation with Hypertonic Saline for a Recurrent Skull Base Hydatid Cyst: Case Report and Review of the Literature

Hydatid cyst is a parasitic disease caused by the tapeworm Echinococcus granulosus. This disease is a rare finding in the head and neck region, and its presentation varies according to the area involved. We report the case of a 25-year-old woman who presented with bilateral neck swelling, which was found on histopathologic examination to be caused by a hydatid cyst. The patient underwent surgical drainage of the cyst and a modified radical mastoidectomy, followed by a 3-month course of treatment with albendazole. However, she experienced a recurrence in the left neck region 1 year later. At that time, reexploration of the left mastoid cavity was performed, with debridement of diseased occipital bone and foramen magnum. Intraoperatively, we used a novel method of saline irrigation with 3% hypertonic saline, previously not tested on exposed nerves, in an attempt to prevent further recurrence. Four years after the second surgery, no disease recurrence was found, and no neurologic sequelae were noted. We conclude that hypertonic saline irrigation can be considered as an option for preventing recurrence in cases that are difficult to clear surgically, especially around cranial nerves, although more studies are needed to document the safety of this approach.

Efficacy of moxifloxacin compared to teicoplanin in the treatment of implant‐related chronic osteomyelitis in rats

Treatment of implant-related chronic osteomyelitis is often difficult and usually consists of implant removal, extensive surgical debridement, and prolonged antibiotic use. This study was performed to assess the efficacy of moxifloxacin compared to a glycopeptide, teicoplanin in chronic implant-related methicillin-sensitive Staphylococcus aureus (MSSA) osteomyelitis. The left femoral medullar cavities of 60 Wistar male rats were contaminated with 100 µl of 10(8) cfu/ml methicillin-sensitive S. aureus (ATCC 29213) and Kirschner wires were placed into the medulla of the femur. After 6 weeks, rats were randomly divided into five groups. In two groups, the Kirschner wires were removed. Experimental groups were as follows: group 1: contaminated, Kirschner wire inside, received teicoplanin; group 2: contaminated, Kirschner wire removed, received teicoplanin; group 3: contaminated, Kirschner wire inside, received moxifloxacin; group 4: contaminated, Kirschner wire removed, received moxifloxacin; group 5: contaminated, Kirschner wire inside, no antibiotics (control group). Groups 1 and 2 received teicoplanin (20 mg/kg once daily), whereas groups 3 and 4 received moxifloxacin (10 mg/kg twice daily) intraperitoneally for 28 days. At the end of the treatment, animals were sacrificed by inhalation anesthesia with ether and femora were retrieved and bacterial counts (cfu/g) were determined. Bacterial counts in all study groups were significantly reduced relative to the control. The decrease of bacterial counts was more prominent in group 4 compared to group 1 (p = 0.001) and group 2 (p = 0.003). Moxifloxacin therapy is an effective alternative to teicoplanin for chronic implant-related MSSA osteomyelitis.

Acute gastric volvulus

An 18-year-old man presented with complaints of sudden onset pain in the epigastrium radiating to the left lower chest, starting 7 days prior followed by non-productive and persistent retching. On examination, the patient had a tachycardia (pulse rate 108 beats/min) and a blood pressure of 102/66 mmHg. His respiratory rate was 22 breaths/min and was afebrile. On chest examination, air entry was markedly reduced on the left side. The abdomen was not distended; an ovoid-shaped tender organ was felt in the epigastrium. The rest of the abdominal examination was normal. A single gentle attempt of nasogastric tube insertion was done, but insertion beyond the first mark was not possible. A plain X-ray study of the chest and abdomen done earlier showed a double bubble sign (Fig. 1), Contrast films showed a dilatated and tortous dumbbell-shaped stomach overlapping the left lower chest (Fig. 2). Although a computed tomography (CT) scan of the abdomen would have been preferable, the barium study had been done before the patient was referred to us [1]. In view of these findings a diagnosis of gastric volvulus with herniation into the left chest cavity was made, and the patient was urgently operated upon after appropriate preparation. The operative findings revealed that the left lobe of the liver and spleen were shifted medially and downwards so that the spleen was lying in the epigastrium (Fig. 3). The stomach was largely missing from the abdomen, and only a small pouch of fundus was visible just below the spleen. The entire distal stomach had herniated through a defect in the diaphragm posterolaterally on the left side. On needle aspiration about 500 ml of barium mixed fluid came out from the stomach pouch, but the stomach still refused to come down into the abdomen. So a thoracotomy was performed by extending the upper end of the laparotomy incision into the left side of the chest and the diaphragm was incised up to the defect posteriorly. The stomach was reduced into the abdominal cavity. It was viable, but inflammed and ballooned out with rotation of [180 anticlockwise (Fig. 4). It was derotated, and emptied by Ryle’s tube aspiration. A gastropexy was done. The defect in the diaphragm was repaired with nonabsorbable sutures, and all the incisions were closed after placing a thoracostomy tube to drainage. The patient improved in the postoperative period, and was discharged on the seventh postoperative day. The normal stomach is stabilised and prevented from twisting into a volvulus by the ligamentous supports, i.e. the gastrohepatic, gastrocolic, oesophagophrenic and gastrosplenic ligaments. The relative fixity of the pylorus and gastro-oesophageal junction also helps to maintain the normal position of the stomach. A volvulus can occur when these attachments are lax or absent. It may also occur secondary to adjoining structural defects like congenital diaphragmatic hernia, hiatus hernia, eventration of diaphragm, paraoesophageal hernia, splenomegaly, or gastric outlet obstruction [2]. Gastric volvulus is classified into three types: organoaxial: the stomach rotates around a longitudinal axis between the gastro-esophageal junction and the pylorus. This is the most common type occurring in approximately 59% of cases, and is usually associated with A. Hai S. Goel S. Shahab S. Kumar Department of Surgery, University College of Medical Sciences and Associated GTB Hospital, University of Delhi, Delhi, India

Biventricular lipoma (first case in literature)

Primary cardiac tumors of the ventricles are very uncommon. Cardiac lipomas are extremely rare primary benign cardiac tumors. Most reported cardiac lipomas have been diagnosed incidentally at autopsy. Lipomas in both ventricular cavities were not reported before. We report the case of a 51-year-old male referred to our hospital complaining of exercise angina during the last month. Transthoracic echocardiogram showed two masses; one of them was in the left venricular cavity and the other one was in the right ventricular cavity. After that we performed coronary angiography and the angiography showed a tree vessel disease. For treatment, surgery was performed and the tumors were resected with performing tree vessels coronary by-pass.

Gastrointestinal: A retroperitoneal liposarcoma that formed a fistula into the descending colon

Liposarcoma frequently occurs in the retroperitoneum and lower extremities, accounting for 9.8–16% of all soft tissue sarcomas. Liposaromas vary by histology and can be classified into four types. Those four types are well differentiated, myxoid/round cell, pleomorphic and dedifferentiated. This classification corresponds to the clinical aspect and prognosis of patients. Dedifferentiated liposarcoma (DDL) has both a well differentiated liposarcoma and a high grade nonlipogenic sarcoma within the tumor. It is difficult to diagnose DDL histologically. DDL can show a variety of histological appearances. The most common phenotype is malignant fibrous histiocytoma. Other phenotypes include leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and angiosarcoma. For DDL, prognosis is generally poor compared with the other types of liposarcoma. It shows high recurrence rate of 40-83%, metastasis rate of 15–30%, and the overall 5-year survival rate of 20%. DDLs often originate in the retroperitoneum, extremities, trunk, testis, and spermatic cord. A 61-year-old man was admitted to our hospital with 38.8°C of fever and general weakness. He had a history of a 20 × 10 cm well-differentiated retroperitoneal liposarcoma and underwent debulking surgery and intraoperative radiotherapy eight years previously. After surgery, there was no remnant mass visible on the abdominal computed tomography (CT) scan. On the current admission, physical examination revealed a palpable mass in the left mid abdomen. CT scan revealed a 8.5 × 8.3 cm sized large mass abutting the descending colon and left kidney in the left retroperitoneal cavity. The tumor encased a segment of the bowel loop and there was air density suspicious of tumor fistulization into the colonic lumen. Colonoscopy showed a fistula into the descending colon 30 cm from the anal verge (Figure 1). A yellowish mass was seen through the fistula with erythematous and edematous mucosal changes around the fistula. We suspected that the liposarcoma had recurred, and the patient underwent left colon segmental resection. The specimen showed a 9.5 × 8.5 cm sized, well-demarcated, yellowish-gray, lobulated, glistening, and firm mass. Microscopic findings showed a dedifferentiated liposarcoma containing a well-differentiated component with fat lobules and a nonlipogenic hypercellular area. There were scattered atypical lipocytes (Figure 2, upper panel) and pleomorphic spindle cells (Figure 2, lower panel, H&E, orig. mag. ×200) consistent with a subtype of malignant fibrous histiocytoma. Contributed by

Detachable coiling for embolotherapy of high-flow pulmonary arteriovenous malformation: case report and review of the literature

Pulmonary arteriovenous malformations (PAVMs) are very rare anomalies of the lung parenchyma. Although many patients are asymptomatic, it carries a high risk of severe cerebral complications, and rarely fatal outcome due to rupture of the malformation. There is a strong association with the Rendu-Osler-Weber disease. The patients should be treated in case of symptomatic PAVMs (paradoxical emboli), and also preventively, when the feeding artery is at least 3 mm in diameter. Embolization is a well-established treatment, which can be very challenging when dealing with very high-flow fistulas, where there is a risk of inadvertent migration of the embolization material in the left cavities of the heart and in the aorta. This report emphasizes the importance of the diagnosis and the embolization indication in pulmonary arteriovenous malformations, and the usefulness of detachable coils in case of high-flow fistulas.

Single-photon transport properties in a waveguide–cavity system

We study single-photon transmission spectra in a waveguide coupled to two cavities embedded with one(two) two-level atom(atoms). When only the left cavity contains a two-level atom, single-photon transmission spectra can be modulated by changing the distance between the two cavities. Phase separation-induced transparency is acquired in such a system when each cavity contains a two-level atom. The influence of the dissipation of cavities and atoms on single-photon transport properties is also analysed. In addition, the experimental design of such an optical system is discussed.

Lack of promoting effects from physical pulmonary collapse in a female A/J mouse lung tumor initiated with 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) with remarkable mesothelial cell reactions in the thoracic cavity by the polymer

Experimental identification of potential chemopreventive or tumor promotive agents in the lung is important. Establishment of short-term bioassay models is therefore a high priority. In an attempt to induce strong promotion effects, in Experiment 1, left thoracotomy was performed on A/J mice at week 3 after initiation with 4-(methylnitrosamno)-1-(3-pyridyl)-1-butanone (NNK) (2 mg/0.1 ml saline/mouse i.p.) at weeks 0 and 1. In Experiment 2, at week 3, 0.2 ml of polymer gel was infused directly into the left cavity of the thorax with thoracotomy to occupy certain thoracic cavity volume and to examine the influence of physical pulmonary collapse. The experiments were terminated after 8, 10, 12 and 16 weeks in Experiment 1, and 12 weeks in Experiment 2 but no clear promotion effects in either experiment or pulmonary collapse due to infused polymer were apparent. However, a pronounced mesothelial cell reaction to the infused polymer was evident on the left lung surfaces and parietal pleura in Experiment 2. In conclusion, the present experiments did not demonstrate any clear lung tumor promotion effects of thoracotomy or physical left lung collapse. It remains possible, however, that alternative approaches might have greater efficacy and these need more consideration. In addition, mesothelial cells reaction was observed with the infused polymer.

Late Gadolinium Enhancement of the Esophagus is Common on Cardiac MR Several Months after Pulmonary Vein Isolation: Preliminary Observations

Pulmonary vein isolation (PVI) as a treatment for atrial fibrillation (AF) is commonly performed. This procedure can damage the esophagus. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance imaging (CMR) offers noninvasive assessment of scar. We sought to examine the prevalence of esophageal hyperenhancement on LGE-CMR prior to and following PVI. Seventy-four patients underwent LGE-CMR prior to and 1.7 +/- 1.9 months post PVI for AF. Transmural esophageal hyperenhancement was visually assessed. The pre- and post PVI esophageal position was measured, relative to the vertebral body. Prior to PVI, 3% (2/74) of patients had esophageal LGE on CMR. At post-PVI follow-up, 30% (23/74) of the studies demonstrated new esophageal hyperenhancement adjacent to an ablation site. Most (74%, 17/27) positive esophageal LGE studies were performed >30 days after PVI, while no (0/9) studies performed >2 months post PVI were positive for esophageal hyperenhancement. The presence of post-procedural esophageal hyperenhancement was not associated with longer ablation time (P = 0.42), use of an irrigated catheter (74% with LGE vs 47% without, P = 0.16), right-sided esophageal location (56% with LGE vs 39% without, P = 0.17), size of left atrium cavity (58 +/- 8 mm with LGE vs 61 +/- 10 mm without, P = 0.15), or the timing of the LGE-CMR study after PVI (36 +/- 10 days with LGE vs 60 +/- 66 days without, P = 0.09). Though rare before PVI, new esophageal LGE is seen in almost one-third of patients after PVI. The clinical implications to remain to be explored, but clinicians should be aware of this frequent imaging finding.

El ecocardiograma

Echocardiography is an ultrasound-based imaging technique that makes it possible to evaluate both the anatomy and function of the heart. The greatest advantage of this technique over others is that it does not use ionizing radiation or iodinated contrast material, so it can be repeated as often as necessary. Standard echocardiographic examination uses four echocardiographic windows: the parasternal, apical, subcostal, and suprasternal. – In the parasternal plane, images are obtained along two axes: the long axis and the short axis. These views enable the aortic valve, left atrium, mitral valve, left ventricle, right ventricle, and ascending aorta to be studied. The M mode is normally used to measure the ventricular diameters and thickness. Volumes are determined from the diameters measured, and the ejection fraction is inferred from the volumes. – The apical plane is divided into four views showing four chambers, five chambers, two chambers, and three chambers. The different apical views show the right and left cavities, the interventricular and interatrial septa, and the mitral, aortic, and tricuspid valves. – The subcostal plane provides an image of the heart in which both the left and right chambers of the heart can be seen. It is the ideal plane for assessing the inferior vena cava as well as the interatrial septum and for determining whether there is pericardial effusion. – The suprasternal plane makes it possible to see the aortic arch and the descending aorta. The different echocardiographic planes enable a complete and thorough examination of the anatomy and function of the heart. Because echocardiography is widely available, very economical, and can be performed at the patient's bedside, it is the most widely used technique in the study of heart disease around the world. To carry out this technique correctly, technicians need to acquire a body of specialized knowledge. Until very recently, no programs to train technicians in this technique were offered in Spain; however, the Complutense University of Madrid and the Spanish Society of Cardiology have just started the first course to train technicians to perform echocardiography.

147 Evaluation of left ventricular function assessed by 2D strain in severe mitral regurgitation with normal ejection fraction

Surgery decision in severe mitral regurgitation (MR) depends on left ventricular ejection fraction ( LVEF ). However better markers are needed to detect early LV dysfunction. We sought to determine the ability of 2D strain assessed by speckle tracking imaging (STI) to detect subclinical LV dysfunction in severe chronic MR. We studied 11 patients (8 men, 69 ± 10 years) who had severe organic MR with a LVEF ≥ 55%, and 10 healthy controls (HC). STI was performed to measure longitudinal strain (LS) in 4 and 2 chambers views, in apical long axis view, and to assess global longitudinal strain (GLS). The etiology of MR was degenerative in 10 patients and congenital in 1 patient. MR was severe in all patients (EROA = 66±23 mm 2 ). Comparing HC vs patients, left atrial area was significantly lower (16,6±2 cm 2 vs 35±10 cm 2 ; p<0,001). There was no difference in LVEF (65,6±6% vs 63,8±3,6% ; p=ns), in end-diastolic volumes (64,5±19 ml/m 2 vs 61,5±17 ml/m 2 ; p=ns), or in GLS (-20±1,1% vs -21±3,6% ; p=ns). In the patient group, we could distinguish one group with increased GLS (n=7, GLS = -23,5±1,3% ; p<0,01 vs HC), and one with a trend for a lowered GLS (n=4, GLS = -16,6 ±0,5%; p=0,125), but this was probably due to a lack of statistical power (n=4). 3 patients in the second group were in atrial fibrillation showing the impact of MR on left cavities. Inter-observer variability was good (r=0,89). LS was significantly lower in septoapical segment in HC vs patients (-21,6 ±3,5% vs -28,6±4,8% ; p<0,0001), as well as in anteroseptobasal (-16±3,4% vs -20,9±4,5% ; p<0,01) and anteroseptomedian (-18,7±2,8% vs -24,9±5,3% ; p<0,01) segments. In patients with chronic organic MR and LVEF ≥ 55%, two populations may be highlighted by 2D-strain: one with significantly increased GLS and one with a trend for a lowered GLS. More studies are required to evaluate causes and clinical consequences.

A Case of Large Intradiploic Epidermoid Cyst of the Temporal Bone

Intradiploic epidermoid cysts of the skull are benign lesions that are derived from the ectodermal cells of the cranium. They are rare tumors and they represent less than 1% of all intracranial tumors. The frontal and parietal bones are the most common sites for the cysts, but the temporal bone is rarely involved. They are slowly growing tumors, and may often reach an enormous size without producing neurological symptoms. For treatment, it is important to completely remove the capsule of the cysts to avoid recurrence. Malignant transformations of the cysts, which are very rare, are generally found in cases which have repeated recurrences or infections. We present a patient with an intradiploic epidermoid cyst of the temporal bone, which is located behind the left mastoid cavity. We removed the cyst successfully through transmastoid approach. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:632-5 Key WordsZZEpidermoid cyst ㆍIntradiploic ㆍMastoid bone.

NUT Midline Carcinoma

NUT midline carcinoma (NMC) is a recently described, undifferentiated carcinoma with specific NUT gene rearrangement, which often involves midline organs such as the nasal cavity, paranasal sinuses, mediastinum, or intrathoracic organs. It was previously considered a disease of children or young adults, but middle-aged or elderly patients have subsequently been seen. Here, the authors report the case of a 54-year-old woman who presented with a left-nasal-cavity mass and diplopia. The tumor enlarged rapidly and extended to the left orbital cavity and brain base despite chemotherapy and radiotherapy. Pathological examination of the resected tumor showed an undifferentiated carcinoma with occasional abrupt keratinizing squamous differentiation. Immunohistochemical analysis with an antibody to NUT revealed that most of the tumor cells were positive. BRD4-NUT gene fusion was demonstrated by fluorescence in situ hybridization, confirming the diagnosis of NMC. This case emphasizes the importance of considering NMC in the differential diagnosis in older adults.

Management of Post-mining Large-scale Ground Failures: Blast Swarms Field Experiment for Calibration of Permanent Microseismic Early-warning Systems

In France, decades of coal and iron-ore mining have left extensive underground cavities beneath or in the vicinity of urban areas. This poses an environmental challenge for society. To ensure post-mining risk management and public safety, wherever remediation is not possible, numerous real-time microseismic monitoring systems are being installed. The objective is to detect remote rock mass fracturing processes, precursory events and acceleration phases for appropriate and timely action. Although no consistent collapse has occurred in any of the monitored areas yet, single 3-D probes record many microseismic events of very low amplitude which create difficulties in the quantitative data analysis. The development of specific quantitative processing has therefore become a major issue in our research work. For that purpose, a field experiment was carried out on six of the instrumented sites. It consisted of sequences of small blasts in mine pillars which were accurately controlled in terms of the location, orientation and energy of the explosive source. The data analysis was used to calibrate parameters (velocity model, 3-D sensor orientation, etc.) for reliable 3-D localization and to develop an empirical law to estimate the source energy from the sensor energy. This work now enables us to analyze real microseismic events with a considerably better level of accuracy and to obtain enough information and confidence to discuss these data in terms of site stability.

Inflammatory Pseudotumor of the Maxillary Sinus

Inflammatory Pseudotumor of the Maxillary Sinus

Colovesical, coloenteric, colocutaneous fistula, and hip septic arthritis secondary to sigmoid diverticulitis

Dear Editor: Diverticulitis associated with free perforation and fecal or purulent peritonitis is a surgical emergency, with an associated mortality of up to 35%. Diverticular perforation into an adjacent organ can be followed by fistula formation. We report the case of a patient referred to our hospital with sigmoid diverticulitis and fecal peritonitis, which subsequently developed a complex fistula, as well as left hip septic arthritis. A 41-year-old male patient was transferred to our hospital after an acute episode of purulent sigmoid diverticulitis 2 months before; a transverse colostomy and drainage were performed. The patient was transferred due to a painful left lower extremity deformity and recurrent urinary tract infections despite antibiotic during the last 6 weeks. He showed physical signs of malnutrition, a left lower extremity flexion and adduction deformity, very limited hip motion due to pain and thigh muscular contracture, a fistulous sinus in the left lower quadrant with fecal discharge, and turbid urine through a urinary catheter. The patient denied any previous history of hip or extremity affection. Urine cultures were positive for Escherichia coli. On radiographs, a left adduction deformity and femoral head destruction suggested septic hip arthritis. The Department of Orthopedic Surgery recommended no urgent drainage since no septic state was found. A cystography showed contrast material passage to the sigmoid and left hip cavity. After a 10-day period of nutrition and systemic antibiotics, the patient was scheduled for a laparotomy. Surgical findings: a paracolic abscess and an inflammatory process affecting the sigmoid, dense adhesions to the bladder fundus, an ileum segment, iliac bone and lateral pelvis abdominal wall; fistulous communications medially from the sigmoid to the bladder and ileum 40 cm from the ileocecal valve, and laterally to the iliac bone, where the sigmoid was densely adhered to and below the inguinal ligament. Approximately 0.5 L of purulent material was drained through a communication with the hip joint cavity. An anastomosis was not considered due to the inflammatory and infectious process. Resection of the sigmoid and left colon distal to the transverse colostomy plus a Hartmann's procedure was performed. The segment of affected ileum and fistulous orifice in the bladder were resected. Ileum anastomosis and bladder repairs were practiced. Pathologic exam revealed perforated sigmoid diverticulitis, colon diverticulosis, fibrous reaction surrounding the bladder wall and ileum fistulous orifices, and absence of malignancy. After an uneventful recovery, the patient is under physical therapy. Hip replacement and bowel continuity reestablishment will be practiced. Hinchey et al. described a grading system for colonic diverticulitis. Stage I diverticulitis involves a pericolic abscess; Stage II, a distant abscess, retroperitoneal or pelvic; Stage III, purulent peritonitis; and Stage IV, fecal peritonitis. Stages III and IV are surgical emergencies, with associated mortalities of up to 35%, depending on the degree of fecal contamination, sepsis and surgical intervenNo disclaimers. There was no financial support. The paper was not presented in any meeting. It includes a list of contribution of each author/coauthor. The three authors participated in conception and design, acquisition of data, critical revision of the article, and final approval. C. M. Nuno-Guzman : J. M. Hernandez-Carlin : F. I. Almaguer Antiguo Hospital Civil de Guadalajara “Fray Antonio Alcalde”, Calle Hospital 278, Guadalajara, Jalisco, Mexico 44280

Modification of the Nuss procedure for pectus excavatum to prevent cardiac perforation

Purpose In a few patients, cardiac perforation and aortic injury have occurred during the Nuss procedure for pectus excavatum. The article details a modification of this procedure that enables the prevention of fatal complications. Methods Our subjects were 22 males and 13 females with pectus excavatum who were aged 8.2 ± 3.7 years. Their Haller's computed tomography index was 5.2 ± 1.5. An introducer is inserted into the pleura between the sternum and thymus instead of the thoracic depression under right thoracoscopic guidance. After the introducer reaches the internal cranial position of the left nipple, the thoracoscope is shifted to the left thoracic cavity. The introducer is subsequently guided to the left highest intercostal space under left thoracoscopic guidance. Results A single bar was inserted in 34 patients; 2 bars were required in 1 patient. The operating time was 95 ± 27 minutes and blood loss was 11 ± 6 g. Cardiac perforation did not occur in any patient. Conclusions Our modified technique has certain advantages: (1) the introducer does not rub against the pericardium and heart; (2) the tip of the introducer can be observed at all times with a thoracoscope; (3) the anterior mediastinum between the left and right thoracic cavities is very narrow at the cranial level; (4) the introducer can be accurately directed to the left highest intercostal space; and (5) hemostasis and no injury of the bilateral thoracic organs can be confirmed.

Inflammatory Pseudotumor of the Maxillary Sinus

Inflammatory Pseudotumor of the Maxillary Sinus

Extramuraler GIST des Magens mit Manifestation durch Spontanruptur und akuter intraabdomineller Blutung mit Hämatoperitoneum

We report on the case of a 38-year-old male patient with a huge extramural gastrointestinal stromal tumour (GIST) of the stomach, located in the left upper and middle abdominal cavity that was diagnosed on the basis of a spontaneous -rupture and consecutive haemoperitoneum. The lesion was resected completely in an emergency operation. The tumour was classified as a high-risk lesion for aggressive biological behaviour and with regard to tumour rupture with perforation of the serosa, an adjuvant systemic therapy was indicated.