Left Tube Research Articles

SIMULTANEOUS BILATERAL SPONTANEOUS PNEUMOTHORAX (SBSP) AS THE FIRST PRESENTATION OF COPD

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: A secondary spontaneous pneumothorax is defined as pneumothorax secondary to underlying lung disease that occurs without a trauma or iatrogenic cause [1,2]. Simultaneous bilateral spontaneous pneumothorax (SBSP) forms a total of 1.3% of all spontaneous pneumothorax cases [3]. CASE PRESENTATION: A 66-year-old male with significant smoking history who presented to the Emergency Department (ED) for exertional shortness of breath of 3 weeks duration associated with mild chest pain and persistent dry cough. The patient initially went to a secondary hospital where he was diagnosed with bilateral pneumothoraces and was treated with bilateral pigtail chest tubes and oxygen therapy. However, he was in moderate respiratory distress; hence he was referred to a tertiary hospital. In ED, his vital signs were normal except for low oxygen saturation. Physical examination was remarkable for moderate distress, decreased breath sounds bilaterally and bilateral pigtail chest tubes attached. Laboratory studies including metabolic panel and complete blood counts were normal except for leukocytosis of 19.7 K/CMM. Computed tomography scan showed 60-70% bilateral pneumothoraxes, 2 chest tubes, and bilateral patchy consolidation (Figure 1). Patient was followed by repeated physical examinations and CXRs. His right pneumothorax improved and the chest tube was removed. However, the left chest tube showed persistent air leak necessitating pleurodesis with Doxycycline initially and Talc later as the patient wanted to be treated conservatively. Later, he became hemodynamically unstable, CXR showed right tension pneumothorax and an urgent right chest tube was inserted which normalized his vital signs. However, shortly after, he became unstable again, repeated CXR showed recurrent right tension pneumothorax, another chest tube was inserted complicated by right hemothorax; hence he was taken emergently for Video-Assisted Thoracoscopic Surgery (VATS) for hemothorax evacuation. Biopsy from VATS showed dense fibrosis and honeycombing emphysematous changes. Right-sided talc pleurodesis was done, and both chest tubes were removed. Repeated CXR demonstrated small left pneumothorax. Patient was discharged home, pulmonary rehabilitation and smoking cessation were strongly recommended. DISCUSSION: SBSP is a rare life-threatening emergency that requires immediate recognition and treatment. The presentation may vary from mild respiratory distress to cardiopulmonary failure. Diagnosis is confirmed on radiological findings and bilateral chest tubes are the initial appropriate treatment which in 82% of cases can stop air leak in 48 hours. However, the persistent air leak is an indication for surgery with VATS being most common. CONCLUSIONS: Presentation of SBSP can vary from mild respiratory symptoms to respiratory failure, diagnosis can be confirmed on chest radiography and the treatment is emergent chest tube placement. Reference #1: [1]Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000 Mar 23;342(12):868-74. Review. PubMed PMID: 10727592. [2] Noppen M, De Keukeleire T. Pneumothorax. Respiration. 2008;76(2):121-7. https://doi.org/10.1159/000135932. Epub 2008 Jun 26. Review. PubMed PMID: 18708734 [3] Esther Graf-Deuel, Andreas Knoblauch: Simultaneous bilateral spontaneous pneumothorax. Chest. 1994;105:1142–6. DISCLOSURES: No relevant relationships by Noor Hajjaj, source=Web Response no disclosure on file for Chandler Patton; no disclosure on file for Julio Pernia; No relevant relationships by Ahmad Sharayah, source=Web Response

2558 Mesenteric Panniculitis in a Young Adult: Case Report and Literature Review

INTRODUCTION: Mesenteric Panniculitis (MP) is an inflammatory condition of adipose tissue located in the small bowel mesentery. The exact cause is unknown although current literature has described some associations that may lead to its development. These include infection, paraneoplasic syndrome, history of multiple abdominal surgeries and lymphoma among others. Here we present a rare case of mesenteric panniculitis accompanied by retroperitoneal fibrosis. CASE DESCRIPTION/METHODS: The patient is a 31 year-old female with a medical history of cholecystectomy, appendectomy and Roux-en-Y gastric bypass surgery who presented to our emergency department complaining of diffuse abdominal pain, lower back pain and non-bloody vomiting for one day. Physical exam was remarkable for a scar over her right lumbar area and splenomegaly. Notable laboratory workup included an alanine transaminase of 54 IU/L, aspartate transaminase of 192 IU/L, alkaline phosphatase of 154 IU/L, total bilirubin of 0.5 mg/dL and hemoglobin of 10 gm/dL. While in the emergency department the patient underwent computed tomography of the abdomen which showed retroperitoneal fibrosis with lymphadenopathy, left sided hydronephrosis and mesenteric panniculitis (Figures 1 and 2). The patient was then admitted for further management. During her admission the gastroenterology service was consulted and their impression was mesenteric paniculitis secondary to multiple abdominal surgeries. The rheumatology service was also consulted and recommended obtaining serologies for IgG-4; ANA; ANCA; ACE; and SPEP all of which returned within normal limits. During her course the patient underwent left nephrostomy tube placement to relieve the left hydronephrosis and was otherwise treated consertivately. She was then discharged home with pain medications and follow up appointments. DISCUSSION: Mesenteric Panniculitis is characterized by inflammation of the small bowel mesentery, specifically the adipose tissue that surrounds it. Current data suggests that MP is a male predominant syndrome with a ratio of 3:1 when compared to females. Symptoms of MP are non-specific and include abdominal pain, diarrhea, weight loss, and fever. Biopsy is the gold standard for diagnosis, but imaging such as CT scan may also aid in its identification. There is no consensus regarding treatment, but many cases have been successfully treated with prednisone. Prognosis of MP is usually favorable with no follow up required if it is not associated with malignancy.

PULMONARY CAVITARY LESION WITH RARE PSEUDOMONAS STUTZERI

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Pseudomonas stutzeri is a gram-negative rod bacterium infrequently associated with clinical infection. We present a case of pulmonary cavitary lesions caused by P.stutzeri. CASE PRESENTATION: A 59-year-old male with history significant for intravenous (IV) heroin abuse (last use 1 week prior), splenectomy and culture negative endocarditis (10 months prior) presented to the hospital with 1 week of chest pain, dyspnea and subjective fevers. Within a few hours of admission, a rapid response was called for altered mental status, chest pain and tachypnea. Computed tomography of the chest revealed a 12cm cavitary left lower lung lesion. He was placed on tuberculosis precautions and subsequently transferred to the Intensive Care Unit (ICU) for further management. Blood cultures were obtained prior to empiric vancomycin plus piperacillin/tazobactam. He required intubation for impending respiratory failure. Bronchoscopy with bronchoalveolar lavage (BAL) was performed demonstrating copious mucus and purulent secretions bilaterally. Approximately 36 hours into his admission, he suffered a PEA (pulseless electrical activity) arrest. Return of spontaneous circulation (ROSC) was achieved after 15 minutes of cardiopulmonary resuscitation (CPR). Physical exam revealed diffuse crepitus, subcutaneous emphysema tracking along posterior thorax extending into left lateral thigh and profound scrotal swelling. Arterial blood gas demonstrated acidemia with hypercarbia. Within less than an hour, he suffered a second PEA arrest. There was concern for ruptured pleural cavitary lesion leading to a tension pneumothorax. Needle decompression performed bilaterally was unsuccessful; surgery at bedside placed left hemithorax chest tube. Again, achieved ROSC after 18 minutes of CPR. Unfortunately, within a few minutes he decompensated into ventricular fibrillation. Further resuscitation efforts a third time were unsuccessful. Post-mortem blood cultures were negative but his BAL cultures were positive for pan-sensitive Pseudomonas stutzeri. All acid-fast bacilli smears and cultures were negative. DISCUSSION: Pseudomonas stutzeri has rarely been reported as a cause of necrotizing pneumonia (1) and may represent only 1% of all clinical Pseudomonas isolates (2). In our patient, the timeline of events, whether the cavitary lesion ruptured from the positive pressure of mechanical ventilation or as a consequence of CPR remains a mystery. CONCLUSIONS: There is debate in the literature regarding the pathogenicity of this organism which is frequently deemed to be colonization rather than pathogenic. However, in the case of this patient, all other infectious work up was negative and no alternative pathogen could be linked to the development of the cavitary lesions. This case emphasizes the necessity of diagnostic testing to identify uncommon pathogens. Reference #1: Lin KH et al, Pseudomonas stutzeri necrotizing pneumonia in pre-existing pulmonary tuberculosis. Intern Med. 2014;53(21):2543-6. 2014 Nov 1. Reference #2: Bisharat, N et al, 10-Years Hospital Experience in Pseudomonas stutzeri and Literature Review. The Open Infectious Diseases Journal, 2012, 6, 21-24. DOI: 10.2174/1874279301206010021 DISCLOSURES: No relevant relationships by Zachary Bugos, source=Web Response No relevant relationships by Brandon Smith, source=Web Response

CANNABIS-ASSOCIATED SECONDARY SPONTANEOUS PNEUMOTHORAX

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Cannabis is the second most commonly smoked substance in US after tobacco. Marijuana smokers, especially young individuals, tend to develop similar symptoms as tobacco smokers. We present a patient with spontaneous secondary pneumothorax due to apical bullous disease possibly due to daily heavy marijuana usage. CASE PRESENTATION: A 30-year-old man with pmh of traumatic left-sided pneumothorax presented to the ED with one week history of progressive pleuritic chest pain and shortness of breath. He denied any history of trauma. Patient reported history of heavy daily marijuana smoking (more than five blunts a day for six years). He denied tobacco use. Physical examination revealed hyperresonance on percussion along with decreased right lung sounds. Bedside US of chest showed absence of lung sliding. Chest x-ray demonstrated large right-sided pneumothorax. Patient underwent left chest tube placement. Repeat CXR showed resolution of pneumothorax. CT scan of the chest was performed and showed multiple bilateral apical sub-pleural bullae, most prominent at the right apex and along the left upper lobe medially. Patient did not have family history of pneumothorax and no benign skin lesions, arachnodactyly, or joint hyper-mobility. Laboratory analysis showed negative HIV test and normal rheumatoid factor, homo-cysteine, and alpha-1 antitrypsin levels. Patient underwent right-sided VATS, right upper lobe wedge resection and mechanical pleurodesis. The patient was clinically and radio-logically stable following the removal of his chest tube and discharged home with the appropriate follow-up appointments DISCUSSION: The exact mechanism of cannabis-induced bullous lung disease and secondary spontaneous pneumothorax is not well known. The proposed mechanism involves common marijuana smoking techniques: breath holding, Valsalva and Muller’s maneuvers. Prolonged Valsalva maneuver during breath holding following deep inhalation of the smoke pressurizes the air in the lungs and could result in barotrauma to the lungs with rupture of sub pleural blebs. Furthermore, marijuana smoking is associated with significant airway inflammation, mucus hypersecretion and ciliated epithelial cell reduction, changes similar to those seen in tobacco smokers [5]. Diagnosis of cannabis-induced secondary pneumothorax is established by a process of exclusion of other apical bullous lung diseases. This patient was a habitual marijuana smoker who consistently performed breath holding and Valsalva maneuvers; he had no other risk factors for development of bullous disease or pneumothorax. The combination of prolonged breath holding and the toxic components in marijuana led to the barotrauma and pneumothorax. CONCLUSIONS: Penumothorax in young population can be secondary to different etiologies. Our case underlines the importance of maintaining a high index of suspicion for Cannabis as a cause of bullous lung disorder. Reference #1: Wu TC, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. N. Engl. J. Med. 1988; 318: 347–51. Reference #2: Tashkin DP, Gliederer F, Rose J et al. Effects of varying marijuana smoking profile on deposition of tar and absorption of CO and δ-9-THC. Pharmacol. Biochem. Behav. 40, 651–656 (1991). Reference #3: Roth MD, Arora A, Barsky SH, Kleerup EC, Simmons M, Tashkin DP. Airway inflammation in young marijuana and tobacco smokers. Am J Respir Crit Care Med 1998;157:928–937. DISCLOSURES: No relevant relationships by Obed Adarkwah, source=Web Response No relevant relationships by dina ahmed, source=Web Response no disclosure on file for Farhad Arjomand; No relevant relationships by Laila Cordero, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Nabil Mesiha, source=Web Response No relevant relationships by Ankur Mogla, source=Web Response No relevant relationships by jad sargi, source=Web Response

Bilateral serous tubal intraepithelial carcinoma associated with high-grade serous carcinoma of the peritoneum

Serous tubal intraepithelial carcinoma (STIC) is now considered a putative precursor lesion of most extrauterine high-grade serous carcinomas (HGSC). It is frequently reported in high-risk women and women with advanced-stage serous carcinoma. This case study reports a serous high-grade carcinoma (HGSC) consisting of a bilateral STIC with a focus of stromal invasion in the left tube, and a peritoneal HGSC. The grossly normal-appearing tubes including the fimbriated ends were sectioned following the SEE-FIM protocol. In both tubes, tumor aggregates were exfoliated extensively to the tubal lumens. The neoplastic epithelia in any location were diffusely positive for p53 in strong nuclear patterns. Pelvic lymph nodes were negative for tumor on serial sections and keratin 7 immunohistochemistry, and there was no evidence of lymphatic vessel involvement. The lack of any evidence of lymphovascular invasion and regional lymph node metastases supports the interpretation of intraluminal and transcoelomic spread, and may be taken as evidence of dissemination of tubal neoplastic cells by exfoliation in this case. The biology of transcoelomic spread is reviewed in this manuscript.

Risk factors associated with increased drainage volumes of chest tubes after transthoracic esophagectomy for esophageal cancer.

Prolonged chest drain placement can extend the postoperative hospital stay after esophagectomy in esophageal cancer (EC) patients. This study aimed to identify whether or not the risk factors associated with this prolonged chest tube placement are clinically important. A total of 138 patients who underwent subtotal esophagectomy for thoracic EC were retrospectively analyzed. Using the 75th percentile of the total drainage volume of chest tubes as a cutoff value, the high-output (HO; n = 35) and low-output (LO; n = 103) groups were compared in terms of the clinicopathological parameters. The median durations of right and left chest tube placement were 6 and 9days, respectively, with a median total drainage volume of 2692ml. When compared with the LO group, the HO group was significantly associated with male gender, a subcutaneous route for reconstruction, blood transfusion, higher morbidity, and prolonged chest drainage and postoperative hospital stays. A multivariable analysis further identified blood loss (p = 0.03) and the subcutaneous route for reconstruction (p = 0.04) as independent risk factors for increased chest tube drainage after esophagectomy. Blood loss and the subcutaneous route of reconstruction are risk factors for increased drainage of chest tube after esophagectomy for EC.

Harvesting the Liver From a Donor With a Biventricular Assist Device (BiVAD)—An Unexpectedly Challenging Procedure: A Case Report

BackgroundOrgan procurement from deceased donors is usually a standard procedure. Nevertheless, the performing surgeon is often confronted with demanding situations, such as atherosclerotic or aneurysmatic aortic disease or even other pathologies, which may alter the surgical steps. We report on an interesting case of solid organ harvesting from a donor with a biventricular assist device (BiVAD) due to global heart failure. Case ReportA 42-year-old male donor with a BiVAD, enlisted for heart transplantation, died of intracerebral hemorrhage. Dressing the surgical field was challenging because the extracorporal portions of all 4 tubes and the pump device rested on the donor's body, covering his whole abdomen. To ensure enough space, the pump and tubes had been covered with sterile swabs and drapes. The second surgical assistant was tasked with holding the device slightly deviated to the left and the ankle elevated at 45°, to avoid any tube kinking. The dissection of the main vessels distally was performed using the standard technique. No encirclement of the proximal aorta beneath the diaphragm was necessary, as the cardiac output could be arrested by clamping the left ventricle's outflow tube. Once the perfusion was completed, the procedure continued in the standard fashion. ConclusionSo far, the literature has no data on organ harvesting from deceased donors with BiVAD. Although such a retrieval is quite challenging and requires an experienced team, the transplantation of the corresponding organs can be performed without any further special technical problems.

Characteristics of the uterine tubes in the fetal period: topographic and morphometric parallels

Topicality of the study is stipulated by the importance of objective data for medicine concerning formation of the structure and topographic-anatomical interrelations of the uterine tubes with adjacent organs and structures during the prenatal period of human ontogenesis. Objective: to find and compare tendencies of changes of the uterine tube morphologic parameters in the two groups of fetuses remote in time, and determine age peculiarities of their topography during perinatal period of development. The experimental material (specimens of fetuses) was divided into two groups: І group – 35 specimens of fetuses deceased during 2017-2019; ІІ group – 105 specimens of fetuses taken from the Museum of the Departments of Anatomy, Clinical Anatomy and Operative Surgery at Higher State Educational Establishment of Ukraine “Bukovinian State Medical University”, collected during 1970-1990. Every group was subdivided into 7 subgroups according to 10 months of the fetal period of development (from the 4th to the 10th months). The results obtained were statistically processed in the licensed statistical package “Statistica 6.0” using nonparametric methods to evaluate the results. Regular changes in the topography of the right and left uterine tubes, changes in their shape and histological structure are observed. Both uterine tubes were found to occupy an ascending position in thirty cases out of sixty examined specimens of early fetuses (4-6 months of age). In twenty cases one uterine tube was found to be in an ascending position, and in ten cases both uterine tubes were placed practically horizontally. The study of uterine tube morphogenesis in 7-month fetuses found that the structure and topography of the uterine tubes in different age periods differ. In two 7-month fetuses the uterine tubes were found to be in an ascending position, in eight cases one uterine tube (the left one – in six cases out of eight) was in a horizontal position, and in ten cases two uterine tubes were directed practically horizontally. During the 8th month of the antenatal development one uterine tube was found to be in an ascending position out of eight cases; in ten cases both uterine tubes were in the position close to a horizontal one; and in two cases the left uterine tube was in a descending position. In 9-month fetuses both uterine tubes were found to be in a horizontal position in twelve cases, in eight cases one of the uterine tubes was in the position close to a descending one. In fourteen fetuses 10 months of development one uterine tube was in a descending position, and only in six cases both uterine tubes were located horizontally. The length of the uterine tubes of 4-7-month fetuses deceased during 2017-2019 was not found to differ reliably. Similar regularity was found in the group of fetuses aged from 9 to 10 months. The length of the uterine tubes of the archival specimens increases reliably every two months. In this group of fetuses the parameters of the uterine tube length aged from 9 to 10 months were found to differ reliably contrary to the length of the uterine tubes in the group of modern specimens of a similar age. Comparison of dynamics in changes of the uterine tube length in the two groups of fetuses remote in time showed that within the frame of one group differences in the morphometric parameters between the right and left uterine tubes are not considerable. Therefore, the study of peculiarities in the structure of the uterine tubes at every stage of the perinatal period found certain peculiarities and regularities of their development.

Single-Cell Transcriptomics Reveals Chemotaxis-Mediated Intraorgan Crosstalk During Cardiogenesis.

We hypothesized that the differentiation processes of cardiac progenitor cell (CP) from first and second heart fields (FHF and SHF) may undergo the unique instructive gene regulatory networks or signaling pathways, and the precise SHF progression is contingent on the FHF signaling developmental cues. We investigated how the intraorgan communications control sequential building of discrete anatomic regions of the heart at single-cell resolution. By single-cell transcriptomic analysis of Nkx2-5 (NK2 homeobox 5) and Isl1 (ISL LIM homeobox 1) lineages at embryonic day 7.75, embryonic day 8.25, embryonic day 8.75, and embryonic day 9.25, we present a panoramic view of distinct CP differentiation hierarchies. Computational identifications of FHF- and SHF-CP descendants revealed that SHF differentiation toward cardiomyocytes underwent numerous step-like transitions, whereas earlier FHF progressed toward cardiomyocytes in a wave-like manner. Importantly, single-cell pairing analysis demonstrated that SHF-CPs were attracted to and expanded FHF-populated heart tube region through interlineage communications mediated by the chemotactic guidance (MIF [macrophage migration inhibitory factor]-CXCR2 [C-X-C motif chemokine receptor 2]). This finding was verified by pharmacological blockade of this chemotaxis in embryos manifesting limited SHF cell migration and contribution to the growth of the outflow tract and right ventricle but undetectable effects on the left ventricle or heart tube initiation. Genetic loss-of-function assay of Cxcr2 showed that the expression domain of CXCR4 was expanded predominantly at SHF. Furthermore, double knockout of Cxcr2/Cxcr4 exhibited defective SHF development, corroborating the redundant function. Mechanistically, NKX2-5 directly bound the Cxcr2 and Cxcr4 genomic loci and activated their transcription in SHF. Collectively, we propose a model in which the chemotaxis-mediated intraorgan crosstalk spatiotemporally guides the successive process of positioning SHF-CP and promoting primary heart expansion and patterning upon FHF-derived heart tube initiation.

English

Women can still conceive naturally or through in vitro fertilization (IVF) with the one oviduct that is properly functioning if only one oviduct is blocked, however, the chances are decreased particularly if the blockage is close to the ovary (hydrosalpinx) because of wash out phenomena and toxic fluid produced by the fallopian tube that is blocked. In situations where only a single tube has hydrosalpinx specialists should advise patients appropriately and must be given options, to choose between undergoing salpingostomy, a surgical process that involves tubal reconstruction to expand their odds of getting pregnant naturally by removing the blockage or IVF treatment. For women with one working oviduct specialists must be on the lookout for ectopic pregnancy. This will enable early diagnosis of ectopic pregnancy and a treatment technique that spares the tube can be utilized. The patient is a woman of African origin with blood group O staying at Manyame Park Harare. She has never married before and has been trying to get pregnant from 2005. She eventually got a successful pregnancy in 2014 and delivered first child in 2015 after several interventions. Her infertility was initially due to the presence of hydrosalpinx on the left fallopian tube, scarring in the fimbriae of left tube, high prolactin level and was subsequently due to loss of the only working tube after ectopic pregnancy. The patient got pregnant whilst she was on bromocriptine, unfortunately the pregnancy did not last to full term. Chlomiphene was later added to her drug regiment and after six cycles she had an ectopic pregnancy which destroyed her only working tube. The patient then tried IVF treatments to achieve pregnancy. She underwent two IVF treatment cycles which failed to achieve pregnancy. The patient finally underwent tubal reconstruction microsurgery which enabled her to have two successful natural pregnancies. Gynaecologists must be vigilant in diagnosis of infertility factors and should give enough appropriate information to female patients when making decisions concerning fertility interventions. Key words: Fertility, in vitro fertilization (IVF), salpingostomy, hydrosalpinx, prolactin, fimbriae. &nbsp

Risk factors for intraoperative hypoxemia during monopulmonary ventilation: an observational study

BackgroundLeft double-lumen endotracheal tubes have been widely used in thoracic, esophageal, vascular, and mediastinal procedures to provide lung separation. Lacking clear objective guidelines, anesthesiologists usually select appropriately sized double-lumen endotracheal tubes based on their experience with 35 and 37Fr double-lumen endotracheal tubes, which are the most commonly used. We hypothesized the patients with a left main bronchus of shorter length (<40mm) had a greater chance of experiencing desaturation during one lung ventilation, due to obstruction in the orifice of the left upper lobe with the bronchial tube. MethodsWe included 360 patients with a left double-lumen intubated between September 2014 and August 2015. The patient's age, sex, height, weight, and underlying disease were recorded along with type of surgical procedure and the desaturation episodes. In addition, the width of the trachea and the width and length of the left bronchus were measured using computed tomography. ResultPatients with a left main bronchus length of less than 40mm who underwent intubation with a left double-lumen endotracheal tubes had significantly higher incidence of desaturation (Odds Ratio (OR: 8.087)) during one-lung ventilation. Other related factors of patients identified to be at risk of developing hypoxia were diabetes mellitus (OR: 5.368), right side collapse surgery (OR: 4.933), and BMI (OR: 1.105). ConclusionsWe identified that patients with a left main bronchus length of less than 40mm have a great chance of desaturation, especially if other desaturation risk factors are present.

Hybrid open and endovascular repair of a blunt traumatic thoracic aortic injury in a 7 year old boy

We describe a 7-year-old boy who sustained a blunt thoracic aortic injury following a rollover motor vehicle crash where the vehicle fell 200 feet down an embankment. The chest x-ray on arrival showed widening of the superior mediastinum, a left-sided hemothorax, and first rib fracture. The screening CTA of the chest revealed bilateral pulmonary contusions, a large left hemothorax, and evidence of aortic injury with active contrast extravasation. The patient was intubated due to respiratory distress and had a left chest tube placed. The patient became hypotensive with greater than 1.5 L of blood from the chest tube, so a resuscitative thoracotomy was performed. Bleeding was controlled with a sponge stick initially and definitively with a Satinsky vascular clamp. Next the patient was transported to the hybrid OR at the adjacent adult hospital with an open chest for endovascular graft placement. The patient was admitted to the PICU post-operatively, transferred to the floor on POD 4, and discharged home on POD 9. Aortic injury after blunt trauma in pre-adolescent children is uncommon and often fatal. Endovascular repair of traumatic thoracic aortic injury in adults is currently the standard of care, but there is a paucity of clinical data to guide management of these types of injuries in pediatric patients.

Efficacy and safety of Cohen Flex-Tip blocker and left double lumen tube in lung isolation for thoracic surgery: a randomized comparative study

BackgroundThe Cohen blocker is one of the lung isolation devices. Unfortunately, most anesthesiologists believe that its efficacy in inducing lung collapse is less than that of the double-lumen tube (DLT). This study has been performed to compare the adequacy of lung collapse and the adverse effects between the Cohen blocker and the left DLT for thoracic operations.MethodForty patients with an age range of 25–50 years and American Society of Anesthesiologist (ASA) physical status I-II of either sex were subjected to an elective thoracic operation with lung isolation achieved by either a left DLT or a Cohen blocker. The patients were distributed randomly into two equal groups (n = 20): group (I) left DLT and group (II) Cohen-blocker. The following parameters were measured: the number of intubation attempts, time for correct positioning, and lung collapse assessment grades either spontaneous (grade 1), assisted with suction (grade II), or with manual disconnection maneuver (grade III). Sore throat and hoarseness were compared between the two groups.ResultsThe first intubation attempt success rate was 90% and 95% (p = 0.871), while the second attempt success rate was 10% and 5% (p = 0.617) in the left DLT and Cohen blocker groups, respectively (non-significant p value). The time for correct positioning was significantly shorter in the left DLT group than in the Cohen blocker group (p < 0.001). Lung collapse showed similar results between the two groups (p = 0.803) regardless of the grade of lung collapse: either spontaneous (grade I), assisted with suction (grade II), or with manual disconnection maneuver (grade III). The left DLT group showed a significantly higher frequency of hoarseness (p = 0.017) and sore throat (p = 0.028) than the Cohen blocker group.ConclusionWe concluded that Cohen blocker can be used as a good alternative to the left DLT for its efficiency in inducing lung collapse with minimal incidence of postoperative hoarseness and sore throat.

Application value of closed single-port thoracoscopic and laparoscopic radical esophagectomy for esophageal cancer

Objective To investigate the application value of closed single-port thoracoscopic and laparoscopic radical esophagectomy for esophageal cancer. Methods The retrospective and descriptive study was conducted. The clinical data of a 49-year-old male patient with esophageal cancer who was admitted to the Fujian Medical University Union Hospital in November 2018 were collected. The patient underwent closed single-port thoracoscopic and laparoscopic radical esophagectomy and three-field lymph node dissection. In the thoracic part, esophageal separation and thoracic lymph node dissection were performed with closed pneumothorax, semi-lateral position and multi suspension methods. In the abdominal part, gastric separation and lymph node dissection were accomplished with lifting of liver lobe and respective separation of greater curvature and lesser curvature of stomach. The operation time, volume of intraoperative blood loss, time for out-of-bed activities, time of postoperative drainage tube removal, volume of thoracic drainage fluid, postoperative complications, postoperative pathological examination results, time for discharge from hospital and results of follow-up were observed. Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence and metastasis of patients after operation up to February 2019. Count data were described as absolute number. Results The patient underwent successfully closed single-port thoracoscopic and laparoscopic radical esophagectomy and three-field lymph node dissection. The operation time and volume of intraoperative blood loss was 310 minutes and 120 mL. The patient resumed out-of-bed activities at 2 days after operation. The abdominal drainage tube, thoracic closed drainage tube and right cervical drainage tube were removed at 2 days after operation with fasting, acid suppression, nutritional support. The thoracic Abel drainage tube and the left cervical drainage tube were removed at 5 days after operation. The volume of thoracic drainage fluid was 550 mL. No obvious sign of anastomotic leakage was found on esophageal angiography at 5 days after operation. The patient recovered well after operation without hoarseness, pulmonary infection and chylothorax. The postoperative examination result of the patient showed mid-thoracic esophageal squamous cell carcinoma (pT3N1M0G3 ⅢB stage). The patient was discharged at 8 days after operation. The patient was followed up for 3 months, and was able to engage in light physical activity. CT reexamination showed no sign of local recurrence or distant metastasis of the tumor. Conclusion Closed single-port thoracoscopic and laparoscopic radical esopahgectomy for esophageal cancer is safe and feasible, with good short-term efficacy. Key words: Esophageal neoplasms; Esophageal cancer; Radical surgery; Thoracoscopy; Laparoscopy; Single port

Use of tracheal ultrasound combined with clinical parameters to select left double-lumen tube size: A prospective observational study.

Left double-lumen tubes (LDLTs) are used in thoracic surgery to allow one-lung ventilation. Their size is usually chosen on the basis of clinical parameters (height, sex). Double-lumen endobronchial tubes are frequently undersized/oversized, risking tube displacement or tracheal trauma. A correlation between ultrasound tracheal diameter and left main bronchus dimension has been demonstrated. We hypothesised that the insertion of undersized/oversized double-lumen tubes is frequent when the size is selected using standard criteria, and that the use of ultrasound to estimate tracheal diameter may help to reduce the frequency of insertion of oversized tubes. Two-step prospective observational study. The operating room of a French University hospital from January 2016 to February 2017. We enrolled 102 and 50 consecutive patients undergoing elective thoracic surgery in Steps 1 and 2 (males 63.7 and 60.0%, age 63 (13) and 63 (11) years, height 170 (13) and 169 (9) cm, respectively). In Step 1, the size of the LDLT inserted was selected on the basis of clinical parameters. Ultrasound data about tracheal diameter were collected to determine cut-off points associating height and tracheal diameter. Cut-off values for ultrasound tracheal diameter were applied retrospectively to test their capability to reduce the insertion rate of oversized tube. In Step 2, the LDLT size was chosen according to the determined combined cut-off values. LDLT size was considered adequate if the bronchial cuff volume required for isolation of the lung (i.e. no difference between inspiratory and expiratory lung volumes) was 0.5 to 2.5 ml of air; undersized and oversized tubes required more than 2.5 ml and less than 0.5 ml, respectively. In Step 1, LDLT size was appropriate/undersized/oversized in 40 (39.2%)/23 (22.6%)/39 (38.6%) of patients. Cut-off values derived from ultrasound measurements would have reduced the use of oversized tubes by 20.6% (P < 0.001). In Step 2, the frequency of use of adequately sized tubes increased (86.0 vs. 39.2%, P < 0.001), and the frequency of insertion of oversized and undersized tubes decreased (6.0 vs. 38.2% and 8.0 vs. 22.6%, both P < 0.001). Combining ultrasound measurement of tracheal diameter and clinical parameters improves the choice of LDLT size.

Misdiagnosis of spontaneous bilateral tubal pregnancy: a case report and review of literature

Purpose of Investigation: Spontaneous bilateral tubal ectopic pregnancy (BTP) is the rarest form of ectopic pregnancy. Materials and Methods: A case of BTP diagnosed during surgery is reported and an algorithm has been proposed for the management of such patients. It is a case of a 32-year-old female at gestational age of nine weeks with spontaneous pregnancy reported vaginal bleeding. Results: The case describes the importance of identifying and examining both tubes at laparoscopy, despite the rarity of bilateral extra-uterine pregnancy. Emergency exploratory laparotomy revealed ruptured ectopic pregnancy along with active bleeding of the right tube (fimbrial region). The left tube was distended with a 3×4-cm mass at the fimbrial region. Conclusion: Bilateral conservative surgery is possible with unruptured ectopic tubal pregnancy.

Setting priorities in the conventional approaches in managing ectopic pregnancy; is it time to reform? A teaching hospital experience.

The aim of the studyTo review the management approaches of ectopic pregnancy (EP) at the Department of Obstetrics and Gynecology at Jordan University Hospital (JUH).Material and methodsAll patients admitted to our department with the diagnosis of EP treated during the study period extending from January 2017 to June 2019. Data were collected retrospectively using the patients’ files anonymously. Main outcome measures: age, parity, ectopic site, presentation, the main risk factor/s and the management plan.ResultsIn total, 65 cases of EP were managed during the study period. Overall, the mean age was 30 years. EP was located in the right tube in 23 cases, and in the left tube in 14 cases. Eleven patients presented with acute abdomen due to rupture of the EP and underwent urgent laparotomy; 7 of these cases were located on the right side. Conservative surgery (laparoscopy versus laparotomy) was the main line of management with attention to preserving the tube patency, followed by medical therapy when the patient fulfilled the criteria or those with pregnancy of unknown location.ConclusionsEP is a life-threatening condition. It is time to reform the priorities in the conventional approach to management. Every effort ought to be applied to preserve the reproductivity of women who are diagnosed with EP at the JUH. We would suggest that salpingostomy needs to be considered the surgical treatment of choice for the majority of these cases.

Awake fiberoptic intubation with double lumen tube for severe predicted difficult airways: Could it be feasible with a rigid fiberoptic stylet?

Awake fiberoptic intubation with double lumen tube for severe predicted difficult airways: Could it be feasible with a rigid fiberoptic stylet?

Penetrantna torakalna povreda u saobraćaju - prikaz slučaja

Introduction: Thoracic trauma requires intensive care treatment since in many cases it could have fatal outcome due to heart, lungs or major blood vessels injuries. Typically chest and internal body organs injuries are caused by falling from significant high, could be seen in firearm or in cold weapon injuries due to penetrating mechanism, but most often are seen in motor vehicle accidents. The case report of severe thoracic trauma which was successfully resolved upon treatment received from prehospital and hospital teams. 54 year old female patient has been injured in a traffic accident, under unclear circumstances, when her car hit the wooden fence. The ambulance arrived on 24-Jun-2017 at 17:45 after they received a call for traffic accident in which a female driver experienced severe trauma. The patient was found stabbed by a large spear-like piece of wooden fence in her right chest. Initial physical exam revealed unconscious female patient with heavy bleeding from the chest wound. Her Glasgow Coma Score was checked as 3. Patient appeared pale and hypotensive with blood pressure of 98/50 mmHg, heart rate of 104/min, and O2 saturation of 90%. The ambulance team performed initial hemostasis and stabilized the foreign body. IV cannula was inserted and normal saline therapy was initiated. Laryngeal Mask Airway was inserted and cervical spine was manually stabilized and the patient was immediately transported to the hospital. At admission patient was unconscious, with heart rate of 70/min and O2 saturation of 70%. Large part of wooden fence 1.5m in length, with rectangle shape (10cmx4cm), was found stabbed in the frontal area of the right chest, penetrating the right breast and exiting at the area of the right armpit. The patient was intubated, thoracic tube/drainage was inserted and foreign body was extracted. Upon performed MSCT of the head, neck, chest and abdomen the additional removal of necrosed tissue and thromboendarterectomy with anastomosis of right axillary artery was performed. The patient was put on mechanical ventilation on the same day at 19:40. During the hospital stay many specialist consultations were performed. On 06-Jul2017 right chest tube was removed. On 12-Jul-2017 left chest tube was removed and percutaneous tracheostomy was performed. On 20-Jul-2017 wound plastic surgery was done. On 21-Jul-2017 the patient was removed from the ventilator. On 26-Jul-2017 Vacuum Assisted Closure therapy was applied. On 08-Aug-2017 Thiersch procedure was done. On 16-Aug-2017 plastic tracheal tube was change for metal tube, which was removed on 28-Aug-2017. During the hospital stay patient received multiple antibiotic therapy, antifungal treatment, gastroprotective therapy, anticoagulant therapy, analgesic treatment, bronchodilator therapy, antihypertensive therapy, cardiovascular therapy, antiepileptic therapy, vitamin supplements, hormone substitution, crystalloid and colloid solutions support, and blood and plasma transfusions. The patient was receiving enteral nutrition during the hospital stay. She was discharged home on 01-Sep-2017. Conclusion: Severe thoracic trauma represents life threatening condition which requires multidisciplinary approach, both on prehospital and hospital levels, especially intrahospital in order to preserve life.

PREGNANCY IN THE RUDIMENTARY UTERINE HORN: A CASE REPORT

ABSTRACTOBJECTIVE: Rudimentary horn is a developmental anomaly of the uterus. Pregnancy in a rudimentary horn is rare, represents a form of ectopic gestation. The diagnosis of the rudimentary horn pregnancy is very difficult before it ruptures.CASE: We present a case of pregnancy in the communicating horn that was difficult to diagnose preoperatively. An emergency exploratory laparotomy was done considering abdominal ectopic pregnancy after the patient was given misoprostol for missed abortion from referral hospital. Our ultrasound evaluation revealed abdominal ectopic pregnancy. Intra operative finding was unruptured rudimentary horn. A non-viable female fetus with a birth weight of 200 g was delivered. The ruptured rudimentary horn and left tube were excised together.CONCLUSION: Despite advances in ultrasound, the diagnosis of pregnancy in the rudimentary horn remains difficult with definitive diagnosis being made at laparotomy. It is very important to have high index of suspicion especially in resource limited setting where most patients present with rupture.KEYWORDS: Rudimentary horn, Ectopic pregnancy, Mekelle University (Ethiopian Journal of Reproductive Health; 2018; 10; 4: 62-66)