Marked Obstruction Research Articles

Endoscopic Diagnosis and Treatment of Benign Small Bowel Stricture

Benign small bowel strictures can occur in association with various conditions, including small bowel Crohn’s disease, nonsteroidal anti-inflammatory drug-induced enteritis, ischemic enteritis, intestinal tuberculosis, radiation enteritis, postoperative adhesions, and anastomotic strictures. Benign small bowel strictures are classified into two categories, low-grade and high-grade. Low-grade small bowel strictures involve a partial reduction of the internal diameter of the small intestine, causing slight obstruction of the passage of food and digestive fluids without significant bowel obstruction symptoms. By contrast, high-grade small bowel strictures involve a severe narrowing of the intestinal lumen, leading to marked obstruction of the passage of food and digestive fluids and pronounced bowel obstruction symptoms. Small bowel strictures can be diagnosed using various methods, including abdominal plain radiography, abdominal computed tomography, computed tomography enterography, magnetic resonance enterography, balloon-assisted enteroscopy, and abdominal ultrasound. Each diagnostic method has unique advantages and disadvantages as well as differences in diagnostic specificity and sensitivity. Therefore, even if small bowel strictures are not observed using a single imaging technique, their presence cannot be completely excluded. A comprehensive diagnosis that combines clinical information from multiple diagnostic modalities is necessary. Therapeutic approaches for managing small bowel strictures include medical therapy, endoscopic balloon dilation using balloon-assisted enteroscopy, and surgical methods such as strictureplasty and segmental resection. Endoscopic balloon dilation, in particular, can help reduce complications associated with repeated surgeries for strictures.

Computational modeling and simulation of stenosis of the cerebral aqueduct due to brain tumor

ABSTRACT Stenosis of the cerebral aqueduct (CA) is featured in many studies relating to elevated intracranial cerebral pressures. It also presents a challenging situation to clinicians. Compressive forces play a lead role in pathological situations such as the presence of tumors and hence can cause obstruction to the flow of cerebrospinal fluid (CSF). Because of this barrier, excessive retention of CSF in the ventricles can occur. This, in turn, can contribute to increased pressure gradients inside the cranium. Most of the numerical models in the literature are restricted to modeling the CSF flow by considering the ventricle walls as rigid material, although in reality they are deformable. This paper, therefore, addresses the same from a holistic perspective by taking into consideration the dynamics of the flexible characteristics of the ventricular wall. It adds novelty to this field by reconstructing anatomically realistic ventricular wall behavior. To do this, the authors aim to develop a computational model of stenosis of the CA due to a brain tumor by invoking a fluid–structure interaction (FSI) method. The proposed three-dimensional FSI model is simulated under two cases: first, simulation of the pre-stenosis case with no interaction of tumor forces and, secondly, a stenosis condition with dynamic interaction of tumor forces. Comparison of the forces with and without a tumor reveals a marked obstruction of CSF outflow after the third ventricle and CA. In addition, a drastic rise in CSF velocity from 21.2 mm/s in the pre-stenosis case to 54.1 mm/s in the stenosis case is observed, along with a net increase in deformation of 0.144 mm on the walls of the ventricle. This paper makes a significant contribution to brain simulation studies for pressure calculations, in which the presence of tumors is a major concern.

Evaluation of Right Ventricular Outflow Tract Stenting as Palliative Treatment in Severely Cyanotic Tetralogy of Fallot: A Systematic Review and Meta-Analysis of Observational Studies.

Background: Tetralogy of Fallot (ToF) is a cardiac malformation that accounts for up to 1/10 of all congenital diseases. Although surgical repair serves as a treatment of choice, it cannot be performed unless weight and anatomical key factors are favorable. The stenting of the right ventricular outflow tract (RVOT) has become an alternative palliative procedure for ToF as an option to alleviate infundibular obstruction with minimal invasion. Methods: A literature search was conducted through 7 databases, followed by the screening and independent assessment of 6 final studies, using the Newcastle-Ottawa Quality Assessment Scale (NOS). Analysis was then conducted using inverse variance analysis, and cumulative data were presented with forest and funnel plots. Results: Studied patients were referred for RVOT stenting due to the marked obstruction of the pulmonary blood flow, a low birth weight, or a small pulmonary artery size. The analysis revealed a significant increase in O2 saturation (mean difference [MD=18%; 13–23.78). The same trend was observed concerning an increase in the Nakata index (MD=54.59; 10.05–99.14), the right pulmonary artery diameter (MD=2.28; 1.20–3.36), and the left pulmonary artery diameter (MD=1.77; 0.22–3.32). Several complications were found, including tricuspid regurgitation and frequent premature beats. Conclusion: RVOT stenting is considered a feasible palliative treatment for ToF, with its high effectiveness in improving patients’ condition, especially their pulmonary flow. While complications are scarce, several conditions should be noted, particularly for fatal complications. Finally, this study has limitations as catheterization details in studies and diverse infants’ conditions may have caused potential bias

Bilateral ureteral endometriosis—an indolent, aggressive, and dangerous condition

To describe an unusual bilateral ureteral reimplantation due to endometriosis and to provide a flowchart of conservative decision making. Video description of a case, demonstrating a step-by-step explanation of the decision planning and description of the surgical steps in a female patient with bilateral ureteral endometriosis who had previously undergone operation for bowel endometriosis, and who presented with extensive disease in the posterior compartment with no symptoms besides bilateral renal function disruption. The study was reviewed and approved by the Hospital Beneficência Portuguesa de São Paulo Institutional Review Board. Tertiary referral center. Deep infiltrating endometriosis involving the ureter has an incidence of 0.1% to 1%, normally affecting the lower one-third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement occurs in 9% of cases. The absence of specific symptoms makes the diagnosis of this condition challenging. Lumbar pain develops when its involvement is complicated by marked obstruction with impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of ureteral decompressive procedures. However, bilateral ureteroneocystostomy is a rare procedure, not exceeding 6% of ureteral reimplantations. This case illustrates a situation in which a patient with a previous bowel segmental resection presented with an advanced bilateral posterior deep infiltrating endometriosis, compromising the lower rectum below the previous anastomosis, vagina, posterior, and lateral parametrium bilaterally and both inferior hypogastric plexi. Hormonal therapy improved endometriosis symptoms but did not control the urinary tract involvement. Along with the patient, considering a high probability of intestinal, urinary, and sexual impairment, a conservative approach was chosen. The procedure started with adesiolysis, accessing the retroperitoneum and identifying both dilated ureters (Figs. 1 and 2). They were dissected as caudally as possible, until endometriosis fibrosis was reached, to have a bigger length of proximal ureter to allow a tension-free ureteroneocystostomy. The Retzius space was developed, and the bladder was freed and mobilized (Fig.3). After cutting the ureter, the proximal end was spatulated. The bladder dome was approximated to the psoas muscle with an interrupted suture to permit a tension-free ureteroneocystostomy. The detrusor muscle was opened for approximately 2 to 3 cm, exposing the vesical mucosa, which was subsequently opened. The posterior ureterovesical anastomosis was performed with running monofilament absorbable 4-0 sutures. A double-J stent was placed, and the anterior ureterovesical anastomosis was completed. The detrusor muscle was loosely closed over the ureter with interrupted absorbable sutures to avoid urinary reflux. A Maryland clamp was used to ensure sufficient entry of the tunnel. All these steps were repeated in the contralateral side. Successful performance of a bilateral laparoscopy tension-free ureteroneocystostomy with bilateral psoas hitch. The postoperative course was uneventful. Renal function was restored. One year after surgery, the patient remained asymptomatic, and endometriotic lesions showed no increase, thus remaining stable. Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision-making process must take into consideration the patient's characteristics and expectations. In selected cases, a conservative approach may be required, when future possible functional disfunctions can be worse than the actual symptoms. In those situations, close surveillance is necessary.

Levels of toll-like receptors 2 and 4 in serum of men with postinfarction cardiosclerosis and its relationship with antiphospholipid syndrome components

Annotation. There is a tendency for an increase of incidence of coronary heart disease (CHD) among young people, with the development of acute myocardial infarction (MI) in the absence of marked atherosclerosis and obstruction of the coronary arteries. Antiphospholipid syndrome (APS), cellular and humoral mediators of immunoinflammatory activation of endothelium are considered as factors of non-obstructive damage to the coronary vessels. New trigger factors for endothelial dysfunction, cardiac fibrosis, and myocardial hypertrophy include toll-like receptors (TLR2 and TLR4). Antiphospholipid antibodies may act as endogenous activators of toll-like receptors. The study of the association between APS components and expression of toll-like receptors in patients with CHD with postinfarction cardiosclerosis remains relevant. The aim is to study the levels of TLR2 and TLR4 and its relationship with APS components in men with postinfarction cardiosclerosis. 164 patients with stable CHD with postinfarction cardiosclerosis (100% of men, age 53.0±9.14 years) and 48 men of control group (without CHD) were examined. Levels of total antiphospholipid antibodies (aPL), antibodies to β2-glycoprotein 1 (anti-β2-GP 1) IgG and IgM, TLR2, TLR4 in serum were determined by ELISA. The studies were conducted in compliance with bioethical standards. Statistical processing of the results was performed in SPSS Statistics 22.0. Determined that men with postinfarction cardiosclerosis showed higher levels of TLR2 and TLR4 (in 1.8–2.2 times, p<0.001) in serum than control group. Higher (in 1.2–1.4 times) levels of TLR2 and TLR4 were found in patients who underwent Q-MI, recurrent MI and had clinical manifestations of APS (stroke, transient ischemic attacks, livedo reticularis). An increase TLR2 and TLR4 levels was closely associated with an increase of aPL and anti-β2-GP 1 of IgG (r = | 0.31 - 0.51 |, p<0.01). Thus, in men with postinfarction cardiosclerosis who had aPL and anti-β2-GP 1 IgG positivity had an unfavorable immunoinflammatory pattern, that characterized by increased expression of TLR2 and TLR4. The imbalance in TLR2 and TLR4 is more pronounced in young CHD patients and associated with Q-MI and recurrent MI.

2133 Bilateral Ureteral Endometriosis - an Indolent, Aggressive and Dangerous Condition

Video Objective Describe an unusual bilateral ureteral reimplantation due to endometriosis and a flowchart of a conservative decision making. Setting Deep infiltrating endometriosis (DIE) involving the ureter has an incidence of 0.1 – 1%, normally affecting the lower third of its segment, up to 4 cm above the vesicoureteric junction. Bilateral ureteral involvement happens in 9% of the cases. The absence of specific symptoms makes its diagnostic challenging. Lumbar pain takes place when its involvement is complicated by a marked obstruction, with an impaired renal function. Decompressive surgery is mandatory. The necessity of ureteroneocystostomy increases along with the severity of hydronephrosis, accounting for 62% of the ureteral decompressive procedures. Even though, bilateral ureteroneocystostomy is a rare procedure, not trespassing 6% of ureteral reimplantations. Interventions This case illustrates a situation where a patient with a history of a bowel segmental resection presents with an advanced bilateral posterior DIE, compromising lower rectum below the previous anastomosis, vagina, parametrium (posterior and lateral) bilaterally and both inferior hypogastric plexus. Hormonal therapy improved endometriosis symptoms, but did not control the urinary tract involvement. Along with the patient, considering a probability of intestinal, urinary and sexual impairment, a conservative approach was decided and a laparoscopy bilateral ureteroneocystostomy was performed with a post-operative close clinical and imaging surveillance. Conclusion Ureteral endometriosis can be aggressive and indolent. Decompressive procedures must be performed. The decision making process must take in consideration patient's characteristics and expectations.

Successful Surgical Intervention in Symptomatic Severe Hypertrophic Subaortic Stenosis

Successful Surgical Intervention in Symptomatic Severe Hypertrophic Subaortic Stenosis Subaortic stenosis is a scarce progressive entity causing left ventricular outflow tract obstruction leading to concentric left ventricular hypertrophy and carrying a considerable risk of morbidity and mortality. We report a 68-year old woman who was symptomatic for more than two years with signs of congestive heart failure and admitted for re-procedural pulmonary vein isolation because of paroxysmal atrial fibrillation. Echocardiography revealed a marked left ventricular outflow tract obstruction due to a fibromuscular membrane just below the aortic valve and moderate aortic valve insufficiency, compatible with a severe subaortic stenosis. Surgical resection of the subaortic membrane, myectomy of the basal septum, bioprosthesis aortic valve replacement and epicardial left atrial appendage closure were successfully performed. The patient was discharged from hospital in good clinical condition. This report is outlining the diagnostic challenge of the rare diagnosis of a symptomatic severe hypertrophic subaortic stenosis in adulthood which is known to carry a considerable risk of morbidity and mortality and surgical intervention as safe therapy of choice in this condition.

Mild proteinuria in a patient with glomerularlimited intravascular large B-cell lymphoma

Intravascular large B-cell lymphoma (IVLBCL) is a rare type of non- Hodgkin lymphoma characterized by a disseminated intravascular proliferation of tumor cells in the lumina of small vessels. Although the kidney is one of the target organs of IVLBCL, lymphoma cells that localize only in glomeruli are extremely rare. We report a 55-year-old Chinese patient diagnosed as glomerular-limited IVLBCL by percutaneous renal biopsy. The patient was referred to our institution for further examination of mild proteinuria and anemia without lymphoma symptoms. He had daily urinary excretion of 0.65 g proteins with normal renal function. Percutaneous renal biopsy showed that lymphoid cell accumulation was encircled within the glomerular capillary lumina only in certain glomeruli, resulting in marked obstruction of capillary structure. However, almost all of the peritubular capillary and tubulointerstitium were intact. Immunohistochemical analysis confirmed the diagnosis of intravascular large B-cell lymphoma. Extensive systemic examinations showed no other organ involvement. With these characteristic changes, glomerularlimited IVLBCL were considered as an exceptional renal manifestation of intravascular lymphoma diagnosised by percutaneous renal biopsy.

Role of Percutaneous Septal Ablation in Hypertrophic Obstructive Cardiomyopathy

HCM is a relatively common genetic mediated primary cardiac disease which may cause sudden death in the young including competative athlets.PTSMA is an alternative therapeutic option for surgical septal myomectomy who are high risk for surgery and presented with severe disabling symptoms due to marked LV outflow obstruction. PTSMA is performed by injection of 1 to 4 ml of 96% to 98% ethanol into the target artery in 0.5 to 1.0 ml aliquots at 1 ml/min. Selection of patients for PTSMA includes those with severe symptoms refractory to maximum medical management associated with LV outflow gradient > 50 mm Hg and basal septal thickness > 18 mm. Successful outcome following septal ablation by LV outflow gradient often reduced to < 20 mm of Hg and improved from symptomatic standpoint. DOI: http://dx.doi.org/10.3329/uhj.v8i2.16083 University Heart Journal Vol. 8, No. 2, July 2012

Hypertrophic obstructive cardiomyopathy and anomalous origin of the right coronary artery. A rare coexistence

We present the case of a 65 year-old patient with a history of hypertension and hypertrophic obstructive cardiomyopathy (HOCM) in whom anomalous origin of the right coronary artery (RCA) was diagnosed. Echocardiography measured left ventricular outflow tract (LVOT) gradient ranged between 80 and 123 mm Hg. Systolic anterior motion (SAM) of the mitral valve was visualised. The angiography showed favorable coronary anatomy for alcohol septal ablation (Fig. 1). Additionally, anomalous RCA origin from the left coronary sinus (CS) in sub-selective contrast injection was diagnosed. Cardiac magnetic resonance (CMR) showed asymmetrical left ventricular hypertrophy up to 22 mm of the base anterior segment, base and mid segments of the interventricular septum and inferior segment. Stress CMR revealed reversible, dipyridamole induced ischaemia in the base segment of the lateral wall, apex segments of the inferior and septal wall, and within papillary muscles. Computed tomography (CT) scan revealed RCA ostium angulation and moderate compression at rest of the proximal RCA segment (Fig. 2). Corrective surgery for HOCM was performed. Based on intraoperative assessment of the anomalous RCA course, no surgical correction was done. The anatomical course of a coronary artery that passes between the aorta and pulmonary artery in a young person is a major risk factor for adverse events, even without symptoms. The co-existence of HOCM with marked LVOT obstruction at rest may potentially increase the sudden cardiac death risk. Recently Moza et al. (Am J Med Sci, 2011; 342: 341–342) reported a similar case, but in a much younger patient, who presented with a two-week history of exertional chest pain. Additionally, the combination of HOCM with left coronary artery originating from the right CS was described. Invasive treatment for asymptomatic patients remains controversial, with growing advocacy for patients with ‘left from right’ as opposed to ‘right from left’ origins. CMR provides relevant information on the extent and functional relevance of ischaemia in HOCM patients, mainly attributed to microvascular dysfunction. The value of CT in assessing anomalous coronary arteries has been established. Miller et al. (Int J Cadiovasc Imag, 2012; 28: 1525–1532) presented a series of 15 patients with abnormal origin of coronary arteries, who were examined by CT. This modality proved to be very accurate in showing the anatomical details, confirmed later during corrective surgery. Accurate depiction of the RCA course can be helpful in planning the operative strategy. Interventional treatment of the LVOT obstruction and SAM is discussed elsewhere. Surgical correction of anomalous course of coronary artery is recommended for all adult patients who are symptomatic or who have clear evidence of exercise-induced myocardial ischaemia and the mid-term results are encouraging.

Left main occlusion in acute coronary syndrome: percutaneous coronary intervention or coronary artery bypass graft

Cardiologia CROATICA Coronary artery disease (CAD) is the narrowing or blockage of the coronary arteries, usually caused by atherosclerosis. It is a leading cause of death worldwide, causing approximately 7.2 million deaths worldwide each year. Complete occlusion of LCA is an unusual manifestation of CAD. The reported angiographic incidence is very low, it is found in 0.03% to 0.8% of patients in different studies. Occlusion of this vessel compromises flow to at least 75% of the left ventricle, unless it is protected by collateral flow or a patent bypass graft. Left main coronary artery disease rarely occurs as an isolated lesion; over 70% to 80% of patients also have multivessel coronary artery disease. Most patients with this condition complain of recurrent typical chest pain and have a history of myocardial infarction. They may also present with symptoms of heart failure. The diagnosis is usually made by angiography, which reveals a right dominant system. Right coronary artery provides collateral circulation to the left system, but up to two thirds of patients have a marked obstruction of the RCA. Our report describes two patients with ST-elevation myocardial infarction, who developed cardiogenic shock. In both cases, coronary angiography was performed immediately, and showed total occlusion of LCA and a right dominant system. The first patient was referred to primary PCI LMCA, and the second patient was referred to intraaortic balloon pump placement and multiple CABG. Six months later, both patients remain stable. Uncertainty surrounds the optimal revascularization strategy for patients with ST-elevation myocardial infarction LMCA occlusion and treatment guidelines in this setting are vague. PCI of the LMCA should be considered as a viable alternative to CABG for selected patients with myocardial infarction, including those with LCA occlusion and less than TIMI flow grade 3, cardiogenic shock, persistent ventricular arrhythmias, and significant comorbidities.

Sevoflurane Inhalation for Severe Bronchial Obstruction in Infants with Bronchiolitis

Bronchiolitis is a lower respiratory tract viral infection which may result in severe bronchial obstruction and respiratory failure despite treatment with beta-adrenergic agonists and glucocorticoids. Here we describe two otherwise healthy infants with severe bronchiolitis whose clinical course was complicated by marked bronchial obstruction and respiratory acidosis refractory to conventional medications (β-stimulants, anticholinergics and corticosteroids) and non-invasive positive pressure ventilation. Sevoflurane inhalation allowed both infants to attain a sustained, clinical improvement in ventilation and one patient to avoid mechanical ventilation. We suggest that sevoflurane inhalation may be a therapeutic option in the treatment of young infants with severe bronchiolitis who respond poorly to conventional therapy.

Case Report: Tracheal collapse in a six-year-old Yorkshire Terrier

A six-year-old male neutered Yorkshire Terrier presented with a 12-month history of paroxysmal coughing. Investigations revealed grade III tracheal collapse, with marked obstruction to airflow at the thoracic inlet on expiration. Medical management, consisting of weight loss, antitussives and anti-inflammatory steroids led to a slight improvement in the dog's signs, however the cough, exercise intolerance and hypoxic episodes continued. A flexible self-expanding metallic stent was placed within the trachea under fluoroscopic guidance. This led to long-term resolution of the dog's clinical signs.

The rapid growth of a pleomorphic adenoma of the parotid gland in the third trimester of pregnancy

IntroductionWe report a case highlighting the multidisciplinary management of a giant pleomorphic adenoma of the parotid gland that showed rapid growth in the third trimester of pregnancy.Case presentationA 43-year-old Caucasian woman presented in her 32nd week of gestation with a tumor of the parotid gland. Ultrasonography of her neck showed a parotid lesion of 40 × 30 × 27.5 mm. A follow-up magnetic resonance imaging scan of the neck four weeks later revealed that the tumor had grown to 70 × 60 × 60 mm, reaching the parapharyngeal space with marked obstruction of the oropharynx of about 50%. After discussing the case with our multidisciplinary tumor board and the gynecologists it was decided to deliver the baby by caesarean section in the 38th week of gestation, and then to perform a surgical resection of the tumor.ConclusionIndications for early surgical intervention of similar cases should be discussed on an individual patient basis in a multidisciplinary setting.

Hemolytic anemia in a patient with hypertrophic obstructive cardiomyopathy

A 66-year-old woman was referred for further evaluation and treatment of normocytic and normochromic anemia with hemoglobin level of 8.6 g/dL. A peripheral blood smear showed fragmented erythrocytes. The patient was then referred to the department of cardiology because of systolic murmur, ECG abnormality, and red cell fragmentation. Transthoracic echocardiography revealed hypertrophic cardiomyopathy with particularly increased interventricular septal thickness of 24 mm and a hyperkinetic wall motion, resulting in marked obstruction to left ventricular outflow tract (pressure gradient of 200 mmHg). Mitral regurgitation due to systolic anterior motion of the mitral valve leaflets was also seen. The cause of anemia was thought to be mechanical intravascular hemolysis due to left ventricular outflow tract obstruction and mitral regurgitation. She was treated with atenolol and the class Ia antiarrhythmic drug cibenzoline to relieve the outflow tract obstruction, and the pressure gradient was reduced to 70 mmHg. After 3 months of treatment, her hemoglobin level had increased to 11.4 g/dL without additional treatment for anemia.

心肺停止に陥ったｐｌａｓｔｉｃ ｂｒｏｎｃｈｉｔｉｓ例

Plastic bronchitis is characterized by marked obstruction of the large airways by bronchial casts. The condition is rare but can occur at any age. Asthma or allergy is often the cause of cast production, but in some instances there is no etiology identified. Especially in children, it is difficult to differentiate plastic bronchitis from bronchial foreign bodies. Bronchoscopic extraction of casts benefits some patients. Plastic bronchitis causes acute respiratory failure. A 2-year old boy with no history of asthma or allergy presented with severe respiratory distress following a 3-day history of upper-respiratory-tract infection. Chest X-ray showed complete collapse of the left lung with mediastinal shift. Bronchoscopy demonstrated obstruction of casts. The patient improved after bronchoscopic extraction of casts. But in the emergency care unit, this patient became very difficult to oxygenate despite aggressive ventilation and suddenly developed cardiopulmonary arrest. This patient was recovered by CPR, and a complete cast of the bronchial tree from carina to the small airways was removed by repeated bronchosopies.

Myths About Surgical Myectomy: Rumors of Its Death Have Been Greatly Exaggerated

One of the most contentious controversies in cardiovascular medicine emerging over the past 5 years is the debate between surgical myectomy and alcohol septal ablation with regard to the management of severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HC).1,2 On the basis of the recommendations of the American College of Cardiology and European Society of Cardiology consensus panel and the views of those investigators and clinicians most invested in HC, surgery remains the primary treatment option for most of the patient subgroup with severe drug refractory heart failure symptoms (New York Heart Association class III or IV) associated with marked obstruction to left ventricular outflow (gradient, ≥50 mm Hg at rest or with physiologic provocation).

Thymic Cyst Causing Superior Venacava Syndrome Relieved by Mediastinoscopy—A Rare Presentation

Superior venacava obstruction is most often caused by intrathoracic malignant masses. The commonest cause of benign superior venacava obstruction is fibrosing mediastinitis. A thymic cyst causing marked superior venacava obstruction is very rare and has not been reported. We hereby present a case of a 40-year-old man with such a finding who presented with chest pain and facial congestion. Evaluation revealed a mediastinal mass causing marked superior venacaval obstruction. He underwent a mediastinoscopy, which showed a cyst. It was drained following which there was complete resolution of symptoms post-operatively. Histopathology of the lesion confirmed a thymic cyst.

Idiopathic airway-centered interstitial fibrosis: report of two cases

Idiopathic airway-centered interstitial fibrosis: report of two cases

The Role of Timely Intervention in Middle Lobe Syndrome in Children

Middle lobe syndrome (MLS) in children is characterized by a spectrum of clinical and radiographic presentations, from persistent or recurrent atelectasis to pneumonitis and bronchiectasis of the right middle lobe (RML) and/or lingula. This study was undertaken to evaluate the effect of early intervention, including fiberoptic bronchoscopy (FOB), in the development of bronchiectasis in MLS. Children with atelectasis of the RML and/or lingula persisting for > 1 month or recurring two or more times despite conventional treatment underwent high-resolution CT (HRCT) scanning and FOB. Appropriate treatment and follow-up were provided, and the effect of the duration of symptoms on clinical outcome and the development of bronchiectasis was investigated. The patient cohort was retrospectively reviewed. We evaluated 55 children with MLS. The median age at diagnosis, duration of symptoms, and duration of clinical deterioration before diagnosis were 5.5 years (range, 3 months to 12 years), 14.5 months (range, 3 to 48 months), and 8 months (range, 3 to 36 months), respectively. FOB revealed marked obstruction in two children (ie, a foreign body and an endobronchial tumor) and positive findings for a culture of BAL fluid in 49.1% of patients. The remaining 53 patients were followed up for a median duration of 24 months (range, 5 to 96 months). The clinical outcome was "cure" in 60.4% of patients, "improvement" in 32.1% of patients, and "no change" in the remaining patients. Bronchiectasis was documented prior to FOB by HRCT scan in 15 patients (27.3%). The duration of the deterioration of symptoms prior to presentation positively correlated with the development of bronchiectasis (p = 0.03) and an unfavorable clinical outcome (ie, improvement or no change) [p = 0.02]; a positive correlation was also found between the duration of symptoms and the development of bronchiectasis (p = 0.04). Timely medical intervention in patients with MLS that includes FOB with BAL prevents bronchiectasis that may be responsible for an ultimately unfavorable outcome.