Single-Stage Bronchoscopy-Guided Protocol for Tracheostomy Decannulation in Adult Patients.

INTRODUCTION: Tracheostomy decannulation is a routine procedure in airway management. There is no standard decannulation method; however, the two commonly practiced approaches are tracheostomy downsizing and intermittent capping, which are both accompanied by multiple visits to the clinic and increase patient discomfort. Herein, we explore fiberoptic bronchoscopy application in a novel single-stage decannulation protocol. METHODS: We conducted a retrospective study on tracheostomy patients eligible for decannulation. Fiberoptic bronchoscopy was performed on patients with spontaneous ventilation for ≥48 h, age ≥18, hemodynamic stability, normal chest X-ray, adequate swallowing, effective cough, adequate consciousness, patent speaking valve, and absent history of recurrent aspiration. Tracheostomy removal occurred after evaluating the airway and ruling out tracheomalacia, tracheitis with stenosis, obstructive granulation tissue, and moderate-to-severe stenosis. We documented patients' demographic and clinical information, along with details of their post-decannulation course. RESULTS: Out of 58 patients admitted for tracheostomy removal, we excluded six patients (10.3%) from the study because, despite clinical indications for successful weaning, they exhibited abnormalities that interrupted the decannulation process. Of the remaining 52 patients, 50 (96.1%) were successfully weaned off, while two needed reinsertion during their hospital course. Bronchoscopy findings were unremarkable in 33 (63.5%) patients, and the most frequently observed abnormalities were paucity of vocal cord movement in 5 (9.6%) patients and granulation tissue formation in 5 (9.6%) patients. No further airway management was necessary after discharge. CONCLUSIONS: Our study introduces the innovative approach of single-stage bronchoscopic decannulation as a potentially beneficial tool for immediate decannulation. Based on our experience, we achieved a relatively satisfactory outcome following single-stage tracheostomy decannulation with bronchoscopy. The approach shows promise in providing valuable airway insights and predicting possible decannulation failures. Further research is needed to evaluate its impact on stress reduction for patients and surgeons, its superiority compared to traditional techniques, its long-term effects on healthcare, and its potential cost-effectiveness.

Esophageal perforation etiology, outcome, and the role of surgical management - an 18-year experience of surgical cases in a referral center.

INTRODUCTION: Esophageal perforation is a surgical emergency with a high rate of morbidity and mortality. Its poor prognosis is mainly associated with previous patient-specific comorbidities and a lack of timely diagnosis and treatment. The objective of this study was to investigate the etiological factors and different surgical methods of treatment with consideration of mortality rate and comorbidities. METHOD: The present cross-sectional study was conducted on patients who underwent surgical intervention due to esophageal injury from 2002 to 2019 (18 years). Demographic and clinical characteristics along with performed surgical interventions were evaluated accordingly. RESULTS: In this study, 69 patients with a mean age of 38.8 years were evaluated, of which 45 (65.2%) cases were men. In terms of location of the perforation, the thoracic portion of the esophagus followed by the cervical and abdominal esophagus were more frequently injured with a rate of 32 (46.4%), 30 (43.5%), and 19 (27.5%) cases, respectively. Accordingly, foreign body ingestion followed by penetrating injuries were the most common causative agents leading to esophageal perforation. CONCLUSION: Obtaining the desired results from the treatment of this condition depends on factors such as patients' previous comorbidities, cause of the rupture, the location of the esophageal damage, and delay in the start of treatment. Since there is no single gold standard treatment strategy, each patient should be individually evaluated.

The effect of suture techniques on the outcome of tracheal reconstruction: An observational study and review of literature.

BACKGROUND: Tracheal resection and anastomosis surgery is a safe operation and is used to treat various benign and malignant diseases of the trachea. However, tracheal stenosis is among the main anastomotic complications following this procedure. Surgeons use both the continuous and the interrupted suture techniques for tracheal anastomosis, but contradicting results in each technique's complications have been reported in various studies. In this study, we aimed to compare the outcome of these two different suture techniques and a relevant literature review. METHODS: Surgical records during a period of 15 years (2005-2019) were screened for tracheal reconstruction surgery in affiliated hospitals of Shiraz University of Medical Sciences, Shiraz, Iran. A total of 82 patients were evaluated based on surgical and suture features, along with their follow-up bronchoscopy for anastomotic complications. RESULTS: Post-operational subclinical restenosis occurred in 8 (15.3%) out of 52 and 10 (33.3%) of 30 patients who underwent continuous and interrupted suturing techniques, respectively. Also, 6 (20%) patients in the interrupted group developed symptomatic restenosis, while in the continuous group, only one patient was clinically symptomatic. The patients with continuous suture technique had a shorter surgery time than patients whose interrupted technique was used (P < 0.001). CONCLUSIONS: Based on our results, we conclude that restenosis is significantly reduced when the continuous technique is applied for tracheal anastomosis; However, the results are contradicting in relevant literature and due to the retrospective nature of our study, further human studies and clinical trials are warranted.

Roles of alpha-7 nicotinic acetylcholine receptors and spleen in the lung injury induced by a repeated saline lavage in rat.

BACKGROUND: The study aimed to determine whether or notα7 nicotinic acetylcholine receptors (α7nAChR) induce anti-inflammatory effects directly in the lung or through the spleen pathway in a sterile model of lung injury by saline lavage. METHODS: Male Sprague Dawley rats were divided into seven groups; Sham, splenectomy (SPX), saline lavage (LAV), LAV treated with α7nAChR agonist nicotine (LAV + NIC), and LAV treated with NIC and a selective α7nAChR antagonist MLA (LAV+MLA+NIC), LAV and splenectomy (LAV+SPX), and LAV+SPX treated with nicotine (LAV+SPX+NIC). Tracheostomy and catheterization of the femoral artery were performed under deep anesthesia. Animals were subjected to volume-controlled ventilation and lung injury by 10 repeated saline lavages. Splenectomy was achieved one week before the induction of lung injury. The recovery phase lasted for 3 h, and drugs were injected 1 h after the last lavage. RESULTS: Mean arterial blood pressure (MBP), heart rate (HR), PaO2, PaO2/FiO2 ratio, and pH decreased, whereas, maximal inspiratory (MIP) and expiratory (MEP) pressures, and PaCO2 increased 1 h after the saline lavage. Nicotine corrected entirely all the above parameters in the LAV + NIC group. MLA or SPX prevented the effects of nicotine on the above parameters, except that MLA had no extra effect on MIP or MEP. In addition, nicotine improved lung compliance in the LAV + NIC and LAV + SPX + NIC groups, though it was inhibited by MLA in the LAV + MLA + NIC group. The increases of plasma and lung tissue malondialdehyde (MDA) in the LAV group were diminished by nicotine, whereas, MLA and SPX prevented these reductions. Besides, nicotine could reduce plasma MDA in the LAV + SPX + NIC group. Total BAL cell count, protein BAL/protein plasma ratio, and lung histological scores were attenuated by nicotine in the LAV + NIC group, whereas, MLA reversed the mentioned alterations in the LAV + MLA + NIC group. However, splenectomy could not stop the decreasing effect of nicotine on the total BAL cell in the LAV + SPX + NIC group. CONCLUSIONS: In this study, we indicated that α7nAChR and spleen play roles in cholinergic anti-inflammatory pathways in saline lavage-induced lung injury. However, our results are in favor of at least some direct effects of α 7nAChR in the lung.

Assessing two methods of repair of duodenal defects, jejunal serosal patch and jejunal pedicled flap, (an experimental animal study).

OBJECTIVE: To evaluate the outcomes of jejunal serosal patch and jejunal pedicled flap procedures for the repair of duodenal injuries. METHODS: The experimental animal-model study was conducted at Shiraz University of Medical Sciences, Iran, in February 2013. Ten mixed-breed male dogs were selected and randomly divided into groups A and B. After general anaesthesia, a large duodenal defect was created in all animals. The defect was repaired with jejunal pedicled flap in group A and jejunal serosal patch in group B. Microscopic healing was scored according to epithelialisation, collagenisation, inflammation, ulcer and necrosis of samples. Kolmogorov-Smirnov and independent t-test were used to indicate normal distributions of data and statistical differences between the two groups respectively. RESULTS: The weight of the animals ranged between 23 and 37 kg and the age range was 12-16 months. All dogs survived the procedures. Anastomotic leakage, intra-abdominal abscess or intestinal obstructions were not detected in gross examination. Healing score was significantly higher in the group A than group B (p < 0.011). However, in terms of surgical findings, no significant difference was detected between the groups (p > 0.05). CONCLUSION: Applying jejunal pedicled flap for repairing large duodenal defects would lead to better histologic outcomes compared to jejunal serosal patch in dogs.

A new brace for maintaining the neck in a suitable position following tracheal reconstruction.

Segmental resection and end-to-end anastomosis is the treatment of choice for patients suffering from tracheal stenosis for whom conservative management is not planned. A complication of this procedure is tension-induced anastomotic failure. To prevent this complication, maintaining the neck in full flexion by means of a suture between the chin and upper chest is a traditional approach. We have designed a new brace (Shiraz brace) that securely supports the neck in this position and decreases the bothersome use of the suture alone.

The aftermath of asbestos prohibition in industry and its association with malignant mesothelioma in the south of Iran: An enduring predicament yet to be resolved.

Purpose: Malignant Mesothelioma (MM) is a rare malignancy of the serosa membranes with a high mortality rate and long latent period. The relationship between a group of mineral fibers known as asbestos and mesothelioma is now well accepted in which people can be exposed to these fibers by various means during their lifetime and has been its usage has banned in many countries, such as Iran, which announced its gradual elimination from 1999 over a period of 7 years by using safe substitutes. However, the mineral particles are able to sustain itself in the environment, air, water, and soil and on the other hand, symptoms may take up to half a century to develop in exposed individuals. Also, there remains a shortage of comprehensive investigation on the effects of asbestos exposure within the familial context (household or domestic exposure) or on individuals residing in proximity to asbestos mines or factories (environmental exposure). Based on the high number of MM cases in Iran, and also our hypothesis that residuals of asbestos in the environment and petroleum products may be the etiological factor for MM, we conducted this study to evaluate the clinic epidemiological features of MM in the south of Iran its relation to possible asbestos exposure. Methods: In this study, we analyzed the demographic features and occupations of confirmed cases of MM in Shiraz, southern Iran along with the follow-up of the patients' disease from 2008 to 2018, while also comparing the features of our patients with a control group compromising of 105 non-MM patients. Results: Among the 35 confirmed cases of MM, with an average age of 61 years, 9 (25.7%) were female, and 26 (74.3%) were male. During our assessment, 12 patients had already died, with a mean time of 11.26 months post-diagnosis. Our findings revealed a higher prevalence of MM among housekeepers and employees of oil companies. In comparison to the control group, individuals with occupational exposure and those residing near refinery locations were at a heightened risk of developing MM. However, based on regression analysis, only occupations associated with refineries exhibited a significant correlation with MM (p = 0.028; OR: 14.602; 95% CI: 1.328-160.499). Conclusion: Both occupational and para-occupational exposure demonstrated a significant correlation with MM, whereas our regression analysis did not affirm geographical and environmental factors as contributors to MM. Despite the industry's prohibition of direct asbestos usage, the persistent existence of asbestos particles in the environment for decades, coupled with the long latency period of MM, warrants further investigation. Health authorities and policymakers should recognize this potential hazard, prompting an enhancement of early detection within at-risk groups.

Pleural epithelioid hemangioendothelioma in a 39-Year-old female: a case report.

BACKGROUND: Epithelioid hemangioendothelioma (EHE) is a rare malignancy of vascular origin which can be primarily be seen in various tissues. EHE originating from the pleura is an even more uncommon subtype which may mimic mesothelioma and pleural carcinomatosis. The prognosis of pleural EHE is poor and there is no consensus on the optimal therapeutic approach. CASE PRESENTATION: A 39-year-old middle-eastern female presented with progressive dyspnea and left shoulder discomfort. Chest computed tomography scan revealed a left side pleural effusion and pleural thickening. Pleuroscopy was done and biopsies were taken which were positive for CD31, CD34, CK, factor 8-R-antigen, and vimentin. Patient was diagnosed with pleural epithelioid hemangioendothelioma (PEHE) and chemotherapy was started and underwent extrapleural pneumonectomy 7 months later. Unfortunately, the patient passed away 10 months after diagnosis due to disease complications. CONCLUSIONS: Once PEHE is suspected in histology it can be confirmed with immunohistochemistry. Chemotherapy, surgery or a combination of both is currently used as the treatment but the standard treatment remains a question.

Hospital-based retrospective analysis of 224 surgical cases of lung hydatid cyst from southern Iran.

BACKGROUND: The lungs are considered the second-most frequent location for hydatid cyst in human. The current retrospective hospital-based study aimed to assess the epidemiological data, clinical presentation, and treatment outcomes of lung hydatid cyst in patients who underwent surgery for this disease in Fars province, southern Iran. METHODS: In this retrospective study, hospital records of 224 pulmonary hydatid cyst patients were assessed in two main university-affiliated hospitals in Fars Province, southern Iran. Clinical features of patients, epidemiological data, cyst features, surgical interventions, and treatment outcomes were reviewed and analyzed. RESULTS: A total of 224 hydatid cyst cases of the lung were reviewed. Male patients accounted for the majority of cases (60.4%). The average age of the patients was 31.13 (± 19.6), ranging from 2 to 94 years old. Of the 224 patients, 145 (75.9%) cases had only one single cyst and mostly 110 (53.9%) located in the right lung. Also, 6 (2.9%) cases had cysts in both lungs. The lower lobe of the lungs was the most common location of the hydatid cyst. The average size of lung hydatid cyst was 7.37 cm (SD = 3.86; rang: 2-24) while for the cyst areas was 42.87cm2 (SD = 52.76; range: 2-488). Regarding the surgical method, 86 (38.6%) cases were operated by lung resection surgery while 137 (61.4%) cases had lung preserving one. The chief complaints of the patients were cough (55.4%) and dyspnea (32.6%). Relapse was documented in 25 (11.16%) of cases. CONCLUSIONS: Lung hydatid cyst is a common infection in southern Iran. Lung preserving surgery is the method of choice for the management of hydatid cyst. Relapse, which was not uncommon in our study, is a challenging feature of hydatid cyst management.

Hypertonic saline solution 5% as an effective cost-beneficial alternative to normal saline for wound healing in patients with diabetic lower-extremity ulcers: a randomized controlled trial.

Background: Diabetic foot ulcer is among the most common complications and causes of mortality and morbidity in patients with diabetes. Herein, we propose using 5% Hypertonic Solution as an alternative to Normal Saline in treating patients with diabetic foot ulcers as an effective cost-benefit therapeutic approach. Methods: In this clinical trial, 100 patients with diabetic foot ulcers were divided into two groups. Foot ulcer was washed and treated three times a day with the 5% hypertonic saline solution in the first group, while the second group was treated with normal saline 0.9% and normal washing. Patients were examined for the size and depth of the wound weekly, and the results were recorded after six weeks. Results: The mean length and width of the wound in the experimental group significantly decreased six weeks after the start of treatment with hypertonic saline (p < 0.05). The wound healing rate was lower after treatment in both groups of patients who had a longer disease duration and higher HbA1c. Conclusion: Treating diabetic foot ulcers with hypertonic saline solution may help improve wound healing. Therefore, rinsing with hypertonic saline is a cheap, safe, simple, and non-invasive treatment protocol for these patients.

Demographic, clinical, and paraclinical features of patients operated with the diagnosis of acute descending necrotizing mediastinitis: a retrospective study in Southern Iran.

INTRODUCTION: Descending necrotizing mediastinitis (DNM) is a type of acute mediastinitis that is rarely reported but is regarded as a fatal disease despite improvements in technological methods and antibiotic therapies. We aimed to determine the demographic, clinical, and paraclinical features of patients diagnosed with acute DNM. METHODS: In this retrospective study, patients' hospital records with a diagnosis of DNM admitted to the Namazi hospital in southern Iran during 18 years (2002-2019) were reviewed. Demographic and clinical features were recorded and subsequently analyzed via SPSS 22. RESULTS: Out of 67 mediastinitis patients, 25 (37.3%) were diagnosed as DNM with an average age of 37.2 ± 16.7 years, and 68% were male. Regarding etiology, 52.0% were due to neck infection. Based on the technique of surgery, 52% of the patients underwent the combined method, which was mostly among type I and IIA DNM, while thoracotomy was mostly performed on type IIB DNM (P = 0.08). Based on the incision, type IIA and IIB had the highest frequency of thoracotomy and cervicothoracic incisions (P = 0.02 and 0.002). Puss discharge was significantly lower in type I DNM (P = 0.01). Based on the presenting symptoms of our patients, the majority (72.0%) had a chief complaint of neck pain, followed by chills and fever (48%). There were no reports of mortality during our short-term follow-up. CONCLUSION: We report one of the largest retrospective studies of DNM patients in our referral center, with a high prevalence of the disease among younger populations, especially under 40 years. The method of treatment should be chosen based on the extent of infection and can be limited to neck exploration in upper mediastinal infections, though thoracic or combined approach in more broad infections.

Near-Complete tracheal obstruction due to mucormycosis: A report of two cases.

We present two cases with diabetes and mucormycosis of the major airways. Both patients underwent fiberoptic bronchoscopic evaluation, showing near-complete occlusion of major airways with creamy necrotic mass lesions. Prompt and accurate diagnosis is vital to limit the extent of tissue destruction and prevent death due to asphyxia.

Main Bronchus Penetration by Thoracostomy Tube: A Rare Inadvertent Complication.

Tube thoracostomy has been known to be a common and invasive, however not innocuous, procedure which is often life-saving. Though, numerous complications have been reported during executing this procedure. In this report, we describe a 27-year-old woman, case of multiple trauma due to car collision that was transferred to our service due to severe right side chest tube air leak and subcutaneous emphysema in which after proper evaluation, it was revealed that the chest tube crossed through the right pleural cavity and penetrated the bronchus intermedius. A literature search failed to identify a similar case. The misplacement was confirmed by fiber optic bronchoscopy and after surgical and intensive care management of the patient, she was discharged with an uneventful post-op course. This case noticeably determines that bearing in mind the extreme risks and the careful checks of the tube location are required, particularly in trauma patients, even in the absence of anatomical abnormalities.

Successful Management of a Huge Pulmonary Hydatid Cyst with Lung-Preserving Surgery.

The lung is the second most commonly involved organ in humans by hydatid disease. Management of large pulmonary hydatid cysts is a great challenge for thoracic surgeons. Lung resections should be considered the last choice for huge pulmonary hydatid cysts when the lung expansion is not optimal after cyst removal. Here, we present a case of huge lung hydatid cyst involving the entire right lower lobe which was successfully managed by lung-preserving surgery in which the postoperative course showed gradual resolution of the involved lobe during a one-year follow-up.

Concomitant of Pulmonary Hydatid Cyst and Aspergilloma: A Rare Coinfection.

The coexistence of cystic echinococcosis (CE) and aspergilloma is rather uncommon. Aspergillus species, saprophytic fungi, can colonize pulmonary cavities that are caused by tuberculosis, sarcoidosis, and CE. Infection by Aspergillus is often occurring in immunosuppressed patients. However, coinfection of aspergilloma with pulmonary hydatid cyst is very unusual, especially in an immunocompetent patient with unruptured cyst. Herein, we report a case of lung hydatid cyst coinfected with Aspergillus in a 42-year-old Iranian man from Southern Iran. Chest X-ray and computed tomography (CT) scan showed a circumscribed cystic lesion in the superior and inferior segment of the lower lobes of right and left lungs that suggests hydatid cyst. Radical surgery (lobectomy) was performed for the patient. Histopathological evaluation reconfirmed the classical laminated layer of hydatid cyst. Moreover, the ectocyst layer of the right lung showed the presence of numerous cluster septate hyphae with acute-angled branching, as seen in the morphology of Aspergillus species. DNA was extracted from the cyst, and the ITS1-5.8s-ITS2 region of the fungal agent was amplified. Sequencing and analysis of seminested PCR product revealed that the isolate has the most similarity with Aspergillus niger. Further attention is recommended to control fungal pathogens during pulmonary hydatidosis. The coexistence of aspergilloma should always be kept in mind for the better management of CE.

Management of Deep Vein Thrombosis (DVT) Prophylaxis in Trauma Patients.

Deep vein thrombosis (DVT) and pulmonary embolism (PTE) are known as venous thromboembolism (VTE). DVT occurs when a thrombus (a blood clot) forms in deep veins of the body, usually in the lower extremities. It can cause swelling or leg pain, but sometimes may occur with no symptoms. Awareness of DVT is the best way to prevent the VTE. Patients with trauma are at increased risk of DVT and subsequent PE because of coagulopathy in patients with multiple trauma, DVT prophylaxis is essential but the VTE prophylaxis strategy is controversial for the trauma patients. The risk factors for VTE includes pelvic and lower extremity fractures, and head injury.

Initial Presentation of HIV Infection With Two Successive Acute Arterial Thromboses: A Case Report.

INTRODUCTION: One of the complications of HIV infection is greater risk of thromboembolic events. A variety of mechanisms has been found to be responsible for prothrombotic tendency in patients with HIV infection. CASE PRESENTATION: A 27-year-old heterosexual smoker man was referred to our center due to a sudden-onset severe left lower extremity pain and claudication since three days prior to admission. In physical examination, end extremity coldness and discoloration as well as left lower extremity pulselessness were found. Color-Doppler sonography revealed a large thrombus in the left common iliac artery and two thrombi in the distal halves of both anterior and posterior tibialis arteries, so the patient was transferred to the operating room for proximal thrombectomy where the blood flow was reestablished and all pulses were then detectable. Two days later, the patient developed another similar episode from knee down and underwent the second thrombectomy. In evaluation, HIV Ab had positive result by ELISA. CONCLUSIONS: This case inspires consideration of HIV infection as a leading cause of thromboembolic event in individuals affected by the first episode of unprovoked one in whom diagnosis of HIV infection has not been established yet.