The role of transbronchial cryobiopsy in lung transplantation.

AIMS: Lung transplant monitoring is usually performed with forceps transbronchial biopsies. These types of biopsy show limited reliability and a high degree of variability, owing to insufficient material and compression artefact, which lead to misinterpretation and, eventually, inappropriate treatment of the transplanted patients. The following study was undertaken to assess the diagnostic yield, histological quality and safety of cryobiopsy (CB) in comparison with conventional forceps biopsy (FB) for sampling lung tissue in transplant recipients. METHODS AND RESULTS: From January to December 2011, 81 consecutive transbronchial biopsies (41 FBs and 40 CBs) were indicated in single or bilateral lung transplantation recipients with clinical acute or chronic lung injury. Lung samples obtained by CB were larger (8.5 ± 6.5 mm in the FB group versus 22.1 ± 12.5 mm in the CB group; P < 0.0001) and had no crush artefacts (P = 0.002), allowing us to increase the diagnostic yield of acute (P = 0.0657) and chronic (P = 0.0053) cellular rejection. DISCUSSION: Transbronchial cryoprobe bronchoscopy allows the harvesting of larger and more expanded lung tissue samples, increasing the diagnostic yield in the monitoring of the lung allograft by means of a safe procedure.

Actinomyces in the mediastinum. Surprise is key in all art.

Introduction: Actinomycosis is an unusual chronic granulomatous infectious disease. They are commensals in various sites of the human body but with little pathogenicity. Actinomyces israelii is the most prevalent species but more than 30 species have been described. Infection of the lower respiratory tract is unusual, the involvement of mediastinum being even rarer. Case report: A 63-year-old man, previously healthy and living in a rural area, presented with a 5-month history of hemoptysis, pleuritic pain, weight loss, and night sweats. Community-acquired pneumonia with a mediastinal mass was documented, for which he received antibiotic management. Thoracoscopy was carried out for diagnosis and resection of the mediastinal mass due to inconclusive findings in the percutaneous biopsy. Pathology reported the presence of filamentous Gram-positive bacteria visible in Grocott staining. Due to the pathology findings, and the fact that no other infectious agents were identified, a diagnosis of actinomycosis was established. Treatment with oral amoxicillin 1g TID for 6 months was initiated. Conclusions: As far as we are aware, we present the sixth case of mediastinal actinomycosis. We present this case to bring attention to this rare but clinically relevant presentation to be considered as a differential diagnosis of mediastinal masses and to emphasize the need for specific anaerobic cultures to improve the diagnostic yield.

Fibrolamellar Hepatocellular Carcinoma and Noncirrhotic Hyperammonemic Encephalopathy.

Fibrolamellar hepatocarcinoma is an infrequent liver tumor, currently considered to be a variant different from hepatocarcinoma. The differences lie in genomic alterations, a greater prevalence of fibrolamellar hepatocarcinoma in young patients, and its lack of association with underlying liver disease. The clinical presentation is unspecific, with symptoms ranging from abdominal pain, malaise, and weight loss to atypical manifestation which include hyperammonemic encephalopathy. We present the case of a 33-year-old woman with no prior medical history who presented with a coma and a diagnosis of inoperable fibrolamellar hepatocarcinoma requiring a cadaver donor transplant. While she was on the waiting list, she received hemofiltration and ammonium benzoate treatment, with progressive improvement in her state of consciousness.

Manejo quirúrgico del quiste adrenal gigante: reporte de caso y revisión de la literatura / Surgical management of giant adrenal cyst: case report and review of the literature

OBJETIVO: Presentar un caso de quiste adrenal (QA) gigante resecado por vía mínimamente invasiva y realizar una revisión narrativa de la literatura disponible al respecto. MATERIALES Y MÉTODOS: Se presenta el caso de un paciente de sexo masculino de 54 años, con una masa retroperitoneal izquierda de crecimiento lento, asintomático, con imágenes y biopsia sugiriendo un QA complejo con sospecha de infiltración renal. Se indica una resección laparoscópica transabdominal. RESULTADOS: Se encuentra como hallazgo intraoperatorio un QA complejo hemorrágico de 9 cm de diámetro, con adherencia a la fascia de Gerota izquierda, logrando exéresis completa del QA por mínima invasión. El paciente evolucionó satisfactoriamente y fue dado de alta al segundo día posoperatorio. Es asintomático en 19 meses de seguimiento. Si bien los QA son benignos, los QA gigantes con crecimiento rápido, sintomáticos o de conversión hemorrágica, pueden ser resecados por adrenalectomía laparoscópica sin aumento de morbimortalidad. DISCUSIÓN: El abordaje laparoscópico de los QA no funcionales gigantes debe ser considerado como el manejo de elección. Es necesaria más evidencia sobre resultados en diferentes abordajes para generar recomendaciones claras. CONCLUSIÓN: Este reporte se suma a la evidencia actual en cuanto al abordaje mínimamente invasivo para QA gigantes hemorrágicos.

OBJECTIVE: Present a giant adrenal cyst (AC) case treated with minimally invasive resection and to perform a narrative literature review available. MATERIAL AND METHODS: A 54 year-old male presents with a left retroperitoneal slow growing mass, no symptoms, with a complex AC evidenced by previous images and mass biopsy, with suspected renal infiltration. A transabdominal laparoscopic resection is indicated. RESULTS: A complex hemorrhagic 9 cm diameter AC was found, with adhesions to left Gerota's fascia. Complete resection of the AC was achieved through minimally invasive approach. The patient had an uneventful clinical recovery and was discharged on the second postoperative day. On 19th month of follow-up is completely asymptomatic. Even though the AC are benign lesions, the symptomatic giant AC, with fast growing ratio, and/or hemorrhagic conversion could be resected though laparoscopic adrenalectomy, with no increased morbidity or mortality. DISCUSSION: The laparoscopic approach for giant non-functional AC should be considered as the standard of care. More evidence is required in terms of surgical approach outcomes to define clear recommendations. CONCLUSION: This report adds to the actual evidence in terms of minimally invasive approach for hemorrhagic giant AC.

A new double-cone nitinol device for PDA occlusion: design, manufacturing and initial in vivo results.

Use of occluder devices for a patent ductus arteriosus (PDA) closure is restricted to small diameter PDAs and involves high device costs. The objective of this study was to develop a new nitinol implant for the closure of a PDA and to evaluate its safety and efficacy in an animal model. The design consists of a device that promotes thrombus formation in the PDA. The device has a double-cone shape with their vertices joined. The cones are made of a nitinol wire helix with dacron fibers attached. The proximal end of the helix can be screwed to a conventional catheter release wire. In vitro testing was performed to verify the effectiveness of the implantation of the device and its releasing system; all trials (n = 30) were successful, showing accurate placement and release of the device. Complete and successful implantation of the device was achieved in all in vivo experiments (n = 5). There was one case of embolization due to premature detachment; a second device was successfully implanted. Histological evaluation after 42.3 +/- 3.1 days demonstrated complete PDA occlusion. The retrieved PDA showed total closure of the defect, endothelization of the PDA outlets and proper lodging of the device.

Fixation of vascular grafts with increased glutaraldehyde concentration enhances mechanical properties without increasing calcification.

Our objective was to study the effect of glutaraldehyde (GLU) concentration, heat, and photooxidation on mechanical properties and calcification of bovine pericardium grafts in an in vivo model. Fresh pericardia were treated as follows: 0.625% GLU for 7 days (standard); 0.625%, 1%, and 3% GLU at 4 degrees C for 20 days and 50 degrees C for additional 20 days; irradiation in cross-linking medium with metilene blue at 0 degrees C for 8 hours. Tissues were subjected to tensile mechanical tests (n = 76). Fixed patches were subcutaneously implanted in mice for 50 days (n = 16 per treatment). Calcification was assessed by atomic absorption spectrophotometry (n = 55) and von Kossa staining (n = 28). Analysis of variance and Tukey's test were used for statistical analysis. The 3% GLU and 3% GLU + heat treatments showed an enhancement of the mechanical properties above standard treatment. No significant difference was found in calcification between treatments. The 3% GLU treatment enhances the mechanical properties of the tissue above standard treatment without increasing calcification and without applying heat; therefore it is recommended for high-strength applications. Supplementary treatments to decrease calcification could be combined with this methodology to obtain a high-strength-low-calcification biomaterial for manufacturing of long-term cardiovascular grafts.

Tumores cardiacos primarios / Primary cardiac tumors

Dentro de las patologías menos conocidas y con tratamientos no claros, se encuentran los tumores cardíacos. Hasta hace una década, la mayoría de diagnósticos de tumores cardíacos se realizaba post mortem y en la literatura sólo se encontraban informes de casos aislados, explicando de esta forma la falta de interés en la investigación de esta patología por parte de los especialistas en cardiología o cirugía cardiovascular. Con el desarrollo de la ecocardiografía y de la cirugía cardiovascular, se vienen diagnosticando más casos de tumores cardíacos primarios o metastáticos, atreviéndose muchos grupos a la intervención quirúrgica paliativa o curativa y con ello aumentando los reportes en la literatura mundial y la experiencia, notando de esta forma que la patología tumoral cardíaca no es tan rara como se creía anteriormente. Se presenta una revisión de la literatura hasta el momento, reportando la frecuencia y las intervenciones sugeridas, los casos de patología cardíaca conocidos por los autores con las características ecocardiográficas, patológicas e histológicas de los casos representativos, sin mayor nivel de evidencia por la incidencia del problema y los pocos casos reportados por centros.

Nocardiosis del sistema nervioso central con compromiso medular: Presentacion de un caso / Nocardiosis of central nervous system with a medullary lesion

La nocardiosis, es una infección causada por un bacilo Gram positivo, presentándose en forma localizada o diseminada, el compromiso del sistema nervioso central puede estar presente en 44 por ciento de los pacientes, pero el compromiso de la médula espinal no es la presentación mas frecuente, además la nocardiosis se presenta usualmente en pacientes inmunocomprometidos, aunque hay casos descritos en pacientes inmunocompetentes. Presentamos el caso de un paciente inmunocompetente con diagnóstico de nocardiosis pulmonar que se encontraba en tratamiento ambulatorio con trimetropin sulfa, que presentó posteriormente compromiso del sistema nervioso central que tenía compromiso medular a pesar de tener un adecuado tratamiento ambulatorio inicial.

Nesidioblastosis en un adulto / Nesidioblastosis in an adult

Se presenta la historia clinica, los estudios imagenologicos y los hallazgos quirurgicos de un hombre de 28 anos con confirmacion inmunohistologica de hiperplasia focal de celulas beta del pancreas (nesidioblastosis)