Is Minimally Invasive Resection of Large Thymoma Appropriate?

BACKGROUND: Current practice patterns suggest open rather than minimally invasive (MIS) approaches for thymomas >4 cm. We hypothesized there would be similar perioperative outcomes and overall survival between open and MIS approaches for large (>4 cm) thymoma resection. METHODS: The National Cancer Database was queried for patients who underwent thymectomy from 2010 to 2020. Surgical approach was characterized as either open or MIS. The primary outcome was overall survival and secondary outcomes were margin status, and length of stay (LOS). Differences between approach cohorts were compared after a 1:1 propensity match. RESULTS: Among 4121 thymectomies, 2474 (60%) were open and 1647 (40%) were MIS. Patients undergoing MIS were older, had fewer comorbidities, and had smaller tumors (median; 4.6 vs 6 cm, P < .001). In the unmatched cohort, MIS and open had similar 90-day mortality (1.1% vs 1.8%, P = .158) and rate of positive margin (25.1% vs 27.9%, P = .109). MIS thymectomy was associated with shorter LOS (2 (1-4) vs 4 (3-6) days, P < .001). Propensity matching reduced the bias between the groups. In this cohort, overall survival was similar between the groups by log-rank test (P = .462) and multivariate cox hazard analysis (HR .882, P = .472). Multivariable regression showed shorter LOS with MIS approach (Coef -1.139, P < .001), and similar odds of positive margin (OR 1.130, P = .150). DISCUSSION: MIS has equivalent oncologic benefit to open resection for large thymomas, but is associated with shorter LOS. When clinically appropriate, MIS thymectomy may be considered a safe alternative to open resection for large thymomas.

Early real-world experience monitoring circulating tumor DNA in resected early-stage non-small cell lung cancer.

OBJECTIVE: The study objective was to evaluate the impact of monitoring circulating tumor DNA on the detection and management of recurrence in patients with resected early-stage non-small cell lung cancer. METHODS: Between October 2021 and March 2023, postoperative circulating tumor DNA was monitored in patients with non-small cell lung cancer (N = 108). Longitudinal blood samples (n = 378 samples) were collected for prospective circulating tumor DNA analysis at 3-month intervals after curative-intent resection. A tumor-informed assay was used for the detection and quantification of circulating tumor DNA. The primary outcome measure was a circulating tumor DNA-positive result. The secondary outcome measure was changes in practice after a circulating tumor DNA-positive result. RESULTS: The mean age of the patients in this cohort was 68.1 years. Of the 108 patients, 12 (11.1%) were circulating tumor DNA positive at least at 1 timepoint postsurgery, of whom 8 (66.7%) had a clinically evident recurrence and the remaining 4 had limited clinical follow-up. Of the 10 patients with recurrent disease, 8 demonstrated circulating tumor DNA positivity and the remaining 2 patients had brain-only metastases. Postoperative clinical care was altered in 100% (12/12) of circulating tumor DNA-positive patients, with 58.3% (7/12) receiving an early computed tomography scan and 100% (12/12) receiving an early positron emission tomography computed tomography scan as part of their surveillance strategy. Among the patients who received an early positron emission tomography scan, 66.6% (8/12) were positive for malignant features. CONCLUSIONS: Routine monitoring of tumor-informed circulating tumor DNA after curative intent therapy improved patient risk stratification and prognostication.

Lung Cancer in Young Patients is Associated With More Advanced Disease but Better Overall Survival.

INTRODUCTION: It is unclear whether nonsmall cell lung cancer (NSCLC) is associated with more aggressive disease and worse overall survival (OS) among younger patients. The aim of this study is to evaluate outcomes in young patients. We hypothesize that young age is associated with more advanced disease upon presentation, but better OS. METHODS: We identified patients with NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized in 3 groups: age≤50, 51-84, and ≥85 y. The outcomes were OS, stage IV NSCLC and clinical nodal metastasis. OS was analyzed using multivariate cox and Kaplan-Meier analysis accounting for stage, comorbidities, and other factors. The association of age, presentation with stage IV NSCLC and node positivity was analyzed using multivariate logistic regression. RESULTS: In total 1,651,744 patients were identified: 92,506 (5.57%) age ≤50, 1,477,723 (88.90%) age 51-84, and 91,964 (5.53%) age ≥85. Multivariate model showed stage IV NSCLC was associated with age ≤50 (OR 1.17 (1.15-1.20) P < 0.001) and ≥85 (odds ratio (OR) 1.03 (1.02-1.04) P < 0.001). Clinical lymph node positivity was associated with age ≤50 (OR 1.27 (1.23-1.30) P < 0.001). Relative to patients 51-84, the ≤50 group was associated with better survival in Stage I (hazard ratio (HR) 0.61 versus 1.00), stage II (HR 1.12 versus 1.50), stage III (HR 2.12 versus 2.53), and stage IV (HR 6.65 versus 7.53). CONCLUSIONS: Patients ≤50-y-old present with more advanced NSCLC, but better OS compared to patients 51-84. These findings suggest the need for increased awareness regarding NSCLC among age groups seen as low risk.

Deletion of newly described pro-survival molecule Pellino-1 increases oxidative stress, downregulates cIAP2/NF-κB cell survival pathway, reduces angiogenic response, and thereby aggravates tissue function in mouse ischemic models.

INTRODUCTION: In the present study, we aimed to explore the functional role of Pellino-1 (Peli1) in inducing neovascularization after myocardial infarction (MI) and hindlimb ischemia (HLI) using Peli1 global knockout mice (Peli1-/-). Recently we have shown that Peli1, an E3 ubiquitin ligase, induce angiogenesis and improve survivability, with decreased necrosis of ischemic skin flaps. METHODS: Peli1fl/fl and Peli1-/- mice were subjected to either permanent ligation of the left anterior descending coronary artery (LAD) or sham surgery (S). Tissues from the left ventricular risk area were collected at different time points post-MI. In addition, Peli1fl/fl and Peli1-/- mice were also subjected to permanent ligation of the right femoral artery followed by motor function scores, Doppler analysis for blood perfusion and immunohistochemical analysis. RESULTS: Global Peli1 knockout exacerbated myocardial dysfunction, 30 and 60 days after MI compared to wild type (WT) mice as measured by echocardiogram. In addition, Peli1-/- mice also showed decreased motor function scores and perfusion ratios compared with Peli1fl/fl mice 28 days after the induction of HLI. The use of Peli1 in adenoviral gene therapy following HLI in CD1 mice improved the perfusion ratio at 28 days compared to Ad.LacZ-injected mice. CONCLUSION: These results suggest new insights into the protective role of Peli1 on ischemic tissues and its influence on survival signaling.

Spontaneous pneumomediastinum secondary to electronic cigarette use.

Vaping, the use of electronic cigarettes, involves different mechanics than conventional combustion cigarettes. Consumers who vape tend to overinhale and then forcefully exhale to eliminate the vapor, which is usually produced in much greater quantity than generated by a regular cigarette. Effectively, they are performing an exaggerated Valsalva maneuver. This can increase their risk for developing potential spontaneous pneumomediastinum. Here we present a case of spontaneous pneumomediastinum secondary to electronic cigarette use.

Impact of Radial Margin Status After Esophagectomy for Adenocarcinoma.

INTRODUCTION: The clinical impact of a positive radial margin after esophagectomy for cancer has not been clearly  identified. The goal of this study was to identify risk factors for a positive radial margin and determine the impact on recurrence and survival. METHODS: Retrospective review of 196 patients with pathological T3 N0-3 esophageal adenocarcinoma undergoing esophagectomy between 2002 and 2017. Mortality data was extracted from Electronic Medical Records and Social Security Death Index. RESULTS: Mean age was 63.7 ± 11.4 years, and there were 166 (84.7%) men. Neoadjuvant therapy was given in 141(71.9%) patients. We identified 29(14.8%) patients with a positive radial margin. Factors significantly associated with a positive radial margin include not receiving neoadjuvant therapy and presence of lymphatic, vascular, or perineural invasion. Overall, there were 94(48%) recurrences during a mean follow-up of 24.7 months. Involvement of the radial margin was not significantly associated with recurrence-free survival (HR 1.24, CI 95% 0.73-2.12, p = 0.425). Overall survival for the entire cohort was 41.6% and 28.9% at 3 and 5 years, respectively. Involvement of the radial margin did not have a significant impact on overall survival (HR 1.23, CI 95% 0.68-2.22, p = 0.493). CONCLUSIONS: The likelihood of encountering a positive margin is associated with lack of neoadjuvant treatment and the presence of lymphatic, vascular, or perineural invasion in the esophagectomy specimen. An involved radial margin after esophagectomy for locally advanced cancer was not associated with tumor recurrence or overall survival in our cohort, and other factors such as lymph node involvement are stronger in determining outcome.

Routine intraoperative jejunostomy placement and minimally invasive oesophagectomy: an unnecessary step?†.

OBJECTIVES: Adequate nutrition is challenging after oesophagectomy. A jejunostomy is commonly placed during oesophagectomy for nutritional support. However, some patients develop jejunostomy-related complications and the benefit over oral nutrition alone is unclear. This study aims to assess jejunostomy-related complications and the impact of intraoperative jejunostomy placement on weight loss and perioperative outcomes in patients with oesophageal cancer treated with minimally invasive Ivor Lewis oesophagectomy (MIE). METHODS: From a prospectively maintained database, patients were identified who underwent MIE with gastric reconstruction. Between 2007 and 2016, a jejunostomy was routinely placed during MIE. After 2016, a jejunostomy was not utilized. Postoperative feeding was performed according to a standardized protocol and similar for both groups. The primary outcomes were jejunostomy-related complications, relative weight loss at 3 and 6 months postoperative and perioperative outcomes, including anastomotic leak, pneumonia and length of stay, respectively. RESULTS: A total of 188 patients were included, of whom 135 patients (72%) received a jejunostomy. Ten patients (7.4%) developed jejunostomy-related complications, of whom 30% developed more than 1 complication. There was no significant difference in weight loss between groups at 3 months (P = 0.73) and 6 months postoperatively (P = 0.68) and in perioperative outcomes (P-value >0.999, P = 0.591 and P = 0.513, respectively). CONCLUSIONS: The use of a routine intraoperative jejunostomy appears to be an unnecessary step in patients undergoing MIE. Intraoperative jejunostomy placement is associated with complications without improving weight loss or perioperative outcomes. Its use should be tailored to individual patient characteristics. Early oral nutrition allows patients to maintain an adequate nutritional status.

Disruption of VEGF Mediated Flk-1 Signaling Leads to a Gradual Loss of Vessel Health and Cardiac Function During Myocardial Infarction: Potential Therapy With Pellino-1.

Background The present study demonstrates that the ubiquitin E3 ligase, Pellino-1 (Peli1), is an important angiogenic molecule under the control of vascular endothelial growth factor (VEGF) receptor 2/Flk-1. We have previously reported increased survivability of ischemic skin flap tissue by adenovirus carrying Peli1 (Ad-Peli1) gene therapy in Flk-1+/- mice. Methods and Results Two separate experimental groups of mice were subjected to myocardial infarction ( MI ) followed by the immediate intramyocardial injection of adenovirus carrying LacZ (Ad-LacZ) (1×109 pfu) or Ad-Peli1 (1×109 pfu). Heart tissues were collected for analyses. Compared with wild-type ( WTMI ) mice, analysis revealed decreased expressions of Peli1, phosphorylated (p-)Flk-1, p-Akt, p- eNOS , p- MK 2, p-IκBα, and NF -κB and decreased vessel densities in Flk-1+/- mice subjected to MI (Flk-1+/- MI ). Mice ( CD 1) treated with Ad-Peli1 after the induction of MI showed increased ß-catenin translocation to the nucleus, connexin 43 expression, and phosphorylation of Akt, eNOS , MK 2, and IκBα, that was followed by increased vessel densities compared with the Ad-LacZ-treated group. Echocardiography conducted 30 days after surgery showed decreased function in the Flk1+/- MI group compared with WTMI , which was restored by Ad-Peli1 gene therapy. In addition, therapy with Ad-Peli1 stimulated angiogenic and arteriogenic responses in both CD 1 and Flk-1+/- mice following MI . Ad-Peli1 treatment attenuated cardiac fibrosis in Flk-1+/- MI mice. Similar positive results were observed in CD 1 mice subjected to MI after Ad-Peli1 therapy. Conclusion Our results show for the first time that Peli1 plays a unique role in salvaging impaired collateral blood vessel formation, diminishes fibrosis, and improves myocardial function, thereby offering clinical potential for therapies in humans to mend a damaged heart following MI .

Surgical Management of Post-Esophagectomy Tracheo-Bronchial-Esophageal Fistula.

BACKGROUND: Post-esophagectomy tracheo-bronchial-esophageal fistula (PETEF) most often develops after anastomotic disruption or gastric conduit necrosis. Ideal surgical management and outcomes for this complication are uncertain. METHODS: A retrospective review of 11 patients undergoing surgical repair of PETEF was performed. RESULTS: The median time between esophagectomy and surgical repair of PETEF was 61 days (range, 7 days to 28 years). Anastomotic leak or gastric conduit necrosis was responsible for PETEF in 6 patients (54.5%), whereas other causes were erosion of a tracheal appliance (n = 2), gastric conduit staple line erosion (n = 1), anastomotic stricture dilation (n = 1), and recurrent esophageal cancer (n = 1). Membranous airway defects were repaired primarily and buttressed with muscle or omental flaps in 8 patients (72.7%), whereas two (18.2%) were repaired with bio-prosthetic patches and one (9.1%) was repaired with a sleeve resection of the bronchus. Anastomotic and neo-esophageal conduit defects were repaired primarily in 3 patients (27.3%), whereas 7 patients (63.6%) underwent conduit take-down and esophageal or pharyngeal diversion, and 1 patient (9.1%) underwent simultaneous fistula repair and colon interposition. Two patients (18.2%) had recurrent fistulas, with 1 patient dying after second fistula closure and the other was discharged with no further attempt at repair. Three patients (27.3%) died postoperatively. Only 3 patients (27.3%) resumed an oral diet after fistula repair. CONCLUSIONS: Surgical treatment is effective for most patients undergoing operative repair of PETEF, notwithstanding a considerable risk of postoperative morbidity and death. Although fistula repair is life saving and prevents further respiratory deterioration, return to oral alimentation is not ensured.

Protective effects of Phyllanthus emblica against myocardial ischemia-reperfusion injury: the role of PI3-kinase/glycogen synthase kinase 3ß/ß-catenin pathway.

Clinical studies of Phyllanthus emblica (P. emblica) have shown that it increases production of nitric oxide, glutathione, and high-density lipoprotein (HDL); decreases low-density lipoprotein (LDL), total cholesterol, triglycerides, and high-sensitivity C-reactive protein (hsCRP); and significantly inhibits platelet aggregation. The following study was designed to examine the effect of P. emblica treatment on myocardial ischemia-reperfusion (I/R) injury and identify the molecular targets and its underlying mechanism(s). Experimental animals were divided into four groups: control sham (CS), P. emblica sham (PS), control I/R (CIR), and P. emblica I/R (PIR). Rats in the P. emblica groups were gavaged with aqueous P. emblica solution (100 mg/kg body weight) for 30 days. After 30 days of gavaging, the I/R group underwent I/R surgery (45-min ischemia) followed by 4 or 30 days of reperfusion. Rats in the sham group underwent surgery without ligation. Left ventricular tissue samples, 4 and 30 days after I/R, were used for Western blot analysis and immunohistochemistry, respectively. Western blot analysis showed upregulation of phosphorylated Akt and GSK3-ß and increased nuclear translocation of ß-catenin in the PIR group versus CIR. PIR rats also indicated reduced 3-nitrotyrosine and Caspase-3 expression. Increased phosphorylation of endothelial nitric oxide synthase (p-eNOS) and upregulation of anti-apoptotic protein Bcl-2 were found in the PIR group. Echocardiography showed increased ejection fraction and fractional shortening and decreased left ventricular internal diameter in experimental subjects compared to controls. There was decreased fibrosis in P. emblica-treated rats compared to controls. The results of this study indicate that P. emblica is capable of upregulating the PI3K/Akt/GSK3ß/ß-catenin cardioprotective pathway, thereby preserving cardiac tissue during ischemia-reperfusion injury.

Prevention of type II endoleak by laparoscopic inferior mesenteric artery ligation.

Abdominal aortic aneurysm repair by endovascular techniques have gained wide acceptance as a treatment option. A potential well-known complication of endovascular repair includes endoleak. Specifically, type II endoleak, which is described as retrograde flow into the aneurysm sac through collateral vessels, can occur in up to 30% of patients. Certain preoperative factors can predict which patients may develop type II endoleak. This article describes laparoscopic inferior mesenteric artery ligation prior to endovascular abdominal aortic aneurysm repair as a viable treatment option in the prevention of type II endoleak.

Resecciones pulmonares en cuña para estudio histopatológico: experiencia de Bucaramanga / Lung wedge resections for histopathologic study: experience in Bucaramanga, Colombia

Introducción. En la gran mayoría de los casos de enfermedad pulmonar intersticial difusa y de nódulos pulmonares indeterminados, se requiere la obtención de tejido pulmonar para llegar a un diagnóstico preciso. El presente estudio presenta la experiencia con las resecciones pulmonares en cuña en una sola institución. Materiales y métodos. Se llevó a cabo un estudio retrospectivo de los pacientes sometidos a resecciones pulmonares en cuña entre 2004 y 2009, en la Fundación Oftalmológica de Santander-Clínica Carlos Ardilla Lülle.Resultados. Se estudiaron 52 pacientes operados durante este periodo. Veintiocho (53,9%) eran hombres; la media de edad fue de 60,5 años. La indicación fue: nódulos en 29 (55,8%) y enfermedad pulmonar intersticial difusa en 23 (44,2%). Los pacientes con nódulos con mayor frecuencia no presentaban ningún síntoma ni hallazgos en el examen físico (p=0,008). El 88,5% de los pacientes fue operado mediante toracoscopia y 76,9% tuvieron una sola resección.La mediana del tiempo quirúrgico fue de 90 minutos fue menor cuando la técnica fue toracoscópica p=0,04) y cuando no se dejó tubo de tórax p=0,0006). No se dejó tubo de tórax en 23,1% de os casos. La media de estancia hospitalaria fue de dos días. La morbilidad y la mortalidad a 30 días fue de 5,8%. En 92% de los casos se estableció un diagnóstico preciso.Conclusiones. La resección pulmonar en cuña en los casos de enfermedad pulmonar intersticial difusa y nódulos indeterminados es segura y puede realizarse con una corta estancia hospitalaria. Puede omitirse el tubo de tórax. En más de 90% de los casos se establece un diagnóstico preciso.

Introduction: In most cases of interstitial lung disease (ILD) and indeterminate pulmonary nodules, lung tissue is needed to achieve a precise a diagnosis. This study seeks to present the experience with lung wedge resections at a single institution. Materials and methods: Retrospective study of patients undergoing lung wedge resections for histopathologic study in the period 2004-2009 at Fundación Oftalmológica de Santander – Clínica Carlos Ardilla Lülle in the city of Bucaramanga, Colombia,.Results: Fifty-two patients were operated on during this period. Twenty-eight (53.9%) were male; mean age was 60.5 years. Indications for surgery were nodules in 29 (55.8%) and ILD in 23 (44.2%). Patients with nodules presented more frequently without symptoms or findings at physical examination (p=0.008). In 88.5% and 76.9% of cases, the thoracoscopic technique was utilized and the number of resections was just one, respectively. Median operative time was 90min and it was shorter when the thoracoscopic technique was employed (p=0.04) and when a chest tube was not left in the pleural space (p=0.0006). A chest tube was not installed in 23.1% of cases. Median hospital length of stay was 2 days. Both morbidity and mortality were 5.8%, respectively. A precise diagnosis was achieved in 92% of patients. Conclusions: Lung wedge resection for ILD and indeterminate nodules is a safe procedure and can be done with a short length of stay. A chest tube can be omitted at the end of the procedure. In more than 90% of cases a precise diagnosis is achieved.

Carcinoma adenoide quístico primario de bronquio lobar: caso clínico / Primary adenoid cystic carcinoma of the lobar bronehus: case report

Primary airway adenoid cystic carcinoma is very uncommon. We report a 60 years old male consulting for hemoptysis and dyspnea. A chest CAT scan showed a mass in the right superior lobar bronehus. The patient was subjected to a right superior sleeve lobectomy and the pathological study of the surgical piece revealed an adenoid cystic carcinoma. The patient received adjuvant radiotherapy. Surgery and radiation therapy are the mainstay of treatment for this type of tumors.

El carcinoma adenoide quístico primario de la vía aérea es una neoplasia muy rara. Reportamos el caso de un paciente de 60 años de edad quien consultó por hemoptisis y disnea de esfuerzo. Una tomografía computarizada del tórax reveló una masa en el bronquio fuente y lobar superior del pulmón derecho. Se realizó una lobectomía superior derecha en manguito. El estudio histopatológico mostró un carcinoma adenoide quístico. Se administró radioterapia adyuvante. La cirugía y la radioterapia son las bases del manejo de este tipo de tumores.

Perforación de íleon terminal y ciego causada por tuberculosis intestinal en un paciente positivo para VIH / Perforation of the terminal ileum and cecum caused by tuberculosis in an HIV positive patient

La tuberculosis es una de las enfermedades infecciosas más prevalentes y su presentación pulmonar es la más frecuente. Sin embargo, debido al aumento en la infección por el virus de la inmunodeficiencia humana (VIH), el envejecimiento de la población, el mayor uso de fármacos inmunosupresores, la inmigración desde áreas endémicas y la aparición de cepas resistentes de Mycobacterium tuberculosis, ha habido un aumento de las presentaciones extrapulmonares. Entre éstas, la tuberculosis abdominal y la gastrointestinal son raras y suelen presentarse clínicamente de manera inespecífica, por lo cual el diagnóstico sólo se logra por medio de imágenes o métodos invasivos para la obtención de tejido. La perforación como complicación de la tuberculosis intestinal es aún menos frecuente. Presentamos el caso de un paciente de 51 años, positivo para VIH, con tuberculosis con compromiso intestinal, quien presentó como complicación la perforación del íleon terminal y el ciego que resultó en su muerte.

Tuberculosis is one of the most prevalent infectious diseases, most frequent in its pulmonary presentation. However, due to the increase in HIV infection, the population getting older, the increase in the use of immunosuppressive drugs, immigration from endemic areas, and the appearance of resistant strains of M. tuberculosis, there has been a rise in the rate of extrapulmonary presentations. Among the extrapulmonary presentations, abdominal and gastrointestinal tuberculosis are rare and usually present with nospecific symptoms, and diagnosis is then achieved through imaging and invasive methods that allow tissue sampling. Perforation as a complication of intestinal tuberculosis is even less frequent. We report the case of a 51-year-old HIV-positive male patient with intestinal tuberculosis who developed perforation of the terminal ileum and cecum resulting in his death.

Miastenia gravis y el timo: pasado, presente y futuro / Myasthenia gravis and the thymus: past, present, and future

La miastenia gravis es una enfermedad neuromuscular autoinmune caracterizada por debilidad y fatiga muscular. Ha sido reconocida desde hace más de tres siglos, pero sólo hasta el siglo XX se desarrollaron intervenciones terapéuticas encaminadas a aliviar los síntomas y alterar el curso clínico de la enfermedad. En la fisiopatología, se destaca el papel del timo como órgano central que contiene todos los elementos necesarios para iniciar y montar una respuesta inmune contra antígenos propios, particularmente, el receptor de acetilcolina en la placa motora. Debido a esto, la timectomía extendida aparece como una alternativa terapéutica que logra la remisión completa de la enfermedad hasta en 75% de los pacientes y la mejoría hasta de 99%.Sin embargo, el abordaje abierto convencional (esternotomía) es bastante agresivo, por lo que, en los últimos años, la cirugía de tórax ha desarrollado técnicas quirúrgicas mediante toracoscopia asistida por video que permiten realizar el mismo procedimiento con menos complicaciones y mejores resultados cosméticos.Debido al beneficio hasta ahora mostrado, se debe ofrecer el tratamiento quirúrgico a todos los pacientes con miastenia gravis generalizada y a una buena proporción de los que padecen síntomas oculares.

Hernias diafragmáticas: desafío clínico y quirúrgico / Diaphragmatic hernias: a clinical and surgical challenge

Las hernias diafragmáticas se definen como el paso del contenido abdominal a la cavidad torácica a través de un defecto en el diafragma. Se dividen en congénitas (anteriores o de Morgagni y postero-laterales o de Bochdalek) y adquiridas (traumáticas).Las hernias diafragmáticas congénitas producen hipoplasia con hipertensión pulmonar en el recién nacido, lo cual genera alteraciones fisiológicas que amenazan gravemente la vida. El diagnóstico puede realizarse en la etapa prenatal mediante diferentes técnicas de imágenes. El tratamiento consiste en estabilizar los parámetros fisiológicos del neonato y, luego, sí se intenta la corrección quirúrgica del defecto.Las hernias diafragmáticas traumáticas se producen después de un traumatismo cerrado o penetrante. El trauma penetrante la produce con mayor frecuencia, cuando compromete la zona toraco-abdominal. La sensibilidad diagnóstica de las imágenes no es alta, lo que dificulta el diagnóstico; sin embargo, la laparoscopia y la toracoscopia presentan mejores rendimientos diagnósticos y pueden ser utilizadas como abordajes para el tratamiento. La corrección del defecto anatómico en el diafragma debe intentarse una vez se ha hecho el diagnóstico, lo que puede lograrse mediante abordajes quirúrgicos por vía abdominal o torácica.

Complicaciones de los tubos de tórax / Complications of tube thoracostomy

El drenaje del espacio pleural es una frecuente práctica clínica de valor diagnóstico y terapéutico. Las indicaciones más frecuentes de este procedimiento tienen que ver con situaciones en las que se producen depósitos de fluidos en esta cavidad, como aire, sangre, linfa, líquido pleural, pus y otros. Es importante conocer la técnica quirúrgica de inserción y las complicaciones más frecuentes derivadas de la colocación de los tubos de tórax.Realizamos una revisión de la literatura existente sobre el tema, enfatizando en estudios que evaluaran las tasas de complicaciones derivadas de las toracostomías cerradas con tubo. Encontramos que la gran mayoría de estudios sobre complicaciones de la colocación de los tubos de tórax son retrospectivos y en el contexto del trauma. Las complicaciones se han clasificado así: por inserción, posicionales e infecciosas. La tasa general de complicaciones se encuentra entre 3,4% y 36%. Las complicaciones por inserción ocurren en 0% a 7,9% de los casos, las posicionales en 2,4% a 33,3% y las infecciosas en 0,8% a 12%, con empiema en 1,1% a 2,7%. También, hay complicaciones anecdóticas reportadas.Las complicaciones producto de la colocación de un tubo de tórax en la cavidad pleural son frecuentes y en muchos casos clínicamente relevantes. El uso de la técnica de disección roma, la habilidad y el conocimiento, la identificación precoz y el manejo de las posibles complicaciones, pueden reducir la morbimortalidad de este procedimiento.

Primary cutaneous inoculation tuberculosis in a healthcare worker as a result of a surgical accident.

In May 2004, a 48-year-old male surgeon, resident in Bucaramanga, Colombia, suffered a superficial cut with a scalpel to the lateral aspect of the mid-phalanx of the second finger of the left hand while performing a pulmonary decortication surgical procedure for tuberculous empyema with pulmonary entrapment. The injury healed normally but, approximately 2 weeks after the event, an erythematous, nonpainful papule of approximately 3 mm in diameter developed, and increased progressively to 7 mm 3 days after its initial appearance. At this time, the papule showed spontaneous secretion of a clear liquid and superficial ulceration (Fig. 1). Approximately 3 weeks after the injury, a Gram stain of the liquid was performed; it showed no bacteria but a moderate leukocyte reaction. Because of the high suspicion of possible tuberculous infection, bacilloscopy of the liquid was performed, and was positive (++) for acid-fast bacteria (Fig. 2). The liquid was cultured and grew Mycobacterium tuberculosis. The culture was sent to the Laboratory of Mycobacteria at the National Institute of Health, Bogota, Colombia for drug resistance testing. Susceptibility was demonstrated against streptomycin, isoniazid, rifampicin, and ethambutol. During this time, the patient presented an ipsilateral painful axillary adenopathy of about 2.5 cm in diameter. The patient consulted with an infectologist, who initiated a Directly Observed Therapy Short Course (DOTS) regimen [first phase (8 weeks): daily, except Sundays, streptomycin 1 g intramuscularly, pyrazinamide 1500 mg orally, isoniazid 300 mg, and rifampicin 600 mg; second phase (18 weeks): twice weekly rifampicin 600 mg and isoniazid 500 mg], accompanied by daily pyridoxine to prevent secondary effects from isoniazid. After 3 weeks of treatment, the finger lesion had disappeared. Treatment was undertaken as described above, with the patient reporting symptoms of vertigo, nausea, epigastralgia, and mild myalgia as the adverse effects of medication. A chest x-ray was taken and reported to be normal. The axillary adenopathy disappeared approximately 6 months after the injury. Nearly 3.5 years after the incident, the patient has not presented any type of symptomatology.