Association between vertebral artery hypoplasia and posterior circulation stroke.

BACKGROUND: The clinical significance of vertebral artery (VA) hypoplasia is under discussion. The aim of this retrospective study is to evaluate a hypothesis of a possible causal link between VA hypoplasia (VAH) and the incidence of posterior circulation stroke (PCS) or TIA depending on the degree of VAH and vascular risk factors. METHODS: A total of 367 symptomatic (PCS or TIA) and 742 asymptomatic subjects, were selected to participate in the study. The extracranial arteries were examined by ultrasound. VAH was defined as VA diameter in entire course <3 mm, although different degrees of VAH were examined. All the symptomatic patients underwent MRI or CT and MRA or CTA. The study assessed all the subjects in terms of their age, gender, co-risk factors (hypertension, hyperlipidemia, diabetes mellitus, peripheral arterial diseases, atrial fibrillation, myocardial infarction), as well as height of 180 healthy volunteers. RESULTS: VAH, regardless of the degree of severity, was more frequent in patients with non-cardioembolic PCS or TIA rather than in asymptomatic patients. The increasing degree of hypoplasia in patients under 65 years of age was a predictor of PCS/TIA, OR = 1.8, 95% CI: 1.3-2.5; p < 0.001. In subjects older than 65 years of age, this association failed. Only in patients aged under 50, VAH was significantly more frequent in the TIA group rather than in the PCS group (68.2% and 50%, respectively; p = 0.047). The optimal VA diameter cutoff point separating PCS/TIA and asymptomatic group was 2.7 mm. This value may vary in different populations, because VA diameter showed a significant dependence on sex as well as anthropometric parameters (height). With the increasing degree of VAH, the likelihood of the occurrence of the distal VA part stenosis/occlusion was growing (OR = 1.6, 95% CI: 1.2-2.1; p = 0.002). The distal VA stenosis/occlusion was likely to occur where the VA diameter was <2.2 mm. CONCLUSIONS: The impact of the VAH on PCS/TIA and its pathogenetic mechanism was significantly influenced by age. The cutoff point of VA diameter, affecting the occurrence of PCS in different populations may vary because VA diameter depends on gender and anthropometric parameters (especially height).

Giant intrapulmonary solitary fibrous tumor with signs of malignancy.

Solitary fibrous tumor (SFT) is an extremely rare mesenchymal neoplasm usually detected in the pleura, which generally follows a benign course. The localization inside lung parenchyma has more rarely been reported. We present a case of a 51-year-old male with a dry cough, dyspnea, chest pain, and increased perspiration. Radiological images revealed a giant circumscribed mass on the right side of the chest. A transbronchial cryobiopsy of the lung was performed and revealed an SFT. The right upper lobectomy through lateral thoracotomy was performed. The pathological examination confirmed an SFT with a central zone of necrosis that is a sign of malignancy. At a 2-year follow-up, the patient is free of symptoms and with no evidence of recurrence. Although the intrapulmonary localization of an SFT is a rare entity, we should be aware of it as a potential malignant pulmonary neoplasm.

Primary Pulmonary Meningioma With Rhabdoid Features.

Only 1% to 2% of meningiomas have primary extrameningeal location, which is mostly head and neck region. Primary pulmonary meningiomas (PPMs) are even more uncommon with up to 50 cases reported in the literature. Only 5 cases of PPM with confirmed or possible malignancy have been previously described. Three-grade classification of meningiomas with the accordingly growing risk of aggressive behavior of the tumor has been proposed by the World Health Organization. As it is based on correlations between morphological and clinical features of intracranial meningiomas, the analogous prediction of ectopic tumors prognosis remains questionable due to scarce number of cases. In this article, we present a rare case of PPM with rhabdoid features (World Health Organization grade III), which lacked other signs of malignancy. The patient is doing well for 2 years after the thoracoscopic wedge resection without evidence of the disease recurrence.

Preoperative predictors of conversion in thoracoscopic surgery for pleural empyema.

OBJECTIVES: Thoracoscopy is an effective treatment method for pleural empyema; however, it is still not well defined as to which patient subgroups could benefit from it the most. The aim of the study was to identify preoperative factors that could facilitate selecting appropriate surgical intervention and to evaluate early postoperative period. METHODS: Seventy-one patients were prospectively included in the study, which was conducted from January 2011 to June 2014. Thoracoscopic surgery for Stage II/III pleural empyema was performed in all patients. Thoracoscopy failed in 18 (25.4%) patients, requiring conversion to thoracotomy. The preoperative factors that could possibly predict conversion were analysed. RESULTS: Obliterated pleural space (12 patients) and failure to achieve lung re-expansion (6 patients) were the main reasons for conversion. Multivariable logistic regression analysis demonstrated that each day of illness [odds ratio 1.1 (95% confidence interval 1.0-1.2], P = 0.004] and frank pus [odds ratio 4.4 (95% confidence interval 1.2-15.3), P = 0.021] were independent predictors of conversion. Using receiver-operating characteristic analysis, it was determined that the duration of illness had a high predictive value for conversion [area under the curve 0.8 (95% confidence interval 0.7-0.9), P < 0.001]. The cut-off value for duration of illness was 16 days (sensitivity 94.4%, specificity 54.7%). The conversion group had a significantly greater need for postoperative intensive care unit stay ( P = 0.022) but a lower rate of reoperations ( P = 0.105). CONCLUSIONS: Duration of illness and frank pus discovered during thoracocentesis can help in selecting the patient for appropriate intervention. Earlier surgery for pleural empyema can reduce the rate of conversion and reoperation.

Successful management of gastropulmonary fistula due to invasive fungal infection after chemotherapy and autologous stem cell transplantation: a case report.

BACKGROUND: Invasive fungal infections (IFI) contribute significantly to mortality and morbidity in patients receiving myelosuppressive chemotherapy for hematologic malignancies. Acquired gastropulmonary fistula is a rare complication of IFI. MATERIAL AND METHODS: We present a case history of a patient with malignant myeloma. She was treated with autologous stem cell transplantation and chemotherapy for three years. She had been treated with antifungal agents as well. Following a specific treatment, she developed an invasive fungal infection (IFI) of the left lung which had been complicated with left gastropulmonary fistula. The patient's general condition was deteriorating, so it was decided to perform a surgical intervention. At the first procedure, open-window thoracostomy was created in order to facilitate treatment by daily packing of the cavity. Four weeks after the thoracostomy, a thoracomyoplasty was performed to repair a gastropleural fistula. During the laparotomy, the gastric fundus was freed from adjacent tissues and repaired. Intrathoracic transposition of the latissimus dorsi and anterior serratus muscle flaps was performed simultaneously to create a new diaphragm. The open-window thoracostomy was left open due to some small bronchial fistulas. The thoracostomy opening healed spontaneously during the following six months. CONCLUSION: We report what is, to the best of our knowledge, the first case of an invasive fungal infection (Geotrichum capitatum) successfully treated with intravenous amphotericin B, voriconazole, and surgery on infected soft tissues (organs) for a patient with multiple myeloma in prolonged neutropenia. The efficacy and safety of the surgery for infected soft tissues requires further evaluation.

[Tracheobronchial surgery]. / Trachejos ir stambiuju bronchu chirurgijos galimybes.

UNLABELLED: During the flowering of cardiothoracic surgery over the past 50 years, surgery of the major airway failed to develop correspondingly. The relative rarity of such cases accounts in past for this laggardness. Surgical diseases of the trachea, whether inflammatory or neoplastic, largely are presented as an obstructive problems of the airway. Surgical management of these lesions is based on simple concept of resection of the involved area of the trachea, when the larynx has not been lost because of affection by the primary disease. Primary end-to-end reconstruction of the trachea has been generally recognized as the ideal method of repair following resection. However, based on Belsey's experience it was widely believed, that only 2 cm at most could be removed and the trachea reconstruction by end-to-end suture in any dependable fashion. During the period of 30 years tracheobronchial surgical reconstructions have been accomplished in 187 patients. CONCLUSION: Management of the patients with stenosis of the trachea and main bronchi must be started promptly. Emergency treatment for the patients with severe tracheal stenosis is rigid bronchoscopy under general anesthesia. Circular tracheal resection is the best method of radical treatment for patients with benign and malignant tracheal narrowing. Sleeve resection is the ideal form of excisional therapy for benign endobronchial tumors, neoplasms of low-grade malignant potential, and bronchostenosis. For patients with tracheobronchial stenosis who are no candidates for surgical reconstruction, tracheobronchial stenting is the management of choice.

[Esophageal achalasia]. / Stemples achaliazija.

UNLABELLED: The purpose of this study was to analyze results of pneumatic dilatation due to esophageal achalasia at the Clinic of General Thoracic Surgery of Vilnius University. MATERIAL AND METHODS: During 25-year period (1973-1998) we have treated 133 achalasia patients. On 125 patients pneumatic dilatation was performed. One hundred five (84%) patients recovered fully. Single course of pneumatic dilatations was sufficient. Recurrence rate was 16% - 3 courses of pneumatic dilatations were performed on 2 (1.6%), 2 - on 18 (14.4%) patients. Complications. The major complication of pneumatic dilatation is esophageal perforation. Most series report its incidence at about 2%. In our study 2 cases (1.6%) of esophageal perforation occurred. Both patients were operated immediately. One (0.8%) died because of purulent complications. CONCLUSION: Pneumatic dilatation is safe and effective method of treatment. In our opinion, it would be the best initial approach. If it failed, then myotomy would be treatment of choice.

[Empyemectomy-treatment of pleural empyema]. / Empiemektomija esant uminei pleuros empiemai.

Empyema thoracis has been recognized as a disease entity since the time of Hippocrates and historically has been associated with high mortality. Over 30 years ago, the American Thoracic Society described three stages in the natural course of empyema, namely the exudative, fibrinopurulent, and organizing phases. Decortication and suction drainage usually result in lung re-expansion, otherwise pleurocutaneous window, intrathoracic transposition of skeletal muscle, or thoracoplasty remain life-saving but now uncommon options for treating a closed-space infection. During last 9 years (1993-2001) 50 patients underwent empyemectomy due to pleural empyema. Three patients died (6%). In 4 cases we had complications-hydropneumothorax. They received punction (3 patients) and 1 received tube toracostomy. In one case urgent retoracotomy was performed due to acute intrapleural bleeding. After successful empyemectomy 47 patients stay at hospital 14 days approximately.

[Odontogenic mediastinitis. Diagnostics and treatment]. / Odontogeninis mediastinitas. Diagnostika ir gydymas.

UNLABELLED: The aim of our work was to evaluate the diagnostic and treatment of patients with odontogenic mediastinitis. METHODS: The last 10 years (1991-2001) 13 males and 4 females, mean age 43 years, with odontogenic mediastinitis were submitted to surgical treatment. Primary odontogenic abscess occurred in all. Before admission to our clinic, 14 patients were treated at stomatological department. Diagnosis was made by clinical manifestation, roentgenographical features and confirmed by findings at mediastinum tissues during operation. RESULTS: All patients at the admission day underwent broad cervicotomies with transcervical mediastinal drainage. In 5 cases this management was associated with mediastinal drainage by transthoracic approach. For another 5 patients thoracotomies were performed late, the last 7 survived without thoracotomy. Six patient died, mortality rate was 35.2%. The reason of the high mortality rate-delay of transthoracic mediastinal drainage in 5 cases, when transcervical was inadequate. CONCLUSION: Ample cervicotomy, associated with transcervical and transthoracic mediastinal drainage can significantly reduce the mortality rate for odontogenic mediastinitis.