Empyema Necessitatis: A Rare Complication of Empyema.

Empyema necessitatis (EN) is an exceedingly rare complication of empyema. EN refers to the expansion and progression of an empyema beyond the thoracic cavity toward the skin wall. Herein, we present the case of a man with EN and detail his clinical course. A 42-year-old male with a prior history of substance use presented to the emergency department with three weeks of fever, cough, and progressively worsening pain overlying the left anterior chest wall. An empiric antibiotic regimen of cefepime, metronidazole, and vancomycin was initiated. Chest X-ray, ultrasound, and chest CT demonstrated a large region of loculation suspicious for a loculated empyema. On day 4 of admission, he underwent a video-assisted thoracoscopy followed by a left minithoracotomy, which confirmed the diagnosis of EN. The patient was discharged on hospital day 16 with marked clinical improvement and monitored for a year via an outpatient clinic. Symptoms did not recur, and there was complete resolution of EN. More predominant in the pre-antibiotic era with the progression of uncontrolled infections, EN is less commonly seen today. As such, EN requires a high degree of clinical suspicion for timely detection and management. Our case illustrates the importance of early intervention with antibiotics and surgical drainage.

Insertion of right ventricular assist device and its removal under local anesthesia.

A patient with acute right ventricular infarction was treated with coronary artery bypass grafting. A few days later developed right ventricular failure and required insertion of a right ventricular assist device through a sternotomy approach (TandemHeart, CardiacAssist, Inc., Pittsburgh, PA, USA). We herein report a technique in which the removal of the right ventricular assist device is performed under local anesthesia without a sternotomy incision.

Tumor of the liver (hepatocellular and high grade neuroendocrine carcinoma): a case report and review of the literature.

We describe a rare hepatic collision tumor composed of a hepatocellular carcinoma and a high-grade neuroendocrine carcinoma. The patient, a 50-year-old man, underwent a partial hepatectomy because of a 5.0-cm mass. The tumor had two distinctive patterns. The majority of the tumor was a high-grade neuroendocrine carcinoma with features of a small cell carcinoma that was positive for chromogranin, synaptophysin, and cytokeratin 19 and negative for hepatocellular antigen and alpha-fetoprotein (AFP). The second component was a moderately differentiated hepatocellular carcinoma that was positive for hepatocellular antigen and AFP and negative for neuroendocrine markers. The two tumors were separated by fibrous bands. In areas where they collided, there was no transition or intermingling of cells between the two components, thus, it is different from the combined type of tumors. After removal of the tumor, the patient had intrahepatic and mesenteric recurrences within a follow-up period of 16 months.

Primary repair of infracardiac total anomalous pulmonary venous connection using a modified sutureless technique.

Primary repair of infracardiac total anomalous pulmonary venous connection is associated with a significant risk of recurrent pulmonary venous obstruction. Herein we describe a technique of primary repair in which a modified sutureless anastomosis is constructed by suturing the left atrium to the posterior mediastinal pleura that surrounds the pulmonary venous confluence.

Large esophageal liposarcoma: a case report and review of the literature.

Liposarcoma is one of the most common neoplasms of adulthood. However, it is exceedingly rare in the gastrointestinal tract. To our knowledge, only 12 cases occurring in the esophagus have been reported in the world literature to date. We report the case of a 42-year-old man with a pleomorphic liposarcoma arising in the esophageal wall. The morphologic, immunophenotypic, and ultrastructural characteristics are presented, as well as the results of literature review.