Severe Esophageal Lichen Planus Treated With Tofacitinib.

Lichen planus is a chronic inflammatory immune disorder that most commonly affects the skin and mucous membranes. Esophageal lichen planus (ELP) is a frequently misdiagnosed and poorly understood form of lichen planus that can be asymptomatic or present with dysphagia and odynophagia caused by the formation of erosions and strictures in the esophagus. These strictures often reduce a patient's quality of life and may lead to emaciation in more severe cases. We present the case of an 89-year-old woman with a history of cutaneous lichen planus (CLP) and mucosal lichen planus that were successfully managed with topical corticosteroids and oral cyclosporine rinses who presented with an esophageal stricture and erosions that were treated unsuccessfully with surgery. Our patient's condition continued to worsen until she presented in an emaciated state and was treated with tofacitinib, which resulted in complete resolution of oral lichen planus (OLP), ELP, and genital lichen planus.

Lung Chordoma: A Discussion.

Chordomas are rare neoplasms arising from remnants of the notochord. We report a case of a 61-year-old woman who underwent workup for bariatric surgery and was found to have bilateral pulmonary nodules on a computed tomographic scan. Video-assisted thoracoscopic wedge resections were performed, and immunohistochemical stains confirmed the diagnosis of chordoma in all lesions. Much of our current knowledge of chordomas comes from axial and extra-axial, nonpulmonary presentations. Surgery appears to be the best treatment option because these tumors are generally chemoresistant. However, there are limited numbers of case reports of this entity.

A Narrative Review of update in per oral endoscopic myotomy (POEM) and endoscopic esophageal surgery.

The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.

Clinical Characteristics and Outcome of Pneumomediastinum in Patients with COVID-19 Pneumonia.

Introduction: Pneumomediastinum (PM) is characterized by the presence of air within the mediastinum. The association between PM and coronavirus 2019 (COVID-19) has not been well established in the current literature. We sought to summarize the limited body of literature regarding PM in patients with COVID-19 and characterize the presentation and clinical outcomes of PM in patients with severe acute respiratory syndrome (SARS)-COV-2 pneumonia at our institution to better define the incidence, prognosis, and available treatment for this condition. Materials and Methods: All patients with a proven diagnosis of COVID-19 and PM between March 18, 2020 and May 5, 2020 were identified through hospital records. Retrospective analysis of radiology records and chart review were conducted. Clinical characteristics and outcomes were collected and descriptive statistics was analyzed. Results: Thirty-six patients met inclusion criteria. Out of the 346 intubated COVID-19 patients, 34 (10%) had PM. The incidence of PM increased for the first 4 weeks of the pandemic, and then began to decrease by week 5. At the endpoint of the study, 12 (33.33%) patients were alive and 24 patients (66.67%) had died. Conclusion: PM, although a rare phenomenon, was more prevalent in COVID-19 patients compared with historical patients with adult respiratory distress syndrome. The etiology of this condition may be attributed to higher susceptibility of patients infected with SARS-CoV-2 to a combination of barotrauma and airway injury.

The Use of Fluorescence Imaging in Colon Interposition for Esophageal Replacement: A Technical Note.

Every field of surgery has seen an explosion of new technologies aimed at improving surgical technique and reducing complications. The use of near-infrared (NIR) fluorescence to assess perfusion has been described in several surgical disciplines. NIR provides the surgeon with real-time perfusion assessment of a target organ or anastomosis and can be invaluable in aiding decision-making during the index operation. In the following article we discuss the use of fluorescence-guided perfusion assessment during colonic interposition for esophageal replacement. To our knowledge this is the first description of the use of fluorescence-guided perfusion assessment during colonic interposition.

Laparoscopic repair of a peritoneopericardial diaphragmatic hernia after a convergent procedure for the treatment of atrial fibrillation.

Peritoneopericardial diaphragmatic hernia is a rare entity involving herniation of abdominal viscera through the diaphragm into the pericardial sac. It is most often seen after blunt abdominal trauma, but can occur following any trans-diaphragmatic intervention. We report on a 56-year-old female with peritoneopericardial diaphragmatic hernia secondary to a convergent procedure for the treatment of atrial fibrillation, who underwent a laparoscopic repair. An anterior abdominal wall laparoscopic approach was employed. Transverse colon and greater omentum were within the hernia sac. The defect measuring 3 cm × 3 cm was repaired using a composite hernia mesh. The total operative time was 78 minutes. No intra-operative and no post-operative complications were observed. Patient remained asymptomatic at a 6-month follow-up. Laparoscopic mesh repair of peritoneopericardial diaphragmatic hernia is safe, feasible and is the procedure of choice for treating these complex hernias.

Simultaneous unilateral anterior thoracoscopy with transcervical thyroidectomy for the resection of large mediastinal thyroid goiter.

BACKGROUND: Almost 25% of thyroid goiters have an intrathoracic component. Although the majority of mediastinal goiters may be approached through a cervical approach, up to a third of substernal goiters require a sternotomy or thoracotomy for resection. As an alternative to conventional sternotomy, we herein describe a combined anterior thoracoscopic and transcervical approach to large mediastinal thyroid goiters. METHODS: Between 2012 and 2015, seven patients with symptomatic thyroid goiters with significant intrathoracic extension were approached via simultaneous cervical exploration and anterior thoracoscopy. Thoracoscopy was performed on the side of maximal goiter extension. RESULTS: Simultaneous thoracoscopy and transcervical thyroidectomy was technically successful in all patients. No patients required conversion to open approach and one patient required reoperation for hemorrhage. CONCLUSIONS: Simultaneous anterior thoracoscopy and cervical exploration is a safe and effective approach to large mediastinal thyroid goiter. Patients with significant intrathoracic goiter extension may benefit from preoperative thoracic surgical evaluation and planned thoracoscopy at the time of thyroidectomy.

Pulmonary patch repair of tracheobronchial necrosis with perforation secondary to caustic ingestion.

Corrosive aerodigestive injury complicated by tracheobronchial necrosis is a rare complication after caustic ingestion that carries a high risk of mortality and morbidity. If left untreated, tracheobronchial necrosis results in perforation, mediastinitis, and death. Pulmonary patch repair is a safe, effective, and easily performed surgical technique for the treatment of tracheobronchial necrosis with perforation. Frequent endoscopic surveillance leads to early diagnosis and prompt operative management to prevent significant morbidity. We describe a pulmonary patch repair of a patient who had stage 3b necrosis of the esophagus and the stomach with tracheobronchial necrosis and perforation after caustic ingestion.

Subdiaphragmatic bronchogenic cyst at the gastroesophageal junction presenting with Dysphagia: a case report.

BACKGROUND: Bronchogenic cysts are benign lesions derived from the primitive foregut. They frequently occur in the mediastinum, most commonly at the subcarinal level. Subdiaphragmatic location for bronchogenic cysts is extremely rare. METHODS: A 40-year-old woman presented with worsening dysphagia and was diagnosed as a bronchogenic cyst arising from infradiaphragmatic esophagus by computed tomographic scan and endoscopic ultrasound-guided aspiration. Total laparoscopic enucleation of the cystic mass was performed. RESULTS: The postoperative esophagogram revealed no leak or reflux and the patient was discharged on day 2. The histopathologic examination revealed a bronchogenic cyst. No recurrence of the cyst or symptoms was noted at 6 months. CONCLUSIONS: Infradiaphragmatic bronchogenic cysts are uncommon and may become symptomatic secondary to compression of surrounding structures. A complete resection by laparoscopy is feasible and represents a safe and minimally invasive alternative to traditional resection through laparotomy or thoracotomy.

Traction esophageal diverticulum: a rare cause of gastro-intestinal bleeding.

Esophageal diverticula are uncommon lesions that are usually classified according to their location (cervical, thoracic, or epiphrenic), or underlying pathogenesis (pulsion or traction), and their morphology (true or false).The majority of esophageal diverticula are acquired lesions that occur predominantly in elderly adults. Pulsion, or false, diverticula are the most commonly encountered type of esophageal diverticula noticed at the level of cricopharyngeus muscle, occur as a localized outpouchings that lacks a muscular coat, and as such their wall is formed entirely by mucosa and submucosa. True, or traction, esophageal diverticulum (TED) is seen in the middle one third of the thoracic esophagus in a peribronchial location, occurs secondary to mediastinal inflammatory lesions such as tuberculosis or histoplasmosis. The resultant desmoplastic reaction in the paraesophageal tissue causes full thickness pinching on the esophageal wall, producing a conical, broad-mouthed true diverticulum. They often project to the right side because subcarinal lymph nodes in this area are closely associated with the right anterior wall of the esophagus. TED usually presents with symptoms such as dysphagia, postural regurgitation, belching, retrosternal pain, heartburn, and epigastric pain. As in patients with pharyngoesophageal (Zenker's) diverticula, pulmonary symptoms are often present but underestimated in TED patients. These symptoms range from mild nocturnal cough to life-threatening massive aspiration. In this particular report we describe a rare case of TED presenting as a symptomatic upper gastrointestinal bleeding. Diagnostic evaluation of TED includes chest X-ray, barium esophagogram and manometry. A significant proportion of lower esophageal diverticula are associated with motility disorders. Management of TED include treating the underlying cause sometimes a surgical resection of diverticulum along with esophageal myotomy is necessitated in symptomatic patients.

Intraoperative staging and surgical management of stage IIIA/N2 non-small cell lung cancer.

Staging of the mediastinum is an integral component of the operative treatment of NSCLC. Systematic sampling and systematic lymph node dissection provide similar and accurate staging information. Systematic lymph node dissection is more likely to identify multiple levels of N2 disease, however, and may be associated with improved survival. During surgery for a right lung cancer, at least mediastinal lymph node levels 4 should be sampled or dissected. When removing a left lung cancer, at least nodal levels 5 and 7 should be assessed. Although every effort should be made to identify N2 disease before surgery, if intraoperative metastases to mediastinal lymph nodes are discovered, the planned operation should proceed. Cisplatin-based adjuvant chemotherapy has moderate but proven survival benefit after resection of N2 disease. The role of PORT remains uncertain.

Sweat gland carcinoma.

Sweat gland carcinoma is a rare malignant tumor of the skin adnexa that can occur in a variety of locations. It is a slow-growing tumor that metastasizes early and often. The rarity of this tumor has led to a relative lack of adequate evidence with regard to treating this entity. Recent advances in immunohistochemical staining have better defined this tumor and have aided in diagnosing its subtypes though histologic grade and presence of regional lymph nodes at the time of diagnosis. These are the best indicators for prognosis and management currently available. Indications for sentinel node biopsy are currently not well defined. Because of the poor prognosis of high-grade sweat gland carcinoma, clinicians should be aware of this entity and be prepared to treat aggressively. Management of sweat gland carcinoma is difficult because extensive study into both surgical and nonsurgical treatment has not been done. We present a case of sweat gland carcinoma of the lower extremity and a review of the clinicopathologic literature of these rare neoplasms, including diagnosis and surgical management.