MANAGEMENT OF ESOPHAGEAL PERFORATION: A CASE REPORT.

Esophageal perforation (EP) is a devastating condition. In modern times it is still associated with substantial morbidity and mortality. 62-year-old male patient came to Surgical Department of the First University Clinic of Tbilisi State Medical University on 17.10.2018 15:00. The patient complained of pain in the chest cavity, especially after eating, shortness of breath, fever, chills, weakness. The patient felt pain in the chest cavity after eating 4 days before hospitalization. CT scan revealed pneumomediastinum, extravasation of contrast medium at the level of the 8th thoracic vertebra. Esophagogastroduodenoscopy revealed a defect in the esophagus at the level of 32 cm from the incisors. Dimensions of defect were 2.0 - 3.0 cm. An urgent operation was performed. Left-sided posterolateral thoracotomy, mediastinotomy, suturing of the defect, buttressing of the sutures with the mediastinal pleura, washing and drainage of the mediastinum and left pleural cavity were performed. A Witzel gastrostomy was performed. After the operation, the patient's treatment continued in the intensive care unit. Since leakage was noted, it was decided to place an esophageal stent in the area of the defect. Stenting was performed on 05.11.2018. A complication in the form of bleeding was noted on 01.12.2018. Bleeding was controlled conservatively. Finally, stent was removed and the patient was discharged from the clinic in good condition on 07.12.2018. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation. Surgery should be undertaken in all patients who do not meet non-operative management criteria. Buttressing the esophageal repair with surrounding viable tissue has been recommended to decrease the risk of leakage. If direct repair of thoracic EP is not feasible esophageal exclusion, diversion, or resection should be performed. Repair over a large size T-tube can be used to create a controlled esophago-cutaneous fistula and minimize mediastinal and pleural contamination. Thus, esophageal perforation continues to present a diagnostic and therapeutic challenge despite decades of clinical experience and innovation in surgical technique.

ULTRASOUND AND CT GUIDED THORACIC BIOPSY APPROACHES - EFFECTIVENESS AND COMPLICATIONS.

Percutaneous needle biopsy of thoracic pathology has gained popularity showing a good accuracy with a less invasive procedure. The purpose of the paper is to present our experience of ultrasound and CT guided thoracic biopsy approaches regarding procedure effectiveness and complications. 398 Image guided percutaneal core biopsy procedures of thoracic pathology (mediastinum, lung, pleura, bone and soft tissue) has been performed to 380 (95.5%) patients. In 18 (4.5%) cases the repeated biopsy procedure has been performed as the obtained specimen appeared to be non-informative. All repeated procedures were needed when the target size was above 2-5 or >5 cm using CT guided biopsy and it was due to tumor necrosis. No complications were detected after US guided procedures; No repeated procedures were needed as the first one enable to obtain the informative biopsy specimen. Procedure related complication were detected in 48 (12.1% of all procedures) CT guided cases in total; among them in 35 (8.8%) cases pneumothorax, in 5 (1.3%) hemothorax and in 7(1.8%) hemophtisis was detected. Slight bleeding along the needle pass with the hematoma formation was detected in 1 (0.2%) case for soft tissue lesion. 47 (11.9%) complications were detected on transpulmonary approach cases and only 1 (hematoma formation - 0.2%) - on extrapulmonary approach. Percutaneous image-guided core biopsy of thoracic lesions is an accurate and safe procedure, which enables to get the tissue material from all thoracic compartments. The vast majority of complications should be expected on transpulmonary approach cases.

IMAGING GUIDED PERCUTANEAL CORE BIOPSY OF THORACIC BONE AND SOFT TISSUE LESIONS - TECHNIQUE AND COMPLICATIONS.

The purpose of the paper is to present our experience of Imaging Guided Percutaneal Core Biopsy (IGPCB) of thoracic bone and soft tissue lesions in terms of procedure planning, biopsy technique, procedure complications and their management. The results of investigation of 81 patients are presented. According to imaging guidance type the patients were subdivided in two main groups - US guided biopsy (26 patients, 26 procedures) and CT guided biopsy (55 patients, 59 procedures). 85 procedures were performed. In 4 cases the repeated biopsy procedure has been performed as the obtained specimen appeared to be non-informative. Adequate tissue material was obtained at the first attempt in 77 (95.1 %) cases; in 4 (4.9%) cases the repeated procedure was needed (when the target size was above 2-5 or >5 cm using CT guided biopsy and it was due to tumor necrosis. Procedure related complications were detected in 1 (%) case (CT guided biopsy). In 1 case the significant pain, requiring administration of additional analgetics in postprocedure period was mentioned. Percutaneous US and CT guided bone and soft tissue lesions biopsy is an effective, highly accurate, and safe method of tissue obtaining for the diagnosis of indeterminate lesions. US is fast, cheap, avoids ionizing radiation, and allows the needle tip to be monitored throughout the procedure. CT has the ability to visualize both bone and soft tissue with the advantage of making easier needle localization into lesions too deep to see on US. CT also allows for better visualization lesions with a large amount of overlying cortex, and deep-seated lesions with extensive overlying soft tissue. CT-guided percutaneous biopsy is a safe and accurate method. US is the preferable tool for biopsy procedure guidance if the target is adequately imaged by US. CT should be used in cases when US imaging is not possible due to visualization problem.

Imaging guided mediastinal percutaneal core biopsy--technique and complications.

165 percutaneous biopsies of anterior, middle and posterior mediastinum lesions were performed to 156 patients. Procedure was guided by US in 40 cases, by CT - in 125 cases. Hydrodissection was used in 5 cases, artificial pneumothorax - in 3 cases in order to avoid transpulmonary needle pass. Post-biopsy CT scan was performed and patients observed for any complications. Adequate tissue for histological diagnosis was obtained in 156 (94.5%) cases at the first attempt; in 9 (5.5%) cases the repeated procedure was needed. No major complications were detected after biopsy procedures; minor complications (pneumothorax, hemothorax and hemophtysis) were detected in 23 (13.9%) cases. No complications were detected after US guided procedures; In 17 (10.3% of all complications) cases pneumothorax, in 4 (2.4%) cases - hemothorax and in 2 (1.2%) cases hemophtisis was detected on CT guided procedures. All hemothorax and hemophtisis and 10 pneumothorax cases happened to be self-limited; in 3 pneumothorax cases aspiration and in 4 cases - pleural drainage was needed. Percutaneous image-guided core biopsy of mediastinal lesions is an accurate and safe procedure, which enables to get the tissue material from all mediastinum compartments. Ultrasound is the most efficient for biopsy guidance, if the target is adequately imaged by it; the advantages of US guidance are: a) possibility of real-time needle movement control b) possibility of real-time blood flow imaging b) noninvasiveness c) cost-effectiveness d) possibility to perform the biopsy at the bedside, in a semiupright position; so, ultrasound is a "Gold Standard" for procedure guidance if the 'target" can be adequately imaged by this technique. If US guidance is impossible biopsy should be performed under CT guidance. Hydrodissection and artificial pneumothorax enables to avoid the lung tissue penetration related complications. Pneumothorax was associated with multiple Needle passes and larger diameter needle use. The safety and biopsy procedure success high rate proves the use of IGMPCB as a first choice procedure when the mediastinal mass morphology is needed.

Understanding autoimmune mechanisms in multiple sclerosis using gene expression microarrays: treatment effect and cytokine-related pathways.

Multiple sclerosis (MS) is a central nervous system disease in which activated autoreactive T-cells invade the blood brain barrier and initiate an inflammatory response that leads to myelin destruction and axonal loss. The etiology of MS, as well as the mechanisms associated with its unexpected onset, the unpredictable clinical course spanning decades, and the different rates of progression leading to disability over time, remains an enigma. We have applied gene expression microarrays technology in peripheral blood mononuclear cells (PBMC) to better understand MS pathogenesis and better target treatment approaches. A signature of 535 genes were found to distinguish immunomodulatory treatment effects between 13 treated and 13 untreated MS patients. In addition, the expression pattern of 1109 gene transcripts that were previously reported to significantly differentiate between MS patients and healthy subjects were further analyzed to study the effect of cytokine-related pathways on disease pathogenesis. When relative gene expression for 26 MS patients was compared to 18 healthy controls, 30 genes related to various cytokine-associated pathways were identified. These genes belong to a variety of families such as interleukins, small inducible cytokine subfamily and tumor necrosis factor ligand and receptor. Further analysis disclosed seven cytokine-associated genes within the immunomodulatory treatment signature, and two cytokine-associated genes SCYA4 (small inducible cytokine A4) and FCAR (Fc fragment of IgA, CD89) that were common to both the MS gene expression signature and the immunomodulatory treatment gene expression signature. Our results indicate that cytokine-associated genes are involved in various pathogenic pathways in MS and also related to immunomodulatory treatment effects.