Severe subglottic stenosis after resection of anterior mediastinal tumor using a double­lumen tube: a case report.

Background: Double­lumen tubes (DLTs) are commonly used for differential pulmonary ventilation during thoracic surgery. Few reports exist on subglottic stenosis among patients who underwent surgery involving DLTs; we lack immediate postoperative period documentation leading up to the onset and subsequent recovery of subglottic stenosis. Herein, we present a case of a 75-year-old woman successfully treated for subglottic stenosis after DLT. Case Description: A 75-year-old woman presented to our hospital with an abnormal chest shadow, which was identified during a medical examination. Chest computed tomography revealed an anterior mediastinal mass with a poor contrast effect measuring 6.0 cm × 3.1 cm × 1.9 cm, which grew from 2.2 to 6.0 cm over 21 months. Low and high signals were detected on T1- and T2-weighted thoracic magnetic resonance imaging, respectively. Concordantly, a thymic cyst was suspected. The patient underwent robotic-assisted thoracoscopic resection via the right lateral approach. A 35-Fr left-sided DLT was used for intubation and differential lung ventilation. Hoarseness and stridor were observed on postoperative day (POD) 1. Laryngoscopy showed submucosal hemorrhage around the vocal cords and mild subglottic stenosis; however, there was no arytenoid dislocation or findings necessitating emergency treatment. On POD 4, her stridor became more severe and laryngoscopy was re-performed and revealed subglottic stenosis progression prompting emergency tracheotomy. The stenosis further progressed, and almost complete airway obstruction was observed on POD 7. By POD 9, partially improving the subglottic stenosis, thereafter the subglottic stenosis was almost completely alleviated by POD 12. The tracheal cannula was removed on POD 22. Trachea-cutaneous fistula closure was performed on POD 35, and she was discharged on POD 42, remaining well. The pathological examination of the anterior mediastinal tumor confirmed the diagnosis of thymic cyst. Conclusions: Airway obstruction owing to subglottic stenosis may occur several days post-surgery with a DLT. Prompt tracheostomy is recommended to prevent complete airway obstruction in patients with progressive subglottic stenosis.

A case of pyothorax after treatment of burn inhalation injury. A case report.

INTRODUCTION: Inhalation injury is a major complication of fire accidents. Delayed onset of tracheal stenosis is one of the chronic complications of inhalation injury. Here, we report a case of acute empyema as a complication of inhalation injury. PRESENTATION OF CASE: A 38-year-old-man who underwent a tracheostomy following an inhalation injury when he was 25-years of age was admitted with a diagnosis of right-side pyothorax. We attributed the pyothorax to insufficient bronchial toilet secondary to preoperative tracheal stenosis and tracheal mucosal damage as a complication of inhalation injury, as confirmed using laryngofiberscopy. Conservative therapy was insufficient, therefore, surgical drainage was performed. At the time of surgery, following general anesthesia induction, the insertion of a single-lumen tube was difficult owing to severe tracheal stenosis. As a result, we performed an emergency tracheostomy followed by empyema curettage. DISCUSSION/CONCLUSION: Tracheal stenosis due to tracheal basal membrane injury and mucosal membrane injury resulted in sputum clearance disorder. These changes led to pyothorax. Preoperative airway safety should be carefully planned when operating on patients with tracheal stenosis.

Rupture of thymoma due to recurrent tumor hemorrhage: a case report.

Background: Rupture of a thymoma is rare, and due to its rarity, the mechanism of rupture remains unclear. Here we report a case of a ruptured thymoma that ruptured due to an increase in the intratumoral pressure caused by recurrent hemorrhaging. Case Description: A 70-year-old woman presented 2 days prior persistent right chest and shoulder pain. A chest computed tomography (CT) scan revealed the presence of a mass occupying the anterior mediastinum and a right pleural effusion. It was diagnosed as an anterior mediastinum tumor. The increase in the levels of inflammatory markers and tumor necrosis observed on CT were suggestive of infection. As the general status of the patient was stable and she initially received antibiotic medical therapy, an improvement in the inflammatory marker levels was observed with antibiotic therapy. A surgical resection was performed 10 days after admission. Median sternotomy revealed a tumor extending from the mediastinum to the right thoracic cavity. Since the adhesion was strong and tumor invasion was suspected, the tumor was completely resected by combining a partial resection of the right middle and lower lobes with the pericardium. Pathological examination revealed that the tumor was a type B2 thymoma with fibrosis, necrosis, hemosiderosis, and hemorrhaging, suggesting recurrent hemorrhaging within the tumor. Conclusions: Based on the findings of our case, recurrent hemorrhaging within the tumor led to an increase in the intratumoral pressure and chronic inflammation and necrosis weakened the tumor wall. These changes contributed to the subsequent rupture.

Lung adenocarcinoma and squamous cell carcinoma difficult for immunohistochemical diagnosis can be distinguished by lipid profile.

In patients with unresectable non-small cell lung cancer, histological diagnosis is frequently based on small biopsy specimens unsuitable for histological diagnosis when they are severely crushed and do not retain their morphology. Therefore, establishing a novel diagnostic method independent of tissue morphology or conventional immunohistochemistry (IHC) markers is required. We analyzed the lipid profiles of resected primary lung adenocarcinoma (ADC) and squamous cell carcinoma (SQCC) specimens using liquid chromatography-tandem mass spectrometry. The specimens of 26 ADC and 18 SQCC cases were evenly assigned to the discovery and validation cohorts. Non-target screening on the discovery cohort identified 96 and 13 lipid peaks abundant in ADC and SQCC, respectively. Among these 109 lipid peaks, six and six lipid peaks in ADC and SQCC showed reproducibility in target screening on the validation cohort. Finally, we selected three and four positive lipid markers for ADC and SQCC, demonstrating high discrimination abilities. In cases difficult to diagnose by IHC staining, [cardiolipin(18:2_18:2_18:2_18:2)-H]- and [triglyceride(18:1_17:1_18:1) + NH4]+ showed the excellent diagnostic ability for ADC (sensitivity: 1.00, specificity: 0.89, accuracy: 0.93) and SQCC (sensitivity: 0.89, specificity: 0.83, accuracy: 0.87), respectively. These novel candidate lipid markers may contribute to a more accurate diagnosis and subsequent treatment strategy for unresectable NSCLC.

Spontaneous closure of a metachronous brochopleural fistula after omentoplasty for a preceding fistula: Case report.

Introduction: A bronchopleural fistula (BPF) after an anatomical lung resection commonly arises singly. We report a case of a metachronous BPF, which developed after omentoplasty of a preceding fistula and subsequently closed without any intervention. Case presentation: A 77-year-old patient underwent omentoplasty for a brochopleural fistula (BPF) following a right lower lobectomy. A sudden massive air leak developed from the novel BPF approximately 1 cm proximal to the preceding fistula 3 days later. The air leak resolved spontaneously without any intervention one week later. The corresponding fistula was found to be completely closed. Computed tomography showed the omental flap covered both fistulae. Conclusion: The present case suggested that a metachronous BPF could develop and a harvested omental flap might migrate even after being anchored.

Sudden hemothorax as a rare initial manifestation of bronchiectasis under a direct oral anticoagulant.

BACKGROUND: A hemothorax as the initial manifestation of bronchiectasis is extremely rare. We report a case of a sudden hemothorax due to exacerbation of clinically latent bronchiectasis under a direct oral anticoagulant. CASE PRESENTATION: A 77-year-old woman presented with chest pain and a fever noted since the day before. She had stage G3 chronic kidney disease and received edoxaban for paroxysmal atrial fibrillation. She had no history of trauma or respiratory symptoms. A chest computed tomography revealed a mass with a surrounding opacity in the right lower lobe with a pleural effusion. Conservative treatment was chosen because of the stable vital signs and her respiratory condition. Her oxygen saturation dropped 7 h later with progressive anemia. Repeated chest computed tomography showed a worsening pulmonary opacity and pleural effusion. She underwent a right lower lobectomy successfully. The histopathological findings suggested that the preceding infection of the subpleural focal bronchiectasis caused the bleeding. In addition, a steep caliber change between the subpleural focal bronchiectasis and proximal normal branch may have caused an intraluminal pressure gradient resulting in a peripheral discharge causing a pleural rupture with a hemothorax. CONCLUSION: The sudden hemothorax could have been the initial manifestation of bronchiectasis. Particular attention should be paid to peripherally localized bronchiectasis even if it is without any clinical symptoms, especially in patients with a comorbidity such as a susceptibility to infections and the use of direct oral anticoagulants.

Placement of KANI® plate inside the chest wall for rib fixation: Prevention for organ injuries caused by crossed rib edges and plate claws.

The claw-type titanium plate has been successfully applied to manage a flail chest. However, rare and life-threatening organ injury occurs due to an insufficient claw bend. We report an ingenuity of surgical fixation using KANI® plates (USCI Japan, Tokyo, Japan) in a flail chest. A 60-year-old man with a severe flail chest underwent a surgical rib fixation. He had multiple rib fractures accompanied by dislocation and protruding crossed rib edges; we assumed a possibility of lung injury during a standard procedure in which the KANI® plates would be placed from outside the chest wall. Therefore, we placed KANI® plates inside the chest wall to ensure sufficient claw bend and to cover crossed rib edges to prevent organ injuries. We propose that our new ingenuity provides a safe and tight rib fixation in rib fractures with protruding crossed rib edges which the standard method cannot flatten.

A 77-Year-Old Man with a Pulse Granuloma of the Descending Colon Identified by Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET) Imaging 19 Months Following Surgical Resection for Rectal Carcinoma.

BACKGROUND Food particles may sometime lodge in the intestinal wall, resulting in a granuloma. Pulse granuloma is associated with the seed of a legume and has a characteristic appearance on histology. This report describes a case of pulse granuloma of the descending colon identified by fluorodeoxyglucose-positron emission tomography (FDG-PET) imaging. Imaging was done 19 months after surgical resection for rectal carcinoma, and the results of imaging alone suggested a tumor metastasis. CASE REPORT A 77-year-old man underwent sigmoid colostomy for sigmoid colon perforation due to obstruction by rectal cancer affecting the upper rectum approximately 2 years ago. Two months later, after his general condition improved, he underwent laparoscopic low anterior resection. On postoperative pathological examination, the lesion was diagnosed as stage II. Nineteen months later, computed tomography showed an irregular nodule on the dorsolateral side of the descending colon. FDG-PET revealed positive results, and peritoneal dissemination was suspected. Because the lesion was localized and there was no other evidence of metastasis, resection was performed. A pathological examination revealed a pulse granuloma with a central legume seed, and no obvious malignant findings were observed. CONCLUSIONS This report has highlighted the importance of imaging and histopathology in cases in which a solitary nodule is present in the bowel in a patient with previous successful treatment for malignancy. Pulse granuloma, or other types of granuloma associated with impacted food material, may be a cause of a solitary nodule, or pseudotumor, in the bowel wall.

Preoperative marking of a submillimeter metastatic pulmonary tumor using a mobile computed tomography scan with a navigation system: A case report.

INTRODUCTION AND IMPORTANCE: Preoperative localization of non-palpable lung nodules plays an important role in video assisted thoracic surgery (VATS). Although percutaneous computed tomography (CT)-guided hook wire marking has become widely accepted, it is accompanied by rare but fatal complications such as air embolisms. We herein report a case of a submillimeter pulmonary nodule successfully localized by a mobile CT scan with a navigation system. CASE PRESENTATION: A 40-year-old-man presented with the two right pulmonary nodules 4 years after a radical left nephrectomy for a renal clear cell carcinoma. One of the nodules was too small to palpate and preoperative marking was applied using a mobile CT scan with a navigation system. We successfully performed VATS wedge resection for both nodules and confirmed a pathological diagnosis of a metastasis from the renal cell carcinoma. The maximum pathological size of the smaller nodule was 500 µm. CLINICAL DISCUSSION: Preoperative marking of the lower lobe lesion in the present case was essential for VATS. Our novel technique was helpful for the precise marking without any morbidity. CONCLUSION: Preoperative marking using a mobile CT scan with a navigation system is safe and easily applicable. It might be a useful option for VATS of non-palpable lung nodules.

[Better Effects of Inventive Nutritional Approaches for Chemotherapy and Conversion Surgery in Stage â £ Gastric Cancer].

The REGATTA trial revealed that chemotherapy is the standard strategy for gastric cancer patients with Stage Ⅳ factors. However, some recent studies have identified the prognostic effect of conversion surgery after complete response to Stage Ⅳ factors during chemotherapy. Here, we report a case with Stage Ⅳ factors successfully treated via intensive chemotherapy and conversion surgery without any adverse events and complications, using preoperative parenteral hyper-nutrition and postoperative enteral nutrition. Nutrition might be the key strategy during the treatment of gastric cancer patients with Stage Ⅳ factors.