Descending necrotizing mediastinitis: a challenging infection. Selected results of a Moroccan bicentric study.

Introduction: Mediastinal infection is a persistent and difficult widespread infectious disease caused by secondary complications of adjacent organs. It spreads easily and is often misdiagnosed because of the lack of typical manifestations. Material and methods: To highlight the clinical features, medical and surgical strategy of descending necrotizing mediastinitis we performed a retrospective study of 25 documented cases during a 10-year period at our hospital, all treated surgically, 10 from the ORL department and 15 from our thoracic surgery department. Results: Patients were aged from 20 to 84 years, with a median age of 41 years, male predominance (19 men and 6 women), sex ratio of 3.6. A cervicotomy (in 40% of cases) was associated or not with videothoracoscopy (one case) or thoracotomy (in 20% of cases) and wide-spectrum antibiotherapy. In the postoperative period, an irrigation-suction system was used on the drains in 15 patients. In 1 case a rethoracotomy was necessary to remove a residual right pyothorax, and one patient required a tracheostomy. Twenty-two (88%) patients recovered from their mediastinitis. Death of 3 patients by sepsis multiorgan failure occurred. Postoperative follow-up during one year was uneventful without recurrence. Conclusions: According to our experience, we believe the more aggressive local treatment is, the better are the results.

Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

Giant Lipoma of the Anterior Neck and Supraclavicular Region.

What are the clinical presentation and potential etiologies of giant lipomas?What is the appropriate imaging procedure for a neck lipoma?What are the differential diagnoses of a giant lipoma?What are the surgical approaches for a giant neck lipoma?

Mediastinal Bronchogenic Cysts Resection in Adults: Results of Vats and Thoracotomy Procedures.

BACKGROUND: The objectives of our study are to evaluate our surgical experience of mediastinal bronchogenic cyst (MBC) and to determine the results of resection by video-assisted thoracic surgery (VATS) and posterolateral thoracotomy (PLT). METHODS: The demographic characteristics, clinical and radiological features intraoperative data, outcomes and fol- low-up information were reviewed and analyzed from 38 patients who underwent resection of a MBC between 2008 and 2019. RESULTS: cystectomy was performed for thirty eight patients included in the present study. Seventeen of them, benefited from VATS cystectomy (VATS group) with 1 conversion to thoracotomy (5.9%) and 21 underwent PLT cystectomy (PLT group). In our series 27 (71.1%) were male. Their average age was 42.6 years. While 09 patients (23.7%) had no symptoms pre-operatively, 29 patients (76.3%) were symptomatic. There were no operative deaths and 3 patients (7.9%) presented postoperative complications. The average duration of hospital stay was 3.2 days for patients who had VATS, but 5.8 days for those who had thoracotomy. Long-term follow-up (range, 1 to 8 years) showed no late complications and no recurrence. CONCLUSION: VATS and PLT are main approaches for the surgical resection of MBCs VATS is a safe procedure, with less pain and time spent at the hospital. Early surgical procedures of MBCs may be recommended to prevent complications. Surgical adhesions are unfavorable conditions to thoracoscopic treatment.

Cervical hibernoma.

Hibernomas, are rare, benign tumors composed of brown fat. They can affect multiple sites, including the head, neck, trunk, and extremities. Their clinical presentation is similar to that of malignant tumors such as liposarcomas, which can lead to mismanagement. Imaging is useful but histopathologic confirmation of the tumor is needed. We present two cases of histology-proven neck hibernoma treated with radical excision.

Reidel's Thyroiditis, a Diagnostic and Management Challenge: A Case Report and Review of the Literature.

Riedel's thyroiditis is a very rare inflammatory condition. It affects not only the thyroid gland but also the adjacent vital structures. It may also be associated with different forms of systemic fibrotic disorders. The exact etiology is unknown, but currently, the most favorable opinion is that it is a localized form of the systemic fibrotic process. We report the case of a 38-year-old woman, presented with a 10-month history of progressive hypothyroidism, dysphonia, and dysphagia. A Doppler ultrasound study revealed massive thyroid enlargement with multiple Eu TIRADS 3 and 4 nodules. Fine needle aspiration was noncontributive on two occasions. A hard subtotal thyroidectomy was performed. Pathological study confirmed Riedel's thyroiditis with the presence of IgG4 antibodies in immunohistochemistry. The patient was successfully treated with levothyroxine replacement and corticosteroid therapy with rapid resolution of obstructive symptoms. The case descriptions highlight the diagnostic challenge of this disease, describe the response to surgical management and corticosteroid therapy, and give a short review of the subject.

Single-stage versus two-stage surgery of pulmonary and hepatic hydatid cysts.

INTRODUCTION: Concomitant lung and liver hydatid cyst is a rare condition. Most surgeons agree that both sites should be resected in one-time surgery. AIM: We present a case series of hepatic and pulmonary hydatid cyst treated in one-stage surgery (OSS) compared with patients who underwent two-stage surgery (TSS). MATERIAL AND METHODS: This retrospective study included 47 patients separated into two groups (33 TSS and 14 OSS) between 2008 and 2019. Data on clinical symptoms, sites, radiological features, techniques, postoperative complications, mean hospital stay and outcome were analyzed separately for TSS and OSS procedures. RESULTS: A total of 33 patients who underwent TSS (70.2%) were compared to 14 patients operated on by OSS (29.8%). No significant differences were found between groups for age (45.3 vs. 42.7, p = 0.45), sex (male: 57.6% vs. 64.2%) and socio-geographic status (urban: 72.7% vs. 78.6%). But there were more postoperative complications (24.3% vs. 14.3%, p = 0.036) in the TSS group, and operative duration (154 minutes vs. 122 minutes, p = 0.047), postoperative hospital stay (13.8 days vs. 8.7 days, p = 0.022), and interruption of activities and work (56 days vs. 31 days, p = 0.045) were longer in the TSS group. There was no difference in postoperative mortality between the 2 groups. CONCLUSIONS: Single-stage surgical management by trans-thoraco-phrenotomy can be recommended to treat dual-seat hepatic and pulmonary hydatid disease with fewer complications and a rapid return to work. This technique is easier and safer for right lung and liver dome hydatid cysts.

Lambert-Eaton myasthenic syndrome revealed after surgery of lung adenocarcinoma.

We report a very rare case of cT1N0M0 lung adenocarcinoma reveling Lambert-Eaton myasthenic syndrome (LEMS). A 69-year-old nonsmoking woman, with several comorbidities consulted for cough and dyspnea. Chest radiograph and CT scanning detected a left lower lobe mass; Needle biopsy confirmed differentiated adenocarcinoma; 18FDG-PET scan and Brain MRI eliminated metastatic disease dissemination. Our patient underwent a left lower lobectomy with mediastinal lymphadenectomy (pT1N0M0), no adjuvant chemotherapy was administrated. One month later patient present a muscle weakness in both lower limbs and fatigability followed by an inability to walk. The diagnosis of LEMS was made from the distinctive electromyogram (EMG) findings and a treatment with Amifampridine (3, 4-diaminopyridine phosphate [3, 4-DAP]) was prescribed with evident efficacy for symptoms.

Single-Stage Transthoracic Surgery of Right Pulmonary and Hepatic Hydatid Cysts: A Retrospective Study of Fourteen Patients.

Background: The association of pulmonary and hepatic hydatid cysts is rare. Managing this condition with low mortality and complications is a challenge. The aim of this study is to put forward our experience in managing both sites in single-stage posterolateral thoracotomy. Patients and Methods: A retrospective study of 14 patients who underwent single-stage posterolateral thoracotomy and phrenotomy to treat right lung and liver hydatid cysts between January 2010 and December 2019 were reviewed. Results: Fourteen of 135 patients (10.4%) with double location of hydatid disease were treated in our department for pulmonary hydatid cysts in the same period. There were nine males and five females who were 20 to 72 years old (average age, 42.7 years). Chest computed tomography (CT) and abdominal scan were performed in all cases. The surgical approach was posterolateral thoracotomy and phrenotomy without laparotomy in all cases. Conservation of hepatic and pulmonary parenchymas was possible in 13 patients (92.8%). Average operative time was 122 minutes (range, 95-210 minutes) and the average post-operative hospital stay was 8.7 days. Post-operative complications occurred in two (14.3%) cases, one was atelectasis and the other persistent biliary and air leakage. There was no post-operative mortality. All patients received post-operative medical treatment for three to six months and there was no recurrence after an average follow-up of 26 months. Conclusion: Single-stage thoracotomy is a better option than thoracotomy and laparotomy for the management of double located hydatid cysts. It has a lower complication rate, shorter hospital stay, and rapid resumption of normal activity.

Clinical features and treatment of bronchial rupture of pulmonary hydatid cyst in children: a retrospective study of 36 patients.

BACKGROUND: The aim of this study was to review the clinical symptoms, radiological data, surgical techniques, and postoperative complications associated with bronchial rupture of pulmonary hydatid cysts in children and evaluate the results of surgical treatment. MATERIALS AND METHODS: A retrospective study of 40 surgical procedures performed for pulmonary hydatid cyst ruptured in the bronchial tree in 36 children (22 boys and 14 girls), aged between 7 and 18 from January 2009 to December 2019. RESULTS: The study included 36 patients with a mean age of 14.7. Most symptoms were cough (63.9%), chest pain (38.9%), hemoptysis (33.3%), and hydatid vomiting (22.2%). Chest X-ray, chest CT scan and abdominal echography was performed in all cases. Surgical approach was posterolateral thoracotomy in all cases. Conservative treatment was possible in 35 patients (97.2%) through cystotomy in 25 cases, pericystectomy in 11 cases, and lobar resection in 1 case (2.8%). Average operative time was 103 min (range: 53 and 185 min) and mean postoperative hospital stay was 5.9 days. The postoperative complications occurred in 4 (11.1%): atelectasis (N = 2), wound site infection (N = 1), and prolonged air leak (N = 1). There was no postoperative mortality. After an average follow-up of 39 months there was no recurrence. CONCLUSION: Ruptured hydatid cyst of the lung into the bronchus. Must be surgically treated and carefully due to the risk of per-operative bronchial flooding. Conservative surgical procedures with precise closure of the bronchial fistulas and capitonnage can complete removal of the cyst with low complications.

Clinical and surgical analysis of lobectomy for destroyed lobe of the lung: A series of 47 patients.

OBJECTIVE: Destroyed lobe of the lung is always secondary to chronic or recurrent lung infections with irreversible damage of pulmonary parenchyma. In this study, we analyzed surgical technique, post-operative complications, mortality, and long-term outcomes of patients undergoing lobectomy of pulmonary lobe destruction. MATERIALS AND METHODS: A retrospective study of 47 patients that underwent lobectomy due to a destroyed lung parenchyma between January 2010 and December 2019 were reviewed with an average follow-up period of 39 months. RESULTS: The study included 47 patients with a mean age of 39.4 years. The etiology of lobe destroyed was tuberculosis in 15 (31.9%), non-tuberculosis bronchiectasis in 20 (42.5%), aspergilloma in 09 (19.1%), hydatid cyst in 2 (4.3%), and a mis-diagnosed intrabronchic foreign body in 1 (2.1%). Surgical approach was through posterolateral thoracotomy in 44 (93.6%) patients and video-assisted thoracoscopic surgery in only 3 patients. Mean operative time was 153 min and mean post-operative hospital stay was 7.9 days. The post-operative complications occurred in five (10.6%): atelectasis (n = 2), wound site infection (n = 1), prolonged air leak (n = 1), and hemothorax in one case. No post-operative mortality was noted. A good clinical result was observed in 87.2% of cases. CONCLUSION: Surgical treatment of destroyed lobe is a high risk associated surgery. Tuberculosis and aspergilloma are the most common etiologies. Favorable result was obtained in selected patient with an excellent perioperative care.

Mediastinal ectopic parathyroid adenomas: diagnostic and therapeutic challenge.

INTRODUCTION: Mediastinal parathyroid adenomas are a rare condition. AIM: Analysis of epidemiological data, clinical manifestation of mediastinal parathyroid adenoma (MPA), including imaging modalities, and therapeutic approach to this condition. MATERIAL AND METHODS: A retrospective study of documented cases of mediastinal parathyroid adenoma that were managed at our Department of Thoracic Surgery of the Military Teaching Hospital Mohammed V, between January 2010 and December 2019. RESULTS: During a 9-year period in our department, 21 documented cases of MPA were treated surgically. Patients ranged in age from 20 to 69 years, with a mean age of 45 years, and there was no gender predominance. The most frequently reported manifestations were osteoarticular, with bone pain in 66.6% (14/21), pathological fractures in 28.5% (6/21), and osteoporosis in 23.8% (5/21). Cervical ultrasound, MIBI scintigraphy and cervico-thoracic computed tomography scan were performed respectively in 28.5% (n = 06/21), in 47.6% (n = 10/21) and 100% (n = 21), and allowed positive diagnosis of MPA. All patients benefited from resection surgery, through a classical transverse cervicotomy which was extended in some cases to the manubrium, and in only one case treated with thoracotomy. CONCLUSIONS: Management of mediastinal parathyroid adenoma is based on the diagnosis imaging assessment step, usually by MIBI scintigraphy. Surgical ablation is a radical treatment. Peroperative hormonal evaluation is mainly recommended.

Bilio-bronchial and bilio-pleuro-bronchial fistulas of hydatic origin.

Bilio-bronchial fistulization is a rare complication of neglected liver hydatid cysts ruptured in the thorax by anatomical contiguity. Because of the bronchopulmonary and hepato-biliary lesions that it can cause and in the context of severe infection, the morbi-mortality remains high in these fragile patients. The diagnosis is based on clinical arguments: biliptysis mainly with a hepato-thoracic syndrome, imaging data showing the fistulous path, and especially bronchial and biliary endoscopy. The pretherapeutic stage aims at correcting the hydrolytic, anemic and nutritional defects, but above all at controlling the hepatobronchial infection after removal of the biliary obstruction (endoscopic sphincterotomy) and by broad-spectrum antibiotic therapy as well as active respiratory physiotherapy. This preparatory step may be sufficient, otherwise surgical sanction is necessary in operable patients to establish the hepato-phreno-thoracic disconnection. The choice of the thoracic or abdominal approach depends on the initial and progressive lesion assessment and on the surgical strategy envisaged.