Ground glass opacity: can we correlate radiological and histological features to plan clinical decision making?

BACKGROUND: The spectrum of ground glass opacity (GGO) is a diagnostic and clinical management quandary. The role of computed tomographic scans in detecting malignant GGO has inter-observer variability. Pure GGO have been traditionally thought to be predominantly benign in nature and has long volume doubling times. This study was undertaken to correlate the findings of radiology and histology of ground glass opacities at our institute. METHODS: This study is a retrospective observational study of patients who underwent lung resection surgery for radiology proven ground glass opacities between January 2010 and December 2018. A total of 115 patients were included in the study based on inclusion and exclusion criteria and were analysed. RESULTS: The patients were divided into two groups; pure GGO (n = 50), mixed GGO (n = 65). The pathological tumour size was ≤ 2 cm in 51% of the patients and 27 patients had the size between 2.1 and 3.0 cm. The predominant histopathologic feature was lepidic predominance in 54 patients followed by 24 patients with acinar predominance. Among patients with radiological tumour size of ≤ 2 cm, pure GGO was present in 48% of the patients. Among patients with pure GGO, 96% of the patients had no solid component. 44 patients had only single CT scan before proceeding to surgery. All these patients had mixed GGO. CONCLUSION: Our study concludes pure GGOs, though lacking solid component have a high propensity to be malignant. The role of repeated CT surveillance in this context without offering curative surgery may be questionable.

Successful use of a mesocaval shunt to treat refractory ascites in a chronic pancreatitis induced portal vein thrombosis.

The state of intense peripancreatic inflammation in chronic pancreatitis can give rise to various vascular complications such as venous thrombosis and arterial pseudoaneurysms. Due to its intimate location with the pancreas, spleno-mesenteric-portal axis suffers the greatest blunt of thrombotic complications. Treatment modalities for such cases of chronic portal vein thrombosis have always been controversial and challenging. Medical management with anticoagulants is both risky and unsatisfactory due to presence of varices, hypersplenism, and persistence of the inflammatory pathology. Although endovascular techniques have been tried in various case reports, there are definite anatomical challenges in cases of long segment porto-mesenteric thrombosis with massive ascites. Surgical shunts have been historically described for cirrhotic and non-cirrhotic portal hypertensive patients. However, its use in patients with refractory ascites due to chronic pancreatitis induced portal vein thrombosis has not been reported in the medical literature. Here, we present a case of an extensive portal vein thrombosis with massive refractory ascites in a patient with alcohol-induced chronic pancreatitis successfully treated with a surgical mesocaval shunt using an interposition small diameter graft.

Thoracic mucormycosis in immunocompetent patients.

BACKGROUND: Mucormycosis is an invasive fungal infection. It is rare and commonly associated with fatal outcomes. METHODS: We report two cases of thoracic mucormycosis in immunocompetent patients. First, is an immunocompetent child with mediastinal mass and extension into the pericardium and left atrium. The second is a young woman with a left pulmonary artery pseudoaneurysm. RESULTS: The first patient could not be salvaged while the second patient was successfully managed with surgical intervention and systemic antifungal treatment. CONCLUSION: Mucormycosis should be considered as a differential diagnosis in the management of immunocompetent patients in patients with pyrexia of unknown origin and a mediastinal mass. Early and aggressive surgical management along with systemic antifungal treatment improves the survival in this subset of patients.

Prominent eustachian valve: An uncommon cause of a common problem during extracorporeal membrane oxygenation support.

Suck down events in an extracorporeal membrane oxygenation (ECMO) circuit, due to vein wall being suctioned onto the cannula inflow ports, lead to low circuit flows. These low flow states can be reversed with fluid administration. We present a patient with a prominent eustachian valve (EV) which was encountered while managing the patient on ECMO post lung transplantation for pleuroparenchymal fibroelastosis. We hypothesize that presence of a prominent EV can induce suck down events and needs to be recognized in the differential diagnosis of this problem. This case adds to the literature to increase the awareness of this rare but significant problem.

Hybrid reconstruction of bronchial dehiscence following lung transplant.

Surgical repair of right-sided bronchial dehiscence post lung transplant is challenging. We report a hybrid reconstruction of the bronchus using an aortic homograft patch with stenting as a novel technique of management of ischemic airway injury following lung transplantation.

Lung transplant graft salvage using aortic homograft for bronchial dehiscence.

The use of aortic homograft in infective pathology is well described. Its use in the repair of post-transplant airway complications has been seldom reported. Herein, we report our experience with the successful use of aortic homograft in the management of post-transplant large airway complications in two patients.

Lung transplant in a recipient with tracheal bronchus.

We describe the intraoperative surgical management of tracheal bronchus encountered in a lung transplant recipient.

Nonbacterial thrombotic endocarditis of a bioprosthetic valve: Questions to ponder before replacement of the valve.

Nonbacterial thrombotic endocarditis (NBTE) of bioprosthetic valves is extremely rare. We report a 67-year-old lady with early bioprosthetic "failure" that at reoperation was proven to be NBTE. The choice of a prosthesis in this condition may have implications for patients' late clinical course.

Concepts of Bicuspid Aortic Valve Repair: A Review.

BACKGROUND: The bicuspid aortic valve (BAV) frequently requires surgical intervention for aortic regurgitation (AR) and aneurysm. Valve-preserving surgery for BAV has evolved over the last 25 years. METHODS: This review summarized experience in BAV repair with a special focus on predictors of failure and specific surgical techniques addressing them. RESULTS: Excellent repair stability can be achieved if a standardized approach addressing all pathologic components of aortic valve and root is used. Anatomic variations must be addressed with special approaches. CONCLUSIONS: Today, BAV repair leads to excellent stability if an anatomy-oriented concept is used. Further improvements of cinical results and reproducibility can be anticipated.

Left Ventricular Pseudoaneurysms in Children-A Case Series.

Left ventricular pseudoaneurysms are very rare in children. In children, left ventricular pseudoaneurysms can occur following infection, trauma, ischemia, or cardiac surgery. The authors report a series of three cases treated at our hospital with two of the cases having a history of extrapulmonary tuberculosis and one patient with a history of varicella zoster infection.

Valve-sparing root reimplantation in anomalous right coronary origin.

Anomalous origin of coronary artery is a rare anomaly. Performing valve-sparing root reimplantation for aortic root pathology in these patients is challenging. There are modified techniques for performing valve-sparing procedures in this rare subset of patients. Herein, we present a case of anomalous right coronary origin from left ostium managed by conventional valve-sparing root reimplantation.

A tale of two bleeds-an uncommon manifestation in neurofibromatosis-1.

Neurofibromatosis type 1 vasculopathy is a well-documented entity in the literature, but a rupture of the thyrocervical artery aneurysm is very rare and only 2 cases have been reported to date. Our patient presented with a right-sided hemiparesis and deviation of the angle of the mouth to the left. He was diagnosed to have hypertensive bleed in the left capsulo-ganglionic area. He then developed a sudden onset of left-sided neck swelling 8 h following admission, which was due to a ruptured thyrocervical artery aneurysm. To the best of our knowledge, our case is the first case in literature to have presented with simultaneous intracerebral bleed and a thyrocervical artery aneurysm rupture.

Congenital bronchoesophageal fistula in an adult-report of a rare case.

Congenital bronchoesophageal fistula (CBEF) is a rare entity in adults. Patients with CBEF present with cough and recurrent respiratory tract infection. Diagnosis is confirmed by barium esophagogram and contrast-enhanced computed tomography. Management is by surgical ligation of the fistula and repair. Concomitant lung resection procedures will be required for any coexisting lung pathology. Thoracoscopic approach can be considered in young, healthy adults where the adhesions are less.

Intrapulmonary teratoma masquerading as hydatid cyst of the lung.

Intrapulmonary teratoma (IPT) is a rare mediastinal teratoma. IPT arise because of abnormal migration of pluripotent stem cells along the developing lung bud. Patients present with chest pain, hemoptysis, and trichoptysis. These tumors have the potential to rupture into adjacent pleura, pericardium, or tracheobronchial tree. The differential diagnosis includes hydatid cyst, fungal ball, lung abscess, and lung parenchymal tumor. We report a case of IPT, which was initially diagnosed as hydatid cyst of the lung due to positive hydatid serology and correlating radiological features. The role of cross-reaction of hydatid antigens with sera of cancer patients needs to be evaluated. Surgical resection of the tumor is advised to avoid complications.

Atlantoaxial dislocation in a patient with nonsyndromic symmetrical dwarfism: Report of a rare case.

Congenital anomalies of the craniovertebral junction (CVJ) are complex developmental defects. We describe a patient with atlantoaxial dislocation (AAD) and short stature whose morphopathologydid not fit into any of the previously described syndromic constellations. The patient underwent a reduction of the AAD followed by fixation with C1-C2 transarticular screws. Although numerous syndromes have been linked to both dwarfism and craniovertebral junction anomalies, this patient did not fit into any of these patterns. It is possible that this may be one of the many as yet unrecognized patterns of congenital anomalies.

Giant inguinoscrotal hernia--report of a rare case with literature review.

Massive inguinoscrotal hernias extending below the midpoint of the inner thigh, in the standing position constitute giant inguinoscrotal hernias. We report a patient who presented with giant right inguinal hernia with bilateral hydrocele for 25 years. He had no cardiorespiratory illnesses. He was taken up for surgery under general anesthesia after preoperative respiratory exercises. Sliding hernia with entire greater omentum, small bowel, and appendix as contents was identified. Meshplasty after omentectomy with bilateral subtotal excision of sac, right orchidectomy, and scrotoplasty were done. Giant inguinoscrotal hernias pose significant problems while replacing bowel contents because of the increase in intraabdominal and intrathoracic pressures. Recurrence is another complication seen after successful surgical management. Various techniques such as preoperative pneumoperitoneum, debulking abdominal contents with extensive bowel resections, or omentectomy and phrenectomy have been tried. Postoperative elective ventilation is also needed in many cases. We describe simple reduction with omentectomy as a viable technique in this patient. He did not need elective ventilation due to preoperative respiratory exercises and preparation and review of the literature.

Carcinoma cecum presenting as right gluteal abscess through inferior lumbar triangle pathway--report of a rare case.

Gluteal abscess commonly follows intramuscular injections with contaminated needles. Carcinoma cecum is known to present with pericolic abscess due to microperforations and may rupture intraperitoneally. Gluteal abscess secondary to perforated carcinoma cecum with pericolic abscess is extremely uncommon. A 50-year-old woman who was receiving intramuscular iron injections for anemia presented with a 10×10-cm abscess in the right gluteal region and a vague mass in the right iliac fossa. After investigations, a diagnosis of perforated carcinoma cecum with pericolic abscess tracking into the right gluteal region was made, and incision and drainage were done. Fine-needle aspiration cytology from the cecal growth revealed adenocarcinoma. Unfortunately, the patient was not willing to undergo definitive treatment. This case is being reported for its rarity and as an uncommon etiology for a common condition.

Gossypiboma presenting as coloduodenal fistula--report of a rare case with review of literature.

The term gossypiboma is used to describe a mass of cotton matrix left behind in a body cavity intraoperatively. The most common site reported is the abdominal cavity. It can present with abscess, intestinal obstruction, malabsorption, gastrointestinal hemorrhage, and fistulas. A 37-year-old woman presented with pain in the right hypochondrium for 2 months following open cholecystectomy. As she did not improve with proton pump inhibitors, an esophagogastroduodenoscopy (EGD) was done, which showed a possible gauze piece stained with bile in the first part of the duodenum. Contrast-enhanced computed tomography (CECT) of the abdomen revealed an abnormal fistulous communication of the first part of duodenum with proximal transverse colon, with a hypodense, mottled lesion within the lumen of the proximal transverse colon plugging the fistula, suggestive of a gossypiboma. Excision of the coloduodenal fistula, primary duodenal repair, and feeding jejunostomy was done. The patient recovered well and is now tolerating normal diet. Coloduodenal fistula is usually caused by Crohn's disease, malignancy, right-sided diverticulitis, and gall stone disease. Isolated coloduodenal fistula due to gossypiboma has not been reported in the literature so far to the best of our knowledge. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.

Solitary tubercular caecal ulcer causing massive lower gastrointestinal bleed: a formidable diagnostic challenge.

Gastrointestinal (GI) haemorrhage is a common surgical emergency accounting for approximately 1% of acute hospital admissions. Lower GI bleed is less common and less severe than upper GI bleed and is usually caused by diverticulosis, neoplasms, angiodysplasia and inflammatory bowel disease. A 51-year-old man presented with massive lower GI bleed. He had no history of tuberculosis. He underwent colonoscopy and an isolated caecal ulcer was noted. Segmental ileocaecal resection was performed and no specific cause was identifiable on histopathology. PCR was performed on this specimen and it was positive for Mycobacterium tuberculosis. This case reports the unusual presentation of tuberculosis as solitary caecal ulcer with massive lower GI bleed and highlights the role of PCR as an adjuvant diagnostic tool for its diagnosis when characteristic histopathological findings are absent.