Fully covered self-expandable metal stent in tracheobronchial disorders: clinical experience.

BACKGROUND: The third-generation fully covered self-expandable metallic stent (SEMS) has been developed to solve the problems of difficult removal and in-stent granuloma formation related to the uncovered or partially covered type. There are few written reports about the performance of this type of stents with early encouraging results. OBJECTIVES: To report and analyse our experience with the Silmet® stent in the management of malignant and benign tracheobronchial disorders. METHODS: We retrospectively reviewed medical records of patients who underwent fully covered SEMS Silmet placement at the Interventional Pulmonology Unit, La Maddalena Cancer Center, Palermo, Italy, between May 2010 and August 2013. RESULTS: Stents were placed in 52 patients with malignant (n = 49) and benign airway obstruction (n = 2) and broncho-oesophageal fistula (n = 1). SEMSs were inserted into the trachea (n = 19), the main bronchi (n = 21) and the peripheral bronchi (n = 31). Besides 1 procedural dislocation, the deployment was successful in all patients with an immediate significant improvement of symptoms (Barthel Index p < 0.001; Medical Research Council score p < 0.001). A radiographic improvement was detected in 48% of patients. The mean follow-up duration was 119 ± 120 days (range 22-549 days). Complications observed were: migration (7.6%), tumour overgrowth (15%), infections (5.7%), granulation tissue formation (3.8%) and mucus plug (3.8%). CONCLUSIONS: The Silmet stent is effective, safe and simple to implant and remove. We suggest its use in cases of tight stenoses, in the treatment of small- to medium-caliber airways or in cases of tortuous airways.

Bile leaks after videolaparoscopic cholecystectomy: duct of Luschka. Endoscopic treatment in a single centre and brief literature review on current management.

BACKGROUND: Laparoscopic cholecystectomy (LC) for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity (0.2-2%). The bile ducts of Luschka (DL)are small ducts which originate from the right hepatic lobe, course along the gallbladder bed, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of bile leaks after cholecystectomy. Aim of our study is build a literature review starting from our experience. PERSONAL EXPERIENCE: Forty four patients with abdominal bile collections post-cholecystectomy by suspected bile leak under-went endoscopic retrograde cholagio-pancreatography (ERCP). A complete cholangiogram was obtained in 42 patients(95.5%). In according to the magnitude of bile leak daily, we subdivided the patients in two groups: a) < 180 ml/daily,and b) > 180 ml/daily. The most common site of the leak was the cystic duct stump (94.5%), followed by DL (2 patient = 5.5%). 10 Fr stent insertion after endoscopic sphincterotomy (ES) was the most common intervention. In 6 patients (14%) a 7 Fr naso-biliary drainage was inserted. On an intention-to-treat basis, endoscopic intervention at ERCP had 100% success rate for resolution of the leak. The median time for resolution of the leak was 8 and 12 days in the first and second group respectively. No mortality ERCP-related were recorded. Early minor complications occurred in 7/42 (16.5%) patients. METHODS: A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles.Cross-references from these articles were also used. RESULTS: ERCP is the most common diagnostic and therapeutic method used in bile leaks post-cholecystectomy. Most patients with DL leaks are symptomatic, and most leaks are detected postoperatively during the first postoperative week. Reduction of intra-ductal pressure with ES and stent or naso-biliary tube insertion will lead to preferential flow of bile through the papilla, thus permitting DL injuries to heal. This is the most common treatment modality used. In a minority of patients,re-laparoscopy is performed. In such cases, the leaking DL is visualized directly and ligation usually is sufficient treatment.Simple drainage is adequate treatment for a small number of asymptomatic patients with low-volume leaks. CONCLUSIONS: DL leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of LC Intraoperative cholangiography does not detect all such leaks. ERCP with ES and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi,can potentially be used in lowering the incidence and in the treatment of DL leaks.

Use of bronchoscopic steam thermal ablation (BTVA) in a clinically compromised patient.

BACKGROUND: Bronchoscopic lung volume reduction (BLVR) techniques improve lung function and increase exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) and BLVR treatment is included in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) treatment guidelines for these patients. BTVA (Intervapor Uptake Medical, Tustin, CA, USA) represents a recent therapy of this group that allows to treat sublobar areas and for this reason is used clinically compromised patients, like in this case report. CASE PRESENTATION: In this paper we describe a case report of an 85-year-old male with severe respiratory failure and a diagnosis of emphysema presented with dyspnea and clinical worsening, despite the best medical therapy practiced. For comorbidity and pathology's features he was excluded from surgical treatment options, like lung volume reduction surgical (LVRS) and from positioning of endobronchial valves (EBV) for the presence of collateral ventilation and he was addressed to BTVA. The procedure was successful for this patient. CONCLUSIONS: This case supports recent suggestions that BTVA can be a good alternative treatment for patients properly selected.

Pleural fluid collections and ultrasound guided percutaneous drainage.

INTRODUCTION: The presence of fluid collection in the pleural cavity is a frequent clinical problem that requires drainage for diagnostic and therapeutic purposes. Aim of our study is the retrospective evaluation of our experience in diagnostic and therapeutic thoracic drainage, to stress the cause of failure and to emphasise the cost-effectiveness of the technique. MATERIALS AND METHODS: From January 1995 to May 2009, 564 therapeutic and diagnostic ultrasound (US) guided percutaneous drainages of pleural fluid collection were performed in 412 patients. RESULTS: The macroscopic, biochemical, cytological and microbiological examination of the drained fluid diagnosed the presence of 80 (19.4%) transudates, 101 (24.5%) non neoplastic exudates, 55 (13.4%) neoplastic exudates, 152 (36.9%) empyema and 24 (5.8%) haemothorax. There were no major complications. Minor complications were present in 23/564 cases (4.0%). CONCLUSIONS: The US guided puncture of the pleural fluid collection allows a high rate of success (in correct detection and drainage of chronic pleural effusions), reduces the rate of complications and is well accepted by patients.

Secondary Carina and Lobar Bronchi Stenting in Patients with Advanced Lung Cancer: Is It Worth the Effort? A Clinical Experience.

BACKGROUND: The lobar airway stenting remains an endoscopic procedure not well standardized in patients with locally advanced lung cancer disease. The goal of this study was to evaluate technical feasibility, clinical outcome, and complications of different stents in patients with malignant lesions involving lobar bronchi, primary and secondary carina. METHODS: Between November 2008 and October 2013, we retrospectively analyzed 146 patients with benign and malignant tracheobronchial stenosis who underwent airway stent insertion below main carina and main bronchi. RESULTS: In all, 170 airway stenting procedures were performed on 146 patients. In all, 51 of them with malignant peripheral airway stenosis underwent stents placement below main carina. In all but one patient, the deployment of stents was successful with improvement of symptoms. The chest radiograph after the procedure detected the lung re-expansion in 29 of 51 patients. The mean follow-up duration was 123 days ± 157. Complications observed included stent migration, tumor overgrowth, infections, granulation tissue formation, and obstruction due to tenacious secretions. Longer survival was observed in patients who received additional treatment after airway stenting compared to those who did not (p <0.01). CONCLUSIONS: Stenting of lobar bronchi and primary or secondary carina is technically feasible, effective, and acceptably safe.

Postoperative laryngeal symptoms in a general surgery setting. Clinical study.

INTRODUCTION: Vocal cord injuries (VI), postoperative hoarseness (PH), dysphonia (DN), dysphagia (DG) and sore throat (ST) are common complications after general anesthesia; there is actually a lack of consensus to support the proper timing for post-operative laryngoscopy that is reliable to support the diagnosis of laryngeal or vocal fold lesions after surgery and there are no valid studies about the entity of laryngeal trauma in oro-tracheal intubation. Aim of our study is to evaluate the statistical relation between anatomic, anesthesiological and surgical variables in the case of PH, DG or impaired voice register. MATERIALS AND METHODS: 50 patients (30 thyroidectomies, 8 videolaparoscopic cholecistectomies, 2 right emicolectomies, 2 left emicolectomies, 1 gastrectomy, 1 hemorrhoidectomy, 1 nefrectomy, 1 diagnostic videothoracoscopy, 1 superior right lung lobectomy, 1 appendicectomy, 1 incisional hernia repair, 1 low anterior rectal resection, 1 radical hysterectomy) underwent clinical evaluation and direct laryngoscopy before surgery, within 6 hours, after 72 hours and after 30 days, to evaluate motility and breathing space, phonatory motility, true and false vocal folds and arytenoids oedema. We evaluated also mean age (56.6 ± 3.6 years), male:female ratio (1:1.5), cigarette smoke (20%), atopic comorbidity (17/50 = 34%), Mallampati class (32% 1, 38% 2, 26% 3, 2% 4), mean duration of intubation (159 minutes, range 50 - 405 minutes), Cormack-Lehane score (34% 1, 22% 2, 22% 3, 2% 4), difficult intubation in 9 cases (18%). No complication during the laryngoscopy were registered. We investigated the statistic relationship between pre and intraoperative variables and laryngeal symptoms and lesions. RESULTS: In our experience, statistically significant relations were found in prevalence of vocal folds oedema in smokers (p < 0.005), self limiting DG and DN in younger patients (p < 0.005) and in thyroidectomy (p < 0.01), DG after thyroidectomy (p < 0.01). The short preoperative use of steroids and antihistaminic to prevent allergic reactions appears not related to reduction or prevention of DN, DG, PH and ST. No statistical relation in incidence of postoperative complications was found for the prolonged intubation, gastro-esophageal reflux, BURP manoeuvre (backward upward right sided pressure) and Mallampati and Cormack-Lehane class more than 2, maintenance with sevoflurane 2% and use of stilet. CONCLUSIONS: Direct laryngoscopy is essential for the detection of arytenoid lesions after orotracheal intubation for general anesthesia. In our opinion, a part of temporary post-operative DN or PH is due to monolateral or bilateral arytenoids oedema, secondary to prolonged or difficult orotracheal intubation, valuable with laryngoscopy 72 hours after surgery. Is necessary to adjunct these complications in the surgical informed consensus scheme.

Asymptomatic bone cement pulmonary embolism after vertebroplasty: case report and literature review.

Introduction. Acrylic cement pulmonary embolism is a potentially serious complication following vertebroplasty. Case Report. A 70-year-old male patient was treated with percutaneous vertebroplasty for osteoporotic nontraumatic vertebral collapse of L5-S1. Asymptomatic pulmonary cement embolism was detected on routine postoperative chest radiogram and the patient was treated with enoxaparin, amoxicillin, and dexamethasone. At the followup CT scan no further migration of any cement material was reported; and the course was uneventful. Discussion. The frequency of local leakage of bone cement is relatively high (about 80-90%), moreover, the rate of cement leakage into the perivertebral veins (seen in up to 24% of vertebral bodies treated) with consequent pulmonary cement embolism varies from 4.6 to 6.8% (up to 26% in radiologic studies); the risk of embolism is increased with the liquid consistency of the cement and with the treatment of some malignant lesions. Patients may remain asymptomatic and develop no known long-term sequelae. Conclusions. Our ancedotal case illustrates the need for close monitoring of patients undergoing percutaneous vertebroplasty and emphasizes the importance of prompt and correct diagnosis and treatment, even if actually there is no agreement regarding the therapeutic strategy.

Carcinoma showing thymus-like differentiation (CASTLE): a case report.

INTRODUTION: Carcinoma showing thymus-like differentiation (CASTLE) is a rare malignant thyroid cancer. We report a case of CASTLE treated with surgery and adjuvant external neck radiation therapy. MATERIALS AND METHODS: We experienced a case of CASTLE in a 63-year-old man, who presented with a neck mass due to enlarged and hard thyroid gland, most notably in the right lobe, without palpable cervical nodes. RESULTS: Total thyroidectomy was performed for both diagnostic and therapeutic purposes. Histologic examination of the specimen showed a "thymus like" thyroid cancer; the tumor, partially circumscribed, lobulated, involved both lobes, and in more points reached the capsule of the organ and infiltrated perithyroid muscle tissue. After immunohistochemical assay (CK19 +, CK20 -, thyroglobulin -, calcitonin -, CD5 +, CD117 +), a diagnosis of CASTLE was made. DISCUSSION: CASTLE is a rare, malignant tumour of the thyroid gland, with histopathological features similar to squamous cell carcinoma, but with a more favourable prognosis. Preoperative diagnosis is difficult. CASTLE is usually cured surgically with total thyroidectomy and selective neck dissection, followed by radiotherapy. CONCLUSIONS: Surgery and radiotherapy are effective to manage thyroid CASTLE tumors.

Cystic mucinous adenocarcinoma of the lung: a case report.

Mucinous cystic tumors of the lung are uncommon, the preoperative pathologic diagnosis is difficult and their biological behavior is still controversial. We report the case of a patient with a clinically benign cystic lesion that post-operatively showed to be consistent with an invasive adenocarcinoma arising in a mucinous cystadenoma of the lung. We underline the difficulty of the clinical pre-operative diagnosis of this cystic neoplasia radiologically mimicking a hydatid cyst, and we report the negative TTF1 immunostaining potentially misleading in the differential diagnosis with metastatic mucinous carcinomas. Finallly, we evidence the presence of a pre-existing mucinous benign lesion suggesting early and complete resection of benign appearing lung cysts because they can undergo malignant transformation if left untreated or they can already harbor foci of invasive carcinoma at the time of the presentation. Even if a good prognosis, better than in other lung carcinomas, with no recurrrence or metastasis after complete surgical exicision, has been reported for cystic mucinous cystoadenocarcinomas, the follow-up showed an aggressive biological behaviour, with the early onset of metastasis, in keeping with P53 positive immunostaining and high Ki-67 proliferation index.