Gastric Pull-up: A Back-up Surgical Solution in the Treatment of Large Hiatal Hernias.

The laparoscopic treatment of the hiatal hernias is nowadays the standard procedure. However, due to the volume and the age of the affliction, there are some situations in which the classical approach is indicated. The latter is associated with specific risks. The appearance of some intra-operatory incidents or accidents could lead to changes in the tactics and the techniques, moreover the abandon of the classical procedure and the use of alternative solutions. These procedures are meant to solve the case with minimum negative effects on the patient. This article presents the case of a 62 year-old female patient, diagnosed with a large type II hiatal hernia on which the surgical team had to intervene through a median xypho-umbilical laparotomy. During the attempt to perform the Nissen procedure, the irreversible lesion of the abdominal esophagus occurred, the esophageal wall having already suffered because of the esophagitis. This led to the restoring of the gastric continuity using the gastric pull-up technique and a cervical anastomosis. The remaining esophagus was removed during the second procedure, 3 moths later. The immediate and the late evolution of the patient was excellent.

Minimally Invasive Thoracic Surgery - Video Assisted Thoracic Surgery: Technique and Indications.

Video-Assisted Thoracic Surgery (VATS) is already practised worldwide, in almost every condition addressed by open thoracic surgery. As part of minimally invasive thoracic surgery (MITS), VATS offers to patients and to healthcare providers excellent results and great satisfactions. Learning and performing VATS use different pathways in trainees and in experienced surgeons. This article presents VATS in its essence: classification, indications, contraindications, instruments and tools, incisions and access, troubleshooting, learning curve and training. We wish that the information helps our colleagues, both trainees and experienced thoracic surgeons, to start and continue performing VATS as standard care in thoracic surgery.

Transcervical Mediastinoscopic Closure of Left-Sided Postpneumonectomy Bronchial Stump Fistula.

INTRODUCTION: This article presents a series of patients on which the transcervical approach was used to close a left-sided postpneumonectomy fistula. MATERIALS AND METHODS: The series comprises nine patients with a left pneumonectomy performed for a tuberculosis-related suppurative disease in five cases and for lung cancer in the remaining four. This procedure can be performed under certain conditions, the most important one being the length of the bronchial stump, which should be at least 1 cm, ideally 1.5 cm. The transcervical stump closure was successfully achieved in all patients, having been more technically demanding in cancer cases with previous lymphadenectomy. The postpneumonectomy infected cavity was subsequently treated. RESULTS: The follow-up continued for at least 1 year; one individual from the cancer patients group died from an uncontrolled sepsis during the postoperative period, another one died 17 months later from metastatic cancer and two of them are alive, with no signs of neoplastic or infectious relapse 15 and 37 months, respectively, after the cervical procedure. One patient from the suppurative disease group had a relapse of the fistula 2 months after surgery, requiring additional surgical procedures to deal with this issue; all the other patients are alive, with no signs of recurrence. CONCLUSIONS: The transcervical approach is a very suitable maneuver in selected patients with a bronchial stump at least 1 cm long, ideally 1.5 cm.

Postintubation Tracheoesophageal Fistula - Diagnosis, Treatment and Prognosis.

Introduction: Postintubation tracheoesophageal fistula is a severe complication occurring under certain conditions in patients that require prolonged mechanical ventilation. MATERIAL AND METHODS: This article focuses on a sample of 11 patients with postintubation tracheoesophageal fistula, operated in our department between 2005 and 2015. The anterior approach with tracheal resection was performed in 10 of these patients, while an atypical surgical technique was preferred in a case involving a large-sized fistula. Three of these patients were subject to surgery while still on the ventilator, in order to help weaning them from mechanical ventilation. Two patients were operated following a relapse of the fistula, after attempts of closing it in other surgical units. Results: Two patients (of those who were still on mechanical ventilation) died from intubation-related complications that persisted after tracheal resection (anastomotic dehiscence with mediastinitis and tracheoarterial fistula in the brachiocephalic arterial trunk). The nine remaining patients improved, with their airways restored and having regained normal deglutition. Conclusions: The surgical approach of this pathology is successful in surgical units that are specialised in tracheal and oesophageal surgery. Adequately timing the surgery is crucial for a good outcome.

Health-Related Quality of Life and Stress-Related Disorders in Patients with Complicated Diverticular Disease under Conservative Management.

Diverticular disease is a common gastrointestinal disorder with increasing prevalence in advanced age. This study aimed to investigate the impact of age and complexity of diverticulitis on health-related quality of life (HRQoL) and stress-related disorders. A cross-sectional study was conducted on 180 patients, including adults (18-64 years) with complicated diverticular disease, the elderly (≥65 years) with complicated diverticular disease, and a control group with uncomplicated symptomatic diverticular disease. HRQoL and stress-related disorders were assessed using the SF-36, GIQLI, HADS, and PHQ-9 questionnaires at baseline and six months after the initial episode of diverticulitis. At diagnosis, the adult group had significantly lower mean physical and mental scores compared with the elderly and control groups (p < 0.001). At the 6-month follow-up, the mean physical score increased for all groups, but the difference between adults and the elderly remained significant (p = 0.028). The adult group had a significantly lower mean GIQLI score at diagnosis compared with the elderly and control groups (p < 0.001), although after 6 months it increased and the difference became insignificant. Anxiety scores at diagnosis were significantly higher in the adult group compared with the control group (p = 0.009). The complexity of diverticulitis and age significantly impacted HRQoL at diagnosis, with adults having lower physical and mental scores compared with elderly patients and controls. Although improvements were observed after 6 months, the difference between adults and the elderly remained significant for physical HRQoL scores. This highlights the need for tailored management strategies and psychosocial support to optimize patient outcomes across age groups and diverticulitis complexity.

Health-Related Quality of Life and Stress-Related Disorders in Patients with Bronchiectasis after Pulmonary Resection.

This multicenter, cross-sectional study investigates the potential correlation between the development of bronchiectasis after lung resection surgery and the health-related quality of life (HRQoL) of the patients. The study aims to provide new insights into the long-term outcomes of patients post-lung resection surgery. The study includes adult patients who underwent lung resection surgery for suspicious lung nodules and developed bronchiectasis within a follow-up period of six months. Bronchiectasis was confirmed by high-resolution computed tomography scans. The patient's health-related quality of life (HRQoL), anxiety, depression, and stress-related disorders were assessed using WHOQOL-BREF, SF-36, HADS, and PSS-10 questionnaires. Out of the 135 patients included in the study, 44 developed bronchiectasis after lung resection surgery. No statistically significant differences were observed between the groups in terms of demographics and medical history. Patients with bronchiectasis demonstrated a lower overall health status, increased deterioration of respiratory symptoms, lower physical activity levels, lower quality of life scores, and experienced more severe anxiety symptoms. Additionally, patients in this group also perceived higher levels of stress; although, the correlation with physical functioning was contradictory. The development of bronchiectasis post-lung resection surgery was associated with poorer quality of life, increased respiratory symptoms, higher anxiety levels, and increased perception of stress. While the correlation between bronchiectasis and HRQoL was statistically significant, the contradictory correlations with stress and physical functioning call for further research. This study underscores the importance of ongoing patient monitoring and the detailed evaluation of respiratory function following lung resection surgery for lung nodules, especially among those who develop bronchiectasis.

Exploring Health-Related Quality of Life in Patients with Anal Fistulas: A Comprehensive Study.

Anal fistulas often cause significant impairment to patients' health-related quality of life (HRQOL). This cross-sectional study aimed to compare the HRQOL between patients with anal fistulas with inflammatory bowel disease (IBD) and those without, hypothesizing significant differences in HRQOL scores between these groups. The secondary objectives were to identify specific aspects of life quality most affected and explore potential variables influencing HRQOL. The study was conducted at the Clinical Emergency Hospital "Pius Brinzeu" in Timisoara, Romania, using a convenience sample of 175 adult patients diagnosed with anal fistulas, stratified into IBD and non-IBD groups. Quality of life was evaluated at initial hospital admission and three months post-treatment using four questionnaires: SF-36, GIQLI, HADS, and the WHOQOL-BREF. Initial SF-36 scores were marginally lower in the IBD group, with mean physical and mental scores of 52.0 and 54.5, respectively. Both groups showed an improvement after intervention, but the mean difference was higher in the IBD group, with an increase of 1.1 in physical score. Initial GIQLI scores were significantly lower in the IBD group (110) compared to the non-IBD group (116). Post-intervention, the mean scores increased to 116 and 121, respectively. HADS scores suggested higher anxiety levels in the non-IBD group (7.5 vs. 6.1), although depression scores were similar. Post-intervention, anxiety scores decreased more substantially in the non-IBD group (-0.9 vs. -0.3). The WHOQOL-BREF scores were lower across all domains for the IBD group at the initial test (physical health: 12.4, psychological health: 14.9, social relationships: 14.4, environment: 13.0). Post-intervention, scores increased marginally in the IBD group (physical health: 12.7, psychological health: 15.9, social relationships: 14.1, environment: 13.8) but varied in the non-IBD group. HRQOL, as measured by multiple questionnaires, is impacted differently in anal fistula patients with and without IBD. These findings highlight the importance of a tailored approach to managing this patient population to improve their quality of life post-treatment.

Acquired benign tracheo­oesophageal fistula secondary to oesophageal stenting for post lye ingestion stenosis: A case report.

Acquired benign trachea-oesophageal fistula is a rare benign pathological entity with varying aetiologies that most often occurs post-intubation. This case report presents the case of a female patient, 31 years old, admitted to the emergency room with sepsis syndrome following bilateral aspiration pneumonia caused by a large trachea-oesophageal fistula. The fistula was the result of intra-tracheal migration of an oesophageal stent placed for post lye ingestion stenosis. Esophageal diversion and partial resection with oesophageal patch to repair the tracheal defect, under general anaesthesia with ventilation using rigid bronchoscopy and high frequency jet ventilation (HFJV), followed at a later date by esophageal replacement with colic graft were the procedures performed with a view to curing the patient. In conclusion, complex cases always require a tailored approach. It is important to note that HFJV may be applied for a longer period of time and the oesophagus can be used as patch for the posterior tracheal wall in selected cases. Staged surgery is also an option when the patients' poor health status does not permit major surgery.

The Utility of Next-Generation Sequencing in the Treatment Decision-Making for Metastatic Non-Small-Cell Lung Cancer.

Next-generation sequencing (NGS) is a fast and relatively inexpensive method to sequence a large number of genes with crucial importance in cancer medicine. Nowadays, NGS is frequently used in diagnostic and therapeutic decisions in oncology; however, recently, it was demonstrated that only a few cancer sites actually benefit from this assessment. Moreover, the association of a mutant gene with a targeted drug is not always as predicted during in-vitro trials and is often not associated with tumor response. To predict the efficacy of such an association several classification systems have been developed. The present review aims to analyze the most important tumor agnostic treatment trials and assess how they shape selecting cancer patients for NGS. Moreover, it aims to determine how mutation-drug associations can be classified by their targetability and level of evidence of efficacy in non-small-cell lung cancer.

A Rare Thymic Tumor - Lipofibroadenoma - Always a Postoperative Surprise.

BACKGROUND/AIM: Thymic lipofibroadenoma is a benign growth of unknown etiology extremely rarely described in the literature, morphologically resembling lipofibroadenoma of the breast. The diagnosis is usually a postoperative surprise and is made by the anatomopathologist. Surgical resection is curative. CASE REPORT: The presented case is the first reported in a woman, to date. The patient was successfully submitted to surgery and complete resection of the giant intrathoracic tumor was performed. The histopathological and immunohistochemical studies came to demonstrated the presence of a thymic lipofibroadenoma while the postoperative outcomes were favorable. CONCLUSION: In cases presenting large intrathoracic tumors complete resection is able to provide a significant improvement of the general condition of the patient, as well as a chance for cure.

Pulmonary metastasectomy--general issues.

Pulmonary metastasectomy has been widely accepted by thoracic surgeons and is applied to the treatment of a variety of histologies, but the evidence that the patient may benefit from lung metastasectomy is not yet elucidated and the best way of integrating oncologic therapies (induction or adjuvant chemotherapy or radiotherapy) with surgical resection are still unknown. When there is no good clinical alternative, the resection of pulmonary metastases can give some patients long-lasting disease free intervals. Patients should be carefully selected on the basis of clinical staging with defined prognostic indicators. In order to obtain suitable results the management of these patients should be based on a multidisciplinary team decision.

Thoracic endometriosis with a long delay in diagnosis.

This paper describes a case of thoracic endometriosis in 36-year-old woman with a long delay in diagnosis. At the admission in the hospital, the patient had a medical history of persistent dysmenorrhea since the age of 13, infertility and an episode of total right pneumothorax two months ago successfully resolved by minimum pleurotomy of the right hemitorax. She came with moderate pain on right hemithorax and dyspnea, which occurred on the first day of menstruation but she did not have any other respiratory symptoms such as hemoptysis, cough. Radiological imaging (chest radiography and computer tomography) at the time of admission confirmed recurrence of the right pneumothorax. She underwent surgical treatment of the right pneumothorax using a single-port video-assisted approach. Intraoperative macroscopic lesions were found catamenial pneumothorax characteristic diagnosis and biopsy material taken (parietal pleura) for histopathology. Immuno-histochemical tests confirmed the diagnosis of thoracic endometriosis. The gonadotropin-releasing hormone analogue was received by the patient early after surgery and there was no clinical or radiological recurrence at a four months follow-up.

A Girl with Disseminated Thoracic Echinococcosis.

We present an unusual case of extensively disseminated pulmonary and thoracic echinococcosis in a 10-year-old girl. Thoracic echinococcosis should be considered in any child from an endemic country with cystic lesions on chest imaging. Confirmation of the diagnosis can be difficult and is important before surgery to reduce the risk of further dissemination and anaphylaxis.

[Complex case with respiratory, endocrine and digestive manifestations--late complications after a colic replacement of the esophagus for lye ingestion]. / Caz complex cu tulburari respiratorii, endocrine si digestive--complicatii tardive post-esofagoplastie cu colon pentru ingestie de soda caustica.

Long term complications after colic replacement of the esophagus are well known and their managment is known as being difficult, due to multiple associated comorbidities; we present the case of a 26-year-old patient with multiple late complications after a coloesophagoplaty for lye ingestion during childhood. The patient finally died despite all the eforts of treatement during a prolonged hospitalisation. We will try to analyse the key moments on patient's evolution and discuss other possible options in this case.

Main bronchial stenosis--sequel of delayed diagnosis after posttraumatic bronchial injury.

Bronchial ruptures due to blunt chest traumas are rarely encountered injuries and frequently late diagnosed. Once the diagnostic is established by bronchoscopy surgical treatment is mandatory and usually, the results are very good. In order to conserve as much as possible lung parenchyma minimal possible resection is required. We present four cases managed in our department by means of main bronchial sleeve resection--two on the right side and two on the left side--with good outcome. We were able to save the entire lung in all four cases despite long-term atelectasis.

[Role of surgery in small cell lung cancer]. / Rolul chirurgiei în tratamentul cancerului bronhopulmonar cu celule mici.

Role of surgery in small cell lung cancer Small-cell lung cancer (SCLC) is a very aggressive neuroendocrine carcinoma that accounts for approximately 10-15% of all lung cancer cases. This histological subtype is a distinct entity with biological and oncological features differing from non-small cell lung cancer (NSCLC). Standard treatment is performed using systemic chemotherapy, and surgery in association with chemotherapy and radiotherapy may be indicated for a minor proportion of cases with limited disease. Since the results after surgical intervention in patients with very early disease are comparable to those for NSCLC, careful staging is required, especially in terms of nodal involvement- use of PET-CT EUS, EBUS and/ or mediastinoscopy is recommended. However, only two randomized control studies have examined the efficacy of surgery in SCLC, and both yielded negative results and are out of date. We review here several studies concerning surgery for SCLC and discuss the results from a practical standpoint.

[Iatrogenic tracheal stenosis in patients with COPD: a medico-surgical challenge]. / Stenoza traheala iatrogena la pacientul cu BPOC: o provocare medico-chirurgicala.

This study analyzes a series of iatrogenic tracheal stenosis occurring in patients with COPD exacerbation which required oro-tracheal intubation. The tracheal stenosis occurred on average after 24 days of intubation and were clinically severe. Treatment algorithm first included bronchoscopic interventional techniques with an immediate success rate of 37%, but the results were unstable in time, requiring tracheal stenting. The surgical approach, which generally is the first choice in the treatment of tracheal stenosis, had discouraging results in these patients, with a low rate of success (20%) and an increased incidence of restenosis. The only solution for those postoperative complications was, again, interventional bronchoscopy. In conclusion, while for various other etiologies of tracheal stenosis the surgical resection is the first choice of treatment, in COPD patients interventional bronchoscopy often remains the only way of solving.

[Respiratory complications following resection and reconstruction of the esophagus]. / Complicatiile respiratorii dupa chirurgia de rezectie si reconstructie esofagiana.

Esophageal resection remains a dreadfull surgical intervention accompanied by consistently higher morbidity and mortality when compared with other surgical procedures. The respiratory complications are the most important contributor to morbidity and mortality after this kind of surgery. Intimate knowledge on risk factors and physiopathology and careful treatment of these complications go with good postoperative results. This article discusses the factors affecting respiratory complications and strategies to reduce the incidence of these complications after esophagectomy

[Aspects of the surgical treatment in plurivisceral echinococcosis--case report]. / Aspecte ale tratamentului chirurgical in echinococoza pluriviscerala---prezentare de caz.

Hydatid disease remains endemic in many parts of the world, most notably the Mediterranean region, Australia, New Zealand, the Middle East, and South America. Plurivisceral echinococcosis is defined as the concomitant or successive presence of hydatidosis in more than one internal organ. It has been noticed that the number of cases with multi-organ localizations and multiple cysts has increased in the last years. As the surgery of plurivisceral echinococcosis remains one of the challenges for the medical world, in this article we present our experience during 2000-2007 with this disease, followed by a case report of one of the most special cases of echinococcosis, discussing the principles of treatment, along with a new classification of this disease. Plurivisceral echinococcosis is associated with higher postoperative morbidity and mortality than uncomplicated cysts, related to organ involvement and surgical treatment. In the sequential approach we recommend resolving first surgically the complicated cysts or those at risk. In the thoracic and abdominal locations, the thoracic cysts will be approached first. The treatment methods will be as conservative as possible. Management of pulmonary and hepatic cysts (diaphragmatic side) simultaneously through the thoracic route is convenient and should be encouraged in patients because this prevents a second operation.

[Videomediastinoscopic transcervical approach of postpneumonectomy left main bronchial fistula]. / Abordarea cervicala video-mediastinoscopica a fistulei de bont bronsic post-pneumonectomie stânga.

Bronchopleural fistulas and empyema are the most devastating complications after lung resection. The optimal management remains a major subject of controversy for thoracic surgeons over the wide variety of therapeutic approaches, none suitable for all patients. In 1996 Azorin et al. reported the first successful mediastinoscopic reclosure by stapling of an insufficient bronchial stump after left pneumonectomy using video-assisted mediastinoscopy. The authors report the first national case of left-sided bronchopleural fistula closure using video-assisted mediastinoscopy, describing their experience with this technique. A 40 years old woman presented to our unit with left thorax empyema after having undergone left pneumonectomy for TB destructed lung with aspergillosis in another hospital. Bronchoscopy revealed a 15 mm long bronchial stump with insufficiency. Despite all advances made over the last decades in perioperative management, bronchopleural fistula after pneumonectomy remains a significant problem in thoracic surgery. Video-mediastinoscopy is an alternative to the open methods as it allows approaching the bronchial stump via the mediastinum. The dissection of the trachea through its natural route enables bronchial mobilization. Positive factors influencing our decision were the virgin mediastinum with no surgical dissection and no radiation therapy applied. The mediastinoscopic approach for bronchial stump closure after pneumonectomy is a novel option in highly selected patients. This is our choice for a long (at least 10 mm) bronchial stump because its morbidity is minimal compared with transpericardial sternotomy or a transthoracic approach. It warrants minimal surgical trauma; however, skilled surgeons with experience in mediastinoscopy have to be prepared to convert to an open technique immediately.