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A 59-year-old man with a history of cerebral palsy and dextroscoliosis died in a group home. He required supplemental oxygen and had no bowel movement for weeks prior to death. At autopsy, the abdomen was markedly distended and there were flexion contractures of the legs. Postmortem computed tomography revealed a dilated digestive tract and fecal loading in the sigmoid and rectum, marked upwardly displaced diaphragm and scoliosis. On internal examination, the diaphragm was displaced rostrally and the rectosigmoid colon contained 2.5 kg of fecaloma with two rectal fecaliths. Severe scoliosis with marked reduction in volume of thoracic cavity was present. Microscopic examination revealed chronic aspiration pneumonia and chronic pulmonary hypertension. Overall, four factors led to respiratory failure: fecaloma; cerebral palsy; scoliosis; and chronic aspiration pneumonia. Based on clinicopathological correlation, the cause of death was determined to be a combination of these factors, and the key acute factor was the fecaloma.

Plexiform cellular schwannoma (PCS) is very rare, and it is not completely understood. We present our experience with 7 additional cases of PCS in infancy and childhood to further characterize its distinctive clinicopathological features. There were 5 females and 2 males with a mean age of 28 months (ranging, 2 months to 8 years). The involved sites included the left forearm ( n = 2), sacrococcygeal region ( n = 2), retroperitoneum ( n = 1), thoracic spinal canal and thoracic cavity ( n = 1), and neck ( n = 1). Tumor sizes ranged from 3 to 13 cm in maximum diameter (mean, 7.1 cm). Histologically, all tumors consisted of abundant spindle cells arranged in a multinodular or plexiform growth pattern, possessing elongated, hyperchromatic nuclei and pale eosinophilic cytoplasm with indistinct cell margins. Mitotic figures were easily identified, with a mean count of 4 per 10 consecutive high power fields (HPF). Immunohistochemically, all tumors were strongly and diffusely positive for S100 protein, SOX10 and H3K27me3. The Ki-67 index ranged from 5% to 30% (mean, 15%). Follow-up (available in 6 cases) revealed that 5 patients experienced local recurrence and were treated by re-excision. There was no evidence of recurrence and metastasis in 3 patients, and the other 2 were alive with the disease. In conclusion, PCS is an uncommon nerve sheath tumor predominantly occurring in infants and children, featuring a plexiform or multinodular growth pattern and exhibiting a tendency toward local recurrence. PCS is easily mistaken as malignant peripheral nerve sheath tumor (MPNST) due to its locally aggressive behaviors and worrisome features, including hypercellularity, hyperchromatism and high proliferative activity. Increased awareness of its potential occurrence and greater familiarity with its characteristic features are helpful for both clinicians and pathologists to avoid misdiagnosis and unnecessary overtreatment.

Congenital Diaphragmatic hernia (CDH) usually presents in the newborn and rarely present as undetected cases in adult life. Defects in the diaphragm can cause abdominal organs to herniate into the thoracic cavity resulting in respiratory distress or strangulation of abdominal organs. Reported here are 3 cases of congenital CDH presenting in adult life. A 59-year-old male presenting with epigastric pain, bilious vomiting and constipation demonstrated an air-fluid level in the anterior mediastinum on chest radiograph. Surgery revealed an anterior Morgagni defect with a loop of terminal ileum herniated and strangulated into the pericardial sac. A15-year-old girl presenting with abdominal pain and pyrexia for 2 days, on CT chest and abdomen revealed right lobe of liver and transverse colon in the right hemithorax with the pericardium pushed to the opposite side. Surgery revealed a large right sided Bochdelaks type hernia. A strangulated gangrenous transverse colon was removed from within the thoracic cavity. In these cases the body had adapted by maintaining total lung volume by compensatory hyperplasia of the contralateral lung allowing the patients to survive with no symptoms for a long duration of time. Even though rare, the possibility of CDH presenting as acute abdomen is important to remember.

This is the case of a specimen of Didelphis albiventris with signs of respiratory difficulty after a dog attack. Thoracic radiographic examination revealed pneumothorax, pulmonary contusion, and rib fracture, but no alteration compatible with diaphragmatic hernia was observed. Pneumothorax was reduced and the other alterations were treated. However, clinical manifestations persisted, and thus a contrast-gastrointestinal radiographic study was performed, showing abdominal organs in the thoracic cavity and loss of diaphragmatic line. The surgical approach was instituted, with access to the diaphragm through median laparotomy. Through the diaphragmatic rupture, present in the left antimere, there were herniated liver and gastric portions, intestinal segments, and omentum. After inspection and repositioning of the abdominal organs, the diaphragm raffia was performed with single sutures interrupted with 3-0 Nylon thread. The patient’s complete recovery occurred 14 days after the surgical procedure, with remission of clinical manifestations and normality of thoracic images in radiographic studies.

Background Postoperative observed air leakage does not always originate from parenchymal defects but may arise from defects in the chest drainage unit, connections or reverse airflow in water seals. We investigated such false air leakage using a new chest drainage unit with a built-in CO2-detector and an electronic chest drainage unit. Methods Two types of chest drainage units were tested in a simple porcine model: A well-known electronic chest drainage unit and a new chest drainage unit with integrated CO2-detector. We created a setup of true air leakage—a parenchymal lesion, and false air leakage—allowing air to flow into the thoracic cavity alongside the chest drain. Results We demonstrated that the new chest drainage unit with a built-in CO2-detector can distinguish between experimentally induced true air leakage and false air leakage. Conclusion Available chest drainage systems do not allow direct assessment of true or false air leakage, which may increase chest drain duration unnecessarily. The integration of a CO2-sensitive color indicator into a chest drainage unit allows simple distinction between false air leak and true air leak, which may improve postoperative management.

Uni-portal video-assisted thoracoscopic approach is currently a popular surgical technique in general thoracic surgery. After operation, a chest tube is usually placed through the incision to drain the effusion and gas from the thoracic cavity. In the conventional method, the retaining stitches should be taken out ten days after removing chest drain. To get better would-healing and avoid unsightly scar, we explored a method of anchoring chest drain and two-layer suture for Uni-portal incision without removing stitches post operation.

Splenosis is acquired ectopic splenic tissue, usually a sequela of trauma. Its imaging appearance is can be deceiving, and at unusual locations may be mistaken for an alternate cause mass lesion. We present one such unusual case of splenosis in a 53 year-old man with history of heart failure involving the thoracic cavity identified as splenosis on nuclear medicine imaging and suspicion was raised given the remote history splenectomy after splenic rupture during trauma. We will discuss the imaging appearances of splenosis on CT, MRI and nuclear medicine studies, with emphasis on using nuclear medicine as a modality of choice to avoid biopsy. We will also go on to include a brief review of literature on this topic in this article. The key facts are role of detailed clinical history and requirement of high index of suspicion to avoid unnecessary intervention in the case of splenosis.

Background Percutaneous radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma (HCC), but delayed thermal damage can cause diaphragmatic hernia (DH). Surgery is recommended for DH, and open surgery is widely accepted. This report presents a case of laparoscopic surgery for strangulated DH that occurred after RFA. Case presentation An 80-year-old woman with a history of hepatitis C-induced liver cirrhosis and HCC was admitted to our institution owing to sudden-onset intense epigastric pain. Twenty-two months earlier, she received RFA treatment for HCC located in segment 6/7. Contrast-enhanced computed tomography revealed herniation of the small intestine into the thoracic cavity, with mesenteric fat haziness. Emergency laparoscopic surgery was performed, and the patient was diagnosed with strangulated DH associated with the prior RFA. The defect was closed using absorbable sutures, and the ischaemic small intestine was resected via mini-laparotomy. The patient was discharged on the 10th postoperative day without complications, and no evidence of DH recurrence 15 months after surgery was noted. Conclusions Laparoscopic surgery seems useful and feasible for strangulated DH.

Liposarcoma is one of the most common soft tissue malignancies, occurring mostly in the extremities and retroperitoneal cavities, and occasionally in the mediastinum of the thoracic cavity. Here, we present a patient undergoing four operations over a period of 33 years because of repeated recurrence of mediastinal liposarcoma. A 34-year-old woman underwent her first surgery for mediastinal liposarcoma in 1986. Ten years later, a recurrent tumour was found during follow-up. The patient underwent a second operation for complete excision. The pathology was liposarcoma, partly myxoid and partly dedifferentiated. The patient remained tumour-free for 22 years, until one year ago, when a third operation was performed to resect the recurrent tumour which was myxoid liposarcoma. Unfortunately, upon computed tomography imaging three months later a fatty mass was spotted which increased rapidly in size. The patient underwent further surgery to achieve radical excision of the recurrent liposarcoma. Postoperative recovery was uneventful, and a follow-up examination showed no recurrence to date. For mediastinal liposarcoma, surgical removal is the treatment of choice. Considering that the tumour is prone to recurrence, the lesion should be removed as thoroughly as possible in the first operation. If the tumour recurs repeatedly, multiple resections are beneficial to patient survival on most occasions.

Congenital diaphragmatic hernia (CDH) is one of the most common major congenital anomalies. In utero visceral organ herniation into the thoracic cavity can result in lung hypoplasia and pulmonary hypertension may ensue. Post-natal mortality rates in isolated CDH remain high reaching up to 80% in severe cases. Several prenatal predictors of morbidity and mortality have been proposed. Reliable predictive markers can aid clinicians in providing effective family counselling, prediction of survival, and propose therapeutic options. Decreased total fetal lung volume (TFLV) via magnetic resonance imaging (MRI) has been reported to be significantly associated with mortality. We report on 2 cases of CDH, with fetal MRI performed at third trimester, focusing on the TFLV and observed-to-expected TFLV. We would like to highlight the importance of predictive mortality calculator which provides statistical data for healthcare providers in counselling families and aids in risk-stratification.

Background: Congenital Lobar emphysema (CLE) is one of the rarest cystic lesions in the thoracic cavity among children. It is often misdiagnosed and managed incorrectly. We are reporting our institutional experience and recommendations regarding the prevention of common errors in the management of this condition. Methods: This study was conducted at the Paediatric Surgery Department, The Children’s Hospital & the University of Child Health Sciences Lahore from January 2015 to December 2018. All the patients who underwent thoracotomy for congenital lobar emphysema at our center were included in the study and their charts were reviewed. Results: A total of 19 patients had been treated at our center in this duration. The mean age of patients was 2.85 ± 2.11 months. Thirteen of them (68%) were male and the most common presenting complaint (94.7%) was respiratory distress. Chest X-ray was done in all of the patients while a CT scan was needed in 11 patients (57.9%). The most involved lobe was left upper (n=15). Lobectomy was done in all patients. Post-operative ventilation was required in 2 patients (10.5%) and pneumonia developed in 2 patients (10.5%). The most significant complication was wound infection (9/19, p=

BACKGROUND: Postsurgical pleural infection is a life-threatening complication after implantation of artificial devices such as ventricular assist devices (VADs). The treatment can be challenging and the evidence in the literature is very limited. Here we report our multidisciplinary approach of the management of pleural infection after VAD implantation. METHODS: Between March 2014 and December 2019, 33 patients developed postoperative pleural infection after VAD implantation and underwent thoracic surgical intervention at our institution. All patients were prospectively enrolled in this analysis. Data were retrospectively analyzed. Primary outcome was the 90-day mortality rate. Length of ICU stay related to pleural infection, chest tube duration, re-thoracotomy rate and length of ventilatory support represented secondary outcomes. RESULTS: The 90-day mortality rate was 6% (2 patients). The mean ICU stay related to the pleural infection was 6 days (2–24 days). Video-assisted thoracoscopic surgery (VATS) was performed in all patients. Conversion to thoracotomy was necessary in 12 cases. Decortication and parietal pleurectomy in addition to hematoma and empyema removal was performed in all patients. Due to diffuse bleeding, packing of the thoracic cavity with temporary thoracic closure was necessary in 10 patients. Depacking was performed after a mean of 3 days (3–7 days). Recurrent empyema or bleeding after definitive chest closure was not observed. Lung resection was performed in 3 patients. CONCLUSIONS: Thoracic surgical management of pleural infection in patients after VAD implantation is challenging and complicated due to the inevitable anticoagulative therapy. A perioperative multidisciplinary management which includes the early involvement of thoracic surgical expertise helps to improve survival in this very complex patient cohort.

Congenital diaphragmatic hernia (CDH) is a developmental defect in the diaphragm that allows abdominal viscera to herniate into the thoracic cavity. Pulmonary hypoplasia and pulmonary hypertension are consequences of this disease process. The incidence is approximately 2.4–4.1/10,000 births, and survival rate is estimated at 70–90 percent. To avoid potentially devastating delays in care, it is crucial that neonatal nurses and care providers in both tertiary and nontertiary care centers be familiar with the pathogenesis of CDH and the standard of care for initial stabilization of the neonate. Novel fetal and postnatal surgical repair techniques are also described here.

Background Bochdalek diaphragmatic hernia is a developmental defect of the posterolateral portion of the diaphragm. This defect may allow abdominal contents to abnormally occupy the thoracic cavity, resulting in most cases in the compression of the developing lungs. Signs are typically shown during early childhood since the defect is usually present during development. In exceptional cases, however, Bochdalek diaphragmatic hernia can be observed in asymptomatic adult patients, or in those whose initial diagnosis may include common respiratory pathologies such as asthma. Case presentation Here we describe the case of a 31-year-old Mestizo female patient admitted to the emergency room owing to sudden onset of pain in the left hypochondrium and in epigastrium, as well as signs of respiratory distress. Soon after admission, the patient entered cardiorespiratory arrest, and advanced cardiac life support was provided for 45 minutes without success. The patient was declared dead 1 hour 40 minutes after admission. Clinical autopsy concluded that cause of death was respiratory failure as a complication of a previously undiagnosed Bochdalek diaphragmatic hernia. Conclusions We report an exceptional case of Bochdalek diaphragmatic hernia as the cause of rapid-onset respiratory failure and death in an adult. Unfortunately, due to its unusual presentation, Bochdalek diaphragmatic hernia is rarely considered among the list of differential diagnoses when admitting an adult patient with respiratory symptoms. By reporting this case, we encourage the medical community and trainees to consider diaphragmatic defects when approaching a patient with sudden onset of abdominal pain with concomitant respiratory symptoms.

Objective: To evaluate and comprehensively analyze the clinical efficacy of recombinant human endostatin combined with Iressa targeted therapy in patients with pleural metastasis of lung adenocarcinoma. Methods: The interval of the selected study period span was from January 2017 to April 2021. The sample source of the study was 42 patients with lung adenocarcinoma admitted to hospital. The random number table method was used for study grouping, and they were further divided into study groups (n = 21, 14 cases with pleural metastasis) and control group (n=21, 13 cases with pleural metastasis), all patients received systemic chemotherapy with pemetrexed and cisplatin. Patients with pleural metastases in the control group were injected with 60 mg cisplatin into the thoracic cavity. Patients in the study group were treated with Iressa (gefitinib) targeted therapy if genetic testing showed epidermal growth factor receptor (EGRF) mutations, and patients with pleural metastases were treated with pleural metastasis with Endo (recombinant human endostatin YH-16) to control pleural effusion. Two sets of related indicators were compared and analyzed. Results: Comparing the short-term disease control rate, treatment effectiveness and long-term survival rate between the two groups shows that the study group has more advantages (P0.05). Based on statistics of the recurrence rate of pleural fluid in the two groups, the study group is significantly lower than the control group (P

Objective. To study the peculiarities of diagnostics and treatment of urolithiasis complications among patients with new coronavirus infection COVID-19. Methods. The prospective cohort study evaluated the treatment outcomes of patients (n=146). The first group (n=30) included patients treated in infectious diseases hospital with a complicated urinary calculi disease and a new coronavirus infection COVID-19, the second group (n=116) included patients treated in the urological department of multidisciplinary non-infectious hospital due to complicated urinary tract stone disease who were not infected by new coronavirus infection COVID-19. As for COVID 19 diagnostics, patients of the first group were done PCR tests that were positive in 19 (63,3%) cases, and thoracic cavity computer tomography scanning (upon admission the percentage of pulmonary tissue involvement varied since 5% up to 90%). Results. Among the patients of the first group, elderly people prevailed (61+15 years) and there were more women among them (66%). The characteristic features of complicated urinary calculi disease in patients with COVID-19 are the prevalence of infectious and inflammatory complications (50%) and a combination of several complications of urolithiasis (40%). Among peculiarities of treatment, patients of the first group in 6.6% of cases underwent the lumbotomy with open nephrostomy, due to the spread of secondary suppurative process over the retroperitoneal space. According to the Clavien-Dindo scale, in the first group of patients the incidence of complications after surgery was 40%, in the second - 13.8%. Mortality rate in the first group reached 30%, in the second - 0.9%. The duration of hospital treatment among patients of the first group reached 21 (5-39) days, among patients of the second group - 8 (1-56) days. Conclusion. The specificity of the course associated with significant morbidity and mortality require further optimization therapeutic approachesto achieve success in patientswith complications of urolithiasis duringCOVID-19outbreak. What this paper adds The peculiarities of diagnostics and treatment of urinary tract stone disease complications among patients with new coronavirus infection COVID-19 have been studied. It is shown that the typical differences of patients with complicated urolithiasis and new coronavirus infection COVID-19 are elderly and old age, being a female, prevalence of pyelonephritis and paranephritis in clinical presentations, and presence of several combined complications of the urolithiasis. Mortality rate upon complicated urolithiasis and new coronavirus infection COVID-19 since the pandemic onset has reached 30% that demands optimization of treatment approaches in patients of this group.

Background Metastases of meningiomas are infrequent and the site of extracranial metastasis such as the bone is extremely rare. Case report A 75-year-old male had a history of five sessions of surgery and gamma-knife treatment for brain meningioma over a period of 29 years. He visited our hospital because he noticed a swelling in his anterior chest 2 years and 6 months after the final treatment. After an open biopsy, histopathological analysis revealed the mass to be a metastatic grade II meningioma. We resected the tumor along with the sternum, ribs, pleura, and pericardium. The patient had recurrences in the thoracic cavity and pericardium postoperatively and received radiation therapy. He also had metastasis in the abdominal cavity, which spread rapidly. Conclusion We report on a rare instance of metastasis to the sternum in a case of atypical meningioma, showing rapid growth and invasion after long-term treatment.

Intercostal pulmonary hernia is a rare condition that may present to the emergency department spontaneously, following blunt trauma or as a complication of thoracic surgery. With the evolution of minimally invasive thoracic surgery pulmonary hernia may become more common. In this case of postoperative chest pain, incisional swelling, and shortness of breath, we present the ultrasound characteristics of a postoperative intercostal pulmonary hernia and its resemblance to subcutaneous emphysema.

Hiatal hernia is a not uncommon anatomic disorder resulting in portions of the bowel occupying space in the thoracic cavity. There are a number of antecedent risk factors including obesity but not hiatal hernias resulting in symptoms. When symptoms do occur, they can include chest pain, nausea, abdominal pain, and gastroesophageal reflux. Cardiac arrhythmias have also been reported as associated conditions resulting from a hiatal hernia. To date, however, a complete heart block secondary to a hiatal hernia has not been reported. An 88-year-old female with a history of GERD (gastroesophageal reflux disease) was found to have a large hiatal hernia at endoscopy after she presented to the emergency department with nausea and abdominal pain. Prior to her scheduled surgical repair, she developed symptomatic third degree heart block which resolved with nasogastric tube deflation of the gastric contents. After surgical repair of the hiatal hernia, she developed episodes of atrial fibrillation with rapid ventricular response and was started on diltiazem. She eventually converted back to normal sinus rhythm and remained dysrhythmia free. In addition to other known arrhythmias associated with hiatal hernia, a complete heart block can also be seen. Acute management requires deflation of the chest occupying hernia. This appears to be the one of the first reported cases of complete heart block caused by hiatal hernia.

Background Malignant obstruction and associated hydronephrosis is a common complication of advanced cervical cancer. Percutaneous nephrostomy (PCN) followed by antegrade stenting is often required to relieve obstruction as retrograde access fails in considerable proportion of such patients. Reno-pleural fistula is a rare complication of PCN which creates a patent connection between the renal collecting system and the thoracic cavity, and urine accumulation in the pleural space can cause pleural effusion (i.e., urinothorax). Upward or downward migration is a complication of indwelling ureteric stents. Further migration with extrusion outside of the urinary tract is uncommon. Herein we present an unprecedented case in adult of ureteric stent upward migration through a reno-pleural fistula into the thoracic cavity managed by thoracoscopy. Case presentation A 66-year-old female was diagnosed of advanced stage cervical cancer with suspicious bladder invasion. Given her bilateral hydronephrosis with impaired renal function, she underwent bilateral PCN and subsequent antegrade ureteric stenting. However, she presented with dyspnea, right back pain, and oliguria four days after bilateral PCN catheter removal. Computed tomography reported massive right pleural effusion and an intrathoracic ureteric stent within reno-pleural fistula. Thoracoscopy with thoracostomy was performed to remove the ureteric stent and urine in right pleural space. A week later, urinothorax had resolved and right PCN was performed again. She was discharged after regaining normal renal function with right PCN and a left ureteric stent in place. Conclusions A reno-pleural fistula can serve as a route for ureteric stent migration and that continuous drainage of urine can cause urinothorax once the stent reaches the thoracic cavity. Anytime a supracostal approach is used for PCN, even when using small caliber catheters, clinicians should pay special attention given the risk of pleural injury and subsequent complications.

There are many studies of single lung ventilation (SLV), which are mostly limited to reducing lung damage by changing ventilation strategies or comparing differences in lung damage caused by different lung isolation devices. There is no study comparing the morphological changes of ventilated lungs using different strategies of artificial lung ventilation. The aim of the study was to examine pathomorphological changes in the ventilated lung during thoracic surgery using SLV. A randomized study was performed on 40 patients who underwent thoracic surgery using SLV. After signing the informed consent, the patients were divided into two groups. In the control group (40 patients) with ventilation “by volume” (VCV), in the study group – ventilation “by pressure” (PCV) with the addition of PEEP 5 mm. During surgery in the thoracic cavity with the help of SLV performed transbronchial biopsy of the parenchyma of the ventilated lung to study the pathomorphological changes after ventilation with different modes. The biopsy was performed using a bronchoscope, which was inserted through the endotracheal tube into the lung, opposite the side of the operation (after the end of SLV and “inclusion” of the collapsed lung). The morphological changes caused by the ventilator were investigated. Pathomorphological examination of the non-collapsed lung (which participated in gas exchange during SLV) was as follows: the control group found significant changes in the alveolar wall with its edema, thickening of the interstitial lung, vascular occlusion, severe inflammatory cell infiltration and damage to alveolar structures. The alveoli collapsed and disappeared. The alveolar structures of the study group were better than the control group: pulmonary interstitial and alveolar exudates, as well as inflammatory cell infiltration were significantly reduced compared to those in the control group. The results of the study suggest that the use of PCV with “moderate” PEEP can significantly improve oxygenation and reduce acute ventilatory injury of the lungs compared to VCV during SLV.

The aim of the study was identifying the features of infection in the site, clinical course of the disease, amount and frequency of patient examinations, family doctor communications and treatment of patients with pneumonia caused by SARS-Cov2. Materials and methods. We examined 23 families of 2–6 members (a total of 78), among them 41 patients with SARS-COV-2 pneumonia. The amount of patient examination (PCR, plain X-ray and CT of the thoracic cavity, coagulogram, blood oxygen saturation) and treatment extent (antibacterial, anticoagulant and oxygen therapy) were considered. Results. The contagiousness of the disease in the families of patients was from 33 % to 100%. The thoracic CT overuse: 73.3 % repeated, 33.0 % triple. Family doctors monitored the treatment only in 14.6 % of cases. The antibacterial therapy administration was 2 times more often than necessary; the treatment was changed by patients themselves or their acquaintances. A hospitalization was offered to patients with a decreased blood oxygen saturation of 92 % and below (29.3 %), and only 2 patients agreed to it. In a lack of treatment efficacy, the patients used respiratory fluoroquinolones (levofloxacin, moxifloxacin), meropenem, linezolid, amikacin, which are among the main drugs for the treatment of resistant tuberculosis. Extensive misuse of antibacterial drugs unnecessarily will result in an alarming increase in antibiotic-resistant infections after the COVID-19 pandemic. Conclusions. Pneumonia caused by SARS-COV-2 is a highly contagious disease in a family cluster (33–100 %). Routine administration of antibacterial drugs (especially levofloxacin, moxifloxanemine, meropenem, linezolid, amikacin) for patients with suspected SARS-COV-2 pneumonia by thoracic CT or PCR-confirmed without proven need is not only unnecessary, but even dangerous due to the potential increase in resistance to these drugs, which are the primary in the treatment of resistant tuberculosis. The anamnesis of the disease, oxyhemometry and coagulogram are of great importance when examining a patient with this pathology.

Purpose Hyperthermic intrathoracic chemotherapy (HITOC) is an additive, intraoperative treatment for selected malignant pleural tumors. To improve local tumor control, the thoracic cavity is perfused with a cisplatin-containing solution after surgical cytoreduction. Since cisplatin is probably carcinogenic to humans, potential contamination of surfaces and pathways of exposure should be systematically investigated to enable risk assessments for medical staff and thus derive specific recommendations for occupational safety. Methods Wipe sampling was performed at pre-selected locations during and after ten HITOC procedures, including on the surgeon's gloves, for the quantitation of surface contaminations with cisplatin. After extraction of the samples with hydrochloric acid, platinum was determined as a marker for cisplatin by voltammetry. Results High median concentrations of cytostatic drugs were detected on the surgeons’ (1.73 pg Cis-Pt/cm2, IQR: 9.36 pg Cis-Pt/cm2) and perfusionists’ (0.69 pg Cis-Pt/cm2, IQR: 1.73 pg Cis-Pt/cm2) gloves. The display of the perfusion device showed partially elevated levels of cisplatin up to 4.92 pg Cis-Pt/cm2 and thus could represent an origin of cross-contamination. In contrast, cisplatin levels on the floor surfaces in the area of the surgeon and the perfusion device or in the endobronchial tube were relatively low. Conclusion With a correct use of personal protective equipment and careful handling, intraoperative HITOC appears to be safe to perform with a low risk of occupational exposure to cisplatin.

A 61-year-old man who was a psychiatric patient and an alcoholic was admitted to hospital after a fall in his bathroom. He showed signs of hemorrhagic shock, and CT scans showed the presence of the right kidney and part of the right retroperitoneum in the right hemithorax, surrounded by liquid. Surgery showed that the right hemidiaphragm was intact and that no intraabdominal viscera prolapsed into thoracic cavity. The bleeding in the right retroperitoneum was evacuated. The surgical report also stated that "the right kidney and ureter were explored and no injuries or active bleeding were found". The patient died the third day after admission. Autopsy revealed a livid swelling covered with parietal pleura in the right half of the thoracic cavity, behind the costophrenic sinus, about 20 × 15x12 cm in size, filled with about 1500 ml of blood, with ectopic right kidney in the right half of the thorax, slightly rotated posteriorly and downwards. The kidney was smaller (80 g in weight), compared to the normally positioned enlarged left kidney (300 g). The right hemidiaphragm was also intact with small Bochdalek's foramen behind the posterior edge, with communication between the right retropleural and retroperitoneal spaces, through which intact elongated right renal artery (15 cm), vein (14 cm) and ureter were passing. The cause of death was hemorrhagic shock due to retroperitoneal bleeding, with coagulation disorder as possible contributing factor. Intrathoracic kidneys may pose many diagnostic and management dilemmas for clinicians and pathologists. Association between a Bochdalek hernia and an intrathoracic renal ectopia is very rare and may be confusing for doctors in different clinical situations.

Background: Fetoscopic endoluminal tracheal occlusion (FETO) improves lung maturation in severe cases of congenital diaphragmatic hernia (CDH) but it does not ameliorate lung compression by herniated abdominal organs. Surgically opening the fetal abdomen (abdominal decompression [AD]) reduces the intrathoracic pressure by diverting the abdominal organs into the amniotic cavity-a probable causal therapy for lung hypoplasia and pulmonary hypertension in CDH. Open surgical abdominal decompression has been reported: we describe a minimally invasive approach in an ovine model of CDH as a probable fetoscopic intervention. Materials and Methods: Eight fetuses were included, 2 were kept as HEALTHY controls. A CDH (left side, liver down) was created by open fetal surgery at midgestation in 6 fetuses, 2 were taken as CDH controls. Fetoscopic abdominal decompression (fAD) was performed 21 days later in 4 animals. The fetuses were retrieved at the end of gestation and evaluated by lung stereology. Results: fAD led to a near total evacuation of the thoracic cavity in 2 of the 4 animals. Fetuses with CDH had a lower total volume and fraction of alveolar air space, a lower volume fraction of the parenchyma, and an increase of the volume fraction of the alveolar septa and atelectasis, as well as an increased mean thickness of alveolar septa compared with HEALTHY fetuses. Fetuses treated with abdominal decompression showed an improvement of stereological parameters. Conclusions: In spite of relevant limitations (pilot study, small groups, spontaneous closure of the abdominal incision) we were able to demonstrate that abdominal decompression for CDH can be performed by fetoscopy. Our results support the hypothesis of causally improving lung development by abdominal decompression, thus implying increased survival in extreme cases of CDH. A refinement of the fetoscopic techniques and direct comparison to FETO appears warranted.

Background Artificial Intelligence (AI) is a promising tool for cardiothoracic ratio (CTR) measurement that has been technically validated but not clinically evaluated on a large dataset. We observed and validated AI and manual methods for CTR measurement using a large dataset and investigated the clinical utility of the AI method. Methods Five thousand normal chest x-rays and 2,517 images with cardiomegaly and CTR values, were analyzed using manual, AI-assisted, and AI-only methods. AI-only methods obtained CTR values from a VGG-16 U-Net model. An in-house software was used to aid the manual and AI-assisted measurements and to record operating time. Intra and inter-observer experiments were performed on manual and AI-assisted methods and the averages were used in a method variation study. AI outcomes were graded in the AI-assisted method as excellent (accepted by both users independently), good (required adjustment), and poor (failed outcome). Bland–Altman plot with coefficient of variation (CV), and coefficient of determination (R-squared) were used to evaluate agreement and correlation between measurements. Finally, the performance of a cardiomegaly classification test was evaluated using a CTR cutoff at the standard (0.5), optimum, and maximum sensitivity. Results Manual CTR measurements on cardiomegaly data were comparable to previous radiologist reports (CV of 2.13% vs 2.04%). The observer and method variations from the AI-only method were about three times higher than from the manual method (CV of 5.78% vs 2.13%). AI assistance resulted in 40% excellent, 56% good, and 4% poor grading. AI assistance significantly improved agreement on inter-observer measurement compared to manual methods (CV; bias: 1.72%; − 0.61% vs 2.13%; − 1.62%) and was faster to perform (2.2 ± 2.4 secs vs 10.6 ± 1.5 secs). The R-squared and classification-test were not reliable indicators to verify that the AI-only method could replace manual operation. Conclusions AI alone is not yet suitable to replace manual operations due to its high variation, but it is useful to assist the radiologist because it can reduce observer variation and operation time. Agreement of measurement should be used to compare AI and manual methods, rather than R-square or classification performance tests.

Pediatric tumors in the apex of the thoracic cavity are often diagnosed late due to the absence of symptoms. These tumors can be quite large at presentation with involvement of the chest wall, sympathetic chain, spine, and aortic arch. The tumors can also extend into the thoracic inlet and encircle the brachial plexus. Depending on the diagnosis, treatment may involve chemotherapy with subsequent surgery or require primary resection. Optimal exposure to resect large apical tumors with thoracic inlet extension is a surgical challenge. To date, several surgical techniques have been described to resect these tumors - including both anterior and posterior thoracic approaches. Each of these techniques can be limited by inadequate exposure of the mass. We describe an alternative approach to surgical resection of these masses that employs an extended sternotomy with a lateral neck incision. This report details two successful resections of large left apical masses with thoracic inlet involvement in children using this technique (Level of evidence 4).

Background Pathologies of the ventral thoracic spine represent a challenge, igniting arguments about which should be the ideal surgical approach to access this area. Anterior transthoracic thoracotomy and a number of posterolateral routes have been developed. Among the latter, costotransversectomy has demonstrated to provide good ventral exposure with a lower, but not negligible, morbidity. The optimal approach should be the one minimizing surgical morbidity on both neural and extraneural structures while optimizing exposure. Methods The authors described the combined, rib-sparing, bilateral approach (CRBA) to the ventral mid/low-thoracic spine. The technique combines a transfacet pedicle partially sparing approach on one side and a transpedicular with transverse process resection on the contralateral one. A laboratory investigation was conducted. The technique was applied in a surgical setting, and a case was reported. Results CRBA is rib-sparing, completely extracavitary, and does not require pleural exposure and paraspinal muscle splitting, thus minimizing potential morbidity. The combination of 2 corridors ensures the greatest exposure compared with standard posterolateral approaches. The only blind corner is limited to a small area just in front of the dural sac. A bimanual approach optimizes control during surgical manipulation, even if the area of maneuverability and cross-section areas of surgical corridors are slightly limited compared to traditional costotransversectomy due to the minimally invasive nature of the procedure. Conclusions CRBA represents a safe and effective option to access the ventral mid/low thoracic spine. It provides great exposure and bimanual manipulation of the surgical target, minimizes potential morbidity, and avoids entrance into the thoracic cavity and paraspinal muscle splitting.

Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is a clinically and histologically distinct variant of inflammatory myofibroblastic tumor that is characterized by an aggressive clinical course and dismal prognosis (1). Histologically, EIMS is composed of sheets of rounded or epithelioid cells with vesicular nuclei, large nucleoli, and eosinophilic to amphophilic cytoplasm, that is often set in a myxoid stroma rich in inflammatory cells. A minor spindle cell component is usually present. Most EIMS harbor RANBP2-ALK or RRBP1-ALK gene fusions and only a single putative case harboring an alternate EML4-ALK fusion has been reported (2-3). Notably, the ALK immunostaining pattern varies depending on ALK fusion partner; RANBP2-ALK is associated with nuclear membranous pattern while RRBP1-ALK shows a perinuclear accentuated cytoplasmic pattern. EIMS typically affects male patients and shows a striking predilection for the abdominal cavity. Exceptionally rare cases have been reported in the thoracic cavity (3 in lung/pleura) and pelvic cavity (1 in ovary) (4-7). To our knowledge, EIMS has not been reported outside the ventral cavity.

Endometriosis is a common clinical condition where functional endometrial tissue is found outside the uterine cavity. Although most of this ectopic tissue tends to occur within the pelvis, on rare occasions, they can also be found in unusual locations, such as the thoracic cavity, perianal, episiotomy scar, and previous abdominal wound sites. This is a case report of a healthy 41-year-old Chinese female who presented with a painful perianal lump which was subsequently investigated and excised. The diagnosis of perianal endometriosis was made upon histological examination of the tissue. Many theories attempt to explain the phenomenon of endometriosis in the perianal region. In this case, the implantation theory is the likely explanation as the patient had a significant history of 3 normal vaginal deliveries which were followed by episiotomies. Advancements in endo-anal ultrasound (EAUS) have aided in the planning of surgery for this lesion.

Combined severe trauma due to road traffic injuries and falls from heights is a global medical, social, and economic problem all over the world.

Objectives Thoracic surgery can cause significant pain, and multiple strategies have been developed to control pain after surgery. We compared 2 bupivacaine formulations given intraoperatively: bupivacaine with epinephrine (1,200,000) or liposomal bupivacaine. Methods This was a randomized, open-label study (NCT03560362). Eligible patients were adults scheduled for a minimally invasive lung procedure. Incision sites were injected with bupivacaine with epinephrine or liposomal bupivacaine before incision, and each intercostal space was injected with 1 mL of bupivacaine with epinephrine or liposomal bupivacaine entering the thoracic cavity. Patient-controlled analgesia was initiated in the recovery room. Pain was recorded using a visual analog scale. The primary outcome was the amount of narcotics taken during the postoperative hospital stay. Results We recruited 50 patients; 25 received bupivacaine with epinephrine, and 25 received liposomal bupivacaine. The treatment groups were similar in age, histology, and procedure performed. There were no statistical differences between the treatment groups in the amount of narcotics required during the hospital stay (36.3 mg for bupivacaine and 38 mg for liposomal bupivacaine) or in pain assessed the day of surgery (5 and 5), the first day (3.5 and 2.3), second day (3 and 2.6), 2 weeks (0 and 1), or 3 months (0 and 0) postoperatively. Hospital length of stay and complications were also similar. Conclusions In a small, randomized study, we did not find significant differences between bupivacaine with epinephrine or liposomal bupivacaine in mitigating pain after minimally invasive lung resection. We currently favor using the less expensive nonliposomal bupivacaine preparations until additional data are available.

Background: Ectopia Cordis (EC) is a rare congenital condition where the heart is partially or completely lies outside the thoracic cavity (extrathoracic), uncovered by pericardium and skin. Many works of literature reported EC is a rare congenital abnormality with an incidence of about 5-8 per 1 million live births and includes about 0.1% of congenital heart diseases. Methods: This was a male baby, weighing 2.900 kg, received with cyanosis with a defect in the anterior chest wall and heart protruding out through it. On initial physical examination, split sternum with complete thoracic EC (beating outside the thoracic cavity with a complete absence of the pericardium with the apex pointing upwards) were reported. Results: The baby’s poor general condition did not allow further radiologic studies and echocardiography could not be performed. By the time, an arrangement had been planned for him to undergo cardiothoracic referral; unfortunately, he ran a downhill course and succumbed within 36 hours of life. Conclusion: The important for submitting such findings will assist our team: pediatric surgeons, obstetricians, pediatricians and, neonatal intensivists to develop future management strategies when they are enrolled or confronted with such cases, by improving the outcome through a precise workup design to provide the optimal evaluation, diagnosis, and management roadmaps of potential cases of EC.

BackgroundTension pneumothorax is one of the leading causes of preventable death on the battlefield. Current prehospital diagnosis relies on a subjective clinical impression complemented by a manual thoracic and respiratory examination. These techniques are not fully applicable in field conditions and on the battlefield, where situational and environmental factors may impair clinical capabilities. We aimed to assemble a device able to sample, analyze, and classify the unique acoustic signatures of pneumothorax and hemothorax.MethodsAcoustic data was obtained with simultaneous use of two sensitive digital stethoscopes from the chest wall of an ex-vivo porcine model. Twelve second samples of acoustic data were obtained from the in-house assembled digital stethoscope system during mechanical ventilation. The thoracic cavity was injected with increasing volumes of 200, 400, 600, 800, and 1000 ml of air or saline to simulate pneumothorax and hemothorax, respectively. The data was analyzed using a multi-objective genetic algorithm that was used to develop an optimal mathematical detector through the process of artificial evolution, a cutting-edge approach in the artificial intelligence discipline.ResultsThe in-house assembled dual digital stethoscope system and developed genetic algorithm achieved an accuracy, sensitivity and specificity ranging from 64 to 100%, 63 to 100%, and 63 to 100%, respectively, in classifying acoustic signal as associated with pneumothorax or hemothorax at fluid injection levels of 400 ml or more, and regardless of background noise.ConclusionsWe present a novel, objective device for rapid diagnosis of potentially lethal thoracic injuries. With further optimization, such a device could provide real-time detection and monitoring of pneumothorax and hemothorax in battlefield conditions.

BACKGROUND Transvenous lead extraction (TLE) carries a significant risk of major complications, namely bleeding into the pericardial sac or thoracic cavity. While echocardiographic imaging has been recommended for intraprocedural monitoring for those complications, no studies had examined the potential benefits of fluoroscopy alone as an alternative to echocardiography. The aim of this study was to evaluate the utility of fluoroscopy for monitoring intrathoracic bleeding complications during TLE. METHODS This is a single-center retrospective study of consecutive patients who underwent TLE of a pacemaker or ICD lead with fluoroscopy-only monitoring. At the beginning of each TLE procedure, baseline fluoroscopic images were obtained for both lung fields and the cardiac silhouette. Similar images were acquired again when hypotension develops during the procedure. RESULTS Fluoroscopy alone (without echocardiographic imaging) was used in 783 consecutive patients (54% women; average age, 71.5 ± 12.9 years) who underwent TLE. There were 93 patients (11.9%) who experienced significant hypotension. Fluoroscopy showed no obvious cause for hypotension in 63 patients. Right ventricular inversion was implied by fluoroscopy in 27 patients. Fluoroscopy detected new pericardial effusion in two patients and new right pleural effusion in one patient, which prompted halting the extraction procedure and therapeutic intervention. Additionally, routine fluoroscopic images revealed the development of an unsuspected new small left pleural effusion in one patient and a pericardial effusion in another. In-hospital mortality rate was 0%. CONCLUSIONS In selected patients undergoing TLE, fluoroscopy can provide valuable information for identifying or excluding cardiovascular causes during periods of intraprocedural hemodynamic instability.

Solitary fibrous tumors (SFTs) are rare mesenchymal tumors most commonly arising from the pleura in the thoracic cavity. The impact of tumor size on risk of recurrence in thoracic SFTs is not well understood. A single institution review was performed on all resected thoracic SFTs (1992–2019) with giant SFT defined as ≥ 15 cm. Clinical information, pathologic characteristics, and long-term survival data were collected, and predictors of recurrence and survival were evaluated with regression and Kaplan–Meier analysis. There were 38 thoracic SFTs resected from patients, with the majority of tumors (n = 23, 60.5%) originating from visceral pleura. There were nine (23.7%) giant SFTs with a mean size 20.4 cm (range 17–30 cm). Mean follow-up time was 81.0 months (range 1–261 months), during which 4 of 38 (10.5%) patients experienced a recurrence within the thorax (range 51–178 months). The presence of tumor necrosis (p = 0.021) and ≥ 4 mitoses per high-powered field (p = 0.010) were associated with SFT recurrence on univariate regression. Overall 5-year, 10-year, and 20-year survival was 78.2%, 72.6%, and 42.4%, respectively, and SFT-related mortality occurred in three patients at 83, 180, and 208 months postoperatively. There were no recurrences or SFT-related mortality among patients with giant SFT. This study represents one of the largest contemporary single institution reviews of long-term outcomes of giant thoracic SFT. Our data suggest that size is not a risk factor for recurrence in thoracic SFTs and long-term survival is excellent for giant SFTs.

Background Bronchopleural fistula, which usually accompanies bronchial fistula and empyema, is a severe complication of lung cancer surgery. Negative-pressure wound therapy can enhance drainage and reduce the empyema cavity, potentially leading to early recovery. This therapy is not currently indicated for bronchopleural fistulas because of the risk of insufficient respiration due to air loss from the fistula. Case presentation A 73-year-old man, who was malnourished because of peritoneal dialysis, was referred to our hospital for the treatment of lung cancer. Right lower lobectomy with mediastinal lymph node dissection was performed via posterolateral thoracotomy, and the bronchial stump was covered with the intercostal muscle flap. His postoperative course was uneventful and he was discharged. However, he was readmitted to our hospital because of respiratory failure and diagnosed as having bronchopleural fistula on the basis of the bronchoscopic finding of a 10-mm hole at the membranous portion of the inlet of the remnant lower lobe bronchus. Thus, thoracotomy debridement and open window thoracostomy were immediately performed. After achieving infection control, bronchial occlusion was performed using fibrin glue and a polyglycolic acid sheet was inserted through a fenestrated wound. Bronchial fistula closure was observed on bronchoscopy; therefore, a negative-pressure wound therapy system was applied to close the fenestrated wound. The collapsed lung was re-expanded and the granulation tissue around the wound increased; therefore, thoracic cavity size decreased and thoracoplasty using the latissimus dorsi was performed. Conclusions This bronchopleural fistula was treated successfully after a right lower lobectomy using an extra-pleural bronchial occlusion and negative-pressure wound therapy.

The macro- and microscopic structure of the lungs of mature rabbits – Oryctolagus cuniculus L., 1758 – European rabbit was studied. This work was performed using comprehensive research methods: anatomical, organometric, histological and histometric. The research was carried out in the conditions of the laboratory of pathomorphology in the Department of Anatomy and Histology. The scientific work was performed on the subject of research work of the Department of Anatomy and Histology of Polissya National University on the theme: “Development, morphology and histochemistry of animal organs in normal and pathological”, according to the state registration number – № 0113V000900. The morphological studies followed the basic rules of Good Laboratory Practice GLP (1981), the provisions of the “General Ethical Principles of Animal Experiments”, adopted by the First National Congress of Bioethics (Kyiv, 2001) and the requirements for the “Rules for carrying out work with experimental animals”, approved by the order of the Ministry of Health № 281 of November 1, 2000 “On measures to further improve the organizational forms of work with the use of experimental animals”. The material for histomorphological studies were pieces of lungs selected from clinically healthy adult rabbits (n = 5). Slices were made from paraffin blocks on a sled microtome MS–2. The thickness of histological sections did not exceed 8–12 μm, which were then stained with hematoxylin and eosin and Van Gizon to study the morphofunctional activity of cells and tissues of the respiratory tract. Histometric studies of histological specimens were performed using a microscope “Micros” with a digital camera at a magnification of × 100–1000. Studies have shown that macroscopically the lungs of mature rabbits have a reflection of the shape of the thoracic cavity, and gradually expands ventrally. The right and left lungs are surrounded by pleural right and left sacs. The pleural cavities of both lungs in the test animals are not interconnected. Organometry showed that the absolute lung mass of rabbits is 18.05 ± 1.32 g, relative to 0.624 ± 0.013 %. The histoarchitectonics of the lungs is formed by the lung lobes. The respiratory department of the lungs is represented by a set of acinuses. The latter are represented by respiratory bronchioles, alveolar passages, alveolar sacs and alveoli that form the alveolar tree. The results of morphometric studies showed that the respiratory (respiratory) part of the lungs of rabbits occupies 39.6 ± 0.62 %, and the connective tissue base, respectively, 58.5 ± 1.27 %. The average volume of alveoli, which are divided into small, medium and large, is 42.3 ± 4.35 thousand μm3. Thus, studies of the macro- and microscopic structure of the lungs of experimental animals are of great general biological importance, as they are an important criterion for objective assessment for the differential diagnosis of diseases of various origins.

BackgroundUnlike subcutaneous lipomas, thoracic cavity lipomas are extremely rare and can develop to be quite large without causing any symptoms. However, managing massive lipoma that involves both chest cavities is usually challenging, especially when considering the approach for excision.CaseWe report our experience of surgical management of a case of a 46-year-old male with huge intrathoracic lipoma that extends bilaterally and is known to be the largest of such kind. The tumor was resected successfully using median sternotomy. Histological analysis confirmed features of lipoma.ConclusionTo remove a bilateral intrathoracic lipoma, various surgical approaches have been documented. In our experience, a median sternotomy allows better exposure, which aids in complete surgical extirpation resulting in the prevention of recurrence.