Comparison of efficacy of lung ultrasound and chest X-ray in diagnosing pulmonary edema and pleural effusion in ICU patients: A single centre, prospective, observational study

Background and Aims While chest X-ray (CXR) has been a conventional tool in intensive care units (ICUs) to identify lung pathologies, computed tomography (CT) scan remains the gold standard. Use of lung ultrasound (LUS) in resource-rich ICUs is still under investigation. The present study compares the utility of LUS to that of CXR in identifying pulmonary edema and pleural effusion in ICU patients. In addition, consolidation and pneumothorax were analyzed as secondary outcome measures. Material and Methods This is a prospective, single centric, observational study. Patients admitted in ICU were examined for lung pathologies, using LUS by a trained intensivist;and CXR done within 4 hours of each other. The final diagnosis was ascertained by an independent senior radiologist, based on the complete medical chart including clinical findings and the results of thoracic CT, if available. The results were compared and analyzed. Results Sensitivity, specificity and diagnostic accuracy of LUS was 95%, 94.4%, 94.67% for pleural effusion;and 98.33%, 97.78%, 98.00% for pulmonary edema respectively. Corresponding values with CXR were 48.33%, 76.67%, 65.33% for pleural effusion;and 36.67%, 82.22% and 64.00% for pulmonary edema respectively. Sensitivity, specificity and diagnostic accuracy of LUS was 91.30%, 96.85%, 96.00% for consolidation;and 100.00%, 79.02%, 80.00% for pneumothorax respectively. Corresponding values with CXR were 60.87%, 81.10%, 78.00% for consolidation;and 71.3%, 97.20%, 96.00% for pneumothorax respectively. Conclusion LUS has better diagnostic accuracy in diagnosis of pleural effusion and pulmonary edema when compared with CXR and is thus recommended as an effective alternative for diagnosis of these conditions in acute care settings. Our study recommends that a thoracic CT scan can be avoided in most of such cases.

Pleural effusion in critically ill patients and intensive care setting

Pleural effusion usually causes a diagnostic dilemma with a long list of differential diagnoses.Many studies found a high prevalence of pleural effusions in critically ill and mechanically ventilated patients,with a wide range of variable prevalence rates of up to 50%-60%in some studies.This review emphasizes the importance of pleural effusion diagnosis and management in patients admitted to the intensive care unit(ICU).The original disease that caused pleural effusion can be the exact cause of ICU admission.There is an impairment in the pleural fluid turnover and cycling in critically ill and mechanically ventilated patients.There are also many difficulties in diagnosing pleural effusion in the ICU,including clinical,radiological,and even laboratory difficulties.These difficulties are due to unusual presentation,inability to undergo some diagnostic procedures,and heterogenous results of some of the performed tests.Pleural effusion can affect the patient’s outcome and prognosis due to the hemodynamics and lung mechanics changes in these patients,who usually have frequent comorbidities.Similarly,pleural effusion drainage can modify the ICUadmitted patient’s outcome.Finally,pleural effusion analysis can change the original diagnosis in some cases and redirect the management toward a different way.

Metagenomic next-generation sequencing for pleural effusions induced by viral pleurisy:A case report

BACKGROUND Viral pleurisy is a viral infected disease with exudative pleural effusions.It is one of the causes for pleural effusions.Because of the difficult etiology diagnosis,clinically pleural effusions tend to be misdiagnosed as tuberculous pleurisy or idiopathic pleural effusion.Here,we report a case of pleural effusion secondary to viral pleurisy which is driven by infection with epstein-barr virus.Viral infection was identified by metagenomic next-generation sequencing(mNGS).CASE SUMMARY A 40-year-old male with a history of dermatomyositis,rheumatoid arthritis,and secondary interstitial pneumonia was administered with long-term oral prednisone.He presented with fever and chest pain after exposure to cold,accompanied by generalized sore and weakness,night sweat,occasional cough,and few sputums.The computed tomography scan showed bilateral pleural effusions and atelectasis of the partial right lower lobe was revealed.The pleural fluids were found to be yellow and slightly turbid after pleural catheterization.Thoracoscopy showed fibrous adhesion and auto-pleurodesis.Combining the results in pleural fluid analysis and mNGS,the patient was diagnosed as viral pleuritis.After receiving Aciclovir,the symptoms and signs of the patient were relieved.CONCLUSION Viral infection should be considered in cases of idiopathic pleural effusion unexplained by routine examination.mNGS is helpful for diagnosis.

A Pleural Effusion Secondary to Unusual Dual Pathology: A Case Report

Pleural effusion is a commonly encountered respiratory disorder. In the majority of cases, a single causative agent is responsible. Pleural effusions resulting from simultaneous involvement of the membranes by two different pathologic processes are unusual.

Clinical Value of Vascular Endothelial Growth Factor Combined with Interferon-γ in Diagnosing Malignant Pleural Effusion and Tuberculous Pleural Effusion

In order to investigate the clinical value of vascular endothelial growth factor （VEGF） combined with interferon-γ （IFN-γ） in diagnosing malignant pleural effusion and tuberculous pleural effusion, 42 cases of malignant pleural effusion and 45 cases of tuberculous pleural effusion in Tongji Hospital, from March 2004 to May 2005, were included, The carcinoembryonic antigen （CEA）, VEGF and IFN-γ levels of pleural effusion were detected by using ELISA, and adenosine deaminase （ADA） activity was determined by using enzyme kinetic analytical method. The sensitivity, specificity, accuracy and area under the curve （AUCR^ROC） of CEA and VEGF, VEGF/IFN-γ ratio, ADA and IFN-γ were measured by receiver operating characteristic curve （ROC）, The results showed that CEA, VEGF levels and VEGF/IFN-γ ratio were significantly higher and the ADA and IFN-γ levels were significantly lower in malignant group than those in tuberculous group （P〈0,01）, The sensitivity, specificity, accuracy and AUCR^ROC of VEGF/IFN-γ ratio （88,7%, 99,8%, 94,4%, 0.96 respectively） were higher than those of CEA （67.8%, 96.1%, 82,4%, 0.78 respectively） and VEGF （81,5%, 84,3%, 82.9%, 0.79 respectively）. The sensitivity, specificity, accuracy and AUCR^ROC of IFN-γ （85.7%, 96,4%, 90.9%, 0.94 respectively） were higher than those of ADA （80,2%, 87,6%, 83.8%, 0,81 respectively）. It was concluded that VEGF/IFN-γ ratio and IFN-γ could be used as valuable parameters for the differential diagnosis of malignant pleural effusion and tuberculous pleural effusion.

Factors related to pleural effusion following hepatectomy for primary liver cancer

BACKGROUND: Pleural effusion frequently complicates hepatectomy and multiple factors contribute to its development following hepatectomy for primary liver cancer. The purpose of this study was to evaluate these factors. METHODS: From March 2003 to May 2005, 228 consecutive patients with primary liver cancer underwent hepatectomy in our department were evaluated retrospectively to identify factors related to postoperative pleural effusion. RESULTS: Among the 228 patients, postoperative pleural effusions arose in 58 (25.4%). Univariate analysis showed significant differences in postoperative ascites, subphrenic collection, Pringle manoeuvre length, drainage amount on postoperative day 1, albumin level on postoperative day 7, alanine aminotransferase (ALT) level on postoperative days I and 3, prealbumin level on postoperative days 3 and 7, and tumor size (P<0.05). Ordinal regression analysis revealed that subphrenic collection, drainage on postoperative day I and ALT plus prealbumin on postoperative days I and 3 were statistically significantly related to postoperative pleural effusion (P<0.05). CONCLUSION: Subphrenic collection and operative injury to the liver appeared to be significantly related to pleural effusion after hepatectomy for primary liver cancer.

Prevention and management of pleural effusion following hepatectomy in primary liver cancer

Postoperative pleural effusion occurs frequently after hepatectomy. The risk factors, prevention and management of postoperative pleural effusion in patients with primary liver cancer (PLC) who have undergone hepatectomy and the value of the argon beam coagulator (ABC) for the prevention of pleural effusion are studied. METHODS:A total of 523 patients with PLC at our institution who had had right hepatectomy from July 2000 to June 2004 were studied retrospectively. Comparative analysis was made to identify the factors contributing to postoperative pleural effusion and the efficacy of various managements. RESULTS:Of the 523 patients whose livers were dissociated using argon beam cutting and/or coagulation, 20(3.8%) developed pleural effusions;whereas in the other 467 patients underwent hepatectomy with suture ligation of the diaphragmatic secondary wound surface during the same period, 49(10.5%) had pleural effusion (P<0.01). The factors contributing to postoperative pleural effusion included subphrenic collection, postoperative hepatic insufficiency with ascites, duration of hepatic occlusion and underlying cirrhosis. CONCLUSIONS: Dissociation of the liver by argon beam cutting and/or coagulation can save suture ligation of the diaphragmatic secondary wound surface and may also prevent postoperative pleural effusion. Pleural drainage using an indwelling central-venous-catheter (CVC) in the pleural cavity is safe and efficacious.

Delayed internal pancreatic fistula with pancreatic pleural effusion postsplenectomy

The occurrence of pancreatic pleural effusion,secondary to an internal pancreatic fistula,is a rare clinical syndrome and diagnosis is often missed.The key to the diagnosis is a dramatically elevated pleural fluid amylase.This pancreatic pleural effusion is also called a pancreatic pleural fistula.It is characterized by profuse pleural fluid and has a tendency to recur.Here we report a case of delayed internal pancreatic fistula with pancreatic pleural effusion emerging after splenectomy.From the treatment of this case,we conclude that the symptoms and signs of a subphrenic effusion are often obscure;abdominal computed tomography may be required to look for occult,intra-abdominal infection;and active conservative treatment should be carried out in the early period of this complication to reduce the need for endoscopy or surgery.

Diagnostic value and safety of medical thoracoscopy for pleural effusion of different causes

BACKGROUND Pleural effusions occur for various reasons,and their diagnosis remains challenging despite the availability of different diagnostic modalities.Medical thoracoscopy(MT)can be used for both diagnostic and therapeutic purposes,especially in patients with undiagnosed pleural effusion.AIM To assess the diagnostic efficacy and safety of MT in patients with pleural effusion of different causes.METHODS Between January 1,2012 and April 30,2021,patients with pleural effusion underwent MT in the Department of Respiratory Medicine,The Second Affiliated Hospital of Xi’an Jiaotong University(Shaanxi,China).According to the discharge diagnosis,patients were divided into malignant pleural effusion(MPE),tuberculous pleural effusion(TBPE),and inflammatory pleural effusion(IPE)groups.General information,and tuberculosis-and effusion-related indices of the three groups were analyzed.The diagnostic yield,diagnostic accuracy,performance under thoracoscopy,and complications of patients were compared among the three groups.Then,the significant predictive factors for diagnosis between the MPE and TBPE groups were analyzed.RESULTS Of the 106 patients enrolled in this 10-year study,67 were male and 39 female,with mean age of 57.1±14.184 years.Among the 74 thoracoscopy-confirmed patients,41(38.7%)had MPE,21 had(19.8%)TBPE,and 32(30.2%)were undiagnosed.Overall diagnostic yield of MT was 69.8%(MPE:75.9%,TBPE:48.8%,and IPE:75.0%,with diagnostic accuracies of 100%,87.5%,and 75.0%,respectively).Under thoracoscopy,single or multiple pleural nodules were observed in 81.1%and pleural adhesions in 34.0%with pleural effusions.The most common complication was chest pain(41.5%),followed by chest tightness(11.3%)and fever(10.4%).Multivariate logistic regression analyses showed effusion appearance[odds ratio(OR):0.001,95%CI:0.000-0.204;P=0.010]and carcinoembryonic antigen(OR:0.243,95%CI:0.081-0.728;P=0.011)as significant for differentiating MPE and TBPE,with area under the receiver operating characteristic curve of 0.977(95%CI:0.953-1.000;P<0.001).CONCLUSION MT is an effective,safe,and minimally invasive procedure with high diagnostic yield for pleural effusion of different causes.

ALK gene expression status in pleural effusion predicts tumor responsiveness to crizotinib in Chinese patients with lung adenocarcinoma

Objective： The relationship between anaplastic lymphoma kinase（ALK） expression in malignant pleural effusion（MPE） samples detected only by Ventana immunohistochemistry（IHC） ALK（D5F3） and the efficacy of ALKtyrosine kinase inhibitor therapy is uncertain.Methods： Ventana anti-ALK（D5F3） rabbit monoclonal primary antibody testing was performed on 313 cell blocks of MPE samples from Chinese patients with advanced lung adenocarcinoma, and fluorescence in situ hybridization（FISH） was used to verify the ALK gene status in Ventana IHC ALK（D5F3）-positive samples. The follow-up clinical data on patients who received crizotinib treatment were recorded.Results： Of the 313 MPE samples, 27（8.6%） were confirmed as ALK expression-positive, and the Ventana IHC ALK（D5F3）-positive rate was 17.3%（27/156） in wild-type epidermal growth factor receptor（EGFR） MPE samples. Twenty-three of the 27 IHC ALK（D5F3）-positive samples were positive by FISH. Of the 11 Ventana IHC ALK（D5F3）-positive patients who received crizotinib therapy, 2 patients had complete response（CR）, 5 had partial response（PR） and 3 had stable disease（SD）.Conclusions： The ALK gene expression status detected by the Ventana IHC ALK（D5F3） platform in MPE samples may predict tumor responsiveness to crizotinib in Chinese patients with advanced lung adenocarcinoma.

Meigs syndrome with pleural effusion as initial manifestation:A case report

BACKGROUND Meigs syndrome is a rare neoplastic disease characterized by the triad of benign solid ovarian tumor,ascites,and pleural effusion.In postmenopausal women with pleural effusions,ascites,elevated CA-125 level,and pelvic masses,the probability of disseminated disease is high.Nevertheless,the final diagnosis is based on its histopathologic features following surgical removal of a mass lesion.Here we describe a case of Meigs syndrome with pleural effusion as the initial manifestation.CASE SUMMARY A 52-year-old woman presented with a 2-mo history of dry cough and oppression in the chest and was admitted to our hospital due to recurrent pleural effusion and gradual worsening of dyspnea that had occurred over the previous month.Two months before admission,the patient underwent repeated chest drainage and empirical anti-tuberculosis treatment.However,the pleural fluid accumulation persisted,and the patient began to experience dyspnea on exertion leading to admission.A computed tomography scan of the chest,abdominal ultrasound,and magnetic resonance imaging confirmed the presence of right-sided pleural effusion and ascites with a right ovarian mass.Serum tumor markers showed raised CA-125.With a suspicion of a malignant tumor,the patient underwent laparoscopic excision of the ovarian mass and the final pathology was consistent with an ovarian fibrothecoma.On the seventh day postoperation,the patient had resolution of the right-sided pleural effusion.CONCLUSION Despite the relatively high risk of malignancy when an ovarian mass associated with hydrothorax is found in a patient with elevated serum levels of CA-125,clinicians should be aware about rare benign syndromes,like Meigs,for which surgery remains the preferred treatment.

Cutaneous myiasis with eosinophilic pleural effusion:A case report

BACKGROUND Cutaneous myiasis is frequently observed;however,eosinophilic pleural effusion induced by this condition is rare.CASE SUMMARY We report the case of a 65-year-old female Tibetan patient from Qinghai Province,who presented to West China Hospital of Sichuan University around mid-November 2011 with a chief complaint of recurrent cough,occasional hemoptysis,and right chest pain.There was no past medical and surgical history of note,except for occasional dietary habit of eating raw meat.Clinical examination revealed a left lung collapse and diminished breathing sounds in her left lung,with moist rales heard in both lungs.Chest X-rays demonstrated a left hydropneumothorax and a right lung infection.Chest computed tomography revealed a left hydropneumothorax with partial compressive atelectasis and patchy consolidation on the right lung.Laboratory data revealed peripheral blood eosinophilia of 37.2%,with a white blood cell count of 10.4×109/L.Serum immunoglobulin E levels were elevated(1650 unit/mL).Serum parasite antibodies were negative except for cysticercosis immunoglobulin G.Bone marrow aspirates were hypercellular,with a marked increase in the number of mature eosinophils and eosinophilic myelocytes.An ultrasound-guided left-sided thoracentesis produced a yellow-cloudy exudative fluid.Failure to respond to antibiotic treatment during hospitalization for her symptoms and persistent blood eosinophilia led the team to start oral albendazole(400 mg/d)for presumed parasitic infestation for three consecutive days after the ninth day of hospitalization.Intermittent migratory stabbing pain and swelling sensation on both her upper arms and shoulders were reported;tender nodules and worm-like live organisms were observed in the responding sites 1 wk later.After the removal of the live organisms,they were subsequently identified as first stage hypodermal larvae by the Sichuan Institute of Parasites.The patient’s symptoms were relieved soon afterwards.Telephonic follow-up 1 mo later indicated that the blood eosinophilia and pleural effusion were resolved.CONCLUSION Eosinophilic pleural fluid can be present in a wide array of disorders.Myiasis should be an important consideration for the differential diagnosis when eosinophilic pleural effusion with blood eosinophilia is observed.

Th17/Treg Imbalance in Malignant Pleural Effusion

Both T helper IL-17-producing cells （Thl7 cells） and regulatory T cells （Tregs） have been found to be increased in malignant pleural effusion （MPE）. However, the possible imbalance between Thl7 cells and Tregs, as well as the association of.Thl7/Treg and Thl/Th2 cells in MPE remains to be elucidated. The objective of the present study was to investigate the distribution of Th 17 cells in relation to Tregs, as well as Thl/Th2 balance in MPE. The number ofThl7, Tregs, Thl, and Th2 cells in MPE and peripheral blood was determined by using flow cytometry. The relationship among the number of Thl7, Tregs, Thl, and Th2 cells was explored. It was found that the number of Thl7, Tregs, Thl, and Th2 cells was all increased in MPE as compared with the corresponding peripheral blood. The number of Thl7 cells was correlated negatively with Tregs in MPE, but not in blood. Thl7 cells and Thl7/Treg ratio were positively, and Tregs were negatively, correlated with Thl cells, but not with either Th2 cells or Th1/Th2 ratio in MPE. This study supports earlier data that both Thl7 cells and Treg are present at higher frequencies in MPE than in the autologous blood. For the first time, we show that Thl7/Treg imbalance exists in MPE.

Initial 12-h Operative Fluid Volume is an Independent Risk Factor for Pleural Effusion after Hepatectomy

Pleural effusion after hepatectomy is associated with significant morbidity and prolonged hospital stays.Several studies have addressed the risk factors for postoperative pleural effusion.However,there are no researches concerning the role of the initial 12-h operative fluid volume.The aim of this study was to evaluate whether the initial 12-h operative fluid volume during liver resection is an independent risk factor for pleural effusion after hepatectomy.In this study,we retrospectively analyzed clinical data of 470 patients consecutively undergoing elective hepatectomy between January 2011 and December 2012.We prospectively collected and retrospectively analyzed baseline and clinical data,including preoperative,intraoperative,and postoperative variables.Univariate and multivariate analyses were carried out to identify whether the initial 12-h operative fluid volume was an independent risk factor for pleural effusion after hepatectomy.The multivariate analysis identified 2 independent risk factors for pleural effusion：operative time [odds ratio（OR）=10.2] and initial 12-h operative fluid volume（OR=1.0003）.Threshold effect analyses revealed that the initial 12 h operative fluid volume was positively correlated with the incidence of pleural effusion when the initial 12-h operative fluid volume exceeded 4636 m L.We conclude that the initial 12-h operative fluid volume during liver resection and operative time are independent risk factors for pleural effusion after hepatectomy.Perioperative intravenous fluids should be restricted properly.

Pleural Effusion and Ascites Associated with Endometriosis-Mimicking Tuberculosis

Objective: To report a case of Endometriosis associated with Pleural effusion. Design: Case report. Setting: Tertiary care center. Patient(s): A 30-year old woman presented with a right pleural effusion complicated with pneumothorax-mimicking TB. Intervention(s): Thoracentesis, pleural biopsy by a video-assisted thoracic surgery, pleurodesis, thoracic wedge resection, CT chest, CT Abdomen, and diagnostic Laparoscopy. Main Outcome Measure(s): After taking a GnRH analog, there was no recurrence of pleural effusion nor ascites. Result(s): Thoracentesis and wedge resection of lung ruled out malignancy. An omental mass biopsy obtained from diagnostic laparoscopy after the patient returned with drug-induced hepatitis, and ascites revealed endometriosis. Conclusion(s): Thoracic endometriosis is rare;however, it should be considered in the differential diagnosis by unknown causes of pleural effusion in reproductive age timeframe in women.

3D spiral channels combined with flexible micro-sieve for high-throughput rare tumor cell enrichment and assay from clinical pleural effusion samples

The sieving and enrichment of rare tumor cells from large-volume pleural effusion(PE)samples is a promising technique for cell-based lung tumor diagnosis and drug tests,which features high throughput and recovery,purification,as well as viability rates of rare target cells as the prerequisites for high sensitivity,specificity,and accuracy of tumor cell analysis.In this paper,we propose a three-dimensional(3 D)sieving method for rare tumor cell enrichment,which effectively eliminates the"dead zones"in traditional two-dimensional(2 D)cell filters with a dimension-raising strategy to satisfy the requirements mentioned above.The prototype device was combined with a funnel-shaped holder,a flexible micropore membrane in the middle,and a3 D spiral fluid channel covered on the membrane as a three-layer ice-creaming cone composite structure.Driven by gravity alone,the device performed as follows:(1)20-fold throughput compared with the 2 D commercial planee hich was up to 20 mL/min for a threefold dilution of whole blood sample;(2)high recovery rates of 84.5%±21%,86%±25%,83%±14%for 100,1000,and 10000 cells/mL,respectively,in 30 mL phosphate buffer saline(PBS)sample,and a 100%positive detection rate in the case of≤5 A549 cells in 1 mL PBS;(3)a typical purification rate of 85.5%±9.1%;and(4)a viability rate of>93%.In the demonstration application,this device effectively enriched rare target cells from large volumes(>25 mL)of clinical pleural effusions.The following results indicated that tumor cells were easy-to-discover in the enriched PE samples,and the proliferation capability of purified cells was(>4.6 times)significantly stronger than that of unprocessed cells in the subsequent 6-day culture.The above evaluation indicates that the proposed easily reproducible method for the effective execution of rare cell enrichments and assays is expected to become a practical technique for clinical cell-based tumor diagnosis.

Unilateral pleural effusion secondary to Takayasu arteritis: a case report and literature review

Takayasu arteritis (TA) is a chronic, nonspecific inflammatory disease of large and medium-sized vessels that primarily involves the aorta and its branches. TA involving the pulmonary arteries has a prevalence ranging from 14% to 86%, which can lead to pulmonary hypertension, a progressive increase in pulmonary artery pressure, and eventually death from right heart failure. The presentation of pulmonary arteritis (PA) is very nonspecific, with a reported misdiagnosis rate of up to 60% and a diagnosis time ranging from 1 month to more than 10 years. The clinical manifestation of pleural effusion is very rare in both TA and PA cases. Based on our literature review, this is the 6th reported case of TA with pleural effusion, and the specific mechanism of TA with pleural effusion is still unclear. The characteristics of this case and the previously reported cases are summarized in this article to improve the understanding of TA and PA and reduce the misdiagnosis rate.

Pleural effusion and ascites in extrarenal lymphangiectasia causedby post-biopsy hematoma: A case report

BACKGROUNDThe renal system has a specific pleural effusion associated with it in the form of“urothorax”, a condition where obstructive uropathy or occlusion of thelymphatic ducts leads to extravasated fluids (urine or lymph) crossing thediaphragm via innate perforations or lymphatic channels. As a rare disorder thatmay cause pleural effusion, renal lymphangiectasia is a congenital or acquiredabnormality of the lymphatic system of the kidneys. As vaguely mentioned in areport from the American Journal of Kidney Diseases, this disorder can be causedby extrinsic compression of the kidney secondary to hemorrhage.CASE SUMMARYA 54-year-old man with biopsy-proven acute tubulointerstitial nephropathyexperienced bleeding 3 d post hoc, which, upon clinical detection, manifested as amassive perirenal hematoma on computed tomography (CT) scan withoutconcurrent pleural effusion. His situation was eventually stabilized byexpeditious management, including selective renal arterial embolization. Despite good hemodialysis adequacy and stringent volume control, a CT scan 1 mo laterfound further enlargement of the perirenal hematoma with heterogeneoushypodense fluid, left side pleural effusion and a small amount of ascites. Thesefluid collections showed a CT density of 3 Hounsfield units, and drained fluid ofthe pleural effusion revealed a dubiously light-colored transudate withlymphocytic predominance (> 80%). Similar results were found 3 mo later, duringwhich time the patient was free of pulmonary infection, cardiac dysfunction andovert hypoalbuminemia. After careful consideration and exclusion of otherpossible causative etiologies, we believed that the pleural effusion was due to theocclusion of renal lymphatic ducts by the compression of kidney parenchymaand, in the absence of typical dilation of the related ducts, considered our case asextrarenal lymphangiectasia in a broad sense.CONCLUSIONAs such, our case highlighted a morbific passage between the kidney and thoraxunder an extraordinarily rare condition. Given the paucity of pertinentknowledge, it may further broaden our understanding of this rare disorder.

Presentation of Boerhaave's syndrome as an upper-esophageal perforation associated with a right-sided pleural effusion:A case report

BACKGROUND Spontaneous esophageal rupture or Boerhaave’s syndrome is a rare and acute disease with a high incidence of misdiagnosis and mortality.Here,we aimed to explore the clinical characteristics,diagnosis,treatment,and prognosis of spontaneous esophageal rupture,and to analyze the causes of misdiagnosis during the treatment of spontaneous esophageal rupture.CASE SUMMARY The clinical features of the patient with spontaneous esophageal rupture misdiagnosed earlier as pleural effusion were retrospectively analyzed and the reasons for misdiagnosis are discussed based on a current review of the literature.The patient was admitted to a local hospital due to shortness of breath accompanied by vomiting and abdominal distension for five hours.Based on the computed tomography(CT)scan analysis,clinically,right pleural effusion was diagnosed.However,the patient was unwilling to undergo right closed thoracic drainage.The patient also had intermittent fevers against infection,and during the course of treatment,he complained of chest pain,following which,he was transferred to our hospital.Grapefruit-like residue drainage fluid was observed.Re-examination of the chest CT scans suggested the presence of spontaneous perforation in the upper left esophagus.Therefore,the patient underwent an urgent esophageal hiatus repair.Unfortunately,the patient died of infection and respiratory failure due to progressive dyspnea after surgery.CONCLUSION Spontaneous esophageal rupture is a rare disease associated with high fatality.The patients do not present typical clinical symptoms and the disease progresses rapidly.This case report highlights the importance of a dynamic review of chest CT scan,not only for the initial identification of segmental injury but also for prioritizing subsequent treatment strategies.Moreover,we have presented some clues for clinicians to recognize and diagnose spontaneous esophageal rupture at rare sites(upper-esophageal segment)through this case report of spontaneous esophageal rupture that caused the patient’s death.We have also summarized the reasons for the misdiagnosis and lessons learned.

Can Left Pleural Effusion Be an Indicator of Gastric Leaks after Laparoscopic Sleeve Gastrectomy?

Background: Coincidental pleural effusion has been observed by computed tomography (CT) scans in individual patients with gastric leaks after laparoscopic sleeve gastrectomy;however, the frequency of this phenomenon has not been investigated in cohort studies. Objectives: This study aimed to assess the diagnostic accuracy of left pleural effusion as an indicator of gastric leaks after laparoscopic sleeve gastrectomy. Setting: University hospital and bariatric surgery center of excellence. Methods: This single-center retrospective analysis included consecutive patients who had undergone laparoscopic sleeve gastrectomy followed by CT scans to investigate suspected gastric leaks from September 2011 to September 2018. The sensitivity, specificity, Youden’s index, and predictive values were estimated using a 2 × 2 cross-tabulation. Results: The study involved assessing the CT scans of 148 patients;80 patients (44 men and 36 women, mean age: 34 years, mean body mass index {BMI}: 46 kg/m2) had positive findings of gastric leaks after laparoscopic sleeve gastrectomy, such as contrast leak, gas leak, and peri-gastric collection (either singly or in combination). The CT findings were negative for gastric leaks in 68 patients (38 men and 30 women, mean age: 33 years, mean BMI: 45 kg/m2). Pleural effusion manifested as a fluid density in the dependent portion of pleural cavity on CT. The sensitivity of left pleural effusion to predict gastric leaks after laparoscopic sleeve gastrectomy was 73.8%, and the specificity was 91.2%. The positive and negative predictive values were 90.8% and 74.7%, respectively, and the Youden’s index was 64.9%. Conclusion: Left pleural effusion exhibits good diagnostic accuracy for gastric leaks after laparoscopic sleeve gastrectomy. Notably, the specificity (91.2%) was very high.