Chimeric ALT Perforator-Free Flap with Vastus Lateralis Muscle for the Obliteration of the Intrathoracic Dead Space Post-Pneumonectomy: A Case Report

Chest wall reconstruction is a surgical procedure aimed at restoring the integrity and function of the chest wall, which may be damaged due to trauma, cancer, infection, or congenital defects. The chest wall plays a vital role in protecting the thoracic organs, supporting the respiratory system, and maintaining the shape of the chest. Therefore, any defect or deformity of the chest wall can have significant functional and aesthetic consequences for the patient. The authors present a case report at Kenyatta National Hospital (KNH) of a dyspneic 47-year-old male patient with a right anterolateral chest wall defect post-pneumonectomy previously complicated by bronchopleural fistula. Past attempts at the chest wall reconstruction had utilized the ipsilateral latissimus dorsi muscle, pectoralis major muscle, and the omental pedicled flaps with limited success. A chimeric anterolateral thigh (ALT) perforator-free flap with vastus lateralis (VL) muscle was used to obliterate the post-pneumonectomy intrathoracic dead space and to provide a cutaneous paddle. This case report aims to show the versatility of the ALT flap for chest wall reconstruction to prevent the post-pneumonectomy syndrome associated with tracheal deviation, inspiratory stridor, and exertional dyspnea. In conclusion, chest wall reconstruction with obliteration of intrathoracic dead space post-pneumonectomy is challenging and needs careful planning and execution.

Right Diaphragmatic Rupture with Passage of an Intrathoracic Ileal Segment Apropos of a Case and Review of the Literature at the Kankan Regional Hospital

Traumatic rupture of the right diaphragmatic dome with herniation of a segment of the hail into the thorax is a rare lesion. It is often the result of a thoraco-abdominal trauma. It can generally lead to early or late cardiopulmonary complications due to compression. The objective of this clinical case is to study the physiopathological mechanisms, the diagnostic and therapeutic modalities of this complication. The diagnosis is often difficult in front of a diaphragmatic rupture since there are no specific clinical signs. In our case, the clinical picture on arrival was that of a high occlusion in an immediate postoperative context. The X-ray which makes it possible to visualize the ascended organs but more difficultly the rupture itself could not be carried out. Treatment is essentially surgical. Although the thoracic approach is preferred by several surgeons because of the difficulties of exposing the diaphragm in the presence of the liver, we chose the abdominal approach instead. The postoperative course is made up of parietal suppuration.

Intrathoracic caudate lobe of the liver:A case report and literature review

Heterotopic supradiaphragmatic livers are rare.A total of 23 cases of primary supradiaphragmatic livers have been reported in the literature.The clinical presentations of heterotopic supradiaphragmatic liver are variable.The simultaneous detection of intrathoracic accessory liver and pulmonary sequestration is extremely rare,and only one case has previously been reported.It is difficult to make a correct diagnosis preoperatively.We presented a 53-year-old woman with complaints of an intermittent,productive cough and dyspnea for two months that was refractory to medical treatment.She had no previous history of trauma or surgery.A chest radiograph only showed a widening of the mediastinum.Contrast-enhanced computed tomography of the chest revealed a well-circumscribed homogenous soft-tissue mass,approximately 4.35 cm×2.5 cm×6.14 cm in size,protruding through the right diaphragmatic crura to the right pleural cavity,attached to the inferior vena cava,esophagus and liver.There was no conclusive diagnosis before surgery.After the operation,we discovered that this patient was the first case of a supradiaphragmatic heterotopic liver,which passed through the inferior vena cava foramen and was coincidentally combined with an intralobar pulmonary sequestration that was found intraoperatively.We discussed its successful management with surgical resection via a thoracic approach and reviewed the published literature.

Intrathoracic major duodenal papilla with transhiatal herniation of the pancreas and duodenum:A case report and review of the literature

Transhiatal herniation of the pancreas is an extremely rare condition.In the published literature we found only eleven cases reported in the period of 1958 to 2011.A coincidental hiatal herniation of the duodenum is described in two cases only.To our knowledge,we report the first case with a hiatal herniation of the complete duodenum and proximal pancreas presenting an intrathoracic major duodenal papilla with consecutive intrahepatic and extrahepatic cholestasis.A 72-yearold Caucasian woman was admitted to our department with a hiatal hernia grade Ⅳ for further evaluation.According to our recommendation of surgical hernia repair soon after the diagnosis of a transhiatal herniation of the proximal pancreas and entire duodenum,we had to respect the declared intention of the patient for a conservative procedure.So we were forced to wait for surgical repair within an emergency situation complicated by a myocardial infarction and reduced general condition.We discuss the therapeutic decision making process and a complete literature review of this rare entity.

Laparoscopic repair of complete intrathoracic stomach with iron deficiency anemia:A case report

BACKGROUND Giant paraesophageal hiatal hernias(HH)are very infrequent,and their spectrum of clinical manifestations is large.Giant HH mainly occurs in elderly patients,and its relationship with anemia has been reported.For the surgical treatment of large HH,Nissen fundoplication is the most common antireflux procedure,and the reinforcement of HH repair with a patch(either synthetic or biologic)is still debatable.CASE SUMMARY We report on a case of giant paraesophageal HH in a middle-aged male patient with reflux symptoms and severe anemia.After performing a series of tests and diagnostic approaches,results showed a complete intrathoracic stomach associated with severe iron deficiency anemia.The patient underwent successful laparoscopic hernia repair with mesh reinforcement and Nissen fundoplication.Postoperatively,reflux symptoms were markedly relieved,and the imaging study showed complete reduction of the hernia sac.More importantly,anemia was resolved,and hemoglobin,serum iron and ferritin level were returned to the normal range.The patient kept regular follow-up appointments and remained in a satisfactory condition.CONCLUSION This case report highlights the relationship between large HH and iron deficiency anemia.For the surgical treatment of large HH,laparoscopic repair of large HH combined with antireflux procedure and mesh reinforcement is recommended.

Primary Pleural Rhabdomyosarcoma: Plain Film, CT and MRI Findings of This Extremely Rare Intrathoracic Tumor

Primary pleural rhabdomyosarcoma is an extremely rare intrathoracic malignancy. We present a case of a previously healthy 2-year-old male complaining of cough and shortness of breath. The plain film, CT and MRI descriptions of this pleural tumor are presented. This is a fast growing tumor that is indistinguishable radiographically from other large intrathoracic tumors such as pleuropulmonary blastoma.

Computer tomography-guided negative pressure drainage treatment of intrathoracic esophagojejunal anastomotic leakage:A case report

BACKGROUND Esophagojejunal anastomotic leakage(EJAL)is a serious and potentially crucial complication of total gastrectomy and represents the major cause of postoperative death,with a mortality rate of up to 50%.However,treatment remains challenging and controversial.We report here the case of a patient whose intrathoracic EJAL was successfully treated with computer tomography(CT)-guided negative pressure drainage treatment.CASE SUMMARY A 69-year-old male patient complained of difficulty swallowing within the last six months.He was diagnosed with esophagogastric junction carcinoma,Siewert II,cT3N0M0 stage II.Total gastrectomy and Roux-en-Y esophagojejunostomy were performed.High fever,left chest pain and dyspnea appeared on postoperative day 5,and EJAL was confirmed by CT,gastroscopy and oral blue-dimethylene tests.Conservative treatment measures were applied immediately,including antibiotics,nasojejunal tubes,and repeated thoracic puncture and drainage under ultrasound guidance.However,without sufficient and effective drainage,the thoracic infection and systemic condition continued to deteriorate.With the cooperation of multiple departments,percutaneous CT-guided drainage(24 Fr 7 mm)in the thoracic cavity was successfully placed near the anastomotic leakage.Because of continuous negative pressure suction,the infection symptoms were effectively controlled and the general situation gradually recovered.Subsequent follow-up examination showed that the patient was in good condition.CONCLUSION Negative pressure drainage via CT may represent an effective minimally invasive approach to treating intrathoracic EJAL.

Endobronchial ultrasound-guided transbronchial needle aspiration in intrathoracic lymphadenopathy with extrathoracic malignancy

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA)for the diagnosis of mediastinal and hilar lymph is poorly studied in patients with extrathoracic malignancies.AIM To evaluate the value of EBUS-TBNA for the diagnosis of enlarged intrathoracic lymph nodes in patients with extrathoracic malignancies.METHODS This was a retrospective study of patients with extrathoracic malignancies who were referred to Peking University Cancer Hospital from January 2013 to December 2018 for EBUS-TBNA due to intrathoracic lymphadenopathy.The specimens were defined as positive for malignancy,negative for non-malignancy(tuberculosis,sarcoidosis,etc.),and without a definitive diagnosis.Sensitivity,negative predictive value(NPV)for malignancy,and overall accuracy were calculated.Complications were recorded.RESULTS A total of 80 patients underwent EBUS-TBNA and had a final diagnosis,among which 50(62.5%)were diagnosed with extrathoracic malignancy with intrathoracic lymph nodes metastasis,14(17.5%)were diagnosed with primary lung cancer with nodal involvement,and 16(20.0%)exhibited benign behavior including tuberculosis,sarcoidosis and reactive lymphadenitis or who had benign follow-up.The diagnostic sensitivity,NPV,and accuracy of EBUS-TBNA for intrathoracic lymphadenopathy in patients with extrathoracic malignancy were 93.8%(n=60/64),80.0%(n=16/20),and 95.0%(n=76/80),respectively.In the multivariate analysis,longer short axis of the lymph node(OR:1.200,95%CI:1.024-1.407;P=0.024)and synchronous lung lesion(OR:19.449,95%CI:1.875-201.753;P=0.013)were independently associated with malignant intrathoracic lymphadenopathy.No characteristics of the lymph nodes and EBUS-TBNA were associated with the location of malignant intrathoracic lymphadenopathy,and no major complication was observed.CONCLUSION EBUS-TBNA is a simple and accurate procedure for the diagnosis of intrathoracic lymphadenopathy with extrathoracic malignancy.

Case Report:Congenital spinal intradural arachnoid cyst associated with intrathoracic meningocele in a child

Congenital spinal intradural arachnoid cyst associated with intrathoracic meningocele is very rare.We report a case in a 9-year-old Chinese boy who presented with a two-week history of progressive paraparesis and gait ataxia.Magnetic resonance imaging revealed that a dorsal intradural extramedullary cystic lesion extended from T1 to T5 and compressed the spinal cord.A left lateral intrathoracic meningocele pouch was found incidentally at the level of T1.The arachnoid cyst as well as meningocele was removed and the spinal cord compression was relieved.Arachnoid cyst was confirmed by histological examination.The patient recovered well postoperatively.This is the second report of such a case in the world according to the available literature.The take-home message for our case is that the surgical approach should be individualized,depending on the size and location.

Formation of a rare curve-shaped thoracolith documented on serial chest computed tomography images:A case report

BACKGROUND Thoracolithiasis is a rare benign condition that manifests with one or more small nodules in the pleural cavity.In most cases,it is asymptomatic and found incidentally on chest imaging or during thoracic surgery.The thoracolithiasis formation process is rarely documented.Herein,we present a case of a rare,large,curve-shaped thoracolith,the formation of which was documented on serial computed tomography(CT)images.CASE SUMMARY A 46-year-old male patient who denied any prior systemic disease was evaluated due to intermittent right-sided lateral chest pain lasting for a year.Chest radiography and CT revealed a circumscribed calcified nodule measuring 3.5 mm in the right lower lung lobe.Nodule biopsy revealed fungal infection,which was treated with antifungal medication.After 2 years of follow-up,the patient developed intermittent chest discomfort caused by pleural adhesions,and underwent video-assisted thoracic surgery with pneumolysis.Postoperatively,he developed empyema,which fully resolved with antibiotic therapy.Thereafter,he was followed up at the outpatient clinic and underwent chest CT twice per year.Over time,we observed thickening of the right distal pleura near the lower posterior mediastinum,and several sporadic calcified nodules with gradually increasing intensity,which eventually merged into a single calcified curve-shaped thoracolith measuring approximately 9 cm in length during the 5-year follow-up.CONCLUSION This study documented the formation of a rare thoracolith shape observed for the first time.

Respiratory Changes in the Superior Vena Cava Area on Inspiratory and Expiratory Chest CT: Comparison between Patients with COPD and with Bronchial Asthma

Purpose: In patients with obstructive lung diseases, alteration of intrathoracic pressure is closely related to hyperinflation and leads to hemodynamic impairments. Both intrathoracic pressure and hemodynamics are affected by the respiratory phase. In fact, a previous study showed that respiratory phasic variations in the superior vena cava (SVC) area significantly correlated with the extent of emphysema. Chronic obstructive pulmonary disease (COPD) and bronchial asthma manifest different pathophysiological changes in hyperinflation and hemodynamics. The current study was conducted to evaluate differences in respiratory variations in the cross-sectional area of the SVC between patients with COPD and with asthma. Materials and Methods: We measured the SVC area and calculated the ratio of the SVC area on inspiratory and expiratory scans (i/e-SVC ratio) in 66 patients with COPD and 16 patients with asthma. The cor-relations of the i/e-SVC ratios with airflow limitation, pulmonary small vessels less than 5 mm2 (%cross-sectional area [%CSA] < 5), and respiratory changes in lung volume (i/e-LV) obtained by inspiratory and expiratory computed tomography (CT) images were evaluated. Results: There was no significant difference in i/e-SVC ratio between COPD and asthma groups. In COPD patients, the i/e-SVC ratio significantly correlated with the %CSA ﹣0.433, P = 0.003), i/e-LV ratio (ρ = ﹣0.371, P = 0.011), and percent of predicted forced expiratory volume in 1 second (FEV1% predicted) (ρ = ﹣0.474, P = 0.001), whereas in asthma patients, there were no significant correlations between the i/e-SVC ratio and those functional parameters. Conclusion: There would be differences in the relationship between intrathoracic pressure and cardiopulmonary hemodynamics between COPD and asthma patients.

Susceptibility of Aedes flavopictus miyarai and Aedes galloisi mosquito species in Japan to dengue type 2 virus

Objective: To evaluate the potential of local mosquitoes to act as vectors for dengue transmission in Japan.Methods: Serotype 2 Th NH28/93 was used to test the dengue susceptibility profiles of Aedes flavopictus miyarai(Ae. f. miyarai), Aedes galloisi(Ae. galloisi) and Aedes albopictus(Ae.albopictus), which were collected in Japan. We used Aedes aegypti from Thailand as a positive control. The mosquitoes were infected with the virus intrathoracically or orally. At 10 or 14 days post infection, the mosquitoes were dissected and total RNA was extracted from their abdomens, thoraxes, heads and legs. Mosquito susceptibility to dengue virus was evaluated using RT-PCR with dengue virus-specific primers. Differences in the infection and mortality rates of the different mosquito species were tested using Fisher's exact probability test.Results: The infection rates for dengue virus administered intrathoracically to Ae. f. miyarai,Ae. galloisi and Aedes aegypti mosquitoes were identical by RT-PCR on Day 10 post infection.All of the body parts we tested were RT-PCR-positive for dengue virus. For the orally administered virus, the infection rates in the different body parts of the Ae. f. miyarai mosquitoes were slightly higher than those of Ae. albopictus mosquitoes, but were similar to the control mosquitoes(P > 0.05). The mortality rates for Ae. f. miyarai and Ae. albopictus mosquitoes were similar(P = 0.19). Our data indicated that dengue virus was able to replicate and disseminate to secondary infection sites in all of the four mosquito species(Japanese and Thai).Conclusions: Ae. albopictus is a well-known candidate for dengue transmission in Japan. However, our data suggest that Ae. f. miyarai from Ishigaki Island(near Okinawa Island) and Ae. galloisi from Hokkaido(Northern Japan) should also be regarded as potential vectors for dengue transmission in these regions. Further studies on these mosquitoes should be conducted.

Bilateral thoracic kidneys combined with inferior vena cava located behind the anterior abdominal wall: A case report and review of literature

Ectopic thoracic kidneys are the rarest form of renal ectopia.Moreover,congenital abnormality of a primary anterior inferior vena cava(IVC)located behind the anterior abdominal wall is extremely rare.To date,only one such case has been reported.Herein,we report a rare case of a 55-year-old Chinese male with bilateral thoracic kidneys combined with an anterior IVC,a malformed liver,and a large-round-folds navel.The classification,clinical characteristics,and management options of a thoracic kidney was also summarized by literature review.To our best knowledge,the simultaneous detection of such multiple complex abnormalities has not been reported.

Accuracy of PET/CT with FDG in mediastinal lymph node staging of patients with NSCLC

PET/CT and contrast enhancement CT (CECT) are the two fundamental non-invasive exams in the preoperative staging of patients with non small cell lung cancer (NSCLC). In the staging of the mediastinum, recent studies show that PET is more accurate than CECT, with an average sensitivity and specificity of 85 vs. 61% and 90 vs. 79%, respectively. However, thanks to its specificity value of 100%, the gold standard remains the mediastinoscopy. The aim of this study was to evaluate the PET/CT accuracy in the intrathoracic lymph node staging. Three hundred and five consecutive patients with proven or suspected non-small cell lung cancer who had an integrated PET/CT study were retrospectively evaluated. Lymph node staging was pathologically confirmed on tissue specimens obtained at surgery. A medline research of papers on accuracy of integrated PET/CT in lymph node staging was also carried out. In this population of patients, a total of 1972 lymph node stations were evaluated. Integrated PET/CT correctly staged 247 out of 305 patients: 188 of 214 (87.8%) N0 patients, 34 of 40 (85.0%) N1 patients and 25 of 51 (49.0%) N2/N3 patients. PET/CT understaged 32 patients (10.5%) and overstaged 26 patients (8.5%). One hundred and forty-three lymph nodes were proved positive for malignancy. PET/CT correctly identified 89 metastatic lymph node stations. The overall sensitivity, specificity, positive and negative predictive value and accuracy of PET/CT were 64.8%, 87.9%, 69.4%, 85.5%, and 81.0% on a per-patient basis and 62.2%, 97.9%, 69.5%, 97.1%, and 95.3%, on a per-nodal-station basis, respectively. According to nodal size, PET/CT correctly identified 67 out of 77 (87.0%) metastatic lymph node stations with a short-axis di-ameter ≥ 10 mm, and 22 out of 66 (33.3%) metastatic lymph node stations with a short-axis diameter &amp;lt;10 mm (p&amp;lt;0.001). The incidence of false negative lymph node metastases at PET/CT was higher in patients with adenocarcinoma (42 out of 54). These data are in agreement with the published literature and confirm that integrated PET/CT is more accurate than CT in detecting nodal metastases;however, the PET/CT exam is not enough accurate to substitute mediastinoscopy.

Complete transthoracic resection of giant posterior mediastinal goiter: A case report and review of the surgical approaches

Intrathoracic goiter(IG) is commonly located in the anterior mediastinum. Here, we report the case of a 54-year-old Chinese woman with successful removal of an intrathoracic goiter and improvement of dyspnea by a right posterolateral thoracotomy approach. Conclusion: Posterior mediastinal thyroid goiter with mediastinal compressive symptoms is an indication for surgery.

Giant Thoracic Meningocele Causing Acute Respiratory Compromise

Objective: The authors report a rare case of giant thoracic meningocele causing acute respiratory compromise, treated with a ventriculoperitoneal shunt. Case Report: We report the case of a 36-year-old with severe scoliosis status post repair over a decade ago, neurofibromatosis type I, and a known large meningocele in the left thoracic cavity, presenting with new acute respiratory compromise. She was taken to the operating room for a lumboperitoneal shunt, but the operation was aborted due to her severe spinal deformity. Two days later, she successfully underwent a procedure for ventriculoperitoneal shunt placement. Upon discharge a week later, the patient was hemodynamically stable, able to move all extremities with good strength, and demonstrated improved oxygenation. In the following 7 months, the patient demonstrated continued minimal requirement on nasal cannula, and MRI showed a stable left thoracic giant meningocele. Conclusion: Ventriculoperitoneal shunting is a method of treating and stabilizing acutely symptomatic giant meningoceles.

Fatal Outcome in a Right Bochdalek Hernia with Renal Ectopia Diagnosed in Adulthood

Diaphragmatic hernias may be acquired or congenital. Among congenital hernias, the most common is Bochdalek hernia and eight out of ten Bochdalek hernias occur on the left side. They are usually diagnosed in the paediatric age group, and it is exceedingly rare for the diagnosis to be established in adulthood. Renal ectopy associated with a Bochdalek hernia is extremely rare, and very few cases are reported worldwide. We are reporting a case of a 73-year-old male patient with a right-sided Bochdalek hernia and renal ectopy. In this case, promp diagnosis and treatment could help to reduce the high risk of death in this kind of patients.

Progress in Diagnosis and Endoscopic Treatment of Stanford B Penetrating Aortic Ulcers

Penetrating aortic ulcers is rare in clinical practice,and it is necessary to intervene in this type of aortic perforating ulcer because it can be accompanied by major arterial dissection and intermural hematoma.With the widespread application and technical advancement of follow-up thoracic aortic endovascular repair(TEVAR),endovascular treatment has become the first choice for symptomatic aortic perforating ulcers.In this review,we will review the diagnosis,diagnosis and endovascular treatment of aortic perforating ulcer.

Cytoreductive surgery with hyperthermic thoracoabdominal chemotherapy in stage Ⅳ ovarian cancer - a technical description

Systemic chemotherapy for peritoneal disease in ovarian carcinoma is associated with a recurrence rate of more than 75%,and most of the cases are confined to the peritoneal cavity.The propensity of locoregional treatment failure has paved the way for the discovery of cytoreductive surgery with intra-cavitary chemotherapy.Cytoreductive surgery(CRS)is the present-day treatment modality for a variety of peritoneal carcinomatosis including ovarian cancer,and multi-visceral resection is critical for completion of CRS.In cases of diaphragmatic infiltration by tumor deposits,partial resection leads to a diaphragmatic rent,which can be used for the perfusion of chemotherapeutic drugs into the pleural cavity.Disease transmission from the peritoneal to pleural cavity is a poor prognostic factor however.Hence,intrathoracic hyperthermic chemotherapy may be a reasonable treatment option for ovarian carcinoma with malignant pleural effusion or pleural deposits.Hyperthermic intraperitoneal chemotherapy(HIPEC)is added to the treatment plan in cases of complete CRS but this is a technically demanding procedure.Therefore,performing hyperthermic intrathoracic chemotherapy on top of CRS and HIPEC may be even more complicated for such advanced cancers.The technique of combining HIPEC and hyperthermic intrathoracic chemotherapy is also commonly known as hyperthermic thoracoabdominal chemotherapy(HITAC).The perioperative morbidity and mortality may be remarkably high in such scenarios.We describe our CRS technique with HITAC,which was performed in three FIGO stage IVA ovarian carcinoma patients with metastatic pleural effusion after complete CRS.The patients were retrospectively identified from a prospectively maintained database.All had partial diaphragmatic resection followed by HITAC as part of CRS treatment.Surgical techniques are outlined along with accompanying intra-operative images.Patient demographics,clinical and follow-up details were also described briefly.No comparative analysis with control patients was done.Adjustments in chemotherapy dose are not mandatory for HITAC.Of three patients,one had intrathoracic recurrence on followup;no mortality was recorded HITAC is a complex and potentially harmful procedure whose toxicity profile is still poorly known.Morbidity was not life-threatening and survival was acceptable.