A 24-Year-Old Man with Spontaneous Right Tension Pneumothorax Presenting with Abdominal Pain with an Initial Symptomatic Diagnosis of Acute Pancreatitis.

BACKGROUND Tension pneumothorax (TP) is a medical emergency resulting in air accumulation in the pleural cavity of the affected side. Later, this air applies pressure on the mediastinal structures, leading to a shift of these structures toward the contralateral side. This shift results in a picture of obstructive shock with a possibly fatal consequence if not detected and treated early. Treatment should not await radiological confirmation, and the red flags in the history and physical examination are enough to proceed with decompressing the affected hemithorax with a large-bore needle. Usually, patients with TP present to the Emergency Department with pleuritic chest pain and shortness of breath, but rare presentations are still possible. CASE REPORT We report a case of a 24-year-old male patient with TP who presented to the Emergency Department with severe epigastric abdominal pain with a clinical picture of acute pancreatitis. X-ray showed a right-sided TP. Immediately, we performed a needle decompression followed by chest tube insertion. Four days later, the patient was discharged home uneventfully. CONCLUSIONS In this case report, we aim to draw the attention of physicians in the Emergency Department to the need to consider the possibility of upper abdominal pain elicited by chest pathologies. Furthermore, we need to investigate the effect of TP on coronary perfusion

pN1 but not pN0/N2 predicts survival benefits of prophylactic cranial irradiation in small-cell lung cancer patients after surgery.

Background Prophylactic cranial irradiation has been shown to reduce brain metastases and provide survival benefits in small-cell lung cancer (SCLC). However, its role in limited-stage SCLC patients after surgery remains unclear. Further, it is unknown whether the effect of prophylactic cranial irradiation is generalizable in these patients with different pathological nodal (N0-N2) stages, a state indicating the presence of tumor metastases. Methods We combined data from a single medical center and Surveillance, Epidemiology, and End Results database. Propensity score matching analyses were performed (1:2) to evaluate the role of prophylactic cranial irradiation in SCLC patients after surgery. Cox proportional hazards regression model was used to identify predictors of survival. Results 124 (18.7%) out of 664 surgically-treated SCLC patients received prophylactic cranial irradiation treatment. Within the entire cohort, multivariate Cox regression analysis identified dataset source, age, pathological T and N stages, adjuvant chemotherapy, resection type, and histology as independent prognostic factors for overall survival. Prophylactic cranial irradiation appeared to be associated with a better overall survival, but the difference is marginally significant (P=0.063). Further, we stratified patients based on the pathological N0-N2 stages using propensity score matching analyses, which showed that prophylactic cranial irradiation treatment was superior to non-prophylactic cranial irradiation treatment for surgically-treated SCLC patients with N1 stage only (univariate analysis: P=0.026; multivariate Cox: P=0.004), but not N0/N2 stage (univariate analysis: P=0.65 and P=0.28, respectively; multivariate Cox: P=0.99 and P=0.35, respectively). Conclusions Prophylactic cranial irradiation provides survival benefits for SCLC patients with pN1 after surgery but not with pathological N0/N2 stage. Our findings may provide helpful stratifications for clinical decision-making of prophylactic cranial irradiation intervention in SCLC patients

Gallbladder polyps between ultrasound and histopathology

BackgroundGallbladder polyps (GBP) are rare. Ultrasound is the most widely used screening method for Gallbladder pathology.AimsWe aim to analyse polyps identified in gallbladders removed by laparoscopy over a 14-year period, and to assess the ability of conventional ultrasound to differentiate GBPs from stones.MethodsThis is a retrospective study of 11,391 patients who underwent laparoscopic cholecystectomy from 2002–2016. Data concerning patients' characteristics, preoperative ultrasound findings, number and size of lesions, histologic features of polyps and gallbladder were collected.ResultsForty-six patients had GBP(s) (0.4 per cent). Mean age was 54(range 17-85), 67.4 per cent were females. Body mass index (BMI) was 30 (range 19-43). GBP(s) were single in 63 per cent of cases. Polyp size ranged between 0.2 and 2.2cm (average 1cm). Preoperative ultrasound successfully differentiated polyps from stones in nine cases (20 per cent). The most common histopathologic pattern was hyperplastic polyps in 18 cases (39.1), followed by cholesterol polyps (28.3 per cent), adenomyoma (13 per cent) and adenoma (8.7 per cent). The rest (10.9 per cent) were malignant polyps (adenocarcinoma). Polyps were associated with chronic cholecystitis in 40/46 patients.ConclusionGBPs are rare. Hyperplastic polyps are the commonest in our region, probably due to chronic inflammation induced by gallstones.   Although ultrasound seems to be sensitive to gallbladder lesions; its utility to differentiate polyps from stones is relatively low. Since one tenth of polyps were hiding malignancy, cholecystectomy is advised especially in elderly people

Electrocautery smoke exposure and efficacy of smoke evacuation systems in minimally invasive and open surgery: a prospective randomized study.

Worldwide, health care professionals working in operating rooms (ORs) are exposed to electrocautery smoke on a daily basis. Aims of this study were to determine composition and concentrations of electrocautery smoke in the OR using mass spectrometry. Prospective observational study at a tertiary care academic center, involving 122 surgical procedures of which 84 were 1:1 computer randomized to smoke evacuation system (SES) versus no SES use. Irritating, toxic, carcinogenic and mutagenic VOCs were observed in OR air, with some exceeding permissible exposure limits (OSHA/NIOSH). Mean total concentration of harmful compounds was 272.69 ppb (± 189 ppb) with a maximum total concentration of harmful substances of 8991 ppb (at surgeon level, no SES). Maximum total VOC concentrations were 1.6 ± 1.2 ppm (minimally-invasive surgery) and 2.1 ± 1.5 ppm (open surgery), and total maximum VOC concentrations were 1.8 ± 1.3 ppm at the OR table 'at surgeon level' and 1.4 ± 1.0 ppm 'in OR room air' away from the operating table. Neither difference was statistically significant. In open surgery, SES significantly reduced maximum concentrations of specific VOCs at surgeon level, including aromatics and aldehydes. Our data indicate relevant exposure of health care professionals to volatile organic compounds in the OR. Surgical technique and distance to cautery devices did not significantly reduce exposure. SES reduced exposure to specific harmful VOC's during open surgery.Trial Registration Number: NCT03924206 (clinicaltrials.gov)

Granulomatous Mastitis: A Rare Cause of Male Breast Lump

Background: Mastitis is a common benign disorder of the female breast. It is frequently associated with tenderness, swelling and nipple discharge. We are describing an extremely rare case of an idiopathic granulomatous mastitis in the male breast. Only 1 previous case was reported. Case Report: A 29-year-old male patient presented with a hard, painless lump in the right breast of 2 weeks duration. The patient underwent surgical excision with margin. The histopathologic findings were consistent with granulomatous mastitis. The case was reported as idiopathic granulomatous mastitis after exclusion of all known causes of the disease. Conclusion: Granulomatous mastitis is rare in females and extremely rare in male breast tissue. Since this disease mimics breast cancer in its clinical picture and radiologic findings are usually not conclusive, surgical excision is recommended in all cases

Thoracoscopic diaphragm plication.

Diaphragmatic paralysis with subsequent eventration and respiratory compromise has a huge impact on the quality of life of affected patients. Many different surgical approaches for correcting this problem have been described in the past, using both transabdominal and transthoracic pathways. Either way, since the procedure in general requires suturing of the diaphragm, minimally invasive techniques have only been adopted very slowly and most thoracic surgeons nowadays still use a minithoracotomy, even when adopting a video-assisted approach.  We have developed a safe and simple completely thoracoscopic technique for diaphragmatic plication, and in this video tutorial we demonstrate our technique

Neoadjuvant immunotherapy facilitates resection of surgically-challenging lung squamous cell cancer.

Background Locally-advanced lung squamous cell carcinoma represents a special subset that is challenging to resect completely with surgery alone. Immunotherapy has achieved great success in treating late-stage lung cancer. However, whether neoadjuvant immunotherapy can facilitate resection of initially locally-advanced and surgically-difficult locally-advanced lung squamous cell carcinoma remains to be investigated. Methods We retrospectively collected clinical records of locally-advanced lung squamous cell carcinoma patients who received neoadjuvant immunotherapy followed by surgery between 2018 and 2020 at a large academic thoracic cancer center. Results A total of 23 patients (22 males, 1 female) with locally-advanced locally-advanced lung squamous cell carcinoma were included, initially clinically staged at IIIA (16, 69.6%), IIIB (n=4, 17.4%), IIB (n=2, 8.7%) and IIIC (n=1, 4.3%). The median interval between final treatment to surgery was 36 days (range, 25-93 days), without treatment-related delay in surgery. The neoadjuvant treatment resulted in a high rate of radical resection (n=20, 87.0%). The final histopathological examination demonstrated 6 (26.1%) cases with pathological complete response and 8 (34.8%) with pathological major response. Comparing with the computed tomography scan-based response, we observed a very low consistency (weighted kappa =0.122, P=0.315) between the computed tomography scan-based and final pathological evaluation. The median follow-up time was 510 days (range, 217-920 days). At the end of the follow-up, 1 patient died. Conclusions Our findings showed the clinical promise of neoadjuvant immunotherapy plus surgery for locally-advanced lung squamous cell carcinoma. Computed tomography scan displays a poor role in assessing the resectability after neoadjuvant immunotherapy

Smoking signature is superior to programmed death-ligand 1 expression in predicting pathological response to neoadjuvant immunotherapy in lung cancer patients.

Background There is a paucity of biomarkers that can predict the degree of pathological response [e.g., pathological complete response (pCR) or major response (pMR)] to immunotherapy. Neoadjuvant immunotherapy provides an ideal setting for exploring responsive biomarkers because the pathological responses can be directly and accurately evaluated. Methods We retrospectively collected the clinicopathological characteristics and treatment outcomes of non-small cell lung cancer (NSCLC) patients who received neoadjuvant immunotherapy or chemo-immunotherapy followed by surgery between 2018 and 2020 at a large academic thoracic cancer center. Clinicopathological factors associated with pathological response were analyzed. Results A total of 39 patients (35 males and 4 females) were included. The most common histological subtype was lung squamous cell carcinoma (LUSC) (n=28, 71.8%), followed by lung adenocarcinoma (LUAD) (n=11, 28.2%). After neoadjuvant treatment, computed tomography (CT) scan-based evaluation showed poor agreement with the postoperatively pathological examination (weighted kappa =0.0225; P=0.795), suggesting the poor performance of CT scans in evaluating the response to immunotherapy. Importantly, we found that the smoking signature displayed a better performance than programmed death-ligand 1 (PD-L1) expression in predicting the pathological response (area under the curve: 0.690 vs. 0.456; P=0.0259), which might have resulted from increased tumor mutational burden (TMB) and/or microsatellite instability (MSI) relating to smoking exposure. Conclusions These findings suggest that CT scan-based evaluation is not able to accurately reflect the pathological response to immunotherapy and that smoking signature is a superior marker to PD-L1 expression in predicting the benefit of immunotherapy in NSCLC patients