Lesioni estese della trachea e dei bronchi principali. Prime esperienze con l’impiego di Polyglycol Acid (PGA) patch riassorbibile

Le lesioni iatrogene della trachea e dei bronchi principali sono molto rare. Il decorso è condizionato principalmente dalla diagnosi precoce, dall’estensione della lesione e da un procedimento curativo adeguato. Nei difetti estesi l’impiego associato di nuovi materiali potrebbe rendere più stabile la sutura iniziale. Metodica e casistica clinica. Sono state esaminate consecutivamente tre lesioni iatrogene della trachea e dei bronchi, che dopo sutura (polidioxanone) sono state ricoperte con Soft PGA Mesh® e fibrina (patch di acido poliglicolico riassorbibile, ZLB Behring Gmbh, Deutschland). Nei primi due pazienti l’ intubazione orotracheale d’urgenza aveva causato una lacerazione longitudinale della parte membranacea della trachea. In una terza paziente (affetta da ileo conseguente a carcinoma del colon in stadio avanzato) ripetuti tentativi di tracheotomia percutanea, in presenza di una trachea deviata da un’arteria lusoria, avevano causato molteplici difetti ed una fistola esofagotracheale di notevoli dimensioni, che venne diagnosticata il giorno successivo. In una quarta paziente la dissezione smussa di un carcinoma dell’esofago in stadio avanzato aveva provocato un’estesa lesione a livello della biforcazione e del bronco principale sinistro. Abbiamo condotto uno studio prospettico sui decorsi. Risultati. I rispettivi trattamenti delle lesioni tracheali mostrarono una tenuta soddisfacente anche se sottoposti a ventilazione meccanica di lunga durata. Il trasferimento in reparto di degenza comune della prima paziente poté essere effetuato dopo 38 giorni di terapia intensiva. La seconda paziente, tetraplegica, venne trasferita in riabilitazione dopo 48 giorni. La terza paziente decedette dopo 15 giorni in seguito ad urosepsi. La quarta paziente, sottoposta a terapia intensiva per 10 giorni, poté essere dimessa dal reparto di degenza comune dopo 23 giorni. Broncoscopie e TC di controllo mostrarono situazioni locali soddisfacenti. Conclusioni. Si constata che l’ulteriore trattamento di lesioni estese della trachea e dei bronchi principali con materiale riassorbibile in forma di patch rende più stabile la sutura iniziale in quanto devia tensioni sopravvenute quali la pressione della cuffia per la ventilazione meccanica

Metastatic renal clear cell carcinoma mimicking stage IV lung cancer

We present a 63-year-old man who was investigated for a lesion in the apex of the left lung and a coexisting osteolytic lesion in the right major trochanter. FNA of the thoracic mass was suggestive for malignancy yet not diagnostic regarding the tumor type and the site of the primary tumor. A diagnosis of a stage IV lung cancer was favored and he underwent a left exploratory thoracotomy in view to resect the primary tumor. An extrapulmonary mass localized to the pleura not involving the ipsilateral lung was disclosed. Multiple biopsies revealed metastatic clear cell RCC. A 5× cm left renal tumor was revealed in a postoperative abdominal CT scan. He was treated with combination of interferon A and vinblastin followed by radical nephrectomy. Twenty-four months after the diagnosis he is alive without evidence of local or distant recurrence. Pleural metastases from RCC are mainly presented as malignant pleural effusions. Thoracic metastatic lesions localized to the pleura, forming solitary or multiple mass(es) have been rarely reported. We review the literature regarding this rare clinical manifestation of the disease and we discuss diagnostic and therapeutic options

Time-dependent mitochondrial-mediated programmed neuronal cell death prolongs survival in sepsis

Objective. To investigate whether apoptosis is a possible mechanism of brain dysfunction occurring in septic syndrome. Design: Experimental prospective study. Setting. Laboratory of Surgical Research at the University of Athens. Subjects: Male pathogen-free Wistar rats. Interventions. Rats (n = 112) were subjected to sepsis by cecal ligation and puncture. Sham-operated animals (n = 40) underwent the same procedure but without ligation or puncture. Septic animals were either randomly divided (n = 62) in six groups and studied at 6,12, 24, 36, 48, and 60 hrs after the operation or monitored (n = 50) for 48 hrs as a survival study group. Sham-operated animals were killed at 6, 12, 24, 36, 48, and 60 hrs after the procedure. Brain and cecum were then removed and postfixed in paraffin sections. Apoptosis was evaluated by light microscopy in hematoxylin and eosin-stained specimens and by transmission electron microscopy. In paraffin-embedded sections, immunostaining for bax, bcl-2, cytochrome c, and caspase-8 was done. Measurements and Main Results., In septic rats, increased apoptosis was detected in neurons of the CA1 region of the hippocampus, in choroid plexus, and in Purkinje cells of the cerebellum. Bax immunopositivity was found decreased after the septic insult (p = .03). Bax immunoreactivity was altered as the septic syndrome evolved; it was up-regulated in the early stages (6-12 hrs) and progressively decreased in the late phases (p = .001). Cytochrome c presented a similar regional pattern of expression and was found to be the sole gene marker carrying an independent prognostic role (p = .03). Both bcl-2 and caspase-8 expression remained at constant levels at all times evaluated. Conclusions. There is evidence that more neurons undergo apoptosis during sepsis than in normal brain tissue in certain sites where the blood-brain barrier is compromised. In this phenomenon, mitochondrial gene regulators such as bax and products such as cytochrome c seem to play important regulating and prognostic roles, respectively