Late Epiphrenic-Retroperitoneal Fistula of an Esophageal Diverticulum Ten Years after Surgical Excision: Report of the First Case

Background: Esophageal fistula is a rare complication of an epiphrenic diverticulum and represents a difficult diagnostic challenge. In the majority of cases in the English literature, the fistula is secondary to the spontaneous perforation of the epiphrenic diverticulum and in only one case an esophagobronchial fistula occurs after resection of an epiphrenic diverticulum. No case of esophageal fistula communicating with the retroperitoneum tissues was found. Case Report: We present a case of 84 years old male admitted in 2017 in our Hospital for the appearance of epigastralgia and cough with traces of blood to sputum, asthenia and night sweats. Ten years before he underwent to a hiatal hernia plastic sec. Nissen and subsequently was reoperated for exeresis of diverticulum of the distal third of the esophagus by thoracotomy. In August 2008, because of esophageal substenosis an operation of posterior gastropexy sec. Hill with the demolition of the previous hiatoplasty was performed. In 2017, a computerized tomography shows a voluminous abscess in the right paravertebral region with development along the muscular plane of the ipsilateral psoas and a fistular path of about 4 cm between the posterior wall of the esophagus and the retroperitoneal collection of the abdomen. Conclusions: Esophageal fistula represents a complex problem of epiphrenic diverticulum and rarely a hidden complication of surgery. Surgery is the treatment of choice in suitable patients

A case of cervico-mediastinal paraganglioma mimicking an ectopic goiter

Introduction and importance: Mediastinal paragangliomas are rare neuroendocrine tumors that originate from extra-adrenal paraganglia, occasionally secreting catecholamines. Nonfunctional mediastinal paragangliomas present nonspecific clinical and radiological features and represent a diagnostic challenge. Case presentation: A 53-year old woman presented with cough and dyspnea increasing over time. CT-scan and ultrasonography showed a large vascularized cervico-mediastinal mass, consistent with an intrathoracic ectopic goiter. Preoperative angiography showed a blood supply from neck vessels. The lesion was completely removed through a cervical approach. The diagnosis of paraganglioma was a histological surprise. The patient is alive without recurrence 30 months after surgery. Clinical discussion: When preoperatively diagnosed, the treatment of choice of a mediastinal paraganglioma is surgical excision. However, a preoperative diagnosis of mediastinal paraganglioma is difficult to obtain, especially in cases of nonfunctional lesions. Distinction between an intrathoracic goiter and a nonfunctional paraganglioma can be extremely difficult and, given the rarity of the latter, an ectopic goiter is suspected in first instance. CT-scan and ultrasonography are of little use in the differential diagnosis. However, scintigraphy with 123I-metaiodobenzylguanidine can be an useful diagnostic tool when a paraganglioma is suspected. In case of vascularized cervico-mediastinal mass, such as paragangliomas or intrathoracic goiter, preoperative angiography should be performed to study the blood supply and orient the surgical approach. Conclusion: Although uncommon, paragangliomas should be considered in the differential diagnosis of mediastinal masses, especially when an ectopic goiter is suspected

Micro-Fragmented Adipose Tissue: A New Minimally Invasive Method for Treatment of Anal Fistula? A Pilot Study

The treatment of Anal fistula continues to be one of the most challenging clinical problems in anorectal surgery. Many sphincter-preserving procedures for the treatment of anal fistula have been recently introduced with the common goal of minimising the injury to the anal sphincters and preserving optimal function. Micro-fragmented adipose tissue injection associated closure of the internal opening with Lipogems® technique is one of them. The properties of autologous adipose-derived stem cells for regenerating tissues and suppressing inflammatory response must be better investigated on anal fistulae, and studies remain in progress. The aim of the present article is to evaluate the safety and efficacy of autologous, micro-fragmented and minimally manipulated adipose tissue injection associated with closure of the internal opening in promoting anal fistula healing

Pancreaticoduodenal Artery Aneurysm Ruptured into Duodenum, Associated with Celiac Trunk Stenosis. Case Report and Review of Literature

Pancreaticoduodenal artery (PDA) aneurysm associated with a celiac artery (CA) occlusion or stenosis is an uncommon event. We report the case of a 63-years old man who presented with acute abdominal pain radiating to the back. During the hospital stay, the patient had an episode of severe hematemesis. He had a gastroscopy and then a surgical exploration. However only with arteriography we found a PDA, which had ruptured into duodenum. The aneurysm was associated with a stenosis of the celiac trunk and was supplied by a dense network of collateral vessels from the SMA. The patient was successfully treated with embolization and was discharged on the 64th postoperative day. Short term and mid term follow-up was uneventful. This case shows the difficulty in diagnosing these rare events in time, indicating that angiography is indispensable to establish a diagnosis and enable nonsurgical treatment

Technical results, clinical efficacy and predictors of outcome of intercostal arteries embolization for hemothorax: A two-institutions’ experience

Background: To evaluate the clinical efficacy and identify the predictors of outcome of intercostal arterial embolization for hemothorax caused by intercostal artery (ICA) injuries. Methods: A retrospective multi-institutional study was conducted. Outcomes were analyzed in 30 consecutive patients presenting with hemothorax caused by active ICA hemorrhage undergoing transcatheter arterial embolization (TAE). Clinical and procedural parameters were compared between outcomes groups. Results: Overall technical success rate was 87% (n=26). Among the 4 failed cases, 2 underwent repeated TAE and 2 underwent additional surgery. Overall 30-day mortality rate was 23%. Low haemoglobin levels and haematocrit, hepatic comorbidities and more than one artery undergoing embolization increased technical failure rate significantly. Survival was poorer in patients with massive bleeding. Conclusions: ICA embolization was found to be a safe and effective method in treating hemothorax caused by active ICA haemorrhage. Careful pre-embolization evaluation may be required for patient with low haemoglobin levels and haematocrit, hepatic comorbidities and active haemorrhage from more than one artery

Phospho-p38 MAPK expression in COPD patients and asthmatics and in challenged bronchial epithelium

Background: The role of mitogen-activated protein kinases (MAPK) in regulating the inflammatory response in the airways of patients with chronic obstructive pulmonary disease (COPD) and asthmatic patients is unclear. Objectives: To investigate the expression of activated MAPK in lungs of COPD patients and in bronchial biopsies of asthmatic patients and to study MAPK expression in bronchial epithelial cells in response to oxidative and inflammatory stimuli. Methods: Immunohistochemical expression of phospho (p)-p38 MAPK, p-JNK1 and p-ERK1/2 was measured in bronchial mucosa in patients with mild/moderate (n = 17), severe/very severe (n = 16) stable COPD, control smokers (n = 16), control non-smokers (n = 9), in mild asthma (n = 9) and in peripheral airways from COPD patients (n = 15) and control smokers (n = 15). Interleukin (IL)-8 and MAPK mRNA was measured in stimulated 16HBE cells. Results: No significant differences in p-p38 MAPK, p-JNK or p-ERK1/2 expression were seen in bronchial biopsies and peripheral airways between COPD and control subjects. Asthmatics showed increased submucosal p-p38 MAPK expression compared to COPD patients (p 2O2), cytomix (tumour necrosis factor-\u3b1 + IL-1\u3b2 + interferon-\u3b3) and lipopolysaccharide (LPS) upregulated IL-8 mRNA at 1 or 2 h. p38 MAPK\u3b1 mRNA was significantly increased after H2O2 and LPS treatment. JNK1 and ERK1 mRNA were unchanged after H2O2, cytomix or LPS treatments. Conclusion: p-p38 MAPK expression is similar in stable COPD and control subjects but increased in the bronchi of mild asthmatics compared to stable COPD patients. p38 MAPK mRNA is increased after bronchial epithelial challenges in vitro. These data together suggest a potential role for this MAPK in Th2 inflammation and possibly during COPD exacerbations

MTOR, p70S6K, AKT, and ERK1/2 levels predict sensitivity to mTOR and PI3K/mTOR inhibitors in human bronchial carcinoids

Bronchial carcinoids (BCs) are rare neuroendocrine tumors that are still orphans of medical treatment. Human BC primary cultures may display resistance to everolimus, an inhibitor of the mammalian target of rapamycin (mTOR), in terms of cell viability reduction. Our aim was to assess whether the novel dual phosphatidylinositol 3-kinase (PI3K)/mTOR inhibitor NVP-BEZ235 is effective in everolimus-resistant human BC tissues and cell lines. In addition, we searched for possible markers of the efficacy of mTOR inhibitors that may help in identifying the patients who may benefit from treatment with mTOR inhibitors, sparing them from ineffective therapy. We found that NVP-BEZ235 is twice as potent as everolimus in reducing cell viability and activating apoptosis in human BC tissues that display sensitivity to mTOR inhibitors, but is not effective in everolimus-resistant BC tissues and cell lines that bypass cyclin D1 downregulation and escape G0/G1 blockade. Rebound AKT activation was not observed in response to treatment with either mTOR inhibitor in the 'resistant' BC cells. In addition to total mTOR levels, putative markers of the sensitivity of BCs to mTOR inhibitors are represented by AKT, p70S6K (RPS6KB2), and ERK1/2 (MAPK3/1) protein levels. Finally, we validated these markers in an independent BC group. These data indicate that the dual PI3K/mTOR inhibitor NVP-BEZ235 is more potent than everolimus in reducing the proliferation of human BC cells. 'Resistant' cells display lower levels of mTOR, p70S6K, AKT, and ERK1/2, indicating that these proteins may be useful as predictive markers of resistance to mTOR and PI3K/mTOR inhibitors in human BCs. \ua9 2013 Society for Endocrinology

Ectopic thymoma simulating a pericardial cyst

We present a case of a 53 year old man with a thymoma near the pericardium, a rare ectopic localisation of thymoma. A round radiodensity found at the right cardiophrenic angle was initially suspected at the echocardiography to be a pericardial cyst. The diagnosis of thymoma was made only after histopathological examination of the surgically re-sected lesion