Multiple esophageal leiomyomas: a case report

Background: Primary intramural benign tumors of the esophagus are rare. Leiomyomas are the most common benign esophageal neoplasms. Multiple esophageal leiomyomas are very rare, with only a few reports on more than ten coexisting lesions. Case study: A male patient presented with progressing dysphagia and a tumor of the esophageal wall, over 10 cm in length, confirmed by magnetic resonance imaging and endoscopic ultrasound examination. There were no changes of the esophageal mucosa. Multiple fine needle aspirations were performed with inconclusive finding. Surgical exploration through right thoracotomy revealed multiple extramucosal tumors from 5 to 25 millimeters in size. A total of 16 tumors were removed by enucleation without opening the esophageal mucosa. Postoperative period was uneventful. Conclusion: Exact preoperative diagnosis of esophageal submucosal tumors may be difficult to establish without open biopsy. Removal by enucleation is the treatment of choice

Gastric tube ulcer perforating the pericardium after subtotal esophagectomy [Perforacija ulkusa želučanog supstituta u perikard nakon subtotalne ezofagektomije]

Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature

CYFRA 21-1 in Non-Small Cell Lung Cancer – Standardisation and Application during Diagnosis

There is no ideal tumour marker at present. The clinical application of CYFRA 21-1 is possible once a thorough standardisation process is carried out. Standardisation is achieved by determining the reference range in asymptomatic population, benign and malignant lung diseases, and benign and malignant diseases of other organs. Furthermore, it depends on knowledge of research population characteristics, patient medical histories and individual diagnostic procedure results, the size of research target samples and the clinically defined control groups. The cut-off level of CYFRA 21-1 for non-small cell lung cancer (NSCLC) is 1.72 ng/mL in the Croatian population. It is based on the clinically applicable sensitivity of 78% and specificity of 95% in benign lung diseases. The cut-off value is verified by clinical findings. For clinicians the level of CYFRA 21-1 is an early sign of NSCLC in relation to all the benign lung diseases and all the benign diseases of other organs, of which it was confirmed that they can influence the above level, provided that NSCLC is verified using standard diagnostic methods. The level of CYFRA 21-1 is also influenced by the time of sampling in relation to other diagnostic invasive procedures. The marker is clinically applicable if clinical findings verify it; otherwise, it is useless. This research has involved 343 healthy persons, 474 patients with a benign disease and 4440 patients with a malignant disease, 2453 of whom suffer from NSCLC. The sensitivity of CYFRA 21-1 in NSCLC is 78%, in squamous cell lung cancer (SQC) 84.6%, in adenocarcinomas (AD) 74.3% and in large cell lung cancer (LCC) 75.3%. The level of CYFRA 21-1 differs significantly between healthy persons, benign and malignant diseases (p<10–3). There are differences between the three histological types of NSCLC (p<10–6) and according to T and N (p<10–3). The level of CYFRA 21-1 prompts clinicians to repeat the clinical procedure during diagnosis, and helps to detect the disease earlier and implement treatment in NSCLC. We have achieved high concordance between marker findings and clinical diagnostic

Adenoidni cistični karcinom distalne traheje: prikaz slučaja

Primary malignant tumors of the trachea are very rare with the incidence of less than two per million people per year, and only ten percent of them are adenoid cystic carcinomas. Eighty percent of all tracheal tumors are malignant. Diagnosis is usually late because the symptoms mimic other conditions such as asthma. Clinical picture may sometimes be dramatic when airway is almost closed and emergency recanalization is necessary. Diagnosis is made by chest computed tomography scan or magnetic resonance imaging. Definitive treatment is surgical resection alone or followed by radiation therapy or radiation therapy alone. Radical resection is only accomplished in about half of all cases because of the submucosal tumor growth and limited length of tracheal resection. The role of adjuvant radiation therapy in negative resection margin cases is not clear but all patients with positive resection margin benefit from radiation therapy. We present a case of a 43-year-old patient with primary adenoid cystic carcinoma of distal trachea treated by emergency bronchoscopic recanalization and resection of the tracheal tumor with end-to-end anastomosis.Primarni maligni tumori traheje su iznimno rijetki s incidencijom manjom od dva slučaja na milijun stanovnika u jednoj godini, a adenoidni cistični karcinom čini samo deset posto. Osamdeset posto svih tumora traheje je maligno. Dijagnoza se obično postavlja kasno, jer su početni simptomi slični astmi. Ponekad je klinička slika dramatična kada dođe do opstrukcije dišnog puta i potrebe za hitnom rekanalizacijom. Dijagnoza se potvrđuje kompjutorskom tomografijom prsišta ili magnetnom rezonancom. Definitivno liječenje je resekcija tumora sama ili uz adjuvantnu radioterapiju, ili radioterapija sama. Radikalna resekcija se postiže samo u oko polovice svih slučajeva zbog submukoznog rasta tumora i ograničene duljine resekcije traheje. Uloga adjuvantne radioterapije u slučajevima s negativnim resekcijskim rubom je nejasna, dok svi bolesnici s pozitivnim resekcijskim rubom imaju koristi od adjuvantne radioterapije. Prikazujemo slučaj 43-godišnjeg bolesnika s adenoidnim cističnim karcinomom distalnog dijela traheje koji je liječen bronhoskopskom rekanalizacijom i resekcijom traheje s terminoterminalnom anastomozom

Adenoidni cistični karcinom distalne traheje: prikaz slučaja

Primary malignant tumors of the trachea are very rare with the incidence of less than two per million people per year, and only ten percent of them are adenoid cystic carcinomas. Eighty percent of all tracheal tumors are malignant. Diagnosis is usually late because the symptoms mimic other conditions such as asthma. Clinical picture may sometimes be dramatic when airway is almost closed and emergency recanalization is necessary. Diagnosis is made by chest computed tomography scan or magnetic resonance imaging. Definitive treatment is surgical resection alone or followed by radiation therapy or radiation therapy alone. Radical resection is only accomplished in about half of all cases because of the submucosal tumor growth and limited length of tracheal resection. The role of adjuvant radiation therapy in negative resection margin cases is not clear but all patients with positive resection margin benefit from radiation therapy. We present a case of a 43-year-old patient with primary adenoid cystic carcinoma of distal trachea treated by emergency bronchoscopic recanalization and resection of the tracheal tumor with end-to-end anastomosis.Primarni maligni tumori traheje su iznimno rijetki s incidencijom manjom od dva slučaja na milijun stanovnika u jednoj godini, a adenoidni cistični karcinom čini samo deset posto. Osamdeset posto svih tumora traheje je maligno. Dijagnoza se obično postavlja kasno, jer su početni simptomi slični astmi. Ponekad je klinička slika dramatična kada dođe do opstrukcije dišnog puta i potrebe za hitnom rekanalizacijom. Dijagnoza se potvrđuje kompjutorskom tomografijom prsišta ili magnetnom rezonancom. Definitivno liječenje je resekcija tumora sama ili uz adjuvantnu radioterapiju, ili radioterapija sama. Radikalna resekcija se postiže samo u oko polovice svih slučajeva zbog submukoznog rasta tumora i ograničene duljine resekcije traheje. Uloga adjuvantne radioterapije u slučajevima s negativnim resekcijskim rubom je nejasna, dok svi bolesnici s pozitivnim resekcijskim rubom imaju koristi od adjuvantne radioterapije. Prikazujemo slučaj 43-godišnjeg bolesnika s adenoidnim cističnim karcinomom distalnog dijela traheje koji je liječen bronhoskopskom rekanalizacijom i resekcijom traheje s terminoterminalnom anastomozom

Intraoperative volume restriction in esophageal cancer surgery: an exploratory randomized clinical trial

Aim To investigate whether the fluid volume administered during esophageal cancer surgery affects pulmonary gas exchange and tissue perfusion. Methods An exploratory single-center randomized clinical trial was performed. Patients with esophageal cancer who underwent Lewis-Tanner procedure between June 2011 and August 2012 at the Department of Thoracic surgery “Jordanovac”, Zagreb were analyzed. Patients were randomized (1:1) to receive a restrictive volume of intraoperative fluid (≤8 mL/kg/h) or a liberal volume (>8 mL/kg/h). Changes in oxygen partial pressure (Pao2), inspired oxygen fraction (FiO2), creatinine, and lactate were measured during and after surgery. Results Overall 16 patients were randomized and they all were analyzed (restrictive group n = 8, liberal group n = 8). The baseline value Pao2/FiO2 ratio (restrictive) was 345.01 ± 35.31 and the value six hours after extubation was 315.51 ± 32.91; the baseline Pao2/FiO2 ratio (liberal) was 330.11 ± 34.71 and the value six hours after extubation was 307.11 ± 30.31. The baseline creatinine value (restrictive) was 91.91 ± 12.67 and the value six hours after extubation was 100.88 ± 18.33; the baseline creatinine value (liberal) was 90.88 ± 14.99 and the value six hours after extubation was 93.51 ± 16.37. The baseline lactate value (restrictive) was 3.93 ± 1.33 and the value six hours after extubation was 2.69 ± 0.91. The baseline lactate value (liberal) was 3.26 ± 1.25 and the value six hours after extubation was 2.40 ± 1.08. The two groups showed no significant differences in Pao2/FiO2 ratio (P = 0.410), creatinine (P = 0.410), or lactate (P = 0.574). Conclusions Restriction of intraoperative applied volume does not significantly affect pulmonary exchange function or tissue perfusion in patients undergoing surgical treatment for esophageal cancer

Descendentni nekrotizirajući medijastinitis

Descending necrotizing mediastinitis is a severe septic infection of the mediastinum, mostly resulting from an infectious process originating from the neck or oral cavity. The mortality rate associated with descending necrotizing mediastinitis remains high (>40%) in spite of the current medical and surgical treatment options. The disease may occur at any age and in either sex. Early diagnosis is of utmost importance to immediately initiate intensive antibiotic therapy or surgical intervention in case of the infectious process descent to the thoracic cavity. A patient with descending necrotizing mediastinitis, initially treated with antibiotic therapy followed by surgical intervention due to the disease propagation, is presented. Intraoperatively, a life threatening complication of the left venous angle erosion developed.Descendentni nekrotizirajući medijastinitis je ozbiljna gnojna infekcija medijastinuma koja najčešće nastaje spuštanjem infekta iz područja usne šupljine ili vrata. Smrtnost je i dalje vrlo visoka (preko 40%) usprkos današnjim mogućnostima liječenja konzervativnim ili kirurškim putem. Bolest se može pojaviti kod svih dobnih skupina, kako kod muškaraca tako i kod žena. U liječenju bolesti najvažnije je rano postavljanje dijagnoze kako bi se odmah započela intenzivna antibiotska terapija, a u slučaju spuštanja gnojnog procesa u prsni koš kirurška intervencija. Prikazuje se bolesnik s descendentnim nekrotizirajućim medijastinitisom koji je u početku liječen antibioticima, a zbog propagacije bolesti i kirurškim zahvatom. Tijekom kirurškog zahvata razvila se za život opasna komplikacija, erozija lijevostranog venskog spoja

Videotorakoskopska biopsija pluća i pleure u dijagnostici kroničnih izljeva prsišta

Chronic pleural effusion requires pleural and lung biopsy in more than 60% of patients. Open lung biopsy was formerly considered as the most reliable diagnostic method, whereas now the procedure is mostly performed via video-assisted thoracoscopy. During the last ten-year period (1995­-2005), 96 patients aged 31-72 (mean age 53) years were operated on at University Department of Thoracic Surgery, Jordanovac University Hospital for Lung Diseases by video-assisted thoracoscopy in general anesthesia. All biopsies were done by clamp sampling from parietal or visceral pleura, and in 31 patients lung tissue was sampled by endostapler wedge resection. Conversion to mini-thoracotomy was needed in only 12 patients, due to massive adhesions. Tissue samples were referred for histopathologic analysis. After the procedure, the patients had a thoracic drain connected to negative pressure. Histopathologic diagnosis was made in almost all patients, yielding a 97% success rate. In 16 patients, drain airflow had to be prolonged to more than 5 days, while the mean drainage duration was 4 days and mean hospital stay 8 days. Talc pleurodesis was performed in most patients with malignant effusion to stop effusion accumulation. Video-assisted thoracoscopic biopsy allows for adequate pleural and lung sampling with a high rate of accuracy. Postoperative mortality and morbidity are lower in comparison with open lung biopsy. It is concluded that video-assisted thoracoscopic biopsy is an efficient and safe method in the diagnosis of chronic pleural effusion.Dugotrajni izljevi pleuralne šupljine zahtijevaju biopsiju pleure i pluća kod više od 60% bolesnika. Ranije se otvorena biopsija pluća smatrala najpouzdanijom dijagnostičkom metodom, dok se danas taj zahvat najčešće izvodi videotorakoskopskim putem. U zadnjih deset godina, od 1995. do 2005. godine, u Klinici za torakalnu kirurgiju "Jordanovac" operirano je videotorakoskopskim načinom 96 bolesnika u općoj anesteziji. Prosječna životna dob bila je 53 godine, s rasponom od 31-72 godina. Sve biopsije su rađene uzimanjem uzoraka hvataljkom s parijetalne ili visceralne pleure, a kod 31 bolesnika uzet je i komadić plućevine klinastom resekcijom uz pomoć endostaplera. Samo kod 12 bolesnika učinjena je konverzija u minitorakotomiju zbog opsežnih priraslica. Svi uzorci su upućeni na patohistološku analizu. Nakon zahvata svaki bolesnik je imao torakalni dren koji je spojen na negativni tlak. Histopatološka dijagnoza postavljena je kod gotovo svih bolesnika, tako da je uspješnost zahvata bila 97%. Kod 16 bolesnika postojao je produženi protok zraka na dren kroz više od pet dana, dok je prosječno vrijeme drenaže iznosilo 4 dana, a prosječni boravak u bolnici 8 dana. Kod većine bolesnika s malignim izljevom rađena je pleurodeza talkom kako bi prestalo nakupljanje izljeva. Videotorakoskopska biopsija omogućava uzimanje kvalitetnog uzorka pleure i plućevine (bioptata) uz visok postotak točnosti. Poslijeoperacijska smrtnost i pobol bili su niži nego kod otvorene biopsije pluća. Zaključak je da je videotorakoskopska biopsija pluća učinkovita i sigurna metoda u dijagnostici kroničnog pleuralnog izljeva

Profilaksa poslijeoperacijske atrijske fibrilacije i resekcija pluća – naša iskustva sa 608 uzastopnih bolesnika

Postoperative atrial fibrillation is a common complication after lung resection. It is burdened by increased mortality and morbidity, prolonged hospitalization, and higher resource utilization in thoracic surgery patients. Therefore, some kind of pharmacological prophylaxis is recommended. In our patients, diltiazem, a calcium antagonist, is administered. We collected data on all 608 patients having undergone lung resection (no less than lobectomy) between November 2012 and May 2015. This period included patients having received diltiazem during their postoperative stay in our Intensive Care Unit and surgical ward, and those that did not receive it. Patients having had atrial fibrillation before the surgery and patients with cardiac pacemaker were excluded from the trial. Other patients were divided into three groups: patients with some kind of antiarrhythmic therapy before and continued after the surgery; patients with diltiazem prophylaxis; and patients without any antiarrhythmic prophylaxis. Th e data collected were statistically analyzed. We found no statistically significant difference in the incidence of postoperative atrial fibrillation among the groups (p<0.05).Poslijeoperacijska atrijska fibrilacija je česta komplikacija resekcije pluća. Ona dovodi do povišenog pobola i smrtnosti, produljenog bolničkog liječenja i povećane potrošnje sredstava u torakokirurških bolesnika. U skladu s tim, savjetuje se neki oblik farmakološke profilakse. U naših bolesnika odabrani lijek je kalcijev antagonist diltiazem. Skupili smo podatke o svih 608 bolesnika podvrgnutih resekciji pluća (ne manjoj od lobektomije) u razdoblju između studenog 2012. i svibnja 2015. Ovo razdoblje uključuje bolesnike koji su primali diltiazem tijekom njihova poslijeoperacijskog boravka u Jedinici intenzivnog liječenja i na kirurškom odjelu te bolesnike koji ga nisu primali. Bolesnici s atrijskom fibrilacijom prije operacije i bolesnici s elektrostimulatorom srca isključeni su iz obrade. Ostali bolesnici podijeljeni su u tri skupine: skupinu liječenu nekim antiaritmikom prije operacije koji su nastavili svoju terapiju i nakon operativnog zahvata, skupinu na profilaksi diltiazemom i skupinu bez profilakse. Skupljeni podaci su statistički analizirani. Nismo našli statistički značajnu razliku između skupina u incidenciji poslijeoperacijske atrijske fibrilacije (p<0,05)

Our Experience in the Management of Congenital Chest Wall Deformities

Deformiteti stijenke prsnog koša su relativno rijetke bolesti nepoznate etiologije koje se javljaju u djetinjstvu i adolescenciji. Primjetna je obiteljska pojavnost deformiteta uz vrlo rijetko spontano izlječenje. Kirurško liječenje predstavlja jedinu mogućnost ispravljanja deformiteta bilo klasičnim operacijskim načinom ili minimalno invazivnom metodom liječenja (endoskopskim putem). Među kirurzima nema ujednačenog stava o tome u kojem je životom razdoblju najbolje učiniti ispravljanje deformiteta, jer su rezultati vrlo dobri bez obzira na primijenjenu metodu liječenja. U ovom radu prikazani su rezultati liječenja kod 105 bolesnika operiranih klasičnim načinom između 1985. i 2005. godine u Klinici za torakalnu kirurgiju Kliničke bolnice za plućne bolesti „Jordanovac“.Chest wall deformities are relatively rare diseases of unknown etiology, which occur in childhood and adolescence. Pectus deformities show familial occurrence with very rare spontaneous resolution. Operative treatment is one of the possible therapeutic options for deformity correction by classic operative procedure or by minimally invasive method of treatment (endoscopic). There is no consensus among surgeons about the age at which correction of the chest wall deformity should best be performed because therapeutic results are very good irrespective of the method of treatment employed. Therapeutic results in 105 patients operated on by the classic method during the 1985-2005 period at University Department of Thoracic Surgery, Jordanovac University Hospital for Lung Diseases in Zagreb, Croatia, are reported