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

Robotic lobectomy: tips, pitfalls and troubleshooting

The robotic approach in thoracic surgery has rapidly gained popularity in recent years. As with the introduction of any new technology, this warrants not only adaptation of the operative technique itself, but also the evolution of appropriate troubleshooting strategies. A selected number of helpful tips and technical procedural manoeuvres have been compiled to prevent intraoperative problems, as well as to overcome challenging situations that can arise during robotic lobectomies. In robotic surgery, as opposed to open surgery or video-assisted thoracic surgery, these tips serve an important purpose for the operating surgeon, as well as the entire surgical team involved in the procedure. All the assembled recommendations have proved their effectiveness and have been successfully used by the authors in many procedures. Furthermore, these manoeuvres have been found to be of great importance in the training and proctoring of thoracic surgeons, fellows and residents (bed-side assistants). This guide of clearly arranged tips and troubleshooting strategies offers surgeons a useful tool to overcome difficult situations in robotic lobectomy and preferably improve the reproducibility and safety of their procedure

Combination of endobronchial bronchoscopic debulking and bronchoplastic segmentectomy of an obstructive neuroendocrine tumour: probably the least invasive approach.

We report the case of a female patient with an obstructing well-differentiated neuroendocrine tumour in the apical segment of the completely atelectatic right lower lobe. Bronchoscopic debulking of the tumour lead to re-ventilation of the remaining lobe, allowing to perform a lung-sparing bronchoplastic resection of the affected segment by uniportal video-assisted thoracic surgery

Diffuse descending necrotizing mediastinitis: surgical therapy and outcome in a single-centre series

OBJECTIVES Descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical infections. The aim of this article was to give an up-to-date overview on this still underestimated disease, to draw the clinician's attention and particularly to highlight the need for rapid diagnosis and adequate surgical treatment. METHODS We present a retrospective analysis of 17 patients diagnosed and treated for advanced DNM between 1999 and 2011 in a tertiary referral medical centre. Hence, this is one of the largest single-centre studies in recent years concerning the diffuse form (i.e. extending into the lower mediastinum) of DNM. Subsequently, we analysed and compared the international literature with our data, with the focus on surgical management and outcome. RESULTS In our series of 17 adult patients, 16 were surgically treated by median sternotomy (n=8) or the clamshell (n=8) approach for diffuse DNM. One patient, referred with septic shock, died 2 days after surgery. The median interval from diagnosis of DNM by cervicothoracic computed tomography scan and thoracic surgery was 6h (range 1-24h) in all but the one patient with fatal outcome (48h). Concomitant cervicotomy was performed in 11 patients (65%) and tracheotomy in 9 (53%). The median duration of hospitalization was 16 days (range 4-50 days), including an intensive care unit stay of 4 days (range 1-50 days). CONCLUSIONS For DNM limited to the upper part of the mediastinum, which applies to the majority of cases, a transcervical approach and drainage may be sufficient. In advanced disease, extending below the tracheal carina, an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients. A timely situational approach via median sternotomy or a clamshell incision allowed us to maintain a very low morbidity, mortality and rate of reoperations, without major complications due to the surgical approach itsel

True aneurysm of the peripheral pulmonary artery due to necrotizing giant cell arteritis

Pulmonary artery aneurysm in adults is a rare diagnosis. Most cases described in the literature are either associated with congenital heart disease or pulmonal arterial hypertension, respectively, or are not true aneurysms but rather pseudoaneurysms, which are usually iatrogenic. We present the case of a 68-year old female patient with the incidental finding of a true aneurysm of the right peripheral pulmonary artery with a maximum diameter of 4 cm. With increasing aneurysm diameter over time, the decision for a surgical resection was made. Complete resection of the aneurysm including lower lobe resection was performed. Histopathological examination showed necrotizing giant cell arteritis as the underlying cause. The postoperative course was uneventful and no signs of further disease activity were detected. To our knowledge, this is the first reported case of a pulmonary artery aneurysm caused by giant cell arteritis, whereas it should be noted that the distinction between Takayasu arteritis and giant cell arteritis is not clearly defined. Considering the high mortality associated with aneurysm rupture, surveillance is advocated for small aneurysms, whereas for larger aneurysms and those showing signs of progression in size despite medical therapy or even dissection, surgical intervention should be considere

A Breakthrough Brought about by Targeting KRASG12C: Nonconformity Is Punished.

KRAS is the most frequently mutated oncogene in lung carcinomas, accounting for 25% of total incidence, with half of them being KRASG12C mutations. In past decades, KRAS enjoyed the notorious reputation of being untargetable-that is, until the advent of G12C inhibitors, which put an end to this legend by covalently targeting the G12C (glycine to cysteine) substitution in the switch-II pocket of the protein, inhibiting the affinity of the mutant KRAS with GTP and subsequently the downstream signaling pathways, such as Raf/MEK/ERK. KRASG12C-selective inhibitors, e.g., the FDA-approved AMG510 and MRTX849, have demonstrated potent clinical efficacy and selectivity in patients with KRASG12C-driven cancers only, which spares other driver KRAS mutations (e.g., G12D/V/S, G13D, and Q61H) and has ushered in an unprecedented breakthrough in the field in recent decades. However, accumulating evidence from preclinical and clinical studies has shown that G12C-targeted therapeutics as single agents are inevitably thwarted by drug resistance, a persistent problem associated with targeted therapies. A promising strategy to optimize G12C inhibitor therapy is combination treatments with other therapeutic agents, the identification of which is empowered by the insightful appreciation of compensatory signaling pathways or evasive mechanisms, such as those that attenuate immune responses. Here, we review recent advances in targeting KRASG12C and discuss the challenges of KRASG12C inhibitor therapy, as well as future directions

Operative versus non-operative management of rib fractures in flail chest after cardiopulmonary resuscitation manoeuvres

OBJECTIVES: Blunt chest trauma after mechanical resuscitation manoeuvres appears to have a significant impact on the often complicated course. Due to a lack of data in the literature, the purpose of this study was to investigate the feasibility and immediate outcome of chest wall stabilization for flail chest in this vulnerable patient population. METHODS: We retrospectively reviewed the medical records of patients after cardiopulmonary resuscitation between January 2014 and December 2018 who were diagnosed with flail chest. We attempted to compare patients after surgery with those after conservative treatment. RESULTS: Of a total of 56 patients with blunt chest trauma after mechanical resuscitation and after coronary angiography, 25 were diagnosed with flail chest. After the exclusion of 2 patients because of an initial decision to palliate, 13 patients after surgical stabilization could be compared with 10 patients after conservative therapy. Although there was no significant difference in the total duration of ventilatory support, there was a significant advantage when the time after stabilization to extubation was compared with the duration of ventilation in the conservative group. The presence of pulmonary contusion, poor Glasgow Coma Scale score or the development of pneumonia negatively affected the outcome, but additional sternal fracture did not. CONCLUSIONS: Surgical stabilization for chest wall instability is well tolerated even by this vulnerable patient population. Our results should be used for further randomized controlled approaches. It is necessary to evaluate the situation with all parameters in an interdisciplinary manner and to decide on a possible surgical therapy at an early stage if possible

Surgical smoke: modern mobile smoke evacuation systems improve occupational safety in the operating theatre.

OBJECTIVES Evaluation of smoke capture efficiency of different mobile smoke evacuation devices with respect to volatile organic compounds and their noise emission. METHODS Electrosurgical incisions were performed on fresh porcine liver in an operating room with vertical laminar flow. The generated surgical smoke was analysed with proton-transfer-reaction mass spectrometry with and without the use of a mobile smoke evacuation system consisting of a smoke evacuator machine, a suction hose and a handpiece. The inlet of the mass spectrometer was positioned 40 cm above the specimen. Various devices were compared: a hard plastic funnel, a flexible foam funnel, an on-tip integrated aspirator of an electrosurgical knife and a standard secretion suction (Yankauer). Also, sound levels were measured at a distance of 40 cm from the handpieces' inlet. RESULTS The smoke capture efficiency of the secretion suction was only 53%, while foam funnel, plastic funnel and integrated aspirator were all significantly more effective with a clearance of 95%, 91% and 91%, respectively. The mean sound levels were 68 and 59 A-weighted decibels with the plastic and foam funnel, respectively, 66 A-weighted decibels with the integrated aspirator and 63 A-weighted decibels with the secretion suction. CONCLUSIONS Carcinogenic, mutagenic and reprotoxic volatile organic compounds in surgical smoke can be efficiently reduced by mobile smoke evacuation system, providing improved protection for medical personnel. Devices specifically designed for smoke evacuation are more efficient than standard suction tools. Noise exposure for the surgeon was lowest with the flexible foam funnel and higher with the other handpieces tested

Successful thoracoscopic management of iatrogenic left subclavian arterial injury: a case report.

The subclavian artery at the thoracic outlet is in the deepest position of the thoracic cavity and is difficult to repair in this narrow space once injured, even if the surgery is converted to a thoracotomy. This article presents a successful left subclavian artery repair procedure at the thoracic outlet using a thoracoscopic approach, with a video demonstration, and describes its technical characteristics. The patient was planned for a left upper lobectomy through three-port thoracoscopic approach. Severe adhesions were found intraoperatively and an accidental left subclavian arterial injury occurred when dissecting the adhesions. We first clamped the proximal portion of the subclavian artery and then directly clamped the rupture site. Our first suture failed due to the limited suture angle and the mutual restriction between the needle holder and atraumatic vascular clamp. To freely control the needle holder, another assistant port was made in the seventh intercostal space (ICS). The arterial injury was finally successfully repaired using pledgetted suture. The operation time was 235 minutes and intraoperative blood loss was 800 mL. The pulsation of the left radial artery was normal postoperatively, and the patient was discharged on postoperative day 6. Appropriate strategies allow attempts to manage intraoperative hyperbaric arterial bleeding from the systemic circulation, such as bleeding caused by subclavian arterial injuries, by means of a thoracoscopic approach without conversion to thoracotomy