A case of transmesocolic hernia in elderly person without a history of operation]

Internal hernia is defined as the herniation of viscera through an anatomic or pathologic opening within the boundaries of peritoneal cavity. Transmesocolic hernia, a subtype of internal hernia, has a herniated sac through the transverse mesocolon. Transmesocolic hernia has been rarely described in the literature, and most of reported cases were associated with a history of operation or congenital anormaly. A 72-year-old female with chronic intermittent abdominal pain and bloating was admitted. Small bowel series showed multiple jejunal loops confined to the left upper quadrant of abdomen. Abdomen spiral computed tomography (CT) showed a cluster of mildly dilated small bowel loops with mesenteries on the same area. On the three-dimensional reconstruction CT scan, a herniated sac through the transverse mesocolon was identified. She was diagnosed as transmesocolic hernia by using the three-dimensional reconstruction CT and small bowel series, without surgical exploration. The symptoms were managed with conservative measures.     

Congenital diaphragmatic hernia presenting as massive gastrothorax

Delayed herniation of abdominal contents through a congenital diaphragmatic hernia may occur beyond the neonatal period. The case of a 29-month-old child with a Bochdalek hernia presenting as acute respiratory failure is presented. Chest radiography showed a tension gastrothorax that was misread as a tension pneumothorax. Tube thoracostomy resulted in clinical improvement by perforating and decompressing the stomach. Nasogastric tube placement confirmed herniation of the stomach into the left chest and is the initial treatment of choice when a tension gastrothorax is identified. A congenital diaphragmatic hernia must be recognized promptly so that rapid gastric decompression and surgical repair of the diaphragmatic defect can be performed.     

Ultrasonographic evaluation of neck and supraclavicular lymph nodes metastasized from lung cancer.

The significance of ultrasonography in the evaluation of metastasized neck and supraclavicular lymph nodes from lung cancer was analyzed. By ultrasonography, the lymph nodes could be visualized clearly as low-echogenic round areas, and the size could be precisely measured in three dimensions. It was also possible to diagnose whether or not the lymph node adhered to the surrounding tissues and to determine the relationship and the connection of supraclavicular lymph node and upper mediastinal lymph node. The therapeutic effect related to the size of the lymph node was evaluable by ultrasonography. Therefore, the ultrasonographic approach to the neck and supraclavicular lymph nodes metastasized from lung cancer is considered to be useful for clinical use.     

Laparoscopic transhiatal approach for resection of an adenocarcinoma in long-segment Barrett's esophagus

Barrett's esophagus(BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcinoma arising in long-segment BE(LSBE) associated with a hiatal hernia that was successfully treated with a laparoscopic transhiatal approach(LTHA) without thoracotomy. The patient was a 42-year-old male who had previously undergone laryngectomy and tracheal separation to avoid repeated aspiration pneumonitis. An ulcerative lesion was found in a hiatal hernia by endoscopy and superficial esophageal cancer was also detected in the lower thoracic esophagus. The histopathological diagnosis of biopsy samples from both lesions was adenocarcinoma. There were difficulties with the thoracic approach because the patient had severe kyphosis and muscular contractures from cerebral palsy. Therefore, we performed subtotal esophagectomy by LTHA without thoracotomy. Using hand-assisted laparoscopic surgery, the esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. A hernial sac was identified on the cranial side of the right crus of the diaphragm and carefully separated from the surrounding tissues. Abruption of the thoracic esophagus was performed up to the level of thearch of the azygos vein via LTHA. A cervical incision was made in the left side of the permanent tracheal stoma, the cervical esophagus was divided, and gastric tube reconstruction was performed via a posterior mediastinal route. The operative time was 175 min, and there was 61 m L of intra-operative bleeding. A histopathological examination revealed superficial adenocarcinoma in LSBE. Our surgical procedure provided a good surgical view and can be safely applied to patients with a hiatal hernia and kyphosis.     

Congenital diaphragmatic hernia: respiratory and vascular outcomes

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly associated with a variable degree of pulmonary hypoplasia (PH) and persistent pulmonary hypertension (PPH). Despite remarkable advances in neonatal resuscitation and intensive care, and new postnatal treatment strategies, the rates of mortality and morbidity in the newborn with CDH remain high as the result of severe respiratory failure secondary to PH and PPH. Later, lung function assessments show obstructive and restrictive impairments due to altered lung structure and lung damage due to prolonged ventilatory support. The long-term consequences of pulmonary hypertension are unknown. Other problems include chronic pulmonary aspiration caused by gastro-oesophageal reflux and respiratory manifestations of allergy such as asthma or rhinitis. Finally, failure to thrive may be caused by increased caloric requirements due to pulmonary morbidity. Follow-up studies that systematically assess long-term sequelae are needed. Based on such studies, a more focused approach for routine multidisciplinary follow-up programs could be established. It is the goal of the French Collaborative Network to promote exchange of knowledge, future research and development of treatment protocols.     

Bochdalek hernia in adulthood: a case report and review of recent literature

A 37-year-old Filipino woman presented with a post road-traffic accident fracture of dorsal spine 12. Chest radiograph revealed evidence of loops of small bowel in the left lung field. She admitted to symptoms of respiratory insufficiency since birth and treatment for tuberculosis in childhood. A pre-operative diagnosis of left traumatic diaphragmatic hernia was not confirmed at laparotomy which revealed typical left congenital Bochdalek hernia with smooth edges and herniation of small bowel and spleen into the left pleural cavity. Following reduction and repair of the hernia, the patient made an uneventful recovery. Chest radiograph remains normal till now, eight years post-operatively.     

Delayed diagnosis of traumatic diaphragmatic hernia during pregnancy

We present a case of delay in diagnosis of diaphragmatic rupture and herniation in a pregnant 25-year-old woman. The diaphragmatic rupture was secondary to trauma sustained five months prior to presentation. Subsequent to her accident, she was provided medical care on multiple occasions for symptoms of intractable nausea, vomiting, and weight loss that were probably related to an expanding uterus and diaphragmatic herniation of abdominal contents. At the time she presented to us the herniation had progressed and she was experiencing severe respiratory difficulty. A nasogastric tube was placed for diagnosis and decompression. A chest radiograph provided the diagnosis of herniation of gastrointestinal contents through the left hemidiaphragm. A healthy 5-lb boy was delivered vaginally and subsequently a left thoracotomy was performed for decompression and repair of the diaphragm. The patient's hospital course after hernia repair was uneventful.     

Respiratory consequences of abdominal hernia in a patient with severe chronic obstructive pulmonary disease

The diaphragm is the most important muscle of respiration. It is believed that the abdominal contents affect diaphragmatic contraction by helping determine its length tension state and by acting as a fulcrum for this muscle to lift the rib cage and thereby increase lung volume. In support of these concepts we describe a patient with severe chronic obstructive pulmonary disease and a large midline hernia of the abdomen who, when standing, had a gastric pressure (Pg) of 4 cm H2O and a maximal transdiaphragmatic pressure (Pdimax) of 14 cm H2O. This was associated with an O2 saturation of 82%, lower thoracic and upper abdominal paradoxical breathing, and severe dyspnea. Once the hernia was reduced there was a rise in Pg to 12 cm H2O, of Pdimax to 27 cm H2O, and of O2 saturation to 89%. There was normalization of the breathing pattern and a decrease in dyspnea. Reduction of this patient's abdominal hernia resulted in an increase in her exercise tolerance.     

Non-traumatic diaphragmatic hernia of the liver in an adult:a case report

BACKGROUND: Diaphragmatic hernia of the liver is a rare clinical entity, usually found after trauma in adults. This study was undertaken to elucidate a misdiagnosis of non-traumatic diaphragmatic hernia of the liver in an adult. METHOD: The clinical data of one patient with non-traumatic diaphragmatic hernia of the liver was analyzed. RESULTS: A tumor in the right lower thorax was revealed by chest X-ray and computed tomography. Non-traumatic diaphragmatic hernia of the liver was not identified until the operation. Pathological analysis confirmed the finding. The patient recovered well. CONCLUSIONS: Non-traumatic diaphragmatic hernia of the liver in an adult is a rare right-sided diaphragmatic hernia, which can move up into the chest cavity. It should be distinguished from lung cancer. The diagnosis and evaluation of non-traumatic diaphragmatic hernia of the liver can help optimize surgical management.     

Terminal ileum gangrene secondary to a type Ⅳ paraesophageal hernia

Type Ⅳ paraesophageal hernia(PEH) is very rare, and is characterized by the intrathoracic herniation of the abdominal viscera other than the stomach into the chest. We describe a 78-year-old woman who presented at our emergency department because of epigastric pain that she had experienced over the past 24 h. On the day after admission, her pain became severe and was accompanied by right chest pain and dyspnea. Chest radiography revealed an intrathoracic intestinal gas bubble occupying the right lower lung field. Emergency explorative laparotomy identified a type Ⅳ PEH with herniation of only the terminal ileum through a hiatal defect into the right thoracic cavity. In this report, we also present a review of similar cases in the literature published between 1980 and 2015 in Pub Med. There were four published cases of small bowel herniation into the thoracic cavity during this period. Our patient represents a rare case of an individual diagnosed with type Ⅳ PEH with incarceration of only the terminal ileum.     

重型颅脑损伤的预后影响因素分析

目的研究影响重型颅脑损伤（TBI）患者预后的相关因素,建立简便、可靠、临床操作性强的TBI患者预后模型,提高重型颅脑损伤的治疗水平。方法回顾性分析236例重型TBI患者的临床资料。将脑疝、CT环池形态、患者年龄、GCS及手术方式作为观察指标,采用χ2检验及多因素Logistic回归分析。患者出院时进行预后分组,采用GCS分级标准,Ⅰ～Ⅱ级患者视为预后不良,Ⅲ～Ⅴ级患者视为预后良好。结果 236例重型TBI患者预后不良129例（54.66%）,其中死亡81例（34.32%）;预后良好107例（45.34%）。影响患者预后的因素依次为脑疝、CT环池形态、患者年龄、GCS。最优预后模型方程为In（P/1-P）=1.232×脑疝＋1.176×环池形态＋1.154×年龄-1.064×GCS＋0.012。结论建立了重型TBI患者预后模型。脑疝、CT环池形态、患者年龄、GCS对重型TBI患者的预后有显著影响,尤其是存在脑疝及环池严重受压者预后不良几率增高。     

Cervical lung herniation associated with upper airway obstruction

We present the case of a 6-year-old boy with reactive airway disease who developed cervical lung herniation resulting in compression of the trachea and audible stridor. This association has never been reported in the pediatric age group, and a review of the literature revealed that lung herniation is a rare condition in the pediatric population. Most patients are asymptomatic. Herniation occurs in the cervical area in approximately one fourth of patients. The diagnosis is usually made by physical examination and confirmed by radiographic studies. Treatment is seldom necessary; most patients require only education and reassurance. Surgical intervention is indicated when respiratory distress, cosmetic concerns, or progressive increase in size occur.     

A case of lung cancer with hyperthyroidism]

We here report a case of metastasis from lung cancer to the thyroid. On presentation, this patient showed painful anterior cervical swelling and right supraclavicular lymph node swelling. Laboratory data showed primary hyperthyroidism. Although subacute thyroiditis was suspected, echo-guided needle aspiration biopsy and lymph node biopsy revealed poorly differentiated squamous cell carcinoma. As a result, primary lung cancer with thyroid metastasis was diagnosed based on mediastinal enlargement on chest X ray films and normal findings in organs other than the lung and thyroid. Chemotherapy for lung cancer induced a decrease in the size of tumor and the normalization of thyroid function. However, 2 months after the normalization, cervical swelling enlarged and a lung mass in right upper lobe and skin tumor appeared. Despite treatment with chemotherapy, she died. Postmortem revealed that the right upper lung carcinoma was the primary lesion and immunohistochemical staining for surfactant protein was positive in the thyroid, skin tumor and lymph node, which revealed these carcinomas had metastasized from lung cancer. To the best of our knowledge, thyrotoxicosis induced by thyroid metastasis of lung cancer is an uncommon case.     

Miliary spread of malignant pleural mesothelioma without a clinically identifiable pleural tumour

Abstract :A 44-year-old man with past minor exposure to blue asbestos presented with supraclavicular lymphadenopathy and miliary shadowing on his chest radiograph. Cytology and electronmicroscopy on material obtained by fine needle aspiration from his cervical lymph node revealed malignant mesothelioma. Malignant mesothelioma cells were also present in bronchoalveolar lavage fluid and on transbronchial lung biopsy. At autopsy the right pleural cavity was studded with small tumour nodules. This case demonstrates that malignant mesothelioma may present as metastatic disease and without evidence on conventional investigations of a primary pleural tumour. (Aust NZ J Med 1991; 21: 460–462)     

Spontaneous intercostal pulmonary hernia: a case report

In pulmonary hernia or pneumocele the lung protrudes through a defect in the chest wall. In this report of a case of spontaneous intercostal lung hernia, we describe the pathogenesis and classification of such hernias, including signs, symptoms, radiological findings and treatment methods. Our patient presented with severe chest pain at the base of the left hemithorax. A chest film and computed tomography of the region showed an left intercostal hernia. Surgical treatment was successful.     

Cervical and thoracic pain

The cervical spine has long been an area in which the assumption is made that no undescribed anatomy and physiology will be forthcoming. Herein described are cervical anatomy and physiology that have not been reported, as well as anatomy that has been extensively described but does not exist. Fresh research needs to be done on the distinctive and poorly understood characteristics of the autonomic nervous system in the cervical spine. Included in research reports are evidence of herniation of intradiscal gas; efficacy of early mobilization of patients with long-standing neck pain; successful surgical treatment relieving severe hemicranial migraine attack; and the use of magnetic resonance imaging in thoracic disk herniation, permitting precise localization and determination of the magnitude of cord compression.     

Massive Deep Venous Thrombosis and Venous Gangrene in a 29-year-old Case: Metastatic Epidermoid Carcinoma with an Unknown Primary

Cancer-associated venous thromboembolism is a severe form of paraneoplastic syndrome. It rarelyleads to venous gangrene. We report a case who presented with multiple deep venous thrombosis and venous gangrene of the lower extremity. During the follow-up period, the patient developed bilateral cervical and right supraclavicular lymphadenopathies. The fine needle aspiration of the lymph nodes revealed metastatic epidermoid carcinoma of an unknown primary. Thrombotic manifestations may complicate the clinicopathological course of malignancies.     

Prevalence and outcome of severe chronic obstructive pulmonary disease exacerbations caused by multidrug-resistant bacteria

PURPOSE OF REVIEW: A bacterial cause is found in about half of all severe chronic obstructive pulmonary disease exacerbations. The aim of this review is to discuss recent findings regarding prevalence, risk factors and outcome of severe chronic obstructive pulmonary disease exacerbations caused by multidrug-resistant bacteria. RECENT FINDINGS: According to the results of recent studies, multidrug-resistant bacteria represented a large proportion of bacteria isolated in chronic obstructive pulmonary disease exacerbations. Prior antibiotic treatment, prior endotracheal intubation, long-term inhaled or systemic corticosteroid use and severe impairment of lung function were identified as risk factors for severe chronic obstructive pulmonary disease exacerbations related to multidrug-resistant bacteria. Although the mortality rate was higher in patients with multidrug-resistant bacteria as compared with patients with other bacteria, multidrug resistance was not independently associated with mortality in these patients. Multidrug-resistant bacteria were, however, significantly associated with inappropriate initial antibiotic treatment. Higher rates of subsequent ventilator-associated pneumonia and mortality were found in patients with severe chronic obstructive pulmonary disease exacerbation who received inappropriate initial antibiotic treatment when compared with those who received appropriate treatment. SUMMARY: Further studies should determine whether administration of broad-spectrum antibiotic treatment could improve the outcome of patients with severe chronic obstructive pulmonary disease exacerbation caused by multidrug-resistant bacteria.     

An unusual presentation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) metastasis to the lymph nodes has been reported in about one-third of autopsies, mostly to the regional chains. Involvement of cervical lymph nodes is extremely rare. We encountered an unusual case of HCC in a patient with chronic liver disease presenting with right-sided anterior cervical lymph node metastasis skipping mediastinal and supraclavicular chains. One should be aware of that unusual site of presentation and metastasis of HCC so as not to miss the diagnosis.     

Case Report: Brown Fat Accumulation of Tc-99m Macroaggregated Albumin in a Lung Perfusion Study in a Patient With Multiple Lung Arteriovenous Malformations and Right-to-Left Shunting

An 18-year-old man was preoperatively assessed for a varicocele and found to be hypoxemic. A Tc-99m macroaggregated albumin lung perfusion scan showed right-to-left shunting, evidenced by increased radiotracer uptake in the brain, kidneys, thyroid gland, and bilateral supraclavicular areas, a typical location for brown adipose tissue. Chest computerized tomography angiogram study showed supraclavicular fat density areas and multiple pulmonary arteriovenous malformations.The authors report a rare case of brown fat visualization on a lung perfusion scan in a patient with right-to-left shunting, likely because of increased perfusion to activated brown adipose tissue.