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Background Ultrasound (US) evaluation of diaphragmatic dysfunction (DD) has proved to be a reliable technique in critical care. In this single-center prospective study, we investigated the impact of US-assessed DD on noninvasive ventilation (NIV) failure in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and its correlation with the transdiaphragmatic pressure assessed using the invasive sniff maneuver (Pdi sniff). Methods A population of 75 consecutive patients with AECOPD with hypercapnic acidosis admitted to our respiratory intensive care unit (RICU) were enrolled. Change in diaphragm thickness (ΔTdi) < 20% during tidal volume was the predefined cutoff for identifying DD+/− status. Correlations between ΔTdi < 20% NIV failure and other clinical outcomes were investigated. Correlation between ΔTdi and Pdi sniff values was analyzed in a subset of ten patients. Results DD+ patients had a higher risk for NIV failure than DD− patients (risk ratio, 4.4; p  <  0.001), and this finding was significantly associated with higher RICU, in-hospital, and 90-day mortality rates; longer mechanical ventilation duration; higher tracheostomy rate; and longer RICU stay. Huge increases in NIV failure (HR, 6.2; p  < 0.0001) and 90-day mortality (HR, 4.7; p  = 0.008) in DD+ patients were found by Kaplan-Meier analysis. ΔTdi highly correlated with Pdi sniff (Pearson’s r  = 0.81; p  = 0.004). ΔTdi < 20% showed better accuracy in predicting NIV failure than baseline pH value and early change in both arterial blood pH and partial pressure of carbon dioxide following NIV start (AUCs 0.84 to DTdi < 20%, 0.51 to pH value at baseline, 0.56 to early change in arterial blood pH following NIV start, and 0.54 to early change in partical pressure of carbon dioxide following NIV start, respectively; p  < 0.0001). Conclusions Early and noninvasive US assessment of DD during severe AECOPD is reliable and accurate in identifying patients at major risk for NIV failure and worse prognosis.

Background Diaphragm dysfunction is highly prevalent in mechanically ventilated patients. Recent work showed that changes in diaphragm shear modulus (ΔSMdi) assessed using ultrasound shear wave elastography (SWE) are strongly related to changes in Pdi (ΔPdi) in healthy subjects. The aims of this study were to investigate the relationship between ΔSMdi and ΔPdi in mechanically ventilated patients, and whether ΔSMdi is responsive to change in respiratory load when varying the ventilator settings. Methods A prospective, monocentric study was conducted in a 15-bed ICU. Patients were included if they met the readiness-to-wean criteria. Pdi was continuously monitored using a double-balloon feeding catheter orally introduced. The zone of apposition of the right hemidiaphragm was imaged using a linear transducer (SL10-2, Aixplorer, Supersonic Imagine, France). Ultrasound recordings were performed under various pressure support settings and during a spontaneous breathing trial (SBT). A breath-by-breath analysis was performed, allowing the direct comparison between ΔPdi and ΔSMdi. Pearson’s correlation coefficients ( r ) were used to investigate within-individual relationships between variables, and repeated measure correlations ( R ) were used for determining overall relationships between variables. Linear mixed models were used to compare breathing indices across the conditions of ventilation. Results Thirty patients were included and 930 respiratory cycles were analyzed. Twenty-five were considered for the analysis. A significant correlation was found between ΔPdi and ΔSMdi ( R  = 0.45, 95% CIs [0.35 0.54], p  < 0.001). Individual correlation displays a significant correlation in 8 patients out of 25 ( r  = 0.55–0.86, all p  < 0.05, versus r  = − 0.43–0.52, all p  > 0.06). Changing the condition of ventilation similarly affected ΔPdi and ΔSMdi. Patients in which ΔPdi–ΔSMdi correlation was non-significant had a faster respiratory rate as compared to that of patient with a significant ΔPdi–ΔSMdi relationship (median (Q1–Q3), 25 (18–33) vs. 21 (15–26) breaths.min −1 , respectively). Conclusions We demonstrate that ultrasound SWE may be a promising surrogate to Pdi in mechanically ventilated patients. Respiratory rate appears to negatively impact SMdi measurement. Technological developments are needed to generalize this method in tachypneic patients. Trial registration NCT03832231 .

BackgroundMinimally invasive liver surgery of postero-superior segments (S4a, S7, S8) remains a challenge. The caudal view, an increased distance between trocars and the operative field, and the liver fulcrum limiting the view, contribute to the difficulty [1, 2]. We and other groups have previously reported the use of intercostal trocars to access subdiaphragmatic tumors (transdiaphragmatic approach) [3–5], only few reports on a laparoscopic total transthoracic approach, none (to our knowledge) dynamic manuscripts of a total transthoracic robotic approach, and none (to our knowledge) that use preoperative port site and anatomic modelling exist. Further, we developed a total transthoracic (thoracoscopic) approach to avoid a hostile abdomen, while bringing viewing axis and instruments close to the target [6–10]. In this context, this report details the advantages of a laparoscopic vs. robotic transthoracic approach. According to institutional protocol, reports of individual cases in print or video format do not require institutional review board approval.PatientA 68-year-old male on peritoneal dialysis with left colon adenocarcinoma and a single synchronous liver metastasis in S6-7 close to the root of the right hepatic vein underwent a laparoscopic transdiaphragmatic metastasectomy. Two years later, the patient developed a recurrent 1.5 cm liver metastasis in S7, which lend itself to a robotic transthoracic approach.TechniqueFollowing 3-D modelling and virtual port placement planning, the first metastasectomy was performed laparoscopically using a transdiaphragmatic approach. The recurrence was managed transthoracically due to more apical, subdiaphragmatic location. For this operation, a robotic approach was optimal as robotic wrist articulation facilitates manipulation via the limited intercostal space. This was particularly helpful during the diaphragmatic reconstruction.ConclusionsTotal transthoracic liver surgery is certainly an advanced procedure requiring superior MIS liver skills. Recommendations for starting with a total transthoracic approach are not unlike from starting a standard, none-transthoracic liver surgery. Early on in the experience we recommend advanced liver MIS skills, and single, small, subdiaphragmatic tumors away from major vessels. Nonetheless, when these recommendations are followed a total transthoracic approach may be safer and result in less access trauma, than traversing a hostile abdomen to reach the posterior-superior liver. Both laparoscopic and robotic transthoracic approaches can facilitate the resection of subdiaphragmatic tumors, especially in patients with hostile abdomens. While the laparoscopic approach has advantages due to a broader spectrum of available surgical tools (flexible tip camera, parenchymal dissection, and energy devices), the robotic wrist articulation facilitates manipulation via the restricted intercostal space.

Background Failure to wean from invasive mechanical ventilation is multifactorial, with diaphragmatic dysfunction a significant contributing factor. Diaphragmatic function can be easily and non-invasively assessed by ultrasound. However, it remains unknown how ultrasound measurements of diaphragm function are affected by changes in apparent work of breathing. Methods In patients undergoing weaning from mechanical ventilation, we evaluated diaphragmatic ultrasound measurements [diaphragmatic excursion (Dex), diaphragmatic thickening fraction (Tfdi)] simultaneously with manometric indices of breathing effort and load [esophageal pressure swings (ΔPes), transdiaphragmatic pressure swings (ΔPdi), and the pressure–time product of esophageal pressure (PTPes)]. These assessments were performed during two distinct phases; during an unassisted spontaneous breathing trial (phase SBT) and during an inspiratory resistive loading with 30 cmH 2 O/L/s (phase IRL), applied during the same SBT. Our primary aim was to evaluate the relationship between diaphragmatic ultrasound and breathing effort using the method of repeated measures correlation. Results Forty-nine patients were enrolled. Dex correlated with ΔPes (r = 0.5, p  < 0.001), ΔPdi (r = 0.55, p  =  < 0.001) and PTPes (r = 0.32, p  = 0.031). Tfdi did not correlate with ΔPes (r = 0.27, p  = 0.052), ΔPdi (r = 0.2, p  = 0.235) and PTPes (r = 0.24, p  = 0.110). Dex and Tfdi increased during IRL compared to SBT [1.44(0.89–1.96) vs. 1.05(0.7–1.59), p  = 0.002], [0.55(± 0.32) vs 0.46(± 0.2), p  = 0.019] as did Pes, Pdi and PTPes [(11.87 (7.86, 18.32) vs. 6.8 (4.6–10.23), p  < 0.001), (10.89 (± 6.42) vs. 7.94 (± 3.81), p  < 0.001), and (181.10 (108.34, 311.7) vs. 97.52 (55.96–179.87), p  < 0.001), respectively]. Conclusion In critical care patients spontaneously breathing under resistive load, diaphragmatic excursion had a weak to moderate correlation with indices of breathing effort and differed between weaning success and failure.

Background Gastroesophageal reflux disease (GERD) pathophysiology is multifactorial. Greater importance has been attributed to a defective lower esophageal sphincter (LES) in comparison to an altered transdiaphragmatic pressure gradient (TPG). This study aims to evaluate the role of the TPG and LES disfunction in GERD pathogenesis. Methods Five hundred consecutive esophageal function tests from patients with clinically suspected GERD were reviewed. Patients were classified according to the pH monitoring in GERD positive or GERD negative. Abdominal pressure, thoracic pressure, TPG (abdominal-thoracic pressures), LES resting pressure (mid-respiratory, expiratory, and EGJ-CI), and LES retention pressure (LES resting pressure-TPG) were determined. Results GERD was present in 296 (59%) individuals. GERD-positive patients were mostly males. LES resting pressure (by all parameters) and thoracic pressure were not different between groups. Abdominal pressure and TPG were higher in GERD-positive patients. LES retention pressure (by all parameters) was lower in GERD-positive patients. DeMeester score had a positive correlation with LES resting pressure, TPG, and LES retention pressure (by all parameters) but not with abdominal pressure and thoracic pressure. Conclusions LES valvular competency as measured by absolute resting pressure was not reliable to predict GERD; however, it was associated with GERD severity. Relative LES pressure (LES retention pressure) predicted GERD presence and severity, but no parameter showed superiority. TPG plays an important role in the pathophysiology of GERD since it is related to GERD presence and severity; still TPG is altered mostly based on a higher abdominal pressure.

Background Diaphragm dysfunction is an important and often unrecognized cause of dyspnea. The current gold standard, transdiaphragmatic twitch pressure (Pdi,tw), requires oesophageal and gastric balloon catheters and is infrequently used in routine care. We evaluated whether ultrafast ultrasound descriptors of costal diaphragm during bilateral phrenic magnetic stimulation can provide a noninvasive alternative for assessing diaphragm contractility. Methods Thirty patients (19 men and 11 women) referred for suspected diaphragm dysfunction (median age 57 [42–63] years) underwent bilateral anterolateral magnetic stimulation with simultaneous ultrafast ultrasound and oesophageal/gastric pressure recordings. Peak diaphragm tissue velocity, acceleration and jerk were extracted. Associations with Pdi,tw were assessed using ridge regression. Diagnostic performance for detecting abnormal Pdi,tw (< 20 cmH2O) was evaluated using Bayesian receiver operating characteristic (ROC) analysis, including posterior mean AUC and 95% credible intervals. Agreement between predicted and measured Pdi,tw was assessed using Lin's concordance correlation coefficient and Passing–Bablok regression. Results Twenty four of 30 patients (80%) had abnormal Pdi,tw. Ultrafast ultrasound descriptors correlated with Pdi,tw (Spearman's ρ: velocity 0.77 [95% CI, 0.57–0.89], acceleration 0.70 [95% CI, 0.41–0.87], jerk 0.67 [95% CI, 0.43–0.85]; all p < 0.0001). The multivariable ridge model explained 66% of the variance in Pdi,tw and showed high agreement with measured values (Lin's concordance correlation coefficient = 0.87 [95% CI, 0.75–0.93]). Bayesian ROC analysis demonstrated strong discrimination of diaphragm dysfunction (AUC = 0.91; 95% credible interval [CrI], 0.76–0.98). Using the clinical threshold of 20 cmH2O, model‐predicted Pdi,tw yielded a sensitivity of 75% and specificity of 100%. The optimal velocity threshold for discriminating abnormal Pdi,tw was 10.25 mm·ms−1 (95% CrI, 6.12–18.58 mm·ms−1). The corresponding thresholds for acceleration and jerk were 408.6 mm·ms−2 (95% CrI, 122.6–952.4) and 3073 mm·ms−3 (95% CrI, 1038.8–11541.4), respectively. Conclusions Ultrafast ultrasound coupled with magnetic phrenic stimulation provides a feasible, noninvasive, nonvolitional assessment of diaphragm contractility. Diaphragm motion descriptors reliably predicted Pdi,tw and enabled accurate identification of diaphragm dysfunction. These findings support further clinical evaluation and warrant larger multicentre validation studies.

IgG4-related disease is a clinically significant immune-mediated condition that can involve multiple organs. In the central nervous system, IgG4-related hypertrophic pachymeningitis is characterized by dural thickening, and the resulting mass effect may lead to various neurological deficits and characteristic imaging findings. A 54-year-old Japanese man presented with a 6-month history of slowly progressive right-sided visual impairment and visual field loss. Neurological examination revealed no abnormalities other than reduced visual acuity and visual field defects. Cranial magnetic resonance imaging revealed marked dural thickening extensively involving the bilateral frontotemporal regions, widespread frontal white matter lesions, and transdiaphragmatic herniation of the rectus gyrus into the sella turcica. The serum IgG4 level was elevated (429 mg/dL), and a dural biopsy revealed inflammatory cell infiltration with IgG4-positive plasma cells, leading to a diagnosis of IgG4-related hypertrophic pachymeningitis. Systemic evaluation, including laboratory screening and trunk computed tomography, revealed no other organ involvement apart from cervical and hilar lymphadenopathy. The patient responded well to steroid treatment (intravenous methylprednisolone followed by tapered oral prednisolone), with gradual improvement of the dural thickening, white matter lesions, rectus gyrus herniation, and visual field defects over 3 months. The serum IgG4 level decreased to 70.3 mg/dL. This case was characterized by pronounced dural thickening, widespread white matter lesions, and unprecedented rectus gyrus herniation into the sella turcica, a combination of features not previously reported. Neurologists should consider IgG4-related disease in the differential diagnosis of hypertrophic pachymeningitis accompanied by white matter lesions because early recognition and treatment may prevent irreversible neurological damage.

[LANGUAGE= \"English\"] Intra-abdominal abscesses usually originate from the gastrointestinal tract, with 70% occurring in the postoperative period. The mortality rate can reach 50%. These abscesses most commonly develop in the subphrenic and subhepatic spaces. Treatments include percutaneous drainage or surgical drainage. In this report, we present a minimally invasive video-assisted trans-diaphragmatic drainage (MIVTD) method through a simple incision using a right intercostal approach. This method was successfully performed on a patient who underwent Graham patch repair with laparotomy due to a diagnosis of peptic ulcer perforation and subsequently developed a right subphrenic multiloculated collection after unsuccessful percutaneous drainage.[LANGUAGE= \"Turkish\"] Karın içi apseler genellikle gastrointestinal sistemden kaynaklanır ve %70'i ameliyat sonrası dönemde görülür. Ölüm oranı %50'ye ulaşabilir. Bu apseler en sık subfrenik ve subhepatik boşluklarda bulunur. Tedavide perkütan drenaj veya cerrahi drenaj uygulanır. Bu yazıda,ülser perforasyonu tanısıyla laparotomi ile Graham yama onarımı uygulanan ve sağ subfrenik multiloküle gelişen hastamızda, sağ interkostal yaklaşımla basit bir kesi ile başarıyla uygulanan minimal invaziv video yardımlı transdiyafragmatik drenaj yöntemini sunuyoruz.

Percutaneous transhepatic biliary drainage (PTBD) is commonly used to relieve biliary obstruction when endoscopic methods are not suitable. Bilothorax, accumulation of bile in the pleural cavity, is a rare but serious complication of PTBD as the procedure can inadvertently breach the pleura, potentially allowing bile to drain into the pleural cavity. This report describes an 82‐year‐old woman with cholangiocarcinoma who developed bilothorax following PTBD due to transpleural puncture associated with a kinked biliary catheter. Pleural fluid analysis confirmed bilothorax, and a drain exchange led to clinical and biochemical improvement. The case underscores a critical anatomical consideration: the pleural cavity extends further caudally than the lung margins and may be violated during any percutaneous intervention. Failure to account for the diaphragmatic pleural reflection depth may result in unintended pleural injury and fluid accumulation. Proceduralists must incorporate detailed pre‐procedural imaging and anatomical awareness to reduce transpleural complications across a range of percutaneous interventions. This report details the case of a patient with cholangiocarcinoma who developed a bilothorax following percutaneous transhepatic biliary drainage (PTBD). Imaging confirmed that a kinked biliary drain had transgressed the pleural reflection, resulting in bile accumulation within the pleural cavity. Although bilothorax is an uncommon complication of hepatobiliary procedures, this case underscores a critical and under‐recognised anatomical vulnerability: the extent of the diaphragmatic pleural reflection, which can extend far below the inferior border of the lung, particularly in the posterior and lateral thoracic regions.