General thoracic surgery services across Asia during the 2020 COVID-19 pandemic

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to "flatten the curve", ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.

Understanding Respiratory Restrictions as a Function of the Scoliotic Spinal Curve in Thoracic Insufficiency Syndrome: A 4D Dynamic MR Imaging Study

BACKGROUND

Over the past 100 years, many procedures have been developed for correcting restrictive thoracic deformities which cause thoracic insufficiency syndrome. However, none of them have been assessed by a robust metric incorporating thoracic dynamics. In this paper, we investigate the relationship between radiographic spinal curve and lung volumes derived from thoracic dynamic magnetic resonance imaging (dMRI). Our central hypothesis is that different anteroposterior major spinal curve types induce different restrictions on the left and right lungs and their dynamics.

METHODS

Retrospectively, we included 25 consecutive patients with thoracic insufficiency syndrome (14 neuromuscular, 7 congenital, 4 other) who underwent vertical expandable prosthetic titanium rib surgery and received preimplantation and postimplantation thoracic dMRI for clinical care. We measured thoracic and lumbar major curves by the Cobb measurement method from anteroposterior radiographs and classified the curves as per Scoliosis Research Society (SRS)-defined curve types. From 4D dMRI images, we derived static volumes and tidal volumes of left and right lung, along with left and right chest wall and left and right diaphragm tidal volumes (excursions), and analyzed their association with curve type and major curve angles.

RESULTS

Thoracic and lumbar major curve angles ranged from 0 to 136 and 0 to 116 degrees, respectively. A dramatic postoperative increase in chest wall and diaphragmatic excursion was seen qualitatively. All components of volume increased postoperatively by up to 533%, with a mean of 70%. As the major curve, main thoracic curve (MTC) was associated with higher tidal volumes (effect size range: 0.7 to 1.0) than thoracolumbar curve (TLC) in preoperative and postoperative situation. Neither MTC nor TLC showed any meaningful correlation between volumes and major curve angles preoperatively or postoperatively. Moderate correlations (0.65) were observed for specific conditions like volumes at end-inspiration or end-expiration.

CONCLUSIONS

The relationships between component tidal volumes and the spinal curve type are complex and are beyond intuitive reasoning and guessing. TLC has a much greater influence on restricting chest wall and diaphragm tidal volumes than MTC. Major curve angles are not indicative of passive resting volumes or tidal volumes.

LEVEL OF EVIDENCE

Level II-diagnostic.

Site-specific Surgical Site Infection Rates for Rib-based Distraction

BACKGROUND

Implantable rib-based distraction devices have revolutionized the treatment of children with early onset scoliosis and thoracic insufficiency syndrome. Unfortunately, the need for multiple skin incisions and repeated surgeries in a fragile patient population creates considerable infection risk. In order to assess rates of infection for different incision locations and potential risk factors, we generated a prospectively collected database of patients treated with rib-based distraction devices.

METHODS

We analyzed a cohort of patients with thoracic insufficiency syndrome from various etiologies that our institution treated with rib-based distraction devices from 2013 to 2016. Surgery type (implantation, expansion, revision/removal), and surgeon adjudicated surgical site infection (SSI) were collected. For this study, we developed a novel, rib-based distraction device surgical site labeling system in which incisions could be labeled as either proximal or distal surgical exposure areas. Treating surgeons documented the operative site, procedure, and SSI site in real-time.

RESULTS

A total of 166 unique patients underwent 670 procedures during the study period, producing 1537 evaluable surgical sites; 1299 proximal and 238 distal. Patients were 6.81±4.0 years of age on average. Forty-seven procedures documented SSIs (7.0%), while 40 (24.1%) patients experienced an infection. Analysis showed significant variation in the rate of infection between implantation, and expansion, and revision procedures, with implantation procedures having the highest infection rate at 13.1% (P<0.01). Infections occurred more frequently at distal sites than proximal ones (P=0.02).

CONCLUSIONS

Our novel, surgeon-entered, prospective quality improvement database has identified distal surgical sites as being at higher risk for SSI than proximal ones. Further, rib-based distraction device implantation procedures were identified as being at a greater risk for SSI than expansion or revision procedures. We believe this data can lead to improved prevention measures, anticipatory guidance, and patient care.

LEVEL OF EVIDENCE

Level II-prognostic study.

[The surgery of diaphragmatic hydatidosis and their complications]

Primary or secondary diaphragmatic echinococcosis is rare, accounting for 1% of the thoracic locations. They may be operative discovery or by their complication, hence a variable symptomatology making this localization a particular entity. The thoracic and abdominal CT allows a complete assessment. Surgery remains the only therapeutic approach. In complicated forms an additional surgery is required for complete care. The prognosis is generally good apart from the risk of recurrence. Through a series of 4 operated patients, we focus on the clinical and therapeutic features of this pathology and its complications.

Perioperative implications of thoracic decortications: a retrospective cohort study

Purpose

An increasing number of thoracic decortications have been performed in Manitoba, from five in 2007 to 45 in 2014. The primary objective of this study was to define the epidemiology of decortications in Manitoba. The secondary objective was to compare patients who underwent decortication due to primary infectious vs non-infectious etiology with respect to their perioperative outcomes.

Methods

Data for this cohort study were extracted from consecutive charts of all adult patients who underwent a decortication in Manitoba from 2007-2014 inclusive.

Results

One hundred ninety-two patients underwent a decortication. The most frequent disease processes resulting in a decortication were pneumonia (60%), trauma (13%), malignancy (8%), and procedural complications (5%). The number of decortications due to complications of pneumonia rose at the greatest rate, from three cases in 2007 to 29 cases in 2014. Performing a decortication for an infectious vs a non-infectious etiology was associated with a higher rate of the composite postoperative outcome of myocardial infarction, acute kidney injury, need of vasopressors for > 12 hr, and mechanical ventilation for > 48 hr (44.4% vs 24.2%, respectively; relative risk, 1.83; 95% confidence interval, 1.1 to 2.9; P = 0.01).

Conclusion

There has been a ninefold increase in decortications over an eight-year period. Potential causes include an increase in the incidence of pneumonia, increased organism virulence, host changes, and changes in practice patterns. Patients undergoing decortication for infectious causes had an increased risk for adverse perioperative outcomes. Anesthesiologists need to be aware of the high perioperative morbidity of these patients and the potential need for postoperative admission to an intensive care unit.

[Hourglass Transmural Lipoma;Report of a Case]

This case report describes a 73-year-old male with an hourglass-type transmural lipoma who was referred because of an abnormal chest shadow. Computed tomography showed a well-defined fatty mass within the intra-and extra-thorax at the right 3rd intercostal portion. Magnetic resonance imaging showed a high-intensity mass that had the same signal level as fat tissue. Therefore, the tumor was diagnosed as an hourglass transmural lipoma. Tumor resection was performed with video-assisted thoracic surgery, and 3rd intercostal muscle tissue approximately 1cm from the tumor border was also resected. The tumor was 6.5×4.5×3.0 cm in size, and histologically diagnosed as an intramuscular lipoma-infiltrating type, without malignancy. Since infiltrating types of intramuscular lipoma often cause recurrence without malignant appearance, tumor specimens require careful examination. Thoracoscopic surgery was useful to determine the excision line from the intra-thorax, for complete resection of the hourglass tumor.

[Hydatidosis bone wall chest: About three cases]

INTRODUCTION

Bone hydatidosis of the chest wall is rarely reported in the literature. Costal and sternal location are uncommon. Through 3 observations and literature review, we report particular pathophysiological and diagnostic aspects of costal and sternal hydatidosis. We also discuss therapeutic and prognostic aspects of this disease. OUR CASES: we report the cases of 45, 41 and 17 years old male patients, 2 of them had previous surgery for thoracic wall mass in general surgery service. Clinical presentation was thoracic wall painful mass sticking to bone. One patient had isolated costal location, the 2 others had sternal location; in one of them, the disease is located in sterno-costo-clavicular area. In all 3 cases, the disease was diagnosed by computed tomography (CT) scan, showing bone lysis or mediastinum enlargement. Patients undergo extended bone resection removing away all destructed parts of the bone. After surgery, albendazole has been prescribed to all patients. No recurrence was observed after 12 months follow-up.

CONCLUSION

Chest wall bone hydatidosis is unusual even in endemic regions, with slow evolution and inconspicuous symptoms. Radiology plays a key role in the management of this disease. Extended surgical resection associated with medical treatment (albendazole) is a reliable treatment without recurrence.

The Evaluation of 13 Patients with Intrathoracic Extrapulmonary Hydatidosis

Cases of intrathoracic extrapulmonary hydatid cysts are very rare. We identified 13 patients with intrathoracic extra-pulmonary hydatid cysts in our clinic over 12 years. Four patients had extra-pulmonary cysts only; nine patients had both intrapulmonary and extrapulmonary cysts. Cysts were identified in the pleural space, extrapleural region, diaphragm and chest wall. Thoracotomy was used in all patients, and extrapulmonary lesions were removed by cyst extirpation from surrounding tissue or by pericystectomy. In one patient with chest wall involvement, partial rib resections were performed because of rib destruction. In two patients with liver cysts passing through the diaphragm to the thorax, the diaphragm was cut, cysts on the liver roof were removed and then the diaphragm was repaired. There was no mortality, morbidity, or disease recurrence during the post-operative period in any of the 13 patients. We conclude that these rare cases give a new insight into hydatid cyst pathophysiology.

Two Young Women with Left-sided Pneumothorax Due to Thoracic Endometriosis

Pneumothorax associated with thoracic endometriosis (TE) generally occurs in women around 30 years old and it usually affects the right pleural cavity. We herein report two cases of TE associated with left-sided pneumothorax in young women. The prevalence of TE in younger patients may be underestimated if these cases are treated as spontaneous pneumothorax. Pneumothorax occurring in younger patients has not been reported to show laterality. TE-related or catamenial pneumothorax in young women must therefore represent a different clinical entity from the condition seen in older patients.

[Thoracic endometriosis with aspecific manifestation]

BACKGROUND

Endometriosis is a common disease, especially in subfertile women. The most common location is in the pelvis, but extragenital locations are also possible. This far less common condition has been described in almost all tissues in the body. Symptoms occurring cyclically are characteristic of endometriosis.

CASE DESCRIPTION

A 37-year-old woman was discovered by chance to have ascites and pleural effusion. She had no symptoms of this. Thoracoscopy showed an image consistent with thoracic endometriosis. After initial drug therapy was unsuccessful, surgical intervention was performed.

CONCLUSION

Thoracic endometriosis is a rare disease, in which the cyclical nature of the symptoms often leads to correct diagnosis. Drug therapy is the preferred treatment for patients.

[Actual respiratory technologies in thoracic surgery: traditional problems and innovative solutions]

The problem of efficient gas exchange maintenance is always actual in anesthetic management of thoracic surgery and determines the selection of appropriate method of anesthesia. The article presents an experience of anesthesia during operations on lungs, trachea, bronchi and mediastinal structures performed from 1963 to 2015. Current concept of safety and efficacy of anesthetic management in thoracic surgery is presented. The role of actual current respiratory technologies and methods of anesthesia per se to maximize the efficiency of gas exchange in all stages of thoracicsurgery is emphasized. Absolute coherence of anesthesiologist and surgeon based on correct interaction is the most important condition of successful surgery. Effectiveness of special respiratory technologies for thoracic surgery associated with one-lung ventilation and prolonged wide dissection of airways is described. The research results and pathophysiological rationale for the use of special respiratory technologies including different variants of differentiated independent lung ventilation especially important for patients with concomitant cardiorespiratory pathology are presented. We reported experience of effective gas exchange maintenance in reconstructive surgery of trachea and main bronchi including traditional mechanical ventilation with "shunt-breath" system, use of jet high-frequency ventilation and relatively new respiratory technology such as flow apnoeic oxygenation.

Intrathoracic Castleman disease

AIM

To analyze patients with Castleman disease who were diagnosed by surgery.

MATERIALS AND METHODS

We retrospectively investigated the postoperative pathological records of operations performed between January 1992 and December 2012 in our hospital. Files of 19 patients with the diagnosis of Castleman disease were analyzed.

RESULTS

There were 13 male and 6 female patients with a mean age of 40.1 + 11.4 (range: 20-57) years. Fifteen thoracotomies and 3 video-assisted thoracoscopies, 12 on the right side and 6 on the left side, and 1 mediastinoscopy were performed. Biopsies and mass excisions were performed in 2 and 17 cases, respectively. Histopathological findings were hyaline vascular-type (n = 16), plasma cellular- type (n = 2), and hyaline vascular plus plasma cellular-type (n = 1) Castleman disease.

CONCLUSION

Castleman disease can occur in all areas of the thorax, but the mediastinum and hilum are the most common locations. Surgical excision is the best method of diagnosis and treatment. Complete excision is curative for local forms of the disease. However, complete excision may not be possible at all times due to local invasion and hypervascularization. Multimodal treatment, including chemotherapy, is recommended in patients with a multicentric form of the disease, and they should be followed closely.

[Intrathoracic-mediastinal myofibroblastic tumor. Report and experience of one case]

BACKGROUND

Inflammatory pseudotumor is a little known and uncommon condition. The debate continues whether it represents an inflammatory lesion or is a true neoplasm. It is considered a reactive process usually characterized by irregular growth of inflammatory cells. It has been described at various sites, the most common being the lung. The aim of this report is to emphasize the difficulty in the initial diagnosis.

CLINICAL CASE

We present the case of a 56-year-old male who reports an 8-month history of dry cough, dyspnea, fatigue, weakness and weight loss of 20 kg. We performed two biopsies, one positive for malignancy without response to medical treatment and the second reporting chronic granulomatous inflammation. The patient underwent sternotomy, revealing a tumor of 20 × 17 × 10 cm, weighing approximately 2 kg. The tumor was dependent on the anterior mediastinum surrounding large vessels, and venous brachiocephalic, pericardium and both pleuras with firm adhesions to the right lung. Pathological report was as follows: inflammatory myofibroblastic tumor with positive immunohistochemistry for CD20 and CD3. Postoperative course was satisfactory and 1 year after surgery there was no evidence of recurrence.

CONCLUSION

Inflammatory pseudotumor is a benign neoplasm of unknown origin with a chronic course. It can simulate a malignant tumor, causing constitutional manifestations, airway obstruction, cardiac alterations or other symptoms according to their location. Diagnosis is based on radiological features and direct biopsy. Treatment of choice is complete resection of the tumor with a favorable long-term outcome.

Intrathoracic caudate lobe of the liver: A case report and literature review

Heterotopic supradiaphragmatic livers are rare. A total of 23 cases of primary supradiaphragmatic livers have been reported in the literature. The clinical presentations of heterotopic supradiaphragmatic liver are variable. The simultaneous detection of intrathoracic accessory liver and pulmonary sequestration is extremely rare, and only one case has previously been reported. It is difficult to make a correct diagnosis preoperatively. We presented a 53-year-old woman with complaints of an intermittent, productive cough and dyspnea for two months that was refractory to medical treatment. She had no previous history of trauma or surgery. A chest radiograph only showed a widening of the mediastinum. Contrast-enhanced computed tomography of the chest revealed a well-circumscribed homogenous soft-tissue mass, approximately 4.35 cm × 2.5 cm × 6.14 cm in size, protruding through the right diaphragmatic crura to the right pleural cavity, attached to the inferior vena cava, esophagus and liver. There was no conclusive diagnosis before surgery. After the operation, we discovered that this patient was the first case of a supradiaphragmatic heterotopic liver, which passed through the inferior vena cava foramen and was coincidentally combined with an intralobar pulmonary sequestration that was found intraoperatively. We discussed its successful management with surgical resection via a thoracic approach and reviewed the published literature.

Pattern of cardiothoracic surgical diseases in a new cardiothoracic surgery unit in Nigeria

BACKGROUND

Cardiothoracic surgical pathologies are available in all geographical regions of the world. Human and material resources are necessary for prompt diagnosis and proper treatment of these cases.

METHODOLOGY

Retrospective analysis of cardiothoracic surgical cases in the first five years of our new cardiothoracic surgery unit was done.

RESULTS

A total of 714 cases were seen during the study period with age range one month to 76 years with mean age of 37.12 +/- 11.24 and male female ratio of 2:1. The yearly admissions from 2007 to 2011 were 14%, 17%, 21%, 21% and 26% respectively. Cardiovascular diseases occurred in 22.30%, with 6% of children suffering from congenital heart defect and 6% of men suffering from acquired vascular disease. Surgical complications of pleuropulmonary tuberculosis occurred in 21.4% while thoracic trauma occurred in upto 21% of the patients. Aerodigestive tract foreign bodies were encountered in 10.1% of cases and Pyogenic diseases occurred in 8.68%. Oesophageal lesions were diagnosed in 6.4% of the patients, pulmonary tumours including primary and secondary tumours were found in 4.3% while nontraumatic chest wall pathologies which included chest wall tumours, congenital deformities and chronic osteomyelities accounted for 3.2%. Mediastinal pathologies occurred in 0.98% and in the remaining 1.5% rare diseases were diagnosed such as third degree heart block, pulmonary embolism and thoracic endometriosis syndrome.

CONCLUSION

This study shows that cardiothoracic surgical pathologies are common in our centre with predominance of thoracic pathologies, and therefore need to prioritize and ensure manpower development for treatment of all kinds of thoracic pathologies.

[Thoracic endometriosis and catamenial pneumothorax]

It was analyzed own experience of diagnosis and treatment of catamenial (menstrual) pneumothorax and thoracic endometriosis and literature review. It is shown that catamenial pneumothorax has specific clinical and instrumental signs allowing to establish the diagnosis before surgery. It was proposed surgical treatment including the removal of trans diaphragmatic way of pneumothorax development, removal of thoracic endometriosis and the establishment of reliable pleurodesis. It was demonstrated that this volume of surgery can be successfully implemented by using of thoracoscopic access. Relapse prevention includes hormonal therapy for the 6 months after surgery under the supervision of an obstetrician-gynecologist.