Surgical Management Of Congenital Thoracic Disorders: A 15-Year Center Experience.

INTRODUCTION: Congenital thoracic disorders represent a spectrum of fetal lung bud development abnormalities, which may affect breathing capacity and quality of life. We aim to evaluate the impact of surgery in the treatment of 4 major congenital conditions. MATERIALS AND METHODS: We performed a retrospective cohort analysis of patients who underwent surgical treatment in our tertiary center, from 2007 to 2022. RESULTS: Over the 15-year period, we treated 33 patients, with a male predominance of 55%. 22 patients (67%) were asymptomatic. When symptomatic, the recurrence of respiratory infections was the most common clinical presentation (18%). In 13 patients (39%), diagnosis was achieved through fetal ultrasonography. This study encompassed 13 patients with pulmonary sequestration (39%), 11 patients with bronchogenic cysts (33%), 7 patients with congenital pulmonary airway malformation (21%) and 2 patients with congenital lobar emphysema (6%). Considering solely lung malformation conditions, we accounted 22 patients with a median age of 3 [1-67] years-old. Surgery comprised bilobectomy (9%), lobectomy (77%), lobectomy with wedge resection (5%), segmentectomy (5%) and wedge resection (5%). Concerning bronchogenic cysts, we treated 11 patients with a median age of 19 [14-66] years-old. We identified 1 hilar, 1 intrapulmonary and 9 mediastinal lesions, of which 4 were paraesophageal, 4 were subcarinal and 1 was miscellaneous. Overall, surgery was conducted by thoracotomy in 61% of patients, VATS in 33% and RATS in 6%. The median drainage time was 3 [1-40] days and median hospital stay was 4 [1-41] days. There were no cases of mortality. Ensuing, 94% of patients experienced clinical improvement after surgery. CONCLUSION: Early diagnosis of congenital thoracic malformations increased considerably with the improvement in imaging technology and prenatal screening. Treatment may include expectant conservative treatment. However, in selected cases, surgery may play an important role in symptomatic control and prevention of disease progression.

Extracorporeal life support use in limited lung function: a narrative review.

Background and Objective: In thoracic surgery, different modalities of extracorporeal life support (ECLS) can be used for cardiorespiratory support in complex scenarios. Decades of learning in clinical practice and physiology associated with technological development led to a great variety of ECLS technologies available. Thoracic surgery procedures with difficult or impossible single lung ventilation may still be performed using different ECLS modalities. The aim of this review is to describe the use of ECLS, with its different modalities, as a solution to perform complex surgeries in a patient with difficult or impossible single lung ventilation. Methods: A literature review was conducted using the terms "extracorporeal life support pulmonary resection" and "extracorporeal life support thoracic surgery", and articles were selected according to defined criteria. Key Content and Findings: To support lung function during thoracic surgery, the most efficient and popular variety of ECLS is venovenous extracorporeal membrane oxygenation. Lung resection on a single lung after pneumonectomy, surgery in a patient with severe hypercapnia and/or low respiratory reserve, carinal and airway surgery, and severe thoracic trauma are the main examples of situations where ECLS may be the solution to provide a safe surgical environment in patients who cannot tolerate single lung ventilation. Multidisciplinarity, selection of patients and careful surgical planning are cornerstones in defining the situations that may benefit from ECLS support. Conclusions: Knowledge on techniques of ECLS are essential for every thoracic surgeon. Although rarely used, these techniques of cardiorespiratory support should be considered when planning complex cases with difficulties in ventilation and emergent situations.

Infection pattern of Echinorhynchus salobrensis (Acanthocephala) in congeneric species of piranha from a Neotropical floodplain region.

Acanthocephalans are obligate endoparasites characterised by the presence of a proboscis with hooks, which are used to adhere and perforate the intestinal wall of their hosts. Individuals of Echinorhynchus salobrensis Machado Filho, 1948 have been reported parasitising the piranhas Serrasalmus maculatus Kner and Serrasalmus marginatus Valenciennes in the upper Paraná River floodplain. Serrasalmus marginatus is considered non-native at this site, and its establishment occurred after the closure of the Itaipu Hydroelectric, which flooded a natural geographic barrier that separated two ecoregions in the Paraná River. Since they are phylogenetically close and have similar biological and ecological characteristics competition for resources caused the non-native species to become dominant over the native one. Considering the specificity of species of Echinorhynchus Zoega, 1776 in serrasalmids, we evaluated the distribution of E. salobrensis along the gastrointestinal tract of S. maculatus and S. marginatus from the upper Paraná River floodplain. All parasites indices of E. salobrensis were higher in the invasive host S. marginatus when compared to the native S. maculatus. There were no significant interaction effects between host species and sex, and host species and/or sex in the presence of the parasite. When we evaluated the effect of E. salobrensis parasitism on the different gut regions and accessory organs, total abundance was significant in the stomach and caecum organs, and in the first and second regions of the intestine. None of the analytical approaches tested showed an effect of the sex of the host or the sex of the parasite on the presence and abundance of the parasite in the gastrointestinal tract. Studies on acanthocephalan parasitism in fish in Brazil focus on fish farm. The fact that two species of selvage carnivorous fish present high rates of acanthocephalan parasitism, added to the fact that most studies with this group are on farmed fish fed with feed, only emphasise the need for continuity in studies of acanthocephalans in the parasitology of aquatic organisms.

COMMUNITY-ACQUIRED THORACIC EMPYEMA - DOES MICROBIOLOGICAL IDENTIFICATION MATTER?

OBJECTIVES: To describe the clinical characteristics, comorbidities and clinical outcome of hospitalized patients with the diagnosis of community acquired thoracic empyema in our hospital, with particular emphasis on the impact of identification of the causative agent. METHODS: We performed a retrospective review of the clinical files of hospitalized adult patients diagnosed with community acquired thoracic empyema between 2012 and 2016. RESULTS: A total of 81 patients (64 men and 17 women), with a mean age of 54.6+-17.3 years, were included in this study. It was possible to identify the microbiological agent in 59.3% (n=48) of the patients. The median length of hospital stay was 29 days (P25=20 and P75=44.5) and a tendency to longer duration was seen in patients with a microbiological isolation (32 days vs 23 days; p=0.056). No significant difference was observed between patients with and without microbiological isolation, regarding the mortality. CONCLUSION: In this group of patients a positive pleural fluid culture tends to be associated with longer lengths of hospital stay, which may lead to speculation that they were more advanced infectious processes at the time of diagnosis.

Temporal effects and changes in the parasitic community of Prochilodus lineatus (Valenciennes, 1837) (Characiformes: Prochilodontidae) in a floodplain.

The construction of dams causes several impacts on aquatic environments, altering the flow of rivers, environmental variables, and all biota present, including parasites. Little is known about how the parasitic community can be influenced in the long term by environmental changes. In this study, it was expected that the impacts caused by environmental disturbances will be directly reflected by the composition of the parasite populations. We evaluated the change in the structure of the Prochilodus lineatus endoparasite community between two periods sampled 15 years apart in the upper Paraná River floodplain. There was a significant difference in the weight-length relationship of P. lineatus between these periods and a total of 15 species of parasites were found: 11 species in Period 1 and nine species in Period 2 and five species occurred in both periods. The species richness and diversity were higher in Period 1, and we observed that the correlation of descriptors (richness, diversity and evenness) increased with fish length in this period. In both periods, digeneans numerically dominated the parasitic community, and we verified changes in the composition of parasites between periods. Both the host and the parasites were possibly affected by the environmental impacts resulting from the construction of dams over time, and it is noteworthy that complex life cycle parasites such as Digenea and Acanthocephala require intermediate hosts to complete their life cycle, and the population responds to fluctuations in the face of modified environments.

LONG TERM FOLLOW-UP IN SURGICAL STAGE I NON-SMALL CELL LUNG CANCER - A SINGLE CENTER EXPERIENCE.

INTRODUCTION: Lung cancer has a high mortality rate with an overall survival of 18% at 5 years. Surgical treatment is the gold standard for early stages and is associated with high rates of resolution with a 5-year survival of 80% reported in large studies. PURPOSE: To determinethe survival of patients with non-small cell lung cancer (NSCLC) in stage IA (T1N0M0) undergoing surgical treatment with curative intent in our center. METHODS: We performed a retrospective review of the clinical records of all patients with pathological stage T1a-c N0 (stage I) who underwent thoracic surgery with curative intent from 2010 and 2017 in our center. Overall survival and lung cancer-specific survival was estimated by the Kaplan-Meier method. RESULTS: 87 patients (54 men and 33 women) with a median age of 66 years (range 36 to 83 years) were included. Lobectomy with systematic lymph node dissection was performed in 67 patients (77%). Adenocarcinoma was the predominant histological subtype (n=69; 79%). Overall survival at 5th years was 86,7%. Patients submitted to limited resection (segmentectomy or wedge resection) had lower overall survival compared to those submitted to lobectomy (66,4% vs 88,7%; p=0.008). CONCLUSIONS: Our results show a high 5-year overall survival rate, in agreement with results from larger series studies. Lung cancer screening, although not yet widely implemented, has been shown to reduce mortality associated with lung cancer. These results reinforce the importance of screening programs for specific populations in order to identify patients in early stages and improve overall survival.

MAJOR PULMONARY SURGERY IN PATIENTS WITH COMPROMISED LUNG FUNCTION.

INTRODUCTION: The risk stratification of lung resection is fundamentally based on the results of pulmonary function tests. In patients considered to be at risk, major surgery is generally denied, opting for potentially less curative therapies. OBJECTIVE: To evaluate the postoperative outcomes of major lung surgery in a group of patients deemed high risk. METHODS: We performed a retrospective review of clinical records of all patients submitted to lobectomy, bilobectomy or pneumonectomy in a 3-year period in a reference Thoracic Surgery Unit. The patients were then divided in two groups: group A composed of patients with normal preoperative pulmonary function and group B which included patients with impaired lung function, defined as FEV1 and/or DLCO ≤60%. RESULTS: A total of 234 patients were included, 181 (77.4%) in group A and 53 (22.6%) in group B. In group B, patients had more smoking habits, were more often associated with chronic obstructive pulmonary disease and were also more frequently submitted to thoracotomy. When surgery was motivated by primary lung cancer this group had a more advanced clinical stage of the disease. In the postoperative period, these patients had longer hospital stay, longer chest drainage time and greater need for oxygen therapy at home, however, no statistically significant difference was noted in morbidity or mortality. CONCLUSIONS: Major thoracic surgery can be safely performed in selected patients considered to be high risk for resection by pulmonary function tests. A potentially curative surgery should not be denied based on respiratory function tests alone.

Does lobar or size-reduced lung transplantation offer satisfactory early and late outcomes?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether size-reduced or lobar lung transplantation (LLTx) offers the same benefit as classic lung transplantation (LTx). Of the 147 papers found using the reported search, 9 were selected to provide the best evidence. Details of the studies regarding authors, date, journal, country of publication, study type, group studied, relevant outcomes and results are given. All studies reported survival rates of LLTx and most compared it with classical LTx. No statistical differences were reported in medium term and long term. Two of the studies reported a higher incidence of postoperative complications, such as the need for cardiopulmonary bypass, reperfusion oedema or primary graft dysfunction, and longer intubation or intensive care unit stay times. Although the largest study showed a significantly worse 1-year survival in LLTx, a sub-analysis considering patients successfully discharged showed similar outcomes at 1, 3 and 5 years when compared with classic LTx patients. We conclude that LLTx is a valid therapeutic option for recipients with significant donor size mismatch, offering similar outcomes as classical LTx in the medium term and long term.

In lung transplantation, are pulmonary grafts from donors deceased from hanging as suitable as grafts from donors deceased from other causes?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether pulmonary grafts from donors deceased from hanging offer the same benefit as grafts from donors deceased from other causes in lung transplantation. Of the 17 papers found, 4 provided the best evidence to answer the question. The authors, date, journal, country of publication, study type, group studied, relevant outcomes and results of these papers are tabulated. One study reported a large cohort of donors and analysed the outcomes by cause of death, reporting no differences in survival. The remaining 3 papers analysed observational studies on the outcomes of lung transplantation using pulmonary grafts from donors deceased from hanging, compared with donors deceased from other causes. No differences in the rates of post-transplantation pulmonary graft dysfunction and long-term overall survival were reported. Although the cohort of donors deceased from hanging is small, we conclude that these donors are an important contribution to the donor pool. Ex vivo lung perfusion may have a role in assessing graft viability in this scenario.

A disease with many faces.

Can you diagnose this man with progressively worsening shortness of breath, mucous productive cough, weight loss, fatigue and a history of suspected pulmonary tuberculosis? http://bit.ly/2VUdnTr.

Isolated Pulmonary Mucormycosis in an immunocompetent patient.

Mucormycosis is a life-threatening fungal infection that occurs mainly in immunocompromised patients. Its occurrence isolated in the lung rare and carries a high mortality risk if untreated. We report the case of a 76-year old male immunocompetent patient, under treatment for pulmonary tuberculosis, admitted to the emergency department with hemoptysis. Bronchoscopy was performed and active bleeding from the middle lobe bronchus was found. Chest CT scan identified a solitary cavitary lesion in the middle lobe. The patient was proposed for urgent open middle lobectomy. Postoperative period was uneventful. Pulmonary mucormycosis was confirmed and adjuvant therapy with Amphotericin B was performed for 30 days. Despite its rarity, mucormycosis prevalence is expected to raise together with increasing number of immunocompromised patients. A high level of suspicion is recommended as early diagnosis can be determinant.

Manubrium resection and reconstruction for mediastinal tumor: a case report.

Primary mediastinal tumours with chest wall involvement represent technical challenges that may offer a survival benefit. Reconstruction with osteossynthesis material, bioprosthesis and muscle flaps is indicated to re-establish the excised component function. We report a case of a 30-year-old male with a primary mediastinal seminoma operated after chemotherapy with need for en bloc resection of the residual mass and manubrium with chest wall reconstruction. This type of surgery is rare and represents a technical challenge. Therefore, it should be performed in referral centers and with a multidisciliplinary approach.

Tumores primários do mediastino com envolvimento da parede torácica representam desafios cirúrgicos que podem proporcionar um benefício na sobrevida. A reconstrução com material de osteossíntese, biopróteses ou retalhos musculares está indicada para restabelecer a função dos segmentos excisados. Reportamos o caso de um doente de 30 anos do sexo masculino submetido a cirurgia após quimioterapia adjuvante por seminoma primário do mediastino com necessidade de ressecção em bloco do tumor residual e manúbrio com reconstrução da parede torácica. Este tipo de cirurgia é rara e representa um desafio a nível técnico, devendo ser realizada em centros de referência e com abordagem multidisciplinar.

Assessment of sulfide production in a full scale wastewater sludge rising main.

Production and build-up of sulfide in wastewater systems, especially downstream of rising mains, may lead to severe odour nuisance, toxic environments and high risk of corrosion. Due to increased population migration towards cities and lower area availability for treatment facilities, rising mains for the conveyance of wastewater sludge are becoming more frequent, and research on sulfide build-up in such cases is needed. In this paper the findings of the work carried out in a full scale wastewater sludge rising main, operated during different seasons and under distinct conditions are presented (comprising both the start-up and normal operation stages of the facility). Results showed a sulfide build-up rate of 3.24 g S-2 m-2 d-1 in the summer and of 2.30 g S-2 m-2 d-1 during the winter. The ratio of sulfate reduction to sulfide production (SO4-2/S-2) was of roughly 3 to 1, as expected. Furthermore, obtained results allowed adjusting a second order polynomial empirical equation for the forecasting of sulfide build-up within the sludge rising main. The obtained equation for sludge significantly differs from existing equations obtained for wastewater. Moreover, this work also allowed obtaining new insight into the positive influence of biofilm and hydraulic retention time in the biological sulfide generation, as well as into its variation along the length of the rising main.

The First 24 Robotic Surgeries of Hospital da Luz.

INTRODUCTION: Robotic assisted thoracic surgery (RATS) has been growing all over the world, presenting itself as an improvement over video-assisted thoracic surgery (VATS). The main advantages are the precision of the movements, as well as the three-dimensional vision with the consequent perception of the depth of the surgical field. Thus, technically more difficult procedures, such as anatomic segmentectomies and bronchoplastic resections, are facilitated. This surgical approach also improves the quality of mediastinal lymph node dissection, extremely important in lung cancer patients. OBJECTIVE: Analysis of the first 24 robotic thoracic surgeries performed at Hospital da Luz. METHODS: All robotic thoracic surgeries performed at Hospital da Luz from 2/6/2016 to this date were evaluated, concerning diagnosis, type of surgery, chest drainage time, hospitalization time, morbidity and mortality. RESULTS: Twenty-four RATS were performed, with patients having a mean age of 60.5 (39-76) years, eleven of them being male. All surgeries were performed with 3 ports of 8mm and a 12mm port for the assistant. Eighteen surgeries of pulmonary resection (75%), five surgeries for mediastinal lesions (20.8%), and one for intercostal nerve harvest for reinnervation of the brachial plexus, were performed. In the pulmonary surgeries, eleven were lobectomies (61.1%), five were anatomic segmentectomies (27.8%) and two wedge resections (11.1%). Neoplastic disease was the reason for the sixteen lung anatomic resections, two for metastatic disease and fourteen for primary lung cancer. In each case, a systemic lymph node dissection was performed. All procedures were performed without intra- or postoperative complications. Mean drainage time was 3.4 days [2-6], and mean hospitalization time was 4.8 days [3-8]. There were no mortality or major morbidity. There were two patients with prolonged air-leak up to 6 days. The morbidity after discharge was 12.5%, consisting of an apical pneumothorax that resolved spontaneously, a basal pleural effusion that resolved with outpatient thoracentesis, and a respiratory infection treated with antibiotic. CONCLUSION: The overall evaluation of this technique is still precocious, but allows to affirm that an experienced surgeon in vats surgery has a faster learning curve with this new approach. The innovation and development of new techniques in thoracic surgery are fundamental in order to allow more effective treatments, with less pain and, when possible, lung parenchyma sparing surgeries in patients with early neoplastic lung disease.

Severe Intraoperative Complications During VATS Anatomical Ressections and their Surgical Resolution in a Portuguese Thoracic Surgery Centre - A 9-Year Review.

INTRODUCTION: Many studies have demonstrated that video-assisted thoracoscopic surgery (VATS) is not only feasible and safe but is actually the approach chosen for an increasing number of pulmonary anatomic resections. There are however few studies reporting on severe intraoperative complications during VATS anatomical ressections and their resolution. OBJECTIVE: Our aim is to analyse the incidence of severe intraoperative complications during VATS anatomical ressections, at our department, in the past nine years, and describe their technical resolution during the surgery. METHODS: We performed the retrospective analysis of the patients submitted to lobectomy, bilobectomy or segmentectomy by VATS or VATS converted to thoracotomy at Hospital de Santa Marta, between May 2008 and September 2017. Severe intraoperative complications were defined as an event that results in a life threatening situation or an injury to a proximal airway, blood vessel or organ that would lead to an unplanned additional anatomical resection. RESULTS: A total of 151 patients were submitted to anatomical ressections, 90,7% (n=137) of them for a primary lung cancer, other indications were metastatic disease 6%(n=9) and benign disease in 3,3% (n=5). The surgery was a lobectomy in 94% of the cases (n=142), a segmentectomy in 5% (n=8), and one bilobectomy. The conversion rate to thoracotomy was 12% (n=18), most of which were for technical/ oncological reasons (n=11), and 7 others were to control bleeding. Four (2,6%) severe intraoperative complications were identified. Three of them (2%) were erroneous transections of bronchovascular structures (left main bronchus, left main pulmonary artery and both left pulmonary veins); and one was a membranous airway injury proximal to the staple line. There were no intraoperative deaths. The three patients with erroneous bronchovascular transection were converted to thoracotomy and the bronchial or vascular re-anastomosis was performed, therefore avoiding a left pneumonectomy. In the patient with the membranous airway injury, the bronchoplastic suture was performed by VATS. All four patients were primary lung cancer patients. In all these cases the patients were discharged alive and well and are undergoing their follow-up program with no signs of disease recurrence. CONCLUSION: Albeit rare, severe complications during VATS Lobectomy can occur but when they happen the thoracic surgeon has to be ready to solve them with the minimal repercussion for the patient.

[Malignant mesothelioma--a diagnostic challenge]. / Mesotelioma maligno um desafio diagnóstico.

Malignant mesothelioma is a rare neoplasm associated, in 80% of the cases, with exposure to asbestos fibres, with a latency period between 20 and 50 years. The treatment is palliative in most cases because of the extension of the disease at the time of diagnosis. Mesothelioma is a resistant tumour to chemotherapy and radiotherapy. Overall survival varies between 4 and 18 months, rarely over 5 years. The authors present a case of a 82-year-old man, ex-sailor, with prostatic neoplasm in hormonal "escape" phase, admitted with cough and dyspnea. The chest radiograph showed extensive right pleural effusion. The diagnostic hypothesis were metastatic, infectious and primitive neoplasm origin. Pleural biopsy revealed epithelial malignant mesothelioma confirmed by thoracoscopy, associated with prolongated occupational exposure to asbestos fibres. Without surgery indication the patient was submitted to chemotherapy with gencitabin and cisplatin associated with pleurodesis. Although he improved clinically, the presence of two malignant neoplasms, a rare situation in clinical practice, is associated with a poor prognosis, especially condicionated by the epithelial malignant mesothelioma in Butchart stage II. Finally, we discussed new differential diagnostic techniques with metastatic adenocarcinoma and target therapies under study.