Establishing a Multidisciplinary Team-Based Pleural Service in the Era of Financial Austerity: The Role of the Thoracic Surgeon.

Medical thoracoscopy/pleuroscopy has become, after bronchoscopy, the second most commonly utilized endoscopic procedure in interventional pulmonology. Due to their common origin, medical thoracoscopy/pleuroscopy and video-assisted thoracic surgery (VATS) are quite similar procedures technically. In contrast to the prevailing attitude that it should predominantly be performed by interventional pulmonologists, we believe that, like all hybrid-in-nature techniques, it should be implemented as part of a combined specialist care service/team. Herewith, we describe our attempt to establish a multidisciplinary pleural disease program during a difficult economic period for our country, comprising thoracic surgeons, pulmonologists and anesthesiologists, all of whom brought in their experience, expertise and resources to establish and develop the service resulting in a hybridization of the technique, with, as reported, quite favorable results.

Basic Operative Tactics for Pulmonary Echinococcosis in the Era of Endostaplers and Energy Devices.

Human echinococcosis is a zoonotic infection caused by the larvae of the tapeworm species Echinococcus. The liver is the most common location for a primary echinococcosis. However, the parasite may bypass or spread from the liver to the lungs, causing primary or secondary pulmonary echinococcosis, respectively. Pulmonary echinococcosis is a clinically challenging condition in which anthelminthic regiments are important, but surgery has the central role in removing the cysts and preventing recurrences. Surgical treatment may involve cystotomy, enucleation, capitonnage, or atypical resections, which occasionally are in combination with hepatic procedures. The utilization of modern devices is greatly underdescribed in surgery for thoracic infections, even though these facilitate much of the work. Therefore, this article aims to describe pulmonary echinococcosis and the role of modern surgical devices in the treatment process. Furthermore, we report surgical treatment of three different cases of pulmonary echinococcosis. Surgeries of uncomplicated and ruptured hepatic or pulmonary cysts are described. Simple small pulmonary echinococcal lesions can be excised by endostaplers both for diagnostic and curative reasons. Larger cysts can be removed by energy devices unless large bronchial air leaks occur. Complicated cysts require treatment by more extensive techniques. Inexperienced surgeons should not abstain but should carefully decide preoperatively how to proceed.

Platelet-Rich Plasma for Pleurodesis: An Experimental Study in Rabbits.

Background and Objectives: This study was designed to evaluate platelet-rich plasma (PRP) as a method of pleurodesis in a rabbit model. Pleurodesis with PRP was compared against the gold-standard use of talc. The secondary evaluation assessed the ideal time for achieving pleurodesis. Materials and Methods: 25 healthy New Zealand white rabbits were assigned to three groups, as follows: 12 animals in the first and second groups, as well as one animal with no intervention in the final group, which was used as a control. The talc pleurodesis group (baseline) underwent pleurodesis with sterile talc, which is the gold-standard sclerosing agent used for pleurodesis. The PRP group underwent pleurodesis using autologous PRP. The last group had one rabbit with no intervention. A total of 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 3 days (72 h) after the intervention, and 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 6 days (144 h) after the intervention. In both the talc and PRP group, FBC and CRP were measured before the intervention and in 3 or 6 days afterwards, respectively. The pleura and the lungs were evaluated histopathologically. Results: Macroscopically, there were no statistically significant differences between the two groups. In terms of microscopic findings, there were no statistically significant differences in inflammatory reactions provoked in the visceral and parietal pleura between the PRP and talc. In addition, with talc pleurodesis, a foreign-body reaction was observed in about 50% of the cases, which was not observed with PRP. In terms of inflammation between 3 and 6 days, there were no statistically significant differences with PRP, there was only a statistically significant difference between 3 and 6 days regarding the parietal pleura in the talc group. Conclusions: The instillation of autologous PRP in the pleural cavity shows promise in achieving pleurodesis. The efficacy of PRP as a pleurodesis agent should be examined further.

Large Intrathoracic Desmoid Tumor and Re-Expansion Pulmonary Edema: Case Report and Review of the Literature.

Re-expansion pulmonary edema is a potentially life-threatening situation following thoracic surgery of a compromised lung. We report the case of a 24-year-old female scheduled for a resection of a large intrathoracic desmoid tumor that presented with re-expansion pulmonary edema at the conclusion of her surgery and discuss the clinical presentation, mechanism and predictors of this entity and review similar cases reported in the literature.

Radiation-Induced Esophageal Cancer: Investigating the Pathogenesis, Management, and Prognosis.

One of the most serious late side effects of irradiation is the promotion of tumorigenesis. Radiation-induced esophageal cancer (RIEC) can arise in a previously irradiated field, mostly in patients previously irradiated for thoracic malignancies such as breast cancer, Hodgkin and non-Hodgkin lymphomas, head and neck cancers, lung cancer, or previous esophageal cancer. RIEC is rare and accounts for less than 1% of all carcinomas of the esophagus. There are little data available in the current literature regarding pathogenesis, diagnosis, treatment, and outcome of esophageal cancer developed in a previously irradiated field. RIEC seems to represent a biologically aggressive disease with a poor prognosis. Although it is difficult to perform radical surgery on a previously irradiated field, R0 resection remains the mainstay of treatment. The use of neoadjuvant and adjuvant chemoradiotherapy remains very helpful in RIEC, similarly to conventional esophageal cancer protocols. The aim of this article is to elucidate this rare but challenging entity.

Treatment of a chronic esophageal perforation after vertebral surgery with external vacuum therapy - a case report.

Esophageal perforations of any cause may escape early diagnosis and progress to lethal mediastinitis despite aggressive management. The treatment and outcome depends on the extent and chronicity of the injury. A CASE REPORT: We present a case of a late-diagnosed cervical esophageal rupture treated successfully with external vacuum therapy. A blunt trauma patient with cervical vertebral column fractures underwent fixation with a titanium bracket. A procedure-related esophageal perforation created an open fistulous communication to the skin. This was diagnosed with one month's delay. In diagnostic endoscopy the prosthesis was visible through a large esophageal defect. Evidence of mediastinitis was absent. The external wound was explored and a standard vacuum device was inserted. Nine weeks of continuous vacuum therapy achieved complete fistula closure and prevented infection. Mediastinitis was avoided and complete oral feeding was resumed. CONCLUSIONS: Different clinical presentations indicate surgical, endoscopic or conservative treatment. In this report, we provide the ground for discussion for the alternative application of the vacuum technology in a case where otherwise surgery would be the definite treatment.

Lung cancer in patients with Idiopathic Pulmonary Fibrosis. A retrospective multicenter study in Greece.

BACKGROUND: Abundant evidence supports an association between Idiopathic Pulmonary Fibrosis (IPF) and lung cancer development. Data on diagnosis and management of patients with IPF and lung cancer are still scarce. PATIENTS AND METHODS: This was a retrospective multicenter study, enrolling 1016 patients with IPF from eight different centers between 2011 and 2018 in Greece. Our aim was to estimate prevalence of lung cancer in patients with IPF in Greece. RESULTS: We identified 102 cases of patients with IPF and lung cancer (prevalence = 10.03% n = 102/1016, mean age±SD = 71.8 ± 6.9, 96 males, mean FVC±SD = 72.7 ± 19.7, mean DLCO±SD = 44.5 ± 16.3). We identified 85 cases (83.3%) of non-small cell lung cancer (35 squamous, 28 adenocarcinoma), and 15 cases (14.7%) of small cell lung cancer. Primary lesion was localized in lower lobes in 57.1% of cases. Lung cancer was diagnosed post IPF diagnosis (mean latency time + SD = 33.2 + 36.1 months) in 57.6% of patients and synchronously in 36.5% of patients. Chemotherapy was applied in 26.7% of cases, while 34.7% of patients underwent surgery. Median survival of patients with IPF and lung cancer was 27.4 months (95% CI: 20.6 to 36.8). CONCLUSIONS: IPF is a risk factor for lung cancer development. In line with current literature, squamous cell carcinoma is the most common histologic subtype in patients with IPF. Large randomized controlled studies on the management of patients with IPF and lung cancer are sorely needed.

A novel anticalcification treatment strategy for bioprosthetic valves and review of the literature.

BACKGROUND AND AIM OF THE STUDY: Glutaraldehyde (Glut) fixed bioprosthetic valves fail due to progressive dystrophic calcification. Many treatments have been proposed to eliminate calcification but none have been entirely successful. Calcitonin (CT) and sodium bisulfite (BSF) have recently been introduced as independent anticalcification reagents. It is postulated that their combined effect, along with the addition of the detergent Tween 80 and alcohol at 37°C, may efficiently minimize tissue calcification due to aldehyde adduct formation and elimination of lipids. MATERIAL AND METHODS: Three groups were created from porcine aortic leaflets: group I (Glut only), group II (Glut with 1% CT, 12.5% BSF, and 1.2% Tween 80 at 37°C), and group III (Glut with 1% CT, 10% BSF, 1.2% Tween 80, and 20% alcohol at 37°C). All tissues were implanted subdermally in three sets of eight (group I), six (group II), and five (group III) Wistar rats. After 4 months, the tissues were retrieved and lyophilized at -40°C at 100 mm Hg. The calcium was measured with a flat atomic absorption technique. RESULTS: The preimplantation calcium (Ca) concentration in mg Ca/gram of tissue was 1.79 ± 0.14 in group I, 1.65 ± 0.28 in group II, and 0.72 ± 0.79 in group III (P = ns). After 4 months, the Ca concentration was 277.55 ± 32.52, 103.54 ± 5.39 (P < .001) and 42.02 ± 15.63 (P < .001), respectively. There was also a significant difference (P < .001) between groups II and III. CONCLUSION: The combination of CT and BSF along with the detergent Tween 80 and alcohol at 37°C mitigates the calcification efficiently as compared to Glut treatment only.

Ultrasound-Guided Interscalene Brachial Plexus Nerve Block With an Ultralow Volume of Local Anesthetic for Post-Thoracotomy Shoulder Girdle Pain.

OBJECTIVES: To evaluate the efficacy of ultrasound-guided interscalene nerve block using an ultralow volume of local anesthetic (5 mL of ropivacaine, 0.75%) for the management of post-thoracotomy shoulder girdle pain. DESIGN: Open-cohort, prospective, single-center study. SETTING: University hospital. INTERVENTIONS: Patients with post-thoracotomy shoulder girdle pain (visual analog scale [VAS] ≥5) received an ultrasound-guided interscalene nerve block. MEASUREMENTS AND MAIN RESULTS: Thirty minutes after block implementation, the VAS was used to quantify pain across the shoulder girdle. The index (I) was calculated to indicate improvement of pain as follows: [Formula: see text] Nerve bocks resulting in I ≥75% were considered excellent. Total tramadol consumption 36 hours after nerve blocks, patients' satisfaction, and complications related to the procedure also were assessed. Patients were segregated in the following 2 groups: group A, which comprised patients with pain in the shoulder area (glenohumeral and acromioclavicular joints) (n = 30), and group B, which comprised patients with pain in the scapula (n = 17). I was significantly greater in group A (88.3% ± 14%) than in group B (43.2% ± 22%). In groups A and B, 90% and 11% of patients, respectively, demonstrated excellent pain control. Total tramadol consumption in group A, 25 (0-100) mg, was significantly less that of group B, 250 (150-500) mg. Patients' satisfaction also was significantly higher in group A compared with group B. No complications were recorded. CONCLUSIONS: Ultrasound-guided interscalene nerve block can substantially alleviate post-thoracotomy pain in the shoulder but not in the scapular area.

Orchitis reveals an extragonadal primary mediastinal thymic seminoma: a coincidence or not?

BACKGROUND: Mediastinal thymic seminomas are rare male germ cell tumors with extragonadal origin that appear predominately with a cystic appearance. CASE PRESENTATION: A 22-year-old male was referred to our department for further investigation of a mediastinal mass discovered incidentally during routine chest X-ray. The patient has denied any symptoms including dyspnea, chest pain, cough, fever, dysphagia, hemoptysis, weight loss, and weakness. His past medical history was remarkable for orchitis, for which he had undergone a bilateral testicular biopsy, without the latter however, indicating the presence of a germ cell tumor or a premalignant lesion. Contrast-enhanced chest computed tomography revealed a lobulated and well-marginated cystic lesion in the anterior mediastinum. Differential diagnosis included mostly a multilocular thymic cyst, a lymphoma, a seminoma, or a soft tissue tumor. Resection of the mass revealed a primary thymic seminoma. CONCLUSIONS: A surgical approach for the management of these tumors might be reasonable considering that an extensive sampling is mandatory to gain an appropriate biopsy preoperatively in order to securely confirm or refute the presence of a mediastinal extragonadal tumor. Orchitis might be a sign of a general disorder of the germ cells which might transform in time.

Results of the modified bi-pectoral muscle flap procedure for post-sternotomy deep wound infection.

PURPOSE: Post-sternotomy deep sternal wound infection (DSWI) is a severe complication of cardiac surgery. The introduction of omental and muscle flaps has resulted in a significant decrease in morbidity and mortality. In this article, we present the findings for a series of 55 consecutive patients with DSWI treated using an alternative bi-pectoral musculofascial flap technique. METHODS: The patients were stratified into two groups (one-or two-stage intervention). Patients with septic wounds initially underwent debridement and wound treatment, while vacuum therapy was used in a subset of the subjects. All patients were treated with wound debridement and bi-pectoral advancement flap reconstruction. RESULTS: 30-day mortality was 5.4%. Most patients (72%) were treated in two stages, while vacuum therapy was used in 20% of the patients. The mean number of hospitalization days was 8 and 12 for the one- and the two-stage groups, respectively. Reconstruction was successful in all but three patients, each of whom developed recurrent infection. No major morbidity was reported at a mean follow-up of 82 months with excellent functional and aesthetic outcomes. CONCLUSIONS: Pectoralis-major muscle flaps remain relevant in the modern management of post-sternotomy mediastinitis. The addition of an omental flap should be considered in cases in which the lower sternum is involved. Prompt diagnosis and a meticulous surgical technique ensure favorable results for the majority of patients.

Repair of gastric defects with an equine pericardial patch.

PURPOSES: The objective of this study was to test the efficacy of an equine pericardial patch for repairing full-thickness defects of the stomach wall. METHODS: Circular defects, 1.5 cm in diameter, were created on the anterior wall of the stomach of 12 female New Zealand rabbits. The defects were repaired by an equine pericardial patch. After euthanasia at different time intervals (3 days to 8 weeks) a macroscopic evaluation of the abdominal cavity (including adhesion scoring), mechanical testing and a histological examination of the stomach were performed. RESULTS: The animals survived the surgical procedure and underwent an uneventful recovery until euthanasia. None of the patches failed. Adhesions were observed in all animals and were significant in 3/12 animals. Bursting pressure testing indicated that the repair was durable and that adequate strength to prevent patch failure was achieved by the second week. A histological examination showed gradual narrowing of the perforation site by mucosal and limited muscular regeneration. CONCLUSIONS: The equine pericardial patch was successfully used to repair a gastric defect in our experimental model, and it seems that it could have potential as a material suitable for further research concerning the repair of upper gastrointestinal defects.

The Belsey Mark IV: an operation with an enduring role in the management of complicated hiatal hernia.

BACKGROUND: The Belsey Mark IV operation has been used for the management of hiatal hernia for over 40 years, but with the introduction of laparoscopic techniques its role has become questionable. To determine the current role of this procedure we present a contemporary series of patients. METHODS: We reviewed fifteen consecutive patients, mean age of 63 years, who underwent a Belsey Mark IV fundoplication for gastroesophageal reflux in the presence of a hiatal hernia in our Department from January 2005 to March 2011. Indications for the thoracic approach included paraesophageal hernias, recurrent hiatal hernias and previous upper abdominal surgery. RESULTS: There was no operative mortality. Immediate postoperative morbidity included 1 case of bleeding, 1 case of pneumonia and 1 case of atrial fibrillation. The mean length of stay was 5.9 days. After a mean follow-up time of 49 months, all patients reported total or partial alleviation of their symptoms. No hernia recurrence was detected during barium swallow examination. CONCLUSIONS: The Belsey approach is a procedure that can be useful as an alternative in selected cases when there are co-morbidities complicating the transabdominal (laparoscopic) approach.

The Impact of COVID-19 Pandemic on Surgical Treatment of Resectable Non-Small Cell Lung Cancer in Greece.

Background: The coronavirus disease (COVID-19) pandemic has posed an unprecedented challenge to health systems, and has significantly affected the healthcare of lung cancer patients. The aim of our study was to assess the impact of COVID-19 on early lung cancer patients' surgical treatment. Methods: All consecutive patients with early-stage non-small cell lung cancer eligible for surgical treatment stage I/II and resectable stage III, referred to our department during the first wave of COVID-19 between February to May 2020, were included and compared with those on the exact corresponding quarter in 2019, one year before the pandemic. Waiting time to surgical treatment, increase of tumor's size and increase on lung cancer stage were recorded and compared. All subjects were followed up for 12 months. Multiple linear and logistic regression models were applied to assess the differences in the management of the studied groups adjusting for potential confounders. Results: Sixty-one patients with early-stage lung cancer were included in the study; 28 (median age 67 years, SD: 7.1) during the pandemic and 33 (median age 67.1 years, SD: 7.5) one year earlier. A significantly longer period of waiting for treatment and an increase in tumor size were observed during the pandemic compared to before the pandemic [median time 47 days, interquartile rate (IQR): 23−100] vs. [median time 18 days, IQR: 11−23], p < 0.001. No significant differences were detected in the increase of the stage of lung cancer between the subgroups. Conclusion: The COVID-19 pandemic had a significant impact on surgical and oncological care, leading to significant delays on treatment and an increase in tumor size in early-stage lung cancer patients.

Mediastinal Teratoma Mimicking Neurofibroma in CT-Guided Biopsy in a Patient With Neurofibromatosis Type 1.

Teratomas are a type of germ cell tumor that may contain several different types of tissue. Neurofibroma is a benign peripheral nerve sheath tumor with the plexiform type being pathognomonic for neurofibromatosis type 1. We report a case of a 33-year-old woman with a background of Neurofibromatosis type 1 who presented with left-sided chest pain and shortness of breath. She was diagnosed with a large mediastinal mass which was confirmed from a CT-guided biopsy as neurofibroma. Following a multidisciplinary team discussion, she underwent mediastinal mass resection and the final histopathology report revealed mediastinal mature teratoma.

Cardiopulmonary bypass assisted resection of mediastinal masses.

We report a recurrent solitary fibrous tumor of the mediastinum that was encircling the right pulmonary artery. The resection of the tumor with the involved right pulmonary artery segment and sequential graft reconstruction of the vessel was facilitated by the use of cardiopulmonary bypass. We review the indications, management, and outcomes of cardiopulmonary bypass for the resection of mediastinal masses.