Video assisted thoracoscopic management of primary spontaneous pneumothorax.

OBJECTIVE: To analyze the outcome of Video assisted Thoracoscopy (Vats) in Primary Spontaneous Pneumothorax (PSP). METHODS: This case series was carried out from Jan 2010 to Jan 2017 in Department of Thoracic Surgery CMH Rawalpindi and Lahore. A total of 98 patients underwent Video-assisted thoracoscopic for PSP. Inclusion criteria were physiologically fit patients with PSP for recurrent attacks, occupational hazards and prolonged air leak. Exclusion criteria included secondary spontaneous pneumothorax, previous pleurodesis and physiologically unfit patient for general anaesthesia. Vanderschueren's thoracoscopic classification was used for macroscopic staging. A 3-port technique was used for apical stapling with partial pleurectomy up to 6th rib. Parietal pleura and diaphragm was also abraded. RESULTS: Occupational hazard was the commonest indication for surgery, n= 39 (39.7%). This was followed by recurrent pneumothorax 37 (37.7%), persistent air leak 19 (19.38%) and contra lateral pneumothorax n=4 (4.08%). Mean age was 22.8 ± 6.5 years. Majority of the cases , 69(70.4%) were in stage 3 of Vanderschueren's classification. Stage 4 were (18.5%) and stage 2 were 7 (7.14%). Mean operative time was 51 ± 14. 4 minutes. Postoperative prolonged air leak occurred in 3 patients and post-operative neuralgia occurred in 8 patients. Mean follow-up was 22 ±5.5 months, range 5-24 months for all patients. One had generalized recurrence and 2 patients had subpulmonic trapping of air. CONCLUSION: Video-assisted thoracoscopic stapling and pleurectomy is an effective definitive treatment for primary spontaneous pneumothorax when indicated with minimal recurrence.

Pediculated Intercostal Muscle Flaps in Bronchiactasis Resectional Surgery for Bronchial Stump Reinforcement.

OBJECTIVE: To determine the outcome of muscle flap to cover the bronchial stump in the resectional surgery for bronchiectasis for prevention of bronchopleural fistula. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Combined Military Hospitals of Quetta, Lahore, and Rawalpindi from January 2006 to August 2017. METHODOLOGY: Patients with localised bronchiectatic changes were included. Patients with carcinoma and without flap resection were excluded. Resectional surgery was performed through posterolateral thoracotomy approach, under general anesthesia with one lung ventilation. Pediculated or bipediculated intercostal muscle flap (ICM) was used to reinforce the bronchial stump. Pediculated ICM flaps were utilised for reinforcement of bronchial stump and bipediculated flaps were used over lesser. RESULTS: Three hundred and ninety-eight cases of bronchiectasis with average age of patients 38.5 ±19.8 years and male to female ratio of 2:1 were included. Bronchiectasis was unilateral in 377 cases. Tuberculous was found in 278 of the cases. Thirty-five had poor lung function tests (FEV1 <1.5%). Eighty-two patients underwent pneumonectomy, 228 patients had lobectomy and 88 patients underwent segmentectomy. Posterior-based pediculated ICM flap was used in 365 patients, and bipediculated ICM flaps in 30 cases. The most common complication was post-thoracotomy neuralgia 53. Bronchopleural fistula, despite transposition of intercostal muscle flap on bronchial stump, was present in 4 patients. CONCLUSION: Application of muscle flap over bronchial stump after resection surgery for bronchiectasis, is simple, safe and effective surgical option to avoid complication of bronchopleural fistula.

A rare presentation of cephalad extension of an anterior mediastinal teratoma - A case report.

We report a case of a 28 year old female who presented to us in November 2016 with a swelling in front of neck for three years and worsening shortness of breath for last one year, causing right sided tracheal deviation and mildSuperior Vena Caval obstruction. X-ray showed a soft tissue density mass in antero-superior mediastinum with cephalad extension. Contrast enhanced CT neck and chest revealed a multi cystic lesion extending from the root of neck to anterior mediastinum causing compression and deviation of trachea, and nearby structures especially Superior Vena Cava (SVC) along with collateral formation. Mass was surgically excised from the neck and mediastinum with uneventful post-operative recovery. Histopathology was consistent with benign mature cystic teratoma.

AN EXPERIENCE OF BRONCHOTOMY AND RESECTIONAL PROCEDURES AFTER FAILED BRONCHOSCOPIC FOERIGN BODY RETRIEVAL.

BACKGROUND: Foreign body bronchus is a surgical emergency and is associated with a high mortality if neglected or complicated. The objective of this study was to analyse the outcome of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval. METHODS: This study of 24 cases of bronchotomy and resectional procedures after failed bronchoscopic foreign body retrieval was done from June 2008 to June 2009 and March 2010 to Sep 2013. Patients after failed retrieval of foreign body by bronchoscopy either by ENT specialists or thoracic surgeons underwent bronchotomy or resectional procedures were included in the study. We used the posterolateral thoracotomy approach for the surgical procedures. RESULTS: Bronchotomy and resectional procedures were done in 24 cases. Age of patients ranged from 2 years to 51 years. Most patients were children and right side was mostly involved. Bronchotomy procedures were 10 (41%) and resectional surgeries were 13 (58%). Emergency lobectonies were 3 out of 13 resectional surgeries. Right intermedius bronchus was opened up and incision was extended in the direction of foreign body in 6 cases and left bronchus intermedius was opened in 4 cases. Haemoptysis was the main symptom in late presenters. Range of objects retrieved in our study was from pins, needles to whistles. CONCLUSION: Retention causes endobronchial obstruction with stasis leading to irreversible damaged parenchyma. Foreign body with structural changes require resection, others can be offered bronchotomy which is a safe procedure for retained non retrievable foreign bodies.