Complication rates rise with age and Haller index in minimally invasive correction of pectus excavatum: A high-volume, single-center retrospective cohort study.

OBJECTIVES: The study objectives were to describe the compounded complication rate of minimally invasive repair of pectus excavatum, identify predisposing risk factors, and evaluate the optimal timing of correction. Minimally invasive repair of pectus excavatum is the standard treatment for pectus excavatum and consists of 2 invasive procedures, for example, correction with bar insertion followed by bar removal after 2 to 3 years. METHODS: A retrospective cohort study identifying children, adolescents, and adults of both genders corrected for pectus excavatum with minimally invasive repair of pectus excavatum between 2001 and 2022. Information on complications related to bar insertion and removal procedures for each individual patient was compiled into a compounded complication rate. Complication severities were categorized according to the Clavien-Dindo classification. RESULTS: A total of 2013 patients were corrected by minimally invasive repair of pectus excavatum with a median age (interquartile range) for correction of 16.6 (5) years. Overall compounded complication rate occurred at a frequency of 16.4%, of which 9.3% required invasive reinterventions (Clavien-Dindo classification ≥IIIa). The complication rate related to bar insertion was 2.6-fold higher compared with bar removal (11.8% vs 4.5%, respectively). Multivariable analysis revealed age (adjusted odds ratio, 1.05; P < .001), precorrection Haller Index (adjusted odds ratio, 1.10; P < .033), and early-phase institutional experience (adjusted odds ratio, 1.59; P < .002) as independent predisposing risk factors. The optimal age of correction was 12 years, and the compounded complication rate correlated exponentially with age with a doubling time of 7.2 years. Complications increased 2.2-fold when the Haller index increased to 5 or more units. CONCLUSIONS: Minimally invasive repair of pectus excavatum is associated with a high compounded complication rate that increases exponentially with age and high Haller Index. Consequently, we recommend repair during late childhood and early adolescence, and emphasize the importance of informing patients and relatives about the significant risks of adult correction as well as the need of 2 consecutive procedures taking the complication profile into account before planning surgery.

Pulmonary cystic echinococcosis acquired during a short-term tourist travel.

Background: Cystic echinococcosis is non-endemic in Denmark and primarily diagnosed in migrants from endemic areas. Here, we report a case of pulmonary cystic echinococcosis in a Danish woman with no history of longer-term stays abroad, only holiday travelling to tourist destinations. This is the first case reported in international literature from Denmark where the causative parasite was identified to species and genotype level. Case: A 27-year-old pregnant Danish woman was admitted for examination because of haemoptysis for three months.Chest X-ray and computed tomography revealed a cystic structure in the left lung and a left-sided thoracotomy was performed to remove the cyst. Postoperative histopathological examination revealed a hyaline membrane and protoscoleces. Subsequently, infection with Echinococcus granulosus was confirmed by molecular methods. The causative agent was further characterised as E. granulosus sensu stricto G1, which is not known to have an established life cycle in Denmark. It was concluded that the infection was most likely acquired during a tourist travel to an endemic country. The patient was treated with albendazole for four weeks. Conclusion: This case of pulmonary cystic echinococcosis in a person who had lived in Denmark and had history of only short-term tourist travelling abroad highlights that the disease may be acquired during tourist travelling. Thus, a diagnosis of cystic echinococcosis should be considered not only in migrants from endemic countries but also in travellers upon incidental findings of a lung or liver cysts. The case also exemplifies the importance of reaching a diagnosis at species and genotype level.

Localized malignant mesothelioma in the stomach and mediastinum.

Localized malignant mesothelioma is rare. It has a histological pattern identical to diffuse malignant mesothelioma but without diffuse serosal spread. Localized malignant mesothelioma typically originates from the pleura, peritoneum or pericardium, but can occasionally develop from organs. Our cases represent what might be the largest mediastinal localized malignant mesothelioma described and the first presentation of the epithelioid type in the stomach of an adult.

Major penetrating thoracic trauma - The importance of collaboration between different specialties.

INTRODUCTION: Penetrating thoracic trauma presents a rare and serious condition with great diversity in impalement mechanisms and following injuries, resulting in a high mortality. This case reports successful management of a severe thoracic trauma and need for collaboration between surgical specialties. PRESENTATION OF CASE: An 18-year-old, otherwise healthy, Caucasian female had penetration of the chest with a wooden post due to a solo car accident and was admitted to a Level 1 trauma center at a university hospital. Trauma computed tomography scan showed costa fractures and fracture of the left clavicular bone. Damage to the subclavian artery, the brachial plexus and pulmonary artery were suspected. Extracorporeal circulation was on standby at surgery. However, removal of the foreign object did not result in any major bleeding. The patient was discharged from hospital on the 19th day after surgery. Fifteen months after the trauma, surgery was performed to remove the first two costae on the left side, as a disfiguring prominence on the neck was the patients' only complaint. DISCUSSION: Initial management of the patient should follow ATLS® principles with stabilization of airways, breathing and circulation. Multidisciplinary approach resulted in reconstruction of vessels, debridement and wound closure. The importance of follow-up after trauma and surgery are underlined by the current case, as the patient required additional surgery at follow up. CONCLUSION: Multidisciplinary approach to the current penetrating trauma resulted in rapid assessment of injuries and management with excellent outcome.

A case of severe flail chest with several dislocated sterno-chondral fractures.

INTRODUCTION: Flail chest is diagnosed clinically by the presence of paradox movement of a segment of the thoracic wall during spontaneous breathing. Radiographic finding confirming a clinical flail chest are fractures of three or more consecutive ribs or costal cartilages in two or more places. Surgical stabilization is associated with a reduced length of hospital stay, time with mechanical ventilation and risk of respiratory complications. PRESENTATION OF CASE: A trauma patient had a Computed Tomography (CT) scan showing multiple costa fractures, sternal fracture, manubrium fracture, sternal displacement and dehiscence of the sternal-costal attachment. The severity of the trauma was visualized after performing a cartilage reconstruction of the trauma CT scan. The patient underwent surgery, using fixation plates to stabilize the thoracic cage, and was then weaned quickly from mechanical ventilation. DISCUSSION: This case indicates, that if a patient has a severe flail chest recognized clinically, but not radiologically, a reconstruction of cartilage can reveal the true severity of the trauma. Indeed, the patient in this case experienced a positive outcome from surgery. However, such a procedure demands correct timing and experience in surgical stabilization of the thoracic wall. Furthermore, the injury required accurate planning with the involved personal before surgery. CONCLUSION: Surgical stabilization of advanced flail chest with concomitant sternal fracture, seems to be a safe procedure, that might reduce the need of mechanical ventilation and the length of stay at the Intensive Care Unit (ICU). Furthermore, cartilage reconstruction of the trauma CT scan can potentially identify a severe flail chest, that might be missed on regular 3D bone reconstruction.

Surgical approach to a mycotic aneurysm of the pulmonary artery presenting with hemoptysis - A case report and a review of the literature.

INTRODUCTION: Mycotic aneurysms of the pulmonary arteries are very rare and have high mortality. Risk groups are intravenous drug users and patients with congenital heart disorders. The surgical approach varies due to a limited number of reported cases. PRESENTATION OF CASE: We present a case of a mycotic aneurysm of the right pulmonary artery in a 56-year old man presenting with recurrent pneumonias, weight loss and hemoptysis. DISCUSSION: There is often a diagnostic delay because of non-specific symptoms mimicking more common disorders. Treatment strategies include conservative management, surgery and endovascular treatment. CONCLUSION: This report demonstrates a rare case of aneurysm of the pulmonary artery presenting with hemoptysis. For rapidly progressing proximal aneurysms of the pulmonary arteries, the midline surgical approach is recommended.

Perioperative gabapentin for the prevention of persistent pain after thoracotomy: a randomized controlled trial.

OBJECTIVES: To evaluate the effect of perioperative gabapentin treatment for the prevention of persistent post-thoracotomy pain and to establish whether gabapentin has a significant therapeutic impact on acute postoperative pain. METHODS: Consecutive patients with pulmonary malignancies scheduled for anterior thoracotomy were enrolled in this randomized, double-blinded, placebo-controlled trial. Patients were given 1200 mg gabapentin or placebo 2 h before surgery followed by increasing doses during 5 postoperative days: 600 mg for day 1; 900 mg for day 2; and 1200 mg for days 3-5. Effective pain relief was provided with perioperative multimodal analgesia with epidural infusion of bupivacaine and morphine for 72 h, and oral acetaminophen, ibuprofen and morphine. The main outcome was persistent post-thoracotomy pain at 6 months. Secondary outcomes included measures of early postoperative post-thoracotomy pain, morphine requirements, recovery and analgesia-related adverse effects over the first 3 weeks as well as persistent post-thoracotomy pain at 3 months. RESULTS: A total of 104 patients were randomly assigned to the intervention or control group; 86 (83%) patients were available for the 14-day analysis, 76 (73%) for the 3-month analysis and 67 (64%) for the 6-month follow-up. At 6 months postoperatively, 47% of patients treated with gabapentin reported persistent post-thoracotomy pain compared with 49% in the placebo group (P = 0.9). No overall clinically or statistically significant differences were observed between groups receiving placebo and gabapentin, respectively, for the secondary outcome measures and treatment-related adverse events. CONCLUSIONS: We found no evidence for the superiority of gabapentin over placebo for the treatment of acute pain following thoracotomy or for the prevention of persistent post-thoracotomy pain.