Outcome of Post-intubation Tracheal Stenosis (PITS) with Primary Resection and Anastomosis.

OBJECTIVE: To ascertain the outcome of primary resection anastomosis in patients of post-intubation tracheal stenosis (PITS) and the associated morbidity. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Department of Thoracic Surgery, Combined Military Hospital, (CMH) Rawalpindi, Lahore and Multan from January 2010 to August 2018. METHODOLOGY: Patients with tracheal stenosis due to prolonged intubation with functional were included. Exclusion criteria were patients having stenosis due to malignant cause, trauma and glottic stenosis involving vocal cords. Clinical examination, computerised tomography (CT) of neck plus chest and fiberoptic bronchoscopy were done in all the patients, while virtual bronchoscopy were done in 35 cases. Sharp dissection, aided by loupes, was the preferred technique. Thyroid tissue and strap muscle were used as flap for high cricoid lesion. Guardian stitch was applied to all cases. Postoperative elective bronchoscopy was performed after a fortnight. RESULTS: Among 43 patients, [26 (60.5%) men and 17 (39.5) women] 18 patients were intubated for days >10 ,18 for <10 and 7 for <3 days. Thirty-four (79.1%) patients were under 40 years of age, while 23 patients had tracheostomy incorporated in surgery. Bronchoscopy evaluation of distance from vocal cords showed involvement of the first ring in six patients, 1st ring normal in 1, 2 rings normal in 17, while 3 or more rings spared in 19 patients. Length of stenotic segment was <2 cm in 17, between 2-3 cm in 21, and between 3-5 cm in five patients. All patients were successfully extubated. Two patients had twin lesions. Seven patients required hyoid bone excision and release. There was one recurrent stenosis managed successfully with dilatation and granulation removal. CONCLUSION: Post-intubation tracheal stenosis (PITS) is curable disease. Primary resection and anastomosis remain the gold standard with acceptable morbidity and mortality. Key Words: Tracheal stenosis, Intubation, Resection, Primary anastomosis.

Outcome Analysis Of Primary Chest Wall Tuberculosis: A Series Of 32 Cases.

BACKGROUND: Chest wall tuberculosis is a rare disease, and although incidence has decreased further with advances in antituberculosis chemotherapy, it remains prevalent in developing countries. Diagnosis is difficult because pus smears or bacterial cultures of aspirate frequently fail to yield tuberculous bacilli. To discuss the characteristics of this rare disease and suggest an optimal strategy for management, we share our experience with 32 patients managed surgically and with antituberculosis chemotherapy. METHODS: In this descriptive case series we retrospectively reviewed the medical records of 32 patients managed from May 2006 to May 2016. RESULTS: Out of 32 cases of chest wall tuberculosis, 59.4% (n=19) patients had a current or previous history of tuberculosis. Presenting complaints were chest pain, a palpable mass and pus discharge in most patients. A preoperative bacteriologic diagnosis was positive in only 3 patients. Generous abscess debridement was done in 21 (65.63%) cases, abscess debridement and partial rib resection in 11 (34.38%), abscess debridement and partial sternum excision in 7 (21.88%), and clavicle excision in 2 (6.25%) patients. Postoperative wound infection was noted in 1 (3.13%) patient. There were no recurrences. CONCLUSION: Chest wall tuberculosis requires generous debridement of diseased tissue including under lying bone, meticulous obliteration of residual dead space by vascular muscle flap, and negative suction drainage in addition to antituberculosis chemotherapy for good post-operative results with acceptable morbidity and mortality.

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.

Intralobar Pulmonary Sequestration With A Patent Bronchus; A Rare Presentation.

A 25 years male working as labourer in Middle East presented with episodic chest pain and productive cough for last 10 years. There was polycystic lesion in left lower chest cavity having separate arterial supply from descending aorta on radiology. It was diagnosed as intralobar sequestration. Operative findings confirmed the presence of separate blood supply from descending aorta and patent bronchial connection of intrapulmonary sequestration to the rest of the lung parenchyma. There are only few case reports in the literature describing this entity. Posterobasal segmentectomy was done with stapling of communicating bronchus.

Decortication as an Option for Empyema Thoracis.

OBJECTIVE: To analyse the outcome and morbidity associated with decortication in empyema thoracis. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Departments of Surgery, Combined Military Hospitals (CMH) of Rawalpindi, Quetta and Lahore, from January 2006 to March 2018. METHODOLOGY: This is a retrospective study of 812 cases of open and VATS (video-assisted thoracic surgery) decortication for empyema thoracis, operated by the same consultants. Only patients with established empyema were included. Those who were unfit for one-lung ventilation, undergoing local anesthesia procedures like rib resection, clagget window or tube windows, with clotted hemothorax and malignant pathology were excluded. Posterolateral serratus sparing thoracotomy was used in open decortications. Multiportal or uniport VATS was employed for video-assisted thoracoscopic decortications (VATD). Histopathology and microbiological sampling was also done in all cases. RESULTS: There were 537 (66.1%) males and 275 (33.9%) females. Age ranged from 1 to 80 years with a mean of 37 years. Open decortication was done in 650 (80%), standard decortication with posterolateral thoracotomy in 458 (56.4%), minithoracotomy was done in 69 (8.4%) patients with loculated empyema, thoracotomy and open decortication with conventional thoracoplasty was done in 21 patients. Twenty-two patients required open decortications with tailored thoracoplasty and muscle flap. Open decortication with intercostal muscle (ICM) flap or primary closure of bronchopleural fistula was performed in 55 patients. VATD was done in 162 cases, out of which 120 were early empyema, and 42 were of chronic empyema; of which 22 required a further utility thoracotomy. Decortication with lung resection and muscle flap reinforcement to bronchial stump was done in 25 patients. Blood transfusion was required in 331 (40.7%). Twenty-six (3.4%) patients developed residual space and collection requiring intervention; and 384 (47.3%) patients had a histopathology diagnostic for tuberculosis. There were 11 (1.3%) deaths. CONCLUSION: Open decortication is still one of the preferred procedures in developing countries. VATD is also increasingly utilised for empyema.

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.

Lung cancer in Pakistan, where do we stand?

Lung cancer is the most common cancer in males and second most common in females after breast cancer. We have compared our data with the international statistics to see where do we stand. In Pakistan, we do not have a valid central cancer registry at present which can provide a true picture of lung cancer. Therefore, we used statistics of GLOBOCON 2012, in order to evaluate the true burden of lung cancer in our population through the recently established data by PHRC (Pakistan Health and Research council). Our analysis showed that data depicting true incidence and mortality of lung cancer in Pakistan are lacking. GLOBOCON 2012 placed lung cancer as the 3rd most common cancer in Pakistan while PHRC 2016 placed it as the 10th most common cancer irrespective of the rise in smoking incidence in Pakistan over the past one decade. This calls for an urgent need to formulate a valid central cancer registry in the country in association with the local bodies.

Emergency Tracheal Surgery for Adenoid Cystic Carcinoma: A Rare Entity.

Primary tumours of the trachea are rare. Adenoid cystic carcinoma (ACC) constitutes less than 1% of these tumours. They occasionally masquerade as asthma. We are presenting a case of a young female, who had been treated for 3 years as asthma. She presented in emergency with severe respiratory difficulty, stridor and decreasing saturation of 85% on room air. Two weeks back, she had a CT scan in a local hospital, but they did not notify the tracheal mass. Her clinical picture and CT scan helped us diagnose the case. She was treated in emergency with primary resection of tracheal mass and anastomosis. The tumor was diagnosed as ACC. Postoperative recovery was uneventful. Continuity of the trachea was restored and adjuvant radiotherapy was given.

Rib Fixation Versus Conservative Management Of Rib Fractures In Trauma Patients.

BACKGROUND: 10-15 % of trauma patient has chest injuries. There is a paradigm shift in the last two decades towards rib fixation from conservative management. Rib fixation results in immediate pain reduction in patients. Although rib fixation shows promising results, conservative management is still preferred. METHODS: The study was carried out in CMH Lahore from Jan 2017 to March 2018. It was a Controlled Prospective study. Convenient sampling was used. 43 patients are included in the study. Patients with four or more fracture ribs were included. Patients followed at one, two and three months with spirometry/X-ray /clinical response. Rib fixation was done in 21 patients while 22 were managed conservatively. Patients were given choice of both the management options and treated as per their choice resulting in two groups. RESULTS: Mean age of patients is 51.35 years. Majority of them were males (86.05%), had haemothorax as confirmed with CT scan (69.80%) and unilateral fracture (79.10%). 7.40% have flail segment. Operative group shows statistically significant improvement in the recovery to work and less post-operative pain when compared to control group. There were no statistical differences among variables such as pre-operative severity and pain index, length of hospital stay, number of days for ventilator support and post op FEV1. There is statistically significant reduction in pneumonia (p <0.05), Acquired respiratory distress syndrome (ARDS) (p <0.05), ventilatory support greater than 1 day (p < 0.05) but there is no statistically significant reduction in. CONCLUSIONS: Rib fixation should be performed early after trauma as it decreases pain, lessens complications and facilitate early recovery to work.

A massive pleural-based desmoid tumour.

A 49-year-old Pakistani male presented with "heaviness" in his chest. Chest radiograph and computed tomography (CT) confirmed a massive left-sided pleural-based opacity. Three years ago, he was investigated for a left-sided lymphocytic, exudative pleural effusion following an episode of dengue fever. Tube thoracostomy removed 1.3 L of fluid. Pleural biopsy and bronchial washings were non-contributory. He received empirical anti-tuberculosis treatment and remained asymptomatic until this presentation. To investigate the new pleural mass, he underwent a video-assisted thoracoscopic surgery, which revealed a 2.2 kg mass in the pleural cavity involving the anterior mediastinum and chest wall and adhered to the visceral pleura. Following conversion to an open thoracotomy, the mass was completely excised, which involved non-anatomical lung resection. Histopathology and immunohistochemistry of the resected tumour were consistent for a desmoid tumour. He was followed up for 9 months with no evidence of tumour recurrence. Predominantly pleural-based desmoid tumour is rare but should be included in the differential diagnosis of spindle cell tumours.

Role Of Clamping Tube Thoracostomy Prior To Removal In Non-Cardiac Thoracic Trauma.

BACKGROUND: The frequently encountered thoracic trauma in surgical emergencies is a major cause of mortality and morbidity. Eighty percent of thoracic trauma can be managed by simple insertion of tube thoracostomy. Though guidelines for insertion are comprehensively explained in literature, an ideal algorithm for discontinuation is not available. A standard and safe defined protocol would eliminate hesitancy in confident removal among general surgeons. The objective of this study was to determine role of clamping trial prior to removal in terms of frequency of recurrent pneumothorax. METHODS: This study was conducted in department of Surgery Combined military hospital/Military Hospital Rawalpindi from April 2013 to March 2014. Total 180 patients with blunt or penetrating thoracic trauma were included in the study. Chest tube (28-36 Fr) was inserted in Trauma centre under strict asepsis. Tubes were then connected to under water seal for minimum six hours. Patients were randomly divided in two equal groups (90 in each). In Group A, Clamping trial was given before attempting removal while in Group B, tube was removed immediately without clamping trial. Patients of both groups were observed two hourly for development of recurrent pneumothorax. Data was analysed using SPSS-18. RESULTS: The comparison of frequency of recurrent pneumothorax in Group A (9 patients, 10%) and in Group B (4 patients, 4.5%) was not found to be statistically significant. (p-value 2.073). CONCLUSIONS: Clamping trial is unnecessary prior to removal of tube thoracostomy in blunt and penetrating non-cardiac thoracic trauma in terms of recurrent pneumothorax.

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.

Pulmonary arteriovenous malformation (PAVM): rare cause of hemoptysis.

Pulmonary arterio-venous malformation is an abnormal communication between pulmonary arteries and pulmonary veins. These lesions are rare and are an important part of the differential diagnosis of common pulmonary problems such as hypoxemia and pulmonary nodules. Pulmonary arterio-venous malformation was diagnosed in a 33 year old man who presented with recurrent episodes of haemoptysis and also had taken anti-tuberculous treatment (ATT) before. Pulmonary angiography revealed fistulous communication between right bronchial artery and right pulmonary vein. He was treated by lobectomy.