Clinical Characteristics and Outcomes of Vaccinated VS Non-Vaccinated Critically Ill COVID-19 Patients: Retrospective Observation Study.

Objective: We aim to identify the clinical characteristics and outcome of vaccine breakthrough infection in critically ill COVID-19 patients and to compare the clinical course of disease between vaccinated and non-vaccinated patients. Methods: A retrospective review of all adult patients aged ≥18 years admitted to the ICU in King Fahd Hospital of the University in Saudi Arabia with positive COVID-19 RT-PCR test between the period of January 1st to August 31st, 2021, were included. The recruited patients were grouped in to "vaccinated and non-vaccinated group" based on their immunization status. The demographic data, co-morbidities, modality of oxygen support, ICU length of stay (ICU LOS) and mortality were collected and analyzed. Results: A total of 167 patients were included. Seventy-two patients (43%) were vaccinated. Cardiovascular diseases were higher among the vaccinated group (33.3% vs 12.6%, p value <0.001). Requirements of Non-invasive ventilation was significantly lower in vaccinated group compared to non-vaccinated group (73.6% vs 91.6%, p value <0.011). The rates of intubation were similar between both groups. The total intubation days was longer in non-vaccinated patients compared to vaccinated patients and the median duration of intubation was 8 days vs 2 days, respectively (p value 0.027). In subgroup analysis, the P/F ratio was significantly higher in patients who received two doses of vaccine compared to single dose (p value <0.002). Conclusion: In critically ill COVID-19 patients, the vaccinated group has significantly less need for Non-invasive ventilation, fewer intubation days and less hypoxia compared to non-vaccinated patients. We recommend more policies and public education nationwide and worldwide to encourage vaccination and raise awareness of the general population.

Negative Pressure Wound Therapy in Closed Colorectal Surgical Incisions: A Systematic Review and Meta-Analysis.

The utilization of negative pressure wound therapy (NPWT) in lowering the incidence of infections in closed colorectal surgical incisions has not been thoroughly established, and recent trials have had conflicting results. This meta-analysis was conducted to synthesize the findings of available trial data and carefully evaluate the effectiveness of this intervention in colorectal surgery. The databases PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were combed for randomized controlled trials (RCTs) that compared negative pressure wound therapy to standard dressing in closed wounds of patients undergoing colorectal surgery. The incidence of surgical site infections (SSIs) was the primary outcome. Secondary outcomes included the occurrence of seroma and hematoma. The trial results were represented as odds ratios (OR) with a 95% confidence interval (CI), and a fixed-effects model was used. Nine studies found eligible were included, and the pooled results revealed that negative pressure wound therapy significantly reduced the incidence of surgical site infections (OR: 0.70; 95% CI: 0.53, 0.93; P= 0.02). Furthermore, there was a significant reduction in seroma (OR: 0.27; 95% CI: 0.08, 0.95; P = 0.04) and hematoma (OR: 0.20; 95% CI: 0.04, 0.96; P = 0.04). The use of negative pressure wound therapy for primarily closed incisions has been increasing, and our results indicate that it is superior to standard surgical dressings in preventing surgical site infections and other wound complications in colorectal surgeries.

Uniportal video-assisted thoracic surgery basal segmentectomy: a single-center retrospective cohort study.

Background: Uniportal video-assisted thoracic surgery (VATS) basal segmentectomy is technically challenging and requires a deep understanding of the segmental anatomy of the lung. This report describes the uniportal VATS segmentectomy of basal segments using a single-direction approach. Methods: A total of 49 patients who underwent uniportal VATS basal segmentectomy between April 2019 and April 2021 were included in this retrospective study. All the surgeries were conducted using a single-direction approach. The resections of segments 7-8 were mainly performed using the interlobar fissure approach, while the resections of segments 9-10 were performed using the inferior pulmonary ligament approach. Results: A total of 33 patients underwent a single basal segmentectomy and 16 patients underwent combined basal segmentectomy/sub-segmentectomy. The median operative time was 120 min (range, 60-180 min), and the median blood loss was 20 mL (range, 10-100 mL). The median chest tube duration was 2 days (range, 1-5 days), and the median hospital stay after surgery was 4 days (range, 2-15 days). The morbidity rate after surgery was 6.1% (3/49). There were no perioperative deaths. The pathological examinations revealed 3 cases of adenocarcinoma in situ (AIS), 33 cases of minimally invasive adenocarcinoma, and 13 cases of lepidic-predominant invasive adenocarcinoma. No recrudescence or mortality was reported during the median follow-up time of 7 months (range, 2-25 months). Conclusions: Uniportal VATS basal segmentectomy is a feasible and reliable technique based on our experience. This single-direction method allows the uniportal VATS basal segmentectomy to be performed in an easy manner with the targeted segmental bronchi and vessels exposed from superficial to deep in order of their appearance while avoiding the repeated turnover of the lung.

Thymolipomatous myasthenia gravis outcomes following thymectomy: a systematic review.

OBJECTIVES: Our goal was to evaluate the effect of thymectomy on the progression of thymolipomatous myasthenia gravis. METHODS: An electronic search performed across PubMed, MEDLINE and Web of Science databases included all article types. We included 15 series comprising 36 cases that met specific criteria, including case reports or case series related to thymolipoma with a myasthenia gravis association, where thymectomy was cited as the primary intervention with postoperative reporting of the prognosis and articles written in the English language. RESULTS: Our study included 17 men (47.2%) and 19 women (52.8%). Tumour sizes varied between 34 × 18 × 7 cm and 2.8 × 2.3 × 1.9 cm; the weight of the tumours ranged between 38 and 1780 g (mean 190, standard deviation 341). The surgical approaches were a median sternotomy in 29 patients (80.6%), a thoracotomy in 1 patient (2.8%), video-assisted thoracoscopic surgery in 2 patients (5.6%) and unreported approaches in 4 (11.1%) patients. The disease was entirely resolved with complete, stable remission in 5 patients (13.9%); symptoms were improved in 19 (52.8%) and stable in 10 patients (27.7%). We identified 2 groups of patients according to their improvement post-thymectomy (improved group and group with no change). CONCLUSIONS: Although the cases were uncontrolled and did not demonstrate strong associations, they do support some hypotheses. We found a significant statistical difference between the 2 groups in terms of age, because younger patients tended to improve to a greater degree post-thymectomy. Also, we found that female patients with thymoma visible on the imaging scans were significantly associated with post-thymectomy myasthenia gravis improvement. REGISTRATION NUMBER IN PROSPERO: CRD42020173229.

Pleural Empyema as a Complication of Pyogenic Liver Abscess: Can the Minimum Achieve the Optimal? A Comparison of 3 Approaches.

BACKGROUND Pyogenic liver abscess is an uncommon entity that is potentially lethal. Pleural empyema and mediastinal collection are 2 rare complications of hepatic abscess that negatively impact the prognosis. CASE REPORT Herein, we report 3 cases of pyogenic liver abscesses complicated by pleural empyema, each approached differently, along with a succinct review of the literature. Case 1: A 29-year-old man diagnosed with Crohn's disease presented with Crohn's disease-associated hepatic abscess complicated by pleural empyema and concurrent mediastinal collection. The patient demonstrated significant improvement after administration of intrapleural fibrinolytic therapy. Case 2: A 42-year-old man with unremarkable past medical history presented with abdominal pain and dyspnea. Upon investigation, he was found to have massive pleural empyema secondary to liver abscess. In contrast to case 1, case 2 required pleural debridement via video-assisted thoracoscopic surgery followed by formal decortication through a posterolateral thoracotomy. Thereafter, a dramatic clinical improvement was observed. Case 3: A 26-year-old man with history of brucellosis 6 months before was transferred to our facility as a case of pleural empyema secondary to transdiaphragmatic extension of liver abscess. Unlike case 1 and 2, this patient was managed by drainage of hepatic and pleural collections under radiological guidance only, without the need for intrapleural fibrinolytic therapy or surgical intervention. CONCLUSIONS The current paper sheds light on one of the uncommon complications of hepatic abscess and contributes to this scant literature by summarizing pertinent publications. Adequate drainage remains the cornerstone of any pus collection management despite the complexity of some encountered cases.

Giant Esophageal Leiomyoma: Diagnostic and Therapeutic Challenges.

BACKGROUND Leiomyoma is a rare, benign, esophageal tumor that does not often measure >10 cm. Here, we report a case of giant esophageal leiomyoma in a 24-year-old man. CASE REPORT A 24-year-old man who smoked and had primary hypertension and glucose-6-phosphate dehydrogenase deficiency presented with a history of shortness of breath and productive cough with yellowish sputum, a long history of dysphagia to solid food, and a weight loss of 7 kg over 2 months. A chest X-ray revealed a mediastinum with a width >8 cm. Computed tomography of the patient's chest revealed a multilobulated mass that originated from the upper and middle thoracic esophagus, caused severe narrowing of his esophageal lumen, and was compressing his trachea and right main bronchus. Resection of the tumor was performed and, because of the large defect after the surgery and the mucosal necrosis, the patient underwent an Ivor-Lewis esophagectomy. His postoperative course was uneventful. He had no symptoms when he was seen in the outpatient clinic for follow-up and fully recovered. CONCLUSIONS Giant esophageal leiomyoma (GEL) is a rare oncological entity that presents several diagnostic and therapeutic challenges because of the scarcity of information in the medical literature on surgical management. The descriptions of techniques for surgical resection of GEL do not include ways to effectively perform subsequent reconstruction. The aim of the present paper was to contribute to this scant information by reporting our experience with performing an Ivor-Lewis esophagectomy to manage a case of GEL.

Thoracic Surgery Consultations in COVID-19 Critically Ill Patients: Beyond Conservative Approach.

INTRODUCTION: Iatrogenic pneumothoracis, barotraumas, and tracheoesophageal fistulae, especially after prolonged intubation, and tracheal stenosis are all entities involving thoracic surgeons' consultation and management. With the surge of COVID-19 cases particularly in the critical care settings, various types of complications have been observed that require intervention from thoracic surgeons. METHODS AND MATERIALS: A retrospective study was conducted in an academic healthcare institute in the Eastern Province of Saudi Arabia. We included all COVID-19 cases admitted to ICU in the period between March 15, 2020, and August 15, 2020, requiring thoracic surgery consultation and management. Non-COVID-19 critical cases and iatrogenic pneumothorax were excluded. RESULTS: Of 122 patients who were admitted to ICU with COVID-19, 18 patients (14.75%) required thoracic surgery consultation and management. We discovered a significant association between the outcomes and reintubation rates and the rate of pneumothorax occurrence. The survival analysis showed improvement in patients who had thoracostomy tube insertion as a management than the group who were treated conservatively. On the other hand, there was a significant difference between the COVID ICU group who had thoracic complication and those who did not regarding the length of hospital stay. CONCLUSION: Noniatrogenic pneumothorax, subcutaneous emphysema, and mediastinal emphysema are well-known thoracic entities, but their presence in the context of COVID-19 disease is a harbinger for worse prognosis and outcomes. The presence of pneumothorax may be associated with better prognosis and outcome compared to surgical and mediastinal emphysema.

Stress and psychological resilience among general surgery residents during COVID-19 pandemic.

OBJECTIVES: To evaluate the impact of coronavirus-19 (COVID-19) pandemic and its consequences on general surgery residents. Methods: Cross-sectional, survey based study including surgical residents in Kingdom of Saudi Arabia and Kingdom of Bahrain. RESULTS: Surgical trainees who participated in our survey (n=234) were young (mean age 28), single (53.8%), and males (65.8%). Approximately half (50.4%) have been deployed to cover the staff shortage in intensive care units (ICUs) or emergency departments (EDs). Half of our trainees (117) scored positive in the screening tool of generalized anxiety disorder (GAD). There was a significant association between experiencing anxiety and male gender (p=0.055), level of training (p=0.002), deployment to cover ICUs (p=0.050), testing positive for COVID-19 (p=0.054) and having an infected family member (p=0.004). CONCLUSION: Coronavirus-19 pandemic has a serious effect on all healthcare workers and surgical residents have experienced a considerable amount of stress. Accordingly, this psychological burden should be appropriately addressed in organizations planning strategies. We suggest formulating guidelines to help surgical trainees to continue their learning process with least psychological burden.

Thymolipoma Association with Myasthenia Gravis: Case Report.

BACKGROUND Thymolipoma, which was described initially by Hall in 1949, is an uncommon benign thymic tumor that represents around 9% of all thymic tumors. The incidence of thymolipoma is around 0.12 out of 100 000 cases per year, with a higher incidence in the younger age population. Thymolipoma incidence has been linked to different autoimmune diseases, including myasthenia gravis, in half of the reported cases. There are 34 reported cases in the literatures documenting such a relationship between thymolipoma and myasthenia gravis. The exact pathogenesis is unclear. However, some genetic findings revealed the presence of myoid cells, which might play a vital role in this association. CASE REPORT A 56-years-old female known to have myasthenia gravis presented to the Emergency Department with acute congestive heart failure, atrial fibrillation, and stroke secondary to infected vegetation from the mitral valve. The patient underwent a semi-urgent mitral valve replacement surgery treating her cardiac presentation along with an extended thymectomy to control her myasthenia gravis disease. The final histopathological assessment of the removed thymus revealed a thymolipoma pathology. CONCLUSIONS The possibility of thymolipoma as an anterior mediastinal mass should be kept in mind when dealing with an older age group of myasthenia gravis patients on steroids. Concomitant heart surgery and thymectomy are feasible, and extended thymectomy is the treatment of choice for thymolipoma in myasthenia gravis patients with a better complete remission rate after resection. However, further comparative studies are needed for a more reliable conclusion of the postoperative myasthenia gravis response after resection.

Intrapulmonary location of benign solitary fibrous tumor.

Intrapulmonary solitary fibrous tumors (SFTs) are sporadic mesenchymal neoplasms that typically arise from visceral or parietal pleura. While accounting for <5% of all pleural tumors, SFTs are known to occur in nearly all bodily organs, including nasopharynx, bladder, prostate, soft tissue of neck, buttocks, extremities, and abdominal wall. Such tumors have been previously designated localized fibrous mesothelioma or pleural fibroma. SFTs have no genetic basis and are unrelated to environmental factors such as tobacco smoking or asbestos exposure. Herein, we describe a 24-year-old woman whose clinical presentation mimicked atypical carcinoid tumor. A diagnosis of intrapulmonary SFT was achieved by surgical resection.

Nonintubated Uniportal Video-Assisted Thoracoscopic Surgery: A Single-Center Experience.

BACKGROUND: We report our surgical technique for nonintubated uniportal video-assisted thoracoscopic surgery (VATS) pulmonary resection and early postoperative outcomes at a single center. METHODS: Between January and July 2017, 40 consecutive patients underwent nonintubated uniportal VATS pulmonary resection. Multilevel intercostal nerve block was performed using local anesthesia in all patients, and an intrathoracic vagal blockade was performed in 35 patients (87.5%). RESULTS: Twenty-nine procedures (72.5%) were performed in patients with lung cancer (21 lobectomies, 6 segmentectomies, and 2 wedge resections), and 11 (27.5%) in patients with pulmonary metastases, benign lung disease, or pleural disease. The mean anesthesia time was 166.8 minutes, and the mean operative duration was 125.9 minutes. The mean postoperative chest tube duration was 3.2 days, and the mean hospital stay was 5.8 days. There were 3 conversions (7.5%) to intubation due to intraoperative hypoxemia and 1 conversion (2.5%) to multiportal VATS due to injury of the segmental artery. There were 7 complications (17.5%), including 3 cases of prolonged air leak, 2 cases of chylothorax, 1 case of pleural effusion, and 1 case of pneumonia. There was no in-hospital mortality. CONCLUSION: Nonintubated uniportal VATS appears to be a feasible and valid surgical option, depending on the surgeon's experience, for appropriately selected patients.

Comparison of non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer.

BACKGROUND: Non-intubated, or awake, video-assisted thoracoscopic surgery has been implemented for non-anatomical lung resection and the results obtained were encouraging to consider the approach for anatomical pulmonary resection. This study was conducted to evaluate the perioperative outcomes of the non-intubated and intubated video-assisted thoracoscopic lobectomy in lung cancer in regards to feasibility and safety. METHODS: A retrospective analysis of 62 consecutive video-assisted thoracoscopic lobectomies (31 lobectomies as non-intubated, 31 lobectomies as intubated) performed in Seoul St. Mary's Hospital, The Catholic University of Korea between January and December 2016. RESULTS: Both groups share comparable clinical characteristics including the age, sex, BMI, FEV1, DLCO, smoking history, lung lobes procedure, histological type and pathological staging. There was no difference in the mean of postoperative hospitalization period (6.9 versus 7.6 days, P=0.578) and the total chest tube duration (5.6 versus 5.4 days, P=0.943) between non-intubated and intubated lobectomy respectively. Both groups had a comparable surgical outcome for the anesthesia duration, operative time, blood loss and postoperative complications. The operative time required for lobe-specific surgery was shorter in the non-intubated group except for the LLL (mean 121.7 minutes for non-intubated group versus 118.3 minutes for the intubated group). The only statistically significant surgical outcome was for the number of dissected lymph nodes between both groups (the mean number of nodes for the non-intubated group was 12.6 versus 18.0 nodes for the intubated group, P=0.003). One patient in the non-intubated group required conversion to single lung intubation and mini-thoracotomy because of bleeding with no conversion in the intubated group. No mortality encountered in either group. CONCLUSIONS: The perioperative surgical outcomes for the non-intubated video-assisted thoracoscopic lobectomy are comparable to the intubated technique. Non-intubated video-assisted thoracoscopic lobectomy is safe and is technically feasible. However, further prospective randomized studies are needed for a better comparison between non-intubated and intubated VATS lobectomy.

Non-intubated thoracoscopic surgery: initial experience at a single center.

BACKGROUND: Non-intubated thoracoscopic surgery is an evolving form of minimally-invasive thoracic surgery. We commenced performing non-intubated thoracoscopic surgery at our center in August 2016. We would like to report our initial experience, over a period of 1 year, with this procedure. METHODS: From August 2016 to August 2017, non-intubated thoracoscopic surgery was performed in a series of consecutive patients who underwent thoracoscopic surgery in those who did not meet any of the following exclusion criteria: body mass index (BMI) >30, expected difficult airway, expected extensive pleural adhesion, severe cardiopulmonary dysfunction, persistent cough or excessive airway secretion, high risk of gastric reflux, and underlying neurological disorder. RESULTS: A total of 115 consecutive patients underwent non-intubated thoracoscopic surgery. Of these, 83 (72.2%) of patients had lung cancers that had undergone pulmonary resection and the other 32 (27.8%) patients were diagnosed with pulmonary metastasis, benign lung diseases, thymic tumor or other conditions. The mean time of anesthesia was 172.4 min and time of operation was 130 min. The mean postoperative chest tube duration was 3.9 days and time of hospital stay was 6.0 days. There were 9 conversions (7.8%) to intubation, due to increased respiratory movement with intraoperative hypoxemia or severe pleural adhesion. There were 16 complications (13.9%) following surgery, but all of these were successfully managed during the period of hospital stay. There was no postoperative mortality. In multivariate analysis, old age and high BMI were significant risk factors for conversion to intubation (hazard ratio =1.122, P=0.038; hazard ratio =1.408, P=0.042, respectively). CONCLUSIONS: Non-intubated thoracoscopic surgery can safely be performed in selected patients.

Acute epiploic appendagitis: A rare cause of acute abdomen and a diagnostic dilemma.

Acute epiploic appendagitis is a relatively rare cause of lower abdominal pain that clinically mimics other acute abdomen conditions that require surgery such as acute diverticulitis or appendicitis. Here, we report a case of a 50-year-old lady who presented with an unusual lower abdominal pain. Awareness of such a clinical condition with its characteristic imaging findings is important to avoid costly hospitalization, unnecessary antibiotic courses, and the morbidity and mortality associated with surgical procedures.