Thoracic Surgeons' Perspective on the Management of Primary Spontaneous Pneumothorax.

OBJECTIVE: The study aimed to determine the current practice of thoracic surgeons in the management of primary spontaneous pneumothorax in Saudi Arabia and to compare the results with the British Thoracic Society guidelines. MATERIAL AND METHODS: This is a questionnaire-based study. The questionnaire included 41 questions and was directed to those involved in the management of primary spontaneous pneumothorax in Saudi Arabia; namely thoracic, cardiac, and general surgeons. It was distributed electronically through email. Out of 47 registered surgeons at the time of the study, 47 responses were obtained with a 100% response rate. RESULTS: Among the participants, 39 were thoracic surgeons. It was noted that all surgeons agreed on ordering an initial chest radiograph and most would order an additional view. Also, approaches varied regarding grading systems used. While 26% of the respondents use the British Thoracic Society grading system, 16% follow the American College of Chest Physicians system, and the rest chose other parameters. The majority of surgeons would choose a chest tube of a size not greater than 28 Fr for initial placement. As for video-assisted thoracoscopic surgery, we noted that 55% of the respondents opted for 3 ports, while 36% would place 2 ports. CONCLUSION: Primary spontaneous pneumothorax is a common condition managed by thoracic surgeons. Various guidelines were established to guide practice. Our study showed some variability in practice which could result in serious medico-legal consequences and can affect the careers of thoracic surgeons. We hope that our results will shed light upon variabilities to influence proper directed management.

Efficacy of Mediastinoscopy in Patients With Isolated Mediastinal Lymphadenopathy.

Background: Since its introduction in 1959 by Carlens (1), Mediastinoscopy has been, for long, used for assessment of the mediastinum (superior and middle) for establishing a histological diagnosis of mediastinal masses of undefined cause, and for Lung carcinomas staging. The use of Mediastinoscopy has been decreasing lately due to the introduction of other less invasive techniques (e.g., endoscopic ultrasound-directed fine needle aspiration cytology), however, it is still a cheap and effective tool that can be utilized in underprivileged centers. Objective: To emphasize how does Mediastinoscopy plays an important role in confirming the clinical diagnosis of isolated mediastinal lymphadenopathy and reviewing its utility. Methods: These are a retrospective analysis of medical charts for patients who underwent diagnostic cervical mediastinoscopy during (2012 - 2018) at a University hospital in Saudi Arabia. The included patients are presented with an isolated mediastinal lymph node enlargement, in the absence of underlying cause and was found to be significant (>1cm in its short axis) by computed tomography. The patient who had a known cause (e.g., Sarcoidosis) or were diagnosed via other tools, was excluded. Results: Mediastinoscopy was performed on 56 patients, 38 of them were males (68%) and 18 females (32%), with a mean age of (37.5 ± 10 years). The patients' most common presenting symptoms were persistent cough (49%), fever of unknown origin (38%) and weight loss (36%) with an average of 2 symptoms per patient, while in 4 patients (7%) lymphadenopathy was discovered incidentally during the CT scan for other reasons. In addition, the histopathological examination of specimens obtained confirmed the most common diagnoses, Sarcoidosis in 17 patients (30%), lymphoma in 12 patients (21%) and TB in 10 patients (18%). The mean hospital stay (calculated from the day of the procedure) was (2.5 ± 4 days) including work up, with only one mortality (2%) and 3 patients (5%) had experienced post-operative complications. Conclusion: The diagnostic Mediastinoscopy is both safe and efficient in the diagnosis of patients with isolated mediastinal lymphadenopathy, requiring a minimal surgical setup and is considered cost-effective. Therefore, it is a valid choice of investigating such cases in other underprivileged centers, as it reaches a tissue-based diagnosis, while other techniques are used for staging purposes.

Modified application of vacuum-assisted closure in thoracic surgery patients.

OBJECTIVE: Surgical site infection (SSI), ranging from superficial, deep and to organ space, is one of the major predictors for morbidity and mortality in patients undergoing thoracic surgery. Care to accelerate SSI healing is taken to shorten hospital stay and reduce costs. The deep application of vacuum-assisted closure (VAC) in thoracic patients is not well established in the literature. In this study, the deep application and safety of VAC therapy in patients with various thoracic pathologies was evaluated. METHOD: A retrospective chart review of all patients who were admitted to the thoracic surgery service between July 2014 and July 2018 and who developed deep SSI was carried out. RESULTS: A total of 12 patients were included, and their demographic data analysed. There were various thoracic pathologies complicated with postoperative deep SSI treated with VAC. The duration of VAC application ranged from 4-40 days with an average hospital stay of 37.6 days. All patients showed clinical, radiological and microbiological improvement rather than developing complications except for one case of mortality due to septicaemia. CONCLUSION: In this study, partial intrapleural VAC therapy was safe for use in patients who underwent thoracic surgery, regardless of the underling pathology, with caution (i.e., with continued monitoring of the patient's tolerance to the treatment). The overall hospital stay may be reduced with the use of VAC. It also decreased perioperative morbidity, secondary to wound infection.

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.

Blunt Traumatic Tracheobronchial Injury: a Clinical Pathway.

Background: Motor vehicle collisions (MVC) are a major burden on healthcare systems. Saudi Arabia is one of the countries with a high mortality rate of MVC. Blunt tracheobronchial injuries are rare; however, it is a catastrophic event that requires a high center of care. Lack of experience and advanced faculty prompt early stabilization and transfer of the victim for advanced care. Due to the uncertainty of management of these injuries, we would like to share our experience in dealing with such injuries. Objective: To address the difficulties in initial management and transfer of patient with blunt traumatic tracheobronchial injuries. Methods: This is a single-center retrospective case-series study including patients admitted as cases of trauma including all age groups with blunt acute tracheobronchial injuries confirmed by imaging or bronchoscope. Results: In our study, four patients with tracheobronchial injuries were identified, and a retrospective analysis was performed. Two of the males and one of the females are adults, while the other two are pediatrics. Two of them have a right main bronchial injury and the other two have a left main bronchial injury. Posterolateral thoracotomy and bronchial anastomosis were performed on all four patients and were followed up. Conclusion: In Saudi Arabia, blunt trauma is a prevalent type of injury, although tracheobronchial injuries are uncommon. In the event of trauma, a high index of suspicion of tracheobronchial injuries in a high mechanism injury warrants prompt treatment. Due to a lack of experienced and specialized hands in this field, management may be delayed, and eventually lead to unfavorable outcomes, hence we thought of a guide to facilitate the decision-making.

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.

Perceptions, barriers, and attitudes toward research among in-training physicians in Saudi Arabia: A multicenter survey.

The outcomes of patient care are improved by adequate knowledge, practical skills, and positive attitude. Currently, there is a lack of data on medical research activities among resident doctors in Saudi Arabia. This study aimed to evaluate the perception, barriers, and research attitudes among various residency programs running in different cities of Saudi Arabia. A total of 434 surgical and medical residents participated in the current study. A cross-sectional study encompassing multiple training centers in the eastern province of Saudi. Convenient sampling technique was used to include all the working training residents. A self-administered questionnaire was formulated for data collection. Descriptive statistics were employed to analyze the data. The mean age of the residents with various specialties was 27.83 ± 2.41 years. Approximately 61.7% had participated in research, while 38.3% had never participated in any research. A total of 26% of junior and 44% of senior residents have one publication only. While 11% of junior and 9% of senior residents have three publications or more. Inadequate facilities for research, lack of baseline research skills, and personal commitments were the reasons which over 60% of respondents had agreed on. Institutional reasons: lack of professional supervisor support and lack of research curriculum in the training program was reported by 308 (71%) and 305(70.3%) residents, respectively. A lack of interest for research was prevailed more in males (19%) compared to females (14%) (OR 1.43, 95% CI: 0.86-2.38, p-value 0.17). A subset of residents had one or three publications, while some had none. A lack of baseline research skills and inadequate facilities for scientific explorations, time, and funds were the main constraints among training residents. However, several residents had a positive attitude toward research but fewer publications. Thus, training in medical research methodology should be obligatory in the residency curriculum in all specialties. Further research is needed.

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.

Sternoclavicular joint osteomyelitis; delayed bone resection with muscle flap: A case report.

INTRODUCTION: Sternoclavicular joint (SCJ) osteomyelitis is a very rare condition. Here, we report an uncommon case of a complicated SCJ osteomyelitis in a patient with an anterior chest wall trauma. PRESENTATION OF CASE: A 61-year-old male a known case of dyslipidemia, hypertension (HTN), and type II diabetes mellitus (T2DM). The patient presented with pain and erythema over the right SCJ following trauma to the same location. Two weeks later, the patient presented with erythematous swelling with a sinus discharging pus, although he was discharged on oral antibiotics, analgesics, and had underwent an incisional drainage. Computerized Tomography (CT) of the chest showed fluid collection surrounding the right SCJ together with joint effusion suggestive of SCJ osteomyelitis. The patient underwent initial debridement and a definitive bone resection with pectoralis muscle flap two weeks following. Five months later, the patient was seen in the outpatient clinic, the wound was completely healed, and he has a normal function of the right arm. DISCUSSION: The management of SCJ osteomyelitis is not well established, yet it can be approached medically, surgically, or both. CONCLUSION: Surgical intervention is indicated in cases of SCJ osteomyelitis after the failure of antibiotic therapy trial. This is especially the case in the presence of abscess and bone destruction. SCJ debridement followed by delayed resection and pectoralis muscle flap might offer better results than merely debridement alone or with resection of the joint.

Intercostal hemangioma: Case report of a rare chest wall tumor in childhood.

INTRODUCTION: Intercostal hemangioma is an extremely rare disease. It is difficult to distinguish intercostal hemangioma from other chest wall tumors. The difficulty in preoperative diagnosis may result in incomplete surgical resection and hence a high rate of recurrence. CASE PRESENTATION: A 14-year-old boy who presented with asymptomatic right lateral chest wall mass with no history of trauma. Different radiological modalities were employed for diagnosis including computed tomography (CT) showed a soft tissue mass 6.5×4×5.6cm in size abutting 5th and 6th ribs. Magnetic resonance imaging (MRI) revealed iso-intense signal in T1 and hyperintense signal in T2, that is higher than that of adjacent muscles in the inferolateral right chest wall which was compatible with intercostal hemangioma. The patient underwent surgery for excision of the mass. Through right posterolateral thoracotomy, there was a well-demarcated mass abutting 5th, and 6th ribs filling the right 5th interspaces. Histopathological examination confirmed the diagnosis of intercostal hemangioma. DISCUSSION: Chest wall hemangiomas are uncommon and mostly arise outside the rib cage. Hemangiomas rarely occur in the intercostal space, and most of these originate from intercostal muscles (Agarwal et al., 2006). Watson and McCarthy postulated two theories for the etiology of hemangiomas. The more widely supported theory claims that hemangiomas are of congenital origin. The other theory proposes a traumatic origin of hemangiomas. CONCLUSION: Complete surgical resection should not be compromised by the resultant chest wall defect to prevent recurrence.