A Giant solitary fibrous tumour resected through median sternotomy.

Solitary fibrous tumour of the pleura (SFT) is rare neoplasms and consist less than 5% of the primary tumours of the pleura. In the English literature, very few cases of giant solitary fibrous tumours have been described. We report a clinical case of an intrathoracic giant SFT of the pleura in a 62-year-old female patient. Additionally, we reviewed the clinical, imaging and histopathological features, the therapeutic management and the clinical course of giant SFTs published in the English literature. For this, we conducted a comprehensive electronic search at the PubMed using the key words giant, huge, big and enormous.

A 27-Year-Old Man With Intermittent Chest Pain During the Last 4 Years.

CASE PRESENTATION: A 27-year-old man from Eritrea presented to the ED complaining about a progressively worse blunt chest pain in the anterior right hemithorax. Chest pain started 4 years ago and was intermittent. During the last 6 months, symptoms got worse, and the patient experienced shortness of breath in mild exercise. For this purpose, he visited another institution, where a chest radiograph was performed (Fig 1). He was advised to visit a pulmonologist for further evaluation, with the diagnosis of a loculated pleural effusion in the right upper hemithorax.

Uniportal Versus Multiportal Video-Assisted Thoracoscopic Lobectomy for Lung Cancer: An Updated Meta-analysis.

OBJECTIVE: We reviewed the available literature on patients with lung cancer undergoing either uniportal (UVATS) or multiport video-assisted thoracoscopic surgery (MVATS). METHODS: Original research studies that evaluated perioperative and long-term outcomes of UVATS versus MVATS were identified, from January 1990 to April 2020. The perioperative, along with the oncologic and long-term survival outcomes, were calculated according to either a fixed or a random effect model, appropriately. The Q statistics and I2 statistic were used to test for heterogeneity among the studies. RESULTS: Twenty studies were included, incorporating a total of 1,469 patients treated with UVATS and 3,231 treated with MVATS. The incidence of complications was lower in patients treated with UVATS [OR: 0.76 (95% CI 0.62, 0.93); p = 0.008]. The chest tube duration was significantly lower in the UVATS group (WMD: - 0.63 [95% CI - 1.03, - 0.23]; p = 0.002). Length of hospital stay (L.O.S.) was also lower in the UVATS patient group (WMD: - 0.54 [- 0.94, - 0.13]; p = 0.009), along with postoperative pain [WMD: - 0.57 (95% CI - 0.97, - 0.18); p = 0.004]. No significant differences were found regarding the mean operative time (M.O.T.), mean blood loss, the number of resected lymph nodes, the 30-day mortality, along with the survival at 1 and 3 years postoperatively. CONCLUSIONS: The present meta-analysis indicates that UVATS is associated with enhanced outcomes in patients undergoing surgery for lung cancer. Well-designed, randomized studies, comparing UVATS to MVATS, are necessary to further assess their long-term clinical outcomes.

Diaphragm and transdiaphragmatic injuries.

The incidence of traumatic diaphragmatic rupture (TDR) is around 0.5% of all trauma patients, located more frequently on the left side (80%), with penetrating trauma being more predominantly the cause (63%) than blunt injuries (37%). TDR typically develops during thoracoabdominal injuries and outcome depends on the severity of the associated organ lesion. Diagnosis is sometimes very difficult: chest X-ray can verify TDR in only 25-70% of cases, although the specificity of a multidetector computed tomography (MDCT) is 100% and 83% for left and right-sided ruptures, respectively. When TDR is a part of a polytrauma, the management of the patient must follow the ATLS (Advanced Trauma Life Support) protocol and surgery is rarely based on the primary survey. The usual scenario involves cases detected during the secondary survey. In acute cases approach is determined by the site of the life-threatening injuries. In the daily surgical routine, in cases of acute TDR, laparotomy provides the best approach to manage the associated abdominal injuries and diaphragmatic rupture. Alternatively a transthoracic approach offer access to reconstruction in cases of delayed. A transdiaphragmatic procedure is offered when during an exploration (laparotomy or thoracotomy), any sign of an injury (bleeding, perforation) is verified through the rupture of the diaphragm in the other cavity (abdomen or chest and vice versa): the injury via a transdiaphragmatic way can be managed. Usually, a simple and small rupture up to 5-6 cm can be reconstructed with No. 0 or 1 monofilament non-absorbable or absorbable interrupted sutures, while for larger defects, interrupted figure-of-eight or horizontal mattress sutures are required. Mesh prosthesis is rarely needed.

Updated meta-analysis of survival after extrapleural pneumonectomy versus pleurectomy/decortication in mesothelioma.

OBJECTIVE: We reviewed the available literature on patients with MPM undergoing either extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D). METHODS: Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1990 to July 2018. The 30 and 90 days mortality, along with the 1-, 2-, 3-, 5-year survival, the median overall survival and the complications were calculated according to both a fixed and a random effect model. The Q statistics and I2 statistic were used to test for heterogeneity among the studies. RESULTS: Fifteen studies were included, incorporating a total of 1672 patients treated with EPP and 2236 treated with P/D. The 30-day mortality was significantly higher in the EPP group [OR 3.24 (95% CI 1.70, 6.20); p < 0.001]. The median overall survival was significantly increased in the P/D group [WMD - 4.20 (- 5.66, - 2.74); p < 0.001]. No significant differences were found regarding the 90-day mortality and the 1-, 2-, 3-, 5-year survival between the EPP and P/D groups. The incidence of postoperative atrial fibrillation, hemorrhage, empyema, bronchopleural fistula and air leak was significantly increased in the EPP group (p < 0.05). CONCLUSIONS: The present meta-analysis indicates that P/D is associated with enhanced outcomes regarding 30-day mortality, median overall survival, and complications. The P/D approach, should, therefore be preferred when technically feasible. However, the decision regarding the procedure of choice should be made on the basis of the disease status and the surgeon's experience. Well-designed, randomized studies, comparing EPP to P/D, are necessary to further assess their clinical outcomes.

A Giant Intrathoracic Malignant Schwannoma Causing Respiratory Failure in a Patient without von Recklinghausen's Disease.

We report an unusual case of a thoracic opacity due to a huge mediastinal malignant schwannoma which compressed the whole left lung and the mediastinum causing respiratory failure in a 73-year-old woman without von Recklinghausen's disease. Although the tumor was resected, the patient failed to wean from mechanical ventilation and died one month later because of multiple organ dysfunction syndrome.

EACTS expert consensus statement for surgical management of pleural empyema.

Pleural infection is a frequent clinical condition. Prompt treatment has been shown to reduce hospital costs, morbidity and mortality. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research. The European Association for Cardio-Thoracic Surgery (EACTS) Thoracic Domain and the EACTS Pleural Diseases Working Group established a team of thoracic surgeons to produce a comprehensive review of available scientific evidence with the aim to cover all aspects of surgical practice related to its treatment, in particular focusing on: surgical treatment of empyema in adults; surgical treatment of empyema in children; and surgical treatment of post-pneumonectomy empyema (PPE). In the management of Stage 1 empyema, prompt pleural space chest tube drainage is required. In patients with Stage 2 or 3 empyema who are fit enough to undergo an operative procedure, there is a demonstrated benefit of surgical debridement or decortication [possibly by video-assisted thoracoscopic surgery (VATS)] over tube thoracostomy alone in terms of treatment success and reduction in hospital stay. In children, a primary operative approach is an effective management strategy, associated with a lower mortality rate and a reduction of tube thoracostomy duration, length of antibiotic therapy, reintervention rate and hospital stay. Intrapleural fibrinolytic therapy is a reasonable alternative to primary operative management. Uncomplicated PPE [without bronchopleural fistula (BPF)] can be effectively managed with minimally invasive techniques, including fenestration, pleural space irrigation and VATS debridement. PPE associated with BPF can be effectively managed with individualized open surgical techniques, including direct repair, myoplastic and thoracoplastic techniques. Intrathoracic vacuum-assisted closure may be considered as an adjunct to the standard treatment. The current literature cements the role of VATS in the management of pleural empyema, even if the choice of surgical approach relies on the individual surgeon's preference.

Thymectomy for thymoma and myasthenia gravis. A survey of current surgical practice in thymic disease amongst EACTS members.

Thymic disorders, both oncological and non-oncological, are rare. Multi-institutional, randomized studies are currently not available. The Thymic Working Group of the European Association for Cardio-Thoracic Surgery (EACTS) decided to perform a survey aiming to estimate the extent and type of current surgical practice in thymic diseases. A questionnaire was addressed to the thoracic and cardio-thoracic members of the society, and the answers received from 114 participants were analysed. High-volume surgeons cooperate more frequently with a dedicated neurologist and anaesthesist (P = 0.04), determine more frequently neurological scores pre- and postoperatively (P = 0.02) and do not operate on thymic hyperplasia in stage I myasthenia gravis (MG) (P = 0.04). High-volume thymoma surgeons more often use a transpleural approach for stage I thymoma < 4 cm (P = 0.01), induction therapy (P = 0.05) and are more likely to have access to a tissue bank (P = 0.04). Both in thymoma and MG surgery, cooperative prospective studies seem to be feasible in dedicated thoracic surgical associations as EACTS.

Prognostic factors in flail-chest patients.

OBJECTIVE: The records of 250 patients presenting with flail-chest injury in a level I trauma centre were reviewed and analysed in order to determine prognostic factors. METHODS: There were 250 consecutive trauma patients with flail chest, 183 men (73.2%) and 67 women (26.8%) ranging in age from 18 to 91 years, admitted to our hospital. The leading cause of injury was road traffic accident. One hundred and six patients (42.4%) were conservatively treated, while 117 (46.8%) needed thoracic drainage. Ventilatory assistance was used in 28 cases (11.2%). Only 19 (7.6%) required thoracotomy and/or laparotomy. The mortality rate reached 8.8%. Patients were divided into three groups: group I consisted of 105 patients (70/35) with an isolated flail chest (Injury Severity Score (ISS): 16); group II included 58 cases (48/10) with extrathoracic fractures (ISS: 25-30); and group III comprised 87 patients (65/22) with injuries to the brain or to thoracic or abdominal organs requiring thoracotomy and/or laparotomy (ISS: >40). Parameters such as age, sex, ISS, presence of extrathoracic fractures, haemopneumothorax and head injury as well as the need for mechanical support in an intensive care unit (ICU) and mortality were evaluated. RESULTS: The mortality rate in group III was higher compared to those of groups I and II (16% vs 3.8% and 6.9%, respectively) and the difference was found to be statistically significant. Laparotomy and thoracotomy affected mortality, while age, pneumothorax and head injury did not. Finally, mechanical support was used only in a few cases. CONCLUSIONS: (1) ISS is the strongest predictor of outcome associated with increased mortality; and (2) mechanical support was not considered a necessity for the treatment of flail chest.

Infections of the mediastinum.

Infections of the mediastinum (ie, mediastinitis) are serious, are associated with high morbidity and mortality, and may result from adjacent disease with direct extension, hematogenous spread, or direct introduction into the mediastinal space. The organs and tissues involved determine the manifestations and approach to treatment of these infections. The most common ones are those secondary to perforation of the esophagus or penetrating trauma, and those that extend from an adjacent infection. Today, the most common cause of mediastinitis is direct invasion of the mediastinum after surgical intervention. Cases of mediastinitis can be classified as either acute or chronic. Two broad categories of acute mediastinitis are acute necrotizing mediastinitis and poststernotomy mediastinitis. Chronic mediastinitis has been arbitrarily subdivided into two categories: (1) granulomatous mediastinitis, and (2) fibrosing or sclerosing mediastinitis. However, these likely represent a continuum of chronic infection. In cases of acute mediastinitis, treatment should always be directed toward the primary pathology and the clinical presentation. In chronic cases, surgical treatment is only palliative.

Lung herniation: a rare complication in minimally invasive cardiothoracic surgery.

OBJECTIVE: Lung herniation, defined as a protrusion of the lung parenchyma with pleural membranes through a defect of the thoracic wall, is a rare entity. As minimally invasive cardiac procedures evolve, different complications may be evident such as lung herniation. A retrospective review of all patients submitted to minimally invasive cardiac or transplant surgery through anterior mini-thoracotomy at our department revealed 16 patients with lung herniation and this experience is analyzed. MATERIALS AND METHODS: From 1996 through 2007, 12 male (75%) and 4 female ranging in age between 23 and 77 years submitted prior either to minimally invasive cardiac or transplant surgery were admitted at our department for a lung hernia. The location was right in eight cases, left in six, and in two cases the herniation was bilateral. The majority of our patients were symptomatic. Twelve of them (75%) complained of pain. The bulge was present regardless of straining. Diagnosis was confirmed by chest X-ray and tomographic scan in all of them. The surgical procedure included identification of the hernial sac and reconstruction of the defect. A variety of materials were used for chest wall reconstruction such as Vicryl and Goretex mesh. RESULTS: There was no perioperative mortality or morbidity. Patients were discharged within 5-7 days postoperatively and in a follow up of 3 months to 8 years no recurrence was observed. CONCLUSIONS: (1) Since the thoracic cage has inherent weakness anteriorly near the sternum, attention is needed when the anterior approach is used. (2) Hernias with persistent pain and entrapped lung usually need reconstruction with a patch in order to avoid late complications such as recurrent pulmonary infections and hemoptysis due to strangulation.

Omental transposition: the final solution for major sternal wound infection.

Sternal osteomyelitis after median sternotomy for cardiac surgery is associated with considerable morbidity and mortality. The ideal reconstruction after sternal debridement is still debated. From 2000 to 2004, we treated 15 patients for sternal osteomyelitis (type IIIB, IVA, IVB) after median sternotomy for cardiac surgery. Total or partial resection of the sternum and extensive debridement were performed in all cases. The defect was covered by omental transposition. In 11 cases, a single-stage operation took place, and a two-stage procedure was employed in 4. All patients had antibiotics postoperatively. There were 3 (20%) deaths due to cardiac failure. Hospital stay ranged from 21 to 45 days. Transient paradoxical movement of the anterior chest wall disappeared within one month. No recurrence was observed during 6 to 24 months of follow-up. Radical debridement along with omental flap transposition provides definitive control of the infection in cases of failure of other semi-conservative or surgical interventions. Prognosis depends on the general condition of the patient.

Muscle-sparing versus posterolateral thoracotomy: a prospective study.

OBJECTIVE: Although the thoracotomy incision is guided in part by the exposure required, both cosmesis and the potential for improved recovery are important factors to be taken into account. We conducted a prospective randomized study in order to compare muscle sparing thoracotomy (MST) and standard posterolateral thoracotomy (PLT) for postoperative pain and physical function during and after hospitalization. MATERIAL AND METHOD: One hundred patients operated from June through December 2004 were recruited in this study. Fifty patients underwent MST of 6-8 cm and 50 had a PLT of more than 8 cm with division of latissimus dorsi and serratus anterior muscles. Operations performed were atypical resections and lobectomies. Pneumonectomies and operations on tumors invading the chest wall or brachial plexus were excluded. Perioperative care was standardized concerning analgetics and physiotherapy. Postoperative pain (quantitated by the visual analogue scale), preoperative and postoperative pulmonary function, shoulder strength, and range of motion were evaluated. RESULTS: There was no difference in demographics, tumor stage, and type of lung resection. Patients were also matched for the number of chest tubes, length of chest tube duration, and length of hospital stay. Pain reported during hospitalization and after hospital discharge within 1 and 2 months did not differ within the two groups (p>0.05). Shoulder function was shown to decrease less in cases of MST, but physical function was not found statistically significant in comparison of the two groups (p>0.05) within 1 month. Rehabilitation was also similar. CONCLUSION: The rates of occurrence of acute or chronic pain and morbidity were equivalent after MST and PLT. It appears that the single advantage of MST over PLT involves the preservation of chest wall musculature in case rotational muscle flaps should be needed along with a better cosmetic result.

Percutaneous radiofrequency thermal ablation of primary and metastatic lung tumors.

OBJECTIVE: Primary lung cancer is the leading cause of death from cancer. For patients with inoperable lung cancer, percutaneous radiofrequency thermal ablation (RFA) under CT-guidance represents a minimally invasive treatment. It can also be applied in combination with radiation therapy and chemotherapy. MATERIALS AND METHODS: In a period of 18 months, RFA under CT-guidance 27 ablations were applied on 22 patients, 14 patients with primary lung cancer and 8 patients with metastatic lung tumor. There were 15 men and 7 women ranging in age between 48 and 79 years. All patients were not surgical candidates either due to the advanced stage or due to comorbid diseases, while five denied surgery. The lesions' size was no bigger than 6 cm (range 1-6 cm) with an average of 3.8 cm. The diagnosis of all treated lesions was obtained with percutaneous biopsy under CT guidance. The procedure was performed under local anesthesia. RESULTS: There were no major complications observed, but a small pneumothorax and a minor hemoptysis in four cases, all conservatively treated. All patients were hospitalized for 24h. Follow-up was initially done in 1, 3, 6 and 12 months after RFA and it was accomplished by personal interview or by telephone call up to December 2005. Median progression free intervals were 26.4 months for primary lung cancer and 29.2 months for metastatic tumor. CONCLUSION: RFA is a minimally invasive technique that can be used as a palliative treatment in nonsurgical candidates with primary or metastatic lung tumor with a low morbidity and mortality.

Massive hemorrhage caused by major pulmonary vessel-cutaneous fistula in the late postoperative period: report of two cases.

Sudden life-threatening hemorrhage caused by erosion of the wall of a thoracic blood vessel such as the aorta, pulmonary artery, or pulmonary vein, in the late postoperative period is extremely rare and presents a challenging emergency. We report the cases of two patients whose only clinical manifestation was a hemorrhagic cutaneous chest wall fistula. Both patients were treated by emergency surgery. The diagnosis and management of this clinical entity requires a high index of suspicion and innovative therapeutic solutions.

Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study.

OBJECTIVE: A prospective randomized study was conducted in order to analyze the role of fibrinolytics in the treatment of complicated parapneumonic effusion. METHODS: From 2001 to 2004, 127 consecutive patients were managed for thoracic empyema. In all cases the cause was bacterial pneumonia. Seventy patients were managed with sole tube thoracostomy (group A) and 57 with combination of tube thoracostomy and streptokinase instillation (group B). Groups were statistically compared for the age, gender, duration of symptoms, quality of pleural fluid, chest imaging, complete drainage, length of hospital stay and mortality. Multivariate analysis was used in order to define the factors that affect outcome. RESULTS: Tube thoracostomy was successful in 47 (67.1%) cases (group A), while fibrinolysis led to a favorable outcome in 50 cases (87.7%) (P<0.05). The length of stay in thoracic surgical department was significantly longer for group A (P<0.001). Mortality rate in group A was significantly higher (P<0.001). Multiple regression analysis disclosed as sole independent favorable factor for pleural drainage, the use of fibrinolysis during the course of chest tube drainage (P=0.006, odds ratio 4.29, 95% CI 1.51-12.14). CONCLUSIONS: Fibrinolytic agents are a useful adjunct in the management of complicated parapneumonic effusions. Intrapleural fibrinolytics, if used early in the fibrinopurulent stage of a parapneumonic effusion, decrease the rate of surgical interventions (VATS or open decortcation) and the length of hospital stay with minor associated morbidity.