The prognostic effect of concomitant COVID-19 with spontaneous pneumothorax.

Background: The aim of this study was to investigate the prevalence of novel coronavirus disease 2019 (COVID-19) in patients hospitalized with primary spontaneous pneumothorax and to evaluate its possible effects on the clinical course, treatment, and the prognosis. Methods: Between April 2020 and January 2021, a total of 86 patients (78 males, 8 females; mean age: 27±5 years; range, 16 to 40 years) who had no underlying lung disease and were diagnosed with the first episode of spontaneous pneumothorax were retrospectively analyzed. At the same time of diagnosis, all patients were screened for COVID-19 via polymerase chain reaction test of nasopharyngeal swabs. According to the test results, the patients were divided into two groups as COVID-19(+) and COVID-19(-). The duration of air leak, hospital stay, recurrence rates and treatment modalities, and mortality rates of the two groups were compared. Results: Following a pneumothorax diagnosis, 18 (21%) patients were diagnosed with COVID-19. In COVID-19(+) patients, the mean air leak and lung expansion duration were significantly longer (p<0.0001 for both). In these patients, the mean length of hospital stay was also significantly longer (p<0.0001). During the median follow-up of six months, no mortality was observed and the recurrence rate was similar between the two groups (p=0.998). Conclusion: Our study results suggest that COVID-19 negatively affects the recovery time in patients with spontaneous pneumothorax.

Prospective analysis of the physiological changes caused by prolonged use of N95-type masks.

INTRODUCTION: The clinical and physiological effects of long-duration use of N95-type masks without ventilation valves, on health-care workers during the coronavirus disease-2019 (COVID-19) pandemic, were evaluated. METHODS: All volunteering personnel working in operating theater or intensive care unit, using nonventilated N95 type respiratory masks, minimum for a 2-h noninterrupted duration were observed. The partial oxygen saturation (SpO2) and heart rate (HR) were recorded before wearing the N95 mask and at 1st and 2nd h. Volunteers were then questioned for any symptoms. RESULTS: A total of 210 measurements were completed in 42 (24 males and 18 females) eligible volunteers, each having 5 measurements, on different days. The median age was 32.7. Premask, 1st h, and 2nd h median values for SpO2 were 99%, 97%, and 96%, respectively (P < 0.001). The median HR was 75 premask, 79 at 1st h, and 84/min at 2nd h (P < 0.001). A significant difference between all three consecutive measurements of HR was achieved. Statistical difference was only reached between premask and other SpO2 measurements (1st and 2nd h). Complaints seen in the group were head ache (36%), shortness of breath (27%), palpitation (18%), and nausea feeling (2%). Two individuals took off their masks to breathe, on 87th and 105th min, respectively. CONCLUSIONS: Long duration (>1 h) use of N95-type masks causes a significant reduction in SpO2 measurements and increase in HR. Despite being an essential personal protective equipment in COVID-19 pandemic, it should be used with short intermittent time periods in health-care providers with known heart disease, pulmonary insufficiency, or psychiatric disorders.

Does elastofibroma dorsi occur more frequently on the same side with the dominant hand?

Background: In this study, we aimed to investigate the correlation between the side of elastofibroma dorsi formation and the dominant-hand of the patients we operated. Methods: A total of 84 patients with elastofibroma dorsi (12 males, 72 females; mean age: 55.5±7.0 years; range, 43 to 74 years) were retrospectively analyzed between April 2007 and May 2019. Dominant hand, location, size, sex, age, occupations and follow-up of the mass were recorded and the pre- and postoperative Visual Analog Scale scores were noted. Results: The mean symptom duration was 9.5±7.8 (range, 3 to 48) months. The lesions were located on the right in 49 (58.3%), on the left in 16 (19%) and bilateral in 19 (22.6%). There was no significant difference between the mass size and age, symptom duration and complication development (p=0.129). A significant relation was found between the formation of the mass on the side of the dominant hand (p=0.010). A significant difference was found between the pre- and postoperative Day 90 Visual Analog Scale scores (p<0.001), indicating a significant decrease in the pain scores. Conclusion: Elastofibroma dorsi has good clinical results after surgical resection. In our series, the patients had significantly more elastofibroma dorsi on their dominant-hand side.

Nuss procedure without videothoracoscopy.

Minimally invasive repair of pectus excavatum (Nuss) operation is the current choice of surgical treatment for pectus excavatum deformities. Technical pitfalls arise in patients with previous thoracic and/or cardiac surgical interventions, due to severe intrathoracic fibrous adhesions. Herein, we describe an original modification technique in a patient with bilateral apical wedge resection and total pleurectomy due to recurrent spontaneous pneumothorax episodes within the past two years. Correction was performed by opening the pleura bilaterally and retrosternal release with digital palpation via a subxiphoid incision, to help to guide the introducer and the pectus bar, without a videothoracoscopic visualization.

Prognostic significance of pathological complete response in non-small cell lung cancer following neoadjuvant treatment.

BACKGROUND: This study aims to investigate the factors associated with pathological complete response following neoadjuvant treatment and to examine the prognostic value of pathological complete response in patients with non-small cell lung cancer undergoing surgical resection. METHODS: Between February 2009 and January 2016, a total of 112 patients (96 males, 16 females; mean age 60±8 years; range, 37 to 85 years) with the diagnosis of non-small cell lung cancer who underwent anatomical pulmonary resection after neoadjuvant treatment were retrospectively analyzed. Demographic, clinical, radiological, and pathological characteristics of the patients were recorded. The patients were classified as pathological complete response and nonpathological complete response according to the presence of tumors in the pathology reports. Predictive factors for pathological complete response and its prognostic significance were analyzed. RESULTS: The mean follow-up was 35±20 (range, 0 to 110) months. Of the patients, 30 (27%) achieved a pathological complete response. Reduction rate in tumor size was significantly higher in the responsive group (32.5±21.6% vs. 19.2±18.8%, respectively) and was a predictor of pathological complete response independent from the T and N factors (p=0.004). Survival of the responsive patients was significantly longer than unresponsive patients (75±9 vs. 30±4 months, respectively; p<0.001). During follow-up, tumor recurrence was seen in 30 patients. Recurrence was observed in only one patient in the responsive group, while 29 patients in the unresponsive group had recurrence or metastasis. CONCLUSION: Tumor shrinkage rate after neoadjuvant treatment in non-small cell lung cancer is a predictive factor for pathological complete response. Survival of patients with a pathological complete response is also significantly longer than unresponsive patients.

Prognostic Importance of the Lymph Node Factor in Surgically Resected Non-Small Cell Lung Cancer.

BACKGROUND: Patients with N1 non-small cell lung cancer represent a heterogeneous population. The aim of this study is to determine the difference of survival rate between subtypes of N1 disease in surgically resected non-small cell lung cancer patients and to compare the survival in these patients with multi-N1 and single N2 (skip metastasis) disease. METHODS: Patients who underwent anatomical pulmonary resection in our institution between 2007 and 2014 with a pathological diagnosis of N1 and single N2 positive non-small cell lung cancer were included in the study. N1 positive patients were divided into three groups as single hilar; single interlobar, lobar, or segmental; and multiple N1 positive patients. These groups were compared among themselves as well as with incidentally found single N2 patients. RESULTS: A total of 1,742 patients who had non-small cell lung cancer underwent anatomical lung resection. The survival was better in single hilar lymph nodes than other subtypes of N1 disease (p = 0.015). There was no statistically significant difference in terms of survival between the other subtypes of N1 disease (p = 0.332). The difference in survival for single N2 disease compared with multi-N1 was not statistically significant (p = 0.054). Also, when we divided the groups as single and multi-N1, there was a significant difference in survival (p = 0.025). CONCLUSION: Single hilar lymph nodes with direct invasion have better survival rate than other subtypes of N1. Also, patients with multiple N1 positive lymph nodes have similar survival results compared with single N2 patients. Our results should be confirmed with larger series to better explain N1 disease.

Thoracoscopic Diagnosis of Follicular Lymphoma Relapsing after 13 Years.

Relapse in lymphoproliferative malignancies is not an exceptional entity and generally occurs within the first 2 or 3 years following the primary treatment. Lymph node biopsy is essential for the diagnosis of relapse and treatment. A 64-years-old woman was referred to our clinic for back pain and dyspnea. Chest X-ray and computed tomography (CT) showed pleural thickening in the right hemithorax and pleural effusion. Hereby, we report a patient with a history of follicular lymphoma treatment 13 years ago, presenting with unilateral pleural effusion and being diagnosed, unpredictably, with relapsing lymphoma by video-assisted thoracoscopic surgery pleural biopsy.

Spontaneous pneumothorax in the elderly: a sign of a malignancy?

BACKGROUND: Spontaneous pneumothorax usually occurs as a result of rupture of a subpleural bleb or emphysematous bulla. Spontaneous pneumothorax, which is more common in younger age groups, might be the first sign of pulmonary malignancy, especially when it manifests in older patients. METHODS: Data of all patients who were treated for spontaneous pneumothorax in our clinic between June 2013 and June 2017 were examined retrospectively. The demographic characteristics, diagnostic methods, pathologic subtypes, and treatment protocols applied in patients diagnosed with malignancy during the treatment period were investigated. RESULTS: Out of 1187 patients, 9 (0.8%) had incidental pulmonary malignancies. Metastatic lung cancer was detected in 2 of 9 patients, while primary lung cancer was detected in the other 7. Six patients were operated on and the other 3 were referred for oncologic treatment for various reasons. CONCLUSIONS: We suggest that cases of spontaneous pneumothorax in advanced age should be evaluated in a more detailed fashion, and further investigations should be carried out with suspicion of an underlying pulmonary malignancy.

International expert consensus on the management of bleeding during VATS lung surgery.

Intraoperative bleeding is the most crucial safety concern of video-assisted thoracic surgery (VATS) for a major pulmonary resection. Despite the advances in surgical techniques and devices, intraoperative bleeding is still not rare and remains the most common and potentially fatal cause of conversion from VATS to open thoracotomy. Therefore, to guide the clinical practice of VATS lung surgery, we proposed the International Interest Group on Bleeding during VATS Lung Surgery with 65 experts from 10 countries in the field to develop this consensus document. The consensus was developed based on the literature reports and expert experience from different countries. The causes and incidence of intraoperative bleeding were summarised first. Seven situations of intraoperative bleeding were collected based on clinical practice, including the bleeding from massive vessel injuries, bronchial arteries, vessel stumps, and bronchial stumps, lung parenchyma, lymph nodes, incisions, and the chest wall. The technical consensus for the management of intraoperative bleeding was achieved on these seven surgical situations by six rounds of repeated revision. Following expert consensus statements were achieved: (I) Bleeding from major vascular injuries: direct compression with suction, retracted lung, or rolled gauze is useful for bleeding control. The size and location of the vascular laceration are evaluated to decide whether the bleeding can be stopped by direct compression or by ligation. If suturing is needed, the suction-compressing angiorrhaphy technique (SCAT) is recommended. Timely conversion to thoracotomy with direct compression is required if the operator lacks experience in thoracoscopic angiorrhaphy. (II) Bronchial artery bleeding: pre-emptive clipping of bronchial artery before bronchial dissection or lymph node dissection can reduce the incidence of bleeding. Bronchial artery bleeding can be stopped by compression with the suction tip, followed by the handling of the vascular stump with energy devices or clips. (III) Bleeding from large vessel stumps and bronchial stumps: bronchial stump bleeding mostly comes from accompanying bronchial artery, which can be clipped for hemostasis. Compression for hemostasis is usually effective for bleeding at the vascular stump. Otherwise, additional use of hemostatic materials, re-staple or a suture may be necessary. (IV) Bleeding from the lung parenchyma: coagulation hemostasis is the first choice. For wounds with visible air leakage or an insufficient hemostatic effect of coagulation, suturing may be necessary. (V) Bleeding during lymph node dissection: non-grasping en-bloc lymph node dissection is recommended for the nourishing vessels of the lymph node are addressed first with this technique. If bleeding occurs at the site of lymph node dissection, energy devices can be used for hemostasis, sometimes in combination with hemostatic materials. (VI) Bleeding from chest wall incisions: the chest wall incision(s) should always be made along the upper edge of the rib(s), with good hemostasis layer by layer. Recheck the incision for hemostasis before closing the chest is recommended. (VII) Internal chest wall bleeding: it can usually be managed with electrocoagulation. For diffuse capillary bleeding with the undefined bleeding site, compression of the wound with gauze may be helpful.

Correlation between meteorological changes and primary spontaneous pneumothorax: Myth or fact?

BACKGROUND: This study aims to investigate the relationship between meteorological changes and the development of primary spontaneous pneumothorax. METHODS: Medical records of 1,097 patients ( 975 males, 122 females; mean age 23.5±4.2 years; range, 17 to 32 years) admitted to our hospital with a diagnosis of primary spontaneous pneumothorax between January 2010 and January 2014 were evaluated retrospectively. Daily mean values for air temperature, wind speed, humidity rate and atmospheric pressure values obtained from the local meteorological observatory were recorded. The four-year study period was separated into two groups as days with at least one primary spontaneous pneumothorax development (group 1) and days without any primary spontaneous pneumothorax development (group 2). RESULTS: Within the study period of a total of 1,461 days, 1,097 cases were recorded in 759 days during which primary spontaneous pneumothorax was observed. Eighty-nine percent of the patients were male. There was no significant difference between the groups in terms of mean air temperature, humidity rate, and wind speed. Atmospheric pressure was significantly lower in group 1 (p<0.001). Decrease in atmospheric pressure with respect to the previous day increased the risk of primary spontaneous pneumothorax development significantly (p<0.001). CONCLUSION: In our study, low atmospheric pressure and significant pressure decreases showed a strong correlation with primary spontaneous pneumothorax. Temperature, wind speed, and humidity values did not influence primary spontaneous pneumothorax development.

The Feasibility of Thoracoscopic Resection in Bronchiectasis.

INTRODUCTION: Minimally invasive surgery is the treatment of choice in early-stage lung cancer. However, experience in infectious lung disease, primarily bronchiectasis, is limited probably because of the presence of dense pleural adhesions, multiple lymph nodes, and spiral bronchial arteries. The present study shows our experience of video-assisted thoracoscopic surgery (VATS) lobectomy and segmentectomy in the treatment of bronchiectasis. MATERIALS AND METHODS: Patients who underwent VATS lobectomy or segmentectomy in our clinic between April 2008 and 2015 were retrospectively evaluated. Surgery was indicated in patients with radiologic localized bronchiectasis who also had a history of recurrent lower respiratory tract infection or expectorating mucopurulent secretion. The patients were analyzed in terms of age, sex, thoracotomy conversion rate, postoperative drainage amount, chest tube removal time, length of hospital stay, morbidity, and mortality. RESULTS: A total of 44 patients initially underwent VATS pulmonary anatomic resection and 41 procedures were completed on 40 patients. One patient had bilateral resection. Fifteen patients were male individuals and 26 were female individuals. The average age was 31.4 (15 to 57) years. Forty lobectomies and 1 segmentectomy were performed. The conversion rate was 6.8%. VATS was performed on 28 patients by 3 ports, 8 patients by 2 ports, and 5 patients by a single port. In terms of anatomic resections, 18 patients underwent left lower lobectomy, 8 right lower lobectomy, 8 middle lobectomy, 6 right upper lobectomy, and 1 patient underwent lingular segmentectomy. No major postoperative complication or mortality was observed. Prolonged air leak was observed in 2 patients and subcutaneous emphysema occurred in 2 patients. The average postoperative drainage amount, chest tube removal time, and length of hospital stay were 320 mL, 3.1 (1 to 11) days, and 4.6 (2 to 11) days, respectively. CONCLUSIONS: VATS pulmonary resection is a safe, feasible, and effective treatment in the surgery of bronchiectasis with low morbidity and mortality rates. Moreover, because of cosmetic results, patients with benign diseases such as bronchiectasis could be initiated by minimally invasive surgery options just like patients with malignancies.

Management and Surgical Outcomes of Concurrent Tuberculosis and Lung Cancer.

Background Concurrent pulmonary tuberculosis (TB) and lung cancer are rarely encountered in Western countries; however, it is more common in developing countries. We aim to share the diagnostic and treatment approaches in this study. Materials and Methods Clinical files of all patients undergoing lung resection for non-small cell carcinoma with concurrent pulmonary TB between February 2006 and December 2012 were investigated retrospectively in terms of patient characteristics, operation methods, definite pathology and stage of tumor, postoperative treatment schemes, and associated complications. Results TB was detected in 17 (1.3%) of 1,266 operated carcinoma patients. Eleven had squamous cell carcinoma and six had adenocarcinoma. Mean age was 54.9 years. Two patients received anti-TB treatment preoperatively. Fifteen patients were given anti-TB treatment postoperatively, as soon as definite microbiological confirmation was obtained, and concurrently given adjuvant therapy after 3 weeks of sole four-drug TB treatment. Pneumonectomy was performed in four (23.5%), sleeve lobectomy in three (17.6%), lobectomy in eight (47%), and bilobectomy in two (11.7%) patients. Postoperative complications occurred in four (23.5%) patients, with bronchopleural fistula being seen in only one pneumonectomy patient. No postoperative mortality or reactivation of TB was seen. Mean survival time was 32 ± 2 months. Conclusion Resection following a 3-week anti-TB treatment or concurrent anti-TB and postoperative adjuvant chemotherapy does not constitute an additional postoperative risk for patients with concomitant lung malignancy and pulmonary TB. The determination of optimum treatment for these patients presents a challenge in developing countries, where TB is still a common disease.

The Effect of Pregabalin and Methylcobalamin Combination on the Chronic Postthoracotomy Pain Syndrome.

BACKGROUND: Chronic postthoracotomy pain (CPTP) consists of different types of pain. Some characteristics of CPTP are the same as those of recognized neuropathic pain syndromes. We aimed to determine the safety and efficacy of pregabalin and methylcobalamin combination (PG-B12) in comparison with diclofenac potassium (DP) in patients with CPTP. METHODS: One hundred consecutive patients with CPTP after posterolateral/lateral thoracotomy were prospectively randomly assigned and evaluated. Fifty patients were given PG-B12 and another 50 patients were given DP treatment. Visual Analogue Scale (VAS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scorings were performed previous to the treatment (day 0) and on the 15th, 30th, 60th, and 90th days. Adverse events were questioned. RESULTS: The mean ages were 58.7 ± 12.2 and 54.6 ± 14.5 years, and the mean durations of pain were 4.01 ± 1.04 and 3.8 ± 1.02 months, respectively. The number of patients with a VAS score less than 5 at the latest follow-up (VAS90 < 5) was 44 (88%) and 18 (36%) in the PG-B12 and DP groups, respectively (p < 0.05). Forty-four patients (88%) in the PG-B12 group and 16 patients (32%) in the DP group had a LANSS score less than 12 at the latest follow-up (p < 0.05). Minor adverse events that did not mandate discontinuation of the treatment were observed in 14 patients (28%) in the PG-B12 group and 2 patients (4%) in the DP group. CONCLUSIONS: PB-B12 is safe and effective in the treatment of CPTP with minimal side effects and a high patient compliance. These results should be supported by multidisciplinary studies with larger sample sizes and longer follow-ups.

Video-assisted minimally invasive diaphragmatic plication: feasibility of a recognized procedure through an uncharacteristic hybrid approach.

BACKGROUND: Diaphragmatic plication is an approved surgical procedure for treatment of symptomatic diaphragmatic paralysis and eventration. We aim to define our minimally invasive technique of plication and objectively assess our surgical outcomes of the largest series reported in the literature so far, using pulmonary function tests. METHODS: Symptomatic patients whom were planned to undergo plication using video-assisted mini-thoracotomy between December 2009 and December 2015 were the cohort of this retrospective study. Single camera port and a utility incision (3-4 cm) were used for access. Data of patient demographics with preoperative and postoperative spirometric results were collected for statistical comparison. RESULTS: Procedure (30 left, 7 right) was completed in 37 (27 male, 10 female) patients. One patient was excluded because of insufficient objective postoperative comparison criteria due to previous permanent tracheostomy. Mean length of surgery was 48.8 ± 19.7 (range: 30-70) min. Postoperative overall morbidity was 8.3 %, with no mortality. The mean length of hospital stay was 3.1 ± 1.7 days. All patients except one (97.3 %) were asymptomatic on discharge and on follow-ups. Significant improvement in measurements of forced expiratory volume in 1st second was observed on postoperative measurements (P < 0.001), with a mean overall increase of 13 % in whole cohort. No recurrence was detected throughout a mean follow-up of 19 months. CONCLUSIONS: Diaphragmatic plication via video-assisted mini-thoracotomy is an effective and curative surgical procedure which can be performed successfully with low morbidity rates. As it combines the rapidity and economical benefits of open thoracotomy with the advantages of video thoracoscopic procedures such as fast recovery and short postoperative hospital stay, it can be preferred as a safe and effective alternative hybrid method compared to standard open or closed techniques, for symptomatic patients with non-functional hemidiaphragm.

The efficacy and economical benefits of blood patch pleurodesis in secondary spontaneous pneumothorax patients.

INTRODUCTION: Prolonged air leak in secondary spontaneous pneumothorax (SSP) patients remains one of the biggest challenges for thoracic surgeons. This study investigates the feasibility, effectiveness, clinical outcomes, and economical benefits of the autologous blood patch pleurodesis method in SSP. MATERIAL AND METHODS: First-episode SSP patients undergoing autologous blood patch pleurodesis for resistant air leak following underwater-seal thoracostomy, between January 2010 and June 2013 were taken into the study. Timing and success rate of pleurodesis, recurrence, additional intervention, hospital length of stay, and complications that occurred during follow-up were examined from medical records, retrospectively. RESULTS: Thirty-one (27 male, 4 female) SSP patients with expanded lungs on chest X-ray and resistant air leak on the 3(rd) post-interventional day were enrolled. Mean age was 53.7 ± 18.9 years (range: 23-81). Twenty-four patients were treated with tube thoracostomy, 2 with pezzer drain, and 5 with 8 F pleural catheter. 96.8% success was achieved; air leak in 29 of 31 patients (93.5%) ceased within the first 24 hours. No procedure-related complication such as fever, pain or empyema was seen. Late pneumothorax recurrence occurred in 4 (12.9%) patients; 1 treated with talc pleurodesis where the other 3 necessitated surgical intervention. CONCLUSIONS: Autologous blood patch pleurodesis is a safe, effective, and easily performed procedure with no need of any additional equipment or extra cost. This method can be applied to all patients with radiologically expanded lungs and continuous air leak after 48 hours following water-seal drainage thoracostomy, to reduce hospital stay duration, unnecessary surgical interventions, and the expenses.

Comparison of Mid-Term Clinical Outcomes of Different Surgical Approaches in Symptomatic Diaphragmatic Eventration.

PURPOSE: There is no data comparing different surgical techniques for diaphragmatic re-positioning for hemi-diaphragmatic eventration in adults. Our aim was to verify the potential pros and cons of two major surgical techniques in symptomatic eventration patients. METHODS: Patients undergoing thoracotomy for diaphragmatic elevation repair either by un-opened (accordion placation) or by opened (double-breasted placation) diaphragmatic technique between January 2007 and August 2013 were analyzed retrospectively, and compared in terms of operative outcomes on 12th and 24th months. RESULTS: Forty-two patients underwent accordion (n = 23) or double-breasted (n = 19) plication. Postoperative drainage was significantly increased (215 ± 66 ml vs. 114 ± 48 ml; P = 0.0082) in double-breasted group. Although the corrected diaphragm was radiologically better preserved in this group, this divergence showed no additional effect on postoperative pulmonary functions or the dyspnea score on 12th or 24th months. No complication particularly related to both techniques or recurrence was noted during follow-up of 28 ± 12 months. CONCLUSIONS: Radiological prospect of corrected diaphragm is better preserved with double-breasted plication, but the significant and permanent improvement of respiratory functions was similar. Since the clinical outcome is equivalent, incision of the diaphragm is not essential.