Perioperative Management of a Patient With Multiple Comorbidities Undergoing Lung Resection for Bronchopulmonary Carcinoid Complicated by SARS-CoV-2 Infection: A Case Report.

We report a case of a high-risk patient with multiple comorbidities who underwent right median lobectomy and lymph node resection due to a carcinoid tumor. The patient's course was complicated by a hospital-acquired severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and a postoperative chest hematoma requiring urgent thoracotomy. Multidisciplinary and timely management resulted in a favorable patient outcome.

Conservative Management of Large Post-Intubation Tracheal Laceration.

ABSTRACT: Tracheal rupture is a very rare but life-threatening complication of endotracheal intubation. It is more common in women and patients older than 50 years old. Overinflation of endotracheal tube cuff and tracheal wall weakening are the most important pathogenetic mechanisms. Laceration sites are located in the posterior membranous wall in most cases. Subcutaneous and mediastinal emphysema and respiratory distress are the most common manifestations. A 55-year-old female presented with postoperative subcutaneous and mediastinal emphysema without dyspnea because of a tear in the posterior tracheal wall. The diagnosis was based on clinical manifestation, chest computer tomography scans (CT), and endoscopic findings. A conservative approach by broad-spectrum antibiotic therapy was decided because of patients' vital signs stability and the absence of esophageal injury. The follow-up showed that there was no lesion in the posterior tracheal wall. Our case showed that in clinically stable patients without mediastinitis and with spontaneous breathing, conservative management of tracheal tears is a safe procedure.

Lung cancer as a predominant feature in a patient with Peutz-Jeghers syndrome: Case report.

Peutz-Jeghers syndrome (PJS) is characterized by mucocutaneous pigmentation and gastrointestinal hamartomatous polyposis, which can lead to intussusception. PJS patients face high lifetime risks for various cancer types, with the majority of patients being diagnosed with tumors along the gastrointestinal tract. Herein, we present the case of a 34-year-old man who carried a germline STK11 pathogenic variant, while lacking the cardinal features of PJS syndrome. Interestingly, he was diagnosed with lung adenocarcinoma despite being a never-smoker. Tumor testing revealed clinically relevant molecular alterations, including the known germline pathogenic variant STK11, a KRAS somatic pathogenic variant, and FGFR3 gene amplification. Treatment with standard chemotherapy and immunotherapy did not have a clinical benefit. Due to clinical deterioration, the patient deceased 18 months after his initial diagnosis prior to having the chance for targeted therapy. Identification of rare hereditary cancer syndromes and the respective presence of tumor biomarkers can provide important alternatives to targeted treatments, including immunotherapy in patients with tumors unresponsive to conventional treatment protocols. This case highlights that although only a small proportion of lung cancer diagnoses will be due to hereditary predisposition, STK11 germline carriers should be under close surveillance for early detection of lung cancer.

Seatbelt-induced extrathoracic lung herniation.

Traumatic lung herniation is an uncommon complication of blunt chest trauma due to seatbelt injury. High index of suspicion, adherence to ATLS guidelines, and cooperation between different surgical specialties for the prompt stabilization of flail chest and primary or prosthetic closure of the defect may ensure a favorable outcome.

Integrating continuous monitoring and evaluation of risk-adjusted outcomes in a cardiac surgical program.

BACKGROUND: The variable life-adjusted display (VLAD) method shows the difference between predicted and observed outcomes over time. Our study aims to implement routine in-house monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery. METHODS: The Society of Thoracic Surgeons (STS) risk score was calculated for 249 isolated and combined coronary and aortic or mitral valve cases performed during a 6-month period. The nine predicted STS variables were operative mortality, permanent stroke, renal failure (RF), prolonged ventilation, deep sternal wound (DSW) infection, reoperation for any reason, short and long length of stay (LOS), and major morbidity or operative mortality. EuroSCORE II was also calculated for the study population. VLAD plots were generated for each variable indicating whether performance is better or worse than expected on the basis of predicted risk of failure. RESULTS: The mortality plot was fluctuating close to baseline risk. The prolonged ventilation, RF, reoperation, morbidity/mortality, and LOS plots were consistently positive, indicating favorable results. The stroke chart showed an upward trend for most of the period until two incidents toward last month led to a steep descent. The DSW infections plot though, indicated a worse-than-expected performance. The VLAD charts were shared in multidisciplinary meetings and clinicians were able to confront the performance with the population-specific expectancies and respond to adverse trends with further actions. CONCLUSION: Graphical tool monitoring of risk-adjusted 30-day mortality and morbidity following cardiac surgery is feasible and allows detection of underperformance and implementation of changes in clinical practice.

The impact of deep sternal wound infections treated by negative pressure on early, 1 year and late mortality: A longitudinal case-control study.

BACKGROUND/AIM: Deep sternal wound infection (DSWI) after cardiac surgery, is a rare complication that can be fatal. Due to a lack of available data, we compared early in-hospital, 1-year and long-term mortality in patients with DSWI. METHODS: Patients undergoing any type of cardiac surgery, in the Cardiothoracic Surgery Department of G. Papanikolaou Hospital, between May 2012 and December 2016, were investigated. All patients who developed DWSI postoperatively, treated with negative pressure wound therapy (NPWT), were included in the group of cases. A random population from the rest of the patients was selected in a 1:2 ratio, representing controls. RESULTS: From a total of 2104 patients, 80 patients (3.8%) developed DSWI (cases group), whereas 180 patients were randomly selected as controls. Early (within 30 days) mortality was significantly higher in the DSWI group compared with controls (15% vs 3.9%, respectively; P = .002). Similarly, more deaths occurred in the cases group compared with controls during the follow-up (ie, 19 vs 12, respectively; P < .001); the majority of deaths (84.2%) occurred within the first year. Long-term survival did not differ between the two study groups during follow-up (median duration = 1072 vs 1022 days for cases and controls, respectively). CONCLUSIONS: DSWI significantly increased early and 1-year mortality in poststernotomy patients treated with NPWT compared with those not developing this complication. However, long-term survival was similar between the two study groups, thus highlighting the beneficial effect of NPWT in terms of clinical outcomes in patients with DWSI.

Serum Creatinine and Chronic Kidney Disease-Epidemiology Estimated Glomerular Filtration Rate: Independent Predictors of Renal Replacement Therapy following Cardiac Surgery.

BACKGROUND: Most studies evaluating predictors of renal replacement therapy (RRT) following cardiac surgery use arbitrary defined limits of preoperative serum creatinine. The aim of this study was to evaluate the effect of preoperative renal function using either estimated-glomerular filtration rate (eGFR) derived using Chronic Kidney Disease-Epidemiology (CKD-EPI) or serum creatinine alone as a predictor for RRT after cardiac surgery. METHODS: In this prospective cohort study, baseline, intraoperative, and postoperative data of all patients who underwent an elective, urgent, or emergency cardiac surgery between 2012 and 2016 in a single center were analyzed in order to identify multivariate parameters determining the need for RRT after surgery. For preoperative renal function, we used serum creatinine levels and eGFR-derived CKD-EPI equation. We also divided our cohort into eGFR groups following the thresholds of the currently proposed CKD classification. RESULTS: From the 1,614 patients (mean age: 65.4 ± 10.6 years; male: 77.6%) that constituted the study population, 42 (2.6%) underwent RRT postoperatively. EUROSCORE II, cardiopulmonary bypass time, cross clamp time, red blood cell (RBC) units transfused, type and urgency of surgery, combined/non combined operation, peripheral vascular disease, heart failure, chronic obstructive pulmonary disease, dyslipidemia, and preoperative renal function were all univariately associated with RRT use. Multivariate regression with bootstrap utilization indicated that CKD-EPI eGFR (OR 0.979; 95% CI 0.956-0.998), heart failure with the New York Heart Association class ≥2 (OR 4.695; 95% CI 1.756-14.061) and RBC units transfused (OR 1.287; 95% CI 1.081-1.850) were independently associated with RRT need. When serum creatinine (OR 2.920, 95% CI1.056-8.074) was used in the model, the associations with RRT were also significant. CONCLUSION: Preoperative renal function, defined by serum creatinine or eGFR by CKD-EPI, NYHA class II-IV, and the number of blood units transfused were all independent predictors of RRT postoperatively.

Pulmonary vein anatomical variation during videothoracoscopy-assisted surgical lobectomy.

PURPOSE: Anatomical variations of pulmonary veins, even though not rare, have important role, especially in patients undergoing lung surgery. We present a case of a single common pulmonary venous drainage of the left upper and lower lobe of the lung. METHOD/RESULT: The common trunk of the left superior and inferior pulmonary vein was misidentified as an inferior pulmonary vein, and it was transected during surgery. CONCLUSION: The surgeon must always be aware of this anomaly and carefully verify the normal anatomical structures before dividing them while performing an upper or lower lobectomy.

Prophylactic antibiotic administration for post cardiothoracic surgery sternal wounds: a retrospective study.

BACKGROUND: Cardiothoracic surgery sternal infections are difficult to treat situations. Until now there are no clear guidelines which or if an antibiotic could be used as prophylactic treatment. PATIENTS AND METHODS: We collected retrospectively data from 535 patients from our hospital which underwent cardiothoracic surgery and recorded several biological parameters and technical aspects of the surgery. RESULTS: It was observed that patients to whom vancomycin was administered had less post surgery infection than those to whom begalin was administered. Male who were treated with vancomycin it was observed that they had 1.67 chances to be treated properly than female. Patients which were hospitalized for more than 7 days before surgery had 62.6% higher chances for post surgery infection. CONCLUSIONS: It was observed that vancomycin can be used as a prophylactic treatment for cardiothoracic surgeries acting efficiently against sternal wounds.

Human immunodeficiency virus infection and pneumothorax.

Pneumothorax is a serious and relatively frequent complication of human immunodeficiency virus (HIV) infection that may associate with increased morbidity and mortality and may prove difficult to manage, especially in patients with acquired immunodeficiency syndrome (AIDS).

The role for medical thoracoscopy in pneumothorax.

Pneumothorax is a life threatening situation that requires fast treatment. There are two major classifications: Primary and Secondary. Staging of pneumothorax is also very important for treatment. Treatment of pneumont can be performed either from thoracic surgeons, or pulmonary physicians. In our current work we provide up-to-date information regarding pneumothorax classification, staging and treatment from the point of view of expert pulmonary physicians.

Unusual causes of pneumothorax.

Pneumothorax is divided to primary and secondary. It is a situation that requires immediate treatment, otherwise it could have severe health consequences. Pneumothorax can be treated either by thoracic surgeons, or pulmonary physicians. In our current work, we will focus on unusual cases of pneumothorax. We will provide the etiology and treatment for each case, also a discussion will be made for each situation.

Bronchoscopic interventions for severe COPD.

Chronic obstructive pulmonary disease (COPD) causes severe handicap among smokers. Most patients have to remain under continuous oxygen therapy at home. Moreover, respiratory infections are very common among these patients and vaccination is obligatory against influenza. Emphysema and bronchiectasis are observed with computed tomography (CT) and in several situations these parenchymal damages are responsible for pneumothorax in one case and pseudomonas aeroginosa infection. Novel mini-invasive techniques are used currently for emphysema treatments which are described extensively throughout our current work.

Approach of the treatment for pneumothorax.

Pneumothorax can occur in several situations such as; chronic obstructive pulmonary disease (COPD) where emphysema is observed or due to a biopsy for malignancy suspicion. In any case it is a dangerous situation that requires immediate attention and treatment. Pneumothorax can be divided in primary and secondary. Staging of pneumothorax is also very important. In our current editorial we summarize etiology and treatment of pneumothorax from a panel of pulmonary physicians, oncologists and thoracic surgeons.

Pneumothorax: observation.

Pneumothorax based on the cause, it can be divided into two large categories; primary and secondary. The staging of pneumothorax plays a crucial role for treatment. Currently both thoracic surgeons and pulmonary physicians can handle efficiently treatment. Pulmonary physicians with the minimally medical thoracoscopy while thoracic surgeons with a more extensive intervention. Experience defines the outcome in most situations and not the method. In our current work we will present data regarding the observation of pneumothorax from a panel of experts.

Pneumothorax after transbronchial needle biopsy.

Currently there several diagnostic techniques that re used by radiologists and pulmonary physicians for lung cancer diagnostics. In several cases pneumothorax (PNTX) is induced and immediate action is needed. Both radiologists and pulmonary physicians can insert a chest tube for symptom relief. However; only pulmonary physicians and thoracic surgeons can provide a permanent solution for the patient. The final solution would be for a patient to undergo surgery for a final solution. In our current work we will provide all those diagnostic cases where PNTX is induced and treatment from the point of view of expert radiologists and pulmonary physicians.

Acute respiratory distress syndrome and pneumothorax.

Acute respiratory distress syndrome (ARDS) can occur during the treatment of several diseases and in several interventional procedures as a complication. It is a difficult situation to handle and special care should be applied to the patients. Mechanical ventilation is used for these patients and several parameters are changed constantly until compliance is achieved. However, a complication that is observed during the application of positive airway pressure is pneumothorax. In our current work we will present definition and causes of pneumothorax in the setting of intensive care unit (ICU). We will identify differences and similarities of this situation and present treatment options.

Transbronchial lung biopsy and pneumothorax.

Mini-interventional procedures are used in the everyday clinical practice by pulmonary physicians and radiologists. Fine needle aspiration and biopsy forceps are the tools mostly used. During these procedures pneumothorax can occur and immediate treatment is necessary. In our current work, we will focus on minimal invasive techniques for biopsy and pneumothorax treatment.