Costal margin injuries and trans-diaphragmatic intercostal hernia: Presentation, management and outcomes according to the Sheffield classification.

BACKGROUND: Costal margin rupture (CMR) injuries are under-diagnosed and inconsistently managed, while carrying significant symptomatic burden. We hypothesized that the Sheffield Classification system of CMR injuries would relate to injury patterns and management options. METHODS: Data were collected prospectively between 2006 and 2023 at a major trauma center in the United Kingdom. Computed tomography scans were interrogated and injuries were categorized according to the Sheffield Classification. Clinical, radiologic, management and outcome variables were assessed. RESULTS: Fifty-four patients were included in the study. Intercostal hernia (IH) was present in 30 patients and associated with delayed presentation ( p = 0.004), expulsive mechanism of injury (i.e. such as occurs with coughing, sneezing, or retching), higher body mass index ( p < 0.001), and surgical management ( p = 0.02). There was a bimodal distribution of the level of the costal margin rupture, with IH Present and expulsive mechanism injuries occurring predominantly at the ninth costal cartilage, and IH Absent cases and other mechanisms at the seventh costal cartilage ( p < 0.001). There were correlations between the costal cartilage being thin at the site of the CMR and the presence of IH and expulsive etiology ( p < 0.001). Management was conservative in 23 and surgical in 31 cases. Extrathoracic mesh IH repairs were performed in 3, Double Layer Mesh Repairs in 8, Suture IH repairs in 5, CMR plating in 8, CMR sutures in 2, and associated Surgical Stabilization of Rib Fractures in 11 patients. There was one postoperative death. There were seven repeat surgical procedures in five patients. CONCLUSION: The Sheffield Classification is associated statistically with presentation, related chest wall injury patterns, and type of definitive management. Further collaborative data collection is required to determine the optimal management strategies. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Primary lung adenocarcinoma in transplanted lung in post bilateral lung transplantation.

Key Clinical Message: Primary lung cancer was reported by a bilateral lung transplant patient without any risk factors. Single lung transplantation should be contemplated instead of double lung transplantation as it has been shown to increase the risk of lung cancers. Abstract: This is a case report of a 37-year-old woman, with no history of smoking, who developed adenocarcinoma in her transplanted lung 17 years post transplantation. The development of lung cancer 17 years after transplantation is considered as a rare finding in this case report. According to the Annual Report on Cardiothoracic Organ Transplantation 2019-2020, the NHS Blood and Transplant Data, approximately 156 lung transplants were performed in the UK during 2019-2020. The third most common primary disease group recipient was cystic fibrosis and bronchiectasis. There are several medical complications described in the recipients' post-lung transplantation, and the increased risk of lung malignancy due to immunosuppression is well-established in comparison to the general population. Most cancers, however, develop in the native lung following a single lung transplant. Several cases of lymphoproliferative malignancies in the transplanted lung have been reported following bilateral lung transplantation. This is a case report of a 37-year-old woman with no history of smoking who developed adenocarcinoma in her transplanted lung 17 years later. This patient underwent lobectomy via thoracotomy and was discharged home in good condition. Only a few cases of patients developing primary lung cancer in the transplanted lung with no recipient risk factor have been reported in the literature to date. The development of lung cancer 17 years after transplantation was a rare finding in this case report.

Right upper lobe pulmonary sequestration masquerading clinically and radiologically as malignancy: a case report.

Bronchopulmonary sequestration is a rare disease in which a non-functional region of pulmonary tissue receives an aberrant vascular supply and lacks normal communication with the tracheobronchial tree. We present the case of a 30-year-old female with a primary complaint of unexplained weight loss and no other additional signs or symptoms. In view of this, computed tomography imaging was ordered, showing a 33HU mass in the right upper lobe. A specialist radiologist reviewed the images and concluded that the most likely differentials were mediastinal lymphoma or thymic malignancy. Video-assisted thoracoscopic surgery was performed, when it was seen that no malignancy was present, but rather a bronchopulmonary sequestration. Histology confirmed the diagnosis; the patient fared well post-operatively. Bronchopulmonary sequestration is a rare pathology, with most cases occurring in the lower lung lobes. This case is highly atypical, due to the lack of clinical features and the lesion radiologically mimicking the appearance of malignancy.

Aplastic Anemia Secondary to Thymectomy in a Patient With Myasthenia Gravis.

It is a well-described phenomenon in the literature that a thymoma can lead to aplastic anemia, and that a thymectomy can be curative for to aplastic anemia. However, the opposite is extremely rare. We present an unusual case of a 60-year-old woman with myasthenia gravis, who was diagnosed with an incidental thymoma found on computerized tomography. Resection of the thymoma treated her myasthenia gravis but led to an aplastic anemia resistant to granulocyte colony-stimulating factor, cyclosporin, and horse antithymocyte globulin treatment. The patient received an allogenic stem cell transplant but unfortunately passed away because of complications.

Giant spinal nerve sheath tumours - Surgical challenges: case series and literature review.

Background: Giant nerve sheath tumours (GNST) are rare and literature on their management is scant. Spinal GNST present as a surgical challenge due to the involvement of anatomical regions often outside the "comfort zone" of a spinal surgeon. This case series aims to identify challenges in the surgical management of GNSTs. Methods: Retrospective case note review of all spinal GNST cases from 2010 to 2016 managed in Sheffield Teaching Hospitals identified 8 patients, 3 of whom were incidental findings (kept under surveillance) and were excluded. 5 cases were treated surgically. Data collected included patient demographic, presenting symptom(s), radiological data, surgical approach to the tumour and challenges encountered, histopathology report and follow up. Results: Our cohort consisted entirely of females (N = 5) with a mean age of 56.4 years (range 45-70). Imaging studies and histopathological diagnoses confirmed 5 GNSTs (four benign schwannomas and one ganglioneuroma). A Single-stage anterior approach was adopted for three patients while a combined anterior-posterior approach was adopted for the remaining two. In one patient, a posterior approach was initially planned, but this was abandoned and converted to an anterior approach following onset of acute superior vena cava (SVC) syndrome secondary to SVC compression by the giant tumour on prone positioning of the patient. PET imaging of case 3 showed intense tracer uptake consistent with malignancy, however histology confirmed WHO grade 1 Schwannoma. The other three non-operated GNSTs are kept under yearly radiological and clinical surveillance. Conclusions: GNSTs are surgically challenging as they often invade territories that are beyond the comfort zone of one single specialty. A multidisciplinary approach with careful pre-operative surgical planning is recommended. Patients in whom a posterior approach is planned should have a trial of prone positioning pre-operatively. Careful interpretation of FDG-PET imaging is recommended due to the possibility of false positive result.

Unifying classification for transdiaphragmatic intercostal hernia and other costal margin injuries.

OBJECTIVES: Taxonomy of injuries involving the costal margin is poorly described and surgical management varies. These injuries, though commonly caused by trauma, may also occur spontaneously, in association with coughing or sneezing, and can be severe. Our goal was to describe our experience using sequential segmental analysis of computed tomographic (CT) scans to perform accurate assessment of injuries around the costal margin. We propose a unifying classification for transdiaphragmatic intercostal hernia and other injuries involving the costal margin. We identify the essential components and favoured techniques of surgical repair. METHODS: Patients presenting with injuries to the diaphragm or to the costal margin or with chest wall herniation were included in the study. We performed sequential segmental analysis of CT scans, assessing individual injury patterns to the costal margin, diaphragm and intercostal muscles, to create 7 distinct logical categories of injuries. Management was tailored to each category, adapted to the individual case when required. Patients with simple traumatic diaphragmatic rupture were considered separately, to allow an estimation of the relative incidence of injuries to the costal margin compared to those of the diaphragm alone. RESULTS: We identified 38 patients. Of these, 19 had injuries involving the costal margin and/or intercostal muscles (group 1). Sixteen patients in group 1 underwent surgery, 2 of whom had undergone prior surgery, with 4 requiring a novel double-layer mesh technique. Nineteen patients (group 2) with diaphragmatic rupture alone had a standard repair. CONCLUSIONS: Sequential analysis of CT scans of the costal margin, diaphragm and intercostal muscles defines accurately the categories of injury. We propose a 'Sheffield classification' in order to guide the clinical team to the most appropriate surgical repair. A variety of surgical techniques may be required, including a single- or double-layer mesh reinforcement and plate and screw fixation.

Evaluation of surgical approaches to anatomical segmentectomies: the transition to minimal invasive surgery improves hospital outcomes.

BACKGROUND: We aim to evaluate the transition process from open to video-assisted thoracoscopic surgery (VATS) anatomical segmentectomies in a regional thoracic surgical unit. METHODS: In a retrospective study from January 2013 to December 2015, we identified all anatomical segmentectomies performed in our unit. Pre, peri and postoperative data were compared between the three years (2013, 2014 and 2015) and according to operative approach. Thoracotomy after VATS intraoperative biopsy was considered a conversion for the purposes of the study. RESULTS: A total of 86 consecutive cases [56 females and 30 males, median age 70 years (range, 43 to 83 years); median FEV1 of 78% predicted (range, 41% to 126%)] were included. There was a significant change in the surgical approach with time. Fifty-two cases underwent VATS (73% via single-port) and 34 open surgeries, including nine conversions. There were no postoperative deaths in the VATS group and one in the open group. Operative outcomes were similar over time with no haemorrhagic events, equivalent R1 resection and nodal stations explored in all lymph node positive patients. In node negative cases however, open surgery was associated with more extensive mediastinal exploration. Patients in 2015 had a shorter hospital stay in comparison to those in previous years [median 4 days (range, 1-15 days) vs. median 6 days (range, 3-27 days), P=0.01]. There were no differences in the incidence of complications or readmissions to hospital over time. CONCLUSIONS: The transition over a short period of time from open to single-port VATS segmentectomy has allowed us to significantly reduce postoperative hospital stay without compromising operative or postoperative outcomes.

A Multicenter Randomized Controlled Trial of Zephyr Endobronchial Valve Treatment in Heterogeneous Emphysema (TRANSFORM).

RATIONALE: Single-center randomized controlled trials of the Zephyr endobronchial valve (EBV) treatment have demonstrated benefit in severe heterogeneous emphysema. This is the first multicenter study evaluating this treatment approach. OBJECTIVES: To evaluate the efficacy and safety of Zephyr EBVs in patients with heterogeneous emphysema and absence of collateral ventilation. METHODS: This was a prospective, multicenter 2:1 randomized controlled trial of EBVs plus standard of care or standard of care alone (SoC). Primary outcome at 3 months post-procedure was the percentage of subjects with FEV1 improvement from baseline of 12% or greater. Changes in FEV1, residual volume, 6-minute-walk distance, St. George's Respiratory Questionnaire score, and modified Medical Research Council score were assessed at 3 and 6 months, and target lobe volume reduction on chest computed tomography at 3 months. MEASUREMENTS AND MAIN RESULTS: Ninety seven subjects were randomized to EBV (n = 65) or SoC (n = 32). At 3 months, 55.4% of EBV and 6.5% of SoC subjects had an FEV1 improvement of 12% or more (P < 0.001). Improvements were maintained at 6 months: EBV 56.3% versus SoC 3.2% (P < 0.001), with a mean ± SD change in FEV1 at 6 months of 20.7 ± 29.6% and -8.6 ± 13.0%, respectively. A total of 89.8% of EBV subjects had target lobe volume reduction greater than or equal to 350 ml, mean 1.09 ± 0.62 L (P < 0.001). Between-group differences for changes at 6 months were statistically and clinically significant: ΔEBV-SoC for residual volume, -700 ml; 6-minute-walk distance, +78.7 m; St. George's Respiratory Questionnaire score, -6.5 points; modified Medical Research Council dyspnea score, -0.6 points; and BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index, -1.8 points (all P < 0.05). Pneumothorax was the most common adverse event, occurring in 19 of 65 (29.2%) of EBV subjects. CONCLUSIONS: EBV treatment in hyperinflated patients with heterogeneous emphysema without collateral ventilation resulted in clinically meaningful benefits in lung function, dyspnea, exercise tolerance, and quality of life, with an acceptable safety profile. Clinical trial registered with www.clinicaltrials.gov (NCT02022683).

Uniportal thoracoscopic management of middle lobe torsion after upper lobectomy.

Lobar torsion is a rare but potentially life-threatening complication following pulmonary resection. Surgical management usually entails an exploratory thoracotomy and resection of the involved lobe if nonviable. We present the case of a 67-year-old woman diagnosed with right middle lobe torsion 5 days after thoracotomy and right upper lobectomy for squamous carcinoma of the lung. A thoracoscopic right middle lobectomy was successfully performed utilizing a single 4-cm port placed along the midaxillary line in the 5th intercostal space.

Diaphragmatic and intercostal muscle tear after an episode of violent sneezing: spontaneous diaphragmatic injury.

Spontaneous diaphragmatic injuries are rare, accounting for approximately 1% of all diaphragmatic injuries. We report a case of a 69-year-old male with a concurrent lower respiratory tract infection who sustained diaphragmatic and intercostal muscle injuries after an episode of violent sneezing. To our knowledge, this is the first reported case of spontaneous diaphragmatic injury after sneezing.

The successful use of octreotide in the treatment of traumatic chylothorax.

Chylothorax is a well-documented complication of thoracic trauma and is associated with mortality rates of up to 75%. The conservative treatment of chylothorax includes pleural drainage and a low-fat diet rich in medium-chain fatty acids, followed by total parenteral nutrition and nothing by mouth. If these measures fail and drainage continues to exceed 1 L/d, surgical thoracic duct ligation is usually recommended. However, many patients are unable to undergo this surgical procedure and require an alternative treatment. We present the cases of 2 adult patients, one of whom developed chylothorax after an elective surgical procedure, and the other after a traffic accident that caused multiple injuries. In both patients, conservative management with the addition of octreotide was successful and negated the need for surgical intervention.

Successful angiographic embolisation of bleeding into the chest wall after chest drain insertion.

Peripheral arterial injuries after blunt or penetrating trauma commonly follow injuries to adjacent soft tissue and bone. The traditional approach to these injuries is by open exploration, with identification and ligation of the bleeding vessel. We describe the case of a type II respiratory failure patient who had an enormous pectoral muscle haematoma following chest drain insertion, in whom the bleeding was only controlled by angiographic embolisation following failure of surgical exploration.

Inhaled nitric oxide for modulation of ischemia-reperfusion injury in lung transplantation.

BACKGROUND: The prophylactic administration of inhaled nitric oxide (NO) during reperfusion after lung transplantation has been shown to reduce neutrophil-induced injury in animal models. There remain questions regarding efficacy in the clinical setting and concerns regarding increased free radical injury. We sought to assess the efficacy of NO in reducing neutrophil infiltration and associated injury if administered from the very onset of reperfusion in clinical lung transplantation. METHODS: Twenty bilateral sequential lung transplant recipients were randomized to receive 20-ppm inhaled NO (NO group) or a standard anesthetic gas mixture (control group) from the onset of ventilation. Bronchoalveolar lavage was performed immediately prior to implantation and after 30 minutes of reperfusion and analyzed for inflammatory cytokine levels and free radical surrogates. Primary graft dysfunction (PGD) scoring was performed prospectively for 72 hours post-transplant. RESULTS: The prophylactic administration of NO during the first 30 minutes of reperfusion had no statistically significant effect on the development of Grade II to III PGD (5 of 10 in NO group and 7 of 10 in control group, p = 0.36) or gas exchange (area under the curve: 429 +/- 296 vs 336 +/- 306; p = 0.64) in the NO and control groups, respectively. Pulmonary neutrophil sequestration, as measured by the transpulmonary arteriovenous neutrophil difference, was not influenced by the administration of NO. Prophylactic NO did not significantly alter the concentration of interleukin-8, myeloperoxidase or nitrotyrosine during transplantation. CONCLUSIONS: This study could not demonstrate a significant effect of inhaled NO during the first 30 minutes of reperfusion in the prevention of neutrophil injury and primary graft dysfunction after lung transplantation.

Prognostic factors in resected satellite-nodule T4 non-small cell lung cancer.

BACKGROUND: The 1997 non-small cell lung cancer staging revisions assigned a T4 descriptor to satellite nodules in the primary tumor lobe. We reviewed our experience of satellite-nodule T4 non-small cell lung cancer following these revisions and evaluated prognostic factors for this group. METHODS: All patients who underwent resection of non-small cell lung cancer between April 1997 and June 2005 with satellite nodule(s) confirmed at pathologic examination were identified from our institutional Lung Tumor Registry. Case notes and pathology reports were reviewed and data collected on possible prognostic factors. Survival was modeled using the Kaplan-Meier method, and survival differences between groups were analyzed using the log-rank test. RESULTS: From 1,276 non-small cell lung cancer patients who underwent resection, 137 were staged pT4, and 35 were T4-satellite nodules. Median follow-up was 25 months (range, 1 to 102 months). Median main tumor size was 3.0 cm (range, 1 to 9.8 cm). Adenocarcinoma or bronchioloalveolar carcinoma was the predominant histologic diagnosis (n = 28; 80%). One-, 3- and 5-year survival was 86%, 69%, and 57%, respectively; median survival was 68 months. During the same period, 137 patients undergoing resection for all T4 lesions had a 1-, 3-, and 5-year survival of 68%, 53%, and 18%, respectively. Adenocarcinoma or bronchioloalveolar carcinoma histologic diagnosis (adenocarcinoma or bronchioloalveolar carcinoma versus squamous, 75% versus 67% 3-year survival; p = 0.0026), female gender (66% versus 49% for males, 5-year survival; p = 0.041), and absence of vascular invasion (no invasion versus vascular invasion, 74% versus 20% 5-year survival; p = 0.0101) were significant predictors of better survival. CONCLUSIONS: Survival for resected T4 non-small cell lung cancer with satellite nodule(s) in the primary lobe is better than for other T4 lesions, and the T4 descriptor may unduly upstage these cases. The current T4 descriptor represents a heterogeneous population.

A pulmonary artery false aneurysm after right middle lobectomy: a case report.

Pulmonary artery false aneurysm is a rare condition, reported to complicate interventional procedures. We report a case of a false aneurysm of the interlobar pulmonary artery following a right middle lobectomy for lung cancer. This is probably the first reported case.

Does magnesium offer any additional benefit in patients having anti-arrhythmic treatment for atrial fibrillation following cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether treatment with magnesium in addition to an anti-arrhythmic is beneficial to patients who have gone into atrial fibrillation after cardiac surgery. Altogether 466 papers were identified using the below mentioned search, of which 8 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. We conclude that while the literature on magnesium prophylaxis and non-cardiac surgical studies on magnesium therapy for atrial fibrillation suggest that magnesium may be of benefit, there are currently no studies in post-cardiac surgery atrial fibrillation to support the use of magnesium therapy for these patients.

Abo-incompatible heart transplantation in infants: the Freeman Hospital experience.

BACKGROUND: Incompatibility of the major blood groups A, B, and O has been an absolute contraindication for heart transplantation. However, because of immunologic immaturity, infants may have relative protection from hyperacute rejection and thus could undergo transplantation with ABO-mismatched organs. METHODS: Since January 2000, the authors have adopted a policy of considering infants for ABO-incompatible heart transplantation. Serum isohemagglutinin titers were measured before, during, and after transplantation. Two infants (3 and 2 months old) and a 21-month-old child underwent ABO-incompatible heart transplantation. During cardiopulmonary bypass, plasma exchange was performed. No other antibody-removal procedures were performed. A routine immunosuppressive regimen was used, and rejection was monitored by endomyocardial biopsies. An additional two patients (31 and 18 months old) were worked up but were unsuitable for ABO-incompatible transplantation because of high isohemagglutinin titers. They were successfully bridged to transplantation and received heart transplants from ABO-compatible donors. RESULTS: All three infants with ABO-incompatible heart transplants are fit and well, 40 months, 30 months, and 12 months postoperatively. All three had serum antibodies to antigens of the donor's blood group before transplantation. No hyperacute rejection occurred. No morbidity attributable to the ABO incompatibility has been observed. CONCLUSIONS: ABO-mismatched heart transplantation may be undertaken safely and without any short-term adverse consequences in infants and young children in whom isohemagglutinin production is not yet established.

Pentoxifylline is as effective as leukocyte depletion for modulating pulmonary reperfusion injury.

OBJECTIVE: Previous studies have suggested the amelioration of lung reperfusion injury when initial reperfusion is undertaken with leukocyte-depleted blood. Pharmacologic agents, such as pentoxifylline, are also effective, but no previous studies have demonstrated which is superior. We investigated these agents in a porcine model of left single-lung transplantation. METHODS: Donor lungs were preserved with modified Euro-Collins solution for a mean ischemic time of 18.6 hours. Gas exchange, pulmonary vascular resistance, neutrophil elastase level, and free radical release (measured on the basis of malonaldehyde levels) were assessed over a 12-hour period. Group A (n = 5) was a control group with no interventions added. Group B was reperfused through an extracorporeal circuit incorporating a leukocyte-depleting filter for 30 minutes before conventional blood flow was restored. Group C was reperfused with the addition of intravenous pentoxifylline (2 mg x kg(-1) x h(-1)). RESULTS: Groups B and C were similar in terms of oxygenation, pulmonary vascular resistance, and free radical release. Group B displayed increased levels of neutrophil elastase. Both groups were superior with regard to these outcome measures compared with control group A. CONCLUSIONS: Pentoxifylline, when administered to recipient animals, attenuates reperfusion injury to a degree similar to that seen with leukocyte-depleted reperfusion. This technique is simple, safe, and as effective as using a more complex extracorporeal circuit incorporating a leukocyte-depleting filter to ameliorate acute lung injury.