Saved by the Clot in Superior Vena Cava Injury.

Penetrating neck injuries (PNIs) can cause injuries to great vessels. Superior vena cava (SVC) injury from a stab to the neck is rare and when it occurs, poses a significant risk of exsanguinating hemorrhage. We report a case of a 17-year female who survived a delayed presentation of five hours after sustaining stab injury to zone 1 of the neck. Her external wound was just above the medial 1/3rd of the clavicle which resulted in SVC laceration. Mechanism and site of injury along with clinical presentation with right hemothorax was highly suspicious for a vascular injury. Exsanguinating hemorrhage was halted by a soft clot in this hypotensive patient. Furthermore, permissive hypotension with judicious resuscitation stabilised the patient enough to undergo a contrast venogram to identify the level of SVC injury. The patient underwent successful surgical repair of SVC. This case illustrates the point that control of bleeding by soft clots does not rule out major vascular injury. Additionally, it demonstrates how permissive hypotension can be helpful as a damage control stepping stone in the management of these critical patients. Key Words: Penetrating neck injury, Permissive hypotension, SVC laceration, Venorrhaphy.

Isolated pericardial cystic Echinococcosis: A rare clinical presentation.

Isolated pericardial Hydatid cyst without involvement of other viscera is a rare condition with reported incidence of 0.5-2% of all cases of cystic echinococcosis even in the countries endemic for the disease. Hydatid disease is a major public health concern in the animal raising regions worldwide. Pericardial hydatid disease can be asymptomatic or present with varying symptoms from atypical chest pain, arrhythmias, rupture and tamponade to anaphylaxis. Early diagnosis and surgical treatment is necessary to prevent fatal complications. Here we report a case of symptomatic isolated pericardial hydatid cyst who presented with epigastric pain.

Effect of Circumference of Open Window Thoracostomy on Chest Wall Closure, Pleural Cavity Clearance, and Lung Expansion.

Introduction Managing chronic empyema thoracis (CET) due to tuberculosis (TB) in debilitated patients is complicated. Open window thoracostomy (OWT) is one of the ways to manage these high-risk patients. Closure of OWT is sometimes difficult to attain. The purpose of this study is to compare the outcome of OWT in terms of chest wall closure in two similar groups. The only difference between these groups was the circumference of the OWT created. This study will benefit patients of CET with OWT to attain early chest wall closure without being subjected to another surgical trauma. Methods This is a prospective comparative study, conducted in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, from August 2019 to July 2020. A total of 48 patients, 22 and 26 patients in group A and group B, respectively, were included in this study. Both groups were matched for age, gender, diagnosis, body mass index, and stage of empyema, with the difference only in the OWT circumference. Results Both groups had a history of multiple chest tube intubations. Among group A patients, a smaller circumference of OWT (20-24 cm; mean 22 cm) was created as compared to group B (30-34 cm; mean 33 cm). Spontaneous OWT closure was seen in 21 (95.5%) patients in group A and seven (26.9%) patients in group B in a time period of 6.2 ± 1.5 and 11.4 ± 0.5 months, respectively (p-value: ≤ 0.001). Pleural cavity clearance was attained in 21 (95.5%) patients in group A and 24 (92.35%) patients in group B in a time duration of 4 ± 1.4 months and 4 ± 4.1 months, respectively (p-value: ≤ 0.97). Complete lung expansion was found in 21 (95.5%) patients in group A and 24 (92.3%) patients in group B in a time duration of 5 ± 1.7 months and 4.7 ± 1.6 months, respectively (p-value: ≤ 0.62). Conclusion This prospective single-center study shows that successful spontaneous early closure of OWT primarily depends on the size of the OWT created. A smaller-sized OWT, if created judiciously, not only closes spontaneously but also facilitates the clearance of purulent discharge and potentially helps in the definitive healing of bronchopleural fistulae and consequent lung expansion, thereby avoiding more invasive procedures like decortication in a debilitated patient. Furthermore, there is no need for a second surgery for closure of OWT.

Role of Anti-Tuberculous Treatment in the Outcome of Decortication for Chronic Tuberculous Empyema.

INTRODUCTION: Chronic tuberculous empyema (CTE) is a common complication of tuberculosis that requires some form of surgical intervention along with anti-tuberculosis therapy (ATT). The aim of this study was to determine the optimum duration of pre-operative ATT in CTE prior to the decortication and its outcomes. MATERIAL AND METHODS: This comparative prospective study was conducted from August 2019 to August 2020 in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. A total of 70 patients were included in the study. They were grouped into two arms: patients operated at or within six weeks of ATT commencement (Group A) and patients operated after six weeks of ATT (Group B). Both groups had 35 participants each. Patients were evaluated based on a self-administered questionnaire. A p-value of less than 0.05 was considered significant. RESULT: In this study, there were 55 (78.6%) males and 15 (21.4%) females with a mean age of 33.5 ± 11.2 years. Diagnosis of CTE was most commonly made through sputum acid-fast bacilli (AFB) smear (n=35, 50%) which most commonly involved right upper (n=20, 28.6%) and lower lung lobes (n=20, 28.6%). Complications such as air leaks, need for ventilator support, need for intensive care unit (ICU) stay, residual collection, and pneumothorax all were significantly higher in Group A (31 patients out of 35) compared to Group B (18 patients out of 35). In Group B, 21 (60%) participants had full post-operative expansion of lungs, compared to eight (22.8%) in Group A (p=0.002). In total five participants had failure to expand lungs; all of them belonged to Group A (p=0.02). CONCLUSION: The optimum timing of surgery and preoperative ATT is crucial for achieving better outcomes and requires good collaboration between the treating pulmonologist and thoracic surgeon. Our study highlights the importance of pre-operative ATT for at least more than six weeks before undertaking decortication for better outcomes and minimizing morbidity.

Morbidity And Mortality Among Patients Sustaining Chest Injury Due To Blunt Force - The Difference Between Young And Elderly.

BACKGROUND: Blunt Chest trauma (BCT) is caused by road traffic accidents (RTAs), falls, assaults, or occupational injuries. Age has been hypothesized to be a predictor of complications and adverse outcomes in the elderly. This study aimed to compare morbidity and mortality in young and elderly patients with BCT. METHODS: This prospective two-arm study was conducted in Jinnah Postgraduate Medical Center, Karachi from July 1st till 31st December 2019 after approval from the Institutional review board. All hemodynamically stable patients with BCT presenting in the emergency were stratified in two groups. Group A included patients age 12-45 years; Group B were of age ≥65 years. Their clinical characteristics, complications, and in-hospital outcomes were compared. Data was analysed using SPSS version 16.0. RESULTS: There were 39 (55.7%) patients in group A and 31 (44.3%) in group B. RTAs were a significant cause of BCT in Group A (p=0.01) and falls in Group B (p=0.003). Lacerations, open wound, and flail chest were significantly more common in Group A (p≤0.05). Complications of BCT including pneumonia and acute respiratory distress syndrome (ARDS) were significantly higher in Group B (p≤0.05). Group B required mechanical ventilation more often (45.2% vs. 12.8%; p=0.003). There were seven deaths in Group B (p=0.002) and none in Group A. CONCLUSIONS: Commonest cause of BCT in the elderly is falling. Similarly, the elderly are more prone to develop pneumonia, ARDS, and the need for ventilatory support. Early intervention to control pain, improve ventilation, and chest physiotherapy reduce the risk of morbidity and mortality.

Pattern and Outcome of Thoracic Injuries in a Busy Tertiary Care Unit.

INTRODUCTION: Thoracic traumas are one of the most commonly encountered injuries in the emergency room. They range from blunt chest injuries due to road traffic accidents to penetrating chest injuries. Immediate medical and surgical interventions are essential to improve the outcome. This study was conducted to assess the pattern of thoracic trauma presenting to the emergency room, their outcome and factors contributing to it. METHODS: This prospective, observational, cross-sectional study was conducted in the Department of Thoracic Surgery, Jinnah Post Graduate Medical Center, Karachi from January 1 until July 31, 2020, with institutional ethical approval. Patients age ≥12 years presenting with traumatic thoracic injury with or without associated injuries were included. Characteristics of their injuries and management outcome were studied. All data was processed through Statistical Package for Social Sciences (SPSS) Statistics version 22 (IBM Corp., Armonk, NY, USA). RESULTS: A total of 199 patients were included; 154 (77.4%) patients were male and 45 (22.6%) patients were female. The most common age group presenting with trauma was the middle age (30-60 years), which included 101 (50.8%) patients. Out of the total, 126 (63.3%) had blunt chest injuries and 73 (36.6%) had penetrating chest injuries. Road traffic accidents were the most common cause of blunt chest injuries seen in 83 (65.8%) patients, whereas gunshot was the most common mode of penetrating chest injuries encountered in 41 (56.2%) cases. Tube thoracostomies were performed in 166 (83.4%) patients and thoracotomies in seven (3.51%) patients. Out of the total, 57 (28.6%) patients required mechanical ventilation and it was associated with blunt trauma, hemothorax, rib fracture, abdominal and head injuries (p ≤0.05). Mortality was seen in 22 (11.1%), which was associated with hemothorax, head injuries, mechanical ventilation and severe blood loss (p ≤0.05). CONCLUSION: Traumatic thoracic injuries are a preventable cause of mortality. Blunt chest injuries are more common than penetrating chest injuries. Proper implementation of public safety measures ensures less frequent and severe outcomes. Emergency department team and specialized thoracic surgeons must come together to manage these critical patients with utmost care.

Management Outcome in Simple and Complex Hydatid Cysts of Lung.

INTRODUCTION: Hydatid cyst (HC) of lung is a frequently encountered entity in Pakistan. The clinical and radiological manifestations of HC in lung depend on the integrity of the cyst. Patients may remain asymptomatic for years in cases of simple HC or may present with a wide variety of complications when it ruptures. The aim of this study was to compare management outcomes in simple and complex HCs. METHODS: This prospective, observational study was conducted from February 2019 until May 2020. Patients were divided into two groups: simple HC (Group A) and complex HC (Group B). Preoperative complications, surgical procedures, postoperative complications, duration of hospital stay, duration of chest tube placement and need for readmission were noted and compared between the two groups. All data was processed through the Statistical Package for the Social Sciences (SPSS) Statistics version 22 (IBM Corp., Armonk, NY). RESULTS: Sixty-two patients were included out of which Group A had 28 (45.2%) patients and Group B had 34 (54.8%) patients. There were 39 (62.9%) males and 23 (37.1%) females. The mean age was 31.11 ± 11.02 years. Preoperative complications in Group B included empyema seen in 10 (28.5%) patients, rupture of cyst into bronchus in 8 (23.5%), biliopleural fistula in 4 (11.7%), hydropneumothorax in 2 (5.8%), bronchopleural fistula in 1 (2.9%), airway compromise in 1 (2.9%) and pneumonia in 1 (2.9%) patient. Group B required longer days of chest tube placement, longer intensive care unit stay and longer hospital stay (p<0.001). The frequency of postoperative intervention was more in group B (p<0.05), therefore requiring readmission. CONCLUSION:  Surgery has favorable outcomes in the management of HC of lung. Complications associated with complex HC not only requires preoperative intervention like chest tubes but can also lead to life-threatening complications. There is also a frequent need for additional procedures during surgery in cases with complex HC along with greater risk of postoperative complications. All these are associated with prolonged hospital stay, readmissions and greater morbidity. Hence, early diagnosis and referral is needed to avoid these preventable complications associated with cyst rupture.