Cardiovascular Collapse after the Induction of Anesthesia Due to the MASS Effect of Unruptured Giant Bullae.

Background and Objectives: Giant bullae rupture easily and cause tension pneumothorax, which can cause problems during general anesthesia. However, the hemodynamic instability that can occur due to the mass effect of an unruptured giant bulla should not be overlooked. Case report: A 43-year-old male patient visited the emergency room with an abdominal wound. There was a giant emphysematous bulla in the left lung. Emergency surgery was decided upon because there was active bleeding according to abdominal CT. After tracheal intubation, the patient's blood pressure and pulse rate dramatically decreased. His blood pressure did not recover despite the use of vasopressors and discontinuation of positive pressure ventilation applied to the lungs. Thus, a bullectomy was immediately performed. The patient's blood pressure and pulse rate were normalized after the bullectomy. Conclusions: If emergency surgery under general anesthesia is required in a patient with a giant emphysematous bulla, it is safe to minimize positive pressure ventilation and remove the giant emphysematous bulla as soon as possible before proceeding with the remainder of the surgery. Tension pneumothorax due to the rupturing of a bulla should be considered first. However, hemodynamic changes might occur due to the mass effect caused by a giant bulla.

Symptomatic unilateral idiopathic giant bullous emphysema : a case report.

BACKGROUND: Idiopathic Giant Bullous Emphysema (or Vanishing Lung Syndrome) is a rare condition which is usually associated with male gender, active smoking and underlying emphysematous disease. We present an unusual case of a giant bulla occurring in the absence of these risk factors. CASE PRESENTATION: A 54-year-old woman presented to the respiratory outpatient clinic with gradually worsening left sided chest discomfort, which was most marked during a recent flight. She had no significant dyspnoea or other symptoms. She had a remote 5-pack-year smoking history. Chest X-Ray revealed a large hyperlucent area in the left upper lobe. CT Thorax found this to be an isolated bulla occupying more than one-third of the hemithorax. The remaining lung parenchyma was normal. A diagnosis of Idiopathic Giant Bullous Emphysema was made. The patient was referred for VATS (Video-assisted thoracoscopic surgery) bullectomy which was carried out without complication. Her symptoms resolved completely following the operation. CONCLUSIONS: This is an unusual case of a solitary giant bulla occurring without major risk factors or underlying lung disease. VATS bullectomy was shown to be an effective therapeutic option, allowing re-expansion of compressed lung tissue and complete resolution of symptoms.

Video-Assisted Thoracoscopic Surgery with Bullectomy and Partial Pleurectomy versus Chest Tube Drainage for Treatment of Secondary Spontaneous Pneumothorax-A Retrospective Single-Center Analysis.

Background and objective: Current guidelines recommend chest tube (CT) drainage as the initial treatment of secondary spontaneous pneumothorax (SSP). Surgery should be considered in cases of persistent air leak or recurrent disease. Video-assisted thoracoscopic surgery (VATS) is nowadays an established surgical treatment for complicated spontaneous pneumothorax. However, reports on VATS-bullectomy with partial pleurectomy (VBPP) for treatment of secondary spontaneous pneumothorax (SSP) are limited. The primary aim of this study was to evaluate and compare the clinical outcomes of patients with secondary pneumothorax treated either by VBPP or CT drainage in our institution. Secondly, we assessed underlying clinical parameters to identify potential risk factors for SSP recurrence. Materials and Methods: Eighty-two patients were included in this study. Long-term recurrence rates and potential risk factors for SSP recurrence were analyzed. Results: Thirty-six patients (43.9%) underwent VBPP, whereas 46 (56.1%) patients subsequently underwent CT treatment. During a median follow-up period of 76.5 months, VBPP patients experienced a significantly low recurrence rate compared to CT patients (VBPP vs. CT: 16.7% vs. 41.3%; p = 0.016). However, VBPP was associated with a higher complication rate and significantly longer length of hospital stay (LOS). Male sex (male vs. female: p = 0.021) and CT treatment (VBPP vs. CT: p < 0.001) were identified as potential risk factors for SSP recurrence. Conclusions: VBPP is a suitable surgical treatment for SSP. However, prolonged LOS and possible complications should be discussed prior to VBPP.

Polyglycolic acid mesh for preventing post-thoracoscopic bullectomy recurrence.

PURPOSE: Thoracoscopic bullectomy is a common treatment modality for spontaneous pneumothorax but can result in a high frequency of postoperative recurrent pneumothorax in young patients. This retrospective study compared the recurrence rate of pneumothorax following conventional thoracoscopic bullectomy to that following bullectomy using a low-density polyglycolic acid mesh to cover the staple line. METHODS: Group A comprised 237 patients who experienced 294 episodes of pneumothorax and underwent thoracoscopic bullectomy alone, and Group B comprised 130 patients who experienced 155 episodes of pneumothorax and underwent bullectomy with polyglycolic acid mesh used to cover the visceral pleura. To compare the postoperative inflammatory response between the two groups, we measured three inflammatory parameters: highest body temperature after surgery, C-reactive protein level on postoperative day 3, and change in eosinophil count from the day before the surgery to postoperative day 3. RESULTS: The recurrence rate was significantly lower in Group B than in Group A (2.6% vs. 24.8%, P < 0.000001). All three inflammatory parameters were significantly higher in Group B than in Group A. CONCLUSIONS: Using a polyglycolic acid mesh covering after thoracoscopic bullectomy resulted in acceptable long-term results (recurrence rate: 2.6%). This method was associated with a slightly elevated inflammatory response.

Outcome and risk factors of recurrence after thoracoscopic bullectomy in young adults with primary spontaneous pneumothorax.

PURPOSE: To investigate the risk factors of recurrence of pneumothorax following thoracoscopic bullectomy in young adults. METHODS: Between January, 2005 and September, 2015, 167 patients aged ≤40 years underwent initial thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) at our hospital. Recurrence-free probability was calculated from the date of surgery to recurrence or last follow-up, using the Kaplan-Meier method. RESULTS: Sixteen (9.6%) of the 167 patients suffered a recurrence (collective total, 16 recurrences). The recurrence-free intervals were 3-107 months (median 25.8 months), and the 5-year recurrence-free probability was 85.9%. Multivariate Cox analysis demonstrated that age ≤23 years (p = 0.029) and a history of ipsilateral pneumothorax before surgery (p = 0.029) were significantly associated with higher risk of recurrence. The 5-year recurrence-free probability was 72.3% for patients aged ≤23 years and a history of ipsilateral pneumothorax before surgery and 94.1% for those with neither of these factors (p = 0.001). Recurrence developed within 3 years after surgery in 14 of the 16 patients. CONCLUSIONS: Patients ≤23 years of age with a history of ipsilateral pneumothorax before surgery are at significantly high risk of its recurrence, frequently within 3 years; thus, the risk of postoperative recurrence of a pneumothorax must be kept in mind.

Management of large primary spontaneous pneumothorax in children: radiological guidance, surgical intervention and proposed guideline.

PURPOSE: Primary spontaneous pneumothorax (PSP) is managed in accordance with the adult British Thoracic Society (BTS) guidelines due to lack of paediatric evidence and consensus. We aim to highlight the differences and provide a best practice surgical management strategy for PSP based on experience of two major paediatric surgical centres. METHODS: Retrospective review of PSP management and outcomes from two UK Tertiary Paediatric hospitals between 2004 and 2015. RESULTS: Fifty children with 55 PSP (5 bilateral) were referred to our Thoracic Surgical Services after initial management: 53% of the needle aspirations failed. Nine children (20%) were associated with visible bullae on the initial chest X-ray. Forty-nine children were assessed with computed tomography scan (CT). Apical emphysematous-like changes (ELC) were identified in 37 children (75%). Ten children had also bullae in the asymptomatic contralateral lungs (20%). In two children (4%), CT demonstrated other lung lesions: a tumour of the left main bronchus in one child; a multi-cystic lesion of the right middle lobe in keeping with a congenital lung malformation in another child. Contralateral asymptomatic ELC were detected in 20% of the children: of those 40% developed pneumothorax within 6 months. Best surgical management was thoracoscopic staple bullectomy and pleurectomy with 11% risk of recurrence. Histology confirmed ELC in 100% of the apical lung wedge resections even in those apexes apparently normal at the time of thoracoscopy. CONCLUSION: Our experience suggests that adult BTS guidelines are not applicable to children with large PSP. Needle aspiration is ineffective. We advocate early referral to a Paediatric Thoracic Service. We suggest early chest CT scan to identify ELC, for counselling regarding contralateral asymptomatic ELC and to rule out secondary pathological conditions causing pneumothorax. In rare instance if bulla is visible on presenting chest X-ray, thoracoscopy could be offered as primary option.

Preoperative risk factors for prolonged length of stay after bullectomy: A single-center retrospective study.

Objective: Prolonged length of stay (LOS) increases the economic burden on patients, therefore, optimizing LOS is a critical clinical challenge for physicians. This study aims to examine the correlation between the postoperative LOS and surgery-related adverse events after bullectomy. We defined prolonged postoperative LOS after bullectomy and analyzed the preoperative risk factors linked to prolonged LOS. Methods: In this retrospective study, we analyzed patient data from thoracoscopic bullectomy performed at our hospital between January 2018 and December 2023. The receiver operating characteristic (ROC) curve was used to identify the optimal cut-off values defining prolonged LOS after bullectomy. It was then characterized as prolonged LOS. Patients were divided into prolonged and normal LOS groups based on their postoperative duration. Further, univariate and multivariate logistic regression analyses were performed to identify preoperative risk factors associated with prolonged postoperative LOS after bullectomy. Results: Among the 152 patients analyzed, binary logistic regression revealed a significant effect of surgery-related adverse events after bullectomy on the LOS (P < 0.001). A postoperative LOS exceeding 3 days was considered prolonged. Among the 152 patients, 38.2 % (58/152) experienced a prolonged LOS out of which 20.4 % (31/152) developed surgery-related adverse events. Multivariate regression analysis revealed that preoperative risk factors associated with prolonged LOS included age ≥60 years (OR = 3.052, 95%CI 1.226-7.586, P = 0.016), current smoking status (OR = 2.754, 95%CI 1.482-6.346, P = 0.025), and ASA grade 3 (OR = 4.783, 95%CI 2.356-9.131, P = 0.003). Conclusion: In summary, the postoperative length of stay beyond 3 days after bullectomy was considered prolonged. The preoperative risk factors associated with prolonged postoperative stays after bullectomy included age (over 60), current smoking, and grade 3 ASA. Therefore, quick identification and intervention in patients with these high-risk factors may promote rapid recovery.

Uniportal versus multiportal video-assisted thoracoscopic surgery for spontaneous pneumothorax.

BACKGROUND: Multiportal video-assisted thoracic surgery (mVATS) is the standard approach for the surgical treatment of spontaneous pneumothorax. However, uniportal VATS (uVATS) has emerged as an alternative aiming to minimize surgical morbidity. This study aims to strengthen the evidence on the safety and efficiency of uVATS compared to mVATS. METHODS: From January 2004 to December 2020, records of patients who had undergone surgical treatment for primary or secondary spontaneous pneumothorax were evaluated for eligibility. Patients who had undergone pleurectomy combined with bullectomy or apical wedge resection via uVATS or mVATS were included. Surgical characteristics and postoperative data were compared between patients who had undergone surgery via uVATS or mVATS. Univariable and multivariable analyses were performed to determine whether the surgical approach was associated with any complication (primary outcome), major complications (i.e., Clavien-Dindo ≥ 3), recurrence, prolonged hospitalization or prolonged chest drainage duration (secondary outcomes). RESULTS: A total of 212 patients were enrolled. Patients treated via uVATS (n = 71) and mVATS (n = 141) were significantly different in pneumothorax type (secondary spontaneous; uVATS: 54 [76%], mVATS: 79 [56%]; p = 0.004). No significant differences were observed in (major) complications and recurrence rates between both groups. Multivariable analyses revealed that the surgical approach was no significant predictor for the primary or secondary outcomes. CONCLUSIONS: This study indicates that uVATS is non-inferior to mVATS in the surgical treatment of spontaneous pneumothorax regarding safety and efficiency, and thus the uVATS approach has the potential for further improvements in the perioperative surgical care for spontaneous pneumothorax.

Contralateral pneumothorax with postpneumonectomy syndrome: report of 18-year-old case.

We herein report a case of an 18-year-old male with left postpneumonectomy syndrome who underwent a bullectomy for right pneumothorax. The patient underwent a left pneumonectomy at the age of 1 year. At the age of 18 years, he developed right pneumothorax, and radiological findings revealed apical bullae in the right pleural cavity extending into the left atrophic thoracic cavity beyond the upper mediastinum. The right thoracoscopic bullectomy was successful. Modifications of selective lobar ventilation during surgery and thoracoscope position were described.

Twenty four-month follow-up after bullectomy, unilateral and bilateral lung volume reduction surgery: a single-center retrospective analysis of consecutive cases.

PURPOSE: While pharmacologic therapy remains the cornerstone of lung emphysema treatment, surgery is an additional therapeutic option in selected patient groups with advanced emphysema. The aim of lung volume reduction surgery (LVRS) is to improve lung function, exercise capacity, quality of life and survival. We sought to determine the therapeutic value of surgical resection in specific patients with lung emphysema. PATIENTS AND METHODS: A retrospective study was performed consisting of 58 patients with lung emphysema who underwent surgical intervention over a 10-year period and were followed for 2 years postoperatively. The clinical characteristics recorded were FEV1 (forced expiratory volume in 1 s), the 6-min walk test (6-MWT), the Modified Medical Research Council (mMRC), body mass index (BMI) and quality of life prior to and 6, 12 and 24 months after surgical intervention. Moreover, all peri- and post-operative complications were noted. RESULTS: Out of 58 emphysema patients (72% male, FEV1 (L) 2.21 ± 0.17, RV (L) 3.39 ± 0.55), 19 underwent surgical bullectomy, 31 unilateral LVRS and 8 sequential bilateral LVRS. Six months after surgery, there was a statistically significant improvement in FEV1, RV, TLC, 6-MWT and mMRC. Over a period of 12 to 24 months postoperatively, clinical benefit gradually declines most likely due to COPD progression but patients still experienced a significant improvement in FEV1. The most common postoperative complications were persistent air leakage (> 7 days), arrhythmia and subcutaneous emphysema in 60%, 51.6% and 22.4%, respectively. No deaths were observed after surgical intervention. CONCLUSION: In a selected patient population, surgery led to significant improvement of lung function parameters, exercise capacity and quality of life. Over a period of 12 to 24 months postoperatively, clinical benefit gradually decreased most likely due to COPD progression.

Simultaneous bilateral bullectomy and coronary artery bypass grafting through median sternotomy approach.

Lung bullae can severely compromise lung function. Smoking is an important cause of chronic obstructive pulmonary disease, as well as coronary artery disease and peripheral arterial disease. Significant diseases in the cardiovascular and thoracic systems may require multiple interventions apart from medical management. We discuss a patient in which simultaneous bilateral bullectomy and coronary artery bypass grafting were performed through the median sternotomy approach.

Efficacy and safety of intraoperative partial spray of 50% glucose for patients with spontaneous pneumothorax.

OBJECTIVES: The management for pneumothorax patients involves surgical intervention, nevertheless postoperative recurrences are often encountered. To reduce the rates of recurrence, thoracic surgeons have experimented with various novel techniques, such as pleural abrasion, chemical pleurodesis, and staple line coverage with absorbable sheets, in addition to bullectomy. And in recent years, there have been reports of the effectiveness of the use of intraoperative glucose intrapleural spray (GIS) containing 50 ml of 50% glucose solution in addition to bullectomy. However, information on the effects and adverse events of GIS is limited. Current study was aimed to assess the efficacy and safety of GIS in preventing recurrence of pneumothorax. PATIENTS AND METHODS: We conducted a retrospective study with 74 cases of bullectomy with or without GIS between 2018 and 2021 at Okazaki City Hospital. Of these cases, 50 received GIS (GIS group) while 24 were treated conservatively (C group). RESULT: The GIS group consisted of 46 males and 4 females, whereas the C group consisted of 23 males and 1 female, with mean ages of 38.5 ± 5.7 years and 30.5 ± 6.7 years, respectively. The GIS group exhibited a mean increase in blood glucose of 23.8 mg/dL postoperatively, and postoperative infections were observed in 2 cases in the GIS group (4.0%) and 2 cases in the C group (8.3%). The NRS scores of the patients in the GIS group and the C group three hours postoperatively were 4.0 and 3.1, respectively (p = 0.28). No prolongation of postoperative drainage period by GIS was observed (1.2 days and 1.4 days in the GIS and C groups, respectively). Postoperative recurrence occurred in two patients from the C group. The postoperative total drainage volumes were 341.8 ± 25.2 ml and 74.2 ± 25.5 ml in the GIS and C groups, respectively, showing a significant increase in drainage volume (p < 0.01). None of them presented dehydration-related symptoms. CONCLUSIONS: The use of intraoperative glucose intrapleural spray is effective and safe in terms of preventing recurrences and postoperative complications.

Prospective Observation Study for Primary Spontaneous Pneumothorax: Incidence of and Risk Factors for Postoperative Neogenesis of Bullae.

PURPOSE: Details of the neogenesis of bullae (NOB), which causes recurrent primary spontaneous pneumothorax (PSP) following bullectomy, have not been reported and risk factors for NOB remain unclear. We aimed to clarify the details of NOB. METHODS: We conducted a prospective study using three computed tomography (CT) examinations performed 6, 12, and 24 months after bullectomy to identify the incidence of and risk factors for NOB. We enrolled 50 patients who underwent bullectomy for PSP. RESULTS: After excluding 11 patients who canceled the postoperative CT examination at 6 months after bullectomy, only 39 patients were analyzed. The incidence of NOB at 6, 12, and 24 months after bullectomy was 38.5%, 55.2%, and 71.2%, respectively. The rate of NOB in the operated lung was almost 2 times higher than that in the contralateral nonoperative lung. Male sex, multiple bullae on preoperative CT, long stapling line (≥7 cm), deep stapling depth (≥1.5 cm), and heavier resected sample (≥5 g) were suggested to be risk factors for NOB. CONCLUSIONS: We recognized a high incidence of postoperative NOB in PSP patients. Bullectomy itself seems to promote NOB. Postoperative NOB occurs frequently, especially in patients who require a large-volume lung resection with a long staple line.

Treating Spontaneous Pneumothorax Using an Innovative Surgical Technique Called Capnodissection Pleurectomy: Case Report.

Spontaneous pneumothorax is one of the most common conditions encountered in thoracic surgery. This condition can be treated conservatively or surgically based on indications and guidelines. Traditional surgical management includes pleurodesis (mechanical or chemical) in addition to bullectomy if the bullae can be identified. Mechanical pleurodesis is usually performed by surgical pleurectomy or pleural abrasion. In this case report, we present a case of a young patient with spontaneous pneumothorax who needed a surgical intervention. We performed a new, innovative surgical technique for surgical pleurectomy where we used carbon dioxide for dissection of the parietal pleura (capnodissection). This technique may provide similar efficiency to the traditional procedure but with less risk of bleeding and complications.

A novel approach to the lung apex avoiding dissection of severe pleural adhesions.

A 70-year-old man was incidentally diagnosed with left pneumothorax. Primary surgery via the caudal thoracic cavity found severe pleural adhesions causing narrowing of the tunnel leading to the lung apex. The point of air leakage was located at the lung apex beyond the tunnel. To stop the air leakage, fibrin glue was injected to the apex via the tunnel; however, leakage reoccurred postoperatively. Considering the lung injury, a novel approach for lung apex without adhesion dissection was chosen for secondary surgery. An axillary skin incision was made at the 2nd intercostal space, and extrapleural dissection proceeded toward the apex. After the pleural space was confirmed by the movement of pleural effusion, the parietal pleura was incised, and a bulla was exposed and resected. The presented procedure to reach the apex of the lung without adhesion dissection could be an option in cases with dense and extensive pleural adhesions.

Bilateral giant emphysematous bullae complicate severe bronchial asthma in a young patient: case report.

Giant bullous emphysema is a progressive bullous disease that affects young male smokers. Bullae are unilateral and mostly present in the apical lobes. Inflammatory diseases are less common cause of underlying emphysematous deterioration of the lung than tobacco smoking or genetic conditions such as Alpha-1 antitrypsin deficiency. The current instance, however, is relatively rare because it involved a nonsmoking 14-year-old boy who was diagnosed with asthma for 8 years, and he was taking bronchodilators inhalers during acute exacerbation of asthma; he presented to the tertiary health facility with on-and-off episodes of difficulties in breathing and chest tightness for 2 weeks despite being on maximal therapy for his asthma. He was diagnosed with bilateral large emphysematous bullae by high-resolution computed tomography scan, where staged bilateral bullectomy was performed. Thoracotomy-based bullae excision is still a feasible option for improving pulmonary function and the overall quality of life of patients with giant bullae emphysema in resource-limited settings.

Feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax patients.

OBJECTIVES: Although early removal of postoperative chest drains can facilitate postoperative recovery, there are risks of undetected bleeding and a need for re-drainage to treat delayed pulmonary air leaks. In this study, we aimed to prospectively examine the feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax (PSP) patients. METHODS: Between January 2021 and November 2021, 30 PSP patients were enrolled in this prospective study. The absence of air leakage was confirmed and radiographic evidence of lung expansion was acquired; the tube was then removed in the operating room. The primary endpoint was postoperative air leakage requiring re-drainage among patients who underwent tube removal in the operating room. The secondary endpoints were postoperative pain (numerical rating scale) on postoperative days (PODs) 1, 7, and 28, morbidity, and postoperative hospitalization time. RESULTS: Four (13.3%) patients were excluded because of underlying pulmonary disease (n = 2) and air leaks (n = 2) detected in the operating room. Chest drainage tubes were removed in the operating room for the remaining 26 patients; none of them required re-drainage. The mean postoperative hospitalization time was 1.2 ± 0.4 days. The mean numerical rating scale scores were 4.2 ± 2 (median: 4.5), 1.6 ± 1.6 (median: 1), and 0.4 ± 0.8 (median: 0) on PODs 1, 7, and 28, respectively. Only one case of hemoptysis occurred as a postoperative complication. CONCLUSIONS: Tubeless thoracoscopic bullectomy for PSP is feasible and may reduce the postoperative hospitalization time; however, it does not significantly reduce pain on POD1.

[Surgical management of primary spontaneous pneumothorax. A national survey of the Emerging Thoracic Surgery Group of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR)]. / Manejo quirúrgico del neumotórax espontáneo primario. Encuesta nacional del Grupo Emergente de Cirugía Torácica de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR).

Introduction: In February 2022, the Emerging Thoracic Surgery Group of the Spanish Society of Pneumology and Thoracic Surgery initiated a multicenter study on the surgical management of primary spontaneous pneumothorax (PSP). As a preliminary step, this survey was developed with the aim of finding out the current situation in our country to specify and direct this project. Method: A descriptive study was carried out based on the results of this survey launched through the Google Docs® platform. The survey was sent to all active national thoracic surgeons, a total of 319. It consisted of 20 questions including demographic, surgical and follow-up data. Results: We obtained 124 responses (39% of all specialists and doctors in training in the national territory). The most consistent indications were: homolateral recurrence for 124 (100%), lack of resolution of the episode for 120 (96.7%), risk professions for 104 (84%) and bilateral pneumothorax for 93 (75%). The approach of choice for 100% of respondents was videothoracoscopy. Of these, 96 contemplated pulmonary resection of obvious lesions (77%). Regarding the pleurodesis technique, pleural abrasion was the technique most used by 70 respondents (56.7%) while 49 (40%) performed chemical pleurodesis with talc either alone or in combination with mechanical pleurodesis. Conclusions: While there is some consistency in some aspects of surgical management of PSP, this survey makes evident the variability in pleurodesis techniques applied among surgeons in our country.

Delayed severe hemothorax caused by a staple line of a bullectomy performed 11 years earlier.

BACKGROUND: At present, relatively few lung surgeries are performed without endostaplers. Although there are few staple-related adverse events, severe events must be shared to improve safety. CASE PRESENTATION: A 74-year-old male suddenly collapsed and was transferred to the Emergency Rescue department. He had shock vitals and contrast-enhanced CT revealed extensive right hemothorax with contrast leakage. He lost consciousness and tension massive hemothorax was suspected. We performed emergency thoracotomy at two sites and were able to achieve hemostasis and save the patient. Upon examining the patient's medical history after his condition stabilized, it was revealed that he was a lung cancer patient who was taking ramucirumab and cilostazol. In addition, the CT scan taken one month before onset revealed the bleeding site of the fifth intercostal artery were almost contact with the staple line from a prior right spontaneous pneumothorax surgery that was performed 11 years previously, which was seemed to damage the intercostal artery. CONCLUSION: Despite the difficulty in achieving hemostasis due to drug administration history, we successfully treated a case of remote period massive hemothorax attributed to staples, thereby saving the patient. When using drugs that increase the risk of bleeding events, it may be important to consider the position of the staple line while assessing the risk. In the emergent or ICU setting, if the initial incision is not effective, the placement of a new second incision may be valuable.

Effect of initiative pulmonary bullectomy on the risk of post-operative pneumothorax in patients with esophageal carcinoma: a propensity score-matched analysis.

Background: Postoperative pneumothorax can lead to additional invasive intervention and extended hospitalization. The effect of initiative pulmonary bullectomy (IPB) during the esophagectomy on preventing postoperative pneumothorax remains controversial. This study evaluated the efficacy and safety of IPB in patients who underwent minimally invasive esophagectomy (MIE) for esophageal carcinoma complicated by ipsilateral pulmonary bullae. Methods: Data from 654 consecutive patients with esophageal carcinoma who underwent MIE from January 2013 to May 2020 were retrospectively collected. A total of 109 patients who had a definite diagnosis of ipsilateral pulmonary bullae were recruited and classified into two groups: the IPB group and the control group (CG). Propensity score matching (PSM, match ratio =1:1), incorporating preoperative clinical features, was used to compare the perioperative complications and analyze efficacy and safety between IPB and control group. Results: The incidences of postoperative pneumothorax in the IPB and control groups was 3.13% and 40.63% respectively, with a significant difference (P<0.001). Logistic analyses indicated that removing ipsilateral bullae was associated with a lower risk (OR 0.030; 95% CI: 0.003-0.338; P=0.005) of incident postoperative pneumothorax. No significant difference was found between the two groups in terms of the incidence of anastomotic leakage (6.25% vs. 3.13%, P=1.000), arrhythmia (3.13% vs. 3.13%, P=1.000), chylothorax (0% vs. 3.13%, P=1.000) and other common complications. Conclusions: In esophageal cancer patients with ipsilateral pulmonary bullae, IPB performed in the same anesthesia process is an effective and safe method for the prevention of postoperative pneumothorax, allowing for a shorter postoperative rehabilitation time, and it does not exert unfavorable effects on complications.