Thoracic Surgery Clinic Research Articles

Spontaneous Pneumomediastinum: Analysis of 11 Cases.

Objectives:The presence of free air in mediastinum is defined as pneumomediastinum. The incidence is between 1/7000-1/32000. In this study, our aim is to discuss our cases with spontaneous pneumomediastinum (SPM), which has low incidence, in the light of the literature.Methods:The files of 11 cases who were diagnosed with SPM in pulmonary diseases and thoracic surgery department and followed up and treated in thoracic surgery clinic between 2012-2018 were retrospectively analyzed. Patients’ age, sex, etiological factors, diagnosis and treatment methods and hospital stay were evaluated.Results:Between the years of 2012-2018, 11 cases with SPM who were not related to trauma were detected. Nine (81.8%) of the patients were male; the median age was 38.5 years. Among the predisposing factors that played a role in the formation of SPM, the most common symptom was dyspnea, while the second most common symptom was coughing seizures. The median duration of hospitalization was 3.8 days, and no mortality was observed.Conclusion:Spontaneous pneumomediastinum is a rare clinical condition, especially in young men. SPM treatment can be conservative or surgical.

AN UNCOMMON CAUSE OF A MEDIASTINAL MASS

SESSION TITLE: Disorders of the Mediastinum SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Thymic neuroendocrine tumors rarely occur as a mediastinal mass, with a reported incidence of 0.01-0.02/100,000. We present a case of thymic neuroendocrine tumor that had gone undiagnosed for 15 years. CASE PRESENTATION: 63 year-old female, lifelong nonsmoker, with past medical history of a mediastinal mass discovered incidentally 15 years ago, mesenteric plasmacytoma s/p colectomy in 2007, and anemia was admitted for new onset HFrEF. She complained of worsening dyspnea for the past few months, lower extremity edema, orthopnea, and gradual weight loss over the past few years. She denied chest pain, fever, chills, dizziness and syncope. She had undergone 2 biopsies of the mass in the past, but results were inconclusive. On physical exam, she was cachectic in appearance. Breath sounds were decreased on the left side. There was 4+ pitting edema of the lower extremities. Labs were remarkable for albumin of 2.6 and BNP of 2709. CXR demonstrated an opacification silhouetting the left mediastinum and heart border. CT of the chest showed a 16x13x10cm upper mediastinal centrally necrotic mass with mass effect on the heart and trachea. PFT was attempted, but the patient could only perform spirometry, which revealed severe restriction. She underwent CT-guided biopsy, which revealed thymic neuroendocrine tumor, typical carcinoid, positive for synaptophysin and chromogranin. Surgical resection of the mass was not possible as the mass was highly vascularized. CT angiogram of the chest demonstrated multiple vascular channels from the mass. Embolization of the right internal mammary artery supplying the mass was done, but the left-sided supply to the mass could not be embolized as the patient felt unwell. She was stable and was discharged with planned follow-up with IR to complete embolization and subsequent possible surgical debulking. DISCUSSION: Thymic neuroendocrine tumors are uncommon, accounting for approximately 5% of all thymic and mediastinal tumors, and are often discovered incidentally. Symptoms can range from asymptomatic to cough, dyspnea, chest pain, and possible endocrinopathies. CXR and CT are part of the initial workup, and diagnosis is confirmed by histological examination and immunohistochemical staining of biopsied tissue. More than half are positive for synaptophysin and chromogranin. Radical resection is the preferred treatment, but if not possible, no standard treatment has been defined as these cases are rare. Response to chemotherapy and radiation is poor. The patient in our case was not a candidate for surgery. CT angiogram identified vessels supplying the mass, and embolization was attempted successfully for one side of the vascular supply, and the other side was to be embolized on an outpatient basis. CONCLUSIONS: The rarity of thymic neuroendocrine tumors causes treatment to be complicated. If surgical resection is not possible, other approaches need to be considered. Reference #1: Lausi P, Refai M, Filosso P, et al. Thymic Neuroendocrine Tumors. Thoracic Surgery Clinics. 2014;24:327-332. Reference #2: Song Z, Zhang Y. Primary neuroendocrine tumors of the thymus: Clinical review of 22 cases. Oncology Letters. 2014;8:2125-2129. Reference #3: Bohnenberger H, Dinter H, Konig A, Strobel P. Neuroendocrine tumors of the thymus and mediastinum. Journal of Thoracic Disease. 2017;9:S1448-S1457. DISCLOSURES: No relevant relationships by Mona Alipour, source=Web Response No relevant relationships by Jennifer Chiu, source=Web Response No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Nabil Mesiha, source=Web Response No relevant relationships by Ankur Mogla, source=Web Response

P3.15-13 Surgical Management of Huge Pulmonary Arteriovenous Malformations: Our Experience

Pulmonary arteriovenous malformations are rare lesions with significant clinical complications. These lesions are commonly seen in patients with hereditary hemorrhagic telangiectasia (formerly Osler-Weber-Rendu syndrome). Formerly called Osler-Weber-Rendu, HHT is an inherited disorder of the vasculature associated with AVMs and telangiectasias. The prevalence of HHT is 1 in 5,000 to 10,000 patients.) are present, the diagnosis is definite. If two criteria are present, the diagnosis of HHT is probable. If less than two criteria are present, the diagnosis is unlikely. Management of arteriovenous malformations (AVMs) remains challenging because of their unpredictable behavior and with high risk mortality. A multidisciplinary approach based on a new classification scheme and improved diagnostic techniques may improve their management. Objectives: The purpose of this study was to review our surgical experience with surgical to manage arteriovenous malformations (AVMs). We diagnosed a 1 patient A. female birthday 02.09.1990 with pulmonary arteriovenous malformacion (PAVMs) .She has been admitted to the thoracic surgery clinic in QKUK Pristine in July 2015 with massive hemoptisis. Unknown initially diagnose .She was presented to QKUK hospital urgently with such clinical signs, epistaxis ,cough, hemopstisi, weakness, sweat, fever, dyspnoea, thoracic malaiseand ,massive right hemothorax with clinical signs of hemorrhagic shock with massive hemoptisi, tachycardia, weak pulse, hypotension, severe anemia et hypovolemiv shock .She was treated with right pleural drainage (avarage 2000ml)and intensive therapy et hemotransfusion (8 flacons).She was treated initially with intensive therapy and hemotransfuzion and after that with hemodynamic parameters stable were treated with surgery.Pacient were completed with all the necessary of emergency examinations as thoracic radiography, biochemical examinations, CT scaner toracal, MRI ,Bronchoscopy, EKG ,cardiac echo and cateterisation ,gaseous exchange . The patient continued with the above-mentioned concerns with dyspnoea epistaxis from time to time. Cyanosis of the lips, fingers in the hands of drumsticks, petekie and ecimosis in the skin and mucous membranes, sleep disorders. After 1.5 years it is re-examined in the cardiology clinic "Nene Hospital Theresa "and is diagnosed with giant dexter pulmonary arteriovenous fistule by Pulmonary angiography. She was treated by surgical approach in 10.06.2016 .Right posterolateral thoracotomy ,segmentectomy IV-r and fistul artereovenosectomy ,pleural deainage. Arteriovenous malformation size ranged. to 10x 8 cm located in the right lung middle lobe. She was treated by anatomical 4-th segmentectomy. Operator and post operative period is good. Clinical and imaging image of ultimate control is smooth.No mortality ,no major complication.Hospital days stay was 5 days. Diagnosis and management of AVMs by surgical therapy resection was with very good results and with limited morbidity and low mortality and no recurrence during early follow-up.

AN UNUSUAL CASE OF DISSEMINATED CRYPTOCOCCOSIS

SESSION TITLE: Chest Infections 3 SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 11:00 AM - 12:00 PM INTRODUCTION: Cryptococcus neoformans is frequently present as an opportunistic pathogen mainly affecting immunocompromised populations.Disseminated infection in immunocompetent population is rare.We describe one such unique case in a young male,whose sole risk factor turned out to be where he lived. CASE PRESENTATION: 23 year old male,non-smoker, was referred to thoracic surgery clinic from an urgent care center for abnormal CT chest. He initially presented to the urgent care center with intermittent chest pain for 2 weeks. Chest x-ray there showed left lower lobe infiltrates and he was treated with oral antibiotics.On persistence of symptoms,he had a CT chest which showed bilateral lower lobe consolidations,hilar and mediastinal lymphadenopathy. He attested to low grade fevers but denied other complaints. Due to concern for possible malignancy he underwent a PET CT,which showed the lower lobe masses to be have FDG uptake of SUV 3.3.It also revealed an expansile bone lesion in the mandible with similar FDG uptake.He then underwent a wedge biopsy of his left lower lobe lesion. Histopathological examination of the specimen revealed organizing pneumonia with fungal organisms consistent with crytococcus neoformans. Cultures were negative.On detailed interview,it was found he lived near a train station which has been a nesting place for pigeons and other birds. Complete work up for risk factors including HIV infection was negative.Patient was started on itraconazole with good clinical and radiological improvement. His 3 month follow up CT shows complete resolution of all the lung and bone lesions. DISCUSSION: Cryptococcus neoformans is ubiquitous encapsulated yeast and is generally considered as an opportunistic pathogen. The lungs are predominantly the primary locus of infection, with extra-pulmonary dissemination through hematogenous route affecting the meninges and, less commonly, the skin, bones, prostate, and other organs. Lung involvement typically consists of granulomatous reactions, and infiltrates. Most cutaneous infection occurs as a sign of disseminated Cryptococcal infection, which can be seen in 10–15% of the cases. Diagnosis is based on cultural examination of blood, cerebrospinal fluid, direct microscopic observation of the pathogen and PAS stain positivity on histochemical analysis. Our patient was negative for repeated cultures, which might indicate the insensitivity of culture at the early stage of infection. Treatment usually involves azoles and in severe cases amphotericin and surgical debridement of the lesions. CONCLUSIONS: Though historically viewed as an opportunistic pathogen, fungal diseases are rapidly increasing in incidence, in its presentation in immunocompetent patients. Our case is unique as < 10 cases has been reported in literature,of disseminated crytococcal infection in an immunocompetent adult, that did not involve the nervous system. Reference #1: 1. Ruan Q, Zhu Y, Chen S, Zhu L, Zhang S, Zhang W. Disseminated cryptococcosis with recurrent multiple abscesses in an immunocompetent patient: a case report and literature review. BMC Infectious Diseases. 2017;17:369. https://doi.org/10.1186/s12879-017-2459-9. Reference #2: S. Suchitha, C. S. Sheeladevi, R. Sunila, and G. V. Manjunath, “Disseminated Cryptococcosis in an Immunocompetent Patient: A Case Report,” Case Reports in Pathology, vol. 2012, Article ID 652351, 3 pages, 2012. https://doi.org/10.1155/2012/652351 DISCLOSURES: No relevant relationships by Anna Abbasi, source=Web Response No relevant relationships by Michael Bergman, source=Admin input No relevant relationships by Prarthna Chandar, source=Web Response No relevant relationships by Kabu Chawla, source=Admin input No relevant relationships by Sakthidev Kulandaisamy, source=Web Response No relevant relationships by William Pascal, source=Web Response No relevant relationships by Arjun Saradna, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

Surgical Treatment for Pulmonary Metastases of Osteosar-Coma

Abstract Introduction. Osteosarcomas represent 40% of bone sarcomas and occur mainly in children and young adults. They are tumors with a high degree of pulmonary metastasis. Pulmonary metastases occur in about 80% of the relapsed patients after primary tumor therapy, whether or not they have received chemotherapy. As therapeutic solutions, both first intention resection of the metastasis and the post-chemotherapy resection or repeated resections in each relapse, represent satisfactory results with prolongation of survival. Material and method. The present study describes a group of 17 patients who were surgically treated for osteosarcoma with different localizations and who presented themselves in the thoracic surgery department during 2011-2016 with suspicion of pulmonary metastases. Three of them were at their second intervention for metastasis resection. Following investigations, 4 of them (23.5%) could not benefit from surgical resection of pulmonary metastases (lesional extension with postoperative vital risk or technical impossibility of metastatic excision). Surgical interventions were curative; lobectomies were performed in 4 cases (30.7%), atypical resections in 8 cases (61.6%) and one pneumonectomy (7.7%). Postoperative progression was favorable in all 13 patients. Discussions and conclusions. Surgical excision of osteosarcoma pulmonary metastases can prolong survival and sometimes even cure disease. In order to benefit from the intervention, the patient should be served by a thoracic surgery clinic in the shortest possible time after the discovery of the pulmonary nodules. Thus, the need for thoracic imaging is required in patients treated for osteosarcoma. Late presentation makes the intervention impossible, particularly because of the lesional extension in the lung parenchyma or the invasion of the adjacent structures, extension given by the number of metastases or their size.

Spontan Pnömotoraksta Klinik Deneyimlerimiz

Spontaneous pneumothorax is one of the common disease, that the thoracic surgery clinics encounters. Observation with O2 support is usually sufficient for small and asymptomatic pneumothorax patients; while the treatment for the symptomatic patients varies from aspiration to open surgical procedures. In this study, we aimed to evaluate spontaneous pneumothorax patients treated in our clinic between 2015 and 2017 in terms of gender, age, treatment modalities and recurrence rates. 41 patients who had spontaneous pneumothorax between 2015 and 2017 were included in the study. These patients were evaluated in terms of gender, age, treatment modalities and recurrence rates. 3 of the 41 patients (7.3%) were female and 38 (92.7%) were male. The overall average age of the patients was calculated as 29.2. Mean age in 35 patients with primary spontaneous pneumothorax was 25.8 (15-41) and 49.3 (26-70) in 6 patients with secondary spontaneous pneumothorax. Observation with oxygen support was sufficient in 3 (7.3%) patients. Twenty six (63.4%) patients recovered with tube thoracostomy, while in 12 (29.3%) patients treatment with chest tube was insufficient and advanced surgical procedure was necessary. Surgical procedures were performed with video assisted thoracoscopic surgery (VATS) or thoracotomy. Thoracotomy was used for patients, who could not tolarate double lumen entubation, who had diffuse bullous-emphysematous changes or extensive pleural adhesions in their lungs. Recurrence was observed in one of the patients who underwent bullae excision and pleural abrasion with VATS.There were no complications during or after the tube thoracostomy or surgical procedure. Tube thoracostomy can be safely applied as a first-line treatment option for symptomatic pneumothorax patients who are in need of intervention or whose pneumothorax do not resorb with O2 support. Additional surgical procedures should be performed in cases of recurrent pneumothorax, prolonged air leak, and expansion problems.

Thoracoscore: Predicting risk of in-hospital mortality for patients undergoing pulmonary resection

Background/Aim. Thoracic surgery is in need of a widely recognized and dependable risk model which could pro-spectively make objective conclusions and retrospectively allow comparison of outcomes. Thoracoscore is the first model with multiple variables developed for predicting in-hospital mortality following pulmonary resections. It is integrated in the British Thoracic Society and National Institute of Health and Clinical Excellence guidelines. However, additional evaluation of Thoracoscore is considerably advised in order to demonstrate its validity and potentially make it a dependable tool for thoracic surgeons across the world. Our study assesses the accuracy of Thoracoscore scoring system in estimating in-hospital mortality in patients under-going pulmonary resections. Methods. Between September 2013 and October 2014 data were retrospectively collected on 196 patients operated on at the Thoracic Surgery Clinic, Institute of Pulmonary Diseases of Vojvodina. The procedures performed were: pneumonectomies, lobectomies and modified lobectomies (including bilobectomy and sleevelobectomy), Wedge resections and atypical resections. The Thoracoscore was calculated based on these nine variables: age, sex, American Society of Anaesthesiologists' (ASA) class, performance status classification, dyspnea score, priority of surgery, procedure class, diagnosis group and co-morbidities score. Results. Study included one hundred and ninety-six patients, average age of 62 ? 9 years, and 61% were males. Predicted mean in-hospital mortality was 3.6 ? 3.2% 95% confidence interval (CI) 3.16?4.06, and mean actual in-hospital mortality was 6/196 (3.1%) (95% CI 1.78?4.42). Patients who were &gt; 65 years old contributed to 3/6 (50%) of in-hospital mortality, and 4/6 (67%)were males. Four of 6 (67%) patients underwent pneumonectomy due to malignant pathology. Thoracoscore was divided into 4 risk groups: low (0?3), moderate (3.1?5), high (5.1?8) and very high (&gt; 8). The correlation between observed and expected mortality was 0.99, by category of risk. Old age, male gender and malignancy showed to be strong indicators of in-hospital mortality. Conclusion. At our department Thoracoscore presented with good performance and as a practical tool for predicting in-hospital mortality among patients undergoing lung resections. However, any risk scoring system needs further validation before implementation and outcomes must be compared to those of other programs.

Comparison of Efficiency of Pleurodesis Between Video Assisted Thoracoscopic Surgery (VATS) and Standard Thoracostomy.

Background:Chemical pleurodesis is generally accepted palliative dyspnea therapy and preventive of re-accumulation of pleural fluid in patients with malignant pleural effusions.Aim:Comparative analyses of efficiency of chemical pleurodesis between Video Assisted Thoracoscopic Surgery (VATS) and standard thoracostomy.Methods:From 01.01.2016-01.01.2017 at the Clinic for Thoracic Surgery of University Clinical Center (UCC) Sarajevo retrospective analysis was performed. Studied patients underwent VATS pleurodesis (G1) and standard thoracostomy pleurodesis (G2), with 60 in each group, respecting defined inclusion and exclusion criteria. Pleurodesis success was examined radiologically over the next three months.Results:Average age of all patients was 63.97±8.75 years. Gender related, 45% were men and 55% were women (F/M=1.47:1). Average hospitalization was 7.22±1.37 (G1: 6.68±1.16; G2: 7.44±1.40; Mann-Whitney U-test: p=0.0016) days. Average thoracic drainage duration was 5.45±1.69, (G1: 4.28±1.15,G2: 6.05±1.58; Mann-Whitney U-test p<0.0001) days. Pleurodesis success after first month was 98.30% in G1, 91.60% in G2 (G1 vs. G2; p=0.2089); after second month was 98.30% in G1, 78.30% in G2 (G1 vs. G2; p=0.0011) and after three months was 91.60% in G1, 63.30% in G2(G1 vs. G2; p=0.0006). Average dyspnea degree (0-5) after the pleurodesis was 0.050±0.22 in G1 and 0.62±0.76 in G2 (Mann-Whitney U-test; p=0.0001). Complication were noticed in 9.2% patients, in G1 3.3%, 15.0% in G2.Conclusion:Difference in pleurodesis efficiency between the G1 and G2 was established after second month and was even more evident after third month in favor of G1. Results show the significant statistical improvement of the degree of dyspnea in G1 as opposite to the G2.

Percutaneous computed tomography-guided permanent 125I implantation as therapy for pulmonary metastasis.

PurposeTo evaluate intermediate-term outcomes after computed tomography (CT)-guided radioactive 125I seed implantation (CTRISI), and to determine prognostic variables associated with outcomes in patients with pulmonary metastases.Material and methodsThoracic surgeons evaluated and performed implantation of 125I radioactive seeds under CT guidance or combined with surgical resection. Patients were monitored in the thoracic surgery clinic for recurrence and survival.ResultsFifty patients (31 men, 19 women; median age, 59 years; range, 16-85) underwent CTRISI. The primary cancer was colorectal in 10 (20%), malignant fibrous histiocytoma in 8 (16%), sarcoma in 5 (10%), renal in 4 (8%), and other in 22 (44%) patients. CTRISI was the sole treatment in 45 patients (90%) and was combined with surgical resection in 5 patients (10%). The actuarial D90 of implanted 125I seeds ranged from 90 to 160 Gy (median, 120 Gy). No procedurally related deaths occurred. At a median follow-up of 41.5 months (range, 7-74 months), 6 patients were alive. The median survival time was 42.1 months (95% confidence interval: 26.5-53.4), and the estimated 1-, 3-, and 5-year overall survival rates were 88.0%, 58.0%, and 26.7%, respectively. Lesion size was an important prognostic variable associated with overall and progression-free survival (p < 0.05).ConclusionsCTRISI is safe in this group of patients with pulmonary metastases and provides reasonable results. Surgical resection remains the standard for resectable cases, but CTRISI offers an alternative for selected patients or may be used as a feasible approach in combination with surgical resection for selected patients.

The Factors Affecting the Distant Recurrence in Patients With Non-Small Cell Lung Cancer and Our Results

SESSION TITLE: Lung Cancer SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: The long-term survival in Non-Small Cell Lung Cancer (NSCLC) following R0 resection is less than fifty percent (50%). The most important cause affecting the mortality following the resection is the development of recurrence. This study aims to determine the factors affecting the recurrence, to increase the awareness concerning this topic and to enlighten to this challenge by virtue of new studies. METHODS: In this study, the data were obtained by studying retrospectively the database belonging to the patients in which complete resection was performed due to the Non-Small Cell Lung Cancer (NSCLC) between January 01, 2008 and December 31, 2012 in the Clinic of Thoracic Surgery of the Konya Training and Research Hospital. The effects of the clinicopathologic variables on the distant recurrence were assessed. Mann Whitney U test were used in the Statistical Analysis. RESULTS: Fifty (50) male patients (87.7%) and seven (7) female patients (12.3%) with Non-Small Cell Lung Cancer (NSCLC) in which resection was performed were included into the study. Distant recurrence was developed in seven (7) of the patients. The relationship between the distant recurrence and clinicopathologic factors were studied. During the three-year follow-up, we obtained statistically significant values in comparison between the parameters affecting the survival such as differentiation (p=0.012), pathological stage (p=0.02), development of distant recurrence (p=0.014), the location of the distant recurrence (p=0.011), the duration spent in the intensive care unit (p=0.018), the length of stay (p=0.018) and the time for the postoperative distant recurrence (0.048). A statistical significance was detected between the distant recurrence and the hilar lymphadenopathies (LAPs) larger than one centimeter in computerized tomography (p=0.049) CONCLUSIONS: We found that the presence of the hilar lymphatic node larger than one centimeter in computerized tomography (CT) is the most important parameter in the development of distant recurrence. As a result, our study in which many parameters were assessed reveals the importance of the detection of the parameters leading to distant recurrence and their prevention beside the treatment regimens of pulmonary carcinoma. The assessment of mediastinal and hilar lymphatic nodes in detail by means of radiological examinations before the surgery and absolutely histopathologically in case of suspicion has a vital role. Furthermore, we suggest that the addition of the systemic dissection of the mediastinal lymphatic node is obligatory in the prevention of the distant recurrence. CLINICAL IMPLICATIONS: It was found that the presence of the hilar lymphatic node larger than one centimeter is related with the development of the distant recurrence. DISCLOSURE: The following authors have nothing to disclose: Ferdane Duran, Suleyman Akin, Mustafa Calik, Hidir Esme No Product/Research Disclosure Information

Surgical Treatment of Pleural Empyema - Our Results.

To analyze the results of the surgical treatment in patients with empyema treated at Clinic for thoracic surgery. In the retrospective study we analyzed 234 patients with empyema which were treated at the Clinic for Thoracic Surgery in 5 year period (2011-2015). The mean age of the patients was 51.94 years. They were treated with pleural drainage, decortications or thoracoplasty. With pleural drainage were treated 165/234 (70.51%) patients, of which successfully were finished 124/165 (75.15%), but 41/165 (24.85%) were indicated after the decortications. A total of 108/234 (46.15%) were treated with decortications from which, primary decortications were indicated in 67/234 (28.63%) patients. 5/234 (2.14%) patients were treated with thoracoplasty - 3 of the patients with decortications and 2 with primary indicated thoracoplasty according to the local findings, long term untreated empyema and bad general condition. The Mean hospitalization was 17.4 days, of which 13.4 days after surgery. In the group with primary drainage it was detected a lethal outcome in 7/124 (5.64%) patients, 5/105 (4.76%) in the group with decortications and 2/5 (40%) in the group with thoracoplasty. Early detection of the parapneumonic effusion and the adequate treatment will prevent the appearance of empyema. If the empyema is detected it is necessary as early as possible to start the treatment with minimally invasive pleural drainage. In earlier stages it is possible to use less invasive decortications, using VATS than the open thoracotomy decortication which is more extensive surgical intervention.

Assessing the clinical feasibility of implementing a novel assessment of frailty: The electronic Rapid Fitness Assessment in diverse thoracic surgery clinics.

e21687 Background: The American College of Surgeons and American Geriatrics Society recommend a geriatric/frailty assessment (GA) in the preoperative evaluation. We previously reported the development and implementation of the electronic Rapid Fitness Assessment (eRFA) in geriatric clinics. The eRFA captures data on multiple GA domains, including functional activity, social support, emotional well-being, weight loss, polypharmacy, and cognitive function. We now report the feasibility of clinical implementation of the eRFA in diverse thoracic surgery outpatient settings. Methods: Over 5 months, the eRFA was implemented until used by 5 surgeons in 2 outpatient clinics. All patients presenting for initial consultation were to complete the self-reported components of the eRFA by themselves or with the help of caregivers using a tablet or desktop computer, before coming to the clinic or in the clinic. A nurse performed the timed “get up and go” test and MiniCog test. A summary report was prepared for the clinician by the time of the encounter, and the data were stored in a database and as part of the electronic medical record. Time to complete the eRFA was recorded. Results: Since initiation in 9/2016, 78% of patients (65/83; median age, 71 [range, 20-88]; 31F:34M) completed the eRFA at initial consultation with a thoracic surgeon. Median time to complete was 9 min (range, 2-50); 75% of surveys were completed by the patient alone, 23% with a caregiver, and 3% by a caregiver alone. A large number of geriatric syndromes were uncovered: 26% of patients (17/65) had abnormalities in word recall, clock drawing, and/or timed “get up and go”; 41% (27/65) needed assistance with activities of daily living; 9% needed a cane or other support to ambulate; and 26% had at least 1 fall in the last year. Conclusions: Administration of the eRFA, an electronic assessment of patient frailty, is feasible in the initial evaluation of thoracic surgery patients. Future steps include characterization of functional reserve of patients considered for surgery, creation of prognostic models, and development of clinical trials to assess means of improving outcomes in this population of patients at risk.

Quality and Value of Subspecialty Reinterpretation of Thoracic CT Scans of Patients Referred to a Tertiary Cancer Center

IntroductionPatients referred to tertiary cancer centers often present with imaging studies performed and interpreted at other health care institutions. Although reinterpretation of imaging performed at another health care institution can reduce repeat imaging, unnecessary radiation dose, and cost, the benefit is uncertain. The purpose of this study is to evaluate the quality of initial imaging studies of patients seeking a second opinion at a tertiary cancer center, to compare the accuracy of initial interpretations to reinterpretations performed by subspecialty trained radiologists at a tertiary oncologic center, and to determine the potential impact on patient management. MethodsAn institutional review board-approved retrospective, single-institution database review was performed in 120 new patients presenting to the thoracic surgery clinics at our institution from 2010 through 2013, with initial chest CTs performed at another institution. Two thoracic radiologists blinded to the interpretation independently assessed the quality and performed a reinterpretation of 52 CTs. Fisher’s exact tests were used to compare the frequency with which clinically important staging parameters appeared in the reinterpretations and initial reports. Discrepancies between the reinterpretations and initial interpretations were adjudicated independently by two thoracic radiologists at different tertiary cancer institutions to determine which interpretations were more accurate. The impact of discrepancies on clinical management was evaluated based on National Comprehensive Cancer Network guidelines. ResultsOf the 52 CTs, 32 (62%) were of inadequate image quality for staging. In 17 of 52 (33%), discrepancies were identified between reinterpretations and initial interpretations. For discrepancies, the reinterpretation was judged to be more accurate for staging than the initial interpretation. In nine of these patients, staging parameters were omitted in the initial interpretations that precluded adequate staging. In the remaining eight patients, six were upstaged, one was downstaged, and one was unchanged by the reinterpretation. ConclusionsImaging studies from outside institutions are of variable image quality and often not adequate for appropriate staging of thoracic malignancies. Reinterpretation can decrease repeat imaging and associated technical costs. Additionally, the accuracy of staging is improved by reinterpretation of CTs by subspecialty trained radiologists and can significantly impact clinical management.

A Case Report of Giant Lung and Liver Hydatic Cyst

Twenty-eight years old female who was presented with fewer and abdominal pain was admitted to our hospital's emergency department (ED). The patient was hospitalized with diagnosis of pneumonia based on the tests performed at ED. She has been having shoulder and abdomen pain for one week without a known history of the disease earlier in the story. Her body temparature was 38.9o C and pulmonary examination was normal. There was no abnormal findings in her laboaratuary tests except that; CRP was 9.1 mg/dl and HGB was 9.82 g/dL. Chest x-ray revealed almost homogeneous density in all zones, especially in the left lung field, but cardiac contour was protected. She did not have cough or sputum, and based on her chest x-ray findings, we decided to examine CT scan of the lungs, suspecting lung mass. CT report demonstrated 17x9x8 cm thick walled cystic lesion in the left lung and 20 cm cystic lesion covering the liver . The patient consulted with a thoracic surgeon with a preliminary diagnosis of hydatic cyst. The patient underwent surgery by by the Thoracic Surgery Clinic. This case was presented because of the late diagnosis, despite the precence of large cysts in the lung and liver.

Surgical Treatment of Traumatic Flail Chest - Twenty Years of Experience

Introduction: Traumatic flail chest is segment of the chest wall, which is caused by multiple fractures or by separation of bone structures (at least three sequential broken ribs or separated into two fracture lines). These injuries are mainly seen in polytrauma patients. Aim of the Study: Our aim is to show the therapeutic benefits of surgical treatment (operative stabilization) of the flail chest. Patients and Methods: We retrospectively analyzed patients who underwent surgery at the Clinic of Thoracic Surgery, University Clinical Centre of the Republic of Srpska, Banja Luka, in the period from 01. 12. 1997 - 04. 06. 2016. Results: 50 patients with traumatic flail chest with average age of 47.42 years were surgically treated in the twenty-year period at the Clinic of Thoracic Surgery, University Clinical Centre of the Republic of Srpska, Banja Luka. The average length of a hospital stay was 15 days. Survival rate in the operated group was 91.43%. Conclusion: If conservative measures such as internal stabilization, the use of analgesics, antibiotics, oxygen therapy and airway toilet does not lead to stabilization of respiratory function, surgical chest wall stabilization is necessary.

How Physicians, Patients, and Observers Compare on the Use of Qualitative and Quantitative Measures of Physician-Patient Communication.

The purpose of this study was to compare several different measures of physician-patient communication. We compared data derived from different measures of three communication behaviors, patient participation, physician information giving, and physician participatory decision-making (PDM) style, from 83 outpatient visits to oncology or thoracic surgery clinics for pulmonary nodules or lung cancer. Communication was measured with rating scales completed by patients and physicians after the consultation and by two different groups of external observers who used rating scales or coded the frequency of communication behaviors, respectively, after listening to an audio recording of the consultation. Measures were compared using Pearson's correlations. Correlations of patients' and physicians' ratings of patient participation (r = .04) and physician PDM style (r = .03) were low and not significant (p > .0083, Bonferroni-adjusted). Correlations of observers' ratings with patients' or physicians' ratings for patient participation and physician PDM style were moderate or low (r = .15, .27, .07, and .01, respectively) but were not statistically significant (p > .0083, Bonferroni-adjusted). Correlations between observers' ratings and frequency measures were .31, .52, and .63 and were statistically significant with p values .005, <.0001, and <.0001, respectively, for PDM style, information giving, and patient participation. Our findings highlight the potential for using observers' ratings as an alternate measure of communication to more labor intensive frequency measures.

Uniportal Video-Assisted Thoracoscopic Surgery

Starting from 1990’s, video-assisted thoracic surgery (VATS) has commonly been used in thoracic surgery clinics. This is a minimally invasive operative technique where the surgery is performed through 2–4 incisions without any rib spreading under the camera vision of surgical field. Including oncological surgery for non-small cell lung cancer, the VATS experience and knowledge has increased in time. These beneficial and successful results encourage thoracic surgeons to perform surgery via smaller sized and number of incisions. This modification brought the definition of ‘Uniportal VATS,’ which seems to be the highlighted future direction in thoracic surgery as reviewed in the present manuscript.

The efficacy of oral anticholinergics for sympathetic overactivity in a thoracic surgery clinic

ObjectiveLittle is known of the success rates of oral anticholinergics for the treatment of primary hyperhidrosis and facial blushing as alternatives to surgical intervention. We examine predictors of success with these medications. MethodsA retrospective review was performed at a single institution, including all patients presenting with symptoms of primary hyperhidrosis, facial blushing, or both from 2004 to 2015. All patients were offered a trial of oral anticholinergics. If oral anticholinergic therapy was not successful, patients were offered surgery. Statistical analyses were performed to compare patients who declined surgery given the trial of oral anticholinergics with those who proceeded with surgery. ResultsA total of 381 patients presented with symptoms of primary hyperhidrosis (86.6%), facial blushing (2.4%), or both (11.0%). A total of 230 patients (60.4%) declined surgery after using oral anticholinergics, and 151 patients (39.6%) chose surgery. Patients who declined surgery were more likely to have symptoms of primary hyperhidrosis without facial blushing (89.6% vs 82.1%; P = .02) or have primary symptoms involving the axilla, torso, scalp, or groin. Patients who proceeded with surgery had higher rates of palmar symptoms as a primary site (77.6% vs 61.1%; P = .01) and were more likely to have facial blushing alone or in combination with primary hyperhidrosis. Presentation with palmar symptoms and greater number of prior therapy attempts were independent predictors of proceeding with surgery after controlling for concomitant symptom type and location (P = .01 and P < .0001, respectively). ConclusionsThe majority of patients presenting with sympathetic overactivity decline surgery when a trial of oral anticholinergics is included in the treatment algorithm. Facial blushing and palmar symptoms were each associated with choosing surgery.

The Diagnostic Value of Pericardial Fluid and Pericardial Biopsy: Single Center Experiences.

Patients with recurrent pericardial effusion and pericardial tamponade are usually treated in thoracic surgery clinics by VATS (video-assisted thoracoscopic surgery) or open pericardial window operation. The diagnostic importance of pathological evaluation of the pericardial fluid and tissue in the same patients has been reported in few studies. We reviewed pathological examination of the pericardial tissue and fluid specimens and the effect on the clinical treatment in our clinic, and compared the results with the literature. We retrospectively analyzed 174 patients who underwent pericardial window operation due to pericardial tamponade or recurrent pericardial effusion. For all patients both the results of the pericardial fluid and pericardial biopsy specimen were evaluated. Clinicopathological factors were analyzed by using descriptive analysis. Median age was 61 (range, 20-94 years). The most common benign diagnosis was chronic inflammation (94 patients) by pericardial biopsy. History of malignancy was present in 28 patients (16.1%) and the most common disease was lung cancer (14 patients). A total of 24 patients (13.8%) could be diagnosed as having malignancy by pericardial fluid or pericardial biopsy examination. The malignancy was recognized for 12 patients who had a history of cancer; 9 of 12 with pericardial biopsy, 7 diagnosed by pericardial fluid. Twelve of 156 patients were recognized as having underlying malignancy by pericardial biopsy (n = 9) or fluid examination (n = 10), without known malignancy previously. Recurrent pericardial effusion/pericardial tamponade are entities frequently diagnosed, and surgical interventions may be needed either for diagnosis and/or treatment, but specific etiology can rarely be obtained in spite of pathological examination of either pericardial tissue or fluid. For increasing the probability of a specific diagnosis both the pericardial fluid and the pericardial tissues have to be sent for pathologic examination.

Electrical Changes in Deeper Cortical Structures During Balanced General Anesthesia with the Aim on Inhalation Anesthetics Effects

Abstract There are many theories that attempt to explain the mechanisms of the effects of inhalation anesthetics - from simpler, pursuing individual effects of anesthetics on the level of the ion channels, to more complex that are looking for uniform global changes in brain activity common to several agents. However, we still don’t have satisfactory and adequate conclusions. We examined a sample of 39 patients undergoing thoracic surgery at the Clinic of Thoracic Surgery under general anesthesia (GA) and we registered their electroencephalographic (EEG) signals before and during operation. After induction of GA by intravenous (i.v.), we used inhalation anesthetics to maintain GA. We used sevoflurane (SEV) in 20 patients and desflurane (DES) in 19 patients. Then we obtained the EEG data and processed them through mathematical and statistical analysis, to discover any changes of electrical activity in the brain during thoracic surgery under GA. The era of digital recording EEG and present possibilities of modern computer techniques allow quantitative analysis of obtained data. We performed the analysis with the software LORETA (low resolution brain electromagnetic tomography). It is a relatively new research method, which in a similar way as computed tomography (CT) or magnetic resonance imaging (MRI) displays even deeper brain electrical activity, which is hiddeen for a classical EEG approach. We described the general changes in brain electrical activity of the deeper cortical structures within the traditional frequency bands (d, q, a, b and g) during GA at 5 mm spatial resolution. We have shown that the source of the well-known cortical EEG changes after the effect of used inhalation anesthetics is caused by changes situated in the deeper brain structures, particularly the limbic system. Significant changes occurred in the cingulate gyrus for most of an EEG frequency ranges. When comparing the data of patients anesthetised with SEV and DES we found similar changes within the d and q rhythms and then the global changes of EEG activity followed during GA.