Drainage Tube Insertion Research Articles

Firearm Injuries in Children: Four-year Experience from a Rural Tertiary Care Centre of Northern India.

Firearm injuries (FAIs) continue to be a global public health problem possessing substantial emotional, physical and financial burdens on hospital resources. Although FAIs are rare in children, their incidence is gradually increasing. The aim of this study was to evaluate various aspects of FAI in children that were managed at a tertiary care centre located in the rural part of India. This clinical observational study of children <18 years of age, all due to FAI, was conducted at a tertiary care centre located in the rural part of India. Data of all children admitted with FAI over 4 years from January 2016 to December 2019 were collected. Recorded data included age, sex, motive (intentional/unintentional) and circumstances leading to injury, type and license status of firearm used, time of injury, pre-hospital care, mode of transport to hospital, duration between injury and arrival to hospital, body parts and organs injured, trauma scores, management, complications, length of hospital stay and outcomes. The recorded data were entered into a worksheet and analysed. Out of 283 cases of FAI admitted, only 24 were children with age <18 years (8.48%). The mean age was 12.66 years (male:female = 2.4:1). Sixteen were intentional (66.67%) and eight were unintentional (33.33%). The family feud was the most common reason in case of intentional FAI (43.75%), and mishandling was the most common reason in case of unintentional FAI. Country made gun was the most common firearm used (62.5%). The chest and upper back were the most common sites of injury (54.16%). Intercostal drainage tube insertion was the most common surgical procedure performed (33.33%). There were three mortalities (12.5%). The present study found that intentional FAIs in children were more common than unintentional FAIs with family feuds and mishandling being the most common causes, respectively. The unlicensed country-made gun was the most common firearm causing injury in children.

The application of wing-shaped window decompression device in the treatment of large odontogenic keratocyst: An observational study.

To enhance the decompression and drainage effects after marsupialization of large odontogenic keratocysts (OKCs) in the jawbone, a novel cyst plug was designed, and its clinical feasibility was investigated. A total of 42 patients with large OKCs requiring decompression were divided into 2 groups: the control group (n = 21), which underwent traditional drainage tube insertion, and the experimental group (n = 21), which received a personalized wing-shaped plug. The clinical efficacy of the wing-shaped plug was assessed, and postoperative recovery times were compared between the 2 groups. The average duration of use for the wing-shaped plug was approximately 14 months. Compared to the control group, the treatment duration in the experimental group was reduced by about 3 months. The wing-shaped plug demonstrated superior fit, comfort, reduced food residue, minimal irritation to surrounding tissues, a more aesthetically pleasing appearance, and less reported pain. The adaptive wing-shaped plug offers improved prognosis for patients undergoing decompression of OKCs and shows significant potential for clinical application.

Cerebrospinal Fluid Parameters Predicting Contralateral Isolated Lateral Ventricle in Adult Tuberculous Meningitis with Hydrocephalus Post-Ventriculoperitoneal Shunt

Hydrocephalus, a major complication in tuberculous meningitis (TBM) patients, often necessitates treatment via ventriculoperitoneal shunt (VPS). However, post-VPS, some patients develop a complication called contralateral isolated lateral ventricle (CILV), leading to persistent hydrocephalus symptoms. This study aims to evaluate cerebrospinal fluid (CSF) parameters in predicting CILV occurrence post-VPS in adult TBM patients. A retrospective analysis was conducted, focusing on the relationship between preoperative CSF parameters and the development of CILV in 40 adult TBM patients who underwent VPS. The study compared CSF parameters from lumbar puncture after admission with those from ventricular CSF post-external ventricular drainage tube insertion. CILV was observed in 6 of the 40 patients following VPS. Statistical analysis showed no significant difference between the CSF parameters obtained via lumbar and ventricular punctures. Notably, the mean CSF glucose level in patients with CILV was significantly lower (1.92mmol/L) compared to the non-CILV group (3.03mmol/L). Conversely, the median adenosine deaminase (ADA) level in the CILV group was higher (5.69 U/L) compared to the non-CILV group (3.18 U/L). The optimal cutoff values for CSF glucose and ADA levels were 1.90mmol/L and 4.80 U/L, respectively, with a sensitivity of 66.67% and 83.33% and a specificity of 88.24% and 79.41%. The study identified elevated ADA levels and decreased glucose levels in CSF as potential risk factors for CILV development in adult TBM patients post-VPS. These findings suggest the necessity for more tailored surgical approaches, in patients with altered CSF parameters to mitigate the risk of CILV.

Re-Expansion Pulmonary Edema as a Life-Threatening Complication in Massive, Long-Standing Pneumothorax: A Case Series and Literature Review.

Re-expansion pulmonary edema is a rare and potentially life-threatening complication that can occur after the rapid re-expansion of a collapsed lung due to pneumothorax or pleural effusion. It has a multifactorial pathogenesis, and risk factors for re-expansion pulmonary edema, such as chronic lung collapse, rapid re-expansion, and changes in pulmonary vascular permeability, have been identified. Clinical manifestations vary, ranging from almost asymptomatic to a rapidly fatal condition, and its incidence may be more common and less fatal than previously believed. The literature emphasizes the importance of early recognition and management to ensure favorable outcomes. However, there is ongoing debate regarding the indications for ventilatory support and the timing of non-invasive or invasive ventilation. Herein, we report a case series of three paradigmatic examples of massive re-expansion pulmonary edema occurring over a period of 10 years in our institution among a population of 815 patients with spontaneous pneumothorax. We also conducted a literature review on re-expansion pulmonary edema, with a particular focus on diagnosis and management. In each case, despite initially normal clinical parameters, severe respiratory distress developed following the insertion of a thoracic drainage tube for a massive spontaneous pneumothorax. Two patients required High-Flow Nasal Oxygen, and one was addressed to intensive management, including CPAP. In all cases, the patient's outcome was optimal.

Introduction of extraperitoneal tunneling method: a way to secure the drain tube in the pelvic cavity after proctectomy.

The effectiveness of closed drainage tube insertion after low anterior resection has been controversial. We believe that drain tube displacement, which occurs up to 35% in real clinical practice, reduces the effectiveness of the drain tube. We report in this video a simple way to secure the drain tube in the pelvic cavity after low anterior resection and introduce a case that used the drain fixation method and treated anastomotic leakage without interventional procedure.

Treatment of external auditory canal stenosis and atresia after transcanal endoscopic ear surgery

PurposeTo discuss the treatment of external auditory canal stenosis or atresia occurring as a complication of transcanal endoscopic ear surgery. Materials and methodsWe retrospectively analyzed the medical records of 11 patients who developed external auditory canal stenosis or atresia after undergoing transcanal endoscopic ear surgery. The 10 patients with stenosis were treated with external auditory canal expansion via drainage tube insertion; 2 of these patients further received local injections of triamcinolone acetonide. One patient with atresia was treated with meatoplasty surgery followed by tube insertion and triamcinolone acetonide injection. ResultsThe stenosis/atresia improved in all patients, and the external auditory canal was unobstructed without restenosis. ConclusionsStenosis/atresia of the external auditory canal after transcanal endoscopic ear surgery should be treated with dilation therapy/meatoplasty in a timely manner to prevent progressive hyperplasia of the scar and regain a normal-sized ear canal.

Does serratiopeptidase prevent thoracic surgery in patients of hydropneumothorax of tubercular aetiology?

Tubercular hydropneumothorax is commonly seen in Indian hospitals. Anti-tuberculosis drugs and intercostal drainage tube (ICD) insertion are the mainstays of treatment. But many patients have to be referred to thoracic surgery for surgical management. This study aims to evaluate the role of serratiopeptidase in successful resolution of tubercular hydropneumothorax and avoidance of thoracic surgery. We conducted a retrospective observational cohort study on 28 patients that were admitted to extrapulmonary TB ward of our hospital. All patients were given anti-TB drugs according to national guidelines and underwent ICD tube insertion. Out of 28 patients recruited, 19 suffering severe chest pain received serratiopeptidase containing analgesic tablets and nine patients of the control group not having severe chest pain received non-serratiopeptidase containing analgesic tablets. Both groups were compared on the basis of successful ICD tube removal. The results were analysed using Chi-square statistic with Yates correction. Of the 19 patients in the intervention group who received serratiopeptidase, 16 had successful recovery while three had to undergo thoracic surgery. Of the nine patients in the comparison group, only one had a successful recovery while the other eight had to be referred to thoracic surgery with ICD tube in situ. The outcome showed a statistically significant difference between the two groups, in terms of ICD tube removal and avoidance of thoracic surgery, with a P value of < 0.001. We conclude that the addition of serratiopeptidase to anti-tubercular drugs regimen can lead to better clinical outcomes and avoidance of thoracic surgery, in patients of tubercular hydropneumothorax.

Which is the More Effective Option for Pleurodesis to Prevent the Recurrence of Malignant Pleural Effusion? Large-Particle Talc or Mistletoe Extract (ABNOVA Viscum Injection).

Malignant pleural effusion affects many patients with advanced cancer. When chemotherapy or radiotherapy fails to relieve malignant pleural effusion and related symptoms, drainage and pleurodesis can help. Although surgical talc pleurodesis is the most widely used method, Viscum album, which has been recently used in surgical or bedside procedures, has demonstrated significant results and is as effective as talc. This study aimed to determine the most effective agent and procedure. Between January 2015 and July 2022, chemical pleurodesis was performed in 137 patients with malignant pleural effusion, using a V. album surgical procedure in 48, a V. album bedside procedure in 55, and a talc surgical procedure in 34 patients. We reviewed patients' clinical responses and disease progression after chemical pleurodesis. The success rate was not significantly different among the V. album surgical procedures (91.7%), V. album bedside procedures (83.6%), and talc surgical procedures (91.2%). However, the total drainage amount and tube insertion duration in both Viscum groups were more effective than those in the talc group. Furthermore, the bedside Viscum group showed significantly lower post-pleurodesis pain scores than the other 2 groups. According to our results, talc and V. album can be considered ideal agents for chemical pleurodesis. However, Viscum pleurodesis showed safer outcomes in terms of ensuring quality of life than talc. Additionally, the bedside Viscum group showed significantly lower pain scores than the other groups. Hence, patients for whom surgical procedures are inappropriate can undergo bedside Viscum pleurodesis without diminishing the therapeutic effect.

Development and Validation of a Nomograph Model for Post-Operative Central Nervous System Infection after Craniocerebral Surgery.

A nomograph model of predicting the risk of post-operative central nervous system infection (PCNSI) after craniocerebral surgery was established and validated. The clinical medical records of patients after cranial surgery in Renmin Hospital of Wuhan University from January 2020 to September 2022 were collected, of whom 998 patients admitted to Shouyi Hospital District were used as the training set and 866 patients admitted to Guanggu Hospital District were used as the validation set. Lasso regression was applied to screen the independent variables in the training set, and the model was externally validated in the validation set. A total of 1864 patients after craniocerebral surgery were included in this study, of whom 219 (11.75%) had PCNSI. Multivariate logistic regression analysis showed that age > 70 years, a previous history of diabetes, emergency operation, an operation time ≥ 4 h, insertion of a lumbar cistern drainage tube ≥ 72 h, insertion of an intracranial drainage tube ≥ 72 h, intraoperative blood loss ≥ 400 mL, complicated with shock, postoperative albumin ≤ 30 g/L, and an ICU length of stay ≥ 3 days were independent risk factors for PCNSI. The area under the curve (AUC) of the training set was 0.816 (95% confidence interval (95%CI), 0.773-0.859, and the AUC of the validation set was 0.760 (95%CI, 0.715-0.805). The calibration curves of the training set and the validation set showed p-values of 0.439 and 0.561, respectively, with the Hosmer-Lemeshow test. The analysis of the clinical decision curve showed that the nomograph model had high clinical application value. The nomograph model constructed in this study to predict the risk of PCNSI after craniocerebral surgery has a good predictive ability.

Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction in Children: Value of Robotic Assistance

AimRetroperitoneal pyeloplasty (RP) for pediatric ureteropelvic junction obstruction (UPJO) performed using retroperitoneoscopy (retro-RP) or robotic assistance (robo-RP) were compared. MethodsAll subjects were Japanese, matched for age, weight, and RP diameters. All RP were performed in the lateral decubitus position at a single institute by the same team using identical protocols. Five independent surgeons were asked to score intraoperative video recordings for perceived difficulty of suturing (DOS; 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; 1 = easy) and rank RP as +1 if robo-RP appeared to be superior, 0 if they appeared to be the same, and −1 if robo-RP appeared to be inferior. ResultsRobo-RP performed 2018-2022 (n = 22) were matched with retro-RP performed 2011-2019 (n = 34). Mean overall operative times were similar (robo-RP: 305.2 ± 57.8 min versus retro-RP: 340.0 ± 117.9 min; p = 0.19), but securing the larger retroperitoneal space required for robo-RP took significantly longer; 50.8 ± 13.9 min versus 24.3 ± 9.6 min; p < 0.0001. Total anastomotic time (TAT) and TAT per suture were both significantly shorter for robo-RP (p < 0.0001). The coefficient of variation for time taken to place one suture was smaller for robo-RP than for retro-RP. DOS was lower for robo-RP with less variance (p < 0.01). Robo-RP had shorter drainage tube insertion, ambulated quicker postoperatively, and shorter hospitalization. Retro-RP had anastomotic complications; leaks (n = 2) and strictures (n = 2, requiring conventional open re-pyeloplasty). Robo-RP had no anastomotic complications and was ranked +1 unanimously. ConclusionsThe RP anastomosis was quicker with less complications and more precise with robotic assistance in matched patients under similar circumstances. Should RP be indicated, robo-RP is recommended. Level of evidenceIII.

Ovarian Carcinoma Presenting as Meigs’ Section Syndrome- A Rare Case Report

Presence of fluid and air within pleural space is known as hydropneumothorax. A large proportion of patients present with shortness of breath, dry cough and pricking type of pleuritic chest pain as a result of pleural involvement. However, fever and constitutional symptoms like loss of appetite and loss of weight is most likely associated with tuberculosis. Meigs’ syndrome is a triad of ascites, hydrothorax and benign ovarian tumours (ovarian fibromas and fibrothecomas). Pseudo-Meigs’ syndrome shows accumulation of ascites, pleural effusion and associated with a pelvic or abdominal tumours. Here, is a case report of a 62-year-old postmenopausal female, who presented with right pleuritic chest pain and breathlessness, since one week. Chest radiograph showed right-sided hydropneumothorax which required an intercostal drainage tube insertion. Upon further evaluation, the primary unknown cancer was found to be of ovarian origin.

Long-term outcome following microwave ablation of lung metastases from colorectal cancer.

PurposeTo retrospectively evaluate the safety and efficacy of percutaneous computed tomography (CT)-guided microwave ablation (MWA) in colorectal cancer (CRC) lung metastases, and to analyze prognostic factors.Materials and methodsData were collected from 31 patients with CRC lung metastases from May 2013 to September 2017. They had removed the CRC, no extrapulmonary metastases, no more than three metastases in the lung, the maximum diameter of the lesions was ≤3 cm, and all the lung metastases could be completely ablated. The ablation procedures were performed using a KY-2000 microwave multifunctional therapeutic apparatus. Efficacy is assessed two to four weeks after ablation, and follow-up are performed every three months for two years. The primary outcome was overall survival (OS). The secondary outcomes were progression-free survival (PFS), and complications. Cox regression analysis was used for the evaluation of the statistical significance of factors affecting the end result of MWA therapy. The Kaplan–Meier method was used for estimation of survival rates.ResultsA total of 45 metastatic lung lesions from CRC in 31 patients were treated with CT-guided MWA procedures. The median OS was 76 months. The one, two, three, and five-year survival rates were 93.5%, 80.6%, 61.3%, and 51.6%, respectively. Multivariate analysis showed that the primary tumor from the rectum (P = 0.009) and liver metastases at the diagnosis of lung metastases (P = 0.043) were risk factors affecting OS, while PFS was a protective factor. The median PFS was 13 months. The maximum diameter of lung metastases lesions (P = 0.004) was a risk factor. The interval between pulmonary metastases and MWA (P=0.031) was the protective factor. Pneumothorax was observed in 13 out of 36 procedures. Four patients developed pneumothorax requiring drainage tube insertion. No patient deaths occurred within 30 days of ablation. Three out of 31 patients (9.67%) were found to have local recurrence of the original lung metastatic ablation foci.ConclusionMWA therapy may be safely and effectively used as a therapeutic tool for the treatment of selected CRC pulmonary metastases, and the prognosis is better in patients without liver metastases at the diagnosis of lung metastases.

A Retrospective Study from 2 Tertiary Hospitals in China to Evaluate the Risk Factors for Surgical Site Infections After Abdominal Hysterectomy in 188 Patients.

BackgroundSurgical site infections in patients after abdominal hysterectomy can increase medical expenses and increase the risk of death in patients. This retrospective study from 2 grade A tertiary hospitals in China aimed to evaluate the risk factors for postoperative surgical site infections (SSIs) in 188 patients undergoing abdominal hysterectomy between September 2013 and June 2021.Material/MethodsOf the 188 patients, 94 patients with SSIs were classified into the infected group, and 94 patients without SSIs were classified into the control group. Wound drainage was sampled for bacterial isolation and culture.ResultsThe suspected risk factors for SSIs after abdominal hysterectomy were body mass index, whether the patient had comorbidities of diabetes mellitus, cancer, or hypoproteinemia, surgical wound classification, whether preoperative skin preparation was performed, whether the patient had chemotherapy, length of incision, amount of blood loss during surgery, duration of surgery, necessity of a second surgery, whether a wound drainage tube was inserted, and whether delayed suturing was used in wound. Of them, body mass index (OR=1.133; 95% CI: 1.012~1.266; P=0.029), more than 3 hours of surgery (OR=0.261; 95% CI: 0.108~0.631; P=0.003), and wound drainage tube insertion (OR=0.223; 95% CI: 0.094~0.531; P=0.001) were the independent risk factors.ConclusionsThe findings support previous studies and showed that risk factors for SSIs after abdominal hysterectomy included increased patient BMI, increased operation duration, and the number of surgical drainage tubes used.

Successful Percutaneous Transhepatic Embolization of the Bronchobiliary Fistula Secondary to Biloma Using n-Butyl Cyanoacrylate and Microcoils

: Bronchobiliary fistula (BBF) is a rare, but serious disease; therefore, early diagnosis and treatment are essential. Recently, the use of a minimally invasive procedure that directly embolizes the BBF has emerged as a useful therapeutic alternative for conventional treatments, such as drainage tube insertion or fistulectomy. Here, we report a case of a 56-year-old man, who was successfully treated with percutaneous transhepatic embolization using n-butyl cyanoacrylate and microcoils and was symptom-free for two years after the procedure. Percutaneous transhepatic embolization can be a successful alternative option for the treatment of BBF. Improved outcomes are expected in long-term follow-ups, especially when n-butyl cyanoacrylate and microcoils are used together.

Endoscopic nasobiliary drainage tube insertion for treatment of afferent loop obstruction in a pregnant woman after Kasai portoenterostomy

Afferent loop obstruction (ALO) is a rare complication of Kasai portoenterostomy (KPE) for biliary atresia. A 23-year-old Japanese woman who had undergone KPE with Roux-en-Y reconstruction for biliary atresia at age 42 days experienced intermittent abdominal pain during pregnancy. From computed tomography findings, she was diagnosed with ALO of the Roux-en-Y limb due to obstruction at the jejunojejunostomy. At 22 weeks of gestation, we inserted an endoscopic nasobiliary drainage (ENBD) tube into the dilated Roux-en-Y limb during double-balloon small-bowel endoscopy for treatment of the ALO. As no findings of jejunojejunostomy obstruction were evident during the endoscopy, we consider the obstruction was caused by flexion of the jejunojejunostomy associated with pregnancy. The ENBD tube afforded good drainage, and decompression of the Roux-en-Y limb was confirmed. We waited until 28 weeks of gestation to remove the ENBD tube, considering both the durability of ENBD tube and continued safety of the fetus. At 39 weeks of gestation, the patient delivered of a live baby boy (2,864 g) via vaginal delivery. ENBD tube insertion could be a minimally invasive option for treating ALO during pregnancy after KPE with Roux-en-Y reconstruction.

A125 A NOVEL TECHNIQUE COMBINING EUS AND SPYGLASS DS SYSTEM GUIDANCE FOR BOTH THE DIAGNOSIS AND MANAGEMENT OF AFFERENT LIMB SYNDROME

BackgroundAfferent limb syndrome is obstruction of a biliary-enteric limb following pancreaticoduodenectomy. In the past, treatment was limited to surgery or insertion of a percutaneous transhepatic biliary drainage tube. A more recent approach to treatment is Endoscopic Ultrasound (EUS)-guided gastrojejunostomy using a lumen apposing metal stent (LAMS). It was first described in two single case reports in 2015 and has been growing in its application. We present a case series of 2 patients where afferent limb syndrome was successfully managed with EUS guided gastrojejunostomy using LAMS.Aims1-To demonstrate a novel technique for diagnosis and management of afferent limb syndrome.MethodsCase # 1- 79 year old female post Whipple’s surgery for ampullary carcinoma, presented two years after surgery with significant nausea and vomiting. CT scan showed obstruction of the afferent loop suspicious for local tumor recurrence. Patient underwent EUS-guided gastrojejunostomy with successful insertion of 20 x 10 mm (AXIOS EC, Boston Scientific) stent.Case # 2-. A 51 year old male with pancreatic CA status post Whipple surgery presented with worsening abdominal pain and nausea. CT scan confirmed afferent limb syndrome. He underwent EUS- guided gastrojejunostomy with successful placement of 10 x 10 mm (AXIOS EC, Boston Scientific).ResultsCase #1: Patient improved dramatically within days and resumed oral diet. Fourteen days later, an upper endoscopy was performed in order to assess the stricture via an anterograde approach. The adult Olympus HQ gastroscope was advanced through the AXIOS stent into the afferent limb to the level of the stenosis where a tight stricture was seen. Multiple biopsies taken and were negative for malignancy. Four weeks later, she continued to tolerate oral diet well with no abdominal pain or discomfort.Case # 2: Patient continued to do well clinically 12 weeks post operation. Follow-up upper endoscopy was performed to determine the etiology of the obstruction but due to a sharp angulation, the gastroscope could not be advanced through the AXIOS stent. As such, we advanced an adult Olympus 1T gastroscope down to the site of the AXIOS stent and then utilized the Spyglass DS system to advanced deep into the afferent limb to the level of the stricture and took multiple biopsies for diagnostic purposes.ConclusionsInterventional endoscopic management of afferent limb syndrome has been evolving in the past few years with EUS guided LAMS gastrojejunostomy becoming a well stablished modality. We have demonstrated this technique with subsequent endoscopic anterograde assessment. In one of these cases, this anterograde assessment was performed using the cholangioscope in conjunction with the gastroscope to overcome unfavorable angulated anatomy which to our knowledge has not been described in the literature previously. Funding AgenciesNone

Pneumomediastinum is a poor prognostic factor in COVID-19 patients – case series and review

During the second wave of COVID-19, a number of patients requiring invasive or noninvasive pressure support ventilation rose significantly. The cases of pneumomediastinum (PM), pneumothorax (PTX), and subcutaneous emphysema (SCE) were also reported, largely attributed to barotrauma with observation of some spontaneous cases. Here, we present seven moderate-to-severe COVID-19 cases with variable severity developing PM with or without PTX and SCE during the course of hospitalization. Five received noninvasive ventilation, of whom two required invasive mechanical ventilation. The remaining two patients received oxygen therapy alone. Two patients required insertion of intercostal chest drainage tubes for pneumothoraces. Appropriate medical management was given to all patients. Three patients improved and were discharged from the hospital, while four expired. The case series highlights need of early diagnosis, constant monitoring, and judicious use of pressure support ventilation to prevent air leak complications in COVID-19 patients in order to improve their prognostic outcomes.

Three-dimensional reconstruction facilitates thoracoscopic anatomical partial lobectomy by an inexperienced surgeon: a single-institution retrospective review.

BackgroundThis study aimed to evaluate the effect of three-dimensional (3D) interactive quantitative surgical planning on the outcome of video-assisted thoracoscopic surgery (VATS) anatomical partial lobectomy (APL), and to investigate the learning curve of 3D reconstruction-assisted VATS APL assisted.MethodsWe retrospectively analyzed 156 cases of solitary pulmonary ground-glass opacity (GGO) lesions in patients who underwent 3D interactive quantitative VATS APL. Digital imaging and communications in medicine data were recorded for each patient. We used Materialise 3-Matic software to make 3D reconstructed images. All surgeries were performed by the same thoracic surgeon at the Cardiothoracic Surgery Department of Yichang Central People’s Hospital between February 28, 2018, and April 20, 2020. The learning curve was evaluated using operative time and the cumulative sum (CUSUM) value of operative time in all cases.ResultsVATS APL was performed in every patient successfully, and there were no conversions to thoracotomy or lobectomy. The median surgical margin distance was 2.2 (range, 2.0–2.8) cm. All patients had an R0 complete cancer resection on histology. The histological subtypes of the segmental lesions included 69 cases of minimally invasive adenocarcinoma (MIA), 61 cases of adenocarcinoma, one case of squamous cell carcinoma, 16 cases of adenocarcinoma in situ (AIS), and nine cases of atypical adenomatous hyperplasia (AAH). The median operation time was 119 (range, 57–245) min, and median intraoperative blood loss was 37 (range, 15–247) mL. The median duration of thoracic drainage tube insertion was 2.3 (range, 1–23) days after surgery. The median length of postoperative hospital stay was 3.7 (range, 3–25) days. There were no cases of perioperative death. During the median postoperative follow-up period of 11 (range, 2–26) months, no tumor recurrence or postoperative death was observed. 3D interactive quantitative surgical planning facilitates safe and efficient VATS APL with a learning curve of 30 cases.Conclusions3D interactive quantitative surgical planning for VATS APL is a feasible option for inexperienced surgeons, with acceptable safety and complications.

Bilateral tension pneumothorax: An unusual complication in a COVID-19 recovered patient.

Sir, The coronavirus disease (COVID)-19 pandemic, which gained momentum in the early months of the year 2020, continues to rage across the world.[1] Accordingly, an increasingly large number of COVID-19 recovered patients are presenting to hospitals for unrelated diseases. We recently encountered a COVID-19 recovered patient, who underwent an elective surgery and later presented with an unusual complication. The patient was a 23-year-old male who had developed a swelling over the right forearm which was first noticed two months back. On examination, a 5 cm by 4 cm sized swelling with superficial ulceration was found on the volar aspect of the right forearm just above the wrist joint. A provisional diagnosis of giant cell tumour of right distal radius was made after imaging and excision of the lesion followed by centralisation of the ulna and wrist arthrodesis was planned. In the preanaesthetic checkup, it was noted that he was a tall and thin-built male. He disclosed that he was diagnosed with COVID-19 about 4 weeks back for which he had been hospitalised and given oxygen by face mask for 4 days. This was followed by an uneventful recovery. He did not have any dyspnoea at rest or on exertion and his exercise tolerance was normal. His vitals and general physical examination as well as systemic examination were unremarkable. All biochemical investigations were normal and the reverse transcription polymerase chain reaction (RT-PCR) for COVID-19 was negative. The preoperative chest radiograph was also normal. The patient was given general anaesthesia (endotracheal intubation with positive pressure ventilation) along with ultrasound-guided right supraclavicular block as the expected duration of surgery was five hours. The surgery was uneventful and he was noted to be recovering well on the morning of postoperative day one. However, in the evening, he complained of sudden onset epigastric pain and dyspnoea. On examination, he had a pulse rate of 130 beats per minute and blood pressure of 80/60 mm of Hg. The arterial blood gas analysis showed an oxygen saturation of 70% along with respiratory acidosis (pH 7.091, pCO277.4 mmHg, pO252.7 mmHg, HCO3-23 meq/L). Cardiac enzymes were normal and the electrocardiogram revealed low voltage QRS complexes. Appropriate management was started and an urgent chest radiograph was ordered. The chest radiograph revealed bilateral tension pneumothorax [Figure 1]. The possibility of supraclavicular block-related pneumothorax was excluded as such a complication would be unilateral and is not common in ultrasound-guided procedures. In view of the tension pneumothorax, two large-bore (16G) needles were inserted into both the 2nd intercostal spaces and urgent intercostal drainage tube (ICD) insertion was attempted. However, the patient suffered a cardiac arrest while the ICD was being inserted. Cardiopulmonary resuscitation was initiated but despite all efforts, the patient could not be revived.Figure 1: Chest radiograph showing bilateral pneumothoraxPneumothorax is a known complication of mechanical ventilation (barotrauma) and several cardiopulmonary diseases. Apart from these causes, smoking, thin and tall habitus and chest trauma are other risk factors for spontaneous pneumothorax. However, spontaneous pneumothorax has been reported in patients recovered from uncomplicated COVID-19 in the absence of mechanical ventilation or lung damage on imaging.[2] Such cases may present weeks after recovery from COVID-19 with pneumothorax. While most such cases have unilateral pneumothorax, bilateral pneumothorax has been reported in only four patients as per our knowledge.[345] Bilateral spontaneous pneumothorax is potentially life-threatening and out of these four cases, only one survived.[5] Our patient had a similar profile and was also tall and thin built; both these factors could have contributed to our case. The cause of spontaneous pneumothorax after COVID-19 is unclear and several causes have been hypothesised. These include alveolar rupture due to inflammation, lung parenchymal ischaemia, aggressive coughing and violent respiratory efforts due to ventilation-perfusion mismatch.[6] However, our patient did not have cough both in the preoperative and postoperative period. Considering the potentially high mortality, clinicians should remain vigilant when dealing with COVID-19 recovered patients and spontaneous pneumothorax should be included in the differential diagnosis when such patients present with chest pain and dyspnoea. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Erector spinae plane block for anesthesia and analgesia for the insertion of a chest drainage tube in a pediatric patient.

Erector spinae plane block for anesthesia and analgesia for the insertion of a chest drainage tube in a pediatric patient.