Chest Tube Research Articles

Complete transection of the bilateral main bronchus in a 5-year-old patient: a case report

BackgroundTracheobronchial injuries caused by blunt chest trauma are rare in children, and such injuries usually involve multiple organs. Most cases involve respiratory failure on the way to the hospital, and the mortality rate is high. Herein, we describe the case of a 5-year-old patient who fell from an electric vehicle, causing complete rupture of the bilateral main bronchus.Case presentationWe treated a 5-year-old patient with complete bilateral main bronchus rupture. Chest computed tomography (CT) failed to detect bronchial rupture. Continuous closed thoracic drainage resulted in a large amount of bubble overflow. Tracheal rupture was suspected. Fibreoptic bronchoscopy revealed complete rupture of the right main bronchus and rupture of the left main bronchus. Emergency tracheoplasty was performed under cardiopulmonary bypass (CPB). During the operation, we found that the bilateral main bronchi were completely ruptured. Postoperative recovery was smooth. The traditional surgical method for treating these injuries is lateral thoracotomy. However, a median sternotomy provides a better opportunity for selective repair. Extracorporeal circulation-assisted surgery is required for patients with unstable breathing.ConclusionComplete fractures of the bilateral main bronchi are rare. Bronchial rupture should be suspected in the presence of expansion defect-dropped lungs and massive air leakage despite tube thoracostomy in haemopneumothorax developing after thoracic trauma. Extracorporeal circulation-assisted tracheoplasty is a relatively safe option for children whose respiratory system is difficult to maintain, thus ensuring oxygenation ventilation and a clear surgical field.

Computed Tomography (CT)-Guided Needle Biopsy of Lung Lesions: A Single Center Experience.

(1) Objective: Lung cancer is one of the leading causes of cancer death among men and women across the globe. The accurate and timely diagnosis of lung lesions is of paramount importance for prognosis. This single-center study is the first to assess the diagnostic yield and complication rate of a computed tomography (CT)-guided needle biopsy of pulmonary parenchymal and pleural nodules in an academic training center in the United States. (2) Methods: This is a retrospective study approved by IRB. Patients who underwent CT-guided needle biopsy between 2016 and 2020 were reviewed. A CT-guided needle biopsy involving mediastinal lesions was excluded, focusing only on lung parenchymal and pleural lesions. A CT-guided needle biopsy aborted at any point during the procedure was also excluded from this study. (3) Results: 1063 patients were included in this study; 532 were males, and 531 were females. Lesion size ranged from 0.26 cm to 9.2 cm. 1040 patients received diagnoses, among which 772 had a specific diagnosis, and 268 had nonspecific inflammatory or non-malignant diagnoses. Twenty-three cases were non-diagnostic. Among the patients with specific diagnoses, 691 were malignant, 5 were hamartomas, 30 were fungal infections, 6 were acid-fast-positive organisms, and 40 were unspecified atypical cells. Of the patients that had a malignant diagnosis, 317 were adenocarcinoma, 197 were squamous cell carcinoma, 26 were a neuroendocrine tumor, 45 were non-small cell carcinoma (undifferentiated), 17 were small cell carcinoma, and 89 were other metastatic malignancies to the lung. Various common complications, including pneumothorax (337), hemorrhage (128), and hemoptysis (17), were observed, and 42 of the cases required chest tube intervention; others were treated with observation. Other rare complications observed included hemothorax (4) and oxygen desaturation (2), and there was no death in this series. (4) Conclusions: CT-guided needle biopsy is a reliable diagnostic modality for patients with lung parenchymal and pleural nodules, and it can effectively distinguish between benign and cancerous lesions before invasive procedures such as video-assisted thoracoscopy (VATs) or thoracotomy are planned. Our study showed a higher rate of pneumothorax and pulmonary hemorrhage compared to the rates established in guidelines, attributable to the varying experience level in a busy training academic center.

First-in-human use of a new robotic electromagnetic navigation bronchoscopic platform with integrated Tool-in-Lesion Tomosynthesis (TiLT) technology for peripheral pulmonary lesions: The FRONTIER study.

As the presentation of pulmonary nodules increases, the importance of a safe and accurate method of sampling peripheral pulmonary nodules is highlighted. First-generation robotic bronchoscopy has successfully assisted navigation and improved peripheral reach during bronchoscopy. Integrating tool-in-lesion tomosynthesis (TiLT) may further improve yield. We performed a first-in-human clinical trial of a new robotic electromagnetic navigation bronchoscopy system with integrated digital tomosynthesis technology (Galaxy System, Noah Medical). Patients with moderate-risk peripheral pulmonary nodules were enrolled in the study. Robotic bronchoscopy was performed using electromagnetic navigation with TiLT-assisted lesion guidance. Non-specific results were followed up until either a clear diagnosis was achieved or repeat radiology at 6 months demonstrated stability. Eighteen patients (19 nodules) were enrolled. The average lesion size was 20 mm, and the average distance from the pleura was 11.6 mm. The target was successfully reached in 100% of nodules, and the biopsy tool was visualized inside the target lesion in all cases. A confirmed specific diagnosis was achieved in 17 nodules, 13 of which were malignant. In one patient, radiological monitoring confirmed a true non-malignant result. This translates to a yield of 89.5% (strict) to 94.7% (intermediate). Complications included one pneumothorax requiring observation only and another requiring an overnight chest drain. There was one case of severe pneumonia following the procedure. In this first-in-human study, second-generation robotic bronchoscopy using electromagnetic navigation combined with integrated digital tomosynthesis was feasible with an acceptable safety profile and demonstrated a high diagnostic yield for small peripheral lung nodules.

Thoracic Ultrasound as an Alternative to Chest X-ray in Thoracic Surgery Patients: A Single-Center Experience.

Background/Objectives: Chest X-ray (CXR) is currently the most used investigation for clinical follow-up after major noncardiac thoracic surgery. This study explores the use of lung ultrasound (LUS) as an alternative to CXR in the postoperative management of patients who undergo major thoracic procedures. Methods: The patients in our cohort were monitored with both a CXR and a lung ultrasonography after surgery and the day after chest drain removal. The LUS was performed by a member of the medical staff of our unit who was blinded to both the images and the radiologist's report of the CXR. Findings were compared between the two methods. Results: In the immediate postoperative evaluation, 280 patients were compared, finding general agreement between the two procedures at 84% (kappa statistic, 0.603). The LUS showed a sensibility of 84.1%, a specificity of 84.3%, a positive predictive value (PPV) of 60.9%, and a negative predictive value (NPV) of 94.8%. We evaluated 219 out of 280 patients in the postdrainage-removal setting due to technical issues. Concordance between the methods in the postdrainage-removal setting was 89% (kappa statistic, 0.761) with the LUS demonstrating an 82.2% sensibility, a 93.2% specificity, a PPV of 85.7%, and an NPV of 91.3%. Conclusions: The results of this study showed a substantial agreement between LUS and CXR, suggesting that the LUS could reduce the number of X rays in certain conditions. The high NPV allows for the exclusion of PNX and pleural effusion without the need to expose patients to radiation. Discrepancies were noted in cases of mild pneumothorax or modest pleural effusion, without altering the clinical approach.

Bleeding in minimally invasive versus conventional aortic valve replacement

BackgroundObservational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting.MethodsThis was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events.ResultsOut of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition (p = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group (p = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion (p = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding.ConclusionsMinimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy.Clinical Trial Registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT02272621.

Small cell lung carcinoma presenting initially with recurrent pneumothoraces: a case report

BackgroundPneumothorax is a non-physiological collection of air in the pleural space. Pneumothoraces can be broadly divided into Primary, Secondary, and Traumatic. Cancer of the lung is a known cause of secondary pneumothorax in both primary and metastatic lesions, however, pneumothorax as the presentation of lung cancer is exceedingly rare. Non-small cell lung carcinoma (NSCLC) has been reported in the literature to present with a pneumothorax, particularly in adeno/squamous cell carcinomas. It is almost completely unheard of for small cell lung carcinoma (SCLC) to present with a pneumothorax.Case PresentationWe present the case of a 62-year-old male patient, presenting twice in two months with spontaneous pneumothorax. The initial management involved admission and chest drain insertion. The patient has a past medical history of COPD and a significant smoking history. On the second admission, he underwent a video-assisted thoracoscopic (VATS) bullectomy and talc pleurodesis. The pathology report of the resected specimen confirmed SCLC with extensive infiltration. No gross evidence of metastatic spread was present on CT. Due to the R1 resection and significant risk of recurrence, the management plan included four cycles of adjuvant chemotherapy with carboplatin and etoposide, and radiotherapy as a consideration upon completion.ConclusionsPneumothorax as the presentation of lung cancer imparts a very poor prognosis, however the reasons for this are largely unknown. Furthermore, the mechanisms underlying spontaneous pneumothorax in lung cancer are also not well understood.

Incidence of Polytrauma in the Casualty Emergency Department of a Tertiary Care Hospital in Dhaka City

Background: Polytrauma is a public health problem in every country. Objective: The purpose of the present study was to assess the incidence of Polytrauma in the Casualty Emergency Department of a tertiary care hospital in Dhaka city. Methodology: This cross-sectional study was carried out in the casualty of Emergency Department of Dhaka Medical College Hospital, Dhaka, Bangladesh. The patients who were admitted from January 2014 to December 2014 were included in this study. This study includes all the patients with polytrauma, most of whom underwent laparotomy or other types of surgery like suprapubic cystostomy, amputation, surgical toileting, chest drainage, but a small number was managed with non-operative approach. Immediately after admission, the patients were subjected to resuscitation, primary survey and history taking including pre-hospital retrieval. A tabulated sheet of questionnaire was given to all the patients and answer was taken by conversation and examination. Results: A total number of 100 patients were recruited for this study. The mean age with SD of the study population was 33.5±12.5 with the range of 3 to 67 years. The male female ratio is 7.33:1. The victims of polytrauma sustained their injury from different kinds of trauma. Out of hundred cases with polytrauma, road traffic accidents was the most common cause which included motor vehicle accident, pedestrian and motor cycle accident and resulted in a total of 63 casualty occupying 63% of the entire series. Polytrauma resulted fall from height occurred in 10 (10%) cases. Stab injury caused polytrauma in 5 (5%) cases. Conclusion: In conclusion majority of the study population is young adult with the predominance of male presented with road traffic accident. Journal of Current and Advance Medical Research, July 2023;10(2):60-64

Comparison of Short-term Efficacy of Neoadjuvant Immunotherapy Combined with Chemotherapy and Surgery Alone for Locally Advanced Resectable Non-small Cell Lung Cancer

Lung cancer is the cancer with the highest incidence and mortality rates in China, and non-small cell lung cancer (NSCLC) accounts for 80%-85% of all malignant lung tumors. Currently, surgical treatment remains the primary treatment modality for lung cancer. In recent years, the effectiveness of immune checkpoint inhibitors for NSCLC has become a consensus, and neoadjuvant immunochemotherapy (nICT) has shown promising efficacy and safety in early to intermediate stage NSCLC. However, there are fewer studies related to nICT for locally advanced NSCLC. This study aims to evaluate the efficacy and safety of nICT therapy in locally advanced resectable NSCLC. 85 confirmed resectable stage IIIA and IIIB patients treated in the Department of Thoracic Surgery, Second Hospital of Lanzhou University, from January 2021 to April 2024, were divided into the nICT group (n=32) and the surgery alone group (n=53). Clinical baseline data, perioperative indicators, postoperative complications, imaging response rate, pathological response rate, incidence of adverse events, and quality of life were compared between the two groups. There were no statistically significant differences in clinical baseline data between the two groups (P>0.05). Incidence of choosing thoracotomy was higher in the nICT group than in the surgery alone group (P=0.002). There were no significant differences in surgical time, intraoperative blood loss, number of dissected lymph nodes, duration of chest tube placement, postoperative hospital stay, and R0 resection rate between the two groups (P>0.05). The overall incidence of postoperative complications was 31.25% in the nICT group and 22.64% in the surgery alone group, with no statistically significant difference (P=0.380). In the nICT group, the objective response rate (ORR) was 84.38%, with 5 cases of complete response (CR)(15.63%), 22 cases of partial response (PR)(68.75%), 15 cases of pathological response rate (pCR)(46.88%), and 11 cases of major pathological reaponse (MPR) (34.38%). During nICT treatment, 12 cases (37.50%) experienced grade 3 treatment-related adverse events, no death induced by adverse events or immune related adverse events. Moreover, the symptoms of the patients were improved after nICT treatment. Neoadjuvant immunochemotherapy shows promising efficacy in locally advanced resectable NSCLC, with manageable treatment-related adverse events. It is a safe and feasible neoadjuvant treatment modality for locally advanced resectable NSCLC.

Assessment of Chest Tube Management Knowledge among Critical Care Nurses in a Tertiary Care Cardiac Hospital: A Descriptive Study

Objectives: Chest tubes play a critical role in managing intra-pleural pressure imbalances and preventing potentially fatal outcomes such as pulmonary collapse. The management of chest tubes is primarily the responsibility of nursing care in patients reliant on this intervention. This study aimed to assess the level of knowledge regarding chest tube management among critical care nurses at a tertiary care cardiac hospital in Karachi, Pakistan. Methodology: This descriptive cross-sectional study utilized a convenient sampling method, involving a sample size of n=120 participants. Data collection involved a structured questionnaire comprising demographic parameters followed by an 18-item questionnaire assessing knowledge of chest tube management. Knowledge scores were calculated as the percentage of correct responses to the 18 knowledge-related questions. Results: Among the 120 nurses surveyed, 59.2% (71) were male, 55% (66) were under 36 years of age, and 66.7% (80) had up to 10 years of work experience. Only 20% (24) had participated in training courses regarding thoracic diseases. The mean knowledge score was 57.3 ± 17.2, with 30% (36) categorized as having low knowledge (<50%), 65% (78) as moderate knowledge (50% to 80%), and 5% (6) as high knowledge (>80%). Conclusion: The study revealed a moderate level of knowledge concerning chest tube management among critical care nurses in a tertiary care cardiac center. There is a need for structured and comprehensive training programs focusing specifically on chest tube management to enhance nurses proficiency in this critical area of patient care.

Right anterior mini thoracotomy for redo cardiac surgery: case series from North America and Europe.

Right anterior mini thoracotomy (RAMT) for aortic valve replacement (AVR) is a minimally invasive procedure that avoids sternotomy. Herein, we report the outcomes of patients who underwent redo-cardiac via a RAMT approach for AVR. This case series reports the clinical outcomes of 14 consecutive redo operations, done in Calgary (Canada) and Gdansk (Poland) between 2020 and 2023. Primary outcomes were 30-day mortality and disabling stroke. Secondary outcomes included surgical times, hemodynamics, permanent pacemaker implantation (PPM), length of ICU and hospital stay, new post-operative atrial fibrillation (POAF), post-operative blood transfusion, incidence of acute respiratory distress syndrome (ARDS), rate of continuous renal replacement therapy (CRRT) and/or dialysis, and chest tube output in the first 12-hours after surgery. Nine patients were male, and the mean age was 64.36 years. There were no deaths, while one patient had a disabling stroke postoperatively. Mean cardiopulmonary bypass and cross clamp-times were 136 min and 90 min, respectively. Three patients needed a PPM, 3 patients needed blood transfusions, and 2 developed new onset POAF. Median lengths of ICU and hospital stays were 2 and 12 days, respectively. There was no incidence of paravalvular leak greater than trace and the average transvalvular mean gradient was 12.23 mmHg. The number of patients requiring redo-AVR is increasing. Redo-sternotomy may not be feasible for many patients. This study suggests that the RAMT approach is a safe alternative to redo-sternotomy for patients that require an AVR.

Role of low-pressure negative pleural suction in patients with thoracic trauma - a randomized controlled trial.

Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD. This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma. Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay. The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema. Therapeutic Study, Level II TRIAL REGISTRATION: This trial was registered with the Clinical Trial Registry of India (CTRI) with registration no. REF/2020/11/038403.

An Analysis of Tube Thoracostomy in Combat Implications for Improved Prehospital Recognition and Treatment.

Thoracic trauma occurs frequently in combat and is associated with high mortality. Tube thoracostomy (chest tube) is the treatment for pneumothorax resulting from thoracic trauma, but little data exist to characterize combat casualties undergoing this intervention. We sought to describe the incidence of these injuries and procedures to inform training and materiel development priorities. This is a secondary analysis of a Department of Defense Trauma Registry (DoDTR) data set from 2007 to 2020 describing prehospital care within all theaters in the registry. We described all casualties who received a tube thoracostomy within 24 hours of admission to a military treatment facility. Variables described included casualty demographics; abbreviated injury scale (AIS) score by body region, presented as binary serious (=3) or not serious (<3); and prehospital interventions. The database identified 25,897 casualties, 2,178 (8.4%) of whom received a tube thoracostomy within 24 hours of admission. Of those casualties, the body regions with the highest proportions of common serious injury (AIS >3) were thorax 62% (1,351), extremities 29% (629), abdomen 22% (473), and head/neck 22% (473). Of those casualties, 13% (276) had prehospital needle thoracostomies performed, and 19% (416) had limb tourniquets placed. Most of the patients were male (97%), partner forces members or humanitarian casualties (70%), and survived to discharge (87%). Combat casualties with chest trauma often have multiple injuries complicating prehospital and hospital care. Explosions and gunshot wounds are common mechanisms of injury associated with the need for tube thoracostomy, and these interventions are often performed by enlisted medical personnel. Future efforts should be made to provide a correlation between chest interventions and pneumothorax management in prehospital thoracic trauma.

Postoperative day 1 discharge following subxiphoid thoracoscopic anatomical lung resection: a single-centre, postoperative enhanced recovery experience.

The goal of this study was to assess the safety and quality of recovery (QOR) after discharge on postoperative day (POD) 1 following subxiphoid thoracoscopic anatomical lung resection within an advanced Enhanced Recovery After Surgery (ERAS) program. A retrospective analysis of prospectively collected data was conducted. Characteristics, perioperative and outcome data, compliance with ERAS pathways and a home-transition QOR survey were analysed using a multivariable logistic regression model. From January 2020 to January 2022, a total of 201 consecutive patients underwent subxiphoid multiportal thoracoscopic anatomical lung resection, comprising 108 lobectomies and 93 sublobar resections (SLRs) (59 complex SLRs and 34 simple SLRs). Among them, 113 patients (56%) were discharged on POD 1, 49% after a lobectomy, 59% after a simple sublobar resection and 68% after a complex sublobar resection. In the multivariable analysis, age > 74 years and duration of the operation were associated with discharge after POD 1, whereas forced expiratory volume in 1 s and complex SLRs were associated with discharge on POD 1. Chest tube removal was achieved on POD 0 in 58 patients (29%), and 138 patients (69%) were free from a chest tube on POD 1. There were 13% with in-hospital morbidity, 10% with 90-day readmission (7% after POD 1 discharge and 14% in patients discharged after POD 1), and 0.5% with 90-day mortality. Patients discharged on POD 1 showed better compliance with the ERAS pathway with early chest tube removal and opioid-free analgesia. The home-transition QOR survey reported a better experience of returning home after discharge on POD 1 and similar pain scores. Postoperative day 1 discharge can be safely achieved in appropriately selected patients after subxiphoid thoracoscopic anatomical lung resection, with excellent outcomes and high quality of recovery, supported by early chest tube removal as a determinant ERAS pathway.

Outcomes of Percutaneous Endoscopic Gastrostomy in Huntington's Disease at a Tertiary Center.

Clinically assisted nutrition and hydration via percutaneous endoscopic gastrostomy (PEG) is a therapeutic option to ameliorate the difficulties associated with enhanced catabolism, weight loss, and dysphagia in Huntington's disease (HD). The objective is to provide insights into demographics, staging (Shoulson-Fahn), complications, weight trajectories, and survival rates in people with HD (pwHD) who underwent PEG. This retrospective study included 705 consecutive pwHD who attended our HD clinic between July 2006 and March 2024, of whom 52 underwent PEG. A control group (n = 52), comprising pwHD without PEG, were closely matched for sex, stage, age, CAG length, and disease burden score at PEG. The study was registered as a service evaluation at the National Hospital for Neurology and Neurosurgery. PEG prevalence was 15.0% (n = 52/347) among manifest pwHD: 4.8% (n = 3/62) for Stage 3; 33.3% (n = 16/48) for stage 4; and 44.1% (n = 30/68) for stage 5. Commonest indications were dysphagia, weight loss, and inadequate oral intake. Complications included chest infection, tube dislodgement, and peristomal and skin infections. Modeling of weight trajectories after PEG found no difference between PEG and non-PEG groups. Mortality rate was 34.6% (n = 18/52) in the PEG and 36.5% (n = 19/52) in the non-PEG groups (P = 0.84). Treatment duration (until study endpoint or death) was 3.48 years (interquartile range = 1.71-6.02; range = 0.23-18.8), with 65.4% (n = 34/52) alive at the study endpoint. PEG in pwHD at-risk for weight loss may help slow weight loss. Prospective studies are required to strengthen PEG decision-making in pwHD. PEG survival was much longer than other dementias, highlighting the need to consider PEG independently in pwHD.

A retrospective study to evaluate the safety and efficacy of intrapleural alteplase in pediatric empyema.

Medical treatment of pediatric empyema consists of appropriate antibiotics, chest tube insertion, and intrapleural fibrinolytic drugs to facilitate pleural drainage. There is a lack of consensus about the drug of choice for fibrinolytic therapy, so this study was designed to evaluate the safety and efficacy of intrapleural alteplase in pediatric empyema. The medical records of all children with empyema treated with intrapleural alteplase at a university hospital between January 2016 and December 2020 were retrospectively reviewed. Efficacy outcomes were assessed by chest tube output before and after the first dose of alteplase, pleural fluid volume before and after therapy, a need for surgical intervention, and length of hospital stay. Safety was assessed by the frequency and severity of side effects. 40 children aged 2 months to 9 years hospitalized with empyema received intrapleural alteplase. Thirty patients (75%) experienced full recovery after three doses of intrapleural alteplase. The median length of hospital stay was 16 days. Chest tube output increased significantly after the first dose of alteplase. Pleural fluid volume decreased significantly after treatment. The most common side effect was pain (30%). Two patients experienced severe complications: 1 had a pulmonary hemorrhage and the other experienced a bronchopleural fistula. These patients recovered fully spontaneously. According to our results, the administration of intrapleural alteplase was safe and effective in facilitating pleural drainage in pediatric patients with empyema. However, further clinical trials will be needed to determine the optimal dose, frequency, and duration of intrapleural alteplase treatment.

Intrapleural Migration of Ventriculoperitoneal Shunt due to Negative Intrathoracic Pressure.

Background Ventriculoperitoneal (VP) shunt is still a mainstay of treatment in centers for infants with aqueductal stenosis which is the most common cause of congenital obstructive hydrocephalus. Shunt migration remains a common complication. Delayed distal shunt tip migration into the thoracic cavity due to negative intrathoracic pressure is a rare occurrence. Case Presentation Authors report a 1-year-old infant presenting with drowsy sensorium, increasing head circumference, and bulging anterior fontanelle. Magnetic resonance imaging of the brain revealed significant obstructive hydrocephalus with periventricular seepage. A large expansile diverticulum of the suprapineal recess extending infratentorially compressing the dorsal midbrain and cerebellum inferiorly. The child underwent an emergency right-side VP shunt (medium pressure) in view of clinical symptoms of raised intracranial pressure. A right iliac fossa infraumbilical transverse incision was taken for placing the abdominal end. Visual confirmation of bowel was done after opening the peritoneum by two operating surgeons prior to inserting the distal catheter. Postoperative course was uneventful. The child presented 3 months later with acute dyspnea and diminished breath sounds on the right hemithorax. Neurologically, the child was active, feeding well, and anterior fontanelle was lax. A chest roentgenogram and computed tomogram (CT) of the thorax revealed complete shunt migration into the pleural space with significant pleural effusion on the right side. The distal shunt system on CT appeared to enter the pleural space below the 8th rib, probably indicating that there was subcostal tunneling of the shunt below the 8th rib space during the first surgery which was inconspicuous and subsequently over a span of 3 months due to sucking effect of negative intrathoracic pressure the shunt gradually migrated into the pleural cavity which led to the effusion. An emergency VP shunt revision was performed. The distal end below the chamber was retunneled subcutaneously into a new incision in the left paraumbilical region. Postoperative chest and abdomen roentgenograms showed resolving effusion and accurate shunt placement. The child required elective ventilation temporarily to tide over the underlying lung collapse and an intercostal tube drainage for the cerebrospinal fluid (CSF) hydrothorax for 2 days to aid in quicker weaning. The child was discharged on the 5th postoperative day. Discussion Intrapleural migration of VP shunts has been contemplated to be due to trauma during surgery, migration across foramen of Bochdalek or Morgagni, and negative intrathoracic pressure. Taub and Lavyne have classified thoracic complications of VP shunt as thoracic trauma during shunt tunneling, supradiaphragmatic migration of shunt or transdiaphragmatic migration of shunt, and pleural effusion complicated by CSF ascites. Transdiaphragmatic migration is commonly seen in pediatric population and supradiaphragmatic migration can be seen in any age group. We believe our case to be a type of supradiaphragmatic migration of the shunt which has occurred slowly over a span of time due to the negative intrathoracic pressure. The idea behind this clinical case image is to edify neurosurgeons, pediatricians, and intensivists to remain wary of such a complication.

The Importance of Exposures in Culture-Negative Endocarditis in an IV Drugs Abuser

Background: infective endocarditis(IE) is a severe and life-threatening disease worldwide (1). Approximately 5% of IE cases have negative blood cultures (4,5). risk factors are exposure to slow-growing bacteria and exposure to Bartonella species. Most patients have nonspecific symptoms such as fever, fatigue, and weight loss. Case Presentation: A 38 years old male with a history of addiction was referred to our center with severe dyspnea, high fever, chest pain, and shortness of breath. He went under CT angiography for pulmonary thromboembolism and TTE. According to the findings, the first diagnosis was right-side endocarditis, which led to septic embolism, so we started empiric antibiotic therapy with vancomycin plus ceftriaxone. After two weeks of constant fever despite broad-spectrum antibiotic therapy and pleural effusion drainage, we changed the antibiotic regimen to vancomycin plus meropenem, and re-sended blood cultures, which were negative 3 times, we considered Q fever, bartonella, and brucellosis as possible causes of culture-negative endocarditis according to the history of staying in the camp. We sent serology tests and blood PCRs to the laboratory of the Pasteur Institute of Iran. All of them were negative, but a serology test confirmed Bartonella henselae with a 1: 2048 titer. In the meantime, we changed the patient’s drug regimen to doxycycline, plus rifampin, due to the high level of creatinine, and warfarin was switched to enoxaparin. Clinically, the patient recovered with no breathing difficulties or chest pain after two weeks of treatment, and the result of the B. henselae IgG follow-up serology was 1:512. Four weeks after admission, the patient was discharged from the hospital with instructions to see a cardiologist, quit abusing IV drugs, and continue taking doxycycline and enoxaparin. Conclusions: The patient’s social history regarding IV-drug abuse and low socioeconomic status are the most important considerations. Because of the increased risk factors in this patients, organisms such as Bartonella henselae, Coxiella burnetii and Brucella should also be investigated when cultures are negative.

Risk factors for enhanced recovery after surgery failure in patients undergoing lung cancer resection with concomitant cardiovascular disease: A single-center retrospective study

ObjectiveEnhanced recovery after surgery (ERAS) has been widely used in patients with lung cancer, and its effectiveness has been confirmed; however, some lung cancers with poor clinical outcomes lead to ERAS failure after radical resection. This study aimed to analyze risk factors associated with ERAS failure after radical resection in patients with lung cancer and concomitant cardiovascular disease. MethodsIn total, 198 patients who underwent ERAS following radical lung cancer surgery for concomitant cardiovascular disease between January 2022 and September 2023 were enrolled in this retrospective study. The patients were categorized into two groups based on the definition of ERAS failure: ERAS success group (n = 152) and ERAS failure group (n = 46). Univariate and multivariate analyses were performed to investigate the risk factors of ERAS failure. ResultsUnivariate analysis showed that gender, tumor location, operation time, estimated blood loss (EBL), suction drainage, and total cholesterol were associated with ERAS failure. Multivariate analysis showed that operation time (odds ratio [OR] = 1.015; P = 0.011) and suction drainage (OR = 3.343; P = 0.008) were independent risk factors for ERAS failure. ConclusionsOperation time and suction drainage were independent risk factors for ERAS failure after radical resection of combined cardiovascular lung cancer. Therefore, improving surgical efficiency and postoperative chest drain management are important for successful ERAS.

Irreversible Electroporation as a Valid Treatment Option for Hepatic Epithelioid Hemangioendothelioma: An International Multicenter Experience

PurposeHepatic epithelioid hemangioendothelioma (HEHE) is a rare tumor with currently no established standard of care. This international multicenter retrospective study assesses the use of percutaneous irreversible electroporation (IRE) as an ablative tool to treat HEHE and provides a clinical overview of the current management and role of IRE in HEHE treatment.Material and MethodsBetween 2017 and 2023, 14 patients with 47 HEHE tumors were treated with percutaneous IRE using CT-scan guidance in 23 procedures. Baseline patient and tumor characteristics were evaluated. Primary outcome measures included safety and effectiveness, analyzed using Common Terminology Criteria for Adverse Events (CTCAE) and treatment response by mRECIST criteria. Secondary outcome measures included technical success, post-treatment tumor sizes and length of hospital stay. Technical success was defined as complete ablation with an adequate ablative margin (intentional tumor free ablation margin > 5 mm).ResultsIRE treatment resulted in technical success in all tumors. Following a median follow-up of 15 months, 30 tumors demonstrated a complete response according to mRECIST criteria. The average tumor size pre-treatment was 25.8 mm, accompanied by an average reduction in tumor size by 7.5 mm. In 38 out of 47 tumors, there was no evidence of local recurrence. In nine tumors, residual tumor was present. There were no cases of progressive disease. Median length of hospital stay was one day. Only one grade 3 CTCAE event occurred, a pneumothorax requiring chest tube placement.ConclusionThe current study provides evidence that IRE is a safe and efficacious minimally invasive treatment option for HEHE.Graphical

Comparison of Intercostal and Subxiphoid Left Pleural Drain After Coronary Artery Bypass Grafting (CABG) Surgery: A Systematic Review and Meta-Analysis.

Coronary artery bypass grafting (CABG), a prevalent surgery for coronary artery disease, often involves left internal mammary artery harvesting, necessitating left pleural drain insertion. This can lead to pain, discomfort, and respiratory issues. This analysis compares outcomes between subxiphoid and intercostal left pleural drain insertion. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, this systematic review and meta-analysis involved searches in MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected based on primary outcomes (postoperative ventilator support duration and pain score) and secondary outcomes (percentage predicted vital capacity (VC), forced VC (FVC), and partial pressure of oxygen (PO2) in arterial blood gas (ABG) analysis). Statistical analysis used a random effect model, pooled risk ratio, and I2 heterogeneity. Nine studies (seven randomized and two nonrandomized) with 412 patients met the inclusion criteria. Pooled analysis indicated reduced ventilation time and postoperative pain with the subxiphoid drain compared to the intercostal drain. Spirometry parameters showed improved VC, FVC, and PO2 in ABG analysis. This meta-analysis suggests that subxiphoid pleural drain insertion in CABG patients is associated with shorter ventilation times, lower pain scores, and improved pulmonary function compared to intercostal drain placement.