Lobectomy Research Articles

Impacts of pleural adhesions on lobectomies for malignant lung tumors.

Pleural adhesions are sometimes troublesome in lung lobectomies, and how they affect such surgeries depends on the degree of the adhesion. Herein, pleural adhesions were categorized according to density, tenacity, and coverage, and the impact of each category on lung lobectomy was investigated. The cases of 510 patients who consecutively underwent lobectomies were retrospectively reviewed. Pleural adhesions were classified into two classes (non-dense and dense) in the category of "Density," 3 classes (loose, firm, and very-strong) in that of "Tenacity," and 3 classes (1-10%, 10-50%, 50-100%) in that of "Coverage." The perioperative findings for each class were compared with those of patients without pleural adhesions. The 50-100% group in the Coverage category was the most affected by pleural adhesions, and the very-strong group in the Tenacity category was the next. In these 2 groups, when compared with the no-adhesion group, significant differences were found in operative time (336, 326 vs 231min), amount of bleeding (187.5, 80 vs 20g), and frequency of prolonged air leakage (20%, 22% vs 3%), respectively. The dense group, firm group, and 10-50% group also significantly affected the perioperative course. As for postoperative complications, prolonged air leakage was the most problematic. The impact of pleural adhesions on lobectomy would be greater if the pleural adhesion is dense, firm, or very-strong and has a coverage of 10% or more. Careful and patient pleural dissection is required, even if this entails a longer operative time, to minimize postoperative complications.

A CASE OF PERSISTENT IN-SITU PULMONARY THROMBOSIS DESPITE LONG-TERM ANTICOAGULATION THERAPY

TYPE: Case Report TOPIC: Pulmonary Vascular Disease INTRODUCTION: In-situ pulmonary thrombosis refers to de novo thrombus formation in the pulmonary arteries without any distant source. In-situ thrombosis has been associated with radiation therapy and lung lobectomy. However, little is known about thrombosis resolution after anticoagulation therapy. We present a case of a patient with a persistent pulmonary thrombus despite adequate anticoagulation therapy. CASE PRESENTATION: A 70-year-old male with a past medical history of chronic obstructive lung disease, right-sided lobectomy secondary to non-small cell lung cancer, and subsequent restrictive lung disease due to lobectomy and radiation therapy presented to the pulmonary clinic with shortness of breath. Further evaluation that included a CT scan of the chest with contrast revealed an incidental in-situ thrombosis in the right main pulmonary artery extending into the right upper lobar branch. There was no evidence of cancer recurrence. Previous imaging did not reveal a similar thrombosis. Venous duplex and echocardiography were normal. The patient was anticoagulated with rivaroxaban for over nine months and remained on anticoagulation. Despite this, follow-up imaging has not demonstrated resolution, propagation, or improvement of the thrombus. After optimization of his comorbidities, the patient has remained symptom-free. DISCUSSION: In-situ pulmonary thrombosis may be associated with prior lung radiation therapy and lobectomy. While studies have shown that most pulmonary embolisms resolve over three months with anticoagulation, little is known about the resolution of in-situ thrombosis. CONCLUSIONS: Pulmonary thrombosis may become chronic despite anticoagulation. Therefore, it may be clinically relevant to identify the speed of clot resolution for evaluating patients with suspected recurrent thrombosis. DISCLOSURE: Nothing to declare. KEYWORD: IN-SITU PULMONARY THROMBOSIS, RADIATION THERAPY, LOBECTOMY, ANTICOAGULATION

Perspective: The Case for Acute Large Vessel Ischemic Stroke in COVID-19 Originating Within Thrombosed Pulmonary Venules.

The main burden of SARS-CoV-2 falls on the lungs but neurological manifestations, the most disabling of which are strokes and which correlate with disease severity, are common. We proffer a novel mechanism for acute COVID-19 stroke whereby pulmonary vein clots developing within the characteristic pulmonary intravascular thrombotic lesions can embolize to the brain. Appreciation of this mechanism requires an understanding of the tricompartmental model of lung parenchyma oxygenation (the alveolus, the bronchial artery, and the pulmonary artery), all of which are compromised in COVID-19. Of these 3 sources, the bronchial artery plays a crucial role in COVID-19 stroke because the unique collaterals from bronchial artery to pulmonary vein which exist under normal physiological conditions (and which maintain venous patency when the pulmonary artery is blocked by embolus) are occluded, thus leading to venular thrombosis in the presence of hypercoagulability. Dislodgement of clots from this source translocates the pathology to the brain and is a disease mechanism, formerly rare, which may account for many cases of large vessel occlusion stroke in COVID-19. This mechanism extends the concept of cardioembolic stroke from endocardium retrogradely into the pulmonary circulation with which the left cardiac chambers lie in direct continuity, and which is an accepted stroke mechanism under other circumstances such as lung lobectomy, where surgical ligation of the pulmonary vein creates a blind sac from which thrombi can embolize. The proposed model is supported by postmortem studies which have demonstrated venular thrombosis and by case reports of pulmonary vein thrombosis in COVID-19. This concept provides a more plausible cause for COVID-19 associated large vessel occlusion stroke than other putative mechanisms, such as cerebral endotheliitis, cytokine storm, and hypercoagulopathy, although it is acknowledged that the latter mechanism contributes to the genesis of pulmonary vein clots. Recognizing that extrapulmonary manifestations including stroke arise within thrombosed pulmonary veins is key to understanding of neurological manifestations of SARS-CoV-2 infection.

Congenital Lobar Emphysema in a Kitten with Concomitant Hiatal Hernia and Nutritional Secondary Hyperparathyroidism.

A 2 mo old domestic shorthair kitten was presented for acute respiratory distress and severe ambulatory difficulties. Thoracic radiography revealed hyperinflation of the left cranial lung lobe and a mass with soft-tissue/gas opacity in the caudal mediastinum, leading to the suspicion of congenital lung lobe emphysema and hiatal hernia. Decreased bone radiopacity and suspected pathological fractures were also present. Complete clinicopathological analyses showed significant ionized hypocalcemia and suspicion of secondary hyperparathyroidism related to an inadequate diet. Lung lobectomy and reduction of the hiatal hernia following a median sternotomy and a cranial laparotomy were performed. IV and oral supplementation of calcium led to a full recovery and improvement in the kitten's walking. A histopathological analysis revealed pulmonary emphysema associated with hypoplastic and irregular bronchial cartilage. Congenital lobar emphysema is a rare disease in both humans and animals. This is the first veterinary report describing a kitten affected by congenital lobar emphysema combined with a hiatal hernia and additionally complicated by secondary nutritional hyperparathyroidism with a good long-term outcome.

Are There Risk Differences Among Various Anatomic Lobectomies?

The article in this issue of The Annals of Thoracic Surgery by Linden and colleagues1 addresses the perioperative risks of the operative resection of different lung lobes. These investigators used The Society of Thoracic Surgeons (STS) database to evaluate operative risks of each of 5 different anatomic lung lobectomies in more than 65 000 patients over a 10-year period, and they found differences in operative outcomes among patients having the various operative lobectomies. On the basis of their multivariate database study, Linden and colleagues1 suggest that understanding these differences may help in evaluating risks while counseling patients and may allow better comparisons of surgical outcomes among providers.

Significant neonatal intraoperative cerebral and renal oxygen desaturation identified with near-infrared spectroscopy.

Near-infrared spectroscopy (NIRS) was used to monitor intraoperative regional oxygen saturation (rSO2) during open (Op) and minimally invasive (MI) surgery performed in neonates (N) and children. NIRS sensors were applied to the forehead and flanks for cerebral rSO2 (C-rSO2) and renal rSO2 (R-rSO2), respectively. MI included laparoscopy (La), retroperitoneoscopy (Re) and thoracoscopy (Th). In children, Op and MI were major operations taking at least 3h (MOp; MMI). Pathological desaturation (PD) was defined as > 20% deterioration in rSO2. Mean ages at surgery were N: 5.2 ± 8.2days, MOp: 2.4 ± 2.9years, and MMI: 3.8 ± 4.3years. Despite significantly shorter operative times in N (169 ± 94min; p < 0.0001), PD was significantly worse; PD(C-rSO2): N = 14/35 (40.0%) versus MOp = 3/36 (8.3%) and MMI = 7/58 (12.1%); p = 0.0006, and PD(R-rSO2): N = 27/35 (77.1%) versus MOp = 6/36 (16.7%) and MMI = 7/58 (12.1%); p < 0.0001, respectively. PD(R-rSO2) occurred immediately with visceral reduction in NOp (Fig.1) and PD was frequent during NMI(Th) (Fig.2). rSO2 was stable throughout MOp and MMI (Fig.3). Fig. 1 Pathological desaturation in renal rSO2 after visceral reduction for gastroschisis. Renal rSO2 deteriorated immediately after viscera were returned to the abdominal cavity rSO2 regional oxygen saturation Fig. 2 Fragility of tissue perfusion during thoracoscopic lung lobectomy in a neonate. Pathological desaturation occurred frequently during neonatal thoracoscopic surgery rSO2 regional oxygen saturation Fig. 3 Changes in cerebral and renal rSO2 according to operative time. Cerebral and renal rSO2 did not appear to change according to operative time during major open and major minimally invasive surgery in children. rSO2 regional oxygen saturation CONCLUSIONS: NIRS is a non-invasive technique for monitoring rSO2 as an indicator of intraoperative stress and vascular perfusion. PD was so significant in neonates that intraoperative NIRS is highly recommended during thoracoscopy and procedures requiring visceral manipulation.

Comparison of extended segmentectomy with traditional segmentectomy for stage I lung cancer

BackgroundFor stage I non-small cell lung cancer (NSCLC), lobectomy and segmentectomy are still controversial operations. Extended segmentectomy was proposed to make larger safe margins than segmentectomy. Image-guided video-assisted thoracoscopic surgery (iVATS) is useful to accomplish extended segmentectomy. We aimed to compare the effects of iVATS extended segmentectomy to the effects of traditional segmentectomy for stage I NSCLC.MethodsThis study is a retrospective analysis in a single institute. Patients with stage I NSCLC who received segmentectomy between January 2017 and September 2020 were included. Patients were distributed to iVATS extended segmentectomy (group A), and traditional segmentectomy (group B). The impacts of the different surgical methods on resection margin were assessed.ResultsThere were 116 patients enrolled in this study. Sixty-two patients distributed in group A, and the other 54 patients in group B. The resection margin to a staple line was 17.94 mm in group A versus 14.15 mm in group B, p = 0.037. The margin/tumor diameter ratio was 2.08 in group A versus 1.39 in group B, p = 0.003. The enough margin rate was 75.81% and 57.41%, respectively, for group A and group B. The subgroup analysis of iVATS extended segmentectomy showed that T1a lesions had larger margin distances than did T1b lesions (19.85 mm vs. 14.83 mm, p = 0.026).ConclusionsThe iVATS extended segmentectomy can provide more resection margin than traditional segmentectomy. Segmentectomy is more suitable to perform when the nodule’s diameter is less than 10 mm.

Management of chronic empyema thoracis in children, a single center retrospective observational study

Abstract: Background: Chronic empyema thoracis (CET) is common in developing and developed countries despite advancement in diagnostic and therapeutic technologies. Some of the cases of CET can be managed with antibiotics and tube drainage alone, some of them managed with less extensive surgical procedure like video-assisted thoracoscopic surgery (VATS) or open decortication alone, while some of the complicated cases need extensive decortication and debridement of necrotic lung tissue or lobectomy. Our aim is to present our experience of management of cases of chronic empyema thoracis in children. Methods and Material: This is a retrospective observational study of cases, managed at tertiary care center with chronic empyema thoracis. Records of cases of CET admitted, referred or transferred to department of pediatric surgery at our center over last three years were studied. Demographic data, clinical, radiological profile, surgical/ non-surgical intervention, hospital stay, aetiology, outcome was analysed. Follow up was up to the last recorded outpatient visit. This study is a retrospective observational study with small number of cases statistical tool are not used to draw any statistical interference. Results: Twenty-nine cases with median age 3 years, male to female ratio was 25:4 were admitted over three years. Pre-operative bronchopleural fistula was seen in four. Five cases were managed conservatively, twenty underwent decortication alone while four cases required decortication along with lobectomy. Tuberculosis was detected in three cases. A pyogenic organism was identified in ten cases only. Post-operative ventilation was required in three patients. There was no mortality. All thrived well at 12-18 months follow up. Conclusions: Management of chronic empyema should be case based. Cases of CET in children can managed with conservative (with appropriate drainage of cavity, proper antibiotics, and nutritional build-up of child), thoracotomy and decortications alone or some time removal of disease lung also required depending on clinical and radiological finding of cases.

Does Operative Duration of Lobectomy for Early Lung Cancer Increase Perioperative Morbidity?

BackgroundLonger bariatric, colorectal, plastic, spine, and urologic operations increase complications and lengths of stay. We aimed to determine whether this is a risk factor for lung lobectomy morbidity. MethodsThe Society of Thoracic Surgeons General Thoracic Surgery Database was queried for early-stage non-small cell lung cancer lobectomy with surgical duration treated as a continuous variable. Univariate and multivariate analyses compared patient and clinical characteristics with perioperative outcomes and procedure durations. Robotic cases were combined with thoracoscopic cases for duration analyses into a minimally invasive group. All analyses were conducted in SAS v9.4 (SAS Institute, Cary, NC) at a significance level of .05. ResultsIn 17,852 patients mean duration of thoracotomy, thoracoscopy, and robotic lobectomies were 178 ± 84, 185 ± 73, and 214 ± 82 minutes, respectively (P < .001). The most common complications were prolonged air leak (12.3%), atrial fibrillation (12%), pneumonia (4.4%), and atelectasis requiring bronchoscopy (4.1%). Procedure duration was associated with increased odds of intraoperative packed red blood cell transfusion (P < .001) and length of stay > 5 days (P < .001) for both thoracotomy and minimally invasive lobectomy. Increased odds of pneumonia (P < .001), atelectasis (P < .001), and unexpected intensive care unit admission (P = .006) for thoracotomy lobectomy were associated with longer procedure duration. Increased lobectomy duration was not associated with readmission (P = .549) or 30-day mortality (P = .208). ConclusionsLonger early-stage lung cancer lobectomy durations are associated with postoperative morbidity and increased length of stay. Although the effects of protracted operation times on long-term survival are unknown, short-term mortality differences were not detected. Measures that decrease operative durations without sacrificing safety and oncologic outcome should be undertaken by surgeons and hospital systems.

Distribution of histopathologic types of primary pulmonary neoplasia in dogs and outcome of affected dogs: 340 cases (2010–2019)

To provide updated information on the distribution of histopathologic types of primary pulmonary neoplasia in dogs and evaluate the effect of postoperative adjuvant chemotherapy in dogs with pulmonary carcinoma. 340 dogs. Medical records of dogs that underwent lung lobectomy for removal of a primary pulmonary mass were reviewed, and histopathologic type of lesions was determined. The canine lung carcinoma stage classification system was used to determine clinical stage for dogs with pulmonary carcinoma. Pulmonary carcinoma was the most frequently encountered tumor type (296/340 [87.1%]), followed by sarcoma (26 [7.6%]), adenoma (11 [3.2%]), and pulmonary neuroendocrine tumor (5 [1.5%]); there was also 1 plasmacytoma and 1 carcinosarcoma. Twenty (5.9%) sarcomas were classified as primary pulmonary histiocytic sarcoma. There was a significant difference in median survival time between dogs with pulmonary carcinomas (399 days), dogs with histiocytic sarcomas (300 days), and dogs with neuroendocrine tumors (498 days). When dogs with pulmonary carcinomas were grouped on the basis of clinical stage, there were no significant differences in median survival time between dogs that did and did not receive adjuvant chemotherapy. Results indicated that pulmonary carcinoma is the most common cause of primary pulmonary neoplasia in dogs; however, nonepithelial tumors can occur. Survival times were significantly different between dogs with pulmonary carcinoma, histiocytic sarcoma, and neuroendocrine tumor, emphasizing the importance of recognizing the relative incidence of these various histologic diagnoses. The therapeutic effect of adjuvant chemotherapy in dogs with pulmonary carcinoma remains unclear and warrants further investigation.

Determining the Effectiveness of Forced-Air Warming Blankets in Maintaining Postoperative Body Temperature: A Randomized Controlled Trial

PurposeThe aim of this study is to determine the effectiveness of forced-air warming blankets in normalizing body temperature in the postoperative period. DesignRandomized controlled trial MethodsThe study sample consisted of patients (N = 67) who underwent lung lobectomy in the Thoracic Surgery Service of a university hospital. Forced-air warming blankets were used in the treatment group and 100% cotton blankets were used in the control group. Patients’ body temperatures were monitored using a tympanic thermometer until it reached 37°C. FindingsThe body temperature of the patients in the treatment group reached 37°C in a shorter time than that of the patients in the control group (52.27 ± 29.79 min and 139.0 ± 81.93 min, respectively; P < .001), and that the perception of comfort of the patients in the treatment and control groups increased (P < .001) after warming. ConclusionsWe recommend that forced-air warming blankets are used for patients undergoing lung lobectomy in order to reach normal body temperature in a shorter time.

Immunoprofiling Reveals Novel Mast Cell Receptors and the Continuous Nature of Human Lung Mast Cell Heterogeneity.

BackgroundImmunohistochemical analysis of granule-associated proteases has revealed that human lung mast cells constitute a heterogeneous population of cells, with distinct subpopulations identified. However, a systematic and comprehensive analysis of cell-surface markers to study human lung mast cell heterogeneity has yet to be performed.MethodsHuman lung mast cells were obtained from lung lobectomies, and the expression of 332 cell-surface markers was analyzed using flow cytometry and the LEGENDScreen™ kit. Markers that exhibited high variance were selected for additional analyses to reveal whether they were correlated and whether discrete mast cell subpopulations were discernable.ResultsWe identified the expression of 102 surface markers on human lung mast cells, 23 previously not described on mast cells, of which several showed high continuous variation in their expression. Six of these markers were correlated: SUSD2, CD49a, CD326, CD34, CD66 and HLA-DR. The expression of these markers was also correlated with the size and granularity of mast cells. However, no marker produced an expression profile consistent with a bi- or multimodal distribution.ConclusionsLEGENDScreen analysis identified more than 100 cell-surface markers on mast cells, including 23 that, to the best of our knowledge, have not been previously described on human mast cells. The comprehensive expression profiling of the 332 surface markers did not identify distinct mast cell subpopulations. Instead, we demonstrate the continuous nature of human lung mast cell heterogeneity.

Lung perforation caused by suture ends as a complication of lung lobectomy in a dog

AbstractA 7‐year‐old female bearded collie was presented with a 6‐month history of coughing. A thoracic and abdominal computed tomography examination revealed a large soft tissue mass within the right caudal and middle pulmonary lobes. A right caudal, middle and accessory lobe lung lobectomy was performed with a combination of manual sutures and staples. A persistent pneumothorax was observed during the 4 days following surgery, and surgical exploration was conducted. Two lung perforations in the cranial pulmonary lobe induced by the suture ends from the first procedure were detected. A right cranial lobectomy using a TA stapler was performed, resulting in a right total pneumonectomy. Seven months after the surgery, the dog was reported to be doing well with no recurrence of clinical signs. To the authors’ knowledge, this is the first case report of a lung perforation caused by suture ends as a complication of lung lobectomy in a dog.

Neutrophilic leucocytosis induced by granulocyte colony-stimulating factor and interleukin-6 in canine primary lung adenocarcinoma.

BackgroundNeutrophilic leucocytosis as a paraneoplastic syndrome may occur in dogs with lymphoma, renal carcinoma, rectal polyps and metastatic fibrosarcoma. However, the information on canine lung adenocarcinoma with neutrophilic leucocytosis is lacking.ObjectiveThis study aimed to describe the clinical features and cytokine profiles of canine patients with primary lung adenocarcinoma and neutrophilic leucocytosis.MethodsTwo dogs (cases #1 and #2), each with a solitary lung adenocarcinoma, were included. Both cases had leucocytosis and underwent lung lobectomy. The resected tumours were analysed for the expression of granulocyte colony‐stimulating factor (G‐CSF), granulocyte macrophage colony‐stimulating factor (GM‐CSF) and interleukin‐6 (IL6) by quantitative real‐time PCR compared with normal lung tissues.ResultsAt the initial examination, neither patient had any clinical signs or fever. White blood cell count (WBC) was 58,300/μl and 32,900/μl in cases #1 and #2, respectively. The gene expression of G‐CSF increased 6.7‐and 19.7‐fold in cases #1 and #2, respectively. The gene expression of IL6 markedly increased (30‐fold) in case #1, whereas it increased slightly (1.9‐fold) in case #2. On the other hand, that of GM‐CSF was slightly changed in both cases. The WBC count postoperatively decreased to within the normal range in both cases. The postoperative survival times were 347 and 118 days in cases #1 and #2, respectively.ConclusionsThis study describes G‐CSF and IL6 producing lung adenocarcinoma associated with neutrophilic leucocytosis in dogs. Canine patients with pulmonary adenocarcinomas that have elevated G‐CSF and IL6 levels may have a guarded prognosis. Further investigations are needed to clarify the prognosis of canine cytokine‐producing lung adenocarcinoma.

Acute ischemic stroke after thoracoscopic lobectomy for the left upper lobe lung cancer: A case report

Cerebral infarction is normally caused by thrombosis in chronic cardiogenic patients. However, it may be an acute appearance after surgery because of thrombus formation in dammaged vascular. The left upper lobectomy is the highest risk factor for cerebral infarction among anatomical lung resection. Here we report a 69-year-old patient who presented with left hemiparesis after left upper lung lobectomy on the fourth day. We strongly suspect that cerebral infarction is one of cardiopulmonary complications after anatomical lung resection in this case

Impact of Chest Wall Resection on Mortality After Lung Resection for Non-Small Cell Lung Cancer

BackgroundLung cancer invading the chest wall is treated with concomitant en bloc lung and chest wall resection (CWR). It is unclear how CWR affects postoperative outcomes of lung resection. We hypothesized that CWR would be associated with increased risk of adverse outcomes after lung cancer resection. MethodsWe performed a retrospective analysis of The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database from 2016-2019. Patients with superior sulcus tumors were excluded. Patient demographic and operative outcomes were compared between those with and without CWR. Chest wall resection was added to existing STS lung risk models to determine the association with a composite adverse outcome, which included major morbidity and death. ResultsAmong 41 310 lung resections, 306 (0.74%) occurred with concomitant CWR. Differences between those with and without CWR included demographic and comorbidities. Patients undergoing CWR were more likely to have the composite adverse outcome (64 of 306 [20.9%] vs 3128 of 41 004 [7.6%] for non-CWR resections, P < .001). Mortality was also increased among the CWR cohort (2.9% vs 1.1%, P = .003). CWR was associated with an increased risk of adverse composite outcome among all lung resection patients in a multivariable model (odds ratio 1.74, P = .0003) and the lobectomy subgroup (odds ratio 2.35, P < .0001). Among institutions with ≥10 lung resections, 49.1% performed lung resections with CWR. ConclusionsConcomitant CWR adds risk of adverse outcomes after lung cancer resection. As a subset of intuitions perform CWR, quality assessments should control for CWR. This variable will be incorporated into the STS lung cancer and lobectomy quality composite measures.

453 An unexpected finding in an asymptomatic patient planned for non-cardiac surgery

Abstract Aims Left ventricular (LV) aneurysms and pseudoaneurysms are two complications of myocardial infarction, either symptomatic or silent, leading to death or serious morbidity in several cases and often precluding non-cardiac surgery. Here the differential diagnosis is challenging and multimodality imaging is often needed to assess the risk of heart rupture. Methods and results A 71 years-old woman was referred to our Cardiology Department for a preoperative evaluation before lung lobectomy. Her past medical history included multiple cardiovascular risk factors and abdominal aorta aneurysm. She also had severe peripheral arterial disease treated with femoral popliteal bypass surgery in June 2021. In August 2021 she suffered from vascular graft thrombosis requiring a redo surgery. During hospitalization, she was found to have a lung adenocarcinoma. The patient had an unremarkable cardiological history and was asymptomatic. EKG was unremarkable. Transthoracic echocardiography revealed a mildly impaired LV systolic function (EF = 40%), an inferolateral basal wall akinesia and a huge aneurysm with intracavitary thrombus and a wide neck arising right below the posterior mitral annulus. The annular distortion caused by the expanding aneurysm contributed to the development of mitral regurgitation (MR) by displacing the annulus and subvalvular apparatus, resulting in restriction of the posterior mitral valve leaflet, coaptation failure, and moderate MR. Coronary angiography demonstrated a severe 3-vessel coronary artery disease. To further characterize the aneurysm, a cardiac magnetic resonance was carried out. T1 weighted inversion recovery LGE 2-chamber and short axis views showed transmural LGE of the inferior wall and confirmed the presence of a saccular dilatation with thin wall, wide neck (5 × 6 cm) and large intracavitary thrombus at high risk of rupture. Since the presence of metastatic lesions was excluded, the patient underwent cardiac surgery followed by elective lobectomy. Intraoperative findings were consistent with LV aneurysm with a thin myocardial wall. Aneurysm and related thrombus were removed and the orifice was closed with a Dacron patch. In the same setting a myocardial revascularization with two coronary artery bypass grafts was also performed. Surgery was successfully performed without any complication. Intraoperative transesophageal echocardiography clearly revealed the aneurysm and witnessed the reduction of MR after the restoration of LV inferolateral wall geometry. Conclusions Our case highlights the importance of thorough evaluation prior to non-cardiac surgery using multimodality imaging, especially when incidental echocardiographic findings in asymptomatic patients occur. A careful pre-operative assessment of patients planned for non-cardiac surgery is the key to favourable postoperative outcome.

Preventative pneumopexy in the management of concurrent right cranial and middle lung lobe torsion following right caudal lung lobectomy in a dog

AbstractA 4‐year‐old female neutered Welsh Springer Spaniel was presented with pneumothorax secondary to a migrating foreign body in the right caudal lung lobe. Within 24 hours following thoracic exploration and hilar lung lobectomy, the patient deteriorated. CT was consistent with lobar torsion. A second median sternotomy identified concurrent right cranial and middle lung lobe torsion. Hilar lobectomy of the affected lobes was performed. To prevent lobar torsion of the remaining lobe, a preventative accessory lobe pneumopexy was performed, potentially averting an additional surgical procedure and reducing total lung capacity to less than the reported minimum critical mass compatible with survival. No complications following accessory lung lobe pneumopexy were encountered in this single case. Although post‐lobectomy lung lobe torsion appears to be rare in dogs, clinicians should be aware of this potentially life‐threatening complication. This case report documents the first description of pneumopexy as a preventative procedure in a dog.

Clinical characteristics and long-term outcome of lung lobe torsions in cats: a review of 10 cases (2000-2021).

Lung lobe torsion is rare in cats. The aim of this multi-institution retrospective study was to describe clinical and diagnostic findings, treatments and outcomes of lung lobe torsion (LLT) in 10 cats. Dyspnoea and tachypnoea were the most common clinical signs. Pleural effusion was present in nine cats at presentation. Fluid analysis confirmed chylothorax in three cats. Nine cats underwent CT and five cats had thoracic radiographs taken. A diagnosis was made preoperatively in six cats, while in the other four cats it was made at exploratory thoracotomy. Affected lung lobes were the right cranial (n = 4/11), left cranial (n = 4/11) and right middle (n = 3/11). One cat had a concurrent torsion of two lung lobes. Lung lobectomy was successfully performed in all cases. Based on clinical, diagnostic and lung histopathology findings, three cats had idiopathic and seven cats secondary LLT. Intraoperative complications included hypotension and hypothermia in four and five cats, respectively. Postoperative complications occurred in six cats and lead to euthanasia or death in four cats, whereas complications resolved in the other two cats. Three cats were euthanased within 5 weeks of discharge. For the three cats surviving long term, including one euthanased at 252 days postoperatively, owner-described outcomes and quality of life were considered good to excellent. Secondary LLT associated with underlying thoracic pathology was associated with high complication rates and poor outcomes. Long-term outcomes of cats undergoing surgery for LLT and surviving the perioperative period were deemed good to excellent.

A service evaluation exploring time on physiotherapy caseload following lung lobectomy surgery

Background The number of lobectomy procedures performed in the United Kingdom (UK) continues to increase annually increasing pressure on thoracic surgical bed capacity. Physiotherapy following thoracic surgery can encourage earlier patient independence helping to reduce hospital length of stay and decrease pressure on hospital beds. The purpose of the service evaluation was to explore whether age, gender, type of surgical incision, day first mobilised and chest drain duration affected time on physiotherapy caseload following lobectomy surgery at one teaching hospital. The findings could support the identification of individuals at risk of longer times on physiotherapy caseloads and help direct physiotherapy rehabilitation provision towards these individuals. Methods A retrospective service evaluation was conducted in a UK teaching hospital. Data were retrospectively collected from 1st July 2015–30th June 2016 for all patients reviewed by the cardiothoracic physiotherapy team following lobectomy surgery. Data were collected from patients’ physiotherapy ward sheets, chest radiograph and an electronic patient database and included: date of surgery; day discharged from physiotherapy; age; gender; type of surgical incision; day first mobilised; day chest drains removed. Results 135 individuals were treated by the physiotherapy team following lobectomy surgery within the data collection period. Time on physiotherapy caseload was longer for females and for those who had longer chest drain durations. Time on physiotherapy caseload was reduced by having a VATS incision and was not affected by the patient’s age. Day mobilised postoperatively was an independent predictor of time on physiotherapy caseload however after adjusting for other covariates it was not statistically significantly associated with time on physiotherapy caseload. Conclusion Reviewing chest drain removal practices and providing more intensive physiotherapy input following thoracotomy are worth greater exploration to ascertain whether these interventions could further reduce time on physiotherapy caseload following lobectomy surgery.