Postoperative Pneumothorax Research Articles

Conventional versus cone-beam computed tomography in lung biopsy: diagnostic performance, risks, and the advantages of tract embolization with gelfoam particle suspension.

With the widespread adoption of computed tomography (CT) technology, the number of detected pulmonary nodules has gradually increased. CT-guided percutaneous needle biopsy has become the primary method for qualitative diagnosis of pulmonary nodules. Benefiting from its three-dimensional (3D) reconstruction capability, cone-beam CT (CBCT) technology has also been widely adopted. Nevertheless, pneumothorax remains the most common complication of these diagnostic and therapeutic procedures. This study assessed the diagnostic accuracy of conventional CT (CCT)- and CBCT-guided coaxial core needle biopsy (CCNB) and the effectiveness of gelfoam particle suspension in reducing complications through tract embolization. A retrospective analysis was conducted on 320 patients who had undergone CCNB for nodules ≤3 cm from January 2020 to June 2022 at Zhongshan People's Hospital, comprising 325 biopsies (145 CCT-guided and 180 CBCT-guided). Gelfoam tract embolization was specifically used in biopsies of patients identified with a high risk of complications. Comparative statistics involved diagnostic outcomes (sensitivity, specificity, accuracy), procedural lengths, complication occurrences, and radiation doses. Diagnostically, both CCT (sensitivity 93.3%, specificity 100%, accuracy 94.1%) and CBCT (sensitivity 92.8%, specificity 100%, accuracy 93.8%) offered a similarly high performance. The CCT technique was preferable in terms of shorter median operational times (19 vs. 24 minutes; P<0.001) and greater radiation exposure (13.9 vs. 10.1 mSv; P<0.001). The complication rates of CBCT and CCT, such as those of pneumothorax (18.9% vs. 20.7%; P=0.69) and hemorrhage (23.9% vs. 18.6%; P=0.25), were comparable. Of note, the comparison of biopsies with and without gelfoam embolization revealed a marked reduction in postoperative pneumothorax incidence (1.24% vs. 7.9%; P=0.004) and the requirement for drainage (0% vs. 4.27%; P=0.02), indicating the effectiveness of this procedure. CCT- and CBCT-guided lung biopsies demonstrate equivalent diagnostic capacities, with CCT providing shorter median operational times. Importantly, gelfoam embolization substantially diminishes the risk of postoperative pneumothorax, underscoring its value in high-risk patients.

Predictive model for intraoperative decision-making in video-assisted thoracoscopic lobectomy: optimizing chest drain placement for high-risk patients.

For years, it has been the common and widely accepted practice in thoracic surgery to place apical and basal drains after a lobectomy to completely drain the pleural cavity. With the development of thoracoscopic technology, it became apparent that the use of a single chest tube provided the same clinical results. However, sometimes tension pneumothorax occurs with the need for additional pleural drainage. The aim of this study was to develop a prognostic model to identify high risk patients intraoperatively and to insert additional pleural drainage to prevent the development of pneumothorax after video-assisted thoracoscopic surgery (VATS) lobectomy. This was a retrospective multicenter study of patients (registry data was analyzed) who underwent VATS lobectomy via a standardized multiport approach between 2014 and 2022. In all cases, a single drain was used postoperatively. We used a machine learning algorithm and data synthesis to expand patient selection according to Riley's method. A total of 418 cases were analyzed in this study. After determining the prognostically significant factors, we performed a binary logistic regression analysis using reverse step-by-step inclusion of variables according to the Akaike information criterion. After validation of the model by bootstrap (400 iterations) and with the original dataset, a nomogram with a specific point distribution for each risk factor was created. The rate of tension pneumothorax was 4.53% (n=66). The most significant variables associated with the need for additional drainage were adhesions, intraoperative lung suturing, fused interlobar fissure, enlarged intrapulmonary lymph nodes, chronic obstructive pulmonary disease (P<0.001). The C-index of the model was 0.957, the mean absolute calibration error was 0.6%, and the slope of the calibration curve was 0.959. A score of 26 points indicated a 95% risk of postoperative tension pneumothorax. The nomogram achieved good predictive performance for tension pneumothorax after minimally invasive lobectomy. High-risk patients could be identified, and additional drainage may be placed intraoperatively to reduce the risk of lung collapse in the postoperative period.

Early chest tube removal on the 1st postoperative day protocol of an enhanced recovery after cardiac surgery programme is safe.

The aim of this study was to assess the safety of early chest tube removal (CTR) protocol on the 1st postoperative day (POD1) of our Enhanced Recovery After Surgery (ERAS) programme by comparing the risk of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. All consecutive patients undergoing elective coronary revascularization and/or valve surgery between 2015 and 2021 were assessed in terms of their perioperative management pathways: conventional standard of care (control group) versus standardized systematic perioperative ERAS programme including an early CTR on POD1 (ERAS group). A propensity score matching was applied. The primary end-point was a composite of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. A total of 3153 patients were included. Propensity score analysis resulted in 2 groups well-matched pairs of 1026 patients. CTR on POD1 was significantly increased from 29.5% in the control group to 70.3% in the ERAS group (P < 0.001). The incidence of the primary end-point was 6.4% in the control group and 6.9% in the ERAS group (P = 0.658). Patients in the ERAS group, as compared with control group, had significant lower incidence of bronchopneumonia (9.0% vs 13.5%; P = 0.001) and higher incidence of mechanical ventilation ≤6 h (84.6% vs 65.2%; P < 0.001), length of intensive care unit ≤1 day (61.2% vs 50.8%; P < 0.001) and hospital ≤6 days (67.3% vs.43.2%; P < 0.001). CTR on POD1 protocol can be safely incorporated into a standardized systematic ERAS programme, enabling early mobilization, and contributing to the improvement of postoperative outcomes. Ethics committee of the French Society of Thoracic and Cardio-Vascular Surgery (CERC-SFCTCV-2022-09-13_23140).

Post-surgery spontaneous pneumothorax: Long-term recurrence rates and follow-up challenges revealed by a written survey.

Spontaneous pneumothorax (SP) is a frequently encountered respiratory condition. Despite advancements in treatment techniques, there is currently no standardized treatment protocol. The aim of this study was to standardize the management of SP by collecting long-term postoperative data through written surveys. Our study included 673 surgeries performed for SP at our institution between January 2011 and December 2019. We administered written surveys via mail to gather data on post-surgery recurrence rates and other related factors. The survey addressed key symptoms, medical consultations, and specific diagnoses of SP after surgery. The effective response rate was 70.7%, with significant differences observed across age groups. Among teenagers, the recurrence rate peaked three years postoperatively, with an ipsilateral recurrence rate of 4.8% and a contralateral incidence rate of 11.8%, both of which were significantly higher than those in other age groups. Additionally, age, sex, postoperative contralateral pneumothorax, and the period before the survey were identified as factors influencing the survey results. This survey highlighted the need for long-term postoperative follow-up for teenagers. While written surveys have limitations, this study provided valuable data for understanding the outcomes of SP. Moving forward, it is advisable to conduct surveys using other effective tools or to continue follow-ups in outpatient clinics.

Anesthesia management experience for pediatric day-case PDA ligation under thoracoscopy assisted by a robot: a retrospective study

BackgroundTo summarize the anesthesia management experience for pediatric day-case patent ductus arteriosus (PDA) ligation under robot-assisted thoracoscopy and explore the key points of anesthesia management for this procedure.MethodsThe clinical data of 72 pediatric patients who underwent robot-assisted thoracoscopic day-case PDA ligation at the Children’s Hospital, Zhejiang University School of Medicine from April 2021 to February 2023 were retrospectively analyzed. 0.3% ropivacaine local infiltration combined with S-ketamine 0.2 mg/kg intravenous injection was used for postoperative analgesia The patient’s basic information and intraoperative conditions were analyzed, which included gender, age, weight, surgery time, anesthesia time, extubation time, intraoperative blood loss, MAP before pneumothorax, PaCO2 before pneumothorax, etc. Postoperative conditions were also monitored, such as PACU stay time, agitation during the recovery period, pain, and the incidence of nausea and vomiting. After discharge, the recovery status was assessed.ResultsA total of 70 pediatric patients who met the criteria for day-case PDA ligation were included in this study. Before the occurrence of pneumothorax, the mean arterial pressure (MAP) of these 70 patients was 69.58 ± 12.52 mmHg, and during controlled hypotension, the MAP was 54.96 ± 11.23 mmHg. Before the occurrence of pneumothorax, the partial pressure of carbon dioxide (PaCO2) was 38.69 ± 3.38 mmHg, and during controlled hypotension, the PaCO2 was 51.42 ± 4.05 mmHg. Three cases experienced agitation during the recovery period, and four cases had mild pain, but there was no moderate or severe pain, nausea, or vomiting. Only 1 case of postoperative respiratory tract infection and 1 case of postoperative pneumothorax occurred. Within 30 days after discharge, the unplanned revisit rate, unplanned readmission rate, and surgical wound infection rate were all 0. The residual shunt rate detected by echocardiography was 0 after 1 month.ConclusionsThe children under the robot-assisted thoracoscopic day case PDA surgeries in this study have limited trauma, little bleeding, and little postoperative pain, though still at a risk of respiratory infection and pneumothorax.

The role of point-of-care ultrasound in the management of neonates with congenital diaphragmatic hernia.

In the last few years, current evidence has supported the use of point-of-care ultrasound (POCUS) for a number of diagnostic and procedural applications. Considering the valuable information that POCUS can give, we propose a standardized protocol for the management of neonates with a congenital diaphragmatic hernia (CDH-POCUS protocol) in the neonatal intensive care unit. Indeed, POCUS could be a valid tool for the neonatologist through the evaluation of 1) cardiac function and pulmonary hypertension; 2) lung volumes, postoperative pleural effusion or pneumothorax; 3) splanchnic and renal perfusion, malrotations, and/or signs of necrotizing enterocolitis; 4) cerebral perfusion and eventual brain lesions that could contribute to neurodevelopmental impairment. In this article, we discuss the state-of-the-art in neonatal POCUS for which concerns congenital diaphragmatic hernia (CDH), and we provide suggestions to improve its use. IMPACT: This review shows how point-of-care ultrasound (POCUS) could be a valid tool for managing neonates with congenital diaphragmatic hernia (CDH) after birth. Our manuscript underscores the importance of standardized protocols in neonates with CDH. Beyond the well-known role of echocardiography, ultrasound of lungs, splanchnic organs, and brain can be useful. The use of POCUS should be encouraged to improve ventilation strategies, systemic perfusion, and enteral feeding, and to intercept any early signs related to future neurodevelopmental impairment.

Ultrasound continuous erector spinae catheter versus paravertebral catheter for pain management in modified radical mastectomy for cancer patients: A randomized double-blind

ABSTRACT Background Regional analgesia provides adequate management of pain during mastectomies and early postoperative period. The erector spinae plane block (ESPB) is a promising regional technique. This study compared the efficacy of ESPB versus paravertebral block (PVB) catheters for pain management in modified radical mastectomy (MRM). Methods This randomized, double-blind, non-inferiority study recruited 70 adult female cases planned for MRM. The patients were equally randomized into two groups: group ESPB and group PVB. The blocks were performed before general anesthesia induction with 20 ml bupivacaine 0.25%, then 0.1 ml/kg/hr continuous infusion through a catheter. Results The duration of block performance was significantly lower in the group ESPB than in the group PVB (P < 0.001). The total morphine consumption in 48 h postoperative was 1.54 ± 3.74 mg in group ESPB and 1.68 ± 3.48 mg in group PVB (P = 0.878). Patients required fentanyl and postoperative morphine in the 1st 48 h, time to 1st request analgesia insignificantly differed between groups. Intraoperative and postoperative heart rate, mean arterial pressure and oxygen saturation, and visual analog scale at rest and movement insignificantly differed between groups. Postoperative pneumothorax occurred in one case in group PVB and did not occur in group ESPB. Conclusions In MRM, analgesic efficacy of preoperative ultrasound-guided ESPB and PVB is comparable, and ESPB is an easier technique and more safer to perform when compared to PVB.

Association between needle track bleeding and postoperative immediate pneumothorax in CT-guided percutaneous transthoracic lung biopsies: a cross-sectional study

The relationship between Needle Track Bleeding (NTB) and the occurrence of postoperative immediate pneumothorax remains unclear. In our cross-sectional study, we conducted a retrospective collected of data from 674 consecutive patients who underwent CT-guided percutaneous transthoracic lung biopsies between 2019 and 2022. A logistic regression model was employed to explore the association between NTB and postoperative immediate pneumothorax, and restricted cubic spline curves was used to investigate the link and its explicit curve shape. A sensitivity analysis was performed by transforming the continuous NTB into categorical variable and calculated an E-value. A total of 453 participants (47.90% male) were included in our analysis. The postoperative immediate pneumothorax rate was 41.05% (186/453). We found a negative correlation between NTB and postoperative immediate pneumothorax (OR = 0.91, 95%CI 0.88–0.95) after adjusting for confounding factors. This relationship was nonlinear, with a key inflection point at NTB of 8 mm. No significant link was noted for NTB > 8 mm (OR = 0.98, 95%CI 0.95–1.02), while a protective association was observed for NTB ≤ 8 mm (OR = 0.74, 95%CI 0.66–0.81). NTB showed a nonlinear, protective correlation with postoperative immediate pneumothorax. However, when NTB exceeded 8 mm, the protective association was not observed.

Complications of prolonged mechanical ventilation after cardiac surgery in children with Down syndrome: A single-center retrospective observational study

Background: Patients with Down syndrome (DS) are known to have an increased risk of congenital heart diseases, which can be a predictor of prolonged mechanical ventilation (PMV) after cardiac surgery. PMV is a factor that enhances postoperative complications and morbidities. Thus, we aimed to explore the risk factors of the PMV, and relevant complications associated with it. Subjects and Methods: This retrospective study included 94 patients with DS who underwent 97 cardiac repair surgeries between 2010 and 2022. Patients were dichotomized into two groups. The first group was with the patients on mechanical ventilation (MV) for &lt;72 h and the PMV group with MV for more than ≥72 h. Results: We reviewed the association between various risk factors and PMV in patients with DS. The presence of seizure disorder (P = 0.028), preoperative administration of prostaglandin (P = 0.028), and continuous positive airway pressure (CPAP) (P = 0.043) had significantly increased risk of PMV. We found a significantly increased incidence of sepsis (P = 0.009), delayed sternal closure (P = 0.01), feeding intolerance (P = 0.014), prolonged intensive care unit (ICU) stay (P = 0.0001), and pulmonary collapse (P = 0.001) in patients with PMV. There was no difference in the incidence of pulmonary hypertension, postoperative respiratory infection, pneumothorax, and chylothorax between children between the two groups. Conclusions: The presence of seizure disorder, preoperative usage of prostaglandin, and CPAP were significant risk factors for PMV. Incidence of sepsis, delayed sternal closure, feeding intolerance, prolonged ICU stay, and pulmonary collapse was significantly higher with PMV.

Utility of routine postoperative chest radiography in patients undergoing clavicle fixation: a retrospective chart review.

Although uncommon, pneumothorax is a potentially serious complication following open reduction and internal fixation (ORIF) of clavicle fractures. In many centres it is routine practice to obtain postoperative chest radiographs following ORIF of clavicle fractures to assess for iatrogenic pneumothorax. Given the need to contain health care costs, the low sensitivity for detecting small pneumothorax and a desire to decrease patient radiation exposure, the practice of ordering chest radiographs following ORIF of clavicle fractures may be unnecessary. All patients undergoing ORIF of clavicle fractures with plate and screw fixation at Kingston Health Sciences Centre between April 2009 and June 2020 were identified from the Discharge Abstract Database (inpatient) and National Ambulatory Care Reporting System (outpatient) using relevant Canadian Classification of Health Intervention procedure codes. Charts were manually reviewed to confirm diagnosis and procedure, and patients with preoperative pneumothorax were excluded. The frequency of postoperative chest radiograph and pneumothorax detection were calculated. Among the 292 patients who underwent ORIF of clavicle fractures during the study period, 17 were excluded for having a pneumothorax on preoperative chest radiograph. Of the remaining 275 patients, 101 (36.7%) had postoperative chest radiographs, of whom none were found to have postoperative iatrogenic pneumothorax. Since 2009, the rate of routine postoperative chest radiography following ORIF of clavicle fractures is 36.7% at our centre. During this time period, none of the 101 patients who had postoperative chest radiographs had a postoperative iatrogenic pneumothorax. To our knowledge, this is the largest series of patients available, and our findings confirm those of several smaller studies. Owing to the low rate of postoperative iatrogenic pneumothorax, we conclude that postoperative chest radiography is unnecessary following ORIF of clavicle fractures.

Surgical approach for complete resection of giant retroperitoneal liposarcoma with diaphragmatic hernia via ninth rib thoracotomy.

Resection of a giant retroperitoneal liposarcoma is difficult and technically demanding, especially for large retroperitoneal tumors accompanied by a diaphragmatic hernia. Technically, the open abdominal approach can be time-consuming and difficult to perform, with possible intraoperative complications and other factors bringing psychological and physical difficulties to the patient. This study reports a safe and feasible approach for the complete resection of a large retroperitoneal tumor complicated by a diaphragmatic hernia. A 58-year-old male patient with persistent upper abdominal pain and distension was treated at a local hospital on 4 July 2022. Computed tomography showed a mixed-density mass on the right retroperitoneum, and liposarcoma was considered. On 6 July 2022, the patient was transferred to our hospital for further treatment. Computed tomography showed a mass with low-density fatty shadow in the right adrenal region. The boundary with the right adrenal gland was unclear. The mass was 102mm × 74mm, and the right lobe of the liver was compressed. Insufficiency of the right middle lobe of the liver was seen due to a right diaphragmatic hernia and left mediastinal deviation. We considered the traditional approach for tumor resection via laparotomy, but we opted to perform a comprehensive evaluation first. The tumor was close to the back of the right kidney and liver, causing the diaphragm to rise because of its proximity to these organs. Exposing the tumor through laparotomy would be difficult, making it challenging to remove. The patient had a diaphragmatic hernia and moderate pulmonary dysfunction; therefore, we decided to enter the abdomen through a thoracotomy of the ninth rib. Using our technique, the tumor was easily visualized and completely removed in approximately 30min. The intraoperative blood loss was 100ml, and no postoperative bleeding, pneumothorax, intestinal fistula, infection, or other complications occurred. The transthoracic approach may be a safer and more feasible resection method than the traditional open approach for patients with giant retroperitoneal liposarcoma with a diaphragmatic hernia.

Results of robot-assisted minimally invasive esophagectomy in 111 consecutive patients: an Asia cohort study

BackgroundRobot-assisted minimally invasive esophagectomy (RAMIE) is becoming increasingly popular as a treatment for esophageal cancer. The purpose of this study was to use the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA, USA) to perform 111 consecutive cases of radical esophageal cancer and report the perioperative data of surgery and postoperative complications and short-term oncological outcomes.MethodsWe retrospectively analyzed 111 patients who underwent RAMIE conducted at Fujian Medical University Union Hospital from August 2016 to January 2021. Each patient’s characteristics, clinicopathological stage, postoperative pathological stage, surgery outcome, postoperative recovery, and short-term oncological outcomes were analyzed.ResultsOf the 111 patients who underwent RAMIE, 77 were male and 34 were female, and the mean age was 62.1 ± 8.8 years. Twenty-seven patients (24.3%) received preoperative neoadjuvant therapies, the most popular of which was preoperative induction chemotherapy in 16 cases (14.4%), followed by preoperative induction radiotherapy in 8 cases (7.2%) and preoperative induction chemotherapy plus immunization in 3 cases (2.7%). The vast majority of patients (110/111, 99.1%) underwent radical resection, with a mean intraoperative bleeding amount of 99.9 ± 68.4 mL and a mean operative time of 271.9 ± 70.0 min. The mean total number of lymph nodes removed was 40.9 ± 16.7, including 21.8 ± 9.0 thoracic lymph nodes. Fifty-five (49.6%) patients had lymph node metastases, including 17 (15.3%) with lymph node metastases in the left recurrent laryngeal nerve, 24 (21.6%) with lymph node metastases in the right recurrent laryngeal nerve, and 7 (6.3%) with lymph node metastases in the bilateral recurrent laryngeal nerve. The positive rate of left recurrent nerve lymph nodes was 4.77%, and he positive rate of right recurrent nerve lymph nodes was 8.38%. The main postoperative complications included pulmonary infection in 24 cases (21.6%), celiac disease in 3 cases (2.7%), tracheoesophageal fistula in 1 case (0.9%), anastomotic fistula in 3 cases (2.7%), postoperative cardiac arrhythmias in 11 cases (9.9%), VTE in 3 cases (2.7%), and pleural effusion (requiring postoperative tube drainage) in 13 cases (11.7%). Additionally, 2 cases of postoperative pneumothorax (1.8%), 1 case of poor incision healing (0.9%), 1 case of incomplete bowel obstruction (0.9%), 1 case of neck hematoma (0.9%), and 1 case of postoperative admission to the intensive care unit (0.9%) occurred. The median length of stay was 10.9 ± 6.1 days, and there were no cases of perioperative death.ConclusionsRobotic esophageal cancer radical surgery is safe and feasible. The surgeon can be proficient in thoracic robotic surgery and mediastinal lymph node dissection and achieve high levels of perioperative safety and short-term efficacy.

The effectiveness of chest T-tube drainage in uniportal video-assisted thoracic surgery.

Uniportal incision located at 4th or 5th intercostal space represents a problem for the correct drainage of distal areas of pleural cavity. The T-shaped tube can drain both the extremities of pleural space. In this study, we evaluated the effectiveness of T-chest tube compared to classic chest tube after uniportal video-assisted thoracic surgery. We compared the effectiveness of T-tube and classic 28 CH chest drainage after different surgical procedures in uniportal video-assisted thoracic surgery: lobectomies, wedge resections and pleural and mediastinal biopsies. As primary end points, drained effusion and evidence of pneumothorax at postoperative day 1, subcutaneous emphysema, tube kinking, obstruction and necessity of repositioning or postoperative thoracentesis were considered. Pain at 6 and 24 h after surgery, pain at tube removal and mean hospitalization were analysed as secondary end points. A total of 109 patients were selected for the study, 51 included to the T-tube group while the other 58 ones to the control group with classic drainage. Patients with T-tube showed a significantly lower rate of pneumothorax (29.4% vs 63.8%; P < 0.001), tube kinking (5.9% vs 27.6%; P = 0.003) and need of repositioning (2.0% vs 12.1%; P = 0.043). No significant results were obtained in subcutaneous emphysema (P = 0.26), tube obstruction (P = 0.32), drained effusion (P = 0.11) and need of postoperative thoracentesis (P = 0.18). Patients with T-tube complained of <6 h after surgery (P < 0.001). Conversely, T-tube removal was reported to be more painful (P < 0.001). Chest T-tube can achieve significantly lower rate of postoperative pneumothorax, kinking and repositioning with less pain 6 hours after surgery compared to classic tube.

Postoperative Chest X-rays After Open Reduction Internal Fixation of Clavicle Fractures May Not Be Cost-effective or Necessary.

To assess the utility of chest x-rays following open reduction internal fixation of clavicle fractures. Particularly in terms of detection of acute postoperative pneumothorax and cost- effectiveness of obtaining routine chest x-rays post-operatively. A retrospective cohort study. Level I trauma centerPatients 236 patients who underwent ORIF from 2013 to 2020 between the ages of 12 and 93. Chest x-ray performed post-operatively. Presence of acute postoperative pneumothorax. Of the 236 patients who underwent surgery 189 (80%) of patients received a CXR post-operatively 7 (3%) of patients experienced respiratory symptoms. All patients who had respiratory symptoms received a post-operative CXR. Those who did not receive a CXR post-operatively did not experience any respiratory complications. Two patients in the cohort had a postoperative pneumothorax, which were both present pre-operatively and unchanged in size post-operatively. Both of these patients were managed with general anesthesia and endotracheal intubation for surgery. The most common finding on CXR post-operatively was atelectasis. The cost of a portable CXR can be upwards of $594 when including technology, personnel fees, and radiological interpretation. Post-operative chest x-rays after clavicle open reduction and internal fixation did not detect any acute postoperative pneumothorax in asymptomatic patients. It is not cost-effective to routinely get chest x-rays in patients following open reduction internal fixation of clavicle fractures. In our study, of the 189 chest x-rays performed, only seven patients experienced postoperative respiratory symptoms. Our healthcare system as a total could have saved upwards of $108,108 in total for these patients as they may have been considered non-reimbursable by an insurance provider.

Persistent bilateral pneumothorax after robotic-assisted inguinal hernia repair: possible relevance to recent esophageal cancer surgery — a case report

BackgroundPostoperative pneumothorax is a well-known but relatively rare complication after laparoscopic surgery. There has been no report describing pneumothorax that persisted for a week or more after laparoscopic surgery. Herein, we report a case of bilateral pneumothorax after laparoscopic surgery, which appears to have occurred by a different mechanism than previously described.Case presentationA 65-year-old male, with a past history of esophagectomy and retrosternal gastric tube reconstruction 4 months earlier, underwent a robotic-assisted inguinal hernia repair. Postoperative chest x-rays revealed the development of bilateral pneumothorax, which became worse on postoperative day (POD) 1 and took more than 9 days to resolve spontaneously. We assumed that intra-abdominal gas replaced by the air after pneumoperitoneum might have migrated into thoracic cavities through an opened esophageal hiatus or along the retrosternal route.ConclusionsLaparoscopic surgery after radical esophagectomy may be associated with an increased risk of postoperative pneumothorax.

Oxidized Regenerated Cellulose versus Polyglycolic Acid for Pleural Coverage in Pneumothorax Surgery.

Objectives: Although surgical intervention for spontaneous pneumothorax (SP) reduces the recurrence rate, thoracoscopic surgery is associated with greater postoperative recurrence rates than open thoracotomy. A polyglycolic acid (PGA) sheet or oxidized regenerated cellulose (ORC) mesh can therefore be used for additional coverage after thoracoscopic surgery, and this study compared the clinical impacts of these two materials. Methods: From 2018 to 2020, 262 thoracoscopic surgeries for primary SP were performed, of which 125 patients were enrolled in this study, and 48 and 77 patients received ORC and PGA coverage, respectively. The clinical characteristics and surgical procedures were reviewed, and the recurrence rates were compared. To obtain more comprehensive evidence, we performed a literature review and meta-analysis comparing ORC and PGA coverage. Results: There were no significant differences in patient characteristics between the two groups. Operating time was slightly shorter in the ORC group than in the PGA group (p = 0.008). The pneumothorax recurrence rate was similar in both groups (PGA: 10.4%, ORC: 6.2%, p = 0.529), but the recurrence-free interval was significantly longer (p = 0.036) in the ORC (262 days) than in the PGA (48.5 days) group. The literature review identified three relevant studies, and the meta-analysis revealed no difference in pneumothorax recurrence rate between the two coverage materials. Conclusions: The two visceral pleural coverage materials, PGA and ORC, did not show significant differences in postoperative pneumothorax recurrence. Therefore, if applied appropriately, the choice of material between ORC and PGA for thoracoscopic pneumothorax surgery does not have a significant impact on the clinical outcome.

Closure of Tracheocutaneous Fistulae in Patients With Challenged Wound Healing.

To describe and evaluate the surgical outcomes of multilayered closure of persistent tracheocutaneous fistulae (TCF) in patients with challenged wound healing. A retrospective chart review of all patients who underwent closure of TCF by the senior author between October 2011 and December 2021 was performed. Age, body mass index (BMI), time between decannulation and TCF repair, medical comorbidities, procedure duration, length of hospitalization, and postoperative complications were recorded. The primary outcomes were closure of the fistula, postoperative subcutaneous emphysema, pneumomediastinum, pneumothorax, wound infection, or breakdown. Outcomes of patients with and without challenged wound healing were compared. Thirty-five patients who underwent TCF repair during the study period were identified. The mean age and BMI were 62.9 years and 28.43 respectively. Twenty-six (74%) patients met criteria for challenged wound healing at the time of the TCF repair. There was 1 (3.84%) minor complication in the challenged wound healing group and none (0%) in the control group (P = 1.00). No patients experienced wound breakdown or air leak noted on exam or chest radiography. Multilayered closure of persistent tracheocutaneous fistulae is a simple technique which is safe and effective even in patients with challenged wound healing.

Portrayal of video-assisted mediastinoscopic lymphadenectomy’s range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective

BackgroundVideo-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious – at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 – to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure.Case presentationWe present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up.ConclusionPresenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA’s important role as a diagnostic and therapeutic tool.

The impact of suction addition to simple water seal on the outcomes after pulmonary surgery: A meta-analysis.

Chest tube drainage during pulmonary surgery is fundamental to removing air and fluid, as well as for lung re-expansion. However, the advantages of adding external suction to the water seal are under debate. The aim of the study was to conduct a meta-analysis in order to assess the effects of adding suction to a simple water seal on the outcomes of lung surgery. A search of the literature up to November 2021 found 14 studies with 2449 lung surgery patients. Of these patients, 1092 received suction drainage and 1357 received a simple water-seal drainage. The studies reported the effects of adding suction to a simple water seal on postoperative outcomes after lung surgery. A randomor fixed-effect model determined the odds ratio (OR) or mean difference (MD) with 95% confidence intervals (95% CIs) to compare the outcomes. In patients undergoing lung surgery, suction resulted in a substantially longer chest tube duration (MD = 0.74, 95% CI: 0.90-1.40, p = 0.03, Z = 2.21) and a smaller postoperative pneumothorax (OR = 0.27, 95% CI: 0.13-0.59, p = 0.02, Z = 2.24) than a simple water seal. However, no differences existed in prolonged air leak (p = 0.91, Z = 0.12), air leak duration (p = 0.28, Z = 1.07) or length of hospital stay (p = 0.23, Z = 1.2) between the 2 approaches. Suction led to considerably longer chest tube duration and lower postoperative pneumothorax, but no significant difference in sustained air leak, air leak duration or length of hospital stay was observed compared to a simple water seal in patients undergoing pulmonary surgery. Further research is needed to validate these findings and increase confidence, particularly regarding the postoperative pneumothorax results.

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

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