Symptomatic Pneumothorax Research Articles

Needle aspiration versus tube thoracostomy in patients with symptomatic primary spontaneous pneumothorax: an updated meta-analysis of randomized controlled trials.

Primary spontaneous pneumothorax (PSP) is an important disease commonly seen in young males. While incidentally diagnosed cases can be managed conservatively, symptomatic patients often necessitate intervention. Chest tube placement (tube thoracostomy) is commonly used, at least in the USA as a primary treatment modality, which requires hospitalization. On the other hand, needle aspiration (NA) has been widely adopted due to simplicity and reported efficacy and safety. No consensus is reached regarding superiority and/or preferred modality, with a lack of guidelines agreement. Therefore, we conducted an updated meta-analysis of randomized controlled trials comparing NA to tube thoracostomy in patients with symptomatic PSP. Prespecified outcomes were immediate success rate, 12-month recurrence rate, post intervention complications rate, and hospital length of stay. We identified and pooled data from six randomized trials, with a total of 759 patients and a median follow up of 12 months. Our analysis showed that NA and tube thoracostomy have similar immediate success rate and 12-month recurrence rate. We also found that NA has less complication rate, need for surgical intervention, and less hospital stays. In conclusion, our review showed that in symptomatic patients with PSP, NA is as effective as tube thoracostomy regarding immediate success rate and 12-month recurrence rate, with the added benefit of less complications rate and need for surgical intervention.

Expectant management in symptomatic spontaneous pneumothorax in a newborn: A case report

Neonatal symptomatic spontaneous pneumothorax particularly in term newborns with no underlying lung diseases is a rare occurrence. Despite continued advances in neonatal medicine, studies of spontaneous symptomatic pneumothorax in neonatal are limited, particularly in Indonesia. In this case report, we present a spontaneous pneumothorax in a previously healthy newborn with no notable risk factors. The newborn developed signs of respiratory distress with significant oxygen desaturation. The pneumothorax was resolved fully with careful observation, CPAP as respiratory support, and without thoracentesis nor chest tube drainage. Early recognition is crucial to prevent complications. Expectant management can be safely considered in newborns with primary spontaneous pneumothorax particularly in resource-limited healthcare settings.

Differences in Possible Risk Factors, Treatment Strategies, and Outcomes of Neonatal Pneumothorax in Preterm and Term Infants.

The study aimed to compare the risk factors, treatment strategies, and early outcomes of symptomatic neonatal pneumothorax (NP) between preterm and term newborns. This retrospective cross-sectional study was conducted in a neonatal intensive care unit between 2015 and 2022, consisting of hospitalized neonates with symptomatic NP. The cases were divided into three groups according to their gestational ages: <340/7 (group 1), 340/7-366/7 (group 2), and ≥370/7 weeks (group 3). Risk factors, treatment strategies, and mortality rates of the study groups were compared using Kruskal-Wallis analysis. Fifty-nine infants with a diagnosis of symptomatic NP were included in the study. The number of participants was as follows: 25 (42.3%) in group 1, 18 (30.5%) in group 2, and 16 (27.1%) in group 3. The need of delivery room (DR) resuscitation was significantly higher in group 1 (40%, P = .003). The surfactant administration rate was significantly higher in group 1 when compared to group 2 and group 3 (68% vs. 22% and 19%, respectively), P < .001. Similarly, the invasive mechanical ventilation percentage was significantly higher in group 1 than group 2 and group 3, P = .014. However, compared to group 3 (63%), the percentage of chest drain insertion (CDI) need was significantly higher in group 1 (96%) and group 2 (89%) (P = .014). Exposure to DR resuscitation and the need for surfactant are the most common risk factors for NP in preterm infants. Although oxygen and/or needle aspiration treatments are less invasive in symptomatic NP, the improvement rate without CDI is very low in preterm infants born before 34 weeks of gestational age. Cite this article as: Tandırcıoğlu U, Koral Ü, Güzoğlu N, Alan S, Aliefendioğlu D. Differences in possible risk factors, treatment strategies, and outcomes of neonatal pneumothorax in preterm and term infants. Turk Arch Pediatr. 2024;59(1):87-92.

The process and safety of removing chest tubes 4 to 12 hours after robotic pulmonary lobectomy and segmentectomy

ObjectiveChest tubes cause pain and morbidity. MethodsThis is a quality initiative study and review of patients who underwent robotic pulmonary resection by 1 surgeon (R.J.C.). The goal was to remove chest tubes within 4 to 12 hours after robotic segmentectomy and lobectomy. Primary outcome was removal without the need for reinsertion, thoracentesis, or any morbidity due to early removal of the chest tube. Secondary outcomes were symptomatic pneumothorax, pleural effusion, chylothorax, subcutaneous emphysema, and chest tube reinsertion or thoracentesis within 60 days of surgery. ResultsBetween January 2018 and December 2022, 590 patients underwent robotic lobectomy or segmentectomy. Chest tubes were removed within 4 to 12 hours postoperatively in 63.5% of patients (375/590). In 2022, this was achieved in 91% after lobectomy (119/128) and 94% after segmentectomy (75/80). There were significantly more chest tubes removed within 4 to 12 hours postoperatively from 2020 to 2022 than pre-2020 (P < .001). Forty patients (6.8%) were discharged home on postoperative day 1 with a chest tube. Sixteen patients (2.7%) had post–chest tube removal increasing pneumothorax and subcutaneous emphysema; none required tube reinsertion. There was no 30-day or 90-day mortality. Twelve patients (2%) had an outpatient thoracentesis for effusion within 60 days. Twenty patients (3.3%) were readmitted, none seemingly related to effusions. Nonsmokers (P = .04) and segmentectomy (P = .001) were associated with chest tube removal within 4 to 12 hours of surgery. ConclusionsChest tubes can be safely removed within 4 to 12 hours after robotic segmentectomy and lobectomy. Factors associated with successful early chest tube removal are nonsmoking, segmentectomy, and team members becoming comfortable with the process.

Pleural decompression procedural safety for traumatic pneumothorax and haemothorax: Kelly clamps versus fine artery forceps.

The present study aimed to determine the difference in force required to puncture simulated pleura comparing Kelly clamps to fine artery forceps. The treatment of symptomatic traumatic pneumothorax and haemothorax involves puncture of the parietal pleura to allow decompression. This is usually performed using Kelly clamps or fine artery forceps. Over-puncture pulmonary injury risk increases with the force used. An experienced single operator performed puncturing of simulated parietal pleura on a thoracic mannequin while wearing a force sensor under gloves. The force imparted at the device tip onto the parietal pleura was estimated by subtracting the force required to hold the device from the total force. Outcome variables were the total maximum force and force imparted by the device. There were 11 simulated procedures completed, seven using Kelly clamps and four using fine artery forceps. After subtracting the force required to hold the chosen forceps, the median value of pleural puncture force using Kelly clamps was 52.91 N (IQR 36.68-63.56) and 10.70 N (IQR 7.64-26.56) using fine artery forceps (P=0.006). A significantly increased force was required to puncture simulated parietal pleura using Kelly clamps compared to fine artery forceps. This higher puncture force will be associated with increased instrument acceleration at the time of pleural puncture, which may result in an increased risk of injury to the underlying lung. Based on these data, clinicians may reduce the risk of pulmonary injury by using fine artery forceps rather than Kelly clamps when performing pleural decompression.

Associations between Covariates and Pneumothorax Observations in CT-Guided Lung Biopsies.

The purpose of this study is to assess the effect of nine covariates on the occurrence or absence of stable or symptomatic pneumothorax. Forty-three patients underwent CT-guided lung biopsies from January 2020 to January 2022 (24 m, 19 f, median age 70 years). All the interventions were carried out with a semi-automatic 18G needle and a 17G trocar in a prone or supine position. Different covariates were measured and correlated to the rate and severity of the pneumothoraces observed. Nominal two-sided t-test p-values for the continuous variables and Fisher’s exact test results for the categorical variables were conducted. The data included the lesion size, distance to the pleura, needle-pleura angle, age, gender, position during the procedure, and the presence of chronic obstructive pulmonary disease. Patients with an observed pneumothorax had an average angle between the needle and the pleura of 74.00° compared to 94.68° in patients with no pneumothorax (p-value = 0.028). A smaller angle measurement correlated with a higher risk of pneumothorax development. The needle-pleural angle plays a vital role in the outcome of a CT-guided lung biopsy. Correctly adjusting the needle-pleural angle can diminish the pneumothorax risk associated with a CT-guided lung biopsy. The study results show that as the needle’s angle deviates from the perpendicular, the pleural surface area experiencing trauma increases, and pneumothorax is more likely to occur.

Safety and Efficacy of Percutaneous Image-Guided Mediastinal Mass Core-Needle Biopsy.

ObjectiveTo retrospectively evaluate the safety and efficacy of percutaneous image-guided mediastinal mass core-needle biopsy.Patients and MethodsRetrospective review of an institutionally maintained biopsy registry identified 337 computed tomography– or ultrasound-guided percutaneous mediastinal mass core needle biopsies between October 2002 and August 2017 in a single quaternary referral center. Mean patient age was 51 (range, 18 to 93) years. Procedural techniques, anticoagulation/antiplatelet therapy, and tumor anatomical characteristics were reviewed. Classification and gradation of complications was based on the Clavien-Dindo system. Diagnostic yield was defined as the ratio of diagnostic biopsy to all biopsies performed.ResultsMean tumor size was 59.2 (range, 10 to 180) mm with 89.9% (n=303) of lesions located in the prevascular (anterior) mediastinum. There was a single major complication (0.3%) of a symptomatic pneumothorax requiring intervention. There were seven (2.1%) minor complications, including three bleeding complications. A transpleural approach was the only variable associated with an increased complication rate (P<.01). Forty-one (12.2%) patients had a biopsy performed while taking an antiplatelet/anticoagulant agent within the therapeutic window, with a single case (0.3%) associated with a minor bleeding complication. Of 18 (5.3%) procedures performed without cessation of anticoagulant/antiplatelet therapy, there were no bleeding complications. Of all 337 biopsies, 322 (95.5%) were diagnostic. None of the analyzed variables were significantly associated with a nondiagnostic biopsy.ConclusionImage-guided percutaneous core-needle biopsy of mediastinal masses is a safe procedure with high diagnostic yield. Further prospective studies are required to assess the complication profile in higher risk patients.

Chest Physical Therapy and Outcomes in Primary Spontaneous Pneumothorax: A Systematic Review

Objective: An intercostal chest drainage (ICD) is a treatment in large or symptomatic primary spontaneous pneumothorax (PSP). Chest physical therapy strategies may be beneficial in patients with PSP in terms of reducing ICD duration. The present study aimed to evaluate if any physical therapy strategies provided good outcomes in patients with PSP. Materials and Methods: The present study was a systematic review. The inclusion criteria were articles published in literature databases conducted in children or adults, had at least one arm of physical therapy strategies, and had the outcomes of either duration of ICD treatment or admission duration. The authors searched five databases in this review. The final search was performed on April 28, 2021. For both outcomes of the present study, mean differences between experimental and control group were calculated and reported with their 95% confidence interval (CI). Results: There were 1,153 articles from five databases after duplication removal. In total, there were 264 articles eligible for full-text article review. Of those, only one article met the study criteria published by Kim and Park in 2012. The study was conducted in 40 patients with pneumothorax compared systematic breathing exercise program or experimental group and control group. The experimental group had significantly better two outcomes than the control group with mean differences of duration of ICD treatment and admission were -2.05 (95% CI: -3.26 to -0.84) and -1.85 (95% CI: -3.08 to -0.62). Conclusion: Chest physical therapy may shorten duration of ICD treatment and reduce length of hospital stay in patients with PSP. Keywords: Deep breathing exercise; Incentive spirometry; Range of motion exercise; Walking exercise; Feedback

Novel folliculin gene mutations in Polish patients with Birt\u2013Hogg\u2013Dub\xe9 syndrome

BackgroundBirt–Hogg–Dubé syndrome (BHDS) is a rare, autosomal dominant, inherited disease caused by mutations in the folliculin gene (FLCN). The disease is characterised by skin lesions (fibrofolliculomas, trichodiscomas, acrochordons), pulmonary cysts with pneumothoraces and renal tumours. We present the features of Polish patients with BHDS.Materials and methodsThe first case of BHDS in Poland was diagnosed in 2016. Since then, 15 cases from 10 families have been identified. Thirteen patients were confirmed via direct FLCN sequencing, and two according to their characteristic clinical and radiological presentations.ResultsBHDS was diagnosed in 15 cases (13 women and 2 men) from 10 families. The mean ages at the time of first pneumothorax and diagnosis were 38.4 ± 13.9 and 47.7 ± 13 years, respectively. Five patients (33%) were ex-smokers (2.1 ± 1.37 packyears), and 10 (67%) had never smoked cigarettes. Twelve patients (83%) had a history of recurrent symptomatic pneumothorax. Three patients had small, asymptomatic pneumothoraces, which were only detected upon computed tomography examination. All patients had multiple bilateral pulmonary cysts, distributed predominantly in the lower and middle, peripheral, and subpleural regions of the lungs. Generally, patients exhibited preserved lung function. Skin lesions were seen in four patients (27%), one patient had renal angiomyolipoma, and one had bilateral renal cancer. Different mutations of the FLCN gene were identified (mainly in exon 6), with two novel heterozygous variants: c.490delA p.(Arg164GlyTer13) and c.40delC p.(His14ThrsfTer41).ConclusionsAll analysed patients with BHDS presented with lung lesions and with less frequent skin and renal lesions than previously reported in other populations. In addition, more frequent mutations located in exon 6 were detected, and two novel FLCN gene mutations were identified.

Neonatal pneumothorax from the perspective of a pediatric surgeon: classification and management protocol: a preliminary algorithm

Background/aimCurrent neonatal pneumothorax classifications based on air volume escaping in pleural space have no contribution on the treatment. Therefore, our aim was to classify neonatal pneumothorax to guide treatment management based on our experiences.Material and methodsThe records of all neonates admitted to our clinics from March 2017 to August 2020 were reviewed. The patients with pneumothorax were identified through the neonatology department patient database search. The study only included the patients with symptomatic pneumothorax and these patients were evaluated into 3 groups based on the changes in peripheral oxygen saturation (SpO2) and clinical features immediately after the tube thoracostomy (TT) procedure. Accordingly, neonatal pneumothorax was divided into 3 types: patients with SpO2 increasing immediately after TT were included in type I, patients whose SpO2 did not change after TT were included in type II, and patients with SpO2 decreasing immediately after TT were included in type III pneumothorax.Results A total of 82 patients were included in the study. Sixty-one percent of these patients had type I, 24% had type II, and 15% had type III pneumothorax. None of the neonates died in type I and II pneumothoraces while 9 of 12 neonates (75%) died within the neonatal period in type III pneumothorax. Although we applied treatments such as high-frequency oscillatory ventilation, selective intubation, continuous negative aspiration, and surgical treatment to our patients that were lost due to type III pneumothorax, we were not successful. We successfully managed our surviving type III pneumothorax patients with a simple pressure cycle ventilator, using a combination of high rates, modest peak airway pressures [18 to 22 cm H2O and no positive end-expiratory pressure (PEEP)], and an autologous blood patch.Conclusion Classification of pneumothoraces into different types significantly contributes to patient treatment planning through a predetermined strategy, not through trial-and-error. High frequency and zero PEEP ventilation can provide significant improvement in risky cases.

Pneumothorax Induced by Computed Tomography Guided Transthoracic Needle Biopsy: A Review for the Clinician.

Percutaneous computed tomography (CT)-guided transthoracic needle biopsy (TTNB) is a valuable procedure for obtaining tissue or cells for diagnosis, which is especially indispensable in thoracic oncology. Pneumothorax and hemoptysis are the most common complications of percutaneous needle biopsy of the lung. According to reports published over the past decades, pneumothorax incidence in patients who underwent TTNB greatly varies. The morbidity of pneumothorax after CT-guided TTNB depends on several factors, including size and depth of lesions, emphysema, the number of pleural surfaces and fissure crossed, etc. Attention to biopsy planning and technique and post-biopsy precautions help to prevent or minimize potential complications. Many measures can be taken to help prevent the progression of a pneumothorax, which in turn might reduce the number of pneumothoraces requiring chest tube placement. A multitude of therapeutic options is available for the treatment of pneumothorax, varying from observation and oxygen treatment, simple manual aspiration, to chest tube placement. When a pneumothorax develops during the biopsy procedure, it can be manually aspirated after the needle is retracted back into the pleural space or by inserting a separate needle into the pleural space. Biopsy side down positioning of the patient after biopsy significantly reduces the incidence of pneumothorax and the requirement of chest tube placement. Aspiration in biopsy side down position is also recommended for treating pneumothorax when simple manual aspiration is unsuccessful or delayed pneumothorax occurred. Chest tube placement is an important treatment strategy for patients with a large or symptomatic pneumothorax. Clinicians are encouraged to understand the development, prevention, and treatment of pneumothorax. Efforts should be made to reduce the incidence of pneumothorax in biopsy planning and post-biopsy precautions. When pneumothorax occurs, appropriate treatment should be adopted to reduce the risk of worsening pneumothorax.

Bilateral spontaneous pneumothorax in a term newborn

Spontaneous pneumothorax in a full-term, apparently healthy infant is rarely seen, although it is a well-known complication of the respiratory distress syndrome. The management is mostly associated with assisted ventilation, birth trauma, meconium aspiration, or prematurity. We report the case of the occurrence of spontaneous bilateral pneumothorax in a healthy neonate, born by spontaneous vaginal delivery at term in the absence of any known predisposing factors. The baby recovered completely with conservative management with an oxygen-enriched atmosphere and needle thoracentesis. Symptomatic spontaneous pneumothorax is a rare occurrence in term newborns. Bilateral spontaneous pneumothorax has only been described only in a handful of case reports until now. Early recognition of progressive respiratory distress and its immediate management is lifesaving and reduces undue interventions, referrals, escalation of treatment costs, and the hospital stay.

Is Routine Chest Radiography Necessary After Endobronchial Ultrasound–guided Fine Needle Aspiration?

Chest radiography is routinely performed after endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) to detect clinically occult pneumothorax. Because the established rate of postprocedure pneumothorax is low, this study sought to determine whether routine chest radiography can be safely eliminated and to ascertain the potential cost reduction with its omission. Patients who underwent EBUS-FNA between January 1, 2017 and December 31, 2018 at Memorial Sloan Kettering Cancer Center (New York, NY) were retrospectively identified. Patient-related factors were summarized using descriptive statistics. Outcomes werecompared using the χ2, Fisher exact, and analysis of variance tests. Univariate regression analysis was used to identify factors predictive of postprocedure pneumothorax. A total of 757 patients were included in the study: 72.4% (548 of 757) underwent routine chest radiography in the postanesthesia care unit. Clinically relevant or radiographically evident pneumothorax developed in 1.5% of patients (11 of 757). Of the patients who underwent chest radiography, 0.5% (3 of 548) required unplanned admission for postprocedure pneumothorax, and 0.2% (1 of 548) required tube thoracostomy. Of the 209 patients who did not undergo chest radiography, none experienced a clinically evident pneumothorax. In total, only 1 patient (0.1%) had symptomatic pneumothorax. The pneumothorax event rate was so low that no association with demographic or clinical factors and no predictive factors could be identified. The number of patients needed to be screened by chest radiography to identify 1 patient requiring deviation from routine management is 183. The potential total cost reduction if routine chest radiography had been eliminated was $33,950. The extremely low rate of postprocedure pneumothorax precluded informative statistical analysis. Routine chest radiography after EBUS-FNA may not be necessary, and its omission may confer a cost savings.

Radiographic Findings of a Symptomatic Pneumothorax During Intercostal Nerve Infiltration

Radiographic Findings of a Symptomatic Pneumothorax During Intercostal Nerve Infiltration

Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial

SummaryBackgroundPrimary spontaneous pneumothorax occurs in otherwise healthy young patients. Optimal management is not defined and often results in prolonged hospitalisation. Data on efficacy of ambulatory options are poor. We aimed to describe the duration of hospitalisation and safety of ambulatory management compared with standard care.MethodsIn this open-label, randomised controlled trial, adults (aged 16–55 years) with symptomatic primary spontaneous pneumothorax were recruited from 24 UK hospitals during a period of 3 years. Patients were randomly assigned (1:1) to treatment with either an ambulatory device or standard guideline-based management (aspiration, standard chest tube insertion, or both). The primary outcome was total length of hospital stay including re-admission up to 30 days after randomisation. Patients with available data were included in the primary analysis and all assigned patients were included in the safety analysis. The trial was prospectively registered with the International Standard Randomised Clinical Trials Number, ISRCTN79151659.FindingsOf 776 patients screened between July, 2015, and March, 2019, 236 (30%) were randomly assigned to ambulatory care (n=117) and standard care (n=119). At day 30, the median hospitalisation was significantly shorter in the 114 patients with available data who received ambulatory treatment (0 days [IQR 0–3]) than in the 113 with available data who received standard care (4 days [IQR 0–8]; p<0·0001; median difference 2 days [95% CI 1–3]). 110 (47%) of 236 patients had adverse events, including 64 (55%) of 117 patients in the ambulatory care arm and 46 (39%) of 119 in the standard care arm. All 14 serious adverse events occurred in patients who received ambulatory care, eight (57%) of which were related to the intervention, including an enlarging pneumothorax, asymptomatic pulmonary oedema, and the device malfunctioning, leaking, or dislodging.InterpretationAmbulatory management of primary spontaneous pneumothorax significantly reduced the duration of hospitalisation including re-admissions in the first 30 days, but at the expense of increased adverse events. This data suggests that primary spontaneous pneumothorax can be managed for outpatients, using ambulatory devices in those who require intervention.FundingUK National Institute for Health Research.

SPONTANEOUS PNEUMOTHORAX DURING PREGNANCY: A RARE CHALLENGE

TYPE: Abstract Publication TOPIC: Disorders of the Pleura PURPOSE: Primary spontaneous pneumothorax (PSP) during pregnancy is a rare condition with serious risks to the mother and the fetus, so rapid recognition and treatment are essential. Since few cases has been described, symptoms of dyspnea and chest pain can be easily misdiagnosed. The aim is to describe a case of a pregnant patient with PSP, managed with chest tube drainage. METHODS: A 30-year-old woman on 28th gestational week (gravida 1/ parity 0), non-smoker, presented at urgency department with sudden pleuritic chest pain and dyspnea. No history of respiratory pathology or trauma. On physical examination, hemodynamically stable, no fever, tachypneic with oxygen saturation 97% on ambient air. Pulmonary auscultation with decreased vesicular murmur on the left hemithorax. No analytic alterations. No fetal distress. The chest radiography showed findings of large left pneumothorax, without mediastinum deviation. A chest drain was placed with reduction of pneumothorax. Given the absence of pulmonary re-expansion, suction treatment was made. RESULTS: The patient had progressive recovering and was hospital discharged asymptomatic. A caesarean section was performed on 39th gestational week, under epidural anesthesia, without complications. The patient maintains a pulmonology follow-up, without new episodes of pneumothorax. CONCLUSIONS: PSP during pregnancy should be part of chest pain and dyspnea differential diagnosis and promptly recognized to prevent severe complications. CLINICAL IMPLICATIONS: Given the symptomatic large pneumothorax, a chest tube was placed. Since the high risk of recurrence during delivery, it is recommended elective assisted delivery with forceps or ventouse extraction to lessen maternal efforts, despite some authors consider the caesarean section a safe option. DISCLOSURE: No significant relationships. KEYWORDS: pneumothorax, pregnancy

Sa1313 ANALYSIS OF SAFETY AND EFFICACY OF PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA: A SINGLE-CENTER EXPERIENCE WITH MID-TERM FOLLOW-UP

Peroral endoscopic myotomy (POEM) has been introduced as a new effective therapeutic option for achalasia. This abstract illustrates our experience with POEM in a large single-center series of achalasia patients with mid-term follow-up. A retrospective review was conducted that included all consecutive patients with achalasia who underwent POEM between January 2016 to December 2018 in a tertiary care center. The primary outcome was clinical response, defined as an Eckardt score lower than 3. Secondary outcomes were procedure-related adverse events (graded according to the ASGE lexicon's severity grading system) and incidence of postoperative gastroesophageal reflux disease. A total of 206 patients (mean age 40.6 years, 94 males) underwent POEM for the treatment of achalasia (35 type I, 137 type II, 34 unspecified). Of these, 40 (19.4%) had received previous treatment for achalasia before POEM, including 27 pneumatic dilation, 8 prior POEM, 3 Heller myotomy, 1 botulinum toxin injection and 1 temporary esophageal stenting. Technical success was achieved in all patients. Posterior myotomy was performed in 70.9% of patients. Adverse events occurred in 20 (9.7%) patients. There were 9 inadverted mucosotomies, 5 pneumonia, 3 cardiac arrhythmia, 2 symptomatic pneumothorax requiring needle decompression, 1 pleural effusion requiring chest tube insertion. Fifteen adverse events were grade as mild, 5 moderate, and none severe. Among 185 patients with median follow-up period of 24 months (IQR 12.0-29.3), clinical success was achieved in 87.0% of patients, and Eckardt scores improved from pre-operative 6.4±1.9 to post-operative 1.4±1.6 (P <0.001). There were no significant differences in the success rate among the achalasia subtypes (P =0.947). Postoperative upper endoscopy revealed esophagitis in 19.5% of patients (5 LA grade A, 12 LA grade B), while 11.9% of patients had post-operative symptoms suggestive of gastroesophageal reflux (GerdQ >7). The present large series add to the evidence that POEM is a safe and effective treatment for achalasia patients, resulting in mid-term symptom relieved in nearly 90% of patients without severe adverse events.

Well-trained gynecologic oncologists can perform bowel resection and upper abdominal surgery safely.

ObjectiveThis study was performed to examine the safety of bowel resection and upper abdominal surgery in patients with advanced ovarian cancer performed by gynecologic oncologists after training in a monodisciplinary surgical team.MethodsWe implemented a monodisciplinary surgical team consisting of specialized gynecologic oncologist for advanced ovarian cancer. In the initial learning period in 65 patients with International Federation of Gynecology and Obstetrics (FIGO) III/IV, a gynecologic oncologist who had a certification as a general surgeon trained 2 other gynecologic oncologists in bowel resection and upper abdominal surgery for 4 years. After the initial learning period, the trained gynecologic oncologists performed surgeries without the certificated general surgeon in 195 patients with FIGO III/IV. The surgical outcomes and perioperative complications during the 2 periods were evaluated.ResultsThe rates of achieving no gross disease after cytoreductive surgery were 80.0% in the initial learning period and 83.6% in the post-learning period (p=0.560). The incidence of anastomotic leakage after rectosigmoid resection, symptomatic pleural effusion or pneumothorax after right diaphragm resection, and pancreatic fistula after splenectomy with distal pancreatectomy in the 2 periods were 2 of 34 (6.0%), 1 of 33 (3.0%), and 3 of 15 (20.0%) patients in the initial learning period, and 12 of 147 (8.2%), 1 of 118 (0.8%), and 11 of 84 (13.1%) patients in the post-learning period, respectively. There were no significant differences between the 2 groups (p=0.270, p=0.440, p=0.520, respectively).ConclusionBowel resection and upper abdominal surgery can be performed safely by gynecologic oncologists.

Clinical Yield of Routine Chest Radiography after Ultrasound-Guided Thoracentesis

To evaluate the clinical yield of routine chest radiography in identifying pneumothorax warranting chest tube decompression in patients undergoing ultrasound-guided thoracentesis. All adult patients without pre-existing pneumothorax who underwent ultrasound-guided thoracentesis by a radiologist within a four-hospital large metropolitan academic health system over a 10-year period were identified. Demographic, clinical, and radiographic report information were obtained. Chest radiographic reports were assessed for the presence of pneumothorax and, if positive, manual image and chart review were performed. Of 2541 consecutive ultrasound-guided thoracentesis procedures, 12 were excluded due to pre-existing pneumothorax, yielding 2529 cases. Mean patient age was 67.7 years; 54.5% were male. Overall, 89 procedures (3.5%) resulted in a postprocedural pneumothorax. Of those, only six (6.7%) had documented changes in patient symptoms. Chest tubes were placed in 15, representing 16.9% (15/89) of cases with postprocedural pneumothoraces and 0.59% (15/2,529) of all procedures. Of these 15, 5 (33.3%) had symptomatic pneumothoraces, most commonly shortness of breath. Following ultrasound-guided thoracentesis, the incidence of pneumothorax requiring chest tube decompression is only 1 in 170. Of the 1 in 30 patients who develop a pneumothorax, only 1 in 6 require a chest tube. This information can inform procedural consent discussions as well as future guidelines about the necessity of routine postprocedural chest radiography.

Lung ultrasound reduces the number of chest X-rays in newborns with pneumothorax.

Aim of the studyTo determine the impact of lung ultrasonography as an imaging method used to diagnose and monitor newborns with symptomatic pneumothorax and to assess the risk factors for pneumothorax and the outcomes in newborns with symptomatic pneumothorax.Material and methodsA single-centre retrospective study enrolled patients born after 32 weeks of gestation, with a diagnosis of pneumothorax in the first week of life. The 118 patients who were included in the study were divided into two groups. Group A (51 infants) comprised those children who were treated between 2007 and 2010, while group B (n=67) those from the years 2013 to 2016. The children from group A were monitored with repeated chest X-rays. Those from group B received repeated lung ultrasonography supported by chest X-ray in those cases where there was diagnostic uncertainty. Comparison was made between the groups with respect to pneumothorax risk factors, treatment methods and the use of imaging during the period of treatment. The statistical analysis used χ2, Mann-Whitney and Student’s t-tests.ResultsThere were no significant demographic or clinical differences between the two groups. Both the use of nCPAP (nasal continuous positive airway pressure) (p<0.001) and diagnosed perinatal asphyxia (p=0.036) were higher in group B. Congenital pneumonia occurred more often in group A (p=0.041). Earlier detection of pneumothorax (p=0.001) and shorter hospital stay (p=0.03) were observed in group B. However, the total number of imaging (lung ultrasound and chest X-ray combined) was higher (p<0.001) in group B.ConclusionThis study confirmed the usefulness of lung ultrasound in monitoring newborns with pneumothorax, moreover significantly limiting X-ray radiation.