Thoracoscopic Decortication Research Articles

Video-assisted thoracoscopic decortication versus open decortication for a better surgery results.

Video-assisted thoracoscopic decortication versus open decortication for a better surgery results.

Seasonal variations of empyema in Taiwan: A 10-year analysis

BackgroundEmpyema is a serious infection in pleural space. Finding out seasonal variations of empyema and its pathogens can help in providing preventive measures, and implicating future researches. MethodsThis study is a 10-year observational study in a single center. Patients with empyema thoracis receiving thoracoscopic decortication between January 2012 and December 2021 were included in the study. ResultsThere were 1082 empyema patients enrolled in this study. No seasonal variation was noted (spring = 25.7 %, summer =25.5 %, autumn = 24.8 %, winter = 24.0 %). However, we observed seasonal variations in pathogens. Streptococcus species had slightly higher prevalence in winter and spring than summer and autumn (54.3 % vs. 45.7 %) without significant difference (p = 0.251). On the contrary, Staphylococcus species occurred more often in summer and autumn than winter and spring (61.5 % vs. 38.5 %) (p = 0.035). Klebsiella species were more likely found in autumn (34.9 %) (p = 0.050), and Pseudomonas species showed no peak prevalence in any season (p = 0.423). The incidence of Streptococcus species increased over the years. ConclusionsAlthough no seasonal variation was found in severe empyema patients requiring surgery, there were seasonal variations for the pathogens in Taiwan. The medical community should focus on Streptococcus species in winter and spring and Staphylococcus species in summer and autumn.

A 78-Year-Old Female Presented with Chest Pain after Falling Down

<p>本文描述一位78歲的女性患者，因跌倒導致右側肋骨骨折，三週後因疑似胸腔延遲性出血合併膿胸入院，住院後發現個案右膝化膿性關節炎合併膿瘍及菌血症，在接受胸腔鏡右側肋膜清創術及針對個案狀況更換多次抗生素治療後，全身性的感染終獲得控制順利出院。針對診斷為創傷性血胸合併膿胸之患者，入院後右膝疼痛常被視為創傷合併之症狀，亦有可能是引起個案跌倒與延遲性出血導致右側膿胸的主因。因此針對患者所陳述的各種主訴與徵候，皆應詳細詢問病史與理學檢查，再綜合檢驗檢查結果的判斷，方能及早作出正確的鑑別診斷與治療計劃，也才能及時給予患者正確的治療，從而降低死亡率及後續可能產生的各種併發症。</p> <p> </p><p>A 78-year-old female patient suffered from a right rib fracture due to a fall. Three weeks later, she was.admitted to the hospital with suspected delayed hemothorax and empyema. Through detailed medical history inquiry and evaluation based on subsequent CT scans and bacterial culture reports, it was con-firmed that she had septic arthritis of the right knee with an associated abscess and bacteremia. After undergoing thoracoscopic decortication of right pleura and multiple changes in antibiotic treatments tailored to her condition, the systemic infection was successfully controlled, and she was eventually discharged. In patients diagnosed with traumatic hemothorax complicated by empyema, the right knee pain upon admission is often considered a symptom of the trauma, but it could also be a signif-icant factor contributing to the patient’s fall and subsequent delayed bleeding leading to right-sided empyema. Therefore, it is essential to thoroughly inquire about the patient’s various complaints and symptoms, conduct a detailed medical history and physical examination, and then make a comprehen-sive judgment based on the results of laboratory and imaging tests to promptly establish an accurate differential diagnosis and treatment plan. This approach will enable timely and appropriate treatment for the patient, reducing the mortality rate and the potential occurrence of various complications.</p> <p> </p>

Thoracoscopic Decortication for Tubercular Empyema in a Lung Transplant Recipient

Tubercular empyema thoracis is a morbid postoperative complication in lung transplant recipients, which significantly impairs graft function and affects the survival rate. This report describes a case of tubercular empyema thoracis in a 42-year-old female, who underwent bilateral sequential lung transplantation for interstitial lung disease (non-specific interstitial pneumonia). She underwent video-assisted thoracoscopic surgery decortication, a preferred surgical approach due to its minimally invasive nature with excellent success rates. This report highlights the effectiveness of tailored surgical interventions and the importance of individualized post-transplant care to optimize patient recovery and graft functionality.

Successful treatment with fenestration followed by daily decortication and negative-pressure wound therapy for acute exacerbation of chronic empyema: a case report.

Most cases of chronic empyema are caused by acute thoracic empyema or tuberculous pleuritis. Open thoracotomy and decortication are traditional treatments for chronic empyema. However, some cases, such as those with thick calcifications around a large cavity, may be difficult to decorticate in a single surgery. We successfully treated a case of chronic empyema with a large cavity surrounded by a thick calcified membrane that was peeled off gradually each day through fenestration of the thoracic cavity with negative-pressure wound therapy (NPWT). The patient was a 47-year-old man who had undergone thoracic drainage for left post-pneumonia empyema at another hospital 10years previously. He presented to our hospital with a fever of 39°C, bloody sputum, and severe fatigue for 3days. Computed tomography showed a 9-cm mass shadow in the left intralobar space and an adjacent 21 × 15 × 9-cm fluid-filled calcified unilocular cavity up to 5mm in thickness. He underwent thoracic drainage for fluid, and empyema was suspected; the fluid was foul-smelling and purulent. The patient did not improve with antibiotics and intrathoracic lavage; therefore, thoracoscopic decortication was performed. The thoracic cavity had a thick calcified membrane filled with dark-red slurry resembling old blood. We attempted decortication; however, the calcified membrane was difficult to remove. Two drains were used for the pleural lavage. However, no improvement was observed with intrathoracic lavage and drainage; therefore, a fenestration was performed. The calcified membrane was peeled off each day for 3months. Gradually, granulation increased and the inflammatory reaction improved. After NPWT, the empyema cavity gradually shrank to 8cm × 6cm × 2cm. A latissimus dorsi flap closure was performed, and the patient was discharged. This is an informative report on the daily decortication of a highly calcified purulent membrane using NPWT in a patient with chronic empyema. The description of this method will aid in the management of patients with chronic empyema and thick calcified membranes.

Culture-Positive and Culture-Negative Empyema After Thoracoscopic Decortication: A Comparison of Short-term and Long-term Outcomes.

Empyema thoracis is a serious infectious disease and is associated with high morbidity and mortality. The perioperative outcomes between culture-positive and culture-negative empyema after thoracoscopic decortication remained controversial, especially since there were no studies that reported the survival outcomes between culture-positive and culture-negative empyema. This single-institute study involved a retrospective analysis. Patients with empyema thoracis who underwent thoracoscopic decortication between January 2012 and December 2021 were included in the study. Patients were grouped into a culture-positive group and a culture-negative group according to culture results obtained no later than 2 weeks after surgery. A total of 1087 patients with empyema received surgery, and 824 were enrolled after exclusion. Among these, 366 patients showed positive culture results and 458 patients showed negative results. Longer intensive care unit stays (11.69 vs 5.64 days, P < .001), longer ventilator usage (24.70 vs 14.01 days, P = .002), and longer postoperative hospital stays (40.83 vs 28.37 days, P < .001) were observed in the culture-positive group. However, there was no significant difference in 30-day mortality between the 2 groups (5.2% in culture negative vs 5.0% in culture positive, P = .913). The 2-year survival was not significantly different between the 2 groups (P = .236). Patients with culture-positive or culture-negative empyema who underwent thoracoscopic decortication showed similar short-term and long-term survival outcomes. A higher risk of death was associated with advanced age, a higher Charlson Comorbidity Index score, phase III empyema, and a cause other than pneumonia.

Esophageal stenting with minimally-invasive surgical intervention for delayed spontaneous esophageal perforation.

Spontaneous esophageal perforation is a challenging surgical emergency with significant morbidity and mortality, and timely primary repair carries good outcomes. However, direct repair for a delayed spontaneous esophageal perforation is not always feasible and is associated with high mortality. Esophageal stenting can provide therapeutic benefits in the management of esophageal perforations. In this study, we review our experience with placing esophageal stents in combination with minimally-invasive surgical drainage to treat delayed spontaneous esophageal perforations. We retrospectively analyzed patients with delayed spontaneous esophageal perforations between September 2018 and March 2021. All patients were treated using a hybrid approach, including esophageal stenting across the gastroesophageal junction (GEJ) to reduce continued contamination, gastric decompression with extraluminal sutures to prevent stent migration, early enteral nutrition, and aggressive minimally-invasive thoracoscopic debridement and drainage of infected material. There were 5 patients with delayed spontaneous esophageal perforation treated with this hybrid approach. The mean duration between symptoms and diagnosis was 5 days, and the interval between symptoms and esophageal stent insertion was 7 days. The median time to oral nutrition and to esophageal stent removal was 43 and 66 days. There was no stent migration or hospital mortality. Three patients (60%) had postoperative complications. All patients were successfully resumed on oral nutrition with esophageal preservation. A hybrid approach combining endoscopic esophageal stent placement with extraluminal sutures to prevent stent migration, thoracoscopic decortication with chest tube drainage, gastric decompression, and jejunostomy tube placement for early nutrition was feasible and effective in the treatment of delayed spontaneous esophageal perforations. This technique offers a less invasive treatment approach for a challenging clinical problem which has traditionally carried a high rate of morbidity and mortality.

Evaluation of uniportal video-assisted thoracoscopic decortication in treatment of drug-resistant tuberculous empyema

Objective: To examine the safety and efficacy of the uniportal video-assisted thoracoscopic decortication in treatment of drug-resistant tuberculosis empyema. Methods: From January 2018 to December 2020, 122 cases of tuberculous empyema treated by decortication in Department of Surgery, Wuhan Pulmonary Hospital were retrospectively analyzed, including 100 males and 22 females, aged(M(IQR)) 29.5(28.0) years (range: 13 to 70 years). According to the surgical approach and drug resistance, patients with drug-resistant tuberculosis who underwent uniportal video-assisted thoracoscopic decortication were included in group A (n=22), and those who underwent thoracotomy decortication were included in group B (n=28). Drug-sensitive patients who underwent uniportal video-assisted thoracoscopic decortication were included in group C (n=72). There was no statistical difference in the baseline data of the three groups (P>0.05). The operation, early postoperative recovery, and prognosis-related indicators were compared among three groups by Kruskal-Wallis test and χ2 test by Mann-Whitney U test and Bonferroni method between groups A and B, groups A and C. Results: The intraoperative blood loss of group A, group B, and group C was 200(475) ml, 300(200) ml, and 225(300) ml, respectively. There was no significant difference in intraoperative hemorrhage (H=2.74, P=0.254) and treatment outcome (χ2=4.76, P=0.575) among the three groups. Compared with group B, the operation time of group A (302.5(187.5) minutes vs. 200.0(60.0) minutes, U=171.0, P=0.007) and postoperative pulmonary reexpansion duration (4.5(3.0) months vs. 3.0 (2.2) months, U=146.5, P=0.032) were longer, and the postoperative drainage duration (9.5(7.8) days vs. 13.0(10.0) days, U=410.0, P=0.044), and the postoperative hospitalization time (12.0(7.8) days vs. 14.5(4.8) days, U=462.2, P=0.020) were shorter. There was no significant difference in complications between group A and group B (63.6%(14/22) vs. 71.4%(20/28), χ2=0.34, P=0.558). Compared with group C, the postoperative drainage duration of group A (9.5(7.8) days vs. 7.0(4.0) days, U=543.5, P=0.031), the postoperative hospitalization time (12.0(7.8) days vs. 9.0(4.0) days, U=533.0, P=0.031) and postoperative pulmonary reexpansion duration (4.5(3.0) months vs. 3.0(2.0) months, U=961.5, P=0.001) were longer. The operation time (302.5(187.5) minutes vs. 242.5(188.8) minutes, U=670.5, P=0.278), and complications (63.6%(14/22) vs. 40.3%(29/72), χ2=3.70, P=0.054) were not different between group A and group C. Conclusions: For drug-resistant tuberculous empyema, the uniportal video-assisted thoracoscopic decortication can achieve the same good therapeutic effect as drug-sensitive tuberculous empyema, and it is as safe as thoracotomy. At the same time, it has the advantage of minimally invasive and can accelerate the early postoperative recovery of patients.

The outcomes of thoracoscopic decortication between fungal empyema and bacterial empyema

BackgroundFungal empyema is an uncommon disease and is associated with a high mortality rate. Surgical intervention is suggested in stage II and III empyema. However, there were no studies that reported the outcomes of surgery for fungal empyema.MethodsThis study is a retrospective analysis in a single institute. Patients with empyema thoracis who underwent thoracoscopic decortication between January 2012 and December 2021 were included in the study. We separated the patients into a fungal empyema group and a bacterial empyema group according to culture results. We used 1:3 propensity score matching to reduce selection bias.ResultsThere were 1197 empyema patients who received surgery. Of these, 575 patients showed positive culture results and were enrolled. Twenty-eight patients were allocated to the fungal empyema group, and the other 547 patients were placed in the bacterial empyema group. Fungal empyema showed significantly longer intensive care unit stay (16 days vs. 3 days, p = 0.002), longer median ventilator usage duration (20.5 days vs. 3 days, p = 0.002), longer hospital stay duration (40 days vs. 17.5 days, p < 0.001) and a higher 30-day mortality rate (21.4% vs. 5.9%, p < 0.001). Fungal empyema revealed significantly poorer 1-year survival rate than bacterial empyema before matching (p < 0.001) but without significant difference after matching.ConclusionsThe fungal empyema patients had much worse surgical outcomes than the bacterial empyema patients. Advanced age and high Charlson Comorbidity Index score are independent predictors for poor prognosis. Prompt surgical intervention combined with the use of antifungal agents was the treatment choice for fungal empyema.

Case report on peri-operative surgical and anaesthetic management of ruptured humongous lung abscess.

IntroductionEarly thoracic empyema is usually treated through video-assisted thoracoscopic (VATS) decortication. Patient selection is important for decortication if an effective surgical outcome is required. Lung isolation techniques are required to provide anesthesia for these patients to facilitate the surgeon while operating on the affected lung. The ultimate target is to protect the non-diseased contra-lateral lung from contamination.Presentation of caseWe are presenting a unique case of 20-year-old female, resident of Karachi, who was brought to the emergency room (ER) with signs of sepsis, hypotension, and multi-organ failure. She was brought to the operating room to undergo video-assisted thoracoscopy (VATS) for lung abscess decortication when her medical therapy had failed. On table decision of right upper lobe resection was made and ventilation strategy had to be modified accordingly.DiscussionThe main anaesthetic aim was to protect the healthy parts of the lung from the abscess. Regular suctioning of secretions during surgery via the double lumen tube (DLT) lumen on the diseased side is recommended. While performing VATS, the lung abscess got ruptured and immediate measures to isolate the lung was taken to assist with surgical resection of the affected lobe. Lobectomy can only be done once the lung was completely isolated and maintaining perfusion and ventilation of the relatively healthy lung help in managing hypoxia.ConclusionPeri-operative management of ruptured lung abscesses required thorough pre-op evaluation, intraoperative lung isolation and ventilation, and postoperative analgesia with combined team effort both surgical and anaesthetic, are vital fundamentals to consider in guaranteeing the best outcome.

Thoracoscopic and Endovascular Management of Retained Haemothoarx Associated with an Intercostal Artery Pseudoaneurysm

Intercostal artery pseudoaneurysm (IAP) is a rare entity and may complicate a percutaneous intervention through an intercostal space or follow thoracic trauma. Its rupture into the pleural space can give rise to haemothorax, which if untreated may lead to a retained haemothorax (RH). Traditionally both the IAP and the RH are managed by a thoracotomy. We report a patient who developed an IAP with haemothorax following a trauma. The diagnosis was established by computed tomography. The patient was treated by endovascular embolisation of the IAP followed by thoracoscopic decortications of the RH.

Uniportal video-assisted thoracoscopic decortication in the treatment of stage III tuberculous empyema: a case report

Background: Stage III tuberculous empyema is a chronic tuberculosis infection in the pleural cavity and usually requires surgical treatment. Pleurectomy is preferred. Due to dense pleural adhesion, pleural exfoliation is necessary and has in the past been performed through thoracotomy. In recent years, video-assisted thoracic surgery (VATS) has undergone rapid development and is applied to the stripping of stage III tuberculous empyema. Some surgeons believe that this method is feasible, safe, and effective, with good short-term and long-term results. However, uniportal (U)-VATS is rarely performed and reported.

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.

The role of lung ultrasonography in predicting the clinical outcome of complicated community-acquired pneumonia in hospitalized children.

This study's objective was to analyze lung ultrasonography (LUS) characteristics in hospitalized pediatric patients with complicated community-acquired pneumonia (CAP). We hypothesized that LUS could be correlated with the clinical outcome in these cases. In this retrospective study, we evaluated the LUS appearances (at admission and five days after the beginning of the treatment) and the progression of complicated CAP. We identified 45 patients who fulfilled the inclusion criteria. Several complications occurred in these subjects during follow-up including: serofibrinous pleurisy (62.2%), empyema (15.6%), encapsulated pleurisy (11.1%), lung abscess (6.7%) and necrotizing pneumonia (2.2%). In addition, 22.2% of the patients required surgical treatment: draining tube (11.1%), decortication (6.7%) and resection (4.4%). Intensive care unit admission was needed in 8.9% of patients. The median duration of hospitalization was 14 [9.7; 19.7] days. The thickness of pleural effusion with a cut-off value of 10 mm seen by LUS was a predictor for the need for continuous thoracic drainage (p<0.01), segmentectomy or thoracoscopic surgery (p=0.03) and prolonged hospitalization over 10 days (p<0.01). Hyperechogenic pleural effusion, presence of septa and fluid bronchogram on 1st LUS evaluation were independent predictors of segmentectomy or thoracoscopic decortication (p<0.01) and of longer hospitalization (p=0.02, p<0.01, p<0.01 respectively). The ultrasound characteristics of complicated CAP can offer valuable information to predict the clinical evolution of CAP and so can help the development of personalized medical management plans in these patients.

A nomogram to predict residual cavity formation after thoracoscopic decortication in chronic tuberculous empyema

OBJECTIVESThe goal of this study was to develop and validate a nomogram for predicting residual cavity formation after video-assisted thoracoscopic decortication in patients with chronic tuberculous empyema (CTE).METHODSWe retrospectively analysed patients who were diagnosed and treated for CTE at our hospital from January 2017 to December 2020. We used univariable and binary logistic regression analyses to identify independent risk factors. A predictive nomogram was developed and validated for predicting the risk of residual cavity formation after video-assisted thoracoscopic decortication in patients with CTE. The receiver operating characteristic (ROC) was used to evaluate the nomogram.RESULTSData from 103 patients were analysed. The contact area between the lung and empyema (P = 0.001, odds ratio [OR] 1.017, 95% confidence interval [CI] 1.007–1.028), calcification (P = 0.004, OR 0.12, 95% CI 0.029–0.501) and thickness of the pleura (P = 0.02, OR 1.315, 95% CI 1.045–1.654) were risk factors for residual cavity formation after video-assisted thoracoscopic decortication. A 50% residual cavity formation rate was used as the cut-off to validate the nomogram model. The area under the ROC curve for the nomogram was 0.891 (95% CI, 0.82–0.963). The sensitivity and specificity of the nomogram were 86.67% and 82.19%, respectively. The calibration curve indicated good consistency between the predicted and actual risks.CONCLUSIONSThe preliminary nomogram could contribute to preventing postoperative residual cavity formation and making appropriate surgical decisions.

Uniportal thoracoscopic decortication for stage Ⅲ tuberculous empyema of 158 cases

Objective: To examine the safety and feasibility of uniportal video-assisted thoracoscopic (VATS) decortication in patients presenting with stage Ⅲ tuberculous empyema. Methods: From August 2017 to July 2020, 158 patients of stage Ⅲ tuberculous empyema underwent uniportal VATS decortication with partial rib resection and customized periosteal stripper in Department of Thoracic Surgery, Shanghai Pulmonary Hospital. There were 127 males and 31 females, aged (M(IQR)) 32(28) years (range:14 to 78 years). Follow-up was performed in the outpatient clinic or via social communication applications, at monthly thereafter. If there was no air leak and chest tube drainage was less than 50 ml/day, a chest CT was performed. If the lung was fully re-expanded, chest tubes were removed. All patients received a follow-up chest CT 3 to 6 months following their initial operations which was compared to their preoperative imaging. Results: There was one conversion to open thoracotomy. The operative time was 2.75 (2.50) hours (range: 1.5 to 7.0 hours), and median blood loss was 100 (500) ml (range: 50 to 2 000 ml). There were no perioperative mortalities. There were no major complications except 1 case of redo-VATS for hemostasis due to excessive drainage and 1 case of incision infection, The incidence of prolonged air leaks (>5 days) was 80.3%(126/157). The postoperative hospital stay was 5.00 (2.25) days (range: 2 to 15 days). All patients were discharged with 2 chest tubes, and the median duration drainage was 21.00 (22.50) days (range: 3 to 77 days). Follow-up was completed in all patients over a duration of 20 (14) months (range: 12 to 44 months). At follow-up, 149 patients(94.9%) recovered to grade Ⅰ level, 7 patients to grade Ⅱ level, and 1 patient to grade Ⅲ level. Conclusion: Uniportal VATS decortication involving partial rib resection and a customized periosteal stripper is safe and effective for patients with stage Ⅲ tuberculous empyema.

Uniportal thoracoscopic decortication: start away from empyema approach

Aim: Video-assisted thoracoscopic surgery (VATS) is now a gold standard in treating early-stage empyema, while much debate still exists considering the effectiveness of this approach for late-stage empyema. Most concerns arise from the crowded rib cage, narrow working space, and ability to free trapped lungs quickly, mainly if uniportal VATS is used. However, unlike uniportal VATS lobectomy, there is no consensus about standard steps for uniportal VATS decortication to ensure smooth and effective surgery. We try to offer standard, easy-to-replicate steps for this approach to evaluate the efficacy and safety of the “start away from empyema” approach for uniportal VATS decortication in the management of stage II and III empyema. Methods: A prospective case series study has been conducted on 25 patients. All patients with stage II and III empyema were admitted to the Cardiothoracic Surgery Department between October 2017 and March 2020. VATS procedure was done under general anesthesia by a double-lumen tube for selective ventilation. Demographic data, preoperative diagnosis, intraoperative findings, hospital stay, and complications were recorded. Results: Twenty-five patients were enrolled in this study with a median age of 35 years. The duration of illness ranged between 14 and 60 days, with a median (IQR) of 25 (17) days. In (88%) of the patients, there was a successful outcome defined as a near-complete resolution on Chest X-ray (scoring of 3 or 4) and chest US (scoring of 2 or 3). Only three (12%) patients had a partially successful outcome. All patients with partial success suffered from infection associated with malignant effusion. Conclusion: “Start away from empyema” approach for uniportal VATS decortication in stage II and III empyema could be safe and effective in treating loculated nonmalignant pleural effusion.

Unanticipated Profound Paralysis and Sugammadex Dosing Implications After Videoscopic Thoracic Surgery.

A bedridden patient with empyema presented for thoracoscopic decortication. During the procedure, despite a post-tetanic count (PTC) of 0 via calibrated quantitative neuromuscular monitoring, persistent diaphragmatic movement impaired operating conditions, so rocuronium was re-dosed. After surgery, the patient had 0 PTC. Sugammadex was titrated to achieve baseline neuromuscular strength, monitoring the effect of each 200-mg dose. Ultimately, 1200 mg was required to achieve baseline strength. We describe monitor troubleshooting, considerations with unexpectedly deep neuromuscular blockade, the importance of routine quantitative neuromuscular monitoring, and one strategy for sugammadex reversal in patients with profound paralysis outside of the standard dosing guidelines.

P034 STRANGULATED DIAPHRAGMATIC HERNIA: TEN CASES REPORTS

Abstract Aim A diaphragmatic hernia (DH) is a protrusion of abdominal contents into the thoracic cavity as a result of a defect within diaphragm. It is most common as a congenital phenomenon; however, there have also been cases where it can be acquired. DH can be life-threatening, resulting in incarceration and strangulation. Material and Methods From June 2009 to April 2021, ten cases of strangulated diaphragmatic hernia were admitted to our Emergency Surgery Department of General Surgery with respiratory and abdominal symptoms. Patients' characteristics, operation details, and postoperative complications were retrospectively analyzed. Results There were 5 (50%) men and 5 (50%) women with a mean age of 66 years (range, 20–85 years). . Emergency surgery was performed by laparoscopic in 4(40%) patients and open in 6(60%) patients. Two patients had a history of penetrating trauma to the left thoracoabdominal region. Segmental bowel resection was performed in 3 patients and total gastrectomy in 1 patient. Reconstruction was not performed in the patient who underwent total gastrectomy due to ischemia and perforation. In the postoperative period, wound infection was observed in 2 patients. Anastomotic leakage was observed in 1 patient and treated with end enterostomy. Empyema was observed in one patient after discharge, the empyema was evacuated and thoracoscopic decortication was performed .The patient who underwent total gastrectomy died due to septic shock and comorbid diseases. Conclusions Strangulated diaphragmatic hernia is a life-threatening condition and requires emergency surgery. Laparoscopic techniques can also be used in treatment.

OUTCOMES OF VIDEO ASSISTED THORACOSCOPIC DECORTICATION VERSUS CONVENTIONAL OPEN DECORTICATION IN PATIENTS WITH STAGE II OR STAGE III EMPYEMA

Objective: To compare outcomes of video assisted Thoracoscopic Decortication (VATD) with conventional open decortication (COD) in patients with stage–II or stage–III empyema thoracic.&#x0D; Study Design: Prospective comparative study.&#x0D; Place and Duration of Study: Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi, Pakistan, from Jun 2018 to May 2019.&#x0D; Methodology: A total 60 patients underwent in this study. Patients of both gender who reported for decortication of empyema thoracic were evaluated. All patients diagnosed to have Stage II or III empyema with age 25-50 years were studied for outcomes. All patients were evaluated for operative time, blood loss, post-operative pain, pneumonitis, duration of airleak and post-operative drainage, duration of chest drains and length of hospital stay.&#x0D; Results: Mean operative time in group-1 was 133.63 ± 8.55 min and in group-2 was 147.83 ± 10.36 min (p-value 0.037). Mean blood loss in group-1 was 296.66 ± 46.11 while in group-2 was 207.30 ± 53.81. Post-operative pain score on VAS for pain was 5.8 ± 1.7 for group-1 and 4.06 ± 1.4 for group-2 (p-value 0.032). Chest tubes were retained for an average of 5.58 ± 0.8 days in group-1 while 3.86 ± 0.8 days in group-2 (p-value &lt;0.001).&#x0D; Conclusion: Video-Assisted Thoracoscopic Surgery Decortication is superior to open decortication in operative management of Stage II and Stage III Empyema thoracic in terms of post op pain, duration of chest intubation, air leak and hospital stay of the patient.