Analysis of primary intrathoracic extrapulmonary hydatid cysts a rare clinical entity

To evaluate the anatomic location of cysts, operative characteristics of intrathoracic extrapulmonary hydatid cyst and to determine the outcome of aggressive surgical interventions.Case series. Thoracic Surgery Unit Lady Reading Hospital Peshawar from 1[st] July 2008 to 30[th] June 2011. All patients admitted to Thoracic unit from July 2008 to June 2011 with intra thoracic hydatid cysts were evaluated prospectively as to age, sex, symptoms, diagnostic procedures, anatomic location of cysts, surgical procedures, complications, and outcomes. Chest radiography, computed tomography, and thoracic and abdominal ultrasonography had been performed preoperatively in all of them. Bronchoscopy and spirometry was also performed in all patients for assessment and operability.Echocardiography had been used in 2 patients to determine the contiguity of the cyst to the pericardium. Cystectomy and wide resection were the chief operative procedures. Most of the patients were having cysts in the pulmonary parenchyma only 10 patients had intrathoracic cysts in extrapulmonary locations. This group of patients was included in the study. We excluded patients who had a parenchymal cyst that had perforated to the pleura, myocardial hydatid and patients who had Total of 149 patients were operated for hydatid cystectomy, out of these 139 patients had pulmonary hydatid and 10 patients had intrathoracic extrapulmonary hydatid cysts. These 10 patients constitute our study group; out of these 7 were men and 3 women whose mean age was 39.14 +/- 16.8 years range, [16-69 years]. Eight [80%] of these were symptomatic, most commonly with chest pain, two patients were asymptomatic. There were 2 [20%] mediastinal hydatid, 2 [20%] diaphragmatic, 2 [20%] pericardial, 2 [20%] oblique fissure, and 1 [10%] each in chest wall and pleural hydatid in our study. Albendazole [10 mg/kg] was prescribed to all patients for as long as 3 months postoperatively. No complication, recurrence, or death occurred during the follow up period of 13 +/- 15.4 months [range, 2-36 months].The extrapulmonary location of Hydatid cysts within the thorax is very rare. This rarity may cause difficulties in diagnosis. To avoid recurrence, it is necessary to resect the affected tissues completely and an anthelmintic medical regimen post operatively

Gastroesophageal anastomosis: single-layer versus double-layer technique-an experience on 50 cases

Considerable controversy exists regarding the optimum technique for gastroesophageal anastomosis. Double layer technique has long been considered important for safe healing but there is evidence that single layer technique is also safe and can be performed in much shorter time. The purpose of this study was to compare the outcome of single layer and double layer techniques for gastroesophageal anastomosis. A prospective randomized study was conducted in cardiothoracic unit, Lady Reading Hospital from Jan 2006 to Jan 2008. Fifty patients with oesophageal carcinoma undergoing subtotal oesophagectomy were randomized to have the anastomosis by single layer continuous or double layer continuous technique [group A [n=24] and B [n=26] respectively]. The demographic data, operative and anastomosis time, postoperative complications and hospital mortality were recorded on a proforma and analyzed on SPSS 10. There was no significant difference between group A and B in terms of age, gender, postoperative complications and duration of hospital stay. Anastomotic leak occurred in 4.2% patients in group A and 7.7% in group B [p=NS]. Mean anastomosis time was 10.04 minutes in group A and 19.2 minutes in group B [p=0.0001]. Mean operative time was 163.83 minutes and 170.96 minutes in group A and B respectively. Overall hospital mortality was 2%; no deaths occurred due to anastomotic leak. Single layer continuous technique is equally safe and can be performed in shorter time and at a lower cost than the double layer technique

Thymectomy for myasthenia gravis: Peshawar experience of 27 cases in five years

To determine the safety and efficacy of Thymectomy for myasthenia gravis. This observational descriptive study was conducted at Departments of Cardiothoracic Surgery and Neurology Lady Reading Hospital Peshawar from January 2002 to December 2006. Computerized clinical data of 27 diagnosed cases of myasthenia gravis that underwent thymectomy were retrospectively analyzed. Patients who were unfit for surgery were excluded from the study. CT scan was done in all patients apart from routine investigations. Preoperative medication included anticholinesterase drug. They all underwent Thymectomy via median sternotomy. A total of 27 patients [09 males and 18 females] with a mean age of 30.5 years [range 15-50 years] were analyzed. The preoperative duration of the disease ranged from 0.5 to 120 months [mean=25.72 +/- 30.68 months]. According to the Myasthenia Gravis Foundation of America [MGFA] clinical classification, 20 [74.07%] patients were in stage two while 7 [25.925%] patients were in stage three. The histology of thymus glands consisted of hyperplasia in 12 [44.4%] patients, normal in 10 [37.1%], atrophic thymus in 3 [11.1%] and thymoma in 2 [7.4%] patients. Hospital mortality was 7.4% [n=2/27] while morbidity was 3.7% [n=1/27]. The mean follow up period was 31.5 months [3-63 months]. Complete remission was achieved in 55.55% [n=15/27] patients, and marked improvement in 25.92% [n=7/27], for a total benefit rate of 80%. Five [18.51%] patients remained unchanged and had no clinical improvement. Thymectomy is a safe and effective treatment for patients with myasthenia gravis

three-year audit of rigid oesophagoscopy at lady reading hospital Peshawar

The number of oesophagoscopies performed annually provides an indication of the extent of oesophageal disorders in any particular setting. The present study aimed to provide such data for rigid oesophagoscopy at the only referral centre for this procedure in Peshawar. An audit of all available records of patients undergoing rigid oesophagoscopies from January 2002 to December 2004, at the Lady Reading Hospital Peshawar was performed. A total of 200 cases of rigid oesophagoscopies were performed during this three-year period of study. The ages of patients ranged from 1 to 90 years, with a two fold male preponderance. The main indication was dysphagia with major causes being oesophageal carcinoma [115, 57.5%], reflux oesophagitis [56, 28%], strictures of various aetiologies [19, 9.5%] and foreign bodies [10, 5%]. Successful dilatation was possible in 70% of cases; the morbidity rate was 4.5% due to perforation observed in 9 cases. The mortality rate was 1.5% due to septicemia in 3 cases. A high rate of rigid oesophagoscopies was observed indicating an increased frequency of oesophageal disorders in this setting. The morbidity and mortality rates observed are within acceptable ranges for this procedure

Use of continuous low pressure suction on chest drain in thoracic surgical unit

To assess the merits and demerits of continuous Low Pressure Suction applied to the chest drain in both preoperative and postoperative thoracic patients. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, ady Reading Hospital Peshawar from Jan 2005 to March 2005. It was a prospective study carried out over the period of three months to assess the benefits of Low Pressure Suction. Patients with Chest trauma, inflammatory disease of the lung and pleura, carcinomas and postoperative patients were included in the study. Patients with multiple trauma and moribund patients were excluded from the study. Postoperative patients were given priority for suction beds. The suction applied to the chest drain ranged from -05 to -20 KPa. It was continuously applied to the chest drain 24hrs a day and 7 days a week and only interrupted at the time of bottle change or patients going to toilets. A total of 180 patients were included in the study, which were divided into two groups depending upon the availability of suction beds. Group I: Included those patients who were put on Continuous Low Pressure Suction. Group II: Included those patients who were not put on Continuous Low Pressure Suction because lack of suction beds. Ninety patients were included in group I and similar number of patients into group II. In group I out of 90 patients 40 were non-operative and 50 were operative. In group II out of 90 patients 55 were non-operative while 35 were operative. Out of operated patients [total 85] full lung expansion was achieved in 42 [84%] in group I and 25 [71.4%] in group II while partial lung expansion was achieved in 08 [16%] in group I and 10 [28.6%] patients in group II. Out of non-operated patients [total 95] full expansion was achieved in 35 [87.5%] in group I and 42 [76.4%] in group II while partial expansion was achieved in 05 [12.5%] patients in group I and 13 [23.6%] in group II. Out of 5 partial expansions in group I suction had to be discontinued in 2 patients because of increasing air leak. Continuous low pressure suction helps to decrease the need for surgery in patients following chest trauma, inflammatory lung disease and decreases morbidity in postoperative patients

experience of 108 cases of esophagectomy using left thoracolaparotomy and cervical anastomosis with feeding jejunostomy, without gastric drainage procedure

Objective: To study efficacy and safety of esophagectomy using left thoracolaparotomy and left neck anastomosis with feeding jejunostomy, but no gastric drainage procedure

Design: An observational descriptive study

Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from June 2002 to September 2004

Subjects and Methods: Computerized clinical data of 108 surgically treated patients during twenty eight months was retrospectively analyzed. Detailed scrutiny of record was carried out to determine the suitability and safety of the surgical procedure and surgical outcome

Results: A total of 108 patients underwent esophagectomy through left thoracolaparotomy and left neck incision. Male: Female was 72: 36, age range was 18 - 72 years with a mean age of 42.3 years. The predominant clinical presentation was dysphagia. Tumor level was upper third of thoracic esophagus in 3 [2.7%], middle third in 48 [44.4%] and lower third in 57 [52.7%] patients. Tumor histology was squamous cell carcinoma in 72 [66.6%] and adenocarcinoma in 36 [33.3%] patients. The mean operative time was 155 [25 +/- ] minutes. Postoperative morbidity was 19.4% [21/108]. The complications were anastomotic leak in 7[6.5%], Hoarseness in 6[5.5%], aspiration in 3[2.7%]; reopening in 1[0.9%] and stricture in 4[3.7%] patients. The overall mortality was 8.3% [9/108]. Deaths were due to anastomotic leak in 3[2.7%] tracheal injury in 2[1.85%], respiratory failure in 2[1.85%] and pulmonary embolism in 2[1.85%] patients. 28 patients were lost to follow-up while incisional hernia was seen in 1, hoarseness in 3 and stricture in 3 patients over a last one month to 2 years follow-up. Recurrence occurred in 3/108 [2.77%]; one developed malignant ascities, after 4 months, one developed nodule in hypopharynx after 18 months, and one developed a subcutaneous nodule on the back after 14 months

Conclusion: Left thoracolaparotomy and cervical anastomosis is a safe approach for carcinoma of the esophagus. A 30 day mortality of 8.3% in a large series of 108 oesophagectomies with 2.7% recurrence and 19.4% morbidity speak volumes for the technique. Omitting a gastric drainage procedure does not adversely effect the outcome, while routine placement of a jejunostomy feeding catheter is a safe and cost effective mode of nutrition. Neck anastomosis gives a generous tumor free margin, a s a 11 except one resection margin was free o f tumor. T his i s further consolidated by only 3 cases of recurrence out of 80, with 28 being lost to follow up

Pneumonectomy for benign lung disease

Objective: This study was done to define morbidity and mortality of elective pneumonectomy for benign lung disease, as well as to recommend safety measures

Design: An observational descriptive study

Place and Duration of study: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from June 2002 to September 2004

Material and Methods: Thirty six patients received elective pneumonectomy. Male : Female 21 : 15. Age range was 4 months to 72 years. Past recurrent or new pulmonary tuberculosis was seen in 33/36 patients. Thirty one patients had chronic hemoptysis, while 6 had massive hemoptysis while thirty two had end stage destroyed lung. Left Right ratio was 24: 12. Double lumen endotracheal tube was used in 32 cases. Standard transpleural pneumonectomy was done in all cases with slight head down tilt of the table. Bronchial closure was done in 2 layers with interrupted Prolene 2/0 and 4/0. Single unclamped chest drain was put in all cases and removed after 24 hours

Results: Thirty day mortality was 1/36 [2.7%]. Morbidity included post pneumonectomy BPF 2, post pneumonectomy empyema 3 and wound infection 1. Both bronchopleural fistula and post pneumonectomy empyema were treated by tube thoracostomy initially, while 2 patients subsequently required additional thoracostoma and later space closure. Of these 1 went on to have thoracoplasty

Conclusion: Pneumonectomy proved effective therapy for end stage destroyed lungs with active / recurrent hemoptysis, but post pneumonectomy empyema and BPF are serious complications. Early clamping of the bronchus and avoiding bearing of bronchus reduce morbidity. There is no need to clamp the chest drain, which should be removed after 24 hours

Presentation and management of empyema thoracis at lady reading hospital Peshawar

Background: Empyema thoracis remains a common thoracic problem with challenging management strategies. We undertook the present study to outline key aspects of the presentation and management of this condition at our tertiary care hospital

Methods: We analyzed 105 consecutive patients treated for empyema thoracis over a one-year period at Thoracic Surgical unit, Lady Reading Hospital Peshawar Pakistan. The study included patients aged 10-60 years of either sex. Patients were subjected to detailed diagnostic and management protocols with a view to define successful diagnostic and management strategies

Results: The majority of patients [68%] were male, with a mean age of 28.5+/-14.2 years, a majority [42%] being in the 10-20 years age group. Common presentation was with fever [73%], cough [65%] and chest pain [60%]. The mean duration of symptoms was 6.1 weeks. Common aetiologies of empyema were pneumonia [46.7%], iatrogenic [21.9%], traumatic [16.2%] and malignancies [11.4%]. Forty patients [38%] underwent an unsuccessful therapeutic procedure prior to admission to the Thoracic unit. In the unit, 58 patients received closed intercostal drainage [31 of which required further intervention], five patients were treated with repeated thoracentesis and 8 patients were subjected to fibrinolytic therapy. The majority of patients underwent a surgical procedure like rib resection [7], decortication [23], thoracoplasty [3] and other procedures in the first instance with only 4 patients requiring further surgery. Majority of patients [97/105, 92.4%] were cured of their disease. The hospital mortality was 7.6%

Conclusion: Multiple therapeutic options exist for the treatment of thoracic empyema. Optimal therapy requires selection of the most appropriate first procedure for each patient with post procedure imaging to avoid inordinate delays between interventions. Early referral of all empyema patients to thoracic units for definitive therapy is recommended

prospective study of penetrating chest trauma and evaluation of role of thoracotomy

Objective: to evaluate the different lines of management of penetrating chest trauma and determine the indications of thoracotomy in patients sustaining penetrating chest trauma

Material and Methods: a prospective study was conducted at the Department of Cardiothoracic Surgery; Postgraduate Medical Institute Lady Reading Hospital, Peshawar from May 1996 to April 1997. One hundred and twenty patients presenting with penetrating chest trauma were included. Those patients who had blunt chest trauma or associated injuries to the spine, abdominal viscera, head and neck and extremities were excluded from the study. All these patients were resuscitated and evaluated on arrival to the hospital. The patients were individualized on the basis of clinical parameters and grouped as stable and unstable. After haemodynamic stabilization decision regarding surgical intervention was made on the basis of clinical feature and radiological examination. In this manner patient were grouped as those requiring conservative management or surgical intervention

Results: out of 120 patients, conservative management was adopted in 12 patients [10%]. Thoracostomy tube was placed in 110 patients [91.66%]. Only 12 patients [10%] underwent early Thoracotomy, 3 for massive hemothorax and lung laceration, 4 for evacuation of clotted hemothorax, 2 for removal of foreign body [bullet] in the lung parenchyma, and one each for empyema, chylothorax and diaphragmatic laceration. Two patients out of three died after emergency thoracotomy. Overall mortality was 2.5% [3 patient out of 110]

Conclusion: early thoracotomy has a definite role both in emergencies and for various complications resulting from penetrating chest trauma. Adequate initial line of management of penetrating chest injuries will minimize life-threatening complications

One year experience of treating carcinoma oesophagus

To audit one year of esophageal workload in a Cardiothoracic unit Material and This study was conducted at Cardiothoracic unit Lady Reading hospital peshawer from 1st January to 31st December 2003, and it comprised of 146 patients presenting with spontaneous dysphagia. Barium swallow and endoscopy/biopsy were done for diagnoses; C.T scan was used to stage the disease and offer possible treatment. Ca esophagus constituted 25.84% of total operative work load in one year. Disease was more common in males; mean age at presentation was 56 years. High incidence was found in Afghan nationals. The common presenting clinical features were dysphagia and weight loss. Barium swallow detected the abnormality in almost all advanced cases. C.T scan was found accurate in[36/41] 87.80% cases in staging the disease. In majority of cases disease arose in the lower 2/3 of the organ and most frequently it was sqamous cell carcinoma.[105/146] 71.91% were inoperable; surgery offered good in operable cases. Carcinoma oesophagus is not uncommon in this part of the world; Efforts should be made to diagnose the disease early, as the treatment is possible and give good in the early stage of disease