Is chest tube clamping necessary before removal? an experience with 2661 cases of tube thoracostomies

Objective: The aim of this study was to evaluate outcome of chest tube removal without clamping and relying only on clinical or radiological status for removal

Study Design: Retrospective descriptive study

Place and Duration of Study: The study was conducted in CMH Rawalpindi over a period of four years

Material and Methods: All patients of tube thoracostomies during Jan 2010 to Dec 2013 were included. Sample size was 2661. 1061 intubations were done for trauma, effusions and pneumothoraces, 905 in thoracostomies, 443 in VATS procedures like decortications, apical staplings, pleural biopsies and thymectomies and 252 in miscellaneous procedures such as open pleural biopsies, thoracoplasties and chest wall resections and reconstructions. Chest tube removal was based on absence of air bubbling in chest bottle, clinically or radiologically expanded lung, less than 6 cm excursion of column of chest tube and fluid output of <50ml [pus] and <100ml [clear fluid]. It was ensured in all cases that chest tube was not blocked and all tubes were removed by a thoracic surgery trainee. Chest tube was not clamped in any patient before removal to see respiratory distress

Results: Tube thoracostomies were performed in a vast variety of procedures. 1940 [72.9%] were males and 721 [27.1%] were females. Mean age was 37 years. In 1529 [57.4%] intubation was done on the right side. In 34 [1.27%] there was recurrent fluid collection. Recurrent pneumothorax was seen in 18 [0.67%] while tension pneumothorax was seen in 4 [0.15%]. Collective complication rate was in 56 [2.1%]. There was no mortality

Conclusion: Current worldwide practice of clamping chest tube before removal to judge respiratory distress can be challenged by our study. Emphasis is laid on clinical judgment, absence of air leak and minimal excursion sign of well expanded lung before removal of chest tube

Frequency of anomalies associated with chest deformity in physically fit male candidates reporting for military recruitment

To identify the frequency of anomalies associated with chest deformity in physical fit male candidates reporting for military recruitment. Observational. Department of Thoracic Surgery, CMH Rawalpindi from 1[st] Jan 2008 to 31 Dec 2011. Normal healthy physically fit young adolescents being recruited for army were scrolled and those exhibiting chest deformity were isolated and subjected to evaluation. Convenience sampling was carried out. All cadidates of chest wall deformity thereafter underwent a thorough physical checkup, pulmonary function tests and echocardiography. A total of 3735 candidates of chest deformity reported at our center for evaluation over this duration. Single deformity patients 3380 [90.5%], mixed deformity patients 355 [95%]. We found that none of the candidates had any derangement of the lung function tests or electrocardiographic abnormality despite their deformity. However echocardiography detected an abnormality in 161 [4.3%] individuals who were otherwise asymptomatic. Chest deformity should be excluded before physical tests, in all the male candidates reporting for enrolment. If slightest of doubt exists that a candidate has chest deformity then he should be evaluated with echocardiography to exclude cardiac abnormality. Although the associated frequency is only 4.3% but this can subsequently result in a grave event like death

Solitary pulmonary nodule a rare case

A middle aged man presented with a solitary pulmonary nodule. He had a diagnostic dilemma as the CT guided FNAC was inconclusive. The frozen section exam reported it to be malignant so a lobectomy was performed for this lesion. The final histopathology report confirmed it to be a very rare tumor of extra skeletal synovial sarcoma

Comparison of electrosurgical versus scalpel skin incision in inguinal hernioplasty in terms of early postoperative pain

Objective: To compare early mean postoperative pain following use of diathermy and scalpel for making skin incision in inguinal hernioplasty

Study design: Double blind, randomized controlled trial

Place and Duration of study: Department of General surgery, Combined Military Hospital Rawalpindi, from September 2011 to February 2012

Methodology: A total of 60 patients who underwent either diathermy skin incision [group A n=30] or scalpel skin incision [group B n=30] were analyzed. Early postoperative pain was compared in both the groups by using visual analogue scale. The inclusion criteria were all adult male and female patients who underwent elective or emergency inguinal hernioplasty under spinal anesthesia. The exclusion criteria were patients with recurrent inguinal hernias and patients operated under general or local anesthesia

Results: Mean VAS was 2.15 + 1.200 in the diathermy group and p value was 0.00, which was significant.In the scalpel group mean VAS was 4.95 + 1.373. Mean percentage of pain score in scalpel was 49.5%, whereas in diathermy group its was 21.5%, which is significantly lower than the scalpel group

Conclusion: Diathermy incision has significant advantage compared with scalpel in terms of reduced early postoperative pain

Video assisted thoracoscopic surgery [vats]; two years experience at thoracic surgery department, combined military hospital Rawalpindi

To review the experience of video-assisted thoracoscopic surgery [VATS] with 202 different cases focusing on indications, operative procedures, side effects and complications. Descriptive Study. Department of Thoracic Surgery, Combined Military Hospital, Rawalpindi, for 2 years from January 2009 till January 2011. Two hundred and two video-assisted thoracoscopic surgeries [VATS] were performed over 2 years. There were 131 [64.9%] males and 71[35.1%] female patients. Total two hundred and two patients were selected who were divided into two groups: diagnostic and therapeutic group. The mean age of the patients was 40.25 years [SD +/- 12.58] with an age range of 13-77 years. There were 131 males [64.9%] and 71 [35.1%] females. The main indications of video-assisted thoracoscopic surgery were diagnostic in 118 patients and therapeutic in 84 patients. Sixty one patients underwent VATS for indeterminate pleural effusion and a definitive diagnosis was made in 90.2% patients. Definitive diagnosis was made in all sixty six patients who underwent VATS for wedge resection/forceps biopsy of pulmonary nodules, mediastinal masses and interstitial lung disease. VATS thymectomy was performed on 13 patients while 3 patients underwent VATS sympathectomy. Conversion to thoracotomy was required in 8.4% [17/202] of the patients. Adhesions were the most common indication of conversion. There was no operative mortality. The overall median duration of chest tube drainage was 4 days and median postoperative hospital stay was 5 days. Postoperative complications were encountered in 5.9% patients [12/202 patients]. No perioperative mortality was encountered in either group. This review indicates that VATS can be performed with minimal morbidity for therapeutic purposes as a current approach for thoracic surgery. It is a safe procedure in many intrathoracic diseases and is associated with less postoperative pain and hospital stay than open thoracotomy

Intestinal tuberculosis presenting as acute abdomen

To study the outcome of intestinal tuberculosis presenting as acute abdomen. Descriptive Study. Bolan Medical Complex Hospital [BMC] Quetta and Combined Military Hospital [CMH] Quetta from Nov 2003 to Nov 2005 from Bolan Medical Complex and from Nov 2005 to Nov 2006 in CMH Quetta. Thirty seven patients of acute abdomen presenting with intestinal obstruction were admitted; 28 from emergency department and 9 from out patient department. Twenty seven patients were from BMC and 10 from CMH Quetta. Patients were diagnosed as having abdominal tuberculosis on the basis of operative findings and histopathological reports. Out of 37 patients presenting with acute abdomen due to intestinal obstruction, 54% were male and 46% were female with M: F ratio of 1: 1.2. Age of the patient ranged from 20 to 50 years, with maximum frequency between 30 to 40 years. Abdominal pain was the commonest presenting feature in all patients followed by constipation in 81.1% patients. Peritonism was seen in 27% patients. Different operative procedures performed were adhesionolysis 65.8%, segmental resection 7.9%, right hemicolectomy 10.5%, stricturoplasty 7.9% and ileostomy 1.3%. Mesenteric lymph node biopsy 40.8%.Intestinal tuberculosis is still a very important surgical problem in our country presenting as acute abdomen. A suspicion must always be kept during laparotomy and adequate tissue histopathology should supplement the diagnosis.

Management of primary spontaneous pneumothorax by video assisted thoracoscopic surgery [VATS]

To evaluate the outcome of treatment of primary spontaneous pneumothorax by VATS. Case Series. Dept. of thoracic Surgery Combined Military Hospital Rawalpindi between April 2007 to Dec 2009. This study included 20 patients with primary spontaneous pneumothorax who were treated by VATS apical stapling and pleural abrasion/ pleurectomy. All patients were operated under one lung ventilation. Three ports of 10mm were used and apical stappling / bullectomy was done with linear cutting stapler [ethicon, autosuture]. This was combined with pleural abrasion/ pleurectomy, Chest was drained via a single chest tube. We had 21 procedures on 20 patients. There were 18 males and 2 females [9:1]. Mean age was 26.4 years. Indications included persistent air leak 7, recurrent attack 12, contralateral recurrence 1 and professional hazard 1. Mean hospital stay was 3.2 days. Complications included minor port site infection 5, intercostals neuralgia 3, delayed lung expansion 2 cases and persistent apical space in 1 case. There is no recurrence. VATS was a reliable approach for managing primary spontaneous pneumothorax with low morbidity

Video assisted thoracoscopic surgery [VATS] lung biopsy for non-responsive patients of interstitial lung disease [ILD]

To study the results of VATS [Video Assisted Thoracoscopic Surgery] Lung Biopsy in Interstitial Lung Disease [ILD] case series. Department of Thoracic Surgery, CMH Rawalpindi from Jan 2009 to Mar 2010. All those patients of ILD [Interstitial Lung Disease] were included who failed to improve after a period of observation including those on empiric therapy, all patients in which BAL [Bronchoalveolar Lavage] and TBLB [Transbronchial Lung biopsy] was inconclusive and all those patients fit to undergo thoracoscopic surgery. Patients excluded were elderly patients, those with systemic disorders frequently associated with ILD and those with known neoplasm likely to have lymphangitic dissemination. We used three thoracoscopic ports, all biopsies were sent for histopathology examination, single chest tube was placed in all cases and it was removed once the airleak ceased. All complications encountered were noted. Fourteen patients were registered during study period. Biopsy showed that 9 had ILD, and 5 did not have ILD. Only complication was a prolonged airleak for 2 days in 2 patients. No mortality was encountered. Thoracoscopic surgical biopsy can be accomplished safely in most cases where there is a diagnostic dilema for interstitial lung disease

Recurrent laryngeal nerve injury; a risk in thyroid surgery

Aim of this study was to find out the frequency of recurrent laryngeal nerve injury in different types of thyroid surgery. An experimental study. The study was carried out at Combined Military Hospital, Rawalpindi from January 2001 to July 2002. Seventy two patients were included in this study. Case selection was done by non probability convenient sampling from surgical out patient department. Age of patients ranged between 15 years to 73 years. Mean age was 36.5 years with maximum prevalence in the range of 31-40 years [31.5%] Male to female ratio was 1:1.7. All patients were evaluated clinically and were advised preoperative routine investigation. All patients had voice analysis along with indirect laryngoscopic examination preoperatively. The commonest presenting complaint in 72 patients was lump front of neck in 69 [95.8%] patients, 48[66.7%] patients were having nontoxic goiter, 15 [20.8%] patients were having toxic goiter and 9 [12.5%] patients were having malignant goiter. Out of all thyroidectomies performed 48 [66.7%] were sub total, 18 [25%] lobectomy with Isthmusectomy, 5 [6.9%] were near total and 1 [1.4%] was total thyroidectomy. Temporary recurrent laryngeal nerve injury occurred in 2 [2.8%] cases. Permanent injuries to recurrent laryngeal nerve occurred in 2 [2.8%] cases, one patient had vocal cord paralysis and other developed vocal cord paresis which improved partially with time. Recurrent laryngeal nerve injury is a potentially dangerous and a serious complication of thyroid surgery. The overall percentage of injury to recurrent laryngeal nerve in thyroid surgery in this study was 4 [5.6%] cases

Bilateral thoracoscopic sympathectomy

A 34 years male Asian presented from skin department as referral case of bilateral increase in sweating both arms from axilla to palms. He was symptomatic for the last three years and was having different treatment from general OPD and Skin Department in the form of astringent local applications and oral medications. He was clerk by profession and had to use frequent cleaning of sweat during his work that was embaressing and was causing jeopardy to his job. He had no associated clinical features of vasospatic conditions. His base line investigations were normal, additional thyroid function and glucose profile was normal. His chest X-ray was normal with no apparent clinical or radiological evidence of lung parenchymal pathology which would hinder thoracocscopic dissection and approach. He went bilateral thoracoscopic surgical sympathectomy first on right side then on left all procedure was performed in modified decubitans position with patient slightly forward approx 15 degree beyond perpendicular. This allowed the ipsilateral lung to fall away from the posterior located sympathetic chain, first in right position under general anesthesia with double-lumen endotracheal intubation so that the lung on the operative side can be deflated. To enhance exposure of the posterior mediastinum an anterior rotation was given. The pleural space was then inspected using a zero degree 5-mm endoscope fifth intercostals space in midaxillary line. This was supplemented by two 5mm working trocars in third intercoastal space, one anterior and posteriorly. The rib spaces and corresponding segment of the sympathetic chain were then visualized [fig. 1] by an area of bright yellow fat and the overlying parietal pleura incised. Using monopolar cautery the sympathetic ganglia at T2, T3 are isolated and individually excised. Dissection was not carried above the upper border of second rib to preserve 5th stellate ganglion [fig. 2]. Finally the bodies of the second and third ribs are horizontally with cautery from the costovertebral angle laterally for 3 to 4 cm, this divided the accessory fibers. Hemostasis was then obtained and chest tube 28 Fr was passed through the axillary port of the endoscope. The procedure was then repeated on the left side. Lung was fully expanded and underwaterseal was finally checked again. A chest roentgenogram was then obtained postoperatively to confirm adequate expansion of the lungs. The patient was then observed for Homer syndrome. Lung was expanded chest tube was removed very next day with full radiological and clinical expansion. Patient was discharged next days. He had complete recovery of symptoms post operatively

Association of mine blast injury with radioopaque foreign body on radiology and assessment of the severity and area involved

To determine the association of mine blast injury with radio-opaque foreign body on radiology and assessment of the severity and area of body involved. Observational study. The study was conducted at CMH Quetta and included cases over a span of one year from Aug 2005 to august 2006. 28 cases which had antipersonnel land mine injuries were taken at random from record and their x-rays were analyzed for radio-opaque material in the filed up imaging films and area of the body involved and severity was grouped. Landmine blast injury is associated with metallic radio-opaque foreign body on radiology. In this small study about 82 percentage have radioopaque material and majority were less than 10 mm. 60.7% percentage had severe injuries with fractures and amputation and major exploration was required. More than 50% involved combined injuries to limb and torso