Two years followup of 1503 cases of esophagectomy over a period of 12 years

Objectives: To determine the early outcomes of 1503 esophagectomies over a period of 12 years

Methods: Computerized clinical data of 1503 cases of Esophagectomy for carcinoma esophagus from June 2002 to May 2014 was retrospectively analyzed. All patients had CT Thorax/ upper abdomen with oral and IV contrast. The operative approaches included left thoracolaparotomy with left neck anastamosis, transhiatal, left thoracolapratomy Reux en-Y, Mckeown with right Thoracotomy, Ivor Lewis and left thoracolaparotomy with left decortication. All operations were done by one surgical team

Results: Out of 1503 patients, 1077 were males and 426 were females with a mean age of 51.6 years. The age range was 17 to 80 years. Out of 1503 cases, 907 had lower one third tumors. 587 had middle one third tumors. Out of 907 lower one third tumors, stomach involvement was present in 312 cases. Histopathology reports showed adenocarcinoma in 802 specimens, squamous cell carcinoma in 682, adenosquamous was 9 and carcinoma in-situe reported in one case. Morbidity was 6% and comprised anastomotic leak in 30 cases, pulmonary complications in 33, wound infection 13, hoarseness 12 and anastomotic strictures developed in 17 cases. Mortality was 2.5% and included aspiration pneumonia respiratory failure in 10 cases, myocardial infarction in 8 cases, anastomotic leak 8, tracheal injury 3 and presumed myocardial infarction in 7 cases

Conclusion: In our experience 1503 cases in 12 years is a very high volume of esophageal workload for malignancy. Our morbidity of 6% and mortality of 2.5% shows that such major operations can be done safely in high volume thoracic centers

Tube thorocostomy: management and outcome in patients with penetrating chest trauma

Penetrating chest trauma is common in this part of the world due to present situation in tribal areas. The first line of management after resuscitation in these patients is tube thoracostomy combined with analgesia and incentive spirometry. After tube thoracostomy following surgery or trauma there are two schools of thought one favours application of continuous low pressure suction to the chest tubes beyond the water seal while other are against it. We studied the application of continuous low pressure suction in patients with penetrating chest trauma. This Randomized clinical controlled trial was conducted in the department of thoracic surgery Post Graduate Medical Institute Lady Reading Hospital Peshawar from July 2007 to March 2008. The objectives of study were to evaluate the effectiveness of continuous low pressure suction in patients with penetrating chest trauma for evacuation of blood, expansion of lung and prevention of clotted Haemothorax. One hundred patients who underwent tube thoracostomy after penetrating chest trauma from fire arm injury or stab wounds were included in the study. Patients with multiple trauma, blunt chest trauma and those intubated for any pulmonary or pleural disease were excluded from the study. After resuscitation, detailed examination and necessary investigations patients were randomized to two groups. Group I included patients who had continuous low pressure suction applied to their chest drains. Group II included those patients whose chest drains were placed on water seal only. Lung expansion development of pneumothorax or clotted Haemothorax, time to removal of chest drain and hospital stay was noted in each group. There were fifty patients in each group. The two groups were not significantly different from each other regarding age, sex, pre-intubation haemoglobin and pre intubation nutritional status. Full lung expansion was achieved in forty six [92%] patients in group I and thirty seven [74%] in group II. Partial lung expansion or pneumothorax was present in three [6%] in group I and 10 [20%] in group II. One patient in group I and three [6%] patients in group II had no response. The mean time to removal of chest drains were 8.2 +/- 3.14 days in group I and 12.6 +/- 4.20 days in group II. The length of hospital stay was 7.2 +/- 2.07 days and 12.4 +/- 3.63 days in group I and II respectively. Clotted Haemothorax requiring surgery developed in three [6%] patients in group I and 8 [16%] patients in group II. Placing chest tubes on continuous low pressure suction after penetrating chest trauma helps evacuation of blood, expansion of lung and prevents the development of clotted Haemothorax. It also reduces the time to removal of chest drains, the hospital stay and the chances of surgery for clotted Haemothorax or Empyema

Surgical interventions in multidrug-resistant tuberculosis: retrospective analysis of 27 patients treated at a tertiary level care center

To assess the results of surgery for Muttidrug- Resistant Tuberculosis [MDR-TB]. Retrospective analysis was done in 27 cases of multidrug- resistant tuberculosis in whom some surgical interventions were carried out at department of Thoracic surgery, Lady Reading Hospital Peshawar between the years 2002 to 2007. There were 18 male and 9 female patients in the age group of 14-54 years. All were sputum positive at the time of surgery. Majority of patients were treated with pulmonary resections [pneumonectomy [n=07], bitobectomy [n=08] and lobectomy [n=10]], while primary thoracoplasty with apicotysis was done in two patients. Post operatively 2[nd] line anti tubercular chemotherapy was prescribed for 24 months. There was one early and one Late death. Postoperative complications were seen in three cases. One patient developed bronchopleural fistula with empyema. At a mean follow-up of one year bacteriological cure was achieved in 24 patients. Judiciously performed adjuvant surgery can yield excellent long term bacteriological cure with acceptable mortality in multidrug- resistant tuberculosis. Morbidity and drug compliance remain as problem areas

Determinants of success of decortication

Background: To find out different factors which lead to failed decortication and to evaluate their management and outcome

Study Design: Retrospective observational descriptive study

Place of Study: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 2003 to Sep 2006

Materials and Methods: Clinical record of 300 patients who underwent decortication tor chronic empyema during the last 3.9 years was retrospectively analyzed and their results evaluated. Detailed scrutiny of the computerized clinical record was carried out to analyze the aetiology of failure of the operation. The variables studied were persistent broncho- pleural fistula, poor postoperative efforts by the patients, wound infection, old chest drain site infection, technical failure and nutritional state of the patient

Results: Of the 300 deoortications performed over the period of 3.9 years, 260 patients had a successful outcome in terms of lung expansion and improved pulmonary functions. In thirty patients [19 males, 11 females with age range of 12 to 70 years] decortications failed to achieve the desired results. These patients had to undergo space obliteration procedures for persistent infected space. Twenty three patients had history of tuberculosis and seven patients had nontuberculous empyema. All patients had chronic empyema with duration of more then 12 weeks before the first operation. All patients were nutritionally compromised. Thoracoplasty [compete or partial] was performed in 25 patients to obliterate the persistent infected space. Five patients with recurrent broncho-pleural fistula had an additional procedure of intercostal muscle reinforcement over the fistulae, in addition to thoracoplasty. All patients had successful obliteration of the persistent space with no mortality and minor wound infection in only three patients

Conclusion: Early referral, old drain site infection control, meticulous closure of broncho pleural fistula and space obliteration procedure in combination primarily instead of secondarily, lead to a successful outcome

Surgical treatment of pulmonary hydatid disease

To study the outcome of surgical treatment of pulmonary hydatid disease.This study comprised of two hundred patients, operated for pulmonary hydatid disease in Cardiothoracic unit, LRH, Peshawar form 01.07.1990 to 30.06.2000. The preoperative work up, apart from history and examination included FBC, LFTs, Blood grouping, chest X-ray PA and Lateral views, Casoni's test, haemagghitination test. Ultra sound abdomen and chest, and CT thoracic. Patients were operated for cystectomy, lobectomy decortication, thoracoplasty and combined pulmonary and hepatic cystectomy as required. All patients were put on post operatively mebendazole for at least 28 days. Patients were followed up for complication. Two hundred patients underwent surgery for pulmonary hydatid cyst over a ten years period. Operations performed were cystectomy 168, lobectomy 24, [primary 18, revision 6], decortications 13 and 1 thoracoplasty. Mortality was 4/200 i.e. 2%. The main/ major morbidity was air leak for which 9/200 patients were re-explored, with resuturing in 3 cases and secondary lobectomy in 6. Cystectomy, without needle aspiration, was found to be the procedure of choice for pulmonary hydatid