Pattern of thoracic surgical diseases at a Tertiary Care Hospital

Objective: to describe the pattern of thoracic surgical diseases at a tertiary care hospital

Study design: descriptive case series

Place and Duration of Study: department of Thoracic Surgery, Ojha Institute of Chest Diseases, Dow University of Health Sciences Karachi, from January 2013 to December 2014

Methodology: records of all the patients admitted, transferred to or referred from other departments / hospital during the study period was retrieved and analyzed. Variables studied included mode of admissions, diagnosis, surgical procedures performed and mortality. Descriptive statistics were used for data presentation

Results: a total of 669 patients were admitted during the study period. There were 382 [57%] males and 287 [43%] females. A total of 626 surgical procedures were performed. Out of these 254 [41%] were carried out under general anesthesia and 372 [59%] in local anesthesia. The most common procedure under general anesthesia was decortication [n=51, 20%]. Most common procedure under local anesthesia was tube thoracostomy [n=119, 32%]. The remaining 43 patients were managed conservatively. The overall mortality was 1.8%

Conclusion: empyema thoracis was the commonest thoracic surgical condition for which patients were admitted

Management challenge in chest wall neoplasms; a 2 year experience

Introduction: Chest wall neoplasms are rare and represent only about 5% of all thoracic neoplasm. We present our 2 years analysis of the clinical features, presentation, diagnosis and treatment of chest wall neoplasms

Study design: Case series study

Place and duration of study: Ojha Institute of Chest Diseases, Dow University of Health Sciences, Karachi, Pakistan from Nov 2012- Oct 2014

Methodology: Between 2012 and 2014, 39 patients with solid chest wall masses were enrolled in the study. Tumors were categorized as benign and malignant, including primary and secondary, after histopathological diagnosis with tissue biopsy. Data on patients' characteristics, symptoms, tumor type and management was recorded and analysed

Results: The study included 39 patients [20 males and 19 females] with age range 18-71years [mean 36.3]. 21[53.8%] patients had benign chest wall tumors while 18[46.1%] patients had malignant tumors. Among malignant tumors, 14[77%] patients had primary malignancy where as 4[22%] patients had chest wall tumor secondary to primary tumor elsewhere. Among these 4, the primary tumor remained unknown in 1 patient. The most common benign solid lesion was chest wal lesion lipoma in 8/21 patients [38%]. Among malignant tumors, chondrosarcoma [4/14, 29%] was the most common

Conclusion: Preoperative needs careful assessment of the patient, radiological imaging and histopathological examination for diagnosis of the tumor in the chest wall. Using a multidisciplinary team approach, excellent results can be available with complete surgical resection, reconstruction of the chest wall and appropriate or neo adjuvant treatment where necessary

Re-recurrent dermatofibrosarcomaprotuberans of the chest wall

Dermatofibrosarcomaprotuberans is a rare, soft tissue tumour with high rate of recurrence. It is locally aggressive, with a low rate of metastasis. We describe the case of a 42 year old man who presented with a re-recurrent, large tumour situated on the anterior chest wall in the sternal region. We did a wide local excision and covered the resulting defect by using bilateral, pectoralis major myocutaneous flaps. Histopathology and immunohistochemical staining findings were consistent with the diagnosis of Dermatofibrosarcoma Protuberance. Post operatively the patient was treated with chemotherapy and radiotherapy

Mediastinal synovial sarcoma

The mediastinum is an uncommon site of synovial sarcoma which is a rare soft tissue malignancy. An 18 year old boy was admitted for right sided chest pain since one year. Based on the CT scan chest findings, tru-cut biopsy of the mass was performed and histopathology initially reported as neurofibroma. The tumor was excised via posterolateral thoracotomy and excisional biopsy established the diagnosis of primary synovial sarcoma arising from the mediastinum. Patient was started on adjuvant chemotherapy at the oncologist tumor board's recommendation and he received 6 cycles of adriamycin and ifosfamide. At last follow up he is free of tumor recurrence

Complications and technical errors of tube thoracostomy and its underwater seal system

To find out the complications and technical errors of tube thoracostomy and its underwater seal system in a tertiary care hospital. Descriptive case series. Department of Thoracic Surgery Jinnah Postgraduate Medical Centre Karachi, from March 2010 to January 2012. All patients above the age of 12 year who were admitted directly or those referred from other centres were included in this study. Indications of chest tube insertion included both traumatic and non traumatic conditions. Data collection included both technical errors as well as complications related to the procedure. There were total of 144 patients managed during study period. This include 102 [70.8%] males and 42 [29.9%] females. The mean age of the patients was 32.2 year. Of total patients, 123 [85.45%] were referred from other hospitals while 21 [14.5%] were admitted directly in the ward. The most common complication related to insertion of chest tube was lung injury, [n=19, 13.19%] which resulted from the use of trocar or due to inadequate separation of the lung from the chest wall. Diaphragm injury occurred in 4 [2.78%] patients. The technical error frequently encountered was kinking of chest tube [n=25, 17.36%], followed by use of small chest tube [n=15, 10.41%]. Tube thoracostomy resulted in number of complications of which lung injury was most common. This occurred mainly due to trocar used for insertion. Kinking of tube was the most common technical error in the series

Thoracoscopic evacuation of retained post-traumatic hemothorax

Post-traumatic retained hemothorax is a major risk factor for empyema thoracis leading to prolonged hospitalization, entrapped lung and a need for decortication. VATS [Video Assisted Thoracoscopy] for retained hemothorax shortens the duration of chest tube drainage and length of stay. From December 2004 to July 2009, 110 consecutive patients underwent VATS for retained or clotted hemothoraces at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi. Majority of the patients were males [n = 91; 82.7%]. Sixty-five patients [59.1%] underwent VATS within 6 days and 45 patients [40.9%] between 7 - 14 days of injury. In 8 patients [7.3%] VATS was abandoned for thoracotomy. Post VATS full lung expansion was achieved in 87 patients [79.0] with complete evacuation of hemothorax. Chest tubes were removed within the first week in 100 patients [90.9%]. In hemodynamically stable patients, VATS is a safe, reliable and effective technique for the evacuation of retained hemothorax. Early intervention within 6 days of injury avoids the need for a thoracotomy and is associated with a better short and long-term outcome

Clinical profile and postoperative outcome in patients with simple and complex aspergilloma of lung

To compare the clinical presentation and results of pulmonary resection in simple and complex aspergilloma of the lung. Observational study. The Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, from January 2003 to December 2008. Fifty-one adult patients with unilateral aspergilloma lung were included in this study. Patients were divided into two groups: A [simple aspergilloma-SA, n=14] and B [complex aspergilloma-CA, n=37], based on the radiological and operative characteristics of the cavitatory lesion and the presence or absence of extensive adhesions with the chest wall. Suitability for resection was assessed with arterial gases, pulmonary function tests and echocardiogram. Results were compared using Fishers exact test. Recurrent hemoptysis was the predominant symptom in both the groups. Exertional dyspnea [A=21.4%; B=56.8%; p=0.03], chest pain [A=21.4%; B=59.5%; p=0.027], cough [A=35.7%; B=70.3%; p <0.05] and postoperative complications like residual pleural space A=14.2%; B=54%; p=0.013] and pleural collection [A=7.1%; B=37.8%; p=0.041] were predominant in group B. Lobectomy was the most common procedure performed in group B [A=28.6%; B=59.5%], while wedge excision was performed in the majority of patients in group A [A=42.9%; B=29.7%]. Recurrence of aspergilloma was seen in 3 patients [8.1%] in group B only. Total number of early and late complications in SA and CA were 7, and 60, respectively. Early mortality was 8.1% and 0.0% in group A and group B, respectively [p=0.552]. The overall mortality was 5.4%. Symptoms were more frequently associated with CA as compared to SA. Surgery for CA was associated with low mortality but significant morbidity, whereas SA had low postoperative morbidity and no mortality

Infected benign cystic terotoma of the mediastinum

A young man aged 22 years presented with shortness of breath, left sided chest pain, mild dry cough, peripheral cyanosis, fever and generalized weakness for three years. He was diagnosed as having a large infected cystic mediastinal mass with tricuspid regurgitation and severe pulmonary hypertension. On thoracotomy, one litre of pus was aspirated and tumour was excised and sent for histopathology. Biopsy report revealed benign cystic teratoma. This case is reported to highlight the management of a huge infected benign cystic teratoma which is rarely found

Perforation operation interval as a prognostic factor in typhoid ileal perforation

To find out significance of perforation-operation interval [POI] in relation to early prognosis in patients with peritonitis due to typhoid Heal perforation [TIP]. Case series. Department of General Surgery, Jinnah Postgraduate Medical Centre [JPMC] Karachi, from October, 2004 to March, 2007. The study included 92 patients with generalized peritonitis diagnosed as typhoid Heal perforation Methods fulfilling the inclusion criteria. All non typhoidal and traumatic perforations were excluded from the study. Data was collected in the proforma designed for the study. The diagnosis of typhoid Heal perforation was established on the basis of history, clinical examination, radiology, isolation of Salmonella Typhi, and a positive Widal test. Histopathological confirmation of the diagnosis was also made. Out of 92 patients, 75 were males [81.5%] and 17 [18.5%] females, with male to female ratio of 4.4:1. The ages ranged between 15 to 50 years. The most common symptoms were fever [100%], abdominal pain [100%], constipation [81.5%], vomiting [76%] and distension of abdomen [69.5%]. The most common signs elicited on abdominal examination were tenderness [100%], guarding [72.8%] and absent gut sounds [65.2%] Out of 92 patients 12 patients [13%] presented within 24 hours of onset of severe abdominal pain [Group A]. Among late presenters, My nine [64.1%] patients presented 25-72 hours after severe abdominal pain [Group B] and twenty one patients [23%] presented after 72 hours [Group C]. Mortality was highest among group C patients [8/21 ;38%], while the mortality among the late presenters [Group B] was 10.2% [6/59]. There r was no mortality in the early presenters [Group A]. Overall mortality was 15.2% [14/92]. The average perforation operation interval in survivors was 44.2 hours as compared to average of non-survivors- 63.9 hours [p <0.01]. Prolonged presentation time leads to a high mortality rate. Once intestinal perforation occurs, early recognition, early referral and aggressive management could decrease the high mortality

Role of urgent thoracotomy in improving the survival of patients with severe chest trauma

To determine the frequency of survival in patients with thoracic trauma, undergoing Urgent Thoracotomy [UT]. Quasi-experimental study. The study was carried out in the Department of Thoracic Surgery, JPMC, Karachi, from January 2005 to June 2007 [30 months]. Fifty two patients, who presented with chest trauma and underwent UT within 48 hours of sustaining thoracic trauma, were included in the study. All patients were assessed by history, physical examination and relevant investigations. A total of 475 patients with acute thoracic trauma needing admission during the study period presented to the Accidents and Emergency Department. Fifty-two [52/475; 10.9%] patients were indicated for UT. The most common indication for UT was massive hemothorax [43/52; 82.6%]. The mean age of the patients was 34.36 +/- 11.02 years. There were 22 [42.2%] blunt injuries and 30 [57.8%] penetrating injuries. Road Traffic Accidents [RTA] were the most frequent cause of blunt chest injuries [15 patients; 75%], while firearm injury was the commonest [21 patients; 70%] cause of penetrating chest trauma. Post thoracotomy mortality was 13.3% [4 out of 30] in patients with penetrating injuries and 18.2% [4 out of 22] in patients with blunt injuries [p < 0.01]. Mortality of UT was 15.3% with survival of 84.7%. Overall survival in 475 patients was 95.58%. Early recognition of treatable injuries and an aggressive approach in management with Urgent Thoracotomy can increase chances of survival of patients suffering from severe chest trauma

Predicting factors of Seroma formation after Breast cancer surgery

To determine the frequency of seroma formation, and the role of hypertension, diabetes mellitus, neoadjuvant chemotherapy and nodal dissection in the development of seroma after breast surgery. Hospital based prospective study with descriptive design [interventional descriptive] from April 2002 to March 2005. Setting: Department of General Surgery [Ward-2], Jinnah Postgraduate Medical Centre, Karachi. 160 patients of Carcinoma Breast who underwent elective surgery. Patients were divided into two groups viz. those who developed seroma [Group-A] and those who did not [Group-B]. The data was tabulated on SPSS version 10.0. Demographic data was represented in frequencies. The effect of various risk factors [hypertension, diabetes mellitus, nodal status, tumour histology] was calculated and presented as relative risk [RR]. Out of 160 patients, there were 157 females and three males, with a sex ratio of 53F:1M. Their ages ranged from 23 to 100 years. A total of 144 patients underwent modified radical mastectomy and 16 breast conservation. Seroma formed in 28 [17.5%] cases. Out of 36 hypertensive patients 22 developed seroma [RR=12.72], while amongst the 28 diabetics two and amongst the 64 patients that received neoadjuvant chemotherapy 12 developed seroma. The total number of axillary lymph nodes in patients who developed seroma ranged from 4-28 as compared to non-seroma group with 4-30; an average of nine [0-25] positive nodes were seen in both the groups. Seroma formation is a common complication of the modified radical mastectomy. The only factor that appeared to contribute to seroma formation in this series was hypertension. Neoadjuvant chemotherapy marginally increased the risk, but diabetes had no role in seroma formation