Surgical management of bronchiectasis: indications, experience and early results

Background: in the developing and the underdeveloped countries pulmonary bronchiectasis is commonly-faced forming a significant cause of morbidity and mortality. Although antibiotics postural drainage is widely applied in the medical management of the disease, resection of the involved segment[s] remains the only treatment modality that can offer a potential cure. In this prospective study, we evaluated our medico-surgical management protocol for pulmonary bronchiectasis [uni or bilateral] stressing on methodology of preoperative evaluation of the extent of the tissue damage caused by bronchiectatic pathology [morphologic and hemodynarnic classification] prior to recommending surgical solution in an attempt to reduce perioperative morbidity and mortality complications to its least

Patients and Methods: this prospective study was carried out in the departments of Cardiothoracic Surgery, and chest internal medicine Kasr El Ainy Faculty of Medicine, Cairo University, as well as the Islamic Charity Hospital of El Agousa from January 2002 till January 2006. The study encompassed 20 patients: 15 men [75%]; and 5 women [25%]. The mean age was 39.5 +/- 4.5 years [range 23-51 years]. Bronchiectasis was unilateral in 14 patients [70%]; and bilateral in 6 patients [30%]. The main presenting symptom was unresolving pneumonia [uncontrollable productive cough] in 10 patients [50%]; progressive dyspnoea and shortness of breath [SOB] in 8 patients [40%]; and troublesome haemoptysis was present in 2 [10%]. The organism cultured in sputum samples was Streptococcus pneumoniae in 7 [35%]; Haemophilus influenzae in 5 [25%]; Staphylococcus aureus in 4 [20%]; Pseudomonas aeruginosa in 2 [10%]; and Klebsiella pneumoniae in 2 [10%]. Preoperative patient management started by complete physical examination; vigorous chest pb ysiotherapy and medical treatment by specific broad-spectrum antibiotic courses, mucolytics, expectorants, bronchodilators.. etc.], for a mean period of 22.5 + 4.5 months [range 3 months84 years]. Preoperative lab investigations consisted of full blood picture, renal-and-hepatic function tests, and coagulation profile. Special investigations included: plain chest radiography, bronchoscopy [rigid or fiberoptic]; high-resolution chest scanning [HRCT]; pulmonary function tests [spirometry and arterial blood gas analysis], and perfusion lung scanning [VQNT matching]. Surgery was planned targeting to remove destroyed non-perfuse lung tissues "Unresolving Pneumonia"; when pathology of lung destruction was progressive [cytic or advanced cylindric forms by HRCT or hemodynamic features]; and when the patient feared death or morbidity complic;itions

Results: we performed 13 lobotomies [65%]; 2 bi-lobotomies [10%]; 3 completion pneumonectomies [15%]; and 2 pneumonectomies [10%] via thoracotomy [15 anterolateral, and 5 posterolateral] 14 done on the right and 6 on the left side. One patient died postoperatively [5%] due to fulminant pneumonia, while 4 [20%] had morbidity events as: surgical wound gaping needing 2ry. stitches to heal [2ry. Intention] in 2 diabetic patients [10%] localized pocket without stump disruption treated by prolonged tube drainage in diabetic patient [5%]; and exploration for stump revision to control prolonged air leak in 1 patient [5%] with previous pseudomonas infection. In 19 survivors, follow-up for 1st. year [January 2005- January 2006] following surgery revealed that 12 patients [60%]; were cured; 5 patients [25%] had disappearance of the majority of their symptoms; while 2 [10%] showed mild symptomatic improvement without serious complications. Previous TB infection; Diabetes mellitus; Cystic pathology, and Pseudomonas infection were factors associated with poor prognosis

Conclusion: surgical resection for bronchiectasis in properly prepared and chosen patients is the final solution after failure of other management modalities. Preoperative morphologic and hemodynamic classification provided an accurate functional classification as to the extent of the histopathology damages and hence allowed proper determination of the patient who is truly in need of surgical resection and guided well the extent of surgical resection which was done with acceptable morbidity

Follow-up of small muscular ventricular septal defects after surgical closure of large ventricular septal defect

Background: closure of ventricular septal defects [VSDs] in infancy due to pulmonary hypertension has greatly replaced pulrnonary artery banding. This approach has been extended to infants with multiple VSDs, closing large VSD and in many cases leaving small muscular VSDs behind. The hemodynamic relevance and rate of closure of these VSDs are unknown. The purpose of this study was to assess the outcome of infants with multiple VSDs after surgical closure of a large VSD leaving another small muscular VSD [s] behind

Patients and Methods: this prospective study was done between January 2004 and December 2005, in the department of Cardio-thoracic Surgery, Abu El-Rish Children Hospital Aff./ Kasr El-Ainy Hospital, Faculty of Medicine, Cairo University. The study sample consisted of 20 infants who were operated for closure of multiple VSDs, closing only the large haemodynamically significant VSD and leaving other small muscular VSD[s]. Tran thoracic echocardiography [TTE], preoperative and postoperative, in the intensive care unit, at hospital discharge, and during follow-up, were performed for all patients. Intra-operative transesophageal echocardiography [TEE] was performed for last 9 patients. Mean follow-up time was 1.5 years [range 0.25- 3.0 years]. Residual defects were graded as absent, < 2 m or between 2 and 4 mm

Results:- due to a pulmonary hypertensive crisis, one patient [5%], died in the 1.C.U comprising our single early postoperative hospital mortality. Morbidity occurred in only one patient [5%] in the form of conduction disturbances which needs implanting a permanent DDD-pacemaker. Follow-up was complete in 17 patients [85%] as only 3 patients [15%] were lots of follow-up. During follow-up no reoperations were necessary for closing a residual VSD. After discharge, all residual defects less than 2 mm closed. Of residual defects greater than 2 mm. only one closed after a man follow-up of 2.4 years. All patients with residual shunts, were hemodynamically stable, requiring no or minimal medication and in none of them endocarditis was noted

Conclusion: our results showed that in infants, postsurgical residual muscular VSDs less than 2mm closed spontaneously in the majority within 1.5 years. Defects greater than 2mm are less likely to close spontaneously. At early follow-up. Residual shunts remained hemodynamically and clinically irrelevant

Surgical management of pulmonary tuberculosis; indications and benefits

Background: mycobacterium tuberculosis is caused by a virulent organism rapidly destroys normal lung tissue leading to an acute illness with systemic side effects with serious morbidity an even mortality. We herewith assess our experience and early results with surgical intervention for thoracic TB and its sequelae according to its past and current indications

Patients and Methods: this retrospective study was carried out in the departments of cardiothoracic surgery, and chest internal, El Agousa Faculty of Medicine, Cairo University; and private practice be- Charity Hospital between 1999 and 2006. It enrolled 30 patients who underwent thoracic surgery for treatment of mycobacterium TB, or its sequelae. There were 20 men [66.6%]; and 10 women [33.3%]. Mean age was 32.5 +/- 1.5 years [range 25-54 years]. Preoperative symptoms lasted for a median of 8 +/- 0.5 years [range 4-15 years]. Twenty-five patients [83.3%] were operated upon primarily for parenchymal MTB, 4 patients [13.3%] had thickened pleurae; 1 [3.3%] for destruction of vertebral body D9 and 3 patients [9.9%] had hemoptysis. 10 patients [33.3%] had multi-drug resistance [MDR-TB]; while 20 patient [66.6%] were drug-sensitive in all patients. Pre- operative chemotherapy was by mean of 4 drugs [range 3-6]; for mean time of 4 +/- 0.5 months [range 3-7 months], based on in- vitro susceptibility. The regimen used included combination[s] of first line and second. Line drugs, while a fluoroquinolone was added in 14 patients [46.6%]

Results: we had one mortality [3.3%] due to uncontrollable ventricular arrhythmias. 18 lobectomies [60%] were performed : 11 right [36.6%], and 7 left [23.3%]; 3 right cavernoplasties [9.9%]; 1 right pneumonectomy [3.3%], 3 left [9.9%] with one of them being a completion pneumonectomy and comprised our single mortality case; pleural decortication as : 2 right [6.6%], 2 left [6.6%], while vertebral body in one patient [3.3%] needed debridement level of D9. At the time of surgery, 26 of our patients [68.6%] were sputum positive, while 4 [13.3%] were sputum negative. Postoperatively, and excluding one mortality case, 24/25 patients [96%], showed conversion to negative sputum over a mean duration of 2 +/- 1.7 months [range 2-4 months], and became culture-negative over mean duration of 3 +/- 2.5 months [range 3-6 months]. One patient relapsed [3.3%] and remained positive. Morbidity occurred to 11 [36.6%] of patients as prolonged air leak in 4 patients [13.3%]; empyema in 3 [9.9%];post-pneumonectomy lung congestion in 1 patient [3.3%]; re- exploration to remove early clotted haemothorax in 1 patient [3.3%]; atelectasis in 1 patient [3.3%]; and chylothorax in 1 patient [3.3%]

Conclusion : the results of our study confirms the good results obtained by lung resection for tuberculosis due to either drug-sensitive [evolving under treatment] or drug-resistant mycobacterial infection, Proper perioperative collaboration must be present between the chest internist and the surgeon for proper timing of surgery and to avoid induction of unneeded complications. Encouraged by the relatively-low rate of morbidity-and-mortality that follows the different types of surgical interventions, and given the increasing global epidemic of TB complications and resistant strains, it seems more likely than ever for surgery to take a more definitive role in treatment of such disease in the near future

Surgical correction of congenital chest wall deformities: technique and early experience in Kasr El Aini hospital

Background: We herewith describe the technique we used in the one-setting surgical correction of different types of congenital chest wall [sternal or rib deformities]: deficient ribs or sternum; pectus excavatum, and the pectus carinatum defects

Patients and Methods: Our study was prospectively-undertaken from 2003 till 2006, in Kasr El Aini University Hospitals, Abul Reesh National Insurance Hospital for Students, and Tanta University. It enrolled 12 patients [7 males and 5 females] having 3 types of congenital sternal deformities: Cleft or Deficient Sternum [DS] [5 patients, 41.6%]; Pectus excavatum [PE] [6 patients, 50%]; and Pectus carinatum [PC] [1 patient, 8.3%]. Our youngest patient - at the time of surgical correction - was a 4 months-old male baby with deficient sternum; while the oldest was a 15-years old young man with pectus carina- tum. The mean age of our patients was 4 years +/- 5.5 months [range 4 months - 15 years]. Patients having PE [or their parents] mainly complained of cosmetic deformity followed by recurrence of chest infection; while CS patients [or their parents], expressed fear of possible trauma to the inadequately-protected heart. Follow-up period was done for all patients for a whole year postoperatively by means of clinical examination and questionnaire questions to the patient [or his or her relatives] asking them to share in the patients evaluation in comparison with the original complaint stating their opinion in grades as : excellent, good, fair [or accepted], and poor

Results: We had no mortality. No significant intraoperative morbidities were found. Blood loss was minimal and no transfusion was required. Postoperatively, transient mild unilateral seroma below the pectoralis muscle [needed a 5-days vacuum drainage] was noticed in 1 patient [8.3%]; mild Chest wall pain [ameliorated by oral and local analgesia] in 1 patient [8.3%]; and lag of cartilage regeneration leading to small anterolateral soft space [managed with increased oral calcium intake] in another patient [8.3%]. No other types of morbidity occurred eg: blood loss needing transfusion; Cardiac arrhythmias; or recurrence of sternal depression [pectus cases]. Postoperative hospital stay time was relatively short with a mean of 8 k 3.5 days [range 4 -13 days]. According to the patients [and or childis parents] words, the postoperative functional results were described as: excellent in 6 patients [50%]; good in 4 patients [33.3%]; and acceptable in 2 patients [16.6%]. Generally-speaking, patients and or their parents accepted the surgical results quite well and reported an obvious decline in the frequency of chest infections, and a favorable improvement in morals together with an increased tolerance for prolonged physical activity

Conclusion: our immediate and short-term results showed that marked congenital sternal de- formities should be surgically corrected once diagnosed after stabilization of the patients clinical condition. The technique[s] we used achieved adequate stabilization with a sound degree of patient safety. The postoperative results were satisfactory and acceptable for surgeons, patients, and their relatives. Longer follow-up results are still awaited