Surgical management of pericardial diseases

Tuberculosis and purulent pericarditis are the most common causes of pericardial effusion and constriction. Chronic constrictive pericarditis is a chronic inflammatory process that involves both fibrous and serous layers of the pericardium and leads to pericardial thickening and compression of the ventricles. The resultant impairment in diastolic filling reduces cardiac function. Pericardiectomy remains the treatment of choice for chronic constriction. A review of 72 cases at department of Cardiothoracic Surgery, Lady Reading Hospital is presented. There was a mortality of 12% and a morbidity of 20%. Forty seven of the 72 cases were tuberculous. The surgical excision of pericardium remains the only available curative treatment for constrictive pericarditis, while open pericardial drainage is required for cardiac tamponade resulting from pericardial effusion

Oesophageal dilatation as palliation for irresectable carcinoma oesophagus

The primary therapeutic goals in patients with advanced oesophageal malignancy are the re-introduction of an enteral diet and early discharge. The endoscopic dilation has been proposed as an alternative technique for palliation in patients not suitable for surgery. To review our experience with oesophageal dilation for the palliation of malignant oesphageal obstruction. A retrospective review was conducted of the notes of all patients who underwent palliative oesophageal dilation in our unit. 100 patients [age range 30-90years] underwent oesophageal dilation for malignant oesophageal obstruction 48% of patients had obstruction at lower one third of esophagus. Median survival was 6 weeks [range 1week to 03 months]. Successful dilation was possible in 70% of cases. During follow up 20% returned to solid diet, 50% required a soft diet and 30% were unable to tolerate any enteral nutrition. The use of oesophageal dilation achieves, good palliation allowing earl y discharge from hospital, re-introduction of an enteral diet

Oesophagectomy for carcinoma esophagus- Peshawar experience of 270 cases in 4 years

To audit the results of 270 Oesophagectomies done for Carcinoma Oesophagus over a 4 year period. This observational descriptive study was conducted at Department of Cardiothoracic Surgery, Lady Reading Hospital and Khyber Medical Centre Peshawar from Sep 2002 to Sep 2006. Computerized clinical data of 270 cases of Oesophagectomy for Carcinoma Oesophagus was retrospectively analyzed. All patients had apart from routine investigations, Barium studies, Endoscopy and biopsy, CT Thorax/Upper abdomen with Oral and I/V Contrast and Abdominal ultrasound. Detailed examination of clinical record was made to determine the surgical outcome. Out of 270 cases 189 were Males 81 were Females with a mean age of 51.6 years. The age range was 17-80 years. In out of two hundred and seventy cases one hundred and sixty two [162/270] [60%] cases had lower one third tumors, one hundred and five [105/ 270] [38.88%] cases had middle one third tumors while three [3/270] [1.11%] tumors were just below the thoracic inlet. Of the one hundred and sixty two lower one third tumors stomach involvement was present in eighty one [81/162] [30%] cases. Adenocarcinoma was present in one hundred and seventeen [117/270] [43.33%] cases, Squamous cell carcinoma was present in one hundred and forty four [144/270] [53.33%], Adenosquamous was six [6/270] [2.22%], Carcinoma in situ was two [2/270] [0.74%] and Leiomyoma was one [1/270] [0.370%]. Morbidity was 28/270 [10.370%] and comprised anastomotic leaks 09, aspiration pneumonia 06, wound infection 03, hoarseness 03, and strictures 03,. Thirty day mortality was 14/270 [5.185%] and included aspiration pneumonia-respiratory failure 02, myocardial infarction 03, anastomotic leak 03, tracheal injury 02 and presumed pulmonary embolism 04. Two hundred and seventy cases in four years is a very high volume of Oesophageal work load for malignancy. Our morbidity of 10.370% and mortality of 5.18% shows that such major operations can be done safely in thoracic centers

Collapse therapy in 21 century an experience of 50 cases

To observe the various indications of thoracoplasty and evaluate their management and outcome. Study Design: An observational descriptive study. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from July 2001 to January 2004. Subjects and During two and a half years study period fifty patients needed thoracoplasty. M: F ratio was 36:14. Aged distribution was 23 - 57 with a mean age of 36.3 years. Indications for surgery were tubercular or parapenumonic empyema in 25[50%] patients, post lobectomy space infection, and broncho pleural fistula [BPF] in 10[20%], destroyed lung with hemoptysis in 8[16%], post pneumonectomy space infection in 4[8%] and upper lobe hemoptysis with poor PFTs in three [6%] cases. A standard subperiosteal extra pleural paravertebral surgical technique was used in all cases. Out of 50 cases 28 [56%] required full thoracoplasty and 22[44%] cases underwent partial thoracoplasty. Postoperatively all patients had a single chest drain on suction for 7 days. Both the drain and stitches were removed after 2 weeks and patients were advised to attend out patient department for follow-up. Patients symptoms index showed remarkable improvement. 100% improvement was needed in patients regarding chest pain, fever, cough, weight loss, hemoptysis and ATT. Postoperative complications were noted in 10 [20%] cases. Four patients had wound infection, 2 had wound dehiscence, residual space in 3 and restricted shoulder mobility in one. There was 1[2%] mortality. This patient had borderline pulmonary functions and had to be ventilated for ventilatory failure. With the persistent problem of pulmonary tuberculosis in the developing countries, thoracoplasty is still an operation of continued relevance for space obliteration in cachectic patients, and as collapse therapy for bleeding lungs with poor PFTs. Most patients are definitively and rapidly cured with limited sequelae

Early surgery for pulmonary tuberculosis

The purpose of our study was to analyze current indications for surgery in tuberculosis and evaluate the outcome of early surgical intervention. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from June 2000 to July 2004. Total number of cases was 132; M: F 105: 27. Age range was 20 to 79 years. Mean age was 48.4 years. The indications for surgical intervention included 5 cases of pulmonary aspergillioma, 9 cases of pneumothorax; 3 cases of pulmonary nodes and masses without histological diagnosis, 15 cases bronchiectasis, 12 cases of massive hemoptysis and 82 cases of pleural empyema while six patients with multi drug-resistant tuberculosis required surgical intervention. The techniques utilized included lobectomy in 45 cases, pleural drainage in 20 cases, segmented pulmonary resection in 32 cases, surgical procedures on the chest wall in 17 cases, pneumonectomy in 10 cases, decortication in 8 cases. In 22 cases two or more procedures were performed on the same patient. In 26[19.6%] cases various complications were noted of which wound infection was the most frequent. There was a mortality rate of 3.3% [4 cases]. Surgical treatment is indicated for the complication of TB and management of MDR TB. Early surgery is beneficial in patients whose disease is still localized and who can tolerate resection surgery; of particular importance is a healthy opposite lung, on which the patient would be dependent during and immediately after surgery

Spontaneous endobroncheal erosion of a bullet - an uncommon presentation of gunshot trauma in remote past

A case of unknown bullet trauma to the lung, in remote past, presented with hemoptysis which was mislabeled as hematemesis. Once labeled, a number of physicians, one after the other, kept on treating her for that symptom. She also consulted a number of specialties and was treated for reflux esophagitis, tuberculosis etc. Meanwhile her x-ray chest revealed a foreign body which was treated as an artifact first, and proved to be a bullet on CT scan. Thoracotomy had to be performed to remove the pathologic right lower lobe of lung

Management of empyema thoracis-Peshawar experience of 450 patients

To observe the various clinical presentations of empyema thoracis and evaluate its management and outcome. An observational descriptive study. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from June 2001 to June 2004. Clinical record of 450 patients who underwent various surgical procedures during 3 years were retrospectively analyzed. Detailed scrutiny of record was carried out to analyze the clinical presentation; various surgical procedures and outcome. There were 270 [60%] male and 180 [40%] female patients. Majority of the patients 310 [68.8%] were in the age range of 20 - 40 years. Common presentation was fever [62%]; cough [26%] and chest pain [11%]. The duration of symptoms was less than 8 weeks in 57% and more than 8 weeks in 42% cases. Common etiologies were pneumonia [31%], post tuberculous [37.7%], traumatic [24%] and iatrogenic [6.6%]. Tube thoracostomy was the initial l ine of management in 200 patients. Decortication was required in 200 patients while 50 patients needed thoracoplasty to obliterate persistent residual pleural space. The mortality was 4% [18/450]. Thirty one [7%] had wound infection, air leak in 18 [4%], wound dehiscence in 9 [2%] and septicemia in 14 [3%] cases. Depending upon the stage, various surgical options exist for the treatment of thoracic empyema. Selection of the most appropriate procedure must be individualized but the basic principle is evacuation of pus from the pleural space, appropriate antibiotic therapy and obliteration of empyema cavity

Diaphragmatic injuries, a retospective analysis of 50 patients

This study seeks to define the clinical presentation, the usefulness of diagnostic tests, surgical management approach and outcome of treatment of diaphragmatic injuries in our trauma patients. An observational descriptive study. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from March 2001 to April 2005. In this retrospective study, 50 patients admitted to our department with diaphragmatic injury were evaluated according to the type of injury, diagnostic methods, associated organ injury, treatment, modality, morbidity and mortality. The average age of patients was 32 years. There were 35 [70%] male and 15 [30%0 female patients, 38 [76%] of these patients sustained blunt and 12 [24%] had penetrating chest injury. The diaphragmatic injury was right sided in 4 and left sided in 46 patients. Thirty nine [78%] patients presented in respiratory distress within 48 hours of in jury while 11 [22%] presented with bowel obstructive symptoms months and years after injury. A chest x-ray on admission suggested the diagnosis in 70% of the cases while chest ultrasonography and contrast studies were required in others. Surgery was emergent in 35 [70%], semi-emergent in 9 [18%] and effective in 6 [12%] cases. Surgical approaches were left thoracotomy [40 patients], left thoracolaprotomy [6 patients] and right thoracotomy [4 patients]. The diaphragmatic repair was achieved by direct suture in 45 cases while prolene Mesh was required in 5 cases. The mortality rate was 6% [n = 3]. Recurrence occurred in one [2%], wound infection in 3 [6%], pleural, space, problem in 1 and chest infection in 2 [4%] patients. A high index of suspicion and early surgical treatment determine the successful management of traumatic diaphragmatic injury with or without the herniation of abdominal organs. The surgical approach is individualized. We prefer the thoracic approach adding laporotomy when necess ary

Management of patients with esophageal artesia with or without tracheoesophageal fistula, a 7 years experience

To see the short term outcome in patients treated for esophageal artesia with or without tracheo-esophageal fistula in our setup. Descriptive and retrospective. Department of Paediatric Surgery and Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 1998 to December 2004 with duration of 7 years. After diagnosis, patients were put on broad-spectrum intravenous antibiotics, intravenous fluids, vitamin K injection and throat suction in a normothermic environment. Diagnosis was established mainly on clinical grounds and supported by passing a big size nasogastric suction tube [size 10 Fr] through the mouth into the esophagus and taking a plain X-ray chest of the patient. After adequate preparation, through a right thoracotomy in 5th intercostals space, fistula repair and esophageal anastomosis was performed extrapleurally in patients with tracheoesophageal fistula while gastrostomy and ce rvical esophagostomy was performed in patients with pure esophageal atresia. Transanastomotic tube was passed as a nasogastric tube size 10 to act as a stent and later on used for tube feeding. A total of 60 patients with esophageal artesia with or without tracheoesophageal fist ula were admitted. There were 40 males and 20 females. Age ranged from 1-7 days. Weight of the newborn patients was in the range of 2 - 3Kg. Four patients had cyanotic congenital heart disease, two were with imperforate anus and two with spina bifida. All patients had some form of bronchopneumonia due to aspiration of upper pouch contents out of whom 30 patients had severe pneumonia. Six patients left the hospital against medical advice and 6 patients died before operation. Forty-eight patients were operated. Esophagostomy and astrostomy was performed for pure esophageal atresia [10 Patients], while in 38 patients, a right thoracotomy in the 5" inter costal space with fistula ligation and esophageal anastomosis was performed. Three out of ten patients with pure esophageal atresia died, while eighteen patients with tracheoesophageal fistula died after surgery. Twenty-seven out of total 48 patients survived and were discharged to home after an average hospital stay of 7 days after surgery. Eleven patients were s een in follow up and treated accordingly. This study shows that majority of these patients presented late because of improper referral system. Delay in diagnosis and management led to various complications such as aspiration pneumonia, dehydration and septicemia with great mortality which is further increased due to nonavailability of the neonatal intensive care facility in our setup. Survival of these patients can be improved by early and proper referral system, specialized medical and surgical team, specialized anesthesia with personnel trained in neonatal anesthesia

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

Surgery for pleuropulmonary tuberculosis

The purpose of our study was to analyze current indications for surgery in pleuropulmonary tuberculosis [TB]. We present our experience with TB patients presenting with indications for surgery between 1998 and 2003. Material and The indications for surgical intervention included 220 cases of empyema, mediastinal lymphadenopathy 48 cases, hemoptysis 25 cases, destroyed lung 24 cases, undiagnosed pleural effusion 24 cases, bronchiectasis 18 cases, cavitary lesion with MDRTB 13 cases and pulmonary aspergilloma 10 cases. Thirteen patients with multidrug-resistant tuberculosis required surgical intervention, although 26 were treated with second line drugs during this period. The techniques utilized included decortication in 152 cases, lobectomy in 62 cases, rib resection for pleural drainage in 50 cases, anterior mediastinotomy in 48 cases, pneumonectomy in 28 cases, open pleural biopsy in 24 cases, and thoracoplasty in 18 cases. In 12 patients [3.1%], two procedures were performed, and in one case, 3 procedures. In 65 cases [17%] there were complications, of which persistent air leakage after decortication and pulmonary resection was the most frequent [n=26]. There was a mortality rate of 2.8% [11 cases]. Conclusions: In our experience, surgery in the treatment of TB is indicated to resolve sequalae or complications, since cases of simple or multidrug-resistant TB can be managed pharmacologically. The morbidity and mortality rates in our series were acceptable

Surgery for hemoptysis - one year experience of 72 patients

To determine aetiology of patients presenting with hemoptysis and evaluate their management and outcome. Study Design: An observational prospective descriptive study. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from 1st Jan 2003 to 31st December 2003. Materials and This prospective study included 72 patients; 51[71%] were males and 21[29%] were females. Male: female ratio was 2.5:1 Age range was from 7 years to 81 years with a mean age of 36.3 years. All the patients had hemoptysis o n presentation while 25[35%] also experienced dyspnoea. Chest radiograph was obtained in all, CT Thorax in 60 [83%] while pulmonary function tests were performed in 68[94%] patients. Out of 72 cases 09 patients had to undergo immediate surgery, 27 underwent surgery within one week after initial stabilization and 36 were operated upon electively. All patients, except 6 pediatrics cases, had one lung ventilation during surgery. The mean operative time was 55[ +/- 20] minutes. Out of 72 patients 30 had lobectomy, 24 had hydatid cystectomy, 9 had wedge excision, 3 had pneumonectomy and 6 had thoracoplasty. Mortality was 2/72 while morbidity was 6/72 comprising 4 wound infections [in the emergency group] and 2 each had persistent air leak and empyema. Hospital stay ranged from 7 - 36 days with mean of 12.6 days. Pathological breakup of the 72 cases was bronchiectasis 30, mycetoma 2, lung abscess 9, hydatid cysts 24, carcinoma 6 and AV malformation 1. Inflammatory lung disease, especially TB and its sequelae is the commonest cause of hemoptysis. Elective surgery with one lung ventilation after initial stabilization in a well equipped and well staffed cardiothoracic unit [OT and ICU] is a safe option for hemoptysis, not responding to medical management

Transthoracic patent ductus arteriosus ligation without chest drain insertion

To study safety of doing Transthoracic, Patent Ductus Arteriosus Ligation without chest tube insertion. Study Design: Observational, Prospective, Descriptive. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from June 2002 to June 2004. Material and methods: This prospective study was done to study the results of this selective approach in forty five [45] patients, operated by transthoracic approach between June 2002 and June 2004 for patent ductus arteriosus ligation. There were 27 females and 18 males, ranging in age from 06 months to 07 years [mean: 2.3 years] and a weight of 6.0 kg to 22.1 kg [mean 11.3 kg]. Patients < 07 years, with no pulmonary pathology, no peroperative pulmonary adhesion, no per operative ruptured ductus arteriosus and with good lung expansion prior to the chest closure were included in this study. Patient more than 07 years of age, with extreme adhesion and those whose patent ductus arteriosus ruptured during dissection were excluded from this study. Parents of the patients were informed about potential risks of this selective approach. Only those patients whose parents had given adequate; informed consent were eligible for this study. There was no mortality. No drain related morbidity Iike pneumothorax, haemothorax or chylothorax occurred. P ostoperatively children had less analgesia, earlier feeds and mobilization. Mothers were not apprehensive about holding or feeding the baby. Consequently there was earlier discharge to home. In addition these children had a more cosmetic scar, and no drain related problems. A selective approach to the use of chest tube in Transthoracic approach for patent ductus arteriosus can be safe, cost effective and patient friendly