Does Preoperative Hookwire Localization Influence Postoperative Acute and Chronic Pain After Video-Assisted Thoracoscopic Surgery: A Prospective Cohort Study.

Purpose: This study aimed to investigate whether preoperative computerized tomography-guided hookwire localization-associated pain could affect acute and chronic postsurgical pain (CPSP) in patients undergoing video-assisted thoracoscopic surgery (VATS). Methods: We enrolled 161 adult patients who underwent elective VATS; sixty-nine patients experienced hookwire localization (Group A) and 69 did not (Group B). Group A was further subdivided into the multiple localization group (n=35, Group Amultiple) and the single localization group (n=34, Group Asingle) according to the number of hookwires. The numerical rating scale (NRS) was used preoperatively, during recovery at the post-anesthesia care unit (PACU), and the first two days, 3 and 6 months postoperatively. Furthermore, multivariate regression analysis was used to identify the risk factors associated with CPSP. The postoperative adverse events, length of hospital stay, and satisfaction in pain management were also recorded. Results: The incidence and severity of acute postoperative pain were similar between Group A and Group B (p > 0.05). The incidence (56.5% vs 30.4%, p = 0.002) and the NRS scores (2.0 [2.0-3.0] vs 1.0 [1.0-2.0], p = 0.011) for CPSP were significantly higher in Group A than in Group B at 3 months postoperatively. On subgroup analysis, compared with Group Asingle, the intensity of CPSP (2.0 [2.0-3.0] vs 2.0 [1.0-2.0], p = 0.005) in Group Amultiple was slightly higher at 3 months postoperatively. Conversely, the CPSP incidence (60.0% vs 29.4%, p = 0.011) was significantly higher at 6 months postoperatively in Group Amultiple. The multivariate regression analysis further validated hookwire localization as a risk factor for CPSP (odds ratio: 6.199, 95% confidence interval 2.049-18.749, p = 0.001). Patient satisfaction relating to pain management at 3 months postoperatively was lower in Group A (p = 0.034). Conclusion: The preoperative pain stress of hookwire localization increased the incidence and intensity of CPSP rather than acute pain at 3 months postoperatively, especially in patients with multiple hookwires.

Comparison of short-term results of subxiphoid and conventional video-assisted thoracoscopic surgery in diagnostic wedge resections.

BACKGROUND: This study aimed to compare early results in patients who underwent subxiphoid wedge resection with those operated on using a multiportal approach. METHODS: We retrospectively evaluated 151 patients who underwent diagnostic wedge resection for suspected interstitial lung disease. Patients who underwent wedge resection via subxiphoid video-assisted thoracoscopic surgery and conventional video-assisted thoracoscopic surgery were compared. RESULTS: The study included 90 men (59.6%) and 61 women (40.4%) with a mean age of 54.8 ± 12 years. Of these, 127 patients underwent conventional video-assisted thoracoscopic surgery and 24 patients underwent subxiphoid video-assisted thoracoscopic surgery. Postoperative complications occurred in 13 patients (8.6%), with no significant difference according to surgical technique. Sex was a significant factor in the rate of complications (12.2% in men vs. 3.2% in women). There was no intraoperative mortality; the 30-day mortality rate was 4% (n = 6). Five nonsurviving patients were in the conventional video-assisted thoracoscopic surgery group and 1 was in the subxiphoid video-assisted thoracoscopic surgery group (p = 0.95). CONCLUSION: The results of this study indicate that the subxiphoid approach reduced procedure time and length of hospital stay in the early period, while there was no significant difference between the techniques in terms of complications or mortality. Based on these findings, we conclude that surgical outcomes were as successful with the subxiphoid approach as with conventional video-assisted thoracoscopic surgery.

Streptococcus Pneumoniae Purulent Pericarditis

Background Bacterial pericarditis represents < 1 % of all cases of pericarditis in the United States. Most cases of bacterial pericarditis are from contiguous spread from underlying pneumonia or mediastinitis. We present a case of pneumococcal pericarditis in a patient with untreated pneumonia. Case A 54-year-old male with a past medical history of recent COVID-19 pneumonia presented with worsening dyspnea for the past 3 weeks. Vitals were T 99.3, BP 122/93, HR 159 BPM, O2 sat 94% on 3 L NC. ECG demonstrated atrial flutter with 2:1 block. CT scan demonstrated a pericardial effusion and bilateral pleural effusions. Decision-making In the ED, he became hypotensive and bedside echo demonstrated large pericardial effusion with RV collapse. Emergent pericardiocentesis produced 750 cc of purulent fluid. Streptococcus pneumoniae was isolated from the initial fluid aspirate. Right thoracostomy tube was placed with pleural fluid gram stain and culture without bacterial growth. Due to continued purulent drainage from the pericardial drain, repeat CT scan demonstrated persistent pericardial effusion and loculated right sided pleural effusion. He underwent video-assisted thoracoscopic surgery with pericardial wash out and window. He improved and was discharged with 6 weeks of Ceftriaxone. Conclusion Purulent pericarditis is typically a fulminant disease associated with high mortality and rapid progression. Prompt identification and management is critical for patient survival. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Successful Diagnosis by Video-Assisted Thoracoscopic Surgical Lung Biopsy in a Case of Progressive Primary Pulmonary Extranodal Natural Killer/T-cell Lymphoma, Nasal Type: A Case Report.

Malignant pulmonary lymphoma is very rare and the majority of which are B-cell lymphomas. Since primary pulmonary extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKL) is difficult to diagnose and associated with poor prognosis and aggressive course, some cases are diagnosed at the postmortem autopsy. We report a case of a 53-year-old man with primary pulmonary ENKL diagnosed by video-assisted thoracoscopic surgery (VATS) lung biopsy. This case explains the importance of VATS lung biopsy and in-depth evaluation, including flow cytometry, chromosome, genetic, and immunostaining tests, when primary pulmonary malignant lymphoma is suspected.

Massive empyema due to Lactococcus garvieae

Introduction Lactococcus garvieae, a zoonotic pathogen, may rarely infect humans through the consumption of fish. Documented manifestations of L. garvieae infection in humans include infective endocarditis, prosthetic joint infections, liver abscesses, peritoneal dialysis-associated peritonitis, osteomyelitis, meningitis, infective spondylodiscitis, acalculous cholecystitis, and urinary tract infection. Case report An 87-year-old female was hospitalized for coffee-ground emesis secondary to acute gastritis after eating cooked fish. One week after her discharge, she developed new-onset confusion and was returned to the hospital. Chest computed tomography revealed total consolidation of the left lung and a multiloculated left pleural effusion. The patient required intubation and direct admission to the intensive care unit. Pleural fluid and blood cultures grew L. garvieae, which was susceptible to ceftriaxone, penicillin, and vancomycin. Despite intensive antibiotic therapy and supportive care for thirteen days, the patient remained in irreversibl e shock, and the family opted for comfort care. Conclusions Heretofore unreported, this case demonstrates that L. garvieae can cause bronchopneumonia and empyema. Copyright © GERMS 2022.

Benefits of Early Thoracic Surgery in the Elderly During the COVID-19 Pandemic: Lessons Learned From Performing a Video-Assisted Thoracotomy.

Elderly patients are often considered poor surgical candidates for intra-thoracic operations due to the number of comorbidities, increased risks associated with general anesthesia, decreased cardiopulmonary reserve, and overall increased frailty. In addition, coronavirus disease 2019 (COVID-19) is a critical psychosocial factor that, through secondary effects, can prevent patients from receiving optimal care. Patients are reduced to having limited contact with family, often a vital support system, which can contribute to feelings of hopelessness, loneliness, and depression. We report the case of a 95-year-old female who presented to the emergency department with increasing supplemental oxygen requirements two weeks after a ground-level fall. She was found to have multiple rib fractures and a left-sided hemothorax. Initial management included aggressive respiratory therapy, multiple pigtail chest tubes, and thrombolytics; however, these measures failed to drain the intrathoracic hematoma. Her care was complicated by the psychosocial and isolation factors of COVID-19 which led to the patient exhibiting symptoms of hopelessness, grief, lack of appetite, and loneliness. As conservative management did not improve her clinical care the patient required a video-assisted thoracoscopic surgery (VATS) to manage the retained hemothorax and facilitate re-expansion of her atelectatic lung. Once the patient was removed from COVID-19 precautions, she was taken to surgery and postoperatively the patient reported minimal pain, participated more in physical therapy, and increased her oral intake. In this unique case, a 95-year-old patient with a hemothorax that was successfully treated with a VATS had her clinical care complicated by the psychosocial implications of COVID-19.

HYPERSENSITIVITY PNEUMONITIS PRESENTING AS SEVERE CYSTIC LUNG DISEASE FOLLOWING COVID-19 INFECTION

SESSION TITLE: Dirty Jobs: Occupational Lung Diseases SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Hypersensitivity Pneumonitis (HP) is a group of immunologically mediated lung diseases. It develops in susceptible individuals with exposure to provoking antigens along with influence from genetic and environmental factors. There remains no standardized approach for assessing the various forms of HP and the diverse nature of the disease makes it difficult and often underdiagnosed. Cystic disease is not uncommon in HP, but the advanced cystic disease seen in our young patient was unique and likely compounded by her pregnancy as well as a previous illness with COVID-19. CASE PRESENTATION: A 26-year-old female construction worker at 12 weeks gestation, with a past medical history of polysubstance abuse and previous COVID-19 infection ten months prior, presented with progressively worsening dyspnea of 9 months. She was admitted with acute hypoxic respiratory failure due to recurrent right pneumothorax requiring multiple thoracenteses and eventually chest tube placement. CT Chest demonstrated severe cystic interstitial fibrosis with emphysematous changes. Initial lung biopsy showed interstitial fibrosis as a possible sequela of COVID-19. Due to her pregnancy and medical complications, she was transferred to a transplant center where she continued to have recurrent pneumothoraces requiring video-assisted thoracoscopic surgery. Autoimmune workup, HP panel, and extended myositis panel were negative. However, a repeat lung biopsy pointed to subacute HP. Despite steroid and immunosuppressant initiation, her hospital course was complicated by cardiac arrest and brain death. She went on to become an organ donor. DISCUSSION: Diffuse cystic lung diseases are characterized by parenchymal destruction of the airway walls leading to expansion of the distal airspaces forming multi-lobular cysts. A broad differential diagnosis for this exists including infection, Langerhans histiocytosis, lymphangioleiomyomatosis, interstitial pneumonia, and HP. The first step to evaluate HP is a detailed history of potential exposures. Our patient worked in construction and was exposed to commonly demonstrated antigens used in paint, plastic, and wood manufacture. Pregnancy appears to trigger symptoms in some patients, seen in prior case reports. Our patient's symptoms began after her COVID infection. Though not clearly studied, some studies have proposed that dysregulation of COVID - 19 immune response triggers interstitial fibrosis as a long-term sequela. Early diagnosis and treatment with steroids are vital to the treatment and prevention of complications such as recurrent pneumothorax. CONCLUSIONS: Covid-19 is an emerging risk factor for the propagation of various immune-mediated diseases. Progression of disease may occur even after the infection has been cured and limited data is available regarding its relation. Early recognition and treatment can be effective life-saving measures in these patients. Reference #1: Baldi BG, Carvalho CRR, Dias OM, Marchiori E, Hochhegger B. Diffuse cystic lung diseases: differential diagnosis. J Bras Pneumol. 2017;43(2):140-149. Reference #2: Densem C, Niven R, Barber P, Bishop P. Development of cryptogenic fibrosing alveolitis during pregnancy. J R Soc Med. 1998;91(11):591-593. Reference #3: Ambardar SR, Hightower SL, Huprikar NA, Chung KK, Singhal A, Collen JF. Post-COVID-19 Pulmonary Fibrosis: Novel Sequelae of the Current Pandemic. J Clin Med. 2021;10(11):2452. Published 2021 Jun 1 DISCLOSURES: No relevant relationships by Anastasia Brit No relevant relationships by Steven Colby No relevant relationships by Patrick Koo No relevant relationships by Vishruth Vyata No relevant relationships by Harika Yadav

PLEUROPARENCHYMAL FIBROELASTOSIS UNCOVERED IN A PATIENT WITH COVID-19 PRESENTING WITH PNEUMOTHORAX

SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: This report describes the case of a patient presenting with pneumothorax and Severe Acute Respiratory Syndrome (SARS) Coronavirus-2 (SARS-cov-2) infection leading to Coronavirus Disease 2019 (COVID-19) pneumonia, with worsening presentation, later found to have underlying Pleuroparenchymal Fibroelastosis (PPFE). CASE PRESENTATION: A 68 year old male with a past medical history of hypertension and type 2 diabetes presented to his primary care clinic with shortness of breath. He underwent a Chest X-Ray as an outpatient which revealed a moderate right-sided pneumothorax (PTX), and he was sent to the Emergency Department by his primary care provider. He was found to be COVID positive on initial workup, also requiring supplemental oxygen. Other routine laboratory tests did not reveal any significant abnormalities. His shortness of breath worsened and on repeat X-rays his pneumothorax increased in size therefore a chest tube was placed by Cardiothoracic Surgery. Computerized Tomography of the chest revealed moderate right pneumothorax, bilateral diffuse ground glass opacities and pulmonary micronodules [Figure 1]. The patient had mild initial improvement and the chest tube was removed but he had recurrence of the PTX and he underwent urgent Video Assisted Thoracoscopic Surgery (VATS), with right upper lobe wedge resection and talc pleurodesis. A biopsy of the resected lung revealed a benign lung with fibroelastotic scarring, diffusely involving subpleural tissue and prominently extending into and entrapping areas of underlying alveolated tissue, with no inflammation, granulomas or pneumonia noted. Workup for tuberculosis, autoimmune disorders, HIV was negative. He eventually was discharged home with close pulmonology and cardiothoracic surgery follow ups, planned for disease surveillance and malignancy workup. DISCUSSION: PPFE is a rare entity, and classified amongst rare causes of idiopathic interstitial pneumonias (IIP) [1]. It is characterized by upper lobe fibrosis, supleural and parenchymal scarring. It can occur at any age, and the usual presentation is of pneumothorax in a thin male, with a shortened anteroposterior diameter of the chest. Radiographic findings typically include subpleural nodular or reticular opacities in the upper lobes, usually sparing the middle and lower lobes. Pathology reveals increased elastic tissue and dense collagen fibers, along with subpleural fibrosis [2]. Pulmonary function testing reveals a restrictive pattern with reduced diffusion capacity and it is usually resistant to steroids [3]. CONCLUSIONS: PPFE is an uncommon cause of insidious, slowly progressive fibrotic lung disease often limited to the upper lobes. It should be suspected in any person presenting with recurrent pneumothorax or blebs without other known inciting causes. Lung biopsy helps establish the diagnosis. Patients with this condition need close pulmonology follow up to assess progression. Reference #1: Travis WD, Costabel U, Hansell DM, King TE Jr, Lynch DA, Nicholson AG, Ryerson CJ, Ryu JH, Selman M, Wells AU, Behr J, Bouros D, Brown KK, Colby TV, Collard HR, Cordeiro CR, Cottin V, Crestani B, Drent M, Dudden RF, Egan J, Flaherty K, Hogaboam C, Inoue Y, Johkoh T, Kim DS, Kitaichi M, Loyd J, Martinez FJ, Myers J, Protzko S, Raghu G, Richeldi L, Sverzellati N, Swigris J, Valeyre D;ATS/ERS Committee on Idiopathic Interstitial Pneumonias. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013 Sep 15;188(6):733-48. doi: 10.1164/rccm.201308-1483ST. PMID: 24032382;PMCID: PMC5803655. Reference #2: Frankel SK, Cool CD, Lynch DA, Brown KK. Idiopathic pleuroparenchymal fibroelastosis: description of a novel clinicopathologic entity. Chest. 2004 Dec;126(6):2007-13. doi: 10.1378/chest.126.6.2007. PMID: 1559 706. Reference #3: Watanabe K. Pleuroparenchymal Fibroelastosis: Its Clinical Characteristics. Curr Respir Med Rev. 2013 Jun;9(4):299-237. doi: 10.2174/1573398X0904140129125307. PMID: 24578677;PMCID: PMC3933942. DISCLOSURES: No relevant relationships by FNU Amisha No relevant relationships by Perminder Gulani No relevant relationships by Hyomin Lim No relevant relationships by paras malik No relevant relationships by Divya Reddy

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

SESSION TITLE: Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: An alveolopleural fistula (APF) is a pathological communication between the pulmonary alveoli and the pleural space. If pneumothorax persists beyond five days, it is labeled as a prolonged air leak (PAL). Herein, we present a patient with respiratory failure, spontaneous pneumothorax with persistent air leak resulting in functional pneumonectomy despite CTS intervention. CASE PRESENTATION: A 60-year-old female with PMH of diabetes, hypertension was initially admitted for right lower extremity cellulitis. About ten days into the admission, patient started becoming progressively hypoxic and was noted to be saturating 82% on room air with crackles noted bilaterally. A CT angiogram showed findings suggestive of multifocal pneumonia. Covid-19 pneumonia was initially suspected despite negative testing and a course of remdesivir and steroids was administered. All other infectious workup returned negative. Patient's oxygenation requirements worsened over the next two weeks eventually requiring intubation. Bronchoscopy with bronchoalveolar lavage showed growth of stenotrophomonas and patient received a course of trimethoprim-sulfamethoxazole. Patient was subsequently extubated and transitioned to high flow nasal cannula. Two weeks later, she developed acute respiratory deterioration due to a right sided pneumothorax requiring emergent pigtail placement and subsequent intubation. She was noted to have a persistent airleak from the chest tube and imaging showed a persistent pneumothorax with possible malpositioning of the chest tube. Despite repositioning of the previous chest tube and a second chest tube insertion, patient's PAL persisted and she underwent video assisted thoracoscopic surgery (VATS) that showed a large bronchopleural fistula emanating from the right upper and middle lobes requiring stapling and surgical pleurodesis. Bronchoscopy prior to VATS did not show any signs of obstruction. Due to prolonged intubation, she underwent tracheostomy placement followed gradually by chest tube removal when no air leak was appreciated. After the removal of the chest tube, her lung gradually formed multiple bullae with no functional residual lung. Despite this, her respiratory status stabilized and she was discharged to a LTACH. DISCUSSION: The likely cause of APF here was the emergent chest tube insertion. APF and PALs are most seen following pulmonary resection or biopsy but can also be seen following spontaneous pneumothorax or traumatic chest tube insertions. Although an endobronchial valve was entertained, the lung damage was extensive enough to have no change in patient's outcome. CONCLUSIONS: Our case demonstrates a rare but complicated hospital course of a patient where a chest tube insertion resulted in non-resolving APF with PAL despite therapeutic interventions in an unfortunate case of "functional pneumonectomy". Underlying pneumonia may have also contributed to the APF resulting in PAL. Reference #1: 1. Liberman M, Muzikansky A, Wright CD, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010;89:891. Reference #2: 2. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg 2006;82:197. Reference #3: 3. Rivera C, Bernard A, Falcoz PE, et al. Characterization and prediction of prolonged air leak after pulmonary resection: a nationwide study setting up the index of prolonged air leak. Ann Thorac Surg 2011;92:1062. DISCLOSURES: No relevant relationships by Mohammed Halabiya No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel

COVID-19 Impact in Thoracic Surgery: a Comparison Between Public and Private Care in a Single-Center Facility

Introduction: Due to restrictions caused by the COVID-19 pandemic, elective procedures were canceled or postponed. This study aims to compare the epidemiological profile of cases from Brazilian’s Public Healthcare System (SUS) and Private Healthcare (PH) in a teaching single-center facility between 2019 and 2021. Methods: Data were gathered from patients who underwent lung resection (LR) by PUCRS’s Sao Lucas Hospital Thoracic Surgery team between 2019 and 2021. Data were obtained by retrospective review of electronic charts in March 2022. A retrospective analysis was made. Results: There were 212 procedures performed, being 80 in 2019, 66 in 2020 and 66 in 2021. In 2019, there were 45 (56.2%), in 2020, 43 (65.1%), and in 2021, 34 (51,5%) LR on SUS. Lobectomies on SUS in 2019 were 19 (42.2%), in 2020, 13 (30.2%), and in 2021, 17;on PH were 19 (54.2%) in 2019, 12 (52.1%) in 2020, and 18 in 2021. On SUS, in 2019 were performed 41 (91%) open thoracic surgeries and in 2020, there were 33 (76%);on PH, in 2019 video-assisted thoracic surgery (VATS) was done in 24 (68.5%) patients, 17 (73.9%) in 2020 and 29 (75%) in 2021. Procedures for oncological disease (primary or metastatic) on SUS in 2019 were performed in 27 (60%) patients, 23 (53.4%) in 2020, and 13 (44,8%) in 2021;on PH, in 2019, there were 23 (65.5%) patients, in 2020 were 15 (65.2%), and 16 (55,2%) in 2021. On SUS there were 24 women in 2019 (53%) and in 2020 (55%);on PH, there were 23 (65%) men in 2019 and 13 (56%) in 2020. The mean age of patients on SUS was 59, and 66 on PH. Clinical staging (CS) for primary lung cancer on SUS in 2019 was 12 (50%) CS I, 8 CS II, 3 CS III, and 1 CS IV;in 2020 was 8 (47%) CS I, 6 CS II, and 3 CS III. On PH, in 2019, there were 12 (66.6%) CS I, 4 CSII, and 2 CS IV;in 2020, 11 (84.6%) CS I and 2 CS II. Conclusions: We found maintenance in the numbers of procedures in 2020 and 2021, but a global reduction in the number of LR on SUS, mainly because the pandemic became worst in its second year, leading to the closure of surgery centers. And a reduction of 17.5% in the number of LR in 2020, compared with 2019. Lobectomies lowered 36.8% on PH and 31.5% on SUS between 2019 and 2020. Albeit there was a reduction in general incidence, LR for oncological reasons predominated. In 2021 it represented 82,8%, with 44,8% on SUS, and 52,2% on PH. There was a higher average age on PH. Open thoracic surgery was most frequent on SUS due to limitations on offered equipment, while VATS predominated on PH (difference: 44.5%). The predominant CS remained equal on both healthcare systems, CS I, which indicates maintenance of early-stage diagnoses. Nevertheless, the overall incidence has diminished (33.33% [SUS] and 8.3% [PH]), a probable reflection of the pandemic. Keywords: COVID-19, Thoracic Surgery, Lung Cancer

Diagnostic Approach and Treatment of Lung Cancer Patients in Portugal: Portuguese Lung Cancer Study Group Survey

Introduction: In Portugal, in 2020, 5415 new lung cancer patients were diagnosed and 4797 deaths were caused by lung cancer. Lung cancer ranks third in terms of cancer incidence and is the leading cause of cancer mortality. Early diagnosis, complete and fast patient assessment and staging, multidisciplinary approach, access to personalized medicine, new treatment options and research are essential to improve survival and quality of life. Access to clinical trials is critical for this improvement.The aim of this study is to assess the techniques available to the diagnostic work-up, treatments, the waiting time and the needs perceived by physicians. Methods: The Portuguese Lung Cancer Study Group launched a survey in order to study the diagnostic approach and treatment of lung cancer patients in Portugal. An online survey with 47 questions was sent to all Portuguese hospitals that treat lung cancer, referring to the pre-COVID-19 pandemic experience. Results: Responses from 31 Portuguese hospitals were collected, between May and September 2020. Availability to bronchoscopy, image-guided transthoracic needle biopsy (TNB), endobronchial ultrasound- transbronchial needle aspiration (EBUS-TNBA), PET/CT, molecular biology testing is presented in table I. In 58% (n=18) the molecular biology test was performed as a "reflex test". About 68% (n=21) of hospitals used next generation sequencing. Two hospitals (7%) reported not having access to liquid biopsies.Video-assisted thoracoscopic surgery was the main surgical technique (61%;n=19). The waiting time for the first radiation oncology consultation was less than 15 days in 71% (n=26). About 61% (n=19) of hospitals had clinical trials. A wide majority of doctors (77%) would like to have more clinical trials. In 71% (n=22) of the hospitals, it was possible to refer patients to Palliative Care receiving systemic anticancer therapy. [Formula presented] Conclusions: Despite the limitations of the methods, this study allowed us to deepen our knowledge about the work-up technologies and treatments available for lung cancer patients in Portugal. It has also identified future opportunities, such as increasing accessibility to some diagnostic tools and clinical trials. Keywords: Diagnosis and treatment approach, Lung Cancer in Portugal, Health Services Research - Portugal

Clinical Features and Surgical Outcomes of Young Patients with Ground Glass Opacity Featured Lung Adenocarcinoma

Introduction: In recent years, with the popularity of low-dose computed tomography (LDCT) and the pandemic of COVID-19 (many young people suspected of having COVID-19 infection also routinely undergo LDCT examination), more and more ground glass opacity (GGO) featured lung adenocarcinoma have been diagnosed in young patients. Many studies have proved that the prognosis of GGO featured lung adenocarcinoma is excellent, the 5-year OS is close to 100%, but lack of attention has been paid to the clinical features and prognosis of GGO featured lung adenocarcinoma in young patients.Thus, our study aims to investigate the clinical characteristics and surgical outcome presenting as GGO featured lung adenocarcinoma in young patients. Methods: Patients aging from 15 to 40 who were diagnosed as lung adenocarcinoma and underwent video assisted thoracoscopic surgery (VATS) were reviewed from January 2017 to December 2018. According to radiological appearance of the patient’s lesions, they were divided into a GGO group and a solid nodule (SN) group. The pathological types, nodules size, surgical methods were analyzed, and the clinical characteristics and prognosis were evaluated between these patients. Results: A total of 165 patients were included, of which 133 were in the GGO group and 32 in the SN group. Both the GGO group and the SN group had a higher proportion of females and non-smokers. Compared with patients (15.63%) in the SN group, there are more patients (27.8%) under the age of 30 in the GGO group. Pathological findings showed a predominance of pre-invasive lesions in the GGO group, although 16.5% of lesions were invasive adenocarcinoma, whereas in the SN group, 96.9% were invasive adenocarcinoma. Compared to the GGO group, the SN group showed significantly worse histological characteristics and prognosis. After a median follow-up time of 41.2±7.2 months (32-56), the 3-year RFS (100%) and OS (100%) of the GGO group were significantly higher than those (93.42% and 96.88%) in the SN group. Conclusions: Young patients with GGO featured lung adenocarcinoma are mainly female and non-smokers. The vast majority of these patients were early-stage with extremely good prognosis after surgery. Further studies are required to better understand the molecular mechanisms causing younger patients to develop GGO featured lung adenocarcinoma and also identify potential targets to develop new treatment options. Keywords: Ground glass opacity, Lung adenocarcinoma, Young patients

Recurrent Primary Spontaneous Pneumothorax Masquerading as a Congenital Pulmonary Airway Malformation in a Young Female

Introduction: Spontaneous pneumothoraxes in children are uncommon, may be idiopathic or associated with underlying pulmonary disease, and can present management challenges. We present a 12-year-old female with recurrent right sided spontaneous pneumothorax in the setting of an asymptomatic SARS-Co-V2 (COVID) infection and imaging concerning for congenital lobar overinflation (CLO) versus congenital pulmonary airway malformation (CPAM), prompting surgical intervention. Case: A 12-year-old pre-menstrual female with remote history of eczema, asthma, and environmental allergies presented from an outside facility with four-days of progressive chest pain and dyspnea on exertion and diagnosis of right-sided spontaneous pneumothorax, improving after pigtail chest tube placement. Physical exam was significant for tall thin body habitus;family history was significant for paternal spontaneous pneumothorax as an adolescent. She was incidentally found to be COVID positive. Chest plain films (CXRs) showed subcutaneous emphysema and persistent right-sided pneumothorax. Clamping trial failed, prompting removal of the pigtail and placement of 12F chest tube with resultant near complete re-expansion. On serial CXRs, a right hilar cystic lucency was newly identified. Chest CT confirmed the right upper lobe (RUL) air-filled cystic structure and abrupt narrowing of the RUL posterior segmental bronchus, concerning for CLO versus CPAM. Chest tube was successfully removed on day 6, and she was discharged home with planned follow-up. Three months later, she was readmitted for recurrent right-sided spontaneous pneumothorax diagnosed after one day of chest pain, cough, and dyspnea. Laboratory testing revealed mild leukopenia and anemia;she was COVID negative. A chest tube was placed and set to wall suction. Due to persistent pneumothorax, this was replaced with a pigtail drain on day 5. CXRs demonstrated persistent cystic RUL lung mass. With her prior COVID infection now resolved, RUL wedge resection was completed via video-assisted thoracoscopic surgery on day 8. She tolerated the procedure well and was discharged on day 10 with resolving pneumothorax. Tissue for pathology results revealed pleural fibrosis and focal hemorrhage without malignancy, most consistent with a ruptured bleb. At one week follow up, she remained stable without complications. Discussion: Pneumothoraxes in tall, thin adolescents are often categorized as primary spontaneous. Most pneumothoraxes resolve with conservative management and often do not require surgical intervention. Congenital lung malformations are a rare secondary cause in children and may be detected on CXR. Chest imaging should be carefully reviewed for congenital malformations requiring specific surgical intervention. These findings, along with the patient's clinical course, may assist in determining management.

Pulmonary artery pseudoaneurysm in a covid survivor

Introduction: Pseudoaneurysm of the pulmonary artery (PAP) is a rare cause of hemoptysis with a wide array of aetiologies. This case report discusses our clinical experience of PAP associated with pulmonary mucormycosis (PM) in a COVID survivor. Case Report: A 58-year-old gentleman presented with a 1-week history of high-grade fever and progressive dry cough. Four weeks before his presentation, he was treated for mildly symptomatic COVID-19 infection with unusually high doses of steroids. On admission, a chest x-ray and CT chest showed a cavitatory lesion in the right lower lobe. He underwent a FOB with BAL and endobronchial biopsy, which were inconclusive. On day 5 of his hospital admission, he had an episode of massive hemoptysis leading to hemodynamic instability. CT showed an increase in the size of the cavity and a pulmonary angiogram showed the descending segmental branch of the right pulmonary artery traversing through the consolidative cavitating lesion with focal dilatation of the same measuring up to 1.5 x 1.9 cm. Consistent hemostasis couldn't be achieved after gluing an interlock coiling of pseudoaneurysm, hence he underwent video-assisted thoracic surgery for right lower lobectomy and stump ligation of the right lobar pulmonary artery. Lobectomy specimen on histopathology revealed large areas of necrosis with aseptate fungal hyphae. He responded well to antifungal therapy during follow on 4th week post discharge. Conclusion: Mucormycosis is characterized by angioinvasion, vessel thrombosis, and subsequent tissue thrombosis. Pseudoaneurysm formation is rarely seen in PM and can be associated with fatal hemoptysis. Irrational use of systemic steroids in the management of COVID makes the patient more vulnerable to an otherwise rare disease.

Effect of COVID-19 on the delivery of care for thoracic surgical patients.

Objective: In this study we aimed to determine the effect of the COVID-19 pandemic on the delivery of care for thoracic surgical patients at an urban medical center. Methods: A retrospective analysis of all thoracic surgical cases from May 1, 2019, to December 31, 2020, was conducted. Demographic characteristics, preoperative surgical indications, procedures, final pathologic diagnoses, and perioperative outcomes were recorded. A census of operative cases, relevant ancillary services, and outpatient thoracic clinics were obtained from our institutional database. Results: Six hundred nineteen cases were included in this study (329 pre-COVID-19 and 290 COVID-19, representing an 11.8% reduction). There were no differences in type of thoracic procedures or perioperative outcomes among the 2 cohorts. Prolonged reduction of thoracic surgical cases (50% of baseline) during the first half of the COVID-19 period was followed by a resurgence of surgical volumes to 110% of baseline in the second half. A similar incidence of cases were performed for oncologic indications during the first half whereas more benign cases were performed in the second half, coinciding with the launch of our robotic foregut surgery program. After undergoing surgery during the pandemic, none of our patients reported COVID-19 symptoms within 14 days of discharge. Conclusions: During the initial surge of COVID-19, while there was temporary closure of operative services, our health care system continued to provide safe care for thoracic surgery patients, particularly those with oncologic indications. Since phased reopening, we have experienced a rebound of surgical volume and case mix, ultimately mitigating the initial negative effect of the pandemic on delivery of thoracic surgical care.

Videothoracoscopic segmentectomy in extralobar pulmonary sequestration: Safe and effective procedure

Extralobar pulmonary sequestration is a rare congenital disease of the primitive foregut. This case report describes an adult with asymptomatic extralobar sequestration who was successfully treated with the video-assisted thoracic surgery. We performed a superior segment-preserving lower lobectomy and complete resection of the sequestered mass due to the atypical incomplete fissure. This approach allowed a patient to recover uneventfully to preserve pulmonary function and it provides patient satisfaction by causing less postoperative pain.

Pre-COVID-19 National Mortality Trends in Open and Video-Assisted Lobectomy for Non-Small Cell Lung Cancer.

INTRODUCTION: In the current era of episode-based hospital reimbursements, it is important to determine the impact of hospital size on contemporary national trends in surgical technique and outcomes of lobectomy. METHODS: Patients aged >18 y undergoing open and video-assisted thoracoscopic surgery (VATS) lobectomy from 2008 to 2014 were identified using insurance claims data from the National Inpatient Sample. The impact of hospital size on surgical approach and outcomes for both open and VATS lobectomy were analyzed. RESULTS: Over the 7-y period, 202,668 lobectomies were performed nationally, including 71,638 VATS and 131,030 open. Although the overall number of lobectomies decreased (30,058 in 2008 versus 27,340 in 2014, P < 0.01), the proportion of VATS lobectomies increased (24.0% versus 46.9%), and open lobectomies decreased (76.0% versus 53.0%, all P < 0.01). When stratified by hospital size, small hospitals had a significant increase in the proportion of open lobectomies (6.4%-12.2%; P = 0.01) and trend toward increased number of VATS lobectomies (2.7%-12.2%). Annual mortality rates for VATS (range: 1.0%-1.9%) and open (range: 1.9%-2.4%) lobectomy did not significantly differ over time (all P > 0.05) but did decrease among small hospitals (4.1%-1.3% and 5.1%-1.1% for VATS and open, respectively; both P < 0.05). After adjusting for confounders, hospital bed size was not a predictor of in-hospital mortality. CONCLUSIONS: Utilization of VATS lobectomies has increased over time, more so among small hospitals. Mortality rates for open lobectomy remain consistently higher than VATS lobectomy (range 0.4%-1.4%) but did not significantly differ over time. This data can help benchmark hospital performance in the future.

Cocaine induced organizing pneumonia

Case Report Cocaine is a potent natural stimulant that is widely used and is among the most common cause of acute drug related emergency department visits in the US. All different forms of cocaine can cause a variety of neuro-psychological, cardiovascular, and pulmonary injuries. Here we present a case of respiratory failure in patient with smokes cocaine in aluminum foil. Case A35-year-old morbidly obese female with no significant medical history except for daily cannabis uses and cocaine in the past who was admitted for progressive cough, dyspnea, and fever for 10 days. She smoked a different kind of marijuana recently. Family mentioned history of smoking cocaine using aluminum foil recently. no chest pain, rash, or joint pain, no recent travels. no family history of similar condition or autoimmune disease. vital signs fever of 38 C, O2 sat of 82% Room air, BP 162/ 90 mmHg, pulse of 124, RR of 34. Patient did have bilateral rales on respiratory examination. WBC was 25,000. ESR of 68, Pro-Cal 0.11. CT angiography of the chest showed bilateral ground glass opacities and patchy consolidation. Pan cultures, viral panel including Covid test, HIV, Autoimmune diseases, and Vasculitis work-up were negative. Bronchoalveolar lavage (BAL) revealed neutrophil 38, lymphocyte 39, Eosinophile 14, Cultures were negative. Urine toxicology screen was not done. Patient was started on broad spectrum antibiotic. Patient was intubated for Video assisted thoracoscopic surgery and biopsy but could not be done due to worsening respiratory status. Based on presentation and investigation findings, diagnosis of Cocaine induced Organizing pneumonia was made. Tapered steroid therapy was added with dexamethasone initial dose of 6 mg then methyleprednisolone 125 mg. patient recovered well, extubated on day 13, switched to oral prednisone and discharged home on room air. Discussion Cocaine is an alkaloid with anesthetic properties that is administered through different routes;inhaled, IV injections, or smoked after chemical modification 'crack'. It may be smoked through different types of pipes or mixed with cigarettes or marijuana. Mechanism of cocaine induced lung injury is thought to be due to inflammatory damage, thermal injury, direct cellular toxicity, barotrauma, or vasospastic ischemia. other possibility in our patient is Smoking in aluminum foil which has food oil substances, and none stick substances can make them toxic when inhaled. Cocaine induced organizing pneumonia with respiratory failure has been reported in young cocaine smokers. Organizing pneumonia BAL cell count has increase in lymphocyte (20-40), neutrophile (5-10) and eosinophile (5-25) with the level of lymphocyte being higher than eosinophile is typical but not diagnostic for COP. Conclusion Organizing pneumonia secondary to cocaine or aluminum foil with typical presentation, radiology imaging, BAL cell count findings and excluding other causes may be diagnosed without the need of lung biopsy.

Application of Continuous Positive Airway Pressure During Video-Assisted Thoracoscopic Surgery.

PURPOSE OF REVIEW: Video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are used for anatomic resection of early stage cancer. These surgical techniques require the use of one-lung ventilation (OLV). During OLV, an obligatory intrapulmonary shunt may produce hypoxemia. One method to correct hypoxemia is with the use of continuous positive airway pressure (CPAP). This review focuses on 1) the lung physiology of OLV; 2) application of CPAP in VATS or RATS during supine and lateral position; and 3) the application of CPAP in COVID-19 patients during OLV. RECENT FINDINGS: Studies have shown the beneficial effects of CPAP to improve oxygenation during OLV while the patient is in the lateral decubitus position. In contrast, studies have shown no benefit on improving oxygenation with CPAP in patients undergoing OLV in supine position. SUMMARY: The application of CPAP to the non-dependent lung is one of the options to treat hypoxemia during VATS or RATS.

Post-coronavirus disease 2019 organizing pneumonia confirmed pathologically by video-assisted thoracoscopic surgery.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has become a global pandemic. Many survivors of serious COVID-19 pneumonia have long-term residual pulmonary disease. However, there is little documentation of the histopathological characteristics of lung sequelae post-COVID-19 and effective treatments. We present two Japanese cases of lung sequelae post-COVID-19. The patients were histopathologically diagnosed with organizing pneumonia (OP) or OP with fibrosis and no diffuse alveolar damage on video-assisted thoracoscopic surgery. Case 1, who had been diagnosed with OP, was successfully treated with corticosteroid and other immunosuppressive agents over a 6-month period. Although case 2, who had been diagnosed with OP with fibrosis, had a partial and unsatisfactory response to immunosuppressive agents, the patient responded to antifibrotic treatment including nintedanib.