Protective measures undertaken during chest tube thoracostomy in COVID-19 outbreak.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a newly emerging infectious disease that was first reported in China and has become a worldwide pandemic. Many surgical procedures are continuing to be performed during this state of pandemic as is thoracic surgery. We present six cases of tube thoracostomy in COVID-19 patients and the modifications to the routine surgical technique. METHODS: We serially attached two closed underwater drainage systems (CUDS) together and added a high-efficiency particulate air (HEPA) filter to the port of the second CUDS, because the intrapleural air, which passes through the CUDS into the air in intensive care unit (ICU), may contain high concentrations of 2019 novel coronavirus (2019-nCoV). Second, we attached the chest drain to the first CUDS in order to prevent the spread of virus during the placement of drain into the pleural cavity. Third, just before opening the parietal pleura, ventilation was put on standby mode and the endotracheal tube was clamped to prevent viral dissemination to the environment. Fourth, we covered the incision with a gauze sponge soaked with sterile saline solution during pleural entry, to prevent viral dissemination into the environment. RESULTS: There were a total of six patients enrolled in our study. All these patients were diagnosed with COVID-19. The surgical indication for the chest tube thoracostomy was tension pneumothorax in all six patents. All patients had lung expansion defects and subcutaneous emphysema after intervention. Unfortunately, all of them succumbed to COVID-19, despite best available treatment. There was no COVID-19 infection reported in the healthcare professionals during this study. CONCLUSIONS: Thoracic surgical procedures may cause dissemination of high amounts of 2019-nCoV in the environment and thus are perhaps the most dangerous surgeries to perform. Variations in the thoracic surgical techniques are necessary in order to protect the healthcare providers from COVID-19.

The effect of meteorological variables on spontaneous pneumothorax in two regions with different altitudes.

Spontaneous pneumothorax (SP) is defined as the presence of free air inside the pleural space. Many studies have reported that meteorological variables may trigger SP, but the mechanism is unknown. The aim of this study was to compare the effects of meteorological variables on the development of SP in two regions with different altitudes. The study was conducted in the Çanakkale (2 m above sea level) and the Erzurum region (1758 m). A total of 494 patients with SP who presented to the hospitals of the two regions between January 2011 and December 2016 were included in the study. The meteorological variables used included ambient temperature, atmospheric pressure, relative humidity, precipitation amount, wind speed, and wind direction (as north and south). The total 2192 days were divided into two as days with and without an SP case presentation. A 4-day period prior to the day a case presented was compared with the other days without any cases to investigate the presence of any lagged effect. Statistical significance was accepted at p < 0.05. Comparison of these two regions showed a significant difference between them. The meteorological variables of the regions that affect SP development were found to be low mean minimum temperature, high daily temperature change, low precipitation, low wind speed and north winds for Erzurum, and only rainy days for Çanakkale. The results have demonstrated that cold weather, sudden temperature changes, north winds, and low wind speed are risk factors for the development of SP at high altitudes.

The effects of analgesic treatment and chest physiotherapy on the complications of the patients with rib fractures that arise from blunt chest trauma.

BACKGROUND: This prospective study aims to investigate the effect of chest physiotherapy and analgesic therapy on the possible complications of isolated rib fractures attributable to blunt thoracic trauma, such as hemothorax and pneumothorax. METHODS: Patients who presented to Çanakkale Onsekiz Mart University School of Medicine Hospital's Emergency Department and Thoracic Surgery outpatient clinics within the first 24 hours of the post-traumatic period and did not have additional intrathoracic complications at presentation with blunt thoracic trauma and who were diagnosed with isolated rib fractures were enrolled in this prospective research study. The groups were designated as the patients who would receive analgesic treatment only (Group A) and the patients who would receive chest physiotherapy and analgesic treatment together (Group B). Patients who had first and second rib fractures or three or more rib fractures and who did not have additional organ injury were hospitalized in the Thoracic Surgery clinics; patients who had other organ trauma were hospitalized in related clinics. Patients were reassessed on their seventh and 30th post-traumatic days with physical examination and radiologic studies. RESULTS: The mean age of the 114 patients were 56.3±16.4 (22-87). There were 37 (32.5%) women and 77 (67.5%) men. Each group included 57 patients. The most common form of trauma was the same-level falls (31.6%). The mean number of rib fractures of all participants was 2.6±0.7 (1-10); the median number was 1.5. Fifty-two (45.6%) patients were hospitalized. The mean length of stay was 4.0±1.1 days. At the end of their treatment and follow-up periods, pleural effusion was found in 28 patients (24.6%) out of 114 enrolled at the side of trauma. Group B had a higher number of patients with pleural effusion (43.9%) than group A (5.3%). We performed tube thoracostomy in four patients, all of which were in group B (p<0.05). CONCLUSION: As a result of this study, chest physiotherapy maneuvers have increased the incidence of late hemothorax in patients with three or more isolated rib fractures. Also, minimal hemothoraces (<300 ml) may spontaneously regress, and no additional surgical treatment are required if the proper follow-up procedures are performed. It is advisable to hospitalize the blunt thoracic trauma patients who have three or more rib fractures and who are planned to undergo chest physiotherapy and or are prone to develop additional complications because of possible risks.

Löfgren's syndrome: an acute variant of sarcoidosis diagnosed by mediastinoscopy.

Löfgren's syndrome is an acute clinical form of sarcoidosis that is first described by Sven Löfgren as bilateral hilar lymphadenopathy together with Erythema Nodosum (EN) and accompanying arthritis/arthralgia. This syndrome has some differences in terms of treatment, prognosis and recurrence compared to sarcoidosis. In this report, we describe a 70 years old lady who admitted with multiple erythematous lesions and arthralgia of both lower extremities and she was diagnosed as Löfgren's syndrome via mediastinoscopy.

A wandering intravascular scalpel fragment after lumbar discectomy: a case report.

Vascular complications after lumbar discectomy are rarely seen. We present a unique and potentially life-threatening postoperative complication from this procedure. A 27-year-old man was admitted to our emergency vascular unit 1 day after a lumbar discectomy, during which a scalpel blade fragmented and a part was lost. Radiological images of the patient were performed and a broken scalpel blade was located anterior to the sacrum. An anterior laparotomy was performed which identified a mass within the left iliac vein that migrated suddenly to the inferior vena cava. An emergency angiography was performed, by which time the scalpel blade had ascended to the right-sided inferior pulmonary artery. It was subsequently removed via a right lateral thoracotomy.

The role of the tissue culture in granulomatous mediastinal lymphadenitis: tuberculosis or not.

AIM: To evaluate the role of the tissue culture via mediastinoscopic biopsy in granulomatous mediastinal lymphadenitis. METHODS: The dossier data of 92 cases with mediastinal lymphadenitis showing granulomatous lymphadenitis features by cervical mediastinoscopy and whose clinical, radiological and bacteriological definitive diagnosis is tuberculosis and sarcoidosis were examined retrospectively. The rate of the positive tissue culture of mediastynoscopic biopsy in the diagnosis of granulomatous lymphadenitis was calculated. RESULTS: There were 65 (71%) females and 27 (29%) males. The mean age of the patients was 42.5 (range 15-75) years. Non necrotizing granulomatous lymphadenitis was detected in 58 (63 %) cases while necrotizing granulomatous lymphadenitis was seen in 34 (37%) cases. There were 29 cases diagnosed with tuberculosis. Acid resistant bacilli culture positive rate was 38% (in 11 cases). There were 21 (62%) cases of necrotizing granulomatous lymphadenitis and eight (14%) cases of non-necrotizing granulomatous lymphadenitis diagnosed with tuberculosis. Culture positivity was identified in two (25%) of eight cases whose differential diagnosis could not be made histopathologically as tuberculosis/sarcoidosis. CONCLUSIONS: In addition to clinical, radiological and histopathological diagnosis, the study aims to highlight the importance of tissue culture in definitive diagnosis, especially undetermined incidents.

How does the type of thoracotomy affect the patient quality of life? A short form-36 health survey study.

PURPOSE: We evaluated whether the quality of life was affected in patients who had undergone various types of thoracotomy using the Short Form-36 Health Survey. METHODS: The patients who had undergone thoracotomy for diagnosis or treatment between January and September 2011 in the Thoracic Surgery Department were investigated to determine the effect of the type of thoracotomy on the quality of life using the Short Form-36 Health Survey. The patients were classified into three groups. In Group I, the latissimus dorsi and the serratus anterior had both been preserved, and there was no muscle dissection, in Group II the latissimus dorsi muscle had been dissected and only the serratus anterior muscle has been preserved, and in Group III both muscles had been dissected, and the standard posterolateral muscle dissection had been performed. RESULTS: A total of 101 patients comprising 64 males (63.37 %) and 37 females (36.63 %), with a median age of 38 years, were included in this study. There were significant differences in all quality of life subscales between Groups I and III and between Groups II and III. The patients in Group I had the highest scores, while the patients in Group III had the lowest scores. There were no significant differences in five of the eight Short Form-36 subscales and one of the two summary scores values between Group I and Group II in females. CONCLUSIONS: We investigated the effect of the type of thoracotomy on the patient quality of life using the Short Form-36 Health Survey, and found that the standard posterolateral thoracotomy had a marked adverse effect on the quality of life compared to muscle-sparing thoracotomy. We also found that it is possible to use thoracotomy with serratus preservation rather than muscle-sparing thoracotomy in cases with benign diseases where a large field of view is required, such as for decortication and pulmonary hydatid cysts, without any significant decrease in the quality of life, especially in females.

Single-incision thoracoscopic surgery of pleural effusions for diagnosis and treatment.

BACKGROUND: Several procedures such as video-assisted thoracoscopic surgery (VATS) are used to make a definite diagnosis in recurrent pleural effusions so that appropriate treatment can be arranged. Single-incision thoracoscopic surgery (SITS) is the most appropriate procedure that can be used for this purpose. The contribution of SITS to diagnosis and treatment is evaluated in this study that we conducted using a single thoracoport in patients with pleural effusion. METHODS: Nineteen consecutive patients with pleural effusion that was recurrent or refractory to medical treatment were included in the study to be diagnosed and treated with SITS. Thoracentesis was performed and pleural fluid samples obtained in all patients before the procedure. Pleural effusion drainage was performed from the 11-mm single skin incision by using a 10.5-mm single thoracoport, and biopsy or talc pleurodesis was performed in the same session when needed. RESULTS: The median age of the patients was 56.68 ± 3.05 years and there were 11 males and 8 females. The total amount of fluid drained by SITS was 1,436 ± 227 mL and the surgery lasted 81.05 ± 5.36 min. In addition, partial decortication and/or deloculation were performed in six patients and talc pleurodesis in nine patients. Fifteen patients were diagnosed with benign and four patients with malignant pleural effusion by thoracentesis, while nine patients were diagnosed with benign and ten patients with malignant pleural effusion by SITS. We therefore had six cases diagnosed as benign with thoracentesis who were diagnosed with malignant disease after SITS. CONCLUSIONS: SITS presents both diagnosis and treatment options together for pleural effusions. We believe SITS should be preferred to conventional three-port VATS to minimize the spread of infection and tumor cells to the chest wall in infectious and malignant diseases.

Is Acrylate Co-monomer (Glubran-2) Useful in the Prevention of Prolonged Air Leaks After Pulmonary Lobectomy?

Many synthetic materials are being used in order to reduce the frequency of prolonged air leak (PAL) in thoracic surgical practice. This study presents our experience with the topical application of acrylate co-monomer (Glubran-2) as a synthetic tissue adhesive in an attempt to decrease troublesome postoperative air leaks in patients undergoing resection for non-small cell lung carcinoma. Of the 112 patients who had undergone resection for lung carcinoma, 69 patients having lobectomy or bilobectomy were included in this study. The application group (group A) consisted of 33 patients where a synthetic tissue adhesive (Glubran-2) was used and compared with the control group (group C, n = 36) retrospectively. There was no difference between the groups regarding demographic details and operative variables. Both groups were compared in view to PAL, chest tube duration, in-hospital stay and hospital costs. There was no significant difference between group A (n = 11, 33 %) and group C (n = 6, 17 %) for the development of PAL (P = 0.11). Hospital stay was 16.1 ± 6.7 days in group A and 15.3 ± 5.8 days in group C (P = 0.66). The surgical cost was significantly higher in group A (€806 ± 127) than the group C (€624 ± 94) (P < 0.001). There was no significant difference between the groups regarding overall hospital costs (P = 0.41). In this study, the use of Glubran-2 following lung resection for non-small cell lung carcinoma did not decrease the incidence of PAL. Neither did it have a favorable effect concerning in-hospital stay nor did it decrease overall hospital costs while increasing surgical costs as expected.

A case of posterior mediastinal ganglioneuroma: the importance of preoperative multiplanar radiological imaging.

Ganglioneuromas are mostly seen in adolescents and young adults and they are neurogenic tumors originating from sympathetic ganglions with a benign histology. Although ganglioneuromas are benign, the treatment is surgical as they can cause pain or compression symptoms, can be locally aggressive and can lead to cord compression. We present a young adult female with a ganglioneuroma of the right posterior mediastinum who presented with lower back pain, together with the clinical features, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) findings, differential diagnosis tips and their contribution to surgical planning.

A rare presentation of a bronchogenic cyst: presternal, subcutaneous and 42-year-old man.

Bronchogenic cysts are generally detected shortly after birth or in early childhood. Most lesions are found in the mediastinum, along the tracheobronchial tree or in the lung parenchyma. Cutaneous or subcutaneous bronchogenic cysts are rarely reported. Our patient was the second case in the English literature who had a cyst over the manubrium sterni in adult life. Surgical total excision is the definitive treatment of extrathoracic bronchogenic cysts, needle aspiration management should not be tried because of association with malignant lesions as mucoepidermoid carcinoma and malign melanoma have been reported to arise from them.

Pericardial cysts: an analysis of 12 cases.

BACKGROUND: Pericardial cysts are usually asymtomatic, benign, congenital mediastinal lesions but may also be acquired after cardiothoracic surgery. The purpose of the study was to evaluate surgical approach and results of our experience with pericardial cysts. PATIENTS AND METHODS: A total of 12 patients who had undergone surgical treatment for pericardial cyst between February 1999 and August 2010 were retrospectively evaluated. All patients were analyzed according to the symptoms, method for the diagnosis, cyst location, management, and outcomes. RESULTS: The mean age was 50.4±17 years (range, 23-68 years) with a female-to-male ratio of 8:4. Pericardial cyst were located in the right hemithorax in 8 (67%) patients and left hemithorax in 4 (33%) patients. The cysts were resected by thoracotomy in 4 (33%) patients and by video-assisted thoracic surgery in 8 (67%) patients. There was an excellent long-term follow-up with no morbidity or mortality. CONCLUSION: Videothoracoscopic surgical removal of pericardial cysts is an excellent surgical intervention without serious morbidity and mortality.

Giant mediastinal mass: thymolipoma.

A 26-year-old man presented with shortness of breath on exertion that was gradually getting worse. His history revealed a mass in the left hemithorax that had been growing on follow-ups. Physical examination only showed that the respiratory sounds were fainter on the left. Thoracic computerized tomography was performed to elucidate the left hemithorax lesion seen on chest x-ray and a giant mass of lipid density extending from the anterior mediastinum to the diaphragm and filling almost the entire left hemithorax was observed. Total excision of the 25 × 21 × 8 cm mass weighing 1580 g was performed with a left thoracotomy. The histopathology investigation of the mass was reported as thymolipoma. The case was presented because it is a rare mediastinal mass.

Lightning strike: a first case of unilateral diaphragmatic paralysis.

Lightning injury is the second most common cause of weather-related deaths in the United States. Despite the several neurological complications such as polyneuropathy, myelopathy, spinal cord injury, motor neuron disease due to the lightning-induced injury, there is no documented case of unilateral diaphragmatic paralysis. We describe the case of a patient with a history of lightning strike at childhood period, prior the onset of isolated, diaphragmatic paralysis, unilaterally. Clinical and electrophysiological findings suggest an injury restricted to the phrenic nerve, unilaterally.