Lobar Lung Transplantation: A Single-Center 10-Year Experience.

BACKGROUND: The shortage of donors for lung transplants is the main limitation of the preceding. Lobar transplantation is an alternative especially useful in patients with short stature and small thoracic cavities. The aim of this study was to perform a descriptive analysis of Portuguese patients who underwent lobar lung transplantation. METHODS: A retrospective study was conducted, and patients submitted to lobar lung transplantation from January 2012 to December 2023 were evaluated. A descriptive analysis was made, including demographic data, lung diseases, waiting list dynamics, pre-transplant evaluations, and post-transplant outcomes. RESULTS: Sixteen lobar transplants were performed with a predominance of female patients and a median age of 47 years. Most patients had interstitial lung disease or bronchiectasis either due to cystic fibrosis or non-cystic fibrosis. The median predicted total lung capacity (pTLC) ratio was 0.73. The median waiting list time was 6 months with 9 urgent transplants and 1 emergent lobar retransplant. Extracorporeal membrane oxygenation (ECMO) was used in pre-, intra-, and postoperative periods. Most transplanted lobes were the median lobe (ML) + right upper lobe (RUL) and left upper lobe (LUL). The median length of stay was 58 days, with complications such as PDG grade 3, bronchial tree ischemia, and concentrical stenosis of bronchial anastomosis. Six patients died in this period, 1 in the immediate postoperative period and 5 during the post-transplant hospitalization, with a median survival of 20.7 months and a 1-year and 5-year survival rate of 60%. CONCLUSION: Our results show a population with an increased waiting list converging in many urgent cases, with an early mortality and high primary graft dysfunction rate. Nevertheless, mid- and long-term survival are promising.

Lung Transplantation in Pulmonary Arterial Hypertension: The Portuguese Experience.

BACKGROUND: In patients with pulmonary arterial hypertension (PAH), refractory to medical therapy, lung transplantation emerges as an option. This study describes the outcomes of 8 PAH patients who underwent lung transplantation. METHODS: A retrospective, single-center study was conducted among patients with PAH who underwent lung transplantation in our center. RESULTS: Patients had a median age of 46 years, with female sex predominance (75%). Causes of HAP were pulmonary veno-occlusive disease (n = 5, 62.5%), idiopathic PAH (n = 2, 25%), and heritable PAH (n = 1, 12.5%). Pre-transplant hemodynamics revealed a median mean pulmonary artery pressure of 58.5 mm Hg (48-86). All patients received bilateral lung transplants with extracorporeal membrane oxygenation support, displaying immediate post-transplant hemodynamic improvement. Primary graft dysfunction grade 3 (PGD 3) was observed in 75% of patients. Five patients (62.5%) died, with a 72.9% survival at 12 months and 29.2% at 24 months post-transplantation. CONCLUSION: Our study reveals the complexity and challenges of lung transplants in patients with PAH. Despite notable immediate hemodynamic improvements, high rates of PGD 3 and the survival rate remain a concern. Further research to define optimal peri and post-transplant management to improve survival is required.

Extracorporeal life support use in limited lung function: a narrative review.

Background and Objective: In thoracic surgery, different modalities of extracorporeal life support (ECLS) can be used for cardiorespiratory support in complex scenarios. Decades of learning in clinical practice and physiology associated with technological development led to a great variety of ECLS technologies available. Thoracic surgery procedures with difficult or impossible single lung ventilation may still be performed using different ECLS modalities. The aim of this review is to describe the use of ECLS, with its different modalities, as a solution to perform complex surgeries in a patient with difficult or impossible single lung ventilation. Methods: A literature review was conducted using the terms "extracorporeal life support pulmonary resection" and "extracorporeal life support thoracic surgery", and articles were selected according to defined criteria. Key Content and Findings: To support lung function during thoracic surgery, the most efficient and popular variety of ECLS is venovenous extracorporeal membrane oxygenation. Lung resection on a single lung after pneumonectomy, surgery in a patient with severe hypercapnia and/or low respiratory reserve, carinal and airway surgery, and severe thoracic trauma are the main examples of situations where ECLS may be the solution to provide a safe surgical environment in patients who cannot tolerate single lung ventilation. Multidisciplinarity, selection of patients and careful surgical planning are cornerstones in defining the situations that may benefit from ECLS support. Conclusions: Knowledge on techniques of ECLS are essential for every thoracic surgeon. Although rarely used, these techniques of cardiorespiratory support should be considered when planning complex cases with difficulties in ventilation and emergent situations.

Blunt Trauma and Right Diaphragmatic Rupture: Unveiling the Impact.

Traumatic diaphragmatic ruptures are rare, yet blunt injuries tend to be more easily overlooked compared to penetrating trauma. The minimal evidence of external injuries makes a high index of suspicion key for diagnosis. We report the case of a right-sided thoracoabdominal blunt trauma that resulted in a diaphragmatic rupture and fractured rib. Although often approached through a midline laparotomy, a definitive right thoracotomy repair was exceptionally performed since the adjacent peritoneum remained uninjured.

Thymoma and myasthenia gravis - an observational study at a tertiary center.

INTRODUCTION: Acquired Myasthenia Gravis (MG) is a rare autoimmune neurological disorder characterized by fluctu- ating paresis of the skeletal muscle due to pathogenic antibodies against the acetylcholine receptor or other elements of the neuromuscular plaque. There is a close relation between MG and thymoma. We aimed to characterize a population of patients with Myasthenia Gravis associated thymoma (MGAT). METHODS: Retrospective and longitudinal study in all patients with MGAT observed at a tertiary center between 2009 and 2020. We assessed epidemiological, clinical, laboratory and therapeutic features of both MG and thymoma. RESULTS: We found 18 patients with an average age of 53 ± 16.2, 13 of them females. Most patients (n=15) presented the generalized MG form. Most frequent Masaoka staging was II (n=7). Regarding the WHO histopathological classification of thymoma, most patients (n=11) presented with type B2 or B3. Thirteen patients underwent extended thymectomy (12 by median sternotomy and 1 by VATS). Of the remaining 5 patients, 4 of them underwent a CT scan guided biopsy, and 1 patient did not accept further work-up. Seven patients were classified as R0 for surgical resection margins and only one of them had recurrence of thymoma. Besides surgery, oncological treatment included radiotherapy and chemotherapy. Five patients expe- rienced a myasthenic crisis during the course of the disease. Three deaths occurred in the studied population. CONCLUSIONS: This study helped to pinpoint important aspects concerning therapeutic orientation of MGAT patients, such as the clinical impact of thymectomy in the course of MGAT, the oncological prognostic value of surgical resection mar- gins, and the importance of preoperative intravenous immunoglobulin. Management of MGAT patients is only possible with a multidisciplinary approach.

COMMUNITY-ACQUIRED THORACIC EMPYEMA - DOES MICROBIOLOGICAL IDENTIFICATION MATTER?

OBJECTIVES: To describe the clinical characteristics, comorbidities and clinical outcome of hospitalized patients with the diagnosis of community acquired thoracic empyema in our hospital, with particular emphasis on the impact of identification of the causative agent. METHODS: We performed a retrospective review of the clinical files of hospitalized adult patients diagnosed with community acquired thoracic empyema between 2012 and 2016. RESULTS: A total of 81 patients (64 men and 17 women), with a mean age of 54.6+-17.3 years, were included in this study. It was possible to identify the microbiological agent in 59.3% (n=48) of the patients. The median length of hospital stay was 29 days (P25=20 and P75=44.5) and a tendency to longer duration was seen in patients with a microbiological isolation (32 days vs 23 days; p=0.056). No significant difference was observed between patients with and without microbiological isolation, regarding the mortality. CONCLUSION: In this group of patients a positive pleural fluid culture tends to be associated with longer lengths of hospital stay, which may lead to speculation that they were more advanced infectious processes at the time of diagnosis.

DOEGE-POTTER SYNDROME BY PLEURAL SOLITARY FIBROUS TUMOR.

INTRODUCTION: Solitary fibrous tumor of the pleura (SFTP) is a rare neoplasm that accounts for less than 5% of all pleural tumors. We present the case of a 73-year-old man with a history of recurrent episodes of severe hypoglycemia secondary to a large malignant SFTP. This paraneoplastic manifestation of SFTP occurs in less than 5% of cases and is referred to as Doege-Potter syndrome. Although rare, this is an important and reversible cause of hypoglycemia, which is resolved by complete surgical resection of the tumor. We describe the pathogenesis, diagnosis, and treatment of Doege-Potter syndrome. Key imaging findings and pathologic correlation are shown.

Combined lung-kidney transplantation: First case in Portugal.

A significant dysfunction of another organ is usually considered an absolute contraindication for lung transplantation, unless multiorgan transplantation is indicated and practical, as is the case of combined lung-kidney transplantation. Few cases of combined lung-kidney transplantation have been described in the literature; however, it is known that, in certain cases, it is the only way to offer an opportunity to selected patients with renal and lung dysfunction. The authors are not aware of any previously published case of a patient receiving both extracorporeal membrane oxygenation and continuous venovenous hemodiafiltration as a bridge for combined kidney-lung transplantation. The authors present the first case of combined lung-kidney transplantation performed in Portugal.

MAJOR PULMONARY SURGERY IN PATIENTS WITH COMPROMISED LUNG FUNCTION.

INTRODUCTION: The risk stratification of lung resection is fundamentally based on the results of pulmonary function tests. In patients considered to be at risk, major surgery is generally denied, opting for potentially less curative therapies. OBJECTIVE: To evaluate the postoperative outcomes of major lung surgery in a group of patients deemed high risk. METHODS: We performed a retrospective review of clinical records of all patients submitted to lobectomy, bilobectomy or pneumonectomy in a 3-year period in a reference Thoracic Surgery Unit. The patients were then divided in two groups: group A composed of patients with normal preoperative pulmonary function and group B which included patients with impaired lung function, defined as FEV1 and/or DLCO ≤60%. RESULTS: A total of 234 patients were included, 181 (77.4%) in group A and 53 (22.6%) in group B. In group B, patients had more smoking habits, were more often associated with chronic obstructive pulmonary disease and were also more frequently submitted to thoracotomy. When surgery was motivated by primary lung cancer this group had a more advanced clinical stage of the disease. In the postoperative period, these patients had longer hospital stay, longer chest drainage time and greater need for oxygen therapy at home, however, no statistically significant difference was noted in morbidity or mortality. CONCLUSIONS: Major thoracic surgery can be safely performed in selected patients considered to be high risk for resection by pulmonary function tests. A potentially curative surgery should not be denied based on respiratory function tests alone.

Lung Necrosis After Paraffin Aspiration.

BACKGROUND: Fire breather´s lung is a rare condition that occurs after hydrocarbon aspiration. Case reports published experienced a good clinical outcome with conservative treatment. To our knowledge, there are no reported cases treated with pulmonary resection. CASE PRESENTATION: We report the case of a 35-year-old female trapeze artist, who suffered an accidental ingestion/ aspiration of liquid paraffin. Persistent fever and elevated inflammatory markers without clinical improvement with antibiotics and bronchoscopy was seen. Computed tomography scan showing middle lobe necrosis and abscess motivated a middle lobectomy for infection control. Postoperative recovery was uneventful. CONCLUSION: There are some cases described in the literature, normally with a favourable evolution with conservative treatment. Therefore, it is important to acknowledge that, in patients where serious complications have arisen, despite medical therapy, surgery may have an important role, and resection of the necrotic lung may prevent its potential life-threatening consequences.

Isolated Pulmonary Mucormycosis in an immunocompetent patient.

Mucormycosis is a life-threatening fungal infection that occurs mainly in immunocompromised patients. Its occurrence isolated in the lung rare and carries a high mortality risk if untreated. We report the case of a 76-year old male immunocompetent patient, under treatment for pulmonary tuberculosis, admitted to the emergency department with hemoptysis. Bronchoscopy was performed and active bleeding from the middle lobe bronchus was found. Chest CT scan identified a solitary cavitary lesion in the middle lobe. The patient was proposed for urgent open middle lobectomy. Postoperative period was uneventful. Pulmonary mucormycosis was confirmed and adjuvant therapy with Amphotericin B was performed for 30 days. Despite its rarity, mucormycosis prevalence is expected to raise together with increasing number of immunocompromised patients. A high level of suspicion is recommended as early diagnosis can be determinant.

Manubrium resection and reconstruction for mediastinal tumor: a case report.

Primary mediastinal tumours with chest wall involvement represent technical challenges that may offer a survival benefit. Reconstruction with osteossynthesis material, bioprosthesis and muscle flaps is indicated to re-establish the excised component function. We report a case of a 30-year-old male with a primary mediastinal seminoma operated after chemotherapy with need for en bloc resection of the residual mass and manubrium with chest wall reconstruction. This type of surgery is rare and represents a technical challenge. Therefore, it should be performed in referral centers and with a multidisciliplinary approach.

Tumores primários do mediastino com envolvimento da parede torácica representam desafios cirúrgicos que podem proporcionar um benefício na sobrevida. A reconstrução com material de osteossíntese, biopróteses ou retalhos musculares está indicada para restabelecer a função dos segmentos excisados. Reportamos o caso de um doente de 30 anos do sexo masculino submetido a cirurgia após quimioterapia adjuvante por seminoma primário do mediastino com necessidade de ressecção em bloco do tumor residual e manúbrio com reconstrução da parede torácica. Este tipo de cirurgia é rara e representa um desafio a nível técnico, devendo ser realizada em centros de referência e com abordagem multidisciplinar.

Third time's the charm.

Can you diagnose this right-sided pleuritic chest pain? http://ow.ly/yYq230dDqcd.

Severe Intraoperative Complications During VATS Anatomical Ressections and their Surgical Resolution in a Portuguese Thoracic Surgery Centre - A 9-Year Review.

INTRODUCTION: Many studies have demonstrated that video-assisted thoracoscopic surgery (VATS) is not only feasible and safe but is actually the approach chosen for an increasing number of pulmonary anatomic resections. There are however few studies reporting on severe intraoperative complications during VATS anatomical ressections and their resolution. OBJECTIVE: Our aim is to analyse the incidence of severe intraoperative complications during VATS anatomical ressections, at our department, in the past nine years, and describe their technical resolution during the surgery. METHODS: We performed the retrospective analysis of the patients submitted to lobectomy, bilobectomy or segmentectomy by VATS or VATS converted to thoracotomy at Hospital de Santa Marta, between May 2008 and September 2017. Severe intraoperative complications were defined as an event that results in a life threatening situation or an injury to a proximal airway, blood vessel or organ that would lead to an unplanned additional anatomical resection. RESULTS: A total of 151 patients were submitted to anatomical ressections, 90,7% (n=137) of them for a primary lung cancer, other indications were metastatic disease 6%(n=9) and benign disease in 3,3% (n=5). The surgery was a lobectomy in 94% of the cases (n=142), a segmentectomy in 5% (n=8), and one bilobectomy. The conversion rate to thoracotomy was 12% (n=18), most of which were for technical/ oncological reasons (n=11), and 7 others were to control bleeding. Four (2,6%) severe intraoperative complications were identified. Three of them (2%) were erroneous transections of bronchovascular structures (left main bronchus, left main pulmonary artery and both left pulmonary veins); and one was a membranous airway injury proximal to the staple line. There were no intraoperative deaths. The three patients with erroneous bronchovascular transection were converted to thoracotomy and the bronchial or vascular re-anastomosis was performed, therefore avoiding a left pneumonectomy. In the patient with the membranous airway injury, the bronchoplastic suture was performed by VATS. All four patients were primary lung cancer patients. In all these cases the patients were discharged alive and well and are undergoing their follow-up program with no signs of disease recurrence. CONCLUSION: Albeit rare, severe complications during VATS Lobectomy can occur but when they happen the thoracic surgeon has to be ready to solve them with the minimal repercussion for the patient.

Major Complications of Videomediastinoscopy and their Resolution - a 5 year experience.

INTRODUCTION: Videomediastinoscopy is an invasive procedure for mediastinal assessment, with low rates of morbidity and mortality. Despite the low risk of complications, they can be potentially lethal if not immediately controlled. OBJECTIVE: The goal of this study is to analyse the overall incidence of complications of videomediastinoscopies, performed in the last 5 years at our department, as well as their resolution and outcomes. METHODS: A retrospective review of all videomediastinoscopies performed at a single institution during a 5-year period was performed. Major complications were defined as life-threatening events. RESULTS: During the study period, from July 2012 to July 2017, were performed 160 mediastinoscopies, 67 were diagnostic and 93 for staging. There were 3 major complications (1.87%), of which a severe haemorrhage from a bronchial artery, a tracheal rupture, and a massive haemorrhage from an innominate artery laceration. In this 3 cases, the diagnosis were lung cancer in 2 patients and lymphoma in the other one. There were no intraoperative deaths. One patient died in the postoperative period due to mediastinitis and disease progression. The patient who suffered innominate artery laceration, had a stroke due to dissection of the right carotid artery. During follow-up, one patient died from progression of oncologic disease, and the other one is alive 4 years later. CONCLUSION: Although mediastinoscopy has a low rate of complications, these can be potentially lethal and the thoracic surgeon should be able to resolve them rapidly. Due to the scarcity of publications on this subject, it is important to describe potential complications of this surgical procedure and their clinical resolution.

Diaphragmmatic eventration: long-term follow-up and results of open-chest plicature.

OBJECTIVE: Diaphragmmatic eventration is a relatively uncommon entity with a simple surgical correction technique--plication of the diaphragm. This study aims to assess the clinical and ventilatory impact of this technique. MATERIALS: From April 1988 to February 2007, we operated on 20 patients (12 men) with diaphragmmatic eventration using the postero-lateral approach and correction by radial plication. The mean age of the patients studied was 56.3+/-15.6 years (range: 13-74 years). A traumatic cause was identified in 13 patients; one patient had a congenital cause and the remainder were of idiopathic origin. Chronic obstructive pulmonary disease and arterial hypertension were present in one-half of the study group, while diabetes mellitus was present in three patients. Dyspnoea was the most common complaint in 75% of the patients, and thoracic pain was present in 25%. The mean forced expiratory volume in 1 s (FEV(1)) and vital capacity (VC) were 66.2+/-15.3% and 70.4+/-16% of the predicted values, respectively. RESULTS: There was no operative mortality. Apart from a patient with moderate/severe pain and another who had pneumonia, there were no other important perioperative complications. Average drainage time was 3.3+/-1.6 days (range: 2-7 days). Hospitalisation time was 6.2+/-1.6 days (5-10 days). Follow-up was complete, for a mean of 59.6+/-55.1 months (4-206 months). There were three late deaths (one sudden, one stroke and one trauma). Eight of the 17 survivors (47%) are asymptomatic. According to the MRC/ATS grading system, the dyspnoea score was 2.06+/-0.97 preoperatively and 1.06+/-1.14 postoperatively (p=0.007). At follow-up, the FEV(1) was 76.1+/-20.1% and the VC was 78.4+/-17.3% (p>0.1). Two patients had chronic pain. CONCLUSION: Plication of the diaphragm is a safe and efficient procedure. Most patients experienced significant clinical improvement with enhancement of the FEV(1) and VC. Chronic surgical pain still remains a potential problem with the classical approach.

Current surgical management of mitral regurgitation.

From Walton Lillehei, who performed the first successful open mitral valve surgery in 1956, until the advent of robotic surgery in the 21st Century, only 50 years have passed. The introduction of the first heart valve prosthesis, in 1960, was the next major step forward. However, correction of mitral disease by valvuloplasty results in better survival and ventricular performance than mitral valve replacement. However, the European Heart Survey demonstrated that only 40% of the valves are repaired. The standard procedures (Carpentier's techniques and Alfieri's edge-to-edge suture) are the surgical basis for the new technical approaches. Minimally invasive surgery led to the development of video-assisted and robotic surgery and interventional cardiology is already making the first steps on endovascular procedures, using the classical concepts in highly differentiated approaches. Correction of mitral regurgitation is a complex field that is still growing, whereas classic surgery is still under debate as the new era arises.