Cervical Mediastinoscopy as a Diagnostic Tool for Mediastinal Lymphadenopathy.

OBJECTIVE: To determine the yield of cervical mediastinoscopy in determining causes of mediastinal lymph node enlargement. STUDY DESIGN: Observational study. Place and Duration of the Study: CMH Rawalpindi, Lahore and Multan, from January 2010 to December 2021. METHODOLOGY: Patients who underwent lymph node biopsy through cervical mediastinoscopy approach were included. Record of the patients including age, gender, clinical presentation, and findings on CT scan chest were noted along with the record of preoperative complications and duration of surgery. Histopathology report was also recorded. RESULTS: Out of 398 patients, 259 (65%) were males and 139 (35%) were females. Out of 338 patients who were operated for diagnostic purpose, 157 (46%) had tuberculosis and 34 (10.1%) had sarcoidosis. Fifty-two (15.3%) were diagnosed to have malignancy including non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), and metastatic carcinoma of unspecified origin. Amongst staging group (n=60), 33 (55%) patients had negative mediastinal disease. Complication rate was 3.8%, including hoarseness of voice in three patients while 2 patients had wound infection requiring intervention. CONCLUSION: Cervical mediastinoscopy is a safe and efficacious means of diagnosis in indeterminate mediastinal lymphadenopathy and staging of lung malignancy. KEY WORDS: Mediastinoscopy, Lymph nodes, Tuberculosis, Lung cancer, Staging.

Management of Malignant Chest Wall Tumors.

OBJECTIVE: To analyse the malignant chest wall tumors in terms of histological types and confer option for resection, stabilisation and reconstruction, along with postoperative morbidity and mortality. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Thoracic Surgery, CMH Rawalpindi, Lahore and Multan from January, 2010 to October, 2018. METHODOLOGY: Patients who had histologically proven malignant tumors of chest wall and breast with bone involvement, and required resection, stabilisation, mesh reinforcement and muscle flap reconstruction, were included. Small soft tissue tumors without bony involvement which did not require reconstruction, primary tumors of spine, pancoast tumors and lung tumors involving chest wall were excluded from the study. Record of these patients including age, gender, histopathological type, reconstruction method used, postoperative complications, mortality and recurrence were noted. Data was analysed using descriptive statistics. RESULTS: The study included 86 patients with 61 (70.9%) males and 25 (29.1%) females; age ranging from 18 to 77 years with mean age of 47.84 ± 12.9 years. Palpable mass was the most common symptom occurring in 61 (70.9%) patients. Twenty-one (24.4%) had breast tumor with chest wall invasion. In the remaining cases, most common histological type was chondrosarcoma occurring in 13 (15.1%) patients, followed by Ewing sarcoma in 12 (14%) patients. The most common complication was post-thoracotomy neuralgia (PTN), occurring in 25 (29.1%) patients. CONCLUSION: Malignant tumors of the chest wall are rare entity which can be effectively treated with chest wall resection, mesh reinforcement for stabilisation and muscle flaps for reconstruction with acceptable postoperative complications, morbidity and mortality. Key Words: Primary, Malignant, Chest wall, Tumors, Chest wall reconstruction, Stability of chest wall.

VATS thoracoscopic decortication for empyema thoracic: A retrospective experience and analysis of 162 cases.

OBJECTIVE: To analyse the experience of empyema thoracis management using video-assisted thoracoscopic surgery. METHODS: The retrospective study was conducted at the Combined Military Hospitals, Rawalpindi and Lahore, Pakistan, and comprised data of empyema thoracis cases who underwent thoracoscopic decortications by the same consultant surgeon between January 2009 and 2018. Uniportal or multiportal video-assisted thoracoscopic decortications was performed. Histopathology and microbiological sampling were done in all cases. RESULTS: Of the 162 cases, 114(70.4%) were males and 48(29.6%) were females. The overall mean age was 44±16.37 years. Three ports were utilised in 58(36%) patients. Hospital stay of 122(75.3%) patients was <5 days post-procedure. Post-thoracotomy neuralgia occurred in 19(11.7%) patients, while 9(5.5%) had surgical site infection. Overall complications were 30(18.5%). There was no mortality. CONCLUSIONS: Video-assisted thoracoscopic decortications was found to be a safe, effective and efficient procedure.

Surgical Management of Paediatric Empyema: Open Thoracotomy versus Video-assisted Thoracic Surgery.

OBJECTIVE: To compare the effectiveness of open thoracotomy and video assisted thoracic surgery (VATS) for empyema thoracis in paediatric population. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: This observational study was conducted at Department of Thoracic Surgery, CMH, Lahore, from October 2013 to August 2018. METHODOLOGY: Medical record of children up to the age of 14 years who were operated for empyema thoracis was reviewed. Patients were divided into two groups: Open thoracotomy, and VATS; and compared for etiology, preoperative treatment, grade of empyema, procedure performed; histopathology and complications, e.g. post-thoracotomy neuralgia, surgical site infection, recurrence over 6 months. RESULTS: A total of 61 paediatric patients were operated for empyema thoracis. Age ranged between 1 to 14 years (mean = 10.25 ±3.30 years). Most common etiology of empyema was tuberculosis in 24 (39.3%) cases, followed by pneumonia in 22 (36.1%). Surgical treatment consisted of open thoracotomy in 40 (65.5%) cases, while 21 (34.5%) underwent VATS. Postoperative X-ray was satisfactory in 38 (95%) cases undergoing open thoracotomy as compared to 21 (100%) cases undergoing VATS (p=value 0.29). There was no recurrence in either of the two groups over a follow-up period of six months. Overall complication rate was 32.5% (13 cases) in cases undergoing open thoracotomy, while 33.3% (7 cases) in VATS group (p=value 0.95). There was one (2.5%) mortality in open thoracotomy group, while no death occurred in VATS group. CONCLUSION: Early surgical treatment, both open as well as VATS, gives satisfactory results in management of paediatric empyema. VATS is a safe alternative to open thoractomy with good success rate and less incidence of complications.

Decortication as an Option for Empyema Thoracis.

OBJECTIVE: To analyse the outcome and morbidity associated with decortication in empyema thoracis. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Departments of Surgery, Combined Military Hospitals (CMH) of Rawalpindi, Quetta and Lahore, from January 2006 to March 2018. METHODOLOGY: This is a retrospective study of 812 cases of open and VATS (video-assisted thoracic surgery) decortication for empyema thoracis, operated by the same consultants. Only patients with established empyema were included. Those who were unfit for one-lung ventilation, undergoing local anesthesia procedures like rib resection, clagget window or tube windows, with clotted hemothorax and malignant pathology were excluded. Posterolateral serratus sparing thoracotomy was used in open decortications. Multiportal or uniport VATS was employed for video-assisted thoracoscopic decortications (VATD). Histopathology and microbiological sampling was also done in all cases. RESULTS: There were 537 (66.1%) males and 275 (33.9%) females. Age ranged from 1 to 80 years with a mean of 37 years. Open decortication was done in 650 (80%), standard decortication with posterolateral thoracotomy in 458 (56.4%), minithoracotomy was done in 69 (8.4%) patients with loculated empyema, thoracotomy and open decortication with conventional thoracoplasty was done in 21 patients. Twenty-two patients required open decortications with tailored thoracoplasty and muscle flap. Open decortication with intercostal muscle (ICM) flap or primary closure of bronchopleural fistula was performed in 55 patients. VATD was done in 162 cases, out of which 120 were early empyema, and 42 were of chronic empyema; of which 22 required a further utility thoracotomy. Decortication with lung resection and muscle flap reinforcement to bronchial stump was done in 25 patients. Blood transfusion was required in 331 (40.7%). Twenty-six (3.4%) patients developed residual space and collection requiring intervention; and 384 (47.3%) patients had a histopathology diagnostic for tuberculosis. There were 11 (1.3%) deaths. CONCLUSION: Open decortication is still one of the preferred procedures in developing countries. VATD is also increasingly utilised for empyema.

Squamous Cell Carcinoma of the Breast.

OBJECTIVE: To analyse the epidemiological characteristics, clinical presentations, and histopathological as well as immunological characteristics of squamous cell carcinoma (SCC) of breast. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Combined Military Hospital, Rawalpindi, from January 1997 to January 2017. METHODOLOGY: Data of all patients, diagnosed as squamous cell carcinoma of breast over defined period of time, were collected and analysed with respect to their clinical presentation, histopathology and receptor status. Year-wise cases of SCC of breast were separated. RESULTS: Thirty patients, diagnosed as squamous cell carcinoma of breast, were identified over a period of 20 years. There was an increase in number of cases diagnosed after 2007 as compared to before 2007. Moreover, 12 (40%) cases were hormonereceptor positive while 18 (60%) were of unknown status. Out of the total, 10 (33%) cases were well differentiated, 17 (57%)were moderately differentiated, while 3 (10%) were poorly differentiated. Seventeen (57%) cases presented as breast masses, 10 (33%) had skin ulceration in addition to breast mass, while 3 (10%) cases presented as fungating masses along with chest wall involvement. CONCLUSION: There is an increased incidence of SCC of breast which can be due to better diagnostic facilities and more awareness amongst doctors about different varieties of breast cancers and their impact on the prognosis of disease.

Laparoscopic cholecystectomy for left sided gallbladder in situs inversus totalis.

Situs inversus totalis is a rare condition affecting intra abdominal and intra thoracic organs. Situs inversus usually remains asymptomatic. Life expectancy is normal in the absence of rare cardiac abnormalities. Left sided gallbladder can occur even without situs inversus totalis. Cholelithiasis is not more common in patients with situs inversus than the general population. However, these patients may pose a diagnostic difficulty. An ultrasound scan can confirm the presence of gallstones and the left-sided gallbladder. Here we present the case of a 40-year female with this diagnosis who was diagnosed on abdominal scanning and underwent laparoscopic cholecystectomy for left sided cholelithiasis.

RIPASA score: a new diagnostic score for diagnosis of acute appendicitis.

OBJECTIVE: To determine the usefulness of RIPASA score for the diagnosis of acute appendicitis using histopathology as a gold standard. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Department of General Surgery, Combined Military Hospital, Kohat, from September 2011 to March 2012. METHODOLOGY: A total of 267 patients were included in this study. RIPASA score was assessed. The diagnosis of appendicitis was made clinically aided by routine sonography of abdomen. After appendicectomies, resected appendices were sent for histopathological examination. The 15 parameters and the scores generated were age (less than 40 years = 1 point; greater than 40 years = 0.5 point), gender (male = 1 point; female = 0.5 point), Right Iliac Fossa (RIF) pain (0.5 point), migration of pain to RIF (0.5 point), nausea and vomiting (1 point), anorexia (1 point), duration of symptoms (less than 48 hours = 1 point; more than 48 hours = 0.5 point), RIF tenderness (1 point), guarding (2 points), rebound tenderness (1 point), Rovsing's sign (2 points), fever (1 point), raised white cell count (1 point), negative urinalysis (1 point) and foreign national registration identity card (1 point). The optimal cut-off threshold score from the ROC was 7.5. Sensitivity analysis was done. RESULTS: Out of 267 patients, 156 (58.4%) were male while remaining 111 patients (41.6%) were female with mean age of 23.5 ± 9.1 years. Sensitivity of RIPASA score was 96.7%, specificity 93.0%, diagnostic accuracy was 95.1%, positive predictive value was 94.8% and negative predictive value was 95.54%. CONCLUSION: RIPASA score at a cut-off total score of 7.5 was a useful tool to diagnose appendicitis, in equivocal cases of pain.

Mucocele of appendix secondary to mucinous cystadenoma.

Mucocele of appendix is a rare disorder characterised by obstructive dilatation of the appendicular lumen by mucinous secretions. More commonly it is caused by mucinous cystadenoma and rarely by mucinous cystadenocarcinoma. Patients are often asymptomatic and may sometimes present with acute appendicitis. It is known to be associated with pseudomyxoma peritonei as a result of rupture of mucocele. A pre-operative diagnosis is necessary to plan careful resection. Ultrasonography and computed tomography are useful tools for the diagnosis of appendiceal mucocele. We report a case of appendiceal mucocele due to mucinous cystadenoma with surgical and histopathological confirmation.

Pulmonary arteriovenous malformation (PAVM): rare cause of hemoptysis.

Pulmonary arterio-venous malformation is an abnormal communication between pulmonary arteries and pulmonary veins. These lesions are rare and are an important part of the differential diagnosis of common pulmonary problems such as hypoxemia and pulmonary nodules. Pulmonary arterio-venous malformation was diagnosed in a 33 year old man who presented with recurrent episodes of haemoptysis and also had taken anti-tuberculous treatment (ATT) before. Pulmonary angiography revealed fistulous communication between right bronchial artery and right pulmonary vein. He was treated by lobectomy.