Lung transplantation: how we do it.

Lung transplantation is considered the gold standard for patients with chronic end-stage pulmonary disease. However, due to the complexity of management and relatively lower median survival as compared to other solid organs, many programs across the world have been slow to adopt the same. In our institution, we started lung transplantation in September 1990. And since then, we performed close to 900 lung transplantations. Here, we describe in detail the operative steps adopted in our institution for a successful lung transplantation. There have been very few variations over the years. We believe that having a standardized technique is one of the important features for success of a lung transplant program.

Asymptomatic presentation of giant bulla of the left apical and anterior segment of the left upper lobe of the lung with near complete atelectasis of the remaining left lung.

Giant bullae may be found in association with emphysema. They present as pockets of entrapped air which grow as the surrounding lung retracts away. As they do not take part in gas exchange and merely occupy space, their presence leads to severe impediment of mechanical ventilation in the adjacent lung parenchyma. Patients may present with dyspnoea, exercise intolerance and a feeling of pressure in the chest. The case of a 54 year old gentleman is presented, who was found to have a giant bulla occupying his left hemithorax on a routine chest X-ray. The patient remained asymptomatic despite the large size of the bulla and was treated with surgical resection via thoracotomy i.e. Bullectomy which is the treatment of choice. If left untreated the condition can be complicated by pneumothorax, infection and a slow progression to malignant changes.

How VATS has changed the management of spontaneous pneumothorax in the 21st century.

OBJECTIVE: To: determine the outcome of patients having undergone Video Assisted Thoracoscopic Surgery (VATS) for spontaneous pneumothrox in terms of hospital stay, complications and recurrence. METHODS: The netrospective study included the review of 39 cases who had presented with spontaneous pneumothorax at the Aga Khan University Hospital, Karachi, Pakistan, between January 2001 to November 2008 and had undergone video assisted thoracoscopic surgery (VATS). RESULTS: The duration of hospital stay (had a range of 3 to 9 days), and the length of chest tube in place (a range of 2 to 8 days), 2 (5.1%) patients developed recurrence after VATS while 3 (7.6%) patients developed bleeding post operatively requiring transfusion and 2 (5.1%) patients developed atelectasis requiring bronchoscopy. CONCLUSION: Compared with figures for thoracotomy data from other studies, it was seen that the length of hospital stay and chest tube placement with VATS was less than that for thoracotomy, and the overall cost as well as post-operative pain was also low. The rate of recurrence was however comparable to that after thoracotomy.

Short-term complications after bilateral internal mammary artery grafting--a retrospective study.

OBJECTIVES: To analyze our experience of conducting Bilateral Internal Mammary Artery (BIMA) grafting, using both pedicled and free grafts for coronary revascularization, assessing the safety and efficacy of the procedure and comparing any differences observed between the two techniques of harvesting the grafts. METHODS: A retrospective cross sectional study was conducted in July 2010 in which all 48 patients undergoing bilateral internal mammary artery grafting for coronary bypass surgery at the Aga Khan University Hospital from 1996 to 2010 were reviewed and evaluated. The main outcome measures were perioperative mortality and early morbidity with particular reference to cerebrovascular accidents, sternal wound complications and re-opening for bleeding. Chi-square test was used to elicit any meaningful associations between patient characteristics and post-operative outcomes. RESULTS: Of the 48 patients undergoing bilateral IMA grafting, 46 were males and 2 females. The mean age was 48 +/- 9.4 years. Dyslipidaemia and smoking were the most common identifiable risk factors for coronary vascular disease. Following the 40 elective and 8 emergent surgeries, there was one hospital death. The most common post-operative complications were arrhythmias and wound infection. Diabetes and obesity were not observed to be associated with an increased risk of developing surgical site infection. CONCLUSIONS: Our study suggests that the short-term efficacy and the safety profile of bilateral IMA grafting for coronary revascularization is clinically acceptable. Long-term follow-up studies should be done to assess the cardiac event-free survival of these individuals evaluating its applicability as a routine for coronary artery bypass grafting in Pakistan.

Congenital diaphragmatic hernia presenting in the sixth decade mimicking pneumonia.

Congenital diaphragmatic hernia presentation in adults is extremely rare. Patients who present with late diaphragmatic hernias complain of a wide variety of symptoms and diagnosis can be difficult. We report a case of a 64 year old male who presented with a six month history of cough, shortness of breath and weight loss. The most common strategy to treat a Bochdalek hernia is via a thoracotomy or laparotomy or both. In our patient the repair was performed with a thoracotomy.

Tuberculous pericardial abscess with impending pericardial effusion and cardiac tamponade.

The case of a 59 year male with acute tuberculous pericardial abscess who presented with cough, dyspnoea, haemoptysis, signs of Tamponade and a large Pleural Effusion is reported. Performing Pericardiocentesis did not improve his symptoms hence he was subjected to surgery. Acute tuberculous pericardial abscess was the diagnosis made after histopathology which was successfully managed with sternotomy along with drainage of pus.

On pump coronary surgical revascularization in a patient with chronic immune thrombocytopenic purpura.

We performed on-pump coronary artery bypass graft surgery on a 54-year-old female, known case of chronic Idiopathic Thrombocytopenic Purpura (ITP), hypertension and dyslipidaemia who had presented to us with progressive exertional shortness of breath and chest pain. The decision of going on with CABG was made after two weeks of preoperative treatment with prednisolone. Her platelet counts pre-operatively and on the 4th post-operative day were 135 x 10(9)/L and 32 x 10(9)/L. She had an unremarkable post-operative recovery, without requiring whole blood or platelet transfusions. We recommend preoperative steroid treatment in patients with chronic ITP undergoing CABG.

Mediastinal seminoma presenting as superior vena cava syndrome and tracheal obstruction.

Malignant germ cell tumours of the mediastinum are rare, presenting mostly in young males. These are bulky tumours, mostly intrathoracic, infiltrating into adjacent structures early in the growth process. Patients may present with symptoms of compression. Occasionally, mediastinal adenopathy and superior vena cava (SVC) syndrome may occur. We discuss a case of a 19 year old boy with six weeks history of progressively worsening shortness of breath and mid-sternal chest heaviness and one month history of swelling of the face and upper limbs. The entire face and upper extremities were grossly oedematous with engorged veins suggesting SVC syndrome. CT scan chest showed a large mediastinal mass 18 x 24 cm extending from the superior mediastinum to the mid pericardial area. The trachea was extrinsically compressed to almost 80% at its distal portion. Mass was resected completely. Post operative course was unremarkable. The final histopathology showed a fibrotic mass with no viable tumour. Surgery followed by radiation therapy has been the usual initial treatment with multimodal chemotherapy showing remarkable results.