A Single-Center Experience on the Treatment Outcomes of Patients with COVID-19-Pleural Disorders: Lessons for the Future.

Background: Pleural disorders in novel coronavirus disease 2019 (COVID-19), responsible for the deaths of more than 6.7 million people worldwide, are relatively uncommon and underappreciated findings. The severity of the pleural disease in these patients correlates with the treatment outcome and overall prognosis. Objective: We aim to review our experience with treatment modalities and prognosis in 45 patients with COVID-19, who were treated at our Clinic between April 2020 and October 2021. Methods: We conducted a retrospective, single-center, cross-sectional study. Demographic data, the type of thoracosurgical intervention(s), and treatment outcome for 45 patients included in this study were recorded for every patient. We analyzed the type and number of treatment modalities according to the pleural disorder, and the outcome of the treatment. Results: Pneumothorax was the most common COVID-19-related pleural disorder, followed by the pleural effusion. Tube thoracostomy was the mainstay of treatment, performed in 84.4% of patients with unilateral pleural complications. In total, 20% of our patients were on mechanical ventilation, and all of them had a fatal outcome. We found statistical significance in comparison to the percentage of fatal outcomes between patients treated with and without mechanical ventilation (p=0.000). Conclusion: COVID-19-related pleural disorders are prognostic markers of disease progression. Mechanically ventilated patients who require tube thoracostomy have an unfavorable prognosis.

Our Experiences in the Treatment of Anterior Chest Wall Infections (2015 - 2021).

Background: Sternotomy is a classical surgical procedure for approaching the heart and mediastinum. Sternotomy wound infections can be superficial or deep. Objective: The aim of this study is to retrospectively evaluate the results of two treatments for deep sternal wound infection (DSWI), closed treatment (debridement, refixation and retrosternal irrigation) and open treatment (debridement, VAC therapy and then pectoral flap). Methods: Retrospective analysis of two methods of treatment of DSWI in the period of six years. The first group (G1): surgical debridement, sternum fixation with, if necessary, retrosternal irrigation. The second group (G2): surgical debridement, open sternum with VAC therapy and subsequent pectoral flap with sternum refixation if necessary. Sternotomy wound infection will be classified according to the depth of the affected areas and the time of infection. Risk factors, outcome, local findings, number of revisions, number of hospital treatment days, types of isolates, etiology of sternotomy, time from onset of sternal instability to first surgical treatment will be observed. Results: The number of patients with DSWI was 16, which represents 1% of all sternotomy in the observed period. Mortality in the DSWI group was 35%. Surgical myocardial revascularization was initially performed in 73% of patients with DSWI. Two risk factors for DSWI were in 32% of patients and 25% had diabetes mellitus. The average time for DSWI development in G1 was 10 days (min 0, max 30) and in G2 was 20 days (min 12, max 30). Number of revisions in G1 (min 1, max 2), G2 (min 1, max 3). Average number of hospital days were in G1 23.50 days (SD 13.15), and in G2 38.17 days (SD 28.65). The sternum was osteomyelitic and fragmented in 20% of patients. More than one revision occurred in 40% of patients. The main initial isolate was Enterococcus faecalis in 27% of all DSWI (dominantly in G1 2/3 of all). Conclusion: We found that there is no statistically significant difference in observed treatments, and that each treatment has its own indications. We suggested that studies with a larger sample are needed for a definite opinion on this issue.

Non Invasive Detection of Coronary Sinus Flow Changes Over Time After CABG.

Background: Coronary New blood in the vascular bed after Coronary Artery Bypass Grafting (CABG) may represent a turning point between ischemia and normal tissue nutrition. Its quantification can help to better understand coronary artery hemodynamics after revascularization. Objective: Quantification of coronary sinus blood flow changes over time after Coronary Artery Bypass Grafting (CABG) using Transthoracic Echocardiography (TTE). Methods: Prospective basic research, with repeated measurements on hospital sample of 61 patients whom CABG was conducted. We performed TTE recordings to measure CS flow before and two times after CABG (1 and 6 postoperative day). We measure CS diameter, Velocity Time Integral (VTI) and systemic hemodynamic data. Data needed for LV mass calculation were recorded once. During statistical analysis we define: α = 0,01, ß = 0,01 (power = 1-ß ß= 0,99), Sample size = 60, Effect size= 0,68. We used ANOVA for Repeated Measures as main statistical test in SPSS. Results: Preoperatively we found low overall CS flow of 181 ±72 ml/min (0,68 ±0,30 ml/gram-LV/min). After surgery there was constant increase of CS flow from 276 ±79 ml/min (1,13 ±0,35 ml/gram-LV/min) first postoperative day, to 355 (±99) ml/min (1,30 ±0,46 ml/gram-LV/min) sixth postoperative day. Discussion: Amount of new blood was statistically significant after CABG with P<0,001. Same result was found after classifying patients per number of graft received, with the highest amount of new blood after four bypasses. Amount of new blood was not different if patient gets two or three bypasses. Conclusion: There was significantly new amount of blood in coronary bed after CABG, with constant increase over first 6 days.

Efficacy of Video-Assisted Thoracoscopic Surgery (VATS) in the Treatment of Primary Pleural Empyema.

BACKGROUND: Video-Assisted Thoracoscopic Surgery (VATS) has recently occupied a significant place in the surgical treatment of primary pleural empyema (PPE). Patients with anamnesis shorter than 4 weeks have a good chance of being cured only by VATS. As it is not easy to define precisely the beginning of the disease, it is difficult to say strictly to which period VATS method will be successful in PPE treatment. OBJECTIVE: The aim of this study was to determine the efficacy of the VATS method in the surgical treatment of primary pleural empyema. METHODS: The study included 50 patients with findings appropriate for PPE over a period of three years, in whom the VATS method was applied in the surgical treatment of pleural empyema. RESULTS: The established total length of treatment was 13.56 ± 7.98 days and the length of hospital treatment after surgery was 9.90 ± 3.315. The duration of thoracic drainage was 8.06 ± 3.005. Treatment was completed by the primary procedure without additional interventions in 94% of patients. Based on the final outcome, all patients from the clinic were discharged as cured. CONCLUSION: The best time to indicate surgical treatment by using VATS method is history of disease in duration of four weeks Debridement or VATS decortication method is safe and efficient surgical procedure, especially in the first two stages. It is recommended to use this method as the first surgical option for patients in early stages of the disease.

Effects of Neoadjuvant Therapy After the Initial Assessment of Operability in Patients with Borderline Operable and Inoperable Stage IIIA Non-small Lung Cancer.

INTRODUCTION: Lung cancer is a neoplasm with the highest mortality rate in the world. The role of neoadjuvant therapy in patients with initially assessed borderline operable or inoperable lung cancer is to improve survival by downstaging the tumor and allowing surgical resection, as well as the potential treatment of micrometastatic disease. AIM: Establishing the justification and efficacy of neoadjuvant therapy after the initial assessment of operability in patients with borderline operable and inoperable histopathologically verified stage IIIA non-small cell lung cancer. METHODS: The retrospective study included 65 patients with initially assessed stage IIIA lung cancer, who underwent neoadjuvant therapy. After the cycles of neoadjuvant therapy, 19 patients who achieved the regression of the tumor underwent surgery. We analyzed the histological type of the tumor, extent, and prevalence of surgical resection, the status of regional lymph nodes, and the achieved R status. RESULTS: Of the total number of patients who underwent neoadjuvant therapy, after reevaluation of the disease, 19 patients (19/65, 29.23% of cases) achieved a clinical response, i.e. tumor downstaging. Of 19 patients who underwent surgery, 16 patients underwent surgical resection, while three patients underwent surgical exploration. The largest number of patients had N0 and N1 status (six patients each). R0 status was achieved in 14 patients (14/16, 87.5% of cases), while R1 in the remaining two. One patient had a fatal outcome. CONCLUSION: Neoadjuvant therapy plays an important role in the treatment of initially assessed borderline operable or inoperable lung cancers. By downstaging the tumor, it allows surgical resection and potential treatment of micrometastatic disease.

Lung adenocarcinoma mimicking pulmonary fibrosis-a case report.

BACKGROUND: Lung cancer is usually presented with cough, dyspnea, pain and weight loss, which is overlapping with symptoms of other lung diseases such as pulmonary fibrosis. Pulmonary fibrosis shows characteristic reticular and nodular pattern, while lung cancers are mostly presented with infiltrative mass, thick-walled cavitations or a solitary nodule with spiculated borders. If the diagnosis is established based on clinical symptoms and CT findings, it would be a misapprehension. CASE PRESENTATION: We report a case of lung adenocarcinoma whose symptoms as well as clinical images overlapped strongly with pulmonary fibrosis. The patient's non-productive cough, progressive dyspnea, restrictive pattern of pulmonary function test and CT scans (showing reticular interstitial opacities) were all indicative of pulmonary fibrosis. The patient underwent a treatment consisting of corticosteroids and antibiotics, to no avail. Histopathology of the lung showed that the patient suffered from mucinous adenocarcinoma. Albeit the immunohistochemical staining was not consistent with lung adenocarcinoma, tumor's morphological characteristics were consistent, and were used to make the definitive diagnosis. CONCLUSION: Given the fact that radiography cannot always make a clear-cut difference between pulmonary fibrosis and lung adenocarcinomas, and that clinical symptoms often overlap, histological examination should be considered as gold standard for diagnosis of lung adenocarcinoma.

Clinical significance of isolated sternal fracture.

BACKGROUND: Isolated sternal fractures (ISF) are uncommon injuries and after exclusion of other concomitant injuries, ISF can be classified as harmless injuries, and can be treated on outpatient basis. OBJECTIVE: Based on literature and own experience to make a simple algorithm in the diagnosis and treatment of ISF. PATIENTS AND METHODS: Retrospective analysis of medical records of patients who were admitted with ISF to the Clinic for Thoracic Surgery of UCC Sarajevo between January 2000 and January 2010. RESULTS: A review included 49 patients with ISF. The average age was 52.67 +/- 12.42 (range 21 to 81) years. Age group between 41 and 61 years was significantly more prone to ISF. Male/female ratio was 2.2:1 (34/15). The major cause of the injury, seen in 77.6% (38/49) cases, was an involvement in road traffic accidents (RTAs). Statistically, there is a significant difference (chi2 = 6.74; p = 0.009) in the frequency of occurrence ISF between drivers [55.1% (27/38)] and passengers [22.4% (11/39)]. Of the remaining eleven patients, four ISF were caused by falls at home, and seven by direct violence to the chest either in sport or in a fight. The sternal view radiography was diagnostic in all patients In most patients [83.7% (41/49)] the enzymatic values were elevated. ECGs were recorded in all cases, of which only 12.2% (6/49) had an abnormality. The average duration of hospitalization was 3.57 +/- 2.01 (range 1 to 7) days. It should be noted that 34.7% of patients were discharged in less than 24h and 73.5% were discharged in under 48h. Commonly used analgesic, metamizol, was applied in 98.0% (48/49) of cases. The combination of tramadol and metamizol was given in 63.3% (32/49) of patients. CONCLUSION: Established results support the view that patients with ISF and no abnormality in ECG and cardiac enzymes during the early hours after injury are expected to have a benign course and can be discharged home within the first 24 to 48 hours. Proposed algorithm can be of assistance In making such decisions.

Surgical treatment of pleural empyema according to disease stage.

UNLABELLED: Para pneumonic effusions are often complications of bacterial pneumonia, occurring in 5-50% patients and in 15% cases it can progress into pleural empyema. Pleural empyema treatment includes drainage of pus, re-expansion of lung by using appropriate antibiotics. Surgical treatment covers implementation of certain thoracic drainage modifications, use of VATS techniques and thoracotomy with pleura decortications. PATIENTS: Research has involved 100 patients with diagnosis and treatment of para pneumonic and meta pneumonic pleural empyema. RESULTS: Based on previously defined phase of pleural empyema it was determined which surgical procedures have been used in definitive treatment of pleural empyema. In case of 31,17% (24/77) patients it has been found that pre-clinical treatment lasted 31 days and longer, and 49,35% (38/77) patients have been admitted at Clinic after 11 to 30 days of pre-clinic treatment. Only in 19.48% (15/77) patients pre-clinic treatment lasted up to 10 days. 79% (79/100) patients were in third phase of disease, 19% (19/100) patients were in second phase and 2% (2/100) patients were in first stage of disease. Among patients with first stage of disease 1 patient was subject to pleural drainage and 1 was subject to decortications. Among patients with second phase of disease 10 patients were subject to pleural drainage and 9 to decortications. Among patients with third phase of disease 20 patients were subject to pleural drainage and 49 to decortications, 4 patients were subject to pleural drainage with rib resection, and 2 were subject to combination of thoracoscopy and drainage, while in case of 4 patients it was necessary to perform additional drainage. CONCLUSIONS: Pleural drainage is first procedure in surgical treatment of pleural empyema, but very often it is not definitive measure of treatment of patients with third phase of disease. Definitive treatment of empyema in third phase is decortications of pleura carried out on 62% patients with this phase of disease. Efficiency of treatment determined on basis of mortality level is satisfactory.

[Conservative surgical treatment of pulmonary hydatid disease in children]. / Konzervativni hirurski tretman plucne hidatidoze kod djece.

BACKGROUND: Hydatide disease is endemic in sheep and cattle-raising areas world wide. Its prevalence is also high in the Mediterranean region including Bosnia and Herzegovina. OBJECTIVE: Retrospective appraisal of the presentation, approach to surgical treatment and outcome of hydatid disease in children at the Clinic for Thoracic Surgery UCC Sarajevo between January 2000 and January 2007. PATIENTS AND METHODS: We surgically treated 58 patients (48 male, 10 female) with a diagnosis of pulmonary hydatid disease with average age of 11,36 +/- 3,78 (range 4 to 15) years. Chest radiographs, computed tomograms and ultrasonography were the main methods of diagnosis. The basic principle of surgery was to preserve lung parenchyme as much as possible. RESULTS: Clinical assessment of the symptoms, plain and lateral chest X-rays and computed tomograms led to the correct diagnosis in 100,0% (58/58) of patients. Solitary lung cyst was found in 68,97% (40/58) patients while the remaining 31,03% (18/58) were multiple cysts in one or more lobes of one or both lungs. Intact cysts were found in 51,35% (38/74) and ruptured cysts in 48,65% (36/74) cases. Lung preserving surgical interventions were done in all of the patients. Postoperative complications were seen in 5,17% (3/58) patients. There was no mortality. Recurrent hydatid cysts were observed in 3,45% (2/58) patients. CONCLUSION: Lung preserving surgical interventions are the treatment of choice for pulmonary hydatid cysts in children. Radical surgical procedures such as segmentectomy, lobectomy and pneumonectomy should be avoided as much as possible.

[Surgery approach of mediastinal benign teratomas in childhood]. / Hirurski tretman medijastinalnih benignih teratoma kod djece.

Benign teratomas are benign tumors of germinative cells which originate from gonad tissue, and are primarily located in the gonads (ovary and testes). Less frequently they may appear extragonadally, mostly in mediastinum region, where they constitute 10% of all tumors in that area. Surgical aproach to treating these teratomas is completely removing mediastinal benign teratomas by anterolateral thoracotomy or transversal sternotomy. The following case report describes teratomas localized in anterior and middle mediastinum, which are surgically completely removed and pathohystologically described as mature cystic teratoma.

[The using doxycycline in procedure chemical pleurodesis of malignancy pleural effusion]. / Primjena doxicyclina u postupku hemijske pleurodeze kod malignih pleuralnih izliva.

UNLABELLED: Pleural effusion is acumulation of liquid in pleural space, wich caused primary of pleural diseases or secundary of systemic diseases. PROBLEM: Pleural effusion are the most frequently caused by malignancy and make worse poor condition of patients with malignancy. Pleural punction is insufficient metod for treatmen of malignancy pleural effusion. The best modefor treatment is pleurodesis using Doxicyclin. PATIENTS AND METHODS: There are embrased all patient hospitalized in thoracis surgery department of KCU Sarajevo in period may 1999. - septembar 2002. whole medicaly treatet in procedure of chemical pleurodesis because of malignant pleural effusion. Examinee group of patients are medicaly treatet in procedure of chemical pleurodesis. Control group of patients are medicaly treatet by pleural punction because of malignanacy pleural effusion, same diseases in both group of patients. The results are present textualy, numberly and graphic printing. RESULTS: Procedure of chemical pleurodesis obtained in mostly patients obliteration of pleural space, and prevent reaccumulation of pleural effusion. Procedure of chemical pleurodesis make quality of life better, complications are rare, mortality conect with procedure is not exist.