Treating Spontaneous Pneumothorax Using an Innovative Surgical Technique Called Capnodissection Pleurectomy: Case Report.

Spontaneous pneumothorax is one of the most common conditions encountered in thoracic surgery. This condition can be treated conservatively or surgically based on indications and guidelines. Traditional surgical management includes pleurodesis (mechanical or chemical) in addition to bullectomy if the bullae can be identified. Mechanical pleurodesis is usually performed by surgical pleurectomy or pleural abrasion. In this case report, we present a case of a young patient with spontaneous pneumothorax who needed a surgical intervention. We performed a new, innovative surgical technique for surgical pleurectomy where we used carbon dioxide for dissection of the parietal pleura (capnodissection). This technique may provide similar efficiency to the traditional procedure but with less risk of bleeding and complications.

The Effect of Pandemic on Lung Cancer Waiting Time - Tertiary Center Experience.

BACKGROUND: Early diagnosis and treatment of lung cancer are crucial to improve the survival and the outcomes in patients who are diagnosed with lung cancer. Many factors can affect the waiting time for lung cancer treatment, however, the corona virus disease 2019 (COVID-19) was one of the major factors that universally slowed down clinical activities in the last three years. We are aiming with this study to demonstrate how this pandemic and other factors affected the lung cancer waiting times for diagnosis and treatment. METHODS: This is a retrospective study including 670 patients who were diagnosed with lung cancer within the NHS Lothian region of Edinburgh - Scotland between March 2019 and November 2023. One hundred patients underwent curative lung resection. Patients were categorised into three groups for sub analysis. The first group included patients diagnosed before the COVID-19 pandemic, the second group included patients diagnosed during the pandemic in 2020, and the third group represents those diagnosed after the mass vaccination program was established and until November 2023. RESULTS: The average waiting time between the referral from the GP to the date of surgery in the three groups was 88.5 days, 81 days, and 83.5 days, respectively. On the other hand, the waiting times elapsing between the first surgical clinic appointment and the date of the surgery itself were 17.6 days, 18.6 days, and 21.5 days, respectively. CONCLUSION: Unexpectedly waiting times elapsing between the referral to surgery and the date of surgery amongst lung cancer patients showed improvement during the COVID-19 pandemic. This is likely due to prioritizing cancer patients. Nevertheless, actions should be considered to decrease the waiting times in general.

Subclavian vein epithelioid hemangioendothelioma: Multidisciplinary surgical approach.

Epithelioid hemangioendothelioma (EHE) is a rare primary vascular tumour, usually malignant. We present the case of a 60-year-old woman who presented with hoarseness of voice and a persistent cough. During evaluation, a left supraclavicular mass was discovered. Initial assessments revealed a 30-mm left supraclavicular mass. Computed tomography angiogram and venogram confirmed an enhancing mass arising directly from the proximal left subclavian vein. After discussion in the joint multidisciplinary team, it was decided to resect the tumour owing to its malignant potential. Histopathology after resection confirmed a completely excised EHE. EHE is a rare vascular sarcoma requiring a multidisciplinary approach. Its main challenge is its unpredictable behaviour.

Multicentric Castleman's disease of the lungs mimicking a multifocal adenocarcinoma.

A female patient presented with fever of unknown origin, night sweats and weight loss. She had no pulmonary symptoms. Investigations revealed bilateral ground glass lung lesions which were subsequently followed-up with imaging. Two years later, a follow-up CT scan revealed an increase in the size of the lesions which exhibited a more solid appearance. A diagnostic biopsy was difficult to perform, and the patient underwent a left upper lobectomy for suspected primary lung malignancy. Histological examination showed lung involvement by Castleman's disease of plasma cell type which displayed a multifocal distribution. There was no evidence of nodal involvement. Following discussion at the multidisciplinary team meeting and correlation with radiology, a diagnosis of multicentric Castleman's disease of the lung was made. Here, we present an unusual case of multicentric Castleman's disease of the lung mimicking primary lung carcinoma. Our case highlights the importance of considering this entity in the differential diagnosis of multifocal lung lesions with a ground glass-like appearance to allow early diagnosis and management.

Classic biphasic pulmonary blastoma (CBPB): a rare primary pulmonary malignancy.

Classic biphasic pulmonary blastoma (CBPB) is a very rare primary pulmonary malignancy with distinctive clinical and pathological features. Usually CBPB presents with either non specific symptoms or is diagnosed incidentally. Histologically CBPB is composed of a mixture of malignant epithelial and stromal cells resembling fetal lung tissue. Surgical resection is the mainstay of treatment with further chemotherapy or radiotherapy on a case-by-case basis. However, due to its rarity, no definite treatment guidelines are available. CBPB overall has a very poor prognosis with a 5-year survival rate of only 15%. Our patient presented with cough and haemoptysis. Her chest radiograph demonstrated a large right-sided lung mass. Further investigations included CT, CT-guided biopsy and PET CT which were discussed at multidisciplinary team meetings. The patient then underwent complete surgical excision. We report this rare malignancy with radiological and pathological features, comparing them with previously reported cases.

Group A Streptococcus necrotising myositis of the limbs secondary to cavitating pneumonia.

Necrotising myositis is a rare complication of Group A Streptococcus infection requiring early and aggressive surgical management to prevent mortality. However, early diagnosis is difficult due to non-specific initial presentation and a low index of clinical suspicion given the paucity of cases. We highlight these challenges and present a case of a 22-year-old woman presenting with cough, fever and severe limb pain refractory to analgesia during the COVID-19 pandemic. We outline potential confounding factors that can delay intervention and offer diagnostic tools that can aid clinical diagnosis of necrotising myositis. In reporting this case, we hope to raise awareness among clinicians to avoid these pitfalls.

Microlobectomy: A Novel Form of Endoscopic Lobectomy.

OBJECTIVE: Microlobectomy is a novel form of videoscopic-assisted thoracic surgery lobectomy. Strict inclusion criteria consist of the following: no intercostal incisions greater than 5 mm, 12 mm subxiphoid port, subxiphoid removal of the specimen, total endoscopic technique with CO2 insufflation, vision through a 5-mm camera, stapling via the subxiphoid port, or with 5-mm stapling devices. METHODS: The combined early experiences of six hospitals from three countries were combined from September 2014 to May 2016. During that time, the study represents a consecutive cohort study of this technique. RESULTS: Seventy-two patients underwent microlobectomy. The median (range) age was 66 (27-82). Half of the patients were female. There were 48 right-sided resections and 24 on the left. There were four segmental resections and there was one right pneumonectomy. Four operations were performed robotically (with 8-mm intercostal incisions). The median (range) operative time was 180 (94-285) minutes and the blood loss was 118 (5-800) mL. There were three conversions to thoracotomy and two conversions to videoscopic-assisted thoracic surgery by means of an intercostal utility incision to complete the operation. The median (range) length of stay was 3 (1-44) days and 30 patients (42%) when home by day 2 and 16 patients (22%) were discharged on day 1. There were no deaths. Five patients (7%) had a prolonged airleak. There were no wound infections and there was one incisional hernia. CONCLUSIONS: We believe that microlobectomy is an interesting novel form of videoscopic-assisted thoracic surgery lobectomy and has several theoretical advantages. We have presented our early results and hope that this will stimulate others to investigate this type of videoscopic-assisted thoracic surgery lobectomy further.

A Glomus Tumor With Recurrence and Malignant Transformation in the Chest Wall: A Cautionary Tale of Seeding?

Glomus tumors are rare tumors most often occurring in the extremities of the limbs. We report a unique case of a glomus tumor, originally arising in the paraspinal region, which was excised and subsequently recurred in the chest wall with malignant transformation. The recurrence is likely to have been caused by wound seeding. To the best of our knowledge, this is the first report in the English literature of a glomus tumor recurrence secondary to the notion of wound seeding.

Intranodal Palisaded Myofibroblastoma Masquerading as N2 Non-Small Cell Lung Carcinoma.

Intranodal palisaded myofibroblastoma is a rare and benign tumor that usually presents in the inguinal region. We report the case of a 68-year-old woman with a right paratracheal mass and right upper lobe non-small cell lung carcinoma initially staged as T1b N2 M0. After mediastinal staging, the right paratracheal mass was found to be an intranodal palisaded myofibroblastoma, which had caused erroneous upstaging of the lung carcinoma to N2 disease. This had the potential of leading to suboptimal treatment of the primary lung carcinoma if formal mediastinal staging had not been performed. To the best of our knowledge, this is the first report in the English literature of an intranodal palisaded myofibroblastoma occurring concurrently with lung cancer. This case highlights the importance of mediastinal staging in lung cancer. Mediastinoscopy remains the gold standard.

Case report: Endobronchial valve placement for treatment of a persistent air leak.

Demonstration of the therapeutic utility of endobronchial valves in elderly high-risk patients unsuitable for surgery http://ow.ly/Y7eEx.

Our inability to predict thromboembolic events after prosthetic valve surgery.

BACKGROUND AND AIM OF THE STUDY: Thromboembolic and bleeding complications detract from outcome for patients with prosthetic heart valves. The study aim was to investigate whether measurement of coagulation activation markers and transcranial Doppler ultrasound microembolic signals (MES) could identify patients at subsequent higher risk of thromboembolism or bleeding events. METHODS: A total of 526 patients (mean age 66 years; 266 males, 260 females) who underwent elective valve replacement surgery was enrolled between April 1999 and October 2002. Clinical assessment and blood sampling for coagulation activation markers was performed preoperatively and at three and 12 months postoperatively. Transcranial Doppler MES were recorded in the first 144 patients. Status was reviewed between 21st April and 9th June 2005, with 99.4% follow up. RESULTS: Among patients, 62% had an aortic valve replaced, and mechanical valves constituted 60% of all implants. The mean follow up was 3.61 years; total follow up was 1,899.2 patient-years (pt-yr). In total, 115 patients died, while 61 experienced a total of 80 thromboembolic events: linearized event rates were 3.94% (mechanical valves) and 4.4% (bioprostheses). There was no difference between mitral and aortic implants, or among bileaflet, tilting-disc mechanical and porcine valves. Atrial fibrillation was not influential. Coagulation activation markers were not associated with thromboembolic events, except for an elevated von Willebrand factor (vWF), which was associated with a five-fold increase in embolic event rate. Fifty-one patients experienced 59 bleeding events; eight patients experienced multiple events. Linearized event rates were 3.37% (mechanical valves) and 2.49% (bioprostheses). The INR was suboptimal in 44-58% of patients. Transcranial Doppler MES were not associated with blood coagulation markers or thromboembolic events. CONCLUSION: Coagulation activation markers (except vWF) and MES did not predict thromboembolic events in valve replacement patients. Thromboembolic and bleeding event rates for West of Scotland patients generally exceeded reported rates: suboptimal anticoagulation appeared common and most likely influenced thromboembolic and bleeding event rates more than any other factor.

A randomized, controlled trial of C0- Vs C2-guided therapeutic drug monitoring of cyclosporine in stable heart transplant patients.

BACKGROUND: Cyclosporine monitoring using 2-hour post-dose samples (C2) is thought to be more efficacious than using pre-dose levels (C0) in managing immunosuppression for transplant patients. We evaluated the effect of C2 monitoring on cyclosporine dose and clinical parameters in stable heart transplant patients. METHODS: 125 stable heart transplant patients were randomized to C0 or C2 monitoring of cyclosporine levels for a period of six months. All patients had both C0 and C2 samples taken, and clinicians were blinded to one of the samples depending on randomization. The primary endpoint was the relative change in cyclosporine (Neoral) dose during the study period and secondary endpoints were change in creatine clearance, mortality, infection, and acute rejection. RESULTS: There was a significant decrease in the cyclosporine dose for the C2 group as compared with the C0 group (-11 mg/day and -26 mg/day respectively, p = 0.0025). No proven rejection episodes occurred in either group and there was no significant difference in the incidence of infection (C0 6, C2 10; p = 0.14), the change in renal function (change in creatine clearance C(0) +0.54 ml/min; C2 -0.16 ml/min; p = 0.61), the number of blood tests or dose adjustments between groups over the study period. Analysis of the blinded samples revealed that the reduction of cyclosporine dose in the C2 group could not be accounted for by reduced immunosuppression . CONCLUSION: C2 monitoring allows a significant cyclosporine dose reduction without compromising patient outcome in stable heart transplant patients. Further studies are required to ascertain whether this dose reduction can be translated into clinical benefit.

Mitral valve replacement with mechanical or bioprosthetic valve.

A presentation on the technique of mitral valve replacement is shown: exposure and excision of the diseased mitral valve is demonstrated along with the use of sub-annular and supra-annular interrupted suture techniques for securing biological and mechanical mitral prostheses. A brief overview of the literature is presented.