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.

Outcome Analysis Of Total Laryngopharyngeal Oesophagectomy In Carcinoma Hypo-Pharynx And Cervical Esophagus, With Stomach Reconstruction.

BACKGROUND: Upper cervical oesophageal and hypo-pharyngeal malignancies pose significant challenges in surgical management. In advanced tumours total laryngopharyngeal esophagectomy (TLPO) and gastric pull up provides excellent result. METHODS: It is a descriptive case series and was conducted from Jan 2010 to Jan 2017. Thirty-five patients underwent TLPO. The inclusion criteria were; tumours of hypo-pharynx which allow tumour free resection margins and cervical oesophageal tumours not involving mediastinal trachea. There were no clinically palpable cervical lymph nodes. Patients with locoregional advanced disease and poor performance status were excluded. All cases underwent standard one stage TLPO with bilateral inter-jugular lymph nodal clearance. Minimal invasive techniques used in three cases. RESULTS: Out of 35 patients, n=21 (60%) of patient had lesion of hypopharynx with post cricoid involvement, n=13 (37.1%) had primary tumour of cervical oesophagus abutting pharynx and cricoid and only one patient had a tumour of hypopharynx with perforation. Histopathological conformation of diagnosis done in all patients preoperatively which showed Well differentiated Squamous cell in n=19 (54.28%), moderately differentiated squamous cell in 28.57% (n=10). Post-operative staging of the patients 74.28% (n=26) fall in stage 3. Operative time was less than 3 hours in 17 patients with two team technique, between 3-4 hours in 8 patients and more than 4 hours in 3 patients. SVT in 14.28% (n=5), Atrial Fibrillation in 5.71% (n=2). Chest complications including pneumothorax in 11.43% (n=4), basal atelectasis in 22.86% (n=8), pulmonary embolism in 2.85% (n=1), aspiration in 8.57% (n=3) and tracheal stenosis in n=1, 5.71% (n=2) cases had anastomotic leak. Postop 28 days mortality was 8.57% (n=3). CONCLUSIONS: TLPO with stomach pull up offer good results in patients with resectable disease with acceptable morbidity and mortality in operable patients.

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.