Effect of Circumference of Open Window Thoracostomy on Chest Wall Closure, Pleural Cavity Clearance, and Lung Expansion.

Introduction Managing chronic empyema thoracis (CET) due to tuberculosis (TB) in debilitated patients is complicated. Open window thoracostomy (OWT) is one of the ways to manage these high-risk patients. Closure of OWT is sometimes difficult to attain. The purpose of this study is to compare the outcome of OWT in terms of chest wall closure in two similar groups. The only difference between these groups was the circumference of the OWT created. This study will benefit patients of CET with OWT to attain early chest wall closure without being subjected to another surgical trauma. Methods This is a prospective comparative study, conducted in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, from August 2019 to July 2020. A total of 48 patients, 22 and 26 patients in group A and group B, respectively, were included in this study. Both groups were matched for age, gender, diagnosis, body mass index, and stage of empyema, with the difference only in the OWT circumference. Results Both groups had a history of multiple chest tube intubations. Among group A patients, a smaller circumference of OWT (20-24 cm; mean 22 cm) was created as compared to group B (30-34 cm; mean 33 cm). Spontaneous OWT closure was seen in 21 (95.5%) patients in group A and seven (26.9%) patients in group B in a time period of 6.2 ± 1.5 and 11.4 ± 0.5 months, respectively (p-value: ≤ 0.001). Pleural cavity clearance was attained in 21 (95.5%) patients in group A and 24 (92.35%) patients in group B in a time duration of 4 ± 1.4 months and 4 ± 4.1 months, respectively (p-value: ≤ 0.97). Complete lung expansion was found in 21 (95.5%) patients in group A and 24 (92.3%) patients in group B in a time duration of 5 ± 1.7 months and 4.7 ± 1.6 months, respectively (p-value: ≤ 0.62). Conclusion This prospective single-center study shows that successful spontaneous early closure of OWT primarily depends on the size of the OWT created. A smaller-sized OWT, if created judiciously, not only closes spontaneously but also facilitates the clearance of purulent discharge and potentially helps in the definitive healing of bronchopleural fistulae and consequent lung expansion, thereby avoiding more invasive procedures like decortication in a debilitated patient. Furthermore, there is no need for a second surgery for closure of OWT.

Video Assisted Thoracoscopy as a therapeutic modality in evacuating retained or clotted haemothoraces.

OBJECTIVE: To determine the role of video-assisted thoracoscopy for evacuating retained / clotted haemothoraces to minimise the duration of chest tube drainage and length of hospital stay. METHODS: The prospective cohort study was conducted from July 2019 to February 2020 at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, and comprised consecutive patients who underwent video-assisted thoracoscopy for retained or clotted haemothoraces. Outcome was measured as evacuation of retained haemothoraces resulting in partial or complete lung expansion and length of hospital stay. Data was analysed using SPSS 22. RESULTS: Of the 160 patients, 128(80%) were males and 32(20%) were females. The overall mean age was 36.08±11.91 years. Overall, 103(64.37%) patients underwent the procedure in within 4-7 days, and 57(35.63%) within 8-14 days. Complete lung expansion was achieved in 95(71.9%) patients when the procedure was performed in the first week, and in 37(28.1%) when performed in the second week (p=0.01). Within the first week, 87(84.4%) patients had shorter duration of stay compared to patients having undergone the procedure in the second week (p=0.001). Relapse of collection was found in 21(13.7%) patients. CONCLUSIONS: Video-assisted thoracoscopy was found to be a safe, reliable and effective technique for the evacuation of retained haemothorax in haemodynamically stable patients. Early intervention resulted in better outcome.

Role of Anti-Tuberculous Treatment in the Outcome of Decortication for Chronic Tuberculous Empyema.

INTRODUCTION: Chronic tuberculous empyema (CTE) is a common complication of tuberculosis that requires some form of surgical intervention along with anti-tuberculosis therapy (ATT). The aim of this study was to determine the optimum duration of pre-operative ATT in CTE prior to the decortication and its outcomes. MATERIAL AND METHODS: This comparative prospective study was conducted from August 2019 to August 2020 in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, Pakistan. A total of 70 patients were included in the study. They were grouped into two arms: patients operated at or within six weeks of ATT commencement (Group A) and patients operated after six weeks of ATT (Group B). Both groups had 35 participants each. Patients were evaluated based on a self-administered questionnaire. A p-value of less than 0.05 was considered significant. RESULT: In this study, there were 55 (78.6%) males and 15 (21.4%) females with a mean age of 33.5 ± 11.2 years. Diagnosis of CTE was most commonly made through sputum acid-fast bacilli (AFB) smear (n=35, 50%) which most commonly involved right upper (n=20, 28.6%) and lower lung lobes (n=20, 28.6%). Complications such as air leaks, need for ventilator support, need for intensive care unit (ICU) stay, residual collection, and pneumothorax all were significantly higher in Group A (31 patients out of 35) compared to Group B (18 patients out of 35). In Group B, 21 (60%) participants had full post-operative expansion of lungs, compared to eight (22.8%) in Group A (p=0.002). In total five participants had failure to expand lungs; all of them belonged to Group A (p=0.02). CONCLUSION: The optimum timing of surgery and preoperative ATT is crucial for achieving better outcomes and requires good collaboration between the treating pulmonologist and thoracic surgeon. Our study highlights the importance of pre-operative ATT for at least more than six weeks before undertaking decortication for better outcomes and minimizing morbidity.

Rigid Bronchoscopy: A Life-Saving Intervention in the Removal of Foreign Body in Adults at a Busy Tertiary Care Unit.

Introduction Foreign body (FB) aspiration is a potentially lethal emergency and is not uncommon in adults. Rigid bronchoscopy (RB) is a useful procedure for the extraction of these FBs, and it has a high success rate. The aim of this study was to document the clinical presentation of FB aspirations and management outcomes of non-vegetative FB extraction using RB as a therapeutic modality. Method This prospective interventional study was conducted in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi from May 2019 to April 2020. Patients of both genders of ages 12 years or above, presenting with FB aspiration were included. RB was performed in all patients. Results Chest radiograph (CXR) identified FBs in all 60 patients, 51 of whom were females and nine males. In 24 (40%) patients, a CT scan was performed to accurately localize the FB. Left bronchus was the most common location of the FB (n=39; 65%). Scarf pin was the most common type (n=45; 75%) of FB, followed by sewing needle (n=7; 11.7%), safety pin (n=5; 8.3%), and tire repair needle (n=3; 5%). In 53 (88.3%) patients, RB was successful in retrieving the FB. Thoracotomy was performed in the remaining seven patients due to inaccessibility. One (1.7%) patient died due to the rupture of the thoracic aortic aneurysm. Conclusion Accidental aspiration of pins and needles can be fatal in adults. RB is a life-saving modality for safely removing these FBs. However, thoracotomy should be used as a life-saving procedure in cases of FBs affecting secondary bronchi or beyond.

Analysis of Injury Patterns and Outcomes of Blunt Thoracic Trauma in Elderly Patients.

Introduction In the elderly population, trauma is a leading cause of utilization of healthcare, institutionalization, disability, and mortality. In this study, we will assess the injury patterns and the factors associated with the outcomes of blunt thoracic trauma in elderly individuals. Methods This prospective observational study was conducted in the Department of Thoracic Surgery, Jinnah Postgraduate Medical Center, Karachi, Pakistan, from September 2019 to April 2020. The study included patients of both genders aged 60 years and above with blunt thoracic trauma. Patients with concomitant neurological injuries and penetrating trauma to the chest were excluded. Results There were a total of 80 patients in this study; majority were males (n = 66 [82.5%]). The mean age was 70.18 ± 8.3 years. Road traffic accident was the most common mode of injury (n = 45 [56.3%]) followed by fall (n = 32 [40%]). Hemothorax and hemopneumothorax were the most common primary diagnosis. Rib fractures were encountered in 72 (90%) patients. Mortality rate was 21.3% (n = 17). Factors significantly related to mortality were age ≥ 80 years (p = 0.00), tension pneumothorax (p = 0.036), pre-existing cardiopulmonary disease (p = 0.032), blood loss ≥ 500 mL (p = 0.004), flail chest (p = 0.018), and chest trauma score ≥ 5 (p = 0.001). Mean hospital stay in our study was 5.3 ± 3.4 days. Factors lengthening hospital stay by more than five days included lung contusion (p = 0.02), more than two rib fractures (p = 0.004), hemopneumothorax (p = 0.026), pneumonia (p = 0.003), acute respiratory distress syndrome (p = 0.003), and flail chest (p = 0.013). Conclusions Elderly patients with blunt thoracic trauma have higher mortality. Proactive evaluation of injuries using the chest trauma score in the elderly population helps in recognizing patients at high risk of mortality and helps in the timely management to prevent adverse outcomes.

Early Functional Results of Surgery for Organizing Phase of Empyema Thoracis in a High Output Centre for Thoracic Surgery.

OBJECTIVE: To determine the early functional outcome of pulmonary decortication (PD) in patients having organized empyema thoracic (ET).  Methodology: This is a prospective study conducted at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Center, Karachi from July 2019 to June 2020. The study included 76 patients referred to the department for assessment and surgery for the indication of organized empyema thoracis. After careful assessment and evaluation of the patients' computed tomography (CT) scans and pulmonary function tests (PFTs) in addition to their symptoms, history, etiology of empyema, physical examination and nutrition status, they were recommended pulmonary decortication to release the underlying entrapped lung. Functional improvement was measured in terms of forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) three to six months after PD. RESULTS: A total of 76 empyema thoracis patients were included in the study. The mean age of participants was 33.4±11.9 years. The mean duration of empyema symptoms was 7.21±3.7 months. Majority were males (n=61; 80.3%). The full-lung expansion was achieved in 43 patients and partial lung expansion was achieved in 27 patients. The lung failed to expand in five patients. There was one death (lung failed to expand) due to respiratory failure as a result of septicemia. Most of the patients who achieved full-lung expansion had tuberculosis (26; 60.5%), followed by penetrating lung injury (7; 16.2%) and ruptured pulmonary hydatid cysts (5; 11.6%). Statistically significant association was found between etiology and full-lung expansion (p=0.042). Early functional improvement was seen in all patients with PD as mean FEV1 improved from 1.23±0.27 to 2.02±0.5 (63% increase; p<0.001) and FVC from 2.10±0.27 to 2.72±0.41 (29.7% increase; p<0.001). CONCLUSION: Based on the results obtained in the present study, it is concluded that pulmonary decortication in carefully selected patients has a vital role in significantly improving early functional results in terms of pulmonary functions.

Plasmacytoma of the thyroid gland.

Among the clinical presentation of plasma cell proliferative disorders the extramedullary plasmacytomas are the most infrequent after multiple myeloma and plasma cell tumours of the bones. The plasmacytoma of the thyroid gland to our knowledge has never been reported from Pakistan so far. We present the clinical picture and clinical challenges posed in diagnosis and treatment by this unusual proliferative disorder.

Lung carcinoma: its profile and changing trends.

BACKGROUND: Lung Carcinoma is the leading causes of morbidity and mortality worldwide with an incidence of 1.3 million cases per year. This study was undertaken to determine prevalence of various histological types of lung carcinoma and to analyse their changing trends with time. METHODS: This is a retrospective analytical study. A total of 330 cases of lung carcinoma were analysed from 2003 to 2008. Cases from Khyber Pakhtunkhwa and Federally Administered Tribal Area (FATA) were included in this study. Furthermore, only cases of lung carcinoma were considered while other malignancies were excluded. RESULTS: Squamous Cell carcinoma was found in 42.7% of cases. Overall male to female ratio was 2.67:1. Prevalence of Squamous Cell carcinoma increased from 32% to 57.9% while that of Small Cell carcinoma increased from 12% to 17.1%. Unspecified type showed decrease from 36% to 5.3%. Increase in the prevalence of Squamous Cell carcinoma was found in both males and females while change in the prevalence of Small Cell carcinoma was found on!y in males. CONCLUSION: Squamous Cell carcinoma was the most prevalent variant of lung carcinoma in our region, followed by Adenocarcinoma. Male to female ratio across different histological patterns did not show significant variation. Increase in the prevalence of Squamous Cell carcinoma was statistically significant in both males and females while in case of Small Cell carcinoma change in its prevalence was also significant in males.

Unilateral blindness as a presenting symptom of lung cancer treated with erlotinib.

A non-smoker young man presented to the ophthalmologist with loss of vision in his left eye. Clinical work-up revealed metastatic deposits in left retina. Broadened workup also showed metastatic disease in the skull and brain. The search for the primary concluded on the histopathological evidence of Non-Small Cell Lung Carcinoma (NSCLC) in the upper lobe of the left lung. After the diagnosis and ascertaining disease extent, localized radiotherapy to whole skull and retina was given, followed by conventional chemotherapy (Gemcitabine, Carboplatin). The results of radiation and chemotherapy were not satisfactory, therefore, patient was placed on a new agent (tyrosine kinase inhibitor) Erlotinib (150 mg per day orally in a single dose). The response was evaluated using clinical and radiological parameters and was found to be satisfactory.

Cancer incidence in the districts of Dir (North West Frontier Province), Pakistan: a preliminary study.

BACKGROUND: Pakistan has a high incidence of cancer. The most severely affected province is the North West Frontier Province, which has districts of low socioeconomic status such as those in Dir. The purpose of this study was to analyze the cancer registry record of patients from the districts in Dir in order to obtain a net cancer incidence for use in proposing future health plans. METHODS: The medical records of 1,105 patients registered at the Institute of Radiotherapy and Nuclear Medicine in Peshawar were traced. Information regarding age, gender and affected sites were obtained. RESULTS: The incidence of cancer increased, with a mean incidence of 15.04 per 100,000 in 2000-2004. Of the 1,105 patients, 62% were male and 38% were female. The most affected female age groups were 41-50 and 51-60; while males in the age groups of 51-60 and 61-70 had the highest risk. The leading cancers were lymph/blood, and cancers of the digestive system, skin and breast. CONCLUSION: The increasing trend of cancer in Dir is alarming. Since this study was a preliminary investigation, it could provide a leading role in prevention, treatment and future planning regarding cancer in Pakistan.

Occupation and cancer incidence in District Dir (NWFP), Pakistan, 2000-2004.

District Dir is a part of North-West frontier Province (NWFP) in Pakistan with poor health, education and socioeconomic and other facilities. Data regarding occupational cancer were here collected from cancer registry of Institute of Radiotherapy and Nuclear Medicine (IRNUM) Peshawar for January-2000 to December-2004 and medical records of 1105 patients were traced and analyzed. It was observed that 61 % (683/1105) were males and 39% females. Farmers accounted for 43.8% of cancers, the second most effected people being housewives with 33.8% then children/students at third place with 12.8%. Cancers in laborers and other people like government employees, businessman and shopkeepers were less often found. The data from a cancer registry for a low socioeconomic region should be helpful for future mass screening and determination of risk factors within the country and in Asia in general region. Increased awareness by education is highly important and may play a beneficial role in diagnosis, treatment and prevention.