Surgical Management in a Paediatric Case of Endobronchial Mucoepidermoid Carcinoma Involving the Carina.

Although mucoepidermoid carcinoma (MEC) is the most diagnosed malignancy of the salivary gland, it rarely localises to the bronchus, accounting for only 0.1-0.2% of all primary lung malignancies. Of those pulmonary MECs, most are found in segmental or lobar bronchi, and they are rarely found in mainstem bronchi, highlighting the novelty of this presentation for thoracic specialists. We present a case report of a seven-year-old female who underwent a carinal resection and a right upper lobectomy for the management of an endobronchial MEC causing right middle lobe (RML) obstruction. Intraoperatively, an exophytic mass originating from the junction of the right main bronchus and bronchus intermedius was identified, causing a partial obstruction of the RML bronchus. Frozen sections demonstrated clear margins and follow-up bronchoscopies have been unremarkable. Given their rarity, endobronchial MECs can be diagnostically difficult and cause uncertainty with respect to their management. Low-grade tumours have a much more favourable prognosis than their high-grade counterparts, with surgical resection being the gold standard of care. Therefore, the index of suspicion, time to diagnosis, and definitive treatment are critical to the outcome.

Outcomes of chest drain management using only air leak (without fluid) criteria for removal after general thoracic surgery-a drainology study.

Background: Chest drain management is a variable aspect of postoperative care in thoracic surgery, with different opinion for air and drain volume output. We aim to study if acceptable safety was maintained using air leak criteria alone. Methods: A 9-year retrospective analysis of protocolised chest drain management using digital drain air leak cut off less than 20 mL/min for more than 6 h for drain removal in patients undergoing general thoracic surgery. We excluded patients if a chest drain was not required nor removed during admission or if patients underwent volume reduction or pneumonectomy. Withdrawal criteria were suspected bleeding or chylothorax. Postoperative films were reviewed to document post-drain removal pneumothorax, pleural effusion, and reintervention (drain re-insertion). Results: Between 2012 and 2021, 1,187 patients had thoracic surgery under a single surgeon. Following exclusion and withdrawal criteria, 797 patients were left for analysis. The mean age [standard deviation (SD)] was 61 [16] years and 383 (48%) were male. Median [interquartile range (IQR)] duration of drain insertion was 1 [1-2] day with a median length of hospital stay of 4 [2-6] days. Post-drain removal pneumothorax was observed in 141 (17.7%), post-drain removal pleural effusion was observed in 75 (9.4%) and re-intervention (reinsertion of chest drain) required in 17 (2.1%). Conclusions: Our results demonstrate acceptable levels of safety using digital assessment of air leak as the sole criteria for drain removal in selected patients after general thoracic surgery.

Are chest drains routinely required after thoracic surgery? A drainology study of on-table chest-drain removals.

Objectives: Advances in perioperative management for thoracic surgery have accelerated the postoperative recovery of patients by decreasing postoperative pain and the incidence of complications. We aimed to study whether it's safe to remove chest drains on table in selected cases. Methods: This was a 5-year retrospective analysis of protocolized chest-drain removal on the operating table. The chest drain was removed in patients undergoing sublobar/wedge lung resection and other minor thoracic procedure (pleural biopsy, mediastinal mass biopsy/resection) via a thoracoscopic approach (video-assisted thoracoscopic surgery). Chest drains were removed at the end of the operation if air leak as documented by the digital drain was less than 20 mL/min. Outcome data on postdrain removal pneumothorax, effusion, and need for further intervention were obtained by reviewing the postoperative chest films, all reported by a radiologist. Results: Between 2016 and 2021, 107 patients underwent drain removal in theater. Mean age (standard deviation) was 58 (17) years and 54 (50.5%) were male. Postdrain removal pneumothorax occurred in 22 patients (21%), pleural effusion in 6 (5.6%), and 21 of 22 postoperative pneumothoraces were managed conservatively without reinsertion of chest drain. As it is our standard policy to leave no pneumothorax in patients undergoing surgical management of primary spontaneous pneumothorax, only 1 such patient (0.9%) had a drain reinserted as a result. The median (interquartile) length of hospital stay was 1 day (1-2), and 14 patients (13%) were discharged on surgery day. Conclusions: Our results demonstrate that on table chest-drain removal in selected cases is safe and repeatable using a digital drain, challenging the practice of routine drain insertion after thoracic surgery.

Impact of society and national guidelines on patient selection for lung cancer surgery in the United Kingdom.

OBJECTIVES: We sought to evaluate the impact of different national clinical guidelines (with consistent and conflicting recommendations) on clinician's practice in the UK. METHODS: In this cohort study, we analysed data from National Lung Cancer Audit comprising all patients diagnosed with lung cancer between 2008 and 2013 within England and Wales for consistent (British Thoracic Society and National Institute of Clinical Excellence) recommendations for lower/more permissive lung function but opposing stage (N2) selection parameters for surgery. RESULTS: From 2008 to 2013, data from 167 192 patients with primary lung cancers were included. The proportion of patients undergoing surgery for lung cancer increased from 9.5% to 20.5% in 2013 (P < 0.001) as the number of general thoracic surgeons in the UK increased from 40 to 81 in the corresponding timeframe. Mean forced expiratory volume in 1 s of surgical patients increased from 76% (22) to 81% (22) in 2013 (P < 0.001). Of the patients undergoing surgery, the proportion of patients with N2 disease across the 6-year interval was broadly consistent between 8% and 11% without any evidence of trend (P = 0.125). CONCLUSIONS: Within 3 years of new clinical guideline recommendations, we did not observe any overall change suggesting greater selection for surgery on lower levels of lung function. When presented with conflicting recommendation, no observable change in selection was noted on surgery for N2 disease. The observed increase in surgical resection rates is more likely due to greater access to surgery (by increasing number of surgeons) rather than any impact of guideline recommendations.