Surgical Management Of Congenital Thoracic Disorders: A 15-Year Center Experience.

INTRODUCTION: Congenital thoracic disorders represent a spectrum of fetal lung bud development abnormalities, which may affect breathing capacity and quality of life. We aim to evaluate the impact of surgery in the treatment of 4 major congenital conditions. MATERIALS AND METHODS: We performed a retrospective cohort analysis of patients who underwent surgical treatment in our tertiary center, from 2007 to 2022. RESULTS: Over the 15-year period, we treated 33 patients, with a male predominance of 55%. 22 patients (67%) were asymptomatic. When symptomatic, the recurrence of respiratory infections was the most common clinical presentation (18%). In 13 patients (39%), diagnosis was achieved through fetal ultrasonography. This study encompassed 13 patients with pulmonary sequestration (39%), 11 patients with bronchogenic cysts (33%), 7 patients with congenital pulmonary airway malformation (21%) and 2 patients with congenital lobar emphysema (6%). Considering solely lung malformation conditions, we accounted 22 patients with a median age of 3 [1-67] years-old. Surgery comprised bilobectomy (9%), lobectomy (77%), lobectomy with wedge resection (5%), segmentectomy (5%) and wedge resection (5%). Concerning bronchogenic cysts, we treated 11 patients with a median age of 19 [14-66] years-old. We identified 1 hilar, 1 intrapulmonary and 9 mediastinal lesions, of which 4 were paraesophageal, 4 were subcarinal and 1 was miscellaneous. Overall, surgery was conducted by thoracotomy in 61% of patients, VATS in 33% and RATS in 6%. The median drainage time was 3 [1-40] days and median hospital stay was 4 [1-41] days. There were no cases of mortality. Ensuing, 94% of patients experienced clinical improvement after surgery. CONCLUSION: Early diagnosis of congenital thoracic malformations increased considerably with the improvement in imaging technology and prenatal screening. Treatment may include expectant conservative treatment. However, in selected cases, surgery may play an important role in symptomatic control and prevention of disease progression.

COMMUNITY-ACQUIRED THORACIC EMPYEMA - DOES MICROBIOLOGICAL IDENTIFICATION MATTER?

OBJECTIVES: To describe the clinical characteristics, comorbidities and clinical outcome of hospitalized patients with the diagnosis of community acquired thoracic empyema in our hospital, with particular emphasis on the impact of identification of the causative agent. METHODS: We performed a retrospective review of the clinical files of hospitalized adult patients diagnosed with community acquired thoracic empyema between 2012 and 2016. RESULTS: A total of 81 patients (64 men and 17 women), with a mean age of 54.6+-17.3 years, were included in this study. It was possible to identify the microbiological agent in 59.3% (n=48) of the patients. The median length of hospital stay was 29 days (P25=20 and P75=44.5) and a tendency to longer duration was seen in patients with a microbiological isolation (32 days vs 23 days; p=0.056). No significant difference was observed between patients with and without microbiological isolation, regarding the mortality. CONCLUSION: In this group of patients a positive pleural fluid culture tends to be associated with longer lengths of hospital stay, which may lead to speculation that they were more advanced infectious processes at the time of diagnosis.

DOEGE-POTTER SYNDROME BY PLEURAL SOLITARY FIBROUS TUMOR.

INTRODUCTION: Solitary fibrous tumor of the pleura (SFTP) is a rare neoplasm that accounts for less than 5% of all pleural tumors. We present the case of a 73-year-old man with a history of recurrent episodes of severe hypoglycemia secondary to a large malignant SFTP. This paraneoplastic manifestation of SFTP occurs in less than 5% of cases and is referred to as Doege-Potter syndrome. Although rare, this is an important and reversible cause of hypoglycemia, which is resolved by complete surgical resection of the tumor. We describe the pathogenesis, diagnosis, and treatment of Doege-Potter syndrome. Key imaging findings and pathologic correlation are shown.

Sternoclavicular joint septic arthritis in a healthy adult: a rare diagnosis with frequent complications.

We report a case of complicated sternoclavicular joint septic arthritis in a previously healthy adult with no risk factors. An 83-year-old female presented to the emergency with a 1-week history of right shoulder pain followed by fever and prostration in the last 48 h. Computed tomography (CT) scan findings were consistent with right sternoclavicular joint (SCJ) septic arthritis complicated by periarticular abscess. Emergent surgical debridement was performed by a surgical team composed of orthopaedic and thoracic surgeons, followed by 6 weeks of antibiotic treatment. This case highlights the diagnosis and surgical treatment of a rare septic arthritis location but with frequent complications as well as the importance of multidisciplinary collaboration.

Combined lung-kidney transplantation: First case in Portugal.

A significant dysfunction of another organ is usually considered an absolute contraindication for lung transplantation, unless multiorgan transplantation is indicated and practical, as is the case of combined lung-kidney transplantation. Few cases of combined lung-kidney transplantation have been described in the literature; however, it is known that, in certain cases, it is the only way to offer an opportunity to selected patients with renal and lung dysfunction. The authors are not aware of any previously published case of a patient receiving both extracorporeal membrane oxygenation and continuous venovenous hemodiafiltration as a bridge for combined kidney-lung transplantation. The authors present the first case of combined lung-kidney transplantation performed in Portugal.

MAJOR PULMONARY SURGERY IN PATIENTS WITH COMPROMISED LUNG FUNCTION.

INTRODUCTION: The risk stratification of lung resection is fundamentally based on the results of pulmonary function tests. In patients considered to be at risk, major surgery is generally denied, opting for potentially less curative therapies. OBJECTIVE: To evaluate the postoperative outcomes of major lung surgery in a group of patients deemed high risk. METHODS: We performed a retrospective review of clinical records of all patients submitted to lobectomy, bilobectomy or pneumonectomy in a 3-year period in a reference Thoracic Surgery Unit. The patients were then divided in two groups: group A composed of patients with normal preoperative pulmonary function and group B which included patients with impaired lung function, defined as FEV1 and/or DLCO ≤60%. RESULTS: A total of 234 patients were included, 181 (77.4%) in group A and 53 (22.6%) in group B. In group B, patients had more smoking habits, were more often associated with chronic obstructive pulmonary disease and were also more frequently submitted to thoracotomy. When surgery was motivated by primary lung cancer this group had a more advanced clinical stage of the disease. In the postoperative period, these patients had longer hospital stay, longer chest drainage time and greater need for oxygen therapy at home, however, no statistically significant difference was noted in morbidity or mortality. CONCLUSIONS: Major thoracic surgery can be safely performed in selected patients considered to be high risk for resection by pulmonary function tests. A potentially curative surgery should not be denied based on respiratory function tests alone.

Lung Necrosis After Paraffin Aspiration.

BACKGROUND: Fire breather´s lung is a rare condition that occurs after hydrocarbon aspiration. Case reports published experienced a good clinical outcome with conservative treatment. To our knowledge, there are no reported cases treated with pulmonary resection. CASE PRESENTATION: We report the case of a 35-year-old female trapeze artist, who suffered an accidental ingestion/ aspiration of liquid paraffin. Persistent fever and elevated inflammatory markers without clinical improvement with antibiotics and bronchoscopy was seen. Computed tomography scan showing middle lobe necrosis and abscess motivated a middle lobectomy for infection control. Postoperative recovery was uneventful. CONCLUSION: There are some cases described in the literature, normally with a favourable evolution with conservative treatment. Therefore, it is important to acknowledge that, in patients where serious complications have arisen, despite medical therapy, surgery may have an important role, and resection of the necrotic lung may prevent its potential life-threatening consequences.

Severe Intraoperative Complications During VATS Anatomical Ressections and their Surgical Resolution in a Portuguese Thoracic Surgery Centre - A 9-Year Review.

INTRODUCTION: Many studies have demonstrated that video-assisted thoracoscopic surgery (VATS) is not only feasible and safe but is actually the approach chosen for an increasing number of pulmonary anatomic resections. There are however few studies reporting on severe intraoperative complications during VATS anatomical ressections and their resolution. OBJECTIVE: Our aim is to analyse the incidence of severe intraoperative complications during VATS anatomical ressections, at our department, in the past nine years, and describe their technical resolution during the surgery. METHODS: We performed the retrospective analysis of the patients submitted to lobectomy, bilobectomy or segmentectomy by VATS or VATS converted to thoracotomy at Hospital de Santa Marta, between May 2008 and September 2017. Severe intraoperative complications were defined as an event that results in a life threatening situation or an injury to a proximal airway, blood vessel or organ that would lead to an unplanned additional anatomical resection. RESULTS: A total of 151 patients were submitted to anatomical ressections, 90,7% (n=137) of them for a primary lung cancer, other indications were metastatic disease 6%(n=9) and benign disease in 3,3% (n=5). The surgery was a lobectomy in 94% of the cases (n=142), a segmentectomy in 5% (n=8), and one bilobectomy. The conversion rate to thoracotomy was 12% (n=18), most of which were for technical/ oncological reasons (n=11), and 7 others were to control bleeding. Four (2,6%) severe intraoperative complications were identified. Three of them (2%) were erroneous transections of bronchovascular structures (left main bronchus, left main pulmonary artery and both left pulmonary veins); and one was a membranous airway injury proximal to the staple line. There were no intraoperative deaths. The three patients with erroneous bronchovascular transection were converted to thoracotomy and the bronchial or vascular re-anastomosis was performed, therefore avoiding a left pneumonectomy. In the patient with the membranous airway injury, the bronchoplastic suture was performed by VATS. All four patients were primary lung cancer patients. In all these cases the patients were discharged alive and well and are undergoing their follow-up program with no signs of disease recurrence. CONCLUSION: Albeit rare, severe complications during VATS Lobectomy can occur but when they happen the thoracic surgeon has to be ready to solve them with the minimal repercussion for the patient.

[Videothoracoscopic anatomic pulmonary segmentary: an initial single-center experience]. / Segmentectomia Pulmonar Anatómica por Videotoracoscopia: Experiência Inicial de um Centro.

The use of minimally invasive surgery for the treatment of lung cancer has been growing worldwide. Between May 2008 and November 2012, we performed 24 videothoracoscopic anatomical lung resections in our department. This includes 22 lobectomies and 2 anatomic segmentectomies, which is known to be a more complex surgery, since it demands a finer dissection of sub-lobar structures. We report the clinical cases of two patients who underwent anatomic segmentectomies. The first one was a 63 year old woman, smoker and with a history of breast cancer 20 years earlier. An incidental 9 mm node was found in the lingula. The patient underwent an anatomic lingulectomy and the frozen section was suggestive of a primary lung cancer. Therefore, we proceeded to a full lymphadenectomy. The final pathology evaluation showed a typical carcinoid tumour (pT1aN0). The second patient was a 50 year old woman, a smoker and with a heavy family history of lung cancer. In a screening CT scan a 8 mm ground glass opacity was identified in the left lower lobe (segment VI). After a VATS wedge resection of the node the frozen section evaluation was compatible with adenocarcinoma. We then proceeded to an anatomic segmentectomy with lymphadenectomy. The definitive pathology evaluation confirmed that it was a pT1a N0 bronchioloalveolar adenocarcinoma. The patients now have 5 and 2 months of follow up respectivelly and neither of them has signs of recurrence and the surgical incision showed a good aesthetic result. Anatomic segmentectomy is the indicated surgery especially in patients with low grade tumours, in early stage lung cancers or in patients without pulmonary function for a lobar resection, and it can be done safely using VATS.