A Cautionary Tale: Undetected H-type Tracheoesophageal Fistula in an Adolescent Male

An H-type tracheoesophageal fistula is a rare congenital anomaly consisting of an abnormal passageway between the esophagus and the trachea without the presence of esophageal atresia. This condition is usually detected early in infancy; however, some patients may receive a delayed diagnosis. Symptoms experienced by people affected with an H-type tracheoesophageal fistula vary greatly and may consist of bouts of coughing when swallowing liquids and recurring lower respiratory infections. The most commonly used initial diagnostic tests can produce falsely negative results. The treatment of choice for the majority of H-type tracheoesophageal fistulas is an open surgical procedure; however, the thoracoscopic approach has proven effective in cases where the fistula is located below the thoracic outlet. In this case report, we describe a patient whose diagnosis of H-type tracheoesophageal fistula was delayed by 13 years and who was successfully treated using thoracoscopic surgery.

Pneumothorax caused by metastatic gestational trophoblastic neoplasia: a case report

INTRODUCTION

Gestational trophoblastic neoplasia (GTN) is a group of malignant neoplasms that arise from abnormal proliferation of trophoblastic tissue. The metastatic spread rate is depended on the histopathological type, with pulmonary metastases being the most common (80%) in patients with metastases. Pneumothorax as a primary manifestation is extremely rare. We hereby discuss a unique case of spontaneous hemi-pneumothorax due to metastatic GTN in a 30-weeks pregnant woman.

CASE PRESENTATION

A 25-year-old woman - G2 P0 A1 - was admitted to our maternal intensive care department with atypical respiratory symptoms. A chest x-ray revealed a large right sided pneumothorax. The patient underwent an urgent percutaneous chest tube. Since halting of the suction resulted in residual pneumothorax, a video-assisted thoracoscopic surgery (VATS) with wig resection of a bullous lesion was performed followed by chemical pleurodesis. Histopathological examination identified the lesion as a gestational trophoblastic metastasis with some features of choriocarcinoma. After primary section Caesarea adjuvant chemotherapy (MTX) was instigated with rapid decline of serum HCG values. Six months after surgery she was doing well with no biochemical or radiographic evidence of recurrent metastasis.

CONCLUSION

Lung metastases are common in patients with metastatic GTN; however, pneumothorax is an extremely rare complication. We report a case of pneumothorax in a 30-week pregnant woman caused by pulmonary spread of GTN from a previous miscarriage. This case illustrates that in patients with pneumothorax and a history of miscarriage, metastatic GTN should be considered as a possible cause.

Intraoperative chylous leak diagnosis by preoperative oral administration of ice cream: a case report

Background

Chylothorax is an intractable postoperative complication of thoracic surgery. Preventing postoperative chylothorax following initial surgery is important. Most cases of chylothorax are caused by injury to the thoracic duct or its branches. However, rare cases might result from injury to the lymphatic vessels in the chest wall. Preoperative oral administration of dairy products is widely recognized as a useful method for identifying the sites of chylous leaks during surgery for chylothoraces. Herein, we report a surgical case of a middle mediastinal tumor, wherein a chylous leak in the chest wall was intraoperatively detected due to scheduled preoperative oral administration of dairy products before the initial surgery, resulting in prevented postoperative chylothorax.

Case Description

A 68-year-old male patient underwent computed tomography, revealing a cystic lesion in the middle mediastinum that was suspected to be a thoracic duct cyst or intrathoracic lymphangioma. A cup of ice cream was orally ingested 1 hour before entering the operating room to intraoperatively detect chylous leakage in case of injury to the lymphatic vessels, including the thoracic duct. The mediastinal tumor was removed via thoracoscopic surgery and histologically diagnosed as a schwannoma with cystic degeneration. Intraoperatively, chylous leakage was observed due to injury to a lymphatic vessel in the chest wall, which was repaired by clipping. The postoperative course was uneventful.

Conclusions

Preoperative oral administration of dairy products was verified to be a useful method not only at the time of re-operation for postoperative chylothoraces but also at the time of initial surgery in cases where chylothorax is of high concern. Although relatively infrequent, chylothorax due to lymphatic vessel injury in the chest wall should be kept in mind.

Short-Term Outcomes and Quality of Life Following Minimally Invasive Esophagectomy in a Tertiary Care Center in Southern India

INTRODUCTION

With the advent of multimodality therapy and minimally invasive surgical approaches, patients suffering from carcinoma esophagus are showing promising outcomes. Hence, the frontier needs to be widened to assess the postoperative quality of life (QoL) of those surviving carcinoma esophagus. The objective of the study was to determine the short-term outcomes of minimally invasive esophagectomy (MIE) /hybrid esophagectomies in carcinoma esophagus and the organ-specific QoL in survivors of MIE for carcinoma esophagus, and to compare health-related QoL in patients following MIE for carcinoma esophagus with the general population.

METHODS AND MATERIALS

A longitudinal study design was used to evaluate the short-term postoperative outcomes of patients undergoing MIE for carcinoma esophagus between July 1, 2021, to July 15, 2022, and analyze the QoL of those patients who survived at one year without tumor recurrence. QoL was assessed using the European Organization for the Research and Treatment of Cancer (EORTC) QoL Questionnaire (EORTC QLQ-C30) and the EORTC QoL Questionnaire - Oesophageal Cancer Module (EORTC QLQ-OES18).

RESULTS

A total of 15 patients who underwent minimal invasive/hybrid esophagectomy for esophageal carcinomawere included. Of these, 13 patients underwent hybrid esophagectomy while two patients underwent thoraco-laparoscopic esophagectomy. Squamous cell carcinoma was observed as the most common histological variant (60%) while 33% were adenocarcinoma and 6.7% lymphoma. The most common site of the tumor was the lower one-third esophagus (60%). Nine out of 15 patients developed postoperative complications needing prolonged ICU stay. One major anastomotic leak as well as one conduit necrosis was observed among 15 cases operated. Median length of hospital stay was 16 (IQR 12-24). QoL was assessed among 12 patients at the one-year follow-up excluding mortality cases and patients with tumor recurrence. The patients following MIE for carcinoma esophagus were observed to have low scores in physical functioning, role functioning, and social function when compared with the general population. Cognitive functioning and emotional function were not found to be significantly different. No statistically significant difference was observed in the global health status among the two groups. There was no significant difference found in the general symptoms score comparison of the MIE patients with the general population. When it comes to organ-specific symptom scales, reflux was observed as a major issue among the patients who survived carcinoma esophagus after undergoing MIE. Dysphagia and dry mouth received low scores suggestive of minor issues. Though analysis of global health QoL scores of those with postoperative complications and those who had uneventful recovery at one year revealed a higher score for the latter, it was not statistically significant.

CONCLUSION

Postoperative complications can prolong hospital stay, delay resuming normal work, and affect the global QoL of patients compared with those who recovered uneventfully. Physical and role functions were observed to be deficient among survived patients when compared with the normal population. Nutritional prehabilitation, cutting-edge surgical practice including minimally invasive techniques, minimizing deviation from normal postoperative recovery by high-quality ICU care, and postoperative rehabilitation are the cornerstones to ensure better QoL.

Veillonella Intrapulmonary Abscess With Empyema

A lung abscess is characterized as a clinical ailment arising from the localized suppurative necrosis of lung parenchyma. This condition primarily results from the complications of aspiration pneumonia due to anaerobic microorganisms originating from the oral cavity. Clinically, patients typically manifest symptoms such as fever, malaise, and a productive cough persisting over several weeks. The majority of lung abscess cases acquired within the community stem from anaerobic bacterial infections, often exhibiting a polymicrobial nature. We present a 51-year-old female with intrapulmonary abscess and empyema, with isolation of Veillonella species. She has a 25-pack-year smoking history. Two weeks prior to arrival at our facility, she experienced intermittent shortness of breath, fever, and subjective fever. Her primary care physician ordered an outpatient computed tomography (CT) which showed evidence of a large right-sided fluid collection. Initial chest X-ray at our facility revealed extensive opacification of the middle and right lower hemithorax, believed to be a large-sized pleural effusion with adjacent pneumonia or atelectasis. She was given a working diagnosis of right-sided empyema. Cardiothoracic surgery was consulted and video-assisted thoracoscopic surgery (VATS) was performed. A very large collection of grossly purulent material was evacuated and revealed a large intrapulmonary abscess. Over 400 cc of frank pus was collected and sent for microbiological analysis. Anaerobic culture demonstrated 3+ Peptostreptococcus species and 3+ Veillonella species. The genus Veillonella consists of a small, strictly anaerobic, gram-negative cocci that lacks flagella, spores, and capsules. This genus obtains energy from the utilization of short-chain organic acids that are present in the oral cavity and intestinal tract. Oral Veillonella is strongly associated with biofilms, causing human oral infectious diseases such as periodontitis and dental caries. Literature states that this organism has been isolated in a limited number of chronic pneumonitis cases. To date, the most common organism isolated from lung abscesses is Streptococcus in adult patients and Staphylococcus aureus in pediatric patients. We strive to elucidate the distinctive clinical presentation evident in this case, alongside a comprehensive understanding of the unusual pathogens identified in the disease's pathogenesis.

Effectiveness of Thoracic Wall Blocks in Video-Assisted Thoracoscopic Surgery, a Network Meta-Analysis

Introduction

Thoracic epidural analgesia (TEA) and thoracic paravertebral blocks (PVB) are well-established techniques for pain management in thoracotomy. Here, we examine the efficacy of various thoracic fascial plane blocks vs TEA and PVB for intraoperative and postoperative analgesia for video assisted thoracoscopy surgery (VATS) with network meta-analysis.

Methods

A search for prospective randomized control studies using adult patients undergoing VATS with general anesthesia. The interventions of interest were any regional anesthesia techniques used for postoperative pain control after VATS. Primary outcomes of interest were 24-hour opioid requirement and 24-hour pain scores. A Bayesian network meta-analysis was conducted.

Results

We identified 42 studies that fulfilled our inclusion criteria. For patients who underwent VATS, TEA (MD = -27MME, 95% CI = -46.2 to -9MME), ESP (MD = -20MME, 95% CI -33 to -7.9MME), PVB (MD = -15MME, 95% CI = -26 to -4.5MME) demonstrated significant opioid sparing efficacy, as well as reduction in cumulative 24-hour static pain scores. However, exclusion of one study due to high risk of bias revealed that TEA did not significantly reduce opioid consumption, nor did it reduce the incidence of PONV, pulmonary complications, or LOS when compared to ESP, SAP, PVB, ICN, or PECS blocks.

Conclusion

Our findings suggest that TEA did not provide superior pain relief compared to ESP, SAP, PVB, ICN, or PECS blocks following VATS. Therefore, we propose ESP as a suitable intervention for the prevention of postoperative pain after VATS.

-8 cm H2 O, the new paradigm in chest drain management following thoracoscopic lung resection?

Background

Chest drain suction of −20 cm H₂O has been used universally after lung resection. After introducing new guidelines,−8 cm H₂O was used routinely for all non‐pneumonectomy, thoracoscopic lung resections. We conducted a review to determine outcomes and safety.

Methods

After introduction of the guidelines data were collected in the study institutions' thoracic surgical database and subsequently analysed.

Results

A total of 155 patients underwent thoracoscopic lung resection. Mean patient age was 61.5 ± 13.6 years. Video‐assisted thoracoscopic surgery was performed in 92.2% (144/155) of patients and robotically‐assisted thoracoscopic surgery was performed in 7.8% (12/155) of patients. Lobectomy was performed in 56.8% (88/155) of patients, segmentectomy was performed in 11.6% (18/155) of patients and wedge resection was performed in 31.6% (49/155) of patients.

Median ICC duration time was 1 day (IQR 1–3). Median length of stay was 3 days (IQR 2–6). For patients undergoing lobectomy median ICC time was 2 days (IQR 1–4.5) and median length of stay was 3.5 days (IQR 2–7), for segmentectomy median ICC time was 1 day (IQR 1–5) and median length of stay was 2 days (IQR 1–5) and for wedge resection median ICC time was 1 day (IQR 1–1) and median admission time was 2 days (IQR 1–4).

Conclusion

A suction level −8 cm H₂O is safe to use for thoracoscopic lung resections from day 0 post‐operatively. A dedicated, prospective study comparing levels of suction should be performed.

Hybrid Ablation for Atrial Fibrillation: Safety & Efficacy of Unilateral Epicardial Access

Hybrid ablation combines thoracoscopic epicardial ablation with percutaneous catheter based endocardial ablation for the treatment of AF. The purpose of this study was to evaluate the safety and efficacy of hybrid ablation surgery for the treatment of atrial fibrillation (AF), and to compare outcomes of unilateral versus bilateral thoracoscopic epicardial ablation. Patients with documented AF who underwent hybrid ablation were followed post-operatively for major events. Major events were classified into two categories consisting of 1) safety, comprising all-cause mortality and major morbidities, and 2) efficacy, which included recurrence of atrial arrhythmia, cessation of antiarrhythmic drugs (AAD), and completeness of lesion set. A total of 84 consecutive patients were consented for hybrid ablation. Patients presented with an average AF duration of 85.9 months before hybrid ablation. 80 patients underwent successful thoracoscopic epicardial ablation. At one-year, 87% (60/69) of patients were free from AF and 73% (50/69) were free from AF and off AAD. 63 patients completed both epicardial and endocardial hybrid ablation with posterior wall isolation achieved in 89% (56/63) of patients. Unilateral epicardial ablation was associated with significantly shorter hospital length of stay compared to bilateral surgical approached (3.9 vs. 6.7 days, p = 0.002) with no difference in freedom from AF between groups at 1 year. Hybrid ablation for atrial fibrillation is effective for patients at high risk for recurrence after catheter ablation. The unilateral surgical approach may be associated with shorter hospital stay with no appreciable effect on procedure success rates. This study evaluates the safety and efficacy of unilateral epicardial access for hybrid ablation in patients with symptomatic atrial fibrillation refractory to antiarrhythmic treatment. Hybrid ablation for atrial fibrillation is effective for patients at high risk for recurrence after catheter ablation. The unilateral surgical approach may be associated with shorter hospital stay with no appreciable effect on procedure success rates.

Serratus Anterior Plane Block as a Primary Anesthetic Technique for Video-Assisted Thoracic Surgery in a Child

Cystic fibrosis (CF) commonly affects those of European descent; however, it can also be found in those of Asian, African, and Caribbean descent. Patients with CF may have significant lung disease, and their perioperative management can be challenging for the anesthesiologist. In this case report, we describe the use of serratus anterior plane block (SAPB) and IV sedation as an alternative to general anesthesia with an endotracheal tube in a patient with CF pulmonary exacerbation presenting to the operating room for a video-assisted thoracic surgery (VATS).

Should Robotic Surgery Simulation Be Introduced in the Core Surgical Training Curriculum?

Introduction: The focus of this research is to qualitatively analyse the literature and address the knowledge gap between robotic surgery simulation (RoSS) and core surgical training curriculum. It will compare the effectiveness and the benefits of using robotic simulators in training as compared to the current standard training methods.

Materials and Methods: A qualitative research of literature was carried out with the use of critical analysis formatting to expand the search. The inclusion criteria entailed selecting academic resources that focused on Robotic Surgery Simulation (RoSS) and core surgical curriculum. The Online databases used in the search took into account information retrieval from stakeholders.

Evidence Synthesis: In this article, we compiled and scrutinized the available relevant literature comparing performance assessments, surgical skills transfer and assessment tools between robotic surgery simulation (RoSS) and current training platforms in open and minimal access surgery. Data that has been published underpins the authenticity of robotic Surgery Simulation (RoSS), based on a combination of observational evaluation and simulation scores.

Conclusion: The introduction of robotic surgery simulation (RoSS) has the potential to bring major improvements in the surgical training curriculum. RoSS platforms are more robust in terms of ensuring rapid surgical skills transfer/ acquisition, assessment is standardized, unbiased and the training covers non-technical skills aspects.

Unusual case of subxiphoid uniportal VATS right upper lobectomy in a patient with interrupted inferior vena cava with azygous continuation

Interrupted IVC (also known as Azygos continuation of the inferior vena cava) is a relatively uncommon congenital condition with prevalence 1.5% (0.2-3%) of the general population (Bass et al.). Although it's usually asymptomatic condition, splenic or cardiac abnormalities could be associated (Hardwick et al.). Incidental diagnosis during prenatal ultrasound screening or by routine imaging is the most common scenario. Special attention is required during right side thoracic procedures surgical resections in order to avoid scarifying the azygos vein that could lead to fatal results (Effler et al.). We herein report a video documented case of right upper lobectomy and mediastinal lymph node dissection for non-small cell carcinoma of lung in a patient who had interrupted hepatic segmental branch of the IVC. The procedure was performed via the subxiphoid uniportal VATS approach.

Paravertebral mediastinal Mullerian cyst resected by video assisted thoracoscopic surgery

Ever since Hattori et al. had described the mediastinal Mullerian cyst in 2005 there has been several new cases described in the literature. We report a 51-year-old woman with an incidentally found 2 cm × 3 cm mass in her left paravertebral mediastinum. She underwent thoracoscopic removal with the impression of a neurogenic tumor and was unexpectedly found with a ciliated cyst of Mullerian origin.

One lung ventilation strategies for infants and children undergoing video assisted thoracoscopic surgery

The advantages of video assisted thoracoscopic surgery (VATS) in children have led to its increased usage over the years. VATS, however, requires an efficient technique for one lung ventilation. Today, there is an increasing interest in developing the technique for lung isolation to meet the anatomic and physiologic variations in infants and children. This article aims to provide an updated and comprehensive review on one-lung ventilation strategies for infants and children undergoing VATS. Search of terms such as ‘One lung ventilation for infants and children’, ‘Video assisted thoracoscopic surgery for infants and children’, and ‘Physiologic changes during one lung ventilation for infants and children’ were used. The search mechanics and engines for this review included the following: Kandang Kerbau Hospital (KKH) eLibrary, PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. During the search the author focused on significant current and pilot randomized control trials, case reports, review articles, and editorials. Critical decision making on what device to use based on the age, weight, and pathology of the patient; and how to use it for lung isolation are discussed in this article. Furthermore, additional information regarding the advantages, limitations, techniques of insertion and maintenance of each device for one lung ventilation in infants and children were the highlights in this article.

Surgical treatment for recurrent spontaneous pneumothorax during twin pregnancy under video-assisted thoracoscopic surgery (VATS)

Spontaneous pneumothorax during pregnancy is a rare pathological condition. Few cases have been reported previously in the literature. There is no universal guideline for the management of this condition yet. We report a case of recurrent spontaneous pneumothorax during twin pregnancy in a 30-year-old woman. Surgical treatment under video-assisted thoracoscopic surgery (VATS) was successfully performed, without subsequent pneumothorax recurrence.

Self-insertion of needles: An unusual cause of empyema thoracis and its thoracoscopic management

Intrapulmonary aberrant needles are rare in clinical practice. Most common cause till date is the intra-thoracic migration of pins and wires commonly used in treatment of fractures and dislocations of upper extremity. Some cases of traumatic intra-thoracic insertion of needles have also been reported. We report a patient of empyema thoracis due to unusual habit of self-insertion of needles in his body because of some myth. The patient was successfully managed by video-assisted thoracoscopic surgery.

Minimal access surgery in children - 5 years institutional experience

Context:

Minimal access surgery (MAS) in children are common place and performed worldwide with gratifying results as the learning curve of the surgeon attains plateau. We share our experience of this technically evolving modality of surgery, performed at our setup over a period of 5 years. We also review and individually compare the data for commonly performed procedures with other available series. Author also briefly discuss potential advantages of MAS in certain debatable conditions performed quickly and with cosmesis as open procedure.

Materials and methods:

We performed 677 MAS in children aged between 7 days and 12 years. Five hundred and sixty-eight of these were Laparoscopic procedures and 109 were Video assisted thoracoscopic surgeries (VATS). In all laparoscopic procedures, the primary port placement was by the Hasson's open technique. We have used 5, 3 and 2 mm instruments. Our study include 259 inguinal hernia, 161 Appendectomies, 95 VATS for empyema, 51 orchiopexies, 49 diagnostic laparoscopy, 29 cholecystectomies, 22 adhesionlysis and other uncommonly performed procedures.

Results:

The ultimate outcome of all the performed procedures showed gratifying trend, the data of which are discussed in detail in the article. Conclusion: As we gained experience the operating time showed a decreasing trend, the complication rates and conversion rate also reduced. The advantages we came across were better postoperative appearances, less pain and early return to unrestricted activities.

A case of solitary pulmonary lymphangioma

Solitary pulmonary lymphangiomas are rare benign lesions thought to result from the development of abnormally proliferating lymphatic vessels. This report describes a case of solitary pulmonary lymphangioma resected under video assisted thoracoscopic surgery and diagnosed using histological and immunohistochemical investigations.