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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.

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.

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.

Introduction: Hydatid cyst (HC) of lung is a frequently encountered entity in Pakistan. The clinical and radiological manifestations of HC in lung depend on the integrity of the cyst. Patients may remain asymptomatic for years in cases of simple HC or may present with a wide variety of complications when it ruptures. The aim of this study was to compare management outcomes in simple and complex HCs. Methods: This prospective, observational study was conducted from February 2019 until May 2020. Patients were divided into two groups: simple HC (Group A) and complex HC (Group B). Preoperative complications, surgical procedures, postoperative complications, duration of hospital stay, duration of chest tube placement and need for readmission were noted and compared between the two groups. All data was processed through the Statistical Package for the Social Sciences (SPSS) Statistics version 22 (IBM Corp., Armonk, NY). Results: Sixty-two patients were included out of which Group A had 28 (45.2%) patients and Group B had 34 (54.8%) patients. There were 39 (62.9%) males and 23 (37.1%) females. The mean age was 31.11 ± 11.02 years. Preoperative complications in Group B included empyema seen in 10 (28.5%) patients, rupture of cyst into bronchus in 8 (23.5%), biliopleural fistula in 4 (11.7%), hydropneumothorax in 2 (5.8%), bronchopleural fistula in 1 (2.9%), airway compromise in 1 (2.9%) and pneumonia in 1 (2.9%) patient. Group B required longer days of chest tube placement, longer intensive care unit stay and longer hospital stay (p

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

Introduction: Thoracic traumas are one of the most commonly encountered injuries in the emergency room. They range from blunt chest injuries due to road traffic accidents to penetrating chest injuries. Immediate medical and surgical interventions are essential to improve the outcome. This study was conducted to assess the pattern of thoracic trauma presenting to the emergency room, their outcome and factors contributing to it. Methods: This prospective, observational, cross-sectional study was conducted in the Department of Thoracic Surgery, Jinnah Post Graduate Medical Center, Karachi from January 1 until July 31, 2020, with institutional ethical approval. Patients age ≥12 years presenting with traumatic thoracic injury with or without associated injuries were included. Characteristics of their injuries and management outcome were studied. All data was processed through Statistical Package for Social Sciences (SPSS) Statistics version 22 (IBM Corp., Armonk, NY, USA). Results: A total of 199 patients were included; 154 (77.4%) patients were male and 45 (22.6%) patients were female. The most common age group presenting with trauma was the middle age (30-60 years), which included 101 (50.8%) patients. Out of the total, 126 (63.3%) had blunt chest injuries and 73 (36.6%) had penetrating chest injuries. Road traffic accidents were the most common cause of blunt chest injuries seen in 83 (65.8%) patients, whereas gunshot was the most common mode of penetrating chest injuries encountered in 41 (56.2%) cases. Tube thoracostomies were performed in 166 (83.4%) patients and thoracotomies in seven (3.51%) patients. Out of the total, 57 (28.6%) patients required mechanical ventilation and it was associated with blunt trauma, hemothorax, rib fracture, abdominal and head injuries (p ≤0.05). Mortality was seen in 22 (11.1%), which was associated with hemothorax, head injuries, mechanical ventilation and severe blood loss (p ≤0.05). Conclusion: Traumatic thoracic injuries are a preventable cause of mortality. Blunt chest injuries are more common than penetrating chest injuries. Proper implementation of public safety measures ensures less frequent and severe outcomes. Emergency department team and specialized thoracic surgeons must come together to manage these critical patients with utmost care.

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.

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.

Leiomyoma are rare esophageal masses. Majority remain asymptomatic but may present with dysphagia when more than five centimeters in size. Barium swallow is the initial diagnostic investigation. Small lesion can be observed. Symptomatic and large lesion should undergo prompt surgical enucleation. Here we presented a case of a 35 year old female presenting with progressive dysphagia and gradual weight loss for 5 years along with regurgitation for one year. Clinical examination was unremarkable. Barium study was suggestive of smooth intramural defect with normal mucosa. Computed tomography showed well defined homogenous opacity located intramuraly at the level of junction of middle and distal third of esophagus with normal surrounding structures. Surgical enucleation was done through a right posterolateral thoracotomy. Muscle defect was repaired and checked for possible leaks. Liquid diet was commenced on 5th postoperative day. Patient was discharged on semisolid diet for two weeks with progression to solid meal.

Intrapulmonary teratoma (IPT) is a rare type of extra gonadal germ cell tumor which can often be misdiagnosed due to its non-specific presentation. Complete surgical resection should be done because of its malignant potential. We report a case of 33 years old female previously treated as tuberculous osteomyelitis of sternum. She presented with chest pain and sudden hemoptysis. Based on the radiological picture she was diagnosed as complex aspergilloma of lung with a thick walled cavity. Hemoptysis was controlled with supportive management. On surgery right upper lobe was densely adherent to the anterior chest wall. Exploration of the cavity revealed a 6×4 cm whitish mass with non-pigmented hair. Right upper lobectomy and wide excision of the mass was performed. Histopathology was consistent with the diagnosis of IPT with no malignant cells.

Intratracheal neurofibromas are rare benign tumors with a tendency to transform into malignant form. Intratracheal neurofibroma remain asymptomatic and are incidentally found during routine radiography or may present with wheeze, cough and lower respiratory tract infection. We recently operated a 38 year old gentleman, who presented with progressive shortness of breath and chronic cough for two years. Examination was normal. CT identified a supracarinal, intratracheal mass. Rigid bronchoscopy revealed a hyper vascular mass, attached to membranous trachea. We performed resection anastomosis via right posterolateral thoracotomy. Histopathology revealed neurofibroma. Patient recovered well and was discharged after eight days.