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Implementing a reform in medical education requires students' awareness regarding the importance of artificial intelligence (AI) in modern medical practice. The objective of this study was to investigate students' perceptions of AI in medical education. A cross-sectional survey was conducted from June 2021 to November 2021 using an online questionnaire to collect data from medical students in the Faculty of Medicine at Kuwait University, Kuwait. The response rate for the survey was 51%, with a sample size of 352. Most students (349 (99.1%)) agreed that AI would play an important role in healthcare. More than half of the students (213 (60.5%)) understood the basic principles of AI, and (329 (93.4%)) students showed comfort with AI terminology. Many students (329 (83.5%)) believed that learning about AI would benefit their careers, and (289 (82.1%)) believed that medical students should receive AI teaching or training. The study revealed that most students had positive perceptions of AI. Undoubtedly, the role of AI in the future of medicine will be significant, and AI-based medical practice is required. There was a strong consensus that AI will not replace doctors but will drastically transform healthcare practices.

Background: Telepathology is the practice of reviewing and exchanging pathological images through telecommunication systems to obtain diagnoses remotely. Studying the factors that make such a system successful and favourable is important to ensure the merits of its implementation in clinical practice., Objective: This study aims to evaluate the success of a telepathology system from the users' perspectives, using specific evaluation criteria, namely: system quality, information quality, technical service quality, user satisfaction, and benefits., Methods: A sequential explanatory mixed methods design was adopted in this study, which consists of two phases. Initially, a questionnaire was distributed via WhatsApp to all of the pathologists (total: 45) working at governmental hospitals in Kuwait. Followed by, semi-structured interviews with ten senior pathologists., Results: Forty pathologists responded to the questionnaire, giving an 89% response rate. There were 42.5% of the respondents aged between 35-44 years old, and 52.5% were male. The quantitative results reveal that most of the respondents were satisfied with the quality of the telepathology system with a mean of 2.6025 (Standard Deviation (SD) = 0.47176), whereas they were dissatisfied with the quality of the information with a mean of 2.4100 (SD = 1.580) and the technical support services with a mean of 2.2750 (SD = 0.99535). In addition, there was disagreement on the benefits of telepathology in clinical practice among the pathologists with a mean of 2.4667 (SD = 0.77552). The qualitative results indicate that the lack of interest in and little experience with using the system were behind the general dissatisfaction of most of the respondents. All of the interviewees were satisfied with the performance of the telepathology system and considered it successful; however, the quality of the technical support services, including training workshops, was deemed deficient., Conclusion: This study concluded that telepathology system in Kuwait is functioning well and has been successful in its implementation; however, pathologists are dissatisfied with it, mainly due to the deficient quality of the technical support services provided. In addition, the successful implementation of such advanced technologies requires careful steps to be taken on multiple levels: technical, organisational, and managerial. Recommendations were suggested., (© 2021. The Author(s).)

Background: With the magnitude and severity of the COVID-19 pandemic, the usual face-to-face consultation within a clinical setting is no longer feasible. Thus, this led to the need for alternate means to provide adequate patient care for surgical patients. This is where the role of smartphones comes into play, in which it is thus of paramount importance. This research study aimed to assess the usefulness of smartphones in surgical practice during COVID-19 pandemic., Methods: This cross-sectional study is based on a questionnaire distributed among surgeons in different levels of practice working at Kuwait governmental hospitals during the COVID-19 pandemic. The questionnaire was developed via Google Docs to collect data for the current study., Results: Out of 600 surgeons, 180 have responded to the questionnaire, giving a response rate of 30%. Of these, 42.8%, 85.5%, and 58.9% were aged between 35 and 44 years, were male, and Kuwaiti nationals, respectively. Almost all of the respondents (99.5%) were using smartphones for hospital-related work. The most common uses of the smartphones involved texting (70%), and viewing or taking images and videos using built-in cameras (60%) either in the emergency department, outpatient clinics, wards, or operating rooms. The majority of the respondents (88%) rated the use of smartphones in practice as important., Conclusion: This study revealed that using smartphones in surgical practice was prevalent among the respondent surgeons in Kuwait during the pandemic. The majority of them considered using smartphones in practice to be important, due to its benefits in facilitating doctor-doctor and patient-doctor communication, reviewing the literature, and making clinical decisions. Guidelines are required for proper and legal use of smartphone devices in medical practice. Accordingly, recommendations are suggested.

Research on leader-member exchange (LMX) has demonstrated that, in addition to the value of LMX as an indicator of quality relationships with leaders, employees also evaluate how their relationship with the leader compares to other employees' relationship with the leader. This finding led to the emergence of LMX social comparison (LMXSC). This study examines how LMX vs. LMXSC relates to work outcomes and considers the employee and perceived supervisor self-concept levels as moderators. We posit that LMX predicts work performance through increased organizational commitment. We further suggest that the relational and collective levels of the self-concept act as contingencies of the relationships among LMX, LMXSC, commitment, and performance. A sample of 250 employee-supervisor dyads was used to test the hypotheses. LMX predicted commitment and, indirectly, performance. The employee and perceived supervisor relational self-concepts acted as moderators of LMXSC, and the perceived supervisor collective self-concept acted as a moderator of LMX and LMXSC. However, not all moderation hypotheses were supported. Unexpected moderating effects involving the employee and perceived supervisor individual self-concepts, as well as main effects, were also uncovered. This study helps differentiate LMX from LMXSC and understand the role of self-conceptions, including self-conceptions attributed by employees to the leader, in leader-member relationships., (© The Author(s) 2019.)

Objective: To compare the Problem-based learning (PBL) with the traditional lecture-based curricula., Methods: The single best answer Multiple Choice Questions (MCQ) and the Objective Structured Clinical Examination (OSCE) were used to compare performance of the lecture-based curriculum with the PBL medical student groups. The reliability for the MCQs and OSCE was calculated with Kuder-Richardson formula and Cronbach's alpha, respectively. The content validity of the MCQs and OSCE were tested by the Independent Subject Experts (ISE). The Student's t-test for independent samples was used to compare the item difficulty of the MCQs and OSCE's, and the Chi-square test was used to compare the grades between the two student groups., Results: The PBL students outperformed the old curriculum students in overall grades, theoretical knowledge base (tested with K2 type MCQs) and OSCE. The number of the PBL students with scores between 80-90% (grade B) was significantly (p=0.035) higher while their number with scores between 60 to 69% (grade C) was significantly p=0.001) lower than the old curriculum students. Similarly, the mean MCQ and the OSCE scores of the new curriculum students were significantly higher (p = 0.001 and p = 0.025, respectively) than the old curriculum students. Lastly, the old curriculum students found the K2-MCQs to be more (p = 0.001) difficult than the single correct answer (K1 type) MCQs while no such difference was found by the new curriculum students., Conclusions: Suitably designed MCQs can be used to tap the higher cognitive knowledge base acquired in the PBL setting.

Aims: Endothelial dysfunction is a key triggering event in the development of cardiovascular diseases and the current study explored this phenomenon in the context of inflammation, apoptosis, reactive oxygen species (ROS) and the phosphatidylinositol 3-kinase (PI3K)/Akt signaling pathway during chronic diabetes., Main Methods: alpha-Lipoic acid (ALA) and wortmannin (WM) were chronically administered to aged Goto Kakizaki (GK) rats, a genetic model of non-obese type II diabetes. Key indices of inflammation, apoptosis and oxidative stress were assessed using western blotting, real-time PCR and immunofluoresence-based techniques., Key Findings: A chronic inflammation (e.g., increased mRNA/protein levels of TNF-alpha, ICAM, fractalkine, CD-68, myeloperoxidase) in connection with increased caspase-based apoptotic cell death and heightened state of oxidative stress (HSOS)- appear to exist in diabetic cardiovascular tissues. An assessment of NF-kappaB dynamics in aged diabetic vessels revealed not only a marked increase in cytosolic phosphorylated levels of IkappaB-alpha, NIK, IKK but also an enhancement in nuclear localization of p65 concomitantly with augmented NF-kappaB-DNA binding activity. Most of the aforementioned cardiovascular-based diabetic abnormalities including reduced activities of PI3K and Akt kinase were ameliorated following chronic ALA therapy. WM, given to GK rats negated the anti-inflammatory and anti-apoptotic actions of ALA., Significance: Our data highlight a unifying mechanism whereby HSOS through an induction of NF-kappaB activity together with an impairment in PI3K/Akt pathway favors pro-inflammatory/pro-apoptotic diabetic vascular milieu that culminate in the onset of endothelial dysfunction, a phenomenon which appears to be amenable to treatment with antioxidants and/or PI3/Akt mimetics (e.g., ALA).

Foreign body (FB) aspiration is commonly seen in children and less commonly in the elderly. However, due to some social and cultural factors, a distinct group of tracheobronchial FB aspiration is increasingly recognized. We sought to assess our experience with such entity. A retrospective review of all cases with veil pin tracheobronchial FB aspiration in a single center over a 13-year period was carried out. There were 35 cases of headscarf tracheobronchial FB aspiration. All were females with mean age of 14 years. All patients experienced coughing and all had positive chest radiography findings. Commonest anatomical location was right main bronchus (32%) followed by left main bronchus (23%). Tracheal pins occurred in 17%. Rigid bronchoscopy was used more often than flexible bronchoscopy (83% vs. 17%, respectively). Repeat bronchoscopy was required in two cases (6%). Thoracotomy was required in one patient (3%). There were no complications or hospital deaths. Headscarf pin aspiration is seen in middle-aged women who inappropriately place the pins between their lips prior to securing their veils. Bronchoscopy is the treatment modality of choice and surgery is rarely required. Preventative educational strategies should be implemented to reduce such an avoidable risk.

Bronchial injuries are rare (1.0%-2.8% of all trauma cases) but potentially fatal, with 80% of patients dying before reaching a medical facility. They occur after penetrating or blunt chest trauma. Bronchial injuries require careful evaluation and meticulous operative repair. Adequate diagnosis is missed initially in up to 68% of cases, particularly in the presence of other organ injuries. An early correct diagnosis and prompt surgical management are mandatory to prevent mortality and morbidity.

Tracheo-innominate fistula (TIF) is a rare complication following percutaneous dilatational tracheostomy (PDT), occurring in < or =1% of cases. It usually develops three days to six weeks after the procedure and is fatal in the majority of cases, even after successful initial repair. We present a successfully treated case of TIF using a Goretex graft to replace the severely destroyed segment of the innominate artery.

Tracheobronchial injuries in children occur rarely. Their diagnosis is often very difficult and needs a high degree of suspicion, with in-depth knowledge of the anatomy of and radiological findings for the chest. With proper surgical management, even a delayed diagnosis can result in normal lung function. We discuss 2 cases of major airway injuries with successful outcomes and present some interesting surgical maneuvers.

This randomised study was designed to compare clinical outcomes for simple aspiration versus tube thoracostomy, in the treatment of the first primary spontaneous pneumothorax (PSP) attack. A randomised trial, comparing simple aspiration with tube thoracostomy, in 137 patients with a first episode of PSP was carried out. Immediate success was obtained in 40 out of the 65 patients (62%) randomly assigned to undergo simple aspiration and in 49 out of the 72 patients (68%) who had been randomly assigned to undergo tube thoracostomy. The 1-week success rates were: 58 (89%) patients in the intention-to-treat simple aspiration group and 63 (88%) patients in the tube thoracostomy group. In the aspiration group, there were more recurrences during the 3-month follow-up period (15 versus 8%), though the difference was not significant. Recurrence rates at 1 and 2 yrs were 16 (22%) and 20 (31%) for patients who had undergone simple aspiration, respectively, and 17 (24%) and 18 (25%) for patients who had undergone tube thoracostomies, respectively. Complications occurred in 5 (7%) patients who had undergone a tube thoracostomy and 1 (2%) patient who had undergone simple aspiration. Analgesia was required in 22 (34%) patients of the simple aspiration group versus 40 (56%) patients of the tube thoracostomy group. These findings suggest that simple aspiration could be an acceptable alternative to tube thoracostomy in the treatment of primary spontaneous pneumothorax.

Objective: To compare the identifiable pulmonary abnormalities during thoracoscopy with the histological findings in patients requiring surgical intervention for recurrent or persistent primary spontaneous pneumothorax (PSP) and correlate these with the postoperative events., Methods: From January 1999 to December 2002, 94 consecutive patients underwent video-assisted thoracoscopic wedge excision and apical pleurectomy for PSP. Vanderschueren's classification was used for macroscopic staging and histological observation for microscopic features. Clinical data of these patients and the outcome of surgery were described., Results: All patients were successfully treated using video-assisted thoracoscopic technique. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 60 cases. The method of management was stapling of an identified bleb or apex of the upper lobe and apical pleurectomy. In 67 cases (71%), clear bullae were found in types III and IV. In 15 cases (16%), type II pleuropulmonary adhesions were identified and in 12 (13%) cases thoracoscopy failed to reveal any abnormality (type I). The actual site of air leakage could be located during thoracoscopy in 24 (26%) patients. Histologically, 74 patients had subpleural bullae/blebs formation and 20 had emphysema without bullae. Fifty-three patients had cellular infiltration and 82 had pleural fibrosis. In the microscopic examination, the actual site of air leakage could be located at the site of subpleural blebs or bullae in 15 patients and elsewhere at the lung surface in five other patients. Postoperative prolonged air leak occurred in 4 out of 12 patients in type I and in two of the remaining patients, p=0.001. Mean follow-up is 48 months (range, 30-60 months) for all patients. Pneumothorax recurred in three patients (3.1%). Two patients from type I (16.6%) and one patient from the other types (1.2%) had recurrence (p=0.01)., Conclusions: Video-assisted thoracoscopic stapling of an identified bleb or apex of the upper lobe and apical pleurectomy represents the standard treatment for the majority of recurrent or persistent PSP. Most patients with surgically treated PSP have subpleural blebs or bullae or isolated emphysema. In type I cases, simple apical excision and apical pleurectomy are not sufficient and perhaps additional talc poudrage might be indicated.

Objective: To assess the incidence and to identify the possible associated risk factors for postoperative pulmonary complications after major lung resection., Subjects and Methods: One hundred and sixty-eight consecutive patients undergoing major lung resection for benign and malignant lung disease over a 3-year period were included in the study. Preoperative assessment clinical parameters, intraoperative and postoperative events were recorded. Pulmonary complications were noted according to a precise definition. The risk of complications associated with age, comorbidity, forced vital capacity (FVC), blood transfusion and extended operation was evaluated using logistic regression analysis., Results: The mean age of the patients was 47.1 years (range 16-80 years), 137 (77%) patients underwent lobectomy, 23 (14%) pneumonectomy, and 15 (9%) bilobectomy. Forty-six (27%) patients developed postoperative pulmonary complications and 2 (1.1%) died within 30 days following the operation. Age > or =65 years (OR 3.7, 95% CI: 1.5-8.6, p = 0.002), the presence of comorbid cardiopulmonary disease (OR 0.2, 95% CI: 0.1-0.5, p = 0.001), FVC <50% (OR 0.2, 95% CI: 0.1-0.8, p = 0.02), blood transfusion (OR 0.2, 95% CI: 0.1-0.4, p = 0.0001), and extended operation (OR 0.2, 95% CI: 0.07-0.6, p = 0.005) were the identified factors associated with the development of postoperative pulmonary complications, which necessitated an increased length of hospital stay., Conclusion: Postoperative pulmonary complications are more likely to develop in patients with age > or =65 years with comorbid cardiopulmonary disease, FVC <50%, blood transfusion, and extended operation., ((c) 2006 S. Karger AG, Basel)

Objectives: To determine the risk factors of spontaneous pneumothorax (SP) in Kuwait., Subjects and Methods: From January 2002 through December 2003, 254 consecutive cases with a diagnosis of SP were reviewed. Analyses of pneumothorax rates by age, sex, smoking, body mass index (BMI) and climatic conditions were evaluated., Results: Of the 254 patients, 242 (95%) were male and 12 (5%) were female; a larger proportion of 180 (88%) were Kuwaitis and 74 (12%) were expatriates. Two hundred and eight (82%) episodes were regarded as primary SP and 46 (18%) as secondary SP. The mean age was 24.5 +/- 5.8 years for primary SP and 45.7 +/- 14.5 years for secondary SP. One hundred and ninety-six (77%) individuals were current smokers. BMI in primary and secondary SP was 19.3 and 22.4, respectively (p < 0.001). There was no relationship between SP and climatic conditions (a rise or fall in temperature, humidity or atmospheric pressure). However, a slight increase in SP occurred in July, probably the hottest month in Kuwait., Conclusions: The data indicate that the most important risk factors of SP in Kuwait are smoking, low BMI and the male gender.

Objective: To report a case of right pulmonary arteriovenous malformation (PAVM) affecting the right upper lobe, following the incidence of empyema thoracis in the contralateral lung., Clinical Presentation and Intervention: A 19-year-old, previously healthy male presented with acute respiratory distress, left pleuritic chest pain, fever and hypoxemia. Clinical findings, laboratory and radiological examinations including pulmonary angiogram were consistent with the diagnosis of left pneumonia complicated with parapneumonic pleural effusion and right upper lobe PAVM. The patient was intubated and ventilated because of persistent hypoxemia. He was successfully treated by percutaneous transcatheter embolization., Conclusion: This case shows that percutaneous transcatheter embolization is a safe and effective first option for the treatment of PAVM., (Copyright 2005 S. Karger AG, Basel.)

Lung resection is uncommon in children because of its limited indications. We reviewed and analyzed the records of 31 children who underwent pulmonary resection between 1994 and 2001. The mean age was 7 years (range 1.6-12 years), and genders were equal. Bronchiectasis, lung abscess, necrotizing pneumonia, and destroyed lung were seen in 14, 12, 3, and 2 patients, respectively. Bronchial stenosis and inflammation of the bronchus was found endoscopically in four patients, and a foreign body in one patient. The indications for surgery in chronic sepsis were: recurrent respiratory tract infections, severe bronchiectasis, recurrent hemoptysis, destroyed lung parenchyma, and lung abscess, while the indications for surgery in acute infections were: failed medical treatment, or empyema. A lobectomy was done on 15 patients, lobectomy and lingulectomy on 4, lobectomy and decortications on 10, and pneumonectomy on 2 with no operative deaths. Intra-operative and post-operative complications were seen in 2 and 4 patients, respectively. Mean follow-up was 3.9 years (range 1.5-5 years). Twenty-eight patients were asymptomatic and three had improved. Respiratory function remained unchanged in 14 children. Mediastinal shift and lung overinflation occurred after pneumonectomy. These results show that lung resection can be done safely in pulmonary infection refractory to conservative medical therapy. Pulmonary resection does not alter respiratory function since the resected segments do not contribute to ventilation.

Unlabelled: The purpose of this study was to review our experience with intrathoracic major bronchial disruptions due to trauma and to describe the diagnosis and treatment., Methods: A retrospective review was performed of major bronchial injuries managed in Kuwait (1995-2001), n=12. Clinical presentation, diagnostic evaluation, surgical management, and outcome were reviewed., Results: The mechanism of injury involved blunt trauma in seven patients and penetrating trauma in five. Tachypnea and subcutaneous emphysema (occurring in 10, 9 of the patients, respectively) are common. Nine patients had pneumothorax and air leak after tube thoracostomy. The diagnosis was confirmed by bronchoscopy in all patients. The majority of the injuries were repaired primarily. Lung resection was necessary in two patients. Four patients sustained complications including death (two patients), atelectasis (one patient), and pneumonia (one patient). Follow-up bronchoscopy revealed no evidence of granulation tissue or stenosis at the site of repair., Conclusion: The diagnosis of intrathoracic major bronchial disruptions required a high index of suspicion and liberal use of bronchoscopy. The majority were repaired primarily with good outcome.

Objective: To review our experience of indications, technique, and complications as they relate to video-assisted thoracoscopic surgery (VATS) in the diagnosis and management of intrathoracic diseases., Subjects and Methods: One hundred and fifty consecutive VATS procedures, which were performed over a 3-year period, were retrospectively evaluated. Indications included recurrent or persistent primary spontaneous pneumothorax (n = 73 patients), lung biopsies for diagnosis of diffuse lung disease (n = 33), pleural biopsies (n = 18), wedge resections of pulmonary nodules (n = 8), bilateral thoracic sympathectomy (n = 6), decortication (n = 5), mediastinal tumor biopsies (n = 5), excision of bullous emphysema (n = 1), and removal of a foreign body from the pleural cavity (n = 1). An alternative method of manipulating thoracoscopic instruments without using a trocar is described., Results: Of the 150 VATS procedures, 127 (85%) were successfully performed, 6 (4%) were converted to thoracotomy and 17 (11%) had complications. The most common complication was prolonged air leak, which occurred in 9 patients. The average postoperative hospital stay was 4 days (range: 2-17). Diagnostic procedures were considered successful in 32 out of 33 lung biopsies and in all 18 patients with pleural diseases, 8 lung nodules, or 5 mediastinal tumor biopsies. The other 86 therapeutic VATS procedures were effective in 82 (95%) patients. Four (5%) patients had a recurrence of the pneumothorax after VATS., Conclusion: Thoracoscopy and the use of a nontrocar technique is a safe and effective method for the diagnosis and treatment of intrathoracic diseases., (Copyright 2004 S. Karger AG, Basel)

Study Objective: To review our experience with specific characteristics, indications, and results of pulmonary resection in children with middle lobe/lingula syndrome., Design: Retrospective cohort study., Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait., Patients and Intervention: Thirteen children with middle lobe, lingula, or both syndromes were treated with pulmonary resection from January 1995 to December 1999., Results: The mean age was 7.5 years (range, 5 to 10 years). Eight patients were girls, and five were boys. All patients underwent high-resolution CT and bronchoscopy. Bronchiectasis and atelectasis of right middle lobe, lingula, or both was noted in nine patients. Bronchial stenosis and inflammation of the bronchus was found endoscopically in four patients. The indications for surgery were recurrent respiratory tract infection with persistent atelectasis and bronchiectasis in nine patients, and recurrent respiratory tract infection with bronchiectasis in four patients. A right middle lobectomy was done on seven patients and a lingulectomy on four patients. Two patients underwent staged thoracotomies (right middle lobectomy and lingulectomy). There were no operative deaths. Only two patients had postoperative complications: atelectasis (n = 1), and pneumothorax (n = 1). Mean follow-up was 3.5 years (range, 3 to 5 years) for all patients. Nine patients were asymptomatic, and four patients had improved., Conclusion: Right middle lobe or lingula syndrome with the presence of bronchiectasis, bronchial stenosis, or failure of lung to re-expand are indications for early pulmonary resection.

A total of 235 children, aged between 7 months and 15 years had bronchoscopy on suspicion of foreign body aspiration. The histories of these patients were studied to examine the diagnostic value of symptoms, signs, and chest x-rays, and rate of negative bronchoscopy. The sensitivity of choking and coughing was high (82% and 80%), but the specificity was poor (37% and 34%). The sensitivity of a chest radiograph was 66%, the specificity was 51%. The sensitivity of asymmetric auscultation was 80% and specificity was 72%. The sensitivity and specificity of combination of symptoms, signs and abnormal chest radiograph was 61% and 83%, respectively. In 206 (87.7%) children a foreign body was identified and extracted. The remaining 29 patients (12.3%) had negative bronchoscopy. A wide variety of objects was recovered, the most common being seeds and peanuts. Foreign bodies were in the right and left main bronchus in 72 (35%), 50 (24.3%) cases, respectively, while in the remaining 84 cases, the foreign bodies were in other parts of the respiratory tree. In 204 (99%) patients with foreign body aspiration, the foreign bodies were removed successfully using a rigid bronchoscopy. Minor complications like subglottic edema and bronchospasm occurred in 4 children. In conclusion, rigid bronchoscopy is a safe procedure and the only tool that will give certainty about the correct diagnosis of foreign body aspiration in children. Asymmetric auscultation is more specific than history and chest radiograph. The combination of history, clinical signs and radiological signs are more specific than each one separately.

Study Objectives: To review our experience with indications, timing, and results of pulmonary resection in infants., Design: Retrospective cohort study., Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait., Patients and Intervention: Forty-seven infants with congenital lung diseases were treated with pulmonary resection from January 1993 to December 2000., Results: The mean age at the time of diagnosis was 90 days (range, 7 days to 11 months). Thirty-four patients were male (72%). Congenital lobar emphysema, congenital cystic adenomatoid malformation, pulmonary sequestration, and atelectasis were seen in 26, 10, 6, and 5 patients, respectively. The indications for surgery were respiratory distress in 32 patients (68%), respiratory tract infections in 12 patients (26%), and the presence of asymptomatic chest radiographic findings in 3 patients (6%). A lobectomy was performed in 42 patients (89%), bilobectomy in 2 patients (4%), left pneumonectomy in 1 patient (2%), and excision of a mass in 2 patients with extralobar sequestration (4%). An emergency lobectomy was performed in seven patients (15%). Only one postoperative death occurred following a left pneumonectomy for extensive congenital adenomatoid malformation due to pulmonary hypertension. Four patients (9%) had postoperative complications: atelectasis (n = 2), prolonged air leak (n = 1), and pneumothorax (n = 1). Mean follow-up was 4 years (range, 1 to 5 years) for all patients. None of the patients had any physical limitations., Conclusion: Pulmonary resection is indicated for the majority of patients with congenital lung malformations. In case of severe respiratory distress, an emergency lobectomy can be performed safely.

Background: The objectives of the study were to review our experience of video-assisted thoracoscopic apical pleurectomy and to evaluate whether suction or water seal is superior in the postoperative treatment of primary spontaneous pneumothorax., Methods: One hundred consecutive patients undergoing thoracoscopy for primary spontaneous pneumothorax from January 1995 to December 1999 were prospectively randomly assigned after surgery to receive suction or water seal to their chest tubes after a brief period of suction., Results: There were 50 patients in each group. The two groups were evenly matched for age and operation performed. The method of management was stapling of an identified bleb or apex of the upper lobe and apical pleurectomy. Postoperative prolonged air leak longer than 5 days occurred in 8 patients (8%), 7 in the suction group and 1 in the water seal group (p = 0.03). The mean duration of chest tube days was lower in the water seal group (2.7 days) than in the suction group (3.8 days; p = 0.004). The mean hospital stay in the water seal group was 3.7 days and in the suction group it was 4.8 days (p = 0.004). Mean follow-up was 48 months (range, 30 to 60) for all patients. Pneumothorax recurred in 2 patients (2%). The recurrences occurred in the first year., Conclusions: Video-assisted thoracoscopic apical pleurectomy is effective and safe for treating primary spontaneous pneumothorax. Placing chest tubes on water seal after a brief period of suction shortens the duration of chest tube placement and hence the hospital stay.

Objective: To report our experience of surgical procedures in the management of hydatid cysts of the lung and to assess the effect of postoperative chemotherapy., Subjects and Methods: In a longitudinal cohort study, 64 consecutive patients who presented with hydatid cysts of the lung from 1994 to 1998 were included. The main measures were: characteristics on presentation, operative techniques, postoperative morbidity, and the outcome of treatment. The mean age was 28 years (range 4-65 years). The most common symptoms were cough, chest pain, fever, and hemoptysis. Chest radiographs and computed tomograms were the main method of diagnosis. Pulmonary cystotomy and capitonnage were performed in 46 patients. Pulmonary resection was needed in 8 of 64 patients. Simultaneous combined resection of hydatid cysts through thoracotomy with transdiaphragmatic removal of liver cysts was performed in one stage in 13 patients., Results: Chest radiographs and CT scans showed a smoothly outlined spherical opacity in 45 patients. Other radiographic findings included ill-defined shadow (in 8 patients), pleural effusion (7 patients), air fluid level (3 patients), and hydropneumothorax in a single patient. There were 8 (12.5%) cases of immediate postoperative complications. These occurred mostly in patients who had cysts larger than 10 cm (p = 0.003). Thirty-four patients were treated by a 3-month course of albendazole chemotherapy. Four patients (6%) had recurrences of the disease during the follow-up period. These recurrences occurred in patients with large cysts >10 cm (p = 0.001)., Conclusion: Conservative surgical methods are the preferred surgical techniques. Postoperative chemotherapy with albendazole for 3 months is recommended., (Copyright 2003 S. Karger AG, Basel)

Aim: Video-assisted thoracoscopic lung biopsy is commonly performed for diagnosis of diffuse interstitial lung disease. This study reports our experience with this technique in terms of diagnostic accuracy, complications and appropriate site for biopsy., Methods: A prospective non-randomized study., Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait., Patients and Intervention: 79 consecutive patients undergoing thoracoscopic lung biopsy for diffuse interstitial lung disease from January 1995 to December 2001. Patients were divided into 2 groups; 34 patients with single biopsy from lingula or right middle lobe (RML) and 45 with 2 biopsies from other sites., Measures: comparison of operative and postoperative data, diagnostic accuracy, and complications between the two groups., Results: The mean age of the patients was 38.9 years (range 15-75 years). There was no difference in the groups in operative time, 24 hours postoperative pleural drainage, chest tube drainage days, and hospital stay. Histologic diagnosis was achieved in 76/79 patients (96%). The diagnostic yield of each group was comparable (32/34 from lingula/RML; 44/45 other sites), (p=0.3). Postoperative complications occurred in 4/34 of patients with single biopsy from lingula or RML and 4/45 patients with 2 biopsies from other sites (p=0.6). There was 1 death in this series., Conclusions: Video-assisted thoracoscopic lung biopsy is an effective procedure. Single lung biopsy from lingula or RML compared to other anatomic sites has an equivalent diagnostic yield.

Objective: To review our experience with bilateral video-assisted thoracoscopic surgery (VATS) for the treatment of bilateral spontaneous pneumothorax (SP)., Design: Retrospective study followed by a telephone interview for follow-up., Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait., Patients and Interventions: Fifteen patients undergoing bilateral VATS for bilateral SP from 1994 to 1999., Results: The mean age of the patients was 22.9 years (range, 17 to 34 years), and 14 were men. All patients were successfully treated using the bilateral video-assisted technique. Operative indications included simultaneous bilateral pneumothorax (n = 7) and contralateral recurrence of SP (n = 8). Twelve patients had primary SP. In the three remaining patients, simultaneous bilateral SP was secondary to sarcoidosis in two patients and histiocytosis X in one patient. Eleven patients had multiple blebs or bullae located in the upper lobes, and 4 patients had no blebs. All blebs or bullae were resected. All patients had gauze pleurodesis. The mean +/- SD operative time was 133.6 +/- 9.1 min. There were no perioperative complications and no deaths attributable to the procedure. Postoperative prolonged air leak occurred in three patients (20%). The mean drainage time was 3 days (range, 2 to 8 days). The mean postoperative hospital stay was 5 +/- 1.7 days. Mean follow-up was 3.3 years (range, 2 to 5 years) for all patients. Pneumothorax recurred in one patient with histiocytosis X after 1 month and required a reoperation on the right side., Conclusions: Bilateral VATS is a safe procedure in the treatment of simultaneous and nonsimultaneous bilateral SP. This avoids the need for subsequent operations.

Nineteen hundred and fifty open heart operations were performed between January 1995 and December 2000 at the cardiac surgery department of Chest Disease Hospital in Kuwait. Sternal closure was delayed in 40 patients (2%), because of hemodynamic instability limiting primary closure in 23 patients and uncontrollable bleeding in 17 patients. Four patients died in the immediate postoperative period while the chest was open, due to persistent low cardiac output secondary to myocardial failure. The sternum was closed in 36 patients on an average of 22 +/- 0.3 hours (range, 8 to 48 hours) postoperatively. Two patients died in the late postoperative period prior to hospital discharge after sternal closure. Wound infections occurred in 8 patients. The 34 survivors (85%) were discharged and followed up for a mean of 13.2 months. This study demonstrates that delayed sternal closure is an effective and life saving decision with unstable hemodynamics and uncontrollable hemorrhage.

Objectives: Echinococcosis remains an endemic surgical problem in countries where sheep and cattle raising is carried out, particularly in many Mediterranean countries. This study aims to evaluate the management of different presentations of pulmonary hydatidosis and their outcome over 15 years., Design: Retrospective study., Setting: Thoracic surgical department, Chest Diseases Hospital, Kuwait., Patients: Sixty patients operated upon for hydatid disease were evaluated pre- and post- operatively; 35 males, 25 females with a mean age of 28.4 years. Most patients were investigated by laboratory, serological and radiological studies. Different surgical techniques were used to remove the hydatid cyst from the lung., Results: The most common presenting symptoms were cough (41 patients), and 12 patients were asymptomatic. Chest X-ray showed a rounded shadow in 42 patients; 19 cases were of vigorous size >10 cm. Thoracotomy was done in 57 patients; two chest wall cases were managed by minimal skin incision and enucleation, one hydatid cyst of the heart was approached through a median sternotomy. The mean hospital stay was 9 days. Postoperative complications occurred in 9 patients; prolonged air leak in 4 patients, pleural effusion in 3, pneumothorax, and wound infection in one patient each. One patient (65 years old) died on the 6th post-operative day most probably from pulmonary embolism. In a follow-up period of 2-15 years, 4 recurrences have been noted., Conclusion: Surgical excision of pulmonary hydatidosis with maximum preservation of the lung parenchyma is the main stay of treatment.

Background: Gastro-oesophageal reflux (GERD) is a common condition. Many patients respond to conservative therapy. Severe symptomatic cases and those who fail medical treatment are referred to surgery. The long-term results of open fundoplication surgery have been good with a more than 90% response after 10 years of follow-up. The introduction of laparoscopic fundoplication achieved the same results with shorter hospital stay, a better cosmetic result and less cost to the health care providers., Patients and Methods: 74 patients who failed medical treatment for GERD were treated by laparoscopic fundoplication. The Toupet procedure was performed in 66 of these patients, the others patients had a Nissen-type fundoplication. The patients were followed up for a mean period (+/- SD) of 14.8 +/- 8.8 months (range 3-33 months)., Results: Most of the patients were males (n = 65). The mean age (+/- SD) of all the patients was 36.1 +/- 9.5 years (range 17-60 years). The majority (93.8%) reported disappearance of symptoms and are not using any antireflux medications. Five patients (6.7%) are considered failures of the procedures. Of these, three patients developed recurrence of reflux symptoms during the follow-up period. The other two patients developed complications, i.e. gas bloat, persistent vomiting and dysphagia which warranted taking down the wraps laparoscopically. Two patients developed a small incisional hernia at the site of the 10 mm port. The mean of hospital stay (+/- SD) was 3.1 +/- 1.3 days (range 1-7 days)., Conclusion: Laparoscopic fundoplication is safe and effectively relieves reflux symptoms in patients who fail medical treatment.

Objective: To evaluate the diagnostic yield of bronchoscopy and mediastinoscopy in adults with isolated mediastinal tuberculous lymphadenitis and to assess the effect of antituberculous treatment., Design: Prospective longitudinal cohort study of 34 patients with mediastinal tuberculous lymphadenitis followed for 6 to 19 months after completion of treatment., Setting: Tertiary care hospital, Kuwait., Patients: 34 consecutive patients who presented with isolated mediastinal lymphadenopathy from 1996 to 1998., Interventions: Bronchoscopy and cervical mediastinoscopy for all patients., Main Outcome Measures: Diagnostic yield of bronchoscopy and mediastinoscopy, and the outcome of treatment in patients with tuberculous lymphadenopathy., Results: The mean age was 35 years (range 15-58). The most common symptoms were cough, fever, and weight loss. The chest radiographs and computed tomograms showed abnormal mediastinal shadows with no evidence of parenchymal disease. All patients had right sided paratracheal lymphadenopathy. Tuberculin skin test gave a weal of >15 mm in 17 patients (50%). Sputum smears and cultures failed to grow acid-fast bacilli in any patient. Seven patients had an endobronchial abnormality and samples taken at bronchoscopy gave a definite diagnosis in 3 (9%). Paratracheal lymph node biopsy and culture by mediastinoscopy diagnosed tuberculosis in all cases. All patients were treated by a six month course of rifampicin and isoniazid supplemented initially by pyrazinamide for two months. Twenty-eight patients had a good response and the remaining patients were treated for a further 3 months., Conclusions: Bronchoscopy has a low diagnostic yield in mediastinal tuberculous lymphadenopathy in the absence of a parenchymal lesion. Mediastinoscopy is a safe but invasive procedure and provides a tissue diagnosis in most cases. Six months treatment with rifampicin and isoniazid supplemented initially by pyrazinamide is adequate treatment for most adults with tuberculous mediastinal lymphadenopathy.

Objective: To describe our surgical technique for, and results of, reinforced primary repair in benign distal oesophageal perforation in early cases., Design: Retrospective study., Setting: Tertiary care hospital, Kuwait., Patients: 15 patients with iatrogenic or traumatic benign distal oesophageal perforation., Intervention: Primary repair with reinforcement using pleura, pericardial flap, or gastric fundus. Of the 3 patients with achalasia, 2 had oesophagomyotomy alone and 1 had oesophagomyotomy with fundoplication. Associated distal obstruction caused by reflux stricture was treated by dilatation and fundoplication in 1 patient., Main Outcome Measures: The causes of perforation, presence of underlying oesophageal disease, time to operation, postoperative leakage, mortality, and follow-up., Results: Perforation was caused by instrumentation in 10 patients, trauma in 3, and ingested foreign bodies in 2. 6 patients had pre-existing oesophageal diseases: achalasia in 3, hiatus hernia in 2, and reflux stricture in 1. 10 patients presented within 12 hours, and 5 patients more than 12 hours after the perforation. 4 postoperative leaks developed. One patient perforated a stress gastric ulcer and then developed pneumonia and died of multiple organ failure. At follow-up, all 14 surviving patients were able to eat a normal diet. 2 patients who had gastric fundus used as a reinforcement tissue developed mild gastro-oesophageal reflux and oesophagitis. Both responded to medical treatment., Conclusion: Primary repair and tissue reinforcement of benign distal oesophageal perforation is safe in early cases and obviates the need for a second operation.

Objective: To review our experience of video-assisted thoracoscopic surgery for the treatment of primary spontaneous pneumothorax., Design: Longitudinal cohort study following up consecutive patients for 3 to 4.3 years., Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait., Patients and Intervention: Seventy-two consecutive patients undergoing thoracoscopy for primary spontaneous pneumothorax from January 1994 to June 1996., Results: The mean age of the patients was 25 years (range, 15 to 40 years), and 67 were men (93%). All patients were successfully treated using video-assisted thoracoscopic technique. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 49 patients. The most common method of management was stapling of an identified bleb, which was done in 56 cases. Pleurodesis was achieved by gauze abrasion (n = 39) and apical pleurectomy (n = 33). Postoperative prolonged air leak occurred in five patients (6.9%). There were no deaths attributable to the procedure. The mean (+/-SD) postoperative hospital stay was 4 +/- 2 days. Mean follow-up is 42 months (range, 36 to 54 months) for all patients. Pneumothorax recurred in four patients (5.5%) in whom pleural abrasion was done. The recurrences occurred in the first year of follow-up, three required a reoperation, and one healed by rest without pleural drainage., Conclusions: Video-assisted thoracoscopic surgery is a safe procedure in the treatment of primary spontaneous pneumothorax. Apical pleurectomy is a more effective way of producing pleural symphysis. Long-term follow-up did not increase the rate of recurrence.

Background: Some patients with diffuse lung disease require a lung biopsy for diagnosis. This study is aimed to compare the clinical results and the efficacy of video-assisted thoracoscopic lung biopsy with the open lung biopsy method for the diagnosis of interstitial lung disease. From January 1996 to December 1998, 61 patients were referred for diagnostic lung biopsy. Thirty two patients were randomly allocated to have a thoracoscopic lung biopsy and twenty nine had an open lung biopsy. Subsequently, various factors were analyzed and compared in both groups., Results: There was no difference between the groups in age and pulmonary function test. Median operative time was 45 minutes for the thoracoscopic biopsies and 60 minutes for the open biopsies (P = 0.009). Median amount of analgesia (Demerol) in the first 24 hours postoperatively was 75 mg. for thoracoscopic biopsies and 150 mg. for open biopsies (P < 0.001). Median duration of insertion of a chest tube in days and 24 hours of pleural drainage was not statistically significant between the two groups. Duration of hospital stay was significantly less for the thoracoscopic biopsy (3 days) compared with an open biopsy (5 days) (P < 0.001). The diagnostic yield of each method was comparable (thoracoscopic biopsy 31/32; open biopsy 27/29) (P = 0.3). Complications occurred in 6/29 of patients undergoing open biopsies and 3/32 patients undergoing thoracoscopic lung biopsies (p = 0.28). There were 2 deaths among patients who had an open lung biopsy., Conclusion: Thoracoscopic lung biopsy has some clinical advantages over open biopsy. These findings suggest that thoracoscopic lung biopsy is an acceptable alternative to open lung biopsy for the diagnosis of diffuse interstitial lung diseases.