Waseem Hajjar

Current Surgical Therapy for Bronchiectasis

Abstract. The ideal classification system for bronchiectasis continues to be debated. As an alternative to the present morphologic classification, a hemodynamic-based functional classification is proposed. This study examines the rationale for and outcome of surgery based on this classification in patients with unilateral or bilateral bronchiectasis. Between July 1987 and January 1997 the morphologic and hemodynamic features in 85 bronchiectatic patients were examined: 18 with bilateral bronchiectasis and 67 with unilateral disease. A policy of unilateral lung resection of the nonperfused bronchiectasis and preservation of the perfused type was adopted in all patients. The mean age at operation was 29.4 ± 9.7 years (range 6–55 years) with a mean follow-up period of 45.2 ± 21.0 months (range 2–120 months). Left-sided predominance of bronchiectasis was evident in this series both in frequency and severity. In those with unilateral disease, bronchiectasis was left-sided in 49 (73.1%) patients and right-sided in 18 (26.9%). The left lung was totally bronchiectatic in 11 (16.4%) patients and the right in 3 (4.4%). Moreover, among the patients with bilateral bronchiectasis, 14 of 18 (77.7%) patients had the left lung more severely involved. Based on the morphologic and hemodynamic features in the investigated patients, two types of bronchiectasis were recognized: a perfused type with intact pulmonary artery flow and a nonperfused type with absent pulmonary artery flow. Lobectomy was performed in 55 patients, basal segmentectomy and preservation of the apical segment in 16, and pneumonectomy in 14. There was no mortality in this series. Altogether 63 patients (74.1%) achieved excellent results, 19 (22.4%) scored good results, and 3 (3.5%) patients had not benefited from surgery at last follow-up. In the face of the general criticism of the traditional morphologic classification, the proposed classification not only predicts whether the involved lung will have a measure of respiratory function with regard to gas exchange but reflects the degree of severity of the disease process. Thus the question of which side to resect and which to preserve is defined more precisely. This classification was found to be logical, physiologically sound, and of proven benefit.

Unusual presentation of rib exostosis

We report two cases of unusual presentation of rib exostosis. The first patient presented acutely with hemorrhagic shock due to massive hemothorax, and the second patient presented with repetitive chest infection complicated by empyema. In both patients, preoperative computed tomographic (CT) scan of the chest revealed rib exostoses, necessitating thoracotomy and rib resection.

Surgery for pulmonary aspergilloma in post-tuberculous vs. immuno-compromised patients

OBJECTIVE To compare the outcome of surgical resection for aspergilloma between patients with post-tuberculous complex and neutropenia. METHODS We retrospectively reviewed our surgical experience with pulmonary resection for aspergilloma in 30 patients. Of the 20 patients with complex aspergilloma complicating healed tuberculosis (group 1), 14 were male and six were female with an average age of 54 years (SD 7). The indication for surgery was recurrent haemoptysis in all and there were 17 lobectomies, two pneumonectomies and one bilateral lobectomy. There were ten patients with acute myeloid or lymphoid leukemia (group 2), six male and four female with an average age of 26 years (SD 4). Twelve lesions required lobectomy in eight and wedge excision in four. RESULTS In group 1 there was one post-operative death (5%), in a patient with massive haemoptysis and completely destroyed lungs with bilateral upper lobe aspergilloma secondary to pneumonia. Morbidity accounted for 25% (five patients), two required re-exploration for bleeding, two had prolonged air leak more than 7 days and one developed empyema. The later was treated with drainage and rib resection. One patient had recurrence of haemoptysis during the follow up period (mean 42 months). In group 2 there was no mortality or morbidity and six patients proceeded to bone marrow transplantation with no complication or recurrence. CONCLUSIONS Surgical resection for pulmonary aspergilloma in selected patients provides the best chance of cure. Pulmonary resection for post-tuberculous complex aspergilloma is associated with higher morbidity than resection for immuno-compromised patients.

Maximal thymectomy in children with myasthenia gravis

OBJECTIVES We performed this study to evaluate the benefit of thymectomy in children with myasthenia gravis (MG). METHODS Over a period of 15 years from 1986 to 2001, we collected data on 30 children with MG and retrospectively reviewed the outcome of maximal thymectomy. RESULTS There were 23 females and seven males with a mean age of 13.2 years (range 4-16). The mean duration of the disease was 19.3 months (range 2-144). According to Osserman classification, there were 14 children in class II; 12 in class III; and four children in class IV. One child in class IV required postoperative ventilation and one was re-explored to drain a pericardial effusion secondary to central line leak. We found ectopic thymic tissue in 10 cases (33.3%). During a mean follow-up period of 53.5 months (range 9-180), complete remission was noted in 13 children (43.4%) and improvement in 14 (46.6%). The remaining three children (10%) did not improve following surgery. Univariate analysis (P < 0.05) showed that ectopic thymic tissue is a significant prognostic factor for outcome. CONCLUSION Maximal thymectomy appears to provide a high rate of remission and improvement in children with MG. However, the presence of ectopic thymic tissue has poor prognostic value.

Predictors of Outcome for Myasthenia Gravis after Thymectomy

The aim of this study was to assess the clinical outcome of patients with myasthenia gravis treated with maximal thymectomy and to identify prognostic variables that predict the outcome. Over 15 years, from 1986 to 2001, we collected data on 100 patients with myasthenia gravis who underwent maximal thymectomy and retrospectively reviewed their outcome. Women comprised 63% and the median age was 25 years (range, 4 to 61). The median duration of the disease was 26 months (range, 1 to 240). According to the Osserman classification, there were seven patients in class I, 31 in class II, 47 in class III, and 15 in class IV. In non thymomatous patients (93 patients), complete remission rate progressively increased from 37.4% to 58.2% and 75% at 3, 10 and 15 years of follow-up respectively. These findings suggest that the complete remission rate is prone to increase with time after maximal thymectomy. The total benefit rate achieved was estimated to be 86% while 14% did not improve at a mean follow-up period of 7.6 years (range, 8 to 180 months). Univariate analysis (p < 0.05) showed that age, thymic histology and ectopic thymic tissue are significant prognostic factors for outcome.

Plasmapheresis before thymectomy in myasthenia gravis: routine versus selective protocols §

OBJECTIVE The value of thymectomy in management of myasthenia gravis (MG) is well recognized. Plasmapheresis (PMP) before thymectomy appears to improve the postoperative outcome. As PMP has its own complications, selective use of PMP preoperatively for patients at risk of post-thymectomy complications would improve the postoperative outcome, and decreases the PMP-related complications. The aim of this study is to evaluate the effectiveness and safety of routine versus selective use of PMP before thymectomy. MATERIAL AND METHODS We performed a retrospective analysis of two different protocols in two institutions comparing the routine (group I) versus selective use (group II) of prethymectomy PMP. The computerized database and the medical records of 164 patients diagnosed with MG who underwent thymectomy between 1998 and 2007, were reviewed. RESULTS In group I, 74 patients were treated with PMP before thymectomy. In group II (90 patients), 35 patients were identified as high-risk and were treated with PMP before thymectomy, and in 55 patients, thymectomy was performed without preoperative PMP. There was significant difference in the recorded PMP-related complications between group I and group II; 25.7% (19 patients) versus 8.9% (8 patients), respectively. There was no difference between the two groups as regards the duration of postoperative mechanical ventilation, intensive care unit (ICU) stay and hospital stay. CONCLUSION This study demonstrated that selective use of PMP before thymectomy may reduce the incidence of PMP-related complications without affecting the overall outcome.

Congenital tracheoesophageal fistula: A rare and late presentation in adult patient.

Congenital H-type tracheoesophageal fistula (TEF) in adults is a rare presentation and can test the diagnostic acumen of a surgeon, endoscopist, and the radiologist. These undetected fistulas may present as chronic lung disease of unknown origin because repeated aspirations can lead to recurrent lung infections and bronchiectasis. Congenital TEFs should be considered in the diagnosis of infants and young adults with recurrent respiratory distress and/or infections. Here, we present the successful management of this rare case in an adult patient.

Clinical use of combined positron emission tomography and computed tomography in thymoma recurrence

The aim of this study is to evaluate the efficacy of hybrid fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) for surveillance and follow-up of thymoma patients to detect recurrent disease. A retrospective chart review was performed on 37 thymoma patients who underwent FDG-PET/CT-scans during postoperative follow-up. The following information was obtained: clinical indication for FDG-PET/CT, the results of the FDG-PET/CT, particularly with regard to the additional diagnostic imaging information, the localization of the disease and subsequent clinical patient management. A total of 51 CT-scans were performed on 37 patients providing sensitivity and specificity for thymoma recurrence of 71% and 85%, respectively. Forty-five FDG-PET/CT-scans were performed on the same group of patients with an overall sensitivity and specificity of 82% and 95%, respectively. Notably, FDG-PET/CT sensitivity when employed for diagnosis of thymoma recurrence in the anterior mediastinum has reached 100% (CT has shown only 55% sensitivity for the detection of anterior mediastinal thymoma recurrence). Our preliminary study demonstrates that during follow-up after thymoma excision, FDG-PET/CT is superior to computed tomography alone in the detection and localization of mediastinal recurrence. In particular, the combined structural and metabolic information of FDG-PET/CT enhances the diagnostic confidence in lesion characterization.

Video-assisted thoracoscopic decortication for the management of late stage pleural empyema, is it feasible?

Background: Video-assisted thoracoscopic surgical decortication (VATSD) is widely applicable in fibrinopurulent Stage II empyema. While, more chronic thick walled Stage III empyema (organizing stage) needs conversion to open thoracotomy, and existing reports reveal a lacuna in the realm of late stage empyema patients management through VATS utilization, particularly Stage III empyema. We prospectively evaluated the application of VATSD regardless of the stage of pleural empyema for the effective management of late stage empyema in comparison to open decortications (ODs) to minimize the adverse effects of the disease. Methods: All patients with pyogenic pleural empyema (Stage II and Stage III) in King Khalid University Hospital (KKUH) (admitted from January 2009 to December 2013) who did not respond to chest tube/pigtail drainage and/or antibiotic therapy were treated with VATSD and/or open thoracotomy. Prospective evaluation was carried out, and the effect of this technique on perioperative outcomes was appraised to evaluate our technical learning with the passage of time and experience with VATS for late stage empyema management. Results: Out of total 63 patients, 26 had Stage II empyema and 37 had Stage III empyema. VATSD was employed on all empyema patients admitted in the KKUH. VATSD was successful in all patients with Stage II empyema. Twenty-five patients (67.6%) with Stage III empyema completed VATSD successfully. However, only 12 cases (32.4%) required conversions to open (thoracotomy) drainage (OD). The median hospital stay for Stage III VATSD required 9.65 ± 4.1 days. Whereas, patients who underwent open thoracotomy took longer time (21.82 ± 16.35 days). Similarly, Stage III VATSD and Stage III open surgery cases showed significance difference among chest tube duration (7.84 ± 3.33 days for VATS and 15.92 ± 8.2 days for open thoracotomy). Significantly, lower postoperative complications were detected in patients treated with VATSD in terms of atelectasis, prolonged air leak, wound infection, etc. Conlcusion: VATSD facilitates the management of fibrinopurulent, organized pyogenic pleural empyema with less postoperative discomfort, reduced hospitalization, and have fewer postoperative complications. VATSD can be an effective, safe first option for patients with Stage II pleural empyema, and feasible in most patients with Stage III pleural empyema.

The use of thoracoscopy to enhance medical students' interest and understanding of thoracic anatomy

AIM: To develop a video-based educational tool designed for teaching thoracic anatomy and to examine whether this tool would increase students’ stimulation and motivation for learning anatomy. METHODS: Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a pre-existing program for first year medical students (n = 150), and included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape that demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert-type questionnaire assessing the videos usefulness. Apart from this, a small group of entirely different set of students was divided into two groups, one group to view the 15-minute video presentation of thoracoscopy and chest anatomy and the other group to attend a 15-minute lecture of chest anatomy using radiological images. Both groups took a 10-item pretest and post-test multiple choice questions examination to assess short-term knowledge gained. RESULTS: Of 150 medical students, 119 completed the questionnaires, 88.6% were satisfied with the thoracoscopic video as a teaching tool, 86.4% were satisfied with the quality of the images, 69.2% perceived it to be beneficial in learning anatomy, 96.2% increased their interest in learning anatomy, and 88.5% wanted this new teaching tool to be implemented to the curriculum. Majority (80.7%) of the students increased their interest in surgery as a future career. Post-test scores were significantly higher in the thoracoscopy group (P = 0.0175). CONCLUSION: Incorporating live surgery using thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores from first year medical students. The video increased students’ interest in learning, in clinically applying anatomic fact, and in surgery as a future career.