Surgical Stabilization of Rib Fractures Improves Outcomes in the Geriatric Patient Population

Introduction Rib fractures in the ≥65-year-old population have been shown to strongly influence mortality and pneumonia rates. There is a growing body of evidence demonstrating improvements in the geriatric patient’s survival statistics and respiratory performances after surgical stabilization of rib fractures (SSRF). We have observed a strong survival and complication avoidance trend in geriatric patients who undergo SSRF. The purpose of our study was to evaluate the outcomes of geriatric patients with rib fractures treated with SSRF compared to those who only receive conservative therapies. Methods We performed a retrospective review of our trauma registry analyzing outcomes of patients ≥65 years with rib fractures. Patients admitted from 2015 to 2019 receiving SSRF (RP group) were compared to a nonoperative controls (NO group) admitted during the same time. Bilateral fractures were excluded. Independent variables analyzed = ISS, mortalities, hospital days, ICU days, pleural space complications, and readmissions. Follow-up was 60 days after discharge. Group comparison was performed using Kolmogorov-Smirnov, Shapiro-Wilk, and Mann-Whitney U tests. Results 257 patients were analyzed: 172 in the NO group with mean age of 75 (65-10) and 85 in the RP group with mean age of 74 (65-96). Mean ISS = 13 (1-38) for the NO group and 20 (9-59) for the RP group ( P < .001). Mean hospital days = 8 (1-39) and 15 (3-49) in NO and RP groups, respectively. Mean ICU days = 10 (1-32) and 8 (1-11) in NO and RP groups, respectively. Deaths, pneumonia, readmissions, and pleural effusions in the NO group were statistically significant ( P < .01). Analysis of complications revealed 4 RP patients (4.7%) with respiratory complications out to 60 days and 65 NO patients (37.8%) ( P < .001). Conclusions Surgical stabilization of rib fractures appears to be associated with a survival advantage and an avoidance of respiratory-related complications in the ≥65-year-old patient population.

P-OGC91 Significance of the number, size and type of drains used for intercostal drainage after oesophagectomy for cancer

Background Pleural space drainage with intercostal drains (ICD) is performed after oesophagectomy to allow the lung to reinflate, remove excess fluid post-operatively, and signal chyle or enteric content. Enhanced recovery protocols encourage the use of the minimum number of drains for the shortest duration to facilitate rapid recovery after surgery. There is wide variability in the type, number and size of drains inserted at operation. This study sought to identify the most effective drain pattern insertion, using the need for respiratory reintervention as the primary end point and secondary outcome of the presence of pleural effusions. Methods All patients undergoing oesophagectomy for cancer in one unit were included between November 2014 and December 2020. The operation performed, drain sizes, sides and type were recorded. Respiratory reintervention was defined as replacement of an ICD, bronchoscopy, pleural aspiration or reintubation. The primary and secondary end points, and potential confounders such as age, histology, pre-operative stage of disease, neoadjuvant therapy, pre-existing lung disease, and anastomotic or chyle leak were recorded. Results The study period encompassed 258 patients who underwent oesophagectomy for cancer. Median age 69 (range 32-82), 211 male, 226 ACA:32 SCC, 224 neoadjuvant therapy, 212 right-sided thoracic operations, 46 left thoracoabdominal approach. Post-operative respiratory reinterventions occurred in 47 patients (18.2%). At least one post-operative pleural effusion was present in 52 patients (20.2%): 9 bilateral; 26 contralateral; 17 ipsilateral to the side of thoracic surgery. 67% of effusions were contralateral to the operated side. The use of two or three ICDs (HR 371683269, p &lt; 1), one or two operative side ICDs (HR 0, p &lt; 1), Blake’s drains in place of rigid ICDs (HR 0.938 [0.422-2.085], p &lt; 0.875), and size 24F compared to 28F drains (HR 0, p &lt; 0.999) are not significantly associated with post-operative respiratory reinterventions. Similarly, the presence of post-operative pleural effusions is not significantly associated with the use of two or three ICDs (HR 240242843, p &lt; 1), one or two operative side ICDs (HR 0, p &lt; 1), Blake’s drains in place of rigid ICDs (HR 1.505 [0.665-3.405], p &lt; 0.327), and size 24F compared to 28F drains (HR 1.055 [0.109-10.2], p &lt; 0.963). Conclusions This study supports the use of contralateral pleural space drainage as two thirds of effusions were contralateral to the operated side. It shows no correlation between the size of drains, number of drains or use of Blakes drains and the likelihood of requiring a post-operative respiratory intervention or development of post-operative pleural effusion. Therefore the ERAS principles of the fewest number of drains for the shortest duration should be adopted.

A simple size-tailored algorithm for the removal of chest drain following minimally invasive lobectomy: a prospective randomized study

Background The pleural space can resorb 0.11–0.36 ml/kg of body weight/hour (h) per hemithorax. There are only a limited number of studies on thresholds for chest drain removal (CDR) and all are based on arbitrary amounts, for example, 300 ml/day. We studied an individualized size-based threshold for CDR–specifically 5 ml/kg, a simple, easily applicable measure. Methods This is a single-center prospective randomized trial enrolling 80 patients undergoing VATS lobectomy. There were two groups: an experimental (E) group, in which once the daily output went down to 5 ml/kg the chest drain was removed and a control (C) group, with chest drain removal as per our current practice of less than 250 ml/day. Results The groups did not differ in pre- and peri- and postoperative characteristics, except for chest drain duration (mean, SD 2.02 ± 0.97 vs. 3.25 ± 1.39 days, p < 0.001) and length of hospital stay (median, IQR 4.5; 3 vs. 6; 2.75 days, p = 0.008) in favor of E group. The re-intervention rate was the same in both groups (once in each group). Conclusion The new threshold for chest drain removal following thoracoscopic lobectomy of 5 ml/kg/d leads to both shorter chest drainage and hospital stay without apparent increase in morbidity. (Clinical registration number: DRKS00014252).

Malignant Pleural Effusions—A Review of Current Guidelines and Practices

Malignant pleural effusion (MPE) occurs in 15% of all cancer patients and usually portends poor prognosis while also serving to limit the patient’s quality of life. Palliation of symptoms has been the goal for the management of these effusions while keeping the patient’s hospital stay to a minimum. Traditionally, this has been achieved by chest tube drainage followed by the instillation of sclerosing agents, such as talc, in the pleural space. A recent increase in evidence for the effectiveness and convenience of indwelling pleural catheters has changed the management of MPE, which is reflected in the guidelines released by the American Thoracic Society as well their European Counterpart (ERS/BTS). In this article, we aim to review the current management practices and guidelines for MPE.

Intrathoracic transposition of the omentum

Complex chest and lung infections with bronchial fistula are life-threatening situations with a mortality rate of up to 20%. If medical treatment fails, these patients require aggressive procedures to heal. Transposition of the omentum is a valuable, nonstandard option in these complex cases with aggressive infection involving the pleural space, with or without a bronchial fistula, when medical treatment is unsuccessful. We present a 29-year-old female patient diagnosed with primary immunodeficiency and invasive fungal infection with involvement of the left upper lobe and mediastinal and vertebral bodies treated with a lobectomy and intrathoracic transposition of the omentum.

Fifteen-minute consultation: A structured approach to children with parapneumonic effusion and empyema thoracis

Parapneumonic effusion is defined as the accumulation of pleural fluid associated with lung infection/pneumonia. Parapneumonic effusions can be uncomplicated or complicated. They are caused by the spread of infection and inflammation to the pleural space, and can develop into empyema thoracis—frank pus in the pleural space. Chest radiograph and thoracic ultrasound are the key imaging modalities for the diagnosis of parapneumonic effusion. Management aims are reducing inflammation and bacteria in the pleural cavity, and enabling full lung expansion. Broad-spectrum intravenous antibiotics, with the addition of chest tube drainage and fibrinolytic therapy for larger collections, are the mainstays of management. This article provides a clear, evidence-based and structured approach to the assessment and management of parapneumonic effusion/empyema thoracis in children and young people.

A Rare Case of Interlobar Pneumothorax

BACKGROUND: Pneumothorax is a severe medical condition characterized by the collection of air in one or several spaces of the pleura. A rare subtype of pneumothorax where air is restricted in interlobar pleural space, mostly due to the previous fibrous pleural adhesions, is known as interlobar pneumothorax. CASE PRESENTATION: We present a rare case of a 58-year-old female admitted to the emergency department due to difficulty on breathing, hemoptysis, and discomfort in the right anterior axillary line, which worsened with inspiration and was associated with breathlessness during physical activity. The diagnosis was confirmed by thoracic multi slice computed tomography (MSCT), showing that air was located between the middle and lower lobes of the right lung , measuring 7 × 5 × 2.5 cm (transversal × oblique cranio-caudal × antero-posterior), representing interlobar pneumothorax. DISCUSSION: Cases of interlobar pneumothorax need to be carefully differentiated and evaluated, while skin folds, overlapping breast margin, interlobar fissure, bullae in the apices, pneumomediastinum, pneumopericardium, inferior pulmonary ligament air collection, pneumatocele, and air collection in the intrathoracic extrapleural space, can mimic pneumothorax and make diagnosing very challenging.