Thoracic Surgery

Omar M. Rashid1/28/2012 – 2/3/2012

ATTDATTD

RESRESDATEDATE PATIENPATIEN

TTPROCEDUREPROCEDURE INDICATIONINDICATION

CassanoCassanoLanningLanningRashidRashid

1/31/11/31/122

Robotic Assisted Thymectomy

Myasthenia Gravis

CassanoCassanoRashidRashid

1/31/11/31/122

Left VATS, Left Left VATS, Left Lower Lobe Lower Lobe Wedge, Wedge, Mechanical Mechanical Pleurodesis, Pleurodesis, Chemical Chemical Pleurodesis Pleurodesis (Doxycycline)(Doxycycline)

Recurrent PTX s/p Recurrent PTX s/p left VATS, wedge left VATS, wedge resection & resection & Pleurectomy for Pleurectomy for non-endometriosis-non-endometriosis-related catamenial related catamenial ptxptx

BrinsterBrinsterRashidRashid

2/1/122/1/12 Trach, PEG, IVC Trach, PEG, IVC filterfilter

Vent dependence Vent dependence s/p s/p thoracoabdominal thoracoabdominal aortic aneurysm aortic aneurysm repairrepair

CassanoCassanoRashidRashid

2/1/122/1/12 Left anterior Left anterior thoracotomy, thoracotomy, wedge lung wedge lung biopsy, biopsy, pericardial pericardial windowwindow

Pericardial Pericardial effusion, pulm effusion, pulm infiltrates (AML, infiltrates (AML, bone marrow txp, bone marrow txp, sepsis)sepsis)

ATTDATTD

RESRESDATEDATE PATIENPATIEN

TTPROCEDUREPROCEDURE INDICATIONINDICATION

CassanoCassanoRashidRashid

2/3/122/3/12 R VATS, lysis of R VATS, lysis of adhesions, adhesions, thoracotomy, thoracotomy, RMLobectomyRMLobectomy

RML mass RML mass (NSCLC)(NSCLC)

CassanoCassanoRashidRashid

2/3/122/3/12 Left VATS, lysis Left VATS, lysis of adhesions, of adhesions, thoracotomy, thoracotomy, hernia repairhernia repair

Left thoracotomy Left thoracotomy incisional herniaincisional hernia

CassanoCassanoRashidRashid

2/3/122/3/12 Left Left thoracotomythoracotomy

Loculated effusionLoculated effusion

ATTDATTD

RESRESDATEDATE PATIENTPATIENT PROCEDURESPROCEDURES COMPLICATIONSCOMPLICATIONS

CassanoCassanoRashidRashid

1/13/121/13/12 Left VATS, Left VATS, wedge wedge resection, resection, pleurectomypleurectomy

Recurrent PTXRecurrent PTX

CassanoCassanoLanningLanningRashidRashid

1/31/121/31/12 Robotic Assisted Thymectomy

POURPOUR(Post-Operative (Post-Operative Urinary Urinary Retention) Retention)

COMPLICATIONS

• Complication –Recurrent Pneumothorax

• Procedure– Left thoracoscopy, wedge lung resection,

pleurectomy

• Primary Diagnosis–Non-Endometriosis Related Catamenial

Pneumothorax

Case• Patient is a 17yr otherwise healthy female presented with

spontaneous ptx in April, underwent left VATS, apical wedge resection, mechanical pleurodesis by Peds Surg, prolonged hospital stay, had recurrent ptx. – Chest CT demonstrated no pathology.– Patient underwent left vats, wedge resection, pleurectomy and

suppression of menses with OCP with unremarkable post-op course.

– In clinic 14days later routine CXR demonstrated recurrence.– Patient underwent left vats, wedge resection, mechanical

pleurodesis, and chemical pleurodesis (doxycycline), menses suppression with Depo-Lupron IM injection followed by Depo-Provera.

Spontaneous Ptx in Women

• Should consider lymphangioleiomyomatosis(LAM) and thoracic endometriosis.

• Recurrence rates can be as high as 71% (UK registry 275 patients 1990-1994)

• Paucity of literature to guide management

• Review of 10yrs cases of women of reproductive age without intrinsic lung disease who had homolateral ptx recurrence

• 179 pts operated on for spontaneous ptx, 35 for homolateral recurrence

Definitions

• Catamenial pneumothorax: 24hrs before to 72hrs after onset of menses– Endometriosis or non-endometriosis related

(pathology)

• Idiopathic: non-catamenial, non-endometriosis related without any lung pathology

Initial Surgery

• 52.3% apical wedge (14 of 19 demonstrated bullous disease)

• 6 cases had resection of endometriosis• 3 cases had diaphragmatic resection• 80% mechanical pleurodesis, 8.6%

pleurectomy, 5.7% talc pleurodesis• 12 cases received hormonal treatment for

mean of 16.7 months

Recurrence

• 6 while on hormonal therapy, 6 after hormonal therapy

• 21 had surgery at first recurrence, 14 had a median of 3 recurrences before repeat surgery

Repeat Surgery

• 13 cases had apical wedge with 12 demonstrating bullous disease

• Diaphragmatic resection in 15 patients• 13 cases had no diaphragmatic resection at all• Hormonal therapy in 24 cases• 1 pt with idiopahtic ptx had a recurrence• 5 recurred (3 ER-CP, 2 nER-CP) (40month follow up)– 2 while on hormonal therapy– 2 mo, 5 mo, 12 mo after completion

Analysis of Complication• Was the complication potentially avoidable?– No

• Would avoiding the complication change the outcome for the patient?– Yes

• What factors contributed the complication?– Patient’s underlying disease

Take Home Points

• Management of catamenial pneumothorax is challenging and requires a multidisciplinary approach

• It is important to have a thorough discussion with patient and family