General Thoracic Surgery Services Across Asia During the 2020 COVID-19 Pandemic

The COVID-19 pandemic of 2020 posed an historic challenge to healthcare systems around the world. Besides mounting a massive response to the viral outbreak, healthcare systems needed to consider provision of clinical services to other patients in need. Surgical services for patients with thoracic disease were maintained to different degrees across various regions of Asia, ranging from significant reductions to near-normal service. Key determinants of robust thoracic surgery service provision included: preexisting plans for an epidemic response, aggressive early action to “flatten the curve”, ability to dedicate resources separately to COVID-19 and routine clinical services, prioritization of thoracic surgery, and the volume of COVID-19 cases in that region. The lessons learned can apply to other regions during this pandemic, and to the world, in preparation for the next one.

Emergency Surgery in Geriatrics: A Retrospective Evaluation in a Single Center

Background
As life expectancy increases in humans, surgical procedures applied to the elderly people are also increasing in parallel with the developments in surgery and postoperative care. A significant number of studies investigating the morbidity-mortality of geriatric patients are related to patients who are undergoing emergency operations. The present study aims to investigate the factors affecting mortality and morbidity after emergency surgery in elderly people.

Methods
The data of 200 patients aged 65 years and over who were operated under emergency conditions in the University of Health Sciences Kartal Dr. Lütfi Kırdar Training and Research Hospital between January and December 2018 were evaluated retrospectively.

Results
Patient’s demographic information, including age, gender, ASA physical status, comorbidities, functional dependency or non-dependency of patients, types of operation, anesthesia technique, duration of operation, intraoperative blood transfusion, the changes of hematocrit levels (during the perioperative period), the outcome after surgery (intensive care admission or ward transfer), were recorded. The risk prediction of short-term mortality has been estimated using CCI and APACHE II scoring systems.

Conclusion
The mean age of the patients was 74.8±6.7 and the number of females (n=134, 67%) outweighed the males. Higher ASA physical status scores, dependent living conditions, long operation time, general anesthesia, intraoperative blood transfusion, low Htc values (<25%), high APACHE II scores and lower scores of 10-years survival by CCI were the factors that affected the acceptance into ICU.

Comparison on Frequencies of Pericardial Effusion and Tamponade Following Open Heart Surgery in Patients With or Without Low Negative Pressure Suction on Chest Tube

Introduction
Pericardial effusion and tamponade are accounted as the two most important complications following open-heart surgeries which are known to increase mortality and morbidity rates. Putting a low negative pressure suction on the chest tube of patients might be a useful way for better drainage and also reducing the occurrence of pericardial effusion and tamponade. In the present study, we aimed to compare the prevalence of pericardial effusion and tamponade in patients undergoing open-heart surgeries with and without low negative pressure suction on the chest tube.
Methods
This clinical trial was performed in 2018-2019 in Tehran, Iran. 100 patients who were candidates for open-heart surgery were entered. After surgeries, patients were divided into two groups: group 1 had a low negative pressure suction on their chest tube and group 2 had no suction. Patients were then observed for clinical and imaging characteristics of pleural effusion and tamponade. Data were gathered and analyzed using SPSS software.
Results
In the present study, we indicated that the prevalence of pericardial effusion is significantly lower in patients with low negative pressure on their chest tube (P=0.04). No significant differences were observed between two groups regarding to: frequency of tamponade and post-operative ejection fraction (P> 0.05).
Conclusion
The usage of a low negative pressure suction on the chest tube following open cardiac surgeries is associated with a lower prevalence of pericardial effusion. We suggest that such systems could be commonly used in cardiac surgeries or surgeries of the thorax.

Ultrasound-guided Thrombin Injection for Treatment of Iatrogenic Femoral Artery Pseudoaneurysms Compared With Open Surgery: First Experiences From a Single Institution

Purpose
The frequency of iatrogenic femoral artery pseudoaneurysm (FAP) diagnoses has recently increased due to the growing use of diagnostic and interventional procedures involving large diameter sheaths, as well as more potent anticoagulation procedures. In this study, we aimed to present our experience with ultrasound-guided thrombin injection (UGTI) in patients with iatrogenic FAP.
Methods
We studied patients with FAP who were under anticoagulant or antiplatelet therapies preoperatively, or who had received a loading dose during an interventional procedure. The outcomes of patients with FAP treated with UGTI were compared with those of patients who underwent open surgical repair for pseudoaneurysms.
Results
Among the 55 patients included in this study, 24 had UGTI while 31 had open surgery. The success rate was 95.8% when taking into consideration primary and secondary attempts. The mean duration of the procedure was shorter in patients with UGTI (10.1 ± 3.54 minutes) when compared with those who underwent open surgery (76.55 ± 26.74 minutes, P ≤ 0.001). In addition, the total complication frequency was significantly higher in the open surgery group (P = 0.005), as was their length of hospital stay (P < 0.001). Cost analysis showed significant differences between UGTI ($227.50 ± $82.90) and open surgery ($471.20 ± $437.60, P = 0.01).
Conclusion
We have found that UGTI is the safer and more effective choice of treatment in appropriate patients with FAP, as opposed to surgery

Effect of Dexmedetomidine Combined with Inhalation of Isoflurane on Oxygenation Following One-Lung Ventilation in Thoracic Surgery

Background: One-lung ventilation (OLV) is commonly used during thoracic surgery. At this time, hypoxemia is considered one of the remarkable consequences of the anesthesia management. Hypoxic pulmonary vasoconstriction (HPV) is the defense mechanism against hypoxia.
Objectives: The aim of the present study was to investigate the effect of infusion of dexmedetomidine on improving the oxygenation during OLV among the adult patients undergoing thoracic surgery.
Methods: A total of 42 patients undergoing OLV by general anesthesia with isoflurane inhalation were randomly assigned into two groups: IV infusion of dexmedetomidine at 0.3 microgram/kg/h (DISO) and IV infusion of normal saline (NISO). Three Arterial Blood Gas (ABG) samples were obtained throughout the surgery. Hemodynamic parameters, PaO2, PaCO2, and complications at recovery phase were recorded. The collected information was analyzed using SPSS software version 22.
Results: In the dexmedetomidine group, the mean hemodynamic parameters had a significant reduction at 30 and 60 minutes following OLV. Administration of dexmedetomidine resulted in a significant increase in the PaCO2 and a reduction in the PaO2 when changing from two-lung ventilation to OLV, where PaO2 reached its maximum value within 10 minutes after OLV in the DISO group, and it began to gradually increase to the end of operation. The duration of the recovery phase, also complications at the recovery phase decreased significantly in DISO group.
Conclusions: The results of the study showed that, dexmedetomidine may improve arterial oxygenation during OLV in adult patients undergoing thoracic surgery, and can be a suitable anesthetic agent for thoracic surgery.

Reversal of Hartmann’s procedure is still a high-morbid surgery?

BACKGROUND: This study evaluated the outcome of the reversal of Hartmann’s procedure based on preoperative and intraoperative risk factors.
METHODS: We retrospectively reviewed 78 cases, whom we applied the Hartmann’s procedure either electively or under emergency conditions in our clinic between the years 2010 and 2016.
RESULTS: Of the cases reviewed in this study, 45 patients were males, and 33 patients were females. Of all cases included in this study, 32 cases were operated due to malignancies, 15 cases were operated due to a perforated diverticulum, and 11 cases were operated due to sigmoid volvulus. Reversal of Hartmann’s was performed in 32 cases. The morbidity and mortality rates for the reversal of Hartmann’s procedure were 37.5% and 0.0%, respectively.
CONCLUSION: The reversal of Hartmann’s procedure appears to be a safe operation with acceptable morbidity rates. If the correct patient selection, correct operation timing and meticulous surgical preparation are performed, the risk of morbidity and mortality of the reversal of Hartmann’s procedure can be minimized.

Determinants of surgeons’ adherence to preventive intraoperative measures of surgical site infection in Gaza Strip hospitals: a multi-centre cross-sectional study

Background
Surgical site infection (SSI) is one of the most common hospital-acquired infections and is associated with serious impact on the rates of morbidity, mortality as well as healthcare costs. This study examined factors influencing the application of several intraoperative preventive measures of SSI by surgeons and surgical residents in the Gaza Strip.

Methods
A cross-sectional study was conducted from December 2016 to February 2017 at the operation rooms of the three major hospitals located in the Gaza-Strip, Palestine. Inclusion criteria for patients were being adult (aged ≥18 years), no history of wound infection at time of operation and surgical procedure under general anaesthesia with endotracheal intubation. The association between different patient- and procedure-related SSI risk factors and adherence to several intraoperative SSI preventive measures was tested.

Results
In total, 281 operations were observed. The mean patient age ± standard deviation (SD) was 38.4 ± 14.6 years and the mean duration of surgery ± SD was 58.2 ± 32.1 minutes. A hundred-thirty-two patients (47.0%) were male. Location and time of the operation were found to have significant associations with adherence to all SSI preventive measures except for antibiotic prophylaxis. Type of operation had a significant association with performing all measures except changing surgical instruments. Patient age did not have a statistically significant association with adherence to any measure.

Conclusion
The results suggest that the surgeon could be a major factor that can lead to a better outcome of surgical procedures by reducing postoperative complications of SSI. Operating department professionals would benefit from clinical guidance and continuous training, highlighting the importance of persistent implementation of SSI preventive measures in everyday practice to improve the quality of care provided to surgical patients.

Neuroschistosomiasis mimicking lower back pain: case report of a rare differential diagnosis in a pediatric patient

Background
Spinal myelitis is an infrequent manifestation of spinal cord infection. It is caused by the Schistosoma species, which are endemic in South America, part of the Middle East, and Africa.

Case presentation
We report the case of a 13-year-old male adolescent complaining of progressive lower back pain and weakness of the lower extremities for 3 days. Initial magnetic resonance imaging revealed typical transverse myelitis. Subsequently, parasite serology showed a markedly elevated level of Schistosoma antibody titers, and cerebrospinal fluid analysis yielded normal results. Because of our presumptive diagnosis of neuroschistosomiasis, the patient was prescribed an empirical regimen of an anti-parasitic agent, after which his neurological deficit promptly subsided. The patient was followed for 1 year and showed a complete long-term resolution of symptoms.

Conclusions
This case highlights the increasing prevalence of neuroschistosomiasis in recent years, particularly in patients with a history of travel to endemic regions. Moreover, the study reports the clinicoradiological features of this enigmatic disorder. This rare occurrence potentiates further studies to address unanswered questions about neuroschistosomiasis.

Risk factors of orthopedic surgical site infection in Jordan: A prospective cohort study

Background
Orthopedic surgical site infection represents a hospital acquired infection among orthopedic surgery patients, which in turn delays normal recovery process and increases hospital length of stay and health care costs. As a result, risk factors for orthopedic surgical site infection should be identified thereby allowing the application of protective interventions that may inhibit the occurrence of such infection.

Objectives
To determine risk factors of surgical site infection in patients undergoing orthopedic surgery in Jordan.

Materials and methods
The study employed prospective, multi-center approach to collect data about orthopedic surgery patients through assessing their health status and reviewing their medical records and monitoring for occurrence of surgical site infection within 90 days after operation.

Results
286 patients met the eligibility criteria from 18 hospitals. Only surgical wound classification and length of postoperative stay wound were found to be significant risk factors for orthopedic surgical site infection.

Conclusion
Surgical wound classification and length of postoperative stay were identified as risk factors for orthopedic surgical site infection. Risk factors that did not predict occurrence of orthopedic surgical site infection can be identified by other research strategies than the one used in this study, which could be conducted retrospectively or by conducting prospective studies that are both community-based and hospital-based with larger sample sizes

Uniportal Thoracoscopic Approach For Pulmonary Hydatid Cyst: Preliminary Results.

Pulmonary hydatid cyst is a preventable parasitary disease with high prevalence in low-medium income countries. Thoracoscopic approach is seen in the literature as small-case groups and multiple-port incisions are observed in these studies. Unlike other thoracoscopic approaches for the surgical treatment, we describe the single-port technique for the first time in our study. We attempt to compare the clinical outcomes and preliminary results of patients with pulmonary hydatid cyst treated with either minimally invasive or thoracotomy.The medical records of 66 patients undergoing surgery for pulmonary hydatid cyst disease between January 2013 and July 2017 were reviewed. The number of patients who underwent thoracotomy was 48, whereas 18 were managed by single-port video-assisted thoracoscopic surgery. Variables statistically compared between the 2 groups were age, diameter of the cystic, operation time, volume and duration of the drainage, postoperative complications, length of stay, duration of narcotic analgesic usage, and pain score.Thoracoscopic approach was superior to conventional thoracotomy in terms of operation time, drainage volume, time to drain removal, hospital stay, narcotic analgesic treatment duration, and postoperative pain scores. All thoracoscopic procedures were concluded successfully, and conversion to open surgery was not required. No postoperative mortality was seen in either group. During the follow-up period, no recurrence was encountered in either group.Uniportal thoracoscopic approach is a safe option for the treatment of hydatid cyst disease. It can be used as an alternative to thoracotomy, depending on the size and location of the lesion.