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Summary A best evidence topic was constructed according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgery (VATS), compared to open lung resection, resulted in improved postoperative clinical outcomes, in patients with localized bronchiectasis indicated for surgery. A total of 1352 papers were found using the reported search, of which 5 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All of the identified studies were retrospective. The conversion rate from VATS to open procedure ranged from 0% to 15.3%. In comparison to thoracotomy, VATS resulted in a significant reduction of postoperative blood loss (1 study), length of hospital stay (2 studies), postoperative complication rate (2 studies), pain scales (2 studies) and chest tube duration (1 study). However, there was a significant increase in operative time (1 study) and whole cost (2 studies). There was no significant difference in the clinical recovery, which was defined by the disappearance or improvement of preoperative symptoms during the follow-up period (3 studies). We conclude that although there is limited high-level evidence, retrospective studies have suggested that VATS could significantly reduce complications rate, postoperative blood loss, pain scales, length of hospital stay and chest tube duration compared to open lung resection in selected patients with localized bronchiectasis.

Objectives To evaluate the role of prophylactic high-dose atorvastatin for prevention of postoperative atrial fibrillation (POAF), inflammatory response attenuation, and myocardial protection after valve replacement cardiac surgery. Design Randomized controlled trial. Setting Assiut University Hospitals. Participants Sixty-four adult patients undergoing cardiac valve replacement surgery. Interventions The participants were equally divided into 2 groups. Group S received 80 mg of atorvastatin (oral tablets), 12 and 2 hours preoperatively, and on the 2nd, 3rd, 4th, and 5th postoperative days. Control group C received placebo at the same time periods. Measurements The incidence of POAF, postoperative white blood cell count, serum C-reactive protein, interleukin 6, and troponin I. Main Results Group S patients showed a lower incidence of POAF compared with the placebo group (p = 0.031). The white blood cell count showed significant reductions in group S compared with group C on the second, third, fourth, and fifth postoperative days. The C-reactive protein level showed significant reductions on the third, fourth, and fifth postoperative days in group S compared with group C (p = 0.001, 0.001, and 0.001, respectively). The serum level of interleukin 6 showed a significant reduction on the fifth postoperative day in group S compared with group C (p = 0.001). There was no significant difference between the 2 groups regarding the troponin I level and inotropic score. Conclusion Prophylactic use of high dose atorvastatin can decrease the incidence of POAF and attenuate the inflammatory process in adult patients undergoing isolated rheumatic cardiac valve replacement surgery.

Background: The key factor following chest wall resection is the preservation of the stability and integrity of the chest wall to support the respiration and protect the underlying organs. The present study aims to evaluate the use of the available grafts and prosthetic materials at our center in chest wall reconstruction with adherence to the proper surgical techniques, good perioperative and postoperative care to obtain good results. Methods: This is a retrospective single center study that concludes all patients underwent chest wall reconstruction for a variety of defects resulting from resection of tumors, trauma due to primarily firearms or motor car accidents, resection of radio necrotic tissues, infection and dehiscence of median sternotomy wounds after cardiac surgery. Results: Study population consisted of 30 patients between January 2015and may 2018, among them were 20 male (70%) and 10 female patients (30%), with a median age of 43 ± 16.3 years, resection and reconstruction was performed in 23 cases (15 neoplastic,5 infective and 3 firearm cases) while reconstruction alone was performed in 7 (traumatic flail chest) cases. Eighteen patients, underwent rib resection with an average 4.18 ± 2.2 ribs (range 2-6). Associated lung resection was performed in 5 patients (27.8 %): diaphragmatic resection was done in 2 cases in addition total sternal resection was performed in 5 cases. Most of the patients (96.7%) had primary healing of their wounds. there was one death (3.3%) in the early postoperative period. The average length of hospital stay for all patients was 8.7 days (range: 5–15). Respiratory complications occurred in three cases in the form of atelectasis and pneumonia at the ipsilateral side of reconstruction. Three cases suffered wound seroma which successfully managed by daily dressing and antibiotic coverage. Conclusions: according to our study and the analysis of similar studies, adequate perioperative preparation of patient undergoing chest wall resection and reconstruction with adherence to effective surgical techniques allowed us to use the available materials at our center for chest wall reconstruction with good and effective results without adding burden in terms of cost on the patient.

Background Stage III empyema still a problem that thoracic surgeons should deal with. We try to reduce the postoperative pain and hospital stay for those patients with using a minimal invasive approach in every case. Methods Prospective study of all cases assigned for one surgeon with diagnosis of turbid and/or hemorrhagic pleural effusion that showed loculations with thick peal or failed simple chest tube drainage admitted to our thoracic surgery service. An informed consent was taken of a trial for thoracoscopic procedure (VATS) with the possibility of open surgery in case that thoracoscopy fail to proceed. Operative technique was to completely remove the fibrous peel at the surface of the lung without parietal decortication. Results Forty-seven patients who met the inclusion criteria were assigned for the study, 38 males and 9 females. Mean age was 45.32 (17-82 years). Twenty-eight cases need only drainage and debridement with lysis of fine adhesions without the need for visceral decortication. The remaining 19 cases were subjected to VATS decortication. Of the 19 cases of decortication, 2 cases (10.52%) need conversion to open thoracotomy and one case converted from uniportal to 2 ports approach. All cases of decorication were discharged with mean drainage days of 5.42 (2-30 days). Mean operative time for decortication cases was 116.68 min (86-140 min). Conclusions Stage III empyema is no longer an absolute contraindication for VATS with the fact that not all cases with a preoperative diagnosis of stage III empyema might need decortication. Moreover, VATS decortication is feasible with a reasonable operative time, short hospital stay and no mortality compared to historical control.

Spinal ganglioneuroma occurs mostly in the thoracic spine causing various manifestations including scoliosis that can be misdiagnosed as idiopathic scoliosis. Few reports exist in the literature on the diagnosis and management of scoliosis secondary to huge ganglioneuroma and usually staged treatment is preferred. In this report, we present a 17-year-old female patient presented with back pain, lower limbs numbness, spinal deformity, and shortness of breath. Plain X-rays showed a 50° right thoracic scoliotic curve. MRI and chest CT revealed a huge extra pulmonary mass shifting the mediastinum with intra spinal extension through the left neural foramina compressing the spinal cord. Percutaneous US guided needle biopsy confirmed the diagnosis of ganglioneuroma. One-stage posterior instrumented correction of scoliosis, spinal cord decompression, and excision of the whole mass from the mediastinum and the spine through posterior approach was done for the patient with smooth postoperative recovery. Chest CT scan was done 2 years after surgery and excluded any local recurrence.

We report a case of 8 years old male child with bronchiectasis and pectus excavatum. Although feasibility and safety of VATS become well-established in treatment of benign pathologies [ 1 ], many surgeons would argue that two benign lesions in a small child should be approached through an open approach especially that bronchiectasis usually has thick adhesions due to repeated infections and a small chest cavity may not allow a full range of movement of staplers. Pectus excavatum is the most common congenital chest wall deformity, and the minimally invasive repair of the pectus excavatum (MIRPE) has become the treatment of choice in the last decade [ 2 ]. Bronchiectasis is an airway chronic disease. Thoracoscopic surgery for localized bronchiectasis is gaining more acceptance every day [ 3 ]. Simultaneous open cardiothoracic operations and pectus repair are being used but still lack satisfactory cosmetic results. Few publications report simultaneous multiport VATS and MIRPE [ 4 , 5 ]. Our case is the first reported example of such combined procedures via Uniportal VATS approach reported in an 8 years old child.

Objective Thoracic Surgery has witnessed a massive revolution in the last 25 years with the standardization of video-assisted thoracoscopic surgery as the best approach of the thoracic operations. Earlier, when thoracic surgery was done through the huge thoracotomy incisions and rib spreading retractors with their excruciating pain, the chest tube pain was masked, but using VATS, has caused surgeons seeking early removal of chest tubes. With advances of the instruments and stapling devices, the amount of air-leak was significantly reduced, diminishing the time needed for chest tube drainage. Methods A prospective study, from May 2014 to December 2016, included 29 patients admitted to the service in Faculty of Medicine, Assiut University. Patients had different clinical presentations. Undergoing VATS procedures (uni-portal VATS in all except one), they were then divided into two groups: study group, those with intra-operative removal of chest tube, (16 patients) and control group (13 patients). Patients would undergo an air-leak test. Results The two groups had a significant difference in the post-operative mean pain score (study group 4.9 & control group 7.8), and hospital stay (study group 1.4 & control group 4). Both groups were similar in occurrence of post-operative pneumothorax (study group 25% & control group 23.1%), with only 2 patients (12.5%) in the study group requiring re-insertion of chest tube. Conclusions Intra-operative removal of chest tube during VATS procedures was a safe technique in well selected patients with an intra-operative successful air-leak test with radiological and clinical follow-up. This technique provided lesser post-operative pain with shorter hospital stay.

The uniportal VATS approach is now taking the lead in the practice of thoracic surgery and is transforming the way we operate. We describe here how to perform a uniportal VATS debridement and decortication, with a special focus on tips and tricks for getting inside an empyema pouch and identifying the optimal plane of cleavage for decortication.

Objectives Cleft sternum is an infrequent anomaly which typically drags parents' attention since birth with subsequent surgical repair in early years of life but few cases ask for surgical consultation at adulthood. We report 3 cases during the last 10 years in whom we use only a release oblique osteochondrotomy incision to primary repair the cleft without the need for a prosthetic material or bone graft. Methods A retrospective descriptive study for three cases of congenital complete cleft sternum surgically repaired between 2004 and 2014 at cardiothoracic surgery department, Assiut University, Egypt. Surgery was done through a vertical midline incision, removal of the redundant skin, and the sternal edges were defined. Pectoralis muscle flap were created on both sides. A sliding cartilage flap was created between the second and fourth costal cartilages, and the sternal bars from both sides were advanced to meet in the midline followed by sternal approximation with stainless steel sutures of appropriate size. Results Mean ages of cases we have operated were 17.6 years ± SD 1.52. All patients recovered smoothly, extubation was done in the operating room and with no need for postoperative mechanical ventilation. Chest wall movement was stable completely. Patients were discharged between 4th – 6th days postoperatively according to pain tolerance. Cosmetic results were acceptable for all patients. Chronic pain/neuralgia were not reported in 2 years follow up period. Conclusions We propose a simple surgical technique for repair of cleft sternum in adulthood without the need for prosthetic material or bone grafts. In comparison with previous techniques, it offers the theoretical advantage of restoring the anatomy without the risk of infection of the prosthesis or hazards of bone graft.

Intrapericardial extracavitary lipomas are very rare. We would like to share our experience with a case of intrapericardial lipoma in a male aged 54 years. His mode of presentation and radiographic investigations are reported. He was successfully managed via a right anterior thoracotomy.

This tutorial shows the resection of a bulla by uniportal video assisted thoracoscopic surgery in bullous lung disease. This disease is a benign condition requiring treatment in cases of severe dyspnea, spontaneous secondary pneumothorax, repeated infection, hemoptysis, and an increase in bulla size. The uniportal VATS approach results in less pain, better cosmoses, and a quicker recovery for the patient.

With the newly emerging interest of minimally invasive surgery in thoracic surgery specialty, more surgeons are skilled enough to try to perform minimally invasive surgery for advanced stages of lung cancer that was formerly deemed as inoperable. This is derived from more interest by the community to ask for less invasive operations and speedy recoveries. Fears about safety, technical feasibility, and oncologic equality to the conventional, open resections are still not fully covered. Surgical options in those cases should be considered if patients have acceptable pulmonary and cardiac performance status with minimal comorbidities. A surgeon is morally certain that all known diseases can be removed, and that conversions should be considered as a safety approach during the operation if needed and not viewed as a failure.

Objective Hemothorax is the most frequent complication from chest trauma. In most of the cases, chest tube will be sufficient for treatment, but in a minority of patients, more intervention will be needed to evacuate a retained hemothorax. We aimed in this study to compare between video-assisted thoracoscopy (VATS) evacuation of retained clotted blood and reinsertion of thoracostomy tube to explore the safety and complications of such techniques. Patients and methods A prospective randomized case–control study was conducted on patients who presented with retained hemothorax admitted to trauma unit from July 2017 to July 2018. Results During the time frame from July 2017 to July 2018, our trauma unit got 44 879 patients. Approximately 14 722 of them needed admission, with only 288 patients requiring primary chest tube for hemothorax, of which 35 patients met the inclusion criteria of this study. They were then divided into two groups: group A (16 patients) underwent evacuation by VATS. The operative time for VATS ranged from 24 to 130 min, with mean time 79.8 min (after VATS), and needed drainage days range from 2 to 7 days, with mean of 3.31 days. One (6.25%) patient need thoracotomy. No wound infection or empyema was present in group A. Control group (group B) included 19 patients in whom the chest tube was reinserted. The needed days of drainage range from 4 to 10 days, with mean 6.47 days, with significant value (P = 0.001). Three (15.78%) patients had wound infection at the site of thoracostomy tube. On follow-up, we noticed four (20.05%) patients with empyema. Conclusion Early VATS for evacuation of retained hemothorax is feasible and safe in trauma patients. Moreover, VATS evacuation leads to shorter hospital stay and less need for open thoracotomy in comparison with reinsertion of a chest tube.

Department of Cardiothoracic Surgery, Faculty of Medicine, Assiut University Heart Hospital, Assiut University, Assiut, Egypt Department of Chest Diseases, Assiut Police Hospital, Assiut, Egypt Corresponding author: Hussein Elkhayat, Department of Cardiothoracic Surgery, Faculty of Medicine, Assiut University Heart Hospital, Assiut University, Assiut, Egypt. Tel: +20-882413773, Fax: +20-882333327, E-mail: dr_khayat@hotmail.com

Sewing needle penetration into the heart is a rare occurrence. Clinical presentation and timing substantially affect the decision of surgeon and management approach. In this article, we report an 18-month case with a sewing needle penetration into the heart which was mistaken as foreign body aspiration showing migration. It should be kept in mind that sharp foreign objects can reach into the thoracic cavity through not only alimentary tract and airways, but also through externally penetrating trauma.