Thoracic Surgery Omar M. Rashid 1/28/2012 – 2/3/2012

ATTDRESDATEPATIENTPROCEDUREINDICATION CassanoLanningRashid1/31/12Robotic Assisted Thymectomy Myasthenia Gravis CassanoRashid1/31/12 Left VATS, Left Lower Lobe Wedge, Mechanical Pleurodesis, Chemical Pleurodesis (Doxycycline) Recurrent PTX s/p left VATS, wedge resection & Pleurectomy for non- endometriosis-related catamenial ptx BrinsterRashid2/1/12 Trach, PEG, IVC filter Vent dependence s/p thoracoabdominal aortic aneurysm repair CassanoRashid2/1/12 Left anterior thoracotomy, wedge lung biopsy, pericardial window Pericardial effusion, pulm infiltrates (AML, bone marrow txp, sepsis)

ATTDRESDATEPATIENTPROCEDUREINDICATION CassanoRashid2/3/12 R VATS, lysis of adhesions, thoracotomy, RMLobectomy RML mass (NSCLC) CassanoRashid2/3/12 Left VATS, lysis of adhesions, thoracotomy, hernia repair Left thoracotomy incisional hernia CassanoRashid2/3/12 Left thoracotomy Loculated effusion

ATTDRESDATEPATIENTPROCEDURESCOMPLICATIONS CassanoRashid1/13/12 Left VATS, wedge resection, pleurectomy Recurrent PTX CassanoLanningRashid1/31/12Robotic Assisted ThymectomyPOUR (Post-Operative Urinary 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 ) 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