Patient Case Discussion
Case Summary
Unreliable Clips in Medical Procedures
The surgical team discussed the case of a 15-year-old male who presented with shortness of breath and cough, leading to a pneumothorax diagnosis. The emergency room placed a chest tube without consulting general surgery, and the patient was sent home with a pigtail connected to a Heimlich valve. A moderator was surprised at this treatment, as it is unusual for such a case to be handled without surgical consultation.
Spontaneous Pneumothorax and Lung Re-Expansion
The team discussed a film that depicted a severe case of spontaneous pneumothorax, which was not caused by tension pneumothorax. They noted the presence of air in the lung and a shift of the trachea, indicating increased pressure. The presenter suggested that the pneumothorax was likely caused by a ruptured bleb. The team also discussed the follow-up films, including one taken on day of life 4, which showed the lung still not fully re-expanded. The presenter clarified that the lung was not fully re-expanded prior to discharge from the emergency room.
Collapsed Lung Treatment and Surgery
Patient was admitted to the hospital and underwent a pigtail catheter procedure. Despite some improvement, the lung was not fully re-expanded and had a persistent air leak. The team decided to proceed with surgery, which involved a VATS procedure, wedge resections, and a thoracodesis. The team clarified that they do not typically perform CT scans for spontaneous pneumothorax cases, except in specific circumstances. The team agreed that the patient should not have been sent home and that a more conservative approach would have been advisable.
Subpleural Blebs and Pneumothorax Pathology
The pathology was discussed of subpleural blebs in a teenager with pneumothorax, noting the presence of subpleural emphysema. It was suggested that the development of these blebs results from overstretch of the lungs, a theory still accepted in medical education. The patient was a tall, thin young man who regularly vaped. Concerns were raised about the long-term safety of using talc in such cases, to which the team responded that talc would not be used and they would opt for mechanical intervention instead.
Talc Pleurodesis and Pneumothorax Risks Discussed
The team discussed the long-term effects of talc pleurodesis. While there are no malignant risks, severe lung scarring could complicate future cancer resections. Dr. Todo emphasized the importance of informing patients about potential scarring and its implications for future surgeries. The group also discussed the need for standardization in care for spontaneous pneumothorax and suggested a protocol based on symptoms and pneumothorax size. One of the moderators shared his experience with a patient who had a persistent small apical pneumothorax post-surgery, which resolved with time. The team also discussed the risk of contralateral pneumothorax, estimated it to be around 15-20%.