Faculty Bibliography

OBJECTIVES/OBJECTIVE:Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may develop end-stage lung disease requiring lung transplantation. We report the clinical course, pulmonary pathology with radiographic correlation, and outcomes after lung transplantation in three patients who developed chronic respiratory failure due to postacute sequelae of SARS-CoV-2 infection. METHODS:A retrospective histologic evaluation of explanted lungs due to coronavirus disease 2019 was performed. RESULTS:None of the patients had known prior pulmonary disease. The major pathologic findings in the lung explants were proliferative and fibrotic phases of diffuse alveolar damage, interstitial capillary neoangiogenesis, and mononuclear inflammation, specifically macrophages, with varying numbers of T and B lymphocytes. The fibrosis varied from early collagen deposition to more pronounced interstitial collagen deposition; however, pulmonary remodeling with honeycomb change was not present. Other findings included peribronchiolar metaplasia, microvascular thrombosis, recanalized thrombi in muscular arteries, and pleural adhesions. No patients had either recurrence of SARS-CoV-2 infection or allograft rejection following transplant at this time. CONCLUSIONS:The major pathologic findings in the lung explants of patients with SARS-CoV-2 infection suggest ongoing fibrosis, prominent macrophage infiltration, neoangiogenesis, and microvascular thrombosis. Characterization of pathologic findings could help develop novel management strategies.

BACKGROUND:Our objective is to assess the feasibility and safety of discharging patients by postoperative day one (POD1) after robotic segmentectomy and lobectomy, and to describe outcomes for patients. METHODS:A retrospective analysis was made of a prospectively collected database of a quality improvement initiative by a single surgeon. Factors associated with discharge by POD1 were evaluated using a multivariate logistic regression model. RESULTS:From January 2018 to July 2020, of 253 patients who underwent robotic anatomic pulmonary resection, 134 (53%) were discharged by POD1, 67% after segmentectomy and 41% after lobectomy. Discharge by POD1 improved with experience and was achieved in 97% of patients after segmentectomy and 68% after lobectomy in the final quartile. Thirty-one patients (12%) were discharged home with a chest tube, including 7 (2.8%) on POD1. On multivariate analysis, never smokers and segmentectomy were associated with discharge by POD1. Conversely, decreased baseline performance status and perioperative complications were associated with discharge after POD1. There were 10 minor morbidities (4%), 6 major morbidities (2.4%), and no 30- or 90-day mortality. There were 4 readmissions (1.6%), of which 1 (0.4%) was after POD1 discharge. Patient satisfaction remained high throughout the study period. CONCLUSIONS:With experience and communication, select patients can be discharged home on POD1 after robotic segmentectomy and lobectomy with excellent outcomes and high satisfaction. Discharge by POD1 was associated with never smokers and segmentectomy, and inversely associated with decreased baseline performance status and perioperative complications.

BACKGROUND:Our objective was to report the incidence, management, and outcomes of patients who developed a secondary pneumothorax while admitted for coronavirus disease 2019 (COVID-19). METHODS:A single-institution, retrospective review of patients admitted for COVID-19 with a diagnosis of pneumothorax between March 1, 2020, and April 30, 2020, was performed. The primary assessment was the incidence of pneumothorax. Secondarily, we analyzed clinical outcomes of patients requiring tube thoracostomy, including those requiring operative intervention. RESULTS:From March 1, 2020, to April 30, 2020, 118 of 1595 patients (7.4%) admitted for COVID-19 developed a pneumothorax. Of these, 92 (5.8%) required tube thoracostomy drainage for a median of 12 days (interquartile range 5-25 days). The majority of patients (95 of 118, 80.5%) were on mechanical ventilation at the time of pneumothorax, 17 (14.4%) were iatrogenic, and 25 patients (21.2%) demonstrated tension physiology. Placement of a large-bore chest tube (20 F or greater) was associated with fewer tube-related complications than a small-bore tube (14 F or less) (14 vs 26 events, P = .011). Six patients with pneumothorax (5.1%) required operative management for a persistent alveolar-pleural fistula. In patients with pneumothorax, median hospital stay was 36 days (interquartile range 20-63 days) and in-hospital mortality was significantly higher than for those without pneumothorax (58% vs 13%, P < .001). CONCLUSIONS:The incidence of secondary pneumothorax in patients admitted for COVID-19 is 7.4%, most commonly occurring in patients requiring mechanical ventilation, and is associated with an in-hospital mortality rate of 58%. Placement of large-bore chest tubes is associated with fewer complications than small-bore tubes.