Various surgical approaches for pericardial fenestration are described in the medical literature and are used in practice. Each of them has its advantages and disadvantages depending on the cause suggesting the need of pericardial fenestration. The purpose of this study is to demonstrate whether the substernal approach after resection of the xiphoid process is a safe and effective approach to the surgical treatment of pericardial tamponade. From 2000 to 2017 in the Clinic of Thoracic Surgery at the University Hospital “Prof. Dr. St. Kirkovich” – Trakia University, Stara Zagora, Bulgaria, and in the Clinic of Thoracic Surgery at the University Hospital for Active Treatment of Pulmonary Diseases “St. Sophia”, Faculty of Medicine, Medical University – Sofia, Bulgaria, a total of seventy-one patients were diagnosed with pericardial effusion, respectively pericardial tamponade, and due to this underwent surgery. In thirty-two of them, the pericardial effusion was accompanied by a malignant pleural effusion (MPE). The VATS – Fenestratio pericardii procedure was performed on 29 patients while substernal pericardial fenestration was performed on the remaining 42 patients. Operative and perioperative mortality was not reported. Operative complications such as bleeding, damage to the coronary artery or myocardium did not occur. The average operating time was 38 min and the average length of hospital stay was 5 days. After resection and removal of the xiphoid process, the surgeon has sufficient and comfortable working space. The substernal approach after resection of the xiphoid process is a safe and effective approach to the surgical treatment of pericardial tamponade.

ABSTRACT Objectives: The aim of this research is by using sociological methods of scientific research for tracking the pain and satisfaction indicators to prove that decreasing the number of ports in the VATS (Video-assisted thoracic surgery) for Malignant Pleural Effusion reduces postoperative pain and improves patient’s satisfaction. Methods: Our study included 117 VATS procedures performed in the period from 01 January 2013 to 31 September 2016. The sociological method used to measure the pain indicator was an interview. The severity of postoperative pain was determined and reported according to a ten-point pain visual analogue scale (VAS). The degree of satisfaction was determined and reported according to a six-point and ten-point grading systems on the basis of a research interview procedure. Results: In the single-port method, the verbal pain scale for all the days covered by the research study statistically showed significantly lower values (P ˂ 0.0001) in comparison with the conventional method (P ˂ 0.0001). With regard to the patient’s satisfaction, determined on the basis of the six-point system, the results were as follows: conventional VATS approach – average 3.1 with a standard deviation of 1.1 and ranging from 0 to 5; single-port VATS approach – average 4.3 with a standard deviation of 1.0 and within the range from 0 to 6. Conventional VATS approach – 6.8 – neutral. Single-port VATS approach – 8.1 – prevailing satisfaction. Conclusions: Based on our study and the studies of other authors, it can be concluded that postoperative pain and satisfaction after VATS in patients with MPE (Malignant pleural effusion) are influenced by the number of ports and the one-port technique shows better results than the conventional three-port method. The research study was registered and approved by the Clinical Research and Ethics Committee at the ‘Prof. Dr. Stoyan Kirkovich’ AD University Multi-Profile Hospital for Active Treatment Hospital, Stara Zagora. According to Protocol No. 11, Ref. No. 12471/30.10.2015 approved are the methods used by the sociological research study which uses predefined indicators to track patients who have undergone conventional VATS and single-port VATS. Indicators: postoperative pain and satisfaction.

BACKGROUND: The present study aims at determining whether there is a statistically significant difference in postoperative survival time after VATS talc pleurodesis for palliative treatment of MPEs with VATS surgical methods -conventional and single-port, as well as revealing whether the histological variation of the primary tumor is a determining factor for postoperative survival time. METHODS: Total 147 patients with MPEs were treated at the Clinic of Thoracic Surgery. Of all 147 patients 117 underwent VATS talc pleurodesis. Survival analysis was performed by the Kaplan-Meier method. The test for comparing the equality of the survival distributions between the study groups was done by use of the Mantel-Cox Log Rank. RESULTS: For conventional VATS talc pleurodesis the Mean Survival Time was estimated at 8.170 months with SEM 1.305. Median Survival Time was estimated at 4.133 months with standard error of Mean (SEM) of 0.731. For single-port VATS talc pleurodesis Mean Survival Time was estimated at 14.849 months with SEM of 4.965. Median Survival Time was estimated at 2.900 months with standard error of 0.907. CONCLUSIONS: Histologically different variants of primary tumor after VATS talc pleurodesis cannot be interpreted as a statistically significant factor for survival (P>0.05). Histologically different types of the pulmonary carcinoma can be interpreted as a statistically significant factor for survival after VATS talc pleurodesis for treating MPE (P<0.05).

Malignant pleural effusions (MPEs) are of great importance for the prognosis of patients with oncological diseases. The current review focuses on the problem of the management of patients with MPEs complicated with trapped lung, which is still a subject of discussion. “Trapped lung” describes the situation in advanced malignant pleural disease in which the lung is unable to fully expand to fill the hemithorax, rendering the parietal and visceral pleura either partly or completely unopposed, with the presence of a residual cavity. A variety of diagnostic approach for the condition of a trapped lung (imaging or invasive) are analyzed. Nowadays the optimal approach to MPE with a trapped lung is still a subject of discussion. In general, the management is a challenge for the thoracic surgeon and medical oncologists and focuses on palliative relieving of the symptoms and reduction of the hospitalization rates rather than on cure, because of the end-stage of the neoplastic disease Different strategies for palliative treatment are debated, including placement of indwelling pleural catheters, surgical decortications (open thoracotomy or closed VATS), pleuroperitoneal shunts and intra-pleural fibrinolytic therapy. The last two are not routinely applicable. Any planned treatment should balance the therapeutic benefit provided against the required period of convalescence for a disease with a limited life expectancy. Randomized controlled multicenter clinical trials in patients with comparable diseases and comorbidity are needed to clarify which is the most appropriate treatment modality. To the present date, VATS decortication seems to be an excellent therapeutic method offering as large as possible macroscopic reduction of the tumor and re-expansion of the lung in surgically fit patients. VATS has a significantly less operative risk than radical invasive surgical interventions, minimizes the surgical trauma and pain, shortens the postoperative in-hospital stay, resulting respectively in susceptible Quality of Life improvement.

Simultaneous occurrence of tuberculosis and lymphoma is a rare combination. A primary malignant disease such as Hodgkin’s disease (HD) can cause inhibition of cell-mediated immunity, which predisposes to concomitant tuberculosis infection. A congenital and acquired immune deficiency, the presence of autoimmune diseases suggests the development of tuberculosis. There is a close link between infectious mononucleosis caused by the Epstein-Barr virus and the development of Hodgkin’s disease. We are describing a patient, aged 52 with simultaneous occurrence of tuberculosis combined with Hodgkin’s lymphoma in a single cervical lymph node material developed with bilateral malignant pleural effusions and ascites, as the Hodgkin’s disease has been determined at IV stage according to the Ann Arbor criteria.

Oesophageal ulcers are a rare pathological finding and usually they are not reason for consideration.The complications they can cause are strictures of the oesophagus as a result of callous chronic ulcer, acute haemorrhage from an oesophageal ulcer or chronic bleeding with development of post-haemorrhagic anaemia, formation of an oesophageal-bronchial fistula, malignant degeneration and perforation with development of mediastinitis and empyema.They occur most frequently in the lower third of the oesophagus, where it is located on the left of the spinal column, just before the card oesophageal junction.Oesophageal ulcers with a higher location to the border between the lower and the middle third of the oesophagus, have also been reported.These ulcers often occur along with a duodenal ulcer and duodenal gastroesophageal reflux.Due to late acceptance of the diagnosis, in most cases after development of mediastinitis and empyema, the treatment is very difficult and with high death rate and incidence rate.The surgical method of treatment with T-tube drainage for release of the oesophageal lumen and the adequate drainage of the mediastinum and the pleural cavity become more and more common in comparison to the conventional methods with removal of the oesophagus and creation of esophagogastrostomy, used widely in the past.

MPE management has been changing over the years as this is due both to the technological advancement of mini-invasive surgical methods and to the change in our knowledge about this manifestation of oncology disorder. Advanced cancer disease and poor general condition in most cases do not allow large-volume and duration of surgical procedures. VATS is becoming an increasingly large share of the operating methods of treatment of spontaneous pneumothorax, thoracic trauma, acute pleural empyema, pleural effusion, benign pleural and pulmonary lesions, secondary metastatic and primary malignant lesions - pleural, pulmonary, mediastinal and bilateral location. Diagnostic and therapeutic capabilities of VATS for simultaneous diagnosis and palliative surgical treatment make it the optimal procedure in MPE management. It should be noted that the preliminary assessment of the patient’s condition and local status with an estimate of survival time often undergoes a radical change after the video-assisted surgical procedure. Improvement is reported with an increase of predetermined survival time and improved performance status, which supports the application of more minimally invasive, non-intubated, “awake” single-port VATS.

Objective: Comparative analysis with emphasis on the advantages and disadvantages of single access thoracoscopic surgery compared to conventional three port in the treatment and diagnosis of malignant pleural effusions. Materials and Methods: Prospective results were compared in 136 patients with malignant pleural effusions operated method VATS for the period 01.01.2013 - 31.05.2016 in the Clinic of Thoracic Surgery at the University Hospital "Prof. Dr. St.Kirkovich" JSC. Stara Zagora. 70 patients were operated with single access and 66 with a conventional three port thoracoscopic surgery. Results: She stayed postoperative days average single VATS 5.7 days, conventional 7.4. Satisfaction of patients after inclusion in the management of hospitalization single VATS - 4.3 out of six in conventional 2.9. Level of post-operative pain in the incision: Single access 1st day 1.8, 2nd day 0.9, the third day 0.2 after 3rd day 0.1 Conventional access - 1st day 6.4, second day 5.0, the third day 4.0, after the third day 1.0. Operativе time: Conventional access - 39 minutes, Single access -20 minutes. Conclusion: VATS single access contributes to a greater degree to reduce the negative impacts on and without worsening a performance status of patients.

OBJECTIVE: The purpose of this study is to answer the question whether the treatment of these patients leads to control of respiratory failure by relieving and eliminating dyspnea and preserving the patients’ ability to care for themselves, as well as achieving reduction of the number of hospitalizations of patients with unsuccessful pleurodesis and effusion persistence. MATHERIAL AND METHODS: 165 patients with malignant pleural effusions were treated in the Clinic of Thoracic Surgery for the period 01 January 2013 – 31 May 2016. 70 patients underwent surgeries with single-port VATS, 66 patients were operated on with conventional VATS, while 29 patients were treated with thoracocentesis and drainage. RESULTS: Of all 165 alone 5 patients, constituting 3.03% of the total number of patients, had to be admitted to the hospital for a second time due to reaccumulation of pleural effusion within the next 30 days. Satisfactory dyspnea control was established, allowing the patients to take care of themselves. CONCLUSION: The surgical procedures – single-port and conventional VATS surgeries, thoracocentesis, drainage and placement of long-term pleural catheter with, or without, pleurodesis constitute part of the procedures achieving control over dyspnea in patients with MPE.