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Thoracic Surgery (VATS) in post COVID pulmonary sequelae

The second wave of COVID-19 pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has emerged as the biggest medical catastrophe impacting the whole human race.

The clinical spectrum of SARS-CoV-2 infection appears to be wide, encompassing asymptomatic infection, mild upper respiratory tract illness to severe viral pneumonia with respiratory failure and even death. Add to it the airborne transmission and high infectivity of the mutant strains which leads to rapid spread of the infection in the community. The symptomatology has drastically changed and in addition to fever and respiratory symptoms patients are also reporting redness in the eyes, rhinitis, pharyngitis, loose stools, nausea-vomiting, skin rashes etc as presenting symptoms.

COVID-19 affected patients have been seen to have pulmonary involvement second week onwards in the disease course. These may progress to severe secondary complications like acute respiratory distress syndrome (ARDS), acute kidney or cardiac injury, secondary infection and liver dysfunction. The characteristic computed tomography (CT) findings in affected patients include bilateral, multilobar ground-glass opacities (GGO) and consolidations with peripheral and posterior distribution.

Several cases of pneumothoraces in patients suffering from COVID-19 or after recovery from Covid-19 have been reported. Apart from pneumothorax few cases of cavitary lesions, lung bullae and alveolo/broncho-pleural fistulae with secondary empyema also have been encountered.

During the second wave many patients have developed pnuemothoraces and this has been the most common complication noted. Many of these patients fail to respond to simple chest tube drainage and negative suction. They continue to have prolonged air leak which may lead to Empyema Thoracis. In a patient without COVID these are indications for surgery right away. But for patients with post COVID complications, the timing of surgery and the surgical approach plays a crucial role in the successful outcome. One lung ventilation and positive pressure ventilation during anasthesia also pose a risk and can significantly worsen the respiratory condition after surgery.

A thorough preop assessement is vital. In the absence of an active air leak, these patients must be optimised and taken for surgery only after complete resolution of consolidative patches on CT wherever possible. The patients with air leak should be managed initially with ICD and negative suction preferably through digital suction device. At places where such devices are not available other devices (eg. Pleur-evac or Atrium) can be utilized. These patients generally have a major lung involvemement requiring Oxygen surpport and are nutritionally deficient as well. Aggressive efforts must be made to optimise them though physiotherapy involving graded mobilisation with oxygen support and provision through nasogastric tube of high protein (100 gm/day) and high calorie diet (2000 Kcal). Such efforts of pre-op optimization go a long way in achieving a good outcome.

Surgery must be planned only after the resolution of parenchymal changes and preferably be done at a high volume centre. Utilising a minimally invasive approach wherever feasible helps immensely in improving outcomes by decreasing post-operative morbidity and keeping shorter hospital stay.

Most of these have a ruptured lesion which shows active air leak. These can be managed with non-anatomical wedge resection of the lung. Major lung resections should be avoided as much as possible (unless mandatory) and efforts should be made to preserve lung parenchyma. Care must be taken while decorticating such lungs to avoid further air leaks. The anesthesia time should be as short as possible to avoid barotrauma to the lung and all the efforts should be made to extubate the patient on table.

Good nutritional support and aggressive chest physiotherapy MUST be continued in the post-operative period and even after discharge (preferably for 6 months). Oxygen support needs to be given to the patients as and when required.

Another dreaded complication is Pulmonary mucormycosis commonly known as “The Black Fungus”. Patients with immunocompromised status (eg. post organ transplant, patients on long term steroids, uncontrolled diabetes, ongoing chemotherapy etc.) are at increased risk of developing this complication. A high level of suspicion is required for diagnosis and once diagnosed patient must be started on the required antifungal medications. The principles of surgery remain the same as discussed earlier but since this disease is very aggressive planning the surgery after resolution of parenchymal changes might not be possible always. Also probability of requirement of major lung resection is high and increases with each passing day. The decision should be tailor-made for each patient. Liason and co-ordination between the chest physician, Intensivist, Anesthetist and Thoracic surgeon is vital for a successful outcome.

Patients with pulmonary thromboembolism need to be managed with long term anticoagulants. Occasionally such patients might develop lung abscess or empyema thoracis (if the abscess cavity ruptures). Such patients warrant a surgery. Again the initial assessment of patient and timing of surgery is crucial to achieve safe and successful outcome. These patients require a major lung resection.

As the pandemic progresses, there will be a rise in such post covid sequelae that will require surgical intervention. Being a referral centre for complicated chest surgical patients, we have seen several of these complications first-hand. Most of these cases can be managed successfully with minimally invasive ie. Video-Assisted Thoracic Surgery (VATS). Aggressive nutritional support and graded aggressive chest physiotherapy play the most important part in their management. Further research and long term follow up of these patients are required to develop more evidence based guidelines.

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