Air leaks are the most common complication after pulmonary resection. Enhanced recovery after surgery (ERAS) programs must be designed to manage parenchymal air leaks. ERAS programs should consider two components when creating protocols for air leaks: assessment and management. Accurate assessment of air leaks using traditional analogues devices, newer digital drainage systems, portable devices and chest X-rays (CXR) are reviewed. Published data suggests that digital drainage systems result in a more confident assessment of air leaks. The literature regarding the management of postoperative air leaks, including the number of chest tubes, the role of applied external suction, invasive maneuvers and discharge with a portable device is reviewed. The key findings are that a single chest drain is adequate in the majority of cases to manage an air leak, the use of applied external suction is unlikely to prevent or prolong an air leak, autologous blood patch pleurodesis may potentially shorten postoperative air leaks and there is sufficient data to support that patients can safely be discharged with a portable drainage system. There is also literature to support the design of protocols for management of postoperative air leaks. Standardization of postoperative care through ERAS programs will allow for the design of larger RCTs to better understand some of the controversies around the management of postoperative air leaks.

Osteosarcoma, the most common primary bone tumor in young individuals, frequently metastasizes hematogenously to the lungs, necessitating pulmonary metastasectomy as a common surgical procedure. While sublobar and lobar resections are accepted approaches, pneumonectomy is considered a major intervention. In this report, we present 2 intriguing cases of patients who underwent pneumonectomy for pulmonary osteosarcoma metastases, emphasizing the challenges of careful patient selection and surgical planning.

A 71-year-old female presented with progressive dysphagia and unexplained weight loss. Computed tomography and esophagogastroduodenoscopy (EGD) revealed invasive esophageal squamous cell carcinoma, which was initially treated with local radiation and esophageal stenting. Over the next year, the patient experienced multiple symptoms and hospital admissions consistent with a malignant tracheoesophageal fistula, despite negative findings on imaging, bronchoscopy, and EGD. Prophylactic antibiotics were initiated based on symptomatology to prevent septic episodes. Stent erosion into the membranous trachea was eventually observed. Neodymium-yttrium-aluminum-garnet laser bronchoscopy was used periodically to debulk the invading tumor around the stent. A percutaneous endoscopic gastrostomy tube was also inserted to facilitate enteral nutrition and avoid aspiration pneumonia. The patient reported significant improvements in respiratory symptoms following each laser debridement and has progressed well beyond the life expectancy associated with malignant tracheoesophageal fistula.

Background: A giant hiatal hernia is defined as having greater than 50% of the stomach herniated into the chest. Giant hernias have an increased risk of gastric volvulus causing acute gastric obstruction and strangulation. Controversy exists regarding surgical intervention for asymptomatic giant hiatal hernias. The goals of this study are to determine the incidence of giant hiatal hernias found on computed tomography (CT), the number of these patients referred for surgical assessment and/or needing emergent surgical intervention. Methods: A diagnostic imaging database for the health district was searched from January 2010 to January 2015. Surgical interventions, emergency department encounters, and surgical referrals were reviewed using personal health records. Results: A total of 357,213 CT reports were searched. Hiatal hernias were identified in 185 patients (50.2%). Type III and IV hiatal hernias were reported in 75 patients (38%) including 30 (16.2%) giant hernias. Type IV hernias had the highest percentage of emergency department visits (36.4%). Seven (23.3%) patients with a giant hiatal hernia required emergent repair compare to no patient with a non-giant hernia. However, only 6 (20%) patients with a giant hiatal hernia were referred for surgical assessment. Conclusions: Emergency department encounters and need for emergent surgical intervention were highest among Type III and IV hiatal hernias. Patients with giant hiatal hernia are at increased risk for needing emergent surgery. Patients with a giant hiatal hernia should be referred for surgical assessment because of an increased risk of needing emergent surgical intervention.

Solitary fibrous tumours of the pleura are a rare finding; those with brain metastases are rarer still. Here, we present the evolution of a pleural solitary fibrous tumour in a 70-year-old male treated surgically, and subsequent brain metastasis requiring emergent craniotomy and excision. The patient received adjuvant radiotherapy to the brain and had no recurrence of brain metastases; however, 1 year surveillance imaging demonstrated metastases to the lungs, liver and spleen for which he received chemotherapy but eventually succumbed to the disease process. Solitary fibrous tumours are most often slow-growing, relatively benign neoplasms. However, up to 10% are malignant. This case highlights the importance of surgical resection of these benign tumours with malignant potential.