Evaluation of surgical approaches to anatomical segmentectomies: the transition to minimal invasive surgery improves hospital outcomes.

BACKGROUND: We aim to evaluate the transition process from open to video-assisted thoracoscopic surgery (VATS) anatomical segmentectomies in a regional thoracic surgical unit. METHODS: In a retrospective study from January 2013 to December 2015, we identified all anatomical segmentectomies performed in our unit. Pre, peri and postoperative data were compared between the three years (2013, 2014 and 2015) and according to operative approach. Thoracotomy after VATS intraoperative biopsy was considered a conversion for the purposes of the study. RESULTS: A total of 86 consecutive cases [56 females and 30 males, median age 70 years (range, 43 to 83 years); median FEV1 of 78% predicted (range, 41% to 126%)] were included. There was a significant change in the surgical approach with time. Fifty-two cases underwent VATS (73% via single-port) and 34 open surgeries, including nine conversions. There were no postoperative deaths in the VATS group and one in the open group. Operative outcomes were similar over time with no haemorrhagic events, equivalent R1 resection and nodal stations explored in all lymph node positive patients. In node negative cases however, open surgery was associated with more extensive mediastinal exploration. Patients in 2015 had a shorter hospital stay in comparison to those in previous years [median 4 days (range, 1-15 days) vs. median 6 days (range, 3-27 days), P=0.01]. There were no differences in the incidence of complications or readmissions to hospital over time. CONCLUSIONS: The transition over a short period of time from open to single-port VATS segmentectomy has allowed us to significantly reduce postoperative hospital stay without compromising operative or postoperative outcomes.

The influence of prior multiport experience on the learning curve for single-port thoracoscopic lobectomy: a multicentre comparative study†.

OBJECTIVES: Competency in video-assisted thoracoscopic (VATS) lobectomy is estimated to be reached after the surgeon completes 50 cases. We wanted to explore the impact of competency in performing multiport VATS lobectomies on completing the needed number of single-port VATS. METHODS: In a retrospective multicentre study, 6 individual surgeons (3 with previous competency in multiport VATS lobectomy and 3 without) submitted their first 50 cases of single-port VATS lobectomies. Extended and sublobar resections were excluded. Pre-, peri- and postoperative data were compared between the groups of surgeons. Chi-square and Wilcoxon's rank tests were used. The less experienced surgeons had previously attended dedicated training courses and visited with experts. RESULTS: A total of 300 cases were included [150 in Group A (surgeons with previous experience performing multiport VATS) and 150 in Group B (surgeons without extensive experience performing multiport VATS)]. Surgeons in Group B performed significantly more elective open lobectomies during their learning curve period than surgeons of Group A (58 vs 1). Patients in Group B were older and had more risk factors. There were 3 in-hospital deaths (respiratory failure, sepsis and fatal stroke). There were no differences between the groups in operative time, intensive care unit admissions, hospital stay, total complications, tumour size or number of N2 stations explored. Only the duration of intercostal drainage (2 vs 3 days, 0.012), incidence of respiratory tract infections (1% vs 7%, P = 0.002) and conversion rates (4% vs 12%, P = 0.018) were better in Group A. Patients characteristics played a role in the development of respiratory infections and longer drainage times but not in the need for conversion. CONCLUSIONS: Overall, postoperative outcomes during the learning curve period for single-port VATS lobectomies are not noticeably affected by previous multiport VATS experience. Less experienced surgeons were more selective in order to achieve competency (more lower lobectomies and more open operations). Competency in single-port VATS lobectomy can be acquired safely with adequate training and good case selection but will be achieved 'faster' with previous competency in multiport VATS lobectomy.

Indication for VATS sublobar resections in early lung cancer.

When dealing with early non-small cell lung cancer (NSCLC) sublobar resections still remain part of the surgical armamentarium. In selected patients with lung cancer, the combination of the potential benefits of parenchyma sparing procedures to the limited trauma provided by Video Assisted Thoracic Surgery (VATS) techniques can become very appealing. Two main groups are included: non-anatomical (wedges) and anatomical (segmentectomies) excisions. We describe the techniques, results and potential indications of both of these techniques.

Initial single-port thoracoscopy to reduce surgical trauma during open en bloc chest wall and pulmonary resection for locally invasive cancer.

OBJECTIVES: En bloc pulmonary and chest wall resection is the preferred method of treatment for locally invasive lung carcinoma. However, it carries major trauma to the chest wall, especially in cases with chest wall involvement distant to the potential location of 'traditional' thoracotomies. We describe an alternative method of estimating the boundaries of chest wall resection employing video assisted thoracoscopic surgery (VATS) and hypodermic needles. METHODS: VATS delineation of boundaries of chest wall involvement by lung cancer has been performed in six patients who gave written consent. In one case the single-port thoracoscopic examination revealed unexpected distant pleural metastases thus preventing from resection. The other 5 patients, three males and two females [median age of 60.5 (range 39 to 75) years] underwent en bloc anatomical lung resection in addition to chest wall excision and reconstruction for T3N0 lung cancer. RESULTS: In these five cases the chest wall opening was restricted to the extent of the rib excision, and the pulmonary resection was performed via the existing chest wall opening without requiring extension of the thoracotomy or any rib spreading. DISCUSSION: Minimally invasive techniques aid to delineate the boundaries of chest wall involvement of lung cancer and intraoperative staging. This helped tailoring the surgical approach and location of the thoracotomy, and prevented rib-spreading or additional thoracotomies in our cases.

The left thoracotomy approach for excision of distal tracheal carcinoma in the presence of right-sided aorta.

Tracheal primary carcinoma is a rare malignancy, and we believe that its presence in a patient with a right-sided aorta has not been described before. We report a case of a primary tracheal squamous carcinoma in a patient with a four-branched right-sided aortic arch. The patient underwent a tracheal resection approached by a left thoracotomy. The surgical exposure was excellent once the ligamentum arteriosum had been divided. All the aortic arch branches and the phrenic, vagus and recurrent laryngeal nerves were identified and preserved.

Initial experience with the use of biological implants for soft tissue and chest wall reconstruction in thoracic surgery.

BACKGROUND: Synthetic materials have traditionally been used for tissue reconstruction in thoracic surgery. New biomaterials have been tested in other areas of surgery with good results. The aim of our study is to evaluate our initial experience using prostheses in extended thoracic surgery. METHODS: A review was performed of all patients who underwent extended surgical procedures requiring soft tissue reconstruction with bioprosthetic materials after thoracic surgery from August 2009 to August 2011. A total of 44 consecutive patients were included. Operations involved radical pleurectomy and decortication for mesothelioma (n = 29), extended operations for thoracic malignancies (n = 8), surgery for trauma or perforated organs or complications (n = 6), and for benign infectious causes (n = 1). RESULTS: A total of 76 patches were used in 44 patients (median of 2; range 1 to 3 per patient). Median hospital stay was 13 (range 5 to 149) days. Three patients died during the postoperative period (6.8%); pulmonary embolism 5 days after intrapericardial pneumonectomy with chest wall reconstruction, fatal pneumonia 26 days after radical pleurectomy and decortication for mesothelioma, and bronchopleural fistula 11 days after pneumonectomy with diaphragm and atrium excision for lung cancer after initial chemoradiotherapy. No other surgical exploration or removal of patches has been required for infection. CONCLUSIONS: Our initial experience of using bioprosthetic patches for soft tissue reconstruction in thoracic surgery has proven satisfactory with overall acceptable results. The infection rates are low even when a proportion of procedures were performed under contaminated environments. Biologic prosthesis should be part of the surgical options to reconstruct soft tissues in thoracic surgery.

Neuronal antibodies and paraneoplastic sensory neuropathy in thymoma.

Thymoma, a common anterior mediastinal tumour, may present with paraneoplastic neurological symptoms. The presence of neuronal anti-Hu paraneoplastic antibodies in thymoma patients is very rare. Here, we describe a patient who presented with symptoms of a sensory peripheral neuropathy in the presence of onconeural antibodies cross-reactive with Hu antigen, in whom an underlying thymoma was diagnosed. Subsequent minimally invasive thymomectomy improved her neurological symptoms significantly.

The fate of abstracts presented at annual meetings of the Society for Cardiothoracic Surgery in Great Britain and Ireland from 1993 to 2007.

Although the presentation of original research to learned societies is valuable, the target should be publication in a peer-reviewed journal. Therefore, the strength of a meeting may be assessed by the rate of the subsequent publication of papers from the presented abstracts. We conducted an analysis of abstracts presented at consecutive annual meetings of the Society for Cardiothoracic Surgery (SCTS) in Great Britain and Ireland over a 15-year period. Abstract books and other documentation from the 1993-2007 meetings were reviewed; abstracts from other major Cardiothoracic Surgery meetings held in 2007 were also reviewed. Medline was searched to identify the peer-reviewed publications arising from each work presented. For abstracts presented at SCTS in 2003-07, the factors potentially associated with publication were analysed by logistic regression. If no publications were identified, authors were contacted through a standardized email questionnaire to ascertain its status and reasons for non-publication. Over the 15-year period, 909 abstracts were presented at the SCTS meetings. The rate of publication rose from ~30% in the mid-1990s to consistently >60% from recent meetings, with a high of 81.3% from 2006. However, in comparison with other Cardiothoracic Surgery meetings in 2007, the chance of subsequent publication from SCTS (66.7%) was lower than from the European Association for Cardio-Thoracic Surgery (75.0%), the American Association for Thoracic Surgery (83.9%) and The Society of Thoracic Surgeons (72.5%) meetings. For abstracts presented at the last five SCTS meetings, publication was most commonly in a speciality journal (56.3%) and the median time for publication was 15 months (range -24 to 63 months) with 14 papers published prior to presentation at the meeting. On regression analysis, the only factor associated with publication was the study design comparing randomized trials and systematic reviews with other types of study (P < 0.01). Of the 90 unpublished abstracts, 48 (53.3%) authors replied to an email questionnaire revealing that 41 (85.4%) were never submitted for publication. The most common reasons given were low priority (29.6%) and low likelihood of acceptance (24.1%). In recent years, the annual meeting of the Society has become a forum for the presentation of high-quality research that usually withstands peer-review, most commonly in a speciality journal. The rate of publication has increased to consistently >60%, although those that remain unpublished are generally never submitted. This compares favourably with national meetings of other surgical societies, although it is lower than other major cardiothoracic meetings which have an affiliated journal. At a time when it has been suggested that medical research in the UK is in decline, cardiothoracic surgery appears to be thriving.

Age and neo-adjuvant chemotherapy increase the risk of atrial fibrillation following oesophagectomy.

OBJECTIVES: Atrial tachyarrhythmias occur in up to 25% of patients after major thoracic surgery. We examined risk factors for new-onset atrial fibrillation (AF) following oesophagectomy in an attempt to guide prophylactic use of anti-arrhythmic strategies. METHODS: Data were extracted from a database of patients who underwent oesophagectomy between 1991 and 2009. Patients with pre-operative arrhythmias were excluded leaving 997 patients for further analysis. Univariate and multivariate logistic regression analyses were performed to identify factors predicting AF, and receiver operating characteristic curves were generated from a model using these predictors. Statistical significance was reflected in a P-value of <0.05. RESULTS: Patients who developed AF (n = 209; 20.96%) were older (median age 70.54 years vs. 66.9 years; P < 0.01) and included 141 males (67.4%) (P = 0.11). Patients with AF were noted to have a higher in-hospital mortality rate (n = 17; 8.1% vs. n = 34; 4.8%) (P = 0.04) and a longer stay in hospital (14 days vs. 12 days; P < 0.01). Multivariate analysis identified advanced age and neo-adjuvant chemotherapy to be independent predictors of the risk of developing AF. Assessment of discriminative ability of a predictive model revealed a c-statistic of just 0.62. CONCLUSIONS: Despite the identification of age and neo-adjuvant chemotherapy as predictors of AF, the moderate discriminative ability of predictive modelling does not support the use of prophylactic anti-arrhythmic drugs. However, the high incidence of AF after major thoracic surgery makes it necessary to understand its underlying mechanisms better before prophylactic strategies are considered.

Accuracy of two scoring systems for risk stratification in thoracic surgery.

We investigate the suitability of the two existing risk stratification systems available for predicting mortality in a cohort of patients undergoing lung resection under a single surgeon. Data from the 290 consecutive patients who underwent pulmonary resection between January 2008 and January 2011 were extracted from a prospective clinical data base. In-hospital mortality risk scores are calculated for every patient by using Thoracoscore and ESOS.01 and were compared with actual in-hospital mortality. The receiver operating characteristic (ROC) curve was used to establish how well the systems rank for predicting patient mortality. Actual in-hospital mortality was 3.1% (n = 9). Thoracoscore and ESOS values (mean ± SEM) were 4.93 ± 0.32 and 4.08 ± 0.41, respectively. The area under the ROC curve values for ESOS and Thoracoscore were 0.8 and 0.6, respectively. ESOS was reasonably accurate at predicting the overall mortality (sensitivity 88% and specificity 67%), whereas Thoracoscore was a weaker predictor of mortality (sensitivity 67% and specificity 53%). The ESOS score had better predictive values in our patient population and might be easier to calculate. Because of their low specificity, the use of these scores should be limited to the assessment of outcomes of surgical cohorts, but they are not designed to predict risks for individual patients.

Thoracoscopic lobectomy through a single incision.

Over the past two decades, video-assisted thoracic surgery (VATS) has revolutionized the way thoracic surgeons diagnose and treat lung diseases. The major advance in VATS procedures is related to the major pulmonary resections. The optimal VATS technique for lobectomy in lung cancer has not been well defined yet. Most of the authors describe the VATS approach to lobectomy via three to four incisions, but the surgery can be performed by only one incision with similar outcomes. This single incision is the same as we normally use for VATS lobectomies performed by double- or triple-port technique, with no rib spreading. As our experience with VATS lobectomy has grown, we have gradually improved the technique for a less-invasive approach. Consequently, the greater the experience we gained, the more complex the cases we performed were, thus expanding the indications for single-incision thoracoscopic lobectomy.

Early outcomes of surgery for oesophageal cancer in a thoracic regional unit. Can we maintain training without compromising results?

OBJECTIVES: Meaningful exposure to oesophageal cancer surgery during general thoracic surgical training is restricted to few centres in the United Kingdom. Our Regional Tertiary Unit remains a rare 'large-volume' oesophagectomy centre. We aimed to determine the proportion of patients operated by trainees and their perioperative outcomes. METHODS: From January 2004 to September 2009, 323 patients (229 male and 94 female, median age of 69 (range 40-92) years) underwent oesophagectomy for carcinoma in our Thoracic Surgical Unit. Data were complete and obtained from a prospective departmental database. The preoperative characteristics, operative data and postoperative results were compared between the 120 patients (37%) operated by a trainee (group T) and the remainder 203 patients operated by a consultant (group C). RESULTS: The overall incidence of mortality, anastomotic leak and chylothorax were 6.5%, 5.3% and 2.2%, respectively. There were no differences in terms of age, gender, tumour location, tumour staging, preoperative spirometry or use of neoadjuvant chemotherapy between the two groups. There was no significant difference between the consultant group and the trainee group in the following key outcome measures: postoperative mortality (8% vs 4%), incidence of respiratory complications (30% vs 25%), hospital stay (14 days vs 13 days) and number of lymph nodes excised (median of 16 vs 14). CONCLUSIONS: Training in oesophageal cancer surgery can be provided in a large-volume thoracic surgical unit. It does not seem to compromise outcomes or use of resources.

Surgical management of pneumothorax: significance of effective admission or communication strategies between the district general hospitals and specialized unit.

A preoperative delay in emergency surgery for spontaneous pneumothorax is associated with a poor outcome after surgery and a prolonged hospital stay. To reduce preoperative delays, all tertiary referrals from district general hospitals to our thoracic surgery unit were processed through a 'clinical decisions unit' (CDU). Prior to the establishment of the CDU, these patients were added to a waiting list for a surgical bed. This study has reviewed the effect of this change in admission policy on the efficiency of treatment for non-elective spontaneous pneumothorax. An intergroup comparison (pre-CDU group vs. post-CDU group) was made of the following parameters: referral to transfer time, transfer to surgery time and length of inpatient stay in the referring and tertiary hospitals. There were no significant differences in gender, diagnosis, treatment in the referring hospitals, postoperative clinical outcome, or indications for or type of surgery. The total length of inpatient stay in the referring and tertiary hospitals was significantly reduced for the post-CDU group (12 vs. 15 days; P<0.001), which was attributed to the earlier transfer of patients (18 vs. 78 hours; P<0.001) hours. Allowing surgical access to a traditional medical admission unit is therefore, cost-effective and significantly improves the efficiency of non-elective pneumothorax surgery.

Lung cancer surgery in the breathless patient--the benefits of avoiding the gold standard.

OBJECTIVE: Lung cancer resection in breathless patients with severe chronic obstructive pulmonary disease (COPD) remains controversial. Whilst open lobectomy remains the gold standard, alternative approaches have been described. We undertook a retrospective, observational study to compare the outcomes of a tailored strategy combining video-assisted thoracoscopic surgery (VATS) lobectomy and anatomical segmentectomy against open lobectomy in these patients. METHOD: Clinical outcomes were studied in 84 consecutive patients (male:female ratio was 56:28, mean age 69.0 years, median preoperative-forced expiratory volume in 1s (FEV(1)) 41%) with a predicted-postoperative FEV(1) < or = 40% (median 32.8% and range 14-40%) who underwent anatomical lung resection for lung cancer. The control group consisted of 35 patients who underwent open lobectomy. The study group comprised 27 patients who underwent anatomical segmentectomy, 18 who underwent VATS lobectomy and four who underwent VATS segmentectomy. RESULTS: There were no significant inter-group differences in age (p=0.87), gender (p=0.49), preoperative FEV(1) (p=0.30) or cardiac co-morbidities (p=0.78). There were more upper lobe resections in the control group (51% vs 94%, p<0.0001). Tumour size tended to be smaller in the study group (p=0.052). There were also more incidences of stage I cancers in the study group (90% vs 71%, p=0.043). The median length of hospital stay was shorter in the study group (8 vs 12 days, p=0.054). There was no significant difference in either in-hospital mortality (8% vs 14%, p=0.48) or recurrence rate (26% vs 20%, p=0.60). However, unadjusted survival was significantly longer in the study group (median survival 54 months vs 20 months, 5-year survival 42% vs 18%, p=0.03). The survival benefit of this group remained significant in multivariate analyses (adjusted survival hazard ratio (HR) 2.39, 95% confidence interval (CI): 1.30-4.39, p=0.005). A subgroup analysis on only uncomplicated stage I cancers found a similarly worse outcome in the control group (p=0.002). After segregating surgical approach and the extent of resection, the VATS approach was identified as the critical factor conferring survival advantage to the study group (hazard ratio (HR) 2.78, 95% CI: 1.21-6.37, p=0.016). CONCLUSIONS: Despite a tailored approach to patients with severe pulmonary dysfunction, there was still significant disparity in survival between groups. Patients who underwent open lobectomy have a worse outcome despite adjusting for confounders. This survival benefit was driven by thoracotomy avoidance through VATS resection. The use of operative techniques to reduce chest-wall dysfunction should be considered in the breathless patient.

Therapeutic surgery for nonepithelioid malignant pleural mesothelioma: is it really worthwhile?

BACKGROUND: Debate remains about the relative prognostic importance of the histologic subtype of malignant pleural mesothelioma. METHODS: From a prospective database, the details of 312 malignant pleural mesothelioma surgical patients were reviewed. A comparison was made of the survival from the three major cell types. RESULTS: One hundred ninety-five patients underwent radical surgery, and 117 underwent nonradical surgery. Final histologic subtype was epithelioid in 218 patients, biphasic in 66 patients, and sarcomatoid in 28 patients. The median survival was 15.3 months in the epithelioid group, 10.1 months in the biphasic group, and 5.0 months in the sarcomatoid group. On univariate analysis in the epithelioid group, age (p = 0.005), International Mesothelioma Interest Group stage (p = 0.001), radicality of the procedure (p = 0.001), leukocytosis (p = 0.016), and preoperative or postoperative chemotherapy (p = 0.012) were significant prognostic factors influencing postoperative survival. In the biphasic group, preoperative anemia was the only significant factor (p = 0.007). In sarcomatoid patients, International Mesothelioma Interest Group stage and radicality of the surgical procedure were significant prognostic variables (p = 0.012 and p = 0.015, respectively). Multivariate analysis in the epithelioid group identified International Mesothelioma Interest Group stage (p = 0.001), radicality of the procedure (p = 0.008), and preoperative or postoperative chemotherapy (p = 0.007) as significant prognostic factors, whereas in the sarcomatoid group, only the International Mesothelioma Interest Group stage (p = 0.012) was significant and the radicality of surgery had no effect. CONCLUSIONS: The extremely poor prognosis of sarcomatoid malignant pleural mesothelioma is independent of the extent of surgery unlike other cell types. Patients with sarcomatoid histology should therefore be considered separately in trials evaluating radical procedures and adjuvant treatment. The treatment of biphasic pleural mesothelioma remains debatable.

Systematic evaluation of quality of care provided to patients undergoing pulmonary surgery helps to identify areas for improvement.

Systematic assessment of care pathways may identify areas of potential improvement beyond that generated by traditional outcome measures alone. This approach was used to audit a single-surgeon's practice of pulmonary resection [182 patients over 21 months, median age of 69 (range 18-86) years] by choosing 10 gold standards in three areas of care. Preoperative: 1) Percentage cancer patients undergoing PET scan prior to surgery, 2) Percentage of patients with predicted postoperative FEV(1) (ppoFEV(1)) <40% who had gas transfer (DLCO) measured. Perioperative: 3) Percentage of operations postponed, 4-5) Percentage of cancer patients undergoing anatomical resections and systematic lymph node excision, 6) Rate of exploratory thoracotomies. Postoperative: 7-8) Risk-adjusted mortality according to thoracoscore and ESOS.01, 9) Percentage patients admitted to intensive care unit (ICU), and 10) Percentage patients discharged directly home from our unit. Postoperative mortality (2.2%), ICU admission (4%), exploratory thoracotomy (2.7%), and home discharge (98%) fared within standards. Only 57% of patients with a ppoFEV(1)<40% had DLCO tested, and eight cases (4.4%) were postponed on the day of surgery. Analysis of the processes of care identified areas for improvement (preoperative preparation of patients, theatre cancellations and intraoperative lymph node management) even in a practice with satisfactory risk-adjusted results.

Video-assisted versus open pulmonary metastasectomy: the surgeon's finger or the radiologist's eye?

OBJECTIVE: The use of VATS metastasectomy remains controversial because of doubt surrounding its ability to remove palpable but CT occult lesions. We aim to evaluate our policy of elective VATS and compare it with our results with open metastasectomy. METHODS: Pulmonary metastasectomy was performed for metastatic colorectal adenocarcinoma in 52 patients: 27 open and 25 VATS over 8 years. The age and sex distribution was similar: median age was 66 for open and 69 years for VATS, p=0.48, 70% male in open and 64% male in VATS, p=0.31. Liver metastases were present in 37% in the open and 32% in the VATS group, p=0.46. The choice of surgical approach was dependent on the distance of the lesion from the surface of the lung. We examined the survival using the Kaplan-Meier method and we tested for differences in the incidence of missed lesions, pulmonary disease progression and repeat metastasectomy. RESULTS: There was no in-hospital mortality. There was no difference in the incidence of missed lesions (1 in VATS, none in open, p=0.48), pulmonary disease progression (11 in open, 9 in VATS, p=0.47) or recurrence in the same lobe (4 in open, 3 in VATS, p=0.54). Median follow-up was 22 (1-70) months and there was no difference to the estimated actuarial survival. Mean survival for the open group was 47 months, SE 6 with 95% CI 36-59 months and mean survival for the VATS group 35.4 months, SE 3 with 95% CI 30-41.3 months. The estimated 1- and 2-year survival was 90% and 80% for open and 90% and 72% for VATS. CONCLUSIONS: The selective use of VATS therapeutic metastasectomy in conjunction with multi-detector CT is justified in metastatic colorectal adenocarcinoma. The insertion of the surgical digit is not mandatory. Trust the radiologist's eye.