Routine placement of an intercostal chest drain during video-assisted thoracoscopic surgical lung biopsy unnecessarily prolongs in-hospital length of stay in selected patients.

OBJECTIVE: Video-assisted thoracoscopic surgical (VATS) lung biopsy is frequently used in the diagnosis of parenchymal lung disease. However, there is still debate over the need for routine use of an intercostal chest drain after this procedure. This study aimed to evaluate the necessity of positioning an intercostal chest drain as an integral part of VATS lung biopsy. METHODS: Data from VATS lung biopsies performed over a 5-year period were retrospectively analysed. Patients in whom there was evidence of air leak intra-operatively following lung biopsy were excluded. Patients in whom no air leak was detected on testing were included in this study. A chest drain was inserted solely according to the surgeons' practice. RESULTS: This study included 175 patients. Of these, 82 patients had an intercostal chest drain positioned during the VATS procedure and 93 did not. There were no significant differences between the two groups in terms of mean (standard deviation (SD)), age (54.4 (14.9) vs 55.8 (13.5) years, p=0.58), gender (63% vs 59% males, p=0.56) or side of procedure (45% vs 56% right side, p=0.22). One patient in the 'no drain' group developed a clinically significant pneumothorax 24h after surgery and required a drain to be inserted. There was also no significant difference between the two groups in the incidence of radiologically detected pneumothorax immediately post-procedure (23% vs 20%, p=0.66) or on postoperative day 1 (26% vs 20%, p=0.63). There was no significant difference in the incidence of pneumothorax on follow-up (at 4-6 weeks) chest radiograph (10% vs 7%, p=0.61). In all cases, the pneumothoraces were small and not clinically significant. However, there was a significant difference in the median (inter-quartile range (IQR)) length of stay between the two groups (3 (2,4) vs 2 (1,3) days, respectively, p<0.001). CONCLUSIONS: The routine use of an intercostal chest drain after VATS lung biopsy unnecessarily increases the length of hospital stay without reduction in the incidence of pneumothorax.

Pseudo-aneurysm formation post apico-aortic conduit.

Apico-aortic conduit (AAC) is an alternative to conventional aortic valve replacement (AVR) in selected high-risk patients. It involves the interposition of a vascular graft with a prosthetic valve from the left ventricular (LV) apex to the descending thoracic aorta. Its use is uncommon but increasing. We describe the complication of pseudo-aneurysm formation following an apico-aortic procedure and its subsequent management.

Extended duration of brachially inserted intra-aortic balloon pump for myocardial protection in two patients undergoing urgent coronary artery bypass grafting.

Intra-aortic balloon pump (IABP) provides myocardial protection for patients who are at risk of myocardial injury during cardiac surgery. The haemodynamic support is crucial in patients with significant and critical coronary artery disease undergoing revascularisation procedures. Traditionally, the femoral arterial access is the preferred route for IABP insertion. This is, however, not always feasible especially in patients with concomitant occlusive peripheral vascular disease. The trans-brachial route can be used as an alternative for percutaneous insertion of the IABP. We report the technique for left trans-brachial insertion of an IABP, and illustrate our experience with two patients requiring urgent coronary artery bypass grafting (CABG) and for whom the IABP duration was over 50 h.

Is an intercostal chest drain necessary after video-assisted thoracoscopic (VATS) lung biopsy?

BACKGROUND: Video-assisted thoracoscopic surgical lung biopsy is a frequently performed procedure as an integral part of the diagnostic armamentarium for parenchymal lung disease. However, there is no evidence in the literature concerning the need for an intercostal chest drain after the procedure. METHODS: A prospective randomized control trial was set up to assess the need for intercostal chest drainage after video-assisted thoracoscopic surgical lung biopsy. Patients who did not have any air leak after the procedure (lung tested while patient was still under anesthetic) was randomized to either having a chest drain or not. The study was powered at 0.9 using an alpha of 0.01. RESULTS: Thirty patients were recruited in each group. There were no significant differences between the two groups in terms of patients' age (mean age, 59 versus 54 years), sex, history of steroid use, immediate postoperative pain scores, and wound complications. No significant pneumothoraces occurred in either group. However in the immediate postoperative phase, 28% and 15% of patients with and without chest drains, respectively, had a small (clinically not significant) pneumothorax (size <10%) on their chest radiograph. Moreover, there was significantly increased in-hospital stay in the chest drain group (median, 3 days versus 1 day; p < 0.001). At 6 weeks' follow-up, all patients had fully expanded lungs bilaterally. CONCLUSIONS: There is no need for an intercostal chest drain in patients undergoing video-assisted thoracoscopic surgical lung biopsy if no air leak is identified at the time of surgery. Patients without a drain are discharged home within 24 hours postoperatively, raising the possibility of this procedure being an outpatient procedure.

Is adhesive paper-tape closure of video assisted thoracoscopic port-sites safe?

Video assisted thoracoscopic surgery (VATS) is used in lung surgery for diagnostic, staging, curative and palliative purposes. The port-sites are usually sutured with dissolvable sutures. The use of adhesive paper-tape for port-site closure was assessed by a prospective randomised double-blind control trial comparing sutured to adhesive paper-tape closure. The following outcomes were assessed: incidence of clinically significant pneumothorax, wound healing using the ASEPSIS score, patient's comfort (pain score using a visual analog score), the time difference between the two techniques of wound closure and cost savings. Thirty patients were recruited in each group. No clinically significant pneumothoraces occurred in either group. There were no significant differences between the two groups in terms of immediate post-operative pain scores, wound cosmesis and wound complications. It was quicker to close the wound with adhesive paper-tape with a mean time of closure per unit length of wound of 9.3 and 2.2s/mm for the groups, respectively. The cost for wound closure (per patient) was $0.8 for the adhesive paper-tape group and $4.00 for the sutures.

Malignant peripheral nerve sheath tumor of the heart.

A 32-year-old man presented with dyspnea, chest pain, palpitations and ankle edema and was found to have a tumor involving the heart. This was diagnosed as malignant peripheral nerve sheath tumor, a rare sarcoma of the heart. Immunohistochemistry was utilized to establish the diagnosis. The details of the patient's clinical course, and imaging findings with morphological and immunohistochemistry data are reported.