Online digital audiometry vs. conventional audiometry: a multi-centre comparative clinical study.

OBJECTIVE: The primary objective of the current study was the validation of a cloud-centralized audiometry system for clinical practice. DESIGN: A cross-sectional study design was used. STUDY SAMPLE: A convenience sample of patients (>10 years old) booked for follow-up appointments were invited to participate. Participants completed both conventional and online digital audiometry in a standard sound treated clinic space during a single clinic visit; tests were completed in random order. Data for both ears were included. Patients were from one of three audiological practices. RESULTS: A total of 41 participants completed both audiometric tests. Validation study results showed that the mean difference between the two audiometric test results remained within 5 dB HL for both air and bone conduction thresholds at all tested frequencies. CONCLUSIONS: Online digital audiometry has been demonstrated as a clinically accurate method for hearing assessment.

The Interest of Performing "On-Demand Chest X-rays" after Lung Resection by Minimally Invasive Surgery.

Background There is a lack of consensus in hospital centers regarding costly daily routine chest X-rays after lung resection by minimally invasive surgery. Indeed, there is no evidence that performing daily chest X-rays prevents postoperative complications. Our objective was to compare chest X-rays performed on demand when there was clinical suspicion of postoperative complications and chest X-rays performed systematically in daily routine practice. Methods This prospective single-center study compared 55 patients who had on-demand chest X-rays and patients in the literature who had daily routine chest X-rays. Our primary evaluation criterion was length of hospitalization. Results The length of hospitalization was 5.3 ± 3.3 days for patients who had on-demand X-rays, compared with 4 to 9.7 days for patients who had daily routine X-rays. Time to chest tube removal (4.34 days), overall complication rate (27.2%), reoperation rate (3.6%), and mortality rate (1.8%) were comparable to those in the literature. On average, our patients only had 1.22 ± 1.8 on-demand X-rays, compared with 3.3 X-rays if daily routine protocol had been applied. Patients with complications had more X-rays (3.4 ± 1.8) than patients without complications (0.4 ± 0.7). Conclusion On-demand chest X-rays do not seem to delay the diagnosis of postoperative complications or increase morbidity-mortality rates. Performing on-demand chest X-rays could not only simplify surgical practice but also have a positive impact on health care expenses. However, a broader randomized study is warranted to validate this work and ultimately lead to national consensus.

Robot-Assisted Thoracoscopic Surgery versus Video-Assisted Thoracoscopic Surgery for Lung Lobectomy: Can a Robotic Approach Improve Short-Term Outcomes and Operative Safety?

Background Minimally invasive surgery has been recently recommended for treatment of early-stage non-small cell lung cancer. Despite the recent increase of robotic surgery, the place and potential advantages of the robot in thoracic surgery has not been well defined until now. Methods We reviewed our prospective database for retrospective comparison of our first 28 video-assisted thoracoscopic surgery lobectomies (V group) and our first 28 robotic lobectomies (R group). Results No significant difference was shown in median operative time between the two groups (185 vs. 190 minutes, p = 0.56). Median preincision time was significantly longer in the R group (80 vs. 60 minutes, P < 0.0001). The rate of emergency conversion for uncontrolled bleeding was lower in the R group (one vs. four). Median length of stay was comparable (6 days in the R group vs. 7 days in the V group, p = 0.4) with no significant difference in the rate of postoperative complications (eight Grade I in both groups, four Grade III or IV in the V group vs. six in the R group, according to the Clavien-Dindo classification, p = 0.93). No postoperative cardiac morbidity was observed in the R group. Median drainage time was similar (5 days, p = 0.78), with a rate of prolonged air leak slightly higher in the R group (25 vs. 17.8%, p = 0.74). Conclusion Perioperative outcomes are similar even in the learning period but robotic approach seems to offer more operative safety with fewer conversions for uncontrolled bleeding.

Video-assisted thoracic surgery for left upper lobectomy for complex lesions: how to extend the indication with optimal safety?

The feasibility of extending the VATS approach to locally advanced NSCLC has been described with good clinical outcome. These complex resections are still technically challenging and patient safety must remain the highest priority. In this article, we describe our routine VATS approach for left upper lobectomy in proximal, locally advanced lesions. Both surgical and anaesthesiology teams are trained during simulation sessions to respond rapidly in case of urgent thoracotomy. Encircling arterial and venous vessels allow control of inadvertent bleeding during difficult dissection. Also, whenever needed the double vessel control technique is a time saver waiting for conversion to thoracotomy.

First Comparison between [18f]-FMISO and [18f]-Faza for Preoperative Pet Imaging of Hypoxia in Lung Cancer.

Hypoxic areas are typically resistant to treatment. However, the fluorine-18-fluoroazomycin-arabinoside (FAZA) and fluorine 18 misonidazole (FMISO) tracers have never been compared in non small cell lung cancer (NSCLC). This study compares the capability of 18F-FAZA PET/CT with that of 18F-FMISO PET/CT for detecting hypoxic tumour regions in early and locally advanced NSCLC patients. We prospectively evaluated patients who underwent preoperative PET scans before surgery for localised NSCLC (i.e., fluorodeoxyglucose (FDG)-PET, FMISO-PET, and FAZA-PET). The PET data of the three tracers were compared with each other and then compared to immunohistochemical analysis (GLUT-1, CAIX, LDH-5, and HIF1-Alpha) after tumour resection. Overall, 19 patients with a mean age of 68.2 ± 8 years were included. There were 18 lesions with significant uptake (i.e., SUVmax >1.4) for the F-MISO and 17 for FAZA. The mean SUVmax was 3 (±1.4) with a mean volume of 25.8 cc (±25.8) for FMISO and 2.2 (±0.7) with a mean volume of 13.06 cc (±13.76) for FAZA. The SUVmax of F-MISO was greater than that of FAZA (p = 0.0003). The SUVmax of F-MISO shows a good correlation with that of FAZA at 0.86 (0.66-0.94). Immunohistochemical results are not correlated to hypoxia PET regardless of the staining. The two tracers show a good correlation with hypoxia, with FMISO being superior to FAZA. FMISO, therefore, remains the reference tracer for defining hypoxic volumes.

Mediastinal Bronchogenic Cyst With Acute Cardiac Dysfunction: Two-Stage Surgical Approach.

We describe a two-stage surgical approach in a patient with cardiac dysfunction and hemodynamic compromise resulting from a massive and compressive mediastinal bronchogenic cyst. To drain this cyst, video-assisted mediastinoscopy was performed as an emergency procedure, which immediately improved the patient's cardiac function. Five days later and under video thoracoscopy, resection of the cyst margins was impossible because the cyst was tightly adherent to the left atrium. We performed deroofing of this cyst through a right thoracotomy. The patient had an uncomplicated postoperative recovery, and no recurrence was observed at the long-term follow-up visit.

Anterior subcarinal node dissection on the left side using video thoracoscopy: an easier technique.

Lobectomy for lung carcinoma is usually associated with complete node dissection, but it is often difficult to perform using video thoracoscopy, especially on the left side. In this case, our team uses an anterior technique for subcarinal lymphadenectomy. After left lobectomy, we lift the bronchial stump by its anterior face to open and dissect the subcarinal space. Exposure is difficult using the more usual technique of posterior subcarinal lymphadenectomy, and the different techniques (often requiring retractors) remain complex because some vessels might be injured. We recommend using anterior lymphadenectomy, which should facilitate video thoracoscopy for lymphadenectomy on the left side.

National review of use of extracorporeal membrane oxygenation as respiratory support in thoracic surgery excluding lung transplantation.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) for respiratory support is increasingly used in intensive care units (ICU), but rarely during thoracic surgical procedures outside the transplantation setting. ECMO can be an alternative to cardiopulmonary bypass for major trachea-bronchial surgery and single-lung procedures without in-field ventilation. Our aim was to evaluate the intraoperative use of ECMO as respiratory support in thoracic surgery: benefits, indications and complications. METHODS: This was a multicentre retrospective study (questionnaire) of use of ECMO as respiratory support during the thoracic surgical procedure. Lung transplantation and lung resection for tumour invading the great vessels and/or the left atrium were excluded, because they concern respiratory and circulatory support. RESULTS: From March 2009 to September 2012, 17 of the 34 centres in France applied ECMO within veno-venous (VV) (n=20) or veno-arterial (VA) (n=16) indications in 36 patients. Ten VA ECMO were performed with peripheral cannulation and 6 with central cannulation; all VV ECMO were achieved through peripheral cannulation. Group 1 (total respiratory support) was composed of 28 patients without mechanical ventilation, involving 23 tracheo-bronchial and 5 single-lung procedures. Group 2 (partial respiratory support) was made up of 5 patients with respiratory insufficiency. Group 3 was made up of 3 patients who underwent thoracic surgery in a setting of acute respiratory distress syndrome (ARDS) with preoperative ECMO. Mortality at 30 days in Groups 1, 2 and 3 was 7, 40 and 67%, respectively (P<0.05). In Group 1, ECMO was weaned intraoperatively or within 24 h in 75% of patients. In Group 2, ECMO was weaned in ICU over several days. In Group 1, 2 patients with VA support were converted to VV support for chronic respiratory indications. Bleeding was the major complication with 17% of patients requiring return to theatre for haemostasis. There were two cannulation-related complications (6%). CONCLUSIONS: VV or VA ECMO is a satisfactory alternative to in-field ventilation in complex tracheo-bronchial surgery or in single-lung surgery. ECMO should be considered and used in precarious postoperative respiratory conditions. Full respiratory support can be achieved with VV ECMO. Indications for and results of ECMO during surgery in patients with ARDS warrant further careful investigation.

Challenging posterior mediastinal mass resection via a minimally invasive approach with neurological monitoring.

We report a novel surgical strategy for the resection of a rare type of posterior mediastinal tumour in a young patient. A melanotic schwannoma arose from the left thoracic sympathetic chain, adjacent to the origin of the artery of Adamkiewicz. Successful excision of this tumour via a minimally invasive approach without arterial or spinal cord injury was possible with the aid of neurological monitoring using spinal-evoked potentials.

A angiografia por subtraçäo digital no diagnóstico da isquemia visceral / Digital subtraction angiography in the diagnosis of visceral eschemia

Oitenta e cinco pacientes hipertensos foram submetidos a angiografia por subtraçäo digital, para exploraçäo de artérias renais e identificaçäo da causa da hipertensäo no período de fevereiro de 1984 a agosto de 1991, nas Clínicas Péan e Bizet, Paris, França. A aortografia abdominal, em várias incidências, permitiu também a observaçäo das artérias digestivas, tronco celíaco e artéria mesentérica superior. As incidências preferencialmente estudadas foram as de perfil, oblíqua anterior esquerda e oblíqua anterior direita. A análise do tronco celíaco e da artéria mesentérica superior se faz na incidência de perfil, e das artérias renais esquerda e direita, nas incidências oblíquas anterior esquerda e direita, respectivamente. Esses pacientes foram submetidos a análise retrospectiva para identificaçäo de lesöes incidentes nas artérias digestivas concomitantes a lesöes arteriais renais. Observou-se alto porcentual de concomitância de lesöes ateroscleróticas em artérias renais e digestivas, variando de 44,7 por cento a 52,9 por cento, para lesöes do tronco celíaco, e de 14,1 por cento a 28,2 por cento, para lesöes da artéria mesentérica superior, o que justifica o estudo minuncioso da aorta abdominal e de seus ramos quando da pesquisa de lesöes arteriais renais ou digestivas