Postoperative recovery with continuous erector spinae plane block or video-assisted paravertebral block after minimally invasive thoracic surgery: a prospective, randomised controlled trial.

BACKGROUND: PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) guidelines recommend erector spinae plane (ESP) block or paravertebral block (PVB) for postoperative analgesia after video-assisted thoracoscopic surgery (VATS). However, there are few trials comparing the effectiveness of these techniques on patient-centric outcomes, and none evaluating chronic postsurgical pain (CPSP). Furthermore, there are no available trials comparing ultrasound-guided ESP with surgically placed PVB in this patient cohort. METHODS: We conducted a two-centre, prospective, randomised, double-blind, controlled trial, comparing anaesthesiologist-administered, ultrasound-guided ESP catheter with surgeon-administered, video-assisted PVB catheter analgesia among 80 adult patients undergoing VATS. Participants received a 20 ml bolus of levobupivacaine 0.375% followed by infusion of levobupivacaine 0.15% (10-15 ml h-1) for 48 h. Primary outcome was Quality of Recovery-15 score (QoR-15) at 24 h. Secondary outcomes included QoR-15 at 48 h, peak inspiratory flow (ml s-1) at 24 h and 48 h, area under the pain verbal response score vs time curve (AUC), opioid consumption, Comprehensive Complication Index, length of stay, and CPSP at 3 months after surgery. RESULTS: Median (25-75%) QoR-15 at 24 h was higher in ESP (n=37) compared with PVB (n=37): 118 (106-134) vs 110 (89-121) (P=0.03) and at 48 h: 131 (121-139) vs 120 (111-133) (P=0.03). There were no differences in peak inspiratory flow, AUC, Comprehensive Complication Index, length of hospital stay, and opioid consumption. Incidence of CPSP at 3 months was 12 (34%) for ESP and 11 (31%) for PVB (P=0.7). CONCLUSIONS: Compared with video-assisted, surgeon-placed paravertebral catheter, erector spinae catheter improved overall QoR-15 scores at 24 h and 48 h but without differences in pain or opioid consumption after minimally invasive thoracic surgery. CLINICAL TRIAL REGISTRATION: NCT04729712.

Altered expression of ACOX2 in non-small cell lung cancer.

Peroxisomes are organelles that play essential roles in many metabolic processes, but also play roles in innate immunity, signal transduction, aging and cancer. One of the main functions of peroxisomes is the processing of very-long chain fatty acids into metabolites that can be directed to the mitochondria. One key family of enzymes in this process are the peroxisomal acyl-CoA oxidases (ACOX1, ACOX2 and ACOX3), the expression of which has been shown to be dysregulated in some cancers. Very little is however known about the expression of this family of oxidases in non-small cell lung cancer (NSCLC). ACOX2 has however been suggested to be elevated at the mRNA level in over 10% of NSCLC, and in the present study using both standard and bioinformatics approaches we show that expression of ACOX2 is significantly altered in NSCLC. ACOX2 mRNA expression is linked to a number of mutated genes, and associations between ACOX2 expression and tumour mutational burden and immune cell infiltration were explored. Links between ACOX2 expression and candidate therapies for oncogenic driver mutations such as KRAS were also identified. Furthermore, levels of acyl-CoA oxidases and other associated peroxisomal genes were explored to identify further links between the peroxisomal pathway and NSCLC. The results of this biomarker driven study suggest that ACOX2 may have potential clinical utility in the diagnosis, prognosis and stratification of patients into various therapeutically targetable options.

Valid consent in the acute hospital setting: perspectives of patients and members of the public.

BACKGROUND: People who interact with healthcare services have an ethical and legal right to control their own lives, to make informed decisions, and to consent to what happens to them. For consent to be considered ethically and legally valid, three key criteria must be met: consent must be given voluntarily; people must be sufficiently informed of all options; and people should have capacity to make the decision to give or withhold their consent. AIM: This study set out to explore, through the use of surveys, the perspectives of patients and public in relation to consent. METHOD: Surveys were developed for patients and the public and administered paper based (patients) and through social media (public). RESULTS: One hundred and forty surveys were posted to patients, with a 38% response rate; 104 responses were received from the public. Ninety-six percent of patients were satisfied that the decision they made was informed; 100% felt they had made a voluntary decision; 98% felt the clinician seemed knowledgeable about the procedure. What matters most to the public were being informed about the risks associated with the proposed procedure and being assured that whatever choice they make they will receive the best care possible. CONCLUSIONS: The results highlight interesting similarities and differences in relation to consent between members of the public thinking about a possible treatment, surgery, or procedure and those patients who have actually been through the process in the past 12 months. Recommendations have been developed on the basis of these findings to co-design improvements in consent practices.

Post-pneumonectomy syndrome: a systematic review of the current evidence and treatment options.

OBJECTIVES: Post-pneumonectomy syndrome (PPS) is rare and predominantly characterised by dynamic airway obstruction due to mediastinal rotation at any time point following pneumonectomy. The objective of this systematic review was to identify the optimal treatment strategy for PPS based on subjective symptomatic relief, objective radiological imaging, and treatment durability. METHODS: A systematic review was performed up to and including February 2022 based on the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. All studies that presented the management of symptomatic patients > 16 years of age with radiologically confirmed PPS were included. The primary outcome was the identification of the optimal treatment strategy and the secondary outcome was durability of the treatment. The Oxford Centre for Evidence Based Medicine level was assigned to each study. RESULTS: A total of 330 papers were identified and reviewed; 41 studies met the inclusion criteria. Data including patient demographics, indication for initial pneumonectomy, presenting symptoms, management approach, outcomes, and follow-up were assessed and analysed. Management approaches were divided into three categories: (a) mediastinal repositioning using implant prostheses; (b) endobronchial stenting; (c) other corrective procedures. One hundred and four patients were identified in total and of those, 87 underwent mediastinal repositioning with insertion of a prosthetic implant. Complications included over- or under-filling of the prosthesis (8.5%) and implant leakage (8.9%). CONCLUSION: Management of PPS using a prosthetic implant to reposition the mediastinum is the treatment of choice. Key adjuncts to optimise surgical approach and minimise complications include pre-operative CT volumetric analysis to guide implant size and intra-operative transoesophageal echocardiography to guide mediastinal repositioning.

An Analysis of JADE2 in Non-Small Cell Lung Cancer (NSCLC).

The JADE family comprises three members encoded by individual genes and roles for these proteins have been identified in chromatin remodeling, cell cycle progression, cell regeneration and the DNA damage response. JADE family members, and in particular JADE2 have not been studied in any great detail in cancer. Using a series of standard biological and bioinformatics approaches we investigated JADE2 expression in surgically resected non-small cell lung cancer (NSCLC) for both mRNA and protein to examine for correlations between JADE2 expression and overall survival. Additional correlations were identified using bioinformatic analyses on multiple online datasets. Our analysis demonstrates that JADE2 expression is significantly altered in NSCLC. High expression of JADE2 is associated with a better 5-year overall survival. Links between JADE2 mRNA expression and a number of mutated genes were identified, and associations between JADE2 expression and tumor mutational burden and immune cell infiltration were explored. Potential new drugs that can target JADE2 were identified. The results of this biomarker-driven study suggest that JADE2 may have potential clinical utility in the diagnosis, prognosis and stratification of patients into various therapeutically targetable options.

A Case Report of Resection of a Mediastinal Paraganglioma: Why All the Fuss?

Mediastinal paragangliomas are rare tumors that have only been reported in individual cases or limited case series. Surgical resection of these tumors can be challenging, as they are highly vascular and intimately related to the great vessels. Surgery is usually performed via median sternotomy with or without cardiopulmonary bypass. We present the case of a mediastinal paraganglioma that was resected via a left-sided posterolateral thoracotomy. Histopathology revealed a completely resected 38-mm paraganglioma with a positive station 5 lymph node, indicative of locally aggressive disease. Hereditary paragangliomas are associated with malignant transformation; therefore, genetic testing is important. These tumors do not respond well to chemoradiotherapy, and consequently lifelong surveillance for early detection of recurrence is recommended.

USO1 expression is dysregulated in non-small cell lung cancer.

Background: USO1 vesicle transport factor (USO1) is a vesicular transport factor crucial for endoplasmic reticulum (ER) to Golgi transport and is required for transcytotic fusion and subsequent binding of the vesicles to the target membrane. USO1 has been studied in multiple cancers revealing high levels of expression and exerting its oncogenic role by increasing cell proliferation and evasion of apoptosis. Furthermore, multiple studies have implicated dysregulation of the Erk signalling pathway in the involvement of USO1 in multiple cancers. Overall survival (OS) in non-small cell lung cancer (NSCLC) remains low despite recent advances in treatments which are mainly due to the late stage of diagnosis and a significant cohort of patients lacking an available targeted therapy. The aim of this study was to investigate USO1 expression in NSCLC. Methods: An in-house NSCLC tissue microarray (TMA) comprising (n=204 patients) was stained for USO1. Scoring intensity (H score) was used to interrogate for correlations between USO1 expression and established prognostic factors, and OS. Further evaluation of the expression of USO1 in NSCLC was done using multiple online datasets including Lung Cancer Explorer (LCE), UALCAN, GEPIA, KM plotter, TIMER2 and MuTarget. Results: USO1, when highly expressed in lung adenocarcinomas (LUADs) leads to a significantly increased OS (P=0.028). There was no significant correlation between age, smoking status, lymph node status, tumour subgroup and stage. USO1 was significantly higher in patients with tumour size <5 cm compared to those ≥5 cm (P=0.016). Overexpression in LUAD occurred at an early stage being significantly upregulated in Stage 1 and N0 tumours. USO1's first neighbours, also involved in ER-Golgi transport have altered expression in LUAD and significantly impact overall survival. Overexpression occurred independently of commonly mutated genes in NSCLC and had no correlation with changes in the TME. Conclusions: This study highlights the importance of USO1 and ER-Golgi vesicular transport system in LUAD. USO1 overexpression occurs as an early event in LUAD and independently of commonly mutated genes in NSCLC and therefore may represent an attractive diagnostic biomarker as well as a potential target for treatment.

Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence.

BACKGROUND: Acute appendicitis remains the most common cause of the acute abdomen in young adults, and the mainstay of treatment in most centres is an appendectomy. However, treatment for other intra-abdominal inflammatory processes, such as diverticulitis, consists initially of conservative management with antibiotics. The aim of this study was to determine the role of antibiotics in the management of acute appendicitis and to assess if appendectomy remains the gold standard of care. METHODS: A literature search using MEDLINE and the Cochrane Library identified studies published between 1999 and 2009, and we reviewed all relevant articles. The articles were critiqued using the Public Health Resource Unit (2006) appraisal tools. RESULTS: Our search yielded 41 papers, and we identified a total of 13 papers within the criteria specified. All of these papers, while posing pertinent questions and demonstrating the role of antibiotics as a bridge to surgery, failed to adequately justify their findings that antibiotics could be used as a definitive treatment of acute appendicitis. CONCLUSION: Appendectomy remains the gold standard of treatment for acute appendicitis based on the current evidence.

Single-centre experience of radiation exposure in acute surgical patients: assessment of therapeutic impact and future recommendations.

BACKGROUND: Radiological investigations have become a key adjunct in patient management and consequently radiation exposure to patients is increasing. The study objectives were to examine the use of radiological investigations in the management of acute surgical patients and to assess whether a guideline-based radiation exposure risk/benefit analysis can aid in the choice of radiological investigation used. METHODS: A prospective observational study was completed over a 12-week period from April to July 2008 for all acute surgical admissions. Data recorded included demographics, clinical presentation, differential diagnosis, investigations, surgical interventions, and final clinical outcome. The use of radiological investigative modalities as an adjunct to clinical assessment was then evaluated against The Royal College of Radiologists (RCR) guidelines. RESULTS: A total of 380 acute surgical admissions (M = 174, F = 185, children = 21) were assessed during the study period. Seven hundred thirty-four radiological investigations were performed with a mean of 1.93 investigations per patient. Based on the RCR guidelines, 680 (92.6%) radiological investigations were warranted and included 142 CT scans (19.3%), 129 chest X-rays (17.6%), and 85 abdominal X-rays (11.6%). Clinically, radiological imaging complemented surgical management in 326 patients (85.8%) and the management plan remained unchanged for the remaining 54 patients (14.2%). This accounted for an average radiation dose of 4.18 millisievert (mSv) per patient or 626 days of background radiation exposure. CT imaging was responsible for the majority of the radiation exposure, with a total of 1310 mSv (82.6%) of the total radiation exposure being attributed to CT imaging in 20.8% of acute admissions. Subgroup analysis demonstrated that 92.8% of the CT scans performed were appropriate. CONCLUSION: Radiation exposure was generally low for the majority of acute surgical admissions. However, it is recommended that CT imaging requests be evaluated carefully, particularly for patients with clinically confirmed pathologies and in younger women.

Thoracic Surgical Oncology: Maintaining a High-Volume Surgical Program During the COVID-19 Pandemic.

Thoracic surgical oncology is a time-sensitive, high-resource, complex surgical speciality to which coronavirus has posed a unique challenge. In response to the evolving situation in mainland Europe, our department rapidly established a coronavirus disease 2019-free site to maintain elective cancer surgery. This necessitated a strict admission pathway and perioperative patient management. It resulted in the maintenance of a high-volume, high-quality thoracic surgical oncology program with no coronavirus disease 2019-positive cases to date. Maintaining satisfactory training levels among surgical and anesthetic trainees has also been achieved. We suggest that this model could be adapted to local resource capabilities.

Left atrial appendage clipping as an adjunctive therapy in lung cancer surgery for patients with atrial fibrillation: a case report.

The left atrial appendage (LAA) is thought to be responsible for the vast majority of embolic strokes, and has become an important target in the surgical management of atrial fibrillation (AF). Epicardial clipping of the LAA has emerged as a potentially safe, durable and effective method of surgical closure, and has been performed both as a stand-alone procedure (thoracoscopic LAA clipping) and as an adjunct in patients undergoing open cardiac surgery. To our knowledge, the use of epicardial clipping in the setting of non-cardiac thoracic surgery for patients with concurrent diagnosis of AF has not been previously reported. This report highlights the case of a 70-year-old gentleman with a diagnosis of AF, who underwent concomitant LAA clipping at the time of elective thoracoscopic left upper lobectomy for a pT2aN0 lung adenocarcinoma. To our knowledge, this is the first report demonstrating the feasibility of LAA clipping as an adjunctive procedure in lung cancer surgery.

Outcomes of left atrial appendage occlusion using the AtriClip device: a systematic review.

Atrial fibrillation increases lifetime stroke risk. The left atrial appendage (LAA) is thought to be the source of embolic strokes in up to 90% of cases, and occlusion of the LAA may be safer than the alternative of oral anticoagulation. Occlusion devices, such as the AtriClipTM (AtriCure, Mason, OH, USA) enable safe and reproducible epicardial clipping of the LAA. A systematic review was performed in May 2018, based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, using the keyword 'AtriClip'. A total of 68 papers were identified and reviewed; 11 studies were included. Data including demographics, medical history intervention(s) performed, periprocedural outcomes and follow-up were assessed and analysed. A total of 922 patients were identified. LAA occlusion was achieved in 902 out of 922 patients (97.8%). No device-related adverse events were reported across the studies. The reported incidence of stroke or transient ischaemic attack post-clip placement ranged from 0.2 to 1.5/100 patient-years. Four hundred and seventy-seven of 798 patients (59.7%) had ceased anticoagulation on follow-up. The AtriClip device is safe and effective in the management of patients with atrial fibrillation, either as an adjunct in patients undergoing cardiac surgery or as a stand-alone thoracoscopic procedure.

Long-term outcomes following partial atrioventricular septal defect (AVSD) repair in Ireland.

BACKGROUND: We describe the long-term results of partial atrioventricular septal defect (AVSD) repair in a single centre encompassing a 22-year period. Described are rates of survival, reoperation and complications. METHODS: We performed a retrospective review of 556 patients undergoing AVSD repair to identify the 51 patients who underwent partial AVSD repair in Our Lady's Children's Hospital, Crumlin, Ireland, between 1993 and 2015 with long-term follow-up where available. RESULTS: A total of 29 (56.8%) of patients were male and mean age at operation was 3.32 years. Mean weight was 13.2 kg. Trisomy 21 was present in 29 (56.8%). Five patients (9.6%) had undergone prior surgery. Mean cardiopulmonary bypass time was 89 ± 36 min and mean aortic cross-clamp time was 57 ± 28 min. One patient underwent partial AVSD repair and concomitant tracheal resection and extracorporeal membrane oxygenation decannulation. One patient was managed with suture atrial septal defect (ASD) closure, the remainder with patch repair of ASD and mitral cleft closure. The length of hospital stay was 9 ± 5 days. Median follow-up was 6.06 years (IQR, 1.65-10.2 years). There were no early mortalities. One patient died 1 year following surgery (1.9%). One patient required reoperation at an interval of 2 years for severe mitral regurgitation (1.9%). CONCLUSIONS: Short- and long-term survival following partial AVSD repair in Ireland revealed excellent results compared with other published series. Reoperation incidence also compared excellently with other reports published in the literature.

Are pregnancy rates compromised following embryo freezing to prevent OHSS?

OBJECTIVE: To compare pregnancy rates with fresh and frozen embryo transfer in patients admitted to Royal Jubilee Maternity Service (RJMS), Belfast between January 1st 2004 and December 31st 2005 with ovarian hyperstimulation syndrome (OHSS). METHOD: A retrospective analysis of all ART cycles (2,283) carried out in RJMS between January 1st 2004 and December 31st 2005 and of all patients admitted to RJMS within 3 weeks of assisted reproduction therapy (ART). RESULTS: The incidence of OHSS requiring admission was 2.01%, which represented 80.70% of post-ART emergency admissions. The eventual pregnancy rate was 52.27% in all women admitted with OHSS. The pregnancy outcome in OHSS patients who received fresh embryo transfer was 56.52% and with frozen embryo transfer 50%. The main indications for fertility treatment in OHSS cases were male factor (31%) and polycystic ovarian syndrome (14%). Two distinct incidence peaks of OHSS were identified--early and late. 77.77% of women who suffered from late onset OHSS had a concurrent positive pregnancy test. CONCLUSION: The pregnancy rate in OHSS cases, both with fresh and subsequently with frozen embryo transfer, was exceptionally high. There was no statistically significant difference between fresh and frozen embryo transfer pregnancy rates. An elective embryo freezing policy to moderate the severity and duration of OHSS does not compromise outcome for women at risk of OHSS.

Herceptin responsive lung adenocarcinoma in the setting of bilateral synchronous lung primaries and breast carcinoma.

The incidence of human epidermal growth factor receptor 2 (Her-2) mutations in lung adenocarcinoma is approximately 3%; however, its significance in the management of these lung cancers remains under investigation. We describe an incidental but unique opportunity to evaluate the response to treatment with herceptin in a patient with bilateral synchronous lung primaries in conjunction with breast carcinoma. Interval imaging following surgical resection of the squamous cell carcinoma while on herceptin treatment delineated the radiological regression of the Her-2 positive lung adenocarcinoma. We feel that this case highlights the potential role for herceptin treatment in Her-2 positive lung adenocarcinomas and demonstrates the importance of screening for these mutations.

Endobronchial cryotherapy facilitates end-stage treatment options in patients with bronchial stenosis: A case series.

In keeping with international trends, lung cancer incidence and mortality are increasing among the Irish population with many patients presenting with advanced disease that excludes the potential for curative management. Consequently palliative treatment options for this patient group are being increasingly explored with various degrees of success. Endobronchial stenosis represents a particularly challenging area of management among these patients and a number of techniques have been described without the identification of a single gold standard. We report our experience of the first time use of endobronchial cryotherapy in Ireland with reference to a case series, including an example of its use in the management of benign disease, in order to support patients with borderline lung function and enable definitive palliative treatment.