Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database.

INTRODUCTION: Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS: We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS: There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS: There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.

Comparative Effectiveness of Surgical Approaches for Lung Cancer.

BACKGROUND: The magnitude of association and quality of evidence comparing surgical approaches for lung cancer resection has not been analyzed. This has resulted in conflicting information regarding the relative superiority of the different approaches and disparate opinions on the optimal surgical treatment. We reviewed and systematically analyzed all published data comparing near- (30-d) and long-term mortality for minimally invasive to open surgical approaches for lung cancer. METHODS: Comprehensive search of EMBASE, MEDLINE, and the Cochrane Library, from January 2009 to August 2019, was performed to identify the studies and those that passed bias assessment were included in the analysis utilizing propensity score matching techniques. Meta-analysis was performed using random-effects and fixed-effects models. Risk of bias was assessed via the Newcastle-Ottawa Scale and the ROBINS-I tool. The study was registered in PROSPERO (CRD42020150923) prior to analysis. RESULTS: Overall, 1382 publications were identified but 19 studies were included encompassing 47,054 patients after matching. Minimally invasive techniques were found to be superior with respect to near-term mortality in early and advanced-stage lung cancer (risk ratio 0.45, 95% confidence interval [CI] 0.21-0.95, I2 = 0%) as well as for elderly patients (odds ratio 0.45, 95% CI 0.31-0.65, I2 = 30%), but did not demonstrate benefit for high-risk patients (odds ratio 0.74, 95% CI 0.06-8.73, I2 = 78%). However, no difference was found in long-term survival. CONCLUSIONS: We performed the first systematic review and meta-analysis to compare surgical approaches for lung cancer which indicated that minimally invasive techniques may be superior to thoracotomy in near-term mortality, but there is no difference in long-term outcomes.

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility.

BACKGROUND: Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS: Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS: Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS: The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Thoracic dog bite wounds in dogs: A retrospective study of 123 cases (2003-2016).

OBJECTIVE: To report the clinical, radiographic, and surgical findings and determine prognostic factors for outcome in dogs with thoracic dog bite wounds. STUDY DESIGN: Retrospective study. ANIMALS: Client-owned dogs (n = 123). METHODS: Medical records of dogs with thoracic dog bite wounds between October 2003 to July 2016 were reviewed for presenting findings, management, and outcomes. Standard wound management included debridement and sterile probing, extending the level of exploration to the depth of the wound. Univariable and multivariable binary logistic regression were used to assess risk factors for exploratory thoracotomy, lung lobectomy, and mortality. RESULTS: Twenty-five dogs underwent exploratory thoracotomy, including lung lobectomy in 12 of these dogs. Presence of pneumothorax (odds ratio [OR] 25.4, confidence interval (CI) 5.2-123.2, P < .001), pseudo-flail chest (OR 15.8, CI 3.2-77.3, P = .001), or rib fracture (OR 11.2, CI 2.5-51.2, P = .002) was associated with increased odds of undergoing exploratory thoracotomy. Presence of pleural effusion (OR 12.1, CI 1.2-120.2, P = .033) and obtaining a positive bacterial culture (OR 23.4, CI 1.6-337.9, P = .021) were associated with increased odds of mortality. The level of wound management correlated with the length of hospitalization (Spearman rank order correlation = 0.52, P < .001) but was not associated with mortality. CONCLUSION: Dogs that sustained pseudo-flail chest, rib fracture, or pneumothorax were more likely to undergo exploratory thoracotomy. Nonsurvival was more likely in dogs with pleural effusion or positive bacterial culture. CLINICAL SIGNIFICANCE: Presence of pseudo-flail, rib fracture, or pneumothorax should raise suspicion of intrathoracic injury. Strong consideration should be given to radiography, surgical exploration, and debridement of all thoracic dog bite wounds.

Minimally Invasive Left Ventricular Assist Device Implantation: A Comparative Study.

Left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. Minimally invasive approach via thoracotomy for LVAD implantation is getting popular due to its potential advantage over the conventional sternotomy approach in terms of reduced risk at re-operation due to sternal sparing. We compared the approaches (thoracotomy and sternotomy) to determine the superiority. Minimally invasive approach involved fitting of the LVAD inflow cannula into left ventricle apex via left anterior thoracotomy and anastomosis of outflow graft to ascending aorta via right anterior thoracotomy. In the sternotomy approach, both the procedures were performed via sternotomy. Outcomes in patients after LVAD implantation were compared depending on these approaches for the surgery. Two hundred and five continuous flow LVAD implantations performed between July 2006 and June 2015 at a single center were divided based on surgical approach, that is, sternotomy (n = 180) and thoracotomy (n = 25) groups. There was no significant difference between the groups in relation to patient demographics, preoperative hemodynamic parameters, laboratory markers, or risk factors. There was no significant difference between the groups in terms of postoperative hemodynamic parameters, laboratory markers, bleeding and requirement of blood products, intensive care unit, and hospital stay or complications of LVAD surgery. There were no significant differences in terms of long-term survival (Log-Rank P = 0.953), however, thoracotomy, compared to sternotomy approach, incurred significantly less requirement of temporary right ventricular assist (4 vs. 19.4%, P = 0.041). Minimally invasive bilateral thoracotomy approach for LVAD implantation in addition to benefits of sternal sparing avoids dilatation of right ventricle and reduces chances of right ventricular failure requiring temporary right ventricular assist.

Changes in quality of life from infancy to school age after esophagoesophagostomy for tracheoesophageal fistula: thoracotomy versus thoracoscopy.

BACKGROUND: We assessed the quality of life (QOL) of postoperative esophageal atresia (EA) with tracheoesophageal fistula (TEF) cases, comparing open with thoracoscopic repair. METHODS: A retrospective review of consecutive EA/TEF repairs (2001-2014) was performed, excluding cases with birth weight less than 2000 g and severe cardiac/chromosomal anomalies. Of 37 cases, 13 had thoracoscopic repair (TR) and 24 had open repair (OR) according to the operating surgeon's preference. QOL was determined regularly by scoring responses to a standard questionnaire about oral intake, vomiting, bougienage, coughing, growth retardation, learning ability, and thoracic deformity. Lower scores reflected poorer outcome. QOL after TR and OR was compared 1 year postoperatively (POQ) and after starting school (ScQ). RESULTS: Subject demographics were similar. Apart from two anastomotic leaks that resolved spontaneously after TR, there were no intraoperative complications or recurrence of TEF. Laparoscopic fundoplication was required for gastroesophageal reflux in four cases (OR 1; TR 3) (p = ns). QOL scores went from 6.5 â†’ 11.5 in OR and 4.6 â†’ 11.3 in TR, respectively. Final ScQ scores were similar, but POQ was significantly higher after OR (p < 0.05). CONCLUSION: Initial QOL scores were significantly lower after TR, but by school age QOL scores were similar.

Robotic-assisted thoracoscopic surgery for lung resection: the first Canadian series.

BACKGROUND: Robotic surgery was introduced as a platform for minimally invasive lung resection in Canada in October 2011. We present the first Canadian series of robotic pulmonary resection for lung cancer. METHODS: Prospective databases at 2 institutions were queried for patients who underwent robotic resection for lung cancer between October 2011 and June 2015. To examine the effect of learning curves on patient and process outcomes, data were organized into 3 temporal tertiles, stratified by surgeon. RESULTS: A total of 167 consecutive patients were included in the study. Median age was 66 (range 27-88) years, and 46.1% (n = 77) of patients were men. The majority of patients (n = 141, 84%) underwent robotic lobectomy. Median duration of surgery was 270 (interquartile range [IQR] 233-326) minutes, and median length of stay (LOS) was 4 (IQR 3-6) days. Twelve patients (7%) were converted to thoracotomy. Total duration of surgery and console time decreased significantly (p < 0.001) across tertiles, with a steady decline until case 20, followed by a plateau effect. Across tertiles, there was no significant difference in LOS, number of lymph node stations removed, or perioperative complications. CONCLUSION: The results of this case series are comparable to those reported in the literature. A prospective study to examine the outcomes and cost of robotic pulmonary resection compared with video-assisted thoracoscopic surgery should be done in the context of the Canadian health care system. We have presented the first consecutive case series of robotic lobectomy in Canada. Outcomes compare favourably to other series in the literature.

CONTEXTE: C'est en octobre 2011 que la chirurgie robotisée a fait son entrée au Canada comme approche à la résection pulmonaire minimalement effractive. Nous présentons à notre connaissance la première série canadienne sur la résection pulmonaire robotisée pour le cancer du poumon. MÉTHODES: Nous avons interrogé les bases de données prospectives de 2 établissements pour recenser les patients ayant subi une résection robotisée pour un cancer du poumon entre octobre 2011 et juin 2015. Nous avons organisé les données en 3 tertiles temporels et nous les avons stratifiées par chirurgien pour mesurer l'effet des courbes d'apprentissage sur les résultats enregistrés chez les patients et du point de vue des procédés. RÉSULTATS: En tout, 167 patients consécutifs ont été inclus dans l'étude. L'âge médian était de 66 ans (entre 27 et 88 ans) et 46,1 % (n = 77) étaient des hommes. La majorité des patients (n = 141, 84 %) ont subi une lobectomie robotisée. La durée moyenne des interventions a été de 270 minutes (intervalle interquartile [IIQ] 96) et la durée médiane des séjours a été de 4 jours (IIQ 3). L'intervention s'est transformée en thoracotomie chez 12 patients (7 %). La durée totale de la chirurgie et le temps passé à la console ont diminué significativement (p < 0,001) selon les différents tertiles, avec un déclin constant jusqu'au cas no 20, suivi d'un effet de plateau. Entre les tertiles, on n'a noté aucune différence significative pour ce qui est de la durée des séjours hospitaliers, du nombre de chaînes ganglionnaires excisées ou des complications périopératoires. CONCLUSION: Les résultats de cette série de cas sont comparables à ceux qui sont rapportés dans la documentation. Une étude prospective, dans le but de comparer les résultats et le coût des résections pulmonaires robotisées à ceux des chirurgies thoracoscopiques vidéo-assistées, s'imposerait dans le contexte des soins de santé canadiens. Nous avons présenté la première série de cas consécutifs de lobectomies robotisées au Canada. Les résultats se comparent favorablement à ceux d'autres séries décrites dans la documentation.

Giant central thoracic disc herniations: surgical outcome in 17 consecutive patients treated by mini-thoracotomy.

PURPOSE: Safe treatment of giant central thoracic disc herniations (cTDHs) remains a surgical challenge due to frequent calcifications, intradural extension and, importantly, the rare exposure of spine surgeons to these lesions. We report our 10-year experience in the management of giant cTDH by mini-thoracotomy and offer a detailed description of the technique. METHODS: 17 patients harboring 17 giant cTDH operated on via a mini-thoracotomy at the authors' institution between 2004 and 2014 were reviewed. All patients presented with myelopathy of varying magnitude. Mean patient age was 47 years. The mean follow-up period was 5.5 years. Median canal compromise of the cTDH was 66 %. cTDH were densely calcified in 7 (41 %), partially calcified in 6 (35 %) and soft in 4 (24 %) patients. Intradural extension of cTDH was noted in six patients (35 %). Benzels' modified myelopathy score of the Japanese Orthopedic Association was adjusted for the evaluation of thoracic myelopathy (mJOA) to assess functional outcomes. RESULTS: Successful removal of the offending cTDH was achieved in all patients. The overall mJOA Score improved from 7.9/13 to 11.1/13. Two patients with giant and densely calcified cTDH experienced a transient post-operative neurological decline. There was a statistically significant correlation between size of cTDH and intradural extension. CONCLUSION: Patients with myelopathy due to giant cTDH can be safely treated by the mini-thoracotomy approach. Postoperative neurological worsening and severe complications or incisional pain are rare. In contrast to complex posterior or thoracoscopic approaches, the mini-thoracotomy is technically straightforward and thus easy to learn for experienced spine surgeons.

[Results of the video-assisted thoracic surgery lobectomy at our department in the last five-year periode]. / Minimálisan invazív tüdolebeny-eltávolítás eredményei osztályunk ötéves anyagában.

OBJECTIVES: Herein we present the results of lobectomies performed with minimally invasive approach (video-assisted thoracic surgery - VATS) at our department during a period of five years. METHODS: Between 1 January 2011 and 31 December 2015, 197 lobectomies (malignant lesions: 176 cases, benign lesions: 21 cases) were performed by three thoracic surgeons and one resident. Demographical data are as follows: 119 female/78 male, mean age: 62.4 years (range: 41-82 years). In 2011 three VATS lobectomies were performed, equaling 2.2 % of all lobectomies in that year. During the upcomig years the number of VATS lobectomies were as follows: 2012: 7 (7.3%), 2013: 13 (12%), 2014: 59 (34.5%) and 2015: 119 (68.5%). In 153 cases multiportal (78%) and in 44 cases uniportal (22%) anterior approach was performed. The resected lobes showed the following distribution: right upper: 85, mid lobe: 5, right lower: 28, left upper: 44, left lower: 34, upper bilobectomy: 1. In two cases sleeve lobectomy was performed. In 8 cases (4%) conversion to thoracotomy was needed and among the 46 uniportal procedures, 5 cases needed to be expanded into biportal approach (11%). RESULTS: During the study period, no intraoperative, or perioperative mortality occured. Mean operative time was 123 minutes (range: 60-135 minutes) and mean time of chest drainage was 4.3 days (range: 1-27 days). Air leakage lasting more than 7 days was present in 11.7%. Reoperation was needed in 4 cases (2%), in two cases due to bleeding, and in two cases because of expansive difficulties due to extended subcutaneous emphysema. Among the 176 VATS lobectomies performed due to malignant lesions, 169 lung cancers and 7 metastases were removed. The distribution according to the stage and histology of lung cancers was as follows: IA: 100 cases, IB: 28 cases, IIA: 17 cases, IIB: 3 cases, IIIA: 16 cases, IIIB: 1 case, and IV: 4 cases; adenocarcinoma: 128 cases, squamous cell carcinoma: 26 cases, large cell carcinoma: 3 cases, small cell lung cancer: 1 case, typical carcinoid: 10 cases, and atypical carcinoid: 1 case. CONCLUSIONS: Over the years VATS lobectomy became a rutin procedure at our institution. Nowadays more than two-thirds of lobectomies are performed with minimally invasive technique. Taking the learning curve of the four thoracic surgeons into consideration, our results correlate with international data.

Surgical management of bronchopulmonary malformations.

BACKGROUND: Bronchopulmonary malformations (BPM) are rare conditions, which typically arise below the carina and can result in significant morbidity (infection and/or hemorrhage) and mortality (respiratory failure). MATERIALS AND METHODS: All children with BPM surgically treated from 2001-2014 at a tertiary care children's hospital were identified. Patient demographics, surgical indications, procedure type, estimated blood loss, pathology, perioperative complications, length of stay, and outcomes were analyzed. RESULTS: A total of 41 BPM patients underwent surgery with 98% overall survival (one abdominal BPM expired) but 100% for thoracic lesions. Resections were performed thoracoscopically (37%), thoracoscopy converted to open (22%), and via thoracotomy (37%). Poor visualization (67%) or inability to tolerate single lung ventilation (33%) led to conversions. No conversions resulted from hemorrhage or received blood transfusions. Patients with prenatally diagnosed BPM were more likely to undergo thoracoscopic surgery (odds ratio [OR], 18.2) versus nonprenatally diagnosed, P = 0.002. Open/converted patients had longer chest tube days (6.2) versus thoracoscopic (2.9), P = 0.048. Additionally, respiratory distress was a more common indication in patients aged <4 mo (OR, 28.0) versus ≥4 mo and <6 kg (OR, 40.5) versus ≥6 kg, P < 0.001. Open resections were more common in patients aged <4 mo (OR, 26.3) versus ≥4 mo, P = 0.002. Operative time was shorter and estimated blood loss (mL/kg) was greater for <6 versus ≥6 kg, P < 0.05. CONCLUSIONS: BPM resections have high overall survival. Chest tube days are shorter among thoracoscopic patients, but conversion to thoracotomy can avoid hemorrhage and need for transfusion. Size and respiratory distress limit use of thoracoscopy in young infants with BPM.

High mortality rate in hemodialysis patients who undergo invasive cardiovascular procedures related to peripheral artery disease - community-based observational study in Kumamoto Prefecture - .

BACKGROUND: Cardiovascular disease is a major cause of mortality in hemodialysis patients. The aim was to assess the relationship of various invasive cardiovascular procedures (ICP) to clinical outcome in hemodialysis patients. METHODS AND RESULTS: A total of 5,813 patients at 76 facilities were on maintenance hemodialysis in Kumamoto Prefecture. Of these, 4,807 patients at 58 institutions were enrolled. Of 4,807 patients, 212 ICP (4.4%) were performed for various cardiovascular diseases in 189 patients (3.9%). ICP included PCI (n=80), endovascular treatment (n=59), radiofrequency catheter ablation (n=8), implantation of permanent pacemaker (n=15) and ICD (n=5), thoracotomy for valvular diseases (n=16), CABG (n=14), bypass surgery for peripheral artery disease (PAD; n=8), and artificial vessel replacement for aneurysm or aortic dissection (n=7). The overall mortality rate was 10.1% (19/189 patients). The mortality rate was highest in patients who underwent ICP for PAD, compared with other ICP (PAD, 18.2%; non-PAD, 6.7%, P=0.017). Infection and PAD were significant predictors of mortality (infection: OR, 8.30; 95% CI: 1.29-65.13, P=0.027; PAD: OR, 3.76; 95% CI: 1.35-10.48, P=0.012). The presence of inflammation/malnutrition factors was associated with high mortality (OR, 15.49; 95% CI: 3.22-74.12, P=0.0006). CONCLUSIONS: In this community-based registry study of 4,807 hemodialysis patients, the mortality rate of PAD patients was high despite ICP.

Atrial septal defect surgery in adults--populational and epidemiological analysis.

UNLABELLED: Atrial septal defect (ASD) is one of the most common congenital heart diseases found in adolescents and adults. Shunt may lead to serious further complications, such as pulmonary hypertension and right heart chambers overload. The aim of this study was the analysis of the population of adult patients with ASD together with the frequency of the annuloplasty tricuspid ring implantation in ASD II and the necessity of anterior mitral valve cusp suturing due to the cleft accompanying ASD I. MATERIALS AND METHODS: The study group consisted of 58 males and 122 females aged 17 to 77. Individuals were divided into three age brackets: 17-30 years old--22%; 31-50--38,5% and 51-77--39,5%. RESULTS: In 92,8% of cases median sternotomy was performed. Other approaches were: right mini- thoracotomy 5%, 2,2% underwent lower hemisternotomy. There were 16 annuloplasties accompanying ASD closure: 13 in ASD II patients, 1 in PFO patient, 2 in ASD I patients. Average size of the pericardiac patch used to ASD type II correction was bigger in patients, who also underwent annuloplasty tricuspid ring implantation (Mann- Whitney U test: -2,25, p=0,024). CONCLUSION: Repair of ostium secundum and sinus venosus ASD can be performed safely via minithoracotomy endoscopic approach with similar outcomes as sternotomy. Beside the mitral cleft suturing in ASD I patients, annuloplasty tricuspid ring implantation is the most common additional procedure. ASD II patients, who had undergone such annuloplasties needed the bigger pericardial patches.

Spectrum of oesophageal perforations and their influence on management.

BACKGROUND: Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non-operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre. METHODS: All patients with oesophageal perforation managed in a single oesophagogastric unit in the U.K. between January 2002 and December 2012 were identified. Gastric perforations and anastomotic leaks were excluded. Data were verified using an endoscopy database, electronic and paper records. Aetiology of perforation, management and outcomes were analysed. RESULTS: There were 101 adult patients with oesophageal perforation. Complete records were not available for five patients and they were excluded from the analysis. The median age was 69.5 years. Thoracic perforations were present in 84 per cent of patients. There were 51 spontaneous perforations, 41 iatrogenic and four related to foreign bodies. Oesophageal malignancy was present in 11 patients. Forty-four patients were managed surgically, 47 without operation and five patients were considered unfit for active treatment. The in-hospital mortality rate for treated patients was 24 per cent and median length of hospital stay was 31.5 days. CONCLUSION: The management of oesophageal perforation requires specialist multidisciplinary input. It is best provided in an environment familiar with the range of treatment modalities. Management decisions should be guided primarily by the degree of contamination rather than the aetiology of the defect. The routine use of stents is unproven and controversial.

Response to preoperative chemotherapy in patients undergoing resection of pulmonary metastasis from soft tissue sarcoma - a predictor of outcome?

UNLABELLED: Approximately 50% of patients with high-grade soft tissue sarcoma (STS) will develop pulmonary metastasis. This is the most frequent cause of death and improving treatment is warranted. Preoperative chemotherapy is used for selected patients, usually those with less favorable prognosis and mainly outside clinical trials. The predicted value of histological and radiological response to preoperative chemotherapy on outcome was the main focus for this investigation. PATIENTS AND METHODS: This retrospective study comprises 93 patients with metachronous lung metastasis from STS who underwent complete metastasectomy alone (n = 41) or metastasectomy following preoperative chemotherapy (n = 52). Clinical data, histological and radiological responses to chemotherapy were recorded and survival analyses performed. RESULTS: The time from initial STS diagnosis to the appearance of metastasis was shorter in the preoperative chemotherapy group than in those treated with surgery alone (p = 0.02). However, no statistical differences in post-metastasis disease-specific survival (DSS) or progression-free survival (PFS) between the groups were demonstrated. Patients in the preoperative chemotherapy group with good (complete) histological response had improved PFS compared with poor responders (p = 0.04). Radiological partial response was an independent, favorable prognostic factor for improved PFS and DSS (p = 0.003). CONCLUSION: Despite having unfavorable disease characteristics, some patients may benefit from preoperative chemotherapy. Both histological and radiological responses to preoperative chemotherapy seem to be prognostic in STS patients undergoing complete pulmonary metastasectomy.

Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs.

OBJECTIVES: Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. METHODS: Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. RESULTS: From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). CONCLUSIONS: In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

Spontaneous hemopneumothorax: epidemiological details and clinical features.

PURPOSES: Spontaneous hemopneumothorax (SHP) may cause life-threatening blood loss. The objective of this study was to elucidate the epidemiological and clinical features of SHP. METHODS: We reviewed the records of 26 patients who underwent surgery for SHP between 1989 and 2010. We evaluated their epidemiology and clinical features by comparing them with those of 681 patients with spontaneous pneumothorax treated during the same period. RESULTS: The proportion of smokers in the SHP group was higher than that in the spontaneous pneumothorax group (P < 0.01). Seventeen cases (65.4 %) of SHP occurred on the left side. The most frequent bleeding area was the superior thoracic aperture (STA:17 cases, 65.4 %), followed by the left superior mediastinum (six cases, 23.1 %). Ten cases had intrathoracic clots greater than 500 mL, which could not be drained preoperatively. The postoperative stay of patients treated with video-assisted thoracic surgery (VATS) was shorter than that of patients treated with open thoracotomy (21 versus five cases; P < 0.05). CONCLUSIONS: A higher proportion of smokers was revealed in the SHP patients. VATS shortened the hospital stay of the patients. The particular areas that should be observed intraoperatively are the STA and the left superior mediastinum.

[Optimization of surgical strategy in complications after thoracic operations demanding recurrent surgical interventions].

A frequency of postoperative complications varied from 1-2% after endoscopic thoracal operations to 4-12% after open operations using thoracotomic access. There isn't any common approach to indications and terms of the recurrent endoscopic intervention. An analysis of postoperative complications was made after 2795 thoracothomies and 3632 videothoracoscopies required the recurrent operation in 139 patients (2.2%). The rethoracoscopies were performed on 62 patients (44.6%), thoracoscopies were carried out after thoracotomies in 40 cases (28.8%) and rethoracotomies were in 37 cases (26.6%). The more frequent indication to recurrent operation was bleeding (26.6%), pleural empyema (20.9%), fragmented pleuritis (11.5%). It was shown that thoracoscopy was an alternative to rethoracotomy as the rethoracoscopy in case of nonmassive intrapleural bleeding, clotted hemothorax, postoperative fragmented pleuritis, non-sanitized empyema region, the presence of sequestrums in this area, limited postoperative pleuritis, chylothorax, bronchopleural fistula of the size of 1-2 mm, leakage of the lung, a foreign body in pleural cavity. The lethality consisted of 35.1% after rethoracotomies and it was 12.7% after recurrent endoscopic operations.

It is feasible to operate on pathological Masaoka stage I and II thymoma patients with video-assisted thoracoscopy: analysis of factors for a successful resection.

BACKGROUND: The objectives of this study were to evaluate the feasibility of video-assisted thoracoscopic (VATS) thymoma resection and to analyze the factors contributing to a successful perioperative period. METHODS: Fifty-one patients with thymoma underwent VATS with the aim of thymoma resection. Four patients underwent minithoracotomy [due to technical difficulties, including small chest cavity, high body mass index (BMI), and disintegration of the capsule] and three patients underwent sternotomy (due to invasion of major vascular structures). The seven open-converted patients and seven other patients who underwent complete VATS thymoma resection but experienced prolonged hospital stay (≥7 days) formed Group B (n = 14), namely, the unsuccessful group, while successful VATS thymoma resection patients formed Group A (n = 37). The groups were compared with each other in terms of the characteristics of patients, tumors, and perioperative period. RESULTS: Patients' characteristics, tumor size, WHO histologic type, and complications were similar in both Groups A and B (p > 0.05). Patients with Masaoka stage I and II thymomas were significantly more frequent in Group A (p < 0.01). Tumor size was a statistically insignificant variable for the determination of a successful VATS thymoma resection (p = 0.3). Masaoka stage and the size of the thymoma did not have any correlation with each other (p > 0.05). CONCLUSIONS: The size of the thymoma was not observed to be correlated with Masaoka stage and it was not noted to be an important factor in successful VATS thymoma resection. A higher Masaoka stage (III and IVa) was found to be the only variable that predicted unsuccessful situations. Thus, Masaoka stage, rather than the size of the thymoma, should be the main concern for the surgeon.

Surgical treatment of lung cancer in octogenarians.

BACKGROUND: As the population ages, octogenarians are becoming the fastest growing patient demographic for non-small-cell lung cancer. We examined lobectomies and 30-day outcomes in this group compared with younger patients to gain insight into the optimal treatment for this challenging group. METHODS: We analyzed data from the American College of Surgeons National Quality Improvement Program for patients with lung cancer undergoing lobectomy during calendar years 2005-2010. We compared clinical risk factors, intraoperative factors, and 30-day operative mortality and major morbidity in octogenarians versus younger patients undergoing either open traditional thoracotomy (OPEN) or video-assisted (VATS) pulmonary lobar resection. RESULTS: Of 2171 patients who had lobar resections for lung cancer, 245 (11%) were octogenarians. Six hundred eight lobectomies (28.0%) were VATS procedures and 1563 (72.0%) were OPEN procedures. The VATS rate increased as patient age increased (34% VATS for octogenarians vs 27% for patients younger than 80 years; P = 0.01). Thoracic surgeons performed VATS with greater frequency compared with general surgeons, especially in octogenarians (41% VATS for thoracic surgeons vs 29% for general surgeons; P < 0.001). Univariate analysis suggests significantly increased major morbidity (pulmonary, renal, and sepsis), but not operative mortality in octogenarians; however, multivariate predictors of major morbidity include OPEN procedures, preoperative decreased functional status, history of chronic obstructive pulmonary disease, preoperative sepsis, prior radiation, diabetes, and dyspnea on exertion (all P < 0.05), but they do not include advanced age. CONCLUSIONS: Comorbidities predict most increased morbidity in octogenarians, and advanced age per se is not an important multivariate predictor of postoperative morbidity or mortality. The frequency of VATS lobectomy increased with increasing patient age, and VATS predisposes to decreased morbidity in octogenarians.

[Thymoma-associated myasthenia gravis: Clinical features and surgical results]. / La myasthénie associée aux thymomes : particularités cliniques et résultats chirurgicaux.

OBJECTIVE: The aim of this study was to compare the characteristics of myasthenic patients with and without thymoma, and the results of thymectomy in both types of patients. MATERIAL AND METHODS: A retrospective study was conducted among 66 patients who underwent thymectomy for myasthenia gravis in our department over a 10-year period (2000-2010). The surgical approach was sternotomy or anterolateral thoracotomy. Patients were divided into two groups according to the presence of thymoma: with (T-MG) and without (NT-MG) thymoma. Complete stable remission (CSR) was the primary endpoint. RESULTS: Median age was 35.09±9.89 years. The NT-MG group had 38 patients (57.57%) and the T-MG group 28 patients (42.43%). There was no difference between the two groups regarding the surgical approach (P=0.52). T-MG patients were older (40.54±15.16 vs. 31.37±9.46) (P=0.008) and predominantly male. There were more generalized forms (P=0.01) and more bulbar involvement (P=0.02) in the T-MG group. The rate of CSR at 5 years was 7% and 17% in the T-MG and NT-MG patients respectively (P=0.70). At 10 years, it was 36% and 94.73% respectively (P=0.03). CONCLUSION: Thymomatous myasthenia gravis is characterized by the severity of its clinical features. Remission rate at 10 years was significantly lower in the myasthenia with thymoma group.