The Effect of Pandemic on Lung Cancer Waiting Time - Tertiary Center Experience.

BACKGROUND: Early diagnosis and treatment of lung cancer are crucial to improve the survival and the outcomes in patients who are diagnosed with lung cancer. Many factors can affect the waiting time for lung cancer treatment, however, the corona virus disease 2019 (COVID-19) was one of the major factors that universally slowed down clinical activities in the last three years. We are aiming with this study to demonstrate how this pandemic and other factors affected the lung cancer waiting times for diagnosis and treatment. METHODS: This is a retrospective study including 670 patients who were diagnosed with lung cancer within the NHS Lothian region of Edinburgh - Scotland between March 2019 and November 2023. One hundred patients underwent curative lung resection. Patients were categorised into three groups for sub analysis. The first group included patients diagnosed before the COVID-19 pandemic, the second group included patients diagnosed during the pandemic in 2020, and the third group represents those diagnosed after the mass vaccination program was established and until November 2023. RESULTS: The average waiting time between the referral from the GP to the date of surgery in the three groups was 88.5 days, 81 days, and 83.5 days, respectively. On the other hand, the waiting times elapsing between the first surgical clinic appointment and the date of the surgery itself were 17.6 days, 18.6 days, and 21.5 days, respectively. CONCLUSION: Unexpectedly waiting times elapsing between the referral to surgery and the date of surgery amongst lung cancer patients showed improvement during the COVID-19 pandemic. This is likely due to prioritizing cancer patients. Nevertheless, actions should be considered to decrease the waiting times in general.

When teams disagree: Investigating the incidence and causes of dissent occurring in cancer multidisciplinary team meetings.

AIM: Multidisciplinary teams (MDT) are commonly involved in the care of patients with cancer. How frequently dissent occurs within MDT has not been studied. This study aimed to determine how frequently dissent was documented in cancer MDT meetings at our institution, the reasons for this, and the opinions of MDT members on how dissent should be documented and communicated. METHODS: A retrospective review of records from cancer MDT meetings at our institution from 2016 to 2020 was performed to identify cases where dissent was documented and the reasons for this. MDT members were invited to complete an online survey assessing their perceptions of how frequently dissent occurred, how comfortable they felt voicing dissenting opinions, and their opinions on how dissent should be documented and communicated. RESULTS: Dissent was recorded in 30 of 7737 MDT case discussions (0.39%). The incidence of dissent varied from 0 to 1.2% between cancer streams. The most common reason for dissent involved the role of surgery. 27% of survey respondents felt either very or somewhat uncomfortable voicing dissenting opinions. Only 3% felt that dissent should not be documented, and none that it should not be communicated in some way, although there were wide ranging of views on how this should occur. CONCLUSION: Dissent was rarely documented within cancer MDT meetings at our institution, likely due to underreporting. Measuring the incidence of dissent within an MDT may be a useful performance metric. MDT should develop policies for how dissent should be managed, documented, and communicated.

Effect of 18F-Fluciclovine Positron Emission Tomography on the Management of Patients With Recurrence of Prostate Cancer: Results From the FALCON Trial.

PURPOSE: Early and accurate localization of lesions in patients with biochemical recurrence (BCR) of prostate cancer may guide salvage therapy decisions. The present study, 18F-Fluciclovine PET/CT in biochemicAL reCurrence Of Prostate caNcer (FALCON; NCT02578940), aimed to evaluate the effect of 18F-fluciclovine on management of men with BCR of prostate cancer. METHODS AND MATERIALS: Men with a first episode of BCR after curative-intent primary therapy were enrolled at 6 UK sites. Patients underwent 18F-fluciclovine positron emission tomography/computed tomography (PET/CT) according to standardized procedures. Clinicians documented management plans before and after scanning, recording changes to treatment modality as major and changes within a modality as other. The primary outcome measure was record of a revised management plan postscan. Secondary endpoints were evaluation of optimal prostate specific antigen (PSA) threshold for detection, salvage treatment outcome assessment based on 18F-fluciclovine-involvement, and safety. RESULTS: 18F-Fluciclovine was well tolerated in the 104 scanned patients (median PSA = 0.79 ng/mL). Lesions were detected in 58 out of 104 (56%) patients. Detection was broadly proportional to PSA level; ≤1 ng/mL, 1 out of 3 of scans were positive, and 93% scans were positive at PSA >2.0 ng/mL. Sixty-six (64%) patients had a postscan management change (80% after a positive result). Major changes (43 out of 66; 65%) were salvage or systemic therapy to watchful waiting (16 out of 66; 24%); salvage therapy to systemic therapy (16 out of 66; 24%); and alternative changes to treatment modality (11 out of 66, 17%). The remaining 23 out of 66 (35%) management changes were modifications of the prescan plan: most (22 out of 66; 33%) were adjustments to planned brachytherapy/radiation therapy to include a 18F-fluciclovine-guided boost. Where 18F-fluciclovine guided salvage therapy, the PSA response rate was higher than when 18F-fluciclovine was not involved (15 out of 17 [88%] vs 28 out of 39 [72%]). CONCLUSIONS: 18F-Fluciclovine PET/CT located recurrence in the majority of men with BCR, frequently resulting in major management plan changes. Incorporating 18F-fluciclovine PET/CT into treatment planning may optimize targeting of recurrence sites and avoid futile salvage therapy.

Cognitive impairment associated with carcinoid syndrome.

OBJECTIVES: To evaluate the cognitive performance of patients with carcinoid syndrome (CS) compared with population norms and cancer patients with non-neuroendocrine (non-NET) liver metastases. BACKGROUND: The release of serotonin into the systemic circulation from metastatic small bowel neuroendocrine tumors (SB NET) causes CS. Many patients with CS followed in a multidisciplinary NET clinic seemed to exhibit a unique cognitive impairment. Because serotonin is known to influence a range of cognitive function, the question arouse as to whether cognitive impairment is another manifestation of CS. METHODS: Patients were recruited from the multidisciplinary NET and the hepatobilary cancer clinics at the cancer center. The CS group consisted of patients with proven SB NETs metastatic to liver; the cancer comparison group consisted of patients with liver metastases from non-NET cancer. All completed a self-reported cognitive questionnaire and a battery of 6 standardized neurocognitive tests. Both groups were compared to age/sex/educational-matched norms. RESULTS: Thirty-six patients with CS and 20 with non-NET metastases were enrolled. Patients with CS reported greater cognitive dysfunction in all cognitive domains than both norms and the comparison cancer group. On cognitive testing, patients with CS demonstrated weakness in initiation, processing speed, visual memory, cognitive efficiency, and delayed verbal recall compared with norms. Although the patients with non-NET cancer also demonstrated some cognitive dysfunction compared with norms, the patients with CS did significantly worse on delayed recall (P = 0.03) and marginally slower on speeded mental flexibility (P = 0.097) compared with patients with non-NET cancer. CONCLUSION: This study confirmed our clinical observation that patients with CS suffer from cognitive impairment that is different from the non-NET cancer group and population norms.

Invasive melanoma of the face: Management, outcomes, and the role of sentinel lymph node biopsy in 260 patients at a single institution.

BACKGROUND AND OBJECTIVES: The face is a common site of melanoma occurrence. The purpose of this study was to examine the management and outcomes of patients with invasive melanoma of the face. METHODS: Patients with invasive melanoma of the face managed at our institution from 1997 to 2008 were retrospectively reviewed. Details of sentinel lymph node biopsy (SNB), disease recurrence, and deaths were recorded. RESULTS: Two hundred sixty patients were reviewed (mean age 68, mean tumor thickness 0.87 mm). Of 100 patients eligible for SNB (tumor thickness ≥ 1 mm, Clark level ≥ IV, or ulceration) this was performed in only 29 (29%), and those who underwent SNB were younger than those who did not (mean age 59 vs. 79 years, P < 0.0001). SNB was successful in 28 (97%), and no complications occurred. SNB was positive in 3 (11%). After mean follow-up of 30 months, nodal recurrence occurred in 9 (3.5%) and distant recurrence in 20 (7.7%). There were 60 deaths (overall mortality 23%); attributed to melanoma in only 16 cases (disease specific mortality 6.2%). CONCLUSIONS: Facial melanoma is associated with low rates of regional recurrence despite underutilization of SNB. Older patients are less likely to undergo SNB. Due to the advanced age of patients with facial melanoma, most deaths occurring are from unrelated causes.

Role of imaging in the preoperative staging of small bowel neuroendocrine tumors.

BACKGROUND: Imaging studies are important in the preoperative staging of patients with small bowel neuroendocrine tumors (NET) and when selecting patients for cytoreduction procedures for metastatic disease. The purpose of this study was to assess the accuracy of preoperative imaging compared with operative findings in the staging of small bowel NET. STUDY DESIGN: Sixty-four patients with small bowel NET undergoing laparotomy and who had preoperative imaging with combinations of CT, MR, and radionuclide scintigraphy were reviewed. Results of imaging studies were compared with operative findings to assess the ability of these investigations to detect mesenteric, peritoneal, and hepatic metastases. RESULTS: Mesenteric nodal metastases were seen on imaging in 47 (73%) patients and were present at laparotomy in 56 (88%) patients. Peritoneal metastases were seen on preoperative imaging in 4 (6%) patients and found at laparotomy in 16 (25%) patients. Hepatic metastases were seen on imaging in 42 patients (66%) and found at laparotomy in 49 (77%). Sensitivity and specificity for detection of hepatic metastases were 77% and 100% for CT, 82% and 100% for MR, 63% and 100% for (123)I-meta-iodobenzylguanadine scintigraphy, and 63% and 100% for (111)In-octreotide. Imaging studies failed to detect hepatic metastases in 7 patients and underestimated the extent of hepatic metastatic disease in 17 patients. CONCLUSIONS: Imaging of small bowel NET, even with combinations of CT, MR, and radionuclide studies, underestimates the extent of peritoneal, mesenteric, and hepatic metastatic disease. Accurate staging of small bowel NET might be best performed at the time of laparotomy.

Does surgery have a role in T4N0 and T4N1 lung cancer?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether [surgery] has a role in [treatment of T4N0 and T4N1 lung cancer]. Altogether more than 151 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that upfront surgery for locally invasive T4 tumours without mediastinal lymph node involvement (T4N0 and T4N1 non-small cell lung cancer) is of benefit in terms of survival rates in carefully selected patients. Overall five-year survival rates following resection of T4N0-N2 tumours vary from 19.1% to 57% (from six studies), within which, involvement of certain structures were found to greatly affect prognosis. Pulmonary artery invasion has a good prognosis (five-year survival; 52.8%) relative to other mediastinal structures [five-year survival: left atrium; N0; 28.94%, N1; 27.92%, N2; 17.95% (three-year survival), aorta; N0; 100%, N1; 37.1%, N2; 0%, superior vena cava (SVC); 11%, -29.4% (from four studies), carina; 28-42.5% (two studies), veterbral bodies; 16%, oesophagus; 12%, pleural dissemination; 0%]. When considering isolated invasion of the pulmonary great vessels there are mixed outcomes, one study reporting reduced mortality (reduced risk -0.483, P=0.004) in contrast to another that found five-year survival of 35.7% with great vessel invasion vs. 58.3% for invasion of all other structures excluding the pulmonary great vessels. The prognostic variables found to be of greatest determinacy were; first, the completeness of resection, wherein five-year survival rates ranged from 37.5 to 46.2% (from three studies) with complete tumour removal, and 15.9-22.4% (from three studies) with incomplete resection, and second, nodal status of the patients, N0/N1 having five-year survival of 43-74% and N2 of 15.1-17.5% (P=0.022 and P=0.007, for two studies). Multiple intralobar lesions represent either multilobar metastasis or NSCLC with multifocal origin and have been found to behave differently to invasive T4 tumours. Reported five-year survival in NSCLC with satellite nodules is 48.2-57% compared with 18-30% from T4 invasive tumours (three studies), respectively (P=0.011) corroborating the change in TNM ipsilobar multifocal T4 disease to be recoded as T3.

Is blood pleurodesis effective for determining the cessation of persistent air leak?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether blood pleurodesis is effective for cessation of persistent air leak (PAL). Altogether more than 43 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that autologous blood pleurodesis has superior outcomes when compared with conservative management for treatment of postoperative PAL. In addition, for PAL causing pneumothorax, blood pleurodesis [optimal volume 100 ml (from two studies)] should be considered in patients who are unsuitable for surgery, talc pleurodesis is ineffective or not viable (including cases complicated by acute respiratory distress syndrome) and a prompt resolution is required. Some 70-81% of patients treated for postoperative air leak resolved within 12 h and 95-100% within 48 h vs. a mean of 3-6.3 days (from two studies) with simple drainage. Resolution of pneumothorax with blood pleurodesis was also significantly shorter (P<0.01). Overall success rates (from all studies) were 92.7% (n=133) from patients having undergone pulmonary surgery (76.6% in one injection, n=111), and 91.7% (n=109) of patients with pneumothorax. Recurrence rates were between 0 and 29% compared with 35-41% for simple drainage, although one controlled study in which the recurrence rate was improved from 16% in controls to 0% in the blood pleurodesis group (at 12-48 months). Minor complication (empyema/fever/pleural effusion) rates varied between studies (0-18%), although they show reduced incidence in line with improving technique over time. A controlled study looking at acute respiratory distress syndrome complicated by pneumothorax showed a significant reduction in mortality (odds ratio 0.6), time to cessation of air leak (P<0.01), weaning time (P<0.01) and intensive treatment unit (ITU) stay (P<0.01) whilst another randomized control study showed significant reduction in hospital stay following pulmonary resection (P<0.001).

Arteriovenous malformation in the anterior mediastinum.

Arteriovenous malformations of the mediastinum are exceedingly rare. A literature search found fewer than 10 reported cases of congenital, posterior mediastinal arteriovenous malformations in adults. We describe a giant anterior mediastinal arteriovenous malformation in a 29-year-old man.

Is video-assisted thoracoscopic surgical decortication superior to open surgery in the management of adults with primary empyema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgical decortication (VATSD) might be superior to open decortication (OD) (or chest tube drainage) for the management of adults with primary empyema? Altogether 68 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATSD has superior outcomes for the treatment of persistent pleural collections in terms of postoperative morbidity, complications and length of hospital stay, and gives equivalent resolution when compared with OD. One study comparing VATSD and chest tube drainage of fibrinopurulent empyema found video-assisted thoracoscopic surgery (VATS) had higher treatment success (91% vs. 44%; P<0.05), lower chest tube duration (5.8+/-1.1 vs. 9.8+/-1.3 days; P=0.03), and lower number of total hospital days (8.7+/-0.9 vs. 12.8+/-1.1 days; P=0.009). Eight studies comparing early and late empyema report conversion rates to OD of 0-3.5% in early, 7.1-46% in late stage and significant reductions in length of stay with VATSD compared with OD both postoperatively (5 vs. 8 days; P=0.001) and in total stay (15 vs. 21; P=0.03). Additionally VATS resulted in reduced postoperative pain (P<0.0001) and complications including atelectasis (P=0.006), prolonged air-leak (P=0.0003), sepsis (P=0.03) and 30-day mortality (P=0.02). Five studies considered only chronic persistent empyema of which two directly compared VATSD to tube thoracostomy (TT). VATS resolved 88% of cases and had mortality rates of 1.3% compared with 62% and 11%, respectively, for TT. Moreover, conversion to OD was 10.5-17.1% with VATS and 18-37% with TT (P<0.05). In agreement with mixed stage empyema, hospital stay was reduced both postoperatively (8.3 vs. 12.8 days; P<0.05) and in total (14+/-1 vs. 17+/-1 days; P<0.05), and when compared with OD (one study), pain (P<0.0001), postoperative air-leak (P=0.004), hospital stay (P=0.020) and time to return to work (P<0.0001) were all reduced with VATS. Additionally, re-operation (4.8% vs. 1%; P=0.09) and mortality (4/123% vs. 0%) were lower in VATS vs. OD.

In elderly patients with lung cancer is resection justified in terms of morbidity, mortality and residual quality of life?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: In [patients over 70 years of age with lung cancer] is [lung resection] when compared with [non-surgical treatment] justified in terms of [postoperative morbidity, mortality and quality of life]? Altogether more than 297 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that patients over 70 years of age undergoing anatomical lung resection respond as well as younger patients in terms of morbidity, mortality and residual quality of life (QoL). Collective analysis of the papers reveals no significant difference in five-year survival rates following surgery for early stage disease (stage I non-small cell lung cancer: <70 years; 69-77%, >70 years; 59-78%), although, elderly patients currently receive far higher rates of palliative care (30-47% in patients 65-70 years vs. 8% in patients under 65 years). Additionally, 30-day mortality rates (5.7% <70 years vs. 1.3-3.3% >70 years), length of hospital stay [1.3 days vs. 1 day (video-assisted mini-thoracotomy) and 4.6 vs. 4.9-5.2 days (thoracotomy) for <70 years vs. >70 years, respectively] and postoperative lung function tests (FEV(1) decrease; 13% <70 years vs. 18% >70 years P=0.34, functional vital capacity decrease; 9% <70 years vs. 14% >70 years P=0.31) are equivalent between the two age groups. Residual QoL following lobectomy (evaluated by patient self-assessment) showed decreased social (P<0.001) and role (P<0.001) functioning but less pain at discharge (P<0.001) in those over 70 years. Global QoL, however, was not influenced by age (global QoL; <70 years 22.2+/-25.3 vs. >70 years 17.6+/-22.9). Pneumonectomy showed statistically significant decreases in physical functioning [six months postoperatively (MPO) P=0.045], role functioning (3 MPO P=0.035), social functioning (6 MPO P=0.006, 12 MPO P=0.001) and general pain (6 MPO P=0.037), but showed no age related differences (<70 years; 81.9+/-19.1, >70 years; 78.0+/-22.8).

Do patients undergoing lung biopsy need a postoperative chest drain at all?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether insertion of an intercostal chest drain prolongs the length of stay of patients undergoing lung biopsy. Altogether 210 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that where an intraoperative check reveals no air leak, chest drain should be avoided if possible in order to discharge patients earlier. Where chest drain is used following video-assisted thoracoscopic surgery lung biopsy, early removal results in reduced pain and earlier discharge. Four studies advocate early chest tube removal, allowing discharge of 95% within 24 h in one study, reduced hospital stay from 3.9+/-2.1 days to 2+/-1 days (P=0.001) in another, and a median stay of 1.2 days (range 0-7 days) in a third. Removal of chest drain within 1 h of the operation was possible in 92% of patients (one study), significantly reducing pain (P=0.03, P=0.005; two studies) and postoperative complications (P=0.01; one study) compared with conventional treatment. Five studies in which patients were managed without chest drain following intraoperative air leak checks, reduced hospital stay vs. conventional management (two studies; 2 vs. 3, P<0.001, 1 vs. 3, P<0.01) but results in no difference in complication rates (three studies: pneumothoraces requiring chest drain; 2 vs. 2, P=non-significant; 0 vs. 0; 0 vs. 0) or pain score (two studies; 0.77 vs. 0.76, P=0.894; 5 vs. 5, P=0.81).

Impairment of cognitive function reported by patients suffering from carcinoid syndrome.

BACKGROUND: Carcinoid syndrome (CS) is characterized by symptoms of diarrhea, flushing, bronchospasm, and valvular heart disease. It has been our impression that patients with CS also exhibit features of cognitive impairment. The purpose of this pilot study was to evaluate if symptoms of cognitive impairment were reported by patients with CS. METHODS: Patients with proven CS completed a 38-question multiple-ability self-report questionnaire (MASQ) to assess symptoms in five cognitive domains: language skills, attention/concentration (A/C), visual-perceptual function, visual memory, and verbal memory. Patients subsequently underwent neurocognitive assessment using a battery of six standardized tests. Results of the MASQ and the cognitive test were compared to published results for healthy individuals. RESULTS: Twenty-one patients with CS were studied. MASQ symptom scores were higher than published norms in all five cognitive domains. Patients reported greatest difficulty with verbal memory (mean +/- SD = 2.74 +/- 0.5), followed by A/C (2.41 +/- 0.65), language (2.31 +/- 0.55), visual memory (2.30 +/- 0.65), and visual-perceptual function (2.17 +/- 0.59). In contrast, neurocognitive tests for verbal memory immediate recall, visual memory, language, and executive function were within the normal range. CS patients, however, scored lower than expected in tests of verbal memory delayed recall and visual-perceptual function. CONCLUSIONS: Patients with CS report high levels of symptoms of impairment in all cognitive domains; however, on formal neurocognitive testing, patients scored lower than expected only in tests of verbal memory delayed recall and visual-perceptual function. These findings appear to confirm our clinical impression that cognitive impairment may be an additional feature of CS. Further studies are needed to confirm and elucidate the cause of this cognitive impairment.

Is skin closure with cyanoacrylate glue effective for the prevention of sternal wound infections?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether cyanoacrylate glue was effective at preventing wound infection following sternotomy incision. Altogether more than 108 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that applying cyanoacrylate glue to a sternal wound has superior outcomes in terms of infection rates, both if applied preoperatively (decreasing from 10.8% to 2.7% or 7.8% to 1.1%, according to two studies) and postoperatively (4.9%-2.1%). This trend is true of both deep surgical site infections (0.6%-0%) and superficial site infections (4.3%-2.1%). Furthermore, in patients who had developed mediastinitis following cardiac surgery rates of recurrent sternal detachment and osteomyelitis were significantly reduced in cases where sealant was applied compared to controls (35.3% vs. 0%). In all studies examining hospital stay, duration was reduced in cases where cyanoacrylate glue was used, both in patients treated for recurrent mediastinitis (24.06 vs. 14.16 days) and those with uncomplicated recovery following cardiac surgery (13 vs. 9 days). In addition, two studies examining the use of cyanoacrylate glue to secure the sternum in complicated cases of recurrent detachment report success rates of 86% and 100%.

Improvement in the accuracy of reporting key prognostic and anatomic findings during thyroidectomy by using a novel Web-based synoptic operative reporting system.

BACKGROUND: Documentation of thyroidectomy is performed traditionally by surgeon-dictated operative reports (DORs). A Web-based system that generates a synoptic report (WebSMR) for thyroidectomy was developed. The purpose of this study was to assess the completeness of documentation in WebSMR compared with DOR. METHODS: In all, 271 DORs and 133 WebSMR were reviewed for the documentation of (1) prognostic information for the MACIS score calculation; (2) key anatomic structures such as recurrent laryngeal nerve (RLN) and parathyroid glands; and (3) nonessential information such as middle thyroid vein (MTV) ligation and sutures used for closure. RESULTS: Overall DOR documented presence/absence of invasion in 27%, completeness of resection in only 3%, and tumor size in 29%, whereas these were recorded in 100% of WEBSMR (P < .001). The MACIS scores could not be calculated from any DOR, whereas WebSMRs have a MACIS calculator incorporated in the software. Although subtle differences were found in reporting anatomic structures depending on training, DORs were good at reporting the status of the RLNs (>95%) and parathyroids (>83%) compared with 100% in WebSMRs. DOR routinely included nonessential information; MTV (80%) and sutures used for closure (93% to 98%). CONCLUSION: Use of the WebSMRs was superior to DORs in documenting key prognostic and anatomic findings without nonessential information, and it produced a superior document that can aid in postoperative care.

In patients with first-episode primary spontaneous pneumothorax is video-assisted thoracoscopic surgery superior to tube thoracostomy alone in terms of time to resolution of pneumothorax and incidence of recurrence?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed whether video-assisted thoracoscopic surgery (VATS) was justifiable for first-episode primary spontaneous pneumothorax (PSP). Altogether 183 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATS has superior outcomes in terms of recurrence rates of pneumothorax (from 0 to 13% according to several studies for VATS vs. 22.8 to 42% for tube thoracostomy alone), duration of chest tube drainage (CTD) (4.56 vs.7.6 days) and mean hospital stay (from 2.4 to 7.8 days vs. 6 to 12 days for CTD) with first-episode PSP compared with conservative treatment. Additionally, even if VATS is associated with an average increased cost of $408, this is mitigated by the reduced length of stay and decreased pneumothorax recurrence, both resulting in a reduction of cost of 42% compared to conservative approach. These findings were not replicated in an article considering primary VATS (PV) vs. secondary VATS (SV) as the best treatment modality for PSP in children. Although the total treatment length of stay was significantly shorter for PV vs. SV (7.1+/-0.96 vs. 10.5+/-1.2, P=0.04), morbidity from recurrent pneumothorax after VATS occurred more frequently after PV than SV (4/14 vs. 0/20, P<0.05). In this article the observed recurrence rate was 54%. Performing PV on all patients with PSP would increase cost by $4010 per patient and require a recurrence rate of 72% or more to financially justify this approach, therefore, the increased morbidity and cost do not justify a strategy of PV blebectomy/pleurodesis in children with spontaneous pneumothorax (SP). Instead, secondary treatment is recommended. Lastly, two articles also examined the rate of recurrence of VATS compared to open thoracotomy (OT). The range was from 0 to 7.7% for OT vs. 10.3 to 13% for VATS, a non-statistical difference.

Large subpectoral hematoma: possible complication of sternotomy post-cardiac surgery.

A 62-year-old female patient developed a significantly enlarged left breast 6 hours after sternotomy for a coronary artery bypass graft operation. This was the result of subpectoral bleeding caused by a sternal wire.