Maintaining safe lung cancer surgery during the COVID-19 pandemic in a global city.

BACKGROUND: SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. METHODS: This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. FINDINGS: 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35-86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3-4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). INTERPRETATION: SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. FUNDING: This work did not receive funding.

Nontraumatic rupture of the costal margin: a single-center experience.

BACKGROUND: Rupture of the costal margin is uncommon. Whilst most often seen after major trauma, we describe its occurrence in patients with no direct chest trauma. METHODS: A search was performed in our thoracic surgery database for all patients with rupture of the costal margin. Patients were excluded if the injury was a result of trauma. Data were collected on sex, age, body mass index, profession, past medical history, smoking status, presenting complaint, mechanism of injury, and management. RESULTS: There were 9 patients with rupture of the costal margin that was caused in all cases by a severe coughing fit. All patients were male and the mean age was 62.5 years (range 47-76 years). Chronic obstructive pulmonary disease was present in 6 cases. Presentations included a palpable defect (5 cases), cough (9 cases), and chest pain (6 cases). On radiological examination, all patients had widening of the rib space, 4 had associated rib fractures, and 5 had lung herniation. Time from injury to presentation was 12 months (range 1-24 months). All patients underwent surgery and were followed-up for 59 months (range 8-129 months). Two patients suffered major complications in the immediate postoperative period. CONCLUSIONS: Rupture of the costal margin, in the absence of direct trauma, is characterized by pain, a palpable defect, and lung herniation. It is associated with widening of the rib space and rib fractures, and can be treated surgically with success but not without significant risks.

A novel approach in managing right-sided haemothorax in neurofibromatosis type 1.

Spontaneous haemothorax due to vasculopathy in patients with neurofibromatosis type 1 is rare but life-threatening. A 56-year-old lady with neurofibromatosis type 1 presented with right-sided chest pain, dyspnoea, and collapse. Computed tomography showed a right-sided hemothorax. Urgent angiography showed contrast leakage from a right subclavian artery pseudoaneurysm. A Gore Viabahn endovascular stent graft was deployed. Completion angiography revealed satisfactory haemostasis. She underwent video-assisted thoracoscopic evacuation of the hemothorax, with good results. This case highlights a novel approach to managing a rare emergency, using combined procedures.

Alternative myocardial protection strategies are necessary in patients with intramural aortic course of anomalous coronary artery.

A 48-year old Caucasian woman presented with chest pain on exertion and was diagnosed with an anomalous origin of dominant right coronary artery, it then ran a short intramural course in the wall of the aorta. Right coronary artery (RCA) was reimplanted on cardiac bypass at normal exit point on the aortic root. The heart was adequately protected with antegrade cold blood cardioplegia via the aortic root and regular direct cardioplegia via the coronary ostia. The patient could not come off cardiopulmonary bypass after surgery and required right ventricular assist device support to be weaned from cardiopulmonary bypass. The patient ultimately recovered well and her right heart function is normalising. We believe that antegrade cardioplegia via the aortic root caused increased pressure in the aorta and squashed RCA in the wall of the aorta causing failure of myocardial protection and stunning of the right ventricle. This could be prevented with alternative myocardial protection strategies like direct cardioplegia via the coronary ostium.

Laceration of anterior mitral leaflet postpercutaneous balloon mitral valvuloplasty for rheumatic mitral stenosis.

A 37-year-old Caucasian female with known rheumatic mitral stenosis was admitted for Balloon mitral valvuloplasty which was complicated with a laceration of anterior mitral leaflet (A2 scallop) resulting in severe mitral regurgitation. Intra-aortic balloon pump (IABP) was instituted and the patient was referred for emergency mitral surgery. During surgery anterior mitral leaflet was excised. Most of the posterior leaflet was preserved. Mitral valve was replaced with St Jude mitral mechanical valve. Operation was uneventful and patient's recovery was uncomplicated. Complications associated with mitral valvuloplasty include ventricular perforation, leaflet laceration, rupture of chordae, sepsis, cardiac tamponade and premature ventricular contractions. Torrential mitral regurgitation postvalvuloplasty is a serious, life-threatening complication. Considering the risk of serious complication associated with percutaneous mitral balloon valvuloplasty (PMBV), this procedure should be performed in qualified cardiac catheterisation labs with a backup facility of cardiac surgery to deal with any potential life-threatening complications.

Occult malignancy presenting as constrictive pericarditis.

Metastatic tumour progression to the pericardium is generally characterised by an effusional pericarditis. It is extremely rare for tumour to metastasise to the pericardium and cause constrictive pericarditis in the absence of a pericardial effusion. We report the recent case of a patient who was referred to our centre with constrictive pericarditis. Following pericardectomy and histopathological analysis this was found to be secondary to an occult metastatic adenocarcinoma.

Kommerell's diverticulum, risk factor for aortic dissection.

A 54-year-old man presented with sharp chest pain and hypertension. He was treated with intravenous antihypertensive with good control of the blood pressure. Chest X-ray showed widened mediastinum, and subsequent computed tomography scan of the chest demonstrated dissection of the descending thoracic aorta. It also showed an aberrant right subclavian artery with retrograde extension of dissection and Kommerell's diverticulum, which is dilatation at the origin of the aberrant subclavian artery.