Smartwatch helps detects lung cancer: Using personal technology to advance healthcare.

The prevalence of smartwatches and other wearable medical technology has been increasing yearly. These watches offer a sensitive tool for capturing cardiac dysrhythmias and can lead to patients seeking earlier medical advice. This case report highlights the importance of clinicians seeking and using the information provided by wearable medical technology which in this case resulted in both the timely treatment of non-sustained ventricular tachycardia and lung adenocarcinoma.

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.

Elective Lung Resections in the Elderly: Where Do We Draw the Line?

INTRODUCTION: The increasing longevity of the Western population means patients with a more advanced age are being diagnosed with resectable disease. With improvements in imaging and diagnostic capabilities, this trend is likely to develop further. As a unit operating on a higher proportion of older patients and with limited literature regarding the population of older than 85 years, we retrospectively compared the outcomes of patients older than 85 years in our unit treated with elective lung resection for non-small cell lung cancer (NSCLC) with those between the age of 80 and 84 years inclusive. METHODS: All patients who underwent elective lung cancer resection between the years 2012 and 2015 were identified from the National Thoracic Surgical Database. RESULTS: A total of 701 elective lung resections were performed during this time frame; 76 patients between the ages of 80 and 84 years and 18 patients older than 85 years. The follow-up period was 3 to 7 years. There was a significant increase in the Thoracic Surgery Scoring System (2.04; 2.96%, p = 0.0015) and a significant reduction in the transfer factor (94.7; 69.5%, p = 0.0001) between the younger and older groups. There were three (3.9%) in-hospital deaths in the 80 to 84 years age group and no in-hospital deaths in the 85 years and older age group. CONCLUSION: This study demonstrates that surgery for early NSCLC can be safely performed in 85 years and older population. This is a higher risk population and parenchymal-sparing procedures should be considered.

Thoracic Surgery during Coronavirus Disease 2019 (COVID-19): The Experience of a Level 1 Trauma Center.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus primarily affecting the respiratory system, was initially diagnosed in Wuhan, China, in late 2019. Identified as coronavirus disease 2019 (COVID-19) by the World Health Organization, the virus rapidly became a global pandemic. The effects on health care worldwide were unprecedented as countries adapted services to treat masses of critically ill patients.The aim of this study is to analyze the effect that the COVID-19 pandemic had on thoracic surgery at a major trauma center during peak prevalence. METHODS: Prospective unit data were collected for all patients who underwent thoracic surgery during March 2020 until May 2020 inclusive. Retrospective data were collected from an earlier comparable time period as a comparison. RESULTS: In the aforementioned time frame, 117 thoracic surgical operations were performed under the care of four thoracic surgeons. Six operations were performed on three patients who were being treated for SARS-CoV-2. One operation was performed on a patient who had recovered from SARS-CoV-2. There were no deaths due to SARS-CoV-2 in any patient undergoing thoracic surgery. CONCLUSION: This study demonstrates that during the first surge of SARS-CoV-2, it was possible to adapt a thoracic oncology and trauma service without increase in mortality due to COVID-19. This was only possible due to a significant reduction in trauma referrals, cessation of benign and elective work, and the more stringent reprioritization of cancer surgery. This information is vital to learn from our experience and prepare for the predicted second surge and any similar future pandemics we might face.

Tophaceous gout in the sternoclavicular joint.

Gouty arthritis commonly occurs in peripheral synovial joints and involvement in the thoracic cage is extremely rare. We report a case of a 52-year-old presenting with a painful bony mass in her sternal notch. Imaging demonstrated a lobulated calcified and necrotic lesion causing mass effect on adjacent structures. Excision biopsy confirmed a benign cystic lesion with amorphous material containing needle-shaped refractile crystals suggestive of uric acid. Tophaceous gout was diagnosed. Presence of a periarticular mass with characteristics of gout should warrant investigation with biopsy and imaging. This can prevent misdiagnosis of malignancy and avoid unnecessary surgery in asymptomatic lesions.

A rare solitary and endobronchial pulmonary hyalinising granuloma requiring bilobectomy.

Pulmonary hyalinising granuloma is a very rare disease often presenting as multiple smooth rounded nodules within the lung parenchyma and mimicking metastatic disease. Solitary pulmonary hyalinising granuloma is an even rarer subgroup, and to our knowledge, there have been no endoluminal pulmonary hyalinising granulomas reported. A 36-year-old female non-smoker with no significant past medical history presented with a persistent cough and was found to have a right lower lobe bronchial lesion causing lower lobe obstruction. After multiple failed attempts at tissue diagnosis from both percutaneous and endobronchial biopsies, and with worsening haemoptysis, the patient underwent a right thoracotomy and lower bilobectomy. The histopathology was reported as a solitary endobronchial pulmonary hyalinising granuloma. Although benign in nature, tissue diagnosis can be difficult in these lesions, especially when presenting as a solitary mass in a central location. This report demonstrates that these lesions can also be found endobronchially necessitating parenchymal resection for diagnosis and obstructive symptoms.

Retrospective Observational Study into the Early Causes of Death Following Surgery for NSCLC.

INTRODUCTION: Respiratory failure has historically been the major cause of mortality after elective lung resections. With improved intubation using fiber-optic scopes, better preoperative respiratory risk assessment, more advanced anesthetic single lung ventilation, and minimally invasive surgical technique, this may have changed. Our objective was to assess the main causes of mortality over the past 10 years in patients undergoing elective lung surgery in a major UK center. MATERIALS AND METHODS: A retrospective unit data search was made for all deaths during the 10-year period between January 2007 and December 2016 inclusive. All inpatient deaths within 30 days of an elective anatomical lung resection for lung malignancies were included. RESULTS: Three-thousand three-hundred sixteen lung resections for malignancy were performed in the 10-year period. There were 44 (1.3%) deaths during this period, 27 (61.4%) after open lobectomies, 8 (18.2%) after video-assisted thoracoscopic surgery lobectomies, 5 (11.4%) after sleeve lobectomies, and 4 (9%) after pneumonectomies. Causes of death included 24 (54.5%) respiratory failure, 10 (22.7%) ischemic bowel, 4 (9%) coronary events, 2 (4.5%) strokes, 2 (4.5%) on table hemorrhage, 1 (2.3%) massive pulmonary embolus, and 1 (2.3%) postoperative hemorrhage. CONCLUSION: Although respiratory failure is still a major cause of mortality in the postoperative patient, bowel ischemia has been found to be the second greatest cause of death. This study highlights the need to identify those at risk of this fatal complication during preoperative assessment and their postoperative management.

Three-Dimensional Printing for Chest Wall Reconstruction in Thoracic Surgery: Building on Experience.

OBJECTIVES: Patients undergoing surgery for locally advanced lung cancer involving the chest wall require anatomical lung with extensive en-bloc chest wall resection and appropriate reconstruction.In this proof-of-concept study, we aimed to produce personalized three-dimensional (3D)-printed chest wall prosthesis for a patient undergoing chest wall resection and reconstruction using clinically obtained computed tomography (CT) data. METHODS: Preoperative CT scans of three patients undergoing chest wall resection were analyzed and the areas of resection segmented. This was then used to produce a 3D print of the chest wall and a silicone mold was created from the model. This mold was sterilized and used to produce methyl methacrylate prostheses which were then implanted into the patients. RESULTS: Three patients had their chest wall reconstructed using this technique to produce a patient specific prosthesis. There were no early complications or deaths. CONCLUSIONS: It is possible to use 3D printing to produce a patient specific chest wall reconstruction for patients undergoing chest wall resection for malignancy that is cost-effective. This chest wall is thought to provide stability in the form of prosthetic ribs as well compliance in the form of an expanded polytetrafluoroethylene patch. Further research is required to measure chest wall compliance during the respiratory cycle and long-term follow-up from this method.

Operative Planning in Thoracic Surgery: A Pilot Study Comparing Imaging Techniques and Three-Dimensional Printing.

BACKGROUND: Careful preoperative planning in thoracic surgery is essential for positive outcomes, especially in video-assisted thoracic surgery (VATS), where palpation and 3-dimensional (3D) imaging is restricted. This study evaluated the ability of different imaging techniques, such as computed tomography (CT) scanning, maximal intensity projection imaging, 3D reconstruction, and 3D printing, to define the anatomy of the hilar structures before anatomical lung resection. METHODS: All patients undergoing elective lung resections by VATS for cancer under a single surgeon were identified over a 3-month period. The surgeon was asked to record the number of pulmonary artery branches supplying the lobe to be resected by using the preoperative CT scans, maximal intensity projection images, and 3D-reconstructed CT images. The lung hilum in 3 patients was printed. These were then compared with the intraoperative findings. RESULTS: The preoperative imaging of 16 patients was analyzed. The lung hilum was printed in a further 3 patients. Although not statistically significant, the 3D prints of the hilum were the most accurate measurement, with a correlation of 0.92. CT, 3D-reconstructed CT, and maximal intensity projection images tended to underrecognize the number of arterial branches and therefore scored between 0.26 and 0.39 in absolute agreement with the number of arteries found at operation. CONCLUSIONS: 3D printing in the planning of thoracic surgery may suggest a benefit over contemporary available imaging modalities, and the use of 3D printing in practicing operations is being established.

Differential Survival Characteristics of Sarcomatoid Subtype in Biphasic Pleural Mesothelioma.

BACKGROUND: Biphasic pleural mesothelioma (BPM) accounts for approximately 10% of all pleural mesothelioma. Our aim was to assess the clinical, radiologic, and pathologic factors impacting survival in BPM and to better identify patients most likely to benefit from active treatment. METHODS: A 10-year retrospective review was made of 214 biopsy-proven BPM cases with minimum 2-year follow-up. Patients with insufficient tissue for analysis were excluded (n = 96). Clinical and pathologic factors were evaluated along with radiologic assessment of pleural thickness. Survival was measured from time of diagnosis. Univariable and multivariable predictors of survival were evaluated. RESULTS: In all, 118 patients were included; 28 underwent pleurectomy/decortication, with 27 receiving additional modalities. Ninety patients underwent chemotherapy (n = 18) or radiotherapy alone (n = 9), 63 received combination therapy, and 27 received best supportive care. Median overall survival was 11.2 months (range, 0.3 to 36.2). At univariable analysis, pleurectomy/decortication (p = 0.0061), radiotherapy (p < 0.0001), and chemotherapy (p < 0.0001) were associated with superior survival when compared with best supportive care alone. Pleurectomy/decortication demonstrated 40% survival improvement compared with no surgery (p = 0.122). In a multivariable model, necrosis was negatively prognostic (hazard ratio 2.1, SE 0.76). Furthermore, increased sarcomatoid component was associated with worse survival without radiotherapy. CONCLUSIONS: BPM prognosis remains poor despite multimodality treatment. Anticancer treatment is associated with superior outcome in this nonrandomized retrospective series. Our findings suggest superior survival for patients with a lower proportion of sarcomatoid disease, with selective benefit of radiotherapy in higher proportions of sarcomatoid disease. When planning active treatment, the potential survival benefits require balancing against associated morbidity and recovery period.

The Requirement of Sutures to Close Intercostal Drains Site Wounds in Thoracic Surgery.

BACKGROUND: Chest drains are used routinely in thoracic surgery. Often a pursestring or mattress suture is used to facilitate closure of the defect on removal of the drain. This stitch can cause an unsightly scar, increase drain removal pain, and necessitate that the patient attend a community health care center to have this removed. The objective of this study was to assess whether this stitch is necessary in modern thoracic surgical practice. METHODS: Data from a single surgeon's practice were collected over an 18-month period. During this time, all patients who underwent both emergency and elective thoracic surgery who had at least one postoperative chest drain of 28F or above inserted were included in the study. The surgeon did not routinely use a suture to close the drain site. RESULTS: In all, 312 patients underwent thoracic surgery during the 18-month period. Each patient had a range of 1 to 3 drains inserted of a size between 28F and 32F. No patients had drain sutures for closure of the drain site. Four patients had pneumothoraces after drain removal requiring further chest drain insertion. Five patients had superficial drain site infections. A single patient had to have a suture inserted at a local hospital owing to leakage from the drain site. CONCLUSIONS: The use of pursestring sutures in thoracic surgery is an outdated practice that causes not only unsightly scars but is also associated with increased pain. Furthermore, these unnecessary pursestring sutures place a burden on the patient and health care system to have them removed.

An Isolated Traumatic Medial Third Clavicular Fracture Requiring Surgical Fixation.

Fractures of the medial clavicle are rare injuries but are associated with significant morbidity and mortality. The current trend is shifting from conservative treatment to surgical intervention to reduce long-term sequelae. We present an isolated medial clavicular fracture associated with significant displacement and demonstrate excellent results after open reduction and internal fixation.

A lateral costal artery complicating video-assisted thorascopic surgery (VATS) pleurectomy.

The lateral costal artery is a rare variant arising from the internal thoracic artery (ITA). It has been associated with steel syndrome after coronary artery bypass using the ITA as a conduit. Clinically, it is under-reported in the literature. We report the presence of a prominent lateral costal artery, coursing below the diaphragm, discovered during video-assisted thorascopic surgery pneumothorax surgery and preventing parietal pleurectomy.

Cardiac sarcoma presenting with abdominal pain and mimicking myxoma on echocardiogram.

Cardiac sarcoma's are highly aggressive tumours. Clear resection margins ± autotransplant, followed by chemotherapy, offers the best survival chance. Therefore, frozen section should be preformed when there is ambiguity in diagnosis.

Simulator Teaching of Cardiopulmonary Bypass Complications: A Prospective, Randomized Study.

OBJECTIVE: Complications of cardiopulmonary bypass (CPB) are rare, but life-threatening events that need prompt and rehearsed actions involving a team. This is not adequately taught to cardiothoracic surgical trainees. The objective of this study was to assess the knowledge of cardiothoracic trainees required to manage these events after simulation-based vs. lecture-based teaching. PARTICIPANTS AND DESIGN: Totally, 17 cardiac surgical trainees with no formal teaching in intraoperative complications of CPB management were randomly assigned by computer to either a study group receiving simulation-based complications of CPB teaching via the Orpheus simulator (n = 9) or a control group receiving complications of CPB teaching via a lecture (n = 8). Each subject undertook a written test comprising 20 multiple choice questions on complications of CPB before and after teaching. Trainees were then asked to rate their satisfaction with each session from 1 to 5, with 5 being most satisfied. SETTING: St George Simulation and Clinical Skills Laboratory, St George's Hospital, London. RESULTS: There was no significant difference in the pretest scores between the 2 groups (p = 0.29). After teaching, both groups showed a statistically significant improvement in their knowledge (p < 0.05). The trainees in the simulation group performed better than the lecture-based group; however, this was not statistically significant (p = 0.21). Satisfaction levels in both the lecture session and the simulation session were very high with means of 4.4/5 and 4.8/5, respectively. CONCLUSION: Despite the familiarity with CPB during surgery, the simulation group performed at least as well as the lecture group. Cardiothoracic trainees would benefit from formal teaching of complications of CPB management via either learning modality being incorporated into their training.

A Survey of Cardiothoracic Surgical Training in the United Kingdom: Realities of a 6-Year Integrated Training Program.

BACKGROUND: In recent years, cardiothoracic (CT) surgical training has faced several challenges, including a reduction in working hours and trainees favoring shorter training programs. We carried out a national survey in the United Kingdom (UK) to assess the CT 6-year training program. METHODS: All CT trainees in the UK (n = 121) were sent an online survey. This was combined with a debate at the Society for CT Surgery of Great Britain and Ireland. RESULTS: Ninety-one (75.2%) of all trainees responded. Despite 56 (68.1%) being rostered for more than a 48-hour week, 31 (34.1%) of all trainees work an extra 10 hours. The majority (56, 61.5%) thought that on-calls and night duty are useful. Just over half of the trainees (47, 51.6%) spend at least 2 full days in the operating room, but 79 (86.8%) thought that this is too little and would spend voluntary time operating. Simulation of operations is thought to be useful; however, few thought that this should take more precedence in their training program. The majority of trainees thought that the current assessment of surgical training is suboptimal and does not examine surgical skill. Similarly, the majority thought that a defined number of operations is required before qualification. CONCLUSIONS: Trainees remain committed to their profession and are willing to dedicate more time perfecting their art. They believe that despite wanting extra operating experience, they will be ready for independent practice at the completion of their training. It rests with training bodies to find alternative assessments for surgical ability and to define experience at the exit point of training.

Simulation-based learning of transesophageal echocardiography in cardiothoracic surgical trainees: A prospective, randomized study.

OBJECTIVES: The Intercollegiate Surgical Curriculum now recommends that cardiac surgical trainees should be able to understand and interpret transesophageal echocardiography images. However, cardiac surgical trainees receive limited formal transesophageal echocardiography training. The objective of this study was to assess the impact of simulation-based teaching versus more traditional operating room teaching on transesophageal echocardiography knowledge in cardiac surgical trainees. METHODS: A total of 25 cardiac surgical trainees with no formal transesophageal echocardiography learning experience were randomly assigned by computer to a study group receiving simulation-based transesophageal echocardiography teaching via the Heartworks (Inventive Medical, London, UK) simulator (n = 12) or a control group receiving transesophageal echocardiography teaching during elective cardiac surgery (n = 13). Each subject undertook a video-based test composed of 20 multiple choice questions on standard transesophageal echocardiography views before and after teaching. RESULTS: There was no significant difference in the pretest scores between the 2 groups (P = .89). After transesophageal echocardiography teaching, subjects within each group demonstrated a statistically significant improvement in transesophageal echocardiography knowledge. Although the subjects within the simulation group outperformed their counterparts in the operating room teaching group in the post-test scores, this difference was not significant (P = .14). CONCLUSIONS: Despite the familiarity with transesophageal echocardiography images during surgery, subjects in the simulation group performed at least as well as those in the operating room group. Surgical trainees will benefit from formal transesophageal echocardiography teaching incorporated into their training via either learning method.

Trainees can learn minimally invasive aortic valve replacement without compromising safety.

OBJECTIVES: Minimally invasive aortic valve replacement (Mini-AVR) is a technically advanced procedure. However, it results in equivalent operative mortality, less bleeding and reduced intensive care/hospital stay when compared with conventional AVR. Our aim was to assess the impact of trainee performance on short-term outcomes of patients undergoing elective and urgent Mini-AVR where a significant proportion were performed by trainees. METHODS: All patients undergoing non-emergency, elective and urgent, isolated Mini-AVR between September 2005 and December 2012 were studied. Operative details and short-term outcomes, with particular attention to trainee performance, were analysed. RESULTS: During the study period, there were 205 Mini-AVR with a median age of 67 years (range 29-86); 74 (36%) operations were performed by trainees. The overall median cross-clamp and bypass times were 42 (range 33-63) and 59 min (range 59-94) for the attending surgeon and 52 (range 42-63) and 71 min (range 59-94) for the trainee (P = 0.03). Five Mini-AVR patients (2.4%) required conversion to full sternotomy for ascending aortic replacement, right ventricular bleeding, coronary artery bypass graft surgery and failure to cardiovert. None of these cases were performed by trainees. Median lengths of intensive care and hospital stay were 1 and 5 days and were not different for attending surgeon and trainee. Only 1 (0.5%) patient died in hospital. CONCLUSIONS: Mini-AVR can be performed with a low conversion rate and hospital stay and taught to trainees without compromising safety.

Perioperative management and outcomes of aortic surgery during pregnancy.

OBJECTIVE: Pathology of the aortic valve and ascending thoracic aorta is an uncommon but life-threatening complication of pregnancy. Cardiac surgery during pregnancy is known to carry a high risk of mortality to both the mother and fetus. We present our experience of performing aortic surgery during the patients' pregnancy. METHODS: All patients undergoing aortic surgery during pregnancy at St George's Hospital, from January 2004 until October 2013, were identified. Surgery was performed using cardiopulmonary bypass at 36°C, with pulsatile perfusion at 70 mm Hg. Fetal blood flow parameters were serially monitored during surgery, via transabdominal and/or transvaginal Doppler ultrasonography. Surgery was performed in the second trimester when possible to allow completion of organogenesis and minimize hemodynamic compromise. RESULTS: Eleven patients underwent aortic surgery. The median age was 28 years (range, 26-31 years), with gestational age 19 weeks (range, 16-21 weeks). Six patients had aortic root dilatation with aortic regurgitation, and 5 had aortic stenosis, one of whom presented with acute type A dissection. Four patients had Marfan syndrome, and 2 had undergone previous cardiac surgery. The operative procedures were aortic root replacement (tissue valve, n = 5; homograft, n = 1), aortic valve replacement (n = 3), valve-sparing root replacement (n = 1), and aortic and mitral valve replacements (n = 1). Mean cardiopulmonary bypass and cross-clamp times were 105 and 89 minutes, respectively. There were no maternal deaths; 8 healthy babies were born at term, and 3 pregnancies resulted in intrauterine demise within 1 week of surgery. CONCLUSIONS: Major aortic surgery during pregnancy carries a high risk to both mother and baby. With appropriate maternal and fetal monitoring, attention to cardiopulmonary bypass, pulsatile perfusion, near-normothermia, and avoidance of vasoconstrictors, these risks may be minimized.