Improved survival with VATS pleurectomy-decortication in advanced malignant mesothelioma.

AIMS: Malignant mesothelioma is increasing in incidence and no current therapy significantly prolongs survival. Previous surgical strategies involved high-risk open procedures without achieving histologically clear resection margins. We present the results of VATS debulking pleurectomy-decortication in advanced disease. METHODS: A consecutive series of patients with suspected malignant mesothelioma underwent thoracoscopic assessment to determine the feasibility of decortication, where this was not possible a biopsy alone was taken. Post-operative radiotherapy was administered to port sites, but no other adjuvant therapy was given. The two groups (biopsy only and pleurectomy-decortication) were composed of patients with histologically confirmed mesothelioma [28 and 51 patients, respectively]. The primary endpoint was comparison of actuarial patient survival. Secondary endpoints included post-operative air leak and duration of hospital stay. RESULTS: The overall actuarial survival was 288 days and 67% of patients had died at the time of data analysis. The groups were matched for patient and tumour-related characteristics including age (66, 64 years, p=0.39) and tumour stage (median IMIG stage 3 [IQR 2-3] both groups, p=0.54). The biopsy only group had fewer air leaks (57, 84%, p=0.01) and a shorter hospital stay (4, 8 days, p=0.03). However, the pleurectomy-decortication group had favourable actuarial survival relative to the biopsy only group (416, 127 days, p<0.001). Multivariate analysis showed early stage (p<0.001), absence of pre-operative fever (p=0.03) and pleurectomy-decortication (p<0.001) as independent predictors of survival. CONCLUSION: VATS pleurectomy-decortication is feasible in the majority of cases and independently improves survival for patients with advanced malignant mesothelioma.

A prospective study on clinical outcome following pleurotomy during cardiac surgery.

BACKGROUND: Due to conflicting reports on pleurotomy-associated morbidity following internal mammary artery (IMA) harvesting, we conducted a prospective study to assess the clinical significance and outcome of pleurotomy during cardiac surgery. METHODS: We included patients undergoing cardiac surgery from November 2000 until January 2001. Participants were divided into two groups: one with routine or incidental left pleurotomy and the other with intact left pleurae. RESULTS: Of the 218 patients registered for this study, 12 were excluded (7 deaths occurred, 5 patients were transferred prior to study completion). Of the 206 remaining, 138 had isolated CABG, 39 had valve surgery and 29 had a combined procedure. Although patients with a left pleurotomy (n= 164) had a higher incidence of left lung atelectasis (67.7% vs. 45.2%; p = 0.007), neither radiographic consolidation (7.5% vs. 7.3%; p = 0.96), effusion (42.5%vs. 46.3%; p - 0.66), nor hospital stay (9 days in both groups; p - 0.83) increased. CONCLUSIONS: Left pleurotomy was found to increase the rate of atelectasis. However, this was not associated with an adverse clinical outcome. Pleurotomy during IMA harvesting can be performed according to operator preference.

Acute hydrothorax in CAPD. Eearly thoracoscopic (VATS) intervention allows return to peritoneal dialysis.

BACKGROUND/AIMS: Hydrothorax is a complication of continuous ambulatory peritoneal dialysis (CAPD) occurring due to pleuroperitoneal fistulae. Several treatments exist with no consensus as to best management. We report on the largest series of video-assisted thoracoscopic surgery (VATS) treated pleuroperitoneal fistulae yet available. METHODS: Between 1995 and 2000, we treated 6 CAPD patients for acute right hydrothoraces using VATS. Data pertaining to size and sterility of hydrothoraces, presence of diaphragmatic defects, surgical procedures performed, morbidity and return to CAPD were obtained. RESULTS: Hydrothoraces were drained in all patients and there were no significant growths on subsequent culture. Fistulae were directly identified and closed in three patients. In the remaining patients, endoclips were placed across the base of small diaphragmatic blebs (the presumed site of communication). Parietal pleurectomy was performed uneventfully in all patients. There was no morbidity, all patients returned to haemodialysis and there have been no recurrences. CONCLUSIONS: Pleuroperitoneal fistulae produce symptomatic hydrothoraces in CAPD patients. A variety of approaches to the problem have been described. This is the largest series of VATS available and shows the usefulness of this approach in both closing the defect and producing an effective pleurectomy to prevent recurrence.

Atraumatic bilateral Achilles tendon rupture: an association of systemic steroid treatment.

A case of bilateral Achilles tendon rupture associated with steroid use is reported. This case illustrates the importance of taking a thorough drug history in cases of tendon rupture. In lower limb tendon rupture all patients, especially those on steroids, should be warned of the increased risk of contralateral injury.