Role of vitamin D supplementation in modifying outcomes after surgery: a systematic review of randomised controlled trials.

BACKGROUND: There is increasing evidence to suggest vitamin D plays a role in immune and vascular function; hence, it may be of biological and clinical relevance for patients undergoing major surgery. With a greater number of randomised studies being conducted evaluating the impact of vitamin D supplementation on surgical patients, it is an opportune time to conduct further analysis of the impact of vitamin D on surgical outcomes. METHODS: MEDLINE, EMBASE and the Cochrane Trials Register were interrogated up to December 2023 to identify randomised controlled trials of vitamin D supplementation in surgery. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. A narrative synthesis was conducted for all studies. The primary outcome assessed was overall postoperative survival. RESULTS: We screened 4883 unique studies, assessed 236 full-text articles and included 14 articles in the qualitative synthesis, comprising 1982 patients. The included studies were highly heterogeneous with respect to patient conditions, ranging from open heart surgery to cancer operations to orthopaedic conditions, and also with respect to the timing and equivalent daily dose of vitamin D supplementation (range: 0.5-7500 mcg; 20-300 000 IU). No studies reported significant differences in overall survival or postoperative mortality with vitamin D supplementation. There was also no clear evidence of benefit with respect to overall or intensive care unit length of stay. DISCUSSION: Numerous studies have reported the benefits of vitamin D supplementation in different surgical settings without any consistency. However, this systematic review found no clear evidence of benefit, which warrants the supposition that a single biological effect of vitamin D supplementation does not exist. The observed improvement in outcomes in low vitamin D groups has not been convincingly proven beyond chance findings. TRIAL REGISTRATION NUMBER: CRD42021232067.

The impact of perioperative non-steroidal anti-inflammatory drugs use on pleurodesis following thoracic surgery.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: in patients who have had {visceral and parietal pleural symphysis}, {do NSAIDs reduce} {the efficacy of pleurodesis}? Sixteen papers were discovered in the search. Of these, 3 human studies were included in the analysis. None showed a significantly higher rate of pleurodesis failure in patients given perioperative NSAIDs. The results from the largest study met criteria for noninferiority. Within the constraints of the study, the results suggest that systemic administration of nonsteroidal anti-inflammatory medication in the perioperative period does not necessarily attenuate effective pleurodesis. However, further study is needed as there is a clear paucity of human-based studies.

A systematic review of the quality of abstracts reporting on randomized controlled trials presented at major international cardiothoracic conferences.

Conference proceedings are widely available and may represent the only report of given research. Poor reporting of randomized controlled trials (RCTs) in conference abstracts may impede interpretability. In 2008, the Consolidating Standards of Reporting Trials group published minimum standards for RCT reporting in conference abstracts (CONSORT-A). We sought to evaluate the reporting quality of abstracts presented at major international cardiothoracic conferences. Abstracts were retrieved for the annual meetings of 5 cardiothoracic societies over 3 consecutive years (2016 to 2018). After screening, those reporting on RCTs were scored by 2 independent reviewers against the 17-item CONSORT-A checklist. The primary endpoint was the total number of checklist criteria reported in individual abstracts. Statistical analysis was performed using STATA ICv16. Of 3233 screened abstracts, 100 (3.1%) reported on RCTs. Average checklist adherence was 35% (median 6/17 items, IQR 2-15) across abstracts. Author contact (n = 0), funding disclosures (n = 3, 2.9%) and randomization methodology (n = 5, 4.8%) were the least-frequently reported. There was no statistically-significant difference in terms of reporting quality between conferences (n = 0.07) or years (p = .06). Trial registration, word count (>300), multicentre trial design and mention of CONSORT in the abstract were associated with higher reporting quality. Reporting quality was not associated with successful full-length publication within 2 years (p = .33). The reporting quality of abstracts of RCTs presented at international cardiothoracic conferences is poor when benchmarked against the CONSORT-A standards. This highlights an area for targeted improvement.

Do older surgeons have safer hands? A retrospective cohort study.

BACKGROUND: For complex surgical procedures a volume-outcome relationship can often be demonstrated implicating multiple factors at a unit and surgeon specific level. This study aims to investigate this phenomenon in lung transplantation over a 30-year period with particular reference to surgeon age and experience, cumulative unit activity and time/day of transplant. METHODS: Prospective databases identified adult patients undergoing isolated lung transplantation at a single UK centre between June 1987 and October 2017. Mortality data was acquired from NHS Spine. Individual surgeon demographics were obtained from the General Medical Council. Student t-test, Pearson's Chi-squared, Logistic Regression, and Kaplan-Meier Survival analyses were performed using Analyse-it package for MicrosoftExcel and STATA/IC. RESULTS: 954 transplants (55.9% male, age 44.4 ± 13.8 years, 67.9% bilateral lung) were performed, with a median survival to follow-up of 4.37 years. There was no difference in survival by recipient gender (p = 0.661), between individual surgeons (p = 0.224), or between weekday/weekend procedures (p = 0.327). Increasing centre experience with lung transplantation (OR1.001, 95%CI: 1.000-1.001, p = 0.03) and successive calendar years (OR1.028, 95%CI: 1.005-1.052, p = 0.017) was associated with improved 5-year survival. Advancing surgeon age at the time of transplant (mean, 48.8 ± 6.6 years) was associated with improved 30-day survival (OR1.062, 95%CI: 1.019 to1.106, p = 0.003), which persisted 5 years post-transplant (OR1.043, 95%CI: 1.014-1.073, p = 0.003). Individual surgeon experience, measured by the number of previous lung transplants performed, showed a trend towards improved outcomes at 30 days (p = 0.0413) with no difference in 5-year survival (p = 0.192). CONCLUSIONS: Our study demonstrates a relationship between unit volume, increasing surgeon age and survival after lung transplantation. A transplant volume: outcome relationship was not seen for individual surgeons.

ERS International Congress 2021: highlights from the Thoracic Surgery and Lung Transplantation Assembly.

The thoracic surgery and lung transplantation assembly of the European Respiratory Society (ERS) is delighted to present the highlights from the 2021 ERS International Congress. We have selected four sessions that discussed recent advances across a wide range of topics including: digital health surveillance in thoracic surgery, emerging concepts in pulmonary metastasectomy, advances in mesothelioma care, and novel developments in lung graft allocation and monitoring. The sessions are summarised by early career members in close collaboration with the assembly faculty. We aim to give the reader an update on the highlights of the conference in the fields of thoracic surgery and lung transplantation.

Uniportal video-assisted versus open pneumonectomy: a propensity score-matched comparative analysis with short-term outcomes.

OBJECTIVES: Uniportal (U-VATS) pneumonectomy in lung cancer patients remains disputed in terms of oncological outcomes, and has not been compared to open approaches previously. We evaluated U-VATS versus open pneumonectomy at a high-volume centre. METHODS: Patients undergoing pneumonectomy for lung cancer between 2014 and 2018 were retrospectively reviewed and divided into two groups based on surgical approach. Propensity-score matching was performed (1:1), and intention-to-treat analysis applied. Overall survival, operative time, intraoperative blood loss, hospital-stay and readmission, pain, time to adjuvant therapy, morbidity and mortality were tested. Statistical analysis was performed using SAS version 9.4 (SAS Institute Inc. NC) RESULTS: 341 patients underwent pneumonectomy; 23 patients with small-cell lung cancer were excluded, thus 318 patients were submitted to surgery by either U-VATS (n = 54) or open (n = 264). After matching, 52 patients were selected from each group. Five patients (9.2%) in the uniportal group required conversion. There was no significant difference in intraoperative outcomes, complication rates, readmission rates or mortality. The U-VATS group experienced significantly shorter hospital stay (mean ± SD; 6.7 ± 2.7 vs 9.1 ± 2.3 days, p < 0.001) and reported less pain postoperatively (p < 0.0001). Adjuvant chemotherapy was initiated sooner after U-VATS (38.1 ± 8.4 vs 50.8 ± 11.5 days, p < 0.0001). Overall survival appeared to be superior in U-VATS when pathology stage was aligned (p = 0.001). CONCLUSIONS: Uniportal VATS is a safe and effective alternative approach to open surgery for pneumonectomy in lung cancer. Complications and oncologic outcomes were comparatively similar. U-VATS showed lower postoperative pain, shorter hospital stay and superior overall survival. The study is a preliminary analysis.

Impact of coronavirus 2019 (COVID-19) on training and well-being in subspecialty surgery: A national survey of cardiothoracic trainees in the United Kingdom.

OBJECTIVES: The coronavirus 2019 (COVID-19) pandemic has overwhelmed health care systems and disrupted routine care internationally. Health care workers face disruption to their work routines and professional development, as well as an elevated risk of infection and morbidity. We sought to establish the impact of the COVID-19 pandemic on the well-being, practice, and progression of all trainees in cardiothoracic surgery in the United Kingdom. METHODS: A 31-item questionnaire was designed, validated, and disseminated via e-mail and an instant-messaging platform. RESULTS: In total, 76 (of 118, 64%) cardiothoracic surgical trainees responded, representing all training grades and programs nationally; 48 (63%) and 24 (32%) were concerned about their physical and mental health, respectively, 25 (33%) had taken time off work due to COVID-19, 65 (86%) had treated patients with COVID-19, 36 of whom (55%) were wearing satisfactory personal protective equipment at the time, 41 (54%) remain concerned about personal protective equipment provision at their institution, 42 (55%) had been redeployed to cover other specialties, and 23 (30%) had encountered ethical dilemmas related to care of patients. There was a significant impact on time spent in outpatient clinics (44% reduction), multidisciplinary team meetings (79% reduction), and operating theaters (78% reduction). In total, 67 (88%) of respondents were concerned about the impact on their training, and 54 (71%) felt that the deviation may require an extension in their planned training time. CONCLUSIONS: The duration and impact of the current pandemic is, as yet, uncertain. Timely sharing of experiences, concerns, and expectations will inform health care and education policy and influence practice in the pandemic era and beyond.

In patients undergoing video-assisted thoracic surgery for lung resection, does three-dimensional endoscopic vision provide superior clinical outcomes?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the use of 3-dimensional endoscopic vision provides superior clinical outcomes to patients undergoing video-assisted thoracic surgery for lung resection. Altogether 231 unique papers were found using the reported search, of which 6 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. Four of the 6 papers demonstrated a statistically significant reduction in operative time, although this difference may not be of sufficient magnitude to be relevant clinically. There was no difference in any other outcomes assessed. We therefore conclude that, in patients undergoing video-assisted thoracic surgery for lung resection, 3-dimensional endoscopic vision has no demonstrable impact on perioperative or oncological outcomes, or cost, although it may reduce operative time.

Hybrid video-assisted thoracoscopic surgery lobectomy and en-bloc chest wall resection for non-small cell lung cancer.

Chest wall invasion is seen in 5% to 8% of patients presenting with lung cancer. We report a case of complete resection of a 14 cm × 9 cm pT3N0M0 squamous cell carcinoma arising from the right lower lobe and invading the lower chest wall posteriorly, in a 75 years old male, via a hybrid thoracoscopic [video-assisted thoracoscopic surgery (VATS)] approach. Following conventional VATS lobectomy, a targeted 10 cm incision was performed to allow wide resection of the 7th to 10th ribs and 6th to 9th transverse processes, with the defect being subsequently reconstructed with a composite rigid prosthesis. The patient made an uneventful recovery, and was discharged on the 3rd postoperative day; with later adjuvant chemotherapy. Thoracoscopic surgery is not currently widely adopted in patients with chest wall invasion, likely due to the technical difficulties. We briefly review the various techniques described in the current literature, whilst emphasising a role for such an approach in highly selected cases.

The Aquamantys(®) system improves haemostasis and pneumostasis in open decortication for thoracic empyema.

BACKGROUND: Decortication for thoracic empyema is associated with significant blood loss and prolonged postoperative air leak. We sought to assess the potential application of an irrigated-tip radiofrequency (RF) sealing device, in an attempt to reduce this morbidity. METHODS: Data for all patients undergoing open decortication (OD) for stage II thoracic empyema, using either conventional approach or facilitated by use of the Aquamantys(®) device, at a single thoracic surgical unit between April 2010 and July 2014, were retrospectively analysed. Unpaired t-test and Fisher's exact test were used for statistical analysis. RESULTS: Thirty-three patients, aged 54±15 years (mean ± SD), and with a Charlson comorbidity index of 2.5±1.9 were included. Preoperative and intraoperative characteristics, including surgical time, were similar in the conventional and Aquamantys(®) groups. Patients in the Aquamantys group were less likely to require red cell transfusion (9/22 vs. 10/11 patients, P=0.024) and received lower volume transfusions [0.0 (2.0) vs. 3.0 (1.6) units (median, IQR), P<0.0001]; chest drain duration was shorter [3.0 (1.0) vs. 6.5 (6.8) days, P=0.006], as was length of postoperative hospital stay [6.0 (8.7) vs. 10.0 (4.6) days, P=0.031]. There was no demonstrable difference in mortality. CONCLUSIONS: Our data indicates that the use of irrigated tip RF ablation is safe and effective in improving pneumostasis and haemostasis in decortication for thoracic empyema; and that this translates to morbidity and logistical benefit.