Andrew J. Drain

Definitive management of advanced empyema by two-window video-assisted surgery.

We describe how 2-window video-assisted thoracoscopic decortication and lung mobilization can provide definitive management of stage III empyema. This technique was used in 52 patients with stage III empyema. None required additional ports or a thoracotomy. Three patients (6%) needed computed tomography-guided drainage of persistent large loculi, but none required further surgery. Chest radiographs at 6 weeks after surgery confirmed full lung expansion and resolution of pleural collection in the other 49 patients (94%).

Death in low-risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FIASCO) study.

Death in low-risk patients is not studied as frequently as it is in other cardiac patients. We, therefore, sought to determine why some low-risk patients die after cardiac surgery. All low-risk patients (EuroSCORE<or=2) who died after cardiac surgery in one institution between 1996 and 2005 were included and meticulously studied by internal and independent external review of preoperative, operative and postoperative information from the case-notes and post-mortem findings. Deaths were classified into non-cardiac and cardiac and further subclassified into unavoidable deaths or due to failure in achieving a satisfactory cardiac outcome (FIASCO). Between 1996 and 2005, there were 16 deaths in 4294 low-risk patients (mortality 0.37%). Internal and external review agreed that nine deaths were non-preventable (CVA, bronchopneumonia, etc.) and that avoidable FIASCO accounted for seven deaths. Of the deaths considered to be preventable, all had probable errors of technique and three also had additional system errors. No cardiac operation is without risk. Mortality, though fortunately rare, can still occur, even in low-risk patients. Despite an extremely low mortality in the low-risk group FIASCO still accounts for nearly one-half of deaths. This suggests that mortality may be reduced even further as part of a quality improvement programme.

Cardiac Surgery in Nonagenarians: Single-Centre Series and Review

Background: Cardiac surgery is widely believed to be an excessively high-risk intervention for very elderly patients with coronary artery or valvular disease. However, as life expectancy and the prospect of sustained quality of life into older age increase, this assumption should be challenged so that surgery is not denied to patients who may derive significant symptomatic benefit with acceptable levels of operative risk. Objective: To evaluate outcomes from cardiac surgery in nonagenarian patients. Design: Analysis of prospectively collected single-centre data and review of outcomes reported in the literature. Results: Twenty-three patients (13 males) aged 90 years or more underwent open cardiac surgery between 1998 and 2007. Four patients died within 30 days of surgery (surgical mortality 17.4%) and all-cause in-hospital morbidity was 74%. Actuarial survival at 1 and 5 years was estimated at 72 and 54%, respectively. Comparison of patients’ survival against age-matched life tables for the English population found a standardised mortality ratio of 0.57 (95% CI: 0.24–0.99; one-sample log-rank test χ2 = 3.93; p < 0.05) representing a significant survival benefit associated with surgery. The majority of patients reported symptomatic improvement reflected by significant decreases in angina and dyspnoea scores. Six single-centre series of nonagenarians and 3 reviews from national databases in the US and UK were identified in the literature. Pooled surgical mortality was 12.7% (95% CI: 8.7–17.3%) with no significant heterogeneity (χ2 = 4.12; p = 0.77; I2 = 0). Conclusion: Cardiac surgery in the elderly carries higher operative risk than in younger patients. However, in selected nonagenarians, surgery can be performed with acceptable morbidity and early mortality, and patients gain significant symptomatic relief and survival benefit.

Cytokine phenotype, genotype, and renal outcomes at cardiac surgery

BACKGROUND Cardiac surgery modulates pro- and anti-inflammatory cytokine balance involving plasma tumour necrosis factor alpha (TNFα) and interleukin-10 (IL-10) together with urinary transforming growth factor beta-1 (TGFβ1), interleukin-1 receptor antagonist (IL1ra) and tumour necrosis factor soluble receptor-2 (TNFsr2). Effects on post-operative renal function are unclear. We investigated if following cardiac surgery there is a relationship between cytokine (a) phenotype and renal outcome; (b) genotype and phenotype and (c) genotype and renal outcome. Since angiotensin-2 (AG2), modulates TGFβ1 production, we determined whether angiotensin converting enzyme insertion/deletion (ACE I/D) genotype affects urinary TGFβ1 phenotype as well as renal outcome. METHODS In 408 elective cardiac surgery patients we measured pre- and 24 h post-operative urinary TGFβ-1, IL1ra and TNFsr2 and pre- and 2 h post-operative plasma TNFα and IL-10. Post-operative responses were compared for each cytokine in patients grouped according to presence or absence of renal dysfunction defined as a drop from baseline eGFR of greater than 25% (as calculated by the method of modification of diet in renal disease (MDRD)) occurring (1) within the first 24 and (2) 48 postoperative hours (early renal dysfunction), (3) on the fifth postoperative day (late renal dysfunction) or (4) at any time throughout the 5 day postoperative period (early and late combined). Patient genotype was determined for TNF/G-308A, TGFβ1-509 C/T, IL10/G-1082A and ACE I/D. RESULTS Post-operative plasma IL-10 and urinary TGFβ1 responses were significantly higher in patients who developed early renal dysfunction. IL1ra and TNFsr2 responses were significantly lower 24h post-operatively in patients who developed late renal dysfunction. Genotype did not alter cytokine phenotype or outcome. CONCLUSIONS/INFERENCES: Cytokine profiling may help predict early and late renal dysfunction. Genotypes studied did not alter phenotype or outcome.

Blood, Sweat, Toil, and Tears of Surgical Training. Part I: Blood

There may be conflict between the requirements of surgical training and those of the clinical service if training has an impact on clinical outcomes. One area of potential impact is perioperative blood loss. We compared total and 12-hour blood loss after 2,079 consecutive cardiac operations performed over 2 years by trainees and consultants. One- and two-way analyses of variance with EuroSCORE and surgeon status as factors were carried out to evaluate the impact of surgeon status on blood loss. There was no difference in blood loss between consultants and trainees. We also compared the rates between consultants and trainees of patients returning to the operating room due to bleeding. This showed a significant difference, with trainees having a higher rate of investigation for bleeding. Cardiac surgical training can be achieved without an adverse effect on blood loss, but it may be associated with a higher rate of re-intervention for bleeding.

Mesothelioma with non-pleural malignancy: a red herring or just an uncommon pairing?

Malignant pleural mesothelioma (MPM) is a highly aggressive cancer of the pleura with a well-established male predominance and causative link with asbestos exposure. We report four cases of female patients with MPM referred for palliation of symptoms thought to be due to previous non-pleural malignancy.With emerging novel treatments for MPM, this article discusses four unusual cases of MPM occurring in the setting of other malignancy, highlights the importance of considering a primary diagnosis of MPM even in patients with other malignancy, and reinforces the benefits of video-assisted surgical biopsy which allows simultaneous diagnosis and treatment.