Douglas West

Indwelling pleural catheters for non-malignant effusions: a multicentre review of practice

Indwelling pleural catheters (IPCs) are commonly used in the management of malignant pleural effusion (MPE). There is little data on their use in non-malignant conditions. All IPC insertions for non-malignant cases from five large UK centres were found using prospectively maintained databases. Data were collected on 57 IPC insertions. The commonest indications were hepatic hydrothorax (33%) and inflammatory pleuritis (26%). The mean weekly fluid output was 2.8 L (SD 2.52). 48/57 (84%) patients had no complications. Suspected pleural infection was documented in 2 (3.5%) cases. 33% (19/57) of patients underwent ‘spontaneous’ pleurodesis at a median time of 71 days. Patients with hepatic disease achieved pleurodesis significantly less often than those with non-hepatic disease (p=0.03). These data support the use of IPCs in select cases of non-malignant disease when maximal medical therapy has failed.

Spontaneous pneumothorax: time to rethink management?

There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.

Pain and recovery are comparable after either uniportal or multiport video-assisted thoracoscopic lobectomy: an observation study.

OBJECTIVES Uniportal approaches to video-assisted thoracoscopic surgery (VATS) lobectomy have been described in significant series. Few comparison studies between the two techniques exist. The aim was to determine whether the uniportal technique had more favourable postoperative outcomes than the multiport technique. METHODS All VATS lobectomies undertaken at a single university hospital during August 2012 to December 2013 were studied. Patients with preoperative opiate use or chronic pain were excluded. Patients were divided into those with uniportal and multiport approaches for analysis. All continuous data were assessed for normality, and analysed with the Mann-Whitney U-tests or t-tests as appropriate. Categorical data were analysed by Fishers exact or χ(2) test for trend as appropriate. RESULTS One hundred and twenty-nine VATS lobectomies were completed. Six were excluded and data were incomplete for 13, leaving 110 (15 uniportal, 95 multiport) for analysis. The demographics of the two groups were similar. There was no significant difference in the Thoracoscore or American Society of Anesthesiologists grades. The median morphine use in the first 24 postoperative hours was 19 mg in the uniportal group and 23 mg in the multiport group, P = 0.84. The median visual analogue pain score in the first 24 h was 0 in the uniportal group and 0 in the multiport group, P = 0.65. There was no difference in the duration of patient-controlled analgesia (P = 0.97), chest drain duration (P = 0.67) or hospital length of stay (P = 0.54). There was no inpatient mortality and no unplanned admission to critical care in either group. CONCLUSIONS Uniportal VATS lobectomy is safe, and there is no appreciable negative impact on the hospital stay or morbidity. Patient-reported pain and morphine use in the first 24 h was low with either technique. Larger prospective studies are needed to quantify any benefit to a particular approach for VATS lobectomy.

Adopting a standardized anterior approach significantly increases video-assisted thoracoscopic surgery lobectomy rates.

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) lobectomy is associated with improved short-term outcomes compared with thoracotomy. Definition of the hilar structures is crucial to safe VATS lobectomy. Several VATS approaches have been described. We report the effect of three surgeons in our institution undertaking standardized anterior approach (SAA) training on the proportion of isolated lobectomies subsequently completed by VATS. Predictors of successful VATS lobectomy were analysed. METHODS Three consultant surgeons undertook SAA training at two different time points. Two were performing VATS lobectomy prior to SAA training. Training involved a 2-day visit to an established SAA unit. Lobectomies performed by these surgeons between April 2011 and December 2012 (20 months), before and after training, were recorded prospectively. Bilobectomies, sleeve resections, pneumonectomies and chest wall resections were excluded. VATS lobectomy proportions before and after training were compared. Independent predictors of completion by VATS rather than thoracotomy were identified by multivariable logistic regression. RESULTS One hundred and sixty-three isolated lobectomies were performed, 97 of these by VATS (59.5%). The mean age was 68.8 (± 10.5) years. Pathology was lung cancer in 137 (84.0%), other primary malignancy in 10 (6.1%), pulmonary metastases in 8 (4.9%) and benign in 8 (4.9%). The VATS lobectomy rate rose from 22.2% before SAA training to 77.3% after, P < 0.001. The effect was significant for both existing and adopting VATS lobectomy surgeons, P = 0.002 to <0.001. The median hospital stay was 4 days after VATS and 5 after thoracotomy, P < 0.001. There were 5 in-hospital deaths after thoracotomy and none after VATS lobectomy, unadjusted P = 0.01. In the final logistic regression model, SAA training was the strongest predictor of successful VATS lobectomy (odds ratio 15.16; 95% confidence interval 6.39, 35.96). CONCLUSIONS Formal training and adoption of the SAA approach were associated with a more than 3-fold increase in our VATS lobectomy rate. The effect was immediate and sustained. This may reflect easier identification of the major structures from the anterior view. In addition, standardization of surgical techniques and perioperative protocols may facilitate efficient team working. VATS lobectomy was associated with a shorter median hospital stay. Units seeking to increase their VATS lobectomy rate should consider group adoption of the SAA approach.

Inspiring the next generation of Cardiothoracic Surgeons: an easily reproducible, sustainable event increases UK undergraduate interest in the specialty

There is believed to be declining interest in cardiothoracic surgical careers among UK medical students. Relative lack of undergraduate exposure to the specialty compared with other surgical specialties may be partly responsible. Using pre- and postintervention analysis, we assessed the ability of a student-led extracurricular engagement event to increase undergraduate interest in the specialty. Fifty-four students attended and 50 (93%) participated in the study. Of the total, 32% of delegates had identified a cardiothoracic mentor, with only 8 and 4% exposed to cardiac and thoracic surgery, respectively, compared with 50% exposed to other surgical specialties. Self-reported understanding of cardiothoracic training increased from 20 to 80% (P < 0.001) after the 1-day event; 77% of delegates reported increased interest in the specialty. We demonstrate that it is possible to provide a free-to-user event that increases engagement using a student-led design. Similar events could increase interest in the specialty and may improve recruitment rates. Current levels of cardiothoracic exposure are very low among UK students.

Giant thoracic mass: an unusual presentation of primary pulmonary Hodgkin's lymphoma

Primary pulmonary Hodgkins lymphoma (PPHL) is rare. PPHL without peripheral lymphadenopathy or hepatosplenomegaly is exceptionally uncommon. We present a 61-year-old woman believed to have a solitary intrapulmonary fibrous tumour on a CT and a CT-guided biopsy, until surgical excision. Histopathology and immunohistochemistry of the excised mass confirmed PPHL. PPHL is a very rare differential diagnosis of large solitary intrapulmonary masses. A CT-guided biopsy is recommended, as it can be diagnostic, reserving excision for cases where the diagnosis remains in doubt.

Hormonal manipulation after surgery for catamenial pneumothorax

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether hormonal manipulation with gonadotrophin-releasing hormone analogues reduces the risk of recurrent catamenial pneumothorax after surgery, compared with surgery alone. Altogether 819 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, date, journal, country of publication, study type, level of evidence, patient group studied, relevant outcomes and results of these papers are tabulated. Of the 7 papers selected, 6 demonstrated a reduction in recurrence of catamenial pneumothorax with the use of gonadotrophin-releasing hormone analogues, whereas in the single paper where surgery alone was performed, no evidence of recurrence was demonstrated. We therefore conclude that, based on very small retrospective observational studies, gonadotrophin-releasing hormone analogues used as an adjunct to surgical intervention may reduce the risk of recurrent pneumothorax, when compared with either no hormonal therapy or oestrogen-progesterone therapy, but should be initiated and supervised by gynaecologists who will be familiar with the therapy and the potential side effects.

Cardiothoracic surgery remains an attractive career in the United Kingdom.

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eReply. Re: is uniport thoracoscopic surgery less painful than multiple port approaches?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was ‘In patients undergoing Video-Assisted Thoracoscopic Surgery (VATS), does a uniport (single-port) or multiport technique convey benefit in terms of postoperative pain?’ Altogether, 255 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studies, study type, relevant outcomes and results of these tables are tabulated. All the available evidence is from small, non-randomized studies. Many were retrospective and methodologically weak. Most studied minor thoracic surgical procedures and a few compare the two approaches in major pulmonary resections. One of the studies compared pain at 24 h for uniport [mean Visual Analogue Scale (VAS) >4.4] and three-port VATS (mean VAS 6.2), for different procedures including lung biopsy and surgery for pneumothorax (P = 0.035). Another study compared pain in the first 36-h post-sympathectomy and found mean pain scores of 0.8 in the uniport group and 1.2 in the two-port group (P = 0.025). Six studies exclusively compared the VAS between uniport and three-port VATS for primary spontaneous pneumothorax. Two studies found no significant difference in pain scores and four found a statistically significant reduction in early postoperative pain scores. One study found that pain scores were similar for lung volume reduction surgery. Two studies compared the mean VAS and morphine use between uniportal and multiportal lobectomies; however, there were no statistically significant differences. From the papers identified in our search, we conclude that uniport VATS may have a small clinical effect in reducing postoperative pain, with the majority of papers looking at the first 72 h following surgery. Often the VAS score was only improved in the uniport patients by 1–2 points, and the studies did not find statistically significant results throughout their investigations, especially when looking at follow-up pain scores. Around one-third of the chosen papers did not find any statistically significant results. Further studies are needed before single-port can be recommended as less painful than multiport thoracoscopic surgery.

Video-assisted thoracoscopic thymectomy

Access from the right chest is generally easier. In this case however, the thymoma was predominantly left-sided and therefore a left-sided approach was preferred. The anesthetist places a double lumen tube to allow isolation of the required lung. The patient is placed with the chest elevated to an angle of around 30 degrees. This allows the plane between the sternum and thymus to be developed easily, while minimizing instrument clashes. The arm lies secured beside the chest (2). The chest wall is prepared from the posterior axillary fold to beyond the sternum, and from the jugular notch to just below the xiphisternum. This leaves the entire sternum exposed, making quick conversion to sternotomy possible if needed.