Hunaid A. Vohra

Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax?

The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which nine papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Postoperative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of four randomised and 25 non-randomised studies performed in 2007 and published in the Lancet, although a second meta-analysis of only the randomised trials did not show this difference.

Does use of intra-operative cerebral regional oxygen saturation monitoring during cardiac surgery lead to improved clinical outcomes?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of cerebral regional oxygen saturation (rSO(2)) monitoring during cardiac surgery can lead to improved clinical outcomes. Altogether 488 papers were found using the reported search, of which eight presented the best evidence to answer the clinical question. The author, year, journal, country of study, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. Four prospective and another four retrospective studies involving adult and paediatric patients undergoing various cardiac surgical procedures were selected. These have demonstrated that prolonged intra-operative cerebral desaturations are associated with adverse neurological outcomes and prolonged hospital stay. Further, interventions carried out by thoughtful use of the cerebral oximeter are associated with significant reduction in neurologic injury, major organ morbidity and mortality (MOMM) and duration of hospital stay. Some studies have indicated decreased ventilation and intensive care unit (ICU) stay times as well. Clinical benefit and the lack of use-associated risk of injury at a modest expense support the use of this device routinely in patients undergoing cardiac surgery.

Does surgery for primary non-small cell lung cancer and cerebral metastasis have any impact on survival?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether surgical resection of non-small cell lung cancer (NSCLC) with cerebral metastasis prolongs survival. Altogether 153 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, date, journal, country of publication, study type, patient group studied, relevant outcomes, results and study weaknesses were tabulated. A vast majority of patients with synchronous presentation underwent cerebral metastasectomy prior to lung resection which led to a rapid regression of neurological symptoms. In these studies, the median survival for the curative intent groups (bifocal therapy+/-adjuvant treatment) ranged from 19 to 27 months (mean 23.12+/-3.3 months) and at 1, 2 and 5 years from 56% to 69% (mean=63.9+/-5.6%), 28% to 54% (mean=38.7+/-11%) and 11% to 24% (mean=18+/-5.7%), respectively. In comparison, the median and 1-year survival of the palliative groups were 7.1-12.9 months (mean=10.3+/-2.9 months) and 33-39.7% (mean=35.3+/-3.8%), respectively. We conclude that in the absence of mediastinal lymph node involvement, surgical resection of NSCLC with complete resection of the brain metastasis improves prognosis. Further, adenocarcinoma, low CEA levels at presentation, response to preoperative chemotherapy before focal treatment and a high Karnofsky performance score (KPS) may have a positive prognostic value.

Does pulmonary valve replacement post repair of tetralogy of Fallot improve right ventricular function

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pulmonary valve replacement (PVR) after repair of tetralogy of Fallot improved outcomes including right ventricular (RV) function. Altogether 730 relevant papers were identified using the below mentioned search, 19 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that PVR after tetralogy of Fallot repair has been shown to improve RV function and to offer symptomatic benefit. Several retrospective reviews report consistent reductions in RV end diastolic and systolic volumes and improvement in RV stroke volume, with one study also finding improvement in left ventricular stroke volume. PVR in this population appears to result in improved clinical outcome and can be performed with low mortality.

Is early primary repair for correction of tetralogy of Fallot comparable to surgery after 6 months of age

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early primary repair for correction of tetralogy of Fallot (TOF) resulted in better outcomes than surgery after 6 months of age. Altogether 650 relevant papers were identified using the below mentioned search, eight papers represented the best evidence to answer the specific question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that early primary repair of TOF has been shown to be comparable to later repair, with several retrospective series concluding that there is no increase in mortality with children under 6 months of age. Freedom from reintervention has also been shown to be similar irrespective of the age primary repair is undertaken. However, it has been observed that length of intensive care unit stay, period of mechanical ventilation and the need for inotropes is increased in patients undergoing primary repair at <3 months of age.

Does surgical correction of coarctation of the aorta in adults reduce established hypertension

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether surgical correction of coarctation of the aorta in adults (>16 years) results in reduction in established hypertension. Altogether 484 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that surgical repair of coarctation of the aorta in adult patients is superior to conservative management in the reduction of established hypertension, with one meta-analysis and several retrospective reviews reporting low morbidity and low risk of re-stenosis. The reduction in blood pressure postoperatively has been demonstrated consistently, with most patients reported as normotensive without medication and the remainder having reduced requirements for antihypertensive medications. In all the papers included here (except one), there was no early mortality and no procedure-related late mortality during mean follow-up ranging from 2 to 14 years. Thus, surgical correction of aortic coarctation is a relatively safe procedure.

Video-assisted thoracic surgery of major pulmonary resections for lung cancer: the Southampton experience §

OBJECTIVEnDespite proven safety and long-term results of video-assisted thoracic surgery (VATS) lobectomy, the technique is not widely adopted in the UK. We set out to start a VATS lobectomy programme against financial and time constraints to meet cancer waiting times. We present clinical outcomes of patients undergoing VATS major pulmonary resections (VMPRs) with emphasis on postoperative events.nnnMETHODSnPatients were deemed suitable for VMPR if on computed tomography (CT)/positron emission tomography (PET); the lesion was suspected to represent lung cancer T1-2, N0-1 and M0. VMPR involved individual hilar structures dissection without rib spreading. Systematic mediastinal nodal dissection was added in the last 64 cases.nnnRESULTSnBetween April 2005 and December 2009, 165 patients were considered suitable for first-time VMPR. Seventy were males and 95 were females. Mean age was 67.5 ± 10.1 (range 34.9-85.5 years) years. Nine patients were not suitable after initial videoscopic assessment and 156 proceeded to VMPR: 150 lobectomies, four bilobectomies, one pneumonectomy and one patient with poor lung function who underwent segmentectomy. There were 23 (14.7%) conversions to thoracotomy. The median operative time for VATS lobectomy was 03:20 ± 00:56 (hh:mm). The median length of hospital stay was 4.0 ± 4.0 days (range 1-25 days, mode 3 days). There were no in-hospital deaths and three (1.9%) out-of-hospital <30 days mortality. Complications included protracted air leak >3 days in 18 (11.5%) cases, intensive care unit (ICU) admission in 18 (11.5%), pneumothorax in 24 (15.4%) respiratory complications in 14 (9%), bronchial complications in six (3.8%) and bleeding requiring exploration in one (0.6%). The median follow-up was 13.6 months (range 0.1-54.4 months). The actuarial survival at 1, 2 and 3 years for all stages was 85.0 ± 3.8%, 82.2 ± 4.2% and 73.5 ± 7.0%, respectively.nnnCONCLUSIONnHigh postoperative events are to be expected when starting a VATS lobectomy programme. Nevertheless, VATS major pulmonary resections are safe and long-term results are not compromised. They should be considered the first choice for T1-2, N0-1 and M0 lung lesions. An aggressive approach to postoperative complications reduced the length of hospital stay to a median of 4 days. Air leak remains the most important cause for prolonged hospital stay.

Is it safe to include octogenarians at the start of a video-assisted thoracic surgery lobectomy programme? §

OBJECTIVEnThe study aimed to investigate the safety of including patients ≥ 80 years of age at the start of a video-assisted thoracic surgery major pulmonary resection (VMPR) programme.nnnMETHODSnPatients were considered for VMPR if the computed tomography/positron emission tomography (CT/PET) was suggestive of T1-3, N0-1 and M0 lesion. Age was not a criterion for exclusion at the very start of the programme. Data were collected prospectively and comparison made between two groups, (A) <80 years of age and (B) ≥ 80 years, in terms of preoperative risk factors, oncological and functional data, operative results, postoperative complications and survival.nnnRESULTSnBetween April 2005 and January 2011, 200 consecutive patients were considered for VMPR. A total of 160 had non-small-cell lung cancer, of whom 136 were in group A, with a median age of 66.5 (range: 42.8-79.4 years) and 24 in group B with a median age of 82 (range: 80-85.5 years). In group B, 13 were men and 11 were women. Rate of conversion to thoracotomy was similar (3 (12.5%) in group B vs 17 (12.5%) in group A, p = 0.65), and so was the mean hospital stay (5.8 ± 3.3 days in group B vs 5.9 ± 4.6 days in group A, p = 0.899). Admission to intensive care unit and atrial fibrillation were significantly higher in octogenarians (six (25%) and six (25%) in group B vs eight (5.9%) and nine (6.6%) in group A, p = 0.008 and p = 0.012, respectively). There was significantly less mean days of air leak in octogenarians (0.06 ± 0.3 days in group B vs 2.8 ± 5.6 days in group A, p = 0.000). Otherwise, there were no age-related differences in relation to morbidity, mortality and the 3-year survival rate.nnnCONCLUSIONnOctogenarians undergoing VMPR have a higher incidence of atrial fibrillation and admission to the intensive care unit for cardiopulmonary support but otherwise are no different from younger age groups when it comes to rate of conversion to thoracotomy, hospital stay, morbidity and mortality. Age should not be an excuse to deny the elderly curative VATS resection. In our experience, accepting octogenarians early in the VMPR programme did not compromise the outcome results.

Use of extra corporeal membrane oxygenation in the management of sepsis secondary to an infected right ventricle-to-pulmonary artery Contegra conduit in an adult patient.

This is the first report in the cardiac surgical literature in a grown-up congenital heart male patient with endocarditis of the Contegra conduit who developed septic shock with cardio-respiratory failure and required treatment with extra corporeal membrane oxygenation (ECMO) in order to stabilize his clinical condition preoperatively.

Surgical intervention for retrograde type A aortic dissection caused by endovascular stent insertion for type B aortic dissection

Retrograde type A aortic dissection after endovascular stent grafting (ESG) for type B aortic dissection is not commonly reported. We report such a complication in a patient 4 weeks after ESG for type B aortic dissection. With the expanding indications for aortic ESGs, knowledge of such a complication and its management is vital because surgeons will face this surgical dilemma more than before.