Jason M. Ali

Chronic Thromboembolic Pulmonary Hypertension: An Underdiagnosed Entity?

Abstract Chronic thromboembolic pulmonary hypertension (CTEPH) is the only cause of pulmonary hypertension for which there is a potential cure, which is in the form of pulmonary endarterectomy. There is a strong link between pulmonary embolism (PE) and the development of CTEPH. Although CTEPH was initially believed to be a rare complication, this belief has been reconsidered following several studies suggesting that up to 8.8% of patients develop CTEPH within the 2 years after PE. However, considering the incidence of PE, there is a significant discrepancy in the number of patients who are diagnosed, referred, and treated for CTEPH. Potential reasons for this include its often vague clinical presentation, the variable association of CTEPH with PE, and discrepancies when interpreting imaging studies. Underdiagnosis of CTEPH is preventing patients from accessing potentially curative therapy. Increased awareness about this condition is an important initial step to improving diagnostic rates and treatment.

Stented CorMatrix® conduit to bypass benign superior vena caval obstruction

Surgical venous bypass is an effective treatment option in the management of benign superior vena caval obstruction. Here, we present CorMatrix® as a novel conduit choice, supported internally by an endovascular stent in an attempt to prevent stenosis and reduce reintervention rate following surgical bypass.

Subxiphoid single incision thoracoscopic surgery approach for thymectomy: a case report

Thoracic surgery is rapidly evolving with minimally invasive strategies now dominating. Thymectomy has traditionally been performed through a sternotomy, but more recently video-assisted thoracoscopic surgery (VATS) approaches have become increasingly popular. To further minimise surgical impact, the uniportal subxiphoid VATS technique has recently been described, using a muscle sparing incision that avoids intercostal nerve injury. A potential advantage that makes this approach particularly suited to thymectomy includes the ability to access both sides of the chest with a single incision. There is also the potential for reduced post-operative pain and chronic thoracostomy neuralgia. Here we describe the management of a patient with thymoma, reporting our procedure and technique for performing uniportal subxiphoid VATS thymectomy.

Subxiphoid approach for spontaneous bilateral pneumothorax: a case report

The development of video-assisted thoracoscopic surgery (VATS) has contributed to reduced pain and improved recovery following thoracic surgery. However, pain remains a major issue. Patients with bilateral pulmonary pathology requiring operative intervention may have even more pain due to bilateral transthoracic incisions. The recently described uniportal subxiphoid VATS approach provides an opportunity to undertake bilateral thoracic surgery through a single incision that avoids the bilateral intercostal nerve damage caused by transthoracic incision and drainage. Here we report a case of a patient requiring bilateral bullectomy and pleurectomy for the management of pneumothorax that was performed successfully by the subxiphoid VATS approach.

Uniportal subxiphoid video-assisted thoracoscopic approach for thymectomy: a case series

BackgroundnMinimally invasive techniques are becoming increasingly popular in thoracic surgery. Although median sternotomy is the traditional approach for thymectomy, video-assisted thoracoscopic surgery (VATS) approaches now predominate. This study reports a case series of the novel uniportal subxiphoid-VATS approach to extended thymectomy.nnnMethodsnOver the period of study (October 2014-January 2017) 17 patients underwent uniportal subxiphoid-VATS extended thymectomy for a thymic nodule at the Shanghai Pulmonary Centre. Ten patients were female, and the mean age of the cohort was 55 years. The mean size of nodule was 23.6 mm.nnnResultsnThe mean operative duration was 2.5 hours, with one conversion to thoracotomy for bleeding. The mean operative blood loss was 115 mL. The median length of hospital stay was 4 days. There were no episodes of phrenic nerve palsies. The 30-day survival was 100%.nnnConclusionsnUniportal subxiphoid-VATS is a feasible and safe surgical approach to extended thymectomy in selected patients, with good post-operative outcomes.

Anticoagulant-Free Off-Pump Left Ventricular Assist Device Implant

Implantable left ventricular assist device (LVAD) therapy is an established treatment for advanced heart failure. LVADs are usually implanted using intra-operative anticoagulation with or without cardiopulmonary bypass. We describe an anticoagulant-free off-pump LVAD implant technique to circumvent potential complications associated with conventional approaches. This technique is safe and is probably the least invasive surgical approach for LVAD implantation.

Robotic Camera Assistance: The Future of Laparoscopic and Thoracoscopic Surgery?:

Introduction. Minimally invasive techniques have become the standard for a variety of procedures across all surgical specialties. There has been a recent move to integrate robotic technology into standard laparoscopic and thoracoscopic surgery with the aim of improving stability of the visual field with the use of robotic camera assistance. The aim of this study was to report on and examine the use of a headset-controlled robotic camera holder, FreeHand. Methods. Between May 2013 and Dec 2016, 105 procedures were observed where the FreeHand robotic camera assistant was used. Observations were made of 43 consultant surgeons in 30 hospitals performing 21 different surgical procedures. During the surgery, the number of scope cleans and collisions were quantified, and surgeons were asked to score from 0 to 5 the setup, ergonomics, usability, and overall experience in a questionnaire. Results. Overall surgeon satisfaction was rated as “good” for setup (4.29), ergonomics of the system (4.12), usability (4.39), and overall experience of the system (4.34). In 8 operations (7.6%), there was a conversion from robotic camera assistant to manual assistant. There were no reported adverse events attributable to the use of the system. Conclusion. This study demonstrates the breadth of surgical procedures that can be performed with a robotic camera assistant. The robotic camera assistant was found to be safe and simple to use and was positively perceived on assessment in multiple procedures spanning several surgical specialties. This work suggests that robotic camera assistants may offer significant benefits to laparoscopic and thoracoscopic surgeons.

Subxiphoid pneumonectomy: the new frontier?

Over the last decade there has been a significant drive towards minimally invasive thoracic surgery. The reported benefits of video-assisted thoracic surgery (VATS) over open surgery include reduced postoperative pain, reduced postoperative complications, reduced length of hospital-stay and period of recovery to normal function (1-4). With increased experience, more advanced procedures are now reportedly performed by VATS in high volume centres, including sleeve and carinal resections (5,6).

The outcome of reoperative pulmonary endarterectomy surgery

OBJECTIVESnPulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH). Despite excellent outcomes following PEA, a small proportion of patients have residual proximal disease or present with recurrent chronic thromboembolic PH and may benefit from further surgery. The aim of this study was to analyse outcomes following reoperative PEA at a high-volume national tertiary referral centre for the management of chronic thromboembolic PH.nnnMETHODSnThis retrospective analysis was performed using our prospectively maintained PH database to identify all patients who underwent reoperative PEA surgery between the commencement of the programme in 1997 and January 2017, and the patients data were collected for analysis.nnnRESULTSnTwelve patients underwent reoperative PEA during the period of study. The mean interval between primary procedure and reoperative procedure was 6.3u2009years. Significant improvements were observed in pulmonary haemodynamics following reoperative PEA. Mean pulmonary arterial pressure decreased from 46.8 to 29.8u2009mmHg (Pu2009<u20090.0001) and pulmonary vascular resistance decreased from 662 to 362u2009dyne·s·cm-5 (Pu2009=u20090.0007). A significant functional improvement in the 6-min walking test distance was also observed, increasing from 327 to 460u2009m at 6u2009months postoperatively (Pu2009=u20090.0018). Median length of hospital stay was 12u2009days. In-hospital mortality was 8.3% with 1-year survival of 83.3%.nnnCONCLUSIONSnReoperative PEA is technically possible and relatively safe, achieving good functional and physiological outcomes. Patients must be carefully selected by a multidisciplinary team, and surgery should be performed in experienced centres.

Does the use of a hot-shot lead to improved outcomes following adult cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Does the use of a hot-shot (terminal warm blood cardioplegia) lead to improved outcomes following adult cardiac surgery? Altogether, 567 papers were found using the reported search, of which 9 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. We conclude that evidence supporting the use of a hot-shot prior to weaning from cardiopulmonary bypass is rather limited. All 8 of the randomized trials to date are small studies which examine heterogeneous groups of patients, and unfortunately, the conclusions are inconsistent, perhaps in part related to the inability to demonstrate statistical significance with small group size. From the evidence, it appears likely that the use of a hot-shot results in more rapid biochemical, electrical and possibly functional myocardial recovery from cardiopulmonary bypass. However, no study has been able to demonstrate that this leads to improved clinical outcomes other than lower incidence of atrial fibrillation.