Kelvin K.W. Lau

Evolution in surgical approach and techniques for lung cancer

To improve is to change; to be perfect is to change often. Sir Winston Churchill (1874–1965) We thoroughly enjoyed reading the succinct review article by Vallieres et al 1 on therapeutic advances in non-small cell lung cancer. The authors pointed out that improvements in chest imaging and use of CT for diagnostic workup and screening have led to many more small tumours, and suspicious nodules being identified. In our practice, this has increasingly changed our management and surgical approach. For example, …

Does repeat thymectomy improve symptoms in patients with refractory myasthenia gravis

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Does repeat thymectomy improve symptoms in patients with refractory myasthenia gravis after thymectomy? A total of 189 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The outcome measures included operative mortality and morbidity, as well as long-term remission rate. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All the studies were small (4-21 patients), retrospective, single institutional case series. There was considerable heterogeneity in the studies. The interval between the first and second operation ranged from less than a year to over 10 years. The operative approach of the initial operation included transcervical, trans-sternal and substernal approaches. The maximal medical therapy received by the patients prior to reoperation varied from anticholinesterase alone to cytotoxic therapy and regular plasmapheresis. The severity of symptoms ranged from Osserman Class IIa to V. The operative approach to re-thymectomy included resternotomy, thoracoscopy and a combination of both. There was no perioperative mortality. One study reported injury to the innominate vein at resternotomy in 3 (14.3%) patients. One study reported myasthenic crisis in 2 patients in the postoperative period. Only one study reported complete remission in 2 patients. In general, however, 52-95% of patients reported some improvement. There was no consistent, objective measure of improvement in these studies. We conclude that repeat thymectomy for patients with refractory myasthenia gravis after previous thymectomy is safe especially for patients whose first procedure was transcervical. Complete remissions are rare but, in these small series, 60-70% of patients report improvement. Clinical improvement appears to be associated with the presence of residual thymic tissue at the second operation, but these cannot be reliably identified on preoperative imaging. Patient selection remains driven by symptoms.

Surgical Trauma and Immune Functional Changes Following Major Lung Resection

Video-assisted thoracic surgery (VATS) has evolved greatly over the last two decades. VATS major lung resection for early stage non-small cell lung carcinoma (NSCLC) has been shown to result in less postoperative pain, less pulmonary dysfunction postoperatively, shorter hospital stay, and better patient tolerance to adjuvant chemotherapy compared with patients who underwent thoracotomy. Several recent studies have even reported improved long-term survival in those who underwent VATS major lung resection for early stage NSCLC when compared with open technique. Interestingly, the immune status and autologous tumor killing ability of lung cancer patients have previously been associated with long-term survival. VATS major lung resection can result in an attenuated postoperative inflammatory response. Furthermore, the minimal invasive approach better preserve patients’ postoperative immune function, leading to higher circulating natural killer and T cells numbers, T cell oxidative activity, and levels of immunochemokines such as insulin growth factor binding protein 3 following VATS compared with thoracotomy. Apart from host immunity, the angiogenic environment following surgery may also have a role in determining cancer recurrence and possibly survival. Whether differences in immunological and biochemical mediators contribute significantly towards improved clinical outcomes following VATS major lung resection for lung cancer remains to be further investigated. Future studies will also need to address whether the reduced access trauma from advanced thoracic surgical techniques, such as single-port VATS, can further attenuate the postoperative inflammatory response.

Single-port video-assisted thoracoscopic lobectomy for early-stage nonsmall cell lung carcinoma

Single-port or uniport video-assisted thoracic surgery (VATS) has been gaining popularity in simple thoracic surgical procedures, such as sympathectomy, and pleural or lung biopsies. Recently, a Spanish group reported its successful attempt in performing singleport major lung resections, including lobectomy and pneumonectomy, in the literature. We describe our approach and surgical technique in single-port VATS right lower lobe lobectomy for early-stage nonsmall cell lung carcinoma.

Systematic evaluation of quality of care provided to patients undergoing pulmonary surgery helps to identify areas for improvement

Systematic assessment of care pathways may identify areas of potential improvement beyond that generated by traditional outcome measures alone. This approach was used to audit a single-surgeons practice of pulmonary resection [182 patients over 21 months, median age of 69 (range 18-86) years] by choosing 10 gold standards in three areas of care. Preoperative: 1) Percentage cancer patients undergoing PET scan prior to surgery, 2) Percentage of patients with predicted postoperative FEV(1) (ppoFEV(1)) <40% who had gas transfer (DLCO) measured. Perioperative: 3) Percentage of operations postponed, 4-5) Percentage of cancer patients undergoing anatomical resections and systematic lymph node excision, 6) Rate of exploratory thoracotomies. Postoperative: 7-8) Risk-adjusted mortality according to thoracoscore and ESOS.01, 9) Percentage patients admitted to intensive care unit (ICU), and 10) Percentage patients discharged directly home from our unit. Postoperative mortality (2.2%), ICU admission (4%), exploratory thoracotomy (2.7%), and home discharge (98%) fared within standards. Only 57% of patients with a ppoFEV(1)<40% had DLCO tested, and eight cases (4.4%) were postponed on the day of surgery. Analysis of the processes of care identified areas for improvement (preoperative preparation of patients, theatre cancellations and intraoperative lymph node management) even in a practice with satisfactory risk-adjusted results.

S16 Molecular profiling of the airway microbiome in COPD

Introduction It is hypothesised that bacteria are important in the pathogenesis of COPD exacerbations and clinical expression of disease. To date, most bacteriological research in COPD has been performed using culture based methods. However, novel molecular approaches offer more detailed evaluation of the airway microbiome that may better inform the role of bacteria in COPD. Aims To characterise the microbial community in COPD and examine whether detectable changes occur with serial longitudinal assessment at stable, exacerbation, follow-up and recovery visits. Methods 115 COPD patients that were part of a clinical trial had sputum samples collected at the four time points. Patients received antibiotics and / or oral corticosteroids after clinical assessment to treat exacerbations. Follow-up and recovery samples were collected 2 and 6 weeks after the exacerbation sample. Real-time quantitative PCR (qPCR) was performed on sputum DNA using universal 16S gene primers and specific gene targets to quantify total bacterial load and the specific pathogens Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis and Staphylococcus aureus. In a subgroup of 30 patients, 454 high-throughput pyrosequencing was performed at each of the 4 visits to examine changes to the global microbiome. Results Quantitative PCR identified one or more pathogens in 94% of stable samples and 97% of exacerbation samples. There was no significant difference in the total bacterial load or any specific pathogen between longitudinal stable and exacerbation samples. 454 pyrosequencing identified Proteobacteria and Firmicutes to be the dominant groups contributing >80% of the sequence reads at phylum level. Haemophilus, Moraxella and Streptococcus were the dominant groups at genus level. Cluster analysis characterised three groups on the basis of the ratio of Proteobacteria to Firmicutes. No significant differences in patient characteristics were observed between microbiome clusters. There was no significant change across visits in the microbial community at either phylum or genus level. No treatment specific effects on the microbiome were observed. Conclusions Molecular profiling identifies heterogeneity in the airway microbiome of COPD patients, with dominance of pathogens routinely identified at culture. However, a precise role for bacteria in COPD remains unclear.

An unusual, iatrogenic cause of massive airleak

A 66-year-old gentleman underwent emergency laparotomy and subsequent re-exploration for a retroperitoneal bleed. On the 10th postoperative day, he suffered a sudden deterioration with severe hypoxia and peri-arrest and was reintubated. Tension pneumothorax was suspected and he underwent needle thoracocentesis and emergent bilateral Seldinger intercostal drain insertion (ICD). He developed gross surgical emphysema (Fig. 1a) and there

Defeating the pores of Kohn.

In the treatment of emphysema with an endobronchial valve, entire lobar treatment is important in achieving adequate atelectasis. This case illustrates that without treatment of the entire lobe, it can fail to collapse even after several years, leading to treatment failure. Intralobar collateral ventilation through the pores of Kohn is demonstrated in this case, as endobronchial valve blockage of the remaining patent anterior segment resulted in the desired atelectasis and significant improvements in pulmonary function.

Malignant Pleural Mesothelioma and the Role of Non– Operative Therapies

Malignant pleural mesothelioma (MPM) is a primary malignancy of the pleura. The main aetiological agent is asbestos. The latency period lasts several decades, and in countries where its use was banned in the 1950’s and 1960’s, the incidence is expected to peak within the coming decade. However, in the many other countries it continues to be mined and used. The incidence in these countries can be expected to continue to rise.

Solitary Bone Plasmacytoma

Can Respir J Vol 20 No 1 January/February 2013 Plasma cell dyscrasias are a group of entities characterized by the neoplastic proliferation of a single clone of plasma cells, typically producing a monoclonal immunoglobulin. Fewer than 5% of patients with a plasma cell dyscrasia present with a single bone (solitary bone plasmacytoma [SBP]) or extramedullary lesion due to malignant plasma cell infiltrate without apparent evidence of systemic myeloma. Most often presenting as a painful lesion (but also asymptomatically), as in the present case of a 64-year-old woman with an enlarging anterior chest wall mass over a six-month period, SBP may be diagnosed during routine clinical or radiological examination for other conditions (Figure 1). A soft tissue extension of the tumour may result in a palpable mass, particularly if a rib is involved. Pathological fracture of ribs and compression fractures of vertebral bodies, as well as cord compression, may be the other presenting features of SBP. For extramedullary plasmacytomas, the lesions may grow in the aerodigestive tracts and cause hoarseness, dyspnea and hemoptysis. Extramedullary