Mathew Doyle

Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer

BACKGROUND Uniportal video-assisted thoracoscopic surgery (VATS) has emerged as a less invasive alternative to the conventional multiportal approach in the treatment of lung cancer. The benefits of this uniportal technique have not yet been characterized in patients undergoing VATS lobectomy. This meta-analysis aimed to compare the clinical outcomes of uniportal and multiportal VATS lobectomy for patients with lung cancer. METHODS A systematic review was conducted using seven electronic databases. Endpoints for analysis included perioperative mortality and morbidity, operative time, length of hospital stay, perioperative blood loss, duration of postoperative drainage and rates of conversion to open thoracotomy. RESULTS Eight relevant observational studies were identified and included for meta-analysis. Results demonstrated a statistically significant reduction in the overall rate of complications, length of hospital stay and duration of postoperative drainage for patients who underwent uniportal VATS lobectomy. There were no significant differences between the two treatment groups in regard to mortality, operative time, perioperative blood loss and rate of conversion to open thoracotomy. CONCLUSIONS The present meta-analysis demonstrated favourable outcomes for uniportal VATS lobectomy in the treatment of lung cancer compared to the conventional multiportal approach. However, long-term follow-up data is still needed to further characterize the benefits of the uniportal approach.

Transcatheter aortic valve implantation versus surgical aortic valve replacement: A meta-analysis of randomized controlled trials

BACKGROUND Transcatheter aortic valve implantation (TAVI) has become a widely utilized method of treatment of severe aortic valve stenosis. The present meta-analysis included all published relevant randomized controlled trials (RCTs) and aimed to compare the safety and efficacy of TAVI compared to surgical aortic valve replacement (AVR). METHOD Nine electronic databases were comprehensively searched. Eligible studies were required to be randomized controlled trials which reported comparative endpoints on both TAVI and AVR. RESULTS Five published RCTs were included in the meta-analysis. A total of 3828 patients were studied. The overall mortality and stroke rates at 30days and 1year were not significantly different between TAVI and AVR. Patients undergoing TAVI were more likely to experience vascular complications, aortic regurgitation and permanent pacemaker insertion, however, they were less likely to encounter acute renal failure and major haemorrhage. CONCLUSIONS The data suggest that TAVI is a safe and efficacious alternative to surgical aortic valve replacement in judiciously selected patients.

Treatment of Intravenous Leiomyomatosis with Cardiac Extension following Incomplete Resection.

Aim. Intravenous leiomyomatosis (IVL) with cardiac extension (CE) is a rare variant of benign uterine leiomyoma. Incomplete resection has a recurrence rate of over 30%. Different hormonal treatments have been described following incomplete resection; however no standard therapy currently exists. We review the literature for medical treatments options following incomplete resection of IVL with CE. Methods. Electronic databases were searched for all studies reporting IVL with CE. These studies were then searched for reports of patients with inoperable or incomplete resection and any further medical treatments. Our database was searched for patients with medical therapy following incomplete resection of IVL with CE and their results were included. Results. All studies were either case reports or case series. Five literature reviews confirm that surgery is the only treatment to achieve cure. The uses of progesterone, estrogen modulation, gonadotropin-releasing hormone antagonism, and aromatase inhibition have been described following incomplete resection. Currently no studies have reviewed the outcomes of these treatments. Conclusions. Complete surgical resection is the only means of cure for IVL with CE, while multiple hormonal therapies have been used with varying results following incomplete resection. Aromatase inhibitors are the only reported treatment to prevent tumor progression or recurrence in patients with incompletely resected IVL with CE.

Rarefaction of the aorta under Dacron wrap: a rare complication

Treatment for ascending aortic dilatation varies from a wait-and-watch approach to aortic replacement. The use of an external prosthesis to gird and support the proximal aorta is safe and durable for selected aortic aneurysms. We report a rare complication in a 62-year-old man with bicuspid aortic valve and coronary artery disease who had undergone coronary artery bypass surgery and ascending aortic wrapping 10 years previously. During subsequent aortic valve surgery, he was incidentally found to have erosion of Dacron wrap through the aortic wall.

Cytoreductive surgery and heated intrathoracic chemotherapy for thoracic extension of Pseudomyxoma peritonei

Background: Thoracic extension of Pseudomyxoma peritonei can occur via trans-diaphragmatic spread of abdominal disease. Cytoreductive surgery with intraoperative intrapleural chemotherapy may prolong survival in an otherwise terminal condition. We evaluate the long-term outcomes of patients undergoing thoracic cytoreductive surgery and intrathoracic intraoperative chemotherapy for pleural extension of Pseudomyxoma peritonei. Methods: All patients who underwent thoracic cytoreductive surgery and heated intrathoracic chemotherapy for thoracic spread of PMP were identified from our prospectively compiled registry. Peri operative outcomes were reviewed and long term results were obtained from follow up and correspondence from other specialists. Long-term mortality was calculated from follow-up data. Results: There were three men and three women. The median age at thoracic surgery was 49.7 years. All patients had undergone previous abdominal surgery for pseudomyxoma. Time from initial cytoreductive surgery to thoracic recurrence ranged from 12.1 to 135 months. There was no perioperative mortality. Follow up range was 8 – 132 months. There were no cases of thoracic disease recurrence following complete thoracic cytoreduction. 5 and 10-year survival was 80% and 40% respectively. Conclusions: Complete cytoreduction and heated intrathoracic intraoperative chemotherapy can provide long-term disease free and overall survival for patients with thoracic recurrence of pseudomyxoma peritonei.

Direct Innominate Artery Cannulation as a Sole Systemic and Cerebral Perfusion Technique in Aortic Surgery

Arterial cannulation is often challenging in thoracic aortic surgery due to the location of the surgery and need for cerebral protection during periods of circulatory arrest. Cannulation sites including the ascending and descending aorta, axillary, carotid and femoral arteries have limitations and are associated with complications due to their proximity to surrounding structures. Therefore, the innominate artery can be used by either direct cannulation or indirect cannulation via a graft as an alternative site. We present a technique of sole direct innominate artery cannulation that is able to provide both systemic and selective antegrade cerebral perfusion during aortic surgery.

Patient Safety During Chest Drain Insertion—A Survey of Current Practice

OBJECTIVES The aim of this study was to identify the degree of awareness of the current guidelines and common practices for pleural drain insertion. METHODS A 10-item questionnaire was sent electronically to junior physicians from 4 different hospitals in the South Eastern Sydney and Illawarra Shoalhaven Local Health District. Participants were asked to give their level of experience and management practices for chest drain insertion. RESULTS A total of 94 junior medical officers from 4 hospitals in the district completed the survey. More than 20% had never inserted a chest drain at the time; 72% had primarily learned from bedside teaching and peer learning, but 11% had no training at all. More than 50% of physicians felt that the biggest threat to the procedure was their own lack of confidence for drain insertion. Despite current guidelines, 25% insert chest drains routinely without the aid of ultrasound. A third of interviewees were aware of local guidelines but had not read them. Most physicians (86%) believe that formal standardized training should be available for junior physicians. CONCLUSIONS Our findings demonstrate the ongoing need for improved procedural training in chest drain insertion, with emphasis on mandatory thoracic ultrasound. We consider it important to continue to raise concern and awareness that chest drain insertion is not a harmless procedure, and further physician procedural competence is required.

Delayed surgical intervention of sternoclavicular joint infection with increased complications

appropriate for the bacteria cultured from the necrotic perineal and scrotal tissues. The patient’s Fournier’s gangrene may have been avoided if there was early recognition of necrotizing fasciitis in the perineum and early debridement. Early surgical intervention is the mainstay of treatment. In this case study, a delay in aggressive wide debridement of the perineal necrotizing fasciitis may have contributed to the extensive progression and development into Fournier’s gangrene. The patient may have benefited from a wide debridement during the initial drainage or a repeat examination under anaesthesia and early redebridement post drainage. While it is difficult to diagnose early necrotizing fasciitis as it shares similar clinical features to severe cellulitis, pain on palpation including areas beyond area of skin involvement, blister or bullae formation particularly haemorrhagic, crepitus and dusky discoloration may point towards necrotizing disease. A Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system has been proposed to help with early diagnosis – parameters such as a WCC of >25 × 10(9)/L or a CRP >150 mg/L indicate a higher risk that the patient may have necrotizing fasciitis. Other parameters include serum haemoglobin, glucose, creatinine and sodium. In our case, the patient retrospectively had a LRINEC score of 8 out of 13 – a score indicating high risk of necrotizing fasciitis. It is important to understand the concept that Fournier’s gangrene is not just urological, but up to 30–40% of Fournier’s gangrene is associated with delayed or inadequate drainage of perianal abscess complicated by necrotizing infection of the perineum. Most recent studies have shown that the most common cause of Fournier’s gangrene is perianal abscess rather than a urological source highlighting the dangers of inappropriate delays in management, inadequate drainage of perianal abscess and failure to recognize necrotizing infections of the perianal region and Fournier’s gangrene.