Michael Shackcloth

Video-assisted thoracoscopic surgery lobectomy at 20 years : a consensus statement

OBJECTIVEnVideo-assisted thoracoscopic surgery (VATS) lobectomy has been gradually accepted as an alternative surgical approach to open thoracotomy for selected patients with non-small-cell lung cancer (NSCLC) over the past 20 years. The aim of this project was to standardize the perioperative management of VATS lobectomy patients through expert consensus and to provide insightful guidance to clinical practice.nnnMETHODSnA panel of 55 experts on VATS lobectomy was identified by the Scientific Secretariat and the International Scientific Committee of the 20th Anniversary of VATS Lobectomy Conference-The Consensus Meeting. The Delphi methodology consisting of two rounds of voting was implemented to facilitate the development of consensus. Results from the second-round voting formed the basis of the current Consensus Statement. Consensus was defined a priori as more than 50% agreement among the panel of experts. Clinical practice was deemed recommended if 50-74% of the experts reached agreement and highly recommended if 75% or more of the experts reached agreement.nnnRESULTSnFifty VATS lobectomy experts (91%) from 16 countries completed both rounds of standardized questionnaires. No statistically significant differences in the responses between the two rounds of questioning were identified. Consensus was reached on 21 controversial points, outlining the current accepted definition of VATS lobectomy, its indications and contraindications, perioperative clinical management and recommendations for training and future research directions.nnnCONCLUSIONnThe present Consensus Statement represents a collective agreement among 50 international experts to establish a standardized practice of VATS lobectomy for the thoracic surgical community after 20 years of clinical experience.

Aspirin and non-small cell lung cancer resections: effect on long-term survival.

OBJECTIVEnSurvival after resections for non-small cell lung cancer remains poor. Recurrent lung cancer remains common. Due to the common risk factor of smoking, cardiovascular deaths occur in the absence of recurrent lung cancer in up to 15% of patients. Aspirin has been proven to reduce cardiovascular mortality as a secondary prophylactic agent, but not as a primary agent. Aspirin being a COX-2 inhibitor has been shown to reduce the chance of metastasis in adenocarcinoma but not squamous carcinoma. We sought to investigate the effect of long-term aspirin therapy on survival post potentially curative surgery.nnnMETHODSnWe analysed a prospective thoracic surgical database, from time period 2003 to date. Patients who were on aspirin pre-operatively, N=412 were compared to non users, N=1353. Patient long-term outcome was assessed utilising the national strategic tracking service that operates in the United Kingdom. Cox proportional hazards analysis was used to determine significant factors affecting survival.nnnRESULTSn100% survival follow up was achieved. Regular users of aspirin had >5% increased survival, which was significant, p=0.05, despite having a higher cardiovascular risk profile. Mode of death data was not available.nnnCONCLUSIONSnAdjuvant aspirin post resection for potentially curative non-small cell lung cancer significantly increases survival. The mechanism of increased survival needs further investigation and is the basis for the trial: Adjuvant Aspirin for Non-Small cell Lung Cancer--The Big A Trial. www.TheBigATrial.co.uk.

Phenoxybenzamine treatment is insufficient to prevent spasm in the radial artery: the effect of other vasodilators

OBJECTIVESnAfter its reintroduction as an arterial graft in coronary artery surgery, the radial artery is now established as an alternative arterial conduit, with good early and midterm patency. However, because of the concern about its vasospasticity, numerous vasodilator strategies have been used. Recently the use of the irreversible alpha-adrenergic antagonist phenoxybenzamine has been proposed. Although this treatment is effective in eliminating the vasoconstriction mediated by noradrenaline, the contribution of other circulating vasoconstrictors to vasospasm could be as important. This study investigates the response of radial arteries treated with phenoxybenzamine to vasoconstrictor stimuli and possible preventative strategies.nnnMETHODSnIn vitro, sections of radial artery, pretreated with phenoxybenzamine after harvesting, were stimulated with maximal concentrations of the vasoconstrictors noradrenaline, vasopressin, angiotensin II, KCl, and endothelin-1. In matched segments of artery, vasoconstrictor responses were recorded in the presence of diltiazem, glyceryl trinitrate, and papaverine and compared with phenoxybenzamine-treated samples.nnnRESULTSnPhenoxybenzamine-treated radial artery failed to respond to noradrenaline but did respond to vasopressin, angiotensin II, endothelin-1, and KCl. Diltiazem was largely ineffective against contractile stimuli apart from KCl. Glyceryl trinitrate and papaverine significantly reduced responses to all of the vasoconstrictors tested.nnnCONCLUSIONnIn phenoxybenzamine-treated sections of radial artery, circulating vasoconstrictor agonists may still contribute to the induction of spasm. Additional vasodilator strategies may be required to completely prevent vasospasm.

Scapular osteochondroma with reactive bursitis presenting as a chest wall tumour

A 32-year-old male presented with a painful, rapidly enlarging chest wall mass. A malignant chest wall neoplasm was suspected. A CT scan was performed which showed a mass extending from under the scapular and an exostosis arising from the anterior surface of the scapular. The mass and exostosis were resected resulting in complete resolution of symptoms. Histological examination showed the mass to be a reactive bursa, with no evidence of neoplasia.

Preventing of chylothorax after oesophagectomy by routine pre-operative administration of oral cream

The anatomy of the thoracic duct varies considerably. This can make it difficult to locate during oesophageal surgery, especially in the fasted patient. We describe the technique of administering cream orally before primary oesophageal surgery, to aid in the identification of the thoracic duct. The duct along with other lymphatic channels can then be ligated as appropriate, helping to reduce the incidence of post-operative chylothorax.

Contained rupture of a myocardial abscess in the free wall of the left ventricle

Contained rupture of the left ventricle is uncommon; rupture secondary to a myocardial abscess is exceedingly rare. A case is presented of a contained rupture of a myocardial abscess in a patient with Staphylococcus aureus septicemia. The rupture was repaired surgically, and the patient survived.

Attenuation of receptor-dependent and -independent vasoconstriction in the human radial artery

BACKGROUNDnVasodilator strategies used to treat bypass grafts in the operating theatre, such as nitrates, phosphodiesterase inhibitors and calcium channel antagonists have a broad but short-lived effect against a variety of vasoconstrictor stimuli. Treatments that react irreversibly with proteins modulating vasoconstriction have the advantage that their effects can last well into the postoperative period. In addition systemic effects are avoided as the treatment is localised to the treated graft. This study investigated the use of two clinically applied drugs; fluphenazine (SKF7171A, HCl), an irreversible calmodulin antagonist and minoxidil sulphate, an irreversible potassium channel opener. Treatments were tested against receptor and non-receptor-mediated contraction in the human radial artery.nnnMETHODnIsometric tension was measured in response to angiotensin II, KCl and vasopressin in 108 radial artery rings (taken from 31 patients undergoing coronary artery bypass grafting). Control responses were compared with rings pretreated with fluphenazine or minoxidil sulphate. Vasopressin responses were also compared in the presence of glyceryl trinitrate or the reversible Rho kinase inhibitor Y27632.nnnRESULTSnFluphenazine pretreatment significantly suppressed vasoconstriction to all agonists tested. Maximal responses to angiotensin II, vasopressin and KCl were reduced by 42+/-19%, 35+/-8% and 48+/-15% respectively, without any measurable effect on the EC(50). Minoxidil sulphate showed no discernable effect. Vasopressin-induced contraction was also reduced by high levels of glyceryl trinitrate (220 microM; 50 microg/ml) or 10 microM Y27632.nnnCONCLUSIONSnThe irreversible calmodulin antagonist fluphenazine has potential to be developed as an inhibitor of contraction in arterial graft vessels. The involvement of Rho kinase indicates that other vasoconstrictors and surgical stress can sensitize radial artery to vasopressin-induced contraction. Strategies targeting this pathway also have future potential.

Late Presentation of Congenital Bochdalek Hernia: A Case Report

A 23-year-old man presented with a long history of dyspnea and wheezing thought to be due to asthma. Abnormal appearance of the left hemithorax was an incidental finding on a chest X-Ray. On further investigations he was found to have congenital Bochdalek hernia which was repaired surgically. All his respiratory symptoms resolved and he was able to discontinue treatment for asthma. We want to emphasise that late presentations can be misleading even to an astute clinician.