Wilson W.L. Li

Shoulder function after thoracic surgery

Thoracic procedures are considered to be among the most painful surgical incisions and are associated with considerable postoperative pain and shoulder dysfunction, severely affecting mobility and activities of daily living. Improper patient positioning, muscle division, perioperative nerve injury, rib spreading, and consequent postoperative pain influence the patients postoperative shoulder function and quality of life. To reduce access trauma and postoperative morbidity, various alternative modalities have been proposed to replace the standard PLT, including muscle-sparing techniques and VATS. Initial evaluations suggest that these alternatives are associated with significantly better postoperative shoulder function. Proper comparative studies using standardized questionnaires, objective evaluations, or quality-of-life assessments are scarce, however. Proper postoperative care, including early mobilization and effective physiotherapy, is a cornerstone in successful patient rehabilitation and rapid return to normal daily activities. Whether upper extremity exercises can contribute to improvement in postoperative shoulder function and the ability to perform activities of daily living needs to be studied further.

Quality of life after lung cancer resection

Lung cancer continues to be the most common cancer in the world, with the highest cancer mortality rate by far. Although resection remains the treatment of choice in early-stage NSCLC, the prognosis remains grim even after surgical treatment. In a patient population with such a high mortality rate, evaluation and preservation of QOL after treatment is imperative. Early-stage lung cancer patients already have significantly lower QOL when compared with the normal population before surgical treatment, with significant impairment in physical and emotional functioning. Lung cancer resection causes further deterioration of QOL, especially in the first 3 to 6 months after surgery. While some studies suggest that QOL returns to baseline levels at 6 to 9 months postoperatively, others report that QOL is still significantly impaired at 6 months and 1 year after surgery. Although prospective studies analyzing long-term postoperative QOL are not available, retrospective data suggest that long-term survivors after lung cancer surgery enjoy good QOL despite impaired physical functioning. QOL studies on VATS lung cancer resection are extremely limited. More prospective, longitudinal studies with larger study populations and longer follow-up periods are needed to portray the course of QOL in lung cancer patients more accurately and to improve postoperative care. Furthermore, comparative studies between VATS and the standard thoracic incisions (including QOL assessments) must be performed to guide clinical decision making regarding selection of optimal access modality for performing lung cancer resection.

A 76-year old man with a torn Freedom SOLO bioprosthesis

We describe a case of a 76-year old male who presented with progressive dyspnoea. He underwent an aortic valve replacement with a Freedom SOLO bioprosthesis 6 years ago. Transthoracic echocardiography showed a moderate-to-severe leakage of the Freedom SOLO bioprosthesis. During surgical reintervention, a partial tear of the left coronary cusp was seen from the commissure of the right coronary cusp to its base. After radiographic and microscopic examination, no clear cause was found for the failure of this Freedom SOLO bioprosthesis. To our knowledge, this is the third failure of a Freedom SOLO bioprosthesis reported in the literature. When the long-term follow-up of the Freedom SOLO bioprosthesis is available, it has to be compared with other bioprosthesis for long-term durability.

Mediastinal Synovial Sarcoma: A Case Report and Literature Review

Synovial sarcomas are uncommon soft tissue tumours. Immunohistochemistry and cytogenetic techniques are essential for proper diagnosis and differentiation from other spindle cell neoplasms. A case of mediastinal synovial sarcoma is described, of which the unusual location, diagnosis and treatment form the basis of this report.

Infective Endocarditis of the Aortic Valve with Anterior Mitral Valve Leaflet Aneurysm

Mitral valve leaflet aneurysm is a rare and potentially devastating complication of aortic valve endocarditis. We report the case of a 48-year-old man who had endocarditis of the native aortic valve and a concomitant aneurysm of the anterior mitral valve leaflet. Severe mitral regurgitation occurred after the aneurysm perforated. The patient showed no signs of heart failure and completed a 6-week regimen of antibiotic therapy before undergoing successful aortic and mitral valve replacement. In addition to the patients case, we review the relevant medical literature.

Role of Government and NGOs

Large-scale disaster relief response consists of a complex interplay among multiple and multidisciplinary actors. While the local government and the affected population are the primary stakeholders, in the face of major calamities so are foreign governments sending aid, international organizations (such as the United Nations and its affiliates), nongovernmental organizations (NGOs) and their donors, and so-called hybrid organizations, such as the various arms of the Red Cross and Red Crescent movement (like the ICRC and IFRC). While speed is certainly crucial in providing disaster relief, immediate action, if uncoordinated, may not be necessarily relevant, appropriate, or even beneficial. In order to provide effective and relevant relief, governments (both the host and those sending aid) and NGOs involved in humanitarian assistance should recognize the roles and responsibilities of each of these players in order to make full use of the already limited resources that can be immediately mobilized in these crisis situations and to avoid duplication (Fig. 6.1). In this chapter, we are going to examine and debate the role and identity of governments, NGOs, and other humanitarian aid players in providing disaster relief.

Reply to Prestipino et al.

We would like to thank Prestipino et al. for their insightful comments [1] regarding our recently published article [2]. Despite ongoing controversy, we agree that continuation of acetylsalicylic acid (ASA) up to the day of surgery has potential benefits. The study of Myles et al., comparing patients undergoing coronary artery bypass grafting (CABG) who were randomized to receive either placebo or ASA prior to surgery, failed to demonstrate significant differences between the control and intervention group [3]. This might partially be due to the study design. In all patients, ASA was discontinued 4 days prior to surgery and a non-loading dose of ASA (100 mg) was administered to patients in the intervention group at the day of surgery. The potential positive effect on clinical outcomes as well as negative effect on bleeding-related complications might therefore be absent due to non-therapeutical levels of the drug. Nevertheless, ASA possesses an important anti-inflammatory effect that might improve clinical outcomes and as such, the 2011 ACC/AHA guidelines for CABG do recommend its administration prior to surgery [4]. In our study, clopidogrel and ticagrelor were discontinued 120 h and 72 h prior to surgery, respectively [2]. In their letter, Prestipino et al. suggest addition of low molecular weight heparin (LMWH) at anticoagulant doses, or glycoprotein IIb/IIIa receptor inhibitors as bridge to surgery. We do not utilize this in our clinical practice for several reasons. As stated by Prestipino et al., LMWH does not provide protection against platelet aggregation and, in our opinion, poses a considerable threat to bleeding-related complications prior, during and after surgery. More importantly, despite discontinuation of dual antiplatelet treatment (DAPT) a few days prior to surgery, the platelet inhibition effect is still present—in a less pronounced extent—for the time prior to surgery. As demonstrated by Gurbel et al., even 48 h after DAPT discontinuation, about 40% inhibition of platelet aggregation is still present [5]. We argue that the clinical benefit of more aggressive antiplatelet treatment does not outweigh the potential risk of bleeding-related complications. In patients at very high-risk for thrombotic complications (e.g. recent stent implantation), a decision to proceed with more aggressive management might be justified. In our opinion, cangrelor, a reversible intravenous P2Y12 receptor antagonist with rapid offset of action, seems to be the most promising modality [6]. In conclusion, we believe that the decision to discontinue DAPT prior to CABG should always be made balancing the potential bleeding-related and thromboembolic complications in mind. Residual platelet inhibition plays an important protective role for a period of time after DAPT discontinuation. In our opinion, bridging therapy after discontinuation of DAPT is potentially justified only in very high-risk patients.