Wilson W. Li

A clinical audit in a multidisciplinary care path for thoracic surgery: An instrument for continuous quality improvement

BACKGROUND Although it is advocated that (major) surgical procedures should be embedded in clinical pathways, the efficacy of such pathways is hardly ever systematically evaluated. The objective of our study was to assess the results of a multidisciplinary care path for patients undergoing thoracic cancer surgery, using a concurrent integrated prospective database. METHODS From April 2006 to December 2008, 169 eligible patients, admitted for thoracic cancer surgery in our institute, gave informed consent to participate in this prospective study. Detailed clinical data concerning patient-, tumour-, treatment- and outcome characteristics were collected. For evaluation of pain and quality of life (QoL), visual analogue scale (VAS) and SF-36 were used respectively. Information retrieved on 94 patients operated in the baseline period (until November 2007) was used in multidisciplinary consensus meetings to develop a new care path. After the introduction of this care path (January 2008) data-collection continued to evaluate outcome using the data of 75 patients operated in the evaluation period (until December 2008). RESULTS Data from the baseline period showed age (p=0.001), indication (p=0.03), postoperative pain (p<0.001) and complications (p<0.001) to be independently related to length of stay (LOS). Subsequently, the package of measures taken in the multidisciplinary care path were evaluated, showing significantly less postoperative pain (p=0.026) and a reduced length of hospital stay (p=0.014). In addition, a (trend towards) improvement in physical quality of life was observed 1 month (p=0.03) and 6 months (p=0.07) postoperatively. CONCLUSION The use of a prospective database integrated in a clinical care path for thoracic cancer patients revealed important improvements of the care process determining short- and long-term outcome. There was a significant reduction in length of hospital stay, postoperative pain and loss of quality of life. Ongoing and multicentre collection of such data can provide surgeons with instruments to further improve quality of care.

The influence of provider characteristics on resection rates and survival in patients with localized non-small cell lung cancer

Surgery remains the mainstay of treatment for localized non-small cell lung cancer (NSCLC). However, wide variations have been reported regarding rates of operative therapy. We examined the influence of characteristics of the hospital of diagnosis on the likelihood of receiving surgical treatment and on survival. We evaluated patients with primary, first-time, localized NSCLC diagnosed from 1998 to 2003 in the region of the Amsterdam Cancer Registry. Treatment and survival data were extracted from the registry database. We investigated which provider characteristics (hospital category, mean annual lung cancer caseload, presence of a cardiothoracic surgery unit) were predictive of receiving surgical treatment and of survival. 1591 patients were diagnosed with clinically localized NSCLC, of which 1097 (69%) had surgery. Resection rates varied significantly between the various hospitals (48-90%, chi(2), P<0.001). Patients diagnosed at specialized centers or higher volume hospitals were more likely to receive surgical therapy, especially for patients over 80 years of age. In addition, there was a trend that octogenarians had higher odds of undergoing surgery when diagnosed in a center with a cardiothoracic surgery unit. Patients had a better survival after resection than without surgery (P<0.001). Survival after surgery did not differ between the various hospital categories. In conclusion, there is wide institutional variability in rates of surgical treatment in lung cancer patients. In addition to patient characteristics, attributes of the hospital of diagnosis also have significant influence on the likelihood of receiving surgical therapy. Future studies should examine the underlying mechanisms for this phenomenon.

Management of large mediastinal masses: surgical and anesthesiological considerations

Large mediastinal masses are rare, and encompass a wide variety of diseases. Regardless of the diagnosis, all large mediastinal masses may cause compression or invasion of vital structures, resulting in respiratory insufficiency or hemodynamic decompensation. Detailed preoperative preparation is a prerequisite for favorable surgical outcomes and should include preoperative multimodality imaging, with emphasis on vascular anatomy and invasive characteristics of the tumor. A multidisciplinary team should decide whether neoadjuvant therapy can be beneficial. Furthermore, the anesthesiologist has to evaluate the risk of intraoperative mediastinal mass syndrome (MMS). With adequate preoperative team planning, a safe anesthesiological and surgical strategy can be accomplished.

Aortic Valve Replacement With the Stentless Freedom SOLO Bioprosthesis: A Systematic Review

This systematic review examined the clinical and hemodynamic performance of the stentless Freedom SOLO (Sorin Group, Milan, Italy) aortic bioprosthesis. The occurrence of postoperative thrombocytopenia was also analyzed. The Freedom SOLO is safe to use in everyday practice, with short cross-clamp times, and postoperative pacemaker implantation is notably lower. Valvular gradients are low and remain stable during short-term follow-up. Thrombocytopenia is more severe than in other aortic prostheses; however, this is without clinical consequences. Within a few years, the 15-year follow-up of this bioprosthesis will be known, which will be key to evaluating its long-term durability.

Stentless vs Stented Aortic Valve Bioprostheses in the Small Aortic Root.

In patients with a small aortic root undergoing aortic valve replacement (AVR), the Freedom SOLO bioprosthesis may be the ideal prosthesis because of its stentless design and supra-annular implantation. This study investigated if the stentless Freedom SOLO has an advantage when compared with a stented bioprosthesis in patients with a small aortic root. From April 2005-July 2014, 269 consecutive patients underwent AVR with either a Freedom SOLO (n = 76) or Mitroflow (n = 193) bioprosthesis size 19mm or 21mm, respectively. This retrospective comparison study presents clinical and echocardiographic follow-up data. In results, operative outcome and survival were similar. At 7 years, cumulative incidence of aortic valve reoperation and structural valve deterioration favor the Freedom SOLO (0% vs 7.1%, P = 0.03 and 0% vs 4.5%, P = 0.08, respectively). Additionally, the postoperative peak and mean valvular gradients favor the Freedom SOLO (21 ± 9mmHg vs 32 ± 12mmHg and 12 ± 5mmHg vs 19 ± 8mmHg, both P = <0.001, respectively). During mid-term follow-up this hemodynamic advantage continued in favor of the Freedom SOLO. Also prosthesis-patient mismatch occurred less frequently in the Freedom SOLO (28% vs 52%, P = 0.001). There were no differences in prosthetic valve endocarditis, thromboembolic, or bleeding events. In conclusion, the stentless Freedom SOLO has several significant advantages for AVR in patients with a small aortic root in comparison with a stented Mitroflow bioprosthesis. The Freedom SOLO shows superior hemodynamic performance with significantly lower valvular gradients that remained stable during mid-term follow-up. Additionally, significantly fewer prosthesis-patient mismatch occurred and the Freedom SOLO showed superior durability.

Ectopic pancreas in a giant mediastinal cyst

Ectopic pancreas located in the mediastium is an extremely rare anomaly. We present a case of an ectopic pancreas located in a giant mediastinal cyst in an 18‐year‐old man. He presented with symptoms of dyspnea due to external compression of the cyst on the left main bronchus. Complete surgical resection was performed through median sternotomy, with relief of the bronchial compression postoperatively. Literature review showed 20 previously reported cases. These masses were usually large (>10 cm), almost exclusively located in the anterior mediastinum, predominately cystic in nature and generally benign. Surgical resection was performed in all reported cases with a favorable prognosis. Due to the size of these masses, operative treatment can be challenging and should be carefully planned, with specific considerations regarding anesthetic and surgical management.

Current Status of Surgical Treatment for Aortic Valve Stenosis

In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve. doi: 10.1111/jocs.12384 (J Card Surg 2014;29:630–637)

eComment. Circulating tumour cells caused by surgical manipulation in patients with lung cancer. Is minimally invasive "no-touch" surgery the solution?

check the peripheral CTC after surgical manipulation, so again your comment is right. Dr P. Rybojad (Lublin, Poland): I’m interested, how did you choose the method? The method you used, is it a kind of flow cytometry or some other method? Dr Hashimoto: The CellSearch system was the only method to capture tumour cells directly. Dr Rybojad: So this is not a flow cytometry? Dr Hashimoto: No. Dr Rybojad: So how does it really work? Have you used antibodies or something else? How did you count the circulating tumour cells, how did you find them? Dr Schmid: How did you identify the cells? Dr Rybojad: I understand these are actual circulating tumour cells. As I understand right now there are two methods, flow cytometry or antibodies. So I wonder, what’s your method? Dr Tanaka: This question is how to check the – Dr Schmid: How to identify: what’s your method for identifying the circulating tumour cells with your system, what is the principle? Dr Tanaka: Okay. In our system, circulating tumour cells were automatically captured with an antibody against an epithelial cell-specific antigen, EpCAM. So, strictly speaking, circulating tumour cells captured in our system means circulating epithelial cells. However, generally speaking, in normal conditions epithelial cells are not contained in the peripheral blood, so epithelial cells present in the peripheral blood roughly means circulating tumour cells. Dr Rybojad: But in some cases, patients with lung cancer express the circulating tumour cells in the blood from the beginning of disease. You had some patients who had count zero. So I wonder how that was possible? What was your method? When you explained that it is epithelial cells, it makes me wonder even more how it happens that some patients didn’t have circulating tumour cells at all at the starting point. Dr Tanaka: Your comment is correct, and the low sensitivity of our system, the CellSearch system, to detect circulating tumour cells is the most critical issue. It is the only established system for clinical use and was approved (by the FDA in the USA) for breast cancer, colon cancer or prostate cancer, but not for lung cancer because of low sensitivity in identifying circulating tumour cells. Circulating tumour cells might be detected more frequently at an early stage with a more sensitive system. Dr Rybojad: The lung tissue is very complex. It differs a lot from breast cancer and colon cancer. You have a lot of epithelial cells here, so it’s very important to distinguish between normal epithelial cells or those which are really circulating tumour cells. But there are several methods right now, so I guess you should maybe use some other methods. Dr Tanaka: Thank you for your important comment. Dr Rybojad: One more brief question about lymph nodes. Did you see any differences between circulating tumour cells in relation to staging? Dr Tanaka: In this study we demonstrated no significant change in circulating tumour cells according to clinical or pathological stage, as well as nodal status. Dr Rybojad: Because in our country some researchers use a method with small IV catheters with antibodies and they found that the amount of circulating tumour cells was very much associated with staging and it really mattered if lymph nodes were involved or not. And the other thing which was found is that the manipulation is an important factor, but not the type of surgery. It doesn’t matter if you perform lobectomy, pulmonectomy or segmentectomy. The amount of circulating tumour cells was dependent on the manipulation. So, open surgery produced more circulating tumour cells than the VATS technique. So there are a lot of things to study.

Lost guidewire protrudes through the heart and chest

A 65-year-old woman was referred to our institution with an ‘iron wire’ that protruded through her chest ( Panel A ). She had no dyspnoea, pain, or fever. Her medical history included a mitral- and tricuspid valve repair 15 years ago and she was on permanent dialysis. Computed tomography scan ( Panel B ) showed a guidewire of ∼40 cm …

Cathether-based interventional strategies for cor triatriatum in the adult – feasibility study through a hybrid approach

BackgroundCor triatriatum is a rare congenital cardiac abnormality, consisting of an obstructing membrane between the pulmonary veins and the mitral valve in varying patterns. The entitiy can mimick the pathophysiology of mitral stenosis, necessitating surgical resection. Occasionally, percutaneous balloon dilatation of the membrane has been successfully performed.Case presentationWe report two cases with cor triatriatum where intraoperative balloon dilatation of the membrane was attempted followed by surgical resection, to explore the feasibility of cathether-based interventional strategies for cor triatriatum.ConclusionsVarious anatomical variations exist of cor triatriatum, depending on the drainage of the pulmonary veins and the drainage of the proximal chamber in the right or left atrium. Only isolated forms of cor triatriatum where all pulmonary veins ultimately drain into the left atrium can be recommended for percutaneous strategies. In addition, several anatomical characteristics should be considered to predict technical success of cathether-based interventional strategies, such as the location of the membrane, the degree of pulmonary vein stenosis, the extent of calcification, and the presence of other (congenital) cardiovascular abnormalities. Furthermore, long-term efficacy of these strategies remains to be confirmed. As such, surgical treatment of cor triatriatum remains the mainstay of treatment in adult patients, especially when other cardiovascular anomalies are present which require surgical correction.