Pre-treatment optimisation with pulmonary rehabilitation of elderly lung cancer patients with frailty for surgery.

OBJECTIVE: Frailty develops as a result of age-related decline in many physiological systems and is associated with increased vulnerability to adverse outcomes following thoracic surgery. We prospectively tested our hypothesis that pre-operative pulmonary rehabilitation (Prehab) improves frailty, as suggested by a frailty index > 3 (FI > 3) and fitness, and thereby reduces the risk of post-surgical complications and death in vulnerable elderly lung cancer patients. METHODS: 221 surgical patients, 80 with FI > 3 vs. 141 patients with FI < 3, following Prehab proceeded to surgery. Their Frailty index (FI), dyspnoea scores, performance status (PS), level of activity (LOA) and six-minute walk test (6MWT) prior to and following Prehab were determined. The post-operative length of hospital stay (LOHS), complications, mortality and mid-term survival at 1100 days were compared. Similarly, outcomes for elderly patient ≥ 70 years with FI > 3 (≥ 70,FI > 3) were compared with younger patients < 70 years with FI ≤ 3 (< 70,FI ≤ 3). RESULTS: Patients with FI > 3 were significantly older, had lower 6MWT and higher thoracoscores hence, 82.5% of patients with FI > 3 vs. 33.3% (p = 0.02) with FI ≤ 3 were considered high risk for surgery and postoperative adverse events. With Prehab there was significant improvement in the FI, dyspnoea scores, PS, LOA and 6MWT. Following surgery, there were no differences in major complication rates (8.8% vs. 9.2% p = ns); LOHS median (IQR) [7 (6.8) vs. 8 (5.5) days]; mortality at 30-days (3.7% vs. 0.7%, p = ns); 90-days (6.3% vs. 2.8%, p = ns) and 1-year survival (81.1% vs. 83.7% p = ns). Survival at 1100 days was (63.2% vs. 71.1%, p = 0.19). Likewise, 87.7% elderly ≥ 70,FI > 3 patients were considered high-risk for surgery and postoperative adverse events vs. 35.1% younger patients < 70,FI ≤ 3 (p = 0.0001). Following Prehab and surgery, there were no significant differences in complications, LOHS, mortality at 365 days between the two groups. Survival at 1100 days for ≥ 70,FI > 3 was 55.2% vs. 79.96% for < 70,FI ≤ 3; (p = 0,01). CONCLUSION: Our study suggests that Prehab optimises vulnerable high-risk elderly lung cancer patients with frailty allowing them to undergo surgery with outcomes of post-surgical complications, LOHS and mortality at 365 days no different to patients with no frailty. However, mid-term survival was lower for elderly patients with frailty.

3D Printing Technology for Chest Wall Reconstruction With a Sternum-Ribs-Cartilage Titanium Implant: From Ideation to Creation.

OBJECTIVE: We describe the use of 3-dimensional (3D) printing technology to plan and reconstruct the sternum, adjoining cartilages, and ribs with a custom-made, anatomically designed, 3D-printed titanium implant for an isolated sternal metastasis complicated with a pathological fracture. METHODS: We imported submillimeter slice computed tomography scan data into Mimics Medical 20.0 software and by manual bone threshold segmentation created a 3D virtual model of the patient's chest wall and tumor. For all-around tumor-free margins, we grew the tumor by 2 cm. The replacement implant was designed in 3D using the anatomical features of the sternum, cartilages, and ribs and manufactured using TiMG 1 powder fusion technology. Physiotherapy was provided prior to and following surgery, and the impact of reconstruction on pulmonary functions was assessed. RESULTS: At surgery, the precise resection, clear margins, and a secure fit were achieved. At follow-up, there was no dislocation, paradoxical movement, change in performance status, or dyspnea. There was a decrease in forced expiratory volume in 1 s (FEV1) from 105% prior to surgery to 82% following surgery and in forced vital capacity (FVC) from 108% to 75%, with no difference in the FEV1/FVC ratio, suggesting a restrictive pattern of impairment. CONCLUSIONS: With 3D printing technology, reconstructing a large anterior chest wall defect with a custom-made, anatomical, 3D-printed titanium alloy implant is feasible and safe, and it preserves the shape, structure, and function of the chest wall, albeit with a restrictive pattern of pulmonary function, which can be addressed with physiotherapy.

Chest Wall Reconstruction With 3D Printing: Anatomical and Functional Considerations.

Large chest wall defects, as a result of wide local excision of chest wall pathology, require skeletal and soft-tissue reconstruction to restore the anatomical shape, structure, and respiratory function of the thorax. Reconstruction is challenging and requires the surgical reconstructive team to understand the anatomic and physiologic morbidity related to the defect and the choice of reconstructive techniques available to restore form and function. Rapidly emerging 3-dimensional (3D) printing technology allows the reconstructive surgical team to customize the therapeutic process of skeletal reconstruction by accurately mimicking the shape and structure of the chest wall being replaced. An integrated knowledge of the anatomy, physiology, mechanics of breathing, and respiratory tests is important to restore form and function. The focus of this article is to review the anatomy, physiology, and assessment of respiratory function from the classical textbooks and integrate this knowledge with the precise anatomy of the chest wall created by 3D printing technology. By doing so, this article will demonstrate how 3D printing may help the reconstructive team to understand the anatomic and physiologic morbidity related to the chest wall defect and the importance of taking each of these aspects into consideration when undertaking chest wall reconstruction of the thorax.

An adult with episodic retrosternal chest pain: an unusual presentation of congenital pulmonary airway malformation - case report.

BACKGROUND: Congenital pulmonary airway malformation (CPAM) with partial anomalous pulmonary venous connection presenting as episodic retrosternal chest pain on exertion in an adult has not been described. CASE PRESENTATION: A 21-year-old female, non-smoker, presented with a 4-year history of sharp, episodic, retrosternal chest pains brought on with exercise. A contrast-enhanced computed tomography (CT) scan showed a grossly overinflated left lower lobe with partial anomalous pulmonary venous drainage into the left hemi-azygos vein. Lobectomy, the recommended treatment of choice, carried out thoracoscopically, was curative with satisfactory mid-term results. Histology confirmed type-II congenital pulmonary airway malformation. CONCLUSIONS: CPAM can present in young adults with unusual symptoms of chest pain on exertion. When suspected a contrast-enhanced CT scan is the gold standard for establishing the diagnosis. An anatomical lung resection is curative with satisfactory medium term results.

Pre-treatment optimization with pulmonary rehabilitation in lung cancer: Making the inoperable patients operable.

BACKGROUND: Anatomical lung resection offers the best prospect of long-term survival in patients with non-small cell lung cancer (NSCLC). However, some patients with significant dyspnoea, impaired performance status (PS), borderline or poor pulmonary function are considered inoperable and instead referred for radiotherapy, chemotherapy or palliative care. The aims of the study were to determine whether pre-operative pulmonary physiotherapy (Prehab), by improving clinical parameters, (i) makes patients suitable for surgery who were considered inoperable on subjective criteria of dyspnoea >3 and PS >2, and objective criteria of diffusing capacity for carbon monoxide (DLCO) <50%; and (ii) thereby allows them to safely receive curative surgery with reduced morbidity and mortality. METHODS: From January 2017 to December 2018 a total of 306 patients were prospectively and sequentially assessed for Prehab and 216 patients with lung cancer studied. Their mean age (95% CI) was 71.7 ± 1.1 years, 50.5% (n = 109) were men and they received Prehab over 39.0 ± 7.0 days averaging 3.1 ± 0.6 sessions. Their dyspnoea scores, PS, level of activity, six minute walk test (6MWT) and frailty index prior to and following Prehab were determined. Following surgery the post-operative length of hospital stay (LOHS), complications and mortality at 30 days, 90 days and 1 year determined. Similar outcomes were determined for (i) high-risk patients with dyspnoea scores >3 and PS >2, and compared with low-risk patients having dyspnoea scores <2 and PS <2 (subjective criteria); and (ii) high-risk patients with DLCO <50% and compared with low-risk patients with DLCO >80% (objective criteria). FINDINGS: In the total cohort following Prehab, there was significant improvement in the dyspnoea scores <2 / ≥2 (40%/60% prior to Prehab vs. 65%/35% following Prehab, p = 0.00002), PS <2 / ≥2 (45%/55% prior to vs. 62%/38% following Prehab, p = 0.003), frailty index ≤3 / >3 (49%/51% vs 70%/30%, p = 0.0006), and 6MWT (306.6 ± 6.8 m vs 354.8 ± 52.7 m, p = 0.04). Post-operative major complication rates were 8.7%; median LOHS was 7 (IQR 6) days; hospital mortality at 30 days 1.3%, 90 days 4.7% and 1 year 16%. Using subjective criteria of dyspnoea scores >3 and PS >2, 100% of high-risk patients were considered inoperable. Following optimization with Prehab 84.2% of the high-risk patients were ready to proceed with radical treatment and 52.6% with surgery, and subsequently 42.8% of patients underwent surgery. Likewise, 78.8% of patients with DLCO <50% were considered inoperable. Following Prehab 86.5% of high-risk patients were ready to proceed with radical treatment and 59.1% with surgery, and 54.6% of high-risk patients underwent surgery. In each category there were no significant differences in complications, LOHS or mortality rates between the high-risk and low-risk patients. INTERPRETATION: Our prospective study showed that with Prehab there was clinical and statistically significant improvement in the dyspnoea scores, PS, level of activity and frailty, particularly in the high-risk group of patients. Importantly, Prehab made previously inoperable patients operable, allowing them to safely undergo curative lung resection. This strategy helps improve resection rates and may contribute to the long term survival of lung cancer patients. FUNDING: This is a Welsh Health Specialised Services Committee (WHSSC) commissioned service.

Chest wall reconstruction with an anatomically designed 3-D printed titanium ribs and hemi-sternum implant.

BACKGROUND: Chest wall resection following wide local excision for bone tumor results in a large defect. Reconstructing this defect is complex and requires skeletal and soft tissue reconstruction. We describe the reconstruction of a large skeletal defect with a three-dimensional (3-D) printed custom-made, anatomically designed, titanium alloy ribs and hemi-sternum implant. METHOD: To design the implant manual bone threshold segmentation was performed to create a 3-D virtual model of the patient's chest and the tumor from sub-millimeter slice computed tomography (CT) scan data. We estimated the extent of resection needed to ensure tumor-free margins by growing the tumor by two cm all around.. We designed the implant using an anatomical image of the ribs and right hemi-sternum and then fabricated a 3D model of them in titanium metal using TiMG 1 powder bed fusion technology. At surgery the implant was slotted into the defect and sutured to the ribs laterally and hemi-sternum medially. RESULTS: Histology confirmed clear all around microscopic margins. Following surgery and at 18 month follow up the patient was asymptomatic with preserved quality of life and described no pain, localized tenderness or breathlessness. There was no displacement or paradoxical movement of the implant. CONCLUSION: Our techniques of CT segmentation, editing, computer aided design of the implant and fabrication using laser printing of a custom-made anatomical titanium alloy chest wall ribs and hemi-sternum for reconstruction is feasible, safe and provides a satisfactory result. Hence, a patient specific 3-D printed titanium chest wall implant is another useful adjunct to the surgical approach for reconstructing large chest wall defects whilst preserving the anatomical shape, structure and function of the thorax.

Impact of preoperative pulmonary rehabilitation on the Thoracoscore of patients undergoing lung resection.

OBJECTIVES: Patients with dyspnoea who are suitable for lung resection have a higher in-hospital mortality following surgery as predicted by the Thoracoscore. We evaluated the role of preoperative pulmonary rehabilitation (PPR) in improving preoperative dyspnoea, performance status and thereby the Thoracoscore and reducing the risk of postoperative mortality, complications and length of stay in such patients. METHODS: From June 2013 until May 2014, we prospectively and sequentially identified high-risk patients in our outpatient clinic with dyspnoea grade ≥2 and performance status ≥1 for lung resection and recruited them for PPR. Thoracoscores, dyspnoea grade and performance status before and after PPR were calculated for all patients. Hospital mortality, complication rates and the length of hospital stay following surgery were compared between those who received PPR with those who did not undergo PPR and instead went straight to surgery. RESULTS: Of the 42 patients (67% females, mean age 67 years [SD 13]) identified, 33 patients received PPR for a mean duration of 7.1 [SD 6.5] days. Their mean Thoracoscores before and after PPR were 6.4 [SD 5.1] and 1.7% [SD 1.3] (P < 0.00009); dyspnoea grade 3.8 [SD 0.6] and 2.2 [SD 0.6] (P < 0.00001); and performance status 2.7 [SD 0.5] and 1.7 [SD 0.6] (P < 0.00001), respectively. The postoperative mortality in those who received PPR and those who did not undergo PPR but went straight to surgery, respectively, was 0 vs 11.1% (P = 0.05), postoperative complication rate was 5.3 vs 37.5% (P < 0.015) and the mean length of hospital stay was 8.7 [SD 3.5] days vs 10.3 [SD 6.2] days (P = 0.26), respectively. CONCLUSIONS: Our prospective study suggests that in those patients with dyspnoea requiring lung resection, PPR significantly improves their exercise capacity, reduces dyspnoea and improves the Thoracoscore. The study also suggests that PPR helps reduce postoperative complications and obviates the increased length of hospital stay and in-hospital mortality that may be otherwise expected.

Coronary revascularisation with Genous stent helps reduce the waiting time for lung resection.

Patients suitable for lung resection for primary lung cancer and with myocardial ischaemia due to significant coronary artery stenosis, despite optimal medical therapy, are considered for either percutaneous or surgical revascularisation prior to thoracic surgery. Percutaneous coronary intervention (PCI) with bare metal stent (BMS) requires patients to initially receive dual anti-platelet therapy of clopidogrel and aspirin for at least 6 weeks, which delays the waiting time for curative lung resection. We report the successful use of the Genous endothelial progenitor cell (EPC) capture stent in two patients requiring PCI for significant coronary artery disease prior to lung resection. Following PCI with Genous stent implantation, both patients received dual anti-platelet therapy for 1 week. Clopidogrel was then discontinued and a week later both safely underwent curative lung resection receiving aspirin alone. At 6 months' follow-up, neither patient had symptoms or electrocardiograph changes suggestive of angina. Our report suggests that in patients requiring PCI prior to lung resection the Genous EPC capture stent is suitable and reduces their waiting time for surgical resection to 2 weeks instead of 6.

The predictors and outcome of recidivism in cardiac ICUs.

OBJECTIVE: Reinstitution of step-up care (recidivism) following cardiac surgery may be associated with increased mortality. This has, however, not been widely reported. METHODS: We, therefore, studied 8113 consecutive patients who underwent coronary artery bypass grafting (CABG), valve replacement/repair or combined valve+CABG surgery between January 1996 and December 2003 to determine the reasons for readmission to the intensive care unit (ICU) and their outcomes in terms of length of stay in (i) the ICU (ii) hospital and (iii) the in-hospital mortality following recidivism. RESULTS: Of the 7717 patients discharged out of the ICU, 2.3% (182) of patients [mean age 70.4+/-8.35 years (range 30-90 years); 65.4% (119) males] required step-up care. Recidivism was 1.8% (101 of 5633) following coronary artery by-pass grafting (CABG) and 3.9% (81 of 2084) following valve replacement/repair+/-CABG (P<0.05). The mean interval from ICU discharge to ICU recidivism was 6.6+/-8.4 days (range 6h to 28 days). The principal reasons for recidivism were (i) respiratory failure requiring reintubation and ventilation in 54.9% (n=100) of patients (ii) cardiovascular instability (including that secondary to dysrhythmias) and heart failure in 23.1% (n=42) (iii) renal failure requiring haemofiltration in 6.6% (n=12) (iv) sepsis in 1.1% (n=2) (v) cardiac tamponade/bleeding requiring re-exploration in 7.7% (n=14) and (vi) gastro-intestinal complications requiring laparotomy in 6.0% (n=11) patients. Multivariate analysis showed that, during primary ICU stay, respiratory complications, low cardiac output state, dysrhythmias, renal failure requiring haemofiltration and re-exploration for bleeding were independent predictors of recidivism. Following recidivism (i) the mean length of stay in the ICU was 6.65+/-6.2 days (range 4h to 51 days), (ii) mean hospital stay was 19.2+/-17.3 days (10-60 days) and (iii) the 30-day in-hospital mortality was 32.4%. CONCLUSIONS: Patients are more likely to require recidivism following valve surgery+/-CABG than CABG alone. Whilst respiratory complications were the most common reasons for recidivism in our study, patients who required mechanical supports to maintain vital functions following surgery were most prone to recidivism. Hence, efforts should be made to treat cardio-respiratory problems early in this group of patients to reduce ICU recidivism.

Aspire porcine bioprosthesis: ten years' experience.

BACKGROUND AND AIM OF THE STUDY: Clinical results of this multicenter study of the Aspire porcine valve were reported previously at eight years; the present report provides an update of valve performance to 10 years postoperatively. METHODS: A total of 749 patients (60% males; mean age 73+/-7 years) underwent implantation with the Aspire (Tissuemed) porcine bioprosthesis between 1991 and 2002, at three institutions. Follow up was complete for 98% of the cohort. The mean follow up period was 51.6+/-39.6 months (range: 0-181 months); total follow up was 3,159 patient-years (pt-yr). RESULTS: There were 617 aortic valve replacements (AVR), 96 mitral valve replacements (MVR) and 32 double valve replacements. There were 62 deaths (8.3%), one of which was valve-related. The late mortality rate was 9.3% per pt-yr (1.2%/pt-yr valve-related). Actuarial freedom from complications at 10 years was: thromboembolism 76+/-4% (2.6%/pt-yr); hemorrhage 73+/-4% (2.8%/pt-yr); structural valve deterioration (SVD) 96+/-2% (0.2%/pt-yr); non-structural deterioration 99+/-1% (0.1%/pt-y); prosthetic valve endocarditis 97+/-1% (0.3%/pt-yr); and reoperation 97+/-1% (0.4%/pt-yr). In patients aged >70 years, the 10-year actuarial freedom from SVD was 98+/-2% for AVR and 93+/-7% for MVR. Preoperative atrial fibrillation (AF) was a significant predictor of late mortality (p <0.001), thromboembolism (p = 0.05) and hemorrhage (p = 0.01). CONCLUSION: The Aspire porcine bioprostheses is a reliable choice for a tissue valve, for both the aortic and mitral positions, especially in patients aged >70 years. In elderly patients the presence of AF is a significant predictor of early and late mortality and morbidity.