Massive solitary fibrous intrathoracic tumor presented as primary lung cancer.

Solitary fibrous tumours (SFT) are rare soft tissue tumours with a primarily benign course. Complete surgical resection is the mainstay treatment. In this case report, a 75-year-old man had a massive intrathoracic SFT which was subsequently surgically resected without complications. Although the clinical presentation and CT features of these tumours can mimic lung cancer, the clinical course is significantly more favourable. Diagnostic examination and surgical treatment of intrathoracic SFT should be considered even in patients with increased post-operative risk.

Intrapleural fibrinolysis and DNase versus video-assisted thoracic surgery (VATS) for the treatment of pleural empyema (FIVERVATS): protocol for a randomised, controlled trial - surgery as first-line treatment.

INTRODUCTION: Pleural empyema is a frequent disease with a high morbidity and mortality. Current standard treatment includes antibiotics and thoracic ultrasound (TUS)-guided pigtail drainage. Simultaneously with drainage, an intrapleural fibrinolyticum can be given. A potential better alternative is surgery in terms of video-assisted thoracoscopic surgery (VATS) as first-line treatment. The aim of this study is to determine the difference in outcome in patients diagnosed with complex parapneumonic effusion (stage II) and pleural empyema (stage III) who are treated with either VATS surgery or TUS-guided drainage and intrapleural therapy (fibrinolytic (Alteplase) with DNase (Pulmozyme)) as first-line treatment. METHODS AND ANALYSIS: A national, multicentre randomised, controlled study. Totally, 184 patients with a newly diagnosed community acquired complicated parapneumonic effusion or pleural empyema are randomised to either (1) VATS procedure with drainage or (2) TUS-guided pigtail catheter placement and intrapleural therapy with Actilyse and DNase. The total follow-up period is 12 months. The primary endpoint is length of hospital stay and secondary endpoints include for example, mortality, need for additional interventions, consumption of analgesia and quality of life. ETHICS AND DISSEMINATION: All patients provide informed consent before randomisation. The research project is carried out in accordance with the Helsinki II Declaration, European regulations and Good Clinical Practice Guidelines. The Scientific Ethics Committees for Denmark and the Danish Data Protection Agency have provided permission. Information about the subjects is protected under the Personal Data Processing Act and the Health Act. The trial is registered at www. CLINICALTRIALS: gov, and monitored by the regional Good clinical practice monitoring unit. The results of this study will be published in peer-reviewed journals and presented at various national and international conferences. TRIAL REGISTRATION NUMBER: NCT04095676.

[Christmas article: Get to know yourself and your colleague].

INTRODUCTION: The field of medical studies is rich in stereotypical conceptions of the practitioners of the various medical specialisations. METHOD: By means of a Kahoot of 25 questions about practitioners of nine different medical specialisations, we were trying to see, if a group of people from the medical field (n = 20) and a control group of librarians (n = 22) would answer the questions correctly. The questions were jokes about various medical specialisations, and people were supposed to guess, which kind of medical doctor they described. RESULTS: Those with a background in medical studies were faster and more precise than the librarians. Some of the stereotypes described by the jokes, were known to both groups, others were not. The most familiar stereotypes were those describing anaesthesiologists as sleepy and psychiatrists as crazy. It appeared, that many of the medical speciality stereotypes took their point of departure in the idea, that doctors resemble their patients. CONCLUSION: The survey has limited data, and therefore the conclusion is not very wide-reaching. Some stereotypes were familiar to both groups, others were not. The data indicate that in some cases, contradictory stereotypes exist about individual specialisations.

The Influence of Suction on Chest Drain Duration After Lobectomy Using Electronic Chest Drainage.

BACKGROUND: Management of chest drains after thoracic surgery remains an area with little consensus. To optimize chest drainage algorithms with electronic chest drainage systems, a randomized controlled trial comparing low variable suction (-5 cm H2O) versus high variable suction (-20 cm H2O) was conducted. METHODS: This was a prospective open label randomized trial in patients undergoing lobectomy. Sample size was calculated from a clinical relevant difference in chest drain duration as 1 full day. End points were chest drain duration and length of hospitalization. Data were analyzed by Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression. RESULTS: The study randomized 106 patients. There was no statistical significant difference in chest drain duration and length of stay between the low-suction and the high-suction groups: Median chest drain duration and hospitalization were 25 hours (interquartile range [IQR] 21 to 55 hours) versus 28 hours (IQR 23 to 77 hours; p = 0.97) and 5 days (IQR 3 to 6 days) versus 5 days (IQR 3 to 7 days; p = 0.75), respectively. Multivariate analysis demonstrated that the diffusing capacity of the lung for carbon monoxide was the only significant predictor of chest drain duration (p = 0.015) and length of hospitalization (p = 0.003). Complications requiring reinsertion of the chest drain were significantly more frequent in the low-suction group (p = 0.03). CONCLUSIONS: There was no clinically relevant difference in chest drain duration or length of hospitalization, but reinsertions of chest drains were significantly more frequent in the low-suction group, a finding suggesting that low suction levels should not be used after lobectomy. Trial registry number is ISRCTN10408356.

Evaluating competency in video-assisted thoracoscopic surgery (VATS) lobectomy performance using a novel assessment tool and virtual reality simulation.

BACKGROUND: Competency-based training has gained ground in surgical training and with it assessment tools to ensure that training objectives are met. Very few assessment tools are available for evaluating performance in thoracoscopic procedures. Video recordings would provide the possibility of blinded assessment and limited rater bias. This study aimed to provide validity evidence for a newly developed and dedicated tool for assessing competency in Video-Assisted Thoracoscopic Surgery (VATS) lobectomy. METHODS: Participants with varying experience with VATS lobectomy were included from different countries. Video recordings from participants' performance of a VATS right upper lobe lobectomy on a virtual reality simulator were rated by three raters using a modified version of a newly developed VATS lobectomy assessment tool (the VATSAT) and analyzed in relation to the unitary framework (content, response process, internal structure, relation to other variables, and consequences of testing). RESULTS: Fifty-three participants performed two consecutive simulated VATS lobectomies on the virtual reality simulator, leaving a total of 106 videos. Content established in previously published studies. Response process Standardized data collection was ensured by using an instructional element, uniform data collection, a special rating program, and automatic generation of the results to a database. Raters were carefully instructed in using the VATSAT, and tryout ratings were carried out. Internal structure Inter-rater reliability was calculated as intra-class correlation coefficients, to 0.91 for average measures (p < 0.001). Test/re-test reliability was calculated as Pearson's r of 0.70 (p < 0.001). G-coefficient was calculated to be 0.79 with two procedures and three raters. By performing D-theory was found that either three procedures rated by two raters or five procedures rated by one rater were enough to reach an acceptable G-coefficient of ≥ 0.8. Relation to other variables Significant differences between groups were found (p < 0.001). The participants' VATS lobectomy experience correlated significantly to their VATSAT score (p = 0.016). Consequences of testing The pass/fail score was found to be 14.9 points by the contrasting groups' method, leaving five false positive (29%) and six false negatives (43%). CONCLUSION: Validity evidence was provided for the VATSAT according to the unitary framework. The VATSAT provides supervisors and assessors with a procedure-specific assessment tool for evaluating VATS lobectomy performance and aids with the decision of when the trainee is ready for unsupervised performance.

[Surgical stabilization of multiple rib fractures can shorten inpatient stay].

Flail chest is a common complication in patients with blunt chest wall traumas resulting in high mortality rates. In this case report a 43-year-old woman was stepped on by a horse, thereby receiving multiple rib fractures and pneumohaemothorax. She was not able to wean from epidural analgesia after ten days and maintained a "thoracic floating feeling". In opposition to the non-operative management previously preferred, a surgical stabilization was then performed in the patient, who was discharged only five days later. Thus, surgical fixation of multiple rib fractures may reduce inpatient stay.

[Osteosynthesis of rib fractures, unstable chest wall, pseudoarthroses, and acquired defects of the chest wall].

Several patients suffer from rib fractures after traumas, and in severe cases it can be life-threatening. Until recently, attempts to perform surgical fixation in patients with instability have been unsuccessful. Chronic non-union causes persistent pain, disability and loss of quality of life. Implementation of surgical stabilization of rib fractures with tailored plates seems to improve pain relief, especially in cases of non-union but also in patients with instability of the chest wall after severe traumas, where advanced pain treatment (epidural catheter) is insufficient or weaning off fails.

External Suction and Fluid Output in Chest Drains After Lobectomy: A Randomized Clinical Trial.

BACKGROUND: Even when air leakage has ceased completely after lobectomy, chest drains are often not removed because of high fluid output. Accepted thresholds for removal vary between institutions but typically range between 200 and 500 mL/d. There is little knowledge whether external suction influences the amount of fluid. METHODS: We randomly assigned (1:1) 106 patients who underwent lobectomy to either low (-5 cm H2O) or high (-20 cm H2O) external suction using an electronic chest drainage system. Only one chest drain was allowed, and we used strict algorithms for chest drain removal, which was delegated to staff nurses: air leakage less than 20 mL/min for 6 hours regardless of fluid output, provided it was serous. The primary end point was fluid output after 24 and 48 hours. RESULTS: Mean fluid output was significantly higher with high suction after both 24 (338 ± 265 mL versus 523 ± 215 mL) and 48 hours (616 ± 366 mL versus 1067 ± 387 mL (p < 0.001). Repeated measure analysis (mixed model) demonstrated that in addition to suction level the surgical approach (video-assisted thoracoscopic surgery/thoracotomy, p = 0.04) and affected lobe (upper/lower, p = 0.001) were significant predictors of fluid production. CONCLUSIONS: Increased suction levels lead to increased fluid output. Thoracotomy and lower lobectomy are associated with increased fluid output in chest drains, which should be taken into consideration if algorithms for chest drain removal include an upper limit of fluid output.

Electronic versus traditional chest tube drainage following lobectomy: a randomized trial.

OBJECTIVES: Electronic drainage systems have shown superiority compared with traditional (water seal) drainage systems following lung resections, but the number of studies is limited. As part of a medico-technical evaluation, before change of practice to electronic drainage systems for routine thoracic surgery, we conducted a randomized controlled trial (RCT) investigating chest tube duration and length of hospitalization. METHODS: Patients undergoing lobectomy were included in a prospective open label RCT. A strict algorithm was designed for early chest tube removal, and this decision was delegated to staff nurses. Data were analysed by Cox proportional hazard regression model adjusting for lung function, gender, age, BMI, video-assisted thoracic surgery (VATS) or open surgery and presence of incomplete fissure or pleural adhesions. Time was distinguished as possible (optimal) and actual time for chest tube removal, as well as length of hospitalization. RESULTS: A total of 105 patients were randomized. We found no significant difference between the electronic group and traditional group in optimal chest tube duration (HR = 0.83; 95% CI: 0.55-1.25; P = 0.367), actual chest tube duration (HR = 0.84; 95% CI: 0.55-1.26; P = 0.397) or length of hospital stay (HR = 0.91; 95% CI: 0.59-1.39; P = 0.651). No chest tubes had to be reinserted. Presence of pleural adhesions or an incomplete fissure was a significant predictor of chest tube duration (HR = 1.72; 95% CI: 1.15-2.77; P = 0.014). CONCLUSIONS: Electronic drainage systems did not reduce chest tube duration or length of hospitalization significantly compared with traditional water seal drainage when a strict algorithm for chest tube removal was used. This algorithm allowed delegation of chest tube removal to staff nurses, and in some patients chest tubes could be removed safely on the day of surgery.

Uncertain added value of Global Trigger Tool for monitoring of patient safety in cancer care.

INTRODUCTION: Monitoring patient safety is a challenging task. The lack of a golden standard has contributed to the recommendation and introduction of several methods. In 2000 the Danish Lung Cancer Registry (DLCR) was established to monitor the clinical management of lung cancer. In 2008 the Global Trigger Tool (GTT) was recommended in Denmark as a tool for the monitoring of patient safety. Ideally, the recommendation of a new tool should be preceded by a critical assessment of its added value. MATERIAL AND METHODS: Data on complications related to lung cancer surgery from the Department of Cardiothoragic Surgery at Odense University Hospital were collected using the DLCR and the GTT in 2008. The capacity of these two methods to identify complications is compared and discussed. RESULTS: A total of 59 complications were registered in the DLCR, while 58 complications were registered using the GTT. The two methods were equally good at identifying complications, but the DLCR seemed to be borderline significantly better at detecting arrhythmia, while the GTT was significantly better at detecting "other events". CONCLUSION: Nearly half of the adverse events identified with the GTT were complications which were also registered by type in the DLCR. The two methods were almost equally good at identifying specific types of complications, but the GTT identified more "other events". The majority of these events were well-known to clinicians. The comparison illustrates why the implementation of new methods should be preceded by critical assessment. In this case, it is crucial to assess whether the current method should be modified by the addition of more patient safety indicators rather than by introducing a new method that partly duplicates existing data.

Reverse airflow in certain chest drains may be misinterpreted as prolonged air leakage.

BACKGROUND: Prolonged air leakage is common after lung resection. We observed that during deep inspiration some patients were able to empty the water-seal of commercial chest drainage systems and retract air back into the chest tube, which subsequently escaped during the following expiration, mimicking "true" air leakage. This led us to perform in vitro and in vivo pressure measurements in chest tube systems and investigate possible relationships with "false" air. METHODS: Commercially available one- and three-chamber drainage systems were used as models for large and small water-seals, respectively. Digital pressure measurements were performed in vitro and in ten selected patients with clinical suspicion of reverse airflow. RESULTS: Repeated measurements in the laboratory demonstrated that in three-chamber chest drainage systems with small water-seals a negative pressure below -30.4 cmH(2)O led to emptying of the water-seal with retrograde flow of air. Retrograde airflow was not possible in one-chamber chest drainage systems. In vivo measurements demonstrated that six of ten highly selected patients were able to create negative pressures below -30.4 cmH(2)O during deep inspiration. CONCLUSION: During deep inspiration some patients are able to create negative pressure large enough to empty small water-seals in commercial chest drainage systems and retract air back into the chest tube. This excess air escapes during the following expiration and may mislead interpretation of continued air leakage even when there is none, subsequently resulting in prolonged and unnecessary chest tube drainage. Any surgeon who treats patients with chest tubes should be aware of this phenomenon.