Video-assisted thoracoscopic lobectomy: which patients require postoperative physiotherapy?

OBJECTIVES: Following major thoracic surgery physiotherapy is recommended to improve reduced lung volume, aid secretion clearance, and improve mobility, however, in many centres physiotherapy provision is variable following minimally invasive video-assisted thoracoscopic surgery (VATS). The objective of this study was to observe frequency of problems potentially amenable to physiotherapy following VATS lobectomy, and to identify associated baseline factors of patients in whom physiotherapy may be beneficial. METHODS: A prospective observational study was performed including all consecutive cancer patients undergoing VATS lobectomy in a regional centre over 4years (2012-2016). Standard postoperative care included early mobilisation by nursing staff from postoperative day one (POD1). Physiotherapy assessment of all patients on POD1 determined presence of issues potentially amenable to physiotherapy intervention, and treatment was commenced. Outcome measures included postoperative pulmonary complication (PPC) development, hospital and high dependency unit (HDU) length of stay (LOS). RESULTS: Of 285 patients, 209 (73%) received physiotherapy to assist/improve reduced mobility, of these 23 (8%) also received sputum clearance therapies and 65 (23%) specific therapy for lung volume loss. The remaining 76 (27%) patients had significantly lower hospital/HDU LOS (P<0.001) reflecting uncomplicated recovery. Chronic obstructive pulmonary disease (COPD), body mass index (BMI), preoperative mobility and age were independently associated with issues potentially amenable to physiotherapy (P=0.013). CONCLUSION: Following VATS lobectomy a large proportion of patients demonstrated issues potentially amenable to physiotherapy. The authors recommend that patients receive routine physiotherapy assessment following this type of surgery to ensure that all issues are identified early. Screening of COPD, BMI, preoperative mobility and age will allow early identification of patients who may benefit most from postoperative physiotherapy and preoperative optimisation, however, these factors cannot predict the need for physiotherapy.

Comparison of recognition tools for postoperative pulmonary complications following thoracotomy.

OBJECTIVES: To evaluate the recognition of postoperative pulmonary complications (PPC) following thoracotomy and lung resection using three PPC scoring tools. DESIGN: Prospective observational study. SETTING: Regional thoracic centre. PARTICIPANTS: One hundred and twenty-nine consecutive thoracotomy and lung resection patients (October 2007 and April 2008). MAIN OUTCOME MEASURES: PPC assessment was performed on a daily basis using three sets of criteria described by Brooks-Brunn, Gosselink et al. and Reeve et al.: the Brooks-Brunn Score (BBS), Gosselink Score (GS) and Melbourne Group Scale (MGS), respectively. The results were compared with treatment for PPC and clinical outcomes including mortality, postoperative length of stay and high dependency unit length of stay. RESULTS: PPC frequency was 13% (17/129) with the MGS, 6% (8/129) with the GS and 40% (51/129) with the BBS. The clinically observed incidence of treated (requiring antibiotic therapy or bronchoscopy) PPC was 12% (16/129). CONCLUSION: PPC treatment following thoracotomy is common. Of the three scoring tools, the MGS outperforms the BBS and the GS in terms of PPC recognition following thoracotomy and lung resection. Patients with a PPC-positive MGS score have a worse outcome as defined by mortality, high dependency unit length of stay and postoperative length of stay. The MGS is an easy-to-use multidisciplinary scoring tool, but further work is required into its use in minimally invasive surgery and in targeting high-risk groups for therapy.

Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors?

BACKGROUND: Postoperative pulmonary complications (PPC) are the most frequently observed complications following lung resection, of which pneumonia and atelectasis are the most common. PPCs have a significant clinical and economic impact associated with increased observed number of deaths, morbidity, length of stay and associated cost. The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors. METHODS: A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months. PPC was assessed using a scoring system based on chest x-ray, raised white cell count, fever, microbiology, purulent sputum and oxygen saturations. RESULTS: Thirty-four of 234 subjects (14.5%) had clinical evidence of PPC. The PPC patient group had a significantly longer length of stay (LOS) in hospital, high dependency unit (HDU) LOS, higher frequency of intensive care unit (ITU) admission and a higher number of hospital deaths. Older patients, body mass index (BMI) > or =30 kg/m(2), preoperative activity <400 m, American Society of Anesthesiologists (ASA) score > or =3, smoking history, chronic obstructive pulmonary disease (COPD), lower preoperative forced expiratory volume in 1 s (FEV(1)) and predicted postoperative (PPO) FEV(1) were all significantly (p<0.05) associated with PPC on univariate analysis. Multivariate analysis confirmed that age >75 years, BMI > or =30 kg/m(2), ASA > or =3, smoking history and COPD were significant independent risk factors in the development of PPC (p<0.05). CONCLUSION: The clinical impact of PPCs is marked. Significant independent preoperative risk factors have been identified in current clinical practice. Potentially modifiable risk factors include BMI, smoking status and COPD. The impact of targeted therapy requires further evaluation.

Experience with video-assisted surgery for suspected mediastinal tumours.

AIM: To assess the therapeutic feasibility of video-assisted thoracoscopic surgery (VATS) in the excision of suspected mediastinal tumours. METHODS: The case notes of 24 consecutive patients referred to a single surgeon between 1997 and 2002 for excision of suspected mediastinal tumours were reviewed. The operative, post-operative and pathological characteristics of patients treated thoracoscopically and by open procedure were analysed. RESULTS: Thirteen of 24 patients underwent thoracoscopic excision. The mean age of the two groups was similar as was the mean operating time and duration of chest drainage. However, patients in the thoracoscopic group had less chest drainage, less pain and a shorter hospital stay. CONCLUSIONS: Video-assisted thoracoscopic excision of mediastinal tumours is a safe and technically feasible procedure and may offer significant post-operative advantages over open procedures.

Necrotizing fasciitis of chest wall complicating empyema thoracis.

Necrotizing fasciitis affecting the chest wall is a rare condition and carries high mortality. It spreads rapidly, requiring early diagnosis and immediate extensive surgical debridement. The case of a 32 year old man afflicted with this uncommon condition following tube thoracostomy for empyema thoracis is described and literature reviewed.

Delayed referral reduces the success of video-assisted thoracoscopic debridement for post-pneumonic empyema.

The aim of this study was to evaluate the effect of preoperative delay on the efficacy of video-assisted thoracoscopic surgery (VATS) for post-pneumonic pleural empyema (PPE). This was a prospective study of 39 consecutive patients with PPE who were treated by VATS with curative intent over a 4-year period. Failure to obtain full lung re-expansion resulted in conversion to thoracotomy. Pre- and post-operative variables were correlated with surgical outcome. VATS debridement was successful in 16 (41%) patients while conversion to open decortication was needed in 23 patients (21 immediate, two delayed), There was no difference in the age/sex distribution of the two groups. In the failed VATS group the delay from hospital admission to operation was longer: 24 (2.1) vs. 16.6 (2.7) days (P = 0.03, 95% CI 0.53-14.3 days); operating time was longer: 128.2 (7.9) vs. 86.2 (10.4) min (P = 0.003, 95% CI 15.2-68.5 min) and post-operative stay was longer: 8.4 (0.8) vs. 5.2 (0.6) days (P = 0.03, 95% CI 1.1-5.3 days). VATS can be used successfully to treat PPE with a faster post-operative recovery when successful than open surgery. Delayed surgical intervention decreases the success of VATS thus earlier referral for surgical intervention in PPE (ideally within 21 days) is advocated to gain its full benefits.

Colonic metastases from primary squamous cell carcinoma of the lung.

Lung cancer is the most common malignancy in the UK. Metastasis to the colon is very rare and only infrequently symptomatic. Here we report a case of squamous cell carcinoma of the lung which presented with symptoms from a colonic metastasis.

Video-assisted thoracoscopic sympathectomy for severe intractable angina.

OBJECTIVE: Endoscopic trans-thoracic sympathectomy is a well documented, safe and successful treatment for palmar and axillary hyperhidrosis. This may also be helpful in the management of patients with intractable angina and advanced coronary disease unsuitable for coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA). We evaluated video assisted thoracoscopic sympathectomy (VATS) in such patients with the aim of improving symptoms and quality of life. METHODS: Video assisted thoracoscopic sympathectomy, a minimally invasive procedure, was performed under general anaesthesia with alternating single lung ventilation. Three stab incisions were made at the level of the fourth intercostal space in the anterior and posterior axillary lines, and at the fifth intercostal space in the mid-axillary line through which an extensive thoracic sympathectomy was performed to include second to the fourth ganglia, bilaterally. RESULTS: A total of 16 patients aged 46-76 (mean 61) years were assessed for VATS. Of these 10 patients had the procedure performed; nine with previous CABG and one with diffuse coronary disease. Six patients were excluded because of an evolving MI (n = 1), left ventricular ejection fraction (LVEF) < 30% (n = 2), and chronic stable angina with no objective evidence of ischaemia (n = 3). All 10 patients had marked symptomatic improvement with reduction of both angina frequency and intensity of attacks. Mean follow-up period 11.5 months. Exercise tolerance and time to onset of angina measured on exercise treadmill was significantly increased post-VATS (P = 0.028) and maintained 1 year post-operative. CONCLUSION: VATS was associated with both reduction in angina symptoms and an increase in exercise time to onset of angina. An improved quality of life was evident.

A physiological comparison of flutter valve drainage bags and underwater seal systems for postoperative air leaks.

BACKGROUND: A study was undertaken to compare the relative physiological effects of underwater seal (UWS) versus flutter valve (FV) pleural drainage systems in the treatment of postoperative air leaks. METHOD: Fourteen patients with air leaks of 1-11 days duration, following lobectomy (n = 5), bullectomy (n = 4), decortication (n = 4), and pleural biopsy (n = 1) were analysed. Intrapleural pressure (IPP) measurements were made using an in-line external strain gauge connected directly to the intercostal tube. Patients were connected simultaneously to both UWS and FV drainage systems and pressures were measured sequentially, isolating each system in turn. Maximum (IPPmax) and minimum (IPPmin) intrapleural pressures were calculated from graphic traces. The degree of lung expansion was recorded by chest radiography. RESULTS: At resting tidal volume IPPmax was significantly higher with the UWS system (mean difference 0.8 mm Hg, 95% CI 0 to 1.6, p = 0.046) and IPPmin was significantly lower with the FV system (1.8 mm Hg, 95% CI 0.3 to 3.3, p = 0.023). The lung was fully expanded in 50% of patients at the time of study. The mean difference in IPPmin between systems was significantly increased when the lung was fully expanded (mean 2.8 mm Hg, 95% CI 0.1 to 5.5, p = 0.042). The mean difference in IPPmax was not affected by the degree of lung expansion (0.79, 95% CI -0.83 to 2.4, p = 0.31). CONCLUSION: The results of this study suggest that, when postoperative air leak exists without a persistent pleural space, the flutter valve may provide a physiologically more effective alternative to the underwater seal drainage system.

Have we got the full picture?

A 59-year-old man with long-standing chronic obstructive airways disease (COPD), became progressively dyspnoeic, and repeatedly blacked-out during forced expiration. Spirometry suggested the possibility of large airways obstruction, and failing to respond to aggressive bronchodilator and steroid therapy, the patient was labelled as being non-compliant. Finally, he was assessed by an otolaryngologist and a cause for upper airway obstruction was suspected. Bronchoscopy and computed tomography (CT) scanning demonstrated tracheomalacia and the patient underwent resection of this segment of abnormal trachea. Tracheomalacia, although rare, results from the substitution of cartilage with fibrous tissue, leading to severe airway compromise. This case emphasizes the fact that although many conditions are uncommon, the total incidence of rare conditions is surprisingly high, and that care needs to be taken at all times in the management of 'labelled' patients with chronic illness, in order not to overlook such life-threatening diagnoses.

Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is now the generally preferred surgical treatment for spontaneous pneumothorax but is more difficult once pleural adhesions have developed. To test the hypothesis that VATS is under-used because of prolonged pleural intubation, we have audited the effect of preoperative management on subsequent surgical outcome. METHOD: Data are expressed as median (range). A prospective audit of clinical outcome in 42 consecutive patients (30 male, 12 female, aged 39 [19-81] years) referred to a Regional Unit for non-elective pneumothorax surgery. VATS was attempted whenever possible. RESULTS: VATS was successful in 32 patients (group V) but 10 (24%) patients (group T) required thoracotomy and decortication of an empyema thoracis. Only seven (17%) patients were operated upon within 7 days of presentation, and 10 patients (24%) waited for more than 21 days. The delay from presentation to operation was significantly longer in group T (22 days vs. 10 days, P < 0.05, Wilcoxon). There were significantly more preoperative pleural interventions in patients in group T than in group V (P < 0.05, Wilcoxon). Postoperative stay was longer in group T (7 days vs. 3 days, P < 0.05) and there was a significant overall correlation between preoperative delay and postoperative stay (r = 0.64). CONCLUSION: Delayed referral for pneumothorax surgery and multiple pleural interventions predispose to pleural sepsis and preclude VATS detrimentally affecting clinical outcome. Changes in referral practice are advocated.

Elective removal of convexo-concave Björk-Shiley valves.

Replacement has been an accepted method for treating advanced cardiac valvular disease for more than 25 years. However, the perfect prosthesis has yet to be developed, judging by the number of devices available. A prosthesis that initially appears promising may cause problems in due course, and indeed some devices have been modified or withdrawn from clinical use. A notable example of a prosthetic valve that has give problems is the Björk-Shiley convexo-concave prosthesis, some models of which have undergone mechanical failure due to strut fracture. We report the elective removal of such a valve and the subsequent examination of the prosthesis. The results of this examination suggest that a policy of elective removal is justified.

Use of retrograde cold crystalloid cardioplegia in a patient with unexpected cold agglutination.

Undetected cold agglutinins were encountered in a patient undergoing coronary artery bypass grafting using antegrade cold blood cardioplegia. Macroemboli were infused into the coronary arterial tree. These were flushed out by the use of retrograde cold crystalloid cardioplegia. Activated cold agglutinins may be hazardous in cold blood cardioplegia.

Late onset tracheo-oesophageal fistula following a swallowed dental plate.

Swallowing dentures and dental plates has been a cause of distress among elderly patients. Tracheo-oesophageal fistula caused by a foreign body is rare and of the cases reported in the literature only one was due to a swallowed denture which resulted in a recurrent laryngeal nerve palsy [4]. We describe a delayed onset tracheo-oesophageal fistula due to a swallowed dental plate in a young patient.

Unusual migration of a Kirschner wire.

Orthopaedic procedures involve utilization of internal fixation devices. Screws, wires and plates are removed due to loosening or infection. Migration of these devices is also well established. We present an unusual case of migration of a Kirschner wire from the right shoulder to the spleen within a period of 12 h. Review of the literature does not reveal any previous occurrence of this nature.

Acute renal failure due to profound haemolysis--an unusual complication of cusp rupture in cardiac bioprostheses.

Haemolysis due to prosthetic cardiac valves is well documented in the literature, with an increased incidence in mechanical prostheses as compared to bioprostheses. We report this unusual complication in two patients who developed profound haemolysis rapidly resulting in acute renal failure following cusp rupture in mitral Ionescu-Shiley valves. One of the patients developed irreversible renal failure in spite of successful reoperation, while renal function normalized in the second case.