Single-cell transcriptomic analysis of human pleura reveals stromal heterogeneity and informs in vitro models of mesothelioma.

The pleural lining of the thorax regulates local immunity, inflammation and repair. A variety of conditions, both benign and malignant, including pleural mesothelioma, can affect this tissue. A lack of knowledge concerning the mesothelial and stromal cells comprising the pleura has hampered the development of targeted therapies. Here, we present the first comprehensive single-cell transcriptomic atlas of the human parietal pleura and demonstrate its utility in elucidating pleural biology. We confirm the presence of known universal fibroblasts and describe novel, potentially pleural-specific, fibroblast subtypes. We also present transcriptomic characterisation of multiple in vitro models of benign and malignant mesothelial cells, and characterise these through comparison with in vivo transcriptomic data. While bulk pleural transcriptomes have been reported previously, this is the first study to provide resolution at the single-cell level. We expect our pleural cell atlas will prove invaluable to those studying pleural biology and disease. It has already enabled us to shed light on the transdifferentiation of mesothelial cells, allowing us to develop a simple method for prolonging mesothelial cell differentiation in vitro.

A case of malignant mesothelioma in a young patient with childhood leukaemia who had received total body irradiation.

This case report explores a 34-year-old male diagnosed with mesothelioma who had no known risk factors. The patient initially was treated for empyema with antibiotics but later represented to hospital with worsening symptoms. He underwent a surgical Video-assisted thoracoscopic surgery procedure and lung biopsy, which revealed a diagnosis of mesothelioma. The young age of the patient as well as absence of significant risk factors for mesothelioma made the diagnosis unexpected. The patient had total body irradiation (TBI) therapy for leukaemia as a child, which increases the risk of developing cancer. However, there are limited studies exploring the risk of pleural mesothelioma post-TBI. Young patients who represent to hospital, with limited response to initial treatment, and suspicious radiological features should be considered for lung biopsy to reduce the risk of a missed diagnosis. Patients with a background of TBI should also be considered for follow-up to monitor for any subsequent malignancy.

Clinical Outcomes and Return to Sports After Open Reduction and Hamstring Tendon Autograft Reconstruction in Patients With Acute Traumatic First-Time Posterior Dislocation of the Sternoclavicular Joint.

BACKGROUND: Traumatic posterior dislocations of the sternoclavicular joint (SCJ) are rare. Multiple case reports, case series, and systematic reviews have been published on the treatment of posterior SCJ dislocations. However, they have usually been of small numbers, described a variety of surgical techniques on a mixture of acute and chronic dislocations, and have not focused on functional recovery or return to sports. PURPOSE/HYPOTHESIS: The purpose of this study was to assess the clinical outcomes and return to sports after SCJ open reduction and reconstruction using a hamstring tendon autograft in patients with an acute first-time traumatic posterior dislocation of the SCJ. We hypothesized that SCJ open reduction and reconstruction would result in high survivorship, good clinical outcomes, and a high rate of return to sports. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This study included all patients who underwent SCJ open reduction and reconstruction within 14 days of sustaining a first-time traumatic posteriorly dislocated SCJ, with a minimum 3-year follow-up. Patient-reported outcomes were assessed by the following scores: short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Rockwood SCJ, modified Constant, and Single Assessment Numeric Evaluation (SANE). Survivorship was defined as no clinical failure, such as instability or recurrent dislocation, and no revision surgery. Return to sports was assessed using a customized questionnaire. RESULTS: A total of 19 patients who underwent surgery were included, with a mean age of 30.8 years (range, 18-52 years). Seventeen patients were available at final follow-up at a mean 94.5 months (range, 37-155 months). At final follow-up, the mean scores were as follows: QuickDASH, 4.3 (range, 0-20.4); Rockwood, 13.9 (range, 12-15); modified Constant, 94.4 (range, 71-100); and SANE, 92.1 (range, 70-100). The construct survivorship was 96%. Of the 14 patients who participated in sports, 12 (86%) returned to their preinjury levels. CONCLUSION: After an acute first-time traumatic posterior SCJ dislocation, open reduction and stabilization with a hamstring tendon autograft, undertaken within 14 days of injury, provides good clinical outcomes and high rates of survivorship and return to sports.

Subxiphoid, Nonintubated, Opioid-Free, Video-Assisted Pneumonectomy: A New Frontier in Thoracic Surgery.

Surgical approaches to major pulmonary resections have evolved from thoracotomy to multiportal video-assisted thoracoscopy (VATS) and subsequently uniportal VATS. The efficacy of this progress has been validated in a multitude of publications demonstrating reductions in complications, patient perception of pain, and postoperative length of stay. More recent advances include subxiphoid extrathoracic access and nonintubated, opioid-free anesthesia. Early publications have demonstrated promising results with respect to safety, technical feasibility, and enhanced recovery. However, there remains a paucity of literature relating to hybrid approaches comprising both subxiphoid and nonintubated, opioid-free anesthesia in the context of pneumonectomy. The current report is the case of a patient undergoing pneumonectomy. Both subxiphoid and nonintubated, opioid-free techniques were utilized. The authors describe preoperative workup, surgical and anesthesia-related caveats, and postoperative recovery. In conclusion, this approach is technically feasible, safe, and may be associated with enhanced recovery.

Opioid-Free Anesthesia for Lung Cancer Resection: A Case-Control Study.

OBJECTIVE: To assess the feasibility and effectiveness of an opioid-free anesthesia (OFA) technique in lung cancer resection surgery versus standard opioid-based techniques. DESIGN: Retrospective, propensity-matched, case-control study. SETTING: A single, specialty cardiothoracic center between January 2018 and July 2019. PARTICIPANTS: Adult patients undergoing lung cancer resection surgery. INTERVENTIONS: A cohort of 83 patients undergoing an OFA technique (OFA group) for lung cancer resection surgery was matched with 83 patients who underwent similar surgery with a standard anesthesia technique (STD group). Outcome measures compared between the 2 groups included postoperative pain scores at 0, 1, and 24 hours; 24-hour postoperative morphine patient-controlled analgesia consumption; recovery room and hospital lengths of stay; and 30-day all-cause mortality. MEASUREMENT AND MAIN RESULTS: No difference was found in median pain scores (interquartile range [IQR]) at 0 hours: STD 0 (0-1), OFA 0 (0-1); p = 0.48. Median pain scores (IQR) at 1 hour were statistically significantly greater in the STD group compared with the OFA group: STD 1 (0-1), OFA 0 (0-1); p = 0.03. There was no difference in median pain scores (IQR) at 24 hours: STD 0 (0-1), OFA 0 (0-1); p = 0.49. Mean postoperative 24-hour patient-controlled analgesia morphine consumption (standard deviation) was similar between groups: STD 21.1 (±18.8) mg, OFA 16.2 (±18.1) mg; p = 0.16. There was no difference in mean time spent in the postoperative recovery (standard deviation) area between the 2 groups: STD 116 (±49) minutes, OFA 108 (±34) minutes; p = 0.27. Median hospital length of stay (IQR) was longer in the STD group compared with the OFA group: STD 4 (2-6) days, OFA 3 (2-4) days; p = 0.002. CONCLUSIONS: This case-control study demonstrated that an OFA technique in lung cancer resection surgery offers a feasible and safe approach, resulting in similar postoperative pain scores and morphine consumption compared with standard opioid-containing techniques.

Uniportal subxiphoid bilateral removal of self-introduced thoracic foreign bodies.

This is a report of a 31-year-old male refugee, who was admitted to Intensive Therapy Unit after being found in severe chest pain after escaping extreme torture from his home country. He was found to have four nails in his thorax. These were removed using a subxiphoid video-assisted thorascopic surgery (VATS) technique. This technique allowed excellent visualization of the right, left and anterior mediastinal part of the chest and therefore preventing damage or injury to surrounding structures. This was particularly useful in a complex case such as this. By avoiding an intercoastal incision and intercostal manipulation, our patient had limited pain post-procedure facilitating an earlier aggressive mobilization program with potential benefit in terms of improved lung expansion, reduction of atelectasis and lung infections. With the right training, the technical challenges of using the technique should be overcome and thus the benefits of subxiphoid VATS will be offered to a larger portion of thoracic surgical patients.

Surgical Management of Thoracic Multiple Exostoses.

Hereditary multiple exostoses is a rare autosomal dominant condition resulting in the development of multiple osteochondromas. We present the case of a 25-year-old woman with hereditary multiple exostoses who was referred for thoracic surgery assessment due to severe right-sided chest pain. Computed tomographic scan allowed preoperative planning for resection of the lesion. Under general anesthesia, right video-assisted thoracoscopic surgery was performed through a cosmetic retromammary incision. Complete removal of the tumor resolved symptoms, and she was discharged 2 days later. We show that video-assisted thoracoscopic surgery with a cosmetically placed muscle-sparing incision allowed accurate resection with faster recovery.

Acute kidney injury after thoracic surgery: a proposal for a multicentre evaluation (MERITS).

OBJECTIVES: Because the mortality rate is very low in thoracic surgery, its use as a quality discriminator is limited. Acute kidney injury (AKI) is a candidate measure because it is associated with increased rates of morbidity and mortality and is partly preventable. The incidence of AKI after thoracic surgery is not well documented. We conducted an audit to determine the incidence and outcomes of AKI. This audit became a pilot project, and the results indicate the feasibility of a larger study. METHODS: Retrospective data on renal function post-thoracic surgery were collected at a tertiary cardiothoracic unit over 12 months. Renal impairment was classified according to the Kidney Disease Improving Global Outcomes criteria. RESULTS: Of 568 patients (mean = 59 ± SD 18; 38% women), AKI was diagnosed in 86 (15.1%) within 72 h post-thoracic surgery based on the Kidney Disease Improving Global Outcomes staging system (stage 1, n = 55; stage 2, n = 25; stage 3, n = 6). Significant differences were found in postoperative length of stay (3 vs 5 days; P < 0.001) of patients with and without AKI. There was a significant difference between the age groups of patients with and without AKI (P < 0.05) in the open surgical group but not in the group having video-assisted thoracoscopic surgery (VATS). There was no significant difference in the mortality rates between patients with and without AKI. CONCLUSIONS: The incidence of AKI after thoracic surgery was 15.1%. AKI was associated with longer hospital stays and was more likely in ≥60-year-old patients after open surgery than after VATS. Reducing AKI could improve patient outcomes. We propose that AKI may be a useful quality measure in thoracic surgery. We are developing a multicentre audit based on this approach.

A hypercoagulable state leading to venous limb gangrene associated with occult lung adenocarcinoma.

We report a case of lung adenocarcinoma-associated hypercoagulability leading to venous limb gangrene, managed successfully with argatroban and then dabigatran. Use of idarucizumab permitted diagnostic investigations, leading to targeted antineoplastic therapy with crizotinib, surgical resection with curative intent, and continued survival over 2 years after the index event.