Simulation in thoracic surgery-A mini review of a vital educational tool to maximize peri-operative care and minimize complications.

Thoracic surgery is an increasingly expanding field, and the addition of national screening programs has resulted in increasing operative numbers and complexity. Thoracic surgery overall has an approximately 2% mortality and 20% morbidity with common specific complications including persistent air leak, pneumothorax, and fistulas. The nature of the surgery results in complications being unique to thoracic surgery and often very junior members of the surgical team feel underprepared to deal with these complications after very little exposure during their medical school and general surgical rotations. Throughout medicine, simulation is being increasingly used as a method to teach the management of complicated, rare, or significant risk occurrences and has shown significant benefits in learner confidence and outcomes. In this mini review we explain the learning theory and benefits of simulation learning. We also discuss the current state of simulation in thoracic surgery and its potential future in aiding complication management and patient safety.

Thoracoscopic segmentectomy versus lobectomy: A propensity score-matched analysis.

Objectives: The aim of this study is to compare the postoperative complications, perioperative course, and survival among patients from the multicentric Spanish Video-assisted Thoracic Surgery Group database who received video-assisted thoracic surgery lobectomy or video-assisted thoracic surgery anatomic segmentectomy. Methods: From December 2016 to March 2018, a total of 2250 patients were collected from 33 centers. Overall analysis (video-assisted thoracic surgery lobectomy = 2070; video-assisted thoracic surgery anatomic segmentectomy = 180) and propensity score-matched adjusted analysis (video-assisted thoracic surgery lobectomy = 97; video-assisted thoracic surgery anatomic segmentectomy = 97) were performed to compare postoperative results. Kaplan-Meier and competing risks method were used to compare survival. Results: In the overall analysis, video-assisted thoracic surgery anatomic segmentectomy showed a lower incidence of respiratory complications (relative risk, 0.56; confidence interval, 0.37-0.83; P = .002), lower postoperative prolonged air leak (relative risk, 0.42; 95% confidence interval, 0.23-0.78; P = .003), and shorter median postoperative stay (4.8 vs 6.2 days; P = .004) than video-assisted thoracic surgery lobectomy. After propensity score-matched analysis, prolonged air leak remained significantly lower in video-assisted thoracic surgery anatomic segmentectomy (relative risk, 0.33; 95% confidence interval, 0.12-0.89; P = .02). Kaplan-Meier and competing risk curves showed no differences during the 3-year follow-up (median follow-up in months: 24.4; interquartile range, 20.8-28.3) in terms of overall survival (hazard ratio, 0.73; 95% confidence interval, 0.45-1.7; P = .2), tumor progression-related mortality (subdistribution hazard ratio, 0.41; 95% confidence interval, 0.11-1.57; P = .2), and disease-free survival (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.35-1.51; P = .4) between groups. Conclusions: Video-assisted thoracic surgery segmentectomy showed results similar to lobectomy in terms of postoperative outcomes and midterm survival. In addition, a lower incidence of prolonged air leak was found in patients who underwent video-assisted thoracic surgery anatomic segmentectomy.

Seldinger chest drain guidewire retained in the pleural cavity-a never event complication.

Intrapleural foreign body is an unusual complication. It most commonly occurs after the trauma but has been rarely seen after diagnostic or therapeutic procedures. We hereby, present an unusual occurrence of a retained guidewire after a chest drain insertion using a Seldinger technique in a patient with coronavirus disease of 2019 pneumonitis. Surgical removal of the guidewire has prevented this foreign body to cause further harm. We further discuss how to identify and prevent such a complication.

Evaluation of surgical approaches to anatomical segmentectomies: the transition to minimal invasive surgery improves hospital outcomes.

BACKGROUND: We aim to evaluate the transition process from open to video-assisted thoracoscopic surgery (VATS) anatomical segmentectomies in a regional thoracic surgical unit. METHODS: In a retrospective study from January 2013 to December 2015, we identified all anatomical segmentectomies performed in our unit. Pre, peri and postoperative data were compared between the three years (2013, 2014 and 2015) and according to operative approach. Thoracotomy after VATS intraoperative biopsy was considered a conversion for the purposes of the study. RESULTS: A total of 86 consecutive cases [56 females and 30 males, median age 70 years (range, 43 to 83 years); median FEV1 of 78% predicted (range, 41% to 126%)] were included. There was a significant change in the surgical approach with time. Fifty-two cases underwent VATS (73% via single-port) and 34 open surgeries, including nine conversions. There were no postoperative deaths in the VATS group and one in the open group. Operative outcomes were similar over time with no haemorrhagic events, equivalent R1 resection and nodal stations explored in all lymph node positive patients. In node negative cases however, open surgery was associated with more extensive mediastinal exploration. Patients in 2015 had a shorter hospital stay in comparison to those in previous years [median 4 days (range, 1-15 days) vs. median 6 days (range, 3-27 days), P=0.01]. There were no differences in the incidence of complications or readmissions to hospital over time. CONCLUSIONS: The transition over a short period of time from open to single-port VATS segmentectomy has allowed us to significantly reduce postoperative hospital stay without compromising operative or postoperative outcomes.

The influence of prior multiport experience on the learning curve for single-port thoracoscopic lobectomy: a multicentre comparative study†.

OBJECTIVES: Competency in video-assisted thoracoscopic (VATS) lobectomy is estimated to be reached after the surgeon completes 50 cases. We wanted to explore the impact of competency in performing multiport VATS lobectomies on completing the needed number of single-port VATS. METHODS: In a retrospective multicentre study, 6 individual surgeons (3 with previous competency in multiport VATS lobectomy and 3 without) submitted their first 50 cases of single-port VATS lobectomies. Extended and sublobar resections were excluded. Pre-, peri- and postoperative data were compared between the groups of surgeons. Chi-square and Wilcoxon's rank tests were used. The less experienced surgeons had previously attended dedicated training courses and visited with experts. RESULTS: A total of 300 cases were included [150 in Group A (surgeons with previous experience performing multiport VATS) and 150 in Group B (surgeons without extensive experience performing multiport VATS)]. Surgeons in Group B performed significantly more elective open lobectomies during their learning curve period than surgeons of Group A (58 vs 1). Patients in Group B were older and had more risk factors. There were 3 in-hospital deaths (respiratory failure, sepsis and fatal stroke). There were no differences between the groups in operative time, intensive care unit admissions, hospital stay, total complications, tumour size or number of N2 stations explored. Only the duration of intercostal drainage (2 vs 3 days, 0.012), incidence of respiratory tract infections (1% vs 7%, P = 0.002) and conversion rates (4% vs 12%, P = 0.018) were better in Group A. Patients characteristics played a role in the development of respiratory infections and longer drainage times but not in the need for conversion. CONCLUSIONS: Overall, postoperative outcomes during the learning curve period for single-port VATS lobectomies are not noticeably affected by previous multiport VATS experience. Less experienced surgeons were more selective in order to achieve competency (more lower lobectomies and more open operations). Competency in single-port VATS lobectomy can be acquired safely with adequate training and good case selection but will be achieved 'faster' with previous competency in multiport VATS lobectomy.

Indication for VATS sublobar resections in early lung cancer.

When dealing with early non-small cell lung cancer (NSCLC) sublobar resections still remain part of the surgical armamentarium. In selected patients with lung cancer, the combination of the potential benefits of parenchyma sparing procedures to the limited trauma provided by Video Assisted Thoracic Surgery (VATS) techniques can become very appealing. Two main groups are included: non-anatomical (wedges) and anatomical (segmentectomies) excisions. We describe the techniques, results and potential indications of both of these techniques.

Completing the audit cycle improves surgical standards in lung cancer. Why do some patients still not receive the best care?

INTRODUCTION: Intraoperative gold standards in the management of lung cancer include performing anatomical resection and mediastinal lymphadenectomy). Our aim was to measure improvement in quality of surgery by reauditing anatomical resection and lymph node excision in patients undergoing lung cancer surgery as per gold standards. METHODS: A complete audit cycle was performed-an initial retrospective analysis of 100 consecutive patients with primary lung cancer operated on by a single surgeon (July 2009-October 2010), followed by a prospective reaudit of 102 patients (November 2010-October 2011). Clinical and pathological data were collected from clinical notes, surgical database, and histopathology reports. Univariate and multivariate analyses were performed to identify further areas of potential improvement. RESULTS: The number of nonanatomical resections dropped from 12% to 6% (p = not significant). The rate of performing excision of at least 1, 2, and 3 mediastinal (N2) lymph node stations improved from 86% to 91%, 63% to 77%, and 40% to 63%, respectively (p = 0.003). On multivariate analysis, failure to perform anatomical resection was related to use of video assisted thoracic surgery (VATS) techniques, previous malignancy, and high-predicted surgical risk by European Society Objective Score .01. Less complete intraoperative lymph node excision was associated with cases performed by VATS and in octogenarians. CONCLUSIONS: There is continued adherence to the guidelines, when considering cases in terms of anatomical resections, and marked improvement in complying with the gold standards for lymph node excision. The use of the audit tool has contributed to improved quality of surgical care in patients operated for lung cancer.

Initial single-port thoracoscopy to reduce surgical trauma during open en bloc chest wall and pulmonary resection for locally invasive cancer.

OBJECTIVES: En bloc pulmonary and chest wall resection is the preferred method of treatment for locally invasive lung carcinoma. However, it carries major trauma to the chest wall, especially in cases with chest wall involvement distant to the potential location of 'traditional' thoracotomies. We describe an alternative method of estimating the boundaries of chest wall resection employing video assisted thoracoscopic surgery (VATS) and hypodermic needles. METHODS: VATS delineation of boundaries of chest wall involvement by lung cancer has been performed in six patients who gave written consent. In one case the single-port thoracoscopic examination revealed unexpected distant pleural metastases thus preventing from resection. The other 5 patients, three males and two females [median age of 60.5 (range 39 to 75) years] underwent en bloc anatomical lung resection in addition to chest wall excision and reconstruction for T3N0 lung cancer. RESULTS: In these five cases the chest wall opening was restricted to the extent of the rib excision, and the pulmonary resection was performed via the existing chest wall opening without requiring extension of the thoracotomy or any rib spreading. DISCUSSION: Minimally invasive techniques aid to delineate the boundaries of chest wall involvement of lung cancer and intraoperative staging. This helped tailoring the surgical approach and location of the thoracotomy, and prevented rib-spreading or additional thoracotomies in our cases.

The left thoracotomy approach for excision of distal tracheal carcinoma in the presence of right-sided aorta.

Tracheal primary carcinoma is a rare malignancy, and we believe that its presence in a patient with a right-sided aorta has not been described before. We report a case of a primary tracheal squamous carcinoma in a patient with a four-branched right-sided aortic arch. The patient underwent a tracheal resection approached by a left thoracotomy. The surgical exposure was excellent once the ligamentum arteriosum had been divided. All the aortic arch branches and the phrenic, vagus and recurrent laryngeal nerves were identified and preserved.

Initial experience with the use of biological implants for soft tissue and chest wall reconstruction in thoracic surgery.

BACKGROUND: Synthetic materials have traditionally been used for tissue reconstruction in thoracic surgery. New biomaterials have been tested in other areas of surgery with good results. The aim of our study is to evaluate our initial experience using prostheses in extended thoracic surgery. METHODS: A review was performed of all patients who underwent extended surgical procedures requiring soft tissue reconstruction with bioprosthetic materials after thoracic surgery from August 2009 to August 2011. A total of 44 consecutive patients were included. Operations involved radical pleurectomy and decortication for mesothelioma (n = 29), extended operations for thoracic malignancies (n = 8), surgery for trauma or perforated organs or complications (n = 6), and for benign infectious causes (n = 1). RESULTS: A total of 76 patches were used in 44 patients (median of 2; range 1 to 3 per patient). Median hospital stay was 13 (range 5 to 149) days. Three patients died during the postoperative period (6.8%); pulmonary embolism 5 days after intrapericardial pneumonectomy with chest wall reconstruction, fatal pneumonia 26 days after radical pleurectomy and decortication for mesothelioma, and bronchopleural fistula 11 days after pneumonectomy with diaphragm and atrium excision for lung cancer after initial chemoradiotherapy. No other surgical exploration or removal of patches has been required for infection. CONCLUSIONS: Our initial experience of using bioprosthetic patches for soft tissue reconstruction in thoracic surgery has proven satisfactory with overall acceptable results. The infection rates are low even when a proportion of procedures were performed under contaminated environments. Biologic prosthesis should be part of the surgical options to reconstruct soft tissues in thoracic surgery.

Neuronal antibodies and paraneoplastic sensory neuropathy in thymoma.

Thymoma, a common anterior mediastinal tumour, may present with paraneoplastic neurological symptoms. The presence of neuronal anti-Hu paraneoplastic antibodies in thymoma patients is very rare. Here, we describe a patient who presented with symptoms of a sensory peripheral neuropathy in the presence of onconeural antibodies cross-reactive with Hu antigen, in whom an underlying thymoma was diagnosed. Subsequent minimally invasive thymomectomy improved her neurological symptoms significantly.

The fate of abstracts presented at annual meetings of the Society for Cardiothoracic Surgery in Great Britain and Ireland from 1993 to 2007.

Although the presentation of original research to learned societies is valuable, the target should be publication in a peer-reviewed journal. Therefore, the strength of a meeting may be assessed by the rate of the subsequent publication of papers from the presented abstracts. We conducted an analysis of abstracts presented at consecutive annual meetings of the Society for Cardiothoracic Surgery (SCTS) in Great Britain and Ireland over a 15-year period. Abstract books and other documentation from the 1993-2007 meetings were reviewed; abstracts from other major Cardiothoracic Surgery meetings held in 2007 were also reviewed. Medline was searched to identify the peer-reviewed publications arising from each work presented. For abstracts presented at SCTS in 2003-07, the factors potentially associated with publication were analysed by logistic regression. If no publications were identified, authors were contacted through a standardized email questionnaire to ascertain its status and reasons for non-publication. Over the 15-year period, 909 abstracts were presented at the SCTS meetings. The rate of publication rose from ~30% in the mid-1990s to consistently >60% from recent meetings, with a high of 81.3% from 2006. However, in comparison with other Cardiothoracic Surgery meetings in 2007, the chance of subsequent publication from SCTS (66.7%) was lower than from the European Association for Cardio-Thoracic Surgery (75.0%), the American Association for Thoracic Surgery (83.9%) and The Society of Thoracic Surgeons (72.5%) meetings. For abstracts presented at the last five SCTS meetings, publication was most commonly in a speciality journal (56.3%) and the median time for publication was 15 months (range -24 to 63 months) with 14 papers published prior to presentation at the meeting. On regression analysis, the only factor associated with publication was the study design comparing randomized trials and systematic reviews with other types of study (P < 0.01). Of the 90 unpublished abstracts, 48 (53.3%) authors replied to an email questionnaire revealing that 41 (85.4%) were never submitted for publication. The most common reasons given were low priority (29.6%) and low likelihood of acceptance (24.1%). In recent years, the annual meeting of the Society has become a forum for the presentation of high-quality research that usually withstands peer-review, most commonly in a speciality journal. The rate of publication has increased to consistently >60%, although those that remain unpublished are generally never submitted. This compares favourably with national meetings of other surgical societies, although it is lower than other major cardiothoracic meetings which have an affiliated journal. At a time when it has been suggested that medical research in the UK is in decline, cardiothoracic surgery appears to be thriving.

Age and neo-adjuvant chemotherapy increase the risk of atrial fibrillation following oesophagectomy.

OBJECTIVES: Atrial tachyarrhythmias occur in up to 25% of patients after major thoracic surgery. We examined risk factors for new-onset atrial fibrillation (AF) following oesophagectomy in an attempt to guide prophylactic use of anti-arrhythmic strategies. METHODS: Data were extracted from a database of patients who underwent oesophagectomy between 1991 and 2009. Patients with pre-operative arrhythmias were excluded leaving 997 patients for further analysis. Univariate and multivariate logistic regression analyses were performed to identify factors predicting AF, and receiver operating characteristic curves were generated from a model using these predictors. Statistical significance was reflected in a P-value of <0.05. RESULTS: Patients who developed AF (n = 209; 20.96%) were older (median age 70.54 years vs. 66.9 years; P < 0.01) and included 141 males (67.4%) (P = 0.11). Patients with AF were noted to have a higher in-hospital mortality rate (n = 17; 8.1% vs. n = 34; 4.8%) (P = 0.04) and a longer stay in hospital (14 days vs. 12 days; P < 0.01). Multivariate analysis identified advanced age and neo-adjuvant chemotherapy to be independent predictors of the risk of developing AF. Assessment of discriminative ability of a predictive model revealed a c-statistic of just 0.62. CONCLUSIONS: Despite the identification of age and neo-adjuvant chemotherapy as predictors of AF, the moderate discriminative ability of predictive modelling does not support the use of prophylactic anti-arrhythmic drugs. However, the high incidence of AF after major thoracic surgery makes it necessary to understand its underlying mechanisms better before prophylactic strategies are considered.

Accuracy of two scoring systems for risk stratification in thoracic surgery.

We investigate the suitability of the two existing risk stratification systems available for predicting mortality in a cohort of patients undergoing lung resection under a single surgeon. Data from the 290 consecutive patients who underwent pulmonary resection between January 2008 and January 2011 were extracted from a prospective clinical data base. In-hospital mortality risk scores are calculated for every patient by using Thoracoscore and ESOS.01 and were compared with actual in-hospital mortality. The receiver operating characteristic (ROC) curve was used to establish how well the systems rank for predicting patient mortality. Actual in-hospital mortality was 3.1% (n = 9). Thoracoscore and ESOS values (mean ± SEM) were 4.93 ± 0.32 and 4.08 ± 0.41, respectively. The area under the ROC curve values for ESOS and Thoracoscore were 0.8 and 0.6, respectively. ESOS was reasonably accurate at predicting the overall mortality (sensitivity 88% and specificity 67%), whereas Thoracoscore was a weaker predictor of mortality (sensitivity 67% and specificity 53%). The ESOS score had better predictive values in our patient population and might be easier to calculate. Because of their low specificity, the use of these scores should be limited to the assessment of outcomes of surgical cohorts, but they are not designed to predict risks for individual patients.

Early outcomes of surgery for oesophageal cancer in a thoracic regional unit. Can we maintain training without compromising results?

OBJECTIVES: Meaningful exposure to oesophageal cancer surgery during general thoracic surgical training is restricted to few centres in the United Kingdom. Our Regional Tertiary Unit remains a rare 'large-volume' oesophagectomy centre. We aimed to determine the proportion of patients operated by trainees and their perioperative outcomes. METHODS: From January 2004 to September 2009, 323 patients (229 male and 94 female, median age of 69 (range 40-92) years) underwent oesophagectomy for carcinoma in our Thoracic Surgical Unit. Data were complete and obtained from a prospective departmental database. The preoperative characteristics, operative data and postoperative results were compared between the 120 patients (37%) operated by a trainee (group T) and the remainder 203 patients operated by a consultant (group C). RESULTS: The overall incidence of mortality, anastomotic leak and chylothorax were 6.5%, 5.3% and 2.2%, respectively. There were no differences in terms of age, gender, tumour location, tumour staging, preoperative spirometry or use of neoadjuvant chemotherapy between the two groups. There was no significant difference between the consultant group and the trainee group in the following key outcome measures: postoperative mortality (8% vs 4%), incidence of respiratory complications (30% vs 25%), hospital stay (14 days vs 13 days) and number of lymph nodes excised (median of 16 vs 14). CONCLUSIONS: Training in oesophageal cancer surgery can be provided in a large-volume thoracic surgical unit. It does not seem to compromise outcomes or use of resources.

Thoracoscopic lobectomy through a single incision.

Over the past two decades, video-assisted thoracic surgery (VATS) has revolutionized the way thoracic surgeons diagnose and treat lung diseases. The major advance in VATS procedures is related to the major pulmonary resections. The optimal VATS technique for lobectomy in lung cancer has not been well defined yet. Most of the authors describe the VATS approach to lobectomy via three to four incisions, but the surgery can be performed by only one incision with similar outcomes. This single incision is the same as we normally use for VATS lobectomies performed by double- or triple-port technique, with no rib spreading. As our experience with VATS lobectomy has grown, we have gradually improved the technique for a less-invasive approach. Consequently, the greater the experience we gained, the more complex the cases we performed were, thus expanding the indications for single-incision thoracoscopic lobectomy.

Surgical management of pneumothorax: significance of effective admission or communication strategies between the district general hospitals and specialized unit.

A preoperative delay in emergency surgery for spontaneous pneumothorax is associated with a poor outcome after surgery and a prolonged hospital stay. To reduce preoperative delays, all tertiary referrals from district general hospitals to our thoracic surgery unit were processed through a 'clinical decisions unit' (CDU). Prior to the establishment of the CDU, these patients were added to a waiting list for a surgical bed. This study has reviewed the effect of this change in admission policy on the efficiency of treatment for non-elective spontaneous pneumothorax. An intergroup comparison (pre-CDU group vs. post-CDU group) was made of the following parameters: referral to transfer time, transfer to surgery time and length of inpatient stay in the referring and tertiary hospitals. There were no significant differences in gender, diagnosis, treatment in the referring hospitals, postoperative clinical outcome, or indications for or type of surgery. The total length of inpatient stay in the referring and tertiary hospitals was significantly reduced for the post-CDU group (12 vs. 15 days; P<0.001), which was attributed to the earlier transfer of patients (18 vs. 78 hours; P<0.001) hours. Allowing surgical access to a traditional medical admission unit is therefore, cost-effective and significantly improves the efficiency of non-elective pneumothorax surgery.