[Show abstract][Hide abstract] ABSTRACT: Background
Malignant pleural mesothelioma incidence continues to rise, with few available evidence-based therapeutic options. Results of previous non-randomised studies suggested that video-assisted thoracoscopic partial pleurectomy (VAT-PP) might improve symptom control and survival. We aimed to compare efficacy in terms of overall survival, and cost, of VAT-PP and talc pleurodesis in patients with malignant pleural mesothelioma.
We undertook an open-label, parallel-group, randomised, controlled trial in patients aged 18 years or older with any subtype of confirmed or suspected mesothelioma with pleural effusion, recruited from 12 hospitals in the UK. Eligible patients were randomly assigned (1:1) to either VAT-PP or talc pleurodesis by computer-generated random numbers, stratified by European Organisation for Research and Treatment of Cancer risk category (high vs low). The primary outcome was overall survival at 1 year, analysed by intention to treat (all patients randomly assigned to a treatment group with a final diagnosis of mesothelioma). This trial is registered with ClinicalTrials.gov, number NCT00821860.
Between Oct 24, 2003, and Jan 24, 2012, we randomly assigned 196 patients, of whom 175 (88 assigned to talc pleurodesis, 87 assigned to VAT-PP) had confirmed mesothelioma. Overall survival at 1 year was 52% (95% CI 41–62) in the VAT-PP group and 57% (46–66) in the talc pleurodesis group (hazard ratio 1·04 [95% CI 0·76–1·42]; p=0·81). Surgical complications were significantly more common after VAT-PP than after talc pleurodesis, occurring in 24 (31%) of 78 patients who completed VAT-PP versus ten (14%) of 73 patients who completed talc pleurodesis (p=0·019), as were respiratory complications (19 [24%] vs 11 [15%]; p=0·22) and air-leak beyond 10 days (five [6%] vs one [1%]; p=0·21), although not significantly so. Median hospital stay was longer at 7 days (IQR 5–11) in patients who received VAT-PP compared with 3 days (2–5) for those who received talc pleurodesis (p<0·0001).
VAT-PP is not recommended to improve overall survival in patients with pleural effusion due to malignant pleural mesothelioma, and talc pleurodesis might be preferable considering the fewer complications and shorter hospital stay associated with this treatment.
The Lancet 09/2014; 384(9948). · 39.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'in [patients with isolated adrenal metastasis from operable/operated non-small cell lung cancer] is [adrenalectomy] superior [to chemo/radiotherapy alone for achieving long-term survival]?' Altogether >160 papers were found using the reported search, of which 3 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that the body of evidence is small, retrospective and not formally controlled. As such interpretation is limited by selection bias in assignment of patients. These limitations notwithstanding, surgical resection is associated with prolonged survival for patients with isolated adrenal metastasis from non-small cell lung cancer (NSCLC). Patient selection is probably critical. Factors that are important are: otherwise early tumour, node (TN) status of the lung primary and R0 resection, long disease-free interval and confidence that there are no other sites of metastasis. Patients with ipsilateral adrenal metastasis may derive the greatest survival benefit from adrenalectomy, since spread to the ipsilateral gland may occur via direct lymphatic channels in the retroperitoneum. Involvement of the contralateral adrenal may signify haematogenous spread and therefore, a more aggressive process. Adrenalectomy must be accompanied by regional lymph node clearance to reduce the chance of further spread from the adrenal itself.
Interactive Cardiovascular and Thoracic Surgery 12/2013; · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Various solutions exist for management of post-pneumonectomy space empyema. We describe the use of a free deep inferior epigastric perforator (DIEP) flap to fill the space and close a pleural window. Previously, flaps involving abdominal muscle or omentum have been used for this purpose. Abdominal surgery to harvest such flaps can impair ventilatory mechanics. The DIEP flap - harvested from the abdomen, and composed primarily of skin and muscle avoids this problem, thus is a desirable technique in patients with impaired lung function. We believe this is the first report of the DIEP flap to close a postpneumonectomy empyema space.
The Annals of thoracic surgery 04/2013; 95(4):e83-5. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Causes of benign emptying of the postpneumonectomy space include small bronchopleural fistulas with spontaneous healing and escape of fluid into the chest wall or diaphragm. We present an additional cause: severe dehydration. As postpneumonectomy empyema usually involves drainage of the pleural space, it is important to be aware of this uncommon cause so as to avoid unnecessary instrumentation and contamination of the postpneumonectomy space.
The Annals of thoracic surgery 03/2013; 95(3):1088-9. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A best evidence topic in thoracic surgery was written according to a structured protocol. This was with the purpose of assisting our management of patients with localized malignant mesothelioma of the pleura (LMM). Although the terminology is used inconsistently, this variant has been formally defined by the WHO as a distinct entity defined as localized disease histologically identical to the diffuse form but without any evidence of pleural spread. Treatments for LMM include different combinations of surgery, chemotherapy and radiotherapy. There is an impression that LMM may have a better outcome than the commoner diffuse form of malignant mesothelioma that has been reported to have a survival between 8 and 14 months. In order to advise our patients on prognosis, we studied the duration of survival after surgical resection of LMM. A total of 150 papers were found, of which 16 represented the best evidence to answer the question. The authors, journal, date, country of publication, study type, relevant outcomes and results of these papers are tabulated. It is difficult to combine the results of these 16 papers because both treatments and results are reported differently. Some report median survival (range: 11.6-36 months) and others disease-free survival (range: 0 months to 11 years). Median survival to the longest follow-up was 29 months when calculated by pooling data from informative papers using the Kaplan-Meier method. Our review suggests that survival in LMM is longer than that generally quoted for the more common diffuse form of malignant mesothelioma. Hence, aggressive treatment of LMM may be reasonable in appropriate patients.
Interactive Cardiovascular and Thoracic Surgery 01/2013; · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery.
A 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected.
The outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis.
This case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.
International journal of surgery case reports. 01/2013; 4(8):669-674.
[Show abstract][Hide abstract] ABSTRACT: Introduction: Structured Light Plethysmography (SLP) is a non-contact method of studying
chest and abdominal motion. SLP allows a representation of chest and abdominal wall
movement which can relate to tidal and spirometic volumes. This can also be studied with a
Methods: We obtained serial data from 10 patients who underwent thoracic surgery. They
were scanned pre and postoperatively with a PneumaScan-P2™ device (PneumaCare,
Cambridge, UK). A checkerboard grid of light was projected onto the patients' chest area.
Two digital cameras, recorded the grid movement during breathing. Data was presented as a
respiratory volume trace over time and as Konno-Mead plots for left v right hemi thorax and
chest v abdomen movement.
Results: In some patients following thoracic surgery we demonstrate reduced chest wall
motion on the operated side. We find improvements in chest wall movement over the
recovery period. In one patient no significant difference in pre and post op scans can be
found. This patient had virtually no pain post-op and returned to work 5 days after his
limited thoracotomy and lung resection.
Conclusions: SLP can objectively measure chest wall movement in thoracic surgery
patients. There may be a role for it in monitoring post-operative recovery and we are
exploring this further.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: Structured Light Plethysmography (SLP) is a non-contact method of studying chest and abdominal motion. SLP allows a 3D representation of chest and abdominal wall movement which can relate to tidal and spirometic volumes. The method also has the potential for regional thoracic volume analysis, volume changes represented by right vs. left hemithorax, chest vs. abdomen or 4 quadrants of the chest surface.
METHODS: We obtained serial data in 4 patients with a PneumaScan-P2TM device (Pneumacare TM, Cambridge UK). These were 1 VATS for right pneumothorax, 1 LVRS for emphysema, 1 left intra-pericardial pneumonectomy and 1 upper lobe and lingular sub-lobar resections. A grid of alternating black and white squares was projected onto the subjects’ chest and upper abdomen. Movements of this grid were captured by the system. Computer analysis enabled the measurement of changes in volume during forced maneuvers pre- and post-operatively to be determined. The relationship between right and left thoracic volume and chest and abdomen were represented by Konno-Mead plots. Unilateral volume changes were represented graphically and as a percentage of total volume.
RESULTS: In some patients following thoracic surgery we demonstrate reduced chest wall motion on the operated side. We find improvements in chest wall movement over the recovery period. In one patient no significant difference in pre- and post-op scans can be found. This patient had virtually no pain post-op and returned to work 5 days after his limited thoracotomy and lung resections.
CONCLUSIONS: SLP can objectively measure chest wall movement in thoracic surgery patients. There may be a role for it in monitoring post-operative recovery and we are exploring this further.
CWIG - EACTS 4th International Chest Wall Interest Group Workshop On Chest Wall Diseases, Istanbul, TURKEY; 06/2012
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVES: Lung cancer staging has improved in recent years. Assuming that contemporary detailed preoperative staging may yield a lower rate of stage change after surgery, we were interested to determine the impact of our lymph node dissections performed at the time of surgical resection. METHODS: We retrospectively analysed a database in our surgical unit that prospectively captured information on all patients assessed and treated for lung cancer. We reviewed the data on patients who underwent lung cancer surgery with curative intent between January 2006 and August 2010 so as to reflect contemporary practice. Prior to potentially curative treatment, patients systematically underwent staging computerized tomography (CT), integrated positron emission tomography (PET) with CT and brain imaging. Enlarged and/or PET-positive nodes were subject to invasive evaluation to establish the nodal status in line with the current guidelines. This was performed by needle aspiration or biopsy usually with ultrasound guidance, endobronchial or endo-oesophageal ultrasound with needle biopsy; mediastinoscopy; mediastinotomy; video-assisted or open surgery. RESULTS: Three hundred and twelve lung cancer resections were performed (a mean age of 68 years [range 42-86] and a male-to-female ratio of 1.14:1). Despite thorough preoperative evaluations, 25.3% of patients had a change in nodal status after lung resection and lymph node dissection; of which 20.8% of patients had a nodal status upstaging. Occult N2 disease was identified in 31 (9.9%) of 312 patients. Patients with cT1 tumours showed a nodal upstaging of 12.3% compared with 25.3% in cT2 tumours. There was no difference in the rate of N2 disease for different tumour histological types. CONCLUSIONS: Despite systematic preoperative staging, there continues to be a high rate of nodal status change following surgical resection and lymph node dissection. If considering non-surgical treatments for the early stage lung cancer, the impact of this discrepancy should be considered. If not, errors in prognosis and in determining correct adjuvant treatment may arise.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 04/2012; · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Persistent air leak (PAL) poses a significant challenge to the thoracic surgeon. Of the numerous methods employed to manage this problem, autologous blood 'patch' pleurodesis (ABPP) remains one of the most controversial, seemingly due to a lack of robust data and consensus of opinion regarding its efficacy, technique of application and its role in clinical practice. Despite a lack of randomized control trials, the evidence to-date has shown ABPP to be an efficacious, cheap, simple, well tolerated and readily available treatment, with minimal side effects and broad range of applications, allowing for earlier chest drain removal, decreased complications and decreased hospital stay. A review is therefore required to assess the role for ABPP in contemporary clinical practice.
Recent studies have demonstrated that ABPP is an effective management for PAL in specific patient groups and there is an argument that it has the potential to be the gold-standard or first-line treatment in certain clinical scenarios such as for patients with interstitial lung disease or acute respiratory distress syndrome.
This review aims to discuss the relevance of recent findings and to suggest a firm role for ABPP in current practice. In addition, the evidence for the efficacy of ABPP will be assessed and compared with other established methods of pleurodesis. Finally, the review will include a summary of relevant research to-date in order to suggest an evidence-based standardized protocol for the application of ABPP.
Current opinion in pulmonary medicine 04/2012; 18(4):333-8. · 3.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pneumothorax during pregnancy is uncommon. Recently ambulatory chest drainage has been advised to treat the pneumothorax and to cover the delivery period. This imposes restrictions on the mother with associated co-morbidity. The authors present a case of recurrent chest-tube resistant pneumothorax during pregnancy which had persisted for 4-weeks. To guide management of a patient referred in the third trimester of pregnancy the authors undertook a systematic review. This led to definitive video assisted thoracoscopic surgery (VATS) for bullectomy and pleurodesis which was successful without either peri-operative or peri-partum complications or recurrence of pneumothorax. Our review suggests that a VATS approach during pregnancy is both safe and effective.
[Show abstract][Hide abstract] ABSTRACT: We report the intermediate clinical outcome following resection of a chest wall sarcoma and layered reconstruction with a deep expanded polytetrafluroethylene patch, four STRATOS titanium rib bridges and an overlying muscle flap. After 21 months there is no evidence of recurrence. The reconstruction remains intact despite trauma sufficient to fracture the ipsilateral scapula and elbow. Exercise capacity, pain control and quality of life are good. We developed a functional computed tomography (CT) algorithm which allowed dynamic imaging. Video images for the first time demonstrate preserved physiological type bucket-handle movement of the ribs in continuity with the rib bridges.
Interactive Cardiovascular and Thoracic Surgery 10/2010; 12(1):80-1. · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 55-year-old previously well man developed a severe pneumonia. Endoscopy found tracheal and esophageal fistulae communicating with the right lung and pleural space. Bilateral main bronchi intubation was required. Emergency surgery was performed with a latissimus dorsi and serratus anterior muscle flap to close the tracheal and esophageal fistulae. The right upper lobe was found to be destroyed and resected. It was possible to salvage the patient who was discharged home despite challenging anesthetic and surgical circumstances.
Interactive Cardiovascular and Thoracic Surgery 09/2009; 9(5):896-8. · 1.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chest wall resection for liposarcoma was performed. To reconstruct the chest wall we used a novel titanium rib bridge system and preserved anatomically equivalent layers.
The Annals of thoracic surgery 06/2009; 87(5):e46-8. · 3.45 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to implement real-time transthoracic ultrasound in a thoracic surgery and lung transplant practice.
Ultrasound units that are light, small, robust, and portable are now available. Obstacles to use include demarcation issues between specialties, training, and a perception that basic ultrasound may be difficult to use. The experience of implementing this is described.
After a training period, 62 studies were performed in 4 months. Patients and clinicians gave positive feedback. The learning time was short, and with ultrasonic guidance, all interventional procedures were successful at the first attempt, without any complications.
Basic transthoracic ultrasound was found to be easy to learn and use by thoracic surgeons, fellows, and specialist nurses. Patients were appreciative. Real-time use may have genuine advantages to patient care.
The Annals of thoracic surgery 06/2009; 87(5):1577-81. · 3.45 Impact Factor