Practice Of Thoracic Surgery Research Articles

The Society of Thoracic Surgeons Thoracic Surgery Practice and Access Task Force: 2014 Workforce Report

The Society of Thoracic Surgeons (STS) has intermittently surveyed its workforce, providing isolated accounts of the current state of thoracic surgical practice. The 63-question survey instrument was received by 4,343 surgeon members of the STS, and responses were gathered between October 1 and November 5, 2014. The return rate was 29.1%. The median age of the active United States thoracic surgeons is 54 years. Women comprise 6.9% of the responders, constituting 6.3% of adult cardiac, 6.1% of congenital heart, and 11.8% of general thoracic surgeons. The decision to pursue a career in thoracic surgery was made before or in medical school by 48.3% of surgeons. Most survey respondents had a mean of 8.7 years of residency training after medical school graduation. The cumulative average educational debt was $62,815. Overall career satisfaction was 43.5% (very or extremely satisfied). STS Database participation greatly increased (89.9%) compared with the 2009 survey. Operative volume over the past 12 months decreased for 26% of surgeons. Malpractice premiums over the past 5 years have averaged between $54,310 and $$57,281. Of those who responded, 43.8% plan to retire between the age of 66 and 70 years. These data provide a current, detailed profile of the specialty. Ongoing challenges remain length of training and educational debt. Case volumes, scope of practice, malpractice costs, and career satisfaction have remained relatively constant. With contraction of the current resident pool and the workforce ages, significant cardiothoracic surgeon shortages may develop as the United States population expands.

Minimally invasive lobectomy for early stage non-small cell lung cancer—it can be done without sacrificing oncologic outcomes

The introduction of minimally invasive surgical techniques to perform lobectomy for non-small cell lung cancer (NSCLC) has significantly changed the practice of general thoracic surgery over the past two decades. Since the first reports of the use of video-assisted thoracic surgery (VATS) to perform lobectomy for NSCLC in the early 1990s (1), many more studies across a wide array of cohorts have reported on short-term and long-term outcomes. Initial studies focused on the feasibility and reproducibility of the procedure (2), and then subsequent studies demonstrated VATS lobectomy had less morbidity compared to thoracotomy (3). Over time, studies have shown that a minimally invasive approach may be particularly beneficial in those patients with higher peri-operative risk due to advanced age or poor pulmonary function (4,5). More recently, experience with robotic-assisted lobectomy has been increasingly reported and a robotic approach appears to provide similar advantages over thoracotomy as a VATS approach (6). Despite these demonstrated benefits, universal adoption of minimally invasive lobectomy for early-stage NSCLC has not occurred (4,7,8).

A survey among Brazilian thoracic surgeons about the use of preoperative 2D and 3D images.

Describe the characteristics of how the thoracic surgeon uses the 2D/3D medical imaging to perform surgical planning, clinical practice and teaching in thoracic surgery and check the initial choice and the final choice of the Brazilian Thoracic surgeon as the 2D and 3D models pictures before and after acquiring theoretical knowledge on the generation, manipulation and interactive 3D views. A descriptive research type Survey cross to data provided by the Brazilian Thoracic Surgeons (members of the Brazilian Society of Thoracic Surgery) who responded to the online questionnaire via the internet on their computers or personal devices. Of the 395 invitations visualized distributed by email, 107 surgeons completed the survey. There was no statically difference when comparing the 2D vs. 3D models pictures for the following purposes: diagnosis, assessment of the extent of disease, preoperative surgical planning, and communication among physicians, resident training, and undergraduate medical education. Regarding the type of tomographic image display routinely used in clinical practice (2D or 3D or 2D-3D model image) and the one preferred by the surgeon at the end of the questionnaire. Answers surgeons for exclusive use of 2D images: initial choice =50.47% and preferably end =14.02%. Responses surgeons to use 3D models in combination with 2D images: initial choice =48.60% and preferably end =85.05%. There was a significant change in the final selection of 3D models used together with the 2D images (P<0.0001). There is a lack of knowledge of the 3D imaging, as well as the use and interactive manipulation in dedicated 3D applications, with consequent lack of uniformity in the surgical planning based on CT images. These findings certainly confirm in changing the preference of thoracic surgeons of 2D views of technologies for 3D images.

A Germany-wide survey on anaesthesia in thoracic surgery

This study's objective was to evaluate current thoracic anaesthesia practice in Germany and to quantify potential differences depending on the hospital's level of care. A four-part online survey containing 28questions was mailed to all anaesthesiology department chairs (n= 777) registered with the German Society of Anaesthesiology and Intensive Care Medicine. The general response rate was 31.5 % (n= 245). High monthly volumes (>50operations/month) of intrathoracic procedures, performed by specialized thoracic surgeons are mostly limited to hospitals of maximum care, university hospitals, and specialized thoracic clinics. In hospitals with a lower level of care, intrathoracic operations occur less frequently (1-5/month) and are commonly performed by general (69.3 %) rather than thoracic surgeons (15.4 %). Video-assisted thoracic surgeries are the most invasive intrathoracic procedures for most hospitals with a low level of care (61.5 %). Extended resections and pneumonectomies occur mainly in hospitals of maximum care and university hospitals. Thoracic anaesthesia is primarily performed by consultants or senior physicians (59.9 %). The double lumen tube (91.4 %) is the preferred method to enable one-lung ventilation (bronchial blockers: 2.7 %; missing answer: 5.9 %). A bronchoscopic confirmation of the correct placement of a double lumen tube is considered mandatory by 87.7 % of the respondents. Bronchial blockers are available in 64.7 % of all thoracic anaesthesia departments. While CPAP-valves for the deflated lung are commonly used (74.9 %), jet-ventilators are rarely accessible, especially in hospitals with a lower level of care (15.4 %). Although general algorithms for a difficult airway are widely available (87.7 %), specific recommendations for a difficult airway in thoracic anaesthesia are uncommon (4.8 %). Laryngeal mask airways (90.9 %) and videolaryngoscopy (88.8 %) are the primary adjuncts in store for a difficult airway. While hospitals with a lower level of care admitted patients routinely (92.3 %) to an intensive care unit after thoracic surgery, larger clinics used the postanaesthesia recovery room (12.5 %) and intermediate care units (14.6 %) more frequently for further surveillance. Thoracic epidural catheters (85.6 %) are predominantly chosen for peri- and postoperative analgesia, in contrast to paravertebral blockade (single shot: 8.6 %; catheter: 8.0 %) (multiple answers possible). Ultrasound is generally accessible (84.5 %) and mostly employed for the placement of central venous (81.3 %) and arterial (43.9 %) lines as well as a diagnostic tool for pulmonary pathology (62.0 %). The study reveals considerable differences in the anaesthetic practice in thoracic surgery. These focus mostly on the postoperative surveillance, the availability of bronchial blockers, and the use of regional anaesthetic techniques. Furthermore, it is evident that specific algorithms are needed for the difficult airway in thoracic anaesthesia. A recommendation for the high-tech work environment of thoracic anaesthesia could enhance the structural quality and optimize patient outcomes. Independent of a hospital's level of care, uniform requirements could help establish national quality standards in thoracic anaesthesia.

Right pneumonectomy for carcinoid tumor extending through the intermediate bronchus and the interlobar artery.

Uniportal video-assisted thoracic surgery (VATS) is the emerging technique in the modern thoracic surgery practice in Assiut University Hospitals in Egypt we try to keep up with the cutting edge of knowledge to deliver the best available service to our patient. So we invite Dr. Diego Gonzalez-Rivas the world pioneer surgeon in uniportal VATS approach to initiate a uniportal VATS program starting with a workshop with live surgery. The workshop was attended by 84 thoracic surgeons from all across Egypt with a high motivation for adopting the technique in the everyday practice. We believe that uniportal will be the first choice approach for thoracic surgeon in Egypt in the upcoming year.

The University of Michigan Cardiac and Thoracic Surgery Program

In 1928, the University of Michigan opened its thoracic surgery residency under the leadership of Dr John Alexander. Initially tasked with providing surgical care for patients with thoracic diseases such as tuberculosis, thoracic surgery subspecialties now provide surgical treatment for a spectrum of diseases, ranging from congenital cardiopulmonary abnormalities to thoracic malignancy to acquired heart and great vessel diseases. Both the residency and the medical center have evolved to mirror the changing practice of thoracic surgery.

Differential expression of HIF-1α, AQP-1, and VEGF under acute hypoxic conditions in the non-ventilated lung of a one-lung ventilation rat model

AimsOne-lung ventilation (OLV) is a standard practice in thoracic surgery. However, OLV can give rise to arterial hypoxemia. Hypoxia-inducible transcription factor-1 alpha (HIF-1α), vascular endothelial growth factor (VEGF) and aquaporin-1 (AQP-1) may be involved in arterial hypoxemia and contribute to cellular injury. Therefore, in the present study, these moieties were investigated in an OLV rat model. Main methodsForty Sprague–Dawley (S–D) rats were randomly divided into four groups: right lung mechanical ventilation for 0.5h (Group A); 1h (Group B); 2h (Group C) and mechanical ventilation of both lungs (control group). Rat lung tissue was examined using electron microscopy. Serum and lung tissue levels of VEGF were measured by ELISA, Western blot analyses were used to detect the protein expression of HIF-1α and immunohistochemical staining and real-time polymerase chain reaction (PCR) were performed to examine protein expression and gene levels, respectively, of VEGF and AQP-1 after hypoxia. Key findingsElectron microscopy revealed that increased duration of OLV was correlated with greater destruction of the non-ventilated lung. The protein expression of HIF-1α was significantly increased in the non-ventilated lungs of the experimental hypoxia groups (A–C) compared to the control group, whereas VEGF and AQP-1 protein expression and gene levels were decreased in the non-ventilated lungs of the hypoxia groups (A–C) compared to the control group. SignificanceThe OLV caused hypoxia in the non-ventilated lung and subsequent injury. The altered expression of HIF-1α, VEGF, and AQP-1 may be involved in the pathological process of lung injury caused by hypoxia.

Evolution of Thoracic Surgery in Canada

BACKGROUND: Canada’s contributions toward the 21st century’s practice of thoracic surgery have been both unique and multilayered. Scattered throughout are tales of pioneers where none had gone before, where opportunities were greeted by creativity and where iconic figures followed one another.OBJECTIVE: To describe the numerous and important achievements of Canadian thoracic surgeons in the areas of surgery for pulmonary tuberculosis, thoracic oncology, airway surgery and lung transplantation.METHOD: Information was collected through reading of the numerous publications written by Canadian thoracic surgeons over the past 100 years, interviews with interested people from all thoracic surgery divisions across Canada and review of pertinent material form the archives of several Canadian hospitals and universities.RESULTS: Many of the developments occurred by chance. It was the early and specific focus on thoracic surgery, to the exclusion of cardiac and general surgery, that distinguishes the Canadian experience, a model that is now emerging everywhere. From lung transplantation in chimera twin calves to ex vivo organ preservation, from the removal of airways to tissue regeneration, and from intensive care research to complex science, Canadians have excelled in their commitment to research. Over the years, the influence of Canadian thoracic surgery on international practice has been significant.CONCLUSIONS: Canada spearheaded the development of thoracic surgery over the past 100 years to a greater degree than any other country. From research to education, from national infrastructures to the regionalization of local practices, it happened in Canada.

Evolution of thoracic surgery in Canada.

Canada's contributions toward the 21st century's practice of thoracic surgery have been both unique and multilayered. Scattered throughout are tales of pioneers where none had gone before, where opportunities were greeted by creativity and where iconic figures followed one another. To describe the numerous and important achievements of Canadian thoracic surgeons in the areas of surgery for pulmonary tuberculosis, thoracic oncology, airway surgery and lung transplantation. Information was collected through reading of the numerous publications written by Canadian thoracic surgeons over the past 100 years, interviews with interested people from all thoracic surgery divisions across Canada and review of pertinent material form the archives of several Canadian hospitals and universities. Many of the developments occurred by chance. It was the early and specific focus on thoracic surgery, to the exclusion of cardiac and general surgery, that distinguishes the Canadian experience, a model that is now emerging everywhere. From lung transplantation in chimera twin calves to ex vivo organ preservation, from the removal of airways to tissue regeneration, and from intensive care research to complex science, Canadians have excelled in their commitment to research. Over the years, the influence of Canadian thoracic surgery on international practice has been significant. Canada spearheaded the development of thoracic surgery over the past 100 years to a greater degree than any other country. From research to education, from national infrastructures to the regionalization of local practices, it happened in Canada.

Spanish survey on anesthetic practice in thoracic surgery (2012-2013)

Gil, Granell M.1; Hortal, F.2; Smaranda, A.2; Cruz, P.2; Olmedilla, L.2; Real, M.2 Author Information

The biomolecular era for thoracic surgeons: the example of the ESTS Biology Club.

Understanding basic mechanisms of lung disease may help to move forward the management of our patients. Molecular biology has affected our diagnostic and therapeutic pathways in the direction of personalized medicine not only for thoracic malignancies. Accordingly, thoracic surgeons are becoming increasingly aware that specific knowledge of genetic and epigenetic alterations may influence their clinical behavior-from the ward to the operating room (OR). In this continuously evolving scenario, surgical societies have perceived the increasing relevance of biomolecular medicine in the practice of modern thoracic surgery. More recently, in the spirit of mutual collaboration between sister societies, the European Society of Thoracic Surgeons (ESTS) has adopted the concept of the American Association for Thoracic Surgery (AATS) incorporating one session dedicated to the Biology Club within the Annual Meeting Program. The aim of the ESTS Biology Club is to outline and sponsor the new profile of the surgeon scientist during the only world meeting exclusively focused on general thoracic surgery. The following article will summarize the significance of this and give an update on molecular biology tools for thoracic malignancies.

European perspectives in thoracic surgery.

Europe, the old Continent, has been the cradle of thoracic surgery from the beginning of the last century. The structure and the activities of the European Society of Thoracic Surgeons (ESTS) activities are directed to enlighten the path, provide the tools and set the standards for a quality inspired practice in thoracic surgery.

European institutional accreditation of general thoracic surgery.

To improve standardization of general thoracic surgery (GTS) practice across Europe, the European Society of Thoracic Surgeons (ESTS) has implemented a program of Institutional Accreditation. We reviewed the methods and rules of engagement of this program. A composite performance score (CPS) including outcome and process indicators is used to measure institutional performance and assess eligibility for accreditation. Eligible units are invited to participate and accept a local audit performed by an external auditors team composed by data inspectors and thoracic surgeons. In addition to data quality, a series of structural, procedural and qualification characteristics are inspected. Once the visit is complete, the team will produce an audit report to be sent to the members of the database committee for deliberation on the institutional accreditation of that unit. The Database committee will send an executive report to the ESTS Executive Committee for their final decision on the accreditation.

State of the art in surgery for early stage NSCLC-does the number of resected lymph nodes matter?

Surgery is the treatment of choice in patients with early stage NSCLC. However, the results remain poor in these patients. Lymph node involvement is the main prognostic factor in patients with NSCLC, but there is still no clear definition of the number of nodes required to consider a lymphadenectomy as complete. Although there is no defined minimum number of lymph nodes required for a complete lymphadenectomy, there are some recommendations to perform this procedure, published by different scientific societies. Current practice in thoracic surgery regarding lymphadenectomy, differs on some points from the guidelines recommendations, with data regarding patients with no mediastinal assessment between 30-45% according to some of the published data. Different studies have probed the fact that the probability of finding a positive node increases with the number of lymph nodes analyzed. Therefore, a complete lymphadenectomy provides proper staging, which helps to identify the patient's real prognosis. Several nonrandomized studies and retrospective series have shown that survival increases in the group of patients with a higher number of lymph nodes removed. There is no contraindication to performing a complete lymphadenectomy. The increase in survival in patients with a complete lymphadenectomy may be due to more accurate staging. Therefore, complete lymphadenectomy should be mandatory even in early stage patients.

Discussion of standard patient combined with case-based learning in humanistic quality cultiva-tion for interns in the department of thoracic surgery

Objective To evaluate the methods of standard patient （SP）combined with case-based learning （CBL ） in humanistic quality cultivation for interns in the department of thoracic surgery. Methods Medical interns in the department of thoracic surgery were divided randomly into experimental（n=30）and control group（n=30）respectively. In experimental group,SP combined with CBL was used while in control group traditional teaching was used. At the end of the study,teaching effect was assessed by the final examination and questionnaires and the data were processed by t test andX2 test. P〈0.05 signifies statistical differences. Results There was no significant difference in test scores between the two groups （P〉0.05）. Scores of history-taking,medical check-up,paper writing quality in the final examination in experimental group were significantly higher than those in control group（P〈0.01）. Satisfaction degrees of doctor-patient communication,responsibility and service attitude in experimental group were better than those of control group（X2=16.484,10.335,20.376,32.851,P〈0.01）. Conclusions SP combined with CBL teaching method can stimulate the students＇ interests in thoracic surgery practice,improve the doctor-patient relationship and strengthen the ability of human-istic concern. It is a better clinical thoracic practice teaching method and it is beneficial to cultivating medical students with humanistic concern. Key words: Standard patient; Case-based learning; Department of thoracic surgery; Hu-manistic quality cultivation

Antineoplastic activity of povidone-iodine on different mesothelioma cell lines: results of in vitro study

Povidone-iodine (PVP-I) or Betadine, owing to its antineoplastic activity, is also used as an adjuvant during intra-abdominal or intrathoracic surgery. However, the protocol of PVP-I administration has not been optimized to achieve the best antitumoural efficacy. We aimed to determine the optimal concentration of PVP-I, the time of incubation and the mechanism of cell death by analysing the effect of different doses and time of administration of PVP-I on the cell viability of different mesothelioma cell lines. Four different cell lines (MET 5A/normal mesothelium; H2052/sarcomatoid mesothelioma; ISTMES2/epithelial mesothelioma; MSTO/biphasic mesothelioma) were incubated with increasing concentrations of diluted PVP-I (0.0001; 0.001; 0.01; 0.1; 1%) for 5, 10, 30, 60 min and 24 h, respectively. Cell viability was determined using cell direct cytotoxicity assay and cell death was determined through flow cytometry assay analysis. The superoxide dismutase activity was assessed functionally through a specific inhibitor to evaluate the mechanism of cell death. The antiproliferative effect of PVP-I varied largely among different cell lines in a dose- and time-dependent manner. At 0.1% concentration for 10 min of incubation, the percentage of viable cells was 0.5 ± 0.1; 0.8 ± 0.5 and 0% (P < 0.01) for MET5A, ISTMES2 and MSTO, respectively. Conversely, the same concentration did not significantly affect the H2052 cell line which was completely suppressed at a 1% concentration of PVP-I. Double staining of Annexin V and DNA showed that PVP-I induced cell death in all four cell lines via necrosis depending on PVP-I concentration. However, H2052 was found to be more resistant than MSTO, ISTMES2 and MET 5A cells lines. The activity of superoxide dismutase was significantly inhibited in all cell lines. Our results confirmed the anti-neoplastic activity of PVP-I especially on ISTMES2 and MSTO cell lines. With respect to chemotherapy pleural irrigation, washing with PVP-I is cost-effective and easy. If confirmed by larger studies, our findings suggest that the intrapleural irrigation with PVP-I (0.1% concentration for 10 min) in patients with epithelial or biphasic mesothelioma undergoing cytoreductive surgery might be applied in thoracic surgery practice to prevent neoplastic cell growth.

Role of emergency VATS in blunt chest trauma patients

Background Thoracic injury directly accounts for 25% of the deaths due to trauma, and is a contributing factor in another 25% of trauma related deaths. As the role of thoracoscopy continues to expand in the practice of thoracic surgery, its role in the management of the trauma patients is also expanding. Objective of the study was to determine the role of emergency VATS in the management of blunt chest trauma patients.

Prognostic factors in pulmonary metastasectomy: spotlight on molecular and radiological markers

Pulmonary metastasectomy is nowadays a common practice in thoracic surgery. Clinical prognostic markers for poor outcome after pulmonary metastasectomy have been proposed in the late 1970's of the last century. Despite new insights in molecular mechanisms and advances in imaging techniques, neither molecular markers nor radiological features of metastases are used as prognosticators in routine clinical practice. Biomarkers associated with aggressive tumour behaviour came into the focus of clinical research and are the basis of personalized medicine. In addition, non-invasive imaging modalities like positron emission tomography and high-resolution computed tomography can provide further information on tumour aggressiveness. Regardless of a myriad of studies assessing prognostic markers in primary tumours, little is known about these markers in metastatic lesions. Furthermore, it has been emphasized that tumour biology of the primary might not reflect the behaviour of the corresponding metastasis. Therefore, information on the biology of metastases is necessary to treat patients adequately. This work reviews potential prognostic biomarkers in patients with pulmonary metastases, grouped in soluble tumour markers, tumour suppressor genes/proto-oncogenes and proteins involved in cell adhesion, tumour growth, cell metabolism and tumour angiogenesis.

Reduction of intraoperative air leaks with Progel in pulmonary resection: a comprehensive review

Intraoperative alveolar air leaks (IOALs) occur in 75% of patients during pulmonary resection. Despite routine use of sutures and stapling devices, they remain a significant problem in the daily practice of thoracic surgery. Air leaks that persist beyond postoperative day 5 often result in increased costs and complications. Several large meta-analyses have determined that sealants as a class reduce postoperative air leak duration and time to chest drain removal, but these results did not necessarily correlate with a reduction in length of postoperative hospital stay. These analyses grouped surgical sealants together of necessity, but differences in efficacy may exist due to the differing product characteristics, study protocols, surgical procedures, and study endpoints. Progel, currently the only pleural surgical sealant FDA-approved for use in lung resection, has demonstrated efficacy and safety in two controlled clinical studies and superiority over standard air leak closure methods in reducing IOALs and length of hospital stay. This paper will review these findings and report on real-world experience with this recently approved pleural sealant.

Impact of resection techniques on postoperative lung function parameters in pulmonary metastasectomy

Pulmonary metastasectomy with curative intent is nowadays a common practice in thoracic surgery. The impact of metastasectomy on respiratory function has become a relevant factor in the treatment algorithm of these patients. However, no sufficient data on the loss of lung function following pulmonary metastasectomy is available to date. A prospective single center study was designed to determine changes in lung function parameters in patients undergoing metastasectomy. Forty-five consecutive patients were included in the study. In 19 patients, metastases were removed by enucleation (laser = 10; electrocautery = 9), in 19 patients by wedge resection, and 7 patients received a lobectomy in order to achieve clear resection margins. Lung function testing was obtained from all patients preoperatively and 3 months after hospital discharge. A significant decrease in FEV1 and VC was found when comparing enucleation/wedge/lobectomy patients (FEV1: 3.4 ± 0.7, 7.6 ± 1.5, 14.2 ± 3.0; VC: 2.4 ± 1.6, 4.7 ± 1.6, 16.9 ± 2.9; respectively). However, no differences were found regarding the loss of FEV1 per resected nodule between laser and electrocautery enucleations. These findings were confirmed by a volumetric analysis of the resected tissue and did not correlate with size of metastases as determined by preoperative CT evaluations. The surgical resection of pulmonary metastases is associated with a detectable but mild loss of lung function. Lung parenchyma sparing resection methods—e.g. electrocautery or laser enucleations—should be preferred over less tissue-sparing techniques.