Publications by authors named "Rammohan Kandadai"

19 Publications

  • Page 1 of 1

Surgical factors associated with new-onset postoperative atrial fibrillation after lung resection: the EPAFT multicentre study.

Postgrad Med J 2020 Dec 11. Epub 2020 Dec 11.

Department of Thoracic Surgery, Castle Hill Hospital, Cottingham, East Riding of Yorkshire, UK.

Purpose Of The Study: Postoperative atrial fibrillation (POAF) is a recognised complication in approximately 10% of major lung resections. In order to best target preoperative treatment, this study aimed at determining the association of incidence of POAF in patients undergoing lung resection to surgical and anatomical factors, such as surgical approach, extent of resection and laterality.

Study Design: Evaluation of Post-operative Atrial Fibrillation in Thoracic surgery (EPAFT): a multicentre, population-based, retrospective, cross-sectional, observational study including 1367 patients undergoing lung resections between April 2016 and March 2017. The primary outcome was the presence of POAF following resection. POAF was defined as at least one episode of symptomatic or asymptomatic AF confirmed by ECG within 7 days from the thoracic procedure or prior to discharge from the hospital.

Results: POAF was observed in 7.4% of patients: 3.1% in minor resection (video-assisted thoracoscopic surgery (VATS): 2.5%; thoracotomy: 3.8%), 9.0% in simple lobectomy (VATS: 7.3%, thoracotomy: 9.9%), 6.0% in complex resection (thoracotomy: 6.3%) and 11.4% in pneumonectomy. POAF was higher in left (4.0%) vs right (2.4%) minor resections, and in left (9.9%) vs right (8.3%) lobectomy, but higher in right (7.5%) complex resections, and the highest in right pneumonectomy (17.6%). No significant variations were observed as per sex, laterality or resected lobes. A positive univariable and multivariable association was observed for increasing age and increasing extent of resection, but not thoracotomy. Median (Q1-Q3) hospital stay was 9 (7-14) days in POAF and 5 (4-7) days in non-AF patients (p<0.001), with an increased cerebrovascular accident burden (p<0.001) and long-term mortality (p<0.001).

Conclusions: Among patients undergoing lung resection, POAF was significantly associated with age, increasing invasiveness of approach and increasing extent of resection. In addition, POAF carried a significant long-term mortality rate and burden of cerebrovascular accident. Appropriate prophylaxis should be targeted at these groups.
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http://dx.doi.org/10.1136/postgradmedj-2020-138904DOI Listing
December 2020

Descending cervical mediastinitis: the multidisciplinary surgical approach.

Eur Arch Otorhinolaryngol 2019 Jul 15;276(7):2075-2079. Epub 2019 May 15.

Department of Thoracic Surgery, Wythenshawe Hospital, Manchester Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.

Purpose: Descending cervical mediastinitis (DCM) is defined as spread of oropharyngeal or odontogenic infection into the mediastinum. It occurs uncommonly and has a high mortality rate.

Methods: Six patients underwent surgery at our centre for DCM between November 2013 and October 2016. Five of six patients underwent drainage of neck collections via a cervical approach, and all six patients subsequently underwent thoracic surgery for drainage of pleural and mediastinal collections.

Results: Four patients required further surgical intervention, of which two subsequently required a third thoracic operation. The average length of stay was 73 days (range 4-193). There were no in-hospital deaths and all patients were discharged from our hospital.

Conclusions: Following diagnosis, prompt surgical intervention from ENT and cardiothoracic surgeons is essential. Our experience demonstrates that favourable outcomes can be achieved in patients with DCM when they are managed aggressively and promptly in specialist centres with appropriate multidisciplinary team involvement.
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http://dx.doi.org/10.1007/s00405-019-05471-zDOI Listing
July 2019

The role of thoracic surgery in extracorporeal membrane oxygenation services.

Asian Cardiovasc Thorac Ann 2018 Mar 14;26(3):183-187. Epub 2018 Feb 14.

Department of Cardiothoracic Surgery, 5295 University Hospital of South Manchester , Manchester, UK.

Background Recent evidence surrounding the use of venovenous extracorporeal membrane oxygenation in treating acute respiratory failure has led to the expansion of extracorporeal membrane oxygenation services worldwide. The high rate of complications related to venovenous extracorporeal membrane oxygenation often requires intervention by specialist thoracic surgeons. This study aimed to investigate the role of specialist thoracic surgeons within the multidisciplinary team managing these high-risk patients. Methods We retrospectively reviewed 90 patients who received venovenous extracorporeal membrane oxygenation at our tertiary referral center between December 2011 and May 2015. Four patients who underwent lung transplantation were excluded. Results We found that 29.1% (25/86) of patients on venovenous extracorporeal membrane oxygenation had undergone a thoracic intervention. A total of 82 interventions were performed: 11 thoracotomies, 49 chest drains, 13 rigid bronchoscopies, 4 flexible bronchoscopies, 4 temporary endobronchial blockers, and 1 sternotomy. Of the 11 thoracotomies, 3 were reexplorations. Survival to discharge for patients who underwent thoracic surgical interventions was 72% (18/25). Conclusions Our experience has demonstrated that a large proportion of patients receiving venovenous extracorporeal membrane oxygenation require a thoracic intervention, many of which are major intraoperative procedures. Patients on venovenous extracorporeal membrane oxygenation have benefited from rapid on-site access to thoracic surgical services to manage these challenging life-threatening complications.
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http://dx.doi.org/10.1177/0218492318760710DOI Listing
March 2018

Prevalence of nodal metastases in lymph node stations 8 & 9 in a large UK lung cancer surgical centre without routine pre-operative EUS nodal staging.

Lung Cancer 2018 01 23;115:127-130. Epub 2017 Nov 23.

North West Lung Centre, University Hospital of South Manchester NHS Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK; The Institute of Inflammation and Repair, The University of Manchester, Manchester, UK.

Introduction: Endoscopic ultrasound (EUS) allows access to the inferior mediastinal lymph node stations (8 and 9) which are beyond the reach of endobronchial ultrasound (EBUS). The addition of EUS to EBUS procedures requires cost and resource investment. This study sought to describe the prevalence of station 8/9 nodal metastases from intra-operative lymph node sampling in a UK region where routine pre-operative EUS is not available.

Methods: A retrospective review of all lung cancer resections at the University Hospital South Manchester from 2011 to 2014. Surgical variables, pre-operative PET variables and survival outcomes were collected and analysed.

Results: 1421 surgical resections were performed in the study period. Lymph node stations 8 and/or 9 were sampled in 52% (736/1421) of patients. Overall, there were 34 patients with lymph node metastases at station 8/9. This represents 2.4% of the study populations and 4.6% of patients in whom stations 8/9 were sampled intra-operatively. Of those patients with station 8/9 metastases, 65% (22/34) had multi-station N2 disease and the majority of the additional N2 disease was present in EBUS-accessible areas (lymph node stations 2, 4 and 7). Two percent (16/736) of patients in whom station 8/9 lymph nodes were sampled intra-operatively had N2 disease that was only accessible endoscopically with EUS. There was no significant difference in overall survival in patients with pathological N2 disease stratified according to whether stations 8/9 were involved or not.

Conclusions: The prevalence of lymph node metastases in stations 8/9 in this UK surgical centre where routine pre-operative EUS is not performed is low at approximately 5%. Given the identification of N2 disease in two-thirds of these patients can potentially be achieved through EBUS alone, this questions whether the resource implications of EUS are justified by the impact on patient management.
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http://dx.doi.org/10.1016/j.lungcan.2017.11.023DOI Listing
January 2018

Adequacy of Intraoperative Nodal Staging during Surgical Resection of NSCLC: Influencing Factors and Its Relationship to Survival.

J Thorac Oncol 2017 12 4;12(12):1845-1850. Epub 2017 Aug 4.

Manchester Thoracic Oncology Centre, University Hospital of South Manchester National Health Service Foundation Trust, Manchester, United Kingdom; The Institute of Inflammation and Repair, The University of Manchester, Manchester, United Kingdom. Electronic address:

Introduction: Adequate intraoperative lymph node sampling is a fundamental part of lung cancer surgery, but adherence to standards is not well known. This study sought to measure the adequacy of intraoperative lymph node sampling at a regional Thoracic Surgery Centre and a tertiary lung cancer center in the United Kingdom.

Methods: This retrospective study analyzed the pathological reports from NSCLC resections over the 4-year period 2011-2014. Adequacy of sampling was assessed against International Association for the Study of Lung Cancer recommendations of at least three mediastinal lymph node stations: station 7 in all patients, station 5 or 6 in left upper lobe tumors, and station 9 in lower lobe tumors. The influence of clinical variables (age, tumor T stage, type of surgery, and laterality) on adequacy of sampling and the effect of adequacy on overall survival were also assessed.

Results: A total of 1301 NSCLC resections were performed from January 11, 2011, to December 31, 2014. Adequate intraoperative lymph node sampling increased significantly from 14% (22 of 160) in 2011 to 53% (206 of 390) in 2014 (p = 0.001). Secondary analysis of clinical variables also revealed that patients with T1a or T4 tumors, those undergoing sublobar resections, those undergoing video-assisted thoracic surgery resections, and those undergoing left-sided resections have significantly higher rates of inadequate lymph node sampling. Overall, there was no statistically significant difference in survival between patients with adequate versus inadequate intraoperative lymph node sampling or when survival was stratified according to overall stage. There was worse survival in inadequate sampling for patients with pN2 disease than for patients with pN2 disease and adequate sampling.

Conclusion: This study provides a much-needed benchmark of current thoracic surgical practice in lung cancer in the United Kingdom and important granularity to facilitate changes to improve adequacy of staging.
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http://dx.doi.org/10.1016/j.jtho.2017.07.027DOI Listing
December 2017

Is there a role for the high-risk multidisciplinary team meeting in thoracic surgery?

Interact Cardiovasc Thorac Surg 2016 Apr 24;22(4):397-400. Epub 2016 Jan 24.

Department of Cardiothoracic Surgery, University Hospitals of South Manchester, Manchester, UK

Objectives: There is little information on the impact of a high-risk multidisciplinary team (HRMDT) for thoracic surgery. In our unit, patients considered high risk for thoracic surgery have been discussed at this meeting since its inception in June 2013. The aim of this study was to audit our selection of patients discussed at the HRMDT and its effect on patient outcomes.

Methods: Data were prospectively collected on all patients (n = 820) who underwent lung resection for lung cancer between July 2013 and September 2014. Patients were analysed as two groups HRMDT versus non-HRMDT. Referral to the HRMDT was at the operating surgeons' discretion. Referred patients usually had a higher-than-expected mortality or morbidity risk for the indicated procedure. The median time from HRMDT to surgery was 27 days (IQR 27.75). The median follow-up for all patients was 415 days (IQR 240).

Results: There were 102 patients in the HRMDT group and 718 in the non-HRMDT group (males 54 vs 46%; P = 0.12). The median duration from HRMDT to surgery was 27 days (IQR 27.75). Mean age (P = 0.0001), cardiac risk score (P = 0.001) and Thoracoscore (P = 0.0001) were significantly higher in the HRMDT group. There was also a significantly higher proportion of pneumonectomies in the HRMDT group (12 vs 4%; P = 0.001). There were no significant differences between the groups in cardiac, cerebrovascular, GI, pulmonary, renal or composite complications. There was no significant difference in 30-day (3 vs 1%; P = 0.24) or 90-day (5 vs 3%; P = 0.48) mortality between the groups. Operated HRMDT patients had better survival at 200 days (P = 0.002), but there was no difference in long-term survival compared with patients turned down for surgery.

Conclusions: Despite a higher predicted mortality rate by Thoracoscore, HRMDT patients had the same outcome as lower risk non-HRMDT patients. Within the HRMDT cohort, survival in the operated patients was significantly better than that in non-operated patients in the short term. The HRMDT has managed to offer patients a radical treatment option who might have been refused surgery prior to this due to their higher risk profile. We would recommend this forum as a means to further assess and discuss high-risk patients.
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http://dx.doi.org/10.1093/icvts/ivv389DOI Listing
April 2016

In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain?

Interact Cardiovasc Thorac Surg 2014 Jun 26;18(6):825-9. Epub 2014 Feb 26.

Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester, UK

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain?'. Altogether more than 200 papers were found using the reported search, of which 14 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. Subcutaneous emphysema is usually a benign, self-limiting condition only requiring conservative management. Interventions are useful in the context of severe patient discomfort, respiratory distress or persistent air leak. In the absence of any comparative study, it is not possible to choose definitively between infraclavicular incisions, drain insertion and increasing suction on an in situ drain as the best method for managing severe subcutaneous emphysema. All the three techniques described have been shown to provide effective relief. Increasing suction on a chest tube already in situ provided rapid relief in patients developing SE following pulmonary resection. A retrospective study showed resolution in 66%, increasing to 98% in those who underwent video-assisted thoracic surgery with identification and closure of the leak. Insertion of a drain into the subcutaneous tissue also provided rapid sustained relief. Several studies aided drainage by using regular compressive massage. Infraclavicular incisions were also shown to provide rapid relief, but were noted to be more invasive and carried the potential for cosmetic defect. No major complications were illustrated.
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http://dx.doi.org/10.1093/icvts/ivt532DOI Listing
June 2014

Should pregnant patients with a recurrent or persistent pneumothorax undergo surgery?

Interact Cardiovasc Thorac Surg 2013 Dec 30;17(6):988-90. Epub 2013 Aug 30.

Department of Cardiothoracic Surgery, University Hospitals of South Manchester, Wythenshawe, UK.

A 29-year old woman at 26 weeks gestation (gravida 3 and para 0) presented with an acute left-sided pneumothorax. She had a 10 pack-year smoking history and no other relevant medical history. Over the next 3 weeks, she had three recurrences of her left-sided pneumothorax, each of which was managed by intercostal drain insertion. During the fourth episode of pneumothorax, after chest drain insertion there was a continued air-leak for 4 days. She was referred to the cardiothoracic service for further management of this problem. A best evidence topic was constructed according to a structured protocol to answer the question: in pregnant patients with a recurrent or persistent pneumothorax, is surgery safer compared with conservative treatment for the wellbeing of the patient and the foetus? The 2010 guidelines for the management of pneumothorax state that there is Level C evidence that simple observation and aspiration are usually effective during pregnancy, with elective assisted delivery and regional anaesthesia at or near term. The guidelines also state Level D evidence that a video-assisted thoracoscopic surgery (VATS) procedure should be considered after birth. Three hundred and eighty-four papers were found, and from these, four papers were identified describing 79 cases of pneumothorax in pregnancy to provide the best evidence to answer the question. Conservative treatment by observation alone with or without tube thoracostomy compared with surgical treatment by VATS or thoracotomy are the options used in the observed literature reviews. All reports observe no difference in outcome to the mother or foetus if a conservative approach (observation or tube thoracostomy) is used compared with surgery prior to the delivery of the baby. However, an initial conservative approach could lead to surgery after delivery for a persistent pneumothorax in as much as 40% of patients. A persistent pneumothorax after delivery that might require surgery delays discharge home and compromises the normal interaction between the mother and new-born child, which might be distressing. For informed consent, the implications of the risk of persistent pneumothorax requiring surgery after delivery where a conservative approach is used initially should be discussed with the patient and family to aid decision making.
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http://dx.doi.org/10.1093/icvts/ivt396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3829509PMC
December 2013

Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence--a National Centre's experience.

J Cardiothorac Surg 2013 Aug 5;8:180. Epub 2013 Aug 5.

Background: Surgery for pulmonary aspergillosis is infrequent and often challenging. Risk assessment is imprecise and new antifungals may ameliorate some surgical risks. We evaluated the medical and surgical management of these patients, including perioperative and postoperative antifungal therapy.

Methods: Retrospective study of patients who underwent surgery for pulmonary aspergillosis between September 1996 and September 2011.

Results: 30 patients underwent surgery with 23 having a preoperative tissue diagnosis while 7 were confirmed post-resection. The median age was 57 years (17-78). The commonest presenting symptoms were cough (40%, n = 12) and haemoptysis (43%, n = 13). Twelve (40%) patients had simple aspergilloma (including 2 with Aspergillus nodules) while the remaining 18 (60%) had chronic cavitary pulmonary aspergillosis (CCPA) (complex aspergilloma). Most of the patients had underlying lung disease: tuberculosis (20%, n = 6), asthma (26%, n = 8) and COPD (20%, n = 6). The procedures included lobectomy 50% (n = 15), pneumonectomy 10% (n = 3), sublobar resection 27% (n = 8), decortication 7% (n = 2), segmentectomy 3% (n = 1), thoracoplasty 3% (n = 1), bullectomy and pleurectomy 3% (n = 1), 6% (n = 2) lung transplantation for associated disease. Median hospital stay was 9.5 days (3-37). There was no operative and 30 day mortality. Main complications were prolonged air leak (n = 7, 23%), empyema (n = 6, 20%), respiratory failure requiring tracheostomy /reintubation (n = 4, 13%). Recurrence of CCPA was noted in 8 patients (26%), most having prior CCPA (75%). Taurolidine 2% was active against all 9 A. fumigatus isolates and used for pleural decontamination during surgery.

Conclusions: Surgery in patients with chronic pulmonary aspergillosis offered good outcomes with an acceptable morbidity in a difficult clinical situation; recurrence is problematic.
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http://dx.doi.org/10.1186/1749-8090-8-180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3750592PMC
August 2013

Is type and screen only policy safe for patients undergoing elective lobectomy?

Eur J Cardiothorac Surg 2013 Dec 31;44(6):1113-6; discussion 116. Epub 2013 May 31.

Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester, UK.

Objective: The purpose of this study was to establish the safety and feasibility of a recently adopted policy to type and screen (TS) (group and save) only for selected patients who had low likelihood of transfusion requirement.

Methods: The TS only policy was applied to patients undergoing first-time elective lobectomy with Hb of >11 g/dl, aged <70 years, with no clotting abnormality and no history of neoadjuvant therapy. A retrospective analysis of prospectively collected data was made of 208 consecutive patients undergoing elective lobectomy from November 2009 to October 2010. The patients who were only type and screened (Group TS, n = 87) were compared with those who had preoperative cross matching (XM) (Group XM, n = 121). The perioperative characteristics, transfusion requirements and outcomes were compared between the two groups.

Results: Preoperative characteristics of the two groups were similar, except that the XM group were significantly older, with lower mean preoperative haemoglobin levels. Postoperative complications (9 vs 13%, P = 0.24) and hospital mortality (0 vs 0.8%, P = 0.5) were similar between TS and XM, respectively. On the day of operation, 16 patients (13%) required transfusion in the XM group. Six patients in the TS group were cross matched, of whom only 3 (3.4%) actually required transfusion. The mean postoperative Hb levels in XM were also significantly lower (12.96 vs 10.88 gm/dl). In the XM group, 260 units of blood were unnecessarily cross matched and had to be returned to the blood bank compared with zero units in the TS group. There was no delay caused by unavailability of blood at the time of clinical need.

Conclusion: Our data suggest that it is safe and feasible to adopt a policy of type and screen only in selected patients undergoing elective lobectomy, who have low likelihood of transfusion requirement.
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http://dx.doi.org/10.1093/ejcts/ezt209DOI Listing
December 2013

Dissection of the pulmonary ligament during upper lobectomy: is it necessary?

Interact Cardiovasc Thorac Surg 2013 Aug 28;17(2):403-6. Epub 2013 Apr 28.

Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester, UK.

A best evidence topic was written according to a structured protocol. The question addressed was whether dissection of the pulmonary ligament during an upper lobectomy would result in improved outcomes. A total of 85 articles were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were complications associated with dissection (atelectasis, bronchial stenosis, bronchial obstruction and bronchial deformation) and preservation (insufficient lung expansion, pooling of effusion and atelectasis) of the pulmonary ligament, ratio (%) of dead space in longitudinal axis (movement of nonoperated lobes), change in the angle (degrees) of main bronchus on the operated side, overall morbidity and mortality, overall survival and conversion rates. In a randomized control trial, the dissection of the pulmonary ligament revealed no significant difference in the dead space ratio or change in the angle of the main bronchus when compared with preservation. Dissection of the ligament, in theory, reduces the free space in the upper thorax by increasing the mobility of the residual lobes. Dissection of the ligament may lead to bronchial deformation, stenosis, obstruction or lobar torsion. Preservation of the ligament may prevent this complication by suppressing the upward movement of residual lobes. However, this may result in pleural effusion in the free thoracic space that may potentially become infected resulting in an empyema or bronchial fistula. Five large case series were analysed; three routinely dissected the pulmonary ligament and two did not. There was no observed difference in clinical outcomes between the two groups. There is no convincing evidence that dissection of the pulmonary ligament in an upper lobectomy significantly improves outcomes and reduces complications.
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http://dx.doi.org/10.1093/icvts/ivt144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715166PMC
August 2013

Incidental Finding of a Left-over Guide-Wire on a Positron Emission Tomography.

Nucl Med Mol Imaging 2012 Dec 20;46(4):320-1. Epub 2012 Sep 20.

Wythenshawe Hospital, Manchester, M23 9LT UK.

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http://dx.doi.org/10.1007/s13139-012-0172-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4043060PMC
December 2012

Invited commentary.

Ann Thorac Surg 2011 Nov 31;92(5):1779. Epub 2011 Oct 31.

Division of Thoracic Surgery, University of Alberta, Royal Alexandra Hospital, 416 Community Services Center, 10240 Kingsway Ave, Edmonton, AB, Canada T5H 3V9.

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http://dx.doi.org/10.1016/j.athoracsur.2010.09.036DOI Listing
November 2011

Trans-oesophageal echo in patients with vertebral osteophytes: not a harmless procedure.

Eur J Cardiothorac Surg 2010 Apr 6;37(4):954. Epub 2009 Nov 6.

Cardiothoracic Department, Liverpool Heart and Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1016/j.ejcts.2009.09.047DOI Listing
April 2010

Routine placement of an intercostal chest drain during video-assisted thoracoscopic surgical lung biopsy unnecessarily prolongs in-hospital length of stay in selected patients.

Eur J Cardiothorac Surg 2009 Oct 13;36(4):737-40. Epub 2009 Aug 13.

Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, Wales, UK.

Objective: Video-assisted thoracoscopic surgical (VATS) lung biopsy is frequently used in the diagnosis of parenchymal lung disease. However, there is still debate over the need for routine use of an intercostal chest drain after this procedure. This study aimed to evaluate the necessity of positioning an intercostal chest drain as an integral part of VATS lung biopsy.

Methods: Data from VATS lung biopsies performed over a 5-year period were retrospectively analysed. Patients in whom there was evidence of air leak intra-operatively following lung biopsy were excluded. Patients in whom no air leak was detected on testing were included in this study. A chest drain was inserted solely according to the surgeons' practice.

Results: This study included 175 patients. Of these, 82 patients had an intercostal chest drain positioned during the VATS procedure and 93 did not. There were no significant differences between the two groups in terms of mean (standard deviation (SD)), age (54.4 (14.9) vs 55.8 (13.5) years, p=0.58), gender (63% vs 59% males, p=0.56) or side of procedure (45% vs 56% right side, p=0.22). One patient in the 'no drain' group developed a clinically significant pneumothorax 24h after surgery and required a drain to be inserted. There was also no significant difference between the two groups in the incidence of radiologically detected pneumothorax immediately post-procedure (23% vs 20%, p=0.66) or on postoperative day 1 (26% vs 20%, p=0.63). There was no significant difference in the incidence of pneumothorax on follow-up (at 4-6 weeks) chest radiograph (10% vs 7%, p=0.61). In all cases, the pneumothoraces were small and not clinically significant. However, there was a significant difference in the median (inter-quartile range (IQR)) length of stay between the two groups (3 (2,4) vs 2 (1,3) days, respectively, p<0.001).

Conclusions: The routine use of an intercostal chest drain after VATS lung biopsy unnecessarily increases the length of hospital stay without reduction in the incidence of pneumothorax.
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http://dx.doi.org/10.1016/j.ejcts.2009.04.067DOI Listing
October 2009

Is an intercostal chest drain necessary after video-assisted thoracoscopic (VATS) lung biopsy?

Ann Thorac Surg 2007 Jul;84(1):237-9

Cardiothoracic Unit, University Hospital of Wales, Cardiff, United Kingdom.

Background: Video-assisted thoracoscopic surgical lung biopsy is a frequently performed procedure as an integral part of the diagnostic armamentarium for parenchymal lung disease. However, there is no evidence in the literature concerning the need for an intercostal chest drain after the procedure.

Methods: A prospective randomized control trial was set up to assess the need for intercostal chest drainage after video-assisted thoracoscopic surgical lung biopsy. Patients who did not have any air leak after the procedure (lung tested while patient was still under anesthetic) was randomized to either having a chest drain or not. The study was powered at 0.9 using an alpha of 0.01.

Results: Thirty patients were recruited in each group. There were no significant differences between the two groups in terms of patients' age (mean age, 59 versus 54 years), sex, history of steroid use, immediate postoperative pain scores, and wound complications. No significant pneumothoraces occurred in either group. However in the immediate postoperative phase, 28% and 15% of patients with and without chest drains, respectively, had a small (clinically not significant) pneumothorax (size <10%) on their chest radiograph. Moreover, there was significantly increased in-hospital stay in the chest drain group (median, 3 days versus 1 day; p < 0.001). At 6 weeks' follow-up, all patients had fully expanded lungs bilaterally.

Conclusions: There is no need for an intercostal chest drain in patients undergoing video-assisted thoracoscopic surgical lung biopsy if no air leak is identified at the time of surgery. Patients without a drain are discharged home within 24 hours postoperatively, raising the possibility of this procedure being an outpatient procedure.
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http://dx.doi.org/10.1016/j.athoracsur.2007.03.007DOI Listing
July 2007

Is adhesive paper-tape closure of video assisted thoracoscopic port-sites safe?

Eur J Cardiothorac Surg 2007 Jul 17;32(1):167-8. Epub 2007 Apr 17.

Cardiothoracic Unit University Hospital of Wales, Cardiff CF14 4XW, United Kingdom.

Video assisted thoracoscopic surgery (VATS) is used in lung surgery for diagnostic, staging, curative and palliative purposes. The port-sites are usually sutured with dissolvable sutures. The use of adhesive paper-tape for port-site closure was assessed by a prospective randomised double-blind control trial comparing sutured to adhesive paper-tape closure. The following outcomes were assessed: incidence of clinically significant pneumothorax, wound healing using the ASEPSIS score, patient's comfort (pain score using a visual analog score), the time difference between the two techniques of wound closure and cost savings. Thirty patients were recruited in each group. No clinically significant pneumothoraces occurred in either group. There were no significant differences between the two groups in terms of immediate post-operative pain scores, wound cosmesis and wound complications. It was quicker to close the wound with adhesive paper-tape with a mean time of closure per unit length of wound of 9.3 and 2.2s/mm for the groups, respectively. The cost for wound closure (per patient) was $0.8 for the adhesive paper-tape group and $4.00 for the sutures.
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http://dx.doi.org/10.1016/j.ejcts.2007.03.021DOI Listing
July 2007
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