Crossed Kirschner’s wires for the treatment of anterior flail chest: an extracortical rib fixation

Objective: Thoracic trauma may be a life-threatening condition. Flail chest is a severe chest injury with high mortality rates. Surgery is not frequently performed and, in Literature, data are controversial. The authors report their experience in the treatment of flail chest by an extracortical internal-external stabilization technique with Kirshner’s wires (K-wires). Methods: From 2010 to 2015, 137 trauma patients (109 males and 28 females) with an average age of 58.89±19.74 years were observed. Seventeen (12.41%) patients presented a flail chest and of these, 13 (9.49%) with an anterior one. All flail chest patients underwent early chest wall surgical stabilization (within 48 hours from the injury). Results: In the general population, an overall morbidity of 21.9% (n=30 of 137) and a 30-day mortality rate of 5.1% (n=7 of 137) were observed. By clustering the population according to the treatment (medical or interventional vs surgical), significant statistically differences between the two cohorts were found in morbidity (12.65% vs. 34.48%, P=0.002) and mortality rates (1.28% vs. 10.34%, P=0.017). In patients undergoing chest wall surgical stabilization, with an average Injury Severity Score of 28.3±5.2 and Abbreviated Injury Score (AIS) of 8.4±1.7, an overall morbidity rate of 52.9% (n=9) and a mortality rate of 17.6% (n=3) were found. Post-surgical device removal, in local anesthesia or mild sedation, was performed 42.8±2.9 days after chest wall stabilization and no cases of wound infection, dislodgment of the wires or osteosynthesis failure were reported. Moreover, in these patients, an early postoperative improvement in pulmonary ventilation (ΔpaO2 and ΔpCO2 : +9.49 and -5.05, respectively) was reported. Conclusion: Surgical indication for the treatment of flail chest remains controversial and debated both due to an inadequate training and the absence of comparative prospective studies between various strategies. Our technique for the surgical treatment of the anterior flail chest seems to be anachronistic, but the aspects described, both in terms of technical features and of outcome and benefits (health, economic), allow to evaluate the effectiveness of this approach. Keywords: Flail chest, Chest trauma, Kirschner’s wire, Injury Severity Score, Abbreviated Injury Score

Disciplinary problems among high achiever students: the types and the causes

This qualitative study has been done to 24 teachers and 72 students from various secondary schools in Penang, Malaysia, in order to investigate the effect of between class ability grouping (BCAG) on high achiever secondary school students. Studies reported that BCAG triggered correspondence bias among teachers, which eventually affect them to show different perception and expectations towards high achiever classes (HAC) and low achiever classes (LAC) students. Symbolic interaction theories explained that individuals tend to be affected by others’ expectation, and therefore behave in a way they were expected to. Therefore, according to the previous studies on BCAG, it was assumed that HAC students would achieve better and would not be significantly involved in disciplinary problems. After semi-structured interview had been conducted in order to collect the data, and two-cycled analyses method, namely In-Vivo and Thematic Analyses had been operated in order to analyze the massive amount of qualitative data, the it was discovered that HAC students were involved with disciplinary problems, such as being disrespectful to teachers, paying less attention in the classroom, neglecting assignments and doing external work during classes. Other findings of this study showed that the disciplinary problems among HAC are related to their self-esteem types due to locus of control difference, as well as bigger issues apart from the competition among themselves. School management system, BCAG itself, reciprocal envy between HAC and LAC students, as well as their inclination towards tuition centers contributed to disciplinary problems among HAC students

Erratum to nodal management and upstaging of disease. Initial results from the Italian VATS Lobectomy Registry

[This corrects the article DOI: 10.21037/jtd.2017.06.12.]

Surgical management of cardiac tamponade: Is left anterior minithoracotomy really safe and effective?

Objective: Cardiac tamponade is a life-threatening clinical entity that requires an emergency treatment. Cardiac tamponade can be caused both by benign and malignant diseases. A variety of methods have been described for the treatment of these cases from needle-guided pericardiocentesis, balloon-based techniques to surgical pericardiotomy. The Authors report their experience in surgical management of cardiac tamponade and an exhaustive review of literature. Methods: This study involved 61 patients (37 males and 24 females) with an average age of 61.80 ± 16.32 years. All patients underwent emergency surgery due to the presence of cardiac tamponade. Results: Cardiac tamponade was caused by a benign disease in 57.40% of patients. In cancer patients group, lung cancer, breast cancer and malignant pleural mesothelioma were the most common neoplasms (17-27, 87%). The average preoperative size of pericardial effusion at M-2D echocardiography was 30.15 ± 5.87 mm. Postoperative complications were observed in 11 patients (18%). The reoperation rate was 3.3% (2 patients) due to relapsed cardiac tamponade. 30-day mortality rate was 3.3%. Overall cumulative survival was 29.9 ± 20.1 months. Twenty-nine patients (47.5%) died during the follow up period. By dividing the population into two groups, group B (benign) and group M (malignant), there was a statistically significant difference (P < 0.001) in terms of survival. Conclusion: In conclusions, anterior minithoracotomy for surgical treatment of cardiac tamponade has to be held into account in patients both with benign diseases and malignancies

Crossed Kirschner’s wires for the treatment of anterior flail chest: an extracortical rib fixation

Objective: Thoracic trauma may be a life-threatening condition. Flail chest is a severe chest injury with high mortality rates. Surgery is not frequently performed and, in Literature, data are controversial. The authors report their experience in the treatment of flail chest by an extracortical internal-external stabilization technique with Kirshner’s wires (K-wires). Methods: From 2010 to 2015, 137 trauma patients (109 males and 28 females) with an average age of 58.89 ±19.74 years were observed. Seventeen (12.41%) patients presented a flail chest and of these, 13 (9.49%) with an anterior one. All flail chest patients underwent early chest wall surgical stabilization (within 48 hours from the injury). Results: In the general population, an overall morbidity of 21.9% (n = 30 of 137) and a 30-day mortality rate of 5.1% (n = 7 of 137) were observed. By clustering the population according to the treatment (medical or interventional vs surgical), significant statistically differences between the two cohorts were found in morbidity (12.65% vs. 34.48%, P = 0.002) and mortality rates (1.28% vs. 10.34%, P = 0.017). In patients undergoing chest wall surgical stabilization, with an average Injury Severity Score of 28.3 ± 5.2 and Abbreviated Injury Score (AIS) of 8.4 ± 1.7, an overall morbidity rate of 52.9% (n = 9) and a mortality rate of 17.6% (n = 3) were found. Post-surgical device removal, in local anesthesia or mild sedation, was performed 42.8 ± 2.9 days after chest wall stabilization and no cases of wound infection, dislodgment of the wires or osteosynthesis failure were reported. Moreover, in these patients, an early postoperative improvement in pulmonary ventilation (ΔpaO2 and ΔpCO2: +9.49 and -5.05, respectively) was reported. Conclusion: Surgical indication for the treatment of flail chest remains controversial and debated both due to an inadequate training and the absence of comparative prospective studies between various strategies. Our technique for the surgical treatment of the anterior flail chest seems to be anachronistic, but the aspects described, both in terms of technical features and of outcome and benefits (health, economic), allow to evaluate the effectiveness of this approach

Conversion due to vascular injury during video-assisted thoracic surgery lobectomy: A multicentre retrospective analysis from the Italian video-assisted thoracic surgery group registry

Objectives: Vascular injuries are among the most severe causes of unplanned conversion during VATS lobectomies. The study aimed to analyse the incidence of vascular injuries and their risk factors during VATS lobectomy. Methods: The Italian VATS lobectomy Registry was used to collect data from 66 Thoracic Surgery Units. From 2013 to October 2016 (out of more than 3,700 patients enrolled) only information from Units with an enrollment &gt;100 VATS lobectomies were retrospectively analysed. Logistic regression analysis was performed on selected variables of the univariate analysis. Results: Ten institutions contributed a total of 1,679 patients. Vascular injuries leading to conversion occurred in 44 (2.6%) patients. Years of experiences were inversely related to the risk of vascular injuries. Univariate analysis showed age, gender, surgical activity, Charlson Index Score and number of resected lymph nodes like significantly associated variables. Multivariate analysis revealed that number of resected lymph nodes, VATS experience ratio (number of VATS lobectomies/total lobectomies performed in the same year at same centre), and surgical activity of the centre were significantly associated with the risk of conversion. Unplanned thoracotomy was correlated with postoperative morbidity. Conclusion: Vascular injuries in VATS lobectomies represented a rare complication which could directly affect the postoperative outcomes. The predictive factors for conversion were multifactorial and depended on characteristics of centres and surgeons’ seniority. Minimally invasive VATS lobectomy approaches did not influence the risk of vascular damages

Standardized uptake value and radiological density attenuation as predictive and prognostic factors in patients with solitary pulmonary nodules: Our experience on 1,592 patients

Background: Multislice computed tomography (MSCT) increased detection of solitary pulmonary nodules (SPNs), changing the management based on radiological and clinical factors. When 18-fluorine fluorodeoxyglucose positron emission tomography combined with computed tomography (18F-FDG-PET/CT) was considered for the evaluation of nodules, the maximum standardized uptake value (SUVmax) more than 2.5 is used frequently as a cut off for malignancy. The purpose of this study is to evaluate SUVmax PET/CT and pulmonary attenuation patterns at MSCT in patients with SPN according to morphological and pathological characteristics of the lesion. Methods: A retrospective study on 1,592 SPN patients was carried out following approval by the Italian Registry of VATS Lobectomies. Results: All patients underwent VATS lobectomy. On histologic examination, 98.1% had primary or second metachronous primary lung cancers. In addition, 10.7% presented occult lymph node metastases (pN1 or pN2) on histological examination. Nodule attenuation on CT was associated with the histology of the lesion (p= 0.030); in particular, pure ground glass opacities (pGGOs) and partially solid nodules were related to adenocarcinomatous histotypes. Conversely, a significant relationship between SUVmax and age, nodule size, pathological node status (pN) was found (P=0.007, P=0.000 and P=0.002 respectively). Conclusions: Nodule attenuation can predict the histology of the lesion whereas SUVmax may relate to the propensity to lymph node metastases. Keywords: Solitary pulmonary nodule (SPN); maximum standardized uptake value; ground glass opacities; lymph node metastases; lung adenocarcinom

Safety of lymphadenectomy during video-assisted thoracic surgery lobectomy: analysis from a national database†

OBJECTIVES The Italian VATS Group database was accessed to evaluate whether preoperative and intraoperative factors may affect the safety of lymphadenectomy (LA) during video-assisted thoracic surgery lobectomy. METHODS All video-assisted thoracic surgery lobectomy procedures performed between 1 January 2014 and 30 March 2017 for non-small-cell lung cancer with cN0 or cN1 disease were identified in the database. LA safety was evaluated based on intraoperative (operative time, bleeding and conversion rate) and postoperative (30-day morbidity and mortality, chest drain duration and length of stay) outcomes and was correlated with the number of resected lymph nodes and the rates of nodal upstaging. Continuous variables were presented as mean ± standard deviation and compared using the unpaired t-test; the X 2 test was used for categorical variables. Univariable analysis was performed on selected variables. Significant variables (P < 0.30) were entered into a Cox multivariable logistic regression model, using the overall and specific occurrence of complications as dependent variables. The Spearman's rank correlation coefficient was applied as needed. RESULTS A total of 3181 cases (2077 men, 65.3%; mean age of 69 years) met the enrolment criteria. Final pathology was consistent with adenocarcinoma (n = 2262, 67.5%), squamous cell (n = 520, 15.5%), typical (n = 184, 5.5%) and atypical carcinoid (n = 48, 1.4%) and other (n = 335, 10%). The mean number of resected lymph nodes was 13.42 ± 8.24; nodal upstaging occurred in 308 of 3181 (9.68%) cases. Six hundred and fifty-five complications were recorded in 404 (12.7%) patients; in this series, no mortality was observed. Univariable and multivariable analyses did not show any association between the extension of LA and intraoperative or postoperative outcomes. The number of resected lymph nodes and nodal upstagings showed a minimal correlation with intraoperative outcomes and a moderate correlation with postoperative air leak (p = 0.35 and p = 0.48, respectively), arrhythmia (p = 0.29 and p = 0.35, respectively), chest drain duration (p = 0.35 and p = 0.51, respectively) and length of stay (p = 0.35). CONCLUSIONS Based on the VATS Group data, video-assisted thoracic surgery LA proved to be safe and displayed good outcomes even when performed with an extended approach

National adoption of video-assisted thoracoscopic surgery (VATS) lobectomy: The Italian VATS register evaluation

Background: The expertise curve of video-assisted thoracoscopic surgery (VATS) lobectomies still stirs debate and controversy both because of the number of procedures to carry out and of the evaluation of the learning threshold. The purpose of our study was the examination of the variables related to the learning curve of the video-assisted approach, to establish what may be an expression of the technical maturity of the surgeon. Methods: The National Register for VATS lobectomy built in 2013 was used to collect data from 65 Thoracic Surgery Units. Out of more than 3,700 patients enrolled, only information from Units with \ue2\u89\ua5100 VATS lobectomies were retrospectively analysed. Unpaired Student's t-tests, Fisher's exact tests, Pearson's \ucf\u872were applied as needed. Cumulative summative analysis and one-way ANOVA were used to identify the expertise curve of VATS lobectomy. Results: Ten institutions contributed a total of 1,679 patients, who were divided into three uniform groups according to the chronological sequence of surgery. The length of utility incision, the number of dissected lymph nodes and the operative time were not statistically significant (P=0.999, P=0.972 and P=0.307, respectively) among groups. Conversion to thoracotomy and postoperative air leaks occurred in 125 (7.44%) and 109 (6.49%) patients, gradually declined in Group 3 with statistical significance (P=0.048 and P=0.00086). Conclusions: The conversion rate and the percentage of air leaks seem to define the expertise of VATS lobectomy, being linked to the ability to manage more complicated surgical cases or intraoperative adverse events