Background: Decortication for thoracic empyema is associated with significant blood loss and prolonged postoperative air leak. We sought to assess the potential application of an irrigated-tip radiofrequency (RF) sealing device, in an attempt to reduce this morbidity.Methods: Data for all patients undergoing open decortication (OD) for stage II thoracic empyema, using either conventional approach or facilitated by use of the Aquamantys ® device, at a single thoracic surgical unit between April 2010 and July 2014, were retrospectively analysed. Unpaired t-test and Fisher's exact test were used for statistical analysis. Results: Thirty-three patients, aged 54±15 years (mean ± SD), and with a Charlson comorbidity index of 2.5±1.9 were included. Preoperative and intraoperative characteristics, including surgical time, were similar in the conventional and Aquamantys ® groups. Patients in the Aquamantys group were less likely to require red cell transfusion (9/22 vs. 10/11 patients, P=0.024) and received lower volume transfusions [0.0 (2.0) vs. 3.0 (1.6) units (median, IQR), P<0.0001]; chest drain duration was shorter [3.0 (1.0) vs. 6.5 (6.8) days, P=0.006], as was length of postoperative hospital stay [6.0 (8.7) vs. 10.0 (4.6) days, P=0.031]. There was no demonstrable difference in mortality. Conclusions:Our data indicates that the use of irrigated tip RF ablation is safe and effective in improving pneumostasis and haemostasis in decortication for thoracic empyema; and that this translates to morbidity and logistical benefit. (4,5).Major thoracic surgical procedures carry significant risk of morbidity; particularly significant haemorrhage, and high-volume or prolonged air leak, with associated prolonged length of hospital stay. Several strategies have been proposed in an attempt to minimize the extent and duration of parenchymal air leak and bleeding. Lung sealants have shown mixed success in reducing air leaks (6). Haemostatic agents may be considered in an attempt to control diffuse bleeding (7).The Aquamantys ® system (Medtronic, Minneapolis, MN, USA) is a single-use portable handheld device with a salineirrigated tip and an adjustable radiofrequency (RF) energy generator system with integrated pump. It was launched commercially in its current form in March 2006, and sells for GBP 290 per disposable unit. The combination of RF energy and saline provides haemostatic sealing of tissues, without charring or carbonisation. It has been widely adopted in a number of other surgical specialties, including orthopaedic, hepatobiliary and neurosurgery (8-10). Reports in the literature of the use of the Aquamantys ® system in a thoracic surgical setting are limited and deal with older, lower-energy models of the device that proved inefficient at sealing lung tissue (11,12). We sought to assess the potential application of this technology in adult patients undergoing OD for stage III post-pneumonic empyema. The primary outcome measures included red cell transfusion requirements as a marker of clinically-significant bleedin...

Oesophagopleural fistula is a recognized complication of pneumonectomy. Surgical repair with direct closure and reinforcement with omentum, muscle or pleural flap is the mainstay of definitive treatment. However, this option might not be suitable for all patients. The authors report on the case of a 63-year old female refusing surgical repair of an oesophagopleural fistula after left pneumonectomy. A novel approach (using an Amplatzer atrial septal occluder device) for fistula closure was attempted. Despite a promising initial result, the procedure failed. This is the first report on the use of a septal occluder to try and close an oesophagopleural fistula.

Streptococcus constellatus is an oropharyngeal commensal Gram-positive coccus, frequently associated with the respiratory tract. S. constellatus is part of the Streptococcus anginosus or milleri group, which has traditionally been considered to have propensity to cause empyema and purulent abscesses, a property that is sometimes overlooked as the severity of infections it causes may have a varying degree. In this case, we present the case of a 54-year-old male with known liver cirrhosis who developed a severe empyema during an acute liver failure episode, requiring extensive decortication and prolonged hospital admission.

Objective To assess whether preoperative incentive spirometer training would influence the development of postoperative pulmonary complications after lung resection. Methods Sixty-two lung resection patients were prospectively investigated; 17 were given an incentive spirometer preoperatively and 45 did not have an incentive spirometer preoperatively. Postoperatively, both arms exercised with an incentive spirometer. The number of repetitions per day, balls raised per repetition, correct technique of exercising, and postoperative pulmonary complications were compared between the 2 groups. Univariate binary logistic regression analysis of potential predictors of postoperative pulmonary complications led to multivariate analysis of independent predictors. Receiver operating characteristic analysis established the cutoff points of predictors. Results The group with no preoperative incentive spirometer developed more postoperative pulmonary complications than the preoperative incentive spirometer group (24.4% vs. 5.9%, respectively, p = 0.045). The preoperative incentive spirometer arm achieved more repetitions per day, balls per repetition, and correct incentive spirometer technique ( p = 0.002, p < 0.001, p = 0.034, respectively). Balls raised per repetition and repetitions per day postoperatively were identified as independent predictors of postoperative pulmonary complications ( p = 0.032 and p = 0.021, respectively). Less than 5 repetitions per day (sensitivity 93%, specificity 77%, p < 0.001) and less than 2 balls per repetition (sensitivity 93%, specificity 77%, p < 0.001) were predictive of postoperative pulmonary complications. Conclusion Preoperative incentive spirometer exposure ensured better compliance with postoperative treatment and a more accurate technique (balls raised per repetition, repetitions per day). These variables correlated with a lower postoperative pulmonary complication rate.

Interrupted type B aortic arch was repaired using aberrant right subclavian artery. In order to gain the full length of this vessel it was mobilised from a left thoracotomy. The aberrant vessel provides autogenous patch material with which to enlarge the ascending aorta and left common carotid artery.

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