Patients undergoing major lung resection who have pleural adhesions have an increased incidence of adverse surgical outcomes and higher pleural morbidity.

Background: Ectopic mediastinal parathyroid adenomas or hyperplasia account for up to 25% of primary hyperparathyroidism (HPT). Two percent of them are not accessible by standard cervical surgical approaches. Surgical resection has traditionally been performed via median sternotomy or thoracotomy and more recently, via video assisted thoracoscopic surgery (VATS). We present our experience with the novel use of Video-Assisted Mediastinoscopy (VAM) for resection of ectopic mediastinal parathyroid glands.

OBJECTIVES Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization. METHODS We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014–August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis. RESULTS PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354€, standard deviation (SD) 7646 vs 5759€, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340€, SD 23 312 vs 13 102€, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022). CONCLUSIONS PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.

INTRODUCTION Unplanned conversion to thoracotomy remains a major concern in video assisted thoracoscopic surgery (VATS) lobectomy. This study aimed to investigate the development of a VATS lobectomy programme over a five-year period, with a focus on the causes and consequences of unplanned conversions. METHODS A single centre retrospective review was performed of patients who underwent complete anatomical lung resection initiated by VATS between January 2010 and April 2015. RESULTS In total, 1,270 patients underwent a lobectomy in the study period and 684 (53.9%) of these were commenced thoracoscopically. There were 75 cases (10.9%) with unplanned conversion. The proportion of lobectomies started as VATS was significantly higher in the second half of the study period (2010-2012: 277/713 [38.8%], 2013-2015: 407/557 [73.1%], p<0.001). The conversion rate dropped initially from 20.4% (11/54) in 2010 to 9.9% (15/151) in 2013 and then remained consistently under 10% until 2015. Conversions were most commonly secondary to vascular injury (26/75, 34.7%). Patients undergoing unplanned conversion had a longer length of stay than VATS completed patients (9 vs 6 days, p<0.001). There was a higher incidence of respiratory failure (10/75 [14.1%] vs 23/607 [3.8%], p<0.001) and 30-day mortality (7/75 [9.3%] vs 6/607 [1.0%], p=0.003) in patients with unplanned conversion than in those with completed VATS. CONCLUSIONS As our VATS lobectomy programme developed, the unplanned conversion rate dropped initially and then remained constant at approximately 10%. With increasing unit experience, it is both safe and technically possible to complete the majority of lobectomy procedures thoracoscopically.

The traumatic lesions of the trachea and main bronchi require emergency surgical treatment. The proper choice of operative approach is largely dependent on the precise early diagnosis and on the determining of the exact location of the lesions. Operative tactics must aim at optimal preservation of the functional lung parenchyma and have to include reconstructive and plastic procedures.

Iatrogenic injury accounts for the second most common cause of acquired diaphragmatic hernias after penetrating trauma. An increased incidence of these hernias has been observed with the widespread use of laparoscopic surgery. We present the case of a 65-year-old woman who initially underwent sigmoid resection for an adenocarcinoma and a subsequent liver resection for metastasis. She was noted to have a left lower lobe pulmonary nodule on surveillance computed tomography, for which she underwent a mini-thoracotomy for a planned resection. At the time of surgery, the pulmonary nodule was discovered to be a diaphragmatic hernia, most probably of iatrogenic origin. We discuss the difficulty in diagnosis given her history and the location of such a lesion. Iatrogenic diaphragmatic hernias are becoming increasingly common given the increased use of laparoscopy. The majority of them are left-sided owing to the liver protecting the right hemidiaphragm. We present the case of a 65-year-old woman who was referred to our service for consideration for resection of a solitary pulmonary nodule in the left lower lobe. She had previously undergone anterior resection for a sigmoid adenocarcinoma and laparoscopic liver resection for metastasis. At the time of surgery, no lesion was identified in the lung and the suspected pulmonary nodule was noted to be a diaphragmatic hernia. We discuss the challenges of diagnosing a small diaphragmatic hernia. Case HistoryA 65-year-old woman was referred with a completely asymptomatic pulmonary nodule, discovered on surveillance computed tomography (CT). This was performed as part of her routine follow-up review for a previous sigmoid adenocarcinoma, for which she had undergone anterior resection in October 2012. Subsequently, in January 2013, she had undergone a laparoscopic partial left hepatic lobectomy for metastasis.CT of the chest in September 2013 revealed a suspected pulmonary nodule (17mm  21mm) in the left lower lobe just above the diaphragm (Fig 1A). CT ten months later showed no significant change in this lesion. The positron emission tomography (PET) showed a lesion in the left lower lobe abutting the diaphragm with a maximum standardised uptake value of 1.9 (Fig 1B). Despite the low uptake, this could still represent a pulmonary metastasis and she therefore underwent a left mini-thoracotomy for removal of this suspected nodule.At the time of surgery, the lung was thoroughly palpated but no pulmonary mass was identified. However, a small lesion on the diaphragmatic surface was noted. It measured approximately 2cm  2cm and appeared cystic in nature (Fig 2). Following further inspection, a defect of 0.5cm  0.5cm could be demonstrated in the diaphragm, directly underlying the lesion, and the mass was deemed to be a diaphragmatic hernia, most likely related to the previous abdominal surgery. The hernia sac was opened to reveal omental fat. A small phrenotomy was performed and the sac content was repositioned in the peritoneal cavity. The hernia sac was excised and the diap...

Objective The study objective was to verify whether the Eurolung score was associated with long-term prognosis after lung cancer resection. Methods A total of 1359 consecutive patients undergoing anatomic lung resection (1136 lobectomies, 103 pneumonectomies, 120 segmentectomies) (2014-2018) were analyzed. The parsimonious aggregate Eurolung2 score was calculated for each patient. Median follow-up was 802 days. Survival distribution was estimated by the Kaplan–Meier method. Cox proportional hazard regression and competing risk regression analyses were used to assess the independent association of Eurolung with overall and disease-specific survival. Results Patients were grouped into 4 classes according to their Eurolung scores (A 0-2.5, B 3-5, C 5.5-6.5, D 7-11.5). Most patients were in class A (52%) and B (33%), 8% were in class C, and 7% were in class D. Five-year overall survival decreased across the categories (A: 75%; B: 52%; C: 29%; D: 27%, log rank P < . 0001). The score stratified the 3-year overall survival in patients with pT1 ( P < . 0001) or pT>1 ( P < . 0001). In addition, the different classes were associated with incremental risk of long-term overall mortality in patients with pN0 ( P < . 0001) and positive nodes ( P = . 0005). Cox proportional hazard regression and competing regression analyses showed that Eurolung aggregate score remained significantly associated with overall (hazard ratio, 1.19; P < . 0001) and disease-specific survival after adjusting for pT and pN stage (hazard ratio, 1.09; P = . 005). Conclusions Eurolung aggregate score was associated with long-term survival after curative resection for cancer. This information may be valuable to inform the shared decision-making process and the multidisciplinary team discussion assisting in the selection of the most appropriate curative treatment in high-risk patients.

Nurse-led clinics are an increasingly used resource in managing postoperative patients and meeting their clinical needs. Since 2007, St James' University Hospital has run a ward-based nurse-led clinic; providing follow-up and management of patients after thoracic surgery. We aimed to assess patient satisfaction with the clinic's ability to manage their postoperative needs. Data were collected prospectively from patients attending the clinic between July and August 2010 using structured patient questionnaires. We evaluated 83 patient feedback questionnaires. The reasons for clinic attendance were predominantly wound assessment and chest drain review. Fifty-four (65%) patients were managed without seeing a doctor, of whom only four (7%) believed seeing a doctor would have been beneficial. Seventy-three (88%) patients stated their needs were met in the clinic and 82 (99%) patients described the overall care they received as good, very good or excellent. This survey highlights that patients are satisfied with a nurse-led service and will hopefully help encourage the development of such services within thoracic surgery.