BACKGROUND:Climate change is the greatest threat to human health. Cardiothoracic patients suffer direct consequences from poor environmental health and we have a vested interest to address this in our practice. As leaders of complex high-end surgery, we are uniquely positioned to effect practical and immediate changes to significantly pare down emissions within the operating theatre, outside the operating theatre and beyond the confines of the hospital. METHODS:We aim to spotlight this pressing issue, take stock of our current efforts, and encourage fellow specialists to drive this agenda. RESULTS:Sustainability in healthcare needs to be formalized as part of the core curriculum in surgical training and awareness generated via carbon audits and life cycle analyses. Practical actions such as reducing unnecessary equipment usage, choosing reusable equipment over single use disposables, judicious use of investigations rooted in clinical reasoning and sharing of resources across services and health systems help reduce the carbon output of our specialty. CONCLUSION:The 'Triple Bottom Line' serves as a good template to calibrate efforts that balance quality against environmental costs. More can be done to advocate for and find solutions for sustainable healthcare with cardiothoracic surgery.

BACKGROUND AND PURPOSE:Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis. METHODS:A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model. RESULTS:23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12-0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = -0.74 days, 95% CI -0.28 to -1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14-1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71-2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant. CONCLUSION:The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.

Intra-osseous hemangiomas are uncommon tumors that can present diagnostic and treatment dilemmas. Bone hemangiomas with papillary and glomeruloid growth patterns are exceptionally rare. We present an example of an intra-osseous hemangioma of the rib displaying aggressive features on both radiology and histology. Morphologically, prominent papillary and glomeruloid architectural patterns were observed, in addition to features of cavernous and capillary hemangiomas. Extensive extra-osseous soft tissue involvement was seen. Awareness of the diverse histological features and locally aggressive behavior of bone hemangiomas is important in avoiding over-interpretation as a malignant lesion.

We share our novel technique using barbed sutures for subcuticular purse-string suture closure during chest tube insertion and removal.

Lung cancer is commonly diagnosed after 40 years old and surgical lung resection is the recommended treatment for early stage lung cancer. The mean age of presentation is around 70 years old but there remained concerns on performing surgery in these patients. These concerns were addressed with advances in surgical technique and we aimed to review our experience of performing curative lung resection in patients above 70 years old. We performed a retrospective review of all patients who underwent curative surgery for primary lung cancers between 2018 and 2021 and compared the outcome between patients 70 years old and above against those who were younger. 289 were reviewed, of which 180 patients (62.3%) were under 70 years old and 109 patients (37.7%) were 70 years old and above. Patients above 70 years had a significantly higher incidence of hypertension, hyperlipidemia, diabetes mellitus, ischaemic heart disease and renal impairment but there was no significant difference in the incidence of previous stroke, atrial fibrillation, congestive heart failure and chronic obstructive pulmonary disease. There was also no significant difference between the pre-operative FEV1 and DLCO between the 2 groups of patients. Patients above 70 years old were at higher risk of developing pneumonia (OR 2.28, 95% CI 1.65-3.13, p = 0.003), respiratory failure (OR 2.71, 95% CI 2.33-3.16, p = 0.020) and unplanned return to the ICU (OR 2.41, 95% CI 1.78-3.27, p = 0.005). Peri-operative mortality was also higher in patients above 70 years old but this was statistically not significant. (OR 1.94, CI 1.18-3.17, p = 0.073). There was no significant difference in the post-operative incidence of cardiac, renal or wound complications. No patients developed a peri-operative stroke. Our study demonstrated that patients above 70 years old may be more susceptible to pulmonary complications such as pneumonia and respiratory failure that may in turn lead to higher peri-operative mortality. Care can be taken to mitigate these complications such as pre-operative pulmonary rehabilitation and early mobilisation but this should not preclude patients above 70 years old from undergoing curative lung resection surgery.

BackgroundPembrolizumab as immunotherapy is increasingly used in adjuvant, neoadjuvant, and standalone therapy and has been described as safe. We share an experience of lung erosion post-thoracic surgery with the use of adjuvant pembrolizumab.Case presentationA 65-year-old Chinese gentleman with metastatic renal cell carcinoma underwent lung metastasis resection and presented with delayed onset pneumothorax while on adjuvant pembrolizumab. Failure of conservative management warranted repeat surgical intervention, and intraoperative findings showed erosion of staple lines possibly caused by poor healing associated with pembrolizumab.ConclusionAdjuvant pembrolizumab may impair wound healing, including stapler line healing. Presentation of delayed pneumothorax in a post-surgical patient undergoing immunotherapy should warrant early surgical intervention.

Objectives We performed a systematic review and meta-analysis of outcomes of lobectomy versus sublobar resection in elderly patients (>= 65) with stage 1 nonsmall cell lung carcinoma (NSCLC). Methods We searched for relevant articles using a set of inclusion and exclusion criteria. Meta-analytic techniques were applied. Results Twelve studies ( n =5834) were chosen. Our results indicate that in the elderly, lobectomy for stage 1 NSCLC confers a survival advantage over sublobar resection. Lobectomy patients had a lower risk of death within 5 years and lower odds of local cancer recurrence. Our results show that lobectomy had a better 5-year cancer-specific survival and 5-year disease-free survival that trended toward significance. The sublobar resection group showed better 30-day operative mortality that trended toward significance. Subgroup analysis of stage 1A cancer demonstrated no difference in 5-year overall survival rates. However, for stage 1B tumors 5-year overall survival favored lobectomy. Conclusion Lobectomy for stage 1 NSCLC in elderly patients is superior to sublobar resection in terms of survival and cancer recurrence and should be afforded where possible. For stage 1A tumors, sublobar resection is noninferior and may be considered. Further randomized controlled trials in this topic is required.

Background Bar displacement is one of the most serious complications following the Nuss procedure for pectus excavatum repair. This paper reports a novel method of bar fixation using ZipFix, a biocompatible cable-tie implant, and shares a series of patients and outcomes. Methods This paper describes the ZipFix stabilisation method and presents a case series of 20 patients with pectus excavatum who underwent the Nuss procedure and ZipFix stabilisation between July 2015 and September 2020. Results A total of 34 ZipFixes were implanted in 20 patients. Six (6) patients had one ZipFix placed and 14 patients had two ZipFixes implanted: 13 were bilateral and one patient had two ZipFixes placed on the right. There was one incidence of asymptomatic posterior superior displacement of the right bar. Two (2) patients had wound infections and one patient had a previously placed bar adjusted and secured with a ZipFix. All patients had full correction of their chest wall deformity with no recurrence. Conclusions This case series shows that the use of ZipFix for Nuss bar fixation is feasible using this technique.

Extracorporeal membrane oxygenation (ECMO) is an invaluable means of supporting critically ill children with refractory respiratory or cardiac failure. Controversy remains; however, whether roller or centrifugal pumps are superior, particularly in infants. We performed a comprehensive search on PubMed, Embase, and Scopus for studies comparing the use of centrifugal and roller pumps in the pediatric and neonatal population from 1973 until March 1, 2020. All prospective and retrospective comparative studies were screened. Single-arm studies and those that included adult patients were excluded. The primary endpoint was survival to discharge. Secondary endpoints were complications (mechanical, cardiac, pulmonary, neurologic, renal, and hemolytic) and requirements for inotropic support. Random effects meta-analyses across all clinical endpoints were conducted. A total of four studies with 9111 patients were included. There was a statistically significant difference in in-hospital mortality, favoring the groups where roller pumps were used. Roller pumps were associated with fewer episodes of hemolysis, mechanical complications, cardiac complications, renal complications, and less inotropic support. ECMO with roller pumps may be associated with lower mortality in children. Roller pumps were associated with fewer complications, as well as reduced hemolysis and use of inotropes.

BACKGROUND:The purpose of this systematic review is to evaluate the efficacy of antifibrinolytics in non-cardiac thoracic surgery.METHODS:We searched for all randomized controlled trials on this topic. A set of strict inclusion and exclusion criteria was developed. Six studies were meta-analysed together then in subgroups of topical tranexamic acid and intravenous aprotinin. We compared postoperative chest drain output, transfusions requirements and duration of hospital stay where available to determine the efficacy of topical tranexamic acid or intravenous aprotinin in reducing blood loss.RESULTS:The use of antifibrinolytics reduces 24-h chest drain output (-290.21 mL [-524.75, -55.66], P = 0.02, I2  = 98%), red blood cell transfusion requirements (-1.27 units [-2.24, -0.30], P = 0.01, I2  = 100%) and shortened duration of hospital stay (-1.81 days [-3.25, -0.36], P = 0.01, I2  = 96%). The subgroup analysis also supported this trend.CONCLUSION:We conclude that the use of antifibrinolytics appears to reduce postoperative blood loss by reducing chest drain output, transfusion requirements and length of stay after thoracic surgery.

Background Extracorporeal membrane oxygenation has been used for COVID-19 patients with refractory hypoxemia. Methods We share our institution’s experience in organizing extracorporeal membrane oxygenation services in Singapore during the COVID-19 pandemic. We also share our first COVID-19 extracorporeal membrane oxygenation case report. Results We encountered initial difficulties in providing extracorporeal membrane oxygenation services in Singapore in view of the considerations of managing COVID-19 patients. By adopting rigorous planning, patient selection, staff training, adhering to infection control measures and preparing transport essentials, we were able to reorganize the extracorporeal membrane oxygenation services to serve the nation’s needs. This culminated in our first successful COVID-19 extracorporeal membrane oxygenation retrieval case. Conclusions Extracorporeal membrane oxygenation is an option for COVID-19 patients but preparation must be taken to prepare the extracorporeal membrane oxygenation teams to deal with this pandemic and future challenges.

The management of massive anterior mediastinal masses (AMM) is challenging. With the burgeoning role of extracorporeal membrane oxygenation support (ECMO) beyond the confines of salvage therapy, more trained clinicians are adopting it as a bridge for high-risk procedures or situations where temporary respiratory or cardiac support is required. We report our experience with using ECMO in the management of massive AMM in this case series of three patients sharing their clinical details and the lessons learned from them.

Covid-19 has touched all corners of the globe and impacted our lives in more ways than one. Thoracic surgeons are frontliners impacted in both our professional and personal capacities. In this commentary we discuss the impact that Covid-19 has had on thoracic surgery as a practice highlighting the discrepant impact upon developed and developing countries, the state of affairs of the “new normal” that we live in and the challenges ahead as we transition from pandemic living to endemic living alongside Covid-19. We need to evolve as the virus does and keep abreast of the latest developments to continue providing excellent care to our patients. While the challenges brought about by the Covid-19 pandemic are unprecedented in this generation, it can bring forth tremendous opportunities for us to redefine excellence in thoracic surgery service delivery in this endemic times.

The role of extracorporeal membrane oxygenation (ECMO) is expanding as surgeons look at its utility beyond rescue treatment and have started adopting it for high-risk procedures to provide temporary airway and hemodynamic stabilization. ECMO needs to be deliberated in all patients with mediastinal masses who have compromised airways as well as in those with compression of heart and great vessels. There is a dearth of literature highlighting the definitive role of ECMO in patients with mediastinal masses. This article reviews the available adult literature and highlights the possible situations where the use of ECMO would be supportive in the management of patients with mediastinal masses.

We present a novel case of a patient with nephrotic syndrome and previous left pneumonectomy who had a massive pulmonary embolism of his remnant right pulmonary artery. He underwent surgical embolectomy and veno-arterial extracorporeal membrane oxygenation (ECMO). Early embolectomy using retrograde pulmonary perfusion and post-operative ECMO helped the patient survive this catastrophic event.

Central MessageWe report an unusual presentation of Aspergillus aortitis in a patient after redo aortic valve surgery who was readmitted with lung consolidation and massive hemoptysis due to ruptured ascending aorta.See Commentary on page 66. We report an unusual presentation of Aspergillus aortitis in a patient after redo aortic valve surgery who was readmitted with lung consolidation and massive hemoptysis due to ruptured ascending aorta. See Commentary on page 66. Invasive Aspergillus infection of the aorta after cardiac surgery is rare.1Sanchez-Recalde A. Mate I. Merino J.L. Simon R.S. Sobrino J.A. Aspergillus aortitis after cardiac surgery.J Am Coll Cardiol. 2003; 41: 152-156Crossref PubMed Scopus (41) Google Scholar Presentation varies greatly, and symptoms are nonspecific.2Ronco F. Simsir S. Czer L. Luo H. Siegel R.J. Incidental finding by two-dimensional echocardiography of a mycotic pseudoaneurysm of the ascending aorta after orthotopic heart transplantation.J Am Soc Echocardiogr. 2010; 23: 580.e1-580.e3Abstract Full Text Full Text PDF Scopus (9) Google Scholar, 3Sharifulin R. Bogachev-Prokophiev A. Varnek Y. Klimko N. Malakhova O. Volkov A. et al.Successful treatment of an aortotomy site Aspergillus infection.Ann Thorac Surg. 2019; 108: e253-e255Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 4Hanvesakul R. Deshpande R. Carr C.S. Akbar N. Aspergillus aortitis: a cause for aortic perforation in a patient following combined aortic valve surgery and liver transplantation.Interact Cardiovasc Thorac Surg. 2004; 3: 544-546Crossref PubMed Scopus (8) Google Scholar Diagnosis is often delayed, and the prognosis is guarded despite intervention.1Sanchez-Recalde A. Mate I. Merino J.L. Simon R.S. Sobrino J.A. Aspergillus aortitis after cardiac surgery.J Am Coll Cardiol. 2003; 41: 152-156Crossref PubMed Scopus (41) Google Scholar We present a case of Aspergillus aortitis after aortic valve surgery presenting with massive hemoptysis due to ruptured aortic pseudoaneurysm. A 51-year-old man with a history of aortic valve and ventricular septal defect repair performed 23 years earlier and hyperlipidemia presented with New York Heart Association class III symptoms of aortic stenosis. The initial cardiac surgery was performed with patch repair of the ventricular septal defect and aortic valve repair with bovine pericardium. On follow-up, the mean transaortic gradient was 43 mm Hg, and the effective orifice area was 0.7 cm2. He underwent a redo sternotomy and aortic valve replacement (21-mm mechanical valve; St Jude Medical, St Paul, Minn). He recovered well and was discharged on postoperative day 8. Echocardiography showed a normal aortic valve prosthesis and ascending aorta. At an outpatient follow-up 6 weeks later, the patient complained of cough with blood-stained secretions. He had no other respiratory symptoms and was afebrile and hemodynamically stable. His warfarin was titrated owing to an International Normalized Ratio (INR) of 3.0. Despite the normalized INR, his hemoptysis persisted, and he presented again with decreased effort tolerance and shortness of breath at rest with low-grade fever. A chest X-ray showed right lower zone opacification with elevated right hemidiaphragm (Figure 1). He was diagnosed with right lower lobe pneumonia and treated with i.v. piperacillin/tazobactam. Echocardiography showed preserved ejection fraction with no pericardial effusion or valvular regurgitation. The next day, his hemoglobin dropped from the baseline of 8.5 g/dL to 6.7 g/dL. His INR increased to 3.33 despite the withholding of warfarin. An urgent chest computed tomography scan revealed a 12.4 × 10.3-cm ascending aorta pseudoaneurysm compressing the right lung (Figure 2). There was moderate right pleural effusion with ground-glass changes in the middle and lower lobes. The patient was transferred to the intensive care unit immediately and warfarin reversed before undergoing emergency surgery.Figure 2Chest X-ray showing right lower lobe consolidation (left) and corresponding coronal thorax computed tomography scan showing the pseudoaneurysm (∗) and mechanical aortic valve (right).View Large Image Figure ViewerDownload (PPT) Before intubation in the operating theatre, the patient had normal blood pressure with good peripheral saturation. He suddenly developed massive frank hemoptysis and pulseless electrical activity collapse right before intubation. Cardiopulmonary resuscitation with chest compression and intubation and cut-down femoral-femoral cardiopulmonary bypass (CPB) were initiated simultaneously. After 20 minutes of Cardiopulmonary resuscitation, CPB was established. The patient was cooled to 24°C, and redo sternotomy was performed under circulatory arrest. The ascending aorta pseudoaneurysm was found to be ruptured above the aortotomy suture line for at least one-half of the aortic diameter. The aorta was cross-clamped proximal to the innominate artery, and CPB was reinstituted. Direct antegrade cardioplegia was administered. The mechanical valve was examined and found to be well sited. The ascending aorta was replaced with a 26-mm straight Gelweave graft (Terumo, Sunrise, Fla). There was profuse bleeding from the right lung, caused by direct parenchymal erosion from the pressurized pseudoaneurysm. This was repaired primarily. The patient was weaned off CPB but required high inotropic support and ventilatory pressure; thus, peripheral venoarterial extracorporeal membrane oxygenation was instituted for circulatory and respiratory support. Postoperatively, the patient's cardiorespiratory function recovered, and extracorporeal membrane oxygenation was discontinued on postoperative day 2. Unfortunately, his neurologic status showed severe hypoxic ischemic encephalopathy, likely related to his collapse and the downtime before reinstitution of CPB. Intraoperative culture of aortic wall tissue grew Aspergillus fumigatus on Sabouraud (Singapore) dextrose agar plates (at 30°C and 37°C) after 1 day (Figure 1). Histology identified nonspecific inflammation and hemorrhage in the adventitia, with foreign body giant cell reaction to adjacent suture material. Aspergillus aortitis is a rare but often fatal complication.1Sanchez-Recalde A. Mate I. Merino J.L. Simon R.S. Sobrino J.A. Aspergillus aortitis after cardiac surgery.J Am Coll Cardiol. 2003; 41: 152-156Crossref PubMed Scopus (41) Google Scholar Diagnosis is often delayed, and many patients are identified postmortem owing to the long incubation time for Aspergillus.4Hanvesakul R. Deshpande R. Carr C.S. Akbar N. Aspergillus aortitis: a cause for aortic perforation in a patient following combined aortic valve surgery and liver transplantation.Interact Cardiovasc Thorac Surg. 2004; 3: 544-546Crossref PubMed Scopus (8) Google Scholar In some instances, a diagnosis of pseudoaneurysm premortem is confirmed only on imaging.2Ronco F. Simsir S. Czer L. Luo H. Siegel R.J. Incidental finding by two-dimensional echocardiography of a mycotic pseudoaneurysm of the ascending aorta after orthotopic heart transplantation.J Am Soc Echocardiogr. 2010; 23: 580.e1-580.e3Abstract Full Text Full Text PDF Scopus (9) Google Scholar Despite antifungal treatment and excision of infected tissue, many patients still die after experiencing initial recovery.4Hanvesakul R. Deshpande R. Carr C.S. Akbar N. Aspergillus aortitis: a cause for aortic perforation in a patient following combined aortic valve surgery and liver transplantation.Interact Cardiovasc Thorac Surg. 2004; 3: 544-546Crossref PubMed Scopus (8) Google Scholar,5Clarke N.S. Sengupta A. Miller A. Jessen M.E. Murthy R.A. Aspergillus aortitis and aortic valve endocarditis after coronary surgery.J Card Surg. 2019; 34: 871-874Crossref PubMed Scopus (1) Google Scholar In the present case, Aspergillus aortitis presented with symptoms suggestive of pneumonia. Low-grade fever could be overlooked by the patient and was not reported at follow-up. The ascending aorta pseudoaneurysm was revealed only on computed tomography. Pericardial effusion or tamponade was prevented by scar tissue owing to his previous surgeries. This limited the pseudoaneurysm and explained why no collections were seen on echocardiography. Under high aortic pressures, the pseudoaneurysm had eroded into the lung and caused massive hemoptysis. In conclusion, invasive Aspergillus infection of the aorta is a rare and aggressive complication with high mortality. Early identification is the only way to improve patient survival. A high suspicion for Aspergillus infection is required after aortic valve surgery, especially if unusual symptoms present. Commentary: Evoke the unlikely, not too lateJTCVS TechniquesVol. 6PreviewWhen speaking of Aspergillus spp (with Aspergillus fumigatus and Aspergillus flavus being responsible of approximately 90% of all clinically evident human contaminations), cardiothoracic surgeons usually think of invasive, prognostically ominous infections most frequently seen in immunocompromised patients. The case reported by Leow and colleagues1 in this issue of the Journal embodies the menace embodied by such a rare entity and its capacity to occur in even immunocompetent hosts. Airborne contamination from these ubiquitous fungal spores represents the elective mode for development of the infection; this case also demonstrates the predilection of Aspergillus to the aortic tissue, the damage induced by surgery (eg, aortotomy, proximal bypass graft anastomosis, cannulation), and its exposure to contaminated air, likely representing the conditions for homing. Full-Text PDF Open Access

CSHN serves in an advisory role to the Global Lung Health Committee, Medtronic, IGNITE Council and Johnson & Johnson. CSHN owns stock in Medtronic; received honoraria from Johnson & Johnson, Medtronic and Siemens Healthineer; and has received advisory fees or rewards from Johnson & Johnson, Medtronic and Siemens Healthineer. LL and HN have no conflict of interests.

Introduction: COVID-19 presented an unprecedented challenge for healthcare workers and systems around the world. Healthcare systems have adapted differently in terms of pandemic planning of regular services, adopting infection control measures and prioritising essential hospital services in the context of a burgeoning COVID-19 patient load and inevitable surge. Methods: We performed a review on current evidence and share our practices at a teaching hospital in Singapore. Results: We outline principles and make recommendations for continuity of delivering essential thoracic surgical services during this current outbreak. Conclusions: The maintenance and provision of thoracic surgery services in this context requires good preplanning and vigilance to infection control measures across all levels. (C) 2020 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Background Primary spontaneous pneumothorax (PSP) is a relatively common clinical entity with high incidence in the young population. Video-Assisted Thoracic Surgery (VATS) bullectomy and chemical or mechanical pleurodesis are two primary modalities of treatment. There has been much debate on the ideal mode of pleurodesis, but the literature on surgical outcomes comparing VATS pleurectomy with talc pleurodesis has been inconclusive. Methods We performed a single-centre 5-year observational retrospective study of 202 patients who underwent VATS bullectomy with talc pleurodesis or parietal pleurectomy. Results There were no significant differences in the demographics, pre-operative and intra-operative characteristics in both groups. Recurrence of pneumothorax, chest tube duration and hospital stay were similar in both groups. However, talc pleurodesis had a shorter operative time compared to pleurectomy. Conclusion Our study demonstrated comparable outcomes between talc pleurodesis and pleurectomy following VATS bullectomy for patients with PSP.