Pleural manometry during thoracocentesis in patients with malignant pleural effusion: A randomized controlled trial

Background

Large-volume therapeutic thoracocentesis may be associated with pulmonary congestion or a more serious complication; re-expansion pulmonary edema (RPE). We investigated whether monitoring pleural pressure with manometry during thoracocentesis would prevent these pulmonary symptoms/RPE and allow larger volume drainage.

Methods

We did a randomized controlled trial involving 110 patients with large malignant pleural effusions. Patients were randomly allocated to obtain thoracocentesis with or without pleural manometry. We measured the incidence of pulmonary congestion symptoms, total fluid aspirated, and pleural pressures in both groups. This trial is listed on ClinicalTrials.gov as NCT04420663.

Results

The mean amount of total thoracocentesis fluid withdrawn from the control group was 945.4±78.9 (mL) and 1690.9±681.0 (mL) from the intervention group (P<0.001). Clinical symptoms of pulmonary congestion appeared in (n=20) (36.3%) of patients in the intervention group while no symptoms appeared in controls (P<0.001). The difference between opening and closing pressures between the non-symptomatic cluster and the symptomatic cluster was (32.8±15.6 versus 42.2±13) respectively (P=0.02). Total fluid withdrawn from the non-symptomatic cluster was 1828.5±505 mL in comparison to 1,450±875 mL in the symptomatic cluster (P=0.04).

Conclusion

Pleural manometry can be used to increase the volume of fluid removed on each occasion in patients with malignant pleural effusion. In our study, pleural manometry was associated with a larger number of pulmonary congestion symptoms/RPE. We believe that manometry may be a useful tool to not exceed a 17 cm H2O gradient in pleural pressure which should be avoided to prevent pulmonary congestion symptoms or RPE. Pulmonary congestion symptoms/RPE are not related to the amount of volume withdrawn but to the gradient of pleural pressure drop. Our conclusion does support the adoption of pleural manometry whenever large-volume thoracocentesis is intended.

The efficacy of oral corticosteroids for treatment of Tietze syndrome: A pragmatic randomized controlled trial

WHAT IS KNOWN AND OBJECTIVE

Tietze syndrome is a rare form of chest wall costochondritis with joint swelling which can cause significant chest pain and decline in ability of daily activities. There is no standardized treatment protocol. The aim of this study was to assess the efficacy of adding oral steroids in addition to other non- steroidal treatment in improvement of pain and quality of life (QOL) in patients with Tietze syndrome.

METHODS

Forty patients with Tietze syndrome were randomly divided into two treatment groups: (1) One week of prednisolone 40 mg daily followed by 1 week of prednisolone 20 mg daily followed by 1 week of 10 mg with 3 weeks of non-steroidal anti-inflammatory drug (NSAID) treatment (n = 20); (2) three weeks of NSAID treatment only (n = 20). A symptom questionnaire was used to rate the major symptoms of Tietze syndrome and costochondritis: Numeric rating scale (NRS) for pain on a scale of 0 (no pain) to 10 (severest pain); the resulting global symptom score was used to evaluate the efficacy of treatment with assessment of joint swelling resolution. The EQ-5D-5L instrument for measurement of QOL was used. Assessments were made on intention to treat basis at baseline and at 1, 2 and 3 weeks followed by a medium term follow period after treatment cessation. The trial was registered at www.isrctn.com ISRCTN11877533.

RESULTS AND DISCUSSION

There was a significant drop in mean NRS pain scores between the groups at 1, 2 and 3 weeks in favour of the steroid group (46.8% vs. 17.7%; p < 0.001, 56.3% vs. 35.8% p < 0.001 and 65.4% vs. 46.7% p < 0.001 respectively). There was a 25.8% (95% CI 13.2-38.8) difference in mean NRS score drop at a median of 6.5 months after treatment cessation in favour of the steroid group over the NSAID only group. Only three cases of mild GIT upset in the steroid group and two cases of mild nausea were reported in the NSAID group. There was an improvement in QOL using the median EQ-5D-5L scoring at 3 weeks in favour of the steroid group 7 (7, 8) versus 10 (8.5-11), (p < 0.001). The improvement in pain scoring and QOL did not correlate with improvement in joint swelling at 3 weeks after treatment with 2/20 (10%) in the steroid arm versus 1/20 (5%) in NSAID arm having an obvious improvement (p = 0.393).

WHAT IS NEW AND CONCLUSION

In this study, addition of short-term oral corticosteroids showed a clear benefit for use at 1, 2 and 3 weeks in improvement of pain and QOL in patients with Tietze syndrome. This difference was maintained at mid-term follow up after treatment cessation. This facilitates the advantage of using steroids as well as excluding their side effects for an accepted timeframe.

Patients after lung resection heading to the high-dependency unit: a cost-effectiveness study for managing lung cancer patients

Background

Recently, most thoracic surgery units allocate patients post lung resection to high-dependency units (HDU) rather than the old trend of intensive care units (ITU). The aim of the study is to assess the safety and efficacy of such a policy. We compared a single group of patients who underwent lobectomies who were admitted to ITU before March 2011 and patients whom their destination was to HDU after that date. Preoperative factors and postoperative outcomes were compared.

Results

A total of 408 patients were studied, 203 post-lobectomy patients were admitted routinely to ITU before March 2011, while 205 patients were admitted to HDU after that date. The mean postoperative length of stay in ITU was 1.2 days while in HDU was 1.1 days. In-hospital mortality for the ITU group was 2.5% (n = 5) while in the HDU group was 1.4% (n = 3) (p = 0.43). ITU readmission was observed in 6.5% (n = 13) in the ITU group and 4.3% (n = 9) in the HDU group (p = 0.31). Total complications were present in 39% in the ITU group and 33% in the HDU group (p = 0.16). The total estimated cost of one ITU day per patient is 850 GBP in comparison with 430 GBP for the HDU group (p = 0.007). The incremental cost-effectiveness ratio of the HDU stay per year was US $32.130/QALY.

Conclusion

The high-dependency unit is a safe destination for post-lobectomy patients. The same concept may apply to all thoracotomy patients. Hospitals could adopt such a policy which offers a better financial option without jeopardizing the level of patient care or outcome.

Is hormonal manipulation after surgical treatment of catamenial pneumothorax effective in reducing the rate of recurrence? A systematic review and meta-analysis

OBJECTIVES

Catamenial pneumothorax CP is a rare form of spontaneous pneumothorax in females forming part of thoracic endometriosis syndrome. Studies have suggested possible benefit from postoperative hormonal administration. As this treatment is inconsistent, we aimed at performing the first meta-analysis to study the efficacy of adding hormonal treatment after surgery to reduce the chances of recurrent catamenial pneumothorax.

METHODS

CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched from inception up to December 15, 2021. Studies reporting five or more patients with end point outcome were included. The main outcome assessed was postoperative recurrence of CP after hormonal manipulation. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. meta- regression for the effect of patient age and follow up period were tested. Publication bias was examined. This trial was registered with PROSPERO under registration number CRD42022325377.

RESULTS

Our electronic search retrieved 644 citations, 48 of which were selected for full-text review. Eleven studies with a combined population of 111 patients fulfilled the inclusion criteria. All patients reached an endpoint of follow up for postoperative recurrence of catamenial pneumothorax after receiving hormonal treatment. Overall study validity was acceptable, with a median score of 6 on the Newcastle Ottawa scale NOS appraising the quality of observational studies. CP is almost always a right-side disease (107/111 = 96.3 %). The risk of postoperative recurrence with hormonal treatment was 17.3 % (8.9 - 25.8 %) with moderate non-significant heterogeneity (I2 = 40.85 %; P = 0.076). The cumulative risk of recurrence for all patients not receiving postoperative hormonal therapy included in our study was 54.2 % (19/35 patients). Meta regression showed age to be a significant predictor of postoperative recurrence (p = 0.03). As the age increases one year, the risk of recurrence decreases by 6 % (0.2 - 3 %). Publication bias was detected by visualizing the funnel plot of standard error, Egger's test with p < 0.01 and Begg & Mazumdar test with p < 0.01.

CONCLUSION

The study included the largest number of CP patients with outcome findings of postoperative recurrence with hormonal treatment despite the small number of studies, non-randomised fashion and publication bias. Our findings recommend the use of hormonal manipulation after thoracic surgical intervention for catamenial pneumothorax unless evident contraindications. Younger patients are at a higher risk of recurrence after surgery.

Thoracic surgery in Egypt

General thoracic surgery operations in Egypt are performed mainly by cardiothoracic surgeons and less oftenly by dedicated thoracic surgeons and general surgeons. This is mainly due to the relatively small number of thoracic surgeons in relation to population as only 210 cardiothoracic surgery specialists and 458 consultants are registered with the Egyptian Medical Syndicate (EMS) in a country with a population of more than 100 million people. Thoracic surgeons in Egypt are faced with a number of burdens, including the need to propagate the service to advanced technology infront of the obstacle of limited resources. Other burdens include higher incidence of TB, trauma and foreign body inhalation related to cultural backgrounds. More centres now are major video-assisted thoracic surgery (VATS) providing centres and others are specialized in more complex surgeries like complicated airway procedures and radical surgery for mesothelioma. As part of the international community, the COVID-19 pandemic has put more burdens on the thoracic surgery service as most centres have reduced their elective surgery workload to less than half of usual. Interestingly, the pandemic has allowed a self-referral screening programme with widespread Computed Tomography (CT) chest being performed among the population allowing thoracic surgeons to operate more on early stage lung cancer. The academic challenges for thoracic surgeons are even more with need for developing national databases. Nevertheless, thoracic surgeons in Egypt are optimistic regarding the future. The rising interest among the younger population will push training programs to meet the interests of enthusiastic junior surgeons. While the ancient history of thoracic surgery in Egypt seems to be extraordinary, the future perspectives promise to be more rewarding.

Airway Surgery for Laryngotracheal Stenosis During the COVID-19 Pandemic: Institutional Guidelines

Objective

The management of laryngotracheal stenosis is challenging, as patients usually require in-time interventions. The current coronavirus disease 2019 (COVID-19) pandemic has added unique challenges to this procedure. The presence of the virus in high concentrations in the aerodigestive tract and the need for an open airway during surgery can increase the risk of aerosolization of the virus and subsequent infection of the surgical, anesthetic, and operating room (OR) personnel.

Design

Retrospective cohort study.

Setting

University hospital.

Participants

Patients who underwent airway interventions between March and October 2020.

Interventions

A protocolized strategy was initiated during the COVID-19 pandemic to facilitate the consistent management of all patients undergoing airway interventions.

Measurements and Main Results

During a seven-month period, 34 patients were managed with this policy. All threatened airways were managed successfully and no healthcare workers dealing with such procedures were infected. Priorities during the current novel coronavirus pandemic are ensuring the safety of healthcare professionals and offering urgent bronchoscopic and surgical airway interventions for patients with progressive symptoms and threatened airways.

Conclusions

Surgical and bronchoscopic management of laryngotracheal stenosis presents a unique challenge during the COVID-19 pandemic, requiring careful consideration of patient triage and the development of protocols that minimize risk to patients and healthcare professionals. Close collaboration between thoracic surgeons and anesthesiology teams is essential to safely navigate and handle these threatened airways while mitigating the risk of viral aerosolization.

Extracorporeal membrane oxygenation (ECMO) in patients with severe COVID-19 adult respiratory distress syndrome: a systematic review and meta-analysis

Background

COVID 19 is the most recent cause of adult respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients failing conventional mechanical ventilation, but its role is still controversial. We conducted a systematic review and meta-analysis on ECMO for COVID-associated ARDS to study its outcome.

Main body

CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched from inception to May 28, 2020. Studies reporting five or more patients with COVID-19 infection treated venovenous with ECMO were included. The main outcome assessed was mortality and ICU/hospital discharge. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. The validity of all the included observational studies was appraised with the Newcastle Ottawa scale. Meta-regression and publication bias were tested. This trial was registered with PROSPERO under registration number CRD42020183861.From 1647 initial citations, 34 full-text articles were analyzed and 12 studies were selected, including 194 patients with confirmed COVID-19 infection requiring ICU admission and venovenous ECMO treatment. Median Newcastle-Ottawa scale was 6 indicating acceptable study validity. One hundred thirty-six patients reached an endpoint of weaning from ECMO with ICU/hospital discharge or death while the rest were still on ECMO or in the ICU. The median Berlin score for ARDS prior to starting ECMO was III. Patients received mechanical ventilation before ECMO implementation for a median of 4 days and ECMO was maintained for a median of 13 days. In hospital and short-term mortality were highly variable among the included studies ranging between 0 and 100%. Random-effect pooled estimates suggested an overall in-hospital mortality risk ratio of 0.49 (95% confidence interval 0.259 to 0.721; I2 = 94%). Subgroup analysis according to country of origin showed persistent heterogeneity only in the 7 Chinese studies with pooled estimate mortality risk ratio of 0.66 (I2 = 87%) (95% CI = 0.39-0.93), while the later larger studies coming from the USA showed pooled estimate mortality risk ratio of 0.41 (95% CI 0.28-0.53) with homogeneity (p=0.67) similar to France with a pooled mortality risk ratio of 0.26 (95% CI 0.08-0.43) with homogeneity (p=0.86). Meta-regression showed only younger age as a predictor of mortality (p=0.02). Publication bias was excluded by visualizing the funnel plot of standard error, Egger's test with p=0.566, and Begg and Mazumdar test with p=0.373.

Conclusion

The study included the largest number of patients with outcome findings of ECMO in this current pandemic. Our findings showed that the use of venovenous ECMO at high-volume ECMO centers may be beneficial for selected COVID 19 patients with severe ARDS. However, none of the included studies involve prospective randomized analyses; and therefore, all the included studies were of low or moderate quality according to the Newcastle-Ottawa scale. In the current era and environment of the pandemic, it will likely be very challenging to conduct a prospective randomized trial of ECMO versus no-ECMO for COVID-19. Therefore, the information contained in this systematic review of the literature is valuable and provides important guidance.

Trial registration

The study protocol link is at www.crd.yorl.ac.uk/PROSPERO under registration number CRD42020183861.

Tailored anaesthesia for thoracoscopic surgery promoting enhanced recovery: The state of the art

PURPOSE OF THE REVIEW

The current review focuses on precise anaesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. The main aim of an enhanced recovery program after thoracic surgery is to reduce postoperative stress response, protect from postoperative pulmonary complications, give hospitals a better financial option and improve overall patient outcome. This can ultimately reduce hospital stay and increase patient satisfaction. With advances in endoscopic, robotic and endovascular techniques, video-assisted thoracoscopic surgery (VATS) can be performed in a minimally invasive way in managing most pulmonary, pleural and mediastinal diseases. As a minimally invasive technique, video-assisted thoracoscopic surgery (VATS) represents an important element of enhanced recovery program in thoracic surgery as it can achieve most of its goals. Anaesthetic management during preoperative, intraoperative and postoperative period is essential for the establishment of a successful enhanced recovery program. In the era of enhanced recovery protocols, non-intubated thoracoscopic procedures present a step forward. This article focuses on the key anaesthetic elements of the enhanced recovery program during all phases of thoracoscopic surgery. Having reviewed recent literature, a systematic review of literature will highlight successful ERAS protocols published for thoracoscopic surgery.

Recurrence of mesothelioma after a macroscopic complete resection procedure: is a second radical surgery justified?

A best evidence topic was written according to a structured protocol. The question addressed was: In patients with mesothelioma who develop a local recurrence after macroscopic complete resection (MCR) surgery, does performing a second radical surgery lead to improvement in survival? A total of 2076 papers were identified using the reported search, of which 3 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. The 2 largest studies included 16 patients each who underwent a second surgery for radical resection of recurrence after MCR for mesothelioma. One study (with 16 chest wall resections) had no in-hospital mortality, whereas the other study showed 2/16 (12.5%) patients dying in the hospital, both of whom had a contralateral pleurectomy. One study correlated the median survival after the second surgery with the time to recurrence and epithelioid pathology. The other study showed better post-recurrence survival after a second surgery, with patients having a significantly longer median post-recurrence survival (16 months) compared with those who received other types of second-line therapy (9 months) and those who received no therapy at all (2 months) (P < 0.0005), although selection bias is a possibility. The last study included 8 patients who underwent a second surgery for radical intent after MCR for mesothelioma. The median time to recurrence was 29 months and the survival after second surgery was 14.5 months with no correlation to disease-free interval (expected due to the small number of patients). In patients presenting with recurrence of mesothelioma after an MCR procedure, radical surgery to resect the recurrent tumour could have a role in improvement of survival in selected patients. Positive prognostic factors include epithelioid pathology and a longer disease-free interval after the first procedure.

Variation in outcome of invasive mechanical ventilation between different countries for patients with severe COVID-19: A systematic review and meta-analysis

BACKGROUND

COVID 19 is the most recent cause of Adult respiratory distress syndrome ARDS. Invasive mechanical ventilation IMV can support gas exchange in patients failing non-invasive ventilation, but its reported outcome is highly variable between countries. We conducted a systematic review and meta-analysis on IMV for COVID-associated ARDS to study its outcome among different countries.

METHODS

CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched up to August 8, 2020. Studies reporting five or more patients with end point outcome for severe COVID 19 infection treated with IMV were included. The main outcome assessed was mortality. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. Subgroup analysis for different countries was performed. Meta-regression for the effect of study timing and patient age and were tested. Publication bias was examined. This trial was registered with PROSPERO under registration number CRD42020190365.

FINDINGS

Our electronic search retrieved 4770 citations, 103 of which were selected for full-text review. Twenty-one studies with a combined population of 37359 patients with COVID-19 fulfilled the inclusion criteria. From this population, 5800 patients were treated by invasive mechanical ventilation. Out of those, 3301 patients reached an endpoint of ICU discharge or death after invasive mechanical ventilation while the rest were still in the ICU. Mortality from IMV was highly variable among the included studies ranging between 21% and 100%. Random-effect pooled estimates suggested an overall in-hospital mortality risk ratio of 0.70 (95% confidence interval 0.608 to 0.797; I2 = 98%). Subgroup analysis according to country of origin showed homogeneity in the 8 Chinese studies with high pooled mortality risk ratio of 0.97 (I2 = 24%, p = 0.23) (95% CI = 0.94-1.00), similar to Italy with a low pooled mortality risk ratio of 0.26 (95% CI 0.08-0.43) with homogeneity (p = 0.86) while the later larger studies coming from the USA showed pooled estimate mortality risk ratio of 0.60 (95% CI 0.43-0.76) with persistent heterogeneity (I2 = 98%, p<0.001). Meta-regression showed that outcome from IMV improved with time (p<0.001). Age had no statistically significant effect on mortality (p = 0.102). Publication bias was excluded by visualizing the funnel plot of standard error, Egger's test with p = 0.714 and Begg&Mazumdar test with p = 0.334.

INTERPRETATION

The study included the largest number of patients with outcome findings of IMV in this current pandemic. Our findings showed that the use of IMV for selected COVID 19 patients with severe ARDS carries a high mortality, but outcome has improved over the last few months and in more recent studies. The results should encourage physicians to use this facility when indicated for severely ill COVID-19 patients.

Venous pectoralis minor syndrome: a rare subdivision of the thoracic outlet syndrome

We analysed data of all patients who had received surgery for rare, isolated venous pectoralis minor syndrome at our tertiary institution from January 2015 to December 2018. Venous duplex scan was the preferred mode of diagnosis in all our patients. We operated on patients via a 5-6 cm deltopectoral groove incision. Ten procedures were performed on 6 patients, of whom 5 were female. The median age was 23 years (range 17-33 years). Three patients (2 female, 1 male) with bilateral pectoralis minor syndrome had separate procedures performed over a course of a few weeks. The median operating time was 22 min (range 15-95 min). Median blood loss was 20 ml (range 5-410 ml). The median hospital stay was 2 days (range 1-5 days). There was one complication in the form of a recurrence on the right side in a patient who had bilateral pectoralis minor syndrome. No other morbidities were recorded. Nine of 10 procedures (90%) were classified by patients as being satisfactory, where symptoms had partially or completely resolved. Our experience emphasizes the need for a systematic search and to maintain a high index of suspicion for venous pectoralis minor syndrome in all patients complaining of painful symptoms related to thoracic outlet syndrome. The deltopectoral groove approach is a simple and straightforward incision with a gentle learning curve.

Thoracoscopic management of early stages of empyema: is this the golden standard?

Background

Empyema is a well-known disease that significantly increases the morbidity and mortality associated with pneumonia. There are a number of treatment modalities available but recently video assisted thoracoscopic surgery (VATS) has been suggested as a reliable tool in management of empyema; particularly in early stages. The aim of this study is to assess the safety and effectiveness of using initial VATS for all surgically fit patients with early stages of empyema.

Methods

Sixty-six patients with early stage empyema were prospectively studied between December 2013 and March 2016. Patients were divided into two groups: group A (28 patients) were managed conservatively without surgery for stage I (exudative) phase empyema by the chest physicians; and group B (38 patients) were managed by the thoracic surgeons by VATS for stage I (exudative) and stage II (fibrino-purulent) empyema. Comparison was made between both groups.

Results

There was no statistically significant difference between the groups from the point of view of age, sex or pre-intervention comorbidities (P>0.05). Average hospital stay in group A was 22 days (7-131 days), it was 4.1 days (2-14 days) in group B (P=0.004; 95% CI: 10.3-25.5) with a resultant lower cost. Three patients (10.7%) in group A suffered from major morbidity during treatment while none in group B suffered a major postoperative morbidity (P=0.039). There were 2 mortalities (7.1%) in group A and no deaths in group B (P=0.094). During a mean follow up period of 8 months [6-14] in group A 14.3% of the patients underwent open decortication, whereas in group B, 5.3% of the patients underwent the same procedure (P=0.047).

Conclusions

Thoracoscopic management of early stages of empyema should be the golden standard of management in surgically fit patients; particularly in the fibro-exudative phase of empyema. It is an effective and safe technique that reduces hospital stay, cost, complications and avoids the need for a decortication via a thoracotomy in most cases.

Video-assisted thoracoscopic thymectomy for non-thymomatous myasthenia gravis: a right-sided or left-sided approach?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was in [patients undergoing video-assisted thoracoscopic thymectomy for myasthenia gravis (MG)] is a [left-sided approach] superior to a [right-sided approach] in terms of [clinical outcome]? Two hundred and fifty-nine papers were found using the reported search. In looking at both procedures, we selected studies with a sizeable number of patients performing or studying both procedures and comparing their outcome. Hence, only 4 studies represented the best evidence to answer the clinical question. The authors, journal, date, country, study type, patient group, relevant outcomes and results of these papers are tabulated. Two studies compared their clinical experience with a right-sided versus a left-sided video assisted thoracoscopic surgery thymectomy approach, while 1 study compared using a bilateral versus a unilateral right-sided approach in patients with non-thymomatous MG. The number of patients studied included 31, 107 and 103 patients, respectively. All 3 studies demonstrated no difference regarding surgical time, intraoperative blood loss, postoperative hospital stay, postoperative complications and therapeutic effects (the last study compared the 5-year complete stable remission rate). All 3 studies concluded that both approaches are feasible, effective and comparable in operative and long-term results for the treatment of non-thymomatous MG. One anatomical study compared both approaches in 10 cadavers, 5 in each group. They studied the size of the specimen resected and visualization of different anatomic sites via each approach. Visualization was superior using the left-sided approach, while a right-sided approach resulted in slightly higher chances of an incomplete resection. The study concluded that a left-sided approach achieves a better chance of radical thoracoscopic thymectomy due to anatomic considerations. In conclusion, despite 1 cadaveric study suggesting that a left-sided approach may achieve more complete resection, possibly due to anatomical considerations, there are no differences in outcomes with either unilateral approach in terms of complications, hospital stay or long-term symptom relief.

Choosing between the modified Ravitch and Nuss procedures for pectus excavatum: Considering the patients's perspective

INTRODUCTION Pectus excavatum (PE) is the most common paediatric chest wall deformity. The majority of patients are treated for cosmetic purposes, with the modified Ravitch and Nuss procedures the most commonly performed. We tested the preferences of healthy individuals over their choice of procedure. METHODS The study was conducted from February to August 2014. A five-item illustrated questionnaire was administered to teenagers and young adults aged 14-26 years over their willingness to seek medical advice if they had PE, provided its cosmetic appearance was the only complaint. They were asked about their preference over the modified Ravitch and Nuss procedures, with the surgical details for both procedures explained by medical professionals, alongside illustrated outcomes. RESULTS Two hundred and two healthy individuals were interviewed. The median age was 19.5 years (14-26 years) and 141 (69.8%) were male. Sixty seven (33.2%) participants refused any intervention, while 11 (5.4%) initially wanted an intervention but refused after understanding the surgical procedures available. Of the 135 respondents who chose surgical correction, 84 (62.2%) preferred the modified Ravitch operation, while 51 (37.8%) preferred the Nuss procedure. The main reason for choosing the modified Ravitch technique was not having something metal in the chest, while most participants who chose the Nuss procedure felt that it was "cosmetically better". CONCLUSIONS Patients have preferences over the choice of procedure for PE repair that can affect the treatment decision. Paediatric and thoracic surgeons should therefore be experienced in performing both procedures.

Is video-assisted thoracoscopic surgery talc pleurodesis superior to talc pleurodesis via tube thoracostomy in patients with secondary spontaneous pneumothorax?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was [in patients with secondary spontaneous pneumothorax (SSP)] is [video-assisted thoracoscopic surgery talc pleurodesis] superior to [talc pleurodesis through tube thoracostomy] in terms of [absence of recurrence and procedure morbidity]? Seventy-three papers were found using the reported search. In looking through our search strategy, we selected studies comparing both procedures and studies performing either procedures and stating their outcome, morbidity mortality and rate of recurrence. Hence, six studies and one society guideline represented the best evidence to answer the clinical question. The authors, journal, date, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Only one study compared both techniques and showed a higher length of hospital stay (14.2 vs 10.6 days; P = 0.033), higher rate of recurrence (30 vs 4.5%; P = 0.016) and higher mortality (5 vs 0%; P = 0.280) with tube thoracostomy talc pleurodesis in comparison with video-assisted thoracoscopic surgery (VATS) talc pleurodesis. Two studies looked at talc pleurodesis via tube thoracostomy (TT) alone for patients with secondary spontaneous pneumothorax (SSP). Talc pleurodesis was associated with an immediate success rate of 78.1 and 78.6%, with a short-term recurrence rate of 21.9 and 21.4%. No mortality was recorded in any study, but 1 patient (1.6%) in one study suffered from respiratory distress. No long follow-up periods were available in both studies; hence, there is no recording of long-term recurrence. Three studies looked at VATS talc pleurodesis alone in SSP patients. The procedure was associated with higher immediate success rates (90-100%) than TT pleurodesis alone with lower recurrence rates (0-10%). Average hospital stay was in the range of 3-4.7 days. Follow-up periods were 18, 22.7 and 24 months with recurrence rate ranging from 0 to 15%. No study was associated with major postoperative morbidity or in-hospital mortality. In conclusion, while there is only one study directly comparing both VATS and tube thoracostomy talc pleurodesis, the best evidence suggests that VATS talc pleurodesis for patients with secondary spontaneous pneumothorax should be considered the treatment of choice as it is associated with a higher immediate success rate, lower recurrence rate and a lower mortality than talc pleurodesis via tube thoracostomy.