Quality of life with minimally invasive repair of pectus excavatum: a systematic review and meta-analysis

Background

Minimally invasive repair of pectus excavatum (MIRPE) is a popular method for surgical correction of PE, and its impact on quality of life is a growing area of interest. We performed a systematic review and meta-analysis to evaluate the impact of MIRPE on the quality of life of patients.

Methods

This study was registered with PROSPERO under reference number CRD42020222061. A literature search of PubMed, Cochrane Library, EMBASE and Scopus was conducted from the date of inception till November 23, 2020. We included studies which administered one or more questionnaires on patients up to 60 years old, parents or both, to assess the quality of life before and after MIRPE. Studies not written in English, abstracts, articles without primary data, reviews and studies which combined data on PE and other deformities were excluded. Risk of bias was assessed using the Risk of Bias in Non-randomised Studies of Interventions and the Cochrane risk of bias tool. A random-effects meta-analysis was performed to obtain mean differences for key themes of quality of life before and after MIRPE. Responses from the same questionnaires, as well as common themes across different questionnaires, were compared.

Results

Of the 20 studies identified for systematic review, 7 studies that reported the responses of 478 patients were included in the meta-analysis. Patients who underwent MIRPE experienced an increased self-esteem [standardized mean difference (SMD): 1.38, 95% confidence interval (CI): 0.95 to 1.81, P<0.00001] and a smaller degree of chest interference with their social activities (SMD: 0.84, 95% CI: 0.60 to 1.08, P<0.00001). These findings were consistent even after the implanted bar was removed.

Conclusions

MIRPE may be associated with a better quality of life for patients with PE as self-esteem and extent of chest interference with social activities are improved after the procedure. The key limitations of this study are the lack of high-quality evidence due to paucity of randomized trials, and the significant heterogeneity in reported outcomes due to variations in the questionnaires and timepoints of administration.

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis

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.

Lung erosion following adjuvant immunotherapy with pembrolizumab: a case report

BACKGROUND

Pembrolizumab 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 PRESENTATION

A 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.

CONCLUSION

Adjuvant 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.

Novel Nuss Bar Fixation Using ZipFix for Pectus Excavatum

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.

From Pandemic to Endemic-Redefining Excellence in Thoracic Surgery Service Delivery

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.

Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication

Background

Lung separation may be achieved through the use of double lumen tubes or endobronchial blockers. The use of lung separation techniques carries the risk of airway injuries which range from minor complications like postoperative hoarseness and sore throat to rare and potentially devastating tracheobronchial mucosal injuries like bronchus perforation or rupture. With few case reports to date, bronchial rupture with the use of endobronchial blockers is indeed an overlooked complication.

Case presentation

A 78-year-old male patient with a left upper lobe lung adenocarcinoma underwent a left upper lobectomy with a Fuji Uniblocker® as the lung separation device. Despite an atraumatic insertion and endobronchial blocker balloon volume within manufacturer specifications, an intraoperative air leak developed, and the patient was found to have sustained a left mainstem bronchus rupture which was successfully repaired and the patient extubated uneventfully. Unfortunately, the patient passed on in-hospital from sepsis and other complications.

Conclusion

Bronchial rupture is a serious complication of endobronchial blocker use that can carry significant morbidity, and due care should be exercised in its use and placement. Bronchoscopy should be used during insertion, and the volume and pressure of the balloon kept to the minimum required to prevent air leak. Bronchial injury should be considered as a differential in the presence of an unexplained air leak.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01430-6.

Incorporation of an intercostal catheter into a multimodal analgesic strategy for uniportal video-assisted thoracoscopic surgery: a feasibility study

Background

Well-controlled postoperative pain is essential for early recovery after uniportal video-assisted thoracoscopic surgery (UVATS). Conventional analgesia like opioids and thoracic epidural anaesthesia have been associated with hypotension and urinary retention. Intercostal catheters are a regional analgesic alternative that can be inserted during UVATS to avoid these adverse effects. This feasibility study aims to evaluate the postoperative pain scores and analgesic requirements with incorporation of an intercostal catheter into a multimodal analgesic strategy for UVATS.

Methods

In this observational study, 26 consecutive patients who underwent UVATS were administered a multilevel intercostal block and oral paracetamol. All of these patients received 0.2% ropivacaine continuously at 4 ml/h via an intercostal catheter at the level of the incision. Rescue analgesia including etoricoxib, gabapentin and opioids were prescribed using a pain ladder approach. Postoperative pain scores and analgesic usage were assessed. The secondary outcomes were postoperative complications, days to ambulation and length of stay.

Results

No technical difficulties were encountered during placement of the intercostal catheter. There was only one case of peri-catheter leakage. Mean pain score was 0.31 (range 0–2) on post-operative day 1 and was 0.00 by post-operative day 5. 16 patients (61.6%) required only oral rescue analgesia. The number of patients who required rescue non-opioids only increased from 1 in the first 7 months to 8 in the next 7 months. There were no cases of hypotension or urinary retention. Median time to ambulation was 1 day (range 1–2). Mean post-operative length of stay was 4.17 ± 2.50 days.

Conclusions

Incorporation of an intercostal catheter into a multimodal analgesia strategy for UVATS is feasible and may provide adequate pain control with decreased opioid usage.

Cross-tissue single-cell landscape of human monocytes and macrophages in health and disease

Mononuclear phagocytes (MNPs) encompass dendritic cells, monocytes, and macrophages (MoMac), which exhibit antimicrobial, homeostatic, and immunoregulatory functions. We integrated 178,651 MNPs from 13 tissues across 41 datasets to generate a MNP single-cell RNA compendium (MNP-VERSE), a publicly available tool to map MNPs and define conserved gene signatures of MNP populations. Next, we generated a MoMac-focused compendium that revealed an array of specialized cell subsets widely distributed across multiple tissues. Specific pathological forms were expanded in cancer and inflammation. All neoplastic tissues contained conserved tumor-associated macrophage populations. In particular, we focused on IL4I1⁺CD274(PD-L1)⁺IDO1⁺ macrophages, which accumulated in the tumor periphery in a T cell-dependent manner via interferon-γ (IFN-γ) and CD40/CD40L-induced maturation from IFN-primed monocytes. IL4I1_Macs exhibited immunosuppressive characteristics through tryptophan degradation and promoted the entry of regulatory T cell into tumors. This integrated analysis provides a robust online-available platform for uniform annotation and dissection of specific macrophage functions in healthy and pathological states.

Antifibrinolytics reduces blood loss in thoracic surgery: a systematic review and meta-analysis

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.

Rescue extracorporeal membrane oxygenation for massive anterior mediastinal masses

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.

Organization of thoracic surgical services during the COVID pandemic

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.

Eomes Expression Defines Group 1 Innate Lymphoid Cells During Metastasis in Human and Mouse

Recent studies have attempted to uncover the role of Group 1 Innate lymphoid cells (ILCs) in multiple physiological contexts, including cancer. However, the definition and precise contribution of Group 1 ILCs (constituting ILC1 and NK subsets) to metastasis is unclear due to the lack of well-defined cell markers. Here, we first identified ILC1 and NK cells in NSCLC patient blood and differentiated them based on the expression of transcription factors, T-bet and Eomes. Interestingly, Eomes downregulation in the peripheral blood NK cells of NSCLC patients positively correlated with disease progression. Additionally, we noted higher Eomes expression in NK cells (T-bet⁺Eomes^hi) compared to ILC1s (T-bet⁺Eomes^lo). We asked whether the decrease in Eomes was associated with the conversion of NK cells into ILC1 using Eomes as a reliable marker to differentiate ILC1s from NK cells. Utilizing a murine model of experimental metastasis, we observed an association between increase in metastasis and Eomes downregulation in NKp46⁺NK1.1⁺ Group 1 ILCs, which was consistent to that of human NSCLC samples. Further confirmation of this trend was achieved by flow cytometry, which identified tissue-specific Eomes^lo ILC1-like and Eomes^hi NK-like subsets in the murine metastatic lung based on cell surface markers and adoptive transfer experiments. Next, functional characterization of these cell subsets showed reduced cytotoxicity and IFNγ production in Eomes^lo ILC1s compared to Eomes^hi cells, suggesting that lower Eomes levels are associated with poor cancer immunosurveillance by Group 1 ILCs. These findings provide novel insights into the regulation of Group 1 ILC subsets during metastasis, through the use of Eomes as a reliable marker to differentiate between NK and ILC1s.

pHLuc, a Ratiometric Luminescent Reporter for in vivo Monitoring of Tumor Acidosis

Even under normoxia, cancer cells exhibit increased glucose uptake and glycolysis, an occurrence known as the Warburg effect. This altered metabolism results in increased lactic acid production, leading to extracellular acidosis and contributing to metastasis and chemoresistance. Current pH imaging methods are invasive, costly, or require long acquisition times, and may not be suitable for high-throughput pre-clinical small animal studies. Here, we present a ratiometric pH-sensitive bioluminescence reporter called pHLuc for in vivo monitoring of tumor acidosis. pHLuc consists of a pH-sensitive GFP (superecliptic pHluorin or SEP), a pH-stable OFP (Antares), and Nanoluc luciferase. The resulting reporter produces a pH-responsive green 510nm emission (from SEP) and a pH-insensitive red-orange 580nm emission (from Antares). The ratiometric readout (R_{580 / 510}) is indicative of changes in extracellular pH (pH_e). In vivo proof-of-concept experiments with NSG mice model bearing human synovial sarcoma SW982 xenografts that stably express the pHLuc reporter suggest that the level of acidosis varies across the tumor. Altogether, we demonstrate the diagnostic value of pHLuc as a bioluminescent reporter for pH variations across the tumor microenvironment. The pHLuc reporter plasmids constructed in this work are available from Addgene.

Two distinct interstitial macrophage populations coexist across tissues in specific subtissular niches

Macrophages are a heterogeneous cell population involved in tissue homeostasis, inflammation, and various pathologies. Although the major tissue-resident macrophage populations have been extensively studied, interstitial macrophages (IMs) residing within the tissue parenchyma remain poorly defined. Here we studied IMs from murine lung, fat, heart, and dermis. We identified two independent IM subpopulations that are conserved across tissues: Lyve1^loMHCII^hiCX3CR1^hi (Lyve1^loMHCII^hi) and Lyve1^hiMHCII^loCX3CR1^lo (Lyve1^hiMHCII^lo) monocyte-derived IMs, with distinct gene expression profiles, phenotypes, functions, and localizations. Using a new mouse model of inducible macrophage depletion (Slco2b1 ^flox/DTR), we found that the absence of Lyve1^hiMHCII^lo IMs exacerbated experimental lung fibrosis. Thus, we demonstrate that two independent populations of IMs coexist across tissues and exhibit conserved niche-dependent functional programming.

CD151, a laminin receptor showing increased expression in asthmatic patients, contributes to airway hyperresponsiveness through calcium signaling

BACKGROUND

Airway smooth muscle (ASM) contraction underpins airway constriction; however, underlying mechanisms for airway hyperresponsiveness (AHR) remain incompletely defined. CD151, a 4-transmembrane glycoprotein that associates with laminin-binding integrins, is highly expressed in the human lung. The role of CD151 in ASM function and its relationship to asthma have yet to be elucidated.

OBJECTIVE

We sought to ascertain whether CD151 expression is clinically relevant to asthma and whether CD151 expression affects AHR.

METHODS

Using immunohistochemical analysis, we determined the expression of CD151 in human bronchial biopsy specimens from patients with varying asthma severities and studied the mechanism of action of CD151 in the regulation of ASM contraction and bronchial caliber in vitro, ex vivo, and in vivo.

RESULTS

The number of CD151⁺ ASM cells is significantly greater in patients with moderate asthma compared with those in healthy nonasthmatic subjects. From loss- and gain-of-function studies, we reveal that CD151 is required for and enhances G protein-coupled receptor (GPCR)-induced peak intracellular calcium release, the primary determinant of excitation-contraction coupling. We show that the localization of CD151 can also be perinuclear/cytoplasmic and offer an explanation for a novel functional role for CD151 in supporting protein kinase C (PKC) translocation to the cell membrane in GPCR-mediated ASM contraction at this site. Importantly, CD151^-/- mice are refractory to airway hyperreactivity in response to allergen challenge.

CONCLUSIONS

We identify a role for CD151 in human ASM contraction. We implicate CD151 as a determinant of AHR in vivo, likely through regulation of GPCR-induced calcium and PKC signaling. These observations have significant implications in understanding the mechanism for AHR and the efficacy of new and emerging therapeutics.

Uncovering what lies beneath a Salmonella enterica empyema

A 67-year-old woman with myelodysplastic syndrome (MDS) and transfusional haemosiderosis developed Salmonella empyema caused by direct extension from splenic abscesses. She was successfully treated with antibiotics, pleural decortication and splenectomy. She had presented with fever after being treated for presumed pneumonia and parapneumonic effusion 2 months prior. CT scan showed splenic abscesses eroding through the diaphragm causing a left pleural empyema. Pleural fluid and spleen bacterial cultures grew Salmonella enterica. She was treated with 4 weeks of antibiotics and underwent surgical pleural decortication and splenectomy in the same sitting. She made a good postoperative recovery. Patients with severe iron overload are susceptible to various types of bacterial sepsis, including salmonellosis. It is unusual for enteric bacterial such as Salmonella to present with empyema, and should prompt a search for intra-abdominal infection. Pleural decortication and splenectomy can be performed during the same surgical sitting and can lead to good surgical outcomes.

Laminin drives survival signals to promote a contractile smooth muscle phenotype and airway hyperreactivity

Increased airway smooth muscle (ASM) mass is believed to underlie the relatively fixed airway hyperresponsiveness (AHR) in asthma. Developments of therapeutic approaches to reverse airway remodeling are impeded by our lack of insight on the mechanisms behind the increase in mass of contractile ASM cells. Increased expression of laminin, an extracellular matrix protein, is associated with asthma. Our studies investigate the role of laminin-induced ASM survival signals in the development of increased ASM and AHR. Antagonizing laminin integrin binding using the laminin-selective competing peptide, YIGSR, and mimicking laminin with exogenous α2-chain laminin, we show that laminin is both necessary and sufficient to induce ASM cell survival, concomitant with the induction of ASM contractile phenotype. Using siRNA, we show that the laminin-binding integrin α7β1 mediates this process. Moreover, in laminin-211-deficient mice, allergen-induced AHR was not observed. Notably, ASM cells from asthmatic airways express a higher abundance of intracellular cell survival proteins, consistent with a role for reduced rates of cell apoptosis in development of ASM hyperplasia. Targeting the laminin-integrin α7β1 signaling pathway may offer new avenues for the development of therapies to reduce the increase in mass of contractile phenotype ASM cells that underlie AHR in asthma.

Video-assisted thoracic surgery repair of subclavian artery injury following central venous catheterization: a new approach

OBJECTIVES

Iatrogenic subclavian artery puncture following central venous catheterization is a rare but potentially fatal complication. There are very few reports in the literature on this condition. We propose the use of video-assisted thoracic surgery (VATS) in the management of these injuries.

METHODS

The technique of VATS to manage subclavian artery injury was described. We presented the first reported case of successful repair of subclavian artery injury using VATS.

RESULTS

Using a two-incisional approach for VATS, the haemothorax was rapidly evacuated and the subclavian artery injury was successfully repaired using pledgetted sutures under direct thoracoscopic visualization. The patient had an uneventful postoperative recovery.

CONCLUSIONS

VATS can be successfully applied to repair subclavian artery injury. The advantages include rapid intrathoracic access, excellent thoracoscopic visualization of the thoracic inlet, and avoidance of the morbidity associated with open thoracotomy.