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201 En-bloc chest wall VATS lobectomy – pushing the boundaries in the UK
Poster abstracts, 11th Annual British Thoracic Oncology Group Conference, 2013: Surgery VATS for suspected malignant pleural effusions in a single thoracic surgical practice over a 39 month period. Results of pleural fluid and biopsies, sent for cytological and histological examination, were analysed. Results: MPE was diagnosed in 99 of 170 (58%) patients; 70 of which were malignant pleural mesothelioma (MPM), 29 adenocarcinoma metastatic to the pleura. Cytology contradicted a benign biopsy result in 1 case. Comparison of results showed that cytology was significantly less effective than histology in diagnosis of malignancy (p < 0.0001, Fisher’s). Cytology was found to have a sensitivity of 25%, specificity 100%, positive predictive value 100% and negative predictive value of 49% for diagnosis of malignancy. Histology had a sensitivity 97%, specificity 100%, positive predictive value 100% and negative predictive value 96% for diagnosis of malignancy. The median volume of pleural fluid submitted was 15 ml (range 0.75 200 ml) with 4 of 33 samples <10 ml and 21 of 137 samples 10 ml diagnostic of malignancy (p = 0.10). Cytology had greater accuracy in metastatic disease (13 of 29) than MPM (12 of 70) (p = 0.002). Conclusion: Cytology does not contribute significantly to diagnosis of MPE at VATS if adequate pleural biopsies can be obtained. The volume of cytology sample does not significantly affect results. Cytology appears to have greater diagnostic value in metastatic disease than MPM. 199 Early experience of a digital chest drainage system in the management of patients with malignant pleural effusion K.H.K. Morcos *, F. Granato, L. Kerr, S. Aftab, A.J.B. Kirk. Golden Jubilee National Hospital, UK Background: Although digital suction devices (DSD) have demonstrated their efficacy in the management of air leak, their role in the treatment of malignant pleural effusion (MPE) is still to be defined. The aim of our study is to investigate the impact of routine use of DSD (Medela Thopaz® drain) in patients with MPE on the length of hospital stay (LOS). Methods: From January 2011 to April 2012, 149 consecutive patients with suspected malignant pleural effusion submitted to pleural biopsy and chest drain insertion at a single institution were retrospectively evaluated. Pathological findings were collected for all patients. In the group of patients with MPE, the impact of the type of drain used (conventional underwater seal versus digital suction device) on the LOS was assessed. Statistical analysis was carried out using Student’s t-test (Statistical significance p < 0.05). Results: Sixty three (42%) patients out of 149 with MPE were included in our study. Malignant mesothelioma was diagnosed in 43 (68.25%) patients. Metastatic lung, breast, ovarian, renal and bladder cancer accounted for the remaining 20 (31.75%) of the total MPE. Conventional underwater seal drain was used in 40 (63.5%) patients (group A), whereas 23 (36.5%) received a digital suction device (Thopaz) (group B). Group B showed a trend towards shorter LOS (6.74± 1.06 days versus 9.43± 1.47 days, p = 0.2078) when compared with group A. Conclusion: Thopaz drain may decrease the LOS and provides electronically tangible data recordings. The routine use of digital suction drains permits early postoperative mobilization and ambulatory pleural suction. 200 Experience with a digital chest drainage suction system (Thopaz) in the management of patients with malignant chest disease K. Morcos *, A.J.B. Kirk. Golden Jubilee National Hospital, Clydebank, UK Background: Digital chest drainage (DCD) systems are being increasingly used in Thoracic Surgery. This study describes a oneyear experience of DCD in the management of patients undergoing Thoracic surgery for the management of malignant disease.
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Patients and Methods: Between October 2011 & September 2012, 642 patients underwent 650 thoracic surgical procedures. In all cases, pleural drainage was by intercostal tube drainage using a DCD system (Thopaz® , Medela UK). 220 were lung resections for primary lung cancer (25 VATS), 98 were various metastasectomies (90 VATS) and 112 were investigative/palliative (52 pleural biopsy +/ pleurodesis, 50 pleurodesis & 10 insertion of tunnelled intrapleural catheters). Drains were removed when airflow on the Thopaz was <50 ml/min for 6 consecutive hours. Duration of chest drainage and hospital stay were compared to a matched group of patients operated on by the same surgeon prior to introduction of Thopaz. Results: In patients undergoing lung resection, patients with Thopaz drains were discharged earlier than those with conventional underwater seal drainage (4.9 v 6.2 days, p < 0.05). This appeared entirely due to the fact that drains were removed earlier. This effect was not as marked in the pleural effusion group, but qualitative measures suggested that these patients were mobilised earlier and had fewer complications. The incidence of trapped lung was less in the Thopaz group (2/112 v 12/153, p < 0.05). Conclusions: DCD for management of patients following lung resection is associated with early drain removal and significantly reduced hospital stay. DCD for the management of malignant pleural effusions may be associated with reduced hospital stay, and contributes to early mobilisation and reduced postoperative complications. Thopaz contributes to improved outcomes in patients undergoing Thoracic Surgery for malignant disease and has become a valuable tool to aid their enhanced recovery. 201 En-bloc chest wall VATS lobectomy pushing the boundaries in the UK S.A. Stamenkovic *, A. Wiggins. Department of Thoracic Surgery, Freeman Hospital, Newcastle upon Tyne, UK Introduction: Video-assisted thoracoscopic surgery (VATS) lung resection celebrates its 20th year in the UK, however the surgeons are only starting to see the benefits of considering this approach to all patients. Methods: An approach for lung cancer invading ribs was considered, as there has been a recent suggestion that the avoidance of ribspreading may reduce thoracotomy pain and neuropraxia, in all settings of lung cancer, including that when the tumour is peripheral in the lung and invading the chest wall. Results: A 60-year man with a 30-pack year history had an incidental finding of an apical right T2a N0 cancer. He had a slight ache in the right anterior chest. FEV1 was 68% and DLCO 91% predicted. PETCT scan suggested no chest wall invasion. A 3 port-VATS approach was made including a 6 cm anterior utility port. Hemithorax review revealed more local advanced tumour than the radiology had suggested invasion into 2nd and 3rd ribs a lateral portion of these ribs were resected before doing a VATS resection of the upper lobe. The ribs were resected by performing a VATS dissection of them internally and then extending the posterior port and using an angled rib cutter to allow safe division. The VATS lobectomy followed a standard course, separately mobilising and dividing each hilar structure. Post-operatively, the patient had significant pain around the drain site only visual-analogue pain score (VAPS) 8, with mild pain in the port wounds. Once the drain was removed, the VAPS decreased to 2 and normal mobility resulted, with discharge the next day (8). Conclusion: VATS surgery should be considered in all patients, including locally advanced cancer. Rib resection is safe and visualised better as a VATS technique, in particular for apical tumours. A straight and longer rib cutter would facilitate internal division of ribs.
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Patients and Methods: Between October 2011 & September 2012, 642 patients underwent 650 thoracic surgical procedures. In all cases, pleural drainage was by intercostal tube drainage using a DCD system (Thopaz® , Medela UK). 220 were lung resections for primary lung cancer (25 VATS), 98 were various metastasectomies (90 VATS) and 112 were investigative/palliative (52 pleural biopsy +/ pleurodesis, 50 pleurodesis & 10 insertion of tunnelled intrapleural catheters). Drains were removed when airflow on the Thopaz was <50 ml/min for 6 consecutive hours. Duration of chest drainage and hospital stay were compared to a matched group of patients operated on by the same surgeon prior to introduction of Thopaz. Results: In patients undergoing lung resection, patients with Thopaz drains were discharged earlier than those with conventional underwater seal drainage (4.9 v 6.2 days, p < 0.05). This appeared entirely due to the fact that drains were removed earlier. This effect was not as marked in the pleural effusion group, but qualitative measures suggested that these patients were mobilised earlier and had fewer complications. The incidence of trapped lung was less in the Thopaz group (2/112 v 12/153, p < 0.05). Conclusions: DCD for management of patients following lung resection is associated with early drain removal and significantly reduced hospital stay. DCD for the management of malignant pleural effusions may be associated with reduced hospital stay, and contributes to early mobilisation and reduced postoperative complications. Thopaz contributes to improved outcomes in patients undergoing Thoracic Surgery for malignant disease and has become a valuable tool to aid their enhanced recovery. 201 En-bloc chest wall VATS lobectomy pushing the boundaries in the UK S.A. Stamenkovic *, A. Wiggins. Department of Thoracic Surgery, Freeman Hospital, Newcastle upon Tyne, UK Introduction: Video-assisted thoracoscopic surgery (VATS) lung resection celebrates its 20th year in the UK, however the surgeons are only starting to see the benefits of considering this approach to all patients. Methods: An approach for lung cancer invading ribs was considered, as there has been a recent suggestion that the avoidance of ribspreading may reduce thoracotomy pain and neuropraxia, in all settings of lung cancer, including that when the tumour is peripheral in the lung and invading the chest wall. Results: A 60-year man with a 30-pack year history had an incidental finding of an apical right T2a N0 cancer. He had a slight ache in the right anterior chest. FEV1 was 68% and DLCO 91% predicted. PETCT scan suggested no chest wall invasion. A 3 port-VATS approach was made including a 6 cm anterior utility port. Hemithorax review revealed more local advanced tumour than the radiology had suggested invasion into 2nd and 3rd ribs a lateral portion of these ribs were resected before doing a VATS resection of the upper lobe. The ribs were resected by performing a VATS dissection of them internally and then extending the posterior port and using an angled rib cutter to allow safe division. The VATS lobectomy followed a standard course, separately mobilising and dividing each hilar structure. Post-operatively, the patient had significant pain around the drain site only visual-analogue pain score (VAPS) 8, with mild pain in the port wounds. Once the drain was removed, the VAPS decreased to 2 and normal mobility resulted, with discharge the next day (8). Conclusion: VATS surgery should be considered in all patients, including locally advanced cancer. Rib resection is safe and visualised better as a VATS technique, in particular for apical tumours. A straight and longer rib cutter would facilitate internal division of ribs.