Image-guided interventions are medical procedures that use computer-based systems to provide virtual image overlays to help the physician precisely visualize and target the surgical site. This field ...has been greatly expanded by the advances in medical imaging and computing power over the past 20 years. This review begins with a historical overview and then describes the component technologies of tracking, registration, visualization, and software. Clinical applications in neurosurgery, orthopedics, and the cardiac and thoracoabdominal areas are discussed, together with a description of an evolving technology named Natural Orifice Transluminal Endoscopic Surgery (NOTES). As the trend toward minimally invasive procedures continues, image-guided interventions will play an important role in enabling new procedures, while improving the accuracy and success of existing approaches. Despite this promise, the role of image-guided systems must be validated by clinical trials facilitated by partnerships between scientists and physicians if this field is to reach its full potential.
Our objective is to show the effect that standardization of surgical trays has on the number of instruments sterilized and on cost.
We reviewed our most commonly used surgical trays with the 3 ...general thoracic surgeons in our division and agreed upon the least number of surgical instruments needed for mediastinoscopy, video-assisted thoracoscopic surgery, robotic thoracic surgery, and thoracotomy.
We removed 59 of 79 instruments (75%) from the mediastinoscopy tray, 45 of 73 (62%) from the video-assisted thoracoscopic surgery tray, 51 of 84 (61%) from the robotic tray, and 50 of 113 (44%) from the thoracotomy tray. From January 2016 to December 2016, the estimated savings by procedure were video-assisted thoracoscopic surgery (n = 398) $21,890, robotic tray (n = 231) $19,400, thoracotomy (n = 163) $15,648, and mediastinoscopy (n = 162) $12,474. Estimated total savings were $69,412. The weight of the trays was reduced 70%, and the nonsteamed sterilization rate (opened trays that needed to be reprocessed) decreased from 2% to 0%. None of the surgeons requested any of the removed instruments.
Standardization of thoracic surgical trays is possible despite having multiple thoracic surgeons. This process of lean (the removal of nonvalue steps or equipment) reduces the number of instruments cleaned and carried and reduces cost. It may also reduce the incidence of "wet loads" that require the resterilization of instruments.
To illustrate the clinical course and difficulties in early diagnosis of coronavirus disease 2019 (COVID-19) in patients after thoracic surgery.
We retrospectively analyzed the clinical course of the ...first 11 patients diagnosed with COVID-19 after thoracic surgery in early January 2020. Postoperative clinical, laboratory, and radiologic records and the time line of clinical course were summarized. Potential prognostic factors were evaluated.
In the 11 confirmed cases (3 female, 8 male), median days from symptom onset to case detection was 8. Insidious symptom onset and misinterpreted postoperative changes on chest computed tomography (CT) resulted in delay in diagnosis. There were 3 fatalities due to respiratory failure, whereas 4 severe and 4 mild cases recovered and were discharged. All patients had once experienced leukocytosis and eosinopenia. Remittent fever and resected lung segments ≥5 were associated with fatality.
The case fatality rate of postsurgical patients subsequently diagnosed with COVID-19 was 27.3%. Insidious symptom onset, postoperative leukocytosis with lymphopenia, and postsurgical CT changes overshadowed the early signs of viral pneumonia. Dynamic symptom monitoring, serial chest CTs, and tests for viral RNA and serum antibody improve the chance for prompt detection of COVID-19. Consideration should be given to preadmission and preoperative screening and strict contact isolation during the postoperative period.
Resection of long-segment trachea is challenging, and although 50% of adult trachea can be removed, anastomotic complications arise proportionally. Different release manoeuvres have been described to ...gain length and reduce tension at the suture line. The aim of the study was to evaluate the outcome when different release manoeuvres have been utilized during resection and reconstruction of the trachea.
From January 2005 to December 2015, 52 patients with long segments of trachea ≥40 mm requiring resection and reconstruction were treated at our institute. Demographic, operative and postoperative data were retrospectively analysed.
Fifty-two patients with long-segment tracheal disorders ≥40 mm were analysed in this stud. Transient swallowing and phonation dysfunction occurred in 17 (32.2%) patients, exclusively in patients who underwent laryngeal release. Swallowing dysfunction was Grade I in all patients, except 2 who suffered Grade II dysphagia and were relieved in the early postoperative period. Forty-five (86.5%) patients were symptom free, and 7 (13.4%) patients were symptomatic (dyspnoea on exertion and/or stridor) and required reintervention. Four (7.6%) patients responded to 1 or 2 sessions of bronchoscopic dilatation, and 3 patients were left with permanent tracheostomies. Patients with neoplastic pathology were followed up without any neoplastic recurrence.
Long-segment resection and reconstruction of the trachea utilizing one or more release manoeuvres can be safely done, with low complication rates. Although swallowing and phonation dysfunction after laryngeal release were commonly encountered (almost one-third of patients), they were mild, transient, self-limited and recovered within 2-3 weeks of the early postoperative period.
Extracorporeal membrane oxygenation (ECMO) for respiratory support is increasingly used in intensive care units (ICU), but rarely during thoracic surgical procedures outside the transplantation ...setting. ECMO can be an alternative to cardiopulmonary bypass for major trachea-bronchial surgery and single-lung procedures without in-field ventilation. Our aim was to evaluate the intraoperative use of ECMO as respiratory support in thoracic surgery: benefits, indications and complications.
This was a multicentre retrospective study (questionnaire) of use of ECMO as respiratory support during the thoracic surgical procedure. Lung transplantation and lung resection for tumour invading the great vessels and/or the left atrium were excluded, because they concern respiratory and circulatory support.
From March 2009 to September 2012, 17 of the 34 centres in France applied ECMO within veno-venous (VV) (n=20) or veno-arterial (VA) (n=16) indications in 36 patients. Ten VA ECMO were performed with peripheral cannulation and 6 with central cannulation; all VV ECMO were achieved through peripheral cannulation. Group 1 (total respiratory support) was composed of 28 patients without mechanical ventilation, involving 23 tracheo-bronchial and 5 single-lung procedures. Group 2 (partial respiratory support) was made up of 5 patients with respiratory insufficiency. Group 3 was made up of 3 patients who underwent thoracic surgery in a setting of acute respiratory distress syndrome (ARDS) with preoperative ECMO. Mortality at 30 days in Groups 1, 2 and 3 was 7, 40 and 67%, respectively (P<0.05). In Group 1, ECMO was weaned intraoperatively or within 24 h in 75% of patients. In Group 2, ECMO was weaned in ICU over several days. In Group 1, 2 patients with VA support were converted to VV support for chronic respiratory indications. Bleeding was the major complication with 17% of patients requiring return to theatre for haemostasis. There were two cannulation-related complications (6%).
VV or VA ECMO is a satisfactory alternative to in-field ventilation in complex tracheo-bronchial surgery or in single-lung surgery. ECMO should be considered and used in precarious postoperative respiratory conditions. Full respiratory support can be achieved with VV ECMO. Indications for and results of ECMO during surgery in patients with ARDS warrant further careful investigation.
Background
A core principle in surgery is that high surgical volumes are conducive toward better outcomes. Ultra-high volume centers (UHVCs) have now emerged in thoracic surgery in China that now ...perform a volume of thoracic operations far greater than even traditional international centers of excellence.
Methods
In 2016, two hospitals in Shanghai performed over 10,000 major pulmonary, esophageal and mediastinal resections each. A qualitative analysis of the lessons learned in achieving such large operation volumes was undertaken.
Results
The advent of these UHVCs gives important insights for not only thoracic surgeons, but for surgical oncologists and surgeons globally. First, these ultra-high volumes were achieved to a large degree by cancer screening—but the success of the screening programs relies on reaching wider patient groups and allowing for affordable ‘self-screening.’ Second, the ultra-high clinical volumes at UHVCs offer unique opportunities for surgical training and research, potentially changing paradigms for academic surgery. Third, these ultra-high volumes may place new stresses on existing healthcare resources and prompt novel management strategies in response.
Conclusions
The UHVCs represent a revolutionary development in modern surgery, and it behooves surgeons to both accept the challenges and harness the advantages they may bring.
Background A dramatic transformation of cardiothoracic surgical education has evolved over the past few decades. Methods We begin by presenting recognized catalysts of this change, organized by whom ...they primarily affect: the trainees, the trainers, and the profession as a whole. Our trainees’ prior training is different, and their current demographics and priorities have changed. There is less incentive to teach, with time-honored traditions of education inadequate to meet the needs of trainees. Concurrently, our profession has to adjust to new regulations, increasing financial constraints, and an expanding body of knowledge and technology. To address these issues requires developing new models of education and assessment that can thrive in today’s environment. We discuss efforts in the United States and abroad, including new training paradigms ranging from restructuring existing models to novel approaches (eg, competency-based training). Training tools are being developed, such as online instruction, simulation-based learning, and regular student-centered assessments. Finally, models that recognize and reward teaching as a scholarly activity are being implemented. Conclusions Like the radical advances we have witnessed in surgical therapy, surgical education requires creative and perhaps disruptive changes if we are to continue to produce well-trained additions to our professional ranks.
Objective This study was undertaken to determine factors associated with in-hospital mortality among patients after general thoracic surgery and to construct a risk model. Methods Data from a ...nationally representative thoracic surgery database were collected prospectively between June 2002 and July 2005. Logistic regression analysis was used to predict the risk of in-hospital death. A risk model was developed with a training set of data (two thirds of patients) and validated on an independent test set (one third of patients). Model fit was assessed by the Hosmer–Lemeshow test; predictive accuracy was assessed by the c-index. Results Of the 15,183 original patients, 338 (2.2%) died during the same hospital admission. Within the data used to develop the model, these factors were found to be significantly associated with the occurrence of in-hospital death in a multivariate analysis: age, sex, dyspnea score, American Society of Anesthesiologists score, performance status classification, priority of surgery, diagnosis group, procedure class, and comorbid disease. The model was reliable (Hosmer–Lemeshow test 3.22; P = .92) and accurate, with a c-index of 0.85 (95% confidence interval 0.83-0.87) for the training set and 0.86 (95% confidence interval 0.83-0.89) for the test set of data. The correlation between the expected and observed number of deaths was 0.99. Conclusions The validated multivariate model Thoracoscore, described in this report for risk of in-hospital death among adult patients after general thoracic surgery was developed with national data, uses only 9 variables, and has good performance characteristics. It appears to be a valid clinical tool for predicting the risk of death.
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