Cardiothoracic surgery

This chapter focuses on cardiothoracic surgery. It begins by outlining the principles of cardiac surgery. The majority of procedures are coronary artery bypass graft (CABG) operations, followed by aortic valve replacements, mitral valve (MV) repair and replacements, and aortic surgeries. Meticulous preoperative work-up is essential. All investigations must be checked; sometimes, even small abnormalities can have significant harmful consequences to the patient outcomes. Many patients are elderly with multiple comorbidities, but most of the patients should be out of ICU within a day or two, and ready to go home in a week. The chapter then looks at coronary artery disease, valvular heart disease, lung cancer, pleural effusion, pneumothorax, and mediastinal disease. It also considers the cardiothoracic ICU.

Salvage Resection of Mediastinal Nonseminomatous Germ Cell Tumor in a Patient with Extrathoracic Involvement upon Progression following High-Dose Chemotherapy

Primary mediastinal nonseminomatous germ cell tumor with extrathoracic metastases is associated with a very high mortality rate, and there is no consensus regarding optimal upfront therapy. Once patients fail the first-line treatment, salvage therapy often fails to effectively control the disease. Resection of the residual mediastinal mass does not appear to achieve long-term control in those who have extrathoracic metastases following conventional first-line systemic therapy. We report a case where a young man presented with symptomatic brain metastases as well as extensive visceral involvement of the liver, small intestine, and lungs. He was successfully managed with multimodality treatment including high-dose chemotherapy with hematopoietic stem cell support following standard first-line chemotherapy, resection of mediastinal disease, lung metastasectomy, and stereotactic brain radiation. He has achieved long-term survival.

The expected indications for video-assisted thoracoscopic surgery in Sub-Saharan Africa

Video-assisted thoracoscopic surgery (VATS) in Sub-Saharan Africa (SSA) is still an evolving surgical procedure that can be used for well-selected patients to treat various pathologies such as pleural disease, lung pathology, esophageal disease, diaphragmatic pathology, mediastinal disease, and other conditions. From the review of literature, over the years, for which VATS has been in use showed that SSA with a good sizeable population has still not embraced the surgical procedure. This is so despite the wide spectrum of diseases and clinical conditions in the region for which VATS can conveniently be applied in other to improve post-operative outcome and reduce post-operate mortality rate. Thus, this review should be a wakeup call for the region and to stimulate the desire in them to make consistent efforts by training doctors and putting the necessary infrastructures in place to ensure the adoption of this method of medical and surgical practice as it decreases post-operative complications and post-operative mortality rates.

Modified technique of closing the port site after multiport thoracoscopic surgery using the shingled suture technique: a single centre experience

Background Due to improvements in operative techniques and medical equipment, video-assisted thoracoscopic surgery has become a mainstay of thoracic surgery. Nevertheless, in multiport thoracoscopic surgery, there have been no substantial advances related to the improvement of the esthetics of the site of the chest tube kept for postoperative drainage of intrathoracic fluid and decompression of air leak after thoracoscopic surgery. Leakage of fluid and air around the site of the chest tube can be extremely bothersome to patients. Methods From March 2019 to April 2020, we used a modified technique of closing the port site in 67 patients and the traditional method in 51 patients undergoing multiport thoracoscopic surgery due to lung disease or mediastinal disease. We recorded patients’ age, gender, body mass index, surgical method, postoperative drainage time, and postoperative complications.The NRS pain scale was used to score the pain in each patient on the day of extubation.The PSAS and the OSAS were used for the assessment of scars one month after surgery. Results In the modified technique group, only one patient (1.49%) had pleural effusion leakage, compared with five patients (9.80%) in the traditional method group (P < 0.05). There were no significant differences in the pain of extubating and wound dehiscence between the two groups. However,the incidence rates of wound dehiscence in the modified technique group were lower than in the traditional method group. There were no post-removal pneumothorax and wound infection in either of the groups. Significant differences in the PSAS and OSAS were observed between the groups,where the modified technique group was superior to the traditional method group. Conclusions The modified technique of port site closure is a leak-proof method of fixation of the chest tube after multiport thoracoscopic surgery. Moreover, it is effective and preserves the esthetic appearance of the skin.

SNPs in genes encoding for IL-10, TNF-α, and NFκB p105/p50 are associated with clinical prognostic factors for patients with Hodgkin lymphoma

Classical Hodgkin lymphoma (cHL) is a B-cell-derived malignant neoplasia that has a unique histological distribution, in which the scarce malignant Hodgkin and Reed-Sternberg cells are surrounded by nonmalignant inflammatory cells. The interactions between the malignant and inflammatory cells are mediated by aberrantly produced cytokines, which play an important role in tumor immunopathogenesis. Single nucleotide polymorphisms (SNPs) in genes encoding cytokines and their regulatory proteins may influence the peripheral levels of these molecules and affect disease’s pathobiology. In this study, we evaluate SNPs in the promoter regions of the genes encoding for two key cytokines in Hodgkin lymphoma: IL-10 (SNP/pIL10–592, rs1800872; and SNP/pIL10–1082, rs1800896) and TNF-α (SNP/pTNF -238, rs361525; and SNP/pTNF -862, rs1800630), as well as an SNP in the intronic region of the NFκB1 gene (SNP/iNFKB1, rs1585215), an important regulator of cytokine gene expression. We then look to their possible association with clinical and laboratory features in cHL patients. Seventy-three patients with cHL are genotyped by qPCR-high resolution melting. The SNPs’ genotypes are analyzed individually for each SNP, and when more than two allelic combinations are identified, the genotypes are also divided into two groups according to proposed biological relevance. By univariate analysis, patients harboring SNP/pTNF -238 AG genotype more frequently have EBV-associated cHL compared to homozygous GG, whereas the presence of mediastinal disease (bulky and nonbulky) is more common in the pIL10–592 AC/CC group compared to the AA homozygous group. Patients with SNP/iNFKB1 AA genotype more frequently have stage IV and extranodal disease at diagnosis. These results indicate that some SNPs’ genotypes for IL-10 and TNF-α genes are associated with prognostic parameters in cHL. For the first time, the SNP/iNFKB1 is described in association with clinical features of the disease.

Anterior Mediastinal Lesion Segmentation Based on Two-Stage 3D ResUNet With Attention Gates and Lung Segmentation

ObjectivesAnterior mediastinal disease is a common disease in the chest. Computed tomography (CT), as an important imaging technology, is widely used in the diagnosis of mediastinal diseases. Doctors find it difficult to distinguish lesions in CT images because of image artifact, intensity inhomogeneity, and their similarity with other tissues. Direct segmentation of lesions can provide doctors a method to better subtract the features of the lesions, thereby improving the accuracy of diagnosis.MethodAs the trend of image processing technology, deep learning is more accurate in image segmentation than traditional methods. We employ a two-stage 3D ResUNet network combined with lung segmentation to segment CT images. Given that the mediastinum is between the two lungs, the original image is clipped through the lung mask to remove some noises that may affect the segmentation of the lesion. To capture the feature of the lesions, we design a two-stage network structure. In the first stage, the features of the lesion are learned from the low-resolution downsampled image, and the segmentation results under a rough scale are obtained. The results are concatenated with the original image and encoded into the second stage to capture more accurate segmentation information from the image. In addition, attention gates are introduced in the upsampling of the network, and these gates can focus on the lesion and play a role in filtering the features. The proposed method has achieved good results in the segmentation of the anterior mediastinal.ResultsThe proposed method was verified on 230 patients, and the anterior mediastinal lesions were well segmented. The average Dice coefficient reached 87.73%. Compared with the model without lung segmentation, the model with lung segmentation greatly improved the accuracy of lesion segmentation by approximately 9%. The addition of attention gates slightly improved the segmentation accuracy.ConclusionThe proposed automatic segmentation method has achieved good results in clinical data. In clinical application, automatic segmentation of lesions can assist doctors in the diagnosis of diseases and may facilitate the automated diagnosis of illnesses in the future.

Modified technique of closing the port site after multiport thoracoscopic surgery using the shingled suture technique: a single centre experience

Background: Due to improvements in operative techniques and medical equipment, video-assisted thoracoscopic surgery has become a mainstay of thoracic surgery. Nevertheless, in multiport thoracoscopic surgery,there have been no substantive improvements in how to improve the aesthetics of the site of the chest tube left for postoperative drainage of intrathoracic fluid and decompression of air leak after the thoracoscopic surgery. Leakage of fluid and air around the site of the chest tube can be extremely bothersome to the patient. Methods: From March 2019 to April 2020, we used modified technique of closing the port site in 67 patients and traditional method in 51 patients who underwent multiport thoracoscopic surgery due to lung disease or mediastinal disease. With our modified technique, the muscle and fat layers are sutured separately and a removal-free, absorbable, continuous intradermal suture is used for the skin closure to assure both a tight closure and a better aesthetic appearance. The traditional method of fixation of the chest tube use two sutures to close the skin on each side of the chest tube.Results: The chest tubes were removed 2–13 days after the thoracoscopic procedure. In the modified technique group,one patients (1.49%) had fluid extravasation, which was better than five patients (9.80%) in the traditional method group (P<0.05).There were no significant differences in subcutaneous emphysema and wound dehiscenc between the two groups.However,the incidence of subcutaneous emphysema and wound dehiscenc in the modified technique group were lower than in the traditional method group.There were no post-removal pneumothorax and wound infection in either groups.Conclusions: This modified technique of port site closure is a leak-proof method of fixation of the chest tube after multiport thoracoscopic surgery and effective with aesthetic appearance of the skin.

Brentuximab vedotin in combination with nivolumab, doxorubicin, and dacarbazine in newly diagnosed patients with advanced-stage Hodgkin lymphoma (Trial in Progress).

TPS8068 Background: Brentuximab vedotin (BV, ADCETRIS) is approved for the treatment of adults with treatment-naïve Stage III or IV cHL in combination with AVD (Connors 2017). Nivolumab is approved for treatment of adults with relapsed/refractory cHL. Both agents have been well tolerated with promising activity when combined with multi-agent chemotherapy. The combination of BV plus nivolumab was evaluated as a frontline treatment option for patients (pts) with cHL who are over 60 years and ineligible for or declined conventional combination chemotherapy (Friedberg, 2018). The ongoing study reported an ORR of 82% in 11 pts and appears well tolerated in this population. In another trial in 93 patients in the first salvage setting, the combination produced a 67% CR rate (Herrera 2018, Moskowitz 2019) and the majority of patients were able to undergo subsequent stem cell transplant. It is reasonable to expect that the combination of BV, nivolumab, A, and D (AN + AD) will result in high response rates and be well tolerated, with potentially less toxicity. Methods: SGN35-027 (NCT03646123) is a phase 2 study designed to evaluate the efficacy and safety of A+AVD when administered with growth factor prophylaxis in pts with stage III/IV cHL (Part A). Part B will evaluate the combination of AN + AD in a similar patient population. The primary objective of Part B is to estimate the CR rate at EOT in pts with treatment-naïve advanced cHL. Patients in Part B will have Ann Arbor Stage IIB/III/IV cHL or Stage IIA cHL with bulky mediastinal disease. Enrollment is ongoing in both parts of the study. Approximately 50 pts will be enrolled in Part B. All pts will be treated with BV 1.2 mg/kg, nivolumab 240 mg, doxorubicin 25 mg/m2, and dacarbazine 375 mg/m2, administered separately by IV infusion on Days 1 and 15 of each 28-day cycle for up to 6 cycles. Efficacy will be assessed by PET/CT scans at C2 and EOT. Disease assessments will be performed periodically during follow up. Disease response and progression will be assessed using Lugano with the incorporation of LYRIC (Cheson 2016). Clinical trial information: NCT03646123 .

Is an analytical dose engine sufficient for intensity modulated proton therapy in lung cancer?

Objective: To identify a subgroup of lung cancer plans where the analytical dose calculation (ADC) algorithm may be clinically acceptable compared to Monte Carlo (MC) dose calculation in intensity modulated proton therapy (IMPT). Methods: Robust-optimised IMPT plans were generated for 20 patients to a dose of 70 Gy (relative biological effectiveness) in 35 fractions in Raystation. For each case, four plans were generated: three with ADC optimisation using the pencil beam (PB) algorithm followed by a final dose calculation with the following algorithms: PB (PB-PB), MC (PB-MC) and MC normalised to prescription dose (PB-MC scaled). A fourth plan was generated where MC optimisation and final dose calculation was performed (MC-MC). Dose comparison and γ analysis (PB-PB vs PB-MC) at two dose thresholds were performed: 20% (D20) and 99% (D99) with PB-PB plans as reference. Results: Overestimation of the dose to 99% and mean dose of the clinical target volume was observed in all PB-MC compared to PB-PB plans (median: 3.7 Gy(RBE) (5%) (range: 2.3 to 6.9 Gy(RBE)) and 1.8 Gy(RBE) (3%) (0.5 to 4.6 Gy(RBE))). PB-MC scaled plans resulted in significantly higher CTVD2 compared to PB-PB (median difference: −4 Gy(RBE) (−6%) (-5.3 to −2.4 Gy(RBE)), p ≤ .001). The overall median γ pass rates (3%–3 mm) at D20 and D99 were 93.2% (range:62.2–97.5%) and 71.3 (15.4–92.0%). On multivariate analysis, presence of mediastinal disease and absence of range shifters were significantly associated with high γ pass rates. Median D20 and D99 pass rates with these predictors were 96.0% (95.3–97.5%) and 85.4% (75.1–92.0%). MC-MC achieved similar target coverage and doses to OAR compared to PB-PB plans. Conclusion: In the presence of mediastinal involvement and absence of range shifters Raystation ADC may be clinically acceptable in lung IMPT. Otherwise, MC algorithm would be recommended to ensure accuracy of treatment plans. Advances in knowledge: Although MC algorithm is more accurate compared to ADC in lung IMPT, ADC may be clinically acceptable where there is mediastinal involvement and absence of range shifters.