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Prepectoral implant-based breast reconstruction (PIBR) has regained popularity, despite decades-long preference for subpectoral implant placement. This paper aims to compare patient-reported outcomes (PRO) between prepectoral and subpectoral approaches to implant-based breast reconstruction (IBBR). The primary PRO was with the BREAST-Q, and postoperative pain scores, while the secondary outcomes were complication rates.A comprehensive literature search of the PubMed library was performed. All studies on patients undergoing IBBR after mastectomy that compared prepectoral to subpectoral placement and PROM or postoperative pain were included.A total of 3789 unique studies of which 7 publications with 216 and 332 patients who received prepectoral and subpectoral implants, respectively, were included for meta-analysis. Patients with prepectoral implant placement had significantly higher satisfaction with the outcome (p = 0.03) and psychosocial well-being (p = 0.03) module scores. The pain was lower in patients with prepectoral implants on postoperative day 1 (p0.01) and day 7 (p0.01). The subgroup analysis of prepectoral breast implants showed that complete acellular dermal matrix coverage had lower rates of wound dehiscence (p0.0001), but there were no significant differences in complications between one-stage and two-stage procedures.Overall, patients with prepectoral implants reported higher BREAST-Q scores and lower postoperative pain and lower complications rates than patients with subpectoral implants. In appropriately selected patients, prepectoral implant placement with ADM coverage, be it the primary placement of an implant or placement of a tissue expander before definitive implant placement, should be the modality of choice in patients who choose IBBR. Further research should focus on patient selection, strategies to reduce cost and cost-benefit analysis of PIBR.

Primary spontaneous pneumothorax (PSP) usually occurs in young adults, with higher incidence in smoker, and patients with narrow chest frame and slim body habitus. Surgery is indicated in the cases of recurrence episodes or persistent lung collapse, and failed conservative management by chest drain insertion. Video assisted thoracoscopic surgery (VATS) bullectomy and pleurodesis is the surgical treatment of choice but uniportal approach has been utilised to further minimise surgical trauma, improve cosmesis without compromising the efficacy of the procedure.This video demonstrated the uniportal procedure for bullectomy and double pleurodesis for PSP. A 2.5 cm incision was made at 4th intercostal space, anterior axillary line. Extra small size wound protector was used and CODuring the period from 2009 to 2015, over 160 cases of PSP were treated using this method by the author. To date, there is no recurrence reported upon follow up at outpatient clinic. There was no mortality and patients resumed active physical activity 8 weeks after the procedure.Uniportal VATS bullectomy and double pleurodesis is a safe procedure for treating PSP and effective in preventing future recurrence of lung collapse. This simple approach should be encouraged and performed by all enthusiastic VATS thoracic surgeons.

Cardiac transplantation is limited by donor availability and carries a considerable perioperative mortality in addition to continuing morbidity and mortality post-transplant. Some patients referred for transplantation may benefit from non-transplant cardiac surgery. This study assessed the results of non-transplant cardiac surgery in this high-risk group of patients over the 5-year period 1996-2001. Twenty-five such patients underwent conventional cardiac surgery and these were highly symptomatic, with angina and dyspnoea. All had impaired left ventricular function, 20 having left ventricular ejection fraction (LVEF)

Although there is increasing number of reported spontaneous coronary artery dissection (SCAD) recently, this is the first successful operative case of myocardial revascularization on triple-vessel SCAD. Emergency coronary artery bypass grafting was performed on a 42-year-old female presented with acute myocardial infarction, who had failed thrombolysis with on-going angina and acute heart failure.

Fournier's gangrene is a polymicrobial necrotising soft tissue infection (NSTI) affecting the perineum and scrotum. It is rapidly progressive and destructive, and is associated with high morbidity and mortality. Management protocol includes prompt diagnosis, early institution of antibiotic therapy and adequate wound debridement, usually requiring multiple operations. The resultant defect can be left to heal by secondary intention, or surgical coverage can be undertaken. We report Fournier's gangrene in a 60-year-old diabetic man and his successful treatment with skin grafting, which utilised a multidisciplinary approach and adjuncts, including negative-pressure wound therapy and hyperbaric oxygen therapy. We also review the literature related to these adjuncts and discuss their usefulness in the management of NSTIs.

Many cardiac surgeons are becoming increasingly familiar with the advantages and application of nitinol sternal thermo-reactive clip (Flexigrip; Praesidia, Bologna, Italy) in sternotomy closure. However, we will be describing an alternative technique of flexigrip clip application that is even easier to perform, with additional advantages of a more precise measurement of sternal width and allowed identification of sternal midline before sternotomy.

Emergency redo surgery is rare, but may be required in patients with conditions such as endocarditis, unstable angina and acute aortic dissection. To date there are no published data on the outcome of these difficult patients. Prospective consecutive data were collected from a single institution on 65 patients (51 male) undergoing coronary artery bypass grafts (27), mitral valve replacement or repair (13), aortic valve replacement (7), aortic surgery (13), and other (combined procedures) (5). Indications for surgery were unstable angina (12), endocarditis (11), resuscitation/catheter lab complications (11), torn prosthetic leaflet (6), aortic dissection (4), paraprosthetic leak (2), other (19). Mean ITU stay was 45 h (0-284) and hospital stay was 13.3 days (0-68). There were 14 intra-operative deaths and 14 further in-hospital deaths (overall mortality 43%). Predicted mortality rates were 26% (Parsonnet), 11% (EuroSCORE) and 31% (EuroSCORE logistic). Mean hospital cost per patient was 18,299 euros (or 32,147 euros per hospital survivor). In conclusion, the mortality in these difficult patients is very high, however, often no other treatment option is available. More sophisticated models, such as EuroSCORE logistic, may allow better prediction of risk in very high risk cases.

Prosthetic heart valve thrombosis is a potentially life-threatening complication of low anticoagulation. We present a case of acute prosthetic mitral valve thrombosis in a patient whose anticoagulation was inadequate after phenindione was changed to low molecular weight heparin. We discuss the diagnosis and treatment of this condition and highlight the danger of long-term low molecular weight heparin use in patients with prosthetic heart valves, especially those in the mitral position. We review the current guidelines for anticoagulation of prosthetic heart valves and discuss potential treatment options if adequate anticoagulation is not achieved by oral anticoagulant alone.

Various modalities for the treatment of hypertrophic pulmonary osteoarthropathy (HPOA) associated with lung cancer have been suggested since 1958. Although the etiology remains speculative, unilateral vagotomy on the side of the lung cancer achieves symptomatic relief. We report a case of a 50-year-old woman with disabling HPOA and inoperable lung cancer who experienced effective pain relief and regained full mobility after video-assisted thoracoscopic surgery was used to perform truncal vagotomy. This relatively safe and simple procedure should be considered for terminal lung cancer patients with intractable HPOA.

Objective: To assess the impact of early corrective surgery on the short and medium term outcome in tetralogy of Fallot (TOF). Materials and methods: All patients under 12 months of age undergoing correction of isolated TOF between February 1997 and July 2003 were reviewed retrospectively. Outcome data for mortality, post-operative care management, major morbidity and clinical follow-up were analysed. Results: Fifty-two operations were performed. The mean age at surgery was 5 months (range 1—12) of whom 16 (30.8%) were less than 3 months old, including 2 neonates, 22 (42.3%) were 3—6 months old and 14 (26.9%) were 7—12 months old. There was 1 (1.9%) early death caused by a cerebrovascular accident and 1 (1.9%) late death secondary to acute infective endocarditis. There were no differences in post-operative morbidities attributable to age. Patients under 3 months old required greater duration of post-operative ventilation, ITU stay and in-hospital stay. At a mean follow-up of 4.0 years (range 1.5—8.0), 33 (63.5%) patients had well-tolerated pulmonary regurgitation (PR) and 3 (5.8%) patients required reoperationfor right ventricular outflow tract obstruction (RVOTO). All patients had right bundle-branch-block but with QRS < 150 ms.Conclusion: Early definitive repair of TOF can be performed safely on patients under 6 months old. Age at surgery does not appear to affect the medium term haemodynamic outcome. However, early surgery does escalate the need for ICU care. This data suggests repair in asymptomatic patients be delayed until 3—6 months of age.

Unclampable calcified aorta is an uncommon condition that all cardiac surgeons may encounter and performing aortic valve surgery in this condition with a non cross-clamping technique of using Foley Catheter has rarely been reported. Aortic valve surgery invariably becomes a high-risk, challenging procedure to cardiac surgeon or even a contraindication to surgery when the ascending aorta cannot be clamped due to extensive calcification precluding safe dissection and clamping. We describe and recommend a non cross-clamping technique of using Foley Catheter and report it successful use in two patients who underwent aortic valve replacement with "porcelain" unclampable aorta.

Objectives. In patients with suspected diffuse interstitial lung disease, open lung biopsy is associated with high mortality (16%). This risk is only acceptable if diagnosis is made and management enhanced. We reviewed the role of VATS techniques in this group to determine the morbidity, mortality and outcomes in terms of diagnosis and enhanced management. Methods. Over the period of 5 years, 78 patients with suspected diagnosis of diffuse interstitial lung disease on clinical and radiological grounds were referred to a single surgical team. The patients’ case notes and histology reports were reviewed retrospectively. Correlation was made with histopathological diagnosis. Results. All 78 patients had sufficient provision of material for histological analysis. Eight patients had a histological diagnosis not consistent with diffuse interstitial lung disease; in all eight patients, this significantly altered the subsequent management. Of the 70 patients with diffuse lung disease, 26 patients (37.1%) had a histological diagnosis of usual interstitial pneumonia. Thirteen patients (18.6%) had a histological diagnosis of unclassifiable diffuse lung disease despite an adequate biopsy. The remaining 31 patients (44.3%) had other positive histological diagnosis made. A difference between pre-operative clinico-radiological and final histological diagnosis sufficient to change prognosis and definitive management was made in 19 patients (27.1%). The mean and median post-operative stay was 2.8 days and 2 days, respectively. The in-hospital mortality was one patient (1.5%) due to adult respiratory distress syndrome. Conclusions. VATS lung biopsy can be performed in this group of patient with low mortality of 1.5%. It provides sufficient material for histological diagnosis in 100% of patients and alters the management and prognosis in a significant number of patients. We propose that the role of VATS and clinico-radiological techniques should be compared in a prospective controlled clinical trial.

A 65-year-old retired professional boxer presented with progressively worsening shortness of breath, peripheral oedema and mild abdominal swelling over a period of 6 months. His only past medical history was hypertension. Subsequent investigations revealed chylous ascites, pericardial constriction and bilateral chylothorax. He had uneventful pericardectomy, and post-operatively the chylothorax resolved only after administration of octreotide for 10 days. The histopathological features of fibrosis, haemosiderin deposition in the pericardium and abundant haemosiderin-laden macrophages are consistent with chronic resolving haemopericardium. These findings suggested that the cause of pericardial constriction was repeated chest trauma from boxing.

Objectives: The role of post-mortem following thoracic surgery has not been previously studied. Most importantly, the clinical diagnosis of thoracic surgical mortality cannot be certain unless post-mortem analysis has been performed. Methods: Consecutive post-mortem data were collected on 110 patients between 1992 and 2001 (66.3% of all in-hospital thoracic surgical deaths). Clinically attributed causes of death were compared with post-mortem findings. Results: A total of 4302 thoracic operations were performed during the 10-year period, with overall mortality 3.8%. The mean age was 63.6 years (range 21‐ 87) with 73.6% male. In the 110 patients undergoing post-mortem examination, the operations performed were pneumonectomy 24.5%, lobectomy 14.5%, oesophagectomy 12.7%, lung biopsy 8.2%, pleurectomy/bullectomy 6.4%, decortication 4.5%, lung volume reduction 1.8%, other thoracic 13.6%, other oesophageal 9.1%, and other procedures 4.5%. The mean time to death was 12.5 days (range 0 ‐ 85). The causes of death were respiratory 47.3%, cardiac 16.4%, multiple organ failure 8.2%, sepsis 6.4%, gastrointestinal 4.5%, haemorrhage/technical failure 10%, and others 7.3%. Post-mortem revealed an unsuspected cause of death in 34 (31%) patients, comprising pulmonary 17, cardiac 5, gastrointestinal 3, haemorrhage/technical failure 2, multiple organ failure 2 and other 5. Conclusion: Post-mortem determined unsuspected diagnoses in a high proportion of patients undergoing thoracic surgery. Post-mortem continues to be the ‘gold standard’ method for attributing the cause of death. Accurate outcome data following thoracic surgery are essential for proper audit, and hence for improvements in clinical practice to occur. q 2003 Elsevier Science B.V. All rights reserved.