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Background Benign metastasising leiomyoma (BML) is a rare and often asymptomatic presentation of smooth muscle tumour of uterine origin, occurring outside the uterus. We present the first case series of pulmonary BML in a contemporary UK population. Patients were identified from prospective histopathological databases spanning from 2003 to 2019. Data was collected retrospectively from physical and electronic data sources. Results Six post-menopausal females were identified with an average age of 44±8 years (mean±SD). Fifty percent of our cohort was asymptomatic with an incidental finding of pulmonary nodules, whilst the others complained of non-specific respiratory symptoms. Five patients (88%) had multiple lesions (median 9, range 2 to 12)—with bilateral distribution, measuring an average of 11 mm (range 7 to 27) in size on cross-sectional imaging. All patients underwent diagnostic surgical pulmonary wedge resection, with no perioperative morbidity. Immunohistochemistry confirmed the presence of ‘spindle cells’, staining positive for smooth muscle actin, desmin and progesterone receptors for all patients (100%), and oestrogen receptors in five patients (87%). Four patients (67%) underwent a hysterectomy prior to diagnosis of BML and one (17%) due to the diagnosis itself. Four patients (67%) underwent oophorectomy, whilst one patient required hormonal suppression therapy. Survival was 100% at a median follow-up of 59.5 months (range 29 to 166). Conclusions BML is a rare clinical entity accounting for a small proportion of patients presenting with pulmonary nodules. Following successful tissue diagnosis, outcomes with conservative or medical management are excellent.

The demands of curtailing the impact of the coronavirus disease 2019 (COVID-19) global pandemic have disrupted the world’s ability to care for patients with thoracic pathologies. Those who undergo thoracic surgical therapeutic procedures are a high-risk category, likely to have impaired lung function but also high risk for exposing clinical teams to aerosolised viral loads. In light of this global pandemic, thorough pre-procedural planning, adequate personal protective equipment (PPE), experienced personnel and judicious anaesthetic and intra-operative measures will serve to be instrumental in ensuring positive patient outcomes whilst still protecting the safety of healthcare workers.

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether the use of 3-dimensional endoscopic vision provides superior clinical outcomes to patients undergoing video-assisted thoracic surgery for lung resection. Altogether 231 unique papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Four of the 6 papers demonstrated a statistically significant reduction in operative time, although this difference may not be of sufficient magnitude to be relevant clinically. There was no difference in any other outcomes assessed. We therefore conclude that, in patients undergoing video-assisted thoracic surgery for lung resection, 3-dimensional endoscopic vision has no demonstrable impact on perioperative or oncological outcomes, or cost, although it may reduce operative time.

Introduction Subxiphoid approach is emerging as an alternative to intercostal video-assisted thoracoscopic surgery (VATS). We sought to compare the clinical efficacy of both approaches. Method A protocol was registered at PROSPERO [CRD42020155686]. Studies were retrieved from literature in July 2020. The Main outcomes were operative duration, intraoperative complications and postoperative length of hospital stay (LoS). Subgroup analysis was performed by procedure type. Results 1469 patients (51% male) were included from 12 observational studies, with 620 (42%) having undergone sVATS. There was a high-moderate risk of bias across included papers. There was no difference in operative duration (MD 13.1 minutes, 95% CI -11.3 to + 37.6; p = 0.29), intraoperative complications (OR 0.17, 95% CI -0.28 to + 0.61; p = 0.47), or LoS (MD -0.8 days, 95% CI -1.8 to + 0.2; p = 0.08). LoS was lower for sVATS thymectomy (MD -1.7 days, 95% CI -2.9 to -0.3; p = 0.01). Acute pain (10-point numerical rating scale) was lower for sVATS (MD -2.2, 95% CI -3.2 to -1.2; p Conclusions There is a potential benefit for sVATS in selected procedures. Well-designed randomised trials with consistent outcome reporting are required.

Introduction Minimally invasive surgery (MIS) for bronchial sleeve lobectomy (SL) remains unproven in safety and efficacy. We sought to evaluate current literature on outcomes following MIS or open surgery (OS) for SL in non-small cell lung cancer (NSCLC). Method The MEDLINE, Embase and Cochrane Library databases were searched in August 2020. Studies of SL comparing MIS to OS were included. The primary outcome was disease-free survival. Data was analysed in Stata SE v16. Results 506 patients (87.9% male) from 5 studies were included, with 325 (64.2%) OS, 164 (32.4%) VATS, and 17 (3.4%) RATS cases. Risk of bias was low to moderate in included papers. There was no difference in disease-free survival (OR -0.20, 95% CI -0.63 - 0.23, p = 0.37), overall survival (OR -0.03, 95% CI -0.63 - 0.58, p = 0.93), 30-day survival (OR -0.60, 95% CI -1.73 - 0.54, p = 0.30), resection margin involvement (OR 0.16, 95% CI -1.07 - 1.39, p = 0.80), or intraoperative bleeding (MD -16.94 ml, 95% CI -63.05 - 39.16, p = 0.47). MIS was associated with longer operative times (MD 53.90 min, 95% CI 36.57 - 71.23, p Conclusions MIS for SL was associated with longer surgical time, shorter postoperative stay, and equivalent oncologic outcomes compared to OS.

Introduction Delivery of surgical services during the Covid-19 pandemic has required the use of enhanced PPE in the operating theatre. We sought to evaluate the impact of this change on surgeon workload and intraoperative patient outcomes. Method Surgeons performing as primary operator completed an online procedure-specific questionnaire on workload ratings for each operative case, using an extension of the validated Surgeon Task Load Index (SURG-TLX) tool (reported on a 20-point scale), together with operative details. Local approval was obtained at individual sites. Data was analysed in Stata SE v16. Results 118 responses (17 surgeons, 7 specialties) were collected from June to September 2020. 77.1% used enhanced PPE. There was no association between enhanced PPE use and overall workload (p = 0.151) as measured with SURG-TLX, although surgeons wearing enhanced PPE commonly reported finding individual procedures harder than expected (37% vs 0%, p Conclusions The use of enhanced PPE is not associated with complications or increased surgeon workload assessed by SURG-TLX. It is, however, associated with difficulty in communicating, and subjectively experiencing more procedural challenge than anticipated.

Structured Abstract Objectives The Covid-19 pandemic has overwhelmed healthcare systems and disrupted routine care internationally. Healthcare workers face disruption to their work routines and professional development, as well as an elevated risk of infection and morbidity. We sought to establish the impact of the Covid-19 pandemic on the wellbeing, practice and progression of all trainees in cardiothoracic surgery in the United Kingdom. Methods A 31-item questionnaire was designed, validated, and disseminated via email and an instant-messaging platform. Results 76 (of 118, 64%) cardiothoracic surgical trainees responded, representing all training grades and programmes nationally. 48 (63%) and 24 (32%) were concerned about their physical and mental health respectively. 25 (33%) had taken time off work due to Covid-19. 65 (86%) had treated Covid-19 patients, 36 of whom (55%) were wearing satisfactory personal protective equipment at the time. 41 (54%) remain concerned about PPE provision at their institution. 42 (55%) had been redeployed to cover other specialties. 23 (30%) had encountered ethical dilemmas related to care of patients. There was a significant impact on time spent in outpatient clinics (44% reduction), multidisciplinary team meetings (79% reduction) and operating theatres (78% reduction). 67 (88%) of respondents were concerned about the impact on their training, and 54 (71%) felt that the deviation may require an extension in their planned training time. Conclusions The duration and impact of the current pandemic is, as yet, uncertain. Timely sharing of experiences, concerns and expectations will inform healthcare and education policy, and influence practice in the pandemic era and beyond., The Covid-19 pandemic poses significant personal and professional challenges to surgical trainees. This national survey of cardiothoracic trainees in the United Kingdom evaluates the early impact on wellbeing, clinical practice and progression.

Background To compare early outcomes of mitral valve repair versus replacement in elderly patients with degenerative mitral valve disease. Methods A retrospective review of prospectively collected clinical data of patients over 75 years of age, who underwent mitral valve surgery for degenerative disease, between 2010 and 2013, was carried out. Those undergoing mitral valve repair and replacement were propensity matched to adjust for baseline clinical differences. Results A total 260 patients were identified: mitral valve repair was undertaken in 145 and replacement in 115 patients. After propensity matching, 78 patients were included in each group. In the entire, unmatched population, in-hospital mortality was significantly higher in those undergoing replacement compared with those undergoing repair (9.6% vs 1.4%, p=0.003). In-hospital death occurred in six (7.7%) of the propensity matched replacement group and none in the repair group (p=0.012). Amongst the propensity matched groups, probability of survival at 1, 2 and 3 years were 0.94, 0.90 and 0.86 respectively for the repair group and 0.85, 0.77 and 0.69 for the replacement group: the HR for death between replacement and repair is 2.5 (1.2-5.4), p=0.012. Conclusions Within the limitations imposed by retrospective analyses, our study demonstrates that, in elderly patients with degenerative disease of the mitral valve, repair is associated with improved short-term and mid-term outcomes compared with mitral valve replacement.

Objectives We aimed to assess whether treatment with ceftriaxone/cefotaxime is associated with lower in-hospital mortality than amoxicillin–clavulanate in pati0ents hospitalized in medical wards for community-onset pneumonia. Methods We conducted a retrospective and multicentre study of patients hospitalized in French medical wards for community-onset pneumonia between 2002 and 2015. Treatments with ceftriaxone/cefotaxime or amoxicillin–clavulanate were defined by their start in the emergency department for a duration of 5 days or more with no other β-lactam. A logistic regression analysis was performed on the overall population, and a propensity score analysis was restricted to patients treated with either ceftriaxone/cefotaxime or amoxicillin–clavulanate. Results 1698 patients (median age, 80 y) were included, of which 716 and 198 were treated with amoxicillin–clavulanate and ceftriaxone/cefotaxime, respectively. In-hospital mortality was 10% (9–12%). In multivariate analysis, factors associated with in-hospital mortality were treatment with ceftriaxone/cefotaxime (aOR 2.9; (1.4–5.7)), pneumonia severity index class 4 or 5 (aOR 7.8 (4.3–15.7)), do-not-resuscitate order (aOR 8.7 (5.2–14.6)) and fluid therapy (aOR 6.3 (2.5–15.1)). The propensity score analysis was performed on 178 patients treated with ceftriaxone/cefotaxime matched with 178 patients treated with amoxicillin–clavulanate; no significant association between treatment with ceftriaxone/cefotaxime and in-hospital mortality was found (OR 1.5 (0.7–3.0)). Conclusion In the largest study aiming to compare amoxicillin–clavulanate and ceftriaxone/cefotaxime in community-onset pneumonia, ceftriaxone/cefotaxime was not associated with lower in-hospital mortality than amoxicillin–clavulanate. Our results suggest that ceftriaxone/cefotaxime should not be preferred over amoxicillin–clavulanate for patients hospitalized in medical wards with community-onset pneumonia.

This work shows the need for targeted improvement to mitigate communication challenges associated with use of enhanced personal protective equipment. The data provide reassurance to surgeons and patients that there is no negative impact on surgeon workload or patient outcomes from use of enhanced personal protective equipment in the operating theatre.

Background: Decortication for thoracic empyema is associated with significant blood loss and prolonged postoperative air leak. We sought to assess the potential application of an irrigated-tip radiofrequency (RF) sealing device, in an attempt to reduce this morbidity. Methods: Data for all patients undergoing open decortication (OD) for stage II thoracic empyema, using either conventional approach or facilitated by use of the Aquamantys ® device, at a single thoracic surgical unit between April 2010 and July 2014, were retrospectively analysed. Unpaired t -test and Fisher’s exact test were used for statistical analysis. Results: Thirty-three patients, aged 54±15 years (mean ± SD), and with a Charlson comorbidity index of 2.5±1.9 were included. Preoperative and intraoperative characteristics, including surgical time, were similar in the conventional and Aquamantys ® groups. Patients in the Aquamantys group were less likely to require red cell transfusion (9/22 vs . 10/11 patients, P=0.024) and received lower volume transfusions [0.0 (2.0) vs . 3.0 (1.6) units (median, IQR), P vs . 6.5 (6.8) days, P=0.006], as was length of postoperative hospital stay [6.0 (8.7) vs . 10.0 (4.6) days, P=0.031]. There was no demonstrable difference in mortality. Conclusions: Our data indicates that the use of irrigated tip RF ablation is safe and effective in improving pneumostasis and haemostasis in decortication for thoracic empyema; and that this translates to morbidity and logistical benefit.

Introduction Extended pleurectomy and decortication is a specialised procedure performed typically in elderly patients with comorbidities (1). The nature of surgery presents significant physiological stress to the cardiovascular system. Here we report an an unexplained complication of EPD that occurred in our operating theatre. Methods A 70 year-old underwent an EPD for mesothelioma, following neoadjuvant chemotherapy. He was an ex-smoker with moderate chronic obstructive airways disease, hypertensive and hyperlipidemic, and a normal preoperative electrocardiogram and echocardiogram. He had an uneventful induction of anaesthesia and the airway was secured with 41 French left double lumen tube, and maintained with desflurane and intermittent boluses of 0.25% levobupivacaine through a thoracic epidural (T4/T5 space). Routine and invasive arterial and central venous pressure monitoring were used. Surgery was uneventful with a blood loss of 250 mls and minimal dysrrhythmias during pericardectomy. At the closure of thoracotomy, sudden marked ST elevation noted was on the five-lead ECG and posterolateral ischaemic changes on a 12-lead recording (see figure 1A), associated with hypotension requiring boluses of adrenaline. No obvious precipitating event was noted. An adrenaline infusion of 0.15microg/kg/min was started to provide cardiovascular stability. Results Once transferred for angiography, the ST segments had normalized (figure 1B) and his adrenaline requirements dropped. A stable plaque in the left anterior descending artery with no flow limitation was detected. A transoesophageal echocardiogram was normal. The patient was extubated the following day on the ICU. A troponin rise (table) and persistent T wave changes (figure 1C) were detected. Discussion Intra-operative dysrhythmias are not uncommon during EPD whilst the pericardium is manipulated but rarely seen at the end of surgery (1-3), but sudden unexplained ST elevation has not to our knowledge previously been reported. Multiple breeches to the visceral pleura occur during surgery, and we speculate a small gas embolus to a coronary artery or sudden hypotension-related myocardial oxygen supply-demand mismatch may explain the severe but transient clinical and electrocardiographic findings and type two myocardial infarction, given the normal coronary angiography and post-operative echocardiography.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether treatment with hormones or pleural symphysis is better than operative procedures such as diaphragmatic repair with mesh to surgically manage recurrent pneumothoraces in patients with catamenial pneumothorax. Diaphragmatic repair with synthetic meshes, hormonal treatment and pleural symphysis are all accepted interventions for the treatment of recurrent catamenial pneumothoraces; however, there is uncertainty over the best combination of treatment. Altogether, 396 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. However, it should be noted that the studies included were small in terms of sample size, and have demonstrated significant bias and surgical heterogeneity. Our literature review found that the recurrence rates of pneumothorax were greatly reduced in the treatment group where surgery and hormone therapy were combined (pooled average recurrence rate of 0%); however, the recurrence rates were significantly higher when these interventions were used alone: hormone therapy alone (58.5%), diaphragmatic repair alone (33.3%) and surgery alone (63.3%). Our results therefore demonstrate that a multimodality approach is required to reduce pneumothorax recurrence rates in patients with catamenial pneumothorax.

Chest wall invasion is seen in 5% to 8% of patients presenting with lung cancer. We report a case of complete resection of a 14 cm × 9 cm pT3N0M0 squamous cell carcinoma arising from the right lower lobe and invading the lower chest wall posteriorly, in a 75 years old male, via a hybrid thoracoscopic [video-assisted thoracoscopic surgery (VATS)] approach. Following conventional VATS lobectomy, a targeted 10 cm incision was performed to allow wide resection of the 7th to 10th ribs and 6th to 9th transverse processes, with the defect being subsequently reconstructed with a composite rigid prosthesis. The patient made an uneventful recovery, and was discharged on the 3rd postoperative day; with later adjuvant chemotherapy. Thoracoscopic surgery is not currently widely adopted in patients with chest wall invasion, likely due to the technical difficulties. We briefly review the various techniques described in the current literature, whilst emphasising a role for such an approach in highly selected cases.

Introduction Pulmonary benign metastasizing leiomyoma (BML) is a rare and often asymptomatic presentation of smooth muscle tumour of uterine origin, occurring within the lung. Just over a hundred individual cases have been described in the literature; with two series of ten patients each, from continental Europe and North America. Objectives We sought to present the first comprehensive descriptive series from a contemporary U.K. population. Methodology Patients at a single U.K. thoracic surgical centre, between 2003 and 2017, were identified from prospective histology databases. Retrospective data was collected from physical and electronic data sources, and cross-referenced for accuracy. Results 6 patients – all postmenopausal females – were identified over a 15 year period. Average age was 44±8 years (mean ±SD). Half of the patients were asymptomatic with an incidental finding of pulmonary nodules, whilst the remaining 50% complained of nonspecific respiratory symptomatology. Plain imaging of the chest failed to reveal any abnormality in 2 (33.3%) patients. 5 (88.3%) patients had multiple lesions – median of 9 (range 2 to 12) – with bilateral distribution; measuring a median 11 mm (range 7 to 27) in size on cross-sectional imaging. All patients underwent diagnostic surgical wedge biopsy, with 5 (88.3%) procedures completed thoracoscopically; and no perioperative morbidity. 4 (66.7%) patients had a history of previous hysterectomy, and a further patient underwent a hysterectomy following the diagnosis of BML – all for uterine leiomyomata. 4 (66.7%) patients underwent oophorectomy, whilst one patient required hormonal suppression therapy. Survival was 100% at a median follow up of 37 months (range 4 to 150). Conclusion BML is a rare clinical entity accounting for a small proportion of patients presenting with pulmonary nodules. Following successful tissue diagnosis, outcomes with conservative or medical management are excellent.

Objectives Malignant pleural effusion (MPE) commonly complicates advanced malignancy and their exact management is still undefined. We undertook a survey to determine the current practice among members of the European Society of Thoracic Surgeons (ESTS). Methods A cross-sectional survey focused on the current practice of management of MPE was developed by the authors. The questions were outlined after a review of the literature and circulated in an Internet-based survey format. Results Computed tomography (125, 92%) and chest X-ray (106, 78%) are the most common imaging modalities performed in the initial evaluation. Video-assisted thoracoscopic surgery for washout and pleurodesis (93, 68%) was reported as the preferred approach to patients with uncomplicated MPE. Sixty-one (45%) of the responding colleagues routinely use large bore chest tubes for draining malignant effusions. Forty-nine (35%) surgeons would not apply suction to the drainage system, whilst 50 (37%) would use -2 kPa or less. Talc (124, 91%) is the most commonly used sclerosing agent for pleurodesis in the context of malignant pleural effusion. The practice of 76 (56%) of the respondents is not informed by any clinical guidelines, whilst 60 (44%) reported adhering to the 2010 British Thoracic Society Pleural Disease Guideline. Seventy-one (52%) declared that the guidance was in need of updating or revision. Conclusions This survey demonstrates the lacking adoption of the existing clinical guidance in this field, as well as the need for more contemporary guidelines for a better-informed practice. The ESTS Working Group on the management of MPE has been established for this purpose.

Recruitment and retention are of paramount importance to medical radiation science (MRS) as a profession. There is a strong demand for MRS practitioners which is expected to continue as the population ages. This study aimed to examine demographic data, factors relating to the career choice of MRS, and future work or study plans of first year MRS students. Questionnaires were distributed to 83 first year students, currently enrolled in MRS at the University of Sydney. A total of 73 completed questionnaires were received. This sample included 30 diagnostic radiography students, 24 nuclear medicine students and 19 radiation therapy students. The top three factors that influenced students' career choices was wanting to help others, followed by wanting to work in a healthcare field, then wanting to work with technology. The most common source of students' career information was family members, friends and health professionals. Among the students, 68.5% were aware of advancement opportunities in their stream of MRS. About half of the students planned to specialise or undertake postgraduate study in MRS, and 39.7% planned to study another degree after graduating. The results of this study indicated that many students chose MRS as a career with the goal of helping others. The most frequently reported source through which the students first heard about the profession was personal contacts. Furthermore, about half of the students were interested in further study. This information can be used by professional organisations, educational programs, or employers to assist in recruitment and retention strategies of MRS students. (author abstract)

In this study, we present our technique for performing video-assisted lobectomy. This is presented in clear, easy-to-follow, sequential steps, noting variations on the most established technique and the rationale for this divergence. We also provide an instrument preference card, some operative tips and high-quality videos.

Purpose: Recognition and appropriate initial first aid of suspected myocardial infarction improves patient outcomes. This study seeks to identify current knowledge patterns with regards to identification and management of acute cardiac events, amongst members of the lay public in Malta. Methods:Volunteers, recruited according to a probability quota sample, submitted to a structured interview detailing demographics and relevant knowledge. Individual chi-squared tests were performed to relate knowledge to expected influences. Results: 599 individuals (49% male, n=291) were interviewed; of whom 36% (n=213) had previously attended formal first aid training, and 4% (n=23) reported having suffered a myocardial infarction (MI) in the past. An average of 6.8 (SD±1.57) out of 9 common acute coronary syndrome (ACS) symptoms, were identified on prompting. Those symptoms least commonly identified were chest pain radiating to the right arm (33%, n=199) and that radiating to the neck, jaw or abdomen (54%, n=321); training failed to improve appreciation of the significance of these symptoms (p=0.38 and 0.51 respectively), as did history of previous MI (p=0.87 and 0.57 respectively). 98% (n=592) of patients would call an ambulance if suspecting a heart attack. 50% (n=300) would administer sublingual nitrate, and 48% (n=285) would administer aspirin if these were previously prescribed to and carried by the patient; training fails to confer benefit (p=0.46 and 0.09 respectively) as does previous ACS (p=0.53 and 0.38). 42% (n=253) of subjects said theywould start cardiopulmonary resuscitationwhen presented with a patient experiencing chest pain and other symptoms suspicious of ACS; training was not associated with any improvement (p=0.486). Conclusions: The lay public is generally appropriately suspicious of ACS, except with less typical symptoms; however, knowledge of appropriate management is poor. This is not improved by current training, nor in patients who have previously suffered a heart attack.