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Abstract We report the case of a patient who underwent a redo surgery for a leaflet escape from a Bjork-Shiley tilting disc mitral prosthesis inserted 18 years previously. The escaped disc remained lodged in the thoracic aorta without any complication. She ultimately died of terminal heart failure 13 years after the second operation. We believe this to be the longest survival with a dislodged leaflet from a mechanical valve. Removal of dislodged disc is recommended in literature but there may be a place for watchful observation in exceptional cases with no haemodynamic compromise.

OBJECTIVES Video-assisted thoracoscopic surgery (VATS) for thymoma has uncertain safety and effectiveness in comparison with trans-sternal resection. This feasibility study compared short- and mid-term outcomes for patients undergoing these two procedures, highlights weaknesses in current research and makes recommendations for long-term technological evaluations in this field. METHODS Consecutive thymoma cases between 2004 and 2010 were identified. Patients were divided into two groups according to surgical approach (Group I trans-sternal; Group II VATS) and comparisons were made between groups. The primary outcome was overall survival. Secondary outcomes included operative morbidity and mortality, hospital stay, recurrence rate and disease-free survival. RESULTS Thirty-nine patients were included (Group I: n = 22 vs Group II: n = 17). There were no differences between groups at baseline for all measured covariates. No deaths occurred within 30 days of surgery. More patients in Group I developed complications (Group I: n = 10 vs Group II: n = 3; P = 0.093), while hospital stay was shorter in Group II (Group I: 6.4 ± 4.6 days vs Group II: 4.4 ± 1.8 days; P = 0.030). Five-year overall survival (Group I: 93.8 ± 6.1% vs Group II: 83.3 ± 11.2%; P = 0.425), 5-year disease-free survival (Group I: 71.0 ± 15.3% vs Group II: 83.3 ± 11.2%; P = 0.827) and recurrence rates at final follow-up (Group I: n = 2 vs Group II: n = 1; P = 0.363) were similar between the groups. CONCLUSION VATS thymectomy for thymoma is feasible, safe and has comparable mid-term oncological outcomes to trans-sternal thymectomy. Future research is required to evaluate long-term oncological outcomes of VATS thymectomy for thymoma in national registries and randomized, controlled trials. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to report the safety and efficacy of video-assisted thoracoscopic (VATS) plication of the diaphragm at our institution between 2006 and 2016., Methods: Adult patients selected on etiology and combination of investigations including plain chest x-ray, computed tomography of chest and abdomen, lung functions in supine and sitting positions, radiological/ultrasonic screening for diaphragmatic movement, and phrenic nerve conduction studies. We incorporated a triportal VATS and Endostitch device for plication, using CO2 insufflation to maximum 12 mm Hg. Bilateral simultaneous plication and high-risk patients were electively admitted to intensive therapy unit postoperatively., Results: Thirty-five patients (24 males) had their diaphragm plicated. The mean age was 56.6 years (range = 23-76 years). The mean body mass index was 32.1 (range = 22.2-45.4). Twenty one were right, 13 left, 2 patients had VATS simultaneous bilateral plication, and 1 had sequential VATS bilateral plication. Paralysis was idiopathic in 17, posttraumatic in 5, postremoval of mediastinal tumor in 4, and postcardiac surgery in 3. All patients presented with lifestyle-limiting dyspnea and orthopnea, three were on nocturnal noninvasive ventilation. Five were diabetic and 16 were smokers. The mean supine forced expiratory volume in the first second was 62.5% of predicted. Twenty two were performed by VATS (63%), three converted to thoracotomy, and 13 were open limited thoracotomy (historic). The mean hospital stay was 4.5 days (range = 1-18, mode 2 days). Intensive therapy unit admission was required in six patients for mechanical ventilation 0 to 3 days. Five patients (14%) had no improvement in symptoms. There were no deaths, no 30-day readmissions, and no long-term neuralgia in this series., Conclusions: We found minimal access VATS plication of the diaphragm to be feasible and safe, but no firm conclusions should be drawn from our limited resources. We report the feasibility of concomitant bilateral VATS plication of the diaphragm in two adults, and this was not previously reported in the adult population. There is a need for further good quality, prospective studies, and randomized controlled studies evaluating efficacy of VATS diaphragmatic plication.

Thymectomy involves the removal of all the soft tissue in the pre-vascular plane of the anterior mediastinum between the two phrenic nerves. Surgical success in controlling myasthenia and the most important factor influencing survival in patients with thymoma depends on complete clearance of thymic tissue. Currently there is a perception that the open (median sternotomy) approach offers better visualisation of the thymic tissue. This perceived advantage is thought to justify the invasive nature of the procedure associated with increased morbidity. Video-assisted thoracoscopic surgery (VATS) for thymectomy has evolved significantly over the last decade, including bilateral and unilateral VATS (either left or right) approaches. The laterality of the approach remains largely on surgeon preferences, with the decision influenced by their experience and training. VATS offers superior illumination and magnification, particularly with the availability of advanced cameras with variable angles that provide better exposure and lighting of the operative field. The use of three-dimensional-operating imaging has also revolutionised the VATS technique. VATS thymectomy is a superior and radical technique in minimising access trauma and removing all thymic tissue that may be scattered in the anterior mediastinum and cervical fat. Other advantages of VATS include less intraoperative blood loss, early removal of chest drains, less requirement for blood products, decreased inflammatory cytokine response, shorter hospital stay and superior cosmesis. There is also a decreased risk of respiratory and cardiac related complications compared to the open (sternotomy) technique. Furthermore, no significant difference has been found in long-term complications and survival rate between VATS and open approaches. Subsequently, the VATS approach should be encouraged as more surgeons are adopting the minimally invasive practice as routine.