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\"'Never, never, never give in', Winston Churchill's famous quotation best sums up the life of Stephen Westaby, the world-leading cardiothoracic surgeon. This book chronicles the triumphs and failures of his surgical life, the lives saved and extended, the innovations (such as artificial hearts) he developed, and his research discoveries. Having spent his childhood in the backstreets of a northern steel town, he went on to become one of the world's preeminent heart surgeons. HIs drive for perfection in his profession took him to the world-renowned Harefield Hospital, the foremost heart surgery centre in Birmingham, Alabama, the newly-created Cardiothoracic Centre in Oxford, and then in 2019 in Wuhan he was the first Western doctor to learn about Covid before the virus was identified. Following on from his two earlier best-selling works, Fragile Lives and The Knife's Edge this volume is written with humour and a doctor's reverence for life and his patients. The Trauma Chronicles gives an unmissable insight into the world of one of the greatest living heart surgeons\"--Publisher's description.

Video-assisted thoracoscopic surgery (VATS) is used increasingly as an alternative to thoracotomy for lobectomy in the treatment of early-stage non-small-cell lung cancer, but remains controversial and worldwide adoption rates are low. Non-randomised studies have suggested that VATS reduces postoperative morbidity, but there is little high-quality evidence to show its superiority over open surgery. We aimed to investigate postoperative pain and quality of life in a randomised trial of patients with early-stage non-small-cell lung cancer undergoing VATS versus open surgery. We did a randomised controlled patient and observer blinded trial at a public university-based cardiothoracic surgery department in Denmark. We enrolled patients who were scheduled for lobectomy for stage I non-small-cell lung cancer. By use of a web-based randomisation system, we assigned patients (1:1) to lobectomy via four-port VATS or anterolateral thoracotomy. After surgery, we applied identical surgical dressings to ensure masking of patients and staff. Postoperative pain was measured with a numeric rating scale (NRS) six times per day during hospital stay and once at 2, 4, 8, 12, 26, and 52 weeks, and self-reported quality of life was assessed with the EuroQol 5 Dimensions (EQ5D) and the European Organisation for Research and Treatment of Cancer (EORTC) 30 item Quality of Life Questionnaire (QLQ-C30) during hospital stay and 2, 4, 8, 12, 26, and 52 weeks after discharge. The primary outcomes were the proportion of patients with clinically relevant moderate-to-severe pain (NRS ≥3) and mean quality of life scores. These outcomes were assessed longitudinally by logistic regression across all timepoints. Data for the primary analysis were analysed by modified intention to treat (ie, all randomised patients with pathologically confirmed non-small-cell lung cancer). This trial is registered with ClinicalTrials.gov, number NCT01278888. Between Oct 1, 2008, and Aug 20, 2014, we screened 772 patients, of whom 361 were eligible for inclusion and 206 were enrolled. We randomly assigned 103 patients to VATS and 103 to anterolateral thoracotomy. 102 patients in the VATS group and 99 in the thoracotomy group were included in the final analysis. The proportion of patients with clinically relevant pain (NRS ≥3) was significantly lower during the first 24 h after VATS than after anterolateral thoracotomy (VATS 38%, 95% CI 0·28–0·48 vs thoracotomy 63%, 95% CI 0·52–0·72, p=0·0012). During 52 weeks of follow-up, episodes of moderate-to-severe pain were significantly less frequent after VATS than after anterolateral thoracotomy (p<0·0001) and self-reported quality of life according to EQ5D was significantly better after VATS (p=0·014). By contrast, for the whole study period, quality of life according to QLQ-C30 was not significantly different between groups (p=0·13). Postoperative surgical complications (grade 3–4 adverse events) were similar between the two groups, consisting of prolonged air leakage over 4 days (14 patients in the VATS group vs nine patients in the thoracotomy group), re-operation for bleeding (two vs none), twisted middle lobe (one vs three) or prolonged air leakage over 7 days (five vs six), arrhythmia (one vs one), or neurological events (one vs two). Nine (4%) patients died during the follow-up period (three in the VATS group and six in the thoracotomy group). VATS is associated with less postoperative pain and better quality of life than is anterolateral thoracotomy for the first year after surgery, suggesting that VATS should be the preferred surgical approach for lobectomy in stage I non-small-cell lung cancer. Simon Fougner Hartmanns Familiefond, Guldsmed AL & D Rasmussens Mindefond, Karen S Jensens legat, The University of Southern Denmark, The Research Council at Odense University Hospital, and Department of Cardiothoracic Surgery, Odense University Hospital.

Malignant pleural mesothelioma incidence continues to rise, with few available evidence-based therapeutic options. Results of previous non-randomised studies suggested that video-assisted thoracoscopic partial pleurectomy (VAT-PP) might improve symptom control and survival. We aimed to compare efficacy in terms of overall survival, and cost, of VAT-PP and talc pleurodesis in patients with malignant pleural mesothelioma. We undertook an open-label, parallel-group, randomised, controlled trial in patients aged 18 years or older with any subtype of confirmed or suspected mesothelioma with pleural effusion, recruited from 12 hospitals in the UK. Eligible patients were randomly assigned (1:1) to either VAT-PP or talc pleurodesis by computer-generated random numbers, stratified by European Organisation for Research and Treatment of Cancer risk category (high vs low). The primary outcome was overall survival at 1 year, analysed by intention to treat (all patients randomly assigned to a treatment group with a final diagnosis of mesothelioma). This trial is registered with ClinicalTrials.gov, number NCT00821860. Between Oct 24, 2003, and Jan 24, 2012, we randomly assigned 196 patients, of whom 175 (88 assigned to talc pleurodesis, 87 assigned to VAT-PP) had confirmed mesothelioma. Overall survival at 1 year was 52% (95% CI 41–62) in the VAT-PP group and 57% (46–66) in the talc pleurodesis group (hazard ratio 1·04 [95% CI 0·76–1·42]; p=0·81). Surgical complications were significantly more common after VAT-PP than after talc pleurodesis, occurring in 24 (31%) of 78 patients who completed VAT-PP versus ten (14%) of 73 patients who completed talc pleurodesis (p=0·019), as were respiratory complications (19 [24%] vs 11 [15%]; p=0·22) and air-leak beyond 10 days (five [6%] vs one [1%]; p=0·21), although not significantly so. Median hospital stay was longer at 7 days (IQR 5–11) in patients who received VAT-PP compared with 3 days (2–5) for those who received talc pleurodesis (p<0·0001). VAT-PP is not recommended to improve overall survival in patients with pleural effusion due to malignant pleural mesothelioma, and talc pleurodesis might be preferable considering the fewer complications and shorter hospital stay associated with this treatment. BUPA Foundation.

Evidence-based studies optimizing chest tube management have been conducted to accelerate the recovery process for lung cancer patients after video-assisted thoracoscopic surgery (VATS). This study is to evaluate whether using the multi-lateral pores chest tube can achieve better drainage performance than conventional-lateral-pore drainage. Data from patients undergoing VATS were consecutively collected from September 2023 to June 2024. The groups were randomized into two subgroups, which were multi-lateral-pores drainage group (MDG) and conventional-lateral-pore drainage group (CDG). The primary outcomes included chest drainage performance, and the secondary outcomes included postoperative complications (PPCs). After screening, 228 patients were randomized into two groups, in which 116 patients in MDG and 112 patients in CDG. The daily drainage volume [199.70 (95%CI: 165.19~234.99) mL/d vs 149.43 (95%CI: 120.70~179.21) mL/d, P<0.01] and total drainage volume [342.79 (95%CI: 291.91~392.63) mL vs 272.68 (95%CI: 225.87~322.11) mL, P = 0.04] in the MDG was significantly higher that that in the CDG. The drainage duration in the MDG was also less than that in the CDG [36.41 (95%CI: 32.23~40.72) h vs 51.02 (95%CI: 46.03~56.38) h, P < 0.01]. The incidence of pleural effusion was lower in the MDG when compared with that in CDG (1.7% vs 9.0%, P = 0.04). No differences were found in the other incidences of chest tube-related PPCs, including pneumothorax (12.0% vs 15.2%, P = 0.15) and subcutaneous emphysema (17.2% vs 17.9%, P = 0.35), however. Based on this single-center analysis, multi-lateral pores chest tube provided better drainage performance after VATS.

Background and objectivesThe evolving surgical techniques in thoracoscopic surgery necessitate the exploration of anesthesiological techniques. This study aimed to investigate whether incorporating a continuous erector spinae plane (ESP) block into a multimodal analgesia regimen is non-inferior to continuous thoracic epidural analgesia (TEA) in terms of quality of postoperative recovery for patients undergoing elective unilateral video-assisted thoracoscopic surgery.MethodsWe conducted a multicenter, prospective, randomized, open-label non-inferiority trial between July 2020 and December 2022. Ninety patients were randomly assigned to receive either continuous ESP block or TEA. The primary outcome parameter was the Quality of Recovery-15 (QoR-15) score, measured before surgery as a baseline and on postoperative days 0, 1, and 2. Secondary outcome parameters included pain scores, length of hospital stay, morphine consumption, nausea and vomiting, itching, speed of mobilization, and urinary catheterization.ResultsAnalysis of the primary outcome showed a mean QoR-15 difference between the groups ESP block versus TEA of 1 (95% CI −9 to –12, p=0.79) on day 0, –1 (95% CI −11 to –8, p=0.81) on day 1 and −2 (95% CI −14 to –11, p=0.79) on day 2.ConclusionsThe continuous ESP block is non-inferior to TEA in video-assisted thoracoscopic surgery.Trial registration numberDutch Trial Register (NL6433).

IntroductionLung cancer is a leading cause of cancer deaths worldwide and surgery remains the main treatment for early stage disease. Prior to the introduction of video-assisted thoracoscopic surgery (VATS), lung resection for cancer was undertaken through an open thoracotomy. To date, the evidence base supporting the different surgical approaches is based on non-randomised studies, small randomised trials and is focused mainly on short-term in-hospital outcomes.Methods and analysisThe VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy for lung cancer study is a UK multicentre parallel group randomised controlled trial (RCT) with blinding of outcome assessors and participants (to hospital discharge) comparing the effectiveness, cost-effectiveness and acceptability of VATS lobectomy versus open lobectomy for treatment of lung cancer. We will test the hypothesis that VATS lobectomy is superior to open lobectomy with respect to self-reported physical function 5 weeks after randomisation (approximately 1 month after surgery). Secondary outcomes include assessment of efficacy (hospital stay, pain, proportion and time to uptake of chemotherapy), measures of safety (adverse health events), oncological outcomes (proportion of patients upstaged to pathologic N2 (pN2) disease and disease-free survival), overall survival and health related quality of life to 1 year. The QuinteT Recruitment Intervention is integrated into the trial to optimise recruitment.Ethics and disseminationThis trial has been approved by the UK (Dulwich) National Research Ethics Service Committee London. Findings will be written-up as methodology papers for conference presentation, and publication in peer-reviewed journals. Many aspects of the feasibility work will inform surgical RCTs in general and these will be reported at methodology meetings. We will also link with lung cancer clinical studies groups. The patient and public involvement group that works with the Respiratory Biomedical Research Unit at the Brompton Hospital will help identify how we can best publicise the findings.Trial registration number ISRCTN13472721

•The pharmacokinetics and pharmacodynamics of ropivacaine at different concentrations (Group L:0.25%, Group M:0.5%, Group H:0.75%) in SAPB were evaluated simultaneously.•The analgesic effects of Group M and Group H were better than Group L.•The Cmax and AUC increased with rising ropivacaine concentration, and both Group H and Group M had significantly higher half-life than Group L•The use of 0.5% ropivacaine is recommended for SAPB to provide satisfactory perioperative analgesia. Investigate the analgesia effects and pharmacokinetics of ropivacaine at different concentrations in Serratus Anterior Plane Block (SAPB) and assess the efficacy and safety. Thirty-six patients undergoing video-assisted thoracoscopic surgery (VATS) pulmonary resections were enrolled. Ultrasound-guided SAPB was induced with 3 mg/kg ropivacaine at different concentrations (0.25%, 0.5%, and 0.75%, referred to as Group L, Group M, and Group H, respectively). The concentration of ropivacaine in the plasma at 1, 15, 30, 45, 60 min, 2, 4, 8, 12, and 24 h after SAPB was determined by LC-MS/MS. Other evaluated measures included the Numerical Rating Scale (NRS) scores at rest and on movement, the frequency of dermatomes blocked, onset time and effective plane, Quality of Requirements(QoR)-15 scale, chronic postsurgical pain, and the level of IL-6 and IL-8. The NRS scores were significantly higher in Group L than those in other groups (P < 0.05), indicating that the analgesic effect of Group L was the worst among the three groups. Group H had a lower effective plane of anesthesia and significantly higher incidence of chronic postsurgical pain. The IL-8 level was significantly lower in Group H than in other groups at 1 min, 1 h, and 24 h after SAPB. The ropivacaine concentrations were the highest in Group H, followed by Group M and Group L. The high blood concentration of ropivacaine in Group H may increase the risk of systemic toxicity from local anesthetics. Compared to Group L and Group H, Group M had superior analgesic effects and better safety. Among the three groups, Cmax, t1/2, and AUC0-∞ differed significantly. For patients undergoing VATS, using 0.5% ropivacaine for SAPB is recommended. [Display omitted]

Local anaesthetic adjuvants have been shown to provide better pain relief and extend the duration of analgesia. But little information is available on which adjuvants are more effective in block extension for thoracic paravertebral block (TPVB) during video-assisted thoracoscopic surgery (VATS). This study aimed to compare the analgesic efficacies of different adjuvants with 0.375% ropivacaine in ultrasound-guided TPVB for VATS. A total of 120 patients who underwent VATS at the study hospital in 2022-2023 were recruited and randomly divided into four groups, including the control group (Group R), which received 20 ml ropivacaine 0.375% for TPVB, and the intervention groups: Group D (0.375% ropivacaine with 1 µg/kg dexmedetomidine in a total of 20 ml for TPVB), group E (0.375% ropivacaine with 0.1 mg/kg dexamethasone in a total of 20 ml for TPVB), and group S (0.375% ropivacaine with 0.5ug/ml sufentanil in a total of 20 ml for TPVB). They received a single-injection ultrasound-guided unilateral T5-level TPVB. The primary clinical outcomes were visual analogue scale (VAS) pain scores at rest and during coughing at 4, 8, 12, 16, 20, 24, and 48 h postoperatively. Secondary outcomes included opioid consumption, number of patient-controlled intravenous analgesics (PCIA) used within 48 h, postoperative rescue analgesia, side effects, quality of recovery after surgery, and length of hospital stay. We found that the VAS pain scores in the resting state during the postoperative period at 12-20 h were lower in Group D than in Group R (P < 0.05). The resting VAS pain scores of Groups E and S were lower than those of Group R during the postoperative period of 12-16 h (P < 0.05). Similar differences were observed in the pain scores during coughing at the same time points. Additionally, the co-administration of adjuvants with ropivacaine were associated with decreased consumption of postoperative opioids, less frequent PCIA use, and earlier time to ambulation. The intergroup pairwise comparisons showed that dexmedetomidine was more effective than dexamethasone and sufentanil in reducing additional postoperative analgesics, the length of chest tube placement and length of hospital stay. Subsequently, we administered questionnaires on the quality of recovery, which was positively correlated with the postoperative analgesic effect. These findings suggest that adjuvant analgesia for TPVB can improve postoperative pain in patients undergoing VATS. However, compared with dexamethasone and sufentanil, dexmedetomidine is more effective in extending the duration of analgesia, reducing the demand of postoperative analgesics, improving the quality of recovery at 48 h postoperatively and shorting the length of hospital stay.

Minimally invasive thoracic surgery is associated with substantial pain that can impair pulmonary function. Fascial plane blocks may offer a favorable alternative to opioids, but conventional local anesthetics provide a limited duration of analgesia. We therefore tested the primary hypothesis that a mixture of liposomal bupivacaine and plain bupivacaine improves the overall benefit of analgesia score (OBAS) during the first three postoperative days compared to bupivacaine alone. Secondarily, we tested the hypotheses that liposomal bupivacaine improves respiratory mechanics, and decreases opioid consumption. Adults scheduled for robotically or video-assisted thoracic surgery with combined ultrasound-guided pectoralis II and serratus anterior plane block were randomized to bupivacaine or bupivacaine combined with liposomal bupivacaine. OBAS was measured on postoperative days 1–3 and was analyzed with a linear mixed regression model. Postoperative respiratory mechanics were estimated using a linear mixed model. Total opioid consumption was estimated with a simple linear regression model. We analyzed 189 patients, of whom 95 were randomized to the treatment group and 94 to the control group. There was no significant treatment effect on total OBAS during the initial three postoperative days, with an estimated geometric mean ratio of 0.93 (95% CI: 0.76, 1.14; p = 0.485). There was no observed treatment effect on respiratory mechanics, total opioid consumption, or pain scores. Average pain scores were low in both groups. Liposomal bupivacaine did not improve OBAS during the initial postoperative three days following minimally invasive thoracic procedures. Furthermore, there was no improvement in respiratory mechanics, no reduction in opioid consumption, and no decrease in pain scores. Thus, the data presented here does not support the use of liposomal bupivacaine over standard bupivacaine to enhance analgesia after minimally invasive thoracic surgery. For minimally invasive thoracic procedures, addition of liposomal bupivacaine to plain bupivacaine for thoracic fascial plane blocks does not improve OBAS, reduce opioid requirements, improve postoperative respiratory mechanics, or decrease pain scores. [Display omitted] •Overall benefit of analgesia scores (OBAS) were similar with plain and liposomal bupivacaine.•Respiratory mechanics, total opioid consumption, and pain scores were also similar.•Pain scores were low with each type of local anesthetic.•Liposomal bupivacaine did not provide benefit over plain bupivacaine.

Patients undergoing thoracoscopic lobectomy often experience significant postoperative pain, which is frequently inadequately managed in elderly patients due to their unique physiological characteristics. Multimodal preventive analgesia has been shown to provide satisfactory pain relief and promote early recovery. The objective is to optimize perioperative pain management in elderly patients by multimodal preventive analgesia through a combination of serratus anterior plane block (SAPB) and oxycodone. A total of 80 elderly patients with lung cancer undergoing elective uniportal video-assisted thoracoscopic lobectomy under general anesthesia were enrolled, classified as American Society of Anesthesiologists (ASA) II or III, were randomly assigned to four groups. Group M1 received ultrasound-guided SAPB with 0.375% ropivacaine combined with intravenous oxycodone. Group M2 received intravenous oxycodone. Group M3 received SAPB, while the control group (Group C) was included for comparison. The primary outcome measures included the Visual Analogue Scale (VAS) scores at rest and during coughing immediately after postoperative tracheal extubation. Secondary outcome measures comprised VAS scores at rest and during coughing at 6 h, 24 h, 48 h, and 72 h postoperatively; intraoperative remifentanil consumption; number of activations of the Patient-Controlled Intravenous Analgesia (PCIA) pump; frequency and dosage of rescue analgesia; intraoperative vasoactive drug consumption; and incidence of postoperative adverse events. The experimental groups had significantly lower VAS scores compared to the control group at all measured time points. In the M1 group, VAS scores at 6 h and 24 h after surgery were significantly lower than those in the other two experimental groups. The secondary outcomes are statistically significant differences among the four groups. Multimodal preventive analgesia based on SAPB and oxycodone can effectively reduce perioperative pain in elderly patients undergoing thoracoscopic lobectomy, decrease intraoperative and postoperative opioid consumption, and facilitate recovery. Trial registration: ChiCTR2400088399.