Faculty Bibliography

BACKGROUND:Independent peer review of mortality cases has potential to identify issues in cardiothoracic surgical patients. The Australian and New Zealand Audit of Surgical Mortality aims to improve surgical care through peer-reviewed assessment of all surgical mortality. The aim of this study was to describe common clinical management issues that contribute to patient mortality in a cohort of Australian cardiothoracic surgical patients. This approach may subsequently provide a basis for quality improvement. METHODS:Cardiothoracic mortality reports to the Australian and New Zealand Audit of Surgical Mortality from February 2009 through December 2015 were reviewed. The surgeon report and assessor comments were coded to identify clinical management issues. These were divided into perioperative stages (preoperative, intraoperative, and postoperative), and at each stage a thematic analysis was performed. RESULTS:Of the 908 cases analyzed, 1371 clinical management issues were identified. Postoperative issues were the most common (n = 552), followed by preoperative (n = 378) and intraoperative issues (n = 370). Communication issues were present at all 3 stages (n = 71). Overall the most common theme was intraoperative technical issues (n = 287). Many of these issues revolved around unintentional injury to anatomic structures during surgery and inadequate myocardial protection. Communication issues commonly related to surgical handover to the intensive care unit and lack of shared decision-making. Also common were consultant surgeons being unaware of patient deterioration or significant changes in management. CONCLUSIONS:The Australian and New Zealand Audit of Surgical Mortality provides valuable insights into issues affecting mortality in cardiothoracic patients. Potentially avoidable management issues play a large role in determining the outcome of these patients. Quality improvement initiatives targeting these areas may be valuable.

Pulmonary alveolar proteinosis is a rare condition characterized by progressive accumulation of surfactant lipoproteins in the alveolar space, leading to poor gas exchange. We describe our technique of whole lung lavage for management of pulmonary alveolar proteinosis.

BACKGROUND:Failure of communication can have potentially severe results in cardiothoracic surgery. Previous literature regarding patient safety highlighted communication as a common area for improvement. This study utilized a qualitative approach to analyze a national mortality audit data set to identify and describe communication issues that could potentially contribute to patient mortality following cardiothoracic surgery. METHODS:We utilized a peer-reviewed audit of surgical deaths after cardiothoracic surgery in Australian hospitals from 2009 to 2015 via the Australian and New Zealand Audit of Surgical Mortality. Cases were identified with clinical management issues then individual analysis of cases highlighting communication issues was undertaken. A total of 91 reports from surgeons and assessors were analysed using a thematic analytic approach. RESULTS:A total of 908 cases of potentially avoidable mortality were identified as being associated with clinical management issues, and communication issues were identified in 91 (10%) of these cases, which served as the basis for this analysis. The study found that failure to achieve shared decision making was the most common theme (n = 38, 41.8%), followed by failure to notify patient deterioration (n = 22, 24.1%), misreporting of patient condition (n = 10, 11.0%) and issues related to informed consent (n = 9, 10.0%). The most frequent communication issues occurred between surgeons and the intensive care unit. CONCLUSIONS:Poor communication was identified in patients who died after cardiothoracic surgery. Communication is an important modifiable factor in patient mortality. Efforts to address teamwork and communication have the potential to improve safety and quality of care for patients undergoing cardiothoracic surgery.

BACKGROUND:Multiple case studies have suggested that video-assisted thoracoscopic sympathectomy (VATS) reduces the occurrence and frequency of symptoms in long QT syndrome (LQTS) [1,2,3]. To date there has not been a literature review to report on the short-term and long-term outcomes of this procedure. Our primary aims are to review the literature findings on the clinical outcomes of VATS sympathectomy for long QT and present a local centre case report on the outcomes of T2-T5 sympathectomy. METHODS:Relevant articles were identified by a systematic search of PubMed, Cochrane and Scopus databases, from November 1985 to October 2015. A total of 520 patients from 21 publications were included for analysis and discussion in three main areas: presenting symptoms and indication for surgery, perioperative complications, and patient quality of life following surgery. Our case study reviews a 49-year-old female with recently diagnosed long QT syndrome and intolerance to beta blocker therapy successfully managed with T2-T5 thoracic sympathectomy. RESULTS:The most common presenting indication for operative management of long QT syndrome was syncope (208/520 patients) and tachyarrhythmia (207/520 patients). T1-T5 left sympathectomy was performed in 15/21 published reports (332/520 patients) with partial stellate removal or in its entirety. Follow-up of patients ranged from 1 month to 11 years. Four patients died in the postoperative period, from fatal arrhythmias. The most common postoperative findings were no symptoms (64/520 patients); tachyarrhythmia (55/520 patients), syncope (45/520 patients), and Horner's syndrome (13/520 patients with 27 patients reporting associated symptoms). Thirteen cases reported on the QTc changes post sympathectomy and 9/13 cases involving 220/520 patients showed marked QTc reduction following surgery. Mean preoperative QTc was 558ms and median 559ms. Mean postoperative QTc was 476ms and median 466ms. Our patient showed a marked reduction in QTc following surgery, with no evidence of arrhythmias and reduced beta blocker dependence. CONCLUSIONS:Surgical management of LQTS has historically involved a left cervicothoracic stellectomy removing stellate ganglia and typically part of the left thoracic sympathetic chain resulting in reduction in symptoms but increasing the risk of Horner's syndrome and intermittent temperature changes [4,5]. Surgical resection of the thoracic ganglia alone for management of LQTS is scarce in the literature. Short-term follow-up in our case study following a T2-T5 sympathectomy revealed reduction in symptoms, no requirement for beta blocker therapy and reduced QTc interval. Further follow-up using greater patient numbers will further support T2-T5 sympathectomy as an option for surgical management of LQTS.

BACKGROUND:F-FDG avidity on positron emission tomography (PET)/computed tomography (CT) are unknown. METHODS:F-FDG PET/CT and biopsy. Subjects were divided into two cohorts: postoperative Tumour, Node, Metastases (TNM) upstaged (US) and not upstaged (UN). The parameters of standardised uptake value (SUV max), pre-scan blood glucose level (BGL), the time interval between staging and surgery were analysed using a two-tailed Mann-Whitney U test. RESULTS:Subjects were aged 31 to 85 years; 75 were male. Ninety-three had adenocarcinoma (AC), 42 had squamous cell carcinoma (SCC). Sixty-four were upstaged after surgery, 40 AC and 18 SCC. For AC, US SUV max was significantly higher (mean US 6.4 (SD 4.6) vs. UN 4.6 (SD 3.4), p=0.03) but not time to surgery (mean US 55 (SEM 7.1) vs. UN 71 (SEM 14.8) days p=0.74). Upstaged were mainly T (imaging and histopathology discordance) and N (unexpected mediastinal or hilar nodal metastases). For SCC, US vs. UN SUV max (mean US 12.0 (SD 5.6) vs. UN 9.4 (SD 5.6), p=0.08) and time to surgery (mean US 48 (SEM 5.3) vs. UN 47 (SEM 5.0) days p=0.66) were not significantly different. Standardised uptake value max and surgical waiting time were not analysed for other tumour types due to small numbers. Pre-PET BGL US vs. UN was not significantly different for all (p=0.52), AC (p=0.32) and SCC (p=0.37) subjects, thus not a confounding factor. CONCLUSIONS:F-FDG PET/CT nodal assessments. Surgical waiting time appears not to be a predictor for both tumour types.

Resection of sternal tumors can leave large defects, which exposes major mediastinal structures, and can affect respiratory mechanics. If feasible, resection is potentially a complex reconstructive challenge to restore normal and functional anatomy using conventional techniques. We report the first Australian use of a three-dimensional-printed titanium and PoreStar prosthesis in a 39-year-old woman for reconstruction after major surgical resection of the sternum for metastatic breast cancer. The patient successfully underwent excision of the sternum and costal cartilages as well as implantation of the prosthesis. We conclude that three-dimensional-printed prostheses are technically feasible to deliver excellent cosmetic result.