Left Upper Lobe Multi-Segmentectomy Versus Lobectomy for Early-Stage Lung Cancer: A Meta-Analysis.

INTRODUCTION: The left upper lobe (LUL) has unique hilar anatomy, and LUL multi-segmentectomy (apical trisegmentectomy and lingulectomy) may result in different outcomes than both single anatomical segmentectomy and left upper lobectomy in the management of early-stage primary lung cancer; however no meta-analyses have been performed. The aim of this meta-analysis is to determine if LUL multi-segmentectomy is non-inferior to left upper lobectomy for long-term survival outcomes, or superior for in-hospital outcomes. METHODS: Electronic databases searches were performed on PubMed, Embase, and the Cochrane Library to identify studies comparing outcomes in LUL multi-segmentectomy vs left upper lobectomy in early-stage lung cancer (clinical stage T2 N0 or less). Long-term postoperative overall and disease-free survival were assessed via reconstruction of Kaplan-Meier survival curves. In-hospital complications and length of stay, as well as long term recurrence were analysed via random effects models. RESULTS: Five relevant studies were identified, including 1,196 patients. Overall survival did not differ at 5 years (multi-segmentectomy 92.6% vs lobectomy 89.3%, P=0.188), but patients undergoing LUL multi-segmentectomy had better disease-free survival at 5 years (93.1% vs 88.4%, P=0.041). Patients undergoing LUL multi-segmentectomy had a shorter mean length of hospital stay (mean difference -0.26 days, 95% CI; -0.39 to 0.14, P<0.01, I2=0.00%). There was no difference in combined in-hospital complications (P=0.14), local recurrence (P=0.35), distant recurrence (P=0.23), or overall recurrence (P=0.39). CONCLUSION: LUL multi-segmentectomy is associated with reduced hospital length of stay, but no difference in long-term overall survival compared with left upper lobectomy in the management of early-stage primary lung cancer.

Conventional Glycaemic Control May Not Be Beneficial in Diabetic Patients Following Cardiac Surgery.

INTRODUCTION: Stress hyperglycaemia is common following cardiac surgery. Its optimal management is uncertain and emerging literature suggests that flexible glycaemic control in diabetic patients may be preferable. This study aims to assess the relationship between maximal postoperative in-hospital blood glucose levels (BSL) and the morbidity and mortality outcomes of diabetic and non-diabetic cardiac surgery patients. METHODS: A retrospective cohort analysis of all patients undergoing cardiac surgery at a tertiary single centre institution from 2015 to 2019 was undertaken. Early management and outcomes of hyperglycaemia following cardiac surgery were assessed via multivariable regression modelling. Follow-up was assessed to 1 year postoperatively. RESULTS: Consecutive non-diabetic patients (n=1,050) and diabetic patients (n=689) post cardiac surgery were included. Diabetics with peak BSL ≤13.9 mmol/L did not have an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L was associated with overall wound complications (5.7% vs 8.8%, OR 1.64 [1.00-2.69], p=0.049) and postoperative pneumonia (2.7% vs 7.3%, OR 2.35 [1.26-4.38], p=0.007). Diabetic patients with postoperative peak BSL >13.9 mmol/L were at an increased risk of overall wound complication (7.4% vs 14.8%, OR 2.47 [1.46-4.16], p<0.001), graft harvest site infection (3.7% vs 11.8%, OR 3.75 [1.92-7.30], p<0.001), and wound-related readmission (3.1% vs 8.8%, OR 3.11 [1.49-6.47], p=0.002) when compared to diabetics with peak BSL ≤13.9 mmol/L. CONCLUSION: In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L is associated with morbidity. In diabetic patients, hyperglycaemia with peak BSL ≤13.9 mmol/L was not associated with an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. Further investigation of flexible glycaemic targets (target BSL ≤13.9 mmol/L) in diabetic patients is warranted.

Deep Sternal Wound Infections After Cardiac Surgery: A New Australian Tertiary Centre Experience.

BACKGROUND: Deep sternal wound infections (DSWI) after cardiac surgery impose a significant burden to patient outcomes and health care costs. The objective of this study is to identify risk factors, microbiological characteristics and protective factors for deep sternal wound infections following cardiac surgery in an Australian hospital. METHODS: We performed a retrospective study on 1,902 patients who underwent cardiac surgery at Fiona Stanley Hospital, a tertiary hospital in Western Australia from February 2015 to April 2019. Patients were grouped into having either deep sternal wound infections or no wound infections. RESULTS: Of 1,902 patients, 26 (1.4%) patients had DSWI. On multivariate analysis, male gender was associated with DSWI with an adjusted odds ratio of 7.390 (95% CI 1.189-45.918, p=0.032). Increased body mass index (BMI) had an odds ratio of 1.101 (95% 1.03-1.18, p=0.008). Increased length of stay (LOS) had an odds ratio of 1.05 (95% CI 1.02-1.08, p=0.002). Left main disease had an odds ratio of 3.076 (95% CI 1.204-7.86, p=0.019). The presence of hypercholesterolaemia had an odds ratio of 0.043 (95% CI 0.009-0.204, p<0.001). Staphylococcus aureus and Staphylococcus epidermidis were the most common organisms found in deep sternal wound infections (23.1% and 26.9% respectively). Polymicrobial growth occurred in 19.2% of patients. One gram of topical cephazolin was applied in 315 patients. None of these patients developed a deep sternal wound infection (p=0.022). CONCLUSION: In a large Australian tertiary centre, male gender, increased BMI, presence of left main coronary artery disease, and increased length of hospital stay are significantly associated with the risk of deep sternal wound infections. Staphylococcus aureus and Staphylococcus epidermidis are common organisms in deep sternal wound infections. Topical antibiotics such as cephazolin are useful in preventing deep sternal wound infections. The presence of hypercholesterolaemia is a protective factor and we hypothesise that this is due to long-term statin use.

Does Enhanced Recovery After Surgery Protocols Reduce Complications and Length of Stay After Thoracic Surgery: A Systematic Review of the Literature.

Enhanced recovery after surgery (ERAS) has an increasingly important role in the perioperative management of thoracic surgical patients. It has been extensively studied in multiple surgical specialties, particularly colorectal surgery, where ERAS protocols have been shown to reduce postoperative length of stay and postoperative complications. Electronic searches of two research databases were performed: PubMed (1972 to October 2023) and Ovid MEDLINE (1946 to October 2023). The literature search was completed on January 4, 2024. Search terms included: "thoracic surgery" and "ERAS" or "Enhanced Recovery After Surgery". The search was limited to studies evaluating humans undergoing thoracic surgery for any indication. The primary outcome was overall morbidity, with secondary outcomes including mortality, length of stay, and pulmonary complications. The search yielded a total of 794 records, of which 30 (four meta-analyses and 26 observational trials) met the relevant inclusion and exclusion criteria. This review suggested the implementation of ERAS protocols can lead to a reduction in postoperative morbidity; however, this was not a consistent finding. The majority of studies included demonstrated a reduction in the length of stay with the implementation of ERAS. Overall, ERAS/ERATS is an important adjunct to the management of patients requiring thoracic surgery, consistently leading to shorter lengths of stay and likely contributing to reduced rates of postoperative morbidity. Further research will be required to determine the impact of the recently released ERATS guidelines.

Coronary artery bypass grafting in octogenarians: an Australian experience.

BACKGROUND: The aims of this study were to describe early and mid-term morbidity and mortality in octogenarian patients undergoing CABG, to determine if outcomes are comparable to younger patients undergoing the same procedure. METHODS: We conducted a retrospective analysis of the first 901 patients who underwent cardiac surgery at a large newly established tertiary hospital in Western Australia from February 2015 to September 2019. Inclusion criteria involved all patients undergoing coronary artery bypass grafting. Exclusion criteria included patients who underwent concomitant valve or aortic procedure. RESULTS: From a cohort of 901 patients, 37 octogenarian patients underwent CABG. Octogenarian patients had a higher rate of post-operative transfusion 35.1% versus 21.4% (P = 0.048), a higher rate of post-op acute kidney injury 40.5% versus 17.2% (P < 0.0001), a higher rate of post-operative atrial arrythmia requiring treatment 40.5% versus 22.5% (P = 0.011) and higher rate of return to theatre (13.5% versus 4.7%, P = 0.018), with bleeding/tamponade being the most likely reason (10.8% versus 2.7%). Octogenarian patients had a longer post-operative length of stay (LOS) with a median LOS of 10 versus 7 days (P < 0.0001). There was no increase in hospital readmission rate, in-hospital mortality or 1 year mortality in octogenarian patients. 24-month and 36-month survivals were 95.2% and 89.6% in octogenarians and 95.3% and 91.5% in the younger group. CONCLUSIONS: Despite an increase in post-operative morbidity and LOS, there was no difference in hospital readmission, in-hospital mortality or 1 year mortality in octogenarian patients who underwent CABG. CABG is safe and remains an important management option for these patients.

Cavernous haemangioma of anterior mitral valve leaflet: diagnostic utility of 3D echocardiography.

Mitral valve (MV) haemangiomas are rare primary cardiac tumours which may cause progressive cardiac failure as well as sudden death. We present a case of a 44-year-old woman referred for surgical correction of symptomatic severe mitral regurgitation. Preoperative two-dimensional transthoracic and transoesophageal echocardiography (TOE) were reported as demonstrating complex bi-leaflet prolapse causing severe mitral regurgitation. The patient was listed for MV surgery. Only on preoperative CT coronary angiogram was a filling defect noted, leading to suspicion of a cardiac tumour. Prior to skin incision, three-dimensional (3D) TOE revealed a 2×3 cm mass attached to the anterior leaflet of the MV. The tumour was subsequently resected, and the MV replaced. Postoperative histopathology confirmed a large cavernous haemangioma of the anterior MV leaflet. This case highlights a rare cause of severe mitral regurgitation and demonstrates the utility of 3D TOE as an adjunctive modality in confirming the suspected diagnosis of a cardiac tumour.

Laparoscopic Pancreaticojejunostomy Anastamosis Using an Articulating Needle Holder.

INTRODUCTION: Pancreaticojejunal anastomosis is a technically challenging stage of the pancreaticoduodenectomy procedure for even the most experienced surgeon. We illustrate a buttressed duct-to-mucosa anastomosis (modified Blumgart technique) during laparoscopic pancreaticoduodenectomy using an articulating needle holder (FlexDex) (Video, Supplemental Digital Content 1, http://links.lww.com/SLE/A299). MATERIALS AND METHODS: While performing a minimally invasive pancreaticoduodenectomy, an articulating needle holder (FlexDex) is introduced through an 8 mm laparoscopic port and used to perform the duct-to-mucosa pancreaticojejunal anastomosis. Parenchymal buttressing using 3/0 double ended barbed suture (Stratafix) and pancreas duct to jejunum using 5/0 Prolene.Approval was obtained from the Office of Ethics and Research Governance at our institution. Consent was gained from the individual patient involved, to submit this intraoperative video for publication. RESULTS: Successful intraoperative pancreaticojejunal anastomosis was performed using the articulating needle holder (FlexDex). The patient recovered from the procedure without complication, with no postoperative pancreatic fistula. CONCLUSIONS: We demonstrate the feasibility of performing a laparoscopic pancreaticojejunal anastomosis using an articulating needle holder (FlexDex).

Does preoperative pulmonary rehabilitation/physiotherapy improve patient outcomes following lung resection?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether preoperative physiotherapy (pulmonary prehabilitation) is beneficial for patients undergoing lung resection. Altogether 177 papers were found using the reported search, of which 10 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. A meta-analysis by Li et al. showed that patients who received a preoperative rehabilitation programme (PRP) had reduced incidence of postoperative pulmonary complications (PPCs) (odds ratio 0.44, 95% CI 0.27-0.71), reduced length of stay (LOS) (-4.23 days, 95% CI -6.14 to -2.32 days) and improved 6-min walking distance (71.25 m, 95% CI 39.68-102.82) and peak oxygen uptake consumption (VO2 peak) (3.26, 95% CI 2.17-4.35). A meta-analysis by Steffens et al. showed that PPCs were reduced in patients with PRP (relative risk 0.49, 95% CI 0.33-0.73) and reduced LOS (-2.86 days, 95% CI -5.40 to -0.33). The results of 3 additional meta-analyses, 4 randomized controlled trials and 1 observational study all provide further support to PRP in enhanced recovery after surgery and the improvement in exercise capacity. We conclude that PRP improves exercise capacity in patients undergoing surgical resection for lung cancer. Moderate quality evidence supports preoperative exercise providing significant reduction in PPCs and hospital LOS. Referral to exercise programmes should be considered in patients awaiting lung resection, particularly those deemed borderline for suitability for surgical resection.