Ultra-early initiation of postoperative rehabilitation in the post-anaesthesia care unit after major thoracic surgery: case-control study.

BACKGROUND: Physiotherapy is a major cornerstone of enhanced rehabilitation after surgery (ERAS) and reduces the development of atelectasis after thoracic surgery. By initiating physiotherapy in the post-anaesthesia care unit (PACU), the aim was to evaluate whether the ultra-early initiation of rehabilitation (in the first hour following tracheal extubation) would improve the outcomes of patients undergoing elective thoracic surgery. METHODS: A case-control study with a before-and-after design was conducted. From a historical control group, patients were paired at a 3:1 ratio with an intervention group. This group consisted of patients treated with the ultra-early rehabilitation programme after elective thoracic surgery (clear fluids, physiotherapy, and ambulation). The primary outcome was the incidence of postoperative atelectasis and/or pneumonia during the hospital stay. RESULTS: After pairing, 675 patients were allocated to the historical control group and 225 patients to the intervention group. A significant decrease in the incidence of postoperative atelectasis and/or pneumonia was found in the latter (11.4 versus 6.7 per cent respectively; P = 0.042) and remained significant on multivariate analysis (OR 0.53, 95 per cent c.i. 0.26 to 0.98; P = 0.045). A subgroup analysis of the intervention group showed that early ambulation during the PACU stay was associated with a further significant decrease in the incidence of postoperative atelectasis and/or pneumonia (2.2 versus 9.5 per cent; P = 0.012). CONCLUSIONS: Ultra-early rehabilitation in the PACU was associated with a decrease in the incidence of postoperative atelectasis and/or pneumonia after major elective thoracic surgery.

Intent-to-cure surgery for small-cell lung cancer in the era of contemporary screening and staging methods.

OBJECTIVES: Our goal was to report on the contemporaneous single-centre experience of patients with small-cell lung cancer (SCLC) who had lung resection with curative intent. METHODS: Between 2005 and 2018, 31 patients were operated on for SCLC with curative intent. There were 11 women and 20 men whose ages averaged 63 ± 10 years. The clinical diagnosis was incidental in 16 patients (51.6%). All patients were screened with high-resolution computed tomography, positron emission tomography and brain imaging. Eight patients (25.8%) had invasive mediastinal lymph node staging. RESULTS: Preoperative tissue diagnosis was unknown or erroneous in 26 patients (83.9%). Lung resections comprised mainly lobectomies (n = 23; 74.2%). Lymphadenectomies harvested a mean of 16.3 ± 3 lymph nodes, leading to upstaging in 38.7% of the cases. An R0 resection was achieved in 28 patients (90.3%). Pathological analysis disclosed pure small cell histological specimens in 24 patients (77.4%). There were no 90-day deaths. Perioperative platinum-based chemotherapy was performed in 27 patients (87.1%); adjuvant thoracic irradiation, in 7 (50%) of the 14 N+ patients; and prophylactic cranial irradiation, in 8 (29.6%) of the 27 potential candidates. Overall, disease-free and disease-specific survival rates at 5 years were 32.9 ± 10%, 35.2 ± 10% and 44.1 ± 11.3%, respectively. CONCLUSIONS: Despite the use of contemporary screening and staging methods, selection of SCLC candidates for surgery remained haphazard, surgery was typically performed in ignorance of the actual histological and adherence to treatment guidelines was inconsistent. Nevertheless, one-third of patients with SCLC who were operated on were cured, even in cases of regional or oligometastatic disease.

Idiopathic Aortic Root to Right Atrial Fistula.

An aorta to right atrium fistula is rare. We report a case of idiopathic aortic root to right atrial fistula with right heart failure and review the literature. doi: 10.1111/jocs.12751 (J Card Surg 2016;31:373-375).