Does a combined procedure for cardiac surgery and thyroidectomy offer acceptable outcomes?

This best evidence topic on cardiothoracic surgery was written using a structured protocol. The question addressed was: 'in an adult patient requiring cardiac surgery, can a thyroidectomy for a large retrosternal goitre be performed with good outcomes as a combined procedure?' Of 150 papers identified through the literature search, 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, study type, patient group studied, relevant outcomes and results were tabulated. This paper includes 3 Level 4 papers and 13 case reports. All papers reported postoperative outcomes and five papers reported intraoperative outcomes. Of a total cohort of 32 patients, 25 were euthyroid prior to combined surgery. Twenty-nine of 32 thyroid surgeries were performed immediately prior to cardiac surgery in the combined procedure sequence. Post-procedural complications including transient recurrent laryngeal palsy and tracheomalacia were reported in 8 patients. There was one intraoperative death. Where reported, all patients were euthyroid on follow-up. All identified papers reported good outcomes with combined thyroidectomy and cardiac surgery.

Is low serum albumin associated with postoperative complications in patients undergoing oesophagectomy for oesophageal malignancies?

A best evidence topic was written according to a structured protocol. The question addressed was: in patients undergoing oesophagectomy for oesophageal malignancy, is low serum albumin associated with postoperative complications? Altogether, 87 papers were found using the reported search, of which 16 demonstrated 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. This paper includes 2 level 2 papers, 12 level 3 papers and 2 level 4 papers. All the papers compared either all or some of the following postoperative complications: mortality, morbidity, anastomotic leak, respiratory and non-respiratory complications, and length of hospital stay. Eleven of the 16 papers found an association between low serum albumin and postoperative complications. Of these, one study showed that low serum albumin combined with low fibrinogen levels (FA score) was predictive of postoperative recurrence of oesophageal cancer. Another study showed that when combined with white cell count and C-reactive protein (CRP, NUn score), serum albumin had a high diagnostic accuracy for major complications after postoperative day 3. The largest study compared the in-hospital mortality in 7227 patients who underwent oesophageal surgery for malignancy. The percentage of in-hospital mortality was associated with low serum albumin (<15.0 vs >35.0 g/l, 21.0 vs 11.3%, P <0.001). Five of the 16 papers found no significant association between low serum albumin and postoperative complications. Of these papers, one showed that low serum albumin was not an independent risk factor, while four others found no association between low serum albumin with respiratory complications, anastomotic leak and postoperative mortality. Instead, these studies found other factors responsible for postoperative complications such as: CRP, smoking, disease duration, malnutrition and low T-cell levels. Taken together, while low serum albumin is associated with postoperative complications, opinion regarding the prognostic value of low serum albumin and nutritional support remains conflicted. Because of the confounding factors encountered in these studies, the clinician should consider the finding of low serum albumin in patients, together with disease and surgical factors to provide optimal care for these patients.

Open surgical repair for chronic type B aortic dissection: a systematic review.

BACKGROUND: The treatment of chronic type B aortic dissection (CBAD) remains complicated. Thoracic endovascular aortic repair (TEVAR) has supplanted open surgical repair (OSR) as the preferred surgical treatment for CBAD. Despite TEVAR's superior short-term results, much less is understood about its long-term outcomes. As much of the understanding of OSR originates from historical report, contemporary series, with modern surgical techniques and technologies, may present an alternative to TEVAR. The present systematic review will assess the short- and long-term outcomes of historic and contemporary series of OSR for CBAD. METHODS: Electronic searches were performed using six databases from their inception to March 2014. Relevant studies with OSRs for chronic type B dissection were identified. Data were extracted by two independent reviewers and analyzed according to predefined clinical endpoints. Studies were sub-classified into the pre-endovascular (historic series) and endovascular era (contemporary series) depending on whether the majority of cases were performed after 1999. RESULTS: Nineteen studies were identified for inclusion for quantitative analysis. Pooled short-term mortality was 11.1% overall, and 7.5% in the nine contemporary studies. Stroke, spinal cord ischemia, renal dysfunction, and reoperation for bleeding were 5.9%, 4.9%, 8.1%, and 8.1%, respectively, for the contemporary series. Absolute late reintervention was identified in 13.3% of patients overall, and in 11.3% of patients in the contemporary series. Aggregated survival at 1-, 3-, 5-, and 10-years of all patients were 82.1%, 74.1%, 66.3%, and 50.8%, respectively. CONCLUSIONS: OSR for chronic type B dissection in the contemporary era offers acceptable results. Management approaches should be considered carefully, taking into account both short-term and long-term complications. More research is required to clarify specific indications for OSR and TEVAR in chronic type B dissections.