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Background: Few data are available concerning the outcome of patients denied venovenous extracorporeal membrane oxygenation (VV-ECMO) relative to severe acute respiratory distress syndrome (ARDS) due to COVID-19. Methods: We compared the 90-day survival rate of consecutive adult patients for whom our center was contacted to discuss VV-ECMO indication. Three groups of patients were created: patients for whom VV-ECMO was immediately indicated (ECMO-indicated group), patients for whom VV-ECMO was not indicated at the time of the call (ECMO-not-indicated group), and patients for whom ECMO was definitely contraindicated (ECMO-contraindicated group). Results: In total, 104 patients were referred for VV-ECMO support due to severe COVID-19 ARDS. Among them, 32 patients had immediate VV-ECMO implantation, 28 patients had no VV-ECMO indication, but 1 was assisted thereafter, and 44 patients were denied VV-ECMO for contraindication. Among the 44 patients denied, 30 were denied for advanced age, 24 for excessive prior duration of mechanical ventilation, and 16 for SOFA score >8. The 90-day survival rate was similar for the ECMO-indicated group and the ECMO-not-indicated group at 62.1 and 61.9%, respectively, whereas it was significantly lower (20.5%) for the ECMO-contraindicated group. Conclusions: Despite a low survival rate, 50% of patients were at home 3 months after being denied for VV-ECMO for severe ARDS due to COVID-19.
RESUMO
Background: The goal of this study was to determine whether an awake prone position (aPP) reduces the global inhomogeneity (GI) index of ventilation measured by electrical impedance tomography (EIT) in COVID-19 patients with acute respiratory failure (ARF). Methods: This prospective crossover study included COVID-19 patients with COVID-19 and ARF defined by arterial oxygen tension:inspiratory oxygen fraction (P aO2 :F IO2 ) of 100-300â mmHg. After baseline evaluation and 30-min EIT recording in the supine position (SP), patients were randomised into one of two sequences: SP-aPP or aPP-SP. At the end of each 2-h step, oxygenation, respiratory rate, Borg scale and 30-min EIT were recorded. Results: 10 patients were randomised in each group. The GI index did not change in the SP-aPP group (baseline 74±20%, end of SP 78±23% and end of aPP 72±20%, p=0.85) or in the aPP-SP group (baseline 59±14%, end of aPP 59±15% and end of SP 54±13%, p=0.67). In the whole cohort, P aO2 :F IO2 increased from 133±44â mmHg at baseline to 183±66â mmHg in aPP (p=0.003) and decreased to 129±49â mmHg in SP (p=0.03). Conclusion: In spontaneously breathing nonintubated COVID-19 patients with ARF, aPP was not associated with a decrease of lung ventilation inhomogeneity assessed by EIT, despite an improvement in oxygenation.
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BACKGROUND: The utility of endoscopic ampullectomy versus surgical ampullectomy remains a topic of debate, particularly for the treatment of malignant tumors. The goal of this study was to prospectively establish the outcomes of endoscopic ampullectomy, with focus on carcinoma. METHODS: From February 2002 to December 2008, 61 patients underwent endoscopic ampullectomy. The ampulloma was discovered fortuitously in the majority of cases (43 patients, 70%). All patients had had an echoendoscopy revealing a T1N0 lesion without invasion of the orifice. RESULTS: Forty-three patients (70%) underwent a monobloc resection. Histological analysis revealed a low-grade dysplastic adenoma in 21 patients (35%), a high-grade dysplastic adenoma in 11 patients (18%), no dysplasia in 16 patients (26%), an adenocarcinoma in 10 patients (16%), and a well-differentiated endocrine carcinoma in 3 patients (5%). Among the ten patients with adenocarcinoma, four with adenocarcinoma of poor prognosis were treated by pancreaticoduodenectomy (PD) with R0 resection, of whom one patient had no more lesion. Two intramucosal adenocarcinomas were cured by endoscopic ampullectomy without any recurrence. Four patients received palliative care after endoscopic ampullectomy due to cephalic pancreatico-duodenectomy contraindication. For the three patients with well-differentiated endocrine carcinomas, one was treated by PD with R0 resection and two were treated solely by endoscopic ampullectomy, without recurrence. Eleven patients (18%) presented with complications. The complication rate was 30.5% for carcinomas versus 14.5% for benign tumors (p < 0.05). CONCLUSION: Endoscopic ampullectomy allows for the oncologic resection of well-differentiated intramucosal carcinomas with negative margins. The risk of complications is greater for papillary carcinomas.