Comparison of percutaneous decannulation and open surgical repair for large-bore arterial access sites of extracorporeal membrane oxygenation.

INTRODUCTION: Following weaning of peripheral venoarterial extracorporeal membrane oxygenation (ECMO) support, removal of cannulas and repair of large-bore arterial sites is traditionally by open surgical repair (OSR). The use of a percutaneous vascular closure device (VCD) offers a minimally invasive alternative to OSR with potential for reduced operative complications, reduced hospital length of stay and in-hospital mortality. METHODS: A systematic review of Medline and Embase databases was conducted for studies comparing VCD-assisted decannulation with OSR following decannulation of peripheral ECMO. The primary endpoint was rate of post-procedural complications, namely wound infection and limb ischaemia. The secondary endpoint was in-hospital mortality. RESULTS: Eight studies, with a total of 685 patients, met inclusion criteria. Forty-eight percent (n = 328) of patients underwent VCD-assisted decannulation with the remainder decannulated by OSR. Pooled analysis demonstrated that patients undergoing VCD-assisted decannulation are at significantly lower risk of overall complications than surgical repair (OR 4.34; 95% CI 2.19-8.57; p < .001). Specifically, there was a substantial decrease in groin infections (OR 6.77; 95% CI 3.07-14.97; p < .001) without notable differences in limb ischaemia or pseudoaneurysm occurrence between the VCD and OSR cohorts. There was a lower incidence of intra-operative bleeding and haematoma in the VCD cohort (p < .001 and p = .002, respectively). CONCLUSION: Vascular closure device-assisted decannulation of peripheral ECMO offers a significantly reduced risk of complications, particularly groin infections and bleeding. Future research should encompass larger cohorts, randomised controlled trials, cost-benefit analyses, and the training of surgeons, cardiologists and intensivists in VCD-assisted decannulation, potentially through the integration of simulation-based training.

In patients supported with peripheral veno-arterial extracorporeal membrane oxygenation, what factors are associated with the development of spinal cord ischaemia?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients supported with peripheral veno-arterial extracorporeal membrane oxygenation, what factors are associated with the development of spinal cord ischaemia'? Altogether, more than 22 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. Of the 28 patients reported by included studies, the thoracic spinal cord was most commonly affected. Twenty patients (71%) survived to hospital discharge and 7 (25%) were reported to have neurological recovery. Potential confounders included coronary angiography, cardiac arrest requiring chest compressions and concomitant intra-aortic balloon pump. Consequently, all papers highlighted the likely multifactorial aetiology of spinal cord infarction in these patients. We propose that close neurological observation, particularly in patients who have received chest compressions, and management of potential aetiological factors is crucial to aid in timely diagnosis and potential prevention of this rare complication. Limiting sedation and neuromuscular blockade to enable neurologic assessment of the lower limbs may allow more timely diagnosis.

Minimally invasive surgical resection of a large primary pulmonary hydatid cyst: a thoracoscopic approach.

Pulmonary hydatid disease is a rare parasitic disease in Australia with few reported cases. The mainstay of treatment in pulmonary hydatid disease is surgical resection followed by medical treatment with benzimidazoles to reduce the risk of recurrence. We present a case of successful resection of a large primary pulmonary hydatid cyst via minimally invasive video-assisted thoracoscopic surgery approach in a 65-year-old gentleman with incidental hepatopulmonary hydatid disease.

A Systematic Review of Microwave Ablation for Colorectal Pulmonary Metastases.

BACKGROUND/AIM: Pulmonary metastases are the second most common site of metastasis in colorectal cancer after the liver, and microwave ablation (MWA) for its treatment has grown in popularity in patients who are not suitable for pulmonary metastatectomy. However, its long-term efficacy remains unknown. MATERIALS AND METHODS: A systematic review was conducted in July 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using PubMed, EMBASE, Scopus, and Cochrane databases. Studies adopting MWA for colorectal cancer pulmonary metastases were included. RESULTS: A total of 488 lesions were ablated in 230 patients across eight studies. The median duration of ablation was 10 minutes. The mean length of stay in hospital was 2.3 days. Complications included pneumothorax in 128 (52%) patients; pneumonia, which occurred in 4 (1.7%) patients, and pulmonary haemorrhage in 23 (10.0%) patients. Complete remission was achieved in 85 (37.0%) patients, local control was achieved in 103 (44.8%) patients, and residual or progressive disease remained in 85 (37.0%). Survival post ablation at 1 year was 89.2% and at 3 years was 40.3%. Post-ablation disease-free survival was 43.2% at 3 years. CONCLUSION: MWA is an alternative treatment for pulmonary metastases of colorectal cancer. It has competitive theoretical properties and local recurrence rate compared to radiofrequency ablation.

Comparison of Microwave and Radiofrequency Ablation in the Treatment of Pulmonary Metastasis of Colorectal Cancer.

BACKGROUND/AIM: Radiofrequency ablation (RFA) for colorectal cancer pulmonary metastases (CRCPulM) has been shown to be safe. Microwave ablation (MWA) has emerged in the treatment for CRCPulM. However, short to long-term efficacy of both modalities have yet to be understood. PATIENTS AND METHODS: This is a retrospective study of 203 patients who received RFA and MWA from 2000-2018 at a major tertiary hospital in Australia. RESULTS: A total of 161 patients underwent RFA and 42 MWA. Median ablation size and time was 4 (range=3-5 cm) vs. 3.5 cm (range=3-4 cm; p=0.0395) and 49 (range=26-65 min) vs. 8 min (5-13 min) in the RFA and MWA groups, respectively (p<0.001). The complication rate was 112 (55%) and 40 (74%) in the RFA and MWA group, respectively (p=0.011). Life-threatening pulmonary haemorrhage occurred in 1 (0.5%) and 4 (7.4%) patients in the RFA and MWA group, respectively (p=0.007). Local recurrences detected after discharge were similar in both groups [28% (p<0.001)]. However, the MWA group demonstrated higher survival rate and less recurrence rate than RFA in the first 24 months of follow up. CONCLUSION: RFA and MWA are competitive treatment methods for CRCPulM. Although MWA has significantly higher complication rate than RFA, it can be performed in a much shorter time and lead to a shorter length of hospital stay.

Aorto-cavitary fistula: a rare case of Enterobacter cloacae infective endocarditis complicated by aortic root abscess and fistula to the right ventricle.

Enterobacter cloacae are a rare cause of infective endocarditis (IE). We present an interesting case of a 51-year-old intravenous drug user with E. cloacae IE of a prosthetic aortic valve and a fistula into the right ventricle. He underwent surgical repair and 6 weeks of intravenous meropenem.

Cytoreductive surgical resection of a rare pulmonary artery intimal sarcoma involving the pulmonary valve and right ventricle: a case report.

Pulmonary artery intimal sarcoma (PAIS) is an extremely rare malignant tumour. It is often misdiagnosed as chronic pulmonary thromboembolism. We describe a complex case in a 70-year-old man with PAIS extending into his right ventricle undergoing salvage cytoreductive surgical resection utilizing bivalirudin for cardiopulmonary bypass anticoagulation due to heparin-induced thrombocytopenia and thrombosis syndrome. The prognosis for PAIS is extremely poor, with a median survival of 1.5 months without surgical resection. Cytoreductive surgical debulking can improve the median survival time to 17 months. The main aim of palliative surgical resection is to improve ventilation-perfusion mismatch and prevent haemodynamic collapse.

Gastrointestinal surgery and the gut microbiome: a systematic literature review.

BACKGROUND/OBJECTIVES: The impact of gastrointestinal surgery on the profile of the human gut microbiome is not fully understood. This review aimed to identify whether there is a change to the profile of the gut microbiome as a result of gastrointestinal surgery. SUBJECTS/METHODS: In August 2018, a systematic literature search was conducted in Medline, PreMedline, Embase, CINAHL and The Cochrane Register of Clinical Trials, identifying and critically appraising studies which investigated changes to gut microbiome pre- and post-gastrointestinal surgery. RESULTS: Of 2512 results, 14 studies were included for analysis. All studies reported post-surgical change to the microbiome. In 9 of the 14 studies, prevalence of specific bacteria had significantly changed after surgery. Improved outcome was associated with higher levels of beneficial bacteria and greater microbiome diversity post-surgery. CONCLUSION: There were methodological limitations in the included studies leading to uncertainty regarding the impact of gastrointestinal surgery alone on the microbiome profile. An ideal future model for research should encompass case-controlled or cohort design with longer term follow-up in a homogeneous patient group. Future research should seek to clarify the gold standard testing method and standardised timing for post-surgical microbiome sample collection. It is imperative that controls for confounders be put in place to attempt to identify the true association between gastrointestinal surgery and changes to gut microbiome.