Visual diagnosis of pectus excavatum: An inter-observer and intra-observer agreement analysis.

BACKGROUND/PURPOSE: Among patients suspected of pectus excavatum, visual examination is a key aspect of diagnosis and, moreover, guides work-up and treatment strategy. This study evaluated the inter-observer and intra-observer agreement of visual examination and diagnosis of pectus excavatum among experts. METHODS: Three-dimensional surface images of consecutive patients suspected of pectus excavatum were reviewed in a multi-center setting. Interactive three-dimensional images were evaluated for the presence of pectus excavatum, asymmetry, flaring, depth of deformity, cranial onset, overall severity and morphological subtype through a questionnaire. Observers were blinded to all clinical patient information, completing the questionnaire twice per subject. Agreement was analyzed by kappa statistics. RESULTS: Fifty-eight subjects with a median age of 15.5 years (interquartile range: 14.1-18.2) were evaluated by 5 (cardio)thoracic surgeons. Pectus excavatum was visually diagnosed in 55% to 95% of cases by different surgeons, revealing considerable inter-observer differences (kappa: 0.50; 95%-confidence interval [CI]: 0.41-0.58). All other items demonstrated inter-observer kappa's of 0.25-0.37. Intra-observer analyses evaluating the presence of pectus excavatum demonstrated a kappa of 0.81 (95%-CI: 0.72-0.91), while all other items showed intra-observer kappa's of 0.36-0.68. CONCLUSIONS: Visual examination and diagnosis of pectus excavatum yields considerable inter-observer and intra-observer disagreements. As this variation in judgement could impact work-up and treatment strategy, objective standardization is urged. LEVELS OF EVIDENCE: III.

Early severe mediastinal bleeding after esophagectomy: a potentially lethal complication.

BACKGROUND: Anastomotic leakage after cervical oesophagogastrostomy is a common and difficult problem. Mediastinal manifestation of anastomotic leakage may lead to mediastinitis with dramatic and potentially lethal outcome. Contamination of the mediastinum can be controlled by endoscopic placement of an expandable metal stent. We present two cases of severe haemorrhage after mediastinal manifestation of anastomotic leakage in patients with and without expandable metal stent (EMS). CASES: This case report describes two cases of severe haemorrhage after thoracolaparoscopic esophagectomy with cervical oesophagogastrostomy. The recovery of both patients was complicated by anastomotic leakage with mediastinal manifestation. In one case, 11 days after placement of an EMS for anastomotic leakage a bleeding occurred in the cervical wound. Angiography during surgery showed contrast leakage in the aortic arch. Despite sternotomy and endovascular catheterization, there were no surgical options to treat this condition and the patient died of exsanguination. In the other case the patient presented with severe hematemesis 11 days after surgery. Shortly after this hematemesis the patient became hemodynamic instable. The patient was taken to the operation theatre, but before any intervention could take place resuscitation was needed and the patient died of exsanguination. CONCLUSIONS: Severe haemorrhage is a rare and potentially lethal complication after esophagectomy. This condition is related to anastomotic leakage with mediastinal manifestation. Awareness of this potentially lethal complication is important for early recognition and treatment of this condition. The role of endoscopic stenting of the cervical anastomosis is controversial and potentially dangerous.

Cardiac herniation after operative management of lung cancer: a rare and dangerous complication.

Cardiac herniation after pneumonectomy is recognized as a rare complication. This case report describes two cases. The mortality rate of this complication remains high as reported in the literature; in early-recognized cases 50 % and in late or unrecognized cases 100 %. In the following two cases a pneumonectomy was performed as a treatment for lung cancer. Within 48 h after the initial operative treatment, the clinical situation of the patients got worse and radiographic examinations showed a strongly deviated heart. After suspicion of the diagnosis, the patients were immediately transferred to the operation theatre for emergency thoracotomy. Per-operative the diagnosis was confirmed and the heart was returned into its original position while the defect in the pericardial sac was closed with a bovine pericardial patch. Both patients survived these procedures and did not suffer from any further complication.

Can the EuroSCORE predict midterm survival after aortic valve replacement?

OBJECTIVES: The EuroSCORE as a predictor for midterm survival after isolated aortic valve replacement (AVR) and combined AVR with coronary artery bypass graft (CABG) surgery was tested. Survival in different risk-stratification groups also was compared to the survival of the general Dutch population. DESIGN: A retrospective analysis of prospectively collected data. SETTING: A single-center study performed in an educational hospital. PARTICIPANTS: All patients (N = 1,652) who underwent AVR with (n = 711) or without (n = 941) CABG surgery from January 2004 through December 2009. INTERVENTIONS: AVR with or without CABG surgery. MEASUREMENTS AND MAIN RESULTS: Univariate Cox regression analyses were used to identify the additive and the logistic EuroSCOREs as independent predictors of midterm mortality. Kaplan-Meier survival curves were used to compare the survival of different patients' risk subgroups, based on both the additive and the logistic EuroSCOREs, with the normal Dutch population matched for age and sex. Both additive and logistic EuroSCOREs were significant predictors of midterm mortality after isolated AVR and AVR with CABG surgery. This was also true for the different risk-stratification groups. Except for survival after AVR with CABG surgery in the high-risk group based on the additive EuroSCORE, no difference was found between survival after surgery and survival of the age- and sex-matched normal population. CONCLUSIONS: Both EuroSCORE models can predict midterm survival after isolated AVR and combined AVR with CABG surgery. However, the EuroSCORE is not a predictor for midterm survival when comparing the patient groups with the general Dutch population matched for age and sex. Except for high-risk patients undergoing AVR with CABG surgery, other risk subgroups have similar midterm survival to that of their age- and sex-matched cohorts of the Dutch population.

Preoperative atrial fibrillation and elevated C-reactive protein levels as predictors of mediastinitis after coronary artery bypass grafting.

BACKGROUND: Mediastinitis is a serious complication after coronary artery bypass grafting (CABG). We studied the risk factors for the development of postoperative mediastinitis in a large group of patients who underwent isolated CABG at Catharina Hospital, Eindhoven, The Netherlands. METHODS: Data of all patients undergoing an isolated CABG between January 1998 and December 2008 were analyzed. Univariate and multivariate logistic regression analyses were performed to investigate the effect of biomedical variables on the development of mediastinitis. Multivariate analyses were used to test for the confounding effect of various risk factors on outcomes. RESULTS: Mediastinitis was present in 100 out of the 11,748 patients. Preoperative atrial fibrillation [odds ratio = 4.26 (2.26 to 8.02)] and an elevated preoperative C-reactive protein level [odds ratio = 1.013 (1.007 to 1.020)] were important independent predictors of the development of mediastinitis. Other significant risk factors were the following: age, chronic obstructive pulmonary disease, diabetes, morbid obesity, use of extracorporeal circulation, use of bilateral internal mammary arteries, reexploration for ischemia, and perioperative myocardial infarction. CONCLUSIONS: Apart from previously described risk factors for the development of postoperative mediastinitis, we found preoperative atrial fibrillation and an elevated C-reactive protein level to be significant predictors of mediastinitis in patients undergoing CABG.

Is the use of Steri-StripTM S for wound closure after coronary artery bypass grafting better than intracuticular suture?

Several methods have been used in wound closure after coronary artery bypass grafting (CABG). In this study, the safety and efficacy of one of these methods, Steri-Strip S is compared with the traditional intracuticular suture method. Eighty-one patients undergoing CABG were prospectively randomized into two groups according to the method of skin closure: Steri-Strip S group and traditional suture group. Comparison between the two methods was done with regards to the length of the wound and the time needed to close it. The median closure time with Steri-Strip S was 5.45+/-3.35 min vs. 7.53+/-3.41 min in the suture group. A pain score of >or=6 at the first postoperative day was found in 30% of the patients in the suture group vs. 14% of the patients in the Steri-Strip S group (P=0.07). Cosmetic evaluation showed a non-significant difference in the linear visual analogue score in favor of Steri-Strip S group compared to the intracuticular suture group (73.1 vs. 70.1) (P=0.07). Steri-Strip S is a fast, safe alternative for wound closure of the sternotomy incision and graft harvesting site. A larger study is needed to establish the potential beneficial effect of Steri-Strip S on wound infection prevention.