Does muscle-sparing thoracotomy as opposed to posterolateral thoracotomy result in better recovery?

A best evidence topic was written according to a structured protocol. The question addressed was whether muscle-sparing thoracotomy (MST), as opposed to posterolateral thoracotomy (PLT), results in better recovery. A total of 108 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. A recent large prospective, randomized, double-blinded, controlled study demonstrated a shorter length of stay in patients undergoing MST. It failed to demonstrate any significant difference in pain reported or pulmonary function. A separate prospective randomized controlled trial focussed on pain, pulmonary function, late shoulder range of motion and late muscle strength. It failed to show any significant difference in these domains between PLT and MST. While the mean 'opening time' is greater when performing a MST, this is negated by a shorter mean 'closing time' when compared with PLT. Overall, the evidence suggests that MST results in greater early (1 week) preservation of skeletal muscle strength and range of motion over PLT. This difference has disappeared at 1 month. There is little evidence to suggest a difference in pulmonary function or pain dependent on the thoracotomy type. Moreover, analgesic consumption is similar. However, there is an inverse relationship between the incision length and the post-thoracotomy syndrome.

What is the role of screening in the management of abdominal aortic aneurysms?

A best-evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether screening asymptomatic individuals for an abdominal aortic aneurysm (AAA) is feasible and improves disease-free survival. Seven studies presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and limitations of the studies are tabulated. In total, four randomized population-based studies have evaluated ultrasound screening for AAA: two British studies, Multicentre Aneurysm Screening Study (MASS) and the Chichester trial, and one each in Viborg County, Denmark and Western Australia. Participants were randomized to receive an invitation to screen or not. The MASS trial randomized 67 770 men, followed participants over 10 years and concluded that screening would almost half AAA-related deaths in men aged 65-74 years. The smaller Chichester trial included only 6040 men but demonstrated a 42% reduction in AAA-related mortality at 5 years, with ongoing benefit at 15 years (11% reduction). The Viborg County trial recruited 12 639 men aged 64-73 years, showed a 66% reduction in AAA-related mortality over 14 years. Finally, the Western Australia trial evaluated 41 000 men but included an older population of 65-83 years old. No benefit was seen in this age group but subgroup analysis of men aged 65-74 showed a significant mortality benefit. Only a small or insignificant benefit in all-cause mortality was seen in any of these studies. A recent meta-analysis of these trials has shown a significant benefit in AAA-related mortality in the long term and concluded that AAA screening is superior to other established screening programmes. The cost-effectiveness of screening was assessed in the MASS and Viborg County trials and was found to be substantially below the cost threshold set by the National Institute of Clinical Excellence for acceptance of interventions. Quality of life was assessed in the MASS and in a case-control study and showed no adverse effects that outweigh the benefits. We concluded that ultrasound screening for AAAs has met all the criteria to become a screening programme and would substantially reduce disease-related death with no adverse effect on quality of life.

Should a patent foramen ovale found incidentally during isolated coronary surgery be closed?

A best evidence topic was written according to a structured protocol. The question addressed was whether incidentally found patent foramen ovale (PFO) during isolated coronary surgery should be closed. A total of 573 papers were found using the reported searches of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. There is currently no evidence to suggest that incidental PFO in patients undergoing cardiac surgery is linked with increased morbidity, mortality or decreased long-term survival. The most significant study identified examined the outcomes of 2277 patients with incidentally found PFO during cardiac surgery of whom 639 underwent closure. After propensity matched analysis, the authors found closure was associated with a significantly higher risk of postoperative stroke with no advantage in terms of long-term survival. A recent survey of 438 cardiac surgeons from the USA showed no consensus on decision-making behind closure, but that factors taken in to account include PFO size, right atrial pressure and a history of paradoxical embolism. This is not surprising given that morphological research has confirmed that larger PFO size is indeed associated with cryptogenic stroke.