The ESTS-AIR database-initial results of a multi-institutional database on airway surgery.

OBJECTIVES: Compared to lung resections, airway procedures are relatively rare in thoracic surgery. Despite this, a growing number of dedicated airway centres have formed throughout Europe. These centres are characterized by a close interdisciplinary collaboration and they often act as supra-regional referring centres. To date, most evidence of airway surgery comes from retrospective, single-centre analysis as there is a lack of large-scale, multi-institutional databases. METHODS: In 2018, an initiative was formed, which aimed to create an airway database within the framework of the ESTS database (ESTS-AIR). Five dedicated airway centres were asked to test the database in a pilot phase. A 1st descriptive analysis of ESTS-AIR was performed. RESULTS: A total of 415 cases were included in the analysis. For adults, the most common indication for airway surgery was post-tracheostomy stenosis and idiopathic subglottic stenosis; in children, most resections/reconstructions had to be performed for post-intubation stenosis. Malignant indications required significantly longer resections [36.0 (21.4-50.6) mm] when compared to benign indications [26.6 (9.4-43.8) mm]. Length of hospital stay was 11.0 (4.1-17.3) days (adults) and 13.4 (7.6-19.6) days (children). Overall, the rates of complications were low with wound infections being reported as the most common morbidity. CONCLUSIONS: This evaluation of the 1st cases in the ESTS-AIR database allowed a large-scale analysis of the practice of airway surgery in dedicated European airway centres. It provides proof for the functionality of ESTS-AIR and sets the basis for rolling out the AIR subsection to all centres participating in the ESTS database.

Long-term follow-up of voice changes after cervical mediastinoscopy.

BACKGROUND: Vocal cord palsy after cervical mediastinoscopy is usually reported at less than 1%. However, its incidence might be underestimated and no follow-up studies are available. Our study aimed to evaluate the incidence of voice changes after cervical mediastinoscopy and report on long-term outcomes, including quality of life, after at least one-year follow-up. METHODS: A retrospective cohort study was performed, considering all patients who underwent cervical mediastinoscopy in our center between January 2011 and April 2016. Patients with pre-existing voice changes, voice changes only after pulmonary resection and patients who underwent neoadjuvant chemo(radio)therapy were excluded. Voice changes with full recovery within 14 days were attributed to intubation-related causes. Follow-up questionnaires, including the standardized Voice Handicap Index, were sent to patients with documented voice changes. RESULTS: Of 270 patients who were included for final analysis, 17 (6.3%) experienced voice changes after cervical mediastinoscopy, which persisted > 2 years in 4 patients (1.5%), causing mild to moderate disabilities in daily living. Twelve patients (out of 17, 71%) were referred for otolaryngology consultation, and paresis of the left vocal cord suggesting recurrent laryngeal nerve injury was confirmed in 10 (3.7% of our total study group). Additionally, 83% of the patients who were referred for otolaryngology consultation received voice treatment. Recovery rate after vocal exercises therapy and injection laryngoplasty was respectively 71% and 33%. CONCLUSIONS: Voice changes after cervical mediastinoscopy is an underreported complication, with an incidence of at least 6.3% in our retrospective study, with persisting complaints in at least 1.5% of patients, leading to mild to moderate disabilities in daily living. These findings highlight the need for appropriate patient education for this underestimated complication, as well as the exploration of possible preventive measures.

Functional outcome after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis.

BACKGROUND: In this study we focus on functional outcomes after (laryngo)tracheal resection and reconstruction for acquired benign (laryngo)tracheal stenosis, with a specific interest in the impact of laryngeal involvement on postoperative outcome. METHODS: All patients who underwent (laryngo)tracheal surgery for benign pathology between 1996 and 2017 in our centre were included in this retrospective study. Surgical outcomes were procedural success rate, and airway- and voice-related complications. Functional results were assessed using (standardized) questionnaires for quality of life, sensation of dyspnea, swallowing function, and voice perception. RESULTS: Of 119 consecutive patients, 47 underwent laryngotracheal resection and reconstruction and 72 underwent segmental tracheal surgery (78% with an end-to-end tracheal anastomosis and 22% with a cricotracheal anastomosis). Overall success rate was 92% and was similar for all groups, with an overall significant improvement in quality of life when compared to the preoperative situation. However, after laryngotracheal surgery, airway-related complications were more common when compared to segmental resections with an end-to-end tracheal anastomosis (30% versus 7%, P=0.003). Additionally, early voice alterations without recurrent nerve palsy were reported twice as often (34% versus 16%, P=0.034) and voice quality experienced during follow-up was significantly worse when compared to segmental resections. Overall response rate to the questionnaires on functional outcome was 63%. CONCLUSIONS: (Laryngo)tracheal surgery is safe and beneficial, with significant functional improvement during mid- and long-term follow-up. However, laryngeal involvement is a predictor for increased surgical airway-related complications. Additionally, voice alterations without recurrent nerve palsy are far more common after laryngotracheal resection and are a serious handicap. This aspect is underexposed in current literature and deserves further attention during preoperative counseling and patient follow-up. However, the results on functional outcome of this current study should be interpreted with caution due to the somewhat low response rate of the questionnaires.

Parenteral bilirubin in healthy volunteers: a reintroduction in translational research.

AIMS: Preclinical results suggest therapeutic potential of mild hyperbilirubinemia in T2DM and cardiovascular disease. Translational data are limited, because an appropriate bilirubin formulation for parenteral human use is lacking. Considering its use in both clinical practice and medical research in the past, we explored the feasibility to reintroduce parenteral bilirubin for translational experiments. METHODS: We developed a preparation method in accordance with good manufacturing practice and evaluated the parenteral applicability in healthy volunteers (n = 8). Explorative pharmacokinetic and safety data were compared to the results from a literature study on the former parenteral use of bilirubin. Bilirubin was administered intra-arterially to raise the local plasma concentration in the forearm vascular bed (n = 4) and intravenously to raise the systemic plasma concentration (n = 4). Finally, pharmacokinetic characteristics were studied following a single bolus infusion (n = 3). RESULTS: During parenteral application, no side effects occurred. Adverse events mentioned during the two-week observation period were in general mild and self-limiting. Three more significant adverse events (appendicitis, asymptomatic cardiac arrhythmia and atopic eczema) were judged unrelated by independent physicians. A dose-concentration relationship appeared sufficiently predictable for both intra-arterial and intravenous administration. In line with existing knowledge, bilirubin pharmacokinetics could be described best according to a two-compartment model with a volume of distribution of 9.9 (±2.0) l and a total plasma clearance of 36 (±16) ml per minute. CONCLUSIONS: Supported by previous reports, our data suggest that it is both feasible and safe to perform translational experiments with parenteral albumin bound bilirubin.

Decreased physical activity is a predictor for a complicated recovery post cardiac surgery.

BACKGROUND: Physical activity (PA) reduces the risk of cardiovascular disease and physically active survivors of a cardiac event are at lower risk of recurrent events. We hypothesized that patients with a decreased PA, undergoing cardiac surgery, are at higher risk for a postoperative complicated recovery (PCR). METHODS: Three thousand three hundred eighty two patients undergoing elective cardiac surgery between January 2007 and December 2013 were included. The group was divided into three subgroups: group A, aged ≤ 65 years (N = 1329); group B, aged > 65 years and ≤ 75 years (N = 1250); and group C aged >75 years (N = 803). To assess PA, the criteria of the Corpus Christy Heart Project were used. A PCR consists of the occurrence of a major postoperative event, defined as any of the following complications: reoperation, deep sternal wound infection, renal failure, stroke, postoperative ventilation > 2 days, intensive care stay ≥ 5 days, hospital stay ≥ 10 days, or hospital mortality. RESULTS: One thousand three hundred sixty seven patients (40%) were considered as patients with a decreased PA. Both in group B (p = 0.001) and in group C (p = 0.003), patients with a decreased PA were significantly associated with an increased risk of a PCR, which was not the case in group A (p = 0.28). Logistic regression analysis identified a decreased PA as an independent predictor for PCR in groups B (p = 0.003, odds 1.71) and C (p = 0.033, odds 1.48), but not in group A (p = 0.11, odds 0.71). CONCLUSION: Decreased physical activity is an independent predictor for a PCR in patients aged 65 years or older undergoing elective cardiac surgery.

Tracheal rupture after intubation and placement of an endotracheal balloon catheter (A-view®) in cardiac surgery.

The endotracheal balloon catheter (A-view®) is a device developed to locate atherosclerotic plaques of the ascending aorta (AA) in cardiac surgery to prevent stroke. The saline-filled balloon is located in the trachea and combines the advantages of transoesophageal echocardiography (e.g. used before performing the sternotomy) and intraoperative epiaortic ultrasound scanning (e.g. complete view of the AA). We report the first severe complication after the use of A-view®. This is a case of a 66-year old woman who underwent elective myocardial revascularization complicated by an intraoperative iatrogenic tracheal rupture of 6 cm, after uncomplicated intubation and the use of an endotracheal balloon catheter (A-view®), which required direct surgical repair with a posterolateral thoracotomy after the myocardial revascularization was completed, weaning from bypass and closure of the median sternotomy.