Does early extubation after cardiac surgery lead to a reduction in intensive care unit length of stay?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early extubation (EE) after cardiac surgery leads to a reduction in intensive care unit (ICU) length of stay (LOS)? A total of 564 papers were found using the reported search, of which 4 were randomized trials and hence 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. EE was defined as extubation in theatre (n = 2), within 6 h of surgery (n = 1) and within 8 h of surgery (n = 1). EE was associated with significantly reduced ICU LOS in all studies. Despite the Society of Thoracic Surgeons using extubation <6 h after surgery as a measure of quality, this study has demonstrated that no standardized definition for EE currently exists. The body of evidence identified in this work has demonstrated that for appropriately selected patients (avoiding patients with multiple comorbidities, advanced age and undergoing complex non-elective surgery) early tracheal extubation is associated with a reduction in ICU LOS without an increase in the rate of postoperative complications.

Traversing the Learning Curve Associated with a New Minimal Access Aortic Valve Replacement Service

Abstract Objective: Isolated aortic valve replacement is a safe and frequently performed cardiac surgical procedure. Although minimal access approaches including right anterior thoracotomy and partial sternotomy have been adopted by some surgeons in recent years, concerns about additional procedural morbidity and mortality during the early phase of the learning curve persist. The aim of this study was to assess the impact of the learning curve on outcomes for a single surgeon implementing a new minimal access aortic valve replacement service. Methods: Ninety-three patients undergoing minimal access aortic valve replacement performed by a single surgeon in our institution between October 2014 and March 2019 were analysed. Patients were divided into tertiles according to procedure order. Endpoints included peri-operative mortality and post-operative complications, and these were compared across tertiles to assess the impact of the learning curve on procedural outcomes. Results: Overall in-hospital mortality was 2.15% (n=2). Despite significantly longer cardiopulmonary bypass and cross-clamp duration in the early tertile, there was no significant difference in the rate of post-operative complications, post-operative length of stay or in-hospital mortality between tertiles. Conclusions: Although our results have demonstrated a significant learning curve effect associated with the introduction of this minimally invasive approach to aortic valve replacement, as demonstrated by the significant reduction in cardiopulmonary bypass and cross-clamp duration over time, our findings suggest that a minimal access aortic valve replacement service can be safely commenced by an experienced surgeon without concerns about the learning curve significantly affecting post-operative morbidity and mortality.

Traversing the Learning Curve Associated with a New Minimal Access Aortic Valve Replacement Service.

OBJECTIVE: Isolated aortic valve replacement is a safe and frequently performed cardiac surgical procedure. Although minimal access approaches including right anterior thoracotomy and partial sternotomy have been adopted by some surgeons in recent years, concerns about additional procedural morbidity and mortality during the early phase of the learning curve persist. The aim of this study was to assess the impact of the learning curve on outcomes for a single surgeon implementing a new minimal access aortic valve replacement service. METHODS: Ninety-three patients undergoing minimal access aortic valve replacement performed by a single surgeon in our institution between October 2014 and March 2019 were analysed. Patients were divided into tertiles according to procedure order. Endpoints included peri-operative mortality and post-operative complications, and these were compared across tertiles to assess the impact of the learning curve on procedural outcomes. RESULTS: Overall in-hospital mortality was 2.15% (n=2). Despite significantly longer cardiopulmonary bypass and cross-clamp duration in the early tertile, there was no significant difference in the rate of post-operative complications, post-operative length of stay or in-hospital mortality between tertiles. CONCLUSIONS: Although our results have demonstrated a significant learning curve effect associated with the introduction of this minimally invasive approach to aortic valve replacement, as demonstrated by the significant reduction in cardiopulmonary bypass and cross-clamp duration over time, our findings suggest that a minimal access aortic valve replacement service can be safely commenced by an experienced surgeon without concerns about the learning curve significantly affecting post-operative morbidity and mortality.

Approach to pneumothorax surgery: a national survey of current UK practice.

BACKGROUND: Pneumothorax is a common condition with various management options. We aimed to determine the current surgical practice in the United Kingdom. METHOD: An online questionnaire regarding surgical strategy was sent to all consultants who were members of the Society for Cardiothoracic Surgery (80 thoracic). RESULTS: Fifty-six consultants, mainly thoracic, responded to the survey. Video-assisted thoracoscopic surgery was unanimously the preferred approach, the majority (59%) using 3 ports. Regarding the timing of surgery, 53 (95%) surgeons would intervene at first presentation with persistent air leak and/or lung collapse, 41 (73%) for a first bilateral pneumothorax, 22 (39%) only for recurrent pneumothorax, and 18 (32%) for the first computed tomography evidence of bullae. Apical bullectomy + pleurectomy was the preferred technique for 26 (46%) surgeons, and apical bullectomy + apical pleurectomy + pleural abrasion was the choice for 13 (23%). Some surgeons were concerned about talc and avoid it. The majority (70%) used a single apical drain with or without 24-48 h suction. Regarding chest radiography, the response was variable but 48% performed immediate postoperative and/or daily chest radiographs. Currently, most surgeons (59%) use digital drains and feel it monitors air leaks better. The perceived chronic pain (1%-3%) and recurrence rates (0%-3%) were stated by 59% and 86%, respectively. CONCLUSION: There is variability in the surgical management of pneumothorax among surgeons across the UK, but they all use video-assisted thoracoscopic surgery as the intervention of choice for pneumothorax surgery, and there is a shift towards early surgical intervention.

Malignant melanoma of parotid gland in a child-our unique experience.

Malignant melanoma (MM) of parotid gland is a rare condition. This pathology is often a result of secondary metastasis from primary lesions in the head and neck skin. A MM arising de novo in parotid gland is very rare. This malignant tumour is more prevalent in adults rather than children and it tends to have several distinct features. Treatment options are limited especially for an advanced lesion. Despite best treatments this condition carries a poor prognosis. This case details our experience in treating a child with MM of parotid gland without other primary cutaneous lesions.