Press tack needle stimulation for blunt chest trauma: a randomized double-blind control trial

Open in a separate window OBJECTIVESBlunt chest trauma is often associated with severe pain, reduced lung function and decreased sleep quality. This study aims to investigate the immediate and long-term effect of acupuncture on these factors using a randomized control double-blind design.METHODSA total of 72 patients were randomized into 2 groups: treatment group (press tack acupuncture) and control group (press tack placebo). The face rating scale, numerical rating scale (NRS), portable incentive spirometer and Verran Snyder-Halpern sleep scale were measured at baseline, immediately after the intervention, and at the 4th day, with 2-weeks and 3-months follow-ups.RESULTSThere were no significant changes between the groups at the baseline measurements, with the exception of hypertension comorbidity. Immediately after the intervention and on the 4th day follow-up, the patients in the treatment group showed a significantly lower face rating scale when compared to the control (P < 0.05). There were no significant changes in any of the other measurements between the groups (P > 0.05). Subgroup analysis revealed that the NRS for turn over on the 4th day was reduced significantly in the treatment group of patients without lung contusion (P < 0.05). For patients without pleural drainage, cough NRS in the treatment group was significantly reduced in the 2-week follow-up (P < 0.05).CONCLUSIONSThis study showed that press tack acupuncture effects on pain reduction were inconclusive. However, future studies on the effect of acupuncture on blunt chest trauma patients are needed.Clinical trial registrationclinicaltirl.gov: {"type":"clinical-trial","attrs":{"text":"NCT04318496","term_id":"NCT04318496"}}NCT04318496.     

Adjuvant chemotherapy improves survival outcomes after complete resection of thymic squamous cell carcinoma: a retrospective study of 116 patients

Open in a separate window OBJECTIVESThe aim of this study was to evaluate the efficacy of adjuvant chemotherapy (ACT) for thymic squamous cell carcinoma after completely resection.METHODSPatients with thymic squamous cell carcinoma treated with complete resection between January 2009 and December 2016 were retrospectively identified. Kaplan–Meier analysis was used to summarize the time-to-event variables. Univariable and multivariable Cox proportional hazards regression analyses were performed.RESULTSA total of 116 patients were analysed with 44 patients in the non-ACT group and 72 patients in the ACT group. No significant difference was found in the 5-year recurrence-free survival (RFS) rate (58.1% vs 51%, P = 0.33) or the 5-year overall survival (OS) rate (77.7% vs 67.1%, P = 0.26) between the ACT group and the non-ACT group. Masaoka stage was the only independent prognostic factor for both RFS and OS. Subgroup analysis showed significant improvement in 5-year RFS for Masaoka stage II patients (P = 0.035) and 5-year OS (P = 0.036) for Masaoka stage III patients when comparing ACT with non-ACT. No chemotherapy-related death occurred. The most frequent adverse effect higher than grade 3 was neutropenia.CONCLUSIONSFor completely resected thymic squamous cell carcinoma, ACT significantly improved the 5-year RFS in Masaoka stage II patients and the 5-year OS in Masaoka stage III patients.     

Reverse left ventricular remodelling after aortic valve replacement for severe aortic insufficiency

 Open in a separate windowOBJECTIVESThe goal of this study was to investigate the long-term outcome of aortic valve replacement (AVR) for severe aortic insufficiency with a focus on pre- and postoperative left ventricular (LV) function to explore predictive factors that influence the recovery of LV function and clinical outcome.METHODSA total of 478 patients who underwent AVR for pure severe aortic insufficiency were grouped according to the preoperative echocardiographical LV ejection fraction (EF): low (LO) EF <35% (n = 43), moderate EF 35–50% (n = 150) or normal EF >50% (n = 285).RESULTSActuarial survival at 10 years post-AVR was 64% with a LO EF, 92% with a moderate EF and 93% with a normal EF (P = 0.016), whereas 10-year rates of freedom from major adverse cerebral and cardiovascular events were 47%, 79% and 84%, respectively (P < 0.0001). Echocardiography at 1 year post-AVR demonstrated that EF substantially improved in all groups. We noted a significant difference in survival (P = 0.0086) and in freedom from major adverse cerebral and cardiovascular events (P = 0.024) between patients with an EF ≥35% and those with an EF <35% in the LO EF group. The multivariable logistic regression model showed that predictive factors for lack of improvement in EF 1 year post-AVR in the LO EF group included plasma brain natriuretic peptide >365 pg/mL (P = 0.0022) and echocardiographic LV mass index) >193 g/m² (P = 0.0018).CONCLUSIONSLong-term outcome post-AVR for severe aortic insufficiency was largely influenced by preoperative LV function. Predictive factors of failure to recover ventricular function post-AVR included EF <25%, pre-brain natriuretic peptide >365 pg/mL or LV mass index >193 g/m².     

Elimination of CO2 insufflation-induced hypercapnia in open heart surgery using an additional venous reservoir

 Open in a separate windowOBJECTIVESCarbon dioxide (CO₂) gas insufflation is used for continuous de-airing during open heart surgery. The aim was to evaluate if an additional separate venous reservoir eliminates CO₂ insufflation-induced hypercapnia and keeps sweep gas flow of the oxygenator constant.METHODSA separate reservoir was used during cardiopulmonary bypass in addition to a standard venous reservoir. The additional reservoir received drained blood and CO₂ gas continuously via a suction drain (1 l/min) and handheld suction devices from the surgical wound. CO₂ gas was insufflated via a gas diffuser in the open wound at 10 l/min. In a cross-over design for each patient, gas and blood were either continuously drained from the additional to the standard venous reservoir or not. CO₂ pressure in arterial blood (PaCO₂) was measured after adjustment of sweep gas flow as necessary and after steady state of PaCO₂ was observed. Mean values for each setup (median 4 times) for each patient were analysed with Wilcoxon rank-sum test.RESULTSTen adult patients undergoing open aortic valve replacement were included. Median PaCO₂ did not differ between setups (5.41; 5.29–5.57, interquartile range vs 5.41; 5.24–5.58, P = 0.92), whereas sweep gas flow (l/min) was lower (2.58; 2.50–3.16 vs 4.42; 4.0–5.40, P = 0.002) when CO₂ gas was not drained from the additional to the standard reservoir.CONCLUSIONSAn additional venous reservoir for the evacuation of blood from the open surgical wound eliminates CO₂ insufflation-induced hypercapnia in open heart surgery keeping PaCO₂ and sweep gas flow constant. This prevents possible CO₂-induced hyperperfusion of the brain and decreases the risk of cerebral particulate embolization during CO₂ insufflation for de-airing in open heart surgery.Clinical trial registration{"type":"clinical-trial","attrs":{"text":"NCT04202575","term_id":"NCT04202575"}}NCT04202575.IRB approval dat and number2018-07-13 and 2018/1091-31.     

Actual incidence of cerebral infarction after thoracic endovascular aortic repair: a magnetic resonance imaging study

 Open in a separate windowOBJECTIVESThe actual incidence of cerebral infarction (CI), including asymptomatic infarction, owing to thoracic endovascular aortic repair (TEVAR) has not been reported in detail. This study was performed to investigate the incidence of post-TEVAR CI by using diffusion-weighted magnetic resonance imaging (DW-MRI) and to determine the risk factors for both symptomatic and asymptomatic CI.METHODSWe examined 64 patients undergoing TEVAR at our institute between April 2017 and November 2020. Aortic atheroma was graded from 1 to 5 by preoperative computed tomography. Cerebral DW-MRIs were conducted 2 days after the procedure to diagnose postoperative CI.RESULTSA total of 44 new foci were detected by post-interventional cerebral DW-MRI in 22 patients (34.4%). Only one patient developed a symptomatic stroke (1.6%), and TEVAR was successfully completed in all cases. Debranching of the aortic arch and left subclavian artery occlusion with a vascular plug was performed in 19 (29.7%) and 12 (18.8%) patients, respectively. The number of patients with proximal landing zones 0–2 was significantly higher in the CI group than in the non-CI group (68.2% vs 11.9%; P < 0.001). The following risk factors were identified for asymptomatic CI: aortic arch debranching (P < 0.001), left subclavian artery occlusion (P = 0.001) and grade 4/5 aortic arch atheroma (P = 0.048).CONCLUSIONSOver one-third of the patients examined by cerebral DW-MRI after TEVAR were diagnosed with CI. High-grade atheroma and TEVAR landing in zone 0–2 were found to be positively associated with asymptomatic CI.Clinical trial registration02-014.     

Prognostic factor analysis for patient outcome of PD-L1 expression in thoracic oesophageal squamous cell carcinoma

Open in a separate window OBJECTIVESThe purpose of this study was to determine the expression of PD-L1 in oesophageal squamous cell carcinoma (OSCC) and the prognostic factors.METHODSPD-L1 expression was investigated by immunohistochemical staining of resected specimens from 50 OSCC patients who were randomly selected from 104 patients with complete follow-up data. The relationships among PD-L1 expression, clinicopathological factors and prognosis were assessed by statistical analysis.RESULTSThe expression of PD-L1 was positive in 27 (54%, positive cells’ proportion > 25%) and negative in 23 (46%, positive cells proportion ≤25%) of 50 cases, and PD-L1 expression was negative in all pericarcinomatous tissues (P > 0.05). The 5-year survival rate of patients with PD-L1-positive expression was 22.2% (6 of 27), which was less than that of patients with PD-L1-negative expression (47.8%; 11 of 23) (P < 0.05). The results showed significant differences in the depth of tumour invasion, lymph node status, postoperative pathological stage and PD-L1 expression (P < 0.05). Multivariable analysis showed that PD-L1 expression was an independent prognostic factor for survival.CONCLUSIONSThe depth of tumour invasion, lymph node status, postoperative pathological stage and PD-L1 expression are important factors affecting the prognosis of patients with thoracic OSCC; in particular, high PD-L1 expression was a significant independent poor prognostic factor in thoracic OSCC patients.     

In-hospital outcomes of patients undergoing concomitant aortic and mitral valve replacement in Germany

 Open in a separate windowOBJECTIVESTo evaluate in-hospital outcomes of concomitant mitral valve replacement (MVR) in patients undergoing conventional aortic valve replacement due to aortic stenosis in a nationwide cohort.METHODSAdministrative data from all patients with aortic stenosis undergoing conventional aortic and concomitant MVR (reason for MVR not specified) between 2017 and 2018 in Germany were analysed.RESULTSA total of 2597 patients with a preoperative logistic EuroScore of 9.81 (standard deviation: 8.56) were identified. In-hospital mortality was 6.8%. An in-hospital stroke occurred in 3.4%, acute kidney injury in 16.3%, prolonged mechanical ventilation of more than 48 h in 16.3%, postoperative delirium in 15.8% and postoperative pacemaker implantation in 7.6% of the patients. Mean hospital stay was 16.5 (standard deviation: 12.1) days. Age [odds ratio (OR): 1.03; P = 0.019], New York Heart Association class III or IV (OR: 1.63; P = 0.012), previous cardiac surgery (OR: 2.85, P = 0.002), peripheral vascular disease (OR: 2.01, P = 0.031), pulmonary hypertension (OR: 1.63, P = 0.042) and impaired renal function (glomerular filtration rate <15, OR: 3.58, P = 0.001; glomerular filtration rate <30, OR: 2.51, P = 0.037) were identified as independent predictors for in-hospital mortality.CONCLUSIONSIn this nationwide analysis, concomitant aortic and MVR was associated with acceptable in-hospital mortality, morbidity and length of in-hospital stay. The regression analyses may help to identify high-risk patients and further optimize treatment strategies.     

Sex differences in outcomes following coronary artery bypass grafting: a meta-analysis

 Open in a separate windowOBJECTIVESPrevious reports have found females are a higher risk of morbidity and mortality following isolated coronary artery bypass grafting (CABG). Here, we describe the differences in outcomes following isolated CABG between males and females.METHODSFollowing a systematic literature search, studies reporting sex-related outcomes following isolated CABG were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was operative mortality. Secondary outcomes included rates of stroke, repeat revascularization, myocardial infarction, major adverse cardiac events, and late mortality. Subgroup analyses were performed for studies published before and after the year 2000 and for the type of risk adjustment.RESULTSEighty-four studies were included with a total of 903 346 patients. Females were at higher risk for operative mortality (odds ratio: 1.77, 95% confidence interval [CI]: 1.64–1.92, P < 0.001). At subgroup analysis, there was no difference in operative or late mortality between studies published prior and after 2000 or between studies using risk adjustment. Females were at a higher risk of late mortality (incidence rate ratio [IRR]: 1.16, 95% CI: 1.06–1.26, P < 0.001), major adverse cardiac events (IRR: 1.40, 95% CI: 1.19–1.66, P < 0.001), myocardial infarction (IRR: 1.28, 95% CI: 1.13–1.45, P < 0.001) and stroke (IRR: 1.31, 95% CI: 1.15–1.51, P > 0.001) but not repeat revascularization (IRR: 0.99, 95% CI: 0.76–1.29, P = 0.95). The use of the off-pump technique or multiple arterial grafts was not associated with the primary outcome.CONCLUSIONSFemales undergoing CABG are at higher risk for operative and late mortality as well as postoperative events including major adverse cardiac events, myocardial infarction and stroke. PROSPERO registrationCRD42020187556     

Women have a higher resection rate for lung cancer and improved survival after surgery

 Open in a separate windowOBJECTIVESSurgery is the standard treatment in early-stage non-small-cell lung cancer and select cases of small-cell lung cancer, but gender differences in its use and outcome are poorly known. Gender differences in surgical resection rates and long-term survival after lung cancer surgery were therefore investigated. METHODSIn Finland, 3524 patients underwent resection for primary lung cancer during 2004–2014. Surgical rate and mortality data were retrospectively retrieved from 3 nationwide compulsory registries. Survival was studied by comparing propensity-matched cohorts. Median follow-up was 8.6 years.RESULTSSurgery rate was higher in women (15.9% vs 12.3% in men, P < 0.0001). Overall survival was 85.3% 1 year, 51.4% 5 years, 33.4% 10 years and 24.2% at 14 years from surgery. In matched groups, survival after resection was better in women after 1 year (91.3% vs 83.3%), 5 years (60.2% vs 48.6%), 10 years (43.7% vs 27.9%) and 14 years (29.0% vs 21.1%) after surgery [hazard ratio (HR) 0.66; confidence interval (CI) 0.58–0.75; P < 0.0001]. Of all first-year survivors, 39.1% were alive 10 years and 28.3% 14 years after surgery. Among these matched first-year survivors, women had higher 14-year survival (36.9% vs 25.3%; HR 0.75; CI 0.65–0.87; P = 0.0002).CONCLUSIONSSurgery is performed for lung cancer more often in women. Women have more favourable short- and long-term outcome after lung cancer surgery. Gender discrepancy in survival continues to increase beyond the first year after surgery.     

Comparing outcomes in patients with end-stage chronic obstructive pulmonary disease: single versus bilateral lung transplants

 Open in a separate windowOBJECTIVESDebate continues on whether a bilateral (BLT) or a single lung transplantation (SLT) is preferred for patients with end-stage chronic obstructive pulmonary disease (COPD). The purpose of this study is to examine the interplay between patient age and transplant type on survival outcomes. METHODSWe performed a retrospective study of lung transplants for COPD at our centre from February 2012 to March 2020 (n = 186). Demographics and clinical parameters were compared between patients based on their age (≤65 vs >65 years old) and type of transplant (single vs bilateral). Cox proportional hazards regression was also performed. P-values <0.05 were considered significant.RESULTSOf the 186 patients with COPD who received lung transplants, 71 (38.2%) received BLTs and 115 (61.8%) received SLTs. There was no significant difference in survival outcomes when looking at patients with single versus BLTs (P = 0.870). There was also no difference in survival between the 2 age groups ≤65 versus > 65 years (P = 0.723). The Cox model itself also did not show a statistically significant improvement in survival outcomes (P = 0.126).CONCLUSIONSLung transplant outcomes in patients with end-stage COPD demonstrated non-inferior results in patients with an SLT compared to patients with a BLT. When we compared the age groups, neither transplant type showed superior survival benefits, suggesting there may be some utility in an SLT in younger recipients.     

Midterm results of stand-alone thoracoscopic epicardial ablation with box lesion for atrial fibrillation

 Open in a separate windowOBJECTIVESThe short-term results of video-assisted thoracoscopic surgical ablation (VTSA) with box lesion have been highly variable, and the actual efficacy requires clarification through longer follow-ups. We aimed to report which patients might benefit more from VTSA with box lesion by longer follow-up.METHODSFrom September 2010 to November 2016, patients with atrial fibrillation (AF) who underwent VTSA with box lesion were screened. All enrolled patients visited the outpatient clinic and underwent 24-h Holter monitoring at 3, 6 and 12 months after surgery and annually thereafter.RESULTSA total of 91 consecutive patients [age, 58.0 (interquartile interval from 52.0 to 62.0) years; male, 71.4%] with paroxysmal (67%) or persistent/long-standing persistent (33%) AF were enrolled. After a median follow-up of 48 months (interquartile interval from 36 to 60 months), freedom from atrial tachyarrhythmias without antiarrhythmic drugs (AADs) was 76.5%, 66.0% and 66.0% for paroxysmal AF and 58.6%, 47.8% and 34.2% for persistent/long-standing persistent AF at 12, 36 and 60 months, respectively (P = 0.017). The preoperative left atrial diameter >40 mm (hazard ratio: 2.837, 95% confidence interval: 1.408–5.716; P = 0.004) and age >50 years (hazard ratio: 2.927, 95% confidence interval: 1.359–6.305; P = 0.006) were associated with recurrences of atrial tachyarrhythmias. In patients with paroxysmal AF and left atrial diameter ≤40 mm (n = 43), freedom from atrial tachyarrhythmias without AADs was 81.4%, 74.3% and 74.3% at 12, 36 and 60 months, respectively.CONCLUSIONSIn patients with paroxysmal AF and left atrial diameter ≤40 mm, 5-year freedom from atrial tachyarrhythmias without AADs was 74.3%, which was better than that in patients with left atrial diameter >40 mm. A larger sample size and improved study design are needed to confirm our conclusions.     

Tracheobronchial stents in patients with malignant airway disease: Finnish tertiary care experience

Open in a separate window OBJECTIVESTracheobronchial stenting has an established role in the palliation of malignant central airway obstruction (CAO). The purpose of this study is to describe the experience with self-expanding metal airway stents in 2 tertiary referral centres, covering a third of the population of Finland.METHODSPatients referred to and treated with airway stenting for malignant CAO using self-expanding metal-stents were identified from electronic patient records, and data were collected using a structured Endoscopic Lower Airway Management instrument. Statistical analysis to reveal factors affecting patient benefit and survival was carried out.RESULTSA total of 101 patients (mean age 65.8) and 116 procedures were identified. Procedure-related mortality was rare (3/101 patients) and complications infrequent. The median survival was 2.3 months [95% confidence interval (CI): 1.4–3.1). Stent benefit was not significantly affected by clinical characteristics. Survival was impacted by the use of adjunct procedures [hazard ratio (HR) 0.36, 95% CI: 0.23–0.58, P < 0.001), procedural urgency (HR 0.40; 95% CI: 0.23–0.71, P = 0.002) and post-treatment chemoradiotherapy (HR 0.29, 95% CI: 0.15–0.56, P < 0.001).CONCLUSIONSThe beneficial impact observed supports the further use of tracheobronchial stenting in malignant CAO. The use of self-expanding metal stents is encouraged.     

Measured versus predicted postoperative pulmonary function at repeated times up to 1 year after lobectomy

 Open in a separate windowOBJECTIVESPostoperative pulmonary function is difficult to predict accurately, because it changes from the time of the operation and is also affected by various factors. The objective of this study was to assess the accuracy of predicted postoperative forced expiratory volume in 1 s (FEV1) at different postoperative times after lobectomy.METHODSThis retrospective study enrolled 104 patients who underwent lobectomy by video-assisted thoracic surgery. Pulmonary function tests were performed preoperatively and postoperatively at 3, 6 and 12 months. We investigated time-dependent changes in FEV1. In addition, the ratio of measured to predicted postoperative FEV1 calculated by the subsegmental method was evaluated to identify the factors associated with variations in postoperative FEV1.RESULTSCompared with the predicted postoperative FEV1, the measured postoperative FEV1 was 8% higher at 3 months, 11% higher at 6 months and 13% higher at 12 months. The measured postoperative FEV1 significantly increased from 3 to 6 months (P = 0.002) and from 6 to 12 months (P = 0.015) after lobectomy resected lobe, smoking history and body mass index were significant factors associated with the ratio of measured to predicted postoperative FEV1 at 12 months (P < 0.001, P = 0.036 and P = 0.025, respectively).CONCLUSIONSPostoperative FEV1 increased up to 12 months after lobectomy by video-assisted thoracic surgery. The predicted postoperative pulmonary function was underestimated after 3 months, particularly after lower lobectomy.     

Impact of gender on 10-year outcome after coronary artery bypass grafting

Open in a separate window OBJECTIVESOur goal was to evaluate the impact of gender on the 10-year outcome of patients after isolated coronary artery bypass grafting (CABG) included in the Italian nationwide PRedictIng long-term Outcomes afteR Isolated coronary arTery bypass surgery (PRIORITY) study.METHODSThe PRIORITY project was designed to evaluate the long-term outcomes of patients who underwent CABG and were included in 2 prospective multicentre cohort studies. The primary end point of this analysis was major adverse cardiac and cerebrovascular events. Baseline differences between the study groups were balanced with propensity score matching and inverse probability of treatment. Time to events was analysed using Cox regression and competing risk analysis.RESULTSThe study population comprised 10 989 patients who underwent isolated CABG (women 19.6%). Propensity score matching produced 1898 well-balanced pairs. The hazard of major adverse cardiac and cerebrovascular event was higher in women compared to men [adjusted hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.03–1.23; P = 0.009]. The incidence of major adverse cardiac and cerebrovascular event in women was significantly higher at 1 year (HR 1.31, 95% CI 1.11–1.55; P < 0.001) and after 1 year (HR 1.11, 95% CI 1.00–1.24; P = 0.05). Mortality at 10 years in the matched groups was comparable (HR 1.04, 95% CI 0.93–1.16; P = 0.531). Women have significantly a higher 10-year risk of myocardial infarction (adjusted HR 1.40, 95% CI 1.17–1.68; P = 0.002) and percutaneous coronary intervention (adjusted HR 1.32, 95% CI 1.10–1.59; P = 0.003).CONCLUSIONSThe present study documented an excess of non-fatal cardiac events after CABG among women despite comparable 10-year survival with men. These findings suggest that studies investigating measures of tertiary prevention are needed to decrease the risk of adverse cardiovascular events among women.     

An ex vivo evaluation of two different suture techniques for the Ozaki aortic neocuspidization procedure

Open in a separate window OBJECTIVESWe investigated the Ozaki procedure using a single interrupted suture technique (SST) and compared this with the standard continuous suture technique (CST) with regard to hydrodynamic valve performance. In addition, both techniques were compared with the native aortic valve (NAV).METHODSEffective orifice area, mean pressure gradient and leakage volume were evaluated in the NAV as well as after an Ozaki procedure using SST or CST in fresh swine aortic roots using a mock circulation loop. The NAV, SST and CST were evaluated under 4 defined hydrodynamic conditions.RESULTSBoth suture techniques resulted in a similar effective orifice area under all conditions [for stroke volume of 70 ml: SST: 1.50 (1.35–1.87) vs CST: 1.57 (1.41–1.72) cm², P = 0.8] and there were no significant differences between both suture techniques and the NAV (P > 0.05). Regarding mean pressure gradient, the Ozaki procedure with SST and CST showed no significant differences [7.23 (5.53–8.91) vs 7.04 (6.65–7.60) mmHg, P = 0.72] and there was no significant difference between both suture techniques and the NAV (P > 0.1). In leakage volume, there was no significant difference between SST and CST [4.49 (3.91–4.99) vs CST: 4.23 (3.58–4.87) ml/stroke, P = 0.34].CONCLUSIONSThe Ozaki procedure with SST performed similarly to that with CST with regard to hydrodynamic performance. Our results suggest that the Ozaki procedure can be performed with SST instead of CST, which may be useful in patients with limited surgical exposure, such as a small annulus.     

Surgery for mediastinal neurogenic tumours: a 25-year single-centre retrospective study

 Open in a separate windowOBJECTIVESMediastinal neurogenic tumours are uncommon and often benign neoplasms mostly located in the posterior mediastinum and usually diagnosed incidentally. We reviewed our results after surgical resection. We compared patient characteristics and tumour nature between children and adults. Differences between thoracoscopic and open approach were analysed.METHODSDepartmental thoracic surgical database was queried for primary mediastinal neurogenic tumours resected between 1992 and 2017. Data included demographics, pathology, tumour nature, symptoms, surgical approach and postoperative morbidity/mortality.RESULTSFifty-one patients (8 children and 43 adults) underwent tumour resection. Pathology revealed nerve sheath tumour in 1 child (12.5%) versus 36 adults (83.7%; P < 0.001) and ganglion cell tumour in 7 (87.5%) versus 5 (11.6%; P < 0.001). Two adults had a paraganglioma. Malignancy was present in 2 children (25%) versus 2 adults (4.6%; P = 0.049). All malignant tumours caused symptoms while most patients with benign tumours (38/47) were asymptomatic (P < 0.001). Surgical approach included thoracotomy, thoracoscopy and cervicotomy (n = 19/31/1) of which 2 were combined neurosurgical approach. All malignant tumours were approached via thoracotomy while the majority of patients with benign tumours (31/47) underwent thoracoscopy (P = 0.007). No significant difference was noted in overall morbidity between thoracoscopic versus open approach (45.2% vs 42.1%; P = 0.83). Hospital stay was significantly shorter following thoracoscopy (7.4 ± 3.3 vs 13.1 ± 9.8 days; P = 0.001).CONCLUSIONSChildren carry a higher incidence to present with a malignant tumour originating from ganglion cells while most tumours in adults are benign, originating from the nerve sheath. The majority of patients with mediastinal neurogenic tumours are asymptomatic. Most tumours are amenable for thoracoscopic resection.     

Impact of skeletonized harvesting of the internal thoracic artery on intrasternal microcirculation considering preparation quality

 Open in a separate windowOBJECTIVESPrevious studies have demonstrated the impact of internal thoracic artery (ITA) harvesting on microcirculation in parasternal tissues. However, the impact of skeletonized ITA harvesting on intrasternal microcirculation is unknown. Intraskeletal tissue perfusion has been proven to be crucial for deep wound healing. Furthermore, the impact of different levels of surgical preparation quality on intrasternal microcirculation has not been investigated yet.METHODSSternal microcirculation (sLDP) was monitored with a novel Laser Doppler Perfusion needle probe, while the ITA was skeletonized in a pig model. To mimic different levels of preparation quality, satellite veins were either coagulated or not during preparation. To show the effect of ideally avoiding any surgical manipulation on sLDP, the ITA was clipped in a third sham-harvested group. RESULTSsLDP was reduced highly significant to 71 [standard deviation (SD): 9]% (P < 0.001) after skeletonized harvesting of the ITA. Coagulation of the satellite veins as a detrimental surgical factor resulted in a significantly stronger reduction of sLDP to 56 (SD: 11)% (P < 0.05) compared to sLDP with non-coagulated satellite veins. ITA clipping reduced sLDP highly significant to 71 (SD: 8)% (P < 0.001) in the sham-operated group.CONCLUSIONSITA harvesting markedly impairs microcirculation of the sternum but remains unavoidable when coronary artery bypass grafting should be performed. Nevertheless, excessive surgical damage and coagulation of satellite veins is avoidable and should be reduced to a minimum to minimize the risk of deep sternal wound healing complications.     

Is the Yedikule-solitary pulmonary nodule malignancy risk score sufficient to predict malignancy? An internal validation study

Open in a separate window OBJECTIVESWe aimed to develop a malignancy risk score model for solitary pulmonary nodules (SPNs) using the demographic, radiological and clinical characteristics of patients in our centre. The model was then internally validated for malignancy risk estimation. METHODSA total of 270 consecutive patients who underwent surgery for SPN between June 2017 and May 2019 were retrospectively analysed. Using the receiver operating characteristic curve analysis, cut-off values were determined for radiological tumour diameter, maximum standardized uptake value and the Brock University probability of malignancy (BU-PM) model. The Yedikule-SPN malignancy risk model was developed using these cut-off values and demographic, radiological and clinical criteria in the first 180 patients (study cohort) and internally validated with the next 90 patients (validation cohort). The Yedikule-SPN model was then compared with the BU-PM model in terms of malignancy prediction.RESULTSMalignancy was reported in 171 patients (63.3%). Maximum standardized uptake value and BU-PM scores were sufficient to predict malignancy (P < 0.001 for both), while the effectiveness of nodule size determined on thoracic computed tomography did not reach statistical significance (P = 0.09). When the Yedikule-SPN model developed with the study cohort was applied to the validation cohort, it significantly predicted malignancy (area under the receiver operating characteristic curve: 0.883, 95% confidence interval: 0.827–0.957, P < 0.001). Comparison of patients in the validation group with Yedikule-SPN scores above (n = 53) and below (n = 37) the cut-off value of 65.75 showed that the malignancy rate was significantly higher among patients with Yedikule-SPN score over 65.75 (86.8% vs 21.6%, P < 0.001, odds ratio = 23.821, 95% confidence interval: 7.805–72.701). When compared with the BU-PM model in all patients, the Yedikule-SPN model tended to be a better predictor of malignancy (P = 0.06).CONCLUSIONSThe internally validated Yedikule-SPN model is also a good predictor of the malignancy of SPN(s). Prospective and multicentre external validation studies with large patients’ cohorts are needed.