Abstract Objective Airway obstruction in children may be caused by conditions such as vascular compression and congenital tracheobronchomalacia. Obstructive pulmonary vascular disease may be a ...detrimental sequel for patients with congenital heart disease. We evaluate our own original external stenting technique as a treatment option for these patients. Methods Ninety-eight patients underwent external stenting (1997-2015). Cardiovascular anomalies were noted in 82 (83.7%). Nine patients had hypoplastic left heart syndrome and 6 had other types of single-ventricular hearts. Results The median age at the first operation was 7.2 months (range, 1.0-77.1 months). The mechanisms were tracheobronchomalacia with (n = 46) or without (n = 52) vascular compression. Patients underwent 127 external stentings for 139 obstruction sites (62 trachea, 55 left bronchus, and 22 right bronchus). The stent sizes varied from 12 to 16 mm. There were 14 (8 in the hospital and 6 after discharge) mortality cases. Nine required reoperation for restenosis and 3 required stent removal for infection. The actuarial freedom from mortality and any kind of reoperation was 74.7% ± 4.6% after 2.8 years. The negative pressure threshold to induce airway collapse for congenital malacia (n = 58) improved from −15.9 to −116.0 cmH2 O. A follow-up computed tomography scan (>2.0 years interval from the operation; n = 23) showed the mean diameter of the stented segment at 88.5% ± 13.7% (bronchus) and 94.5% ± 8.2% (trachea) of the reference. Conclusions External stenting is a reliable method to relieve airway compression for small children, allowing an age-proportional growth of the airway.
Objective Our study describes the results from surgical slide tracheoplasty (STP) in children with long segment tracheal stenosis. Methods Demographic and preoperative conditions, operative details, ...and outcome measures, including the need for endoscopic airway intervention and mortality, were collected for children undergoing STP between February 1995 and December 2012. Results One hundred one patients (median age, 5.8 months; range, 5 days-15 years) underwent STP. Seventy-two patients (71.3%) had associated cardiovascular anomalies. Preoperative ventilation was necessary in 56 patients (55.4%), whereas extracorporeal membrane oxygenation was required in 10 patients (9.9%). Abnormal bronchial arborization was present in 39 children (38.6%), which included 13 patients (12.8%) with an anomalous right upper lobe bronchus and 17 patients (16.8%) with tracheal trifurcation. Airway stenosis extended into 1 or both bronchi in 24 patients (23.7%) and preoperative malacia was present in 24 patients (23.7%). STP was extended into the bronchus in 47 patients (46.5%). Overall survival was 88.2% (mortality in 12 patients). Post-STP balloon dilation was necessary in 45 patients (44.6%) and stenting was required in 22 patients (21.8%). Multivariate analysis revealed preoperative extracorporeal membrane oxygenation ( P < .05), preoperative malacia ( P < .001), and bronchial stenosis ( P < .05) to be adverse predictors of survival. Preoperative malacia was a significant risk factor for stenting ( P < .05). Conclusions STP is a versatile and reliable technique associated with low morbidity and mortality when compared with previous strategies for children with long segment tracheal stenosis. The presence of preoperative bronchomalacia is a significant risk factor for death and postoperative stenting.
Left ventricular assist devices (LVADs) are increasingly used in patients with heart failure. To study the impact of stroke on clinical outcomes after continuous-flow (CF-) LVAD implantation, we ...evaluated our single-center experience.
From 2006 to 2013, we implanted the HeartMate II CF-LVAD in 230 patients. We used standard statistical methods to evaluate our results.
Of our study group, 185 patients (80.4%) received the CF-LVAD as a bridge to transplantation. Strokes occurred in a total of 39 patients (17%), an incidence rate of 0.064 strokes per person-year: 19 (48.7%) were embolic, and 20 (51.3%) were hemorrhagic. The stroke-free rate at 6 months after HeartMate II implantation was 92.6%, at 12 months, 89.6%, and at 24 months, 86.1%. Baseline demographic characteristics did not differ significantly, except that stroke patients had a lower incidence of coronary artery disease (p = 0.004) and prior cardiac surgery (p = 0.001). We noted a trend toward an increased risk of stroke in patients with CF-LVAD-related infections (p = 0.053). The survival rate in stroke (versus stroke-free) patients at 6 months was 84.6% (versus 84.2%); at 12 months, 71.8% (versus 81.6%); and at 24 months, 53.9% (versus 74.7%; p = 0.0019). During a median follow-up time of 761 days, mortality risk in stroke patients was 2.01 times that of stroke-free patients (hazard ratio = 2.01; p = 0.004).
Stroke while on CF-LVAD support was associated with significant mortality. To reduce the risk of stroke, it is essential to further elucidate risk factors, to optimize anticoagulation, and to further understand the impact of LVAD-related infections.
OBJECTIVE
We described a cohort of 100 children with a wide variety of airway obstruction who underwent stent positioning in the last 7 years. The study examined the outcomes of this treatment in the ...largest series of paediatric patients reported in the literature with special concern over safety and clinical effectiveness.
METHODS
We performed a retrospective analysis of 100 consecutive paediatric patients who underwent stent insertions between January 2005 and May 2012. Statistical analysis was performed and exact likelihood was used.
RESULTS
A total of 235 stents were placed for severe airway obstruction. One hundred and twelve silicone stents (cylinder, hourglass or Y-shaped), 120 metallic stents (covered Nitinol stents, expandable coronary and vascular stents) and 3 biodegradable polydioxanone (PDS) stents were used. Eighty patients presented clinical improvement after stent insertion, 17 were weaned off mechanical ventilation and 3 showed no significant clinical improvement 95% confidence interval (CI) 0.1-8.0%. Complications were different according to stent type. In our cohort, no fatal stent-related complications have been observed. At follow-up (median 41.4 months, range 1.1-145.4) complete resolution was registered for 60 patients (66%; 95% CI 55-76%), 17 are still under treatment, 9 were lost to follow-up, 8 underwent surgery and 6 died of causes not stent related.
CONCLUSION
Airway stenting represents a conservative treatment before more invasive surgical procedures and can be very effective when performed in selected children and in specialized centres by physicians experienced in rigid and flexible bronchoscopy.
Postoperative pulmonary complications are associated with increased morbidity. Identifying patients at higher risk for such complications may allow preemptive treatment.
Patients with an American ...Society of Anesthesiologists (ASA) score >1 and who were scheduled for major surgery of >2 hours were enrolled in a single-center prospective study. After extubation, lung ultrasound was performed after a median time of 60 minutes by 2 certified anesthesiologists in the postanesthesia care unit after a standardized tracheal extubation. Postoperative pulmonary complications occurring within 8 postoperative days were recorded. The association between lung ultrasound findings and postoperative pulmonary complications was analyzed using logistic regression models.
Among the 327 patients included, 69 (19%) developed postoperative pulmonary complications. The lung ultrasound score was higher in the patients who developed postoperative pulmonary complications (12 7-18 vs 8 4-12; P < .001). The odds ratio for pulmonary complications in patients who had a pleural effusion detected by lung ultrasound was 3.7 (95% confidence interval, 1.2-11.7). The hospital death rate was also higher in patients with pleural effusions (22% vs 1.3%; P < .001). Patients with pulmonary consolidations on lung ultrasound had a higher risk of postoperative mechanical ventilation (17% vs 5.1%; P = .001). In all patients, the area under the curve for predicting postoperative pulmonary complications was 0.64 (95% confidence interval, 0.57-0.71).
When lung ultrasound is performed precociously <2 hours after extubation, detection of immediate postoperative alveolar consolidation and pleural effusion by lung ultrasound is associated with postoperative pulmonary complications and morbi-mortality. Further study is needed to determine the effect of ultrasound-guided intervention for patients at high risk of postoperative pulmonary complications.
The quality of surgical care in the Veterans Health Administration improved markedly in the 1990s after implementation of the Veterans Affairs (VA) National Surgical Quality Improvement Program (now ...called the VA Surgical Quality Improvement Program). Although there have been many recent evaluations of surgical care in the private sector, to date, a contemporary global evaluation has not been performed within the VA health system.
To provide a contemporaneous report of noncardiac postoperative outcomes in the VA health system during the past 15 years.
A retrospective cohort study was conducted using data from the VA Surgical Quality Improvement Program among veterans who underwent inpatient general, vascular, thoracic, genitourinary, neurosurgical, orthopedic, or spine surgery from October 1, 1999, through September 30, 2014.
Rates of 30-day morbidity, mortality, and failure to rescue (FTR) over time.
Among 704 901 patients (mean SD age, 63.7 11.8 years; 676 750 96% male) undergoing noncardiac surgical procedures at 143 hospitals, complications occurred in 97 836 patients (13.9%), major complications occurred in 66 816 (9.5%), FTR occurred in 12 648 of the 97 836 patients with complications (12.9%), FTR after major complications occurred in 12 223 of the 66 816 patients with major complications (18.3%), and 18 924 patients (2.7%) died within 30 days of surgery. There were significant decreases from 2000 to 2014 in morbidity (8202 of 59 421 13.8% vs 3368 of 32 785 10.3%), major complications (5832 of 59 421 9.8% vs 2284 of 32 785 7%), FTR (1445 of 8202 17.6% vs 351 of 3368 10.4%), and FTR after major complications (1388 of 5832 23.8% vs 343 of 2284 15%) (trend test, P < .001 for all). Although there were no clinically meaningful differences in rates of complications and major complications across hospital risk-adjusted mortality quintiles (any complications: lowest quintile, 20 945 of 147 721 14.2% vs highest quintile, 18 938 of 135 557 14%; major complications: lowest quintile, 14 044 of 147 721 9.5% vs highest quintile, 12 881 of 135 557 9.5%), FTR rates (any complications: lowest quintile, 2249 of 20 945 10.7% vs highest quintile, 2769 of 18 938 14.6%; major complications: lowest quintile, 2161 of 14 044 15.4% vs highest quintile, 2663 of 12 881 20.7%) were significantly higher with increasing quintile (P < .001). However, across hospital quintiles, there were significant decreases in morbidity (20.6%-29.9% decrease; trend test, P < .001 for all) and FTR (29.2%-50.6% decrease; trend test, P < .001 for all) during the study period. After hierarchical modeling, the odds of postoperative mortality, FTR, and FTR after a major complication were approximately 40% to 50% lower in the most recent study year compared with 15 years ago (P < .001 for all).
For the past 15 years, morbidity, mortality, and FTR have improved within the VA health system. Other integrated health systems providing a high volume of surgical care for their enrollees may benefit by critically evaluating the system-level approaches of the VA health system to surgical quality improvement.
To compare a simultaneous vs sequential approach to residual post chemotherapy mass resections in metastatic testis cancer.
A retrospective review was performed of patients who underwent ...retroperitoneal and thoracic/cervical resection of post chemotherapy residual masses between 2002 and 2018. Group 1: “Simultaneous” (Combined Retroperitoneal and Thoracic/Cervical resections on the same date); Group 2: “Sequential” (Retroperitoneal and Thoracic/Cervical resections at separate dates).
During the study period, 35 simultaneous and 17 sequential resections were performed. The median age at surgery was 28 years (Range 16-61). The median follow-up from last surgical procedure was 62.7 months (Range 0.4-194). Histology revealed teratoma in 38 (73.1%) patients, necrosis in 8 (15.4%) and viable tumor in 6 (11.5%). Discordant pathology findings between thoracic/cervical and abdominal resections were noted in 16 (30.8%) patients.
No differences were observed between the simultaneous vs sequential groups in median operating time (585 minutes vs 545 minutes, P = .64), blood loss (1300 vs 1300 mls, P = .42), or length of stay (9 vs 11 days, P = .14). There was no difference between the 5-year (65.7% vs 68.6%) relapse-free survival between the 2 groups (P = .84) or the 5-year (88.6% vs 100%) overall and disease-specific survival (P = .25).
Simultaneous resection of retroperitoneal and thoracic/cervical post chemotherapy metastases is a feasible in some patients. It requires multidisciplinary collaboration and a longer primary procedure.
OBJECTIVES
The aim of the present study was to monitor performance and learning effects for thoracic aortic surgery. In addition, we evaluated the volume–outcome relationship of patients undergoing ...surgery of the thoracic aorta, comparing the results of two higher-volume surgeons (HVSs) with six lower volume surgeons.
METHODS
A total of 867 thoracic aortic procedures (elective cases n = 753 and Type A acute dissection n = 114) were performed from 2003 to 2013 by eight surgeons (range 28–238 procedures) at our institution. Departmental and individual performance was monitored using control charts, with a predetermined acceptable failure rate of 10%. Perioperative death or one or more of four adverse events constituted failure. Moreover, results of two higher-volume operators (n = 460; 53%) were compared with those of six lower-volume operators (n = 407; 47%).
RESULTS
The incidence rate of in-hospital mortality for elective cases was 2% and for Type A dissection repair 9.6%. Institutional control charts revealed that the surgical process was under control for all the study periods apart from small periods of worse than expected performance which were congruent with new surgeons joining the programme. The predominant surgical failure was reoperation for bleeding. There were differences between surgeons with regard to the learning curves and performance. No significant differences were observed between high- and low-volume surgeons in terms of mortality and morbidity for elective cases. However, high-volume surgeons presented a trend suggesting a higher mortality rate in Type A aortic dissection repair (17.1 vs 6.3%; P = 0.09).
CONCLUSIONS
Thoracic aortic surgery can be performed with similar results by high- and low-volume surgeon. Control charts can facilitate learning effects and performance monitoring. Implementation of continuous departmental and individual performance monitoring is practicable.
Stroke volume variation (SVV) and pulse pressure variation (PPV) are used as indicators of fluid responsiveness, but little is known about the usefulness of these dynamic preload indicators in ...thoracic surgery, which involves an open thoracic cavity and 1-lung ventilation (OLV). Therefore, we investigated whether SVV and PPV could predict fluid responsiveness, and whether the thresholds of these parameters should be adjusted for thoracic surgery.
This was a prospective, controlled study conducted in a tertiary care center. Eighty patients scheduled for an elective lobectomy requiring OLV were included (n = 40, video-assisted thoracoscopic surgery (VATS); n = 40, open thoracotomy). Twenty minutes after opening the thoracic cavity, 7 mL/kg hydroxyethyl starch was administered for 30 minutes. Various hemodynamic parameters were measured before and after fluid challenge.
Among the 80 patients enrolled in this study, 37% were fluid responders (increase in stroke volume index ≥10%). SVV before fluid challenge was not different between nonresponders and responders (mean ± SD: 7.1 ± 2.7% vs 7.4 ± 2.6%, P = .68). This finding was true regardless of whether the surgery involved open thoracotomy or VATS. PPV before fluid challenge showed the difference between nonresponders and responders (mean ± SD: 6.9 ± 3.0% vs 8.4 ± 3.2%; P = .045); however, the sensitivity and specificity of the threshold value (PPV = 7%) were low (58% and 62%, respectively) and the area under the receiver operating characteristics curve was only 0.63 (95% confidence interval, 0.52-0.74; P = .041).
Dynamic preload indicators are not useful for predicting fluid responsiveness in VATS or open thoracic surgery.
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