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Journal and News Scan
Here is a new guideline on the surgical treatment of Atrial Fibrillation. It is a difficult area for guidelines and here we address just some of the issues involved including the energy sources, left atrial appendage, warfarin management and indications for surgery.
We are pleased to announce that the SCTS iData web application, designed to support shared decision making, is now available to use at www.idata.scts.org. Acting as a ‘window’ into National Adult Cardiac Surgery Audit (NACSA) data, the iData app allows users to place filters on CABG, AVR and MV data to gain access to a report showing aggregated analysis of every patient receiving heart surgery in the UK between April 2008 – March 2012. Reports provide a running total of procedures as you add each filter, with the option to generate a report at any time. Reports show users averages of: · In-hospital mortality · 1 Year mortality · EuroSCORE · EuroSCORE II · Post-operative length of stay Instructions · You must select an operation type (CABG, AVR or MV) on the first screen and an operation type on the second screen before applying any further filters or generating a report · Each additional variable selected will reduce the sample size on which the resultant report is based. Clinical judgement must be used to keep sample sizes as large as possible, and caution exerted when viewing results based on small samples · For Internet Explorer Users: the app only works on versions of Internet Explorer supported by Microsoft (i.e. IE10) The application will soon be available to download onto iOS devices for free from the Apple store. You can view a demo of the iOS app on YouTube here. Queries and feedback should be directed to NACSA Project Manager, Rebecca Cosgriff (firstname.lastname@example.org). We hope that you find the iData application useful; the latest in a series of outputs from the National Adult Cardiac Surgery Audit including: · www.bluebook.scts.org – Hospital and national level activity, trends and data quality · www.scts.org/patients - Hospital and consultant level activity and in-hospital risk adjusted mortality · http://www.scts.org/heartsurgerybluebook/ - what patients can expect from their heart surgeons
Emerging studies suggest that early administration of dual antiplatelet therapy may be better than monotherapy for prevention of early recurrent stroke and cardiovascular outcomes in acute ischemic stroke and transient ischemic attack (TIA). The authors performed a meta–analysis of randomized, controlled trials evaluating dual versus mono antiplatelet therapy for acute noncardioembolic ischemic stroke or TIA. For patients with acute noncardioembolic ischemic stroke or TIA, dual therapy was more effective than monotherapy in reducing risks of early recurrent stroke. The results of the CHANCE study are consistent with previous studies done in other parts of the world. Methods The authors assessed randomized, controlled trials investigating dual versus mono antiplatelet therapy published up to November 2012 and the CHANCE trial (Clopidogrel in High–risk patients with Acute Non–disabling Cerebrovascular Events), for efficacy and safety outcomes in adult patients with acute noncardioembolic ischemic stroke or TIA with treatment initiated within 3 days of ictus. In total, 14 studies of 9012 patients were included in the systematic review and meta–analysis. Results Dual antiplatelet therapy significantly reduced risk of stroke recurrence (risk ratio, 0.69; 95% confidence interval, 0.60–0.80; P<0.001) and the composite outcome of stroke, TIA, acute coronary syndrome, and all death (risk ratio, 0.71; 95% confidence interval, 0.63–0.81; P<0.001) when compared with monotherapy, and nonsignificantly increased risk of major bleeding (risk ratio, 1.35; 95% confidence interval, 0.70–2.59, P=0.37). Analyses restricted to the CHANCE Trial or the 7 double–blind randomized, controlled trials showed similar results.
The authors surveyed the effects of particulate air pollution on the development of lung cancer and the adenocarcinoma subtype in 17 European cohorts totalling over 300,000 members and over 4 million person-years at risk. Over 2,000 lung cancers were diagnosed during the follow-up period. Particulate pollution was associated with a 20% increase in the risk of lung cancer and a 50% increase in the risk of adenocarcinoma.
129 pts with Barrett's esophagus with either no or low grade dysplasia were randomized to ablation with the argon plasma coagulator (APC) or observation. Ablation of >95% of Barrett's mucosa was initially achieved in 61 of 63 in the APC group. This decreased to 21 of 32 at long-term follow-up (>84 mos). The length of Barrett's decreased in the surveillance group from 4.2 cm at presentation to 2.7 cm at long-term follow-up. Sporadic low grade and high grade dysplasia developed in both groups, indicating that persistent surveillance is required.
The ACOSOG Z4032 trial compared sublobar resection alone to sublobar resection with brachytherapy. This study compared surgical outcomes for wedge resection vs segmental resection, which were surgical options as part of the trial. Wedge resection was associated with a closer resection margin (8mm vs 15mm), a lower rate of nodal upstaging (1% vs 9%), fewer nodal stations sampled (1 vs 3), and a higher rate of no nodal sampling/dissection (41% vs 2%).
Factors affecting RV to PA conduit durability were investigated in a multi-institution study involving 429 infants <2 years old. Conduit durability at a median f/u of 6 years was 63%. Earlier replacement was associated with a smaller z-score, and durability was reduced with implantation of allografts from aorta or PA compared to use of a valved bovine jugular vein.
The efficacy of deep hypothermic circulatory arrest (DHCA) on preserving neurocognitive function is uncertain. This study compared 29 pts undergoing aortic surgery with DHCA to 33 who did not require DHCA. Cognitive scores preop and postop were similar for both groups. A similar number of pts (11 vs 13) experienced neurocognitive deficits postoperatively, including a decline in types of memory function. Time under DHCA was not associated with the incidence of neurocognitive deficits. Overall, cardiac surgery caused some problems with memory. DHCA, when required, preserved neurocognitive function.
In the US, preoperative beta-blockade is a hospital quality metric that must be addressed at the time of each operation. This study reviewed STS Database data for isolated CABG in nearly 44,000 pts. After risk adjustment, beta-blockade had no effect on mortality, morbidity, or hospital resource utilization. The authors suggest that beta-blockade is not a useful quality metric for CABG.
This article is a transcription of a roundtable discussion on surgical management of esophageal cancer involving recognized experts in the field. Topics include conduit preparation, pyloric drainage, conduit preconditioning, postoperative reflux, the role of surgery in multimodality therapy, and the choice of incisions for esophagectomy.