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Journal and News Scan

Source: JAMA Surgery
Author(s): Jialin Mao, Philip Goodney, Jack Cronenwett, Art Sedrakyan

In this study of low volume surgeons (defined as performing fewer than 1 index operation annually) the authors studied outcomes in New York state for open AAA repair (OAR) and carotid endarterectomy (CEA).   About 50% of surgeons performing these operations were low volume surgeons.  Low volume surgeons had higher rates of operative mortality for OAR (OR 2.09; 95% CI 1.41 - 3.08) and of postoperative MI (OR 1.83; 1.03 - 3.26) and stroke (OR 1.78; 1.21 - 2.62) for CEA.  Health care resource utilization was higher for low volume surgeons for OAR and CEA.

Source: JAMA Surgery
Author(s): Jason C. Pradarelli, Joseph P. Thornton, Justin B. Dimick

This editorial outlines the changing legal landscape for device manufacturers.  The authors discuss a recent legal judgment against Intuitive (da Vinci robot) that found the company failed to notify a hospital regarding a new robot user, indicating that Intuitive held responsibility for ensuring safe implementation of their systems in clinical settings.

Source: New England Journal of Medicine
Author(s): A. Laurie Shroyer, Brack Hattler, Todd H. Wagner, Joseph F. Collins, Janet H. Baltz, Jacquelyn A. Quin, G. Hossein Almassi, Elizabeth Kozora, Faisal Bakaeen, Joseph C. Cleveland, Jr., Muath Bishawi, and Frederick L. Grover, for the Veterans Affairs ROOBY-FS Group

The 5-year outcomes of a Veterans Affairs trial of off-pump vs on-pump CABG are reported.  Mortality in the off-pump group was 15.2% compared to 11.9% in the on-pump group (RR 1.28; p=0.02).  Composite adverse events were more common in the off-pump group (31.0% vs 27.1%; RR 1.14; p=0.046).  Repeat CABG was more common for the off-pump group (1.4% vs 0.5%; p=0.02).  No differences were observed in nonfatal MI, death from cardiac causes, or repeat revascularization.

Source: Annals of Thoracic Surgery
Author(s): Julia Dumfarth, MD, PhD, Sven Peterss, MD, Markus Kofler, MD, Michaela Plaikner, MD, Bulat A. Ziganshin, MD, Thomas Schachner, MD, Maryann Tranquilli, RN, Michael Grimm, MD, John A. Elefteriades, MD

The Yale group retrospectively reviewed their experience with DeBakey type I aortic dissections to evaluate whether patients with bovine aortic arches had a unique distribution of entry sites and differential outcomes.  A total of 315 patients were included in the study, of which 49 (16%) had a bovine aortic arch.  The authors found that those patients with bovine aortic arches were 6 times more likely to have arch tears and 2.7 times more likely to suffer a stroke as those without bovine aortic arches. 

Source: Annals of Thoracic Surgery
Author(s): Colleen G. Koch, MD, MBA, Daniel I. Sessler, MD, Edward J. Mascha, PhD, Joseph F. Sabik III, MD, Liang Li, PhD, Andra I. Duncan, MD, Nicole M. Zimmerman, MS, Eugene H. Blackstone, MD

The Cleveland Clinic group performed a randomized clinical trial comparing transfusion triggers of 24% vs. 28% from 2007-2014.  The study included 722 patients who underwent either CABG or valve surgery.  While the lower trigger group received fewer transfusions, adverse outcomes did not differ between the groups.  Because the lower trigger group had equivalent outcomes but fewer transfusions, the authors recommend using a lower trigger perioperatively.

Source: Journal of Visualised Surgery
Author(s): Ricardo Navarro, Rodrigo Benavidez

In an era of VATS surgery this is a very interesting article documenting advanced in thoracotomy and open chest surgery. 

It shows us that open surgeons are also significantly improving their techniques, and the very large postero-lateral thoracotomy with rib cutting and costo-transverse ligament division may in most cases be replaced by muscle sparing and smaller incision techniques while still allowing a full open operation. 

This is a very courageous and interesting article, and we should all acknowledge that modern thoracotomy is very different from the thoracotomies of the past. 


Well done Dr Navarro.

Source: News from around the web.
Author(s): Claire Vernon

Patient Care

A heart team at Kingston Health Sciences Centre in Ontario performs the first hybrid cardiac ablation for atrial fibrillation in Canada.

A five-year-old boy from Newcastle, South Africa, is among the youngest and smallest people to receive a heart ventricular assist device.

Surgical teams in Armenia already use minimally invasive procedures in the abdominal cavity, and they will soon add them to their arsenal of tools for treating lung cancer.

A cardiac surgery resident in Edmonton, Canada, has designed paper toys that help teach pediatric patients about their hearts and hospital stays.

News outlets highlight athletic successes of transplant patients including a cyclist from Fairlie, United Kingdom, and a swimmer from Michigan, USA, who medaled in the World Transplant Games in Málaga, Spain.

Two paramedics in New York, USA, responded immediately when a nurse suffered a cardiac arrest in their home during a postsurgical follow-up visit.


Drugs and Devices

Surgeons have implanted the first Biostage Cellspan esophageal implant, in which a patient’s stem cells are seeded onto an esophageal scaffold.


Research, Trials, and Funding

Physicians from the Cleveland Clinic in Ohio wrote a letter to the New England Journal of Medicine where they report a decrease in nitroprusside and isoproterenol usage at 47 US hospitals following price hikes in the cost of each drug.

A highly-detailed, 3D representation of the cardiac conduction system in the intact human heart is published in Scientific Reports.

The University of Maryland School of Medicine has received a grant to establish the first cardiac xenotransplantation research center in the USA.

Source: Annals of Surgery
Author(s): Predina, Jarrod D.; Newton, Andrew D.; Keating, Jane; Barbosa, Eduardo M. Jr.; Okusanya, Olugbenga; Xia, Leilei; Dunbar, Ashley; Connolly, Courtney; Baldassari, Michael P.; Mizelle, Jack; Delikatny, Edward J.; Kucharczuk, John C.; Deshpande, Charuhas; Kularatne, Sumith A.; Low, Phillip; Drebin, Jeffrey; Singhal, Sunil

This prospective study evaluated whether intraoperative molecular imaging (IMI) with a folate receptor targeted contrast agent visible in the near-infrared spectrum improved the detection of peripheral malignant lung nodules.  Fifty patients undergoing surgery for peripheral nodules had a preoperative PET scan and were imaged intraoperatively.   IMI identified 95% of nodules and 9 additional lesions not seen preoperatively.  IMI sensitivity was greater than that of PET (96% vs 74%) and had a greater positive predictive value (94% vs 89%).  IMI improved management in 30% of patients.

Source: The Annals of Thoracic Surgery
Author(s): Viktor Hraska, Mathieu Vergnat, Peter Zartner, Chris Hart, Phillip Suchowerskyj, Benjamin Bierbach, Ehrenfried Schindler, Martin Schneider, Boulos Asfour

Hraska and colleagues present a retrospective study of outcomes following congenitally corrected transposition of the great arteries using the morphologically left ventricle as the systemic pumping chamber. Patients were followed for a median of 5 years, with a range up to 20 years. Overall survival and event-free survival were good, and only one of the 63 patients had worse than mild dysfunction of the morphologically left ventricle.

This research was presented at the 2017 Annual Meeting of The Society of Thoracic Surgeons, and the audio discussion that followed the presentation accompanies the article.

Source: BMJ
Author(s): Pierre-Benoit Pagès, Halim Abou Hanna, Anne-Claire Bertaux, Ludwig Serge Serge Aho, Pierre Magdaleinat, Jean-Marc Baste, Marc Filaire, Richard de Latour, Jalal Assouad, François Tronc, Christophe Jayle, Jérome Mouroux, Pascal-Alexandre Thomas, Pierre-Emmanuel Falcoz, Charles-Henri Marty-Ané, Alain Bernard

Despite VATS lobectomy being 25 years old, we do need definitive results urgently and from large randomised clinical trials in order to demonstrate the remarkable advantage for the patients undergoing major lung resection by minimally invasive approach. Looking forward to seeing the results of this French multicentric trial and from the ongoing VIOLET trial from UK.