Fractional flow reserve and instantaneous wave-free ratio in coronary artery bypass grafting: a meta-analysis and practice review

Objective

Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are invasive methods to assess the functional significance of intermediate severity coronary lesions. Both indexes have been extensively validated in clinical trials in guiding revascularisation in patients with stable ischaemic heart disease undergoing percutaneous coronary intervention (PCI) with improved clinical outcomes. However, the role of these tools in coronary artery bypass grafting (CABG) is less clear.

Methods

A meta-analysis of randomised trials and observational studies was carried out to help in determining the optimal strategy for assessing lesion severity and selecting graft targets in patients undergoing CABG. Electronic searches were carried out on Embase, MEDLINE, and Web of Science. A group of four authors independently screened and then assessed the retrieved records. Cochrane's Risk of Bias and Robins-I tools were used for bias assessment. A survey was conducted among surgeons and cardiologists to describe current attitudes towards the preoperative use of functional coronary investigations in practice.

Results

Clinical outcomes including mortality at 30 days, perioperative myocardial infarction, number of grafts, incidence of stroke, rate of further need for revascularisation, and patient-reported quality of life did not differ in CABG guided by functional testing from those guided by traditional angiography.The survey revealed that in half of the surgical and cardiology units functional assessment is performed in CABG patients; there is a general perception that functional testing has improved patient care and its use would clarify the role of moderate coronary lesions that often need multidisciplinary rediscussions; moderate stenosis are felt to be clinically relevant; and anatomical considerations need to be taken into account together with functional assessment.

Conclusions

At present, the evidence to support the routine use of functional testing in intermediate lesions for planning CABG is currently insufficient. The pooled data currently available do not show an increased risk in mortality, myocardial injury, and stroke in the FFR/iFR-guided group. Further trials with highly selected populations are needed to clarify the best strategy.

Systematic Review Registration

ClinicalTrials.gov, identifier (CRD42023414604).

Oesophagopleural fistula after pneumonectomy: A systematic review and case series

INTRODUCTION

There is a paucity of data on the optimal management of oesophagopleural fistula (OPF) following pneumonectomy. The current published literature is limited to case reports and small case series. Although rare, OPF can have a significant impact on both the morbidity and mortality of patients.

METHODS

Two cases of OPF managed at our institution were reported. A systematic review was then conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance concerning OPF following pneumonectomy. Demographic, operative and management data were analysed.

FINDINGS

Systematic review-identified data pertaining to 59 patients from 31 papers was collated. Median patient age was 59.5 years with pneumonectomy performed typically for malignancy (68%) or tuberculosis (19%). Median time from pneumonectomy to a diagnosis of OPF was 12.5 months. Twenty-five per cent of the patients had a synchronous bronchopleural fistula. Management of OPF in this setting is heterogenous. Conservative management was often reserved for asymptomatic or unfit patients. The remainder underwent endoscopic or surgical correction of the fistulae or a combination of the two with varying outcomes. Median follow-up was 18 months. All-cause mortality was 31% (18/59) with a median duration from pneumonectomy to death of 35 days (range 1-1,095).

CONCLUSIONS

Major heterogeneity of management for this rare complication hinders the introduction of standardised guidance of post-pneumonectomy OPF. Surgical and endoscopic intervention is feasible and can be successful in specialist centres. Adopting an multidisciplinary team approach involving both oesophagogastric and thoracic surgery teams and the introduction of a registry database of postoperative complications are likely to yield optimal outcomes.

Comparing the surgical management of acute paediatric scrotal pain between adult urologists and general surgeons in the UK: an observational study

INTRODUCTION

Acute scrotal pain is a common paediatric surgical emergency. Assessment and timely exploration are required to rule out testicular torsion (TT) and prevent unnecessary morbidity.

METHODS

A retrospective observational cohort study was carried out at two district general hospitals in the UK for boys aged ≤16 years presenting with acute scrotal pain between January 2014 and October 2017 managed by adult general surgery (AGS) at one hospital and adult urology (AU) at the other.

RESULTS

Some 565 patients were eligible for inclusion (n=364 AGS, n=201 AU). A higher proportion of patients underwent surgical exploration at AGS compared with AU (277/346 (80.1%) vs 96/201 (47.8%); p<0.001). Of those who underwent exploration, 101/373 (27.1%) had TT, of whom 25/101 (24.8%) underwent orchidectomy and 125/373 (33.5%) had torted testicular appendage. There was no statistically significant difference in rates of orchidectomy between AGS (19/68, 27.9%) and AU (6/33, 18.2%) with testicular salvage rates of 72.1% and 81.8%, respectively (p=0.334). Patients were twice as likely to be readmitted at AGS as at AU (28/346 (8.1%) vs 8/201 (4.0%); p=0.073).

CONCLUSION

Although intraoperative findings were similar between adult general surgeons and urologists, there were significant differences in surgical management, with a higher rate of surgical exploration by general surgeons. Testicular salvage and 30-day postoperative morbidity rates at both institutions were acceptable but the readmission rate was high at 6.6%. It is not known why there is a heterogeneity in management of acute scrotal pain between specialist centres, and further prospective investigations are warranted.

1363 Oesophago-Pleural Fistula After Pneumonectomy; A Systematic Review

Introduction

Oesophago-pleural fistula (OPF) is an infrequent but highly complex complication of pneumonectomy with a mortality of up to 63%. There is a paucity of data on the optimal treatment strategy.

Method

Systematic review was conducted in line with PRISMA guidance concerning OPF following pneumonectomy. Demographic, operative and management data were analysed.

Results

30 full manuscripts of the 76 abstracts were included in the analysis. Data was limited to case reports or small series. In total, information for 58 patients was included. Median age was 59 years, with a median follow up time was 18 months. Most authors adopted sepsis control with chest drainage and pleural lavage and the mean number of interventions was 1.6. Overall mortality was 31% (18/58). There was no significant difference between the time to presentation following left (29.2+/-39.28 months) and right pneumonectomy (66.24+/-110.62) (p = 0.2271) nor any significant difference between successful outcomes following intervention for OPF after left (11/14) compared to right pneumonectomy (31/41) (p = 0.8219) or 90-day mortality (p = 0.4571). However, 26% of patients had synchronous broncho-pleural fistula and 90-day mortality was significantly higher in these patients (6/15 vs 6/43. p = 0.0395). 25 patients who underwent additional pericardial, oesophageal or a nodal resection or intervention at the time of pneumonectomy had a significantly reduced mean time to presentation with OPF (21.49+/-60.15 vs. 84.99+/-114.31. p = 0.0148) and a higher 90-day mortality (8/25 vs 3/32. P = 0.0414).

Conclusions

Major heterogeneity of management hinders the introduction of standardised guidance of post-pnuemonectomy OPF. An MDT approach involving Oesophago-gastric and Cardio-Thoracic Surgery is vital.

466 Resection or Enucleation for Extremely Giant Hepatic Haemangiomata? A Case Report and Review of The Literature

Background

Cavernous hepatic haemangiomas are benign liver tumours and although common when small, giant haemangiomas (usually accepted as being greater than 10cm) are infrequent. Treatment is indicated in patients who are symptomatic or if diagnosis is unclear, although with giant haemangiomas, many support expectant management of asymptomatic lesions due to the risk of major complications. Traditionally hepatic resection has been the primary treatment option for these lesions, but a variety of other techniques, including enucleation, have been described as safe and effective alternatives. There remains equipoise in respect of the best management of giant haemangiomas above 10cm. Cases of such size are rare and so there is a paucity of data available.

Case presentation

We present a case of a 65-year-old male who underwent successful anatomical liver resection for a 5kg giant cavernous haemangioma of 26cm diameter following its incidental identification during an ultrasound scan. We also discuss and compare the role of resection and enucleation for the treatment of haemangiomata greater than 20cm in diameter.

Conclusions

This case demonstrates successful resection of an unusually giant haemangioma which, in contrast to the majority of literature, provides a valuable addition to the limited evidence base for management of this condition by anatomical resection.

The pharmacodynamics and pharmacokinetics of the 5HT1B/1D-agonist zolmitriptan in healthy young and elderly men and women

OBJECTIVE

Zolmitriptan is a selective 5HT1B/1D-agonist for the treatment of migraine. In this study we investigated the cardiovascular and central nervous system effects and the pharmacokinetics of zolmitriptan in young and elderly adults.

METHODS

Twelve young adult and 12 elderly volunteers received single doses of 5, 10, and 15 mg zolmitriptan during a randomized, double-blind, placebo-controlled study. Blood pressure, heart rate, ECG, and central nervous system effects were monitored, and pharmacokinetic parameters of zolmitriptan and its metabolites calculated.

RESULTS

Zolmitriptan did not affect heart rate and had little effect on systolic blood pressure in the young adults. In the elderly, mean peak supine systolic blood pressure values were 9 to 16 mm Hg higher after zolmitriptan than after placebo. Mean peak diastolic pressure was 6 to 10 mm Hg higher in both age groups. These changes were transient. Postural changes in blood pressure were unaffected. There was a dose-related increase in sedation, but the magnitude of the effects was small. Mean observed peak plasma concentration (Cmax) and area under the plasma concentration-time profile [AUC(0-infinity)] for zolmitriptan and its active N-desmethyl metabolite were similar in both age groups but higher in young women than in young men. Metabolite/parent ratios probably the result of greater first-pass metabolism in young men. Zolmitriptan half-life was 2.8 to 3.6 hours in the elderly compared with 2.7 to 2.9 hours in young adults. Mean Cmax and AUC(0-infinity) for the inactive, N-oxide, and the indole acetic acid metabolites were higher in the elderly, associated with lower renal clearance.

CONCLUSIONS

Zolmitriptan was well tolerated, with an effect of age on its effects on blood pressure and the pharmacokinetics of its metabolites. The data suggest no need for dose adjustment for age. In young subjects, concentrations were higher in women than in men, but the differences were insufficient to justify dosage adjustment.