Surgical mediastinal lymph node staging for non-small-cell lung carcinoma

Background

The current preferred approach for surgical mediastinal staging of non-small-cell lung carcinoma is video-assisted mediastinoscopy. An alternative technique in which lymph nodes are resected instead of biopsied is video-assisted mediastinoscopic lymphadenectomy (VAMLA) that is suggested to be superior in detecting N2 disease. Yet, evidence is conflicting and furthermore limited by sample size. The objective was to compare mediastinal staging through VAMLA and video-assisted mediastinoscopy.

Methods

A single-center cohort study was conducted. All consecutive patients that underwent surgical mediastinal staging of non-small-cell lung carcinoma by VAMLA (2011 to 2018) were compared to historic video-assisted mediastinoscopy controls (2007 to 2011). Patients with negative surgical mediastinal staging underwent subsequent anatomical resection with systematic regional lymphadenectomy. Primary outcome was the sensitivity and negative predictive value for detecting N2 disease.

Results

Two-hundred-sixty-nine video-assisted mediastinoscopic lymphadenectomies and 118 video-assisted mediastinoscopies were performed. The prevalence of N2 disease was 20% and 26% respectively in the VAMLA and video-assisted mediastinoscopy group, while the rate of unforeseen pN2 resulting from lymph node dissection during anatomical resection was 4% and 11%, respectively. Invasive staging using VAMLA demonstrated superior sensitivity of 0.82 and a negative predictive value of 0.96 when compared to video-assisted mediastinoscopy (0.62 and 0.89, respectively), offering a 64% decrease in risk of unforeseen pN2 following anatomical resection. However, VAMLA is also associated with a 75% risk increase on complications (P=0.36).

Conclusions

We conclude that performing invasive mediastinal lymph node assessment for staging of non-small-cell lung carcinoma, VAMLA should be the preferred technique with superior sensitivity and negative predictive value in detecting N2 disease. Though, VAMLA is also associated with an increased risk of complications.

The learning curve of video-assisted mediastinoscopic lymphadenectomy for staging of non-small-cell lung carcinoma

OBJECTIVES

The objective of this study was to define the learning process of video-assisted mediastinoscopic lymphadenectomy (VAMLA) by the assessment of consecutive procedural metrics.

METHODS

We conducted a single-centre retrospective observational study of all consecutive VAMLAs performed between 2011 and 2018 for the staging of non-small-cell lung carcinoma. Learning curves were assessed using non-risk adjusted cumulative observed minus expected (CUSUM) failure charts of complications. Boundary lines were defined by the acceptable and unacceptable complication rates of 4.5% and 15.0%. The Kruskal-Wallis test with post hoc analysis was used to assess trends in operation time and blood loss.

RESULTS

Two-hundred-thirty-six unique VAMLAs by 4 surgeons performing their first procedures were evaluated. CUSUM charts of surgeons A and B showed a typical learning curve with an initial incline, followed by a turning point towards lower complications rates after 16-17 cases, whereas surgeons C and D showed an average performance. The median time between consecutive VAMLAs was shorter for surgeons A and B (13.0 vs 28.5-38.0 days for surgeons C and D). Overcoming the learning curve, complication rates of surgeons A and B decreased from 19% to 3% and from 18% to 5%, respectively. Operation time and blood loss showed a significant improvement after, respectively, 81-100 and 61-80 procedures compared to the first 20 procedures.

CONCLUSIONS

VAMLA is a safe procedure to adopt and perform with acceptable complication rates from the first operation onward, regardless of the caseload. To overcome its learning curve, 16-17 cases are required, preferably at least 1 per 2 weeks.

Optical imaging versus CT and plain radiography to quantify pectus severity: a systematic review and meta-analysis

Background

Computed tomography (CT) and two-view chest radiographies are the most commonly used imaging techniques to quantify the severity of pectus excavatum (PE) and pectus carinatum (PC). Both modalities expose patients to ionizing radiation that should ideally be avoided, especially in pediatric patients. In an effort to diminish this exposure, three-dimensional (3D) optical surface imaging has recently been proposed as an alternative method. To assess its clinical value as a tool to determine pectus severity we conducted a systematic review in which we assessed all studies that compared 3D scan-based pectus severity measurements with those derived from CT-scans and radiographies.

Methods

Six scientific databases and three registries were searched through April 30th, 2019. Data regarding the correlation between severity measures was extracted and submitted to meta-analysis using the random-effects model and I²-test for heterogeneity.

Results

Five observational studies were included, enrolling 75 participants in total. Pooled analysis of participants with PE demonstrated a high positive correlation coefficient of 0.89 [95% confidence interval (CI): 0.81 to 0.93; P<0.001] between the CT-derived Haller index (HI) and its 3D scan equivalent based on external measures. No heterogeneity was detected (I²=0.00%; P=0.834).

Conclusions

3D optical surface scanning is an attractive and promising imaging technique to determine the severity of PE without exposure to ionizing radiation. However, further research is needed to determine novel cut-off values for 3D scans to facilitate clinical decision making and help determine surgical candidacy. No evidence was found that supports nor discards the use of 3D scans to determine PC severity.

Is visceral flow during intra-aortic balloon pumping size or volume dependent?

AIM

We evaluated the influence of intra-aortic balloon size and volume on mesenteric and renal flows.

METHODS

Thirty healthy swine underwent 120-minute ligation of the left anterior descending coronary artery followed by 6 hours of reperfusion. Then, they were randomly assigned to the following five groups of animals, with six animals in each group: no intra-aortic balloon pump (IABP), a short 35-mL IABP, a short 40-mL IABP, a long 35-mL IABP and a long 40-mL IABP. Superior mesenteric artery (SMA) and renal flows were measured at baseline (t₀), at 2-hour ischemia (t₁) and every hour thereafter until 6 hours of reperfusion (from t_R1 to t_R6).

RESULTS

SMA flows increased significantly at t_R1 only in the two short IABP groups (p<0.001) and balloon volume did not appear to affect flows which, at any experimental time-point, were comparable using 35 mL or 40 mL balloons (p>0.05). Renal flows appeared to be influenced by balloon length, but not by volume. Indeed, flows in the renal arteries rose during IABP treatment; the increase was significantly higher in the short balloon groups and throughout the whole reperfusion (all, p<0.001).

CONCLUSIONS

Changes in visceral perfusion during IABP assistance were significantly related to balloon length, but not to its volume. This could be relevant for the evolution of balloon engineering design in order to reduce the incidence of mesenteric ischemia following IABP. Further research is necessary to confirm these findings.

Surgical ablation in patients undergoing mitral valve surgery: impact of lesion set and surgical techniques on long-term success

AIMS

To assess the results and impact of lesion set and surgical technique on long-term success of surgical ablation during mitral surgery.

METHODS AND RESULTS

The patient population consisted of 685 subjects with persistent and long-standing persistent atrial fibrillation (AF) undergoing cardiac surgery for mitral valve disease as the primary indication and concomitant ablation between January 2003 and January 2012 at three institutions. One hundred and sixty-six underwent unipolar (24.2%), 371 (54.2%) bipolar, and 148 (21.6%) had combined ablation. Median follow-up was 58.4 months (interquartile range 43.3-67.9). To appropriately account for death, a competing risk model was employed to identify predictors of cumulative incidence of recurrent AF among lesion set and surgical techniques. Eight-year freedom from recurrent arrhythmia without antiarrhythmic drugs was 0.60 ± 0.02. Success rate was higher using bipolar radiofrequency (RF) (P < 0.001), after performing mitral isthmus line (P = 0.003) and following the biatrial technique (P < 0.001). Competing risk regression revealed that use of unipolar RF [sub-hazard ratio (SHR) 2.41 (1.52-3.43), P < 0.001], combined unipolar/bipolar ablation [SHR 1.93 (0.89-2.57), P = 0.003] and the absence of right atrial ablation [SHR 2.79 (1.27-3.48), P < 0.001] were predictors of cumulative incidence of long-term recurrence.

CONCLUSIONS

Our experience suggests that the use of bipolar clamp improves long-term results in surgical treatment of AF and that right-sided ablation should be routinely added. Randomized studies are necessary to confirm our findings.

Comparing short versus standard-length balloon for intra-aortic counterpulsation: results from a porcine model of myocardial ischaemia-reperfusion

OBJECTIVES

We compare a short and a standard-size balloon with same filling volumes to verify the differences in terms of visceral flow, coronary circulation and haemodynamic performance during aortic counterpulsation in an animal model of myocardial ischaemia-reperfusion injury.

METHODS

Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned to have intra-aortic balloon counterpulsation (IABP) with a 40-ml short-balloon (n = 6) or a 40-ml standard-length balloon (n = 6), or to undergo no IABP implantation (controls, n = 6). Haemodynamics and visceral and coronary flows were measured at baseline (t0), at 2 h of ischaemia (t1) and every hour thereafter until 6 h of reperfusion (from tR1 to tR6), respectively.

RESULTS

Mesenteric flows increased significantly at tR1 only in the short-balloon group (P < 0.001) and it was constantly higher than in the standard-balloon group regardless of mean arterial pressure, systemic vascular resistance and cardiac output (CO; all, P < 0.001). Renal blood flows were significantly increased during IABP treatment with values constantly and significantly higher in short balloons at any following experimental step (all, P < 0.05). IABP improved CO and coronary blood flow, and reduced afterload, myocardial resistances and myocardial oxygen consumption without differences between the short and the standard-length balloon (all, P > 0.05).

CONCLUSIONS

The short balloon prevents visceral ischaemia and, compared with the standard-size balloon, it does not lose IABP beneficial cardiac and coronary-related effects. Further studies are warranted to confirm our findings.

Guideline adherence in antithrombotic treatment after concomitant ablation surgery in atrial fibrillation patients

OBJECTIVES

We investigated real-life oral anticoagulation (OAC) treatment after surgical ablation and examined its adherence to current recommendations. We also explored factors related to OAC use preoperatively and at follow-up.

METHODS

One hundred and fifteen patients with atrial fibrillation (AF) were evaluated during 12-month follow-up after surgery. Patients were divided into two categories according to the congestive heart failure, hypertension, age ≥75 years, diabetes and prior stroke [or transient ischaemic attack or thromboembolism] (CHADS2) score: 60 patients were assigned to the high-risk group (CHADS2 score ≥2) and 55 to the low-risk group (CHADS2 score ≤1). OAC use was defined as guideline adherent, undertreatment or overtreatment.

RESULTS

Baseline overall guideline adherence was 62%. OAC was underprescribed in high-risk patients and overprescribed in low-risk patients (both, P < 0.001). The only factor associated with OAC use after logistic regression analysis were age >75 years (P = 0.01) and preoperative AF > paroxysmal (P = 0.013). Overall guideline adherence at 12-month follow-up showed a trend towards a better adherence in the sinus rhythm (SR) subgroup (74% vs 55%, P = 0.02). OAC was underprescribed in high-risk patients and overprescribed in low-risk patients (both P < 0.001). After logistic regression analysis, preoperative OAC use (P = 0.007) and other indications for OAC (P = 0.01) were predictors of anticoagulation treatment.

CONCLUSIONS

Real-life OAC prescription in AF patients showed a moderate guideline adherence, with high-risk patients being undertreated and low-risk patients being overtreated. These findings stress the importance that antithrombotic treatment in patients undergoing AF surgery needs to be critically re-evaluated.