Search

A differential ventilation-perfusion scan demonstrated that the left lung only received 19% of total perfusion. (b) Solid white tumour is evident occluding the left pulmonary artery at the hilium of the lung. gl Macroscopic evaluation of the resected specimen demonstrated a tumour spanning 80 mm which invaded adjacent lung parenchyma and hilar lymph nodes (Fig. [Extracted from the article]

Background: Cardiac surgical units must balance trainee education with the duty to provide optimal patient care. This is particularly challenging with valvular surgery, given the lower volume and increased complexity of these procedures. The present meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes following valvular surgery.Methods: Medline, Embase and CENTRAL databases were systematically searched for studies reporting clinical outcomes according to the training status of the primary operator (consultant or trainee). Data were extracted and meta-analysed according to pre-defined endpoints.Results: Eleven observational studies met the inclusion criteria, reporting on five patient cohorts undergoing mitral valve surgery (n=3975), six undergoing aortic valve replacement (AVR) (n=6236) and three undergoing combined AVR and coronary artery bypass grafting (CABG) (n=3495). Perioperative mortality was not significantly different between trainee and consultant cases for mitral valve surgery (odds ratio [OR] 0.92; 95% confidence interval [CI], 0.62-1.37), AVR (OR 0.67; 95% CI, 0.37-1.24), or combined AVR and CABG (OR 1.07; 95% CI, 0.40-2.85). The incidences of perioperative stroke, myocardial infarction, arrhythmias, acute renal failure, reoperation or wound infection were not significantly different between trainee and consultant cases. There was a paucity of mid-term survival data.Conclusions: Valvular surgery cases performed primarily by trainees were not associated with adverse perioperative outcomes. These findings suggest the rigorous design of cardiac surgical trainee programs can sufficiently mitigate trainee deficiencies. However, studies with longer follow-up duration and echocardiographic data are required to assess long-term durability and safety. [ABSTRACT FROM AUTHOR]

Introduction: There is a paucity of data on the impact of allogenic blood transfusion (ABT) on morbidity and survival outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).Methods: Nine hundred and thirty-five consecutive CRS/HIPEC procedures were performed between 1996 and 2016 at a high-volume institution in Sydney, Australia. Of these, 337(36%) patients required massive ABT (MABT) (≥5 units). Peri-operative complications were graded according to the Clavien-Dindo classification. The association of concomitant MABT with 21 peri-operative outcomes and overall survival (OS) was assessed using univariate and multivariate analyses.Results: In-hospital mortality was 1.8%. Patients requiring MABT had more extensive disease as reflected by a higher peritoneal cancer index (≥17) (70 vs. 29%, p < 0.001) and longer operative times (≥9 h) (82 vs. 35%, p < 0.001). After accounting for confounding factors, MABT was associated with in-hospital mortality (relative risk (RR), 7.72; 95% confidence interval (CI), 1.35-10.11; p = 0.021) and grade III/IV morbidity (RR, 2.05; 95% CI, 1.42-2.95; p < 0.001). MABT was associated with an increased incidence of prolonged hospital stay (≥28 days) (RR, 1.86; 95% CI, 1.26-2.74; p = 0.002) and intensive care unit stay (≥4 days) (RR, 1.83; 95% CI, 1.24-2.70, p = 0.002). It was also associated with a significant OS in patients with colorectal cancer peritoneal carcinomatosis (RR 4.49; p < 0.001) and pseudomyxoma peritonei (RR, 4.37; p = 0.026), but not appendiceal cancer (p = 0.160).Conclusion: MABT is an independent predictor for poorer peri-operative outcomes including in-hospital mortality and grade III/IV morbidity. It may also compromise long-term survival, particularly in patients with colorectal cancer peritoneal carcinomatosis. [ABSTRACT FROM AUTHOR]

Risk assessment tools are increasingly used in surgery. In cardiac surgery, risk models are used for patient counselling, surgical decision-making, performance benchmarking, clinical research, evaluation of new therapies and quality assurance, among others. However, they have numerous disadvantages which need to be considered. This article evaluates the utility of risk assessment tools in cardiac surgery including a discussion of their advantages and disadvantages. [ABSTRACT FROM AUTHOR]

Cardiac surgery has embraced and encouraged the use of large, multi-institutional datasets in clinical practice. From a research perspective, database studies have facilitated an increased understanding of cardiac surgery. Among other uses, they have allowed an investigation of disease incidence and mortality, high risk groups, disparities in health care delivery and the impact of new devices and techniques. Databases are also important tools for clinical governance and quality improvement. Despite their obvious utility, clinical databases have limitations; they are subject to treatment bias, contain missing data and cannot establish causality. Moreover, the ongoing maintenance of the database requires significant human and financial resources. In the future, inclusion of more detailed follow-up data and integration with other datasets will improve the utility of clinical databases. [ABSTRACT FROM AUTHOR]

Background: The elderly population (age >70 years) incurs greater mortality and morbidity following CABG. Off-pump coronary artery bypass (OPCAB) may mitigate these outcomes. A retrospective analysis of the results of OPCAB in this population was performed.Methods: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for elderly patients (n=12697) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=11676) with OPCAB (n=1021) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analyses was performed after cross-matching the database with the national death registry to identify long-term mortality.Results: High-risk patients were more prevalent in the ONCAB group (p<0.05). OPCAB patients received fewer distal anastomoses than ONCAB patients (2.4±1.1 vs 3.3±1.0, p<0.001). Thirty-day mortality and stroke rates between OPCAB and ONCAB were not significantly different (2% vs 2.5% and 1.1% vs 1.8%, respectively). There was a non-significant trend towards improved 10-year survival in OPCAB patients using multivariate analysis (78.8% vs. 73.3%, p=0.076, HR 0.83; 95% CI 0.67-1.02).Conclusions: Mortality and stroke rates following CABG surgery are extremely low in the elderly suggesting that surgery is a safe management option for coronary artery disease in this population. OPCAB did not offer a significant advantage over ONCAB with regards to 30-day mortality, stroke and long-term survival. Further prospective randomised trials will be necessary to clarify risks or benefits in the elderly. [ABSTRACT FROM AUTHOR]

Background: Coronary artery bypass graft surgery (CABG) has been established as the preferred intervention for coronary revascularisation in the high-risk population. Off-pump coronary artery bypass (OPCAB) may further reduce mortality and morbidity in this population subgroup. This study presents the largest series of high-risk (AusSCORE > 5) OPCAB patients in Australia and New Zealand.Methods: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for high-risk patients (n=7822) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=7277) with the OPCAB (n=545) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analysis was performed after cross-matching the database with the national death registry to identify long-term mortality.Results: The ONCAB and OPCAB groups had similar risk profiles based on the AusSCORE. Thirty-day mortality (ONCAB vs OPCAB 3.9% vs 2.4%, p=0.067) and stroke (ONCAB vs OPCAB 2.4% vs 1.3%, p=0.104) were similar between the two groups. OPCAB patients received fewer distal anastomoses than ONCAB patients (2.5±1.2 vs 3.3±1.0, p<0.001). The rates of new postoperative atrial arrhythmia (28.3% vs 33.3%, p=0.017) and blood transfusion requirements (52.1% vs 59.5%, p=0.001) were lower in the OPCAB group, while duration of ICU stay in hours (97.4±187.8 vs 70.2±152.8, p<0.001) was longer. There was a non-significant trend towards improved 10-year survival in OPCAB patients (74.7% vs. 71.7%, p=0.133).Conclusions: In the high-risk population, CABG surgery has a low rate of mortality and morbidity suggesting that surgery is a safe option for coronary revascularisation. OPCAB reduces postoperative morbidity and is a safe procedure for 30-day mortality, stroke and long-term survival in high-risk patients. [ABSTRACT FROM AUTHOR]

Aims BRCA1 has a role in maintaining normal nuclear DNA content during cell division and its inactivation may result in DNA aneuploidy and cancer progression. BRCA 1-linked breast cancers are more aneuploid and have a worse prognosis, but this has not been elucidated in ovarian cancers. This study explores the potential difference in ploidy status between BRCA 1-mutated and sporadic ovarian carcinomas. It also explores the potential association between BRCA 1 mutation site and DNA ploidy status. Methods This study compared DNA ploidy status of tumor blocks from 23 BRCA 1-mutated ovarian carcinomas with that of 23 sporadic ovarian carcinomas matched for histologic subtype, patient age, stage and grade. DNA content of the nuclei was measured by Feulgen- Schiff staining followed by image cytometry and compared. Results BRCA 1-linked tumors with a stop codon closer to the N-terminal (between 1 and 500 aa; 6/6, 100%) had a significantly higher frequency of nondiploidy compared with those with stop codon above 500 aa (7/12, 58%) ( P = 0.033). A diploid peak was detected in 28% of BRCA 1-mutated ovarian cancers and in 33% of sporadic ovarian cancers. Conclusions The present study concluded that ovarian tumors with mutations closer to the N-terminal of BRCA 1 may have a higher risk of DNA aneuploidy. There is no significant difference between BRCA 1-mutated and sporadic ovarian carcinomas with respect to the DNA content. [ABSTRACT FROM AUTHOR]

Objective: To review the effect of cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) on health-related quality of life (HRQOL) in patients with peritoneal carcinomatosis. Background: CRS and HIPEC is increasingly performed with curative intent for peritoneal carcinomatosis. Significant morbidity rates are reported in the context of limited life-expectancy, necessitating accurate post-operative HRQOL outcome data. Methods: A systematic review of clinical studies published after January 2000 was performed using strict eligibility criteria. Key outcomes measures were post-operative HRQOL compared to pre-operative levels and reference populations. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis. Tau2 and I2 values and Funnel plots were analysed for consistency and bias. Results: 15 studies (1583 patients) were included. HRQOL declines at the 3-4 month time-point before becoming similar or better compared to pre-operative levels at 1 year. The pooled-effects of combined post-operative functional assessment of cancer therapy and European organisation for research and treatment quality of life questionnaire scores were significantly improved from baseline on overall health status (p = 0.001) and emotional health (p = 0.001). Physical health (p = 0.83), social health (p = 0.48) and functional health (p = 0.24) remain similar. HRQOL after 1 year is less clear, but benefits may persist up to 5 years especially on overall and physical health domains. Evidence is conflicted and inconclusive on HRQOL compared to reference populations. Levels of consistency and bias were acceptable. Conclusions: CRS and HIPEC for peritoneal carcinomatosis can confer small to medium benefits for HRQOL. These results should be interpreted with in caution due to the small studies and absence of more randomised controlled trials. [ABSTRACT FROM AUTHOR]

Aims: Percutaneous coronary intervention (PCI) is being increasingly performed on elderly patients with acceptable peri-procedural outcomes and long-term survival. We aim to systematically review the health-related quality of life (HRQOL) following PCI in the elderly which is an important measure of procedural success. Methods: A systematic review of clinical studies before September 2012 was performed to identify HRQOL in the elderly after PCI. Strict inclusion and exclusion criteria were applied. Quality appraisal of each study was also performed using pre-defined criteria. HRQOL results were synthesised through a narrative review with full tabulation of results of all included studies. Results: Elderly patients have significant improvements in cardiovascular well-being. Early HRQOL appears improved from baseline, but recovery in physical health may be slower than in younger patients. HRQOL is comparable to an age-matched general population and younger patients undergoing PCI. Conservative management is not able to offer the same HRQOL benefits. Coronary artery bypass graft surgery may be superior to PCI in the very elderly. Significant heterogeneity and bias exists. Lack of appropriate data precluded meta-analysis. Conclusion: HRQOL after PCI in the elderly can improve for at least 1 year across a broad range of health domains, and is comparable to an age-matched general population and younger patients undergoing PCI. Given a limited number of articles and patients included, more prospective studies are needed to better identify the benefits for elderly patients. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Introduction: The management of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM) is a clinical dilemma. Yttrium-90 (Y90) radioembolization is a potentially safe and effective treatment for patients with CRCLM who have failed conventional chemotherapy regimens. Methods: A systematic review of clinical studies before November 2012 was performed to examine the radiological response, overall survival and progression-free survival of patients who underwent Y90 radioembolization of unresectable CRCLM refractory to systemic therapy. The secondary objectives were to evaluate the safety profile of this treatment and identify prognostic factors for overall survival. Results: Twenty studies comprising 979 patients were examined. Patients had failed a median of 3 lines of chemotherapy (range 2-5). After treatment, the average reported value of patients with complete radiological response, partial response and stable disease was 0 % (range 0-6 %), 31 % (range 0-73 %) and 40.5 % (range 17-76 %), respectively. The median time to intra-hepatic progression was 9 months (range 6-16). The median overall survival was 12 months (range 8.3-36). The overall acute toxicity rate ranged from 11 to 100 % (median 40.5 %). Most cases of acute toxicity were mild (Grade I or II) (median 39 %; range 7-100 %) which resolved without intervention. The number of previous lines of chemotherapy (≥3), poor radiological response to treatment, extra-hepatic disease and extensive liver disease (≥25 %) were the factors most commonly associated with poorer overall survival. Conclusion: Y90 radioembolization is a safe and effective treatment of CRCLM in the salvage setting and should be more widely utilized. [ABSTRACT FROM AUTHOR]

Introduction: There is increasing evidence to suggest that cancer-associated inflammation is associated with poorer long-term outcomes. Various markers have been studied over the past decade in an attempt to improve selection of patients for surgery. This meta-analysis explored the association between the neutrophil-lymphocyte ratio and prognosis following curative-intent surgery for solid tumours. Methods: Studies were identified from US National Library of Medicine (Medline) and the Exerpta Medica database (EBASE) performed in March 2013. A systematic review and meta-analysis were performed to generate combined hazard ratios for overall survival (OS) and disease-free survival (DFS). Results: Forty-nine studies containing 14282 patients were included. Elevated NLR was associated with poorer overall survival [HR: 1.92, 95% CI (1.64-2.24)] (p < 0.001) and disease-free survival [HR: 1.99, 95% CI (1.80-2.20)] (p < 0.001). Significant heterogeneity was found with an I2 of 77% and 97% for OS and DFS respectively. Subgroup analyses demonstrated that gastro-intestinal malignancies; mainly gastric [HR: 1.97, 95% CI (1.41-2.76)], colorectal [HR: 1.65, 95% CI (1.21-2.26)] and oesophageal [HR: 1.48, 95% CI (0.91-2.42)] cancers were predictive of OS (I² = 54.3%). A separate analysis for studies using an NLR cutoff of 5 demonstrated significantly poorer outcomes [HR: 2.18, 95% CI (1.74-2.73)] (p = 0.002) with less heterogeneity (I² = 58%). Conclusion: Elevated NLR correlates with poorer prognosis. It potentially represents a simple, robust and reliable measure that may be useful in identifying high-risk groups who could benefit from adjuvant therapy. [ABSTRACT FROM AUTHOR]

Background There is a paucity of data on the impact of smoking status on outcomes after concomitant aortic valve replacement and coronary artery bypass graft (AVRCABG) surgery. Methods Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who were nonsmokers, previous smokers, and current smokers using chi-square test and t-test. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. Results Concomitant AVR-CABG surgery was performed in 2,563 patients; smoking status was recorded in 2,558 (99.8%) patients. Of these, 1,052 (41.1%) patients had no previous smoking history, 1,345 (52.6%) patients were previous smokers, and 161 (6.3%) patients were current smokers. The 30-day mortality rate was 3.5% in nonsmokers, 4.1% in previous smokers, and 3.1% in current smokers (p = nonsignificant). The incidence of perioperative complications was similar in the three groups. The mean follow-up period for this study was 36 months (range, 0-105 months). After adjusting for differences in patient variables, the incidence of latemortality was higher in previous smokers (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.14-1.81; p = 0.002) compared with nonsmokers. A trend toward increased late mortality in current smokers was noted (HR, 1.34; 95% CI, 0.86-2.08; p = 0.201). [ABSTRACT FROM AUTHOR]

This article presents a review of data in literature that deals with coronary artery bypass graft (CABG) surgery in older people. It discusses the burden of coronary artery disease in the ageing population, the impact of CABG on health-related quality of life and the factors that influence health-related quality of life. Guidelines for future study are included.

Abstract: Background: Recent data suggest that hepatectomy for patients with colorectal liver metastases (CLM) with concomitant extrahepatic disease (EHD) achieve encouraging survival result. The authors examine the clinical efficacy of this treatment approach through a systematic review of the published literature. Methods: Electronic search of the MEDLINE and PubMed databases (January 2000 to January 2011) to identify studies reporting outcomes of hepatectomy for CLM with resection of EHD was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies. Results: Twenty-two studies were examined. This comprised 1142 patients. The median disease-free survival was 12 (range, 4–22) months, median overall survival was 30 (range, 14–44) months and median 5-year survival rate was 19% (range, 0–42%). Median 5-year survival of patients with R0 hepatectomy with resection of EHD was 25% (range, 19–36%). Survival based on site of EHD include lung; median survival (M/S) was 41 (range, 32–46) months, porto-caval lymph node; M/S was 25 (range, 19–48) months, peritoneal metastases; M/S was 25 (range, 18–32) months. Conclusion: In the era of effective systemic therapies, surgical resection of CLM and concomitant EHD in carefully selected patients may achieve survival results superior to non-surgically treated patients. This treatment strategy may be considered appropriate especially when a R0 hepatectomy and complete resection of EHD may be achieved. [ABSTRACT FROM AUTHOR]

Abstract: Background: Recent data suggest that hepatectomy for patients with colorectal liver metastases (CLM) with concomitant extrahepatic disease (EHD) achieve encouraging survival result. The authors examine the clinical efficacy of this treatment approach through a systematic review of the published literature. Methods: Electronic search of the MEDLINE and PubMed databases (January 2000 to January 2011) to identify studies reporting outcomes of hepatectomy for CLM with resection of EHD was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies. Results: Twenty-two studies were examined. This comprised 1142 patients. The median disease-free survival was 12 (range, 4–22) months, median overall survival was 30 (range, 14–44) months and median 5-year survival rate was 19% (range, 0–42%). Median 5-year survival of patients with R0 hepatectomy with resection of EHD was 25% (range, 19–36%). Survival based on site of EHD include lung; median survival (M/S) was 41 (range, 32–46) months, porto-caval lymph node; M/S was 25 (range, 19–48) months, peritoneal metastases; M/S was 25 (range, 18–32) months. Conclusion: In the era of effective systemic therapies, surgical resection of CLM and concomitant EHD in carefully selected patients may achieve survival results superior to non-surgically treated patients. This treatment strategy may be considered appropriate especially when a R0 hepatectomy and complete resection of EHD may be achieved. [Copyright &y& Elsevier]

OBJECTIVES Women undergoing isolated coronary artery bypass graft (CABG) surgery have been previously shown to be at an independently increased risk for post-operative morbidity and mortality. The current study evaluates the impact of sex as an independent risk factor for early and late morbidity and mortality following isolated CABG surgery. METHODS Data obtained between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program was retrospectively analysed. Demographic, operative data and post-operative complications were compared between male and female patients using chi-square and t-tests. Long-term survival analysis was performed using Kaplan–Meier survival curves and the log-rank test. Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively. RESULTS CABG surgery was undertaken in 21 534 patients at 18 Australian institutions; 22.2% were female. Female patients were generally older (mean age, 68 vs. 65 years, P < 0.001) and presented more often with congestive heart failure (P < 0.001), hypertension (P < 0.001), diabetes mellitus (P < 0.001) and cerebrovascular disease (P < 0.001). Women demonstrated a greater 30-day mortality (2.2% vs. 1.5%, P < 0.001) on univariate analysis but not on multivariate analysis (P = 0.638). Similarly, women demonstrated a greater late mortality than men on univariate analysis (P = 0.006) but not on multivariate analysis (P = 0.093). Women had a decreased risk of early complications including new renal failure (P = 0.001) and deep sternal wound infection (P = 0.017) but were more likely to require red blood cell transfusion (P < 0.001). CONCLUSIONS Female patients undergoing isolated CABG surgery have a greater 30-day mortality which may be accounted for by a poorer pre-operative risk factor profile. Further investigation is required into the reasons for differential outcome after CABG based on sex. [ABSTRACT FROM AUTHOR]

Several studies have shown that postoperative atrial fibrillation (POAF) is associated with poorer short- and long-term outcomes after isolated coronary artery bypass grafting surgery. Nevertheless, there is considerable debate as to whether this reflects an independent association of POAF with poorer outcomes or confounding by other factors. We sought to investigate this issue. Data obtained from June 2001 through December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who developed POAF and those who did not using chi-square and t tests. The independent impact of POAF on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. Excluding patients with preoperative arrhythmia, isolated coronary artery bypass grafting surgery was performed in 19,497 patients. Of these, 5,547 (28.5%) developed POAF. Patients with POAF were generally older (mean age 69 vs 65 years, p <0.001) and presented more often with co-morbidities including congestive heart failure (p <0.001), hypertension (p <0.001), cerebrovascular disease (p <0.001), and renal failure (p = 0.046). Patients with POAF demonstrated a greater 30-day mortality on univariate analysis but not on multivariate analysis (p = 0.376). Patients with POAF were, however, at an independently increased risk of perioperative complications including permanent stroke (p <0.001), new renal failure (p <0.001), infective complications (p <0.001), gastrointestinal complications (p <0.001), and return to the theater (p <0.001). POAF was also independently associated with shorter long-term survival (p = 0.002). In conclusion, POAF is a risk factor for short-term morbidity and decreased long-term survival. Rigorous evaluation of various therapies that prevent or decrease the impact of POAF is imperative. Moreover, patients who develop POAF should undergo strict surveillance and be routinely screened for complications after discharge. [ABSTRACT FROM AUTHOR]

OBJECTIVE The advent of percutaneous aortic valve implantation has increased interest in the outcomes of conventional aortic valve replacement in elderly patients. The current study critically evaluates the short-term and long-term outcomes of elderly (≥80 years) Australian patients undergoing isolated aortic valve replacement. METHODS Data obtained prospectively between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analysed. Isolated aortic valve replacement was performed in 2791 patients; of these, 531 (19%) were at least 80 years old (group 1). The patient characteristics, morbidity and short-term mortality of these patients were compared with those of patients who were <80 years old (group 2). The long-term outcomes in elderly patients were compared with the age-adjusted Australian population. RESULTS Group 1 patients were more likely to be female (58.6% vs 38.0%, p < 0.001) and presented more often with co-morbidities including hypertension, cerebrovascular disease and peripheral vascular disease (all p < 0.05). The 30-day mortality rate was not independently higher in group 1 patients (4.0% vs 2.0%, p = 0.144). Group 1 patients had an independently increased risk of complications including new renal failure (11.7% vs 4.2%, p < 0.001), prolonged (≥24 h) ventilation (12.4% vs 7.2%, p = 0.003), gastrointestinal complications (3.0% vs 1.3%, p = 0.012) and had a longer mean length of intensive care unit stay (64 h vs 47 h, p < 0.001). The 5-year survival post-aortic valve replacement was 72%, which is comparable to that of the age-matched Australian population. CONCLUSION Conventional aortic valve replacement in elderly patients achieves excellent outcomes with long-term survival comparable to that of an age-adjusted Australian population. In an era of percutaneous aortic valve implantation, it should still be regarded as the gold standard in the management of aortic stenosis. [ABSTRACT FROM AUTHOR]

Abstract: Background: Systemic chemotherapy is the mainstay of treatment for metastatic breast cancer with the role of surgery being strictly limited for palliation of metastatic complications or locoregional relapse. An increasing number of studies examining the role of therapeutic hepatic metastasectomy show encouraging survival results. A systematic review was undertaken to define its safety, efficacy and to identify prognostic factors associated with survival. Methods: Electronic search of the MEDLINE and PubMed databases (January 2000–January 2011) to identify studies reporting outcomes of hepatectomy for breast cancer liver metastases (BCLM) with hepatectomy was undertaken. Two reviewers independently appraised each study using a predetermined protocol. Safety and clinical efficacy was synthesised through a narrative review with full tabulation of results of all included studies. Results: Nineteen studies were examined. This comprised of 553 patients. Hepatectomy for BCLM was performed at a rate of 1.8 (range, 0.7–7.7) cases per year in reported series. The median time to liver metastases occurred at a median of 40 (range, 23–77) months. The median mortality and complication rate were 0% (range, 0–6%) and 21% (range, 0–44%), respectively. The median overall survival was 40 (range, 15–74) months and median 5-year survival rate was 40% (range, 21–80%). Potential prognostic factors associated with a poorer overall survival include a positive liver surgical margin and hormone refractory disease. Conclusion: Hepatectomy is rarely performed for BCLM but the studies described in this review indicate consistent results with superior 5-year survival for selected patients with isolated liver metastases and in those with well controlled minimal extrahepatic disease. To evaluate its efficacy and control for selection bias, a randomised trial of standard chemotherapy with or without hepatectomy for BCLM is warranted. [Copyright &y& Elsevier]

Objectives: Women undergoing isolated coronary artery bypass graft (CABG) surgery have been previously shown to be at an independently increased risk for post-operative morbidity and mortality. However, there are considerably less data on whether this trend remains true in patients undergoing concomitant aortic valve replacement (AVR) and CABG surgery. The aim of our study was to investigate this pertinent issue. Methods: Data obtained between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program were retrospectively analysed. Demographic, operative data and post-operative complications were compared between male and female patients using χ2 and t tests. Long-term survival analysis was performed using Kaplan-Meier survival curves and the log-rank test. Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively. Results: Concomitant AVR and CABG surgery was undertaken in 2,563 patients; 31.8% were female. Female patients were older (mean age 76 vs. 73 years; p < 0.001) and presented more often with hypertension (p < 0.001) but less often with severely impaired ejection fraction (p < 0.001), peripheral vascular disease (p < 0.001) and triple vessel disease (p < 0.001). Women did not demonstrate an increased risk of 30-day mortality (4.8 vs. 3.3%) on univariate (p = 0.069) or multivariate (p = 0.236) analysis. Female gender was independently associated with post-operative myocardial infarction (p = 0.022) and red blood cell transfusion (p < 0.001). There was no difference in long-term survival between men and women on multivariate analysis (p = 0.413). Conclusion: Female gender is not associated with poorer short- or long-term outcomes after concomitant CABG and AVR surgery. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Background: Hilar cholangiocarcinoma (HC) is invariably fatal without surgical intervention. The primary aim of the current study was to report overall survival and recurrence-free survival outcomes after surgical resection of HC. Methods: Between December 1992 and December 2009, 85 patients were evaluated; of these, 42 patients underwent potentially curative surgery. These patients are the principal subjects of this study. Patients were assessed monthly for the first 3 months and then at 6-month intervals after treatment. Recurrence-free survival and overall survival were determined; 18 clinicopathologic and treatment-related factors associated with recurrence-free survival and overall survival were evaluated through univariate and multivariate analyses. Results: No patient was lost to follow-up evaluation. The median follow-up period was 20 months (range, 0–106 mo). The median recurrence-free survival and overall survival after resection was 15 and 28 months, respectively. The 5-year survival rate was 24%. Two factors were associated with overall survival: histologic grade (P = .002) and margin status (P = .033). Only histologic grade (P = .029) was associated with recurrence-free survival. Conclusions: Surgical resection is an efficacious treatment for HC. Patient selection based on identified prognostic factors can improve treatment outcomes. [Copyright &y& Elsevier]

Background: Resection of hepatocellular carcinoma (HCC) is potentially curative; however, recurrence is common. To date, few or no effective adjuvant therapies have been adequately investigated. This study evaluates the efficacy of adjuvant iodine-131-lipiodol after hepatic resection through the experience of a single-center hepatobiliary service of managing this disease. Patients and methods: All patients who underwent hepatic resection for HCC and received adjuvant iodine-131-lipiodol between January 1991 and August 2009 were selected for inclusion into the experimental group. A group composed of patients treated during the same time period without adjuvant iodine-131-lipiodol was identified through the unit's HCC surgery database for comparison. The endpoints of this study were disease-free survival and overall survival. Results: Forty-one patients who received adjuvant iodine-131-lipiodol after hepatic resection were compared with a matched group of 41 patients who underwent hepatic resection only. The median disease-free and overall survival were 24 versus 10 months ( P = 0.032) and 104 versus 19 months ( P = 0.001) in the experimental and control groups, respectively. Rates of intrahepatic-only recurrences (73 vs. 37%; P = 0.02) and surgical and nonsurgical treatments for recurrences (84 vs. 56%; P = 0.04) were higher in the experimental group compared to the control group. Conclusion: The finding of this study corroborates the current evidence from randomized and nonrandomized trials that adjuvant iodine-131-lipiodol improves disease-free and overall survival in patients with HCC after hepatic resection. The lengthened disease-free survival after adjuvant iodine-131-lipiodol allows for further disease-modifying treatments to improve the overall survival. [ABSTRACT FROM AUTHOR]

Background: Identification of clinicopathological determinants that predict for risk of recurrence and overall survival after undergoing potentially curative hepatic resection for hepatocellular carcinoma is a strategy towards personalizing therapy to improve outcome. Through evaluation of a center's experience with treatment of a disease, determinants unique to the treated patient cohort may be identified.Methods: Ninety-seven patients with hepatocellular carcinoma underwent liver resection. Clinical, treatment, and histopathological variables were collected and evaluated using univariate and multivariate analyses with disease-free survival (DFS) and overall survival (OS) as the endpoints.Results: The median follow-up period of 19 (range, 1 to 188) months from the time of hepatic resection. The median DFS and OS after resection of HCC were 17 and 41 months, respectively. Five-year overall survival rate was 45%. Eight independent factors associated with disease-free and overall survival were identified through a multivariate analysis. Three factors: Child-Pugh score (DFS p = 0.045, OS p = 0.001), histopathological grade (DFS p < 0.001, OS p < 0.001), and histological diagnosis of cirrhosis (DFS p < 0.001, OS p < 0.001) predicted for both disease-free and overall survival.Conclusion: Integrating the knowledge of identified prognostic factors into clinical decision making may provide a clinicopathological signature that could identify patients at greatest risk of treatment failure such that novel interventions may be applied to improve the survival outcome. [ABSTRACT FROM AUTHOR]

Objectives: This systematic review objectively evaluates the safety and outcomes of extended pancreaticoduodenectomy with vascular resection for pancreatic cancer involving critical adjacent vessels namely the superior mesenteric-portal veins, hepatic artery, superior mesenteric artery, and celiac axis.Methods: Electronic searches were performed on two databases from January 1995 to August 2009. The end points were: firstly, to evaluate the safety through reporting the mortality rate and associated complications and, secondly, the outcome by reporting the survival after surgery. This was synthesized through a narrative review with full tabulation of results of all included studies.Results: Twenty-eight retrospective studies comprising of 1,458 patients were reviewed. Vein thrombosis and arterial involvement were reported as contraindications to surgery in 62% and 71% of studies, respectively. The median mortality rate was 4% (range, 0% to 17%). The median R0 and R1 rates were 75% (range, 14% to 100%) and 25% (range, 0% to 86%), respectively. In high volume centers, the median survival was 15 months (range, 9 to 23 months). Nine of 10 (90%) studies comparing the survival after extended pancreaticoduodenectomy with vascular resection versus standard pancreaticoduodenectomy reported statistically similar (p > 0.05) survival outcomes. Undertaking vascular resection was not associated with a poorer survival.Conclusions: The morbidity, mortality, and survival outcome after undertaking extended pancreaticoduodenectomy with vascular resection for pancreatic cancer with venous involvement and/or limited arterial involvement is acceptable in the setting of an expert referral center and should not be a contraindication to a curative surgery. [ABSTRACT FROM AUTHOR]

Background: Intrahepatic cholangiocarcinoma is rare, but its incidence is rapidly increasing in developed countries. Early detection and surgical extirpation offer the only hope for cure. Given the rarity of intrahepatic cholangiocarcinoma, there is limited knowledge regarding its natural history, clinicopathological characteristics, or outcomes following surgery. The primary aim of the current study is to report overall survival and recurrence-free survival outcomes following resection of intrahepatic cholangiocarcinoma. The secondary aim is to evaluate the impact of prognostic variables on outcomes.Methods: Between November 1990 and November 2009, 88 patients were evaluated for their suitability for potentially curative surgery; of these, 40 patients underwent potentially curative surgery. These patients are the principal subjects of the current analysis. Patients were assessed at monthly intervals for the first 3 months and then at six monthly intervals after treatment. Recurrence-free survival and overall survival were determined; 17 clinicopathological and treatment-related factors associated with recurrence-free survival and overall survival were evaluated through univariate and multivariate analyses.Results: No patient was lost to follow-up. The median follow-up was 31 months (range = 0-142 months). The median recurrence-free survival and overall survival after resection were 21 and 33 months, respectively. The 5-year survival rate was 28%. Four factors were associated with overall survival: carbohydrate antigen 19.9 (p = 0.020), clinical stage (p = 0.018), histological grade (p = 0.020), and lymph node metastases (p = 0.003). Two factors were associated with recurrence-free survival: carbohydrate antigen 19.9 (p = 0.002) and margin status (p = 0.002).Conclusion: Hepatic resection is an efficacious treatment for intrahepatic cholangiocarcinoma. Clincopathological factors can predict outcome and should be used in the preoperative assessment of operability. [ABSTRACT FROM AUTHOR]

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with colorectal peritoneal carcinomatosis (CRPC). This treatment modality is associated with relatively high rates of perioperative morbidity and mortality. This study evaluated the clinical and treatment-related risk factors for perioperative morbidity and mortality in patients with CRPC who underwent CRS and PIC. Sixty-three consecutive patients who underwent CRS and PIC for CRPC were evaluated. Adverse events were rated from grades I to V with increasing severity. Clinical and treatment-related risk factors for grades III and IV/V morbidity were determined. There were no perioperative deaths (0%). The grades III and IV morbidity rates were 14 and 17%, respectively. A peritoneal cancer index >12 ( p = 0.019), transfusion >4 units ( p = 0.028), number of peritonectomy procedures >3 ( p = 0.013), left upper quadrant peritonectomy procedure ( p < 0.001), and number of primary colonic anastomosis >1 ( p = 0.004) were associated with grade IV morbidity on univariate analysis. Only left upper quadrant procedure was associated with grade IV morbidity on multivariate analysis ( p = 0.002). Only number of primary colonic anastomosis >1 ( p = 0.037) was associated with grade III morbidity on univariate analysis. This also was associated with grade III morbidity on multivariate analysis ( p = 0.028). CRS and PIC has an acceptable risk of perioperative morbidity in carefully selected patients with CRPC. Patients who require extensive surgery have the highest risk for a severe adverse event. Preoperative evaluation of patients is essential to improve perioperative outcome. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with early and late outcomes after concomitant aortic valve replacement and coronary artery bypass graft surgery in octogenarians.

This article discusses a study which evaluated the analgesic effect of right subdiaphragmatic irrigation with ropivacaine on shoulder tip pain in patients undergoing laparoscopic cholecystectomy (LC). The researchers found that the incidence and intensity of right-sided shoulder tip pain was similar at four hours and three days following LC. They concluded that irrigation of the right subdiaphragmatic space by ropivacaine was ineffective in reducing shoulder tip pain.

The article discusses the need for Australian medical schools to provide anatomy teaching in an undergraduate level for surgical training. It notes that the practice of basic surgical skills in a dissecting laboratory can be provided in anatomy education by dissection. It mentions that comprehension of pathophysiology underlying surgical conditions can be improved by a sound anatomical knowledge.

Abstract: Background: Indigenous Australians have higher rates of cardiovascular disease and comorbidities compared to their non‐indigenous counterparts. Aims: We sought to evaluate whether indigenous status per se portends a worse prognosis following isolated coronary artery bypass grafting (CABG). Methods: The outcomes of 778 Indigenous Australians (55 ± 10 years; 32% female) enrolled in the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry were compared to 36 124 non‐Indigenous Australians (66 ± 10 years; 21% female) following isolated CABG. In a secondary analysis, patients were propensity‐matched by age, sex, renal function, diabetes and ejection fraction (778 individuals in each group). Results: Indigenous Australians were younger and more likely to be female and current smokers and to have diabetes, hypertension, renal impairment, heart failure and previous CABG (all P < 0.04). Indigenous patients had fewer bypasses with arterial conduits (including less internal mammary artery use) and a higher number of distal vein anastomoses (P < 0.001). Postoperative bleeding rates were higher in indigenous patients (P = 0.001). However, in‐hospital and 30‐day all‐cause mortality and rates of 30‐day readmission were similar between both groups, although cardiac mortality was higher in the indigenous cohort (1.5% vs 0.8%, P = 0.02). With propensity‐matching, rates of postoperative complications were similar among the two groups, with the exception of bleeding, which remained higher in Indigenous Australians (P = 0.03). Conclusions: Despite procedural differences and higher rates of baseline comorbidities, Indigenous Australians do not have worse short‐term outcomes following isolated CABG. Given the higher rates of baseline comorbidities and lower rates of arterial conduit use, it will be essential to determine long‐term outcomes. [ABSTRACT FROM AUTHOR]

Background: The aortic root replacement procedure (ARR), is often considered the gold standard in the management of aortic root and ascending aorta aneurysms. Our aim was to review the Australian experience with this procedure to ascertain early and late outcomes of mortality and morbidity.Methods: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for patients undergoing ARR. Preoperative, intraoperative and postoperative variables were analysed. Multiple regression was performed to determine independent predictors of 30-day mortality and permanent stroke, and predictors of late death. Survival estimates were obtained by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index database.Results: Between January 2001 and December 2011, 954 patients underwent ARR with a mean age of 56±15.2 years. The overall 30-day mortality was 5.9% (n=56) with a permanent stroke rate of 2.3% (n=21). The elective surgery mortality was 3.6%. Long-term survival was estimated as 84.4% and 68.7% at 5 and 10 years, respectively.Conclusions: Aortic root replacement surgery reveals acceptable early mortality, low postoperative stroke rates, and acceptable long-term survival. [ABSTRACT FROM AUTHOR]

Abstract: Background: Neuroendocrine tumours (NET) most commonly metastasize to the liver. Hepatic resection of NET hepatic metastases (NETHM) has been shown to improve symptomology and survival. Methods: A systematic review of clinical studies before September 2010 was performed to examine the efficacy of hepatic resection for NETHM. As a secondary end-point, the impact of treatment on safety and symptomology were determined and prognostic variables were identified. The quality of each study was also assessed using predefined criteria incorporating 9 characteristics. Clinical outcome was synthesized through a narrative review with full tabulation of results of all included studies. Results: Twenty-nine included reported survival outcomes with a median 3-, 5- and 10-year overall survival of 83% (range, 63–100%), 70.5% (range, 31–100%), and 42% (range, 0–100%), respectively. The median progression-free survival (PFS) was 21 months (range, 13–46 months) and median 1-,3-,5- and 10-year PFS of 63% (range, 50–80 %), 32% (range, 24–69%), 29% (range, 6–66%) and 1% (range, 0–11%), respectively. Poor histologic grade, extra-hepatic disease and a macroscopically incomplete resection were associated with a poor prognosis. Studies reported a median rate of symptomatic relief from surgery in 95% of patients (range, 50–100%). Conclusion: Hepatic resection for NETHM provides symptomatic benefit and is associated with favourable survival outcomes although the majority of patients invariably develop disease progression. [Copyright &y& Elsevier]

Abstract: Background: There has been an interest in the interdisciplinary and multimodality approach that combines chemotherapy and radiation therapy as a preoperative treatment for patients with resectable pancreatic cancer. Methods: Literature search of databases (Medline and PubMed) to identify published studies of preoperative chemoradiation for resectable pancreatic cancer (potentially resectable and borderline resectable) was undertaken. Response to treatment and survival outcomes was examined as endpoints of this review. Results: Seventeen studies; eight phase II studies, and nine observational studies, comprising of 977 patients were reviewed. Gemcitabine-based chemotherapy with radiotherapy was the most common preoperative regimen. Following preoperative treatment, pancreatic surgical resection was performed in 35–100% (median=61%) of patients after a range of 6–32 weeks (median=7 weeks). Rate of pathological response was complete in 5–15% of patients, partial in 33–60% and minimal in 38–42%. The median overall survival ranged from 12 months to 40 months (median=25 months) with a 5-year overall survival rate ranging between 8% and 36% (median=28%). Patients who underwent chemoradiation but did not undergo surgery survived a median period of 7–11 months (median=9 months). Conclusion: Preoperative gemcitabine-based chemoradiation followed by restaging and surgical evaluation for pancreatic resection may identify a sub-population of patients with resectable disease who would benefit the most from surgery. Investigation of this schema of preoperative therapy in a randomized setting of resectable pancreatic cancer is warranted. [Copyright &y& Elsevier]

Objective: Optimal utilisation of theatre time increases efficiency and reduces the cost of health care. The accuracy of surgical time estimation between different members of the theatre team has not been well documented, and may aid in more efficient utilisation of available theatre time. This study aims to identify the cohort of theatre staff with greatest accuracy in estimating orthopaedic surgical time. Methods: This study was conducted in a prospective fashion using consecutive orthopaedic trauma and elective operative lists over a period of 3 months. Prior to each operating list, a senior member of each of the anaesthetic, orthopaedic and scrub/scout nursing teams predicted the surgical duration for orthopaedic procedures after being provided with information regarding the individual cases. The absolute difference between estimated and actual surgical times was calculated. Results: When expressed as a percentage difference from true surgical time, the orthopaedic team provided the most accurate estimates, with a mean difference of 33.0%. This was followed by nursing staff (40.5%) and anaesthetics (50.9%). Similarly, a higher proportion of estimates by the orthopaedic team were within the limits of 20% underestimation and 10% overestimation (deemed clinically significant). Conclusions: Surgical times for orthopaedic trauma and elective cases are most accurately estimated by the operating team. These estimates should be implemented when planning theatre utilisation, and may benefit computer algorithms for theatre scheduling. What is known about the topic? The ability of surgeons, nurses and anaesthetists to accurately predict surgical times is often debated, with heated discussions if additional cases can fit onto a scheduled list. What does the paper add? Our paper demonstrated that despite all groups being inaccurate with timing predictions, orthopaedic surgeons were the most accurate. What are the implications for practitioners? With ever-growing pressure on health systems, it is paramount that available theatre resources are utilised with maximal efficiency. [ABSTRACT FROM AUTHOR]

Background: Valve sparing aortic root reconstruction (VSARR) has become an alternative to traditional aortic root replacement with a valved conduit. There have been various modifications but the two broad types are aortic root reimplantation and the aortic root remodelling procedure. We present the early and late outcomes following valve sparing aortic root reconstruction surgery in Australia.Methods: We reviewed the ANZSCTS database for patients undergoing these procedures. Preoperative, intraoperative and postoperative variables were analysed. Multivariable regression was performed to determine independent predictors of 30-day mortality. We also obtained five- and 10-year survival estimates by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index.Results: Between January 2001 and January 2012, 169 consecutive patients underwent VSARR procedures. The mean age of the study population was 54.4 years with 31.4% being females. Overall, nine patients (5.9%) died within 30 days post procedure and five patients (3%) had permanent strokes. However, out of 132 elective cases, only five patients died (3.8%). Independent predictors of 30-day mortality were female gender [OR 5.65(1.24-25.80), p=0.025], preoperative atrial arrhythmia [OR 6.07(1.14-32.35), p=0.035] and acute type A aortic dissection [OR 7.71(1.63-36.54), p=0.01]. Long-term survival was estimated as 85.3% and 72.7% at five- and 10-years, respectively.Conclusions: Along with an acceptable rate of early mortality and stroke, VSARR procedures provide good long-term survival according to the ANZSCTS database. As promising procedure for pathologies that impair the aortic root integrity, they can be adopted more widely, especially in Australian and New Zealand centres with experienced aortic units. Future studies are planned to assess freedom from valve deterioration and repeat surgery. [ABSTRACT FROM AUTHOR]

Background & Aims Liver transplantation is the only curative intervention for terminal liver disease. Accurate long-term quality of life (QOL) data are required in the context of improved surgical outcomes and increasing post-transplant survival. This study reviews the long-term QOL after primary liver transplantation in adult patients surviving 5 or more years after surgery. Methods A literature search was conducted on PubMed for all studies matching the eligibility criteria between January 2000 and October 2013. Bibliographies of included studies were also reviewed. Two authors independently performed screening of titles and abstracts. Consensus for studies included for review was achieved by discussion between authors based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. Results Twenty-three studies (5402 patients) were included. QOL following liver transplantation remains superior to preoperative status up to 20 years post-operatively. More post-operative complications predicted worse QOL scores especially in physical domains. Benefits in functional domains persist long-term with independence in self-care and mobility. Employment rates recover in the short-term but decline after 5 years, and differ significantly between various aetiologies of liver disease. Overall QOL improves to a similar level as the general population, but physical function remains worse. Participation in post-operative physical activity is associated with superior QOL outcomes in liver transplant recipients compared to the general population. QOL improvements are similar compared to lung, kidney and heart transplantation. Heterogeneity between studies precluded quantitative analysis. Conclusions Liver transplantation confers specific long-term QOL and functional benefits when compared to preoperative status. This information can assist in providing a more complete estimate of the overall health of liver transplant recipients and the effectiveness of surgery. Guidelines for future studies are provided. [ABSTRACT FROM AUTHOR]

Background: The outcomes of surgery for acute Stanford Type A aortic dissection (ATAAD) extend beyond mortality and morbidity. The aim of this systematic review was to summarise the literature surrounding health related quality of life (HR-QOL) following ATAAD, compare the outcomes to the standardised population, and to assess the impact of advanced age on HRQOL outcomes following surgery.Methods: A systematic review of studies after January 2000 was performed to identify HR-QOL in patients following surgery for ATAAD. Electronic searches of three databases were performed and clinical studies extracted by two independent reviewers. Strict inclusion and exclusion criteria were applied. Quality appraisal was conducted utilizing predefined criteria on pilot forms. HR-QOL results were synthesized through a narrative review of included studies.Results: There was significant attrition in HR-QOL of patients following surgery for ATAAD. Outcomes fared worse when compared to an age adjusted normative population. Of note, elderly patients were physically vulnerable, whereas younger populations may be more mentally vulnerable to postoperative sequalae. The included studies were quite heterogeneous in their study designs, methods, HR-QOL measures reported and follow up time-frames which limited direct comparison between studies.Conclusion: HR-QOL outcomes are adversely affected when compared to preoperative status and physical health demonstrates significant attrition over time. HR-QOL outcomes are worse off when compared to an age matched general population. In terms of age, advancing age is associated with worse physical component scores but emotional health may fare better than younger patients. [ABSTRACT FROM AUTHOR]

Background: Frailty is associated with poorer outcomes in cardiac surgery, but the heterogeneity in frailty assessment tools makes it difficult to ascertain its true impact in cardiac surgery. Slow gait speed is a simple, validated, and reliable marker of frailty. We performed a systematic review and meta‐analysis to examine the effect of slow gait speed on postoperative cardiac surgical patients. Methods: PubMED, MEDLINE, and EMBASE databases were searched from January 2000 to August 2021 for studies comparing slow gait speed and "normal" gait speed. Primary outcome was in‐hospital mortality. Secondary outcomes were composite mortality and major morbidity, AKI, stroke, deep sternal wound infection, prolonged ventilation, discharge to a healthcare facility, and ICU length of stay. Results: There were seven eligible studies with 36,697 patients. Slow gait speed was associated with increased likelihood of in‐hospital mortality (risk ratio [RR]: 2.32; 95% confidence interval [CI]: 1.87–2.87). Additionally, they were more likely to suffer from composite mortality and major morbidity (RR: 1.52; 95% CI: 1.38–1.66), AKI (RR: 2.81; 95% CI: 1.44–5.49), deep sternal wound infection (RR: 1.77; 95% CI: 1.59–1.98), prolonged ventilation >24 h (RR: 1.97; 95% CI: 1.48–2.63), reoperation (RR: 1.38; 95% CI: 1.05–1.82), institutional discharge (RR: 2.08; 95% CI: 1.61–2.69), and longer ICU length of stay (MD: 21.69; 95% CI: 17.32–26.05). Conclusion: Slow gait speed is associated with poorer outcomes in cardiac surgery. Frail patients are twofold more likely to die during hospital admission than nonfrail counterparts and are at an increased risk of developing various perioperative complications. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the role of radioembolization and systemic chemotherapy as a combined modality therapy for unresectable colorectal liver metastases. Patients and methods: Prospective database of a major yttrium-90 microsphere radioembolization treatment center in Sydney, Australia, that included 140 patients with unresectable colorectal liver metastases was analyzed. Tumor response, overall survival, treatment-related complications and an evaluation of its role as a combined modality therapy with systemic chemotherapy were performed. Results: One hundred and thirty-three patients (95%) had a single treatment, and seven patients (5%) had repeated treatments. Response following treatment was complete in two patients (1%), partial in 43 patients (31%), stable in 44 patients (31%), and 51 patients (37%) developed progressive disease. Combining chemotherapy with radioembolization was associated with a favorable treatment response ( P = 0.007). The median overall survival was 9 (95% CI 6.4-11.3) months with a 1-, 2-, and 3-year survival rate of 42, 22, and 20%, respectively. Primary tumor site ( P = 0.019), presence of extrahepatic disease ( P = 0.033), and a favorable treatment response ( P < 0.001) were identified as independent predictors for survival. Conclusion: Combined modality therapy appears to improve tumor response rates. Survival is influenced by tumor site, presence of extrahepatic disease, and response to therapy. Yttrium-90 microsphere radioembolization is safe and may best be combined with systemic chemotherapy for patients with unresectable colorectal liver metastases. [ABSTRACT FROM AUTHOR]