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Pulmonary thromboendarterectomy (PTE) is the current gold standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) and is a viable treatment option for chronic thromboembolic pulmonary disease (CTEPD). The progressive nature of both diseases severely impacts health-related quality of life (HRQoL) across a variety of domains. This systematic review was performed to evaluate the impact of PTE on short- and long-term HRQoL. A literature search was conducted on PubMed for studies matching the eligibility criteria between January 2000 and September 2022. OVID (MEDLINE), Google Scholar, EBSCOhost (EMBASE), and bibliographies of included studies were reviewed. Inclusion of studies was based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. The structure of this systematic review follows the PRISMA guidelines. This systematic review was prospectively registered in the PROSPERO register (CRD42022342144). Thirteen studies (2184 patients) were included. Within 3 months post-PTE, HRQoL improved in both CTEPD and CTEPH as measured by disease-specific and generic questionnaires. HRQoL improvements were sustained up to 5 years postoperatively in patients with CTEPH post-PTE. PTE remains the gold standard for treating CTEPH and improving HRQoL. Residual pulmonary hypertension and comorbidities such as COPD and coronary artery disease decrement HRQoL over time. The impact of mPAP and PVR on HRQoL outcomes postoperatively remain ambiguous. Pulmonary thromboendarterectomy remains the gold standard for treating CTEPH and has shown to improve HRQoL outcomes at 3-month sustaining improvements up to 5-year postoperatively. Residual pulmonary hypertension and comorbidities hinder HRQoL outcomes post-PTE., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s). Pulmonary Circulation published by Wiley Periodicals LLC on behalf of the Pulmonary Vascular Research Institute.)

Purpose of Review: Low-volume prostate cancer is an established prognostic category of metastatic hormone-sensitive prostate cancer. However, the term is often loosely used to reflect the low burden of disease across different prostate cancer states. This review explores the definitions of low-volume prostate cancer, biology, and current evidence for treatment. We also explore future directions, including the impact of advanced imaging modalities, particularly prostate-specific membrane antigen (PSMA) positron emission tomography (PET) scans, on refining patient subgroups and treatment strategies for patients with low-volume prostate cancer., Recent Findings: Recent investigations have attempted to redefine low-volume disease, incorporating factors beyond metastatic burden. Advanced imaging, especially PSMA PET, offers enhanced accuracy in detecting metastases, potentially challenging the conventional definition of low volume. The prognosis and treatment of low-volume prostate cancer may vary by the timing of metastatic presentation. Biomarker-directed consolidative therapy, metastases-directed therapy, and de-escalation of systemic therapies will be increasingly important, especially in patients with metachronous low-volume disease., Summary: In the absence of validated biomarkers, the management of low-volume prostate cancer as defined by CHAARTED criteria may be guided by the timing of metastatic presentation. For metachronous low-volume disease, we recommend novel hormonal therapy (NHT) doublets with or without consolidative metastasis-directed therapy (MDT), and for synchronous low-volume disease, NHT doublets with or without consolidative MDT and prostate-directed radiation. Docetaxel triplets may be a reasonable alternative in some patients with synchronous presentation. There is no clear role of docetaxel doublets in patients with low-volume disease. In the future, a small subset of low-volume diseases with oligometastases selected by genomics and advanced imaging like PSMA PET may achieve long-term remission with MDT with no systemic therapy., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Lung transplantation is the definitive treatment for end-stage lung disease. There has been uncertainty regarding whether single or bilateral lung transplantation confers patients' greater health-related quality of life. This systematic review was performed to evaluate the impact of single lung transplantation (SLTx) against bilateral lung transplantation on short- and long-term health-related quality of life., Methods: A literature search was conducted on PubMed for studies matching the eligibility criteria between January 2000 and January 2022. OVID (MEDLINE), Google Scholar, EBSCOhost (EMBASE), and bibliographies of included studies were reviewed. Inclusion of studies was based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. The structure of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review was prospectively registered in the PROSPERO register (CRD42022344389)., Results: Ten studies (1916 patients) were included. Within 12 mo posttransplantation, there was no evidence of the improved health-related quality of life with respect to the type of lung transplantation procedure. Bilateral lung transplantation patients reported significantly greater scores in both the physical and mental health domains of health-related quality of life. Bilateral lung transplantation offered significantly better health-related quality of life outcomes at later follow-up periods. Bilateral lung transplantation showed a significantly slower reduction in health-related quality of life physical composite scores relative to SLTx., Conclusions: Bilateral lung transplant (BLTx) recipients perceive the greater health-related quality of life beyond 1-y post-lung transplantation. BLTx recipients better retain their health-related quality of life long-term posttransplantation than those receiving SLTx., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Lung transplantation represents the definite treatment for CF patients with advanced-stage pulmonary disease. Recent major developments in the treatment of CF indicate the need for an evaluation of lung transplantation as the current best practice in end-stage disease. This systematic review was performed to evaluate the impact of lung transplantation on health-related quality of life in patients with CF., Methods: PubMed was searched for studies matching the eligibility criteria between January 2000 and January 2022. OVID (MEDLINE), Google Scholar, and EBSCOhost (EMBASE) as well as bibliographies of included studies were also reviewed. Applying predetermined eligibility criteria, the included studies were selected. Predetermined forms were used to conduct a quality appraisal and implement data tabulation. Results were synthesized by narrative review. This systematic review was prospectively registered in the PROSPERO register (CRD 42022341942)., Results: Ten studies (1494 patients) were included. Lung transplantation results in improvements in HRQoL in CF patients relative to their baseline waitlisted state. Up to five years postoperatively CF patients retain their HRQoL at levels similar to the general population. There are several modulating factors that impact HRQoL outcomes in CF patients post-LTx. Compared to lung recipients with other diagnoses CF patients achieve either greater or equal levels of HRQoL., Conclusion: Lung transplantation conveys improved HRQoL to CF patients with the advanced-stage pulmonary disease for up to five years, and to levels comparable to the general population and non-waitlisted CF patients. This systematic review quantifies, using current evidence, the improvements in HRQoL gained by CF patients following lung transplantation., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2023. Published by Elsevier España, S.L.U.)

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.

Objective: Frailty is an increasingly recognized marker of poor surgical outcomes in cardiac surgery. Frailty first was described in the seminal "Fried" paper, which constitutes the longest-standing and most well-recognized definition. This study aimed to assess the impact of the Fried and modified Fried frailty classifications on patient outcomes following cardiac surgery., Methods: The PUBMED, MEDLINE, and EMBASE databases were searched from January 2000 until August 2021 for studies evaluating postoperative outcomes using the Fried or modified Fried frailty indexes in open cardiac surgical procedures. Primary outcomes were one-year survival and postoperative quality of life. Secondary outcomes included postoperative complications, intensive care unit (ICU) length of stay (LOS), total hospital LOS, and institutional discharge., Results: Eight eligible studies were identified. Meta-analysis identified that frailty was associated with an increased risk of one-year mortality (Risk Ratio [RR]:2.23;95% confidence interval [CI]1.17 -4.23), postoperative complications (RR 1.78;95% CI 1.27 - 2.50), ICU LOS (Mean difference [MD] 21.2 hours;95% CI 8.42 - 33.94), hospital LOS (MD 3.29 days; 95% CI 2.19 - 4.94), and institutional discharge (RR 3.29;95% CI 2.19 - 4.94). A narrative review of quality of life suggested an improvement following surgery, with frail patients demonstrating a greater improvement from baseline over non-frail patients., Conclusions: Frailty is associated with a higher degree of surgical morbidity, and frail patients are twice as likely to experience mortality within one-year post-operatively. Despite this, quality of life also improves dramatically in frail patients. Frailty, in itself, does not constitute a contraindication to cardiac surgery.

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., (© 2022. The Author(s).)

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., (© 2021 Wiley Periodicals LLC.)

Background: Infective endocarditis is a disease that carries high morbidity and mortality. The primary endpoint of this study is to assess factors associated with in-hospital mortality in patients undergoing valvular surgery for infective endocarditis. The secondary endpoint of this study is to assess the incidence of post-operative stroke, renal failure, complete heart block and recurrence., Methods: Between the years of 2015 to 2019, a total of 89 patients underwent surgery for infective endocarditis at Fiona Stanley Hospital, Western Australia. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2019 as well as patients electronic medical record. A number of preoperative and perioperative factors were assessed in relation to patient mortality and morbidity. Univariate and multivariate logistical regression analysis was done to assess for the association between factors and in-hospital morbidity and mortality., Results: A total of 89 patients underwent surgery for infective endocarditis from 2015 to 2019, affecting a total of 101 valves. The mean age of patients was 53.7 ± 16.5. A total of 79 patients had a positive blood culture pre-operatively, with Staphylococcus Aureus being the most frequently cultured organism (39%). Fourteen patients (16%) were deemed emergent and underwent surgery within 24 h of review. A total of five patients died within their hospital stay postoperatively. Variables significantly associated with mortality on univariate analysis were intravenous drug use, emergent surgery, perioperative dialysis, perioperative inotropes, cardiopulmonary bypass time and cross clamp time. Only CBP time was significantly associated with mortality on multivariate analysis. A total of 19 patients (21%) required hemodialysis after surgery, 10 patients sustained a postoperative stroke (11%), 11 patients developed a complete heart block post operatively (12%) and endocarditis recurred in 10 patients (11%)., Conclusion: Prolonged cardiopulmonary bypass times were significantly associated with mortality. This study is novel to report a lower mortality rate than previously quoted in the literature. We also report our findings of organisms, preoperative embolic phenomena and surgery in a Western Australian population. We recommend that all patients with endocarditis are discussed in multidisciplinary forum., (© 2021. The Author(s).)

A 57-year-old woman presented with chest pain. Electrocardiography (ECG) revealed an inferior ST-segment elevation myocardial infarction. Thrombolysis was initiated and repeat ECG showed reduction of ST elevation. The patient reported ongoing pain and developed hypotension. Fluoroscopy of the chest demonstrated gross tracheal deviation and collapse of the left lung. This case highlights the importance of maintaining a broad differential diagnosis and of harnessing the various skills within a multidisciplinary team.

Background: We sought to evaluate the outcomes following right ventricle to pulmonary artery (RV-PA) conduit placement in pediatric patients, excluding those with a RV-PA conduit for the Ross procedure which is associated with improved conduit durability, partly related to its orthotopic position., Methods: Outcomes for 119 patients who underwent RV-PA conduit placement at a single institution from January 2004 to December 2016 were reviewed. Primary outcome measures were reintervention-free survival (RFS) and overall survival. Survival analyses were performed using the Kaplan-Meier method, and risk factors associated with reintervention were evaluated., Results: The median age at the time of conduit placement was 6 months (interquartile range, IQR: 1-14), and the median length of follow-up was 63 months (range: 0-156). During follow-up, 39 patients required conduit-related reintervention, while 6 patients died perioperatively with an overall survival of 90% at 10 years. Among the remaining 113 patients, the RFS at one, five, and ten years was 91% (84%-95%), 72% (60%-80%), and 33% (16%-50%), respectively. The median time to conduit replacement in the series was 43.5 months (IQR: 19.3-76.2). The use of a pulmonary homograft was associated with improved RFS ( P = .03), and this was particularly pronounced in comparison with aortic homografts in neonates. Infection was the indication for replacement in only one patient., Conclusions: The majority of the conduits placed during the neonatal period required conduit replacement before the age of five years. Endocarditis was not a common indication for replacement. In neonates and infants, we prefer pulmonary homografts for most indications.

Despite advances in modern surgery, congenital heart disease remains a medical challenge and major cause of infant mortality. Valved conduits are routinely used to surgically correct blood flow in hearts with congenital malformations by connecting the right ventricle to the pulmonary artery (RV-PA). This review explores the current range of RV-PA conduits and describes their strengths and disadvantages. Homografts and xenografts are currently the primary treatment modalities, however both graft types have limited biocompatibility and durability, and present a disease transmission risk. Structural deterioration of a replaced valve can lead to pulmonary valve stenosis and/or regurgitation. Moreover, as current RV-PA conduits are of a fixed size, multiple subsequent operations are required to upsize a valved conduit over a patient's lifetime. We assess emerging biomaterials and tissue engineering techniques with a view to replicating the features of native tissues, including matching the durability and elasticity required for normal fluid flow dynamics. The benefits and limitations of incorporating cellular elements within the biomaterial are also discussed. Present review demonstrates that an alignment of medical and engineering disciplines will be ultimately required to produce a biocompatible and high-functioning artificial conduit.

Objective: Endovascular aneurysm repair (EVAR) and open repair (OR) of abdominal aortic aneurysms (AAAs) are increasingly performed in elderly patients (>75 years of age) with satisfactory results. Quality of life (QOL) is increasingly considered a primary goal of intervention after AAA repair. However, there is currently no consensus on QOL after these procedures in elderly patients., Methods: A systematic review was performed using strict eligibility criteria. Clinical studies reporting QOL in elderly patients (average age >75 years) after EVAR and OR were included. Quality appraisal and data tabulation were performed using predetermined forms. Data were synthesized by narrative review. Study quality was assessed., Results: Thirteen studies with 1272 patients were included. After elective EVAR, disease-specific and generic QOL scores demonstrated an initial postoperative deterioration. By 4 to 6 weeks postoperatively, mental health components have improved to scores similar to or better than those at baseline. Physical health components take up to 3 months to return to baseline. After this, 36-Item Short-Form Health Survey and EuroQol-5 Dimension scores are maintained at preoperative levels for 1 to 3 years. In emergent EVAR, long-term survivors may have QOL comparable to that of the general population. Elective OR appears to have comparable QOL for up to 3 years compared with a matched population. QOL after emergent OR seems poor. Data on OR in elderly patients remain limited., Conclusions: QOL after EVAR and OR declines early, with a 4- to 6-week delay in mental health recovery and 1- to 3-month delay in physical health recovery. QOL eventually returns to baseline and can be maintained in the long term. This review supports AAA repair in elderly patients from a QOL perspective., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The impact of concomitant urologic procedures (UPs) on perioperative and long-term outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is uncertain., Methods: In total, 935 consecutive CRS/HIPEC procedures were performed between 1996 and 2016 in Sydney, Australia. Among these, 73 (7.8%) involved concomitant UP. The association of concomitant UP with 21 perioperative outcomes and overall survival was assessed using univariate and multivariate analyses., Results: In-hospital mortality was 1.8%. Patients requiring UP were more likely to require transfusion of ≥5 units of red blood cells (P=0.031) and have a complete cytoreduction (79% vs. 60%, P<0.001). On multivariate analysis, UP was not associated with in-hospital mortality (2.7% vs. 1.7%, P=0.407) or grade III/IV morbidity (52% vs. 41%, P=0.376). The incidence of ureteric fistula (4% vs. 1%, P=0.004), return to theater (26% vs. 14%, P=0.005) and digestive fistula (22% vs. 11%, P=0.005) was higher in the UP group. The addition of a UP did not significantly impact overall survival for appendiceal cancer (P=0.162), colorectal cancer (P=0.315), or pseudomyxoma peritonei (P=0.120)., Conclusions: Addition of a UP was not associated with an increased risk of grade III/IV morbidity or poorer long-term survival after CRS/HIPEC.

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., (© 2018 Royal Australasian College of Physicians.)

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., (Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Introduction: This systematic review and meta-analysis was performed to evaluate the impact of preoperative atrial fibrillation (preAF) on early and late outcomes after aortic valve replacement (AVR)., Evidence Acquisition: Medline, EMBASE, and CENTRAL were systematically searched for studies that reported AVR outcomes according to the presence or absence of preAF. Data were independently extracted by two investigators; a meta-analysis was conducted according to predefined clinical endpoints. Studies including patients undergoing concomitant atrial fibrillation surgery were excluded., Evidence Synthesis: Six observational studies with 8 distinct AVR cohorts (AVR± concomitant surgery) met criteria for inclusion, including a total of 6693 patients. Of these, 1014 (15%) presented with preAF. Overall, perioperative mortality was increased in patients with preAF (odds ratio [OR] 2.33; 95% CI: 1.48-3.67; P<0.001). Subgroup analysis of patients undergoing isolated AVR also demonstrated preAF as a risk factor for perioperative mortality (OR 2.49; 95% CI: 1.57-3.95; P<0.001). PreAF was also associated with acute renal failure (OR 1.42; 95% CI: 1.07-1.89; P=0.02) but not stroke (OR 1.11; 95% CI: 0.59-2.12; P=0.74). Late mortality was significantly higher in patients with preAF (hazard ratio [HR] 1.75; 95% CI: 1.33-2.30; P<0.001). This relationship remained true when only patients who underwent isolated AVR were analyzed (HR 1.97; 95% CI: 1.11-3.51; P=0.02)., Conclusions: PreAF is associated with an increased risk of early- and late-mortality after AVR. These data support the more widespread utilization of concomitant AF ablation.

Background: Peritoneal dissemination of small bowel adenocarcinoma (SBA) is rare but is associated with a dismal prognosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a promising treatment option. We evaluated our experience of CRS-HIPEC for the treatment of SBA., Patients and Methods: Sixteen consecutive patients underwent CRS-HIPEC for small bowel malignancy between 2003 and 2016. Clinopathological and treatment-related factors were obtained from a prospective database. The study's endpoints of disease-free (DFS) and overall (OS) survival were evaluated using the Kaplan-Meier method. Prognostic variables were identified through univariate and multivariate analyses., Results: Follow-up was complete in all patients. The median follow-up was 20.6 (range=0.2-62) months. The was no in-hospital mortality and grade III/IV morbidity was 25%. The median OS after CRS-HIPEC was 24.7 months, with a 36-month survival of 34%. The median DFS was 11.3 months, with a 36-month DFS of 8%. Two factors were associated with a poorer OS on univariate analysis; only peritoneal cancer index >10 was associated with a poorer OS on multivariate analysis (p=0.032)., Conclusion: CRS-HIPEC in selected patients with peritoneal dissemination of SBA is associated with reasonable mid-term survival outcomes but treatment failure is common. High disease burden, quantified by the PCI is associated with poor outcomes. A large, prospective, multi-institutional study is needed to further evaluate the outcomes of CRS-HIPEC for SBA., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

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.

Background: There is a paucity of data on the impact of splenectomy on peri-operative outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). We report the largest series to date which addresses this topic., Methods: Nine hundred and thirty six consecutive patients underwent CRS/HIPEC from 1996 to 2016 at a high-volume institution in Sydney, Australia. Of these, 418 (45%) underwent splenectomy. Peri-operative complications were graded according to the Clavien-Dindo Classification. The association of splenectomy with 19 peri-operative outcomes was assessed using univariate and multivariate analyses., Results: In-hospital mortality was 1.8%. Patients undergoing splenectomy had a higher disease burden (peritoneal cancer index ≥17) (71% vs. 22%, P<0.001) and underwent a longer operation (≥9 hours) (73% vs. 34%, P<0.001). Even after accounting for confounding factors, splenectomy was independently associated with an increased risk of grade III/IV morbidity [relative risk (RR), 1.94; 95% confidence interval (CI), 1.29-2.91; P=0.01], infective complications (RR, 1.63; 95% CI, 1.09-2.44; P=0.018), pancreatic leak (RR, 5.2; 95% CI, 1.81-14.89, P=0.002) and intra-abdominal collection (RR, 1.86; 95% CI, 1.23-2.84, P=0.004). It was also an independent risk factor for long hospital stay (≥28 days) (RR, 1.98; 95% CI, 1.25-3.11; P=0.003). Splenectomy was not associated with in-hospital mortality (RR, 1.68; 95% CI, 0.32-9.32, P=0.556)., Conclusions: Splenectomy is an independent risk factor for poorer peri-operative outcomes. Minimizing the likelihood of inadvertent splenic injury through careful dissection and routine vaccination can improve outcomes., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Introduction: There is uncertainty about whether hepatic resection (HR) combined with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is effective., Methods: Nine hundred and thirty-five consecutive CRS/HIPEC procedures were performed between 1996 and 2016 of which 132(14%) involved concomitant HR. Peri-operative complications were graded according to the Clavien-Dindo Classification. The association of concomitant HR with 19 peri-operative outcomes and overall survival (OS) was assessed using univariate and multivariate analyses., Results: Patients undergoing HR had a lower peritoneal disease burden (peritoneal cancer index <17) (46 vs 29%, P < 0.001) and underwent a shorter operation (<9 h) (53 vs 42%, P = 0.019). After accounting for confounding factors, HR was not associated with in-hospital mortality (Relative risk [RR], 2.47; 95% confidence interval [CI], 0.52-11.77; P = 0.577) or grade III/IV morbidity (RR, 1.18; 95%CI, 0.74-1.90; P = 0.488). Moreover, HR was not associated with an increased risk of other complications on univariate or multivariate analysis. Median OS for all colorectal cancer patients was 32.3 month with resected HM versus 30.5 months without HM (P = 0.587)., Conclusion: Given prudent patient selection, concomitant HR does not compromise peri-operative outcomes or survival after CRS/HIPEC., (© 2017 Wiley Periodicals, Inc.)

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., (Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Radical cystectomy and urinary diversion is the treatment of choice for invasive bladder cancer. Quality of life (QOL) is an important outcome of surgery. This review compares the QOL after continent and incontinent urinary diversion in radical cystectomy for patients with primary invasive bladder cancer., Methods: A systematic review and meta-analysis of clinical studies published after January 2000 was performed according to the PRISMA guidelines. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis using standardized response means. Heterogeneity and bias was assessed by Tau(2) and I(2) values and Funnel plots., Results: Twenty-nine studies (3754 patients) were included for review. Pooled post-operative FACT and SF-36 scores showed no difference in overall QOL between continent and incontinent diversion (p = 0.31). Subgroup analysis demonstrated greater improvement in physical health for incontinent (p = 0.002) compared to continent diversions, but no differences in mental health (p = 0.35) and social health (p = 0.81). Qualitative analysis showed patients with neobladder had superior emotional function and body image compared to cutaneous diversion. QOL may improve to similar or better levels compared to baseline after 1 year, but data remains scarce. Patients report poor urinary and sexual function after surgery compared the general population. Long-term QOL is unclear. Levels of heterogeneity and bias were low., Conclusions: QOL after radical cystectomy is comparable after either continent or incontinent urinary diversion. Post-operative QOL may improve, but urinary and sexual dysfunction remains inferior to the general population. Patient choice is key to selection of reconstruction method., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

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., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

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., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objective: In recent years, concerns have been raised about the learning opportunities available to cardiac surgical trainees. This meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes after coronary artery bypass graft (CABG) surgery., Methods: Medline, EMBASE, and the Cochrane Library were systematically searched for studies that reported CABG outcomes according to the training status of the primary operator (consultant vs trainee). Data were independently extracted by 2 investigators; a meta-analysis was conducted according to predefined clinical endpoints., Results: Sixteen observational studies (n = 52,966) met criteria for inclusion, with 8 studies (n = 36,479) reporting propensity-adjusted analyses. Trainee cases were associated with increased aortic crossclamp duration (mean difference: 4.80; 95% confidence interval [CI], 0.76-8.83) and cardiopulmonary bypass duration (mean difference: 4.24; 95% CI, 0.00-8.47). Perioperative mortality was similar for CABG performed primarily by trainees versus consultants (odds ratio 0.98; 95% CI, 0.81-1.18). No significant difference was found in the incidence of perioperative stroke, myocardial infarction, acute renal failure, reoperation for bleeding, or wound infection. Trainee operator status was not associated with increased midterm mortality (hazard ratio 1.00; 95% CI, 0.90-1.11). In subgroup analysis that included 5 studies and 8025 patients, off-pump CABG trainee cases were not associated with increased perioperative mortality or morbidity., Conclusions: With appropriate supervision, conventional CABG can be performed by trainee surgeons without an adverse impact on perioperative outcomes or midterm survival. Data regarding off-pump CABG are limited, and further research is warranted to ascertain the impact of trainee operator status on long-term outcomes after off-pump CABG., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

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., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Despite advances in chemotherapy and radiotherapy, gastrectomy is the only curative intervention for gastric carcinoma. This study reviews post-operative health-related quality of life (HRQOL) after gastrectomy., Methods: A literature search was conducted on PubMed for all studies published after January 2000 matching strict eligibility criteria. Bibliographies of included studies were also reviewed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesised by narrative review according to PRISMA guidelines with full tabulation of results of all included studies., Results: A total of 21 studies (3,575 patients) were included. Post-operative HRQOL improvements were demonstrated across most or all domains in different HRQOL instruments. Patients experienced declines in HRQOL 1 month after surgery, but reached at least pre-operative levels with recovery by 1 year. The greatest improvements were demonstrated in the emotional health domain with favourable functional benefits. Partial gastrectomy appears to be superior to total gastrectomy in physical, emotional and functional health domains. However, patients remain susceptible to gastrointestinal symptoms following surgery, which negatively impact upon HRQOL. Post-operative complications did not appear to affect HRQOL. Most studies were prospective, but data is heterogeneous., Conclusions: Gastrectomy results in significant HRQOL benefits across a broad range of health domains. This is critical outcome of surgery and an important consideration in pre-operative decision making.

Background: Unresectable intrahepatic cholangiocarcinoma (ICC) portends a poor prognosis despite standard systemic treatments which confer minimal survival benefits and significant adverse effects. This study aimed to assess clinical outcomes, complications and prognostic factors of TAE therapies using chemotherapeutic agents or radiation., Methods: A literature search and article acquisition was conducted on PubMed (MEDLINE), OVID (MEDLINE) and EBSCOhost (EMBASE). Original articles published after January 2000 on trans-arterial therapies for unresectable ICC were selected using strict eligibility criteria. Radiological response, overall survival, progression-free survival, safety profile, and prognostic factors for overall survival were assessed. Quality appraisal and data tabulation were performed using pre-determined forms. Results were synthesized by narrative review and quantitative analysis., Results: Twenty articles were included (n=929 patients). Thirty three percent of patients presented with extrahepatic metastases. After treatment, the average rate of complete and partial radiological response was 10% and 22.2%, respectively. Overall median survival time was 12.4 months with a median 30-day mortality and 1-year survival rate of 0.6% and 53%, respectively. Acute treatment toxicity (within 30 days) was reported in 34.9% of patients, of which 64.3% were mild to moderate in severity. The most common clinical toxicities were abdominal pain, nausea and vomiting, and fatigue. Multiplicity, localization and vascularity of the tumor may predict worse overall survival., Conclusions: Trans-arterial therapies are safe and effective treatment options which should be considered routinely for unresectable ICC. Consistent and standardized methodology and data collection is required to facilitate a meta-analysis. Randomized controlled trials will be valuable in the future.

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. BRCA1-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 BRCA1-mutated and sporadic ovarian carcinomas. It also explores the potential association between BRCA1 mutation site and DNA ploidy status., Methods: This study compared DNA ploidy status of tumor blocks from 23 BRCA1-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: BRCA1-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 BRCA1-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 BRCA1 may have a higher risk of DNA aneuploidy. There is no significant difference between BRCA1-mutated and sporadic ovarian carcinomas with respect to the DNA content., (© 2014 Wiley Publishing Asia Pty Ltd.)

Objectives: To evaluate the impact of preoperative atrial fibrillation (pre-op AF) on early and late mortality after isolated coronary artery bypass graft (CABG) surgery., 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 analyzed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients with and without pre-op AF. The independent association of pre-op AF on early mortality, perioperative complications, and late mortality was determined., Results: Isolated CABG surgery was performed in 21,534 patients; 1312 (6.1%) presented with pre-op AF. Pre-op AF patients were older (mean age, 71 years vs. 65 years, p<0.001) and had more comorbidities reflected in a higher additive EuroSCORE (8.4±3.5 vs. 6.5±3.2, p=0.001). Even after accounting for confounding factors, however, pre-op AF was associated with a 63% increase in 30-day mortality [4.2% vs. 1.4%; hazard ratio (HR), 1.63; 95% confidence interval (CI), 1.17-2.29; p=0.004] and 39% increase in late mortality (5-year survival, 78% vs. 90%; HR, 1.39; 95% CI, 1.20-1.61; p<0.001)., Conclusion: Pre-op AF is an independent predictor of poor early and late outcomes. Pre-op AF should be considered, therefore, in the development or update of risk stratification models for CABG surgery., (Copyright © 2014. Published by Elsevier Ltd.)

Introduction: We report the largest series to date on the safety and efficacy of yttrium-90 (90Y) radioembolization for the treatment of unresectable, chemorefractory colorectal cancer liver metastases (CRCLM)., Methods: A total of 302 patients underwent resin-based 90Y radioembolization for unresectable, chemorefractory CRCLM between 2006 and 2013 in Sydney, Australia. All patients were followed up with imaging studies at regular intervals until death. Radiologic response was evaluated with the response criteria in solid tumors criteria. Clinical toxicities were prospectively recorded. Survival was calculated by the Kaplan-Meier method, and potential prognostic variables were identified on univariate and multivariate analysis., Results: Median follow-up in the complete cohort was 7.2 months (range 0.2-72.8), and the median survival after 90Y radioembolization was 10.5 months with a 24-month survival of 21%. On imaging follow-up of 293 patients who were followed up beyond 2 months, complete response to treatment was observed in 2 patients (1%), partial response in 111 (38%), stable disease in 96 (33%), and progressive disease in 84 (29%). Four factors were independently associated with a poorer prognosis: extensive tumor volume, number of previous lines of chemotherapy, poor radiological response to treatment, and low preoperative hemoglobin. One hundred fifteen (38%) developed clinical toxicity after treatment; most complications were minor (grade I/II) and resolved without active intervention., Conclusions: 90Y radioembolization is a safe and effective treatment for unresectable, chemorefractory CRCLM.

Background: Total knee replacement is a highly successful and frequently performed operation. Technical outcomes of surgery are excellent, with favorable early postoperative health-related quality of life. This study reviews intermediate and long-term quality of life after surgery., Methods: A systematic review and meta-analysis of all studies published from January 2000 onward was performed to evaluate health-related quality of life after primary total knee replacement for osteoarthritis in patients with at least three years of follow-up. Key outcomes were postoperative quality of life, function, and satisfaction compared with the preoperative status. Strict inclusion and exclusion criteria were applied. Quality appraisal and data tabulation were performed with use of predefined criteria. Data were synthesized by narrative review and random-effects meta-analysis utilizing standardized mean differences. Heterogeneity was assessed with the tau(2) and I(2) statistics., Results: Nineteen studies were included in the review. Intermediate and long-term postoperative quality of life was superior to the preoperative level in qualitative and quantitative analyses. The pooled effect in combined WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) and KSS (Knee Society Score) outcomes was a marked improvement from baseline with respect to the total score (2.17; 95% CI [confidence interval], 1.13 to 3.22; p < 0.0001) and the pain (1.72; 95% CI, 0.97 to 2.46; p < 0.00001) and function (1.26; 95% CI, 0.87 to 1.64; p < 0.00001) domains. Most patients were satisfied with the surgery and derived substantial benefits for daily functional activities. Tau(2) (0.20 to 1.10) and I(2) (90% to 98%) values implied significant clinical and statistical heterogeneity., Conclusions: Total knee replacement confers significant intermediate and long-term benefits with respect to both disease-specific and generic health-related quality of life, especially pain and function, leading to positive patient satisfaction. Recommendations for necessary future studies are provided., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

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., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: There is controversy regarding the role of yttrium-90 (90Y) radioembolization in the management of advanced, unresectable hepatocellular carcinoma (HCC)., Methods: Forty-five consecutive patients underwent resin-based 90Y radioembolization for unresectable, HCC between 2006 and 2013 in Sydney, Australia. All patients were followed up with imaging studies at regular intervals until death. Radiologic response was evaluated with the Response Criteria in Solid Tumors (RECIST) criteria. Clinical toxicities were prospectively recorded. Survival was calculated by the Kaplan-Meier method and potential prognostic variables were identified on univariate and multivariate analysis., Results: Follow-up in the complete cohort was 7.8 (range, 0.1-41.8) months. The median survival after 90Y radioembolization was 27.7 months with a 36-month survival of 26%. By RECIST criteria of the 40 patients followed-up beyond 2 months, a complete response (CR) to treatment was observed in 1 patients (3%), partial response (PR) in 18 (45%), stable disease (SD) in 11 (22%) and progressive disease (PD) in 10 (25%). On multivariate analysis only radiological response to treatment was independently associated with improved survival: CR/PR to treatment vs. SD vs. PD; p < 0.001. Thirteen patients (29%) developed clinical toxicity after treatment; all complications were minor (grade I/II) and resolved without active intervention., Conclusion: Radioembolization with 90Y is a safe and effective treatment for unresectable HCC., (Copyright © 2014. Published by Elsevier Ltd.)

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., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: There are a paucity of data on the treatment of unresectable, chemoresistant breast cancer liver metastases (BRCLM) with yttrium-90 (Y90) radioembolization., Methods: Forty patients underwent resin-based Y90 radioembolization for unresectable, chemoresistant BRCLM between 2006 and 2012 in a single institution. All patients were followed up with imaging studies at regular intervals as clinically indicated until death. Radiologic response was evaluated with the Response Criteria in Solid Tumors criteria. Clinical toxicities were prospectively recorded as per the National Cancer Institute Common Toxicity Criteria. Survival was calculated by the Kaplan-Meier method and potential prognostic variables were identified on univariate and multivariate analysis., Results: Follow-up was complete in all patients. The median follow-up was 11.2 (range 0.6-30.5) months and the median survival after Y90 radioembolization was 13.6 months, with a 24-month survival of 39 %. On imaging follow-up of 38 patients who survived beyond 1 month of treatment, a complete response (CR) to treatment was observed in two patients (5 %), partial response (PR) in 10 patients (26 %), stable disease (SD) in 15 patients (39 %), and progressive disease (PD) in 11 patients (29 %). Two factors were associated with an improved survival on multivariate analysis: CR/PR to treatment (vs. SD vs. PD; p < 0.001) and chemotherapy after radioembolization (vs. no chemotherapy; p = 0.004). Sixteen patients (40 %) developed clinical toxicity after treatment; all complications were minor grade I/II and resolved without active intervention., Conclusion: This study provides supportive evidence of the safety and efficacy on Y90 radioembolization for the treatment of unresectable, chemoresistant BRCLM. Further prospective investigation is required to assess the suitability of this treatment in this population.

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.

In this article, we review two liver-directed therapies that are currently used for the palliative treatment of primary and secondary hepatic malignancies, transcatheter arterial chemoembolization (TACE), including a new type of TACE with drug-eluting beads, and radioembolization. Important developments and administration techniques for all therapies are discussed, as well as their integration into the current routine clinical care for management of metastatic colorectal cancer. According to published data from clinical trials, as presented in this review, both radioembolization and TACE/TACE with drug-eluting beads have been proven to be safe and effective in selected patients with chemorefractory liver metastases from colorectal cancer. For patients with unresectable liver-only or liver-dominant disease who have failed standard chemotherapy options or for whom chemotherapy is contraindicated, new modalities, such as those discussed, are particularly valid and promising if clinical guidelines for patient selection and treatment administration are followed., Competing Interests: Financial & competing interests disclosure L Bester is a paid consultant of Sirtex. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.

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 I(2) 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 (I(2) = 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 (I(2) = 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., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Postoperative atrial fibrillation (POAF) is a known complication of cardiac surgery. There is a paucity of data on the effects of POAF on short-term and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting (AVR-CABG )., Methods: We retrospectively reviewed data on patients without preexisting arrhythmia who underwent isolated first-time AVR-CABG between June 2001 and December 2009 using the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program. Preoperative characteristics, early postoperative outcomes and late survival were compared between patients who developed POAF and those who did not. Propensity score matching was performed to account for the differences between the two groups., Results: Isolated AVR-CABG surgery was performed in 2028 patients without preexisting arrhythmias at 18 Australian institutions, of whom 894 (44.1%) developed POAF. POAF patients were generally older (mean age, 75 vs. 73 years, P < 0.001). From the initial study population, 715 propensity-matched patient-pairs were derived; the overall matching rate was 80.0%. In the matched groups, 30-day mortality was similar in both groups (3.5 vs. 2.1%, P = 0.16). Patients with POAF, however, were more likely to develop perioperative complications, including new renal failure, prolonged ventilation (>24 h), multisystem failure and readmission within 30 days of surgery (all P < 0.05). Patients with POAF also had a significantly greater length of hospital stay (P < 0.001). Seven-year survival was not significantly different between the two groups (72 vs. 75%, P = 0.11)., Conclusion: POAF was not associated with an increased risk of early or late mortality. It is, however, associated with poorer perioperative outcomes. It is important to evaluate potential treatment strategies for POAF.

Background: Ablative strategies have been used to treat and facilitate hepatic resection (HR) in patients with otherwise unresectable colorectal liver metastases (CLM). We evaluated the efficacy of HR, concomitant HR and ablation and isolated ablation on recurrence and survival outcomes after treatment of CLM in patients with 1-4 and ≥5 lesions, respectively., Methods: A retrospective review of a prospectively collected hepatobiliary surgery database was performed on patients who underwent treatment for isolated CLM between 1990 and 2010. Pre-operative and treatment characteristics were compared between patients who underwent HR, concomitant HR and ablation and ablation alone. The impact of treatment modality on survival and recurrence outcomes was determined., Results: A total of 701 patients met inclusion criteria; 550 patients (78%) had 1-4 lesions and 151 patients (22%) had ≥5 lesions. Overall median survival for the entire cohort was 35 months with 5- and 10-year survival of 33% and 20%, respectively. Overall median and 5-year recurrence-free survival (RFS) was 13 months and 21%, respectively. For patients with 1-4 lesions, median survival was 37 months with 5-year survival of 36%. Stratified by procedure type, 5-year survival was 41% in patients who underwent HR, 35% in patients who underwent concomitant HR and ablation and 13% in patients who underwent ablation alone (P<0.001). For patients with ≥5 lesions, median survival was 28 months with 5-year survival of 23% without difference between treatment groups (P=0.078)., Conclusions: HR appears to be the most effective strategy for patients with 1-4 lesions. When ≥5 lesions are present, ablative strategies are useful in facilitating HR in otherwise unresectable patients.

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 (AVR-CABG) 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 late mortality 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)., Conclusion: Smoking is not associated with adverse outcomes after concomitant AVR-CABG surgery. Smoking status should not, therefore, preclude these patients from undergoing this procedure. Given the adverse effect of smoking on overall cardiovascular morbidity and mortality and late postoperative mortality, patients should be encouraged to quit smoking., (Georg Thieme Verlag KG Stuttgart · New York.)

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.)