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BACKGROUND: This study compared clinical and hemodynamic in-hospital outcomes of patients undergoing sutureless vs rapid deployment aortic valve replacement (SURD-AVR) in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR). METHODS: We examined 4695 patients who underwent isolated or combined SURD-AVR. The "sutureless" Perceval valve (LivaNova PLC, London, United Kingdom) was used in 3133 patients and the "rapid deployment" Intuity (Edwards Lifesciences, Irvine, CA) in 1562. Potential confounding factors were addressed by the use of propensity score matching. After matching, 2 well-balanced cohorts of 823 pairs (isolated SURD-AVR) and 467 pairs (combined SURD-AVR) were created. RESULTS: Patients who received Perceval and Intuity valves showed similar in-hospital mortality and rate of major postoperative complications. Perceval was associated shorter cross-clamp and cardiopulmonary bypass times. In the isolated SURD-AVR group, patients receiving Perceval were more likely to undergo anterior right thoracotomy incision. Postoperative transvalvular gradients were significantly lower for the Intuity valve compared with those of the Perceval valve, either in isolated and combined SURD-AVR. The Intuity valve was associated with a lower rate of postoperative mild aortic regurgitation. CONCLUSIONS: Our results confirm the safety and efficacy of SURD-AVR regardless of the valve type. The Perceval valve was associated with reduced operative times and increased anterior right thoracotomy incision. The Intuity valve showed superior hemodynamic outcomes and a lower incidence of postoperative mild aortic regurgitation. ispartof: ANNALS OF THORACIC SURGERY vol:114 issue:3 pages:758-+ ispartof: location:Netherlands status: published

Background Aortic valve surgery (AVS) is the gold standard treatment for symptomatic aortic valve (AV) disease patients. We report the temporal trends in the incidence of patients requiring isolated AVS in an unselected statewide population and their mortality outcomes over 17-years. Methods Patients were identified from the New South Wales, Australia, Admitted-Patient-Data-Collection registry between 1-July-2001 and 31-December-2018. Annual case-volumes and survival outcomes, adjusted for age, sex, referral source, endocarditis, concomitant coronary-artery-bypass-grafting, comorbidities including atrial fibrillation, hypertension and Charlson comorbidity index, were compared across calendar years. Results The study cohort comprised 16436 patients who underwent isolated AVS (mean age: 72.2 ± 11.3y; 67.5% males). Annual case-volume increased from 768 to 1048 cases between 2002 and 2017 (r2 = 0.82; p Conclusion The volume of AVS has increased progressively over time and has been associated with increased use of bioprosthetic valves and markedly improved 30-day and 1-year survival.

Background The increasing use of antegrade cerebral perfusion (ACP) during aortic arch surgery has corresponded with a trend toward warmer target temperatures for hypothermic circulatory arrest. This meta-analysis examined the clinical outcomes using colder or warmer circulatory arrest targets with ACP. Methods Electronic searches were performed using four databases from their inception to February 2017. Comparative studies of adult patients who underwent aortic arch operations using ACP at different circulatory arrest temperatures were included. Data were extracted by 2 independent researchers and analyzed according to predefined end points using a random-effects model. Results The literature search identified 18 comparative studies, with 1,215 patients in the "cold" cohort and 1,417 in the "warm" cohort. Mean hypothermic circulatory arrest temperatures were 20.3°C and 26.5°C in the cold and warm groups, respectively. A trend existed for increased permanent neurologic deficit overall when colder targets were used (odds ratio, 1.45; 95% confidence interval, 0.98 to 2.13; p = 0.06); this became significant when adjusted estimates were aggregated (odds ratio, 1.65; 95% confidence interval, 1.06 to 2.55; p = 0.03). No difference in the mortality rate was seen when adjusted effects were aggregated. Temporary neurologic deficit, postoperative dialysis, ventilator time, and intensive care unit stay were significantly reduced in the warm cohort overall. No significant differences in reexploration for bleeding were found. Conclusions ACP with warmer circulatory arrest temperatures may reduce the incidence of permanent neurologic deficit as well as potentially other clinical outcomes. Further studies are required to determine the safe circulatory arrest durations for visceral organs at warmer temperatures.

To analyze presentation, management, and outcomes of acute aortic dissections with proximal entry tear in the arch.Patients enrolled in the International Registry of Acute Aortic Dissection and entry tear in the arch were classified into 2 groups: arch A (retrograde extension into the ascending aorta with or without antegrade extension) and arch B (only antegrade extension into the descending aorta or further distally). Presentation, management, and in-hospital outcomes of the 2 groups were compared.The arch A (n = 228) and arch B (n = 140) groups were similar concerning the presence of any preoperative complication (68.4% vs 60.0%; P = .115), but the types of complication were different. Arch A presented more commonly with shock, neurologic complications, cardiac tamponade, and grade 3 or 4 aortic valve insufficiency and less frequently with refractory hypertension, visceral ischemia, extension of dissection, and aortic rupture. Management for both groups were open surgery (77.6% vs 18.6%; P .001), endovascular treatment (3.5% vs 25.0%; P .001), and medical management (16.2% vs 51.4%; P .001). Overall in-hospital mortality was similar (16.7% vs 19.3%; P = .574), but mortality tended to be lower in the arch A group after open surgery (15.3% vs 30.8%; P = .090), and higher after endovascular (25.0% vs 14.3%; P = .597) or medical treatment (24.3% vs 13.9%; P = .191), although the differences were not significant.Acute aortic dissection patients with primary entry tear in the arch are currently managed by a patient-specific approach. In choosing the management type of these patients, it may be advisable to stratify them based on retrograde or only antegrade extension of the dissection.

Objective To review the evidence on neurologic complications in adult extracorporeal membrane oxygenation (ECMO) patients with regard to incidence, pathophysiology, risk factors, diagnosis, monitoring techniques, prevention, and management. Design Literature review. Setting Observational studies and case reports from a variety of institutions. Participants Adult ECMO patients. Interventions Six electronic databases were searched from their dates of inception to October 2016. Measurements and Main Results The range of neurologic complications reported in adult ECMO patients included stroke, intracranial hemorrhage, and brain death. Due to a lack of standardized reporting, their true incidence may have been underestimated significantly. A variety of pathophysiologic mechanisms and risk factors have been proposed. Some of these are specific to venoarterial ECMO, whereas others may be more relevant to venovenous ECMO (eg, rapid correction of hypercarbia). With regard to diagnosis and monitoring, clinical examination alone can be challenging and insufficiently sensitive, particularly for the confirmation of brain death. Computed tomography is the main imaging modality for acute neurologic assessment because magnetic resonance imaging is not feasible in these patients. Options for neuromonitoring are limited, although cerebral near-infrared spectroscopy may be useful. There are very limited data to guide the management of specific complications such as intracranial hemorrhage, which remains a leading cause of mortality in ECMO patients. Conclusions ECMO can be lifesaving and is being used increasingly for severe respiratory and/or cardiac failure. However, it remains associated with significant neurologic morbidity and mortality. Greater research clearly is needed to determine the best approach to the assessment and management of neurologic complications in this rapidly growing patient population.

A small proportion of patients with malignant pleural mesothelioma (MPM) achieve pathological complete response (CR) following treatment with current practice induction chemotherapy. Our analysis of 58 patients with MPM treated with platinum-based chemotherapy showed 4 patients (7%) attained pathological CR at subsequent extrapleural pneumonectomy (EPP). Patient and tumour factors such as age, gender, smoking habit, histological subtype, and clinical stage were not found to be associated with pathological CR. Patients with pathological CR had longer disease-free survival (29.2 vs. 13.8 months; p = 0.08) and overall survival (76.4 vs. 23.4 months; p = 0.06) but this did not reach statistical significance. Our study suggests that patients who achieve pathological CR after chemotherapy may have improved survival in MPM.

Background Transcatheter aortic valve implantation (TAVI) has become a widely utilized method of treatment of severe aortic valve stenosis. The present meta-analysis included all published relevant randomized controlled trials (RCTs) and aimed to compare the safety and efficacy of TAVI compared to surgical aortic valve replacement (AVR). Method Nine electronic databases were comprehensively searched. Eligible studies were required to be randomized controlled trials which reported comparative endpoints on both TAVI and AVR. Results Five published RCTs were included in the meta-analysis. A total of 3828 patients were studied. The overall mortality and stroke rates at 30days and 1year were not significantly different between TAVI and AVR. Patients undergoing TAVI were more likely to experience vascular complications, aortic regurgitation and permanent pacemaker insertion, however, they were less likely to encounter acute renal failure and major haemorrhage. Conclusions The data suggest that TAVI is a safe and efficacious alternative to surgical aortic valve replacement in judiciously selected patients.

Background There have been a myriad of studies investigating the effectiveness of N-acetylcysteine (NAC) in the prevention of contrast induced nephropathy (CIN) in patients undergoing coronary angiography (CAG) with or without percutaneous coronary intervention (PCI). However the consensus is still out about the effectiveness of NAC pre-treatment due to vastly mixed results amongst the literature. Objectives The aim of this study was to conduct a meta-analysis and trial sequential analysis to determine the effects of pre-operative NAC in lowering the incidence of CIN in patients undergoing CAG and/or PCI. Methods A systematic literature search was performed to include all randomized controlled trials (RCTs) comparing NAC versus control as pretreatment for CAG and/or PCI. A traditional meta-analysis and several subgroup analyses were conducted using traditional meta-analysis with relative risk (RR), trial sequential analysis, and meta-regression analysis. Results 43 RCTs met our inclusion criteria giving a total of 3277 patients in both control and treatment arms. There was a significant reduction in the risk of CIN in the NAC treated group compared to control (OR 0.666; 95% CI, 0.532–0.834; I2=40.11%; p=0.004). Trial sequential analysis, using a relative risk reduction threshold of 15%, indicates that the evidence is firm. Conclusions The results of the present paper support the use of NAC in the prevention of CIN in patients undergoing CAG±PCI. Future studies should focus on the benefits of NAC amongst subgroups of high-risk patients.

Contrast-induced acute kidney injury (CI-AKI) is a potential complication in coronary angiography (CAG) and percutaneous coronary interventions (PCI). Prior randomized controlled trials (RCTs) have suggested that statins may play a role in reducing rates of CI-AKI, however it is not clear how firm the current evidence is.The aim of this study was to conduct a meta-analysis and trial sequential analysis to determine the effects of statins in lowering CI-AKI rates in CAG and PCI.A systematic literature search was performed to include all RCTs comparing statins (treatment arm) versus low-dose statins or placebo (control arm) as pretreatment for CAG and/or PCI. A traditional meta-analysis and several subgroup analyses were conducted using traditional meta-analysis with relative risk (RR), trial sequential analysis, and meta-regression analysis.14 RCTs met our inclusion criteria giving a total of 2992 statin treated (49.6%) and 3041 control patients (50.4%). There was a significant reduction in CI-AKI in the statin group compared to controls (3.7% vs 8.3%, RR, 0.46; p=0.00001). Trial sequential analysis using a relative risk reduction threshold of 20%, power 80% and type 1 error of 5%, indicated that the evidence is firm. A greater risk reduction in CI-AKI in the statin group significantly correlated with higher estimated glomerular filtration rate (eGFR; p=0.003) CONCLUSIONS: The present trial sequential analysis provides support for statins in reducing the incidence of CI-AKI in patients undergoing CAG/PCI. This effect appeared to be greater in patients with higher eGFR.

Current American Heart Association Guidelines (2007) advise against routine use of antibiotics for the prevention of infective endocarditis during invasive dental procedures in native valve disease. A 59 year-old man with known moderate aortic regurgitation presented with fevers, night sweats and

There is renewed interest in performing segmentectomies and wedge resections for selected patients with early-stage non-small cell lung cancer. However, comparative data on sublobar resections versus lobectomies include 'intentionally selected' patients who could tolerate either procedure, or 'compromised' patients who could only undergo sublobar resections due to significant comorbidities or insufficient cardiopulmonary reserve. To address this important point, the present meta-analysis aimed to compare the survival outcomes of sublobar resections and segmentectomies versus lobectomies based on patient selection and surgical intent.A systematic review was performed using 6 online databases to identify all comparative studies that presented survival data on sublobar resections versus lobectomy procedures. These studies were then categorized according to the patient selection process for those who underwent sublobar resections. Patients were considered 'intentionally selected' if they could have tolerated either procedure, 'compromised' if they underwent a sublobar resection due to ineligibility for a lobectomy, or 'non-specified'.Fifty-four studies, including a single randomized controlled trial, involving 38,959 patients were found to meet the predefined selection criteria. For sublobar resections, comparative data demonstrated no significant difference in overall survival in the 'intentionally selected' group, but a significantly worse outcome for sublobar resections in the 'compromised group'. Similarly, for the comparison of segmentectomies versus lobectomies, available data demonstrated no significant difference in overall survival in the 'intentionally selected' group, but a significantly worse outcome for segmentectomy in the 'compromised group'.The present meta-analysis was the first to emphasize the patient selection process to compare 'intentionally selected' and 'compromised' patients who underwent sublobar resections versus lobectomies. Our results suggested that segmentectomies may be a feasible alternative for selected patients who could tolerate either procedure. These patients generally had tumours that were2cm, located peripherally with favourable histopathology, and with ground-glass opacity on imaging.

This article describes how I perform a minimally invasive aortic root replacement, also known as the Mini-Bentall procedure. In particular, it highlights the details on how to perform the "French Cuff" technique to ensure an absolute proximal annular hemostasis. Six consecutive patients underwent the Mini-Bentall procedure using the "French Cuff" technique. Five patients did not have any transfusion and one patient had two pooled platelets. Five patients were extubated on table in the operating room and one patient was extubated 12 hours after the procedure. All patients were discharged home within 7 days after the procedure without any surgical complications.

0.61; 95% CI, 0.24–1.58; I 2 = 0%; P = 0.31) or postoperative MACCE (RR, 0.78; 95% CI, 0.34–1.78; I 2 = 0%; P = 0.55), with no significant heterogeneity detected (Fig. 1). From data of 1664 patients, 30-day mortality rates of hybrid and CABG approaches were comparable (RR, 0.88; 95% CI, 0.34–2.33; I 2 = 0%; P = 0.80). Postoperative myocardial infarction (RR, 0.67; 95% CI, 0.49–0.93; I 2 =0 %; P= 0.01) and blood transfusions (RR, 0.54; 95% CI, 0.40–0.74; I 2 =

Background: Surgical interventions for aortic aneurysm and dissection remain associated with high risk of mortality and morbidity. Advances in operative techniques have led to a variety of options for the cardiac surgeon, including endovascular and hybrid approaches. Debate remains over which of these techniques provide optimal outcomes for the patient. The present systematic review and meta-analysis aims to evaluate long term patient survival and identify short-term outcomes for conventional (open) aortic arch repair and hybrid aortic arch repair (HAR). Methods: An electronic literature search was conducted according to predefined inclusion criteria for hybrid and conventional aortic arch repair surgery. Digitized survival data was extracted from identified studies’ Kaplan-Meier curves and used to re-create individual patient data for aggregated survival analysis. Post-operative morbidity and mortality were analyzed using random-effects model meta-analysis. Results: Nine studies were included, containing 841 hybrid arch repair and 1,182 conventional arch repair patients. Pooled Kaplan-Meier analysis of all patients demonstrated higher survival in hybrid arch repair patients than conventional arch repair patients, however, this was noted to be sensitive to results from a particular study. Overall results showed for the hybrid repair cohort, survival at 1, 2, 3, 5 and 7 years was 87%, 85%, 83%, 78% and 75%, respectively. Survival in the conventional repair cohort at 1, 2, 3, 5 and 7 years was 84%, 82%, 80%, 75% and 71%, respectively. Statistically significant findings from meta-analysis showed hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with reduced risk of spinal cord injury. Conclusions: Pooled Kaplan-Meier analysis of all studies showed long-term survival outcomes for hybrid and conventional aortic arch repair patients are heterogeneous and sensitive to the results of particular studies. Superior results from particular centres and the low number of comparative studies mean that more data is required to make definitive findings with regards to the long-term survival outcomes of either procedure. Hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with lower risk of spinal cord injury. Surgeons should consider their own center’s experience and patient suitability when deciding between hybrid or conventional aortic repair techniques.

Objective Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment to aortic valve replacement (AVR) for selected patients with severe aortic stenosis. The present systematic review was conducted to analyze the cost-effectiveness of this novel technique within reimbursed healthcare systems. Methods Two reviewers used 7 electronic databases from January 2000 to November 2012 to identify relevant cost-effectiveness studies of TAVI versus AVR or medical therapy. The primary endpoints were the incremental cost-effectiveness ratio (ICER) and the probability of cost-effectiveness. The eligible studies for the present systematic review included those in which the cost-effectiveness data were measured or projected for TAVI and either medical therapy or AVR. All forms of TAVI were included, and all retrieved publications were limited to the English language. Results Eight studies were included for quantitative assessment. The ICER for TAVI compared with medical therapy for surgically inoperable patients ranged from US$26,302 to US$61,889 per quality-adjusted life year gained. The probability of TAVI being cost-effective compared with medical therapy ranged from 0.03 to 1.00. The ICER values for TAVI compared with AVR for high-risk surgical candidates ranged from US$32,000 to US$975,697 per quality-adjusted life year gained. The probability of TAVI being cost-effective in this cohort ranged from 0.116 to 0.709. Conclusions Depending on the ICER threshold selected, TAVI is potentially justified on both medical and economic grounds compared with medical therapy for patients deemed to be surgically inoperable. However, in the high-risk surgical patient cohort, the evidence is currently insufficient to economically justify the use of TAVI in preference to AVR.

Background In the era of TAVI, there has been renewed interest in the outcomes of conventional AVR for high-risk patients. This study evaluates the short- and long-term outcomes of AVR in octogenarians. Methods A retrospective review was performed of all 117 patients aged ≥80 years who underwent AVR, (isolated AVR (n = 60) or AVR + CABG (n = 57),) from August 2005 to February 2011 at Royal Prince Alfred Hospital and Strathfield Hospital. Univariate analysis was used to compare pre- and post-operative variables between younger and older subgroups (age 80–84, n = 82; age 85–89, n = 35 respectively). Long-term survival data was obtained from the National Death Index at the Australian Institute of Health and Welfare and survival curves were constructed using the Kaplan–Meier method. Results The median age was 83 years (interquartile range, 81–85 years), 46.2% were females, the median EuroSCORE was 10.89% (interquartile range, 8.20–16.45%) and 16.2% of patients had a EuroSCORE ≥20%. The difference between subgroups for history of stroke was significant (p = .042). Post-operative complications included pleural effusion (12.8%), new renal failure (4.3%) and respiratory failure (4.3%). The rate of major adverse events was extremely low, with no cases of stroke. The 30-day mortality rate was 3.4%. There was a significant difference between subgroups for 30-day mortality (p = .007). 38.9% of patients were discharged home, 11.5% were transferred to another hospital and 38.9% spent a period of time in a rehabilitation institution post discharge. In terms of long-term survival, the six-month, one-year and three-year survival was 95.6%, 87.6% and 58.4% respectively. Conclusions Surgical AVR yields excellent short- and long-term outcomes for potentially high-risk, elderly patients.

Introduction The efficacy of coronary artery bypass graft (CABG) surgery for patients with ischemic heart disease is dependent on the patency of the selected conduit. The left internal thoracic artery is considered to be the best conduit for CABG. However, the preferred conduit between the radial artery (RA) and saphenous vein (SV) remains controversial. The present meta-analysis aims to establish the current level IA evidence on patency outcomes comparing the RA and SV. Methods Electronic searches were performed using 6 databases from their inception to March 2012. Two reviewers independently identified all relevant randomized controlled trials (RCTs) comparing patency outcomes of RA and SV grafts after CABG. Data were extracted and meta-analyzed according to angiographic end points at specified follow-up intervals. Results Five relevant RCTs were identified for inclusion in the present meta-analysis. Angiographic results indicated that the RA was significantly more likely to be completely patent and less likely to be associated with graft failure or complete occlusion at 4 years' follow-up and beyond. However, the RA was significantly more likely to be associated with string sign at 1 year of follow-up. Conclusions While acknowledging the limitations of heterogeneous surgical techniques, results from the present meta-analysis suggest potential superiority of the RA compared with the SV at midterm angiographic follow-up. However, the increased incidence of string sign associated with the RA is of potential clinical concern. Further research should be directed at correlating angiographic findings of string sign and graft failure to clinical symptoms and major adverse cardiac and cerebrovascular events at long-term follow-up.

Introduction: The primary objective of the present systematic review was to evaluate the safety and efficacy of extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma. Methods: A systematic review of relevant studies identified through five online search databases was performed. Two reviewers independently appraised each study. Results: Thirty-four of 58 relevant studies from 26 institutions containing the most updated data were evaluated for survival and perioperative outcomes after EPP. The median overall survival varied from 9.4 to 27.5 months, and 1-, 2-, and 5-year survival rates ranged from 36 to 83%, 5 to 59%, and 0 to 24%, respectively. Overall perioperative mortality rates ranged from 0 to 11.8%, and the perioperative morbidity rates ranged from 22 to 82%. Quality of life assessments from three studies reported improvements in nearly all domains at 3 months postoperatively. Patients who underwent trimodality therapy involving EPP and adjuvant chemoradiotherapy had a median overall survival of 13 to 23.9 months. Discussions: The current evidence suggests that selected patients with malignant pleural mesothelioma may benefit from EPP, especially when combined with neoadjuvant or adjuvant chemotherapy and adjuvant radiotherapy.

Several large series have demonstrated that performing off-pump coronary artery bypass surgery without manipulating the ascending aorta (anaortic) utilising all-arterial grafts provides superior protection against neurological injury. Recent series comparing percutaneous coronary intervention (PCI) with surgical revascularisation have demonstrated superior results for surgery over PCI. However, a significant criticism of coronary artery surgery remains the higher incidence of neurological injury when compared to PCI. We present a simple and reproducible technique for anaortic, total-arterial off-pump coronary artery revascularisation.

Objectives The present systematic review objectively assessed the safety and clinical effectiveness of transcatheter aortic valve implantation for patients at high surgical risk with severe aortic stenosis. Methods Electronic searches were performed in 6 databases from January 2000 to March 2009. The end points included feasibility, safety, efficacy, and durability. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies. Results The current evidence on transcatheter aortic valve implantation for aortic stenosis is limited to short-term observational studies. The overall procedural success rates ranged from 74% to 100%. The incidence of major adverse events included 30-day mortality (0%–25%), major ventricular tachyarrhythmia (0%–4%), myocardial infarction (0%–15%), cardiac tamponade (2%–10%), stroke (0%–10%), conversion to surgery (0%–8%), moderate to major paravalvular leak (4%–35%), vascular complication (8%–17%), valve-in-valve procedure (2%–12%), and aortic dissection/perforation (0%–4%). The overall 30-day major adverse cardiovascular and cerebral events ranged from 3% to 35%. The mean aortic valve area ranged from 0.5 to 0.8 cm2 before and 1.3 to 2.0 cm2 after transcatheter aortic valve implantation. The mean pressure gradient ranged from 34 to 58 mm Hg before and 3 to 12 mm Hg after transcatheter aortic valve implantation. There was no significant deterioration in echocardiography measurements during the assessment period. Death rate at 6 months postprocedure ranged from 18% to 48%. No studies had adequate follow-up to reliably evaluate long-term outcomes. Conclusions The procedure has a potential for serious complications. Although short-term efficacy based on echocardiography measurements is good, there is little evidence on long-term outcomes. The use of transcatheter aortic valve implantation should be considered only within the boundaries of clinical trials.

Aims This study is the first to evaluate the clinical and treatment-related risk factors for perioperative toxicity and mortality in patients with peritoneal recurrence that underwent iterative cytoreductive surgery (CRS) with or without perioperative intraperitoneal chemotherapy (PIC). The aim is to improve patient selection. Methods Fifty-seven consecutive iterative CRS procedures were performed in 40 patients between June 2000 and September 2008. Forty-seven patients were administered PIC. Adverse events were rated from grades I to V with increasing severity. Grade I toxicity was self limiting; grade II required medical intervention; grade III required an invasive intervention; grade IV required returning to intensive care unit or operating theatre; and grade V resulted in patient death during hospital stay. Risk factors for grades III and IV/V toxicity were determined. Results The mortality rate was 2%. The grades III and IV/V toxicity rate was 18% and 19%, respectively. A peritoneal cancer index ≥16 ( p =0.020), operation length ≥9h ( p =0.045), number of peritonectomy procedures ≥2 ( p =0.045) and a suboptimal cytoreduction ( p =0.031) were the risk factors for grade IV/V toxicity. Conclusions Iterative CRS and PIC procedures have an acceptable rate of perioperative toxicity in carefully selected patients. Patients with high tumour burden requiring extensive surgical dissection are at highest risk of a severe adverse event. Thorough preoperative evaluation of patients is necessary to improve both perioperative and postoperative outcomes.

Objective This study aimed to evaluate the perioperative and long-term outcomes associated with extrapleural pneumonectomy for patients with malignant pleural mesothelioma. Methods From October 1994 to April 2008, 70 patients were selected for extrapleural pneumonectomy. Univariate analysis was performed using the Kaplan–Meier method and compared using the log-rank test. Multivariate analysis with entering and removing limits of P less than .10 and P greater than .05, respectively, was used. The prognostic factors included age, gender, side of disease, asbestos exposure, histology, positron emission tomography, date of surgery, neoadjuvant chemotherapy, completeness of cytoreduction, lymph node involvement, perioperative morbidity, adjuvant radiotherapy, and pemetrexed-based chemotherapy. Results The mean age of patients was 55 years (standard deviation=10). Fifty-eight patients had epithelial tumors. Six patients received neoadjuvant chemotherapy, 28 patients received adjuvant radiotherapy, and 16 patients received postoperative pemetrexed-based chemotherapy. Forty-four patients had no lymph node involvement. The perioperative morbidity and mortality were 37% and 5.7%, respectively. Complications included hemothorax (n = 7), atrial fibrillation (n = 6), empyema (n = 4), bronchopulmonary fistula (n = 3), right-sided heart failure (n = 2), pneumonia (n = 1), constrictive pericarditis (n = 1), acute pulmonary edema (n = 1), small bowel herniation (n = 1), and disseminated intravascular coagulopathy (n = 1). The median survival was 20 months, with a 3-year survival of 30%. Asbestos exposure, negative lymph node involvement, and receipt of adjuvant radiation or postoperative pemetrexed-based chemotherapy were associated with improved survival on both univariate and multivariate analyses. Conclusion The present study supports the use of extrapleural pneumonectomy-based multimodal therapy in carefully selected patients with malignant pleural mesothelioma.

Background Liver resection of large hepatocellular carcinomas (HCC), measuring at least 10 cm remains a controversial debate. Multiple studies on HCCs treated with surgical resection and/or ablation had shown variable results with 5-year survival rates ranging from 0% to 54.0%. The aim of this study was to evaluate the survival of patients with HCCs measuring at least 10 cm and to identify the potential prognostic variables affecting the outcome. Methods Retrospective analysis was performed on the prospectively updated HCC database. A total of 44 patients with tumours measuring 10 cm or more were ‘curatively’ treated with surgical resection with or without ablation. Patient demographics, clinical, surgical, pathology and survival data were collected and analysed. Results Thirty-one patients received surgical resection alone. Thirteen other patients were treated with a combination of surgical resection and ablation. The median follow-up duration was 14.5 months. The overall median survival at 1, 3 and 5 years were 66.4%, 38.1% and 27.8%, respectively. The median time to tumour recurrence was 10.7 months and the 1, 3 and 5-year disease-free survival were 49.6%, 23.9% and 19.1%, respectively. Univariate analysis demonstrated cirrhosis, microvascular invasion, poor tumour differentiation and ethnicity to adversely affect survival. For overall survival, only cirrhosis, poor tumour differentiation and ethnicity were significant on multivariate analysis. Portal vein tumour thrombus, microvascular invasion and ethnicity were identified on univariate analysis to significantly affect disease-free survival. Conclusion Surgical treatment offers good survival to patients with large HCCs (≥10 cm). Both cirrhosis and poor tumour differentiation are independent variables prognostic of adverse survival.

Background. Surgical resection is the most effective therapy for liver cancer. Intraoperative blood loss during liver resection remains a major concern due to association with higher postoperative complications. The InLine radiofrequency ablation device (ILRFA) has achieved promising results in liver surgery with minimal blood loss and no increase of postoperative complications. In this multicentre controlled study, 108 patients undergoing liver resection were investigated. Patients and methods. A total of 108 patients underwent liver resections in 4 medical centres; the prospective sequential cohort study consisted of 54 ILRFA and 54 ultrasonic surgical aspirator transections as the control group. Results. The type of liver resection performed was very similar in both groups. The median number of RFA deployments was 3 (range 1–12) with a median coagulation time of 9 (range 3–36) min. Median blood loss was 165±20ml (range 5–675) in the ILRFA and 654±83ml (range 80–3600) in the control group (p

Aims Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has been reported as a treatment option for patients with peritoneal carcinomatosis from colorectal carcinoma. Methods Thirty patients with colorectal peritoneal carcinomatosis underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy. All appendiceal cancers were excluded. All patients were followed until January 2006 or death. Univariate analysis was performed to evaluate significant prognostic factors for overall survival, defined from the time of surgery. Results There were 13 male patients. The mean age at the time of surgery was 54 years. There was no hospital mortality. The mean duration of hospital stay was 27 days. The overall median survival was 29 months, with 1- and 2-year survival of 72% and 64%, respectively. Twenty-one patients had complete cytoreduction and their 1- and 2-year survival rates were 85% and 71%, respectively. Univariate analysis demonstrated that patients with non-mucinous colorectal adenocarcinoma, Peritoneal Cancer Index (PCI) ≤13, and complete cytoreduction were associated with an improved survival. Conclusions This study reported on 30 patients who underwent cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis. Patients with mucinous tumour had relatively more extensive intraperitoneal disease. Non-mucinous colorectal adenocarcinoma, PCI ≤13, and complete cytoreduction were associated with an improved survival.

Background The liver resection margin is prognostically significant for patients with colorectal liver metastases. Management plans for patients with suboptimal resection margins have not been adequately addressed. This article reports the long-term results of edge cryotherapy in 120 patients with suboptimal resection margins. Methods A retrospective analysis of prospectively collected clinical data of 120 patients with suboptimal hepatic resection margins was performed. Morbidity, mortality, recurrence, and survival results were analyzed. Results The median length follow-up was 30 months (range 1 to 139). The median disease-free interval was 19 months (range 2 to 139). Cryosite, remaining liver, and extrahepatic recurrence rates were 10%, 36%, and 47%, respectively. The median survival was 39 months (range 1 to 139), and 1-, 3-, and 5-year survival rates were 89%, 55%, and 36%, respectively. Cryosite and extrahepatic recurrence were independently associated with a reduced survival outcome. Comments Edge cryotherapy to suboptimal liver resection margins can achieve a lower local recurrence rate and a longer survival advantage.

Background. The most common site of colorectal extra‐abdominal metastases is the lung. The relative risk of lung metastases after resection and cryotherapy has not previously been compared. Methods. All patients underwent an extensive preoperative staging including clinical examination, abdominal computed tomography (CT) and abdominal angio‐CT to assess their hepatic disease. Two groups of patients were compared in this study (hepatic resection alone and hepatic cryotherapy with or without resection). A retrospective analysis of prospectively collected data was performed to assess the incidence and disease‐free interval of pulmonary metastasis after surgical treatment of colorectal liver metastasis. Results. This paper clearly shows two differences regarding pulmonary metastases between patients treated with resection only and cryotherapy with or without resection. Among the 10 clinical variables, cryotherapy had the greatest correlation with pulmonary metastases (p=0.004). A patient who undergoes hepatic resection only has a probability of 35% for developing pulmonary recurrence, compared with 51% following cryotherapy. Cryotherapy was also independently associated with shorter pulmonary disease‐free interval (p=0.036). Conclusion. There clearly is a higher risk of pulmonary metastasis after cryotherapy than after resection, whether this is related to selection of patients or a direct deleterious procedural effect requires more study.

Introduction: The value of synchronous liver resection and cryotherapy ablation remains controversial for colorectal metastases where complete resection is not possible by conventional liver surgery alone. Objective: To review the long-term survival of patients treated using this approach at our institution. Methods: A review was undertaken of data held in the prospectively collected liver surgery database of all patients who underwent synchronous liver resection and cryotherapy. Survival analysis was performed and data recorded on the total number of metastases at initial surgery and the number of lesions treated by cryoablation. Results: Ninety-three patients with colorectal metastases underwent synchronous liver resection and cryotherapy. Data were available on 86 patients with a median follow-up of 18 months (range 1–83). The median number of metastases at initial surgery was four (range 2–11) and the number of lesions treated by cryotherapy ablation was two (range 1–8). Eighty-four per cent had a hepatic artery catheter inserted at surgery and at least one cycle of post-operative hepatic artery chemotherapy. One-, three- and five-year survival was 85%, 43% and 19% respectively, with a median survival of 33 months (95% confidence interval 19.9–42.1). Site of recurrence was recorded and presented. Conclusions: Patients with liver metastases that are not amenable to resection alone can achieve worthwhile median survival with synchronous liver resection and cryotherapy ablation

technique, which avoids all manipulation of the aorta, has been shown to significantly reduce neurological injury compared to an on-pump technique (level 2a) and also an offpump technique with side-clamp (level 2a). During aortic arch surgery, the addition of antegrade cerebral perfusion (level 2a) or retrograde cerebral perfusion (level 3b) to deep hypothermic circulatory arrest (14.1 20 8C) is beneficial. Current evidence suggests that moderate hypothermic circulatory (20.1 28 8C) arrest may also be used with antegrade cerebral perfusion (level 2a). Other beneficial techniques include slow rewarming to avoid hyperthermia (level 2b) and alpha-stat pH management in adults to optimise cerebral blood flow (level 2b). During open repair of extensive thoracoabdominal aneurysms, in addition to reconstruction of the Artery of Adamkiewicz, spinal cord protection may be provided by reimplantation of segmental arteries (level 2b), neurophysiological monitoring with motor or sensory evoked potentials (level 2b), possibly staging repair to allow adaption of the collateral blood supply (level 2b), distal aortic perfusion (level 2b), cerebral spinal fluid drainage (level 2a) alone or with an intrathecal vasodilator (level 2c) or regional spinal cord hypothermia (level 2c) Increased understanding of molecular pathways involved in neurological injury and recovery will lead to novel pharmacological agents and techniques that may have future applications, such as the free radical scavenger edaravone or remote ischaemic preconditioning.

renal dysfunction, and reoperation for bleeding were 5.9%, 4.9%, 8.1%, and 8.1%, respectively, for the contemporary series. Absolute late reintervention was identified in 13.3% of patients overall, and in 11.3% of patients in the contemporary series. Aggregated survival at 1-, 3-, 5-, and 10-years of all patients were 82.1%, 74.1%, 66.3%, and 50.8%, respectively. Conclusions: OSR for chronic type B dissection in the contemporary era offers acceptable results. Management approaches should be considered carefully, taking into account both short-term and long-term complications. More research is required to clarify specific indications for OSR and TEVAR in chronic type B dissections.

Background: Establishing the relative merits of ministernotomy (MS) and minithoracotomy (MT) approaches to minimally invasive aortic valve replacement (MIAVR) is difficult given the limited available direct evidence. Network meta-analysis is a Bayesian approach that can combine direct and indirect evidence to better define the benefits and risks of MS and MT. Methods: Electronic searches were performed using six databases from their inception to June 2014. Relevant studies utilizing a minimally invasive approach for aortic valve replacement were identified. Data were extracted and analyzed according to predefined clinical endpoints. Both traditional and Bayesian meta-analysis approaches were conducted. Results: Compared to full sternotomy, MT was associated with longer cardiopulmonary bypass (CPB) duration (WMD, 9.99; 95% CI, 3.91, 16.07; I 2 =55%; P=0.001) and cross-clamp duration (WMD, 7.64; 95% CI, 2.86, 12.42; P=0.002; I 2 =74%). When compared to MS using network meta-analysis, no significant difference in duration was detected. Postoperative outcomes including 30-day mortality, stroke, and reoperation for bleeding and wound infection were comparable between MS and MT using both traditional and Bayesian meta-analysis techniques. Conclusions: The current evidence demonstrates that MIAVR via MS or MT is a safe and efficacious alternative to conventional median sternotomy. MT may be associated with longer CPB and cross-clamp durations, but has similar post-operative outcomes compared to MS. An individualized approach tailored to both the patient and surgical team is likely to provide optimal outcomes.