157 results on '"Dunning, Joel"'
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2. Statistical and data reporting guidelines for the European Journal of Cardio-Thoracic Surgery and the Interactive Cardiovascular and Thoracic Surgery
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Hickey, Graeme L, Dunning, Joel, Seifert, Burkhardt, Sodeck, Gottfried, Carr, Matthew J, Burger, Hans Ulrich, Beyersdorf, Friedhelm, Hickey, Graeme L, Dunning, Joel, Seifert, Burkhardt, Sodeck, Gottfried, Carr, Matthew J, Burger, Hans Ulrich, and Beyersdorf, Friedhelm
- Abstract
As part of the peer review process for the European Journal of Cardio-Thoracic Surgery (EJCTS) and the Interactive CardioVascular and Thoracic Surgery (ICVTS), a statistician reviews any manuscript that includes a statistical analysis. To facilitate authors considering submitting a manuscript and to make it clearer about the expectations of the statistical reviewers, we present up-to-date guidelines for authors on statistical and data reporting specifically in these journals. The number of statistical methods used in the cardiothoracic literature is vast, as are the ways in which data are presented. Therefore, we narrow the scope of these guidelines to cover the most common applications submitted to the EJCTS and ICVTS, focusing in particular on those that the statistical reviewers most frequently comment on.
- Published
- 2015
3. Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)
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European Association, for Percutaneous Cardiovascular Interventions, Wijns, William, Kolh, Philippe, Danchin, Nicolas, Di Mario, Carlo, Falk, Volkmar, Folliguet, Thierry, Garg, Scot, Huber, Kurt, James, Stefan, Knuuti, Juhani, Lopez-Sendon, Jose, Marco, Jean, Menicanti, Lorenzo, Ostojic, Miodrag, Piepoli, Massimo F, Pirlet, Charles, Pomar, Jose L, Reifart, Nicolaus, Ribichini, Flavio L, Schalij, Martin J, Sergeant, Paul, Serruys, Patrick W, Silber, Sigmund, Sousa Uva, Miguel, Taggart, David, ESC Committee, for Practice Guidelines, Vahanian, Alec, Auricchio, Angelo, Bax, Jeroen, Ceconi, Claudio, Dean, Veronica, Filippatos, Gerasimos, Funck-Brentano, Christian, Hobbs, Richard, Kearney, Peter, McDonagh, Theresa, Popescu, Bogdan A, Reiner, Zeljko, Sechtem, Udo, Sirnes, Per Anton, Tendera, Michal, Vardas Panos, E, Widimsky, Petr, EACTS Clinical Guidelines, Committee, Alfieri, Ottavio, Dunning, Joel, Elia, Stefano, Kappetein, Pieter, Lockowandt, Ulf, Sarris, George, Vouhe, Pascal, von Segesser, Ludwig, Agewall, Stefan, Aladashvili, Alexander, Alexopoulos, Dimitrios, Antunes, Manuel J, Atalar, Enver, Brutel de la Riviere, Aart, Doganov, Alexander, Eha, Jaan, Fajadet, Jean, Ferreira, Rafael, Garot, Jerome, Halcox, Julian, Hasin, Yonathan, Janssens, Stefan, Kervinen, Kari, Laufer, Gunther, Legrand, Victor, Nashef Samer, A M, Neumann, Franz-Josef, Niemela, Kari, Nihoyannopoulos, Petros, Noc, Marko, Piek, Jan J, Pirk, Jan, Rozenman, Yoseph, Sabate, Manel, Starc, Radovan, Thielmann, Matthias, Wheatley, David J, Windecker, Stephan, and Zembala, Marian
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myocardial ,revascularization ,medicine.medical_specialty ,business.industry ,Judgement ,Medizin ,MEDLINE ,Conflict of interest ,EuroSCORE ,Evidence-based medicine ,medicine.disease ,Coronary artery bypass surgery ,Cardiothoracic surgery ,Internal medicine ,medicine ,Cardiology ,Medical emergency ,Cardiology and Cardiovascular Medicine ,Risk assessment ,business - Abstract
Guidelines and Expert Consensus Documents summarize and evaluate all available evidence with the aim of assisting physicians in selecting the best management strategy for an individual patient suffering from a given condition, taking into account the impact on outcome and the risk–benefit ratio of diagnostic or therapeutic means. Guidelines are no substitutes for textbooks and their legal implications have been discussed previously. Guidelines and recommendations should help physicians to make decisions in their daily practice. However, the ultimate judgement regarding the care of an individual patient must be made by his/her responsible physician(s). The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules). Members of this Task Force were selected by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) to represent all physicians involved with the medical and surgical care of patients with coronary artery disease (CAD). A critical evaluation of diagnostic and therapeutic procedures is performed including assessment of the risk–benefit ratio. Estimates of expected health outcomes for society are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to predefined scales, as outlined in Tables 1 and 2 . View this table: Table 1 Classes of recommendations View this table: Table 2 Levels of evidence The members of the Task Force have provided disclosure statements of all relationships that might be perceived as real or potential sources of conflicts of interest. These disclosure forms are kept on file at European Heart House, headquarters of the ESC. Any changes in conflict of interest that arose during the writing period were notified to the ESC. The Task Force report received its entire financial support from the ESC and EACTS, without any involvement of the pharmaceutical, device, or surgical industry. ESC …
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- 2010
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4. EACTS/ESCVS best practice guidelines for reporting treatment results in the thoracic aorta
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Turina, Marko Ivan, Shennib, Hani, Dunning, Joel, Cheng, Davy, Martin, Janet, Muneretto, Claudio, Schueler, Stephan, von Segesser, Ludwig, Sergeant, Paul T, EACTS/ESCVS committee, Turina, Marko Ivan, Shennib, Hani, Dunning, Joel, Cheng, Davy, Martin, Janet, Muneretto, Claudio, Schueler, Stephan, von Segesser, Ludwig, Sergeant, Paul T, and EACTS/ESCVS committee
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Endovascular treatment of the thoracic aorta (TEVAR) is rapidly expanding, with new devices and techniques, combined with classical surgical approaches in hybrid procedures. The present guidelines provide a standard format for reporting results of treatment in the thoracic aorta, and to facilitate analysis of clinical results in various therapeutic approaches. These guidelines specify the essential information and definitions, which should be provided in each article about TEVAR: Definitions of disease conditions Extent of the disease Comorbidities Exact demographics of the patient material Description of the procedure performed Devices which were utilized Methods for reporting early and late mortality, and morbidity Reinterventions and additional procedures Statistical evaluation It is hoped that strict adherence to these criteria will make the future publications about TEVAR more comparable, and will enable the readership to draw their own, scientifically validated conclusions about the reports
- Published
- 2009
5. The pectus care guidelines: best practice consensus guidelines from the joint specialist societies SCTS/MF/CWIG/BOA/BAPS for the treatment of patients with pectus abnormalities.
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Dunning J (UK), Burdett C (UK), Child A (UK), Davies C (UK), Eastwood D (UK), Goodacre T (UK), Haecker FM, Kendall S (UK), Kolvekar S (UK), MacMahon L (USA), Marven S (UK), Murray S (UK), Naidu B (UK), Pandya B (UK), Redmond K (UK), and Coonar A (UK)
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- Humans, Funnel Chest surgery, Funnel Chest therapy, Sternum abnormalities, Consensus, Pectus Carinatum therapy
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Pectus defects are a group of congenital conditions found in approximately 1 in 250 people, where the sternum is depressed back towards the spine (excavatum), protrudes forwards (carinatum) or more rarely is a mixture of both (arcuatum or mixed defects). For the majority of patients, it is well tolerated, but some patients are affected psychologically, physiologically or both. The deformity becomes apparent at a young age due to the growth of the ribs and the cartilage that links them to the sternum. The majority of defects are mild and are well tolerated, i.e. they do not affect activity and do not cause psychological harm. However, some young people develop lower self-esteem and depression, causing them to withdraw from activities (such as swimming, dancing) and from interactions that might 'expose' them (such as sleepovers, dating, going to the beach and wearing fashionable clothes). This psychological harm occurs at a crucial time during their physical and social development. A small number of patients have more extreme depression of their sternum that impedes their physiological reserve, which can occur when engaging in strenuous exercise (such as running) but can also limit moderate activity such as walking and climbing stairs. The effects can be so extreme that symptoms occur at rest or cause life-threatening compression of the major blood vessels and organs. The group of patients with physiological impairment usually also suffer from low self-esteem and depression. This paper summarizes the current evidence for the different treatment strategies for this condition, including supportive care, psychological support and non-surgical techniques including bracing and vacuum bell therapy. We also consider surgical techniques including the Ravitch procedure, the Nuss procedure (minimally invasive repair of pectus excavatum), pectus implants and other rare procedures such as Pectus Up. For the majority of patients, supportive care is sufficient, but for a minority, a combination of the other techniques may be considered. This paper also outlines best practice guidance for the delivery of such therapies, including standardized assessment, consent to treatment, audit, quality assurance and long-term support. All the interventions have risks and benefits that the patient, parents and clinicians need to carefully consider and discuss when deciding on the most appropriate course. We hope this evidence review of 'Best Practice for Pectus' will make a significant contribution to those considerations and help all involved, from patients to national policy makers, to deliver the best possible care., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2024
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6. Results of an exploratory survey within ESTS membership in 2022 on current trend of robotic-assisted thoracic surgery and its training perspectives.
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Gandhi S, Novoa Valentin NM, Brunelli A, Schmitt-Opitz I, Lugaresi M, Daddi N, Decaluwe H, Batirel H, Veronesi G, Baste JM, Lyberis P, and Dunning J
- Abstract
Objectives: Robotic-assisted thoracic surgery (RATS) is increasingly used in our specialty. We surveyed European Society of Thoracic Surgeons membership with the objective to determine current status of robotic thoracic surgery practice including training perspectives., Methods: A survey of 17 questions was rolled out with 1 surgeon per unit responses considered as acceptable., Results: A total of 174 responses were obtained; 56% (97) were board-certified thoracic surgeons; 28% (49) were unit heads. Most responses came from Italy (20); 22% (38) had no robot in their institutions, 31% (54) had limited access and only 17% (30) had full access including proctoring. Da Vinci Xi was the commonest system in 56% (96) centres, 25% (41) of them had dual console in all systems, whereas RATS simulator was available only in half (51.18% or 87). Video-assisted thoracic surgery (VATS) was the most commonly adopted surgical approach in 81% of centres (139), followed by thoracotomy in 67% (115) and RATS in 36% (62); 39% spent their training time on robotic simulator for training, 51% on robotic wet/dry lab, which being no significantly different to 46-59% who had training on VATS platform. There was indeed huge overlap between simulator models or varieties usage; 52% (90) reported of robotic surgery not a part of training curriculum with no plans to introduce it in future. Overall, 51.5% (89) responded of VATS experience being helpful in robotic training in view of familiarity with minimally invasive surgery anatomical views and dissection; 71% (124) reported that future thoracic surgeons should be proficient in both VATS and RATS. Half of the respondents found no difference in earlier chest drain removal with either approach (90), 35% (60) reported no difference in postoperative pain and 49% (84) found no difference in hospital stay; 52% (90) observed better lymph node harvest by RATS., Conclusions: Survey concluded on a positive response with at least 71% (123) surgeons recommending to adopt robotics in future., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)
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- 2024
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7. European guidelines for the surgical management of pure ground-glass opacities and part-solid nodules: Task Force of the European Association of Cardio-Thoracic Surgery and the European Society of Thoracic Surgeons.
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Cardillo G, Petersen RH, Ricciardi S, Patel A, Lodhia JV, Gooseman MR, Brunelli A, Dunning J, Fang W, Gossot D, Licht PB, Lim E, Roessner ED, Scarci M, and Milojevic M
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- Humans, Heart, Advisory Committees, Thoracic Surgery, Thoracic Surgical Procedures
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- 2023
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8. Preclinical evaluation of Versius, an innovative device for use in robot-assisted thoracic surgery.
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Aresu G, Dunning J, Routledge T, Bagan P, and Slack M
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- Cadaver, Humans, Pneumonectomy methods, Thoracic Surgery, Video-Assisted methods, Robotics, Thoracic Surgery
- Abstract
Objectives: The adoption of robot-assisted thoracic surgery (RATS) has helped to overcome some of the challenges associated with surgeons performing conventional video-assisted thoracic surgery. The Versius Surgical System (CMR Surgical, Cambridge, UK) has been developed iteratively in line with surgical team feedback to improve the surgeon's experience and patient outcomes. The goal of this study was to assess the use of the device in RATS in a preclinical setting and to fulfil Idea, Development, Exploration, Assessment, Long-Term Follow Up-Devices stage 1 (Idea)., Methods: Four cadaveric sessions were conducted between November 2018 and December 2020, during which device performance in a range of thoracic operations was assessed. Procedures were categorized as either completed or not completed, and surgeons evaluated the device's ability to successfully complete necessary surgical steps. Port and bedside unit positions were recorded., Results: In total, 22/24 (91.7%) thoracic procedures were successfully completed, including 17/18 lobectomies, 2/3 thymectomies and 3/3 diaphragm plications, in 9 cadaver specimens. One thymectomy could not be completed due to cadaver anatomy and 1 lobectomy was not completed due a console system fault. Port and bedside unit configurations were successfully validated for all procedures, and lead surgeons deemed the device to be well-suited for thoracic surgery., Conclusions: This preclinical study demonstrated the successful use of the device in RATS in cadaveric models and supports progression to small-scale clinical studies, as part of Idea, Development, Exploration, Assessment, Long-Term Follow Up-Devices stage 2a (Development)., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)
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- 2022
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9. European Society of Thoracic Surgeons electronic quality of life application after lung resection: field testing in a clinical setting.
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Pompili C, Trevis J, Patella M, Brunelli A, Libretti L, Novoa N, Scarci M, Tenconi S, Dunning J, Cafarotti S, Koller M, Velikova G, Shargall Y, and Raveglia F
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- Electronics, Humans, Longitudinal Studies, Lung surgery, Lung Neoplasms surgery, Pneumonectomy adverse effects, Prospective Studies, Quality of Life, Thoracic Surgery, Video-Assisted adverse effects, Surgeons
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Objectives: Technology has the potential to assist healthcare professionals in improving patient-doctor communication during the surgical journey. Our aims were to assess the acceptability of a quality of life (QoL) application (App) in a cohort of cancer patients undergoing lung resections and to depict the early perioperative trajectory of QoL., Methods: This multicentre (Italy, UK, Spain, Canada and Switzerland) prospective longitudinal study with repeated measures used 12 lung surgery-related validated questions from the European Organisation for Research and Treatment of Cancer Item Bank. Patients filled out the questionnaire preoperatively and 1, 7, 14, 21 and 28 days after surgery using an App preinstalled in a tablet. A one-way repeated measures analysis of variance was run to determine if there were differences in QoL over time., Results: A total of 103 patients consented to participate in the study (83 who had lobectomies, 17 who had segmentectomies and 3 who had pneumonectomies). Eighty-three operations were performed by video-assisted thoracoscopic surgery (VATS). Compliance rates were 88%, 90%, 88%, 82%, 71% and 56% at each time point, respectively. The results showed that the operation elicited statistically significant worsening in the following symptoms: shortness of breath (SOB) rest (P = 0.018), SOB walk (P < 0.001), SOB stairs (P = 0.015), worry (P = 0.003), wound sensitivity (P < 0.001), use of arm and shoulder (P < 0.001), pain in the chest (P < 0.001), decrease in physical capability (P < 0.001) and scar interference on daily activity (P < 0.001) during the first postoperative month. SOB worsened immediately after the operation and remained low at the different time points. Worry improved following surgery. Surgical access and forced expiratory volume in 1 s (FEV1) are the factors that most strongly affected the evolution of the symptoms in the perioperative period., Conclusions: We observed good early compliance of patients operated on for lung cancer with the European Society of Thoracic Surgeons QoL App. We determined the evolution of surgery-related QoL in the immediate postoperative period. Monitoring these symptoms remotely may reduce hospital appointments and help to establish early patient-support programmes., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2021
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10. The Reamer-Irrigator-Aspirator technique for manubriosternal non-union repair†.
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Naruka V, Nardini M, McVie J, and Dunning J
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Autologous bone graft is used in the treatment of fracture non-unions. A novel approach to treat painful manubriosternal non-unions is described with bone graft harvested from the femur and plating., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2019
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11. Medical student exposure to cardiothoracic surgery in the United Kingdom.
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Gasparini M, Jayakumar S, Ayton S, Nardini MN, and Dunning JD
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Objectives: There has been declining interest in cardiothoracic surgery amongst medical graduates. This survey examines the exposure of British medical students to cardiothoracic surgery in various settings and its relationship with students' interest in the speciality., Methods: A questionnaire composed of 14 quantitative and qualitative items was distributed amongst 162 medical students. The survey included questions on demographics, interest in cardiothoracic surgery, mechanisms of exposure to the speciality and desire to pursue a career in cardiothoracic surgery before and after exposure., Results: Amongst the surveyed students, 71.0% reported exposure to cardiothoracic surgery as part of their medical school curricula and 24.7% reported extracurricular exposure. Of the students, 46.7% reported clinical exposure. Overall, 27.1% of students reported interest in a career in cardiothoracic surgery, which was higher amongst students who had curricular (29.6%), clinical (35.5%) or extracurricular exposure (50.0%). Amongst interested students, 43.2% engaged in extracurricular cardiothoracic activities compared with 16.1% of students not interested in pursuing the speciality. Confidence in career choice after exposure increased more in interested students (20.4%) than not interested students (1.6%). Students rated exposure and mentorship as the most important factor in promoting a career in cardiothoracic surgery., Conclusions: Medical students with an interest in cardiothoracic surgery are more likely to organize independent attachments in the speciality and attend extracurricular events; however, many students might fail to identify cardiothoracic surgery as an area of interest because of the lack of exposure at medical school., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2019
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12. Statistical primer: sample size and power calculations-why, when and how?
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Hickey GL, Grant SW, Dunning J, and Siepe M
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- Data Interpretation, Statistical, Humans, Patient Dropouts statistics & numerical data, Research Design, Software, Clinical Trials as Topic methods, Sample Size
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When designing a clinical study, a fundamental aspect is the sample size. In this article, we describe the rationale for sample size calculations, when it should be calculated and describe the components necessary to calculate it. For simple studies, standard formulae can be used; however, for more advanced studies, it is generally necessary to use specialized statistical software programs and consult a biostatistician. Sample size calculations for non-randomized studies are also discussed and two clinical examples are used for illustration.
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- 2018
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13. Outcomes from the Delphi process of the Thoracic Robotic Curriculum Development Committee.
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Veronesi G, Dorn P, Dunning J, Cardillo G, Schmid RA, Collins J, Baste JM, Limmer S, Shahin GMM, Egberts JH, Pardolesi A, Meacci E, Stamenkovic S, Casali G, Rueckert JC, Taurchini M, Santelmo N, Melfi F, and Toker A
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- Clinical Competence, Consensus, Curriculum, Humans, Learning Curve, Robotic Surgical Procedures methods, Surgeons organization & administration, Thoracic Surgical Procedures methods, Education, Medical, Graduate methods, Robotic Surgical Procedures education, Surgeons education, Thoracic Surgery organization & administration, Thoracic Surgical Procedures education
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Objectives: As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery., Methods: In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds., Results: Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners., Conclusions: Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing.
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- 2018
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14. Robotic right middle lobectomy with a subxiphoid utility port.
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Jayakumar S, Nardini M, Papoulidis P, and Dunning J
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- Adenocarcinoma of Lung diagnosis, Aged, Equipment Design, Humans, Male, Neoplasm Staging, Pain, Postoperative, Xiphoid Bone, Adenocarcinoma of Lung surgery, Pneumonectomy methods, Robotics instrumentation
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We present the case of a 74-year-old man with Stage IIa pulmonary adenocarcinoma, for which he underwent a robotic right middle lobectomy. A 4-armed, 5-port approach was used. Four intercostal ports were created above the ninth rib using the Cerfolio's technique. The subxiphoid port was created in the midline, 5 cm down from the xiphisternum. The robot offers higher image quality, depth perception and improved articulation of the instruments, allowing for more accurate dissection and stitching. The usage of a subxiphoid utility port reduces the clashing between instruments, offers a good angle for stapling and provides a direct view of the instruments entering into the chest. Specimen removal through the subxiphoid port may reduce postoperative pain and enhance patient recovery. The use of the subxiphoid approach as a utility port for robotic surgery is promising and may be a suitable replacement for the traditional utility port.
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- 2018
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15. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery.
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Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, and Landmesser U
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- Adult, Europe, Humans, Cardiac Surgical Procedures, Cardiovascular Agents therapeutic use, Perioperative Care standards, Quality Improvement, Thoracic Surgery
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- 2018
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16. Video-assisted thoracic surgery mediastinal germ cell metastasis resection.
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Nardini M, Jayakumar S, Migliore M, and Dunning J
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- Adult, Humans, Male, Mediastinal Neoplasms diagnosis, Mediastinal Neoplasms secondary, Neoplasm Metastasis, Teratoma diagnosis, Teratoma secondary, Tomography, X-Ray Computed, Mediastinal Neoplasms surgery, Metastasectomy methods, Teratoma surgery, Testicular Neoplasms pathology, Thoracic Surgery, Video-Assisted methods
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Thoracoscopy can be safely used for dissection of masses in the visceral mediastinum. We report the case of a 31-year-old man affected by metastatic germ cell tumour and successfully treated with a 3-port posterior approach video-assisted thoracic surgery., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2017
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17. Left video-assisted thoracoscopic surgery for hemidiaphragm traumatic rupture repair.
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Nardini M, Jayakumar S, Elsaegh M, and Dunning J
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- Diaphragm injuries, Female, Humans, Male, Rupture, Accidents, Traffic, Diaphragm surgery, Hernia, Diaphragmatic, Traumatic surgery, Thoracic Surgery, Video-Assisted methods
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Diaphragmatic laceration is not a rare condition after blunt thoraco-abdominal trauma following road traffic accidents. Diagnosis is sometime difficult and clinical presentation devious. Video-assisted thoracic surgery is a safe approach in order to confirm diagnosis and treat, like in this this case of an 86-year-old lady with grade IV injury., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2017
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18. Chylopericardium with symptoms of tamponade on the grounds of extensive neck vein thrombosis.
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Nardini M, Katsogridakis E, Migliore M, and Dunning J
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Chylopericardium is a recognized complication of thoracic trauma, surgery or malignancy. Idiopathic or primary presentations, however, are rarely encountered in clinical practice. The severity of its presentation varies from the complete absence of symptoms to cardiac tamponade. We present the case of a 23-year-old woman with chylopericardium and extensive neck vein thrombosis that was managed surgically with a pericardial window., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2017.)
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- 2017
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19. European Association for Cardio-Thoracic Surgery expert consensus statement on the prevention and management of mediastinitis.
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Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T, Sousa-Uva M, Licht PB, Dunning J, Schmid RA, and Cardillo G
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- Europe, Humans, Consensus, Disease Management, Mediastinitis prevention & control, Societies, Medical, Surgical Wound Infection prevention & control, Thoracic Surgery, Thoracic Surgical Procedures adverse effects
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Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2017
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20. A view of the Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) trial from the coalface.
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Dunning J
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- Colorectal Neoplasms surgery, Humans, Pneumonectomy, Lung Neoplasms surgery, Metastasectomy
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- 2016
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21. Corrigendum to 'Statistical and data reporting guidelines for the European Journal of Cardio-Thoracic Surgery and the Interactive CardioVascular and Thoracic Surgery' [Eur J Cardiothorac Surg 2015;48:180-93]†.
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Hickey GL, Dunning J, Seifert B, Sodeck G, Carr MJ, Burger HU, and Beyersdorf F
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- 2016
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22. Methodology manual for European Association for Cardio-Thoracic Surgery (EACTS) clinical guidelines.
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Sousa-Uva M, Head SJ, Thielmann M, Cardillo G, Benedetto U, Czerny M, Dunning J, Castella M, Gudbjartsson T, Howell N, Hazekamp M, Kolh P, Beyersdorf F, Pagano D, and Kappetein AP
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- Europe, Evidence-Based Medicine methods, Evidence-Based Medicine standards, Humans, Societies, Medical standards, Thoracic Surgery standards, Practice Guidelines as Topic, Thoracic Surgical Procedures standards
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The goal of all clinical guidelines is to assist patients and practitioners in making healthcare decisions. However, clinical guidelines have been questioned about their quality, transparency and independence. Based on the revision of manuals by other scientific cardiothoracic organizations, this document provides instructions for the development of European Association for Cardio-Thoracic Surgery (EACTS) clinical guidelines and other types of evidence-based documents. Four key areas have been addressed: (i) selection of taskforce members and transparency of relations with the industry, (ii) methods for critical appraisal of medical evidence, (iii) rules for writing recommendations and (iv) review process. It is hoped that, by adopting this methodology, clinical guidelines produced by the EACTS will be well balanced, objective and, importantly, trusted by physicians and patients who benefit from their implementation., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
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- 2015
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23. Statistical and data reporting guidelines for the European Journal of Cardio-Thoracic Surgery and the Interactive CardioVascular and Thoracic Surgery.
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Hickey GL, Dunning J, Seifert B, Sodeck G, Carr MJ, Burger HU, and Beyersdorf F
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- Biomedical Research standards, Europe, Humans, Peer Review standards, Publishing standards, Research Design standards, Data Interpretation, Statistical, Periodicals as Topic standards, Research Report standards, Thoracic Surgery standards
- Abstract
As part of the peer review process for the European Journal of Cardio-Thoracic Surgery (EJCTS) and the Interactive CardioVascular and Thoracic Surgery (ICVTS), a statistician reviews any manuscript that includes a statistical analysis. To facilitate authors considering submitting a manuscript and to make it clearer about the expectations of the statistical reviewers, we present up-to-date guidelines for authors on statistical and data reporting specifically in these journals. The number of statistical methods used in the cardiothoracic literature is vast, as are the ways in which data are presented. Therefore, we narrow the scope of these guidelines to cover the most common applications submitted to the EJCTS and ICVTS, focusing in particular on those that the statistical reviewers most frequently comment on., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
- Published
- 2015
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24. A comparison of outcomes between bovine pericardial and porcine valves in 38,040 patients in England and Wales over 10 years.
- Author
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Hickey GL, Grant SW, Bridgewater B, Kendall S, Bryan AJ, Kuo J, and Dunning J
- Subjects
- Animals, Bicuspid Aortic Valve Disease, Bioprosthesis adverse effects, Cattle, England, Female, Heart Defects, Congenital surgery, Heart Valve Diseases surgery, Heart Valve Prosthesis Implantation adverse effects, Humans, Male, Postoperative Complications, Retrospective Studies, Swine, Treatment Outcome, Wales, Aortic Valve surgery, Bioprosthesis statistics & numerical data, Heart Valve Prosthesis Implantation instrumentation, Heart Valve Prosthesis Implantation mortality
- Abstract
Objectives: Biological valves are the most commonly implanted prostheses for aortic valve replacement (AVR) surgery in the UK. The aim of this study was to compare performance of porcine and bovine pericardial valves implanted in AVR surgery with respect to survival and reintervention-free survival in a retrospective observational study., Methods: Prospectively collected clinical data for all first-time elective and urgent AVRs with or without concomitant coronary artery bypass graft (CABG) surgery performed in England and Wales between April 2003 and March 2013 were extracted from the National Institute for Cardiovascular Outcomes Research database. Patient life status was tracked from the Office for National Statistics. Time-to-event analyses were performed using log-rank tests and Cox proportional hazards regression modelling with random effects/grouped frailty for responsible cardiac surgeons., Results: A total of 38,040 patients were included (64.9% bovine pericardial; 35.1% porcine). Patient characteristics were similar between the groups. The median follow-up was 3.6 years. There was no statistically significant difference in survival (P = 0.767) (the 10-year survival rates were 49.0 and 50.3% in the bovine pericardial and porcine groups, respectively) or reintervention-free survival. The adjusted hazard ratio for porcine valves was 0.98 (95% confidence interval 0.93-1.03). Sensitivity analysis in small valve sizes showed no difference in reintervention-free survival. After adjustment, there was some evidence of a protective effect for porcine valves in relatively younger patients (P = 0.075)., Conclusions: There were no differences in reintervention-free survival between bovine pericardial and porcine valves used in first-time AVR ± CABG up to a maximum of 10 years., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
- Published
- 2015
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25. The use of octreotide in the treatment of chylothorax following cardiothoracic surgery.
- Author
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Ismail NA, Gordon J, and Dunning J
- Subjects
- Animals, Benchmarking, Chylothorax diagnosis, Chylothorax etiology, Dogs, Evidence-Based Medicine, Female, Humans, Male, Middle Aged, Octreotide adverse effects, Parenteral Nutrition, Total, Reoperation, Risk Factors, Treatment Outcome, Chylothorax drug therapy, Octreotide therapeutic use, Thoracic Surgical Procedures adverse effects
- Abstract
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Is octreotide (a long-acting somatostatin analogue) effective in patients with post-operative or traumatic chylothorax as a part of conservative management to reduce lymphorrhagia?' Altogether 180 papers were found using the reported search, of which 20 represented the best evidence to answer the clinical question. One case was reported twice and therefore was excluded, leaving us with 19 papers. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Although rare, iatrogenic and traumatic chylothorax have been well described in the literature. At present, there have been no randomized controlled clinical trials on the use of octreotide in chylothorax. Sixteen of 19 papers found octreotide to be effective in the treatment of chylothorax. Octreotide was found to have no complementary effect in three reports. Two of the papers were retrospective studies: one a randomized controlled trial in canines, and the remainder were case reports and case series. The two retrospective studies showed a success rate of 87-90% in the use of octreotide as an adjunct to conservative management for the treatment of chylothorax and hence preventing the need for further surgery. Experimental study in canines has shown significant drain reduction and earlier fistula closure, although transferability of this result to human is difficult to interpret. Twelve case reports found octreotide effective in reduction of the volume and arrest of chylothorax. Most reported benefit in 2-3 days of administration of octreotide. The general consensus is for conservative management with octreotide to be instituted for 1 week before consideration of surgery, although some authors have advocated for a large volume chylothorax, especially after oesophageal surgery with no response to conservative management with octreotide, to be operated on sooner. We concluded that octreotide is effective in the management of moderate to large volume chylothorax., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
- Published
- 2015
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26. Thoracoscopic diaphragm plication.
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Dunning J
- Subjects
- Carbon Dioxide administration & dosage, Carbon Dioxide pharmacology, Diaphragm innervation, Humans, Minimally Invasive Surgical Procedures methods, Patient Safety, Pneumothorax, Artificial methods, Respiratory Paralysis physiopathology, Respiratory Paralysis surgery, Thoracic Surgery, Video-Assisted methods, Treatment Outcome, Diaphragm surgery, Peripheral Nerve Injuries surgery, Phrenic Nerve injuries, Thoracic Surgery, Video-Assisted instrumentation
- Abstract
Diaphragm plication is a relatively common operation in thoracic surgery and can be a major benefit to patients who have suffered phrenic nerve injury and who are left short of breath as a result [1]. With the advent of video-assisted thoracoscopic surgery (VATS) many surgeons have attempted diaphragm plication endoscopically. Barriers to implementation of VATS diaphragm plication include concerns regarding initial port entry with such a high diaphragm, the technical ability to suture by VATS and concern regarding the placement of sutures to a thin diaphragm draped tightly over a spleen, liver or large intestine. We present a simple way to overcome these barriers using carbon dioxide to increase the size of the hemithorax and relax the tension on the diaphragm, an Endostitch device that makes pledgeted suturing straightforward and a novel endograsper that allows a wide range of angles to be achieved when handling the diaphragm., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
- Published
- 2015
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27. Manubrium-limited sternotomy decreases blood loss after aortic valve replacement surgery.
- Author
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Burdett CL, Lage IB, Goodwin AT, White RW, Khan KJ, Owens WA, Kendall SW, Ferguson JI, Dunning J, and Akowuah EF
- Subjects
- Adult, Aged, Aged, 80 and over, Databases, Factual, Female, Heart Valve Prosthesis Implantation adverse effects, Heart Valve Prosthesis Implantation mortality, Humans, Length of Stay, Logistic Models, Male, Middle Aged, Plasma, Platelet Transfusion, Postoperative Hemorrhage etiology, Postoperative Hemorrhage mortality, Retrospective Studies, Risk Factors, Sternotomy adverse effects, Sternotomy mortality, Time Factors, Treatment Outcome, Young Adult, Aortic Valve surgery, Heart Valve Prosthesis Implantation methods, Manubrium surgery, Postoperative Hemorrhage prevention & control, Sternotomy methods
- Abstract
Objectives: Minimally invasive surgical approaches for aortic valve replacement (AVR) are growing in popularity in an attempt to decrease morbidity from conventional surgery. We have adopted a technique that divides only the manubrium and spares the body of the sternum. We sought to determine whether patients benefit from this less-invasive approach., Methods: We retrospectively analysed our prospectively maintained database to review all isolated aortic valve replacements performed in an 18-month period from November 2011 to April 2013., Results: One hundred and ninety-one patients were identified, 98 underwent manubrium-limited sternotomy (Mini-AVR) and 93 had a conventional median sternotomy (AVR). The two groups were well matched for preoperative variables and risk (mean logistic EuroSCORE mini-AVR 7.15 vs AVR 6.55, P = 0.47). Mean cardiopulmonary bypass and aortic cross-clamp times were 10 and 6 min longer, respectively, in the mini-AVR group (mean values 88 vs 78 min, P = 0.00040, and 66 vs 60 min, P = 0.0078, respectively). Mini-AVR patients had significantly less postoperative blood loss, 332 vs 513 ml, P = 0.00021, and were less likely to require blood products (fresh-frozen plasma and platelets), 24 vs 36%, P = 0.042. Postoperative complications and length of stay were similar (discharge on or before Day 4; mini-AVR 15 vs AVR 8%, P = 0.17). Valve outcome (paravalvular leak mini-AVR 2 vs AVR 1%, P = 1.00) and survival (mini-AVR 99 vs AVR 97%, P = 0.36) were equal., Conclusions: A manubrium-limited approach maintains outcomes achieved for aortic valve replacement by conventional sternotomy while significantly reducing postoperative blood loss and transfusion of blood products., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)
- Published
- 2014
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28. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI).
- Author
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Kolh P, Windecker S, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol Ç, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Sousa Uva M, Achenbach S, Pepper J, Anyanwu A, Badimon L, Bauersachs J, Baumbach A, Beygui F, Bonaros N, De Carlo M, Deaton C, Dobrev D, Dunning J, Eeckhout E, Gielen S, Hasdai D, Kirchhof P, Luckraz H, Mahrholdt H, Montalescot G, Paparella D, Rastan AJ, Sanmartin M, Sergeant P, Silber S, Tamargo J, ten Berg J, Thiele H, van Geuns RJ, Wagner HO, Wassmann S, Wendler O, and Zamorano JL
- Subjects
- Europe, Female, Humans, Male, Thoracic Surgery organization & administration, Thoracic Surgery standards, Myocardial Revascularization methods, Myocardial Revascularization standards
- Published
- 2014
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29. Is thymectomy in non-thymomatous myasthenia gravis of any benefit?
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Diaz A, Black E, and Dunning J
- Subjects
- Adult, Benchmarking, Evidence-Based Medicine, Female, Humans, Male, Myasthenia Gravis diagnosis, Patient Selection, Remission Induction, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, Myasthenia Gravis surgery, Thymectomy adverse effects
- Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was if thymectomy in non-thymomatous myasthenia gravis was of any benefit? Overall, 137 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The outcome variables were similar in all of the papers, including complete stable remission (CSR), pharmacological remission, age at presentation, gender, duration of symptoms, preoperative classification (Oosterhius, Osserman or myasthenia gravis Foundation of America (MGFA)), thymic pathology, preoperative medications (steroids, immunosuppressants), mortality and morbidity. We conclude that evidence-based reviews have shown that relative rates of thymectomy patients compared with non-thymectomy patients attaining outcome indicate that the former group of patients is more likely to achieve medication-free remission, become asymptomatic and clinically improve (54%, P < 0.01), particularly patients with severe and generalized symptoms (P = 0.007). Patients with generalized myasthenia gravis showed 11% stronger association with favourable outcomes after thymectomy. Some studies show early remission rates (RRs), as early as 6 months post-thymectomy, of 44%. Overall, the reported remission rate for non-thymomatous myasthenia gravis is between 38 and 72% up to 10 years of follow-up. Among these patients, those with thymic hyperplasia show the best complete stable remission rates (42%, P < 0.04) in the majority of studies. Age showed variability across the studies and the cut-off was also different among them. Overall age < 45 years showed a higher probability of achieving complete stable remission during follow-up (81% benefit rate (BR), P < 0.02). Pharmacological improvement is reported between 6 and 42%. However, the certainty of these benefits has not been established due to factors such as the confounding differences between myasthenia gravis patients receiving and not receiving thymectomy, the non-randomized nature of class II studies and the lack of Class I evidence to support its use. There is currently a randomized trial ongoing looking at thymectomy by sternotomy vs controls and the results are eagerly awaited.
- Published
- 2014
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30. Is cryoanalgesia effective for post-thoracotomy pain?
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Khanbhai M, Yap KH, Mohamed S, and Dunning J
- Subjects
- Analgesia adverse effects, Benchmarking, Evidence-Based Medicine, Female, Humans, Male, Middle Aged, Pain Measurement, Pain, Postoperative diagnosis, Pain, Postoperative etiology, Treatment Outcome, Analgesia methods, Cold Temperature adverse effects, Cryotherapy adverse effects, Pain, Postoperative prevention & control, Thoracotomy adverse effects
- Abstract
A best evidence topic was written according to a structured protocol. The question addressed was whether cryoanalgesia improves post-thoracotomy pain and recovery. Twelve articles were identified that provided the best evidence to answer the question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were pain scores, additional opiate requirements, incidence of hypoesthesia and change in lung function. Half of the articles reviewed failed to demonstrate superiority of cryoanalgesia over other pain relief methods; however, additional opiate requirements were reduced in patients receiving cryoanalgesia. Change in lung function postoperatively was equivocal. Cryoanalgesia potentiated the incidence of postoperative neuropathic pain. Further analysis of the source of cryoanalgesia, duration, temperature obtained and extent of blockade revealed numerous discrepancies. Three studies utilized CO2 as the source of cryoanalgesia and four used nitrous oxide, but at differing temperatures and duration. Five studies did not reveal the source of cyroanalgesia. The number of intercostal nerves anaesthetized in each study varied. Seven articles anaesthetized three intercostal nerves, three articles used five intercostal nerves, one article used four intercostal nerves and one used one intercostal nerve at the thoracotomy site. Thoracotomy closure and site of area of chest drain insertion may have a role in postoperative pain; but only one article explained method of closure, and two articles mentioned placement of chest drain through blocked dermatomes. No causal inferences can be made by the above results as they are not directly comparable due to confounding variables between studies. Currently, the evidence does not support the use of cryoanalgesia alone as an effective method for relieving post-thoracotomy pain.
- Published
- 2014
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31. Does tranexamic acid stop haemoptysis?
- Author
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Moen CA, Burrell A, and Dunning J
- Subjects
- Antifibrinolytic Agents adverse effects, Benchmarking, Evidence-Based Medicine, Hemoptysis etiology, Humans, Patient Selection, Risk Factors, Thromboembolism chemically induced, Time Factors, Tranexamic Acid adverse effects, Treatment Outcome, Antifibrinolytic Agents therapeutic use, Hemoptysis drug therapy, Tranexamic Acid therapeutic use
- Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Does tranexamic acid stop haemoptysis'? Altogether 49 papers were found using the reported search strategy, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This consisted of one systematic review including a meta-analysis of two double-blind randomized controlled trials (RCTs), the two RCTs, one cohort study, two case-series and seven case reports. Main outcomes included bleeding time, bleeding volume and occurrence of thromboembolic complications after start of treatment. Based on results from the meta-analysis, no difference in remission of bleeding within 1 week was found between tranexamic acid (TA) and placebo groups (odds ratio 1.56, 95% CI: 0.44-5.46). However, overall bleeding time was significantly shorter for the TA group (weighted mean difference -19.47, 95% CI: -26.90, -12.03 h). In one RCT, TA reduced both the duration and the volume of bleeding compared with patients receiving placebo (both P < 0.0005). However, the other RCT failed to find a difference in bleeding time (P = 0.2). In these studies, no patient suffered from thromboembolic complications. Two case reports, however, describe development of pulmonary embolism during TA treatment. Several case reports on the use of TA for treatment of haemoptysis secondary to cystic fibrosis were found. In general, they suggest that TA may be a useful and well-tolerated medication for the treatment of intractable haemoptysis in this patient group. We conclude that limited research on the use of TA for treatment of haemoptysis exists. As aetiology of haemoptysis as well as length of treatment, dosage and form of TA administration varied between the studies, strong recommendations are difficult to give. Current best evidence, however, indicates that TA may reduce both the duration and volume of bleeding, with low risk of short-term thromboembolic complications, in patients with haemoptysis.
- Published
- 2013
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32. Guideline for the surgical treatment of atrial fibrillation.
- Author
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Dunning J, Nagendran M, Alfieri OR, Elia S, Kappetein AP, Lockowandt U, Sarris GE, and Kolh PH
- Subjects
- Ablation Techniques methods, Ablation Techniques standards, Heart Atria surgery, Humans, Randomized Controlled Trials as Topic, Atrial Fibrillation surgery, Cardiac Surgical Procedures methods, Cardiac Surgical Procedures standards
- Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is ∼1-2% of the general population, but higher with increasing age and in patients with concomitant heart disease. The Cox-maze III procedure was a groundbreaking development and remains the surgical intervention with the highest cure rate, but due to its technical difficulty alternative techniques have been developed to create the lesions sets. The field is fast moving and there are now multiple energy sources, multiple potential lesion sets and even multiple guidelines addressing the issues surrounding the surgical treatment of AF both for patients undergoing this concomitantly with other cardiac surgical procedures and also as stand-alone procedures either via sternotomy or via videothoracoscopic techniques. The aim of this document is to bring together all major guidelines in this area into one resource for clinicians interested in surgery for AF. Where we felt that guidance was lacking, we also reviewed the evidence and provided summaries in those areas. We conclude that AF surgery is an effective intervention for patients with all types of AF undergoing concomitant cardiac surgery to reduce the incidence of AF, as demonstrated in multiple randomized studies. There is some evidence that this translates into reduced stroke risk, reduced heart failure risk and longer survival. In addition, symptomatic patients with AF may be considered for surgery after failed catheter intervention or even as an alternative to catheter intervention where either catheter ablation is contraindicated or by patient choice.
- Published
- 2013
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33. Dissection of the pulmonary ligament during upper lobectomy: is it necessary?
- Author
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Khanbhai M, Dunning J, Yap KH, and Rammohan KS
- Subjects
- Benchmarking, Evidence-Based Medicine, Female, Humans, Male, Middle Aged, Pneumonectomy adverse effects, Pneumonectomy mortality, Postoperative Complications mortality, Postoperative Complications prevention & control, Risk Factors, Treatment Outcome, Dissection adverse effects, Dissection mortality, Ligaments surgery, Pneumonectomy methods
- Abstract
A best evidence topic was written according to a structured protocol. The question addressed was whether dissection of the pulmonary ligament during an upper lobectomy would result in improved outcomes. A total of 85 articles were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were complications associated with dissection (atelectasis, bronchial stenosis, bronchial obstruction and bronchial deformation) and preservation (insufficient lung expansion, pooling of effusion and atelectasis) of the pulmonary ligament, ratio (%) of dead space in longitudinal axis (movement of nonoperated lobes), change in the angle (degrees) of main bronchus on the operated side, overall morbidity and mortality, overall survival and conversion rates. In a randomized control trial, the dissection of the pulmonary ligament revealed no significant difference in the dead space ratio or change in the angle of the main bronchus when compared with preservation. Dissection of the ligament, in theory, reduces the free space in the upper thorax by increasing the mobility of the residual lobes. Dissection of the ligament may lead to bronchial deformation, stenosis, obstruction or lobar torsion. Preservation of the ligament may prevent this complication by suppressing the upward movement of residual lobes. However, this may result in pleural effusion in the free thoracic space that may potentially become infected resulting in an empyema or bronchial fistula. Five large case series were analysed; three routinely dissected the pulmonary ligament and two did not. There was no observed difference in clinical outcomes between the two groups. There is no convincing evidence that dissection of the pulmonary ligament in an upper lobectomy significantly improves outcomes and reduces complications.
- Published
- 2013
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34. Does video-assisted thoracic surgery provide a safe alternative to conventional techniques in patients with limited pulmonary function who are otherwise suitable for lung resection?
- Author
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Oparka J, Yan TD, Ryan E, and Dunning J
- Subjects
- Benchmarking, Evidence-Based Medicine, Forced Expiratory Volume, Humans, Length of Stay, Lung physiopathology, Male, Middle Aged, Pneumonectomy adverse effects, Pneumonectomy mortality, Postoperative Complications mortality, Postoperative Complications therapy, Respiratory Function Tests, Risk Assessment, Risk Factors, Thoracotomy, Time Factors, Treatment Outcome, Lung surgery, Pneumonectomy methods, Thoracic Surgery, Video-Assisted adverse effects, Thoracic Surgery, Video-Assisted mortality
- Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: does video-assisted thoracic surgery provide a safe alternative to conventional techniques in patients with limited pulmonary function who are otherwise suitable for lung resection? Altogether, more than 280 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One of the largest studies reviewed was a retrospective review of the Society of Thoracic Surgeons database. The authors compared 4531 patients who underwent lobectomy by video-assisted thoracic surgery (VATS) with 8431 patients who had thoracotomy. In patients with a predicted postoperative forced expiratory volume in 1 s (ppoFEV1%) of <60, it was demonstrated that thoracotomy patients have markedly increased pulmonary complications when compared with VATS patients (P = 0.023). Another study compared perioperative outcomes in patients with a ppoFEV1% of <40% who underwent thoracoscopic resection with similar patients who underwent open resection. Patients undergoing thoracoscopic resection as opposed to open thoracotomy had a lower incidence of pneumonia (4.3 vs 21.7%, P < 0.05), a shorter intensive care stay (2 vs 4 days, P = 0.05) and a shorter hospital stay (7 vs 10 days, P = 0.058). A similar study compared recurrence and survival in patients with a ppoFEV1% of <40% who underwent resection by VATS or anatomical segmentectomy (study group) with open resection (control group). Relative to the control group, patients in the study group had a shorter length of hospital stay (8 vs 12 days, P = 0.054) and an improved 5-year survival (42 vs 18%, P = 0.02). Analysis suggested that VATS lobectomy was the principal driver of survival benefit in the study group. We conclude that patients with limited pulmonary function have better outcomes when surgery is performed via VATS compared with traditional open techniques. The literature also suggests that patients in whom pulmonary function is poor have similar perioperative outcomes to those with normal function when a VATS approach to resection is adopted.
- Published
- 2013
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35. Is there a survival advantage of incomplete resection of non-small-cell lung cancer that is found to be unresectable at thoracotomy?
- Author
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Dall K, Ford C, Fisher R, and Dunning J
- Subjects
- Benchmarking, Carcinoma, Non-Small-Cell Lung mortality, Carcinoma, Non-Small-Cell Lung secondary, Evidence-Based Medicine, Female, Humans, Lung Neoplasms mortality, Lung Neoplasms pathology, Lymphatic Metastasis, Male, Middle Aged, Neoplasm, Residual, Survival Analysis, Survival Rate, Time Factors, Treatment Outcome, Carcinoma, Non-Small-Cell Lung surgery, Lung Neoplasms surgery, Pneumonectomy adverse effects, Pneumonectomy mortality, Thoracotomy adverse effects, Thoracotomy mortality
- Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: in patients with non-small-cell lung cancer that is found to be unresectable at thoracotomy, is incomplete resection superior for achieving survival advantage? Altogether more than 400 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. In total, data from an estimated 1083 patients were analysed. Three-year survival rates varied from 0 to 22% in incomplete resection and from 0 to 10% in exploratory thoracotomy. Median survival ranged from 6.5 to 19.1 months in incomplete resection and from 5.3 to 17 months in exploratory thoracotomy. The majority of studies (8/9) found survival in incomplete resection to be superior. However, only 3/9 studies presented statistical analysis of results. The largest of these found superior postoperative survival in incomplete resection (including residual nodal disease), one study showed a significant survival difference for R1 but not R2 resection and another with small patient numbers (n = 29) found no significant difference. We conclude that the best evidence suggests that there may be a survival advantage from incomplete resection of non-small-cell lung cancer when there is microscopic (R1) or nodal residual disease, but not when macroscopic residual (R2) disease remains.
- Published
- 2013
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36. The elephant in the room.
- Author
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Dunning J
- Subjects
- Humans, Internship and Residency, Nurse Practitioners, Resuscitation, Workforce, Intensive Care Units organization & administration, Patient Safety, Thoracic Surgery organization & administration
- Published
- 2013
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37. eComment. Local solutions to arrests on the ward.
- Author
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Dunning J
- Subjects
- Female, Humans, Male, After-Hours Care, Cardiac Surgical Procedures adverse effects, Heart Arrest surgery, Sternotomy
- Published
- 2012
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38. Static sac size with a type II endoleak post-endovascular abdominal aortic aneurysm repair: surveillance or embolization?
- Author
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Patatas K, Ling L, Dunning J, and Shrivastava V
- Subjects
- Aged, Angiography, Endoleak therapy, Follow-Up Studies, Humans, Male, Severity of Illness Index, Tomography, X-Ray Computed, Aortic Aneurysm, Abdominal surgery, Embolization, Therapeutic methods, Endoleak diagnosis, Endovascular Procedures adverse effects
- Abstract
A best evidence topic was written according to a structured protocol. The question addressed was whether embolization is superior to surveillance for a type II endoleak associated with a static sac size post-endovascular abdominal aortic aneurysm repair (EVAR). Four hundred and sixty-one papers were identified, of which 10 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, and relevant outcomes and results are tabulated. A review of the available literature suggests that most type II endoleaks are innocuous and will seal spontaneously during the long-term follow-up, even when they persist for more than 6 months. An analysis of the large European Collaborators on Stent-Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry that includes prospective data on 2463 patients from 87 European hospitals showed that type II endoleaks were not associated with an increased risk of rupture; this correlates well with the large single-centre studies included in this review. Based on the available evidence, we conclude that the management of most isolated type II endoleaks should be conservative-with close radiological follow-up--even when persistent, with intervention restricted to theoese associated with sac enlargement >5 mm over a 6-month period or >10 mm when compared with pre-EVAR diameter.
- Published
- 2012
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39. EACTS guidelines for the use of patient safety checklists.
- Author
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Clark SC, Dunning J, Alfieri OR, Elia S, Hamilton LR, Kappetein AP, Lockowandt U, Sarris GE, and Kolh PH
- Subjects
- Evidence-Based Medicine methods, Heart Defects, Congenital surgery, Heart-Lung Transplantation standards, Humans, Safety Management methods, Safety Management standards, Checklist standards, Medical Errors prevention & control, Patient Safety standards, Thoracic Surgical Procedures standards
- Abstract
The Safety Checklist concept has been an integral part of many industries that face high-complexity tasks for many decades and in industries such as aviation and engineering checklists have evolved from their very inception. Investigations of the causes of surgical deaths around the world have repeatedly pointed to medical errors that could be prevented as an important cause of death and disability. As a result, the World Health Organisation developed and evaluated a three-stage surgical checklist in 2007 demonstrating that complications were significantly reduced, including surgical infection rates and even mortality. Together with the results from other large cohort studies into the utility of the surgical checklist, many countries have fully implemented the use of surgical checklists into routine practice. A key factor in the successful implementation of a surgical checklist is engagement of the staff implementing the checklist. In surgical specialties such as our own it was quickly seen that there were many important omissions in the generic checklist that did not cover issues particular to our specialty, and thus the European Association for Cardio-Thoracic Surgery embarked on a process to create a version of the checklist that might be more appropriate and specific to cardiothoracic surgery, including checks on preparations for excessive bleeding, perfusion arrangements and ICU preparations, for example. The guideline presented here summarizes the evidence for the surgical checklist and also goes through in detail the changes recommended for our specialty.
- Published
- 2012
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40. Does adding ketamine to morphine patient-controlled analgesia safely improve post-thoracotomy pain?
- Author
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Mathews TJ, Churchhouse AM, Housden T, and Dunning J
- Subjects
- Analgesia, Patient-Controlled adverse effects, Analgesics adverse effects, Analgesics, Opioid adverse effects, Benchmarking, Evidence-Based Medicine, Humans, Ketamine adverse effects, Morphine adverse effects, Pain Measurement, Pain, Postoperative etiology, Treatment Outcome, Analgesia, Patient-Controlled methods, Analgesics therapeutic use, Analgesics, Opioid therapeutic use, Ketamine therapeutic use, Morphine therapeutic use, Pain, Postoperative prevention & control, Thoracotomy adverse effects
- Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'is the addition of ketamine to morphine patient-controlled analgesia (PCA) following thoracic surgery superior to morphine alone'. Altogether 201 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This consisted of one systematic review of PCA morphine with ketamine (PCA-MK) trials, one meta-analysis of PCA-MK trials, four randomized controlled trials of PCA-MK, one meta-analysis of trials using a variety of peri-operative ketamine regimes and two cohort studies of PCA-MK. Main outcomes measured included pain score rated on visual analogue scale, morphine consumption and incidence of psychotomimetic side effects/hallucination. Two papers reported the measurements of respiratory function. This evidence shows that adding ketamine to morphine PCA is safe, with a reported incidence of hallucination requiring intervention of 2.9%, and a meta-analysis finding an incidence of all central nervous system side effects of 18% compared with 15% with morphine alone, P = 0.31, RR 1.27 with 95% CI (0.8-2.01). All randomized controlled trials of its use following thoracic surgery found no hallucination or psychological side effect. All five studies in thoracic surgery (n = 243) found reduced morphine requirements with PCA-MK. Pain scores were significantly lower in PCA-MK patients in thoracic surgery papers, with one paper additionally reporting increased patient satisfaction. However, no significant improvement was found in a meta-analysis of five papers studying PCA-MK in a variety of surgical settings. Both papers reporting respiratory outcomes found improved oxygen saturations and PaCO(2) levels in PCA-MK patients following thoracic surgery. We conclude that adding low-dose ketamine to morphine PCA is safe and post-thoracotomy may provide better pain control than PCA with morphine alone (PCA-MO), with reduced morphine consumption and possible improvement in respiratory function. These studies thus support the routine use of PCA-MK instead of PCA-MO to improve post-thoracotomy pain control.
- Published
- 2012
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41. Does blood transfusion increase the chance of recurrence in patients undergoing surgery for lung cancer?
- Author
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Churchhouse AM, Mathews TJ, McBride OM, and Dunning J
- Subjects
- Humans, Incidence, Neoplasm Recurrence, Local etiology, Risk Factors, Lung Neoplasms surgery, Neoplasm Recurrence, Local epidemiology, Pneumonectomy, Preoperative Care adverse effects, Transfusion Reaction
- Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether blood transfusion increases the chance of recurrence in patients undergoing surgery for lung cancer. Altogether 468 papers were found using the reported search, of which 21 represented the best evidence to answer the clinical question. The authors, journal date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Nineteen cohort studies (two of which examined the same or similar data sets as two other studies already included), one comment article and one meta-analysis were identified. In total, the outcomes of 5378 patients undergoing surgical resection for lung cancer were analysed. The transfusion rate varied between 15 and 67%. The primary endpoints in all 21 papers were recurrence, survival or disease-free survival. We conclude that the research undertaken to examine the relationship between blood transfusion and lung cancer recurrence, survival and disease-free survival comes to no definite conclusion. Half of the papers relating to recurrence state that there is no significantly increased risk of recurrence with transfusion, whereas the other half state that there is. However, four of the five papers examining disease-free survival demonstrate a significant adverse relationship between this primary outcome and blood transfusion. With regard to survival, five of the papers reviewed showed no effect of blood transfusion, whereas five showed some form of adverse effect. Although there is no overwhelming agreement among the presented evidence, there is a slightly larger body of evidence supporting the theory that blood transfusions are associated with poorer outcomes in patients undergoing resection for lung cancer. However, whether this is a direct effect, or a surrogate marker for other factors such as anaemia, is unclear.
- Published
- 2012
- Full Text
- View/download PDF
42. Radial artery versus saphenous vein conduits for coronary artery bypass surgery: forty years of competition--which conduit offers better patency? A systematic review and meta-analysis.
- Author
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Athanasiou T, Saso S, Rao C, Vecht J, Grapsa J, Dunning J, Lemma M, and Casula R
- Subjects
- Bias, Coronary Angiography, Coronary Stenosis surgery, Humans, Vascular Patency, Coronary Artery Bypass methods, Radial Artery transplantation, Saphenous Vein transplantation
- Abstract
The internal thoracic artery is the most effective conduit for coronary artery bypass surgery; however, most patients have multivessel disease and require additional saphenous vein or radial artery grafts. In this systematic review of the literature and meta-analysis, we aim to compare reported patency rates for these conduits and explore if differences are homogeneous across follow-up intervals. A literature search was performed using Embase, Medline, Cochrane Library, Google Scholar and randomised controlled trial databases to identify studies published between 1965 and October 2009. All studies reporting angiographic comparison of saphenous vein and radial artery conduit patency were included, irrespective of language. The end point was angiographic graft patency stratified over different follow-up intervals. Meta-analysis was performed according to recommendations from the Cochrane Collaboration and Meta-analysis Of Observational Studies in Epidemiology guidelines. We used a random-effect model and the odds ratio as the summary statistic. A total of 35 studies were identified. They reported early patency (≤ 1 year, 6795 grafts), medium-term patency (1-5 years, 3232 grafts) and long-term patency (>5 years, 1157 grafts). Significant variation of comparative patency existed across different follow-up intervals. Early saphenous vein patency was similar to radial artery patency with odds ratio of 1.04 (95% confidence interval 0.68-1.61). Medium-term saphenous vein patency, however, deteriorated significantly (odds ratio 2.06, 95% confidence interval 1.29-3.29). Similarly, long-term patency was better for radial artery conduits (odds ratio 2.28, 95% confidence interval 1.32-3.94). Heterogeneity was due to angiographic patency characteristics and related to risk of bias. In conclusion, the findings of this systematic review of the published literature and meta-analysis support the use of radial artery in preference to saphenous vein conduits for coronary artery bypass surgery., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)
- Published
- 2011
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43. Can leucocyte depletion reduce reperfusion injury following cardiopulmonary bypass?
- Author
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Loberg AG, Stallard J, Dunning J, and Dark J
- Subjects
- Aged, Cardiopulmonary Bypass adverse effects, Coronary Artery Bypass adverse effects, Coronary Stenosis diagnostic imaging, Coronary Stenosis mortality, Coronary Stenosis surgery, Evidence-Based Medicine, Female, Follow-Up Studies, Humans, Intraoperative Care methods, Leukocyte Count, Male, Middle Aged, Radiography, Reperfusion Injury mortality, Stroke Volume, Survival Rate, Treatment Outcome, Cardiopulmonary Bypass methods, Coronary Artery Bypass methods, Leukocyte Reduction Procedures methods, Reperfusion Injury prevention & control
- Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Can leucocyte depletion (LD) reduce reperfusion injury following cardiopulmonary bypass?'. Altogether more than 74 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that there appears to be little or no clinical benefit gained from the use of LD treatment. The majority of studies, looking at outcomes including the duration of hospital and intensive care unit (ICU) stay, intubation time, inotropic support required and postoperative arrhythmias, found the results comparable between patients receiving LD treatment and controls. Biochemical parameters of reperfusion inflammation and cardiac damage are reduced in many studies, suggesting an attenuation of reperfusion injury at a cellular level, but this does not appear to be transferable to clinical improvement. However, one study using patients with severely low left ventricular ejection fractions (LVEF), found those receiving LD treatment required less inotropic support and experienced a significant increase in LVEF postoperatively when compared with controls, indicating that the benefit of LD may depend on preoperative status and susceptibility to reperfusion damage. In conclusion, LD should not be used routinely in cardiac surgery.
- Published
- 2011
- Full Text
- View/download PDF
44. Transthoracic versus transhiatal esophagectomy for distal esophageal cancer: which is superior?
- Author
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Colvin H, Dunning J, and Khan OA
- Subjects
- Diaphragm surgery, Esophageal Neoplasms mortality, Esophagectomy adverse effects, Evidence-Based Medicine, Female, Follow-Up Studies, Hospital Mortality trends, Humans, Male, Neoplasm Staging, Postoperative Complications mortality, Postoperative Complications physiopathology, Risk Assessment, Survival Analysis, Thoracotomy methods, Time Factors, Esophageal Neoplasms pathology, Esophageal Neoplasms surgery, Esophagectomy methods
- Abstract
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether transthoracic esophagectomy (TTE) or transhiatal esophagectomy (THE) resection provides superior outcomes for patients with distal esophageal cancer. Two hundred and sixteen papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that THE is associated with significantly less pulmonary complications as well as fewer wound infections, chylous leakage but a higher rate of cardiac complications, vocal cord paralysis and anastomotic leakage as compared with TTE. Overall, THE is associated with a reduced perioperative morbidity as evidenced by with a shorter hospital stay and decreased in-hospital mortality rates. With regard to long-term outcomes, although there is no evidence that TTE or THE result in different overall long-term survival rates, there is some evidence that TTE offers superior five-year survival rate in a sub-group of patients with a limited number of involved lymph nodes.
- Published
- 2011
- Full Text
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45. Is the preservation of the phrenic nerve important after pneumonectomy?
- Author
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Burns J and Dunning J
- Subjects
- Animals, Benchmarking, Evidence-Based Medicine, Exercise Tolerance, Humans, Lung Volume Measurements, Pulmonary Gas Exchange, Respiration, Artificial, Respiratory Insufficiency etiology, Respiratory Insufficiency physiopathology, Risk Assessment, Time Factors, Trauma, Nervous System etiology, Trauma, Nervous System physiopathology, Treatment Outcome, Diaphragm innervation, Lung physiopathology, Phrenic Nerve injuries, Pneumonectomy adverse effects, Respiratory Insufficiency prevention & control, Trauma, Nervous System prevention & control
- Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is the preservation of the phrenic nerve important after pneumonectomy? Altogether more than 49 papers were found using the reported search, of which four represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that care should be taken to preserve the integrity of the phrenic nerve wherever possible. The abnormal diaphragmatic motion which occurs as a consequence of phrenic nerve damage significantly reduces expiratory lung volumes, gas exchange and exercise capacity in already compromised patients. Phrenic nerve injury can also lead to a prolonged need for mechanical ventilation; this alone carries a risk of complication, such as infection. Plication of the paralyzed hemi-diaphragm has proved effective in reducing respiratory insufficiency after pneumonectomy. The aim of this is to fix and flatten the diaphragm, thus mimicking the role of a functioning phrenic nerve. Furthermore, the function of a preserved phrenic nerve remains normal for up to 11 years post pneumonectomy. Therefore, deterioration in function may highlight a recurrence in disease or a change in the post pneumonectomy space.
- Published
- 2011
- Full Text
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46. Is a sleeve lobectomy significantly better than a pneumonectomy?
- Author
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Stallard J, Loberg A, Dunning J, and Dark J
- Subjects
- Aged, Benchmarking, Carcinoma, Non-Small-Cell Lung mortality, Carcinoma, Non-Small-Cell Lung pathology, Evidence-Based Medicine, Female, Humans, Lung Neoplasms mortality, Lung Neoplasms pathology, Middle Aged, Neoplasm Recurrence, Local, Patient Selection, Pneumonectomy adverse effects, Pneumonectomy mortality, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, Carcinoma, Non-Small-Cell Lung surgery, Lung Neoplasms surgery, Pneumonectomy methods
- Abstract
A best evidence topic was written according to a structured protocol. The question addressed was 'whether a sleeve lobectomy results in a better survival rate than a pneumonectomy in suitable patients?' Altogether, more than 327 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude in the biggest meta-analysis of nearly 3000 patients, the five-year survival was 50% for sleeve lobectomy compared to 30% for pneumonectomy. Operative mortality was 3% vs. 6% for pneumonectomy, and locoregional recurrence was 17% vs. 30%. These results are broadly consistent across all the 13 cohort studies presented here many of which document a 20-year single centre experience or more. There are significant issues in all cohort studies on this subject as, due to their non-randomized nature, the reason for not performing a sleeve resection may well have been more advanced disease, which would necessarily mean that the pneumonectomy patients would have a lower expected survival and higher local recurrence. In addition, there have been many large cohort studies to date and thus no more are required, as future studies are unlikely to resolve this issue. Thus, the only study that would adequately correct for this issue would be a randomized trial, but to prove a 10% increase in five-year survival a 300 patient study would be needed. This is bigger than any study ever done in this area and as some centres took 30 years to collect these numbers of potential sleeve patients an RCT is not a realistic possibility. Therefore, we conclude that no more cohort studies should be performed, as the results will be consistent with the meta-analyses and an RCT to eliminate their bias is unattainable, and thus no more research should be done on this topic and surgeons should use the figures presented above and in more detail in this best evidence topic to govern their management in the future.
- Published
- 2010
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47. Does the use of non-steroidal anti-inflammatory drugs after cardiac surgery increase the risk of renal failure?
- Author
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Acharya M and Dunning J
- Subjects
- Anti-Inflammatory Agents, Non-Steroidal therapeutic use, Humans, Renal Insufficiency chemically induced, Risk Factors, Anti-Inflammatory Agents, Non-Steroidal adverse effects, Cardiac Surgical Procedures, Pain, Postoperative drug therapy, Renal Insufficiency etiology
- Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief post-cardiac surgery increases the risk of renal failure. Altogether 53 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We identified 11 studies, comprising one meta-analysis, seven randomised controlled trials (RCTs), and three retrospective studies. The meta-analysis of 1065 patients across 20 RCTs established that the risk of renal failure was not significantly higher with perioperative NSAID usage [odds ratio (OR) 0.95, 95% confidence interval (CI) 0.37-2.46]. Furthermore, there was no statistically significant difference in serum creatinine levels between NSAID and control groups. Six RCTs agreed that postoperative NSAID therapy was not associated with an elevation in serum creatinine levels suggestive of renal failure. One of these RCTs was conducted in a paediatric population undergoing congenital heart surgery, and achieved equivalent results. Another large RCT found a non-significant increase in the incidence of renal failure/dysfunction in patients receiving the cyclo-oxygenase 2 (COX-2) selective drugs parecoxib and valdecoxib vs. placebo (placebo vs. parecoxib and valdecoxib: relative risk (RR) 2.4, 95% CI 0.6-9.2, P=0.20) whilst highlighting the potential adverse vascular effects of this drug class. In contrast, one RCT assessing these COX-2 inhibitors detected a significant increase in the incidence of oliguria in this group compared to controls (parecoxib/valdecoxib: 14.5%, controls: 9.9%, P=0.187) as well as renal dysfunction (parecoxib/valdecoxib: 1.9%, controls: 0%, P=0.184). Three retrospective studies within paediatric populations, including one cohort study and two chart reviews, found various parameters of renal function, such as serum creatinine and blood urea nitrogen, to be similar between ketorolac and control groups. We conclude that NSAIDs are not associated with an increased risk of renal failure after cardiac surgery when administered at optimal 'renal' doses, within early postoperative settings, to patients at low-risk of renal dysfunction in whom NSAIDs are not contraindicated.
- Published
- 2010
- Full Text
- View/download PDF
48. Is video-assisted thoracoscopic surgical decortication superior to open surgery in the management of adults with primary empyema?
- Author
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Chambers A, Routledge T, Dunning J, and Scarci M
- Subjects
- Aged, Benchmarking, Chest Tubes, Empyema, Pleural mortality, Evidence-Based Medicine, Humans, Length of Stay, Male, Patient Selection, Risk Assessment, Risk Factors, Thoracostomy adverse effects, Thoracostomy instrumentation, Thoracostomy mortality, Time Factors, Treatment Outcome, Drainage adverse effects, Drainage instrumentation, Drainage mortality, Empyema, Pleural surgery, Thoracic Surgery, Video-Assisted adverse effects, Thoracic Surgery, Video-Assisted mortality
- Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgical decortication (VATSD) might be superior to open decortication (OD) (or chest tube drainage) for the management of adults with primary empyema? Altogether 68 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATSD has superior outcomes for the treatment of persistent pleural collections in terms of postoperative morbidity, complications and length of hospital stay, and gives equivalent resolution when compared with OD. One study comparing VATSD and chest tube drainage of fibrinopurulent empyema found video-assisted thoracoscopic surgery (VATS) had higher treatment success (91% vs. 44%; P<0.05), lower chest tube duration (5.8+/-1.1 vs. 9.8+/-1.3 days; P=0.03), and lower number of total hospital days (8.7+/-0.9 vs. 12.8+/-1.1 days; P=0.009). Eight studies comparing early and late empyema report conversion rates to OD of 0-3.5% in early, 7.1-46% in late stage and significant reductions in length of stay with VATSD compared with OD both postoperatively (5 vs. 8 days; P=0.001) and in total stay (15 vs. 21; P=0.03). Additionally VATS resulted in reduced postoperative pain (P<0.0001) and complications including atelectasis (P=0.006), prolonged air-leak (P=0.0003), sepsis (P=0.03) and 30-day mortality (P=0.02). Five studies considered only chronic persistent empyema of which two directly compared VATSD to tube thoracostomy (TT). VATS resolved 88% of cases and had mortality rates of 1.3% compared with 62% and 11%, respectively, for TT. Moreover, conversion to OD was 10.5-17.1% with VATS and 18-37% with TT (P<0.05). In agreement with mixed stage empyema, hospital stay was reduced both postoperatively (8.3 vs. 12.8 days; P<0.05) and in total (14+/-1 vs. 17+/-1 days; P<0.05), and when compared with OD (one study), pain (P<0.0001), postoperative air-leak (P=0.004), hospital stay (P=0.020) and time to return to work (P<0.0001) were all reduced with VATS. Additionally, re-operation (4.8% vs. 1%; P=0.09) and mortality (4/123% vs. 0%) were lower in VATS vs. OD.
- Published
- 2010
- Full Text
- View/download PDF
49. Should patients with asymptomatic severe mitral regurgitation with good left ventricular function undergo surgical repair?
- Author
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Ogutu P, Ahmed I, and Dunning J
- Subjects
- Adult, Aged, Atrial Fibrillation etiology, Atrial Fibrillation physiopathology, Atrial Fibrillation surgery, Benchmarking, Disease Progression, Evidence-Based Medicine, Female, Heart Failure etiology, Heart Failure physiopathology, Heart Failure surgery, Humans, In Vitro Techniques, Male, Middle Aged, Mitral Valve Insufficiency complications, Mitral Valve Insufficiency mortality, Mitral Valve Insufficiency physiopathology, Patient Selection, Practice Guidelines as Topic, Risk Assessment, Severity of Illness Index, Time Factors, Treatment Outcome, Cardiac Surgical Procedures adverse effects, Cardiac Surgical Procedures mortality, Mitral Valve Insufficiency surgery, Ventricular Function, Left
- Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'Does severe asymptomatic mitral regurgitation (MR) require surgery or is watch and wait the optimal strategy?'. Over 103 papers were found using the reported search, and 10 represented the best evidence to answer this clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No studies in the modern era have shown significant survival benefit for patients undergoing surgery for asymptomatic severe MR if they have good left ventricular (LV) function. The progression rate to surgery on developing symptoms is 10% per year in these patients. Ling et al. reported a 63% incidence of congestive heart failure and 30% incidence of chronic atrial fibrillation (AF) at 10 years for conservative treatment, during which period 90% either underwent surgery or died. In addition, one study of 478 patients with good LV operated on in the 1980s showed a 76% 10-year survival in patients who were NYHA I/II but only a 48% 10-year survival in patients with NYHA III/IV although this group was older and had more AF. Early surgery has very good peri- and postoperative survival rates, and the American Heart Association currently recommend that these patients may be operated on if the chance of repair is >90%. Patients may, therefore, be reassured that either strategy is acceptable.
- Published
- 2010
- Full Text
- View/download PDF
50. Should patients undergoing cardiac surgery with atrial fibrillation have left atrial appendage exclusion?
- Author
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Dawson AG, Asopa S, and Dunning J
- Subjects
- Aged, Aged, 80 and over, Animals, Atrial Fibrillation complications, Benchmarking, Catheter Ablation, Evidence-Based Medicine, Female, Humans, Male, Middle Aged, Patient Selection, Risk Assessment, Thromboembolism etiology, Thromboembolism prevention & control, Treatment Outcome, Atrial Appendage surgery, Atrial Fibrillation surgery, Cardiac Surgical Procedures adverse effects
- Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Should patients undergoing cardiac surgery with atrial fibrillation (AF) have left atrial appendage (LAA) exclusion?' Altogether 310 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that despite finding five clinical trials including one randomised controlled trial, that studied around 1400 patients who underwent LAA occlusion, the results of these studies do not clearly show a benefit for appendage occlusion. Indeed of the five studies, only one showed a statistical benefit for LAA occlusion, with three giving neutral results and in fact one demonstrating a significantly increased risk. One reason for this may be the inability to achieve acceptably high rates of successful occlusion on echocardiography when attempting to perform this procedure. The highest success rate was only 93% but most studies reported only a 55-66% successful occlusion rate when attempting closure in a variety of methods including stapling, ligation and amputation. Currently, the evidence is insufficient to support LAA occlusion and may indeed cause harm especially if incomplete exclusion occurs.
- Published
- 2010
- Full Text
- View/download PDF
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