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

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

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

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

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

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

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

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

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

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

Background: Cytoreductive surgery and perioperative intraperitoneal chemotherapy (PIC) is recognized as an effective treatment modality for patients with pseudomyxoma peritonei. This study investigates its role as a secondary definitive treatment procedure after earlier primary treatments. Study design: Patients with pseudomyxoma peritonei undergoing secondary cytoreduction combined with PIC were identified from a prospective database. Retrospective analysis investigated the outcomes, prognostic factors, critical time points, and impact of malignant dedifferentiation. Survival analysis was performed via the Kaplan-Meier method and compared via the log-rank test. Results: The median time to progression after secondary cytoreduction was 28 months (95% CI 14 to 41 months), median survival was 97 months (95% CI 82 to 113 months), and 10-year survival was 25%. Median overall survival from initial diagnosis was 17 years and 10-year survival rate was 75%. Forty-five patients remained disease free (63%). Requiring an urgent treatment (waiting time < 60 days) after disease progression (p = 0.045) and having moderate or severe symptoms (p = 0.033) were associated with a shorter time to progression. Improved survival was associated with patients who had low-grade tumors (p = 0.029), and those who required less urgent treatment (wait > 30 days) after disease progression (waiting up to 15 days, p = 0.010; waiting up to 30 days, p = 0.005). Malignant dedifferentiation appeared to affect survival from initial diagnosis (p = 0.062) and after secondary cytoreduction (p = 0.006). Conclusions: Secondary cytoreduction with PIC achieves long-term survival. Tumors that undergo malignant dedifferentiation appear to adversely affect survival, and this may support the rationale for early definitive treatment with cytoreduction and PIC. [ABSTRACT FROM AUTHOR]

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

Background: Radical cystectomy and urinary diversion is the treatment of choice for invasive bladder cancer. Quality of life (QOL) is an important outcome of surgery. This review compares the QOL after continent and incontinent urinary diversion in radical cystectomy for patients with primary invasive bladder cancer. Methods: A systematic review and meta-analysis of clinical studies published after January 2000 was performed according to the PRISMA guidelines. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects metaanalysis using standardized response means. Heterogeneity and bias was assessed by Tau2 and I2 values and Funnel plots. Results: Twenty-nine studies (3754 patients) were included for review. Pooled post-operative FACT and SF-36 scores showed no difference in overall QOL between continent and incontinent diversion (P = 0.31). Subgroup analysis demonstrated greater improvement in physical health for incontinent (p = 0.002) compared to continent diversions, but no differences in mental health (p = 0.35) and social health (p = 0.81). Qualitative analysis showed patients with neobladder had superior emotional function and body image compared to cutaneous diversion. QOL may improve to similar or better levels compared to baseline after 1 year, but data remains scarce. Patients report poor urinary and sexual function after surgery compared the general population. Long-term QOL is unclear. Levels of heterogeneity and bias were low. Conclusions: QOL after radical cystectomy is comparable after either continent or incontinent urinary diversion. Post-operative QOL may improve, but urinary and sexual dysfunction remains inferior to the general population. Patient choice is key to selection of reconstruction method. [ABSTRACT FROM AUTHOR]

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

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

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

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

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

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

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

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

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

Background: Cardiac surgical units must balance trainee education with the duty to provide optimal patient care. This is particularly challenging with valvular surgery, given the lower volume and increased complexity of these procedures. The present meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes following valvular surgery., Methods: Medline, Embase and CENTRAL databases were systematically searched for studies reporting clinical outcomes according to the training status of the primary operator (consultant or trainee). Data were extracted and meta-analysed according to pre-defined endpoints., Results: Eleven observational studies met the inclusion criteria, reporting on five patient cohorts undergoing mitral valve surgery (n=3975), six undergoing aortic valve replacement (AVR) (n=6236) and three undergoing combined AVR and coronary artery bypass grafting (CABG) (n=3495). Perioperative mortality was not significantly different between trainee and consultant cases for mitral valve surgery (odds ratio [OR] 0.92; 95% confidence interval [CI], 0.62-1.37), AVR (OR 0.67; 95% CI, 0.37-1.24), or combined AVR and CABG (OR 1.07; 95% CI, 0.40-2.85). The incidences of perioperative stroke, myocardial infarction, arrhythmias, acute renal failure, reoperation or wound infection were not significantly different between trainee and consultant cases. There was a paucity of mid-term survival data., Conclusions: Valvular surgery cases performed primarily by trainees were not associated with adverse perioperative outcomes. These findings suggest the rigorous design of cardiac surgical trainee programs can sufficiently mitigate trainee deficiencies. However, studies with longer follow-up duration and echocardiographic data are required to assess long-term durability and safety., (Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

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

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

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

Cardiac surgery has embraced and encouraged the use of large, multi-institutional datasets in clinical practice. From a research perspective, database studies have facilitated an increased understanding of cardiac surgery. Among other uses, they have allowed an investigation of disease incidence and mortality, high risk groups, disparities in health care delivery and the impact of new devices and techniques. Databases are also important tools for clinical governance and quality improvement. Despite their obvious utility, clinical databases have limitations; they are subject to treatment bias, contain missing data and cannot establish causality. Moreover, the ongoing maintenance of the database requires significant human and financial resources. In the future, inclusion of more detailed follow-up data and integration with other datasets will improve the utility of clinical databases., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: The elderly population (age >70 years) incurs greater mortality and morbidity following CABG. Off-pump coronary artery bypass (OPCAB) may mitigate these outcomes. A retrospective analysis of the results of OPCAB in this population was performed., Methods: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for elderly patients (n=12697) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=11676) with OPCAB (n=1021) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analyses was performed after cross-matching the database with the national death registry to identify long-term mortality., Results: High-risk patients were more prevalent in the ONCAB group (p<0.05). OPCAB patients received fewer distal anastomoses than ONCAB patients (2.4±1.1 vs 3.3±1.0, p<0.001). Thirty-day mortality and stroke rates between OPCAB and ONCAB were not significantly different (2% vs 2.5% and 1.1% vs 1.8%, respectively). There was a non-significant trend towards improved 10-year survival in OPCAB patients using multivariate analysis (78.8% vs. 73.3%, p=0.076, HR 0.83; 95% CI 0.67-1.02)., Conclusions: Mortality and stroke rates following CABG surgery are extremely low in the elderly suggesting that surgery is a safe management option for coronary artery disease in this population. OPCAB did not offer a significant advantage over ONCAB with regards to 30-day mortality, stroke and long-term survival. Further prospective randomised trials will be necessary to clarify risks or benefits in the elderly., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Coronary artery bypass graft surgery (CABG) has been established as the preferred intervention for coronary revascularisation in the high-risk population. Off-pump coronary artery bypass (OPCAB) may further reduce mortality and morbidity in this population subgroup. This study presents the largest series of high-risk (AusSCORE > 5) OPCAB patients in Australia and New Zealand., Methods: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for high-risk patients (n=7822) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=7277) with the OPCAB (n=545) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analysis was performed after cross-matching the database with the national death registry to identify long-term mortality., Results: The ONCAB and OPCAB groups had similar risk profiles based on the AusSCORE. Thirty-day mortality (ONCAB vs OPCAB 3.9% vs 2.4%, p=0.067) and stroke (ONCAB vs OPCAB 2.4% vs 1.3%, p=0.104) were similar between the two groups. OPCAB patients received fewer distal anastomoses than ONCAB patients (2.5±1.2 vs 3.3±1.0, p<0.001). The rates of new postoperative atrial arrhythmia (28.3% vs 33.3%, p=0.017) and blood transfusion requirements (52.1% vs 59.5%, p=0.001) were lower in the OPCAB group, while duration of ICU stay in hours (97.4±187.8 vs 70.2±152.8, p<0.001) was longer. There was a non-significant trend towards improved 10-year survival in OPCAB patients (74.7% vs. 71.7%, p=0.133)., Conclusions: In the high-risk population, CABG surgery has a low rate of mortality and morbidity suggesting that surgery is a safe option for coronary revascularisation. OPCAB reduces postoperative morbidity and is a safe procedure for 30-day mortality, stroke and long-term survival in high-risk patients., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

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

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

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

Objective: To review the effect of cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) on health-related quality of life (HRQOL) in patients with peritoneal carcinomatosis., Background: CRS and HIPEC is increasingly performed with curative intent for peritoneal carcinomatosis. Significant morbidity rates are reported in the context of limited life-expectancy, necessitating accurate post-operative HRQOL outcome data., Methods: A systematic review of clinical studies published after January 2000 was performed using strict eligibility criteria. Key outcomes measures were post-operative HRQOL compared to pre-operative levels and reference populations. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis. Tau2 and I2 values and Funnel plots were analysed for consistency and bias., Results: 15 studies (1583 patients) were included. HRQOL declines at the 3-4 month time-point before becoming similar or better compared to pre-operative levels at 1 year. The pooled-effects of combined post-operative functional assessment of cancer therapy and European organisation for research and treatment quality of life questionnaire scores were significantly improved from baseline on overall health status (p=0.001) and emotional health (p=0.001). Physical health (p=0.83), social health (p=0.48) and functional health (p=0.24) remain similar. HRQOL after 1 year is less clear, but benefits may persist up to 5 years especially on overall and physical health domains. Evidence is conflicted and inconclusive on HRQOL compared to reference populations. Levels of consistency and bias were acceptable., Conclusions: CRS and HIPEC for peritoneal carcinomatosis can confer small to medium benefits for HRQOL. These results should be interpreted with in caution due to the small studies and absence of more randomised controlled trials., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

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

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

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

Introduction: There is increasing evidence to suggest that cancer-associated inflammation is associated with poorer long-term outcomes. Various markers have been studied over the past decade in an attempt to improve selection of patients for surgery. This meta-analysis explored the association between the neutrophil-lymphocyte ratio and prognosis following curative-intent surgery for solid tumours., Methods: Studies were identified from US National Library of Medicine (Medline) and the Exerpta Medica database (EBASE) performed in March 2013. A systematic review and meta-analysis were performed to generate combined hazard ratios for overall survival (OS) and disease-free survival (DFS)., Results: Forty-nine studies containing 14282 patients were included. Elevated NLR was associated with poorer overall survival [HR: 1.92, 95% CI (1.64-2.24)] (p < 0.001) and disease-free survival [HR: 1.99, 95% CI (1.80-2.20)] (p < 0.001). Significant heterogeneity was found with an I(2) of 77% and 97% for OS and DFS respectively. Subgroup analyses demonstrated that gastro-intestinal malignancies; mainly gastric [HR: 1.97, 95% CI (1.41-2.76)], colorectal [HR: 1.65, 95% CI (1.21-2.26)] and oesophageal [HR: 1.48, 95% CI (0.91-2.42)] cancers were predictive of OS (I(2) = 54.3%). A separate analysis for studies using an NLR cutoff of 5 demonstrated significantly poorer outcomes [HR: 2.18, 95% CI (1.74-2.73)] (p = 0.002) with less heterogeneity (I(2) = 58%)., Conclusion: Elevated NLR correlates with poorer prognosis. It potentially represents a simple, robust and reliable measure that may be useful in identifying high-risk groups who could benefit from adjuvant therapy., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

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

Background and Aim of the Study: Currently, insufficient data exist relating to the impact of smoking status on outcomes after isolated aortic valve replacement (AVR) surgery., Methods: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (SCTS) Cardiac Surgery Database Program was analyzed retrospectively. Demographic and operative data were compared between patients who were non-smokers, previous smokers and current smokers, using chi-square and t-tests. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively., Results: Isolated AVR surgery was performed in 2,790 patients; smoking status was recorded in 2,784 cases (99.8%). Of these patients 1,346 (48.3%) had no previous smoking history, 1,232 (44.3%) were previous smokers, and 206 (7.4%) were current smokers. The 30-day mortality rate was 2.3% in nonsmokers, 2.7% in previous smokers, and 0.5% in current smokers (p = NS). The incidence of perioperative complications was generally similar in the three groups, but current smokers were at an increased risk of pneumonia (p = 0.030) and postoperative myocardila infarction (p = 0.007). The mean follow up period for the study was 37 months (range: 0-105 months). After adjusting for differences in patient variables, the incidence of late mortality was not higher in previous smokers (HR 1.13; 95% CI 0.87-1.46; p = 0.372) or current smokers (HR 1.25; 95% CI 0.66-2.36; p = 0.494) compared to non-smokers., Conclusion: Smoking status does not necessarily portend a poorer perioperative outcome in patients undergoing isolated AVR.

Background: Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has been consistently associated with high volume blood loss and red blood cell (RBC) transfusion. This study evaluates the effectiveness of the introduction of a novel protocol to reduce blood loss and subsequent intra-operative transfusion in patients with high volume disease., Methods: One hundred and thirty-one consecutive patients with high volume disease (peritoneal cancer index ≥16) who underwent CRS and PIC were evaluated. Group I consisted of the sixty patients (46%) treated before June 2006. Group II consistent of the seventy-one (54%) patients treated after June 2006 under the new protocol. The clinical and treatment-related data of patients in the two groups were compared., Results: Group II was associated with reduced intra-operative red blood cell transfusion (P<0.001), reduced cryoprecipitate transfusion (P=0.020), reduced platelet transfusion (P<0.001), reduced fresh frozen plasma transfusion (P=0.024), reduced operation length (P<0.001), reduced crystalloid administration (P<0.001) and reduced colloid administration (P<0.001). Group II was also associated with increased transfusion of FFP in the first half of the surgical intervention relative to the second half [FFP1(st)(:)FFP2(nd) ratio >1 (P<0.001)] and increased transfusion of RBC in the first half of the surgical intervention relative to the second half [RBC1(st)(:)RBC2(nd) ratio ≥1 (P=0.016)]., Conclusion: Early administration of fresh frozen plasma combined with restrictive fluid resuscitation may reduce overall intra-operative transfusion of RBC and other blood components.

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

Several studies have shown that postoperative atrial fibrillation (POAF) is associated with poorer short- and long-term outcomes after isolated coronary artery bypass grafting surgery. Nevertheless, there is considerable debate as to whether this reflects an independent association of POAF with poorer outcomes or confounding by other factors. We sought to investigate this issue. Data obtained from June 2001 through December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who developed POAF and those who did not using chi-square and t tests. The independent impact of POAF on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. Excluding patients with preoperative arrhythmia, isolated coronary artery bypass grafting surgery was performed in 19,497 patients. Of these, 5,547 (28.5%) developed POAF. Patients with POAF were generally older (mean age 69 vs 65 years, p <0.001) and presented more often with co-morbidities including congestive heart failure (p <0.001), hypertension (p <0.001), cerebrovascular disease (p <0.001), and renal failure (p = 0.046). Patients with POAF demonstrated a greater 30-day mortality on univariate analysis but not on multivariate analysis (p = 0.376). Patients with POAF were, however, at an independently increased risk of perioperative complications including permanent stroke (p <0.001), new renal failure (p <0.001), infective complications (p <0.001), gastrointestinal complications (p <0.001), and return to the theater (p <0.001). POAF was also independently associated with shorter long-term survival (p = 0.002). In conclusion, POAF is a risk factor for short-term morbidity and decreased long-term survival. Rigorous evaluation of various therapies that prevent or decrease the impact of POAF is imperative. Moreover, patients who develop POAF should undergo strict surveillance and be routinely screened for complications after discharge., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The proportion of elderly (≥80 years) patients undergoing coronary artery bypass surgery (CABG) is increasing., Methods: A retrospective analysis of data, collected by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program between June 2001 and December 2009 was performed. Isolated CABG was performed in 21,534 patients; of these, 1,664 (7.7%) were at least 80 years old (group 1). Patient characteristics, morbidity, and short-term mortality of these patients were compared with those aged less than 80 years (group 2). The long-term outcome of group 1 patients after CABG surgery was compared with an age and sex-matched Australian population., Results: Patients over 80 years old were more likely to be female (36.6% vs 17.3%, p < 0.001) and presented significantly more often with heart failure, hypertension, and triple-vessel disease (all p < 0.05). The 30-day mortality was higher in group 1 patients (4.2% vs 1.5%, p < 0.001). Group 1 patients also had an increased risk of complications, including prolonged (>24 hours) ventilation (14.2% vs 8.2%, p < 0.001), renal failure (7.3% vs 3.4%, p < 0.001), and mean intensive care unit stay (60.7 vs 42.5 hours, p < 0.001). The 5-year survival of elderly patients (73%) was comparable with the age-matched Australian population. Independent risk factors for 30-day mortality in group 1 patients included preoperative renal failure (p = 0.010), congestive heart failure (p = 0.014), and a nonelective procedure (p = 0.016)., Conclusions: Elderly patients who undergo isolated CABG have significantly lower perioperative risks than have been previously reported. The long-term survival of these patients is comparable with an age-adjusted population., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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