[Scrutiny of pulmonary metastasectomy]. / Pulmonell metastasektomi bör sättas under luppen - Klinisk praxis utan bevisad effekt på överlevnad.

Scrutiny of pulmonary metastasectomy Patients fulfilling the criteria for pulmonary metastasectomy are heavily selected, belong to the benign end of the malignancy spectrum and have automatically a favourable survival. The current five-year survival of 40% is probably due to selection mechanisms, and the possible contribution of surgery is not proven. Further studies are necessary. Sweden seems to have uniquely good conditions to make the necessary investigations.

Improved total quality by monitoring of a cardiothoracic unit. Medical, administrative and economic data followed for 9 years.

To describe monitoring of a cardio-thoracic department from a total quality aspect point of view and to follow the development over 9 years. During the time period 1994-2002 a total of 10,828 cardio-thoracic operations were performed. Capacity, demographic, risk, quality, outcome and economic data were prospectively collected in various registries and analysed. Mean (and median) age increased from 64.2 to 65.3 (66-67). Patients above 70 years increased from 33.6 to 38.7% and above 80 from 2.9 to 5.5%. Operative mortality was unchanged over the time periods at slightly over 2%, with 1-year mortality 6-7%. Mortality for primary, elective coronary artery bypass grafting was 0.26% during the last 3 years. The rate of postoperative complications remained unchanged or decreased with few exceptions: Patients with postoperative confusion increased from 5.0 to 8.1% and patients with a need for face mask ventilation increased from 2.4 to 4.0%. Mean postoperative ventilation time was unchanged at around 22 h, whereas the median decreased from 9.5 to 5.3 h. The workload created by elderly patients was especially noticeable in the intensive care unit (ICU) as both number of postoperative deviations and ICU hours increased as a function of age. Cost per operation decreased by 11%. Total medical rationalisation was higher as salaries increased over time. Mean length of stay decreased by 3 days. Hospital staff hours per operation decreased whereas hospital staff hours per patient hour increased. Physician cost per operation was unchanged. Patient, staff and referring physician satisfaction was high. Several areas for improvement have been found. Monitoring and general feedback of total quality factors has shown itself a powerful tool to detect and follow large and subtle changes in the practice of cardio-thoracic surgery. Most followed factors show improvement in spite of an increase in mean and median age. Several areas may be defined where further development might decrease the trauma to the patient. Aiming at a total quality and patient safety system, monitoring is an essential prerequisite.

Defence, counterattack, retreat?

Cardio-thoracic surgery is facing changes which are imposed upon us from two sources, medical development within cardiology and the general demographic and economic development of the western world. These two developments have to be faced. This treaty describes one way of thinking in our response to the changes. Using old strategic principles our options are attack, defence and retreat. The three options are described in some detail. In order to be well prepared, knowledge and preparation for all three options is necessary in meeting the challenges of the future.

Medium-term survival and quality of life of Swedish octogenarians after open-heart surgery.

OBJECTIVE: Operative mortality after open-heart interventions in the octogenarian population is relatively well known. Less has been reported on the medium term survival and quality of life of this growing subgroup of patients. METHODS: One hundred and eighty-three consecutive patients aged between 80 and 84 years when they underwent open-heart surgery between January 1995 and June 2000 were retrospectively analysed. The patients were followed up for 36 months as regards survival and compared, after matching for age and gender, to survival in the general Swedish population. The health-related quality of life (HRQOL) of surviving patients was assessed in February 2001 using the SWED-QUAL questionnaire. After matching for differences by age and gender, survival results were compared to Swedish national survival data, and functioning and well-being to the corresponding national norm data. Pre-, intra- and post-operative variables were evaluated as predictors for mortality, survival and quality of life. RESULTS: The 30-day mortality rate was 4.6% (n = 8). The 36-month survival rate, that was 85.6%, did not differ significantly (P = 0.078) from that of a cohort of the Swedish population matched for age and gender. There was no significant difference in survival between male and female patients (P = 0.545). Systemic hypertension was the only variable found to be a statistically significant predictor of 36-month mortality (P = 0.009). As concerns HRQOL, patients had significantly better physical functioning, satisfaction with physical functioning, relief of pain and emotional well-being (P < 0.01) and similar quality of sleep (P = 0.106) as the normal population. Male patients and male normal population responders had similar HRQOL (P > 0.05) while female patients reported significantly better HRQOL than their population counterparts on all five dimensions (P < 0.01). CONCLUSIONS: Patients 80-84 years of age may be operated on with acceptable operative mortality and benefit from improved functioning and well-being. Survival and quality of life after open-heart surgery among patients aged 80-84 years of age are comparable to, or even better than in the general Swedish population.

Five-year mortality for stable angina in a medical practice study and a randomized trial.

OBJECTIVE: Evolution of revascularization and medical therapy has increased the probability of improved survival in patients with stable angina. The present investigation tests the hypothesis that medical practice will generate lower mortality than randomly assigned bypass surgery in the European Coronary Surgery Study (ECSS) two decades earlier. METHOD: Using eligibility criteria of ECSS, a clinical decision strategy (CDS) cohort of 362 patients was selected from a nationwide study of medical practice in Sweden. Access to the individual data allowed common protocol design to compare 5-year mortality between CDS and surgical strategy of ECSS. RESULTS AND INTERPRETATION: CDS advised bypass surgery (BS) or percutaneous transluminal coronary angioplasty (PTCA) in 93% and medical treatment alone in 7%, while 94% of 394 patients randomized to surgery (Euro-S) in ECSS obtained BS. Operative mortality was 3.2% for Euro-S while no operative deaths occurred in CDS reflecting medical progress during two decades. However, the 5-year mortality for CDS decreased first when the risk ratio was adjusted for age, diabetes mellitus and hypertension (RR = 0.49 with 95% CI 0.26-0.93) p = 0.03 suggesting a need for improved comprehensive medical care.

Delirium after coronary bypass surgery evaluated by the organic brain syndrome protocol.

OBJECTIVE: The aim was to evaluate symptoms of delirium from a psychogeriatric perspective occurring postoperative to coronary bypass surgery. DESIGN: Patients, > or = 60 years, scheduled for coronary bypass surgery (n = 52) were enrolled in a prospective descriptive study. The patients were evaluated before and several times after surgery by the Organic Brain Syndrome scale, and delirium was diagnosed according to psychiatric codes. RESULTS: Of the 52 patients, 23% presented delirium. These patients were older than the control group, 73.5 +/- 4.2 and 69.3 +/- 5.9 years, respectively (mean +/- SD, p < 0.01), and had more frequently a history of previous stroke (p < 0.05). Emotional delirium was seen in 83%, hyperactive delirium in about 40%, and 25% were classified to have a psychotic delirium. A major finding was a 58% frequency of hallucinations and illusions among patients with delirium, and a similar rate among those without delirium. CONCLUSION: Delirium is common after cardiac surgery in particular in older patients, but is often under-diagnosed. Hallucinations were common in both delirious and non-delirious patients.

Is there an association between release of protein S100B during cardiopulmonary bypass and memory disturbances?

OBJECTIVE: The use of protein S100B as a marker of brain cell injury in conjunction with cardiopulmonary bypass (CPB) has recently been questioned. The present study investigates functional brain injury based on the relation between S100B and memory disturbances. METHODS: Four hundred and fifteen low-risk coronary artery bypass patients exposed to CPB were examined. The protein S100B was sampled during and after surgery. Explicit and implicit memory function was assessed preoperatively and at discharge from hospital. Possible associations between the release of the protein S100B and memory function were studied. RESULTS: Serum concentration of S100B peaked at termination of CPB (0.895 +/- 0.84 microg/l) and decreased gradually; 7 h post CPB (0.436 +/- 0.59 microg/l), day 1 (0.149 +/- 0.27 microg/l) and day 2 (0.043 +/- 0.15 microg/l). High levels of S100B (>1.5 microg/l) 7 h post CPB were associated with a significant (-1 SD) decline of explicit memory function (p = 0.006); this was not seen at termination of CPB (p = 0.834). Predictors of memory decline were S100B 7 h post CPB, length of stay in hospital and concomitant neurological disorders. Postoperative S100B concentration was higher among patients with atrial fibrillation (p = 0.022). CONCLUSION: Only high levels of protein S100B found 7 h post CPB were associated with decline of explicit memory function, not the release seen during CPB. Thus, when using protein S100B, only values several hours remote from surgery should be used as a brain cell injury marker.