Management of acute aortic services during the COVID-19 pandemic: a retrospective cohort study from the Middle East.

COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, the authors investigated the impact of the COVID-19 pandemic on their urgent aortic program. Methods: The authors included consecutive patients presenting with TAAD (n=36) in the years 2019 and 2020 [pre-pandemic period (2019; n=16) and the pandemic era (2020; n=20)] at a tertiary care centre. Patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes, and length of stay were determined retrospectively using chart review and were compared between both years. Results: An increase occurred in the absolute number of TAAD referrals during the pandemic era. Patients were featured by younger age of presentation (pre-pandemic group: 47.6±18.7, and the pandemic group: 50.6±16.2 years, P=0.6) in contrast to Western data but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital stay [20 (10.8-56) vs. 14.5 (8.5-53.3) days, P=0.5] and intensive care unit stay [5 (2.3-14.5) vs. 5 (3.3-9.3) days, P=0.4] were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference. There was no significant difference in the rates of in-hospital mortality between both groups [12.5% (2) vs. 10% (2), P=0.93]. Conclusions: Compared with the pre-pandemic era (2019), there was no difference in resource utilisation and clinical outcomes of patients presenting with TAAD during the first year of COVID-19 pandemic (2020). Structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in critical healthcare scenarios. Future studies are required to further investigate aortic care delivery during such challenging pandemics.

Thoracic surgery in United Arab Emirates.

The United Arab Emirates (UAE) has undergone a significant change in its population and economy in the last decades and in parallel its healthcare system has evolved rapidly to provide advanced, innovative and world-leading care. At the forefront of this revolution in healthcare is the development of a multidisciplinary multimodality thoracic service provision, offered at quaternary referral hospitals amalgamating academics, training, research and innovation. Previously, thoracic service care was limited to single providers at various public and private hospitals, usually performing lower complexity cases. Most complex thoracic cases were repatriated outside the UAE. This practice was replaced with the opening of Cleveland Clinic Abu Dhabi (CCAD), in 2015, which created a multidisciplinary thoracic program. This included the start of a mini-invasive surgical and lung transplantation program. Since that time other public and private hospitals have emerged providing care in a similar model. The impact of these programs has been a decreased transfer of patients abroad for treatment. Under the umbrella of the Emirates Thoracic Society (ETS) a platform for greater collaboration aimed at improving patient care, potential research and physician education has been created. Direct links have been established with world-leading Thoracic surgery and Respiratory Medicine Centers facilitating this development and offering support and guidance. This article charts these changes in thoracic care in the recent past, present, and delineates plans for the future in the UAE.

A Randomized Trial to Compare Serratus Anterior Plane Block and Erector Spinae Plane Block for Pain Management Following Thoracoscopic Surgery.

OBJECTIVE: Comparison of ultrasound (US)-guided erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) in video-assisted thoracic surgery (VATS) patients. The primary outcome was to compare perioperative and postoperative (48 hours) opioid consumption. METHODS: A total of 60 patients were randomized into two groups (N = 30): an ESPB group and an SAPB group. All the patients received intravenous patient-controlled postoperative analgesia and ibuprofen 400 mg intravenously every eight hours. Visual analog scale (VAS) scores, opioid consumption, and adverse events were recorded. RESULTS: Intraoperative and postoperative opioid consumption at 0-8, 8-16, and 16-24 hours and rescue analgesic use were significantly lower in the ESPB group (P < 0.05). Static/dynamic VAS scores were significantly lower in the ESPB group (P < 0.05). There was no significant difference between static VAS scores at the fourth hour. There were no differences between adverse effects. Block procedure time and one-time puncture success were similar between groups (P > 0.05 each). CONCLUSION: US-guided ESPB may provide better pain control than SAPB after VATS. QUESTION: Even though there are studies about analgesia management after VATS, clinicians want to perform the technique that is both less invasive and more effective. FINDINGS: This randomized trial showed that US-guided ESPB provides effective analgesia compared with SAPB. MEANING: Performing single-injection ESPB reduces VAS scores and opioid consumption compared with SAPB.

Efficacy of an Ultrasound-Guided Erector Spinae Plane Block for Postoperative Analgesia Management After Video-Assisted Thoracic Surgery: A Prospective Randomized Study.

OBJECTIVES: Investigate whether an ultrasound-guided erector spinae plane block (ESPB) can be used to manage postoperative pain in video-assisted thoracic surgery (VATS) patients. DESIGN: Prospective, randomized study. SETTING: Single institution, academic university hospital. PARTICIPANTS: Adult patients who underwent VATS under general anesthesia between September 2018 and March 2019. INTERVENTIONS: This study was an interventional study. MEASUREMENTS AND MAIN RESULTS: A total of 60 patients were randomly assigned into 2 groups (n = 30 per group): an ESPB group and a control group. In the ESPB group, a single-shot ultrasound-guided ESPB was administered preoperatively. The control group received no such intervention. All of the patients received intravenous patient-controlled postoperative analgesia, and they were assessed using visual analogue scale (VAS) scores, opioid consumption, and adverse events. There were no statistically significant intergroup differences with respect to the age, sex, weight, American Society of Anesthesiologists status, anesthesia duration, and surgery length (p > 0.05 for each). The opioid consumption at 1, 2, 4, 8, 16, and 24 hours and the active and passive VAS scores at 0, 2, 4, 8, 16, and 24 hours were statistically lower in the ESPB group at all of the time periods when compared with the control group (p < 0.05). In the control group, the nausea and itching rates were higher, but there were no intergroup differences in terms of other adverse effects. CONCLUSIONS: A preemptive single-shot ESPB may provide effective analgesia management after VATS.

Extended resection: is it feasible for pulmonary metastases?

BACKGROUND: Extended resections may be necessary to achieve tumor-free borders for secondary pulmonary malignancies. This study was performed to analyze the outcomes that result from extended resections of pulmonary metastases. METHODS: Between February 1991 and December 2008, a total of 25 extended pulmonary resections (resection of the chest wall and diaphragm, vascular procedures, sleeve resections, pneumonectomies, atrial resections, and completion pneumonectomies) were performed on 250 patients undergoing 319 metastasectomy procedures. The extended resection group was analyzed in terms of disease-free interval, type of resection, operative morbidity, mortality, and survival and was then compared with patients who underwent lobar or sublobar resections. RESULTS: The extended resection group consisted of 14 male and 11 female patients. The mean disease-free interval was 36.02 (minimum 6, maximum 132) months. The extended resection rate was 10%. After 30 days, all patients were alive. For all extended metastasectomy groups, actuarial 5-year survival rates from the time of the extended metastasectomy were 16.3%. Mean survival times of patients who underwent extended resection and lobar or sublobar resection were 40 months (SD = 11) (95% confidence interval, 19-61) and 20 months (SD = 3) (95% confidence interval, 14-26), respectively. This difference was not statistically significant (P = 0.09) (Fig. 2). In the subgroup analysis, survival in the extended resections and lobar or sublobar resections groups was not statistically significant (osteosarcoma, P = 0.758; epithelial tumor, P = 0.11). CONCLUSIONS: Extended resections, which can be performed during pulmonary metastasectomies of patients with tumor-free surgical borders, may establish curative benefits, with low rates of mortality and morbidity.

Spinal accessory nerve palsy following gunshot injury: a case report.

Injuries to the spinal accessory nerve are rare and mostly iatrogenic. Pain, impaired ability to raise the ipsilateral shoulder, and scapular winging on abduction of the arm are the most frequently noted clinical manifestations. As a seldom case, a 20 year-old male with spinal accessory nerve palsy after penetrating trauma by gunshot was reported. Three months after the injury, he was complaining about left arm pain in abduction to shoulder level and a decreased range of movement. On physical examination, wasting of the left trapezium with loss of nuchal ridge and drooping of the shoulder were found. On neurological examination of the left trapezius and sternomastoid muscles, motor function were 3/5 and wide dysesthesia on the neck, shoulder and arm was present. The bullet entered just above the clavicle and exited from trapezium. Radiological studies were normal, where electromyography (EMG) showed neuropathic changes. Surgical exploration showed the intact nerve lying on its natural course and we performed external neurolysis for decompression. The postoperative period was uneventful. Dysesthesia has diminished slowly. He was transferred to physical rehabilitation unit. In his clinical control after 3 months he had no dysesthesia and neurological examination of the left trapezius and sternomastoid muscles motor function were 4/5. EMG showed recovery in the left spinal accessory nerve.

Carotid endarterectomy under local anesthesia: single institutional experience.

The aim of this study is to review our experience and results of carotid endarterectomy performed under local anesthesia. We evaluated 300 patients who had undergone carotid endarterectomy with local anesthesia in our department. Surgical indication, outcome, operative technique, and complications were assessed. The patients were 58.20+/-2.76 years old and 153 (51%) were symptomatic. The perioperative course was uneventful. A shunt was inserted because of neurological deterioration in 20 patients (6.6%) with full recovery of the deficit after shunt insertion. Operative time was 52.02+/-12.86 min. There were 9 patients with postoperative neurological complications with one patient who died after 34 days. The remaining 8 patients with reversible neurological deficits recovered and were symptom-free on discharge. The mean length of hospital stay was 2.11+/-1.34 days. Carotid endarterectomy performed under local anesthesia is associated with low morbidity and mortality rates. The surgeon can assess the neurological status during the procedure and provide for a more meticulous endarterectomy. It is also associated with decreased shunt usage, decreased operative time and shorter length of hospital stay.

Life-threatening hemoptysis in a child: the only symptom.

An 8-year-old girl was evaluated for hemoptysis, 50 mL/day, which lasted for 3 days. Computed thoracic tomography detected a mass lesion in the right lower lobe. During rigid bronchoscopic examination, exanguinating hemoptysis occurred, and a Fogarty balloon catheter was placed in the right intermediate bronchus. Thoracotomy revealed a 2 x 2-cm mass in the right lower lobe. Common basal segmentectomy was performed. Pathological frozen-section analysis confirmed the diagnosis of perforated hydatid cyst.

Bronchial sleeve resections for carcinoid tumor in the first decade of life.

Two male patients who were admitted to our department with wheezing, and symptoms of recurrent pneumonia, aged 7 and 10 years, were both diagnosed to have endobronchial masses in the right intermediate bronchus. We employed bronchial sleeve resections with pathological results of carcinoid tumor. Patients were discharged on postoperative days 7 and 8, respectively. The aim of this study is to emphasize the bronchial sleeve resection as a technically feasible procedure in the first decade of life.

Dose-related effects of theophylline added to modified Euro-Collins solution used for hypothermic preservation of lung.

OBJECTIVE: To investigate the dose-related effects of theophylline in prevention of ischemia-reperfusion injury of the lung. DESIGN: Experimental study. SETTINGS: University hospital. PARTICIPANTS: Thirty Wistar rats. INTERVENTIONS: In experimental group 1 (G-I) (n = 5) 20 mg/L, in G-II (n = 5) 100 mg/L, in G-III (n = 5) 400 mg/L, and in G-IV (n = 5) 1000 mg/L of theophylline was added to modified Euro-Collins solution and perfused the lungs. Lungs were extracted without an ischemic period in control group 1 (C-I) and perfused with modified Euro-Collins solution in control group 2 (C-II). Lungs were kept in a hypothermic state for 6 hours and then ventilated for 30 minutes with 100% O(2). MEASUREMENTS AND MAIN RESULTS: Tissue levels of dien congugate (DC) and malonylaldehyde (MDA) were measured. Comparison of 6 groups revealed statistically significant differences for DC and MDA (p < 0.0001 for both comparisons). Both DC and MDA levels of C-II were found to be higher than G-III and G-IV (p = 0.008). DC and MDA levels of G-III and G-IV were significantly lower than G-I and G-II (p = 0.008 for all comparisons). CONCLUSION: The results of this study showed that 400 mg/L and 1000 mg/L of theophylline added to the modified Euro-Collins solution decreased the intermediate products of lipid peroxidation. Theophylline merits further investigation in ischemia-reperfusion studies as a potentially beneficial agent.

Invasive staging of superior mediastinum in non-small cell lung cancer patients with specific indications.

This prospective study was done between February 2001 and December 2002 on 84 non-small cell lung cancer patients who were apparently operable. We selectively performed mediastinoscopy to 46 patients (54.76%, group 1) with the following indications: clinical T4 tumor, high operative risk, radiologically enlarged mediastinal lymph nodes, clinical T3 tumors with central location, radiologically identified mediastinal lymph nodes of any size with adeno or large cell carcinoma histology. Other 38 patients (45.23%, group 2) underwent thoracotomy without mediastinoscopy. Sensitivity, specificity, negative predictive value and positive predictive value of the indications were calculated. Cost analysis was done in the 84 patients and the results were compared with alternative mediastinal staging strategies (vs. routine, and vs. selectively to patients with radiologically positive mediastinal lymph nodes) if they had been applied to our population. Group 1 had higher selectivity to differentiate N2 patients (p=0.02). Sensitivity, specificity, negative predictive value and positive predictive value of indications were calculated as: 0.85, 0.54, 0.92 and 0.36, respectively. Our approach was most economical in terms of total cost per patient and money spent unnecessarily per patient. Mediastinal evaluation in operable lung cancer patients should decrease the number of surgical procedures, N2 disease found at thoracotomy and cost.