Does Enhanced Recovery After Surgery Protocols Reduce Complications and Length of Stay After Thoracic Surgery: A Systematic Review of the Literature.

Enhanced recovery after surgery (ERAS) has an increasingly important role in the perioperative management of thoracic surgical patients. It has been extensively studied in multiple surgical specialties, particularly colorectal surgery, where ERAS protocols have been shown to reduce postoperative length of stay and postoperative complications. Electronic searches of two research databases were performed: PubMed (1972 to October 2023) and Ovid MEDLINE (1946 to October 2023). The literature search was completed on January 4, 2024. Search terms included: "thoracic surgery" and "ERAS" or "Enhanced Recovery After Surgery". The search was limited to studies evaluating humans undergoing thoracic surgery for any indication. The primary outcome was overall morbidity, with secondary outcomes including mortality, length of stay, and pulmonary complications. The search yielded a total of 794 records, of which 30 (four meta-analyses and 26 observational trials) met the relevant inclusion and exclusion criteria. This review suggested the implementation of ERAS protocols can lead to a reduction in postoperative morbidity; however, this was not a consistent finding. The majority of studies included demonstrated a reduction in the length of stay with the implementation of ERAS. Overall, ERAS/ERATS is an important adjunct to the management of patients requiring thoracic surgery, consistently leading to shorter lengths of stay and likely contributing to reduced rates of postoperative morbidity. Further research will be required to determine the impact of the recently released ERATS guidelines.

Coronary artery bypass grafting in octogenarians: an Australian experience.

BACKGROUND: The aims of this study were to describe early and mid-term morbidity and mortality in octogenarian patients undergoing CABG, to determine if outcomes are comparable to younger patients undergoing the same procedure. METHODS: We conducted a retrospective analysis of the first 901 patients who underwent cardiac surgery at a large newly established tertiary hospital in Western Australia from February 2015 to September 2019. Inclusion criteria involved all patients undergoing coronary artery bypass grafting. Exclusion criteria included patients who underwent concomitant valve or aortic procedure. RESULTS: From a cohort of 901 patients, 37 octogenarian patients underwent CABG. Octogenarian patients had a higher rate of post-operative transfusion 35.1% versus 21.4% (P = 0.048), a higher rate of post-op acute kidney injury 40.5% versus 17.2% (P < 0.0001), a higher rate of post-operative atrial arrythmia requiring treatment 40.5% versus 22.5% (P = 0.011) and higher rate of return to theatre (13.5% versus 4.7%, P = 0.018), with bleeding/tamponade being the most likely reason (10.8% versus 2.7%). Octogenarian patients had a longer post-operative length of stay (LOS) with a median LOS of 10 versus 7 days (P < 0.0001). There was no increase in hospital readmission rate, in-hospital mortality or 1 year mortality in octogenarian patients. 24-month and 36-month survivals were 95.2% and 89.6% in octogenarians and 95.3% and 91.5% in the younger group. CONCLUSIONS: Despite an increase in post-operative morbidity and LOS, there was no difference in hospital readmission, in-hospital mortality or 1 year mortality in octogenarian patients who underwent CABG. CABG is safe and remains an important management option for these patients.

Silver nitrate therapy for persistent tracheocutaneous fistula following prolonged tracheostomy and invasive ventilation: A case report.

We report the case of a man with severe Guillain-Barré syndrome who developed a persistent tracheocutaneous fistula (TCF) following prolonged tracheostomy and mechanical ventilation. Following tracheostomy decannulation, the TCF had a deleterious effect on non-invasive positive pressure ventilation efficacy and ability to effectively clear airway secretions due to air leaking from the patent stoma. This case highlights a non-surgical approach to TCF management that is not well-described in the literature and presents an alternative management option for cohorts of patients in which the risk associated with surgical interventions may be undesirable.

Does preoperative pulmonary rehabilitation/physiotherapy improve patient outcomes following lung resection?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether preoperative physiotherapy (pulmonary prehabilitation) is beneficial for patients undergoing lung resection. Altogether 177 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. A meta-analysis by Li et al. showed that patients who received a preoperative rehabilitation programme (PRP) had reduced incidence of postoperative pulmonary complications (PPCs) (odds ratio 0.44, 95% CI 0.27-0.71), reduced length of stay (LOS) (-4.23 days, 95% CI -6.14 to -2.32 days) and improved 6-min walking distance (71.25 m, 95% CI 39.68-102.82) and peak oxygen uptake consumption (VO2 peak) (3.26, 95% CI 2.17-4.35). A meta-analysis by Steffens et al. showed that PPCs were reduced in patients with PRP (relative risk 0.49, 95% CI 0.33-0.73) and reduced LOS (-2.86 days, 95% CI -5.40 to -0.33). The results of 3 additional meta-analyses, 4 randomized controlled trials and 1 observational study all provide further support to PRP in enhanced recovery after surgery and the improvement in exercise capacity. We conclude that PRP improves exercise capacity in patients undergoing surgical resection for lung cancer. Moderate quality evidence supports preoperative exercise providing significant reduction in PPCs and hospital LOS. Referral to exercise programmes should be considered in patients awaiting lung resection, particularly those deemed borderline for suitability for surgical resection.

Minimally Invasive Aortic Valve Replacement Via Right Anterior Mini-Thoracotomy: Propensity Matched Initial Experience.

BACKGROUND: Aortic valve replacement by way of a right anterior mini-thoracotomy (RAMT) has shown excellent results in terms of mortality and morbidity. The aim of the present study was to compare RAMT aortic valve replacement (AVR) with conventional full sternotomy in regards to early perioperative outcomes and mortality. METHODS: This was a retrospective, observational, cohort study of prospectively collected data from patients who underwent isolated, first time AVR between January 2013 and October 2016. Fifty-three RAMT patients were matched to a control group (conventional full sternotomy) using propensity score analysis. RESULTS: The characteristics of the two cohorts were similar. The in-hospital mortality was 1.9% utilising the RAMT approach versus 5.7% using the sternotomy approach (p=0.34). Ventilation times were similar in both groups (7 [5-2] vs 8 [5-13] hrs; p=0.61). However, ICU length of stay was significantly longer in the RAMT group (median, 46.5 [23-59.5] vs 20 [14-23] hrs; p<0.001), which translated into a significantly longer postoperative hospital length of stay for the RAMT group (median, 8 [6-12] vs 6 [5.5-9.5] days; p=0.04) compared to the sternotomy group. RAMT was associated with a trend towards a higher incidence of postoperative AF in comparison to the sternotomy group, although this was not statistically significant (41.5% vs 28.3%; p=0.17). Patients in the RAMT group had lower 4-hour chest drain output (102.5 vs 1141ml; p=0.0.07). There was no statistically significant difference in rates of non-red cell transfusions between the two groups, (17%vs28.3%; p=0.10). The occurrence of stroke, re-exploration for bleeding, red-cell transfusion and wound infection was similar in both groups. CONCLUSIONS: Right anterior mini-thoracotomy in patients undergoing isolated aortic valve surgery is a safe approach in select patients, although associated with longer cardiopulmonary bypass times and ICU length of stay.

Study on the time taken for patients to achieve the ability to self-care their new stoma.

BACKGROUND: Stoma formation in colorectal surgery is a recognized independent cause of prolonged hospital stay. It has been shown that preoperative stoma education and siting leads to a reduction in the length of hospital stay. Despite this, the length of time to independent stoma management and the variables that affect this has not been well studied. We conducted a prospective case series to analyse this. METHODS: A total of 107 consecutive colorectal surgery patients undergoing stoma formation at two separate large metropolitan hospitals, one private funded and the other government funded, were enrolled in a prospective case series. The primary outcome evaluated was independent management of stoma at discharge from hospital. Logistic regression analysis was performed to determine the factors associated with achieving independent stoma management at discharge. RESULTS: The median length of stay was 9 days (range: 4-71). In our study, 71% of patients achieved self-care at the time of discharge from hospital (76/107 patients). The median length of time taken to achieve independent management of a stoma was 7 days (interquartile range: 6-9). Factors associated with increased chance of independent management of stoma at discharge included younger age, male, preoperative siting and treatment in a public hospital. CONCLUSION: Our study supports that preoperative stoma education in combination with post-operative stoma education is superior to post-operative stoma education alone. Interestingly, treatment in a private hospital is associated with a higher likelihood of failure to achieve independent stoma management at discharge. This is unexpected and not explained by our data.

Pericardial Synovial Sarcoma: A Rare Clinical Entity.

Synovial sarcoma is an extremely rare form of primary malignancy of the pericardium. We present a case of primary synovial sarcoma of the pericardium followed by a review of the literature.

Mycotic Pseudoaneurysms of the Coronary Arteries.

BACKGROUND: Mycotic coronary artery aneurysms are rare and are often fatal without early recognition and prompt surgical management. METHODS: We present a case of mycotic pseudoaneurysm of the left main coronary artery (LMCA) after disseminated methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia. A review of the literature in regards to the surgical management of coronary artery mycotic pseudoaneurysms was conducted. RESULTS: There were 26 reported cases of surgical management of coronary artery mycotic pseudoaneurysms. Coronary artery bypass surgery (CABG) and excision was the most common management (73.1% of cases reviewed). CONCLUSION: This case highlights the difficultly in diagnosing mycotic coronary artery pseudoaneurysms.