Short- and long-term mortality after deep sternal wound infection following cardiac surgery: experiences from SWEDEHEART.

OBJECTIVES: Deep sternal wound infection (DSWI) is a serious complication after open-heart surgery. We investigated the association between DSWI and short- and long-term all-cause mortality in a large well-defined nationwide population. METHODS: A retrospective, nationwide cohort study, which included 114676 consecutive patients who underwent coronary artery bypass grafting (CABG) and/or valve surgery from 1997 to 2015 in Sweden. Short- and long-term mortality was compared between DSWI patients and non-DSWI patients using propensity score inverse probability weighting adjustment based on patient characteristics and comorbidities. Median follow-up was 8.0 years (range 0-18.9). RESULTS: Altogether, 1516 patients (1.3%) developed DSWI, most commonly in patients undergoing combined CABG and valve surgery (2.1%). DSWI patients were older and had more disease burden than non-DSWI patients. The unadjusted cumulative mortality was higher in the DSWI group compared with the non-DSWI group at 90 days (7.9% vs 3.0%, P < 0.001) and at 1 year (12.8% vs 4.5%, P < 0.001). The adjusted absolute difference in risk of death was 2.3% [95% confidence interval (CI): 0.8-3.9] at 90 days and 4.7% (95% CI: 2.6-6.7) at 1 year. DSWI was independently associated with 90-day [adjusted relative risk (aRR) 1.89 (95% CI: 1.38-2.59)], 1-year [aRR 2.13 (95% CI: 1.68-2.71)] and long-term all-cause mortality [adjusted hazard ratio 1.56 (95% CI: 1.30-1.88)]. CONCLUSIONS: Both short- and long-term mortality risks are higher in DSWI patients compared to non-DSWI patients. These results stress the importance of preventing these infections and careful postoperative monitoring of DSWI patients.

[Outcome of Icelandic patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) abroad].

BACKGROUND: Peritoneal carcinomatosis is a known complication of colorectal cancer and has long been considered very difficult to manage. The survival has been reported to be under two years after systemic chemotherapy with or without palliative surgery. The most recent method of treatment is compiled of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) and has been suggested to significantly increase survival. The aim of this study was to research the cases of Icelandic patients undergoing this treatment overseas and the impact it has had on their disease. METHODS: A retrospective study of all Icelandic patients who have undergone CRS-HIPEC treatment abroad 2008-2017. Information was retrieved from medical records and from registry of the Icelandic Health Insurance committee of medical treatments abroad. RESULTS: A total of 11 patients have undergone CRS-HIPEC treatment after having received their initial treatment in Landspitali University Hospital. All of the surgeries were performed in the United States by the same surgeon in the years 2008-2017. The group consists of 10 women and 1 man with a mean age of 53 years. The cause of peritoneal carcinomatosis was appendiceal cancer for 7 patients (67%) and colon cancer for 3 patients (27%). One patient had a primary malignancy of the peritoneum, mesothelioma. Three patients suffered complications within 30 days of surgery, 2 had infection and 1 had an anastomotic leak. Another patient had a late complication of bowel stenosis and later a fistula. Five patients have completed their five year observation period post surgery without diagnosis of recurrence and mean follow-up time was 44 months. Out of 11 patients, 10 are still alive. Five have been diagnosed with recurrence of disease. CONCLUSION: Icelandic patients who have undergone CRS-HIPEC treatment have in most cases done well and survival is comparable to other studies. Half of the survivors did not have recurrence of disease within 5 years of surgery. Prognosis has improved since the introduction of this treatment and every reason to keep sending selected Icelandic patients abroad to receive it.

Pulmonary carcinoid tumours: incidence, histology, and surgical outcome. A population-based study.

BACKGROUND: Pulmonary carcinoids (PCs) represent only a minority of all primary pulmonary malignancies but they are the most common type of pulmonary malignancy diagnosed in children and adolescents. In this nationwide study, we analyzed data on all PC tumours in the Icelandic population over a 60-year period and concentrated especially on incidence and patient outcomes. METHODS: We studied all cases of PCs diagnosed in Iceland in the period 1955‒2015. Histological specimens were re-evaluated and the tumours were staged according to the TNM system (seventh edition). Survival was estimated using the Kaplan-Meier method, with a mean follow-up of 15.7 years. RESULTS: Altogether, 88 patients (median age 51.0 years, 65.9% women) were diagnosed with PCs in the study period. The incidence increased from 0.19/100,000/year in the first decade (1955‒1964) to 0.58/100,000/year in the last decade (2005‒2015), with a mean increase of 29.0% per decade of the study period (p < 0.001). The rise in incidental detection was, however, not significant. The median tumour diameter was 2.2 cm (range 0.4‒7.0) and typical histology was seen in 74 patients (84.1%). The other 14 patients (15.9%) had atypical histology. In all, 90.9% of the patients underwent pulmonary resection, 81.2% of them with lobectomy, with all of them surviving at least 30 days postoperatively. Most patients (n = 52, 62.7%) were stage IA at diagnosis, 15 (18.1%) were stage IB, nine (10.8%) were stage IIA, and three were stage IIIA (3.6%). Four patients (4.8%) had distant metastases (stage IV), two of whom had typical histology. Five-year survival was 89.8% for all patients: 93.2% for patients with typical histology and 70.7% for those with atypical histology. CONCLUSION: The incidence of PCs in Iceland has increased significantly over the last six decades, which cannot be explained by a rise in incidental detection at chest imaging. Most patients have localized disease and a favourable histology, where the long-term outcome is excellent.

Improved long-term survival following pulmonary resections for non-small cell lung cancer: results of a nationwide study from Iceland.

BACKGROUND: We studied the outcome of pulmonary resection with curative intent for non-small cell lung cancer (NSCLC) in a nationwide study covering a 24-year period, focusing on survival. METHODS: All patients who underwent pulmonary resection for NSCLC in Iceland in the period 1991-2014 were reviewed for demographics, TNM stage and survival. Median length of follow-up was 45 months. Three 8-year periods were compared, overall survival was estimated, and prognostic factors for survival were identified. RESULTS: Altogether, 652 surgical resections were performed on 644 individuals (52% females): 492 lobectomies (75%), 77 pneumonectomies (12%), and 83 sublobar resections (13%). Mean age increased from 65 to 68 yrs during the study period (P=0.002). The number of cases operated at stage IA increased substantially between the first and last periods (29% vs. 37%; P<0.001). Survival improved from 75% to 88% at 1 year and from 38% to 53% at 5 years (P<0.001). Independent prognostic factors for mortality were advanced TNM stage (HR =2.68 for stage IIIA vs. I), age (HR =1.04), ischaemic heart disease (HR =1.26), any minor complication (HR =1.26), and sublobar resection (HR =1.33), but surgical margins free from tumour growth (HR =0.59) and treatment during the latter two eight-year periods were predictors of lower mortality. The best survival was seen between 2007 and 2014 (HR =0.61, 95% CI: 0.48-0.78; P<0.001). CONCLUSIONS: Survival of patients who have undergone pulmonary resection for NSCLC has improved significantly in Iceland. This may be explained by the increased number of patients diagnosed at lower stages and improved preoperative staging, with fewer understaged patients.