A meta-analysis to compare Dacron versus polytetrafluroethylene grafts for above-knee femoropopliteal artery bypass.

BACKGROUND: Surgical revascularization for lower limb ischemia remains an important component for optimization of quality of life and symptoms in patients with peripheral arterial disease. In the absence of a vein graft, prosthetic alternatives are considered. The objective of this meta-analysis was to establish which prosthetic graft, Dacron or polytetrafluroethylene (PTFE), has the better long-term patency in patients undergoing an above-knee femoropopliteal arterial bypass. METHODS: This meta-analysis was performed by use of Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search of all relevant databases was performed from 1990 to 2013 with the Medical Subject Headings "Dacron," "polytetrafluroethylene," "PTFE," "above knee," "femoropopliteal," and "bypass" combined with the Boolean operator "AND." The inclusion criteria were randomized controlled trials, use of Dacron vs PTFE prosthetic conduits, and completion of an above-knee femoropopliteal arterial bypass involving adult patients older than 18 years presenting with disabling claudication, rest pain or tissue loss, occlusion of the superficial femoral artery, and reconstitution of the above-knee popliteal artery. Whenever studies included above- and below-knee data, only the above-knee arterial bypass data were extracted and analyzed. Graft patency rates were calculated with RevMan 5.1 software provided by the Cochrane Collaboration. RESULTS: Ninety-one publications were reviewed. After exclusion of duplicate, nonrandomized, and alternative bypass surgery studies, eight randomized controlled trials were identified and included in the meta-analysis. Two of the included trials represented follow-up evaluation of two previous studies, and for the purpose of this analysis, the initial and follow-up studies were subsequently evaluated as one trial. In this meta-analysis, 1192 patients were assessed, including 601 Dacron and 591 PTFE above-knee lower limb arterial bypasses. Primary patency was calculated from all included studies. However, only four studies provided data to evaluate secondary patency. Mean age reported was 66 years. Although all studies described cardiovascular comorbidities and risk factors including myocardial ischemia, diabetes, hypertension, and smoking, exact patient numbers were not consistently provided. Included studies evaluated grafts from 5 to 8 mm. Although primary and secondary patency rates at 12 months were not significantly different (relative risk [RR], 0.78; P = .08, and RR, 0.84; P = .52), 24-, 36-, and 60-month primary patency rates were significantly better with Dacron compared with PTFE grafts (RR, 0.79; P = .003; RR, 0.80; P = .03; RR, 0.85; P = .02). Statistical analysis also supported higher secondary patency rates for Dacron at 24 months (RR, 0.75; P = .02) and 60 months (RR, 0.76-0.77; P = .03-.27). Although primary patency was similar between grafts (28% vs 28%; P = .12), secondary patencies were better with Dacron at 10 years (49% vs 35%; P = .01). Antiplatelet and anticoagulation protocols varied between the trials. There was no difference in amputation, overall morbidity, or mortality rates between the two surgical graft populations. CONCLUSIONS: Current evidence suggests that Dacron prosthetic grafts are superior to PTFE grafts in above-knee femoropopliteal arterial bypass procedures. Further randomized trials targeting standardization of confounding variables, particularly graft size and best medical therapy, are warranted.

Glomus tumor of the mediastinum.

Glomus tumors are rare benign myoepithelial neoplasms that can present with intractable pain. We report the case of a 59-year-old gentleman who presented with upper abdominal and chest pain caused by a posterior mediastinal glomus tumor arising from the spinal column, which required surgical resection. As glomus tumors usually develop in the limbs, this case highlights the complexity of diagnosis and treatment of glomus tumors when they present in rare locations.

Is early surgical management of chylothorax following oesophagectomy beneficial?

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether the initial surgical management of chylothorax after oesophagectomy results in a better outcome. Altogether 357 papers were found as a result of the reported search, of which 4 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 were tabulated. Three studies were retrospective and from single centres with small patient numbers, while one study was a prospective, randomized controlled trial, from which a subgroup analysis was included in our results. We conclude that although all studies to date have had very small patient numbers and some contradictory results, there is some evidence that early surgical intervention of chylothorax following oesophagectomy reduces hospital stay when compared with conservative treatment.

Prognostic factors in malignant pleural mesothelioma: role of talc pleurodesis.

OBJECTIVE: To examine baseline characteristics associated with survival in patients with malignant pleural mesothelioma. METHODS: 122 patients with histologically proven malignant pleural mesothelioma during the period 2000-2010 were studied. Survival was evaluated by the Kaplan-Meier method with the logrank test. Cox regression analysis was used to estimate the hazard ratios for possible prognostic factors. RESULTS: 105 (86%) patients had complete survival follow-up; 91 died and 14 (13.3%) were alive at the end of the observation period starting from the day of diagnosis. The median survival was 286 days (95% confidence interval: 212-359). Talc pleurodesis was performed in 59 patients, and 17 had surgical interventions (2 chest wall resections, 2 extrapleural pneumonectomies, and 13 decortications). Chemotherapy was used in 41 patients, port-site radiation in 68, and combined therapy in 26. Cox regression analysis identified talc pleurodesis (p=0.04), chemotherapy (p<0.001), port-site radiation (p<0.001), and combined chemotherapy and port-site radiation (p<0.006) as favorable prognostic factors after adjusting for age, sex, histologic subtype, smoking, and performance status. CONCLUSIONS: Surgical intervention including decortications and extrapleural pneumonectomy had no effect on survival in this series. Chemotherapy and radiation to port sites independently and in combination were associated with improved overall survival in malignant pleural mesothelioma patients. Talc pleurodesis was an independent determinant of survival, but further studies are warranted.

Does ligation of the thoracic duct during oesophagectomy reduce the incidence of post-operative chylothorax?

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether prophylactic thoracic duct ligation during oesophagectomy results in a lower incidence of post-operative chylothorax. 29 relevant papers were found using the reported search, of which 5 papers represented the best evidence to answer the clinical question. The authors, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. Of these studies, only one was a prospective randomised controlled study with sizeable patient numbers. This was also the most recent study and demonstrated a significant decrease in post-operative chylothorax incidence following intra-operative thoracic duct ligation. Of the four remaining retrospective studies, one showed an increase in chylothorax rate following ligation whilst three showed a reduction in the incidence of chylothorax (although in only one of these three studies was this decrease statistically significantly). We conclude that for patients undergoing oesophagectomy, although there are conflicting results from retrospective studies, prospective randomised controlled trial evidence points to prophylactic ligation of the thoracic duct as an effective measure to reduce the incidence of post-operative chylothorax.