Successful Implementation of Enhanced Recovery After Surgery (ERAS) in Paediatric Cardiac Surgery in Australia.

BACKGROUND & AIM: Fast-track or enhanced recovery after surgery (ERAS) is a care pathway for surgical patients based on a multidisciplinary team approach aimed at optimising recovery without increasing risk with protocols based on scientific evidence, which is monitored continuously to ensure compliance and improvement. These protocols have been shown to reduce the duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay (LOS) following paediatric cardiac surgery. We present the first structured implementation of ERAS in paediatric cardiac surgery in Australia. METHODS: All patients enrolled in the ERAS pathway between October 2019 and July 2023 were identified. Demographic and perioperative data were collected retrospectively from hospital records for patients operated before June 2021 and prospectively from June 2021. A control group (non-ERAS) was identified using propensity matching from patients who underwent similar procedures and were not enrolled in the ERAS pathway (prior to October 2019). Patients were matched for age, weight, and comprehensive Aristotle score. Outcomes of interest were duration of postoperative mechanical ventilation, ICU LOS, readmission to the ICU, hospital LOS, cardiac reintervention rate, postoperative complication rate, and number of 30-day readmissions. RESULTS: Of 1,084 patients who underwent cardiac surgery during the study period (October 2019-July 2023), 121 patients (11.2%) followed the ERAS pathway. The median age at the time of surgery was 4.8 years (interquartile range [IQR] 2.8-8.8 years). The most common procedure was the closure of atrial septal defect (n=58, 47.9%). The median cardiopulmonary bypass and cross-clamp times were 40 min (IQR 28-53.5 minutes) and 24.5 min (IQR 13-34 minutes) respectively. The majority were extubated in the operating theatre (n=108, 89.3%). The median ICU and hospital LOS were 4.5 hrs (IQR 4.1-5.6 hours) and 4 days (IQR 4-5 days) respectively. None of the patients required readmission to the ICU within 24 hrs of discharge from the ICU. Three (3) patients (2.5%) required reintervention. When compared with the non-ERAS group, the duration of postoperative mechanical ventilation, ICU and hospital LOS were significantly lower in the ERAS group. There was no significant difference in the ICU readmission rate, reintervention rate, complication rate, and number of 30-day readmissions between both groups. CONCLUSIONS: ERAS after paediatric cardiac surgery is feasible and safe in select patients with low preoperative risk. This pathway reduces the duration of postoperative mechanical ventilation, ICU and hospital LOS without increasing risks, enabling the optimisation of resources.

An overview on the principles of management of haemoptysis.

Haemoptysis is a frequently encountered presentation in thoracic surgery practice. Most of the patients present with chronic haemoptysis while 5% of them will present with life-threatening acute haemoptysis. Emergency surgery used to be the first-line management in acute life-threatening haemoptysis which resulted in significant morbidity and mortality. With advancements in interventional procedures, most of these acute presentations are now being managed conservatively by interventionists. In a country like India with a high incidence of tuberculosis and other infectious diseases of the lungs, haemoptysis is even more common. While interventional procedures help to tide over the crisis and earn valuable time to stabilise a haemorrhaging patient, surgical resection is the definitive management most of the time. This review will endeavour to establish the definition, aetiology, emergency, and definitive management of a patient who presents with haemoptysis.

Thoracic hydatid cysts: an analysis of surgical management in a tertiary care centre in India.

INTRODUCTION AND PURPOSE: Though hydatidosis is a ubiquitous zoonosis endemic to India, there is a dearth of literature regarding the management of thoracic hydatid disease (THD) in India. There are no surgical guidelines available. The aim of this study is to analyse the details of THD operated upon in a tertiary care hospital in India and propose a protocol for its management. METHODS: The case files of all adult patients operated upon for THD in our institution between 2009 and 2019 were retrieved and a retrospective study done. RESULTS: A total of 186 patients, 103 (55.4%) males and 83 (44.6%) females, with a mean age of 34.2 years were studied. The commonest symptom was cough as in 83 (44.6%) patients. Complications were seen in 22 (11.8%) patients. Computerized tomogram (CT) was confirmatory in most patients. Isolated pulmonary disease was seen in 135 (72.6%) patients with 153 (82.3%) uni-lobar involvement. Right lower lobe was most frequently involved as in 56 (30.1%). Extra-pulmonary, intra-thoracic involvement was seen in 6 (3.2%) and synchronous extra-thoracic disease in 45 (24.2%) patients. All patients were initiated on anthelmintics. Postero-lateral thoracotomy was the commonest surgical approach. Twenty (10.7%) patients required lung resections. The mean hospital stay was 5.9 days. Air leak, seen in 10 (5.4%) patients, was the commonest post-operative complication. There was single in-hospital mortality. Age, diabetes mellitus, secondary bacterial infection of the cyst and cyst characteristics were found to significantly affect the surgical outcomes. CONCLUSION: Surgery, the treatment of choice for THD, can be done with negligible morbidity and mortality and should be expedited to prevent complications. Risk factors should be identified pre-operatively for better decision-making. Adequate concurrent medical therapy may prevent recurrences. Prolonged follow-up is mandatory to detect late recurrences.

Surgical management of empyema thoracis - experience of a decade in a tertiary care centre in India.

INTRODUCTION AND PURPOSE: Empyema thoracis (ET) is defined as the accumulation of pus in the pleural cavity. Early stages of ET are treated medically and the late stages surgically. Decortication, thoracoplasty, window procedure (Eloesser flap procedure) and rib resections are the open surgical procedures executed. There are no strict guidelines available in developing nations to guide surgical decision-making, as to which procedure is to be followed. METHODS: Details of all adult patients treated surgically for ET, between the years 2009 and 2019, and maintained in a live database in our institute, were retrieved and analysed. Medically managed patients were excluded. RESULTS: There were 437 patients in the study. The average age was 38 years. There was right side preponderance with a male:female ratio of 5:1. Tuberculosis was the commonest aetiology identified in 248 (57%) patients and diabetes was the commonest co-morbidity present in 97 (22%) patients. There was a higher incidence of a window procedure (WP) in tubercular patients 145 (59%). Only 26 (14%) of the non-tubercular patients underwent a WP. Post-operative complications were persistent air leak in 12 (6%) patients and premature closure of a window in 7 (4%) patients. There were 4 (0.9%) post-operative mortalities. CONCLUSION: Surgical management of late stages of ET provides good results with minimal morbidity and mortality. In developing nations like India, the high incidence of tuberculosis and late presentations make the surgical management difficult and the strategies different from those in developed nations. No clear guidelines exist for the surgical management of ET in developing nations. There is a need for a consensus on the surgical management of empyema in such countries.

Primary mediastinal germ cell tumours: real world experience in the low middle income (LMIC) setting.

PURPOSE: Primary mediastinal germ cell tumours (PMGCTs) are rare; with limited data available about their outcomes and optimal treatment in the low middle income countries setting. We studied the clinical profile of patients with PMGCT treated at our centre in order to estimate their survival outcomes and to identify prognostic factors affecting the same. PATIENTS AND METHODS: Fifty-seven patients with PMGCTs treated between April 2001 and June 2019 were included. Baseline characteristics, details of first line chemotherapy, response rates, toxicity and surgical outcomes were noted. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS: Among 57 male patients (seminoma = 20 and nonseminomatous = 37), the median follow-up was 10 months (range: 1-120 months). For mediastinal seminoma, 9 (45%) and 11 (55%) patients had good and intermediate risk disease, respectively. Nineteen patients (95%) received BEP (Bleomycin, etoposide and cisplatin) chemotherapy. 94.7% had partial responses and median event-free survival was not reached. All patients were alive and disease free at 2 years. For primary mediastinal nonseminomatous germ cell tumours (PMNSGCTs), all patients were poor risk. Thirty-four (91.8%) received BEP/EP chemotherapy as first line. Responses were PRM+ (partial response with elevated markers) in 7 (20.5%) and PRM- in 12 (35.2%). The incidence of febrile neutropenia was 50% and 55.8% in seminole and PMNSGCT, respectively. The median OS was 9.06 months and median PFS was 4.63 months for PMNSGCT. The proportion of patients alive at 1 year and 2 years were 35% and 24.3%, respectively. CONCLUSION: Primary mediastinal seminomas are rarer and have better survival outcomes. Treatment of PMNSGCT is still a challenge and is associated with poorer survival outcomes.