Validation of Cardiac Surgery-Associated Neutrophil Gelatinase-Associated Lipocalin Score for Prediction of Cardiac Surgery-Associated Acute Kidney Injury.

BACKGROUND: The Cardiac Surgery-Associated Neutrophil Gelatinase-Associated Lipocalin (CSA-NGAL) score has been developed to stratify patients with cardiac surgery-associated acute kidney injury (CSA-AKI). Its predictive power needs to be validated to guide clinical decision for such high-risk patients. METHODS: A prospective study was conducted on 637 consecutive adult patients who developed postoperative AKI after cardiac surgery with cardiopulmonary bypass. AKI was defined according to Kidney Disease: Improving Global Outcomes criteria (KDIGO). The CSA-NGAL score was calculated. Assessment of the diagnostic performance of the scoring model was performed by area under the receiver operating curve analysis. RESULTS: The area under the curve for the postoperative Urinary NGAL showed an area under the curve ([standard error (SE)] 0.80 (0.38); p<0.001; 95% CI 0.72-0.87). Its sensitivity for CSA-AKI in the first 24 hours was 66% and specificity was 80% (cut-off value 300.1 ng/mL). There was a positive correlation between NGAL score and KDIGO criteria, with a significant increase in postoperative mean Urinary NGAL values as the KDIGO stage increased. CONCLUSION: The CSA-NGAL score has a high sensitivity, specificity and positive predictive value that can translate into improved outcomes and resource allocation. It is believed that adding it to the existing clinical scoring systems for AKI prediction will be productive.

Does the Nuss procedure for treating pectus excavatum compromise the long term internal mammary artery flow? A systematic review.

INTRODUCTION: The Nuss procedure is the most common procedure used to treat patients with pectus excavatum. The effect of the Nuss bars on the long-term internal mammary artery flow (IMA) is not well studied. This could have an impact on patients requiring a coronary artery bypass grafting surgery after the Nuss procedure. We performed a systematic review to study the impact of the Nuss bars on the IMA long term flow. METHODS: A Medline search from January 1990 to August 2020 was performed using [Nuss OR thoracoscopic pectus OR minimally invasive pectus] AND [Internal mammary OR Internal thoracic OR IMA OR ITA]. English language papers only were included. This trial was registered with PROSPERO under registration number CRD42021234010. RESULTS: A total of 48 papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. One study looked at the IMA flow via computed tomography (CT)-angiography on the 10th postoperative day after the Nuss procedure and found 15 out of 34 patients (44%) to have abnormal IMA blood flow but with no clinical consequences. Two studies looked at the IMA flow after removal of the Nuss-bar. The first study utilized CT-angiography on the 5th postoperative day after Nuss-bar removal and found four out of the six patients studied (67%) to have abnormal flow. The last study was composed of 19 patients and looked at IMA flow during the presence of the Nuss-bars and after its removal utilizing Doppler-angiography. It found 11 out of 19 patients (58%) to have abnormal blood flow with the bars in place. After removal of the bars, only two patients (10%) were found to have unilateral IMA obstructed flow. CONCLUSION: In patients undergoing the Nuss procedure for management of pectus excavatum, the internal mammary artery flow is compromised in 44%-58% of patients with the bar in situ. When these patients are assessed 10 days following removal of the bar, some reversal of compromised IMA flow is evident. However, in up to 67% of patients, abnormal IMA flow remains. Further studies are required to determine whether this abnormal flow is permanent, which will require examining patients at longer follow-up intervals. Patients undergoing coronary artery bypass grafting who have a history of a Nuss procedure should receive preoperative IMA imaging.

Is surgical resection superior to bronchoscopic resection in patients with symptomatic endobronchial hamartoma?

A best evidence topic was written according to a structured protocol. The question addressed was: in surgically fit patients with biopsy proven symptomatic endobronchial hamartoma (EH), is surgical resection superior to bronchoscopic resection in terms of outcome. A total of 756 articles were identified using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. Three studies included patients who had either bronchoscopic or surgical treatment of EH in the same study. Modalities of surgery included performing a lobectomy, segmentectomy, bronchotomy and a pneumonectomy. Complete resection was 100% in the surgical group and ranged from 8% to 100% in the group treated bronchoscopically. Morbidity was present in 1 patient in a single study (6.6%) in the form of a pneumothorax after a bronchoscopic resection. No mortality was recorded in any study. A follow-up period of 16.2, 26 and up to 60 months showed recurrence of 26.7%, 12% and 0% respectively in the groups treated by bronchoscopy and no recurrence in the surgical group. Four studies looked at bronchoscopic treatment only for EH. Modalities of treatment included mechanical resection, laser, cryotherapy and Argon plasma coagulation. Complete resection ranged from 50-100% with patients achieving only partial resection requiring repeated endoscopic sessions. Morbidity was present in 3 out of the 4 studies; 1 case of pneumothorax in each of 2 studies (4.4% and 2%) and 25% morbidity rate in the third study (pneumothorax/airway stenosis). No mortality was present in any study. One study reported no recurrence after a median follow-up of 12.2 months, while another reported 50% recurrence, although the follow-up period was not stated. The final study included patients with EH treated only by surgical resection due to end stage lung damage caused by prolonged endobronchial obstruction. The majority of resections (71.4%) were in the form of lobectomies. Two major morbidities were recorded (28.5%) with no mortality. After a mean follow-up period of 7 years, no recurrences were recorded. To conclude, in biopsy proven symptomatic EHs, bronchoscopic treatment should be the first choice except in patients with end stage lung damage requiring surgical resection. Morbidity is low with pneumothorax the most common complication. Patients may require multiple sessions for complete removal as a significant recurrence rate is present, but is usually managed effectively by repeated bronchoscopic management.