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American Journal of Respiratory and... Dec 2023Assessing the early use of video-assisted thoracoscopic surgery (VATS) or intrapleural enzyme therapy (IET) in pleural infection requires a phase III randomized... (Randomized Controlled Trial)
Randomized Controlled Trial
Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial-MIST-3.
Assessing the early use of video-assisted thoracoscopic surgery (VATS) or intrapleural enzyme therapy (IET) in pleural infection requires a phase III randomized controlled trial (RCT). To establish the feasibility of randomization in a surgery-versus-nonsurgery trial as well as the key outcome measures that are important to identify relevant patient-centered outcomes in a subsequent RCT. The MIST-3 (third Multicenter Intrapleural Sepsis Trial) was a prospective multicenter RCT involving eight U.K. centers combining on-site and off-site surgical services. The study enrolled all patients with a confirmed diagnosis of pleural infection and randomized those with ongoing pleural sepsis after an initial period (as long as 24 h) of standard care to one of three treatment arms: continued standard care, early IET, or a surgical opinion with regard to early VATS. The primary outcome was feasibility based on >50% of eligible patients being successfully randomized, >95% of randomized participants retained to discharge, and >80% of randomized participants retained to 2 weeks of follow-up. The analysis was performed per intention to treat. Of 97 eligible patients, 60 (62%) were randomized, with 100% retained to discharge and 84% retained to 2 weeks. Baseline demographic, clinical, and microbiological characteristics of the patients were similar across groups. Median times to intervention were 1.0 and 3.5 days in the IET and surgery groups, respectively ( = 0.02). Despite the difference in time to intervention, length of stay (from randomization to discharge) was similar in both intervention arms (7 d) compared with standard care (10 d) ( = 0.70). There were no significant intergroup differences in 2-month readmission and further intervention, although the study was not adequately powered for this outcome. Compared with VATS, IET demonstrated a larger improvement in mean EuroQol five-dimension health utility index (five-level edition) from baseline (0.35) to 2 months (0.83) ( = 0.023). One serious adverse event was reported in the VATS arm. This is the first multicenter RCT of early IET versus early surgery in pleural infection. Despite the logistical challenges posed by the coronavirus disease (COVID-19) pandemic, the study met its predefined feasibility criteria, demonstrated potential shortening of length of stay with early surgery, and signals toward earlier resolution of pain and a shortened recovery with IET. The study findings suggest that a definitive phase III study is feasible but highlights important considerations and significant modifications to the design that would be required to adequately assess optimal initial management in pleural infection.The trial was registered on ISRCTN (number 18,192,121).
Topics: Humans; Thoracic Surgery, Video-Assisted; Feasibility Studies; Communicable Diseases; Pleural Diseases; Sepsis; Enzyme Therapy
PubMed: 37820359
DOI: 10.1164/rccm.202305-0854OC -
JAMA May 2023There are limited data on the outcomes of transcatheter edge-to-edge mitral valve repair for degenerative mitral regurgitation (MR) in a real-world setting.
IMPORTANCE
There are limited data on the outcomes of transcatheter edge-to-edge mitral valve repair for degenerative mitral regurgitation (MR) in a real-world setting.
OBJECTIVE
To evaluate the outcomes of transcatheter mitral valve repair for degenerative MR.
DESIGN, SETTING, AND PARTICIPANTS
Cohort study of consecutive patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry who underwent nonemergent transcatheter mitral valve repair for degenerative MR in the US from 2014 through 2022.
EXPOSURE
Transcatheter edge-to-edge mitral valve repair with the MitraClip device (Abbott).
MAIN OUTCOMES AND MEASURES
The primary end point was MR success, defined as moderate or less residual MR and a mean mitral gradient of less than 10 mm Hg. Clinical outcomes were evaluated based on the degree of residual MR (mild or less MR or moderate MR) and mitral valve gradients (≤5 mm Hg or >5 to <10 mm Hg).
RESULTS
A total of 19 088 patients with isolated moderate to severe or severe degenerative MR who underwent transcatheter mitral valve repair were analyzed (median age, 82 years; 48% women; median Society of Thoracic Surgeons predicted risk of mortality with surgical mitral valve repair, 4.6%). MR success was achieved in 88.9% of patients. At 30 days, the incidence of death was 2.7%; stroke, 1.2%; and mitral valve reintervention, 0.97%. MR success compared with an unsuccessful procedure was associated with significantly lower mortality (14.0% vs 26.7%; adjusted hazard ratio, 0.49; 95% CI, 0.42-0.56; P < .001) and heart failure readmission (8.4% vs 16.9%; adjusted hazard ratio, 0.47; 95% CI, 0.41-0.54; P < .001) at 1 year. Among patients with MR success, the lowest mortality was observed in patients who had both mild or less residual MR and mean mitral gradients of 5 mm Hg or less compared with those with an unsuccessful procedure (11.4% vs 26.7%; adjusted hazard ratio, 0.40; 95% CI, 0.34-0.47; P < .001).
CONCLUSIONS AND RELEVANCE
In this registry-based study of patients with degenerative MR undergoing transcatheter mitral valve repair, the procedure was safe and resulted in successful repair in 88.9% of patients. The lowest mortality was observed in patients with mild or less residual MR and low mitral gradients.
Topics: Aged, 80 and over; Female; Humans; Male; Cardiac Surgical Procedures; Cohort Studies; Heart Failure; Mitral Valve; Mitral Valve Insufficiency; Cardiac Catheterization; Registries
PubMed: 37219553
DOI: 10.1001/jama.2023.7089 -
Critical Care (London, England) May 2023Cytokine adsorption using the CytoSorb® adsorber has been proposed in various clinical settings including sepsis, ARDS, hyperinflammatory syndromes, cardiac surgery or... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Cytokine adsorption using the CytoSorb® adsorber has been proposed in various clinical settings including sepsis, ARDS, hyperinflammatory syndromes, cardiac surgery or recovery after cardiac arrest. The aim of this analysis is to provide evidence for the efficacy of the CytoSorb® adsorber with regard to mortality in various settings.
METHODS
We searched PubMed, Cochrane Library database and the database provided by Cytosorbents™ (01.1.2010-29.5.2022). We considered randomized controlled trials and observational studies with control groups. The longest reported mortality was defined as the primary endpoint. We computed risk ratios and 95%-confidence intervals and used DerSimonian and Lairds random effects model. We analysed all studies combined and divided them into the subgroups: sepsis, cardiopulmonary bypass surgery (CPB), other severe illness, SARS-CoV-2 infection and recovery from cardiac arrest. The meta-analysis was registered in advance (PROSPERO: CRD42022290334).
RESULTS
Of an initial 1295 publications, 34 studies were found eligible, including 1297 patients treated with CytoSorb® and 1314 controls. Cytosorb® intervention did not lower mortality (RR [95%-CI]: all studies 1.07 [0.88; 1.31], sepsis 0.98 [0.74; 1.31], CPB surgery 0.91 [0.64; 1.29], severe illness 0.95 [0.59; 1.55], SARS-CoV-2 1.58 [0.50; 4.94]). In patients with cardiac arrest, we found a significant survival advantage of the untreated controls (1.22 [1.02; 1.46]). We did not find significant differences in ICU length of stay, lactate levels, or IL-6 levels after treatment. Of the eligible 34 studies only 12 were randomized controlled trials. All observational studies showed moderate to serious risk of bias.
INTERPRETATION
To date, there is no evidence for a positive effect of the CytoSorb® adsorber on mortality across a variety of diagnoses that justifies its widespread use in intensive care medicine.
Topics: Cytokines; Adsorption; Thoracic Surgery; Cardiopulmonary Bypass; Postoperative Complications
PubMed: 37259160
DOI: 10.1186/s13054-023-04492-9 -
Journal of Cancer Research and Clinical... Aug 2023Day surgery has been widely carried out in medical developed countries such as Europe and the United States with high efficiency, safety and economy. The development of...
BACKGROUND
Day surgery has been widely carried out in medical developed countries such as Europe and the United States with high efficiency, safety and economy. The development of thoracic day surgery started late, and currently only a few top three hospitals carry thoracic day surgery. In recent years, with the continuous in-depth application of the concept of accelerated rehabilitation surgery (ERAS) in the field of surgery, thoracic surgery ERAS has also entered clinical practice with remarkable results. At present, the application of day surgery in the field of thoracic surgery is still in its infancy, and the application of robot-assisted thoracic surgery in thoracic surgery has brought new opportunities for the popularization of day surgery in thoracic surgery.
METHODS
We retrospectively reviewed 86 patients underwent thoracic day surgery under the application of robot-assisted surgery system and through systematic randomization method choose 86 patients underwent conventional thoracic surgery under the application of robot-assisted surgery system at our Institute between 2020 and 2022. We analyzed the clinical and pathological features between the two groups.
RESULTS
The clinical feature of location of the nodules, the size of nodules, pN, histology and postoperative complications were homogenous between the two groups. The average age was significantly higher in the conventional mode group, the ratio of male patients and the patients with history of smoking were significantly lower in day-surgery mode group. The major surgical method in conventional mode group was lobectomy resection (48.8%). While the segmental resection was the major surgical in day surgery mode group. The hospital stay and the time of drain was significant longer in conventional mode group. And the total medical cost in conventional was more than day-surgery mode group. While the histology and postoperative complications were homogenous between the two groups.
CONCLUSION
Before this, day surgery and robotics assistant surgery in thoracic surgery had been proved feasibility and safety. However, there was no report of day surgery unit robotics assistant thoracic surgery. Our clinical practice demonstrated that the method of day surgery unit robotics thoracic surgery is feasibility and safety enough.
Topics: Humans; Male; Robotics; Ambulatory Surgical Procedures; Thoracic Surgery; Retrospective Studies; Feasibility Studies; Postoperative Complications; Thoracic Surgery, Video-Assisted; Lung Neoplasms
PubMed: 37037929
DOI: 10.1007/s00432-023-04731-0 -
BMC Medical Education Jul 2023Video-assisted thoracic surgery (VATS) has become the standard for lung cancer diagnosis and treatment. However, this surgical technique requires specific and dedicated... (Review)
Review
BACKGROUND
Video-assisted thoracic surgery (VATS) has become the standard for lung cancer diagnosis and treatment. However, this surgical technique requires specific and dedicated training. In the past 20 years, several simulator systems have been developed to promote VATS training. Advances in virtual reality may facilitate its integration into the VATS training curriculum. The present review aims to first provide a comprehensive overview of the simulators for thoracoscopic surgery, focused especially on simulators for lung lobectomy; second, it explores the role and highlights the possible efficacy of these simulators in the surgical trainee curriculum.
METHODS
A literature search was conducted in the PubMed, EMBASE, Science Direct, Scopus and Web of Science databases using the following keywords combined with Boolean operators "AND" and "OR": virtual reality, VR, augmented reality, virtual simulation, mixed reality, extended reality, thoracic surgery, thoracoscopy, VATS, video-assisted thoracoscopic surgery, simulation, simulator, simulators, training, and education. Reference lists of the identified articles were hand-searched for additional relevant articles to be included in this review.
RESULTS
Different types of simulators have been used for VATS training: synthetic lung models (dry simulators); live animals or animal tissues (wet simulators); and simulators based on virtual or augmented reality. Their role in surgical training has been generally defined as useful. However, not enough data are available to ascertain which type is the most appropriate.
CONCLUSIONS
Simulator application in the field of medical education could revolutionize the regular surgical training curriculum. Further studies are required to better define their impact on surgeons' training programs and, finally, on patients' quality of care.
Topics: Animals; Thoracic Surgery, Video-Assisted; Computer Simulation; Virtual Reality; Augmented Reality; Robotic Surgical Procedures; Simulation Training; Clinical Competence
PubMed: 37501111
DOI: 10.1186/s12909-023-04482-z -
Heart, Lung & Circulation Jun 2023Non-small cell lung cancer is the most common malignancy of the elderly, with 5-year survival estimates of 16.8%. The prognostic benefit of surgical resection for early...
PURPOSE
Non-small cell lung cancer is the most common malignancy of the elderly, with 5-year survival estimates of 16.8%. The prognostic benefit of surgical resection for early lung cancer is irrefutable and maintained irrespective of age, even in patients over 75 years. Concerningly, despite the prognostic benefit of surgery there are deviations from standard treatment protocols with increasing age due to concerns of increased morbidity and mortality with surgery, without evidence to support this.
METHOD
A state-wide retrospective registry study of Queensland's Cardiac Outcomes Registry's (QCOR) Thoracic Database examining the influence of age on the safety of Lung Resection (1 January 2016-20 April 2022).
RESULTS
This included 1,232 patients, mean age at surgery was 66 years (range 14-91 years), with 918 thoracotomies performed. Three deaths occurred within 30-days (0.24%). Octogenarians (n=60) had lower rates of smoking (26% vs 6%), respiratory, cardiovascular, and cerebrovascular disease suggesting this subset of patients is carefully selected. Octogenarian status was not associated with an increased all-cause morbidity (p=0.09) or 30-day mortality (p=0.06). Further to this it was not associated with re-operation (4.4% vs 8.3%, p=0.1), increased postoperative stay (6.66 vs 6.65 days, p=0.99) or myocardial infarction. An independent predictor of morbidity was male sex (OR 1.58, CI 1.2-2.1 p=0.001).
CONCLUSION
Age ≥80 years did not increase surgical morbidity or mortality in the appropriately selected patient and should not be a barrier to referral for consideration of surgical resection.
Topics: Aged, 80 and over; Humans; Male; Aged; Adolescent; Young Adult; Adult; Middle Aged; Carcinoma, Non-Small-Cell Lung; Lung Neoplasms; Octogenarians; Thoracic Surgery; Retrospective Studies; Pneumonectomy; Treatment Outcome; Age Factors; Postoperative Complications
PubMed: 37003939
DOI: 10.1016/j.hlc.2023.03.005 -
Journal of Cardiothoracic Surgery Nov 2023The successful implementation of the Enhanced recovery after surgery (ERAS) concept in thoracic surgery has made it possible to complete the surgery in the day surgery... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The successful implementation of the Enhanced recovery after surgery (ERAS) concept in thoracic surgery has made it possible to complete the surgery in the day surgery unit. However, it is still unclear whether day surgery for lung cancer patients can achieve the same or even better results.
METHODS
A systematic literature search was completed in common databases for studies published before May 2022 and the data analyzed using the Review Manager 5.3 software.
RESULTS
We ultimately included 7 retrospective articles that met our criteria for the study. The results of age, smoking status, comorbidity and pulmonary function tests in day surgery group were better than in inpatient surgery group. Minimally invasive surgical method with segmentectomy was more used in day surgery group than in normal surgery group. The 30-day mortality was also lower in Day surgery group and it displayed that early discharged patients had fewer overall complications than the inpatient surgery group.
CONCLUSIONS
We demonstrate that younger patients, patients receiving segmental resections by VATS, and those with better pulmonary function tests or without comorbidity can be discharged early with low rates of complications and 30-day mortality, especial with ERAS program.
Topics: Humans; Lung Neoplasms; Retrospective Studies; Inpatients; Thoracic Surgery; Ambulatory Surgical Procedures; Pneumonectomy; Thoracic Surgery, Video-Assisted
PubMed: 38007507
DOI: 10.1186/s13019-023-02462-4 -
Journal of Robotic Surgery Jun 2023Robotic-Assisted Thoracic Surgery (RATS) is considered one of the main issues of present thoracic surgery. RATS is a minimally invasive surgical technique allowing... (Review)
Review
Robotic-Assisted Thoracic Surgery (RATS) is considered one of the main issues of present thoracic surgery. RATS is a minimally invasive surgical technique allowing enhanced view, accurate and complex movements, and high ergonomics for the surgeon. Despite these advantages, its application in lung procedures has been limited, mainly by its costs. Since now many different approaches have been proposed and the experience in RATS for lungs ranges from wedge resection to pneumonectomy and is mainly related to lung cancer. The present narrative review explores main approaches and outcomes of RATS lobectomy for lung cancer. A non-systematic review of literature was conducted using the PubMed search engine. An overview of lung robotic surgery is given, and main approaches of robotic lobectomy for lung cancer are exposed. Initial experiences of biportal and uniportal RATS are also described. So far, retrospective analysis reported satisfactory robotic operative outcomes, and comparison with VATS might suggest a more accurate lymphadenectomy. Some Authors might even suggest better perioperative outcomes too. From an oncological standpoint, no definitive prospective study has yet been published but several retrospective analyses report oncological outcomes comparable to those of VATS and open surgery. Literature suggests that RATS for lung procedures is safe and effective and should be considered as a valid additional surgical option.
Topics: Humans; Robotic Surgical Procedures; Retrospective Studies; Thoracic Surgery; Prospective Studies; Thoracic Surgery, Video-Assisted; Lung Neoplasms
PubMed: 36542242
DOI: 10.1007/s11701-022-01512-8 -
Minerva Anestesiologica Nov 2023Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management... (Review)
Review
Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management is to promote effective coughing and early mobilization to reduce atelectasis and ventilation disorders induced by pulmonary contusion. The incidence of chronic pain can affect more than 35% of patients after both thoracotomy and thoracoscopy as well as after chest trauma. As the severity of acute pain is associated with the incidence of chronic pain, early and effective pain management is very important. In this narrative review, we propose to detail systemic and regional analgesia techniques to minimize postoperative pain, while reducing transitional pain, surgical stress response and opioid side effects. We provide the reader with practical recommendations based on both literature and clinical practice experience in a referral level III thoracic trauma center.
Topics: Humans; Pain Management; Thoracic Surgery; Chronic Pain; Thoracic Surgical Procedures; Thoracoscopy; Pain, Postoperative; Thoracotomy
PubMed: 37671536
DOI: 10.23736/S0375-9393.23.17291-9