Postoperative Chest Drainage Research Articles

Effectiveness of Tranexamic Acid in Reducing Postoperative Blood Loss in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting.

BackgroundOff-pump coronary artery bypass grafting (OP-CABG) is an accepted surgical option in treating ischemic heart disease and has proven safer than traditional on-pump CABG in terms of reducing perioperative bleeding, coagulopathy, avoiding cardiopulmonary bypass machine and its related morbidity. However, there is evidence that shows the risk of bleeding in OP-CABG due to surgical trauma, heart manipulations, and heparin-protamine exposure. We aim to evaluate the effectiveness of tranexamic acid (TxA) in reducing blood loss and related perioperative complications in patients undergoing OP-CABG.MethodAn individual matched cohort study was conducted at a cardiac centre over a period of one year. We enrolled a total of 60 patients undergoing OPCABG in our study. The basic strategy was to enroll every possible intervention patient until the desired sample size (30 in each group) was achieved and then to select and enroll controls, using a prospective individual matching strategy. Preoperative cardiac risk evaluation was done using the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) in both groups. The intervention group (I) received TxA 10 mg/kg over 10 minutes at the time of induction while the control group (C) did not receive any TxA. Postoperative blood loss was measured by observing chest drain output 24 hourly till the chest drain tube was removed. Perioperative complications were also recorded.ResultsDemographics and baseline characteristics were comparable among groups (p > 0.05). The mean volume of postoperative blood loss in the I group at 24 hours and 48 hours were 352.67 ml and 86.83 ml, respectively. On the other hand, in the C group, the mean volume of postoperative blood loss was 602.00 ml and 166.3 ml. The data showed a statistically significant difference in the postoperative chest drainage output between the groups (unpaired t-test, p < 0.05) and exhibiting a significant reduction in postoperative blood loss in the I group. However, there was no significant difference in blood transfusion requirements in both of the groups (Mann Whitney U test, p > 0.05). The mean duration of postoperative complications, inotropic support, intermittent positive pressure ventilation, intensive care, and hospital stay were also comparable depicting no significant effect of TxA on reducing the perioperative morbidity.ConclusionThis study showed the significance of TxA in reducing bleeding in the postoperative period in patients undergoing OP-CABG.

Utilization of extracorporeal membrane oxygenation in DCD and DBD lung transplants: a 2-year single-center experience.

Donation after circulatory death (DCD) has the potential to expand the lung donor pool. We aimed to assess whether DCD affected the need for perioperative extracorporeal membrane oxygenation (ECMO) and perioperative outcomes in lung transplantation (LTx) as compared to donation after brain death (DBD). All consecutive LTxs performed between April 2017 and March 2019 at our tertiary center were analyzed. Donor and recipient preoperative characteristics, utilization of ECMO, and perioperative clinical outcomes were compared between DCD and DBD LTx. Multivariate models (frequentist and Bayes) were fitted to evaluate an independent effect of DCD on the intra- and postoperative need for ECMO. Out of 105 enrolled patients, 25 (23.8%) were DCD LTx. Donors' and preoperative recipients' characteristics were comparable between the groups. Intraoperatively, mechanical circulatory support (MCS) was more common in DCD LTx (56.0% vs. 36.2%), but the adjusted difference was minor (RR=1.16, 95% CI 0.64-2.12; P=0.613). MCS duration, and first and second lung ischemia time were longer in the DCD group. Postoperatively, DCD recipients more commonly required ECMO (32.0% vs. 7.5%) and the difference remained considerable after adjustment for the pre- and intraoperative covariates: RR=4.11 (95% CI 0.95-17.7), P=0.058, Bayes RR=4.15 (95% CrI 1.28-13.0). Sensitivity analyses (two DCD-DBD matching procedures) supported a higher risk of postoperative ECMO need in DCD patients. Incidence of delayed chest closure, postoperative chest drainage, and renal replacement therapy was higher in the DCD group. Early postoperative outcomes after DCD LTx appeared generally comparable to those after DBD LTx. DCD was associated with a higher need for postoperative ECMO which could influence clinical outcomes. However, as the DCD group had a significantly higher use of EVLP with more common ECMO preoperatively, this might have contributed to worse outcomes in the DCD group.

A Retrospective Study of Microporous Polysaccharide Hemostatic Powder Combined with Other Repair Materials for Reducing Postoperative Pulmonary Air Leakage during Pulmonary Segmentectomy

背景与目的解剖性肺段切除术在肺结节及早期肺癌中的应用愈加广泛，术后肺漏气是其术后常见并发症之一。本研究旨在探究胸腔镜下精准肺段切除手术术中修补材料的应用对于减少术后肺漏气的效果。方法本研究纳入2018年8月1日-2019年7月31日在江苏省人民医院胸外科拟行胸腔镜下肺段切除术的入院患者，根据术中处理段间交界面时使用材料的差异进行分组：采用微孔多聚糖止血粉+纤维蛋白粘合胶+可吸收性聚乙醇酸补片的患者划分为A组，而采用纤维蛋白粘合胶+可吸收性聚乙醇酸补片的患者划分为B组。收集并记录所有患者的术前基础信息及术后的每日胸腔引流量、胸腔引流管的留置时间、拔除胸腔引流管前的胸片、拔除胸腔引流管后的胸片、血常规以及术后住院时间，并分析术中修补材料的应用对术后肺漏气的影响。结果两组患者胸腔引流管留置时间（P=0.019）、术后住院时间（P=0.017）具有统计学差异。结论在肺段切除术中段间交界面的处理上使用微孔多聚糖止血粉+纤维蛋白粘合胶+可吸收性聚乙醇酸补片相比于使用纤维蛋白粘合胶+可吸收性聚乙醇酸补片能更好地减少患者术后漏气的发生及缩短术后住院时间。

Propensity-matched analysis of two port approach versus three port approach for totally thoracoscopic mitral valve replacement.

BackgroundTo objectively evaluate the feasibility, safety, effectiveness and short-term outcome of totally thoracoscopic mitral valve replacement via two port approach, we conducted a retrospective study comparing two port approach with three port approach for mitral valve replacement.MethodsData for all thoracoscopic mitral valve replacement were analyzed from Guangdong Cardiovascular Institute between January 1, 2016 and December 31, 2017. To account for selection bias between two port approach and three approach, one-to-one propensity score caliper matching without replacement was performed. The clinical data of the two groups were collected, including preoperative cardiac function, operative data, postoperative complications, and short-term outcome.ResultsA total of 330 patients who underwent totally thoracoscopic mitral replacement via two port or three port from January 1, 2016 to December 31, 2017 were enrolled (two-port group: n=103; three-port group: n=227). Propensity score matching resulted in 71 matched pairs with improved balance post matching in baseline covariates. The baseline differences between two groups were eliminated (P>0.05 for all baseline variables). The cardiopulmonary bypass time (min) (154.27±57.02 vs. 142.68±51.33 P=0.183) and the aortic cross-clamp time (min) (106.99±106.98 vs. 90.16±31.63 P=0.206) in the two-port group were not significantly different from those in the three-port group. No significant difference was observed between the two groups in mechanical ventilation time, duration of intensive care unit stay, or amount of postoperative chest drainage. No perioperative death or re-exploration for bleeding was found in either group. As for other postoperative complications, two groups had the similar rate of lung infection lung infection (1.41% vs. 1.33% P=1.000) or acute renal failure (1.41% vs. 1.41% P=1.000).ConclusionsNo significant differences in cardiopulmonary bypass time, aortic cross-clamp time, overall operative time, perioperative mortality, or complications were observed between two-port and three-port totally thoracoscopic mitral valve replacement. Two-port totally thoracoscopic mitral valve replacement is a safe, effective, and feasible procedure for mitral valve replacement.

Long-term outcome in mediastinal malignancies: video-assisted thoracoscopic versus open surgery.

There are not many studies comparing long-term oncological outcomes between video-assisted thoracoscopic surgery (VATS) and open surgery for mediastinal malignancies. This study aimed to compare perioperative and long-term outcomes of these two techniques in the treatment of mediastinal malignancies. This is a retrospective study: patients with mediastinal malignancies underwent VATS or open surgery from 2010 to 2013 and were followed until 2019. The primary endpoints were long-term oncological outcomes, including tumor recurrence and mortality. Secondary endpoints were perioperative outcomes (operative duration, blood loss, pain, chest drainage duration, hospital length of stay, and complications). There were 36 patients in the VATS group and 49 patients in the open group. The median follow-up duration was 90months. VATS significantly reduced operation time (84.6 versus 124.8min), blood loss (59.8 versus 235.2ml), postoperative pain score (4.9 versus 6.7), the duration of chest tube drainage (2.1 versus 3.1days), and postoperative hospital stay (5.2 versus 8.0days). The two groups were comparable regarding the recurrence rate (2.4 versus 2.1/100 person-years) and mortality rate (0.8 versus 0.9/100 person-years). Compared with open surgery, VATS is less traumatic, reduces postoperative chest drainage, and shortens hospital stay with comparable long-term oncological outcomes. We advocate the VATS approach as a favored option for the resection of mediastinal malignancies.

Analysis of the Value of Laparoscopy Combined with Right Thoracic Small Incision Ivor-Lewis in the Treatment of Cardia Cancer Under X-ray Biomedical Imaging

In order to explore the accuracy of image segmentation algorithm in the biological image segmentation of cardia cancer patients with X-ray barium meal imaging and the effect of laparoscopy combined with right thoracic small incision Ivor Lewis on the prognosis of patients with cardia cancer, 185 patients diagnosed with cardiac cancer in xxx hospital from June 2015 to December 2018 were taken as research objects. Based on X-ray barium meal images, the efficiency of manual segmentation and the proposed watershed based minimum error threshold algorithm for image segmentation was compared. Based on the segmentation results, 185 patients with cardiac cancer were divided into the control group (n = 105) and the test group (n = 80), and the control group received traditional Ivor Lewis surgery, while the test group received laparoscopic Ivor Lewis surgery combined with a small incision in the right chest. Postoperative comparison was made between the two groups of patients on the 3rd day after the operation in the number of lymph node dissection, the incidence of postoperative complications, and the pain score 24 h after the operation. The results showed that the minimum error threshold algorithm based on watershed presented in this study was significantly more accurate than manual segmentation in the segmentation of X-ray barium meal images of cardiac cancer patients. The intraoperative blood loss, postoperative out-of-bed activity time and hospitalization time of the experimental group were significantly lower than that of the control group, and the differences were statistically significant (P &lt; 0.05). The complication rates of postoperative chest drainage volume, postoperative 24 h pain score, postoperative pulmonary infection, bleeding and anastomotic fistula in the 2 d test group were all lower than those in the control group, and the differences were statistically significant (P &lt; 0.05), which indicated that the watershed based minimum error threshold algorithm proposed in this study can effectively achieve the segmentation of X-ray barium meal images of patients with cardiac cancer, while the laparoscopy combined with the right thoracic small incision Ivor Lewis can effectively improve the quality of life of patients.

Nonintubated uniportal thoracoscopic segmentectomy for lung cancer

Uniportal thoracoscopic segmentectomy under intubated general anesthesia with one-lung ventilation has recently been introduced for the management of lung cancer patients with small tumors or compromised cardiopulmonary function. However, uniportal thoracoscopic segmentectomy without endotracheal intubation had rarely been performed. Therefore, in this study, we aimed to evaluate the feasibility and safety of this novel technique. From January 2014 to November 2018, 32 lung cancer patients were treated using nonintubated uniportal thoracoscopic segmentectomy under a combination of target-controlled infusion of propofol, nasal high-flow oxygen therapy, intrathoracic intercostal nerve blockade, and vagal nerve blockade. Sixty-two other lung cancer patients who underwent initial planning nonintubated multiportal thoracoscopic segmentectomy during the same period were included as the control group. Preoperative dye localization was required in 18 (56.3%) patients of uniportal group. No patients required conversion to tracheal intubation or thoracotomy. Two patients were converted from the one-port to the two-port approach due to severe adhesions in the pleural cavity. The mean durations of anesthetic induction and surgery were 12.7min and 101.1min, respectively. Postoperative complications were noted in two patients (2/32, 6.3%) of uniportal group: one had subcutaneous emphysema and the other had prolonged air leaks over 3 days. The median durations of postoperative chest drainage and hospital stay were 1 and 3 days in uniportal group, respectively. Nonintubated uniportal thoracoscopic segmentectomy is technically feasible and safe for selected patients. It can be an attractive alternative to intubated thoracoscopic segmentectomy for patients with early lung cancer.

Is tubeless uniportal video-assisted thoracic surgery for pulmonary wedge resection a safe procedure?

Tubeless uniportal video-assisted thoracic surgery (VATS), using a uniportal approach and non-intubated anaesthesia while avoiding postoperative chest drain insertion, for patients undergoing thoracoscopic surgery has been demonstrated to be feasible in selected cases. However, to date, the safety of the procedure has not been studied. We reviewed consecutive patients undergoing non-intubated uniportal VATS for pulmonary wedge resection at 2 medical centres between August 2016 and October 2019. The decision to avoid chest drain insertion was made in selected candidates. For those candidates in whom a tubeless procedure was performed, postoperative chest X-rays (CXRs) were taken on the day of the surgery [operation (OP) day], on postoperative day 1 and 1-2 weeks later. The factors associated with abnormal CXR findings were studied. Among 135 attempts to avoid chest drain insertion, 13 (9.6%) patients ultimately required a postoperative chest drain. Among 122 patients in which a tubeless procedure was performed, 26 (21.3%) and 47 (38.5%) had abnormal CXR findings on OP day and postoperative day 1, respectively. Among them, 3 (2.5%) patients developed clinically significant abnormal CXRs and required intercostal drainage. Primary spontaneous pneumothorax was independently associated with a higher risk of postoperative abnormal CXRs. Tubeless uniportal VATS for pulmonary wedge resection can be safely performed in selected patients. Most patients with postoperative abnormal CXRs presented subclinical symptoms that spontaneously resolved; only 2.5% of patients with postoperative abnormal CXRs required drainage.

Does Early Drain Removal Affect Postoperative Pericardial Effusion after Congenital Cardiac Surgery?

BackgroundPatients undergoing cardiac surgery require postoperative chest drainage. However, the drain is difficult to keep in place in children with congenital heart disease. Since 2015, at Kyungpook National University Hospital, the chest tube is removed on postoperative day 1 in patients who have undergone simple congenital cardiac surgery (i.e., closure of an atrial or ventricular septal defect). In this study, we evaluated the relationship between the duration of drain placement and the likelihood of pericardial effusion after congenital cardiac surgery.MethodsThe medical records of patients who underwent closure of an atrial or ventricular septal defect at our hospital between January 2014 and December 2016 were reviewed. In total, 162 patients who received follow-up echocardiography and had information available on postoperative pericardial effusion after the repair procedure were enrolled.ResultsEchocardiography was performed at a median of 5 days (range, 4 to 6 days) postoperatively before discharge from the hospital. Pericardial effusion occurred in 21 patients (13.0%), of whom only 3 (1.9%) had moderate or greater pericardial effusion, regardless of the drain duration. All patients improved during outpatient follow-up without invasive management. No patient had severe complications because of pericardial effusion. The duration of drain placement did not affect the incidence of postoperative pericardial effusion (p=0.069). Operative survival was 100%.ConclusionBased on our study, we recommend removing the drain as soon as its role is complete, generally on postoperative day 1, because early removal does not increase the incidence of pericardial effusion in patients undergoing simple congenital cardiac surgery.

Wide Variation in Perioperative Care in Anatomical Lung Resections in the Netherlands: A National Survey

This study aimed to describe perioperative care after anatomical lung resection in the Netherlands, before publication of Enhanced Recovery After Surgery/European Society of Thoracic Surgeons (ERAS/ESTS) guidelines in 2019. An online survey was sent to all 43 Dutch lung surgical centers in December 2017, addressing topics in the 4 phases of perioperative care (preoperative, admission, perioperative, postoperative). Respondents were requested to report care that would be delivered to a standardized patient without perioperative complications. To compare current care with ERAS/ESTS guidelines, we assigned an ERAS/ESTS score per hospital, weighted for evidence level per recommendation. Higher scores indicate higher application of recommendations. Response rate of centers was 100%, median response rate per question was 98% (interquartile range 94-100). Some perioperative recommendations are commonly applied (>85%), such as minimally invasive surgery and regional anesthesia; others, such as admission carbohydrate drinks, are not (<35%). Wide variation was observed regarding patient counselling, pre- and postoperative admission logistics, anemia correction, fluid management, pain management, and chest drain management. Median 62% (interquartile range 53%-72%) of the maximum ERAS/ESTS score was achieved. Large variation in ERAS/ESTS score between hospitals were found in all phases (preoperative: 6.0 [6.5-10.5] points, admission: 5.0 [1.0-6.0] points, perioperative: 21.5.0 [16.0-22.5] points, postoperative: 8.0 [5.0-8.5] points). Large variation exists in perioperative care after anatomical lung resection in the Netherlands. Given previously published data linking variation in perioperative care to variation in outcomes, standardization of perioperative care in lung surgery, preferably based on the ERAS/ESTS guidelines, may be warranted but requires further study.

Comparative analysis of different surgical methods for treating esophageal atresia

Objective To investigate the difference in the clinical efficacy by thoracoscopy or thoracotomy for treating esophageal atresia. Methods Thirty-one cases of type-Ⅲ esophageal atresia undergoing surgical treatment from February 2015 to May 2018 at the Department of Pediatric Surgery of Fujian Provincial Maternity and Children′s Hospital were included, and according to the different surgical methods they were divided into thoracoscopic group (15 cases) and thoracotomy group (16 cases). The operation duration, blood loss, postoperative chest drainage time, posto-perative hospital stay and postoperative complications were analyzed between 2 groups. Results The mean time of operation was (181.33±13.86) min in the thoracoscopic surgery group and (139.06±10.98) min in the thoracotomy group, the thoracoscopic group had longer operation duration than thoracotomy group, and there was a significant difference in operation duration between two groups (t=9.44, P=0.000); mean blood loss was (3.07±0.96) mL in the thoracoscopic surgery group and (5.06±1.12) mL in the thoracotomy group, the thoracoscopic group had less amount of blood loss than thoracotomy group, and there was a significant difference in blood loss between two groups(t=-5.29, P=0.000); mean postoperative chest drainage time was(11.67±1.34) d in the thoracoscopic group and (12.25±1.06) d in the thoracotomy group, and there was no significant difference in postoperative chest drainage time between two groups(t=-1.34, P=0.19); mean time of postoperative hospitalization time was(15.20±0.94) d in the thoracoscopic group and (16.00±0.96) d in the thoracotomy group, and there was a significant difference in the postoperative hospitalization time between two groups (t=-2.33, P=0.027); the anastomotic leak rates were 33.33% (5 cases) versus 25.00% (4 cases) with closed or open approaches, respectively; anastomotic stricture rates were 40.00%(6 cases) versus 31.25% (5 cases) with closed or open approaches, respectively.There was no significant difference in postoperative incidence of anastomotic fistula and anastomotic stenosis between two groups. Conclusions Compared with thoracotomy in the treatment of esophageal atresia, thoracoscopic approach has smaller incision and less bleeding, less chest deformity, short hospital stay postoperatively, so it is safe and effective.However, the surgeon must have experience in doing thoracoscopic operation. Key words: Thoracoscopic surgery; Thoracotomy; Esophageal atresia

Effects of autologous platelet-rich plasma on postoperative outcomes in patients undergoing Sun′s procedure

Objective To evaluate the effect of autologous platelet-rich plasma (aPRP) on postoperative outcomes in the patients undergoing Sun′s procedure. Methods One hundred and sixteen patients with acute Stanford type A aortic dissection of both sexes, aged 18-64 yr, with body mass index of 19-34 kg/m2, of American Society of Anesthesiologist physical status Ⅳ, were divided into aPRP group (group A) and control group (group C) by a random number table method, with 58 cases in each group.After anesthesia induction and intubation, aPRP preparation was completed before surgery in group A, and surgery began in group C. After heparin neutralization, group A received retransfusion of platelet-rich plasma, while group C received conventional fluid management.Thromboelastography was performed on all patients, and the results were recorded.The intraoperative amount of allogeneic blood products and blood loss were recorded in two groups.Plasma concentrations of tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were recorded after anesthesia induction (T0), immediately after completion of aPRP preparation (T1), 3 h after heparin neutralization (T2), and at 24 and 48 h after surgery (T3, 4). The volume of postoperative chest drainage and amount of allogeneic blood products, mechanical ventilation time, lengths of intensive care unit and hospital stay, incidence of important complications and fatality rate within 30 days after surgery were also collected. Results Compared with group C, the intraoperative amount of allogeneic blood products and blood loss were significantly reduced, α angle and MA values of thromboelastograph were larger, plasma concentrations of TNF-α and IL-6 were reduced at T2, 3, postoperative chest drainage volume and allogeneic blood transfusion were reduced, the postoperative mechanical ventilation time and length of hospital stay were shortened, and the incidence of pulmonary complications was reduced in group A(P 0.05). Conclusion aPRP can improve postoperative outcomes in the patients undergoing Sun′s procedure. Key words: Platelet-rich plasma; Aneurysm, dissecting; Prognosis

Preoperative 3D-CT bronchography and angiography facilitates single-direction uniportal thoracoscopic anatomic lobectomy.

Competency in video-assisted thoracoscopic surgery (VATS) lobectomy is estimated to be reached after 50 cases. Preoperative identification of individualized pulmonary vascular drainage is essential for the safe and fluent performance of single-direction uniportal VATS (UVATS) anatomic lobectomy. Digital anatomy models established by three-dimensional computed tomography bronchography and angiography (3D-CTBA) is therefore utilized to accumulate variations of the right upper lobe (RUL) veins, as right upper lobectomy is considered to be the most complicated and challenging procedure. This study aims to investigate the perioperative outcomes and learning curve of single-direction UVATS RUL lobectomy assisted with 3D-CTBA. The patients who underwent single-direction intercostal UVATS anatomic RUL lobectomy after 3D-CTBA simulation by the same surgeon at Xuzhou Central Hospital between January 2017 and April 2019 were retrospectively reviewed (3D-CTBA group), and consisted of 99 males and 54 females, with a mean age of 61.6 years, with the variations of the RUL vein being assessed preoperatively. They were further divided into group A (30 cases), B (30 cases), C (30 cases), and D (63 cases), in accordance with the order of surgery. Meanwhile, the first 35 cases of single-direction UVATS RUL lobectomy by another experienced surgeon (after the learning curve of this procedure) who did not use 3D-CTBA was enrolled as a control group. The operation time, intraoperative blood loss, stations and numbers of harvested lymph nodes, the incidence of conversion to multiport VATS or thoracotomy, thoracic tube retention for drainage, complications defined under the Clavien-Dindo system, pain score, and postoperative hospital stay were analyzed. The previous surgical experience of the two surgeons was also evaluated. A significant difference was evident among the 5 groups in terms of age, smoking history, the proportion of neoadjuvant chemotherapy, and T staging of the tumors (P<0.05, respectively). As for the 3D-CTBA group, a total of 29 cases (19.0%) of anomalous RUL posterior segmental pulmonary vein (PV) (V2) drainage were recorded, while the other 124 patients indicated the central type (V2a. Cent.). Of the uncommon RUL V2, they could be further classified into 4 types [V2a. Post. (5/153, 3.3%), VX2a. Ant. (17/153, 11.1%), VXX2a. Ant. (3/153, 2.0%), and nonspecific complicated (4/153, 2.6%)]. Single-direction UVATS lobectomy was performed in every patient successfully. No perioperative mortality, major bleeding, conversion to thoracotomy, the addition of incisions, or 30-day unplanned readmission was recorded. One patient in group B reported an injury of a bronchial artery. All cases had an R0 resection. The operation time of group A (109.8±25.4 min) was significantly longer than that of group B (79.7±11.1 min), C (77.0±12.1 min), D (69.3±16.0 min), and the control (86.1±17.9 min, P<0.001 respectively). Moreover, the operation time of the patients in group B, C, and D was slightly shorter than the control, although without significance (P>0.05, respectively). Furthermore, the duration of chest tube drainage in group A (3.7±2.2 days) was noticeably longer than that in group B (3.0±0.9 days), C (2.7±1.6 days), D (2.6±0.8 days), and the control (2.7±1.6 days, P=0.004 among the groups). Similarly, postoperative hospital stay in group A (3.9±2.3 days) was noticeably longer than that in group B (3.0±1.0 days), C (2.8±1.8 days), D (2.6±0.8 days), and the control (2.8±1.8 days, P=0.002 among the groups). The 5 groups indicated comparable stations and numbers of the harvested lymph nodes, intraoperative blood loss, postoperative total chest drainage volume, incidence of complications, and pain scale on the 14th day after surgery (P>0.05, respectively). Preoperative 3D-CTBA digital anatomy facilitates the safe and fluent performance of single-direction UVATS anatomic right upper lobectomy, with a learning curve of 30 cases. High-quality trials for better evidence are called for to verify these findings.

Impact of Perioperative Levosimendan Administration on Risk of Bleeding After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials.

Levosimendan, a calcium sensitizer and potassium channel opener, has been demonstrated to improve myocardial function without increasing oxygen consumption and to show protective effects in other organs. Recently, a prospective, randomized controlled trial (RCT) revealed an association between levosimendan use and a possible increased risk of bleeding postoperatively. Levosimendan's anti-platelet effects have been shown in in vitro studies. Current studies do not provide sufficient data to support a relation between perioperative levosimendan administration and increased bleeding risk. Our goal was to investigate the relation between perioperative levosimendan administration and increased bleeding risk using a meta-analysis study design. The PubMed, Ovid, EMBASE and Cochrane Library databases were searched for relevant RCTs before July 1, 2019. The outcome parameters included reoperation secondary to increased bleeding in the postoperative period, the amount of postoperative recorded blood loss, and the need for transfusion of packed red blood cells (RBCs) and other blood products. A total of 1160 patients in nine RCTs (576 in the levosimendan group and 584 in the control group) were included according to our inclusion criteria. Analysis showed that perioperative levosimendan administration neither increased the rate of reoperation secondary to bleeding nor increased the amount of postoperative chest tube drainage when compared with the control group. In terms of blood product transfusion, levosimendan did not influence the requirement for RBC transfusion, platelet transfusion nor fresh frozen plasma (FFP) transfusion. Levosimendan also did not shorten or prolong the aortic cross-clamp time or the cardiopulmonary bypass time. The analyzed parameters, including reoperations due to bleeding, postoperative chest drainage and the requirement for blood products, revealed that levosimendan did not increase postoperative bleeding risk. More studies with a larger sample size are needed to address a more reliable conclusion due to study limitations.

Minimally invasive and conventional surgical treatment of primary benign cardiac tumors

BackgroundPrimary cardiac tumors are rare and the majorities are benign. Conventional surgical treatment uses median sternotomy, while minimally invasive surgery from right anterolateral minithoracotomy has become an alternative method in recent years. In this study, we summarized the surgical outcomes of both approaches.MethodsFrom January 2008 to August 2018, 50 patients with primary benign cardiac tumors underwent either conventional or minimally invasive surgery in our department. The baseline data were collected. The peri-operative data and follow up results were compared between the two groups.ResultsThere were19 men and 31 women enrolled in this study with a mean age of 55.0 ± 17.5 years. The most common site of the tumor was left atrium (n = 40, 80%), followed by right atrium (n = 8, 16.0%), right ventricle (n = 1, 2.0%) and left ventricle (n = 1, 2.0%). All patients underwent surgery uneventfully, including 33 cases (66.0%) of median sternotomy and 17 cases (34.0%) of right anterolateral minithoracotomy. No significant differences were found between the two groups in terms of cardiopulmonary bypass time, aortic cross-clamp time, postoperative intubation time, intensive care unit days and length of the hospital stay. Patients with right anterolateral minithoracotomy had less post-operative chest drainage (536 ± 159 vs 773 ± 255 ml, P < 0.01) and transfusion rate (5.9% vs 33.3%, P = 0.033) than those who had sternotomy. There was no peri-operative death, and all the patients were alive and free of recurrence at the latest follow-up.ConclusionsSurgical resection of primary benign cardiac tumors is safe, effective and durable. The right anterolateral minithoracotomy provides the same postoperative recovery as standard median sternotomy, but less transfusion. It can be considered as a promising alternative approach.

Effect of high body mass index on perioperative complications under thoracoscope radical resection of lung cancer and its clinical efficacy

Objective To investigate the effect of high body mass index (BMI) on perioperative complications under thoracoscope radical resection of lung cancer and its clinical efficacy. Methods A total of 235 patients who received pulmonary radical resection under thoracoscope between January 2012 and December 2017 in Department of Thoracic Surgery of the First Hospital of Lanzhou University were retrospectively analyzed. The patients were divided into normal BMI group (BMI≥18.5 kg/m2 and BMI < 24.0 kg/m2, n = 147) and high BMI group (BMI≥24.0 kg/m2, n = 88) according to BMI in China. The incidence of postoperative complications and clinical efficacy were compared by using χ 2 test and t test. Logistic regression was used to identify that if high BMI was the independent risk factor of postoperative pulmonary infection in patients with lung cancer. Results The incidence of the complications in high BMI group was higher than that in normal BMI group, including pulmonary infection [17.0% (15/88) vs. 6.1% (9/147), χ2 = 7.162, P < 0.05], pulmonary atelectasis [11.4% (10/88) vs. 3.4% (5/147), χ2 = 5.840, P < 0.05], respiratory failure [5.7% (5/88) vs. 0.1% (1/147), χ2 = 5.535, P < 0.05] and poor wound healing [10.2% (9/88) vs. 3.4% (5/147), χ2 = 4.578, P < 0.05]. Postoperative recovery time [(7.1±1.4) d vs. (6.7±0.8) d, t = 2.706, P < 0.05], chest drainage tube removal time [(3.8±1.6) d vs. (3.4±0.7) d, t = 3.089, P < 0.05] in high BMI group were longer than those in normal BMI group. Multiple-factor analysis showed that the independent risk factors were diabetes, high blood pressure, high BMI, long operation time, old age, smoking history (all P < 0.05). Conclusions The incidence of pulmonary infection, pulmonary atelectasis and poor wound healing for the patients with high BMI is increased. Besides, postoperative recovery time and chest drainage tube removal time are prolonged. High BMI is an independent risk factor of pulmonary infection. Key words: Body mass index; Lung neoplasms; Lobectomy; Perioperative complications

Preoperative thromboprophylactic administration of low-molecular-weight-heparin significantly decreased the risk of intraoperative bleeding compared with heparin in patients undergoing video-assisted lobectomy for lung cancer.

Due to the threat from venous thromboembolism (VTE) after major thoracic surgery, especially for cancers, guidelines recommend either heparin sodium (unfractionated heparin) or low-molecular-weight-heparin (LMWH) for those patients at high risk of deep vein thrombosis (DVT). However, risk of bleeding remains a major concern for pre-operative administration of anti-coagulation agents. Therefore, this study aimed to compare the bleeding risk of preoperative administration of LMWH and heparin in patients undergoing video-assisted thoracic surgery (VATS) lobectomy for lung cancer. A retrospective, single-center study was designed. A total of 130 patients diagnosed with lung cancer were included from August 2016 to January 2018. These patients were divided into two groups. The preoperative administration of heparin group (PH group) had received heparin 5,000 IU, BID (twice a day) both pre- and post-operatively. And the LMWH group (PL group) had received LMWH 4,000 IU, QD (once a day) both pre- and post-operatively. These anticoagulants would not be ceased until patient was discharged or 24-hour postoperative chest drainage volume exceeded 500 mL. Both preoperative and postoperative coagulation parameters including platelet count (PLT), hemoglobin value (HGB), international normalized ratio (INR), prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), thrombin time (TT), postoperative drainage parameters and intraoperative bleeding volume were compared. A total of 62 patients were collected in PH group, while 68 patients comprised PL group. Preoperative coagulation parameters, hematologic data and demographic data were comparable. Preoperative duration of two agents (P=0.414), operation time (P=0.155), postoperative HGB (P=0.943), PLT (P=0.244), INR (P=0.469), PT (P=0.651), TT (P=0.407), FIB (P=0.151), drainage duration (P=0.800), duration of heparin and LMWH (P=0.778) were all comparable between the two groups. Compared with PL group, intraoperative bleeding volume (105.11 and 50.26, P<0.001) and postoperative mean drainage volume (251.52 and 216.90 mL, P=0.025) of PH group were significant more. Postoperative APTT (30.17 vs. 28.20 seconds, P=0.022) was significantly longer in PH group. Compared with preoperative administration of heparin, preoperative thromboprophylactic administration of LMWH significantly decreased the risk of intraoperative bleeding in VATS lobectomy.

Retrograde autologous priming in surgery of thoracic aortic aneurysm.

Surgery of thoracic aortic aneurysm (TAA) is associated with blood loss and coagulopathy and a high need for red blood cell (RBC) volume. Retrograde autologous priming (RAP) decreases haemodilution during cardiopulmonary bypass (CPB). The aim of this study was to show the effect of RAP during surgery of TAA repair on haemodilution, the need for RBC transfusion and the postoperative course compared to conventional CPB (cCPB). A retrospective study was performed on 120 patients with TAA. Half of these patients underwent cCPB and the other half received RAP. Statistical analysis was performed using IBM SPSS statistics 23. The χ2 test, the Fisher's exact tests, the independent t-test and the Mann-Whitney U-test were used. Statistical significance was assumed at P-value <0.05. Lower blood product requirements were observed for the RAP group regarding the transfusion of intraoperative RBC (0.87 ± 1.33 vs 1.97 ± 2.43, P = 0.013), postoperative RBC (0.57 ± 1.4 vs 1.32 ± 1.82, P = 0.002) and postoperative fresh frozen plasma (0.52 ± 1.63 vs 1.48 ± 3.32, P = 0.036). The postoperative drainage loss showed significantly lower measurements for the RAP group after 6 h (295.9 ± 342.6 vs 490.6 ± 414.4 ml, P ≤ 0.001), 12 h (450.1 ± 415.5 vs 652.1 ± 463.9 ml, P < 0.001) and 24 h (693.1 ± 483.9 vs 866.4 ± 508.4 ml, P = 0.004). RAP is a safe and easy method to reduce RBC transfusion in TAA surgery without any adverse effects on the clinical outcome. We were also able to show beneficial effects on fresh frozen plasma requirements and postoperative chest drainage volume. Furthermore, improved microcirculation can be suspected. In consequence, we have implemented RAP as a clinical standard during thoracic aortic surgery.

Ultrafiltration and reinfusion of residual cardiopulmonary bypass pump blood: A prospective non-randomized controlled study.

The aim of the study was to investigate whether processing residual pump blood with ultrafiltration could increase the increment of hemoglobin after residual pump blood reinfusion and evaluate its influence on plasma-free hemoglobin (pFHb) level and postoperative renal function. Sixty adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were assigned to 2 groups, based on pump blood processing strategy: ultrafiltration plus reinfusion (n=30) or reinfusion (control; n=30). Increment in hemoglobin and pFHb after reinfusion (ΔHgb, ΔpFHb), reinfusion volume, postoperative chest drainage volume (first 24h), duration of mechanical ventilation, changes in serum creatinine, and prevalence of AKI were compared between the 2 groups. Higher levels of both ΔHgb and ΔpFHb were observed after reinfusion in the ultrafiltration group [ΔHgb 1.8±1.1g/dL vs. 1.2±0.6g/dL, P=0.03, ΔpFHb 100 (0, 200) mg/L vs. 0 (-100, 0) mg/L, P=0.03]. The reinfusion volume was lower in the ultrafiltration group [550 (325, 615) mL vs. 1000 (900, 1180) mL, P<0.001]. No differences were found in postoperative chest drainage volume (first 24h), duration of mechanical ventilation, changes in serum creatinine, and prevalence of AKI. Compared to the unprocessed group, ultrafiltration before reinfusion of residual pump blood improved the hemoglobin level and reduced volume loading. Despite an increase in pFHb, the processing procedure was not related to postoperative kidney injury.

Management of Pleural Effusion After Mediastinoscopic Radical Esophagectomy.

Trans-hiatal and -cervical approach mediastinoscopic radical esophagectomy (TMrE) for esophageal cancers is a less-invasive procedure and does not require for trans-thoracic approach management. However, some patients suffer from pleural effusion after TMrE. In the present study, we investigated the clinicopathological factors of patients needing drainage of pleural effusion (DPE) after TMrE. This study included 118 patients who underwent TMrE between 2010 and 2016. There were 43, 34 and 41 patients that underwent none, a single, and two or more DPEs respectively. Left-side DPE was significantly more frequent compared to right-side DPE. Change in the C-reactive protein (CRP) levels after surgery was significantly higher in patients with multiple DPEs than patients with none or a single DPE. The hospitalization days were significantly longer for patients with multiple DPEs. Pleural effusion accumulates due to continuous inflammation. Although a temporary DPE is sometimes performed, post-operative chest drainage tubes are not necessarily needed.