The latest medical research on Cardiothoracic Surgery

Prone positioning (PP) has benefits in patients with acute respiratory distress syndrome (ARDS). The objective of this study was to compare the effects and complications of PP in obese vs non-obese patients with moderate-to-severe ARDS after cardiothoracic surgery.

We retrospectively analysed a database established in 2014-2021 in an intensive care unit (ICU). The primary end-point was the change in PaO2/FiO2 induced by PP. Secondary end-points included pressure ulcers, mediastinitis, and ICU mortality. The groups with vs without obesity (body mass index >30 kg/m2) were compared and a mixed linear model was built to identify factors associated with the PaO2/FiO2 change.

81 patients with ARDS (36 with vs 45 without obesity) and 189 PP sessions were included. PP duration was 17.2 ± 4.5 h in obese and 18.0 ± 3.8 in non-obese patients (p = 0.23). Mean number of sessions was 2.6 ± 1.4 in obese and 2.1 ± 1.3 in non-obese patients (p = 0.10). Median PaO2/FiO2 increase after the first PP session was 75.0% [14.5-123.0] and 72% [15.5-130.5] in the groups with vs without obesity (p = 0.67). Stage 3/4 pressure ulcers were more common in the obese group (44.4% vs 22.2%; p = 0.03) and occurred chiefly on the face. No significant differences between the obese and non-obese groups were found for mediastinitis (16.7% vs 8.9%, p = 0.33) or ICU mortality (22% vs 20%, p = 0.81).

Improvement of oxygenation was not statistically different between patients with vs without obesity. Pressure ulcers were more common in the obese group, whereas mediastinitis was not. No patient experienced wound dehiscence.

When final pathology shows pathologic N1 or N2 disease after a pulmonary segmentectomy for early stage non-small cell lung cancer (NSCLC), completion of lobectomy could be considered and recommended as an option for treatment. We explored outcomes after segmentectomy for clinical stage IA NSCLC with occult pN1 or pN2 disease.

We identified clinical stage IA NSCLC undergoing segmentectomy or lobectomy from the National Cancer Database (NCDB) between 2010 and 2020. We categorized patients by pathologic N diseases (pN0/pN1/pN2). We compared segmentectomy to lobectomy adjusting for patient and clinical characteristics. We explored survival using time-varied Cox regression, 30-day, 90-day mortality, and unplanned 30-day readmission using logistic regression, and length-of-stay using Poisson regression.

Of 123,085 clinical IA NSCLC, 7.9% underwent segmentectomy. Pathology showed 2.8% pN1 and 1.9% pN2 after segmentectomy, and 6.5% pN1 and 3.7% pN2 after lobectomy. For pN1, segmentectomy conferred 33% better survival within 2 years (aHR = 0.67, p = 0.03), but similar survival after 2 years (aHR = 1.06, p = 0.7). For pN2, segmentectomy had similar survival with lobectomy (aHR = 0.96, p = 0.7). For all clinical IA NSCLC, segmentectomy was associated with lower 30-day mortality (aOR = 0.55, p < 0.001), 90-day mortality (aOR = 0.57, p < 0.001), readmission (aOR = 0.86, p = 0.01), and shorter length-of-stay (aRR = 0.76, p < 0.001) than lobectomy.

Outcomes after segmentectomy for clinical stage IA NSCLC may be associated with better short-term mortality, readmission rate and length-of-stay. Survival with occult pN1 and pN2 after segmentectomy are at least equivalent to lobectomy in completely resected clinical stage IA patients. A completion lobectomy may not be needed after pN1 and N2 findings after the permanent pathology was released.

The appropriate antithrombotic regimen after a Fontan operation is yet to be elucidated. Hence, this study aimed to compare the incidence of thromboembolic events in patients with and without receiving warfarin for thromboprophylaxis in a large post-Fontan population.

This retrospective cohort study used data from the Diagnosis Procedure Combination database in Japan, between April 2011 and March 2022. We identified all patients who underwent a Fontan operation and excluded those who were born before 2010, died during the hospitalization, or received mechanical heart replacement. Propensity score overlap weighting was performed between patients discharged with warfarin (with or without aspirin) and the control group (only aspirin, or neither aspirin nor warfarin). Cox and Fine-Gray hazards models compared thromboembolic and bleeding events.

We identified 2,007 eligible patients, including 1,670 warfarin-users and 337 non-users. The mean follow-up duration was 2.1 years. The crude proportions of thromboembolic events were 3.0% and 3.0% and those of bleeding events were 0.4% and 0.3% in the warfarin and control groups, respectively. There was no significant difference in thromboembolic events between the groups (sub-distribution hazard ratio: 0.77; 95% confidence interval: 0.39-1.51; P = 0.45) or bleeding events (sub-distribution hazard ratio: 0.78; 95% confidence interval: 0.09-7.03; P = 0.83).

Warfarin use at discharge after a Fontan operation may not be necessary for thromboembolism prophylaxis in paediatric patients, based on large-scale real-world data, with a mean postoperative follow-up duration of 2.1 years. There is room for further studies to reconsider routine warfarin use in patients post-Fontan operation.

Non-operative management (NOM) with antibiotics alone for pediatric uncomplicated appendicitis is accepted to be safe and effective. However, the relative cost-effectiveness of this approach compared to appendectomy remains unknown. We aimed to evaluate the cost-effectiveness of non-operative versus operative management for pediatric uncomplicated acute appendicitis.

A trial-based real-world economic evaluation from the healthcare sector perspective was performed using data collected from a multi-institutional non-randomized controlled trial investigating NOM versus surgery. The time horizon was 1 year, with costs in 2023 US dollars. Ratio of costs-to-charges (RCC)-based data for the initial hospitalization, readmissions, and unplanned emergency department visits were extracted from the Pediatric Health Information System (PHIS). Utility data were derived from patient-reported disability days and health-related quality-of-life scores. Multiple scenarios and one-way deterministic and probabilistic sensitivity analyses accounted for parameter uncertainty. Willingness-to-pay (WTP) threshold was set at $100,000 per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). Primary outcome measures included total and incremental mean costs, QALY, DALY, and incremental cost-effectiveness ratios (ICERs).

Of 1,068 participants, 370 (35%) selected NOM and 698 (65%) selected urgent laparoscopic appendectomy. Operative management cost an average of $9,791/patient and yielded an average of 0.884 QALYs while NOM cost an average of $8,044/patient and yielded an average of 0.895 QALYs. NOM was both less costly and more effective in base case and scenario analyses using disability days and alternate methods of calculating utilities.

NOM is cost-effective compared to laparoscopic appendectomy for pediatric uncomplicated appendicitis over 1 year.