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Background Post-operative pulmonary complications (PPCs) are an important source of morbidity and mortality after major abdominal and thoracic surgery. The use of neuromuscular blocking drugs in general anaesthesia is an important risk factor for PPCs. The incomplete reversal of this neuromuscular blockade at the end of surgery leads to residual weakness of respiratory muscles and predisposes to aspiration of pharyngeal contents, hypoventilation, and thus to PPCs such as atelectasis and pneumonia. Two reversal drugs for neuromuscular blocking agents are available: neostigmine and sugammadex. Compared with neostigmine, sugammadex use results in more rapid reversal of neuromuscular blockade, and small clinical efficacy studies have suggested an associated lower incidence of PPCs. The comparative clinical effectiveness of the two drugs in reducing length of hospital stay or mortality is uncertain. Moreover, a potential safety concern with sugammadex is the relatively high incidence of life-threatening allergic reactions in countries where this drug has been widely used over the last decade. Methods SINFONIA is a pragmatic, randomised, open-label, parallel group, superiority trial with an internal pilot which aims to compare the clinical and cost effectiveness of the two available drugs for reversal of neuromuscular blockade, sugammadex and neostigmine, in patients aged 50 years or older undergoing major abdominal or non-cardiac thoracic surgery. The trial will randomise 2500 patients from approximately 40 centres in the UK. The primary outcome will be days alive and out of hospital at 30 days (DAH-30), with key secondary outcomes of PPC incidence, quality of life, and mortality up to 180 days. An embedded observational study will investigate the rate of allergic sensitisation following exposure to sugammadex. Discussion The SINFONIA trial addresses an important question for anaesthetists and for patients undergoing major abdominal and thoracic surgery. The choice of reversal agent for neuromuscular blockade between sugammadex and neostigmine is currently largely a matter of anaesthetist preference. A growing body of evidence suggests that sugammadex may reduce the incidence of post-operative pulmonary complications relative to neostigmine. This pragmatic clinical effectiveness trial will provide robust evidence as to the effects of the two drugs on patient-centred outcomes such as DAH-30, as well as on cost effectiveness and the incidence of allergic sensitisation. Trial registration The trial was registered on the ISRCTN database ( https://www.isrctn.com ) prior to opening to recruitment (registration no 15109717).

The PulMiCC trial is a randomized controlled trial testing the effect on survival of pulmonary metastasectomy in patients with colorectal cancer. In stage 1 of the trial patients with treated primary colorectal cancer metastatic to the lungs are invited to consent for protocol-based evaluation of their suitability for metastasectomy. The evaluation is as in current practice and includes PET/CT. A decision for or against metastasectomy may be based on the opinion of the clinicians and the preference of the patient. If there is uncertainty the patient is invited to consent to have the treatment arm assigned by randomization in stage 2 of PulMiCC. More than 300 patients have entered stage 1 and more than 70 are in stage 2.

Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations. By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission. 9 440 503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186 336 (65·8%) of 283 131 patients who were readmitted after coronary artery bypass grafting, to 142 142 (83·2%) of 170 789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189 384 [23%] of 834 070 patients readmitted to index hospital vs 36 792 [13%] of 276 976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio [OR] 0·74, 95% CI 0·66–0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45–0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61–0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91–0·94) than did patients who were less likely to be readmitted to the index hospital. In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care. None.

Background Patients undergoing major elective or urgent surgery are at high risk of death or significant morbidity. Measures to reduce this morbidity and mortality include pre-operative optimisation and use of higher levels of dependency care after surgery. We propose a pragmatic multi-centre randomised controlled trial of level of dependency and pre-operative fluid therapy in high-risk surgical patients undergoing major elective surgery. Methods/Design A multi-centre randomised controlled trial with a 2 * 2 factorial design. The first randomisation is to pre-operative fluid therapy or standard regimen and the second randomisation is to routine intensive care versus high dependency care during the early post-operative period. We intend to recruit 204 patients undergoing major elective and urgent abdominal and thoraco-abdominal surgery who fulfil high-risk surgical criteria. The primary outcome for the comparison of level of care is cost-effectiveness at six months and for the comparison of fluid optimisation is the number of hospital days after surgery. Discussion We believe that the results of this study will be invaluable in determining the future care and clinical resource utilisation for this group of patients and thus will have a major impact on clinical practice. Trial Registration Trial registration number - ISRCTN32188676

Our study aimed to evaluate factors influencing perioperative and long-term outcomes of patients undergoing curative-intent chest wall resection and reconstruction. A retrospective single-centre analysis was conducted on all patients undergoing curative-intent chest wall resection and reconstruction from 2010 to 2023. Perioperative outcome was analysed for the entire cohort. Overall survival and disease-free survival were analysed using the Kaplan-Meier method and log-rank test and multivariable Cox proportional hazards regression models with a particular focus on patients with lung cancer and chest wall involvement. A total of 143 consecutive patients (median age 62 years, 44.1% females) were included, and 75% of patients received perioperative systemic therapy or radiation. Rib resection alone was performed in 69.9%, additional sternal resection in 16.1%, spine resection in 11.9% and clavicle resection in 2.1%. Additional resections included the lung (n = 75), diaphragm (n = 6), pericardium (n = 2), subclavian vein (n = 2), pulmonary artery (n = 1) and multiple structures (n = 22). Reconstruction was performed using synthetic protheses (n = 89), metallic (n = 6) or combinations of materials (n = 32). Median tumour diameter was 10 cm; 88% were malignant. Local recurrence rate was 9.5%. Median disease-free survival (86 events) was 36 months, and median overall survival (62 events) was 80 months. The 5-year disease-free survival and overall survival were 54.1% and 74.1%, respectively. In patients with lung cancer, overall survival was significantly affected by age (P = 0.028), histology (P < 0.001), resection size >10 cm (P = 0.018), postoperative performance status (P < 0.001) and postoperative complications (P < 0.001) in multivariable analysis and disease-free survival by postoperative performance status (P < 0.001). Postoperative performance status is correlated with overall survival after chest wall resection.

Background Resection of intrathoracic tumor with cardiopulmonary bypass (CPB) remains a relatively under-reported intervention in literature, and its role in managing locally advanced mediastinal and lung cancers is a topic of ongoing debate. Our aim was to review our experience and assess the role of CPB for treating locally advanced mediastinal and lung cancers. Methods Between 2015 and 2020, this study initially included 10 patients with primary locally advanced thoracic malignancies with apparent adjacent cardiovascular invasion demonstrated by thoracic imaging scans. Operation was performed based on a multidisciplinary tumor board consensus. Eventually, 8 patients (3 primary lung cancers and 5 mediastinal cancers) received either salvage or elective resection with CPB; two completed surgery without requiring CPB. Results Regarding the extent of adjacent structure involvement, 4 patients presented with involvement of the superior vena cava (SVC), 1 involved the right atrium (RA), 2 involved the SVC and RA, and 1 involved the SVC, the origin of main pulmonary artery, and the ascending aorta. Thirty-day mortality occurred in two of three patients receiving salvage surgery due to respiratory insufficiency. With the long-term follow-up, one patient died of recurrence 25 months postoperatively, one survived with recurrence 30 months postoperatively, and four were alive without recurrence for 35, 36, 49, and 107 months after operations. Conclusion In certain patients, particularly for elective surgical candidates rather than salvage resection, CPB allows for extended resection of locally advanced thoracic cancers with acceptable perioperative safety and survival.

To compare postoperative outcomes between hydrogel-coated chest drains (HCDs) and conventional non-coated drains (NCDs) in patients undergoing general thoracic surgery, using a propensity score-matched analysis. This retrospective multi-institutional study included adult patients who underwent thoracic surgery across 4 European centres between February and September 2022. Patients were grouped according to drain type (HCD vs NCD), and a propensity score-matched analysis was performed to account for 16 preoperative and intraoperative covariates. The primary outcome was length of postoperative hospital stay (LOS). Secondary outcomes included in-hospital complications, intensive care unit (ICU) admission, chest drain reinsertion, readmission, duration of drainage, and in-hospital mortality. Subgroup analysis was performed in patients undergoing anatomical lung resections. A total of 773 patients were included (HCD n = 362; NCD n = 411). After matching, 724 patients were analysed. HCD use was associated with a significantly shorter LOS (average treatment effect of the treated population -1.87 days; 95% CI -3.04 to -0.695; P = .002), lower odds of ICU admission (odds ratio [OR] 0.29; 95% CI 0.16-0.53; P < .001), and lower in-hospital complication rates (OR 0.38; 95% CI 0.26-0.55; P < .001). Rates of pneumonia (5.2% vs 13.4%; P = .001), atrial fibrillation (2.2% vs 9.0%; P < .001), and retained pleural effusion (0.8% vs 3.6%; P = .015) were significantly lower in the HCD group. There were no significant differences in drain duration, readmission, or mortality. In the anatomical resection subgroup, HCDs were similarly associated with reduced LOS and complications. Hydrogel-coated drains are associated with fewer postoperative complications and shorter hospital stay compared to conventional drains, particularly in anatomical lung resections. These findings support further prospective evaluation to define the role of HCDs in routine thoracic surgical practice.

Prognostic models are of little clinical value unless they are shown to work in other samples. Douglas Altman and colleagues describe how to validate models and discuss some of the problems

Abstract Objectives Perioperative veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be used during non-elective thoracic surgery to manage hypoxaemia and facilitate complex surgical procedures. However, outcome data in this setting remain limited, particularly regarding bleeding and thrombotic risks. We aimed to evaluate whether perioperative VV-ECMO during non-elective thoracic surgery is associated with increased 90-day all-cause mortality compared with VV-ECMO used for medical indications, using a propensity score-matched analysis. Secondary outcomes included major bleeding and thrombotic events. Methods This retrospective bi-centre cohort study included adults treated with VV-ECMO for acute respiratory failure between January 2011 and January 2025 in 2 university intensive care units. Patients were categorized according to ECMO indication: perioperative thoracic surgery or medical. A propensity score was built using multivariable logistic regression, followed by 1:4 nearest-neighbor matching without replacement. The primary endpoint was 90-day mortality; secondary endpoints included major bleeding and thrombotic events. Results Among 372 patients, 44 (12%) received perioperative VV-ECMO. Ventilator-associated pneumonia (78% vs 57%, P = .01) and haemothorax (36% vs 2%, P < .001) were more frequent in the perioperative group. Ninety-day mortality did not differ between groups, both before (54% vs 51%, P = .71) and after matching (log-rank P = .95). Multivariable Cox analysis confirmed no association between surgical ECMO and mortality (HR = 1.003, 95% CI [0.64-1.57]). No significant differences were found in major bleeding (48% vs 47%, P = 1.00) or thrombotic events (41% vs 32%, P = .31) between groups. Conclusions Perioperative VV-ECMO during non-elective thoracic surgery was not associated with increased 90-day mortality, bleeding, or thrombotic complications compared to medical VV-ECMO, both before and after matching. These findings support its use in carefully selected patients. Clinical trial registration number NCT07016685 Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has become a cornerstone in the management of severe acute respiratory distress syndrome (ARDS), with its use having expanded markedly during the COVID-19 pandemic,1,2 thereby accelerating global adoption in intensive care units (ICUs). Graphical Abstract