General Thoracic and Cardiovascular Surgery最新文献

Background: The effectiveness of bilateral internal mammary artery (BIMA) grafting during multivessel coronary artery bypass grafting (CABG) is uncertain in patients with mildly decreased renal function (glomerular filtration rate 60-89 ml/min/1.73 m²). We compared outcomes of bilateral versus single IMA (SIMA) grafting in this population.

Methods: We analyzed 933 patients with mildly decreased renal function who underwent isolated primary CABG using BIMA (n = 454) or SIMA (n = 479) at our center. Patients receiving radial artery grafts or no IMA grafts were excluded. Inverse probability treatment weighting was used to create a well-balanced cohort. 6-year survival and the cumulative incidence of major adverse cardiac or cerebrovascular events (MACCE)-including death, stroke, myocardial infarction, revascularization, and rehospitalization-were assessed.

Results: The median age of the entire cohort was 68.0 years (IQR 61.5-74.0). Median follow-up time was 4.63 years (IQR 4.46-4.82). In well-balanced cohort, BIMA group had a higher number of total distal anastomoses (P < 0.001), with similar rate of complete revascularization (P = 0.101). BIMA group had significantly higher 6-year survival compared to SIMA group (91.9% [87.7-96.3%]; 85.9% [81.7-90.2%]; P = 0.046), which was reconfirmed on multivariable Cox regression analysis (Hazard ratio: 0.505 [0.268-0.953], P = 0.035). MACCE incidence was significantly lower with BIMA (23.5% vs. 40.5%, P < 0.001).

Conclusion: Among patients with mildly decreased renal function, the BIMA group was associated with longer survival and lower major adverse cardiac or cerebrovascular events after multivessel CABG.

Objective: Postoperative inflammation can promote immunosuppression and cancer recurrence. The present study investigated the correlation between serum C-reactive protein (CRP) levels after minimally invasive esophagectomy and long-term patient outcomes with large scale of cases.

Methods: Data from 329 patients who underwent minimally invasive esophagectomy were analyzed. Serum CRP levels were measured from postoperative day (POD) 1 to 7, 10, and 14. Low and high CRP groups were stratified by the median CRP values for each POD. Overall survival (OS) was defined as the time from esophagectomy to patient death. Relapse-free survival (RFS) was defined as the time to disease relapse or death from other cause.

Results: The high CRP group on PODs 5-7 and 10 had a significantly lower OS rate than the low CRP group. The high CRP group on POD 6, 7, and 10 also had a significantly lower RFS rate than the low CRP group. A high CRP level on POD 7 was identified as an independent risk factor for poor OS/RFS. In contrast, preoperative CRP levels (before esophagectomy) were not identified as a risk factor for unfavorable OS/RFS. The high CRP group had a higher mortality rate from other diseases than the low CRP group (15.0% vs 8.9%). Secondary malignancies tended to be more frequent in the high CRP group than in the low CRP group (26.1% vs 6.3%).

Conclusion: Elevated CRP levels in the immediate postoperative period after minimally invasive esophagectomy, particularly on POD 7, were significantly associated with poor OS and RFS.

Objective: Renal dysfunction, including acute kidney injury (AKI) and chronic kidney disease (CKD), is a major complication following lung transplantation (LT) and is associated with increased morbidity and mortality. This study aims to evaluate the clinical significance of AKI in relation to the development of post-LT CKD and poor prognosis.

Methods: Among 133 patients who underwent LT, 116 were included in the analysis. AKI was defined according to the Kidney Disease Improving Global Outcomes criteria. AKI was classified into early AKI (E-AKI), occurring within a few hours to one week postoperatively, and late AKI (L-AKI), occurring between one week and one month after LT. The Major Adverse Kidney Event within 30 days following LT (MAKE30)-a composite outcome that includes all-cause mortality, new renal replacement therapy, or persistent renal dysfunction-was also used in this study. Univariate and multivariate analyses were conducted to identify factors associated with the development of CKD. Overall survival (OS) was analyzed using the Kaplan-Meier method.

Results: The proportions of patients who developed E-AKI, L-AKI, MAKE30, and CKD were 73%, 31%, 15%, and 46%, respectively. Multivariate analysis identified older age and the occurrence of MAKE30 as independent predictors of post-LT CKD. Notably, all recipients aged 50 years or older who experienced either L-AKI or MAKE30 subsequently developed CKD. In addition, the incidence of MAKE30 was marginally correlated with reduced OS.

Conclusion: The occurrence of L-AKI and MAKE30 following LT is associated with the development of CKD and MAKE30 also has a negative impact on OS.

Introduction: Chest wall sarcomas are rare malignant mesenchymal tumors arising from soft tissue, cartilage and bones. Wide resection is usually the treatment option but often results in postoperative complications after resection of the chest wall. In this study, we reviewed cases of chest wall sarcoma treated with resection of the sternum or ribs and examined the factors that could cause complications.

Materials and methods: We enrolled consecutive patients with sarcoma who underwent chest wall surgery with resection of the sternum or ribs between January 2007 and October 2022. We collected data on age, sex, tumor location and size, histology, and detailed resection data of the lung, diaphragm, ribs, sternum, and postoperative complications.

Results: Seventy-one patients were included in the study. The 5-year overall survival and disease-free survival rates were 76.8% and 56.8%, respectively. Age ≤ 63 years was associated with poor disease-free survival (p = 0.019) in the multivariate analysis. Nineteen patients (26.7%) had postoperative complications such as surgical site infections and respiratory disorders. None of the patients died after surgery. Resection of 4 or more ribs was positively correlated with the occurrence of complications (p = 0.040), with an occurrence rate of 45%.

Conclusion: The current study is one of the largest to focus on postoperative complications associated with surgery for chest wall sarcoma with resection of the ribs or sternum. This study suggests that careful postoperative management is advisable when 4 or more ribs are resected during surgery for chest wall sarcoma.

Objectives: Cardiovascular disease is an escalating global health concern, leading to an increasing demand for cardiac surgeries. Nutrition plays a critical role during the perioperative period. Enhanced Recovery After Surgery (ERAS) protocols emphasize the importance of early gastrointestinal function restoration. Among nutritional metrics, protein intake is more closely associated with improved outcomes than total energy intake. This study aims to assess perioperative protein intake in cardiac surgery patients and identify factors associated with malnutrition.

Methods: In this prospective observational study, 197 patients undergoing elective cardiac surgeries at two hospitals in Shanghai were enrolled. Protein intake during the first 7 postoperative days was measured using 24-h dietary recall. Nutritional status was evaluated using the NRS-2002 score and serum albumin levels on admission, as well as on postoperative day 3 and 7. Generalized estimating equations (GEE) were used to identify predictors of malnutrition.

Results: The average protein intake was 0.58 ± 0.24 g/kg/day, which was below the recommended 1.5 g/kg/day, with only 4.1% of patients meeting this target. Advanced age (OR = 1.045, 95% CI: 1.026-1.065, p < 0.05) and elevated white blood cell count (OR = 1.195, 95% CI: 1.127-1.266, p < 0.05) were identified as independent risk factors for malnutrition. The use of oral nutritional supplements (ONS) was protective (OR = 0.628, 95% CI: 0.4-0.988, p < 0.05). Patients with malnutrition on postoperative day 7 had significantly longer hospital stays (p < 0.05).

Conclusion: Patients undergoing cardiac surgery frequently experience significant perioperative protein deficits. Early nutritional intervention, particularly for elderly patients or those with elevated inflammatory markers, may help reduce malnutrition and enhance recovery.

Objectives: We compared early outcomes of total arch repair (TAR) and ascending aorta replacement (AAR) for acute aortic dissection type A (AADA) using the nationwide Japan Cardiovascular Surgery Database (JCVSD) and examined the role of the frozen elephant trunk (FET) technique in TAR.

Methods: Of 17,075 JCVSD patients undergoing urgent or emergent conventional surgery for AADA in 2013-2016, redo cases and those undergoing valve/root or coronary surgery were excluded (included n = 12,288). Four propensity score-matched analyses for treatment with AAR or TAR (n = 4272 each) were established.

Results: After matching, procedure times were significantly longer and incidences of re-exploration for bleeding (5.9 vs. 3.9%, P < 0.0001) or spinal cord injury (4.8 vs. 3.3%, P = 0.0003) were significantly higher in the TAR group than AAR group. In-hospital mortality rate was significantly higher in the TAR group than AAR group (9.5 vs. 7.0%, P < 0.0001). When FET was used, the incidences of some of morbidities improved and the difference in in-hospital mortality between TAR and AAR groups disappeared (8.3 vs. 7.7%, P = 0.6583). However, the incidence of re-exploration for bleeding was still high (5.7 vs. 3.0%, P = 0.0066) and the incidence of spinal cord injury became pronounced (6.7 vs. 2.9%, P = 0.0002).

Conclusions: TAR was associated with longer procedure time and higher incidences of postoperative morbidities and mortality. FET holds promise for improving outcomes of TAR. However, spinal cord injury has emerged as another serious concern and its clinical role remains unclear.

Objectives: Pulmonary air leakage is a major complication in patients undergoing lung resection, particularly with the increasing use of segmentectomy in Japan. We developed a non-biological polyethylene glycol (PEG) hydrogel sealant to control pulmonary air leakage. This study compared the adhesiveness, expansion, and safety of PEG hydrogel with those of fibrin glue.

Methods: Adhesiveness was evaluated using isolated ventilated pig lungs subjected to a stepwise increase in airway pressure. A pleural defect was created, and PEG hydrogels with elastic moduli (G') = 38.2, 646, 3900, and 7780 Pa were applied alongside fibrin glue with G' = 7260 Pa. PEG hydrogel with G' = 7780 Pa and fibrin glue were also applied to isolated deflated pig lungs, which were then inflated to assess expandability. Additionally, a pleural defect was created in rat lungs, and PEG hydrogel or fibrin glue was applied. The rats were observed for 2 and 4 weeks to evaluate safety.

Results: No air leakage was observed in pig lungs treated with PEG hydrogel with G' = 7780 Pa. In contrast, air leakage occurred with PEG hydrogels of other stiffnesses and fibrin glue. PEG hydrogel with G' = 7780 Pa exhibited strong adherence to the pleural surface compared to fibrin glue following lung expansion. All rats survived, and the PEG hydrogel remained intact without peeling at 2 and 4 weeks.

Conclusion: The PEG hydrogel is entirely non-biological and poses no infection risk. It demonstrates potential advantages over fibrin glue in preventing postoperative air leakage.

Objectives: As indications for segmentectomy in small lung cancers expand, accurate preoperative computed tomography (CT) evaluation has become increasingly important. Irregularly shaped tumors require objective measurement techniques. This study assessed new segmentectomy criteria for early-stage non-small-cell lung cancer (NSCLC) using three-dimensional (3D) CT tumor volume.

Methods: In total, 200 segmentectomies and 691 lobectomies for clinical stage 0/IA NSCLC were retrospectively analyzed. Preoperative 3D-CT was performed to measure total tumor volume and solid component volume. To assess the predictive value of solid component volume and solid component ratio for recurrence and mortality, the receiver operating characteristic (ROC) curves for the segmentectomy and lobectomy groups were plotted individually. Based on the cut-off values derived from the ROC curves in the segmentectomy group, all cases were stratified into four categories ("volume high risk + ratio high risk", "volume high risk + ratio low risk", "volume low risk + ratio high risk", "volume low risk + ratio low risk"). Recurrence-free survival was analyzed using the log-rank test.

Results: The cutoff values were 2063.4 mm³ and 28.3% for segmentectomy and 4705.0 mm³ and 73.0% for lobectomy. A significant difference in the 5-year recurrence-free survival between segmentectomy and lobectomy was found only in the volume high-risk + ratio high-risk category (48.1% vs. 66.9%).

Conclusions: This exploratory analysis suggests that 3D-CT tumor quantification may aid in refining segmentectomy criteria; however, external validation is necessary before clinical application.

Objective: This study was performed to investigate the relationship between the preoperative hemoglobin A1c concentration and late postoperative coronary flow reserve improvement after coronary artery bypass grafting.

Methods: The data of 61 patients who underwent isolated coronary artery bypass grafting were retrospectively analyzed. Coronary flow reserve was measured preoperatively, in the early postoperative period (mean: 2.5 months), and in the late postoperative period (mean: 25 months). The patients were classified into two groups based on their preoperative hemoglobin A1c concentration: Group N (< 7%) and Group D (≥ 7%). Further classification was based on the duration of diabetes mellitus (< 10 years or ≥ 10 years).

Results: There was no significant difference in early postoperative coronary flow reserve between the two groups. However, in the late postoperative period, Group N exhibited significantly greater coronary flow reserve improvement than Group D (p = 0.012). There was a significant correlation between a lower preoperative hemoglobin A1c concentration and greater late postoperative coronary flow reserve improvement (R² = 0.13, p = 0.019). Patients with a longer history of diabetes mellitus and a higher preoperative hemoglobin A1c concentration had poorer coronary flow reserve improvement in the late postoperative period.

Conclusions: The preoperative hemoglobin A1c concentration predicted coronary flow reserve improvement in the late postoperative period after coronary artery bypass grafting.