The treatment of complex pathologies of the aortic arch and proximal descending aorta represents a significant challenge for cardiac surgeons. Various surgical techniques and prostheses have been implemented over the past several decades, all with varying degrees of success. The introduction of the frozen elephant trunk (FET) technique facilitates one-stage repair of such pathologies. The present systematic review and meta-analysis aims to assess the safety and efficacy of the FET approach in the current literature.Electronic searches were performed using six databases from their inception to July 2013. Relevant studies utilizing the FET technique were identified. Data were extracted and analyzed according to predefined clinical endpoints.Seventeen studies were identified for inclusion for qualitative and quantitative analyses, all of which were observational reports. Pooled mortality was 8.3%, while stroke and spinal cord injuries were 4.9% and 5.1% respectively. Cardiopulmonary bypass time, myocardial ischemia time, and circulatory arrest time strongly correlated with perioperative mortality in a linear relationship, while moderate correlations between cerebral perfusion time and mortality, and circulatory arrest time and spinal cord injury, were also identified. Five-year survival, reported in five studies, ranged between 63-88%.Overall, results of the present systematic review and meta-analysis suggest that the FET procedure can be performed with acceptable mortality and morbidity risks.
A recent concern of deep hypothermic circulatory arrest (DHCA) in aortic arch surgery has been its potential association with increased risk of coagulopathy, elevated inflammatory response and end-organ dysfunction. Recently, moderate hypothermic circulatory arrest (MHCA) with selective antegrade circulatory arrest (SACP) seeks to negate potential hypothermia-related morbidities, while maintaining adequate neuroprotection. The present meta-analysis aims to compare postoperative outcomes in arch surgery using DHCA or MHCA+SACP as neuroprotective strategies.Electronic searches were performed using six databases from their inception to January 2013. Two reviewers independently identified all relevant studies comparing DHCA with MHCA+SACP, as defined by a recent hypothermia temperature consensus. Data were extracted and meta-analyzed according to pre-defined clinical endpoints.Nine comparative studies were identified for inclusion in the present meta-analysis. Stroke rates were significantly lower in patients undergoing MHCA+SACP (P=0.0007, I(2)=0%), while comparable results were observed with temporary neurological deficit, mortality, renal failure or bleeding. Infrequent and inconsistent reporting of systemic outcomes precluded analysis of other systemic outcomes.The present meta-analysis indicated the superiority of MHCA+SACP in terms of stroke risk.
Surgical management of aortic arch pathologies still faces significant challenges, especially if the pathology involves the proximal descending aorta. A novel solution, named the frozen elephant trunk approach, encompasses a hybrid stent-graft that is placed during conventional arch surgery in the descending aorta to exert an expansive radial force. This obviates the need for second-stage surgery, while limiting the residual patency of the false lumen and minimizing wall stress. The objective of this systematic review is to assess the safety and efficacy of the frozen elephant trunk technique in aortic ach pathologies.We included all studies that used hybrid-stent grafts, or stented the proximal descending aorta under direct visualization during conventional arch surgery. Six electronic databases were searched (inception to June 2013), limited to studies that have reported 10 patients or more in the English language.Sixteen observational studies, with 1,409 patients, were identified. A variety of commercial and custom-made stent-grafts were used, with varying pathology indications. Overall mortality was 8.5% (range, 0-18.2%). One-year survival, reported in six studies, was 85.6% (range, 70-97%), while five-year survival was 71.5% (range, 63-88%). Stroke and spinal cord injury was identified in 5.3% and 5.5% of patients respectively, while renal failure and reoperation for bleeding was 12.0% and 8.9% respectively. No other endpoints were sufficiently reported.The frozen elephant trunk approach represents a reasonably safe procedure to repair the arch and proximal descending aorta. While promising, these results require long-term studies to assess durability and freedom from reoperation. Further regulatory approval is also required to permit widespread employment of specialized commercial hybrid stent-grafts.
Summary A previously unreported pancreatic duct was found by Liu (1989) in Pekin ducks. This duct has now been consistently found in six breeds of domestic ducks and six species of wild ducks in China. For purposes of Nomina Anatomica Avium it is hereby called the ‘first pancreatic duct’( Ducius pancreaticus primus ) since it enters the duodenum at or near the flexure where the descending duodenum becomes the ascending duodenum. All other pancreatic ducts enter the duodenum later, closer to where it joins the jejunum. This first pancreatic duct drains the caudal extremity of the dorsal lobe of the pancreas and can be easily exteriorized for experimental purposes. Within the parenchyma of the dorsal lobe of the pancreas this duct communicates with the dorsal pancreatic duct. In the present study of the gross anatomy of the pancreatic lobes of domestic and wild Chinese ducks we describe and illustrate variations in position and number of all biliary and pancreatic ducts.
Background: Observational studies on the prognostic role of thyroid transcription factor 1 (TTF-1) in non-small cell lung cancer (NSCLC) are controversial.
Methods: To clarify the impact of TTF-1 in NSCLC survival, we performed this meta-analysis that included eligible studies. The combined hazard ratios and their corresponding 95% confidence intervals were calculated in terms of overall survival.
Results: A total of 17 studies with 2,235 patients were evaluable for this meta-analysis. The studies were categorized by histology, disease stage and patient race. Our results suggested that TTF-1 overexpression had a favorable impact on survival of patients with NSCLC, the HR (95% CI) was 0.49 (0.42 to 0.55) overall, 0.46 (0.38-0.54) in Asian patients, 0.52 (0.42-0.63) in non-Asian patients, 0.45 (0.38-0.52) in adenocarcinoma, 0.63 (0.39-0.86) in stage I NSCLC, 0.43 (0.33-0.53) in stage IIIb-IV NSCLC. The data collected were not sufficient to determine the prognostic value of VEGF in patients with squamous cell lung carcinomas. But there was a high heterogeneity between the studies.
Conclusions: TTF-1 overexpression indicates a favorable prognosis for patients with NSCLC, this effect appears also significant when the analysis is restricted in lung AC patients, stage I and stage IIIb-IV NSCLC.
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