Alpha1-antitrypsin deficiency (AATD) disease is associated with several inflammatory conditions due to unprotected proteolytic activity of neutrophil elastase and proteinase 3. We observed that patients with ATTD develop early complications post-transplant. The aim of the study was to identify potential differences in outcomes between AATD and emphysema without AATD (E) following lung transplant. We retrospectively reviewed the data of 41 patients (27 E and 14 AATD) transplanted between 2005 and 2017. Data collection includes functional baseline of recipients and complications as primary outcome, and secondary end points of survival. The majority (79%) of AATD patients received double lung transplant. Main complications in AATD cohort included 3 bowel ischemia and perforation, 1 liver cirrhosis and 4 anastomotic complications causing death in 2 patients. Comparison rate of FEV1 decline in AATD and E group in year 1, 5 and 10 showed no statistical difference (P=0.18; P=0.67), same as FEV1 pre and post-transplant between groups. Mortality was higher in AATD (36%) compare to E (30%). Survival curve showed no difference between both groups with median survival AATD 10.8 years (95% CI 0.54 to 5.336) and E 6.4 years (95% CI 0.19 to 1.86, P=0.64). AATD transplant recipients are predisposed to complications related to their primary underlying disease when compare to E group. However, FEV1 decline had similar trends in both groups with no difference in overall survival.
Dempsey and Miller drew attention to the inadequacy of medical treatments for idiopathic pulmonary fibrosis (IPF) and the optimism provided by the emergence of pirfenidone.1However, only a cursory note was given to lung transplantation, which seems to have been dismissed by the authors, who describe patients as “too frail or old” with “serious …
Abstract Background The deep serratus anterior plane block (SAPB) is a promising novel regional anaesthesia technique for blockade of the anterolateral chest wall. Evidence for the efficacy of SAPB versus other analgesic techniques in thoracic surgery remains inadequate. Aims This study compared ultrasound‐guided continuous SAPB with a surgically placed continuous thoracic paravertebral block (SPVB) technique in patients undergoing videoscopic‐assisted thoracic surgery (VATS). Methods In a single‐centre, double‐blinded, randomized, non‐inferiority study, we allocated 40 patients undergoing VATS to either SAPB or SPVB, with both groups receiving otherwise standardized treatment, including multimodal analgesia. The primary outcome was 48‐hr opioid consumption. Secondary outcomes included numerical rating scale (NRS) for postoperative pain, patient‐reported worst pain score (WPS) as well as functional measures (including mobilization distance and cough strength). Results A 48‐hr opioid consumption for the SAPB group was non‐inferior compared with SPVB. SAPB was associated with improved NRS pain scores at rest, with cough and with movement at 24 hr postoperatively ( p = .007, p = .001 and p = .012, respectively). SAPB was also associated with a lower WPS ( p = .008). Day 1 walking distance was improved in the SAPB group ( p = .012), whereas the difference in cough strength did not reach statistical significance ( p = .071). There was no difference in haemodynamics, opioid side effects, length of hospital stay or patient satisfaction between the two groups. Conclusions The SAPB, as part of a multimodal analgesia regimen, is non‐inferior in terms of 48‐hr opioid consumption compared to SPVB and is associated with improved functional measures in thoracic surgical patients. ClinicalTrials.gov Identifier: NCT03768193. Significance The SAPB interfascial plane block is an efficacious alternative method of opioid‐sparing analgesia in high‐risk thoracic surgical patients as part of an enhanced recovery programme.
Alpha1-antitrypsin deficiency (AATD) is characterized by low level of apha-1 antitrypsin, which predispose lung to unprotected proteolytic activity. We observed in our centre that patients with AATD suffer from severe bronchial anastomotic complication. We wanted to determine whether there is difference in post-transplant airway complications between AATD emphysema and emphysema without AATD (EMPH). We performed a retrospective analysis to compare the post-transplantation course of patients with AATD and EMPH. Data collection includes demographic and functional baseline of recipients, primary outcome as bronchial anastomotic complication and secondary end points as survival data. A total of 163 patients were transplanted from January 2005 to May 2016 in our centre, with follow up until August 2016. Out of these, 34 patients had either diagnosis of AATD (35.3%) or EMPH(64.7%). There was a male preponderance of 75% in AATD. Both groups had predominantly double lung transplant. Population with AATD was younger compare to EMPH (mean age 53.5 ± 7.9 vs 60 ± 4.6, p ‹ 0.01). There was no statistical difference in FEV1 pre and post-transplant between groups. 4 (33%) AATD patients had bronchial anastomotic complication (versus 0 in EMPH, p value = 0.011) with median onset 4 months post-transplant, and odd ratio of 1.5 (95%CI, 1.005-2.238). Survival curve showed no difference between both group (p=0.512) with mean survival AATD 29.6 ± 4.3 months and EMPH 44.2 ± 10.8 months. This observation study extends the available knowledge. The findings indicate that AATD patients may have higher risk for developing bronchial anastomotic complication. More robust data and multicentre analysis would be needed for further confirmation.
Median sternotomy has been the most commonly used approach for thymectomy to date. Recent advances in video-assisted thoracoscopic surgery (VATS) and robotic access with CO2 insufflation techniques have allowed more minimally invasive approaches. However, prior reviews have not compared robotic to both open and VATS thymectomy.A systematic review was conducted in accordance with the PRISMA guidelines using PubMed, Embase and Scopus databases. Original research articles comparing robotic to VATS or to open thymectomy for myasthenia gravis, anterior mediastinal masses, or thymomas were included. Meta-analyses were performed for mortality, operative time, blood loss, transfusions, length of stay, conversion to open, intraoperative and postoperative complication rates, and positive/negative margin rates.Robotic thymectomy is a valid alternative to the open approach; advantages include: reduced blood loss [weighted mean difference (WMD): -173.03, 95% confidence interval (95% CI): -305.90, -40.17, P=0.01], fewer postoperative complications (odds ratio: 0.37, 95% CI: 0.22, 0.60, P<0.00001), a shorter hospital stay (WMD: -2.78, 95% CI: -3.22, -2.33, P<0.00001), and a lower positive margin rate (relative difference: -0.04, 95% CI: -0.07, -0.01, P=0.01), with comparable operative times (WMD: 6.73, 95% CI: -21.20, 34.66, P=0.64). Robotic thymectomy was comparable with the VATS approach; both have the advantage of avoiding median sternotomy.While randomized controlled studies are required to make definitive conclusions, current data suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach. Long-term follow-up is required to further delineate oncological outcomes.
Pneumothorax is a common presentation to acute healthcare services in Ireland, however there is wide variation in management approaches between centres. There is robust evidence to demonstrate that ambulatory management of pneumothorax is feasible and safe. The purpose of this study was to evaluate whether the implementation of an integrated care pathway (ICP) for pneumothorax patients with a focus on ambulatory care would be economically beneficial for the healthcare system.This study developed, implemented and evaluated an ICP for all patients presenting with pneumothorax, with a specific focus on ambulatory management for suitable patients. The ICP was designed to be utilised in the Irish healthcare setting, and was evaluated using a prospective multi-centre observational study, with a rigorous economic analysis at the centre of study design.Implementation of the ICP resulted in a statistically significant reduction in inpatient length of stay of 2.84 days from 7.4 to 4.56 days (p = 0.001). The incremental per patient cost reduction of treating a patient according to the pneumothorax ICP was 2314 euro. There were no adverse events related to drain insertion at the study sites.This study demonstrates therefore that standardisation of care for pneumothorax patients with a focus on ambulatory management are economically beneficial for the publicly-funded healthcare service. It is envisaged that this work will be used to inform healthcare policy at a national level across Ireland.
The data that support the findings of this study are available in PubMed. These data were derived from the following resources available in the public domain: PubMed. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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