Publications
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Athanasiou T, Patel V, Garas G, et al., 2016, Mentoring perception, scientific collaboration and research performance: is there a ‘gender gap’ in academic medicine? An Academic Health Science Centre perspective, Postgraduate Medical Journal, Vol: 92, Pages: 581-256, ISSN: 1469-0756
OBJECTIVES: The 'gender gap' in academic medicine remains significant and predominantly favours males. This study investigates gender disparities in research performance in an Academic Health Science Centre, while considering factors such as mentoring and scientific collaboration. MATERIALS AND METHODS: Professorial registry-based electronic survey (n=215) using bibliometric data, a mentoring perception survey and social network analysis. Survey outcomes were aggregated with measures of research performance (publications, citations and h-index) and measures of scientific collaboration (authorship position, centrality and social capital). Univariate and multivariate regression models were constructed to evaluate inter-relationships and identify gender differences. RESULTS: One hundred and four professors responded (48% response rate). Males had a significantly higher number of previous publications than females (mean 131.07 (111.13) vs 79.60 (66.52), p=0.049). The distribution of mentoring survey scores between males and females was similar for the quality and frequency of shared core, mentor-specific and mentee-specific skills. In multivariate analysis including gender as a variable, the quality of managing the relationship, frequency of providing corrective feedback and frequency of building trust had a statistically significant positive influence on number of publications (all p<0.05). CONCLUSIONS: This is the first study in healthcare research to investigate the relationship between mentoring perception, scientific collaboration and research performance in the context of gender. It presents a series of initiatives that proved effective in marginalising the gender gap. These include the Athena Scientific Women's Academic Network charter, new recruitment and advertisement strategies, setting up a 'Research and Family Life' forum, establishing mentoring circles for women and projecting female role models.
Acharya A, Markar S, Sodergren M, et al., 2016, Adjuvant chemotherapy confers no survival benefit following curative surgery for peri-ampullary adenocarcinoma: a Meta-Analysis, 19th Annual Scientific Meeting of the Association-of-Upper-Gastrointestinal-Surgeons-of-Great-Britain-and-Ireland, Publisher: Wiley, Pages: 24-24, ISSN: 1365-2168
Soylu E, Harling L, Ashrafian H, et al., 2016, A systematic review of the safety and efficacy of distal coronary artery anastomotic devices in MIDCAB and TECAB surgery., Perfusion, Vol: 31, Pages: 537-543, ISSN: 0267-6591
BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) techniques may improve recovery and reduce hospital stay following coronary artery bypass surgery (CABG). However, working in a limited space with indirect visualisation would greatly benefit from a simple, high-quality and reproducible automated distal anastomotic method. Several devices have been developed; however, their uptake has been limited due to uncertainty around their impact on patient outcomes. METHODS: A systematic review of the literature identified six studies, incorporating 139 subjects undergoing MIDCAB or TECAB surgery using a distal anastomotic device. RESULTS: The overall 30-day mortality was 0.7% (1/137). No cardiac specific mortality was observed. For each outcome of perioperative myocardial infarction (MI), postoperative stroke and haemorrhage, only a single event was observed for each (n=1/136, 1/138 and 1/136, respectively). The overall device failure rates were low, with the use of additional sutures only reported in a single case with the Magnetic Vascular Port (MVP) device. Anastomotic time ranged from a mean of 3.32 minutes with the MVP device to 20 minutes with the C-Port device. CONCLUSIONS: These results demonstrate the overall acceptable early outcomes of distal anastomotic devices for use in minimally invasive coronary bypass surgery. Future research should focus on designing adequately powered, comparative, randomised trials, focusing on major adverse cardiac and cerebrovascular events (MACCE) outcomes in both the short and long-term, with clear case-by-case reasons for device failure and a comparison of anastomotic times. In this way, we may determine whether such devices will facilitate the minimal access and robotic coronary procedures of the future.
Wong KA, Hodgson L, Garas G, et al., 2016, How can cardiothoracic and vascular medical devices stay in the market?, Interactive Cardiovascular and Thoracic Surgery, ISSN: 1569-9293
Surgeons, as the consumers, must engage in commercial activity regarding medical devices since it directly has impacts on surgical practice and patient outcomes. Unique features defy traditional economic convention in this specific market partly because consumers do not usually pay directly. Greater involvement with commercial activity means better post-market surveillance of medical devices which leads to improved patient safety. The medical device industry has exhibited astonishing levels of growth and profitability reaching $398 billion on a global scale with new product development focusing on unmet clinical need. The industry has rapidly emerged within the context of an ageing population and a global surge in healthcare spending. But the market remains fragmented. The split of consumer, purchaser and payer leads to clinical need driving demand for new product development. This demand contributes to potentially large profit margins mainly contained by regulatory burden and liability issues. Demographic trends, prevalence of diseases and a huge capacity to absorb technology have sustained near unparalleled growth. To stay in the market, incremental development over the short term is essentially aided by responsiveness to demand. Disruptive product development is now more likely to come from multinational companies, in an increasingly expensive, regulated industry. Understanding healthcare organization can help explain the highly complex process of diffusion of innovations in healthcare that include medical devices. The time has come for surgeons to become actively involved with all aspects of the medical device life cycle including commercial activity and post-market surveillance. This is vital for improving patient care and ensuring patient safety.
Bouras G, Markar SR, Burns EM, et al., 2016, Linked Hospital and Primary Care Database Analysis of the Incidence and Impact of Psychiatric Morbidity Following Gastrointestinal Cancer Surgery in England, Annals of Surgery, Vol: 264, Pages: 93-99, ISSN: 1528-1140
Athanasopoulos LV, Moscarelli M, Speziale G, et al., 2016, Are adjunct subvalvular techniques more effective than isolated restrictive annuloplasty for treating ischemic mitral regurgitation?, Perfusion, Vol: 32, Pages: 92-96, ISSN: 0267-6591
This review focused on whether subvalvular techniques are more effective than isolated restrictive annuloplasty in addressing ischemic mitral regurgitation (MR). Searching identified 445 papers and, following a selection process, we ended up with 10 articles. Two were propensity-matched studies, four retrospective and four prospective, non-randomized studies. The end points of interest were late recurrence of MR, other early echocardiographic outcomes of mitral function and early mortality. All studies focusing on echocardiographic measurements showed improved results in the groups where subvalvular repair techniques were used. In almost all studies, the recurrence of MR postoperatively was less when subvalvular techniques were used. No difference in early or in-hospital mortality was demonstrated in all four studies that included comparisons. We conclude that subvalvular techniques in combination with annuloplasty are safe and may better address ischemic MR than the use of annuloplasty ring alone.
Aziz O, Albeyati A, Derias M, et al., 2016, Anastomotic leaks can be detected within 5 days following ileorectal anastomosis: A case-controlled study in patients with familial adenomatous polyposis, Colorectal Disease, Vol: 19, Pages: 251-259, ISSN: 1463-1318
AIM: To determine the earliest time point at which anastomotic leaks can be detected in patients undergoing total colectomy (TC) with primary ileorectal anastomosis (IRA) for Familial Adenomatous Polyposis (FAP). METHOD: A case-controlled study of 10 anastomotic leak patients versus 20 controls following laparoscopic TC with IRA for FAP (from 96 consecutive patients between 2006-2013). Panel time-series data regression was performed using a double subscript structure to include both variables. A generalized least squares multi-variate approach was applied in a random effects setting to calculate correlations for observations, with anastomotic leak being the dependent variable. Univariate and multivariate regression calculations were then performed according to individual observations at each recorded time point. Time-series analysis was used to determine when a variable became significant in the leak group. RESULTS: Multivariate analysis identified a significant difference between leak and control groups in mean heart rate (p=<0.001), mean respiratory rate (p=0.017), and mean urine output (p=0.001). Time-point analysis showed that heart rate was significantly different between leak and control groups at post-operative day 4.25. Multivariate analysis identified a significant difference between groups in ALT (p=0.006), Bilirubin (p=0.008), Creatinine (p=0.001), Haemoglobin (p=<0.001), and Urea (p=0.007). There were no differences between groups with regards to markers of inflammation such as albumin, white blood cell count, neutrophil count, and CRP. CONCLUSION: Anastomotic leaks can be detected early (within 4.5 days of surgery) through changes in physiological, blood test, and observational parameters, providing an opportunity for early intervention in these patients to salvage the anastomosis. This article is protected by copyright. All rights reserved.
Athanasiou T, Ashrafian H, Harling L, et al., 2016, Bailouts to LIMA Damage for Avoiding Conversion in Minimal Access Coronary Procedures, Annals of Thoracic Surgery, Vol: 102, Pages: E173-E176, ISSN: 1552-6259
St John ER, Al-Khudairi R, Ashrafian H, et al., 2016, Diagnostic accuracy of intraoperative techniques for margin assessment in breast cancer surgery: a meta-analysis, Annals of Surgery, Vol: 265, Pages: 300-310, ISSN: 1528-1140
OBJECTIVE: The aim of this study was to conduct a systematic review and meta-analysis to clarify the diagnostic accuracy of intraoperative breast margin assessment (IMA) techniques against which the performance of emerging IMA technologies may be compared. SUMMARY OF BACKGROUND DATA: IMA techniques have failed to penetrate routine practice due to limitations, including slow reporting times, technical demands, and logistics. Emerging IMA technologies are being developed to reduce positive margin and re-excision rates and will be compared with the diagnostic accuracy of existing techniques. METHOD: Studies were identified using electronic bibliographic searches up to January 2016. MESH terms and all-field search terms included "Breast Cancer" AND "Intraoperative" AND "Margin." Only clinical studies with raw diagnostic accuracy data as compared with final permanent section histopathology were included. A bivariate model for diagnostic meta-analysis was used to attain overall pooled sensitivity and specificity. RESULTS: Eight hundred thirty-eight unique studies revealed 35 studies for meta-analysis. Pooled sensitivity (Sens), specificity (Spec), and area under the receiver operating characteristic curve (AUROC) values were calculated per group (Sens, Spec, AUROC): frozen section = 86%, 96%, 0.96 (n = 9); cytology = 91%, 95%, 0.98 (n = 11); intraoperative ultrasound = 59%, 81%, 0.78 (n = 4); specimen radiography = 53%, 84%, 0.73 (n = 9); optical spectroscopy = 85%, 87%, 0.88 (n = 3). CONCLUSIONS: Pooled data suggest that frozen section and cytology have the greatest diagnostic accuracy. However, these methods are resource intensive and turnaround times for results have prevented widespread international adoption. Emerging technologies need to compete with the diagnostic accuracy of existing techniques while offering advantages in terms of speed, cost, and reliability.
Harling L, Lambert J, Ashrafian H, et al., 2016, Elevated serum microRNA 483-5p levels may predict patients at risk of post-operative atrial fibrillation, European Journal of Cardio-thoracic Surgery, Vol: 51, Pages: 73-78, ISSN: 1873-734X
Objective: Atrial fibrillation (POAF) is the commonest post-operative cardiac arrhythmia, affecting approximately 1 in 3 patients undergoing coronary artery bypass grafting (CABG). Although its aetiology is complex, atrial substrate changes may pre-dispose to its onset. This study aims to ascertain the atrial microRNA signature of POAF and determine the potential for circulating microRNA as a pre-operative biomarker for this arrhythmia.Methods: 34 patients undergoing non-emergent, on-pump CABG were prospectively recruited. Right atrial biopsies were taken intra-operatively and snap frozen for RNA extraction. Plasma was obtained at 24 hours pre-operatively and at 2 and 4-days post-operatively. POAF was defined by continuous Holter recording. Inter-group comparisons were performed using student t-test or ANOVA as required. Receiver operating characteristics (ROC) analysis was used to determine the diagnostic accuracy of pre-operative serum miRNA as a POAF biomarker. Results: 16 microRNA were differentially expressed in the atrial myocardium of POAF patients when compared to those maintaining sinus rhythm (SR). MiR-208a was the most under-expressed (FC:2.458) and miR-483-5p the most over-expressed (FC:1.804). Mir-483-5p also demonstrated significant overexpression in the pre-operative serum of these patients, with ROC analysis demonstrating an overall predictive accuracy of 78%. Conclusions: This study provides the first description of atrial myocardial and circulating plasma microRNA in POAF patients. Our findings suggest POAF may be associated with pre-existing atrial substrate differences predisposing to arrhythmogenesis. Moreover, this study highlights the potential for miR-483-5p in biomarker development. Further work must now perform prospective, targeted validation of these results in a larger patient cohort.
Jarral OA, Baig K, Pettengell C, et al., 2016, National survey of UK consultant surgeons’ opinions on surgeon-specific mortality data in cardiothoracic surgery, Circulation-Cardiovascular Quality and Outcomes, Vol: 9, Pages: 414-423, ISSN: 1941-7705
BackgroundIn the UK, cardiothoracic surgeons have led the outcome reporting revolution seen over the last twenty years. The objective of this survey was to assess cardiothoracic surgeons opinions on the topic, with the aim of guiding future debate and policymaking for all subspecialties.Methods and ResultsA questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the UK (n=361). Logistic regression, bivariate correlation and the chi-square test were used to assess whether there was a relationship between answers and demographic variables. Free text responses were analysed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favour, 7.8% neither) oppose the public release of surgeon-specific mortality data (SSMD) and associate it with a number of adverse consequences. These include risk-averse behaviour, ‘gaming’ of data and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free text-responses suggest this is because most believe that quality of care is multifactorial and not represented by an individual’s mortality rate. ConclusionsThere is evident opposition to SSMD amongst UK cardiothoracic surgeons who associate this with a number of unintended consequences. Policy makers should refine their strategy behind publication of SSMD and possibly consider shift towards team based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed prior to introducing major initiatives to avoid unforeseen consequences and disagreements.Key wordsQuality assessment, outcomes research
Athanasopoulos LV, Casula RP, Bacon R, et al., 2016, Surgical removal of brachiocephalic junction endovascular stent migrated to the right atrium in a high risk patient., J Card Surg, Vol: 31, Pages: 590-591
Markar SR, Mikhail S, Malietzis G, et al., 2016, Influence of Surgical Resection of Hepatic Metastases From Gastric Adenocarcinoma on Long-term Survival: Systematic Review and Pooled Analysis, Annals of Surgery, Vol: 263, Pages: 1092-1101, ISSN: 1528-1140
Zaman J, Harling L, Ashrafian H, et al., 2016, Post-operative atrial fibrillation is associated with a pre-existing structural and electrical substrate in human right atrial myocardium, International Journal of Cardiology, Vol: 220, Pages: 580-588, ISSN: 1874-1754
BackgroundPost-operative atrial fibrillation (POAF) is a major health economic burden. However, the precise mechanisms in POAF remain unclear. In other forms of AF, sites of high dominant frequency (DF) in sinus rhythm (SR) may harbour ‘AF nests’. We studied AF inducibility in relation to substrate changes using epicardial electrograms and cardiomyocyte calcium handling in the atria of AF naïve patients.MethodBipolar electrograms were recorded from the lateral right atrial (RA) wall in 34 patients undergoing coronary surgery using a high-density array in sinus rhythm (NSR). RA burst pacing at 200/500/1000 ms cycle lengths (CL) was performed, recording episodes of AF > 30 s. Co-localised RA tissue was snap frozen for RNA and protein extraction.ResultsElectrograms prolonged during AF (76.64 ± 29.35 ms) vs. NSR/pacing (p < 0.001). Compared to NSR, electrogram amplitude was reduced during AF and during pacing at 200 ms CL (p < 0.001). Electrogram DF was significantly lower in AF (75.87 ± 23.63 Hz) vs. NSR (89.33 ± 25.99 Hz) (p < 0.05), and NSR DF higher in AF inducible patients at the site of AF initiation (p < 0.05). Structurally, POAF atrial myocardium demonstrated reduced sarcolipin gene (p = 0.0080) and protein (p = 0.0242) expression vs. NSR. Phospholamban gene and protein expression was unchanged. SERCA2a protein expression remained unchanged, but MYH6 (p = 0.0297) and SERCA2A (p = 0.0343) gene expression was reduced in POAF.ConclusionsHuman atrial electrograms prolong and reduce in amplitude in induced peri-operative AF vs. NSR or pacing. In those sustaining AF, high DF sites in NSR may indicate ‘AF nests’. This electrical remodelling is accompanied by structural remodelling with altered expression of cardiomyocyte calcium handling detectable before POAF. These novel upstream substrate changes offer a novel mechanism and manifestation of human POAF.
Abdullahi YS, Athanasopoulos LV, Moscarelli M, et al., 2016, What are the benefits of a minimally invasive approach in frail octogenarian patients undergoing aortic valve replacement?, Journal of Geriatric Cardiology, Vol: 13, Pages: 514-516, ISSN: 1671-5411
Sara J, Markar SR, George M, et al., 2016, PROGNOSTIC SIGNIFICANCE OF PERITONEAL LAVAGE CYTOLOGY IN STAGING GASTRIC CANCER: SYSTEMATIC REVIEW AND META-ANALYSIS, 18th World Congress of the European-Society-for-Medical-Oncology (ESMO) on Gastrointestinal Cancer, Publisher: OXFORD UNIV PRESS, Pages: 85-85, ISSN: 0923-7534
Cappelletti S, Ciallella C, Aromatario M, et al., 2016, Takotsubo Cardiomyopathy and Sepsis: A Systematic Review., Angiology, ISSN: 1940-1574
Takotsubo cardiomyopathy (TTC) is characterized by a systolic dysfunction localized in the apical and medial aspect of the left ventricle. It is usually related to physical or emotional stress. Recent evidence highlighting the role of infection led us to analyze the links between TTC and sepsis. A systematic review of the literature was undertaken to assess any trends in clinical findings, diagnosis, and outcomes in such patients. We identified 23 selected papers reporting a total of 26 patients, having sepsis, in whom TTC occurred. For each case, we collected data identifying population characteristics, source of sepsis, clinical disease description, and the results of cardiovascular investigations. The majority of patients were females (n = 16), mean age was 62.8 (14.0 standard deviation) years, and clinical outcome was favorable in 92.3% of the cases once the management of sepsis was initiated. A better understanding of the mechanisms of sepsis-associated TTC may generate novel strategies to treat the complications of this cardiomyopathy and may even help predict and prevent its occurrence.
Patel VM, Ashrafian H, Uzoho C, et al., 2016, Leadership behaviours and healthcare research performance: prospective correlational study, Postgraduate Medical Journal, Vol: 92, Pages: 663-669, ISSN: 1469-0756
OBJECTIVES: The aims of the study were to determine whether differences in leadership self-perception/behaviour in healthcare researchers may influence research performance and to evaluate whether certain leadership characteristics are associated with enhanced leadership efficiency in terms of motivation, effectiveness and satisfaction. DESIGN AND PARTICIPANTS: All Faculty of Medicine Professors at Imperial College London (n=215) were sent the Multifactor Leadership Questionnaire (MLQ) Self form as a means of evaluating self-perception of leadership behaviours. MAIN OUTCOME MEASURES: For each professor, we extracted objective research performance measures (total number of publications, total number of citations and h index) from 1 January 2007 to 31 December 2009. The MLQ measured three leadership outcomes, which included motivation, effectiveness and satisfaction. Regression analysis was used to determine associations. RESULTS: A total number of 90 responses were received, which equated to a 42% response rate. There were no significant correlations between transformational, transactional or passive/avoidant leadership behaviours and any of the research performance measures. The five transformational leadership behaviours (ie, idealised attributes (IA), idealised behaviours (IB), inspirational motivation (IM), intellectual stimulation (IS), individual consideration (IC)) were highly significant predictors of leadership outcomes, extra effort (all B>0.404, SE=0.093-0.146, p<0.001), effectiveness (IA, IM, IS, IC B>0.359, SE=0.093-0.146, p<0.001; IB B=0.233, SE=0.103, p=0.026) and satisfaction (IA, IM, IS, IC B>0.483, SE=0.086-0.139, p<0.001; IB B=0.296, SE=0.101, p=0.004). Similarly, contingent reward was a significant predictor of extra effort (B=0.400, SE=0.123, p=0.002), effectiveness (B=0.353, SE=0.113, p=0.002) and satisfaction (B=0.326, SE=0.114, p=0.005). CONCLUSIONS: This study demonstrates that transformational leadership and contingent rewa
Currie AC, Askari A, Rao C, et al., 2016, The potential impact of local excision for T1 colonic cancer in elderly and comorbid populations: a decision analysis., Gastrointestinal Endoscopy, ISSN: 1097-6779
BACKGROUND: Population-based bowel cancer screening has resulted in increasing numbers of patients with T1 colonic cancer. The need for colectomy in this group is questioned due to the low risk of lymphatic spread and increased treatment morbidity, particularly for elderly, comorbid patients. This study examined the quality-of-life benefits and risks of endoscopic resection compared with results after colectomy, for low-risk and high-risk T1 colonic cancer. METHODS: Decision analysis using a Markov simulation model was performed; patients were managed with either endoscopic resection (advanced therapeutic endoscopy) or colectomy. Lesions were considered high risk according to accepted national guidelines. Probabilities and utilities (perception of quality of life) were derived from published data. Hypothetical cohorts of 65- and 80-year-old, fit and unfit patients with low-risk or high-risk T1 colonic cancer were studied. The primary outcome was quality-adjusted life expectancy (QALE) in life-years (QALYs). RESULTS: In low-risk T1 colonic neoplasia, endoscopic resection increases QALE by 0.09 QALYS for fit 65-year-olds and by 0.67 for unfit 80-year-olds. For high-risk T1 cancers, the QALE benefit for surgical resection is 0.24 QALYs for fit 65-year-olds and the endoscopic QALE benefit is 0.47 for unfit 80-year-olds. The model findings only favored surgery with high local recurrence rates and when quality of life under surveillance was perceived poorly. CONCLUSIONS: Under broad assumptions, endoscopic resection is a reasonable treatment option for both low-risk and high-risk T1 colonic cancer, particularly in elderly, comorbid patients. Exploration of methods to facilitate endoscopic resection of T1 colonic neoplasia appears warranted.
Jarral OA, Harling L, Athanasiou T, 2016, Frozen elephant trunk reconstruction for right-sided aortic arch with aberrant left subclavian artery and aneurysm of the descending aorta: a case report, Journal of Cardiothoracic Surgery, Vol: 11, ISSN: 1749-8090
A 59-year old man being investigated for back pain was found to have aneurysmal dilatation of a right-sided aortic arch and descending thoracic aorta together with an aberrant left subclavian artery. He underwent repair of this utilising the frozen elephant trunk technique, which dealt with all three pathologies in one-stage. He made an unremarkable recovery and was discharged home on the 8th post-operative day. This case report further demonstrates the flexibility and safety of the frozen elephant trunk in dealing with complex aortic pathology as a single-stage procedure.
Cheng Z, Kidher E, Jarral OA, et al., 2016, Assessment of hemodynamic conditions in the aorta following root replacement with composite valve-conduit graft, Annals of Biomedical Engineering, Vol: 44, Pages: 1392-1404, ISSN: 0090-6964
This paper presents the analysis of detailed hemodynamics in the aortas of four patients following replacement with a composite bio-prosthetic valve-conduit. Magnetic resonance image-based computational models were set up for each patient with boundary conditions comprising subject-specific three-dimensional inflow velocity profiles at the aortic root and central pressure waveform at the model outlet. Two normal subjects were also included for comparison. The purpose of the study was to investigate the effects of the valve-conduit on flow in the proximal and distal aorta. The results suggested that following the composite valve-conduit implantation, the vortical flow structure and hemodynamic parameters in the aorta were altered, with slightly reduced helical flow index, elevated wall shear stress and higher non-uniformity in wall shear compared to normal aortas. Inter-individual analysis revealed different hemodynamic conditions among the patients depending on the conduit configuration in the ascending aorta, which is a key factor in determining post-operative aortic flow. Introducing a natural curvature in the conduit to create a smooth transition between the conduit and native aorta may help prevent the occurrence of retrograde and recirculating flow in the aortic arch, which is particularly important when a large portion or the entire ascending aorta needs to be replaced.
Aggarwal R, Harling L, Efthimiou E, et al., 2016, The Effects of Bariatric Surgery on Cardiac Structure and Function: a Systematic Review of Cardiac Imaging Outcomes, Obesity Surgery, Vol: 26, Pages: 1030-1040, ISSN: 1708-0428
BackgroundObesity is associated with cardiac dysfunction, atherosclerosis, and increased cardiovascular risk. It can be lead to obesity cardiomyopathy and severe heart failure, which in turn raise morbidity and mortality while carrying a negative impact on quality of life. There is increasing clinical and mechanistic evidence on the metabolic and weight loss effects of bariatric surgery on improving cardiac structure and function in obese patients.ObjectivesThe objective of this study was to quantify the effects of bariatric surgery on cardiac structure and function by appraising cardiac imaging changes before and after metabolic operations.MethodsThis is a comprehensive systematic review of studies reporting pre-operative and post-operative echocardiographic or magnetic resonance cardiac indices in obese patients undergoing bariatric surgery. Studies were quality scored, and data were meta-analyzed using random effects modeling.ResultsBariatric surgery is associated with significant improvements in the weighted incidence of a number of cardiac indices including a decrease in left ventricular mass index (11.2 %, 95 % confidence intervals (CI) 8.2–14.1 %), left ventricular end-diastolic volume (13.28 ml, 95 % CI 5.22–21.34 ml), and left atrium diameter (1.967 mm, 95 % CI 0.980–2.954). There were beneficial increases in left ventricular ejection fraction (1.198 %, 95 %CI −0.050–2.347) and E/A ratio (0.189 %, 95 %CI −0.113–0.265).ConclusionsBariatric surgery offers beneficial cardiac effects on diastolic function, systolic function, and myocardial structure in obese patients. These may derive from surgical modulation of an enterocardiac axis. Future studies must focus on higher evidence levels to better identify the most successful bariatric approaches in preventing and treating the broad spectrum of obesity-associated heart disease while also enhancing treatment strategies in the management of obesity cardiomyopathy.
Harling L, Chaudhry UAR, Ashrafian H, et al., 2016, Reply., Ann Thorac Surg, Vol: 101, Pages: 2024-2025
Moscarelli M, Athanasiou T, Sevdalis N, et al., 2016, Controlled Exponentially Weighted Moving Average Chart in Cardiac Surgery: A Simulation Study Across 9 Italian Cardiac Centers, SEMINARS IN THORACIC AND CARDIOVASCULAR SURGERY, Vol: 28, Pages: 253-258, ISSN: 1043-0679
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Moscarelli M, Emmanuel S, Athanasiou T, et al., 2016, The role of minimal access valve surgery in the elderly. A meta-analysis of observational studies., International Journal of Surgery, ISSN: 1743-9191
BACKGROUND: Minimal access valve surgery, both mitral and aortic, may be related to improvement in specific post-operative outcomes, therefore may be beneficial for the subgroup of the elderly referred for valve surgery. METHODS: A systematic literature review identified several different studies, of which 6 fulfilled criteria for meta-analysis. Outcomes for a total of 1347 patients (675 conventional standard sternotomy and 672 minimally invasive valve surgery) were assessed with a meta-analysis using random effects modeling. Heterogeneity, subgroup analysis with quality scoring were also assessed. The primary endpoint was early mortality. Secondary endpoints included intra and post-operative outcomes. RESULTS: In the context of elderly patients, minimal access valve surgery conferred comparable early mortality to standard sternotomy (odd ratio (OR) 0.79, CI [0.40,1.56], p = 0.50) with no heterogeneity (p = 0.13); it was also associated with reduced mechanical intubation time (OR 0.48, CI [0.30,0.78], p = 0.003) and reduced post-operative length of stay (weighted mean difference (WMD) -2.91, CI [-3.09, -2.74] p < 0.00001), however both cardio-pulmonary bypass time and cross clamp time were longer (WMD 24.29, CI [22.97, 25.61] p < 0.00001 and WMD 8.61, CI [7.61, 9.61], p < 0.00001, respectively); subgroup analysis demonstrated statistically significant reduced post-operative length of stay for both minimally invasive aortic and mitral surgery (WMD -2.84, CI [-3.07, -2.60] p < 0.00001 and WMD -2.98, CI [-3.25, -2.71] p < 0.00001 respectively). CONCLUSIONS: Despite a prolonged cardiopulmonary bypass and cross clamp time, minimally invasive valve surgery is a safe alternative to standard sternotomy in the elderly, with similar early mortality, and improvements in intubation time as well as length of stay.
Acharya M, Harling L, Moscarelli M, et al., 2016, Influence of Body Mass Index on outcomes after minimal-access aortic valve replacement through a J-shaped partial upper sternotomy, Journal of Cardiothoracic Surgery, Vol: 11, ISSN: 1749-8090
Objective: Minimal-access aortic valve replacement (MAAVR) may reduce post-operative blood loss and transfusion requirements, decrease post-operative pain, shorten length stay and enhance cosmesis. This may be particularly advantageous in overweight/obese patients, who are at increased risk of post-operative complications. Obese patients are however often denied MAAVR due to the perceived technical procedural difficulty. This retrospective analysis sought to determine the effect of BMI on post-operative outcomes in patients undergoing MAAVR.Methods: Ninety isolated elective MAAVR procedures performed between May 2006-October 2013 were recruited. Intra- and post-operative data were prospectively collected. Ordinary least squares univariate linear regression analysis was performed to determine the effect of BMI as a continuous variable on post-operative outcomes. One-way ANOVA and Chi-squared testing was used to assess differences in outcomes between patients with BMI <25 (n=36) and BMI ≥25 (n=54) as appropriate.Results: There was no peri-operative mortality, myocardial infarction or stroke. Univariate regression demonstrated longer cross-clamp times (p=0.0218) and a trend towards increased bypass times (p=0.0615) in patients with higher BMI. BMI ≥25 was associated with an increased incidence of hospital-acquired pneumonia (p=0.020) and new-onset atrial fibrillation (p=0.036) compared to BMI <25. However, raised BMI did not extend ICU (p=0.3310) or overall hospital stay (p=0.2614). Similar rates of sternal wound complications, inotrope requirements and renal dysfunction were observed in both normal- and overweight/obese-BMI groups. Furthermore, increasing BMI correlated with reduced mechanical ventilation time (p=0.039) and early post-operative blood loss (p=0.004).Conclusions: Our results demonstrate that within the range of this study, MAAVR is a safe, reproducible and effective procedure, affording equivalent clinical outcomes in both overweight/obese a
Patel N, Alexander J, Ashrafian H, et al., 2016, Meta-analysis comparing differing methods of endoscopic therapy for colorectal lesions, WORLD JOURNAL OF META-ANALYSIS, Vol: 4, Pages: 44-54, ISSN: 2308-3840
Patel N, Patel K, Ashrafian H, et al., 2016, Colorectal endoscopic submucosal dissection: Systematic review of mid-term clinical outcomes., Digestive Endoscopy, Vol: 28, Pages: 405-416, ISSN: 0915-5635
With a drive towards minimally invasive surgery, endoscopic submucosal dissection (ESD) is now gaining popularity. In a number of East Asian countries, ESD is now the treatment of choice for early non-metastatic gastric cancer, but the outcomes of ESD for colorectal lesions are unclear. The present review summarizes the mid-term outcomes of colorectal ESD including complication and recurrence rates. A systematic literature search was done in May 2014, identifying 20 publications reporting the outcomes of colorectal ESD which were included in this review. En-bloc resection rates, complete (R0) resection rates, endoscopic clearance rates, complication and recurrences rates were analyzed. Statistical pooling was done to calculate weighted means using random effects modeling. Twenty studies reporting the outcomes of 3060 colorectal ESD procedures were reported. Overall weighted en-bloc resection rate was 89% (95% CI: 83-94%), R0 resection rate 76% (95% CI: 69-83%), endoscopic clearance rate 94% (95% CI: 90-97%) and recurrence rate 1% (95% CI: 0.5-2%). Studies that followed up patients for over 1 year were found to have an en-bloc resection rate of 91% (95% CI: 86-96%), R0 resection rate of 81% (95% CI: 75-88%), endoscopic clearance rate 93% (95% CI: 90-97%) and recurrence rate of 0.8% (95% CI: 0.4-1%). Colorectal ESD can be carried out effectively and safely with a 1% recurrence rate. Further studies with longer follow-up periods are required to determine whether colorectal ESD is a viable alternative to conventional surgical therapy.
Askari A, Nachiappan S, Currie A, et al., 2016, Selection for laparoscopic resection confers a survival benefit in colorectal cancer surgery in England., Surgical Endoscopy, ISSN: 0930-2794
INTRODUCTION: Laparoscopic surgery is being increasingly used in colorectal cancer resections. The aim of this national study was to determine whether laparoscopy confers a long-term survival advantage in colorectal cancer. METHODS: A national administrative data set (Hospital Episode Statistics-HES) encompassing all elective hospital admissions in England between 2001 and 2011 was analysed. All patients that had a colorectal cancer resection (open or laparoscopic) were identified. Cox hazard regression was used to determine differences in overall survival (10 year) between the open and laparoscopy groups. RESULTS: A total of 141,682 patients underwent elective surgery for colorectal cancer, of which 20.9 % (n = 29,550) had a laparoscopic procedure. The median 5-year survival in the open group was 36.1 months compared with 46.1 months in the laparoscopic group (p = <0.001). Survival analysis demonstrated laparoscopy to be an independent predictor of survival. Patients who underwent laparoscopic resection were 18 % less likely to die than patients who had an open CRC resection (HR 0.82, CI 0.79-0.83, p < 0.001). This survival benefit persisted even when initial post-operative mortality (90 day) was excluded (HR 0.87, CI 0.85-0.90, p < 0.001). Subgroup analysis, exploring the effect of CRC laparoscopic surgery on survival in the elderly (>79 years old), demonstrated similar survival benefit amongst patients treated using laparoscopy (HR 0.90, CI 0.86-0.94, p < 0.001). Patients not undergoing adjuvant chemotherapy were more likely to survive if they underwent laparoscopic resection (HR 0.81, CI 0.78-0.83, p < 0.001). Similarly, patients undergoing adjuvant chemotherapy demonstrated a survival benefit if a minimal access surgical approach was utilised (HR 0.86, CI 0.81-0.91, p < 0.001). CONCLUSION: Laparoscopy confers a survival benefit, irrespec
Williams GJ, Nicolaou M, Athanasiou T, et al., 2016, Suture needle handling in the operating theatre; what is the safest method? A survey of surgical nursing opinion, INJURY PREVENTION, Vol: 22, Pages: 135-139, ISSN: 1353-8047
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