title: The need for thoracic surgery in adult patients receiving extracorporeal membrane oxygenation: a 16-year experience.
abstract: OBJECTIVE
  Patients on extracorporeal membrane oxygenation (ECMO) are at risk from thoracic complications such as bleeding or pneumothorax, which may subsequently necessitate thoracic surgical intervention. We aimed to: 1) analyse the indication and nature of thoracic surgical intervention in these patients and 2) analyse the effect of a change in the ECMO circuit from roller pump to centrifugal pump on transfusion requirements pre and post thoracotomy.
  
  
  METHODS
  We retrospectively reviewed a prospectively collected database of 569 adults put on ECMO between 1995 and 2011. Patients undergoing thoracotomy were identified and outcomes were statistically analysed.
  
  
  RESULTS
  Forty thoracotomies were performed in 18 patients [61% male, median age 31 (14-56) years, one bilateral procedure]. The indications for ECMO included: pneumonia 14/18 (78%), trauma 2/18 (11%) and other 2/18 (11%). Median duration on ECMO was 13 (1-257) days and the time to initial thoracotomy was 10 (1-183) days. The indications for thoracotomy were: excessive bleeding post chest drain insertion (11/19, 58%), uncontrolled air leak (9/19, 47%) and pleural effusion (4/19, 21%). The primary operations were 12/19 (63%) evacuation of haemothorax, 3/19 (16%) lung repair, 2/19 (11%) diagnostic lung biopsy and 2/19 (11%) other. Ten patients needed a further 21 thoracotomies (3 lobectomies); average 2 (1-5) per patient. In total, 30/40 (75%) thoracotomies were performed for bleeding complication. The change from roller to centrifugal pump trended towards a reduction in mean transfusion requirements in these patients following thoracotomy (11.5 versus 4 units, p=0.14). The in-hospital mortality was 7/18 (39%) patients. There were no statistically significant predictors of poor outcome.
  
  
  CONCLUSIONS
  The need for thoracotomy whilst on ECMO is 3.2% in this large series. Intervention may be complicated, thus, either ECMO specialists should have thoracic training or thoracic surgeons should be on-site. Potential mortality is high and, although not statistically significant, a difference in transfusion requirements was observed following the change of circuit.
authors.affiliation: Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, UK. vijayjoshi@doctors.net.uk
authors.forename: V
authors.initials: V
authors.lastname: Joshi
authors.forename: C
authors.initials: C
authors.lastname: Harvey
authors.forename: A
authors.initials: A
authors.lastname: Nakas
authors.forename: D A
authors.initials: DA
authors.lastname: Waller
authors.forename: G J
authors.initials: GJ
authors.lastname: Peek
authors.forename: R
authors.initials: R
authors.lastname: Firmin
mesh_terms: D000293:Adolescent; D000328:Adult; D001803:Blood Transfusion; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D013908:Thoracotomy / Q000401:mortality; D055815:Young Adult
keywords: cardiothoracic surgery; extracorporeal membrane oxygenation; pleura; pulmonary; thoracic surgery