Clinical implications and risk factors of acute pancreatitis after cardiac valve surgery

Risk factors for postoperative acute pancreatitis after thoracic aortic surgery

BACKGROUND

We aimed to investigate the incidence and risk factors of postoperative acute pancreatitis (PAP) following thoracic aortic surgery with circulatory arrest.

METHODS

One hundred fifty-two patients who underwent thoracic aortic surgery with circulatory arrest between February 2015 and March 2023 were retrospectively reviewed. Postoperative acute pancreatitis was defined as the presence of two or more of the following criteria: (1) abdominal pain, (2) postoperative amylase or lipase levels greater than three times the upper limit of normal, and (3) evidence of pancreatitis on postoperative computed tomography (CT) scan. Univariate and multivariate analyses were performed to find risk factors for PAP.

RESULTS

Nine patients (5.9%) developed PAP without mortality. All of the nine patients had elevated pancreatic enzymes and evidence of pancreatitis on CT. They improved with conservative therapy. In multivariate analysis, only cross-clamp time was found to be a significant risk factor for PAP (adjusted odds ratio, 1.04; 95% confidence interval, 1-1.08; p = 0.042).

CONCLUSION

The incidence of PAP after thoracic aortic surgery with circulatory arrest was 5.9%, and cross-clamp time is an independent risk factor for PAP.

A case of contained rupture of the superior mesenteric artery with no distal flow causing mesenteric ischemia following double heart valve replacement surgery

A visceral artery aneurysm (VAA) is a very rare and lethal vascular anomaly with dramatic consequences. The overall incidence of VAA is 5% of all abdominal artery aneurysms. The involvement of the superior mesenteric artery is even rare (incidence of 3.5-8% of all VAA). The development of superior mesenteric artery pseudoaneurysm following cardiac surgery is scarcely reported in the literature. We report a case of contained rupture of the superior mesenteric artery with no distal flow causing acute mesenteric ischemia (AMI) following double heart valve replacement surgery.

Gastrointestinal complications after cardiac surgery

Gastrointestinal complications after cardiac surgery are relatively rare entities but carry a high mortality. We identified over 70 articles written since 2010 using the PubMed database. We included 40 in our review. The most common complications include paralytic ileus, gastrointestinal bleeding, and bowel ischemia. Patients who undergo cardiac procedures are at risk for poor perfusion of the gastrointestinal tract and, thus, at risk for resulting complications. Risk factors for these complications include peri-operative use of vasopressors, prolonged operative time, and the time of cardiopulmonary bypass. Presentation of gastrointestinal complications tends to differ as patients after open heart surgery can remain intubated, and exams can be limited. Early recognition and aggressive therapy are paramount. We aim to provide a review that will help the reader get familiar with the most common gastrointestinal complications that can negatively affect outcomes after cardiac surgery.

Two cases of pararenal artery aortic aneurysm treatment after pancreaticoduodenectomy and abdominal aortic aneurysm stent grafting

BACKGROUND

Acute pancreatitis caused by surgical procedures may occur less frequently in surgeries for aortic aneurysm involving the abdominal branch. However, in such cases, the associated mortality rate increases significantly. There have been few reports on abdominal aortic aneurysm surgery after pancreatoduodenectomy; as such the incidence of postoperative pancreatitis remains unclear.

CASE PRESENTATION

Two cases of pararenal artery aortic aneurysm after pancreaticoduodenectomy and endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm are reported. In the first case, a 74-year-old man was diagnosed with abdominal aortic aneurysm and duodenal cancer 6 years earlier and underwent pancreaticoduodenectomy after EVAR. Subsequently, the abdominal aorta expanded to 58 mm at the level of the renal artery proximal to the EVAR site. Graft replacement was performed through a left thoraco-retroperitoneal incision. However, the patient died from acute pancreatitis, believed to be caused by intraoperative manipulation. Given this initial experience, in the second case, a 77-year-old man had undergone a pancreaticoduodenectomy for a gastrointestinal stromal tumor 17 years earlier and EVAR for an abdominal aortic aneurysm 10 years earlier. The abdominal aorta had expanded to 50 mm immediately below the right renal artery on the proximal side of the EVAR. Subsequently, hematuria was noted, and he was diagnosed with right ureteral cancer. Autologous transplantation of the left kidney and EVAR was performed avoiding manipulation of the area around the pancreas and achieved good results. Combined right renal and ureteral resections were performed 20 days after EVAR.

CONCLUSIONS

While performing aortic surgery after pancreaticoduodenectomy, surgeons should avoid manipulating tissues around the pancreas.

The correlation between bowel complications and cardiac surgery

Although advances in knowledge and technology have improved outcomes in surgical cardiac patients over the last decade, complications following cardiac operations still remain to be potentially fatal. Gastrointestinal complications, in particular, tend to have high rates of reintervention and mortality following cardiac surgery, with ischemia and hemorrhage being two of the commonest underlying causes. The intention of this review is to identify which risk factors play important roles in predisposing patients to such complications and to gain better insight into the pathogenesis of the sequelae. Furthermore, strategies for prevention have been discussed to educate and increase awareness of how adverse cardiac surgical outcomes can be minimized.

Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality

BACKGROUND

Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality.

METHODS

We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality.

RESULTS

Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality.

CONCLUSIONS

Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.

Risk score for predicting abdominal complications after coronary artery bypass grafting

BACKGROUND

Although early abdominal complications after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) are rare, the associated mortality remains high.

AIM

To develop a risk score for the prediction of early abdominal complications after CABG with CPB.

METHODS

This retrospective study was performed in the Federal State Budgetary Establishment “Federal Center of Cardiovascular Surgery” of the Ministry of Health of Russia (the city of Chelyabinsk) and included data of 6586 patients who underwent CABG with CPB during 2011-2017. The risk factors taken for evaluation were compared between patients with early abdominal complications (n = 73) and without them (n = 6513). We identified the most important risk factors and their influence on the development of early abdominal complications after CABG with CPB.

RESULTS

Gender and the presence of postinfarction cardiosclerosis, chronic kidney disease, or diabetes in the anamnesis did not affect the occurrence of abdominal complications. The leading risk factors of the early abdominal complications after CABG with CPB were multifocal atherosclerosis, extracorporeal membrane oxygenation, intra-aortic balloon pump, atrial fibrillation, perioperative myocardial infarction, and the need for resternotomy in the postoperative period. The average value of the predicted probability was 0.087 ± 0.015 in patients with early abdominal complications after CABG with CPB and 0.0094 ± 0.0003 in patients without these complications. The percentage of correct classification turned out to be 98.9%. After calculating a score for each of the leading risk factors, we counted a total score for each particular patient. The highest risk was noted in patients with a total score of 7 or more.

CONCLUSION

The developed score predicts the risk of early abdominal complications after CABG with CPB and makes it possible to stratify patients by risk groups.

Gastrointestinal complications following on-pump cardiac surgery-A propensity matched analysis

Background

Gastrointestinal complications following on-pump cardiac surgery are orphan but serious risk factors for postoperative morbidity and mortality. We aimed to assess incidence, perioperative risk factors, treatment modalities and outcomes.

Material and methods

A university medical center audit comprised 4883 consecutive patients (median age 69 [interquartile range IQR 60–76] years, 33% female, median logistic EuroScore 5 [IQR 3–11]) undergoing all types of cardiac surgery including surgery on the thoracic aorta; patients undergoing repair of congenital heart disease, implantation of assist devices or cardiac transplantation were excluded. Coronary artery disease was the leading indication for on-pump cardiac surgery (60%), patients undergoing cardiac surgery under urgency or emergency setting were included in analysis. We identified a total of 142 patients with gastrointestinal complications. To identify intra- and postoperative predictors for gastrointestinal complications, we applied a 1:1 propensity score matching procedure based on a logistic regression model.

Results

Overall, 30-day mortality for the entire cohort was 5.4%; the incidence of gastrointestinal complications was 2.9% and median time to complication 8 days (IQR 4–12). Acute pancreatitis (n = 41), paralytic ileus (n = 14) and acute cholecystitis (n = 18) were the leading pathologies. Mesenteric ischemia and gastrointestinal bleeding accounted for 16 vs. 18 cases, respectively. While 72 patients (51%) could be managed conservatively, 27 patients required endoscopic/radiological (19%) or surgical intervention (43/142 patients, 30%); overall 30-day mortality was 12.1% (p<0.001). Propensity score matching identified prolonged skin-to-skin times (p = 0.026; Odds Ratio OR 1.003, 95% Confidence Interval CI 1.000–1.007) and extended on-pump periods (p = 0.010; OR 1.006, 95%CI 1.001–1.011) as significant perioperative risk factors.

Comment

Prolonged skin-to-skin times and extended on-pump periods are important perioperative risk factors regardless of preoperative risk factors.

Acute pancreatitis after coronary artery bypass surgery treated by plasmapheresis

Acute pancreatitis (AP) is a common disorder and an important cause of morbidity and mortality. There are different causes of AP, including gallstones and excessive alcohol consumption. AP after coronary artery bypass grafting (CABG) surgery is seen less frequently but it is associated with a high mortality rate due to its atypical and misleading symptoms. Supportive treatment, pain management, and treatment of complications are used in the treatment of AP. The treatment of hypertriglyceridemia-induced pancreatitis is plasmapheresis, which is an extracorporeal separation of blood components to assist in the removal of inflammatory mediators. Here we present the case of a 60-year-old male patient who developed severe AP (Ranson Score: 6) without hypertriglyceridemia after CABG. The patient received supportive treatment, but the response to conventional therapy was not predictable. Thus, plasmapheresis was started, and the patient was treated with plasmapheresis successfully. The use of plasmapheresis in patients with this condition is a new treatment modality as far as we know. This case illustrates the efficient and safe use of the plasmapheresis treatment modality in a patient with AP without hypertriglyceridemia.

PANCREATITIS OR NOT?--Elevated lipase and amylase in ICU patients

Elevation in serum levels of pancreatic enzymes (Hyperamylasemia and/or Hyperlipasemia) can occur in any Intensive Care Unit (ICU) patient either as a result of true acute pancreatitis (AP) or as a reflection of a non-pancreatic disease. Although most patients may not have clinical pancreatitis, identifying true acute pancreatitis in the ICU setting may be critical in the presence of associated co-morbid conditions of the disease for which the patient is being managed. With neither amylase nor lipase being specific for pancreatitis, it is important for the clinician to be aware of different causes of hyperamylasemia and hyperlipasemia, especially when clinical diagnosis of pancreatitis is unclear. This review will focus on understanding different non-pancreatic conditions where there is elevation of pancreatitis enzymes and to identify true acute pancreatitis in critically ill patients without typical symptoms.