Successful surgical reconstruction of atypical variant mirror hand anomaly in a 2-year-old female child: a unique case report

Introduction

Mirror hand is an extremely rare congenital abnormality characterized by polydactyly and duplication of the ulna, with the absence of the radius and thumb. Atypical presentations of mirror hand were described, including the presence of the radius in a few cases; here the authors report one of the atypical cases of mirror hand that underwent successful management.

Case presentation

A 2-year-old and 7-month-old female child presented with 7 well-developed digits, with an absent thumb; the X-ray imaging of the forearm showed a well-formed ulna and radius with proximal fusion. The patient has good shoulder movement, minor limitations in supination and pronation, and elbow flexion restriction. The patient underwent multiple surgical interventions for pollicization. Follow-up revealed a significant improvement of hand function and appearance.

Clinical discussion

In the literature review, mirror hand is a rare congenital malformation and has many varieties. The management of this deformity is a challenge and differs from case to case; here the authors described a novel variant of this deformity and its successful management.

Conclusion

Mirror hand is a rare congenital abnormality and has a wide spectrum of variants. The management challenge, but with early pollicization with appropriate functional considerations, the outcome is promising.

Ultrasensitive Optical Detection and Elimination of Residual Microtumors with a Postoperative Implantable Hydrogel Sensor for Preventing Cancer Recurrence

In vivo optical imaging of trace biomarkers in residual microtumors holds significant promise for cancer prognosis but poses a formidable challenge. Here, a novel hydrogel sensor is designed for ultrasensitive and specific imaging of the elusive biomarker. This hydrogel sensor seamlessly integrates a molecular beacon nanoprobe with fibroblasts, offering both high tissue retention capability and an impressive signal-to-noise ratio for imaging. Signal amplification is accomplished through exonuclease I-mediated biomarker recycling. The resulting hydrogel sensor sensitively detects the biomarker carcinoembryonic antigen with a detection limit of 1.8 pg mL-1 in test tubes. Moreover, it successfully identifies residual cancer nodules with a median diameter of less than 2 mm in mice bearing partially removed primary triple-negative breast carcinomas (4T1). Notably, this hydrogel sensor is proven effective for the sensitive diagnosis of invasive tumors in post-surgical mice with infiltrating 4T1 cells, leveraging the role of fibroblasts in locally enriching tumor cells. Furthermore, the residual microtumor is rapidly photothermal ablation by polydopamine-based nanoprobe under the guidance of visualization, achieving ≈100% suppression of tumor recurrence and lung metastasis. This work offers a promising alternative strategy for visually detecting residual microtumors, potentially enhancing the prognosis of cancer patients following surgical interventions.

Orthopedic Challenges in Avascular Necrosis Management: A Case Report of Surgical Complications and Multidisciplinary Care

A 52-year-old woman, with a multifaceted medical background encompassing spinal cord injury, pneumonia, and recurrent hospitalizations, presents with enduring left hip and leg discomfort ultimately diagnosed as avascular necrosis (AVN). She previously underwent intraosseous direct anterior arthroplasty (DAA) of the left hip during the removal of orthopedic artifacts. Despite enduring hypertension, severe trochanter dislocation, and prosthesis fracture, she recovered and required additional surgery to address the dislocation and fracture. This case underscores the challenges in diagnosing and treating AVN, emphasizing the importance of meticulous postoperative care and a multidisciplinary approach. Challenges highlighted by AVN include delayed diagnosis, intricate surgical procedures, and the potential need for further interventions due to hardware complications and infection as seen in this patient.

Quadratus lumborum block versus transversus abdominis plane block for inguinal hernia repair: A systematic review and meta-analysis with trial sequential analysis

INTRODUCTION

Postoperative pain management is crucial for patient recovery with Quadratus Lumborum Block (QLB) and Transversus Abdominis Plane Block (TAPB) emerging as potential techniques. We aimed to compare the analgesic efficacy of QLB and TAPB in patients undergoing inguinal hernia repair.

METHODS

We performed a systematic review of Cochrane, EMBASE, and MEDLINE databases to identify randomized controlled trials comparing QLB and TAPB in patients undergoing inguinal hernia repair. Outcomes included postoperative pain and opioid consumption. Statistical analysis was performed using RevMan 5.4. The review protocol was registered at PROSPERO (CRD42023445513).

RESULTS

We included five RCTs encompassing 255 patients. QLB was associated with a significant decrease in postoperative pain (MD -0.45; 95% CI -0.75 to -0.14; and p = 0.004; I2  = 94%). However, we found no difference in 24-h opioid consumption between QLB and TAPB groups.

CONCLUSION

QLB may offer superior pain reduction. However, its effect on opioid consumption remains unclear.

Management of Postthyroidectomy Hypoparathyroidism and Its Effect on Hypocalcemia-Related Complications: A Meta-Analysis

OBJECTIVE

The aim of this Meta-analysis is to evaluate the impact of different treatment strategies for early postoperative hypoparathyroidism on hypocalcemia-related complications and long-term hypoparathyroidism.

DATA SOURCES

Embase.com, MEDLINE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and the top 100 references of Google Scholar were searched to September 20, 2022.

REVIEW METHODS

Articles reporting on adult patients who underwent total thyroidectomy which specified a treatment strategy for postthyroidectomy hypoparathyroidism were included. Random effect models were applied to obtain pooled proportions and 95% confidence intervals. Primary outcome was the occurrence of major hypocalcemia-related complications. Secondary outcome was long-term hypoparathyroidism.

RESULTS

Sixty-six studies comprising 67 treatment protocols and 51,096 patients were included in this Meta-analysis. In 8 protocols (3806 patients), routine calcium and/or active vitamin D medication was given to all patients directly after thyroidectomy. In 49 protocols (44,012 patients), calcium and/or active vitamin D medication was only given to patients with biochemically proven postthyroidectomy hypoparathyroidism. In 10 protocols (3278 patients), calcium and/or active vitamin D supplementation was only initiated in case of clinical symptoms of hypocalcemia. No patient had a major complication due to postoperative hypocalcemia. The pooled proportion of long-term hypoparathyroidism was 2.4% (95% confidence interval, 1.9-3.0). There was no significant difference in the incidence of long-term hypoparathyroidism between the 3 supplementation groups.

CONCLUSIONS

All treatment strategies for postoperative hypocalcemia prevent major complications of hypocalcemia. The early postoperative treatment protocol for postthyroidectomy hypoparathyroidism does not seem to influence recovery of parathyroid function in the long term.

A Review of Chronic Lateral Ankle Instability and Emerging Alternative Outcome Monitoring Tools in Patients following Ankle Ligament Reconstruction Surgery

Ankle sprains are exceedingly common injuries in both athletes and the general population. They account for 10 to 30% of all sports injuries. Although the vast majority of lateral ankle ligament injuries respond successfully to conservative management, the absolute number of those that progress to chronic lateral ankle instability (CLAI) remains considerably important. This condition is characterized by persistent symptoms and may be associated with short-term and long-term complications and functional deficits. There is still a lack of ideal postoperative management of CLAI patients. Furthermore, an evidence-based rehabilitation phasing does not exist and most of the published studies regarding this subject suggest some protocols based on a wide variety of functional assessment scores and other modalities that are not accurate enough. Moreover, the literature that assesses the ability to return to work (RTW) and return to sport (RTS) in the general population and athletes operated for CLAI most commonly shows aggregated results with global rates of RTW or RTS without describing a detailed timeline based on the readiness of patients to return to each level of activity. Although stress radiographs and MRI have been assessed as potential tools to improve postoperative management of CLAI patients, the first modality is limited by its low sensitivity to detect laxity and the second one by its static character and its inability to predict neither the healing process phase nor the mechanical properties of the repaired/reconstructed ligaments. Bioelectrical impedance, mechanical impedance and near-infrared spectroscopy are non-invasive methods of measurement that could be potential assessment tools to help surgeons improve the postoperative management of patients after CLAI surgery.

Changes in Management at the Postoperative Visit After In-Office Wide Awake Local Anesthetic No Tourniquet Carpal Tunnel Release

PURPOSE

Patients are commonly seen for two postoperative visits following carpal tunnel release (CTR), the first visit being at 1-2 weeks and the second at approximately 6 weeks. Our study aimed to determine if these visits led to changes in postoperative medical management.

METHODS

A retrospective review was conducted of 748 procedures performed in an in-office procedure room under wide awake local anesthetic no tourniquet between August 2020 and December 2022. Charts were reviewed for changes in management related to the patient's CTR. Management changes involving a separate diagnosis or solely an additional follow-up visit were classified as unrelated to postoperative CTR care.

RESULTS

A total of 730 patients returned for follow-up. There were 100 patients (13.7 %) who had a CTR-related change in management at the first postoperative visit. Most management changes at this timepoint were due to superficial surgical site infection. There were 29 patients (4.0 %) who had a CTR-related change in management at their second postoperative visit, most commonly a referral to therapy for stiffness or hypersensitivity.

CONCLUSIONS

While postoperative visits for CTR may have intangible benefits, changes in CTR-related care occur only in 17.7% of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Lung Ultrasound Reduces Chest X-rays in Postoperative Care after Thoracic Surgery: Is There a Role for Artificial Intelligence?-Systematic Review

BACKGROUND

Chest X-ray (CXR) remains the standard imaging modality in postoperative care after non-cardiac thoracic surgery. Lung ultrasound (LUS) showed promising results in CXR reduction. The aim of this review was to identify areas where the evaluation of LUS videos by artificial intelligence could improve the implementation of LUS in thoracic surgery.

METHODS

A literature review of the replacement of the CXR by LUS after thoracic surgery and the evaluation of LUS videos by artificial intelligence after thoracic surgery was conducted in Medline.

RESULTS

Here, eight out of 10 reviewed studies evaluating LUS in CXR reduction showed that LUS can reduce CXR without a negative impact on patient outcome after thoracic surgery. No studies on the evaluation of LUS signs by artificial intelligence after thoracic surgery were found.

CONCLUSION

LUS can reduce CXR after thoracic surgery. We presume that artificial intelligence could help increase the LUS accuracy, objectify the LUS findings, shorten the learning curve, and decrease the number of inconclusive results. To confirm this assumption, clinical trials are necessary. This research is funded by the Slovak Research and Development Agency, grant number APVV 20-0232.

IFABP levels predict visceral malperfusion in the first hours after open thoracoabdominal aortic repair

Introduction

Intestinal ischemia after open thoracoabdominal aortic repairs, is a rare but devastating complication, associated with high mortality. Notoriously challenging to diagnose, visceral malperfusion necessitates immediate surgical attention. Intestinal fatty acid-binding protein (IFABP) has been proposed as a biomarker for the diagnosis of intestinal wall damage. In this prospectively conducted, observational study we evaluated the diagnostic capacity of IFABP levels in patients' serum and their correlation with visceral malperfusion.

Methods

23 patients undergoing open thoracoabdominal aortic repairs were included in this study and 8 of them were diagnosed postoperatively with visceral malperfusion-defined as a partial or complete thrombotic occlusion of the superior mesenteric artery and/or the coeliac trunk. IFABP levels and laboratory parameters often associated with intestinal ischemia (leucocytes, CRP, PCT and lactate) were measured at baseline, directly postoperatively, and at 12, 24 and 48 h after surgery. Postoperative visceral malperfusion-as revealed in CT angiography-was assessed and the predictive ability of IFABP levels to detect visceral malperfusion was evaluated with receiver-operator curve analysis.

Results

Patients with visceral malperfusion had a relevant risk for a fatal outcome (p = .001). IFABP levels were significantly elevated directly postoperatively and at 12 h after surgery in cases of visceral malperfusion. High IFABP concentrations in serum detected visceral malperfusion accurately during the first 12 h after surgery, with the maximum diagnostic ability achieved immediately after surgery (AUC 1, Sensitivity 100%, Specificity 100%, p < .001).

Conclusion

We conclude, that IFABP measurements during the first postoperative hours after open thoracoabdominal aortic surgery can be a valuable tool for reliable and timely detection of visceral malperfusion.

A review of hydrogels used in endoscopic submucosal dissection for intraoperative submucosal cushions and postoperative management

Endoscopic submucosal dissection (ESD) has been clinically proved to have prominent advantages in the treatment of early gastrointestinal cancers over traditional surgery, including less trauma, fewer complications, a quicker recovery and lower costs. During the procedure of ESD, appropriate and multifunctional submucosal injected materials (SIMs) as submucosal cushions play an important role, however, even with many advances in design strategies of SIMs over the past decades, the performance of the submucosal cushions with postoperative management function seems to be still unsatisfactory. In this review, we gave a brief historical recount about the clinical development of SIMs, then some common applications of hydrogels used as SIMs in ESD were summarized, while an account of the universal challenges during ESD procedure was also outlined. Going one step further, some cutting-edge functional strategies of hydrogels for novel applications in ESD were exhibited. Finally, we concluded the advantages of hydrogels as SIMs for ESD as well as the treatment dilemma clinicians faced when it comes to deeply infiltrated lesions, some technical perspectives about linking the clinical demand with commercial supply were also proposed. Encompassing the basic elements of SIMs used in ESD surgery and the corresponding postoperative management requirements, this review could be a good reference for relevant practitioners in expanding the research horizon and improving the well-being index of patients.

Perioperative Management of Patients Undergoing Total Pancreatectomy with/without Islet Cell Autotransplantation: A Single Center Experience

Total pancreatectomy (TP) and islet cell autotransplantation (IAT) are complex operations that require intensive postoperative monitoring with standardized protocols. There are few studies detailing immediate perioperative management. The purpose of this study was to describe the perioperative management of post-pancreatectomy patients in the first week following surgery to guide clinicians in addressing salient points from different organ systems. This is a retrospective cohort review of prospectively collected data from September 2017 to September 2022 at a single institution, including patients 16 years and older who underwent TP or TPIAT for chronic pancreatitis. Patients were maintained on a heparin drip (TPIAT), insulin drip, and ketamine infusion. Primary outcomes were complications in the first 5 days following surgery and ICU length of stay (LOS). Secondary outcomes included overall LOS and mortality. Of 31 patients, 26 underwent TPIAT, and 5 underwent TP. Median ICU LOS was five days (IQR 4-6). The most common immediate postoperative complications were reintubation [n = 5 (16%)] and bleeding [n = 2 (6%)]. Median insulin drip use was 70 h (IQR 20-124). There was no mortality. Patients were extubated quickly and progressed well on the protocol. Immediate postoperative complications were generally minor and without long-term effects.

Fluid balance in pediatric postoperative liver transplant recipients

BACKGROUND

Positive fluid balance (FB) is associated with poor outcomes in critically ill children but has not been studied in pediatric liver transplant (LT) recipients. Our goal is to investigate the relationship between postoperative FB and outcomes in pediatric LT recipients.

METHODS

We performed a retrospective cohort study of first-time pediatric LT recipients at a quaternary care children's hospital. Patients were stratified into three groups based on their FB in the first 72 h postoperatively: <10%, 10-20%, and > 20%. Outcomes were pediatric intensive care unit (PICU) and hospital length of stay, ventilator-free days (VFD) at 28 days, day 3 severe acute kidney injury, and postoperative complications. Multivariate analyses were adjusted for age, preoperative admission status, and Pediatric Risk of Mortality (PRISM)-III score.

RESULTS

We included 129 patients with median PRISM-III score of 9 (interquartile range, IQR 7-15) and calculated Pediatric End-stage Liver Disease score of 15 (IQR 2-23). A total of 37 patients (28.7%) had 10-20% FB, and 26 (20.2%) had >20% FB. Greater than 20% FB was associated with an increased likelihood of an additional PICU day (adjusted incident rate ratio [aIRR] 1.62, 95% CI: 1.18-2.24), an additional hospital day (aIRR 1.39, 95% CI: 1.10-1.77), and lower likelihood of a VFD at 28 days (aIRR 0.85, 95% CI: 0.74-0.97). There were no differences between groups in the likelihood of postoperative complications.

CONCLUSIONS

In pediatric LT recipients, >20% FB at 72 h postoperatively is associated with increased morbidities, independent of age and severity of illness. Additional studies are needed to explore the impact of fluid management strategies on outcomes.

Measurement of Postoperative Quality of Pain in Abdominoplasty Patients-An Outcome Oriented Prospective Study

(1) Background: Postoperative pain is a frequently underestimated complication significantly influencing surgical outcome and patient satisfaction. While abdominoplasty is one of the most commonly performed plastic surgery procedures, studies investigating postoperative pain are limited in current literature. (2) Methods: In this prospective study, 55 subjects who underwent horizontal abdominoplasty were included. Pain assessment was performed by using the standardized questionnaire of the Benchmark Quality Assurance in Postoperative Pain Management (QUIPS). Surgical, process and outcome parameters were then used for subgroup analysis. (3) Results: We found a significantly decreased minimal pain level in patients with high resection weight compared to the low resection weight group (p = 0.01 *). Additionally, Spearman correlation shows significant negative correlation between resection weight and the parameter "Minimal pain since surgery" (rs = -0.332; p = 0.013). Furthermore, average mood is impaired in the low weight resection group, indicating a statistical tendency (p = 0.06 and a Χ² = 3.56). We found statistically significant higher maximum reported pain scores (rs = 0.271; p = 0.045) in elderly patients. Patients with shorter surgery showed a statistically significant (Χ² = 4.61, p = 0.03) increased claim for painkillers. Moreover, "mood impairment after surgery" shows a dramatic trend to be enhanced in the group with shorter OP duration (Χ² = 3.56, p = 0.06). (4) Conclusions: While QUIPS has proven to be a useful tool for the evaluation of postoperative pain therapy after abdominoplasty, only continuous re-evaluation of pain therapy is a prerequisite for constant improvement of postoperative pain management and may be the first approach to develop a procedure-specific pain guideline for abdominoplasty. Despite a high satisfaction score, we detected a subpopulation with inadequate pain management in elderly patients, patients with low resection weight and a short duration of surgery.

A Practical Assessment of the Postoperative Management in Lung Cancer Surgery

Postoperative management after major and minor thoracic surgeries is crucial for patient recovery and can be challenging. Major thoracic surgeries, such as extensive pulmonary resections, especially in patients with poor health status, may require intensive surveillance, particularly during the first 24-72 h after surgery. Moreover, thanks to the demographic development and medical progress in perioperative medicine, more patients with comorbidities undergoing thoracic procedures require proper management in the postoperative period to improve prognosis and decrease hospital stay. Here, we summarize the main thoracic postoperative complications in order to clarify how to prevent them through a series of standardized procedures.

Postoperative Airway Management after Submandibular Duct Relocation in 96 Drooling Children and Adolescents

The aim of this study was to evaluate our institutions airway management and complications after submandibular duct relocation (SMDR). We analysed a historic cohort of children and adolescents who were examined at the Multidisciplinary Saliva Control Centre between March 2005 and April 2016. Ninety-six patients underwent SMDR for excessive drooling. We studied details of the surgical procedure, postoperative swelling and other complications. Ninety-six patients, 62 males and 34 females, were treated consecutively by SMDR. Mean age at time of surgery was 14 years and 11 months. The ASA physical status was 2 in most patients. The majority of children were diagnosed with cerebral palsy (67.7%). Postoperative swelling of the floor of the mouth or tongue was reported in 31 patients (32.3%). The swelling was mild and transient in 22 patients (22.9%) but profound swelling was seen in nine patients (9.4%). In 4.2% of the patients the airway was compromised. In general, SMDR is a well-tolerated procedure, but we should be aware of swelling of the tongue and floor of the mouth. This may lead to a prolonged period of endotracheal intubation or a need for reintubation which can be challenging. After extensive intra-oral surgery such as SMDR we strongly recommend a extended perioperative intubation and extubation after the airway is checked and secure.

Randomized Controlled Trial Comparing Early Mobilization vs Six Weeks of Immobilization in a Walking Cast Following Total Ankle Replacement

Rehabilitation for patients after total ankle replacement traditionally involves weeks of immobilization in a plaster cast followed by progressive mobilization. In a small randomized trial, we compared teh outcomes of patients who received a 3-component cementless, unconstrained, mobile-bearing prosthesis and were initially immobilised in a plaster cast for 6 weeks to thoese who received the same prosthesis but were allowed to mobilise early. Gait, clinical, patient-reported, and radiologic outcomes were measured. The study included 20 patients, 10 in the plaster cast group and 10 in the early mobilization group, and the demographics of the groups did not differ significantly. All patients were followed-up for 24 months. There were no significant differences between the 2 groups 2 years after surgery in ankle dorsiflexion, spatiotemporal gait characteristics, American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, Timed Up and Go Test times, WOMAC (pain, stiffness, function) scores, SF-36 (quality-of-life) scores, or patient satisfaction (pain relief, daily-living, recreational activities, and overall) (all p > .05). Bone mineral density decrease of the medial malleolus and increase at middle tibia, calculated with DEXA scans, was significantly better in early mobilization than plaster cast group at one and 2 years postoperatively, but this was also the case preoperatively. The lack of differences in outcomes suggests that early ankle mobilization may be a safe and reliable method to enhance recovery following ankle arthroplasty with a 3-component cementless, unconstrained, mobile-bearing prosthesis. Compared to traditional plaster casting, patients who are engaged in early mobilization after arthroplasty may enjoy similar functional, mobility, quality-of-life, pain relief, activity level, and satisfaction outcomes.

Case Report: Wernicke's encephalopathy after gastric surgery presenting as lactic acidosis and refractory thrombocytopenia

Wernicke's encephalopathy (WE) is a severe neuropsychiatric disorder, mainly resulting from a nutritional deficiency of thiamine. WE is hard to detect at an early stage. Less than 20% of WE can be diagnosed during a patient's lifetime, and WE tends to occur in patients with chronic alcoholism. Therefore, a large proportion of non-alcoholic WE patients are misdiagnosed. Lactate is an important by-product of anaerobic metabolism when the aerobic metabolism is blocked without thiamine, which can potentially serve as an alerting index for WE. Here, we report a case of a patient with WE who suffered gastric outlet obstruction following postoperative fasting, accompanied by lactic acidosis and refractory thrombocytopenia. A 67-year-old non-alcoholic woman who suffered hyperemesis for 2 months was diagnosed with gastric outlet obstruction (GOO). Gastric biopsies with endoscopy revealed gastric cancer, and total gastrectomy, together with D2 nodal dissection, was performed. She developed a coma with refractory thrombocytopenia rapidly after the surgical procedures were performed. The above conditions were treated not by the administration of antibiotics but by that of thiamine. We also found before the start of the procedures that she had a high level of blood lactate for a long period of time. Early diagnosis of WE is important because permanent injury can be caused to the central nervous system. Even today, the diagnosis of WE mainly depends on clinical symptoms, but occasionally, a typical triad occurs among WE patients. Therefore, a sensitive index for early diagnosis is critical for WE. Rising levels of blood lactate as a result of thiamine deficiency can serve as a warning for WE. In addition, we noted that this patient had a non-typical thiamine-sensitive refractory thrombocytopenia.

Postoperative protocols following endoscopic skull base surgery: An evidence-based review with recommendations

BACKGROUND

Postoperative management strategies for endoscopic skull base surgery (ESBS) vary widely because of limited evidence-based guidance.

METHODS

The PubMed, EMBASE, and Cochrane databases were systematically reviewed from January 1990 through February 2022 to examine 18 postoperative considerations for ESBS. Nonhuman studies, articles written in a language other than English, and case reports were excluded. Studies were assessed for levels of evidence, and each topic's aggregate grade of evidence was evaluated.

RESULTS

A total of 74 studies reporting on 18 postoperative practices were reviewed. Postoperative pain management, prophylactic antibiotics, and lumbar drain use had the highest grades of evidence (B). The literature currently lacks high quality evidence for a majority of the reviewed ESBS precautions. There were no relevant studies to address postoperative urinary catheter use and medical intracranial pressure reduction.

CONCLUSION

The evidence for postoperative ESBS precautions is heterogeneous, scarce, and generally of low quality. Although this review identified the best evidence available in the literature, it suggests the urgent need for more robust evidence. Therefore, additional high-quality studies are needed in order to devise optimal postoperative ESBS protocols.

Acute kidney injury post-abdominal surgery in infants: implications for prevention and management

Acute kidney injury (AKI) is common in critically ill infants and is associated with long-term sequelae including hypertension and chronic kidney disease. The etiology of AKI in infants is multifactorial. There is robust literature highlighting the risk of AKI after cardiothoracic surgery in infants. However, risk factors and outcomes for AKI in infants after abdominal surgery remains limited. This article reviews the epidemiology and association of abdominal surgery with postoperative AKI and suggests methods for AKI management and prevention. Postoperative AKI may result from hemodynamic shifts, hypoxia, exposure to nephrotoxic medications, and inflammation. Infants in the intensive care unit after intraabdominal surgeries have a unique set of risk factors that predispose them to AKI development. Prematurity, sepsis, prolonged operation time, emergent nature of the procedure, and diagnosis of necrotizing enterocolitis increase risk of AKI after intrabdominal surgeries. Prevention, early diagnosis, and management of AKI post-abdominal surgery is imperative to clinical practice. Close monitoring of urine output, serum creatinine, and fluid status is necessary in infants after abdominal surgery. A recent study suggests elevated levels of a urinary biomarker, neutrophil gelatinase-associated lipocalin (NGAL), 24 h after an abdominal procedure may improve early prediction of AKI. Identification of risk factors, avoidance of nephrotoxic medications, careful fluid balance, early detection of AKI, and maintenance of hemodynamic stability is imperative to potentially prevent and/or mitigate AKI.

The Utility of Routine Postoperative Radiographs in the Asymptomatic Total Hip Arthroplasty Patient

BACKGROUND

Total hip arthroplasty (THA) patients often receive routine radiographs in the year following their index surgery. This study sought to investigate the clinical and economic value of obtaining routine postoperative hip radiographs for asymptomatic patients following primary elective THA.

METHODS

A retrospective cohort study of consecutive patients who underwent primary elective THA from 2016 to 2019 was conducted. Patients undergoing nonelective or revision THA, radiographic follow-up <10 months, and patients aged <18 years were excluded. All radiographs were reviewed for abnormalities in the first postoperative year by an arthroplasty fellowship-trained orthopaedic surgeon, blinded to the symptoms of the patient.

RESULTS

Of the 327 patients (351 hips) included, 57.2% were women and 68.2% were White, with an average age of 65 years (range, 22-97 years) and average body mass index of 29.1 kg/m² (range, 16.2-49.8 kg/m²). Only four (0.4%) radiographic series revealed abnormalities with the potential to alter postoperative management. One patient experienced a change in management directly related to their abnormal finding (closed reduction for dislocation at 10.2 months postoperatively). The remaining three abnormal radiographic findings included femoral stem subsidence, progressive radiolucencies around an acetabular component, and cement mantle fracture. The average cost for each radiographic series was $155.27, resulting in total direct charges of $167,691.60.

CONCLUSION

Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. Consideration should be given to limit postoperative radiographs following standard elective THA, while reserving postoperative radiographic evaluation for patients who are symptomatic.

LEVEL OF EVIDENCE

Level III.

Onset of Adverse Abdominal Events Due to Intestinal Ischemia-Reperfusion Injury after Aortic Cross-Clamping Is Associated with Elevated HSP70 Serum Levels in the Early Postoperative Phase

Tissue injury of the viscera during open thoracoabdominal aortic (TAA) reconstructions has been reported as the aftermath of the ischemia-reperfusion mechanism following supracoeliac aortic cross-clamping. Abdominal complications after open aortic reconstructions, although rare through the intraoperative implementation of selective visceral artery blood perfusion, are associated with high rates of reinterventions and a poor prognosis. Recent animal experiments demonstrated that provoking mesenteric ischemia in rats induces the leukocyte-mediated transcription of heat-shock protein 70 (HSP70), a chaperone belonging to the danger-associated molecular pattern proteins (DAMPs). Translating these findings clinically, we investigated the serum levels of HSP70 in patients undergoing open aortic reconstructions with supracoeliac clamping. We postoperatively observed a relevant induction of HSP70, which remained significantly elevated in cases of postoperative abdominal complications (paralytic ileus, abdominal compartment syndrome, and visceral malperfusion). The receiver-operator curve analysis revealed the reliable prognostic accuracy of HSP70 as a biomarker for these complications as soon as 12 h post-operation (AUC 0.908, sensitivity 88.9%, specificity 83.3%). In conclusion, measuring HSP70 serum levels in the early postoperative phase may serve as a further adjutant in the diagnostic decision making for both the vascular surgeon and intensivist for the timely detection and management of abdominal complications following open TAA surgery.

Early-start antiplatelet therapy after operation in patients with spontaneous intracerebral hemorrhage and high risk of ischemic events (E-start): Protocol for a multi-centered, prospective, open-label, blinded endpoint randomized controlled trial

Background

For severe spontaneous intracerebral hemorrhage (sSICH) patients with high risk of ischemic events, the incidence of postoperative major cardiovascular/cerebrovascular and peripheral vascular events (MACCPE) is notable. Although antiplatelet therapy is a potential way to benefit these patients, the severe hemorrhagic complications, e.g., intracranial re-hemorrhage, is a barrier for early starting antiplatelet therapy.

Objectives

This randomized controlled trial aims to identify the benefit and safety of early starting antiplatelet therapy after operation for sSICH patients with high risk of ischemic events.

Methods

This study is a multicenter, prospective, randomized, open-label, blinded-endpoint trial. We will enroll 250 sSICH patients with a high risk of ischemic events (including cerebral infarcts, transient ischemic attack, myocardial infarction, pulmonary embolism, and deep venous thrombosis). The participants will be randomized in a 1:1 manner to early-start group (start antiplatelet therapy at 3 days after operation) and normal-start group (start antiplatelet therapy at 30 days after operation). The early-start group will receive aspirin 100 mg daily. The control group will not receive antithrombotic therapy until 30 days after operation. The efficacy endpoint is the incidence of MACCPE, and the safety endpoint is the incidence of intracranial re-hemorrhage.

Discussion

The Early-Start antiplatelet therapy after operation in patients with spontaneous intracerebral hemorrhage trial (E-start) is the first randomized trial about early start antiplatelet therapy for operated sSICH patients with a high risk of ischemic events. This study will provide a new strategy and evidence for postoperative management in the future.

Clinical trial registration

ClinicalTrials.gov, identifier NCT04820972; Available at: https://clinicaltrials.gov/ct2/show/NCT04820972?term=NCT04820972&draw=2&rank=1.Chinese Clinical Trial Registry, identifier ChiCTR2100044560; Available at: http://www.chictr.org.cn/showproj.aspx?proj=123277.

Assessment of changes in blood pancreatic lipase activities using FDC-v-LIP in dogs that underwent various surgical procedures

OBJECTIVE

To describe the perioperative changes in blood pancreatic lipase activity and explore the contributing clinical factors associated with these changes.

DESIGN

Prospective observational study.

SETTING

University teaching hospital.

ANIMALS

One hundred and four dogs underwent various surgical procedures under general anesthesia.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Blood pancreatic lipase activities, which were measured using FUJI DRI-CHEM v-Lip-P (FDC-v-Lip), significantly increased postoperatively compared to preoperative measurements (premedian 58.5 U/L [range, 23-157] vs. postmedian 80 U/L [range, 22-1000], P < 0.0001). The patient with a postoperative increase in FDC-v-Lip over the normal range (35 dogs [33.6%]) had significantly higher preoperative FDC-v-Lip values.

CONCLUSIONS

In this study, dogs had significantly increased pancreas-specific lipase activities after surgical procedures under general anesthesia. Direct contributors to the increase and its relevance to clinical and histological pancreatitis should be determined in the future.

Reappraisal of liver transplantation for erythropoietic protoporphyria: A deadly combination of disease recurrence and biliary complication

BACKGROUND

Erythropoietic protoporphyria (EPP) is a rare inherited disorder that causes the accumulation of protoporphyrin in the erythrocytes, skin, and liver. Severe protoporphyric hepatopathy results in liver failure, requiring both liver and bone marrow transplantation as a life-saving procedure and to correct the underlying enzymatic defect, respectively.

CASE PRESENTATION

We report a 20-year-old man who underwent split liver transplantation using a right trisegment and caudate lobe graft for EPP-induced liver failure, but succumbed to a deadly combination of early relapse of EPP and subsequent, intractable, late-onset bile leakage from the cut surface of segment 4. EPP recurrence most likely created a high-risk situation for bile leakage from the non-communicating bile ducts of segment 4; therefore, this case shed light on the potential relationship between EPP recurrence and biliary complications.

CONCLUSION

Physicians should recognize the potentially rapid and life-threatening progression of protoporphyric hepatopathy that leads to liver failure. For young patients with EPP, LT and sequential BMT should thoroughly be considered by a multidisciplinary team as soon as hepatic reserve deterioration becomes evident. Split liver transplantation should preferably be avoided and appropriate post-transplant management is critical before protoporphyrin depositions to the bile duct and hepatocyte causes irreversible damage to the liver graft.

Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons

Surgical re-explorations represent 3-5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: "planned" and "unplanned". Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs. 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs. 7%, p = 0.004), prolonged intubation (46.8% vs. 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs. 7%, p = 0.91) and DSWI rates (1.8% vs. 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

Evaluate the Effectiveness of Enhanced Recovery After Surgery Versus Conventional Approach in Benign Gynecological Surgeries: A Randomized Controlled Trial

Objective

This study aimed to evaluate the effectiveness of enhanced recovery after surgery (ERAS) model versus conventional approach in benign gynecological surgeries (incorporating various routes of surgery).

Methods

This was a randomized controlled trial wherein patients undergoing gynecological surgery for benign indications from January 2019 to July 2020 were recruited and randomized into ERAS and conventional protocol groups using block randomization. The intended primary outcome was to compare the median length of hospital stay in both groups. “Fit for discharge” criteria were used to assess the length of stay as patients who belonged to hilly terrain with limited transportation facilities stayed for a longer duration.

Results

A total of 180 patients were recruited and 90 each was randomized into ERAS and conventional protocol groups. The difference in length of hospital stay between ERAS (36 hours, range 24-96 hours) and conventional group (72 hours, range: 24-144 hours) was significant (p<0.01). A statistically significant difference was noted in the time for recovery of bowel function and tolerance for diet in the ERAS group. No significant difference in complications and readmission (within 30 days) rate was seen between the two groups. Quality of life as assessed by the World Health Organization Quality of Life Brief Version (WHO-QOL BREF) on the day of discharge and day 30 was higher in the ERAS group in physical and psychological domains, while no difference was seen in environmental and social domains.

Conclusion

This study as an institutional experience strengthens the existing evidence regarding the efficacy of ERAS in reducing hospital stay and improving quality of life compared to the conventional perioperative management protocol.

A case of feline large granular lymphocyte lymphoma with complete remission and long survival by surgical resection and adjuvant nimustine administration

A 7‐year‐old spayed female Scottish Fold cat presented with a 4‐week history of anorexia, weight loss and vomiting. Abdominal ultrasonography revealed a jejunal mass and a slightly enlarged jejunal lymph node. A fine‐needle aspiration of the mass revealed many round cells with multiple small intracytoplasmic magenta granules. The mass was diagnosed as a large granular lymphocyte (LGL) lymphoma based on cytology. The LGL lymphoma was completely resected via open surgery. The histologic and cytologic evaluations showed no neoplastic findings in the jejunal lymph node, liver, spleen, kidney or bone marrow. The LGL lymphoma was localized to the jejunum. Postoperatively, the cat received chemotherapy with nimustine, l‐asparaginase and prednisolone. The cat is currently receiving nimustine every 6 weeks, without adverse events, and treatment has been administrated a total of 18 times up until day 552. The cat is in a good condition, and the LGL lymphoma has not recurred. Nimustine should be considered one of the effective chemotherapeutic agents in the treatment of feline LGL lymphoma cases in the future.

Perioperative Outcomes Following Kidney-Pancreas Transplantation in Alberta, Canada: Research Letter

Background:

Simultaneous kidney-pancreas transplantation (SPK) has benefits for patients with kidney failure and type I diabetes mellitus, but is associated with greater perioperative risk compared with kidney-alone transplantation. Postoperative care settings for SPK recipients vary across Canada and may have implications for patient outcomes and hospital resource use.

Objective:

To compare outcomes following SPK transplantation between patients receiving postoperative care in the intensive care unit (ICU) compared with the ward.

Design:

Retrospective cohort study using administrative health data.

Setting:

In Alberta, the 2 transplant centers (Calgary and Edmonton) have different protocols for routine postoperative care of SPK recipients. In Edmonton, SPK recipients are routinely transferred to the ICU, whereas in Calgary, SPK recipients are transferred to the ward.

Patients:

129 adult SPK recipients (2002-2019).

Measurements:

Data from the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) were used to identify SPK recipients (procedure codes) and the outcomes of inpatient mortality, length of initial hospital stay (LOS), and the occurrence of 16 different patient safety indicators (PSIs).

Methods:

We followed SPK recipients from the admission date of their transplant hospitalization until the first of hospital discharge or death. Unadjusted quantile regression was used to determine differences in LOS, and age- and sex-adjusted marginal probabilities were used to determine differences in PSIs between centers.

Results:

There were no perioperative deaths and no major differences in the demographic characteristics between the centers. The majority of the SPK transplants were performed in Edmonton (n = 82, 64%). All SPK recipients in Edmonton were admitted to the ICU postoperatively, compared with only 11% in Calgary. There was no statistically significant difference in the LOS or probability of a PSI between the 2 centers (LOS for Edmonton vs Calgary:16 vs 13 days, P = .12; PSIs for Edmonton vs Calgary: 60%, 95% confidence interval [CI] = 0.50-0.71 vs 44%, 95% CI = 0.29-0.59, P = .08).

Limitations:

This study was conducted using administrative data and is limited by variable availability. The small sample size limited precision of estimated differences between type of postoperative care.

Conclusions:

Following SPK transplantation, we found no difference in inpatient outcomes for recipients who received routine postoperative ICU care compared with ward care. Further research using larger data sets and interventional study designs is needed to better understand the implications of postoperative care settings on patient outcomes and health care resource utilization.

Risk factors for Takotsubo syndrome following cardiac surgery: A case-control study

OBJECTIVE

Takotsubo syndrome following cardiac surgery is a rare occurrence. However, early diagnosis is essential to prevent treatment which could increase the left ventricular outflow tract pressure gradient in patients with Takotsubo syndrome, and lead to cardiogenic shock. Therefore, our study aimed to identify the incidence of Takotsubo syndrome after cardiopulmonary bypass and the associated risk factors and prognosis.

METHODS

We retrospectively studied 5773 patients who underwent cardiopulmonary bypass between February 2007 and July 2017. Among these, Takotsubo syndrome was diagnosed in 52 (0.9%). To evaluate the risk factors for Takotsubo syndrome, 104 of the remaining 5721 patient were randomly selected as the control group (1:2 ratio). Univariate and multivariate logistic regression analyses were used for risk factor analysis.

RESULTS

Majority of patients (69.2%) in the Takotsubo syndrome group underwent mitral valve surgery, compared with 32.7% in the control group. The following risk factors of Takotsubo syndrome were identified: atrio-ventricular valve surgery (odds ratio (OR) 10.5; 95% confidence interval (CI), 2.6-42.5; p = 0.001); and the immediate postoperative use of epinephrine (OR, 3.3; 95% CI, 1.0-10.7; p = 0.05) and dobutamine (OR, 4.8; 95% CI, 1.72-13.3; p = 0.003). Hypertension was a significant protective factor against Takotsubo syndrome following cardiac surgery (OR, 0.22; 95% CI, 0.06-0.73; p = 0.01).

CONCLUSION

Takotsubo syndrome following cardiac surgery is rare. Immediate postoperative use of epinephrine and doputamine, as well as atrio-ventricular valve surgery were factors associated with the development of Takotsubo syndrome.

Efficacy and safety of acupuncture treatment as an adjunctive therapy after knee replacement: Single-center, pragmatic, randomized, assessor blinded, pilot study

INTRODUCTION

Total knee replacement (TKR) is a surgical procedure that is being increasingly performed as a result of population aging and the increased average human life expectancy in South Korea. Consistent with the growing number of TKR procedures, the number of patients seeking acupuncture for relief from adverse effects, effective pain management, and the enhancement of rehabilitative therapy effects and bodily function after TKR has also been increasing. Thus, an objective examination of the evidence regarding the safety and efficacy of acupuncture treatments is essential. The aim of this study is to verify the hypothesis that the concurrent use of acupuncture treatment and usual care after TKR is more effective, safe, and cost-effective for the relief of TKR symptoms than usual care therapy alone.

METHODS/DESIGN

This is an open-label, parallel, assessor-blinded randomized controlled trial that includes 50 patients with TKR. After screening the patients and receiving informed consent, the patients are divided into two groups (usual care + acupuncture group and usual care group); the patients will then undergo TKR surgery and will be hospitalized for 2 weeks. The patients will receive a total of 8 acupuncture treatments over 2 weeks after surgery and will be followed up at 3, 4, and 12 weeks after the end of the intervention. The primary outcome is assessed using the Korean version of the Western Ontario and McMaster Universities Arthritis Index (K-WOMAC), and the secondary outcome is measured using the Numerical Rating Scale (NRS), Risk of Fall, and Range of Motion (ROM). Moreover, the cost per quality-adjusted life years (QALYs) is adopted as a primary economic outcome for economic evaluation, and the cost per NRS is adopted as a secondary economic outcome.

ETHICS AND DISSEMINATION

This trial has received complete ethical approval from the Ethics Committee of Catholic Kwandong University International St. Mary's Hospital (IS17ENSS0063). We intend to submit the results to a peer-reviewed journal and/or conferences.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03633097.

Biopolymer Immune Implants' Sequential Activation of Innate and Adaptive Immunity for Colorectal Cancer Postoperative Immunotherapy

Surgical resection is the first-line therapy for colorectal cancer (CRC). However, for advanced CRC, the curative effect of surgical resection is limited due to either local recurrence or distal metastasis. Postoperative in situ immunotherapy, presents a promising option for preventing tumor recurrence and metastasis, owing to the fact that surgeons have unique opportunities and direct access to the surgical site. Herein, a designed biopolymer immune implant for CRC post-surgical therapy, characterized with tissue adhesion, sustained drug release, and sequential elicitation of innate immunity, adaptive immunity, and immune memory effects, is reported. With gradual release of the loaded resiquimod (R848) and anti-OX40 antibody (aOX40), the immune implant can eradicate residual tumors post-surgery (with no tumor recurrence in 150 days), inhibit the growth of distal tumors and elicit immune memory effects to resist tumor re-challenge. Immunological analysis reveal that the biopolymer immune plant treatment leads to a two-stage action, with enhanced natural killer cells (NK cells) infiltration and activation of dendritic cells (DCs) in the first several days, then a greatly increased population of infiltrating T cells, and finally immune memory effects are established. The reported biopolymer immune implants provide a valuable and clinically-relevant option for post-surgical CRC management.

The Association of Insomnia with Depression and Anxiety Symptoms in Patients Undergoing Noncardiac Surgery

OBJECTIVE

Insomnia is common in patients undergoing surgery. It can increase the rate of postoperative complications, interfere with patient recovery, and decrease hospital satisfaction. However, there are few studies on perioperative insomnia. This study was conducted to investigate the differences in the demographic, health status, and clinical characteristics of patients with and without insomnia postoperatively, and to identify the potential risk factors of insomnia.

METHODS

There were 299 non-cardiac surgery patients, 165 females, and 134 males, with a mean age of 55 years, enrolled in the study. The Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and Montreal Cognitive Assessment (MoCA) were administered to all the patients preoperatively. The Visual Analogue Scale (VAS) was used preoperatively, and at the end of the surgery, and then one day, two days, and three days after surgery. The PHQ-9, the GAD-7, and the ISI were repeated three days after surgery. Insomnia was diagnosed by the ISI as being a score of 8-28 (mild: 8-14; moderate-severe: 15-21; severe: 22-28). The patients were divided into group A (with insomnia, N=78) and group B (without insomnia, N=221) according to their ISI score three days after surgery. The general clinical data of the two groups were analyzed first, and then binary logistic regression analysis was conducted to assess the risk factors of insomnia.

RESULTS

A total of 299 non-cardiac surgery patients with a mean age of 55 years were enrolled in the study. Of the included patients, the number of females was 165 and the number of the male was 134. The incidence of insomnia at 3 days postoperatively was 26.1% (78/299). The average points that group A patients scored in the ISI, PHQ-9, and the GAD-7 were significantly higher than those in group B. The VAS score three days after surgery was significantly higher in group A. The PHQ-9 and the GAD-7 three days after surgery showed significantly higher depression and anxiety scores in group A. Logistic regression showed that the ISI (p<0.001, 95% CI=1.218-1.500) and the GAD-7 (p=0.003, 95% CI=1.041-1.218) preoperatively, and the PHQ-9 postoperatively (p<0.001, 95% CI=1.226-1.555), were risk factors of insomnia.

CONCLUSION

Insomnia is common and can worsen after surgery. The present study suggests that depression and anxiety are risk factors for insomnia after surgery. There is a need for further research and the development of strategies for depression and anxiety management to ensure better sleep quality for patients, which will be of significant benefit to their health.

CLINICAL TRIAL REGISTRATION

The study was registered at clinical trial (NCT04027751); Trial registration: clinical trial, NCT04027751. Registered 22 July 2019; https://clinicaltrials.gov/ct2/show/NCT04027751?cond=NCT04027751&cntry=CN&draw=2&rank=1.

Anesthesia and Perioperative Considerations for Patients With Myasthenia Gravis

Patients with neuromuscular diseases such as myasthenia gravis can present as complicated anesthetic cases. This article reviews anesthetic considerations for optimal perioperative care of patients with myasthenia gravis. The pathophysiology of myasthenia gravis, cholinergic and myasthenic crises, and perioperative management are discussed; this includes the pharmacology of acetylcholinesterase inhibitors vs sugammadex, extubation criteria, pain management, and risk factors for postoperative myasthenic crisis. Anesthesia recommendations include reversal of nondepolarizing neuromuscular blockade agents with sugammadex, obtaining sufficient spontaneous breathing with absolutely no residual curarization before extubation, limited use of opioids and sedatives, avoidance of routine admission to the intensive care unit, and consideration of peripheral nerve blocks for adjunct pain control.

Prevalence of Multidrug-Resistant Organisms in Patients Undergoing Free Flap Reconstruction

OBJECTIVES/HYPOTHESIS

The purpose of this study is to evaluate the relationship between antibiotic prophylaxis and prevalence of multidrug-resistant organisms (MDRO) in patients undergoing head and neck cancer reconstruction.

STUDY DESIGN

Retrospective Chart Review.

METHODS

Retrospective review of patients who underwent head and neck free flap reconstruction at our institution between 2009 to 2016.

RESULTS

Of the 145 patients that underwent head and neck tumor removal surgery using free tissue flaps to cover the defect and therafter received antibiotic prophylaxis, 30 (20.7%) developed postoperative surgical site (n = 17, 55.7%) or distant (n = 13, 43.4%) infections. Seven had a multidrug-resistant infection, the most common with Methicillin-Resistant Staphylococcus aureus (MRSA). There was no significant relationship between antibiotic spectrum or duration to the development of postoperative infections or MDRO. Pseudomonas and MRSA infections were low overall with only one multidrug-resistant Pseudomonas infection.

CONCLUSIONS

The choice of antibiotic prophylaxis should cover organisms these patients are at highest risk for including anaerobes and Gram-negative organisms. A shorter duration of antibiotic prophylaxis should be considered given no increased risk of postoperative infection nor MDRO. Finally, one must be aware of the potential threat of multidrug-resistant Pseudomonas and MRSA amongst this vulnerable population and identity these with culture driven treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1881-E1887, 2021.

Generalized convulsive status epilepticus after retrograde type A aortic dissection surgery

INTRODUCTION

Generalized convulsive status epilepticus is defined as a generalized and convulsive seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. For the first time, we present a case with retrograde type A aortic dissection after endovascular repairment and received thoracotomy intensely.

CASE REPORT

The patient experienced frequent generalized seizures in the immediate postoperative period, and status epilepticus was considered for his medical history, clinic symptoms and related examinations.

DISCUSSION AND CONCLUSION

Generalized convulsive status epilepticus should be alert for avoiding delay in the rehabilitation particularly after aortic dissection surgery. Under the good condition of ventilation, combining morphine with midazolam or diazepam can more effectively relieve the symptoms.

Permanent pacemaker implantation after cardiac surgery: Optimization of the decision making process

BACKGROUND

Conduction disturbances necessitating permanent pacemaker (PPM) implantation after cardiac surgery occur in 1% to 5% of patients. Previous studies have reported a low rate of late PPM dependency, but there is lack of evidence that it might be related to implantation timing. In this study, we sought to determine whether PPM implantation timing and specific conduction disturbances as indications for PPM implantation are associated with late pacemaker dependency and recovery of atrioventricular (AV) conduction.

METHODS

Patients with a PPM implanted after cardiac surgery were followed in an outpatient clinic. Two outcomes were assessed: AV conduction recovery and PPM dependency, defined as the absence of intrinsic rhythm on sensing test in VVI mode at 40 bpm.

RESULTS

Of 15,092 patients operated between September 2008 and March 2019, 185 (1.2%) underwent PPM implantation. One hundred seventy-seven of these patients met the criteria for inclusion into this study. Follow-up data were available in 145 patients (82%). Implantation was performed at ≤6 days after surgery in 58 patients (40%) and at >6 days after surgery in 87 patients (60%). The median time from implantation to last follow-up was 890 days (range, 416-1998 days). At follow-up, 81 (56%) patients were not PPM dependent. Multivariable analysis showed that PPM implantation at ≤6 days after surgery is a predictor of being not PPM dependent (odds ratio [OR], 5.40; 95% confidence interval [CI], 2.43-12.04; P < .001) and of AV conduction recovery (OR, 4.96; 95% CI, 2.26-10.91; P < .001). Sinus node dysfunction as indication for PPM implantation was predictive of being not PPM dependent (OR, 6.59; 95% CI, 1.67-26.06; P = .007).

CONCLUSIONS

We recommend implanting a PPM on postoperative day 7 to prevent unnecessary implantations and avoid prolonged hospitalization.

Evaluation of Pain Management after Surgery: An Observational Study

Background and Objectives: Choosing a pain management strategy is essential for improving recovery after surgery. Effective pain management reduces the stress response, facilitates mobilization, and improves the quality of the postoperative period. The aim of the study was to assess the effectiveness of pain management in patients after surgery. Materials and Methods: The study included 216 patients operated on in the following surgical wards: the Department of Cardiosurgery and the Department of General and Endocrine Surgery. Patients were hospitalized on average for 6 ± 4.5 days. Patients were randomly selected for the study using a questionnaire technique with a numerical rating scale. Results: Immediately after surgery, pre-emptive analgesia, multimodal analgesia, and analgosedation were used significantly more frequently than other methods (p < 0.001). In the subsequent postoperative days, the method of administering drugs on demand was used most often. Patients with confirmed complications during postoperative wound healing required significantly more frequent use of drugs from Steps 2 and 3 of the World Health Organization (WHO) analgesic ladder compared with patients without complications. Conclusion: The mode of patient admission for surgery significantly affected the level of pain perception. Different pain management methods were used and not every method was effective.

A chest tube may not necessary in children thoracoscopic lobectomy

Drainage of the thorax postoperatively using chest tubes is a standard procedure in thoracic surgery. However, chest tubes can induce pain and immobilization, increase risk of infection, deteriorate the ventilation capacity, and increase difficulty of postoperative management, particularly in children. This study aimed to investigate the safety and effect of excluding chest tubes after performing thoracoscopic lobectomy in selected children.A retrospective review of medical records was performed in West China Hospital of Sichuan University from January 2014 to June 2018. Patients who underwent thoracoscopic lobectomy without chest tubes were recorded. Patients with accompanying severe pulmonary infection, extensive thoracic adhesions, or undeveloped interlobar fissure were excluded.In total, 246 patients underwent thoracoscopic lobectomy without a chest tube, and none required chest drain insertion or reintervention during hospitalization and follow-up at 90 days postoperatively. Among them, 2 (0.81%) patients developed a delayed pneumothorax which was found after being discharged, and resolved spontaneously in 2 weeks. No hemothorax, atelectasis, and bronchial fistula were found. Furthermore, 202 (82.1%) patients developed subcutaneous emphysema, which was asymptomatic and spontaneously resolved within 3 to 7 days. The length of postoperative hospital stay was 2 days; patients were discharged in the 3rd day postoperatively. Patients could recover to free mobilization and resume regular diet at 6 hours postoperatively. All patients were followed up for at least 3 months; no other complications were found, and all patients recovered well.This study showed that chest tube placement in selected patients may be unnecessary in children undergoing thoracoscopic lobectomy. The minimally invasive procedure and meticulous resection have been the preconditions of this procedure, which may contribute to a rapid recovery and can avoid the chest tube-related complications effectively.

Air leak pattern shown by digital chest drainage system predict prolonged air leakage after pulmonary resection for patients with lung cancer

Background

A common cause of complications after a pulmonary resection procedure is prolonged air leakage. Recently introduced digital drainage systems provide accurate recording of air leak data for later review. We investigated the clinical usefulness of the continuous stream of data recorded by such a device.

Methods

We analyzed data obtained from 299 patients with pulmonary malignancy who underwent a pulmonary resection procedure for lung cancer patients with use of a digital chest drainage system. Postoperative air leak patterns were divided into 4 groups and their correlation with prolonged air leakage after pulmonary resection was evaluated.

Results

The incidence of prolonged air leak was 10% (30/299). The postoperative air leak patterns noted in the present patients were divided into none (n=217, 73%), intermittent (n=21, 7%), decrease (n=40, 13%), and variable (n=21, 7%). The incidence of prolonged air leak in each group was 0.5% (1/217) in the none group, 24% (5/21) in the intermittent group, 20% (8/40) in the decrease group, and 76% (16/21) in the variable group. The amount of air leakage immediately after surgery was highest in the variable group. Patients in the intermittent and variable groups had longer durations of air leakage and chest tube placement. The frequency of postoperative interventional treatment was significantly higher in the variable group as compared to the others. Chest tube reinsertion for pneumothorax and increased subcutaneous emphysema after the initial chest tube removal was only seen in the intermittent group.

Conclusions

Advantages of digital drainage system use are continuous monitoring and recording capabilities, which show the detailed air leak pattern after pulmonary resection. That pattern can be used to predict the durations of air leakage and chest tube drainage, as well as for producing an air leak management algorithm.

Seizure outcomes of supratentorial brain tumor resection in pediatric patients

Background

This study aims to identify the prevalence of and risk factors for seizure development after supratentorial brain tumor resection in pediatric patients. This could be used to guide the postoperative management and usage of anti-epileptic drugs (AEDs).

Methods

Retrospective study was conducted for patients between 0 and 21 years with supratentorial tumor resection between 2005 and 2015 at a single institution.

Results

Two hundred patients (114 males/86 females) were identified. Median age at resection (±SD) was 9.025 ± 5.720 years and mean follow-up was 4 ± 2 years. Resection was gross total in 82 patients (41%) and partial in 118 patients (59%); 66 patients (33%) experienced preoperative seizures, and 67 patients (34%) experienced postoperative seizures; 18 patients (27%) had early seizures, and 49 patients (73%) had late seizures. Univariate analysis identified risk factors for postoperative seizures as: preoperative seizures (P < 0.001), age less than 2 years (P = 0.003), temporal location (P < 0.001), thalamic location (P = 0.017), preoperative hyponatremia (P = 0.017), World Health Organization grade (P = 0.008), and pathology (P = 0.005). Multivariate regression identified 5 robust risk factors: temporal location (odds ratio [OR] 4.7, 95% CI: 1.7-13.3, P = 0.003), age <2 years (OR 3.9, 95% CI: 1.0-15.4; P = 0.049), preoperative hydrocephalus (OR 3.8, 95% CI: 1.5-9.4; P = 0.005), preoperative seizure (OR 2.8, 95% CI: 1.2-6.5; P = 0.016) and parietal location (OR 0.25, 95% CI: 0.06-0.99; P = 0.049). Extent of resection did not correlate with seizure development (P > 0.05).

Conclusions

This study reveals 5 risk factors for postoperative seizures after resection of supratentorial tumors. These factors should be considered in postoperative management of these patients.

Postoperative chest tube placement after thoracoscopic wedge resection of lung for primary spontaneous pneumothorax: is it mandatory?

Background

The goal of present study is to assess the efficiency and feasibility of postoperative care without positioning of chest tube after video-assisted thoracoscopic surgery (VATS) in patients with primary spontaneous pneumothorax (PSP).

Methods

We conducted a prospective randomized trial of patients who have undergone video-assisted thoracoscopic wedge resection surgery for PSP. During the period of April 2015 until December 2016, 119 eligible patients undergoing VATS for PSP were consecutively included. We divided the patients into two groups at random: (I) avoiding chest tube (ACT) group, comprising 58 patients in whom chest tube was not placed intra or postoperatively, and (II) indwelling chest tube (ICT) group, comprising 61 patients in whom chest tube was placed conventionally. Primary end point was to evaluate and analyze the postoperative clinical data and relevant morbidities between two groups.

Results

The mean postoperative length of hospital stay (3.57±0.79 vs. 5.39±0.97 days) and postoperative pain (1.37±0.78 vs. 2.53±0.63) in ACT group were significantly lower than in the ICT group (P<0.05). However, there were no statistical differences between two groups regarding other clinical data and postoperative morbidities. There were no patients who experienced significant adverse events postoperatively.

Conclusions

Postoperative management without chest tube placement is safe and feasible approach for patients undergoing thoracoscopic wedge resection for PSP.

Early negative fluid balance is associated with lower mortality after cardiovascular surgery

BACKGROUND

Early fluid expansion could prevent postoperative organ hypoperfusion. However, excessive fluid resuscitation adversely influences multiple organ systems. This retrospective, observational study aimed to investigate the relationship between early negative fluid balance and postoperative mortality in critically ill adult patients following cardiovascular surgery.

METHODS

In total, 567 critically ill patients who had undergone cardiovascular surgery and whose intensive care unit length of stay (LOS) was more than 24 hours were enrolled. The baseline characteristics, daily fluid balance and cumulative fluid balance were obtained. Patients were followed until discharge or day 28. Multivariate logistic regressions adjusted by propensity score were used to analyze the relationship between early negative fluid balance and postoperative mortality.

RESULTS

Overall, postoperative mortality was 6.2% (35/567). Acute Physiology and Chronic Health Evaluation II on admission (odd ratios [OR] 1.110), acute kidney injury stage (OR 1.639) and renal replacement therapy received (OR 3.922) were the independent risk factors of postoperative mortality, whereas negative daily fluid balance at day 2 (OR 0.411) was the protective factor. Patients with a negative daily fluid balance at day 2 had lower postoperative mortality (3.4% vs. 12.2% in the positive fluid balance group), lower acute kidney injury (AKI) stage, were less likely to receive renal replacement therapy (RRT) and experienced shorter hospital LOS compared with those with a daily positive fluid balance.

CONCLUSION

This retrospective, observational study indicates that early negative fluid balance is associated with lower postoperative mortality in critically ill patients following cardiovascular surgery. Further prospective, randomized trials are needed to prove the benefits from the restrictive fluid management strategy.

Postoperative Management of Multiple Primary Cancers Associated with Non-small Cell Lung Cancer

BACKGROUND/AIM

Modern treatment for primary cancers has improved survival. Therefore, increased numbers of patients with multiple primary cancers (MPC) associated with lung cancer may be expected. The aim of the present study was to report MPC associated with lung cancer and discuss patients' characteristics and postoperative management.

PATIENTS AND METHODS

Overall, 973 consecutive patients who underwent surgery for non-small cell lung cancer (NSCLC) were retrospectively studied.

RESULTS

NSCLC with MPC was observed in 148 patients (15.2%). MPC comprised 24 synchronous (2.5%) and 124 metachronous (12.7%) diseases. Of the 124 metachronous patients, NSCLC was detected before cancers were detected in other organs (lung cancer first (LCF)) in 25 (20.2%) patients and subsequently in other organs after treatment (other organs, primary cancer-first (OCF)) in 99 (79.8%) patients. MPC was significantly associated with advanced age (p<0.0001) and chronic obstructive pulmonary disease (COPD) (p=0.0040). The leading sites of MPC in patients with synchronous tumors and those with OCF were the digestive organs. In contrast, the leading site of MPC in patients with LCF was the lung. In the latter, at least two primary lung cancers were detected within 5 years as well as 5 years after surgery for the treatment of the first detected lung cancer, while primary cancers of other organs were detected within 5 years.

CONCLUSION

Advanced age and COPD may represent a high-risk of MPCs. Therefore, we recommend careful follow-up to detect MPC in the lung as well as the digestive organs beyond 5 years after treatment of the first cancer.

Conventional trabeculectomy versus trabeculectomy with the Ex-PRESS® mini-glaucoma shunt: differences in postoperative interventions

PURPOSE

To compare the postoperative interventions and outcomes between conventional trabeculectomy and trabeculectomy with the Ex-PRESS® mini-glaucoma shunt device (Ex-Press).

METHODS

This was a retrospective, comparative, single-facility study. We analyzed the cases of 108 glaucoma patients who underwent trabeculectomy and were followed for >1 year. Thirty-nine eyes underwent a conventional trabeculectomy (conventional group) and 69 eyes underwent a trabeculectomy with an Ex-Press (Ex-Press group). As evaluation items, we examined postoperative intraocular pressure (IOP), the surgical success rate, postoperative complications, the number of days to laser suture lysis, and needling.

RESULTS

Trabeculectomy significantly decreased the patients' IOP values from 27.8±7.9 to 11.1±3.9 mmHg in the conventional group (p<0.001) and from 27.7±9.2 to 11.5±3.7 mmHg in the Ex-Press group (p<0.001) after 1 year. The success rate was not significantly different between the groups. The timing of the first laser suture lysis was significantly sooner in the Ex-Press group, and the Ex-Press group showed significantly less choroidal detachment due to low IOP.

CONCLUSION

Earlier laser suture lysis in patients whose trabeculectomy treatment includes an Ex-Press is required to obtain the outcomes comparable to those of conventional trabeculectomy.

Enhanced Recovery after Vascular Surgery

The beginnings of the enhanced recovery after surgery (ERAS) program were first developed for patients in colorectal surgery, and after it was established as the standard of care in this surgical field, it began to be applied in many others surgical areas. This is multimodal, evidence-based approach program and includes simultaneous optimization of preoperative status of patients, adequate selection of surgical procedure and postoperative management. The aim of this program is to reduce complications, the length of hospital stay and to improve the patients outcome. Over the past decades, special attention was directed to the postoperative management in vascular surgery, especially after major vascular surgery because of the great risk of multiorgan failure, such as: respiratory failure, myocardial infarction, hemodynamic instability, coagulopathy, renal failure, neurological disorders, and intra-abdominal complications. Although a lot of effort was put into it, there is no unique acceptable program for ERAS in this surgical field, and there is still a need to point out the factors responsible for postoperative outcomes of these patients. So far, it is known that special attention should be paid to already existing diseases, type and the duration of the surgical intervention, hemodynamic and fluid management, nutrition, pain management, and early mobilization of patients.

Chinese consensus statement on standard procedure and perioperative management of bronchial thermoplasty

Bronchial thermoplasty (BT) is a non-pharmacologic therapy for severe asthma. The proper procedure and perioperative management are very important for the effectiveness and safety of BT. China Asthma Alliance assembled a group of experts in asthma and BT to review the literature, drew on their own experiences, discussed, and then finalized by consensus to establish this standard practice guideline. This practice guideline is designed to guide clinicians as to proper patients' selection, preoperative assessment, postoperative management and follow-up. This practice guideline also proposed "China Alair System Registry Study (NCT02206269)" as the real-world study to enhance clinical utility of BT.