Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus

There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine 'fit-for-discharge' status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.

The role of atrial vessels in aortic root and mitral valve operations

BACKGROUND

For the last 90 years, several authors have focused on studying the blood supply to the conduction system in the human heart. However, an important gap has been maintained between this topic and cardiac surgical procedures when they should have been closely matched. This paper is aimed at clarifying the morphology of the conduction system and its blood supply and assessing its role in cardiac surgical procedures.

METHODS

Twenty human hearts were dissected after antegrade and retrograde injection. After dissection, different surgical procedures were simulated. Finally, we assessed the damage that these procedures might have caused either to the conduction system or to the vessels supplying it.

RESULTS

Kügel's artery, the right superior descending artery, and the sinoatrial node artery were found to be harmed by the surgical procedures performed. In all these cases, these vessels were supplying part of the conduction system.

CONCLUSIONS

All the vascular structures described in the paper play a very important role in the blood supply to the conduction system, and they become vulnerable during aortic root and mitral valve surgical procedures.

The first septal artery supplies the atrioventricular node

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New findings on the origin of the blood supply to the atrioventricular node. Clinical and surgical significance

The anatomy of the heart's conduction system and of its blood supply have been research topics for many years. However, several proposals have never been demonstrated. In this paper, we describe 2 vascular conduits that have never before been objectively shown to supply the conduction system. Twenty human hearts from subjects aged between 15 and 65 years--with and without coronary disease--were dissected after anterograde and retrograde injection with latex butaclor E-650 by means of a technique developed by the authors. In 40% of these hearts, Kugel's artery was found to supply the atrioventricular node. The right descending superior artery supplied the atrioventricular node in 70% of the hearts dissected. These findings may be of major significance both in clinical cardiology and in cardiovascular surgery.