Intraoperative hypotension and postoperative acute kidney injury: A systematic review

BACKGROUND

There is no consensus regarding safe intraoperative blood pressure thresholds that protect against postoperative acute kidney injury (AKI). This review aims to examine the existing literature to delineate safe intraoperative hypotension (IOH) parameters to prevent postoperative AKI.

METHODS

PubMed, Cochrane Central, and Web of Science were systematically searched for articles published between 2015 and 2022 relating the effects of IOH on postoperative AKI.

RESULTS

Our search yielded 19 articles. IOH risk thresholds ranged from <50 to <75 ​mmHg for mean arterial pressure (MAP) and from <70 to <100 ​mmHg for systolic blood pressure (SBP). MAP below 65 ​mmHg for over 5 ​min was the most cited threshold (N ​= ​13) consistently associated with increased postoperative AKI. Greater magnitude and duration of MAP and SBP below the thresholds were generally associated with a dose-dependent increase in postoperative AKI incidence.

CONCLUSIONS

While a consistent definition for IOH remains elusive, the evidence suggests that MAP below 65 ​mmHg for over 5 ​min is strongly associated with postoperative AKI, with the risk increasing with the magnitude and duration of IOH.

Delayed suprachoroidal hemorrhage after descemet stripping automated endothelial keratoplasty (DSAEK)

This study, a case series of 2 patients and a literature review, aims to describe the second and third known cases of delayed suprachoroidal hemorrhage after Descemet stripping automated endothelial keratoplasty. The suprachoroidal hemorrhage is defined as the presence of blood in the suprachoroidal space; final visual acuity is rarely greater than 0.1 (decimal scale). Both cases presented had known risk factors: high myopia, previous ocular surgeries, arterial hypertension, and being under anticoagulant therapy. The diagnosis of delayed suprachoroidal hemorrhage was made at the 24-hour follow-up visit, as they recalled a sudden and tremendous acute pain hours after surgery. Both cases were drained through a scleral approach. Delayed suprachoroidal hemorrhage is a rare but devastating consequence that can occur after Descemet stripping automated endothelial keratoplasty. Awareness of the most critical risk factors allows for early identification, which is of paramount importance for the prognosis of these patients.

The impact of neoadjuvant systemic treatment on postoperative complications in breast cancer surgery

PURPOSE

The aim of the study was to analyze the impact of neoadjuvant systemic treatment (NST) on postoperative complications and the beginning of adjuvant treatment.

METHODS

This study includes data from a prospectively maintained database including patients with breast cancer (BC) stage I-IV with or without NST undergoing breast cancer surgery between January 2010 and September 2021.

RESULTS

Out of 517 enrolled patients, 77 received NST, 440 had primary breast surgery. After NST patients underwent surgery after a meantime of 34 days (26.5-40 days). No statistical significance could be found comparing the complication grading according to the Clavien Dindo classification. The complications were most frequently rated as grade 3b. There were no complications with grade 4 or higher. When differentiating into short and long-term, the overall rate of short-term complications was 20.3% with no significant difference between the two groups (20.8% vs. 20.2%). Regarding long-term complications, there was more impairment of shoulder mobility (26.0% vs. 9.5%, p ≤ 0.001) and chronic pain (42.9% vs. 28.6%, p ≤ 0.016) for patients with NST. The beginning of the administration of the adjuvant treatment was comparable in both groups (46.3 days vs. 50.5 days).

CONCLUSION

In our cohort, complications between both groups were comparable according to Clavien Dindo. This study shows that NST has no negative impact on postoperative short-term complications and most importantly did not lead to a delay of the beginning of adjuvant treatment. Therefore, NST can be safely admitted, even when followed by extensive breast reconstruction surgery.

Surgical complications in COVID-19 patients in the setting of moderate to severe disease

The coronavirus disease 2019 (COVID-19) pandemic has had a considerable impact on the work of physicians and surgeons. The connection between the patient and the surgeon cannot be replaced by telemedicine. For example, the surgical staff faces more serious difficulties compared to non-surgical specialists during the COVID-19 pandemic. The primary concerns include the safest solutions for protecting healthcare staff and patients and the ability to provide adequate surgical care. Additionally, the adverse effects of any surgery delays and the financial consequences complicate the picture. Therefore, patients' admission during the COVID-19 pandemic should be taken into consideration, as well as preoperative measures. The COVID-19 situation brings particular risk to patients during surgery, where preoperative morbidity and mortality rise in either asymptomatic or symptomatic COVID-19 patients. This review discusses the recent factors associated with surgical complications, mortality rates, outcomes, and experience in COVID-19 surgical patients.

Cervical laminoplasty with unilateral C4-5 foraminotomy: Technical note and case series

OBJECTIVE

The open-door laminoplasty technique is widely used in the treatment of multilevel cervical myelopathy. Despite the satisfactory functional and radiological results of this technique, postoperative C5 palsy is still a severe and disabling complication with a variable incidence in the literature. The objective of this article is to describe and demonstrate the surgical technique step by step with the addition of unilateral C4-5 foraminotomy and to evaluate the results obtained to date, with special emphasis on C5 palsy.

MATERIAL AND METHODS

Retrospective study of 20 patients operated on for cervical myelopathy using the "extended" laminoplasty technique, which is described step by step.

RESULTS

Between January 2013 and April 2019, 20 patients were operated on using the extended laminoplasty technique. Only one patient (5%) presented postoperative C5 palsy. The postoperative recovery rate of the modified JOA (Japanese Orthopaedic Association) score was 54.5%, similar to that observed in other series.

CONCLUSION

The extended cervical laminoplasty technique with unilateral C4-5 foraminotomy was developed and demonstrated for the prevention of C5 palsy. The results were analysed and an incidence of C5 palsy coinciding with the lowest percentage reported in the literature was obtained. A prospective randomised study would be useful to assess the role of preventive unilateral C4-5 foraminotomy.

Cervical laminoplasty with unilateral C4-5 foraminotomy: Technical note and case series

OBJECTIVE

The open-door laminoplasty technique is widely used in the treatment of multilevel cervical myelopathy. Despite the satisfactory functional and radiological results of this technique, postoperative C5 palsy is still a severe and disabling complication with a variable incidence in the literature. The objective of this article is to describe and demonstrate the surgical technique step by step with the addition of unilateral C4-5 foraminotomy and to evaluate the results obtained to date, with special emphasis on C5 palsy.

MATERIAL AND METHODS

Retrospective study of 20 patients operated on for cervical myelopathy using the "extended" laminoplasty technique, which is described step by step.

RESULTS

Between January 2013 and April 2019, 20 patients were operated on using the extended laminoplasty technique. Only one patient (5%) presented postoperative C5 palsy. The postoperative recovery rate of the modified JOA (Japanese Orthopaedic Association) score was 54.5%, similar to that observed in other series.

CONCLUSION

The extended cervical laminoplasty technique with unilateral C4-5 foraminotomy was developed and demonstrated for the prevention of C5 palsy. The results were analysed and an incidence of C5 palsy coinciding with the lowest percentage reported in the literature was obtained. A prospective randomised study would be useful to assess the role of preventive unilateral C4-5 foraminotomy.

The valdoni technique for bowel anastomosis. A rare complication

BACKGROUND

Valdoni technique involves leaving the mucosa layer, between the two anastomosed bowel tract intact, providing for a subsequent breakage of the intestine. It is a technique that allows you to keep the operating field clean.Surgical technique and Case Report: We describe the Valdoni technique. We also report a case of 75 years old man affected by an ascending colon cancer with no metastasis. The patient underwent right hemicolectomy. Making the anastomose, the surgeon did the Valdoni technique, with no intraoperative complications.The postoperative course was characterized by an abdominal pain with swollen abdomen, no flatus and vomit. A computed tomography (CT) revealed a sub-stenosis of the anastomose. We decided to do an urgent colonoscopy, with a resection of the mucosa layer not totally opened, using a Needle-knife Precut. The post procedure course was uneventful. The patient was discharged three days later.

CONCLUSION

Valdoni technique allows the surgeon to keep the operating field clean. It is a valid alternative when the surgeons have to make a colonic anastomosis, doing open surgery.

Retained gallbladder secondary to retrieval bag rupture during laparoscopic cholecystectomy-A case report

INTRODUCTION

Retrieval bags are used in laparoscopic cholecystectomies to reduce the risk of bile and gallstone spillage during removal of the gallbladder. Retrieval bag rupture is rare, and its complications have never been previously documented.

PRESENTATION OF CASE

A 17-year-old female presented three months post-laparoscopic cholecystectomy with a tender periumbilical mass. Her operative report noted difficulty removing the retrieval bag from the infra-umbilical port site. Imaging of the lump revealed an intra-abdominal fluid collection communicating with the umbilicus. A diagnostic laparoscopy uncovered significant pus in the peritoneal cavity and a gallbladder remnant with multiple gallstones. A combination of sharp and blunt dissections was used to free the gallbladder remnant from its adherent surroundings for removal. A peritoneal washout was performed following extraction of the retained gallstones. The patient's presentation could be traced back to her laparoscopic cholecystectomy where it was confirmed that the retrieval bag ruptured during removal. This would have transected the gallbladder, causing its remnants and associated gallstones to be retained in the peritoneal cavity.

DISCUSSION

Retrieval bag rupture can result in retained gallbladder remnants in the peritoneal cavity. Abdominal abscess can manifest months after the initial operation.

CONCLUSION

Retrieval bags should be inspected following removal to ensure it is completely intact. Surgeons should consider extending the fascial incision if there is any difficulty during removal. Any damage to the retrieval bag mandates immediate pneumoperitoneum for further exploration of retained products. Governance bodies should incorporate practice guidelines related to retrieval bag rupture as these are currently not present.

Hospitalization costs and clinical outcomes in CABG patients treated with intensive insulin therapy

BACKGROUND

The financial impact of intensive (blood glucose [BG] 100-140mg/dl [5.5-7.8mM] vs. conservative (141-180mg/dl (7.9-10.0mM) glucose control in the ICU in patients, with and without diabetes, undergoing coronary artery bypass graft (CABG) surgery is not known.

METHODS

This post-hoc cost analysis determined differences in hospitalization costs, resource utilization and perioperative complications in 288 CABG patients with diabetes (n=143) and without diabetes (n=145), randomized to intensive (n=143) and conservative (n=145) glucose control.

RESULTS

Intensive glucose control resulted in lower BG (131.4±14mg/dl-(7.2±0.8mM) vs. 151.6±17mg/dl (8.4±0.8mM, p<0.001), a nonsignificant reduction in the median length of stay (LOS, 7.9 vs. 8.5days, p=0.17) and in a composite of perioperative complications including wound infection, bacteremia, acute renal and respiratory failure, major cardiovascular events (42% vs 52%, p=0.10) compared to conservative control. Median hospitalization costs were lower in the intensive group ($39,366 vs. $42,141, p=0.040), with a total cost savings of $3654 (95% CI: $1780-$3723), than conservative control. Resource utilization for radiology (p=0.008), laboratory (p=0.014), consultation service (p=0.013), and ICU utilization (p=0.007) were also lower in the intensive group. Compared to patients without perioperative complications, those with complications had longer hospital length of stay (10.7days vs. 6.7days, p<0.001), higher total hospitalization cost ($48,299 vs. $32,675, p<0.001), and higher resource utilization units (2745 vs. 1710, p<0.001).

CONCLUSION

Intensive glycemic control [BG 100-140mg/dl (5.5-7.8mM)] in patients undergoing CABG resulted in significant reductions in hospitalization costs and resource utilization compared to patients treated with conservative [BG 141-180mg/dl (7.9-10.0mM)] glucose control.

Acute appendicitis in children: not only surgical treatment

PURPOSE

An accurate diagnosis of acute appendicitis is important to avoid severe outcome or unnecessary surgery but management is controversial. The aim of study was to evaluate, in younger and older children, the efficacy of conservative management for uncomplicated appendicitis and the outcome of complicated forms underwent early surgery.

METHODS

Children with acute appendicitis were investigated by clinical, laboratory variables and abdominal ultrasound and divided in two groups: complicated and uncomplicated. Complicated appendicitis underwent early surgery; uncomplicated appendicitis started conservative treatment with antibiotic. If in the next 24-48h it was worsening, the conservative approach failed and patients underwent late surgery.

RESULTS

A total of 362 pediatric patients were included. One hundred sixty-five underwent early appendectomy; 197 patients were at first treated conservatively: of these, 82 were operated within 24-48h for failure. The total percentage of operated patients was 68.2%. An elevated association was found between surgery and ultrasound.

CONCLUSIONS

Conservative treatment for uncomplicated appendicitis had high percentage of success (58%). Complications in operated patients were infrequent. Our protocol was effective in order to decide which patients treat early surgically and which conservatively; specific red flags (age and onset) can identified patients at most risk of complications or conservative failure.

TYPE OF STUDY

treatment study.

LEVEL OF EVIDENCE

II.

Endoscopic Management of Eroded Bands Following Banded-Gastric Bypass (with Video)

BACKGROUND

Banded-gastric bypass is a highly effective bariatric procedure, yet the possibility of band erosion remains a significant drawback. Surgical removal of eroded bands may be associated with significant morbidity. In this study, we assess the efficacy and safety of a solely peroral endoscopic approach for the management of eroded bands in patients with a banded-gastric bypass.

MATERIALS AND METHODS

Starting January 2012, all patients with banded-gastric bypass and an eroded band were subjected to an attempt at peroral endoscopic removal using endoscopic scissors and/or argon plasma coagulation (APC), regardless of the circumference of band eroding inside the lumen.

RESULTS

Sixteen patients presented with eroded bands, 2 were deemed not amenable to endoscopic removal as only part of the thickness was eroded. Of the 14 patients where endoscopic attempts were performed, 12 (86%) were completely removed successfully, while 2 (14%) were cut but could not be extracted and only the intraluminal portion was trimmed. Complete resolution of symptoms occurred in 13 (93%) while in 1 patient (7%) there was partial improvement. Only one endoscopic session was performed per patient with a median time of 37.5 min per session (22-55 min). No complications were encountered.

CONCLUSION

Endoscopic removal of eroded gastric bands in patients with banded-gastric bypass is effective and safe in the majority of patients. When bands are adherent to the gastric wall, removal of the intraluminal portion of the band may lead to full or partial improvement of symptoms. Endoscopic band removal can be attempted even when a small part of band circumference has eroded.

A Randomized Trial to Assess the Contribution of a Novel Thorax Support Vest (Corset) in Preventing Mechanical Complications of Median Sternotomy

Objectives

Mechanical complications of median sternotomy may cause significant morbidity and mortality in cardiac surgical patients. This study was aimed at assessing the role of Posthorax support vest (Epple, Inc., Vienna, Austria) in the prevention of sternal complications and the improvement of anatomical healing in patients at high risk for mechanical sternal dehiscence after cardiac surgery by mean of median sternotomy.

Methods

A prospective, randomized, study was performed and 310 patients with predisposing factors for sternal dehiscence after sternotomy for cardiac surgery were included. The patients were divided into two groups: patients who received the Posthorax support vest after surgery, and patients who did not. Primary variables assessed included the incidence of mechanical sternal complications, the quality of sternal healing, the rate of re-operation, the duration of hospitalization, rate and duration of hospital, re-admission for sternal complications. Secondary variables assessed were the post-operative pain, the number of requests for supplemental analgesia and the quality of life measured by means of the EQ-5D format.

Results

Patients using vest demonstrated a lower incidence of mechanical sternal complications, a better anatomical sternum healing, lower hospital stay, no re-operations for sternal dehiscence before discharge and lower re-admissions for mechanical sternal complication. In addition, patients using a vest reported a better quality of life with better freedom from limitations in mobility, self-care, and pain.

Conclusions

Our findings demonstrate that the use of the Posthorax vest reduces post-sternotomy mechanical complications and improves the healing of the sternotomy, the clinical course, and the post-operative quality of life.

Brain tumour presenting with burns: Case report and discussion

Descriptions of burns as the presenting features of underlying neurological pathology are very rare, with only two previously published case reports available. Both of these reports featured meningioma as the pre-existing pathology and both described burn excision and wound healing, prior to surgical tumour ablation. The authors describe the case of a 35-year-old female, who presented with 25% total body surface area burns and recent global neurological deterioration. MRI imaging revealed a large intracranial tumour. Multidisciplinary management included rigorous non-surgical burn wound care and early craniotomy and tumour excision. This proceeded without complication. Burn excision and skin grafting was carried out successfully, two weeks later. This case differs from the previous two reported cases, which both described burn excision, as a pre-requisite to neurosurgery. This case establishes that the presence of a burn wound is not a total contra-indication to intracranial surgery.

Surgical removal of a large vaginal calculus formed after a tension-free vaginal tape procedure

Vaginal calculus is a rare disorder which has been reported in association with urethral diverticulum, urogenital sinus anomaly, bladder exstrophy and the tension-free vaginal tape (TVT) procedure. We report a 42-year-old woman who presented with persistent, intractable urinary tract infection (UTI) following a TVT procedure. Cystoscopy demonstrated an eroded tape with the formation of a bladder calculus, and the patient underwent laser cystolithotripsy and cystoscopic resection of the tape. Following this procedure, her UTI completely resolved and she remained asymptomatic for several years. Seven years later she presented with a solid vaginal mass. Pelvic examination followed by transvaginal ultrasonography and magnetic resonance imaging demonstrated a large vaginal calculus located at the lower third of the anterior vaginal wall adjacent to the bladder neck. This video presents the transvaginal excision and removal of the vaginal calculus.

Colopleural fistula caused by aspergillus: an extremely rare complication after lung resection-case report

A colopleural fistula is a rare condition reported to be caused by Crohn's disease, a malignant tumor of the gastrointestinal tract, and other clinical conditions. Some studies have noted that a sub-diaphragmatic abscess, usually organized following abdominal surgery, may play some role in the formation of this type of fistula. Therefore, a colopleural fistula is a complication very rarely encountered by thoracic surgeons after lung resection.We experienced an extremely rare case of colopleural fistula following a left lower lobectomy for lung aspergillosis. Here, we report a 71-year-old man with a surgical history of proximal gastrectomy for gastric cancer. He underwent left lower lobectomy of the lung for aspergillosis, and a colopleural fistula occurred on the second operative day as a complication. Aspergillus might be responsible for forming a fistula between the colon and lung via the diaphragm, and lung surgery manifested this rare condition. Although some reports suggest that surgical treatment is mandatory to cure this fistula, an immediate colostomy in our case reduced the internal pressure of the colon, thus enabling spontaneous closure of the fistula with appropriate drainage and antibiotics. The patient was discharged in a good condition.

Intraoperative bronchial stump air leak control by Progel® application after pulmonary lobectomy

Diffuse tracheobronchial calcification is a physiological condition associated with advanced age, especially in women. A calcified bronchus can be fractured during major lung resections (lobectomy, bilobectomy, and pneumonectomy), exposing patients to intraoperative air leakage and broncho-pleural fistula (BPF) occurrence. We retrospectively evaluated the use of Progel® application on the suture line of bronchial stump after pulmonary lobectomy analysing the intraoperative air leak and BPF occurrence. Between January 2014 and December 2014, Progel® was applied in 11 patients who presented intraoperative bronchial fractures after suture resection by mechanical staplers and air leak from bronchial stump, in order to treat air leakage. Patients were 7 men and 4 women, aged between 56 and 81 years (mean age 71.2 ± 12.1 years). Surgical procedures included 6 upper lobectomies (4 right, 2 left), 1 bilobectomy and 4 lower lobectomies (3 right, 1 left). Mean hospital stay was 4.5 ± 2.6 days (2-8 days). None of the patients had postoperative air leakage. No Progel® application-related complications occurred. No other major complications occurred. No mortality occurred. Progel® proved to be useful in treating intraoperative air leakage during major lung resections, particularly those occurring as a result of fracture of the bronchus from a mechanical stapler.

Outcome of patients with reduced ankle brachial index undergoing open heart surgery with cardiopulmonary bypass

OBJECTIVES

In open heart surgery using cardiopulmonary bypass, perfusion of the lower extremities is markedly reduced which may induce critical ischaemia in patients with pre-existing peripheral artery disease. Whether these patients have an increased risk for amputation and should better undergo peripheral revascularization prior to surgery remains unclear.

METHODS

From 1 January 2009 to 31 December 2010, 785 consecutive patients undergoing open heart surgery were retrospectively included. In 443 of these patients, preoperative ankle brachial index (ABI) measurements were available. The cohort was divided into four groups: (i) ABI < 0.5, (ii) ABI 0.5-0.69, (iii) ABI 0.7-0.89 or (iv) ABI ≥ 0.9. Follow-up data of 413 (93.2%) patients were analysed with regard to mortality and amputations.

RESULTS

The groups differed significantly in terms of age, cardiac risk factors, performed cardiac surgery and renal function. Postoperative delayed wound healing was significantly associated with lower ABI (25.9, 15.2, 27.0 and 9.6% in Groups I-IV, respectively, P = 0.003), whereas 30-day mortality was not significantly higher in patients with lower ABI (0, 4.3, 8.1 and 3.9%, respectively, P = 0.4). Kaplan-Meier models showed a significantly lower long-term survival over 4 years in patients with reduced ABI (P = 0.001, long-rank test) while amputations occurred rarely with only one minor amputation in Group II (P = 0.023).

CONCLUSIONS

Patients with reduced ABIs undergoing heart surgery showed more wound-healing disturbances, and higher long-term mortality compared with those with normal ABIs. However, no perioperative ischaemia requiring amputation occurred. Thus, reduced ABIs were not associated with increased peripheral risks in open heart surgery but ABI may be helpful in selecting the site for saphenectomy to potentially avoid delayed healing of related wounds in legs with severely impaired arterial perfusion.

Advantages of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography in detecting post cardiac surgery infections

The 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT) offers an excellent negative predictive value. Consequently, it is a reliable tool for excluding an infectious phenomenon in case of negativity. In case of persistent fever of unknown origin after cardiac surgery and in combination with other bacteriological examinations and medical imaging, we can rely on FDG-PET/CT to confirm or eliminate deep infections and prosthetic endocarditis. For this reason, FDG-PET/CT should be considered among the examinations to be performed in case of suspected infection after cardiac surgery. We have reported the case of a 76-year-old man who presented with a fever of unknown origin and recurrent septic shocks after a biological Bentall procedure combined with left anterior descending (LAD) coronary artery revascularization by the left internal thoracic artery. We performed a FDG-PET/CT which showed external iliac vein and right common femoral vein hyperfixation with infiltration of adjacent soft tissues, highly suspected to be an infectious process.

LEARNING OBJECTIVE

The aim of this case report is to show that FDG-PET/CT, in combination with other bacteriological examinations and medical imaging, can be extremely helpful in detecting deep infectious sources, even during the early postoperative period.

Early complications of volar plating of distal radius fractures and their relationship to surgeon experience

BACKGROUND

Fractures of the distal radius are among the most common fractures in adults. Recently, there has been a trend towards open reduction and internal fixation of these fractures through a volar approach. The purpose of this study was to assess the early complications of volar locking plate fixation of distal radius fractures with an emphasis on defining the relationship between surgeon experience and incidence of complications.

MATERIALS AND METHODS

Following IRB approval, we conducted a retrospective chart review of the initial 96 distal radius fractures (92 patients) treated by open reduction and internal fixation of distal radius fracture using a volar locked plate. Our outcome measurements were incidence of postoperative complications and radiographic loss of reduction.

RESULTS

Twenty-two complications occurred in 21 patients. Of these, five complications (5%) required surgical treatment or hospitalization. Seventeen complications (18%) required no surgical intervention or hospitalization. Transient nerve dysfunction was the most common complication, accounting for 12 of 22 complications. The first 30 patients experienced significantly more complications than those treated later in the series (p = 0.03). There was a trend towards increased incidence of complications in cases where more than 10 days elapsed between injury and surgery or where supplementary Kirschner wire fixation was used. There was no correlation between patient age, sex, severity of fracture, or presence of ulnar styloid fracture and the development of complications or loss of reduction.

DISCUSSION

The incidence of complications decreased significantly with increased surgeon experience, suggesting that many of these early complications are avoidable.