Acute Postoperative Phase Research Articles

Neurocognitive and Neuromuscular Rehabilitation Techniques after ACL Injury, Part 1: Optimizing Recovery in the Acute Post-Operative Phase- A Clinical Commentary.

Anterior cruciate ligament (ACL) injury rates are on the rise, despite improved surgical techniques and prevention programs. While traditional rehabilitation emphasizes the restoration of motion, strength, and physical performance, emerging research highlights the importance of addressing neurocognitive deficits that can persist after injury. These deficits, including altered proprioception, impaired motor control and muscle recruitment, as well as heightened reliance on visual feedback, can significantly increase the risk of re-injury and impede return to sport. The purpose of this clinical commentary is to outline a proposed comprehensive approach to rehabilitation that challenges the neurocognitive system to optimize rehabilitation outcomes and reduce reinjury risk. Thus, this clinical commentary discusses the rationale for integrating neurocognitive training into all phases of ACLR rehabilitation, from initial injury to eight weeks post-surgery. It details the neurophysiological changes caused by ACL injury and presents evidence supporting the use of exercises that challenge visual attention, decision-making, and motor planning. A comprehensive rehabilitation framework incorporating both physical and neurocognitive components is proposed, aiming to improve long-term outcomes and reduce re-injury risk. Level of Evidence: 5.

Postoperative pain after parotid surgery-comparison between superficial/total parotidectomy and extracapsular dissection: a prospective observational study.

To evaluate postoperative pain and discomfort after parotid surgery with regard to different surgical approaches. This clinical study was carried out at a single tertiary referral center (2021-2022) and included 2 groups of adult patients (mean age 56.6 ± 12.7 vs. 53.4 ± 14.1years) following elective parotid surgery due to a parotid tumor of any entity.The first group (SP/TP group) consisted of 31 patients after superficial parotidectomy (SP) or total parotidectomy (TP) (n = 31). The second group (ECD group) included all patients who had undergone extracapsular dissection (ECD) (n = 51). Primary endpoints comprised pain on ambulation as well as maximum and minimum pain (NRS 0-10) on the first three postoperative days (PODs). A neuropathic pain component (evaluated on POD 1 and 3), the analgesic score (collected from the patient file on POD 1-3), treatment-related side-effects/pain-associated impairments, and patient satisfaction (all measured on the 1st POD) were defined as secondary endpoints. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire and the painDETECT® questionnaire. Comparisons were performed using independent t tests, Wilcoxon tests, and χ2 tests, and the respective effect sizes were calculated. Looking at the first postoperative day, patients of both groups (SP/TP vs. ECD) reported comparable pain on ambulation (2.8 ± 2.0 vs. 2.6 ± 1.8; p = 0.628, r = 0.063), maximum (3.5 ± 2.2 vs. 3.5 ± 2.3; p = 0.992, r = 0.002) and minimum pain (1.1 ± 1.04 vs. 1.0 ± 1.2; p = 0.206, r = 0.157). Furthermore, there were no significant differences in pain-related restrictions or pain medication requirement. The patients in both groups were equally satisfied with their pain therapy (p = 0.282, R = 0.135). The sum score of the painDETECT® questionnaire delivered clearly negative (< 12) results on average (POD1: 6.81; POD3: 6.59); no significant difference between the groups was found (p = 0.991, R2 < .001). Neither surgical technique on the parotid gland was significantly superior to the other in terms of postoperative pain perception. Overall, postoperative pain can be classified as mild to moderate following parotid surgery. A neuropathic pain component could be excluded for the acute postoperative phase. The study was registered in the German Registry for Clinical Studies (DRKS) (application No.: DRKS00016520).

Preoperative risk factors for 90-day postoperative mortality outcome in patients with non-occlusive mesenteric ischemia.

The mortality rate for non-occlusive mesenteric ischemia remains high even after patients survive the acute postoperative period with tremendous treatment efforts, including emergency surgery, which is challenging. The aim of this study was to explore the preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. This single-center, retrospective cohort study included patients diagnosed with non-occlusive mesenteric ischemia who underwent emergency surgery between August 2014 and January 2023. All patients were divided into survival-to-discharge and mortality outcome groups at the 90-day postoperative follow-up. Preoperative factors, including comorbidities, preoperative status of vital signs and consciousness, blood gas analysis, blood test results, and computed tomography, were compared between the two groups. Twenty patients were eligible, and 90-day mortality was observed in 10 patients (50%). The mortality outcome group had significantly lower HCO3- (20.9 vs. 14.6, p = 0.006) and higher lactate (4.4 vs. 9.4, p = 0.023) levels than did the survival outcome group. The median postoperative time to death was 19 [2-69] days, and five patients (50%) died after postoperative day 30, mainly because hemodialysis was discontinued because of hemodynamic instability in patients requiring hemodialysis. Low preoperative HCO3- and high lactate levels may be preoperative risk factors for 90-day postoperative mortality in patients with non-occlusive mesenteric ischemia. However, patients on hemodialysis die from discontinuing hemodialysis even after surviving the acute postoperative phase. Therefore, indications for emergency surgery in patients with risk factors for postoperative mortality should be carefully determined.

Single-Joint Type Hybrid Assistive Limb for Knee Training in the Acute Postoperative Phase After Opening Wedge High Tibial Osteotomy: A Feasibility and Safety Trial.

Opening wedge high tibial osteotomy (OWHTO) influences the knee extensor mechanism, the range of passive motion of knee extension and persistent quadriceps, and anterior knee pain and weakness. Rehabilitation should focus on quadriceps strength and improving joint mobility. The single-joint hybrid assistive limb device (HAL-SJ) is a wearable exoskeleton cyborg. In this study, we investigated the feasibility and safety of HAL-SJ training after the early postoperative period following OWHTO and whether the use of this device can improve functional outcomes, including knee muscle extensor strength and knee extension range of motion without knee pain. Patients who had been diagnosed with knee osteoarthritis and had undergone OWHTO were assessed for eligibility in this prospective trial conducted at our institution between June 2015 and November 2020. The participants were split into two groups, i.e., 10 patients in the hybrid assistive limb (HAL) group and eight patients in the control group. We initiated HAL-SJ therapy on postoperative day 8 and continued it until the patient's discharge. During the hospitalization period, patients engaged in HAL-SJ-assisted knee extension exercises. This exercise routine encompassed five sets, each comprising 10 repetitions, and was conducted twice a week. We conducted assessments aimed at detecting any potential adverse events that could be linked to HAL training. Assessment of the knee extension angle via the visual analog scale (VAS) and strength assessments using a hand-held dynamometer (HHD) were conducted. To compare clinical outcomes before and after OWHTO, knee extension angle, the VAS, HHD, Japanese Orthopaedics Association (JOA) score, and the Japanese Knee Osteoarthritis Measure (JKOM) were assessed at four distinct time points. No adverse events were observed during the study. The assessment of clinical outcomes before and after OWHTO demonstrated a gradual improvement in outcomes. The single-joint hybrid assistive limb device in patients who underwent OWHTO appears to be potentially safe. It contributed to enhanced muscle activity efficiency by reducing knee pain and improving knee extension angles in the early postoperative phase.

Duloxetine as an Analgesic in Patients Who Do Not Have Central Sensitivity Undergoing Single-Setting, Bilateral Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

BackgroundPain control and patient satisfaction after total knee arthroplasty (TKA) have room for improvement. While studies have reported better analgesic outcomes with antidepressants like duloxetine in patients who do not have central sensitivity (CS), we undertook this trial to determine the short and midterm analgesic role of low-dose duloxetine in patients who do not have CS. MethodsThis prospective, double-blinded, randomized, placebo-controlled trial was conducted in 106 patients undergoing single-setting, bilateral TKA under spinal anesthesia. There were 2 matched groups, with one given 20 mg of duloxetine and the other given a placebo (similar in appearance and weight) from preoperative day 2 to postoperative day 28. Follow-ups were scheduled at 48-hours, 1-week, 2-weeks, 4-weeks, and 3-months. Pain was measured using a visual analogue scale at rest and visual analogue scale at mobilization (mVAS). Secondary measures included additional non-steroidal anti-inflammatory drug consumption, patient satisfaction, and safety profile. ResultsThe visual analogue scale at rest in the duloxetine group was better in the first 48 hours (6.38 ± 1.32 versus 7.02 ± 0.99; P = .017), 1-week (4.76 ± 1.24 versus 5.89 ± 1.06; P < .001), and 2-weeks (3.34 ± 1.19 versus 4.26 ± 1.02; P < .001) follow-up. The mVAS remained significantly higher in the duloxetine group in the first 48 hours (7.23 ± 1.12 versus 8.21 ± 0.69; P < .001), 1-week (5.83 ± 1.11 versus 6.82 ± 0.92; P < .001), and 2 weeks (3.70 ± 0.89 versus 4.60 ± 1.03; P < .001) follow-up. Both outcomes became comparable from 4-week follow-up onward. Patient satisfaction (8.44 ± 1.68 versus 7.17 ± 1.04; P < .001) and additional non-steroidal anti-inflammatory drug consumption (2,770 ± 533.05 versus 3,566.04 ± 464.54; P < .001) were better in the duloxetine group, with a comparable safety profile. ConclusionsIn patients who did not have CS, persistent pain after bilateral TKA can be managed safely and successfully by a daily dose of 20 mg Duloxetine, improving patient satisfaction and analgesic consumption in the acute postoperative phase.

Changes in Cerebral Oxygenation in the Prefrontal Cortex During Cardiopulmonary Exercise Testing in Patients After Cardiovascular Surgery.

Oxygenated haemoglobin (O2Hb) and total haemoglobin (THb) concentrations rise with increasing exercise load during the cardiopulmonary exercise test (CPX); however, this elevated response is impaired in patients with chronic heart failure. Furthermore, the changes occurring in patients during the acute phase of cardiac surgery are unknown. This study aimed to measure cerebral oxygenation in the prefrontal cortex (PFC) during CPX in patients during the acute post-operative phase following cardiovascular surgery. Fourteen patients in the acute phase of post-cardiovascular surgery period were enrolled. CPX was administered between the post-operative period and discharge. The protocol employed the ramp method (10W/min) after 3-min rest and 3-min warm-up periods. Levels of O2Hb, deoxygenated haemoglobin (HHb), THb, and the regional cerebral oxygen saturation (rSO2) in the PFC were measured from the resting state through the end of CPX using near-infrared spectroscopy. The mean values of O2Hb, HHb, and THb levels and rSO2 were compared at rest, warm-up, anaerobic threshold, and peak points. At the peak, O2Hb and rSO2 declined significantly, and HHb rose significantly compared to the respective values at rest; no significant changes were observed in THb. These findings suggest that the oxygen supply to the PFC is reduced in patients with reduced cardiac function following cardiovascular surgery.

Ultrasonographic Evaluation of Upper Esophageal Sphincter for Dysphagia During the Acute Postoperative Phase of Anterior Cervical Surgery.

A retrospective study. To verify the pathophysiology of dysphagia during the acute postoperative phase of anterior cervical surgery and to identify its predictive features, using ultrasonographic (US) examination for upper esophageal sphincter (UES). There are no clinical studies investigating dysphagia after anterior cervical surgery, using US examination for UES. We enrolled patients who underwent anterior cervical spine surgery between August 2018 and March 2022. Dysphagia was evaluated using the Eating Assessment Tool-10 (EAT-10) questionnaires. The US examination was performed preoperatively and 2 weeks postoperatively. Three US parameters for morphologic measurements (outer diameter, inner diameter, and muscle thickness) and 4 for functional measurements (displacement, time to relax, passing duration, and time to contract) were assessed. To verify the pathophysiology of postoperative dysphagia, we examined the change in the ratios of US parameters (=US parameter 2 weeks postoperatively /US parameter at baseline ) and the existence of significant correlations with change in the EAT-10 score (=EAT-10 2 weeks postoperatively -EAT-10 at baseline ). To identify the predictive features, the baseline US parameters were compared between dysphagia (+) and dysphagia (-) groups. A total of 46 patients (mean age, 61.3y; 78.3% male) were included for analysis. A greater increase of the EAT-10 score after surgery was positively correlated with change ratios of the muscle thickness and time to contract and negatively with change ratio of the inner diameter. The dysphagia (+) group exhibited significantly greater inner diameter and smaller muscle thickness at baseline than the dysphagia (-) group. Dysphagia during the acute postoperative phase of anterior cervical surgery is caused by the physical narrowing of the inner lumen due to muscle thickening of the UES and sphincter contractile dysfunction. In addition, a baseline UES morphology characterized by a greater inner diameter and a thinner muscle layer is predictive of postoperative dysphagia.

Longitudinal Examination of Swallowing Safety and Vocal Fold Mobility in Cardiac Surgical Patients

BackgroundAspiration and vocal fold mobility impairment (VFMI) are frequently reported in adults after cardiac surgery (CS) and impede recovery. Preoperative and postoperative laryngoscopic evaluations have not been undertaken, masking the incidence and evolution of dysphagia and VFMI in CS patients. We therefore sought to determine frequency of unsafe swallowing and VFMI before and after CS. MethodsThirty-five adults undergoing elective CS enrolled. Participants underwent fiberoptic endoscopic evaluations of swallowing and VFMI before and after surgical procedure. Trained raters performed duplicate, blinded ratings with the validated Penetration-Aspiration Scale, and a laryngologist performed blinded ratings of VFMI. Descriptive, Wilcoxon signed rank, and McNemar tests were performed. ResultsPreoperative swallowing safety profiles were 60% safe, 34% penetration, and 6% aspiration. Postoperative swallowing safety profiles were 14% safe, 63% penetration, and 23% aspiration. Significant differences in preoperative to postoperative swallowing outcomes were noted for Penetration-Aspiration Scale scores (P < .0001), unsafe swallowing (40% vs 86%; χ2 = 12.8; P = .0003), and aspiration (6% vs 23%; χ2 =6; P = .01). No differences in VFMI were noted preoperatively to postoperatively (partial VFMI, 9% vs 23%; P > .05). ConclusionsA 4-fold increase in aspiration was observed in CS patients. No cases of vocal fold paralysis were observed across time points. These data highlight the utility of instrumental laryngoscopic evaluations during the acute postoperative phase.

Outcomes of mitral valve replacement with complete annular decalcification.

This study aimed to examine the clinical outcomes of mitral valve replacement (MVR) in patients with severe mitral annular calcification (MAC) who required extensive decalcification and mitral annular reconstruction. We reviewed 15 patients with severe MAC who underwent MVR between January 2016 and May 2022. In all cases, the calcified mitral annulus was resected completely using a Cavitron Ultrasound Surgical Aspirator, and a new annulus was created using bovine pericardium. In the acute postoperative phase, strict afterload reduction therapy using an intra-aortic balloon pump (IABP) was administered. The mean age of patients was 73 ± 8 years, and 13 (86.7%) were women. Concomitant aortic valve replacement was performed in 11 (73.3%) patients, tricuspid annuloplasty in 9 (60.0%), coronary artery bypass grafting in 1 (6.7%), and arrhythmia surgery in 7 (46.7%). The mean aortic cross-clamp and cardiopulmonary bypass times were 143 ± 32 min and 175 ± 34 min, respectively. In 13 patients, an IABP was used for 2 or 3 days postoperatively. There were no in-hospital deaths, left ventricular ruptures, or other MAC-related complications. Postoperative echocardiography revealed no paravalvular leakages. Our strategy for managing severe MAC is safe and reproducible even in relatively high-risk patients. Afterload reduction using an IABP in the acute postoperative phase may reduce the risk of fatal complications after extensive decalcification and mitral annular reconstruction.

Primary total elbow arthroplasty, is there a correlation between smoking and postoperative complications? A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program Database

BackgroundSmoking has been suggested to be correlated with increased rates of several postoperative complications following total joint arthroplasty. As the utilization of total elbow arthroplasty (TEA) continues to rise, identifying modifiable factors to best optimize the patient is crucial. The goal of this study is to identify if a correlation exists between smoking status and 30-day postoperative complications following TEA. MethodsData were obtained from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2021 using Current Procedural Terminology code 24363 (Arthroplasty, elbow, with distal humeral and proximal ulnar prosthetic replacement; total elbow). Patients were placed into 1 of 2 cohorts based on smoking status. A multivariate logistic regression was used to compare rates of postoperative complications between cohorts and odds ratios (ORs) were calculated to evaluate risk of postoperative complications. ResultsSmoking was not found to be significantly correlated with any recorded complication, including surgical site infection (OR = 1.98, P = .219), sepsis (OR = 0.84, P = .879), hospital readmission (OR = 1.9, P = .136), return to operating room (OR = 1.06, P = .913), pulmonary embolism (OR = 0.91, P = .933), and blood loss requiring transfusion (OR = 0.36, P = .211). DiscussionThis study suggests no significant correlation between smoking and increased rates of complications following TEA in the 30-day postoperative window, such as postoperative surgical site infection, hospital readmission, or sepsis. ConclusionThis study found no significant correlation between smoking and complications within the 30-day postoperative window, supporting the safety of TEA procedures for smokers. However, perioperative smoking cessation is still recommended as part of medical optimization before surgery. The results provide a valuable tool for risk stratification in TEA patients, especially smokers, during the acute postoperative phase. Decisions regarding TEA surgery should involve shared decision-making between the surgeon and patient, considering multiple factors.

Feasibility and Efficacy of the Newly Developed Robotic Hybrid Assistive Limb Shoulder Exercises in Patients with C5 Palsy during the Acute Postoperative Phase.

Background and Objectives: Although postoperative C5 palsy is a frequent complication of cervical spine surgery, no effective therapeutic rehabilitation approach has been established for postoperative C5 palsy. The purpose of this study was to find evidence confirming the effectiveness and feasibility of robotic Hybrid Assistive Limb (HAL) shoulder exercises for C5 palsy. Materials and Methods: In this before-after, uncontrolled case series clinical study, we performed a mean of 11.7 shoulder training sessions using a shoulder HAL immediately after the onset of C5 palsy in seven shoulders of six patients who developed postoperative C5 palsy and had difficulty raising their shoulder during the acute postoperative phase of cervical spine surgery. Shoulder HAL training was introduced as early as possible after evaluating the general condition of all inpatients who developed C5 palsy. Patients underwent shoulder abduction training using shoulder HAL on an inpatient and outpatient basis at 2-week or 1-month intervals. Adverse events associated with shoulder HAL training were investigated. The shoulder abduction angle and power without the shoulder HAL were evaluated before shoulder HAL usage, at every subsequent session, and upon completion of all sessions. Results: Severe adverse events due to shoulder HAL training were not reported. After completion of all shoulder HAL sessions, all patients showed improved shoulder elevation, while shoulder abduction angle and power improved over time. Conclusions: Shoulder elevation training with HAL in patients in the acute stage of postoperative C5 palsy has the potential to demonstrate improvement in shoulder joint function with a low risk of developing severe adverse events.

The Effect of Steroid and Mannitol Combination Treatment on Postoperative Rehabilitation of Multiple Metacarpal Bone Fractures.

Background and Objectives: The expedient resolution of postoperative soft tissue edema is particularly important in hand surgery. Prolonged edema and pain become an obstacle to postoperative rehabilitation, delay return to daily life, and in severe cases, lead to a permanent decrease in range of motion. Based on the common physiology between postoperative hand swelling and complex regional pain syndrome (CRPS), we sought to determine if postoperative mannitol and steroid administration to multiple metacarpal bone fracture patients effectively reduces hand swelling and pain and is beneficial for hand rehabilitation. Materials and Methods: From March 2015 to February 2019, 21 patients who received closed pinning for multiple metacarpal fractures were included in a retrospective cohort study. The control group (n = 11) underwent a routine recovery, while the treatment group (n = 10) received dexamethasone and mannitol injections for five days postoperatively. Serial changes in the degree of pain and fingertip-to-palm distance (FPD) were measured in both groups. The duration from surgery to the initiation of rehabilitation and time to full grip was also compared. Results: Compared to the control, the treatment group showed a faster alleviation of pain scores from the postoperative fifth day (2.91 versus 1.80, p = 0.013), and faster recovery of FPD from postoperative two weeks (3.27 versus 1.90, p = 0.002). Time to physical therapy initiation (6.73 versus 3.80 days, p = 0.002) and full grip achievement (42.46 versus 32.70 days, p = 0.002) were also faster in the treatment group. Conclusions: The steroid-mannitol combination treatment for multiple metacarpal bone fracture patients in the acute postoperative phase promoted the reduction of hand edema and pain, leading to the earlier initiation of physical therapy, rapid improvement in joint motion, and faster achievement of full grip.

Does Facial Fracture Management Require Opioids? A Pilot Trial of a Narcotic-Minimizing Analgesia Protocol for Operative Facial Trauma.

Opioid minimization in the acute postoperative phase is timely in the era of the opioid epidemic. The authors hypothesize that patients with facial trauma receiving multimodal, narcotic-minimizing pain management in the perioperative period will consume fewer morphine milligram equivalents (MMEs) while maintaining adequate pain control compared with a traditional analgesia protocol. An IRB-approved pilot study evaluating isolated facial trauma patients compared 10 consecutive prospective patients of a narcotic-minimizing pain protocol beginning in August 2020 with a retrospective, chart-reviewed cohort of 10 consecutive patients before protocol implementation. The protocol was comprised of multimodal nonopioid pharmacotherapy given preoperatively (acetaminophen, celecoxib, and pregabalin). Postoperatively, patients received intravenous (IV) ketorolac, scheduled acetaminophen, ibuprofen, and gabapentin. Oxycodone was reserved for severe uncontrolled pain. The control group had no standardized protocol, though opioids were ad libitum. Consumed MMEs and verbal Numeric Rating Scale (vNRS) pain scores (0-10) were prospectively tracked and compared with retrospective data. Descriptive and inferential statistics were run. At all recorded postoperative intervals, narcotic-minimizing subjects consumed significantly fewer MMEs than controls [0-8h, 21.5 versus 63.5 ( P = 0.002); 8-16h, 4.9 versus 20.6 ( P = 0.02); 16-24h, 3.3 versus 13.9 ( P = 0.03); total 29.5 versus 98.0 ( P = 0.003)]. At all recorded postoperative intervals, narcotic-minimizing subjects reported less pain (vNRS) than controls (0-8h, 7.7 versus 8.1; 8-16h, 4.4 versus 8.0; 16-24h 4.3 versus 6.9); significance was achieved at the 8 to 16-hour time point ( P = 0.006). A multimodal, opioid-sparing analgesia protocol significantly reduces opioid use in perioperative facial trauma management without sacrificing satisfactory pain control for patients.

Interactive Combinations Between Gait Speed and Physical Function at Acute Phase Can Predict the Physical Activity at 2 Years After Total Knee Arthroplasty Using Classification and Regression Tree Analysis

ObjectiveTo clarify the interactive combinations of various clinical factors associated with physical activity (PA) at 2 years after total knee arthroplasty (TKA) using classification and regression tree (CART) analysis. DesignA retrospective cohort study. SettingA single university hospital. Participants286 patients who underwent TKA (N=286). Main Outcome MeasuresPA was assessed preoperatively, 3 weeks, and 2 years after TKA. Physical functions, namely, 10 m walking test (10MWT), timed Up and Go test, 1-leg standing time, isometric knee extension and flexion strength, knee joint stability, knee pain, femora-tibial angle, and the passive knee extension and flexion angle, were measured before surgery as a baseline and 3 weeks after TKA as acute phase. CART analysis was conducted to clarify the interactive combinations that accurately predict the PA at 2 years after TKA. ResultsThe results of CART analysis indicated that gait speed (≥1.05 m/s) at the acute phase after TKA was the primal predictor for the postoperative PA at 2 years. The highest postoperative PA at 2 years was determined by gait speed (≥1.05 m/s) and PA (>74.5) at the acute phase. The PA at baseline and at acute phase, as well as the body mass index were also selected as predictors of postoperative PA at 2 years. ConclusionThe present study suggested that acquiring gait speed (≥1.05 m/s) and PA (>74.5) in the postoperative acute phase is the predictive of a high PA at 2 years after TKA.

Global left ventricular myocardial work efficiency in left bundle branch pacing versus right ventricular septal pacing: preliminary results of a randomized trial

Abstract Background Recently, the concept of left bundle branch pacing (LBBP) has emerged in clinical practice, in an attempt to prevent the deteriorating effects of right ventricular pacing (Vp). Purpose The aim of this study is to compare the effect of Vp on left ventricular (LV) dyssynchrony in patients with atrioventricular block (AVB) and preserved ejection fraction (EF), subjected to either LBBP or right ventricular septal pacing (RVSP). Methods Patients with AVB are randomized 1:1 to LBBP or RVSP. The effect of Vp is evaluated by echocardiographic indices of dyssynchrony, such as global myocardial work efficiency (GWE) and peak systolic dispersion (PSD). GWE represents the ratio of constructive work divided by the sum of constructive and wasted work [1]. Successful LBBP is defined by the presence of right bundle branch block paced QRS morphology in lead V1 and stim to LV activation time &amp;lt;75 msec [2]. No back-up right Vp lead was used in LBBP group. Results We conducted a preliminary analysis of the first 20 patients. Enrollment is still ongoing and total follow-up period is one year. We sought to investigate the acute effect of Vp on LV dyssynchrony 24 hours post procedure. Patients' baseline characteristics were similar in both groups and are presented in Table 1. One crossover was noted from LBBP to RVSP group, due to high ventricular capture threshold during implant. Implantation time was increased in LBBP arm (130±17.4 min in LBBP versus 47.7±4.5 min in RVSP group, p=0.004). Left bundle branch potential was recorded in 3 out of 10 LBBP patients. No statistically significant difference was demonstrated in GWE between the two groups (91.3% in LBBP versus 87.4% in RVSP group, p=0.052). PSD was numerically shorter in LBBP (53.3 msec) versus in RVSP (63.6 msec), p=0.114. There were no complications during both the acute perioperative phase and the running period of the follow-up. Moreover, no acute ventricular threshold capture rise, or lead dislodgement has been observed in neither group. The increased implantation time may be attributed to the more demanding technique, or the learning curve period required in the arm of LBBP. In the present analysis, a remarkable difference regarding GWE in favor of the LBBP group was demonstrated, although statistically not significant. However, even in this initial phase of the study, there is a trend of better LV synchrony and less wasted myocardial work in the LBBP group. The final difference of these indices will be assessed at the end of the one-year follow-up, when comparative results will be available. Conclusion LBBP is a novel, safe pacing method. Despite the longer procedural time and the risk of crossover, LBBP seems to offer better – without however statistical significance – LV synchrony even in the acute postoperative phase compared to RVSP. Longer follow-up studies are required to test whether LBBP compared to RVSP confers substantial clinical benefit. Funding Acknowledgement Type of funding sources: None.

Evaluation of chronological changes in videofluorographic findings after transoral videolaryngoscopic surgery to reveal mechanism of dysphagia

ObjectivesTransoral surgery preserves good swallowing function in most cases, however, postoperative dysphagia sometimes leads to fatal complication such as aspiration pneumonia. We investigated the chronological changes in swallowing function have not been revealed relationship with dysphagia. The primary aim of this study was to reveal the mechanism of dysphagia following transoral surgery by analyzing chronological videofluorography (VF) findings. Moreover, the secondary aim of this study was to evaluate the relationship between mechanism of dysphagia and risk factors of patients to clarify the risk for dysphagia lead to prevention of postoperative complications. Methods22 patients who underwent transoral videolaryngoscopic surgery (TOVS) for either supraglottic or hypopharyngeal cancer were evaluated swallowing function. We performed VF during the preoperative, postoperative acute, and stable phases and investigated the chronological changes in the VF findings. The following parameters were evaluated by VF: horizontal distance of laryngeal movement, vertical distance of laryngeal elevation, laryngeal elevation delay time (LEDT), Bolus Residue Scale (BRS) scores, and Penetration Aspiration Scale (PAS) scores. Additionally, we evaluated risk factors for postoperative aspiration by investigating relationships between preoperative VF parameters, age of patients, history of radiation therapy, resection area, tumor (T) stage, postoperative Numeric Rating Scale (NRS), and PAS and BRS scores. ResultsThe median time at which oral feeding was resumed in this study was 9 (2–200) days. The patients who had postoperative acute PAS scores of 4 and above exhibited delays in resuming oral ingestion after surgery. TOVS did not impair laryngeal elevation and LEDT; however, the BRS and PAS scores temporarily worsened in the acute phase compared to the preoperative scores. These scores almost recovered to their preoperative states in the stable phase, and both the BRS and PAS scores worsened and recovered concurrently. Patients who exhibited poor vertical distance in laryngeal elevation as observed via preoperative VF or who had histories of radiation therapy had worse PAS scores in postoperative acute phase VF. Patients with broad resection areas had worse BRS scores in postoperative acute phase VF. ConclusionTOVS didn't impair the function of laryngeal elevation and elicitation of the swallowing reflex whereas pharyngeal bolus clearance, laryngeal penetration, and aspiration temporarily deteriorated concurrently but eventually almost recovered to their baseline values.Patients with histories of radiotherapy, poor laryngeal elevation, and broad resection areas are at the risk of postoperative dysphagia after TOVS. Patients with these risk factors need appropriate evaluation before resuming postoperative oral intake.

Periodic quadriplegia during the acute postoperative phase of cervical laminoplasty: a case report and literature review

The use of antibiotics can, in rare cases, induce neuromuscular blockade (NMB), resulting in paralytic symptoms. Although such antibiotic-induced NMB has been described in the anaesthesiology and infectious disease literature, it is an unfamiliar clinical entity in the fields of neurosurgery and spinal surgery. Herein, we report a case of periodic quadriplegia due to NMB induced by perioperative prophylactic antibiotic of cefazolin, resulting in highly confusing paralytic symptoms during the acute postoperative phase of cervical laminoplasty, together with a review of the relevant literature.

165. Risk of revision surgery following cervical disc replacement vs anterior cervical discectomy and fusion: population based cohort study

<h3>BACKGROUND CONTEXT</h3> In recent years, cervical disc replacement (CDR) has gained popularity for cervical degenerative disorders. The rationale for CDR over anterior cervical discectomy and fusion (ACDF) is preservation of segmental motion and physiological spinal kinematics, which is hoped to delay development of adjacent segment disease and reoperation rates. Superiority of CDR over ACDF in rates of secondary surgeries has not been demonstrated in long-term follow-up. <h3>PURPOSE</h3> This study compares rate of reoperation in CDR and ACDF for treatment of cervical degenerative disc disease using population-based data for the province of Ontario. <h3>STUDY DESIGN/SETTING</h3> A population-based cohort study was conducted using health administrative databases including patients undergoing ACDF or CDR between October 2005 to March 2018. <h3>PATIENT SAMPLE</h3> Patients receiving CDR vs ACDF were identified using physician service claims and hospital discharge abstracts. <h3>OUTCOME MEASURES</h3> The primary outcome was revision surgery in the cervical spine defined as an operation more than 30 days after the index procedure. Secondary outcomes were immediate/acute complications within the first 30 days after the index operation, readmissions and length of hospital stay. <b>METHODS:</b> Cox proportional hazard models were used to identify predictors of time to revision surgery. Predictors of the binary outcome of an immediate complication within 30 days were estimated using logistic regression. <h3>Results</h3> A total of 5,207 patients were included. Mean follow-up was 2,728 days for CDR and 2,542 days for ACDF. Among 4,937 ACDF procedures, 7.5% underwent subsequent revision surgery and among 270 CDR procedures, 8.9% had revision surgery. While the study groups did not differ in their risk of revision surgery (adjusted HR 1.20, 95% CI 0.78-1.85), CDR was associated with a lower probability of an acute complication (adjusted OR 0.41, 95% CI 0.21-0.80). Among other factors, multi-level surgery was an independent predictor of acute complication [OR= 1.33 (95% CI 1.06 – 1.66)]. CDR patients experienced shorter mean (±SD) length of hospital stay [1.42 (±0.87) vs. 2.00 ± (3.08) d for ACDF]. <h3>Conclusions</h3> This study does not demonstrate superiority of CDR over ACDF in revision surgery at the index and/or adjacent level of the cervical spine for single and multi-level procedures. CDR may have an advantage over ACDF in the acute postoperative phase, with a shorter length of hospital stay and lower probability of acute complication. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Preserving Right Pre-motor and Posterior Prefrontal Cortices Contribute to Maintaining Overall Basic Emotion.

Basic emotions such as happiness, sadness, and anger are universal, regardless of the human species, and are governed by specific brain regions. A recent report revealed that mentalizing, which is the ability to estimate other individuals’ emotional states via facial expressions, can be preserved with the help of awake surgery. However, it is still questionable whether we can maintain the ability to understand others’ emotions by preserving the positive mapping sites of intraoperative assessment. Here, we demonstrated the cortical regions related to basic emotions via awake surgery for patients with frontal glioma and investigated the usefulness of functional mapping in preserving basic emotion. Of the 56 consecutive patients with right cerebral hemispheric glioma who underwent awake surgery at our hospital, intraoperative assessment of basic emotion could be successfully performed in 22 patients with frontal glioma and were included in our study. During surgery, positive responses were found in 18 points in 12 patients (54.5%). Of these, 15 points from 11 patients were found at the cortical level, mainly the premotor and posterior part of the prefrontal cortices. Then, we focused on cortical 15 positive mappings with 40 stimulations and investigated the types of emotions that showed errors by every stimulation. There was no specific rule for the region-emotional type, which was beyond our expectations. In the postoperative acute phase, the test score of basic emotion declined in nine patients, and of these, it decreased under the cut-off value (Z-score ≤ −1.65) in three patients. Although the total score declined significantly just after surgery (p = 0.022), it recovered within 3 months postoperatively. Our study revealed that through direct electrical stimulation (DES), the premotor and posterior parts of the prefrontal cortices are related to various kinds of basic emotion, but not a single one. When the region with a positive mapping site is preserved during operation, basic emotion function might be maintained although it declines transiently after surgery.

Individualized Perioperative Blood Pressure Management for Adult Moyamoya Disease: Experience from 186 Consecutive Procedures

BackgroundIn adult patients with moyamoya disease (MMD) underwent combined revascularization, cerebral infarction during the acute postoperative phase is common and can lead to neurological dysfunction after revascularization in MMD patients. The aim of this study was to share the experience of individualized perioperative blood pressure (BP) management for adult MMD patients in one single center. MethodsWe retrospectively reviewed 144 adult patients with MMD who underwent 186 procedures of combined revascularization at our institution from March 2013 to July 2019. Clinical features and outcomes were analyzed, in particular regarding cerebral infarction and hyperperfusion syndrome (HPS). All of the patients received individualized management perioperatively, especially about the blood pressure management according to the characteristics of moyamoya disease. ResultsPostoperative cerebral infarction and HPS within 14 days after revascularization were recorded. Cerebral infarction occurred in four (2.1%) procedures among four patients. No patients suffered from a malignant cerebral infarction and only one patient had permanent neurological deficits. The incidence of HPS was 10.8% and no one presented with intracranial hemorrhage. All of the symptoms were reversible without any brain parenchymal injury. ConclusionsOur findings suggest that we can decrease the incidence and extent of cerebral infarction in adult MMD patients following combined revascularization by individualized perioperative BP management.