Additional Invasive Interventions Research Articles

Comparison Of Antegrade And Antegrade/Retrograde Blood Cardioplegia Applications In Cardiopulmonary Bypass Accompanıed Cardiac Surgery

Introduction: Ischemic heart disease (IHD) is among the leading causes of death worldwide. Sometimes, cardiopulmonary bypass (CPB) is inevitable in the treatment of heart diseases by open heart surgery procedures. Myocardium protection is of great importance in CPB cases. Various techniques and applications exist for the protection of the myocardium.
 Objective: In this study, it was aimed to determine the perioperative and postoperative early outcomes of coronary artery bypass grafting (CABG) operations with CPB by comparing intermittent antegrade and intermittent antegrade (Initial) combined with retrograde (Maintenance) blood cardioplegia applications.
 Materials and Methods: 240 patients with similar characteristics who underwent CPB-guided CABG operation were included. Two groups were formed as Antegrade (Group 1) and Antegrade/retrograde (Group 2). The preoperative, intraoperative, and early postoperative results of the groups were compared.
 Results: Gender, age, body surface area, flow, ejection fraction percentages, EuroSCORE and LMCA lesion presence values were similar in both groups (p>0.05). Cross-clamp time, total perfusion time, mean activated clotting time during CPB and perioperative drainage were similar in both groups (p>0.05). There was no statistically significant difference between the sodium, potassium, calcium, glucose, and lactate levels evaluated after CPB of the two groups (p>0.05). In addition, there was no statistically significant difference between the two groups in terms of defibrillation requirement, inotropic requirement, and IABP requirement after CPB. (p>0.05).
 Conclusion: Similar results were observed between antegrade cardioplegia alone and antegrade combined with retrograde cardioplegia in CPB-guided CABG operations. For this reason, we think that the antegrade cardioplegia technique alone will be more advantageous in terms of ease of application, not requiring additional invasive intervention, and eliminating the risks of the necessity of additional intervention. Furthermore, we think that the importance of case-based evaluation in cardioplegia techniques should not be ignored.

Effect of initiative pulmonary bullectomy on the risk of post-operative pneumothorax in patients with esophageal carcinoma: a propensity score-matched analysis.

Postoperative pneumothorax can lead to additional invasive intervention and extended hospitalization. The effect of initiative pulmonary bullectomy (IPB) during the esophagectomy on preventing postoperative pneumothorax remains controversial. This study evaluated the efficacy and safety of IPB in patients who underwent minimally invasive esophagectomy (MIE) for esophageal carcinoma complicated by ipsilateral pulmonary bullae. Data from 654 consecutive patients with esophageal carcinoma who underwent MIE from January 2013 to May 2020 were retrospectively collected. A total of 109 patients who had a definite diagnosis of ipsilateral pulmonary bullae were recruited and classified into two groups: the IPB group and the control group (CG). Propensity score matching (PSM, match ratio =1:1), incorporating preoperative clinical features, was used to compare the perioperative complications and analyze efficacy and safety between IPB and control group. The incidences of postoperative pneumothorax in the IPB and control groups was 3.13% and 40.63% respectively, with a significant difference (P<0.001). Logistic analyses indicated that removing ipsilateral bullae was associated with a lower risk (OR 0.030; 95% CI: 0.003-0.338; P=0.005) of incident postoperative pneumothorax. No significant difference was found between the two groups in terms of the incidence of anastomotic leakage (6.25% vs. 3.13%, P=1.000), arrhythmia (3.13% vs. 3.13%, P=1.000), chylothorax (0% vs. 3.13%, P=1.000) and other common complications. In esophageal cancer patients with ipsilateral pulmonary bullae, IPB performed in the same anesthesia process is an effective and safe method for the prevention of postoperative pneumothorax, allowing for a shorter postoperative rehabilitation time, and it does not exert unfavorable effects on complications.

Optimal management of long-term air leakage after lung resections for cancer

Lung resection is the main diagnostic and therapeutic surgical intervention in terms of lung cancer management. Air leak through pleural drains often occurs after lung resections due to damage to the pulmonary parenchyma. Therefore, proper drainage of the pleural cavity is very important for the successful outcome of the operation. The installation of a single pleural drainage after anatomical resection, the refusal to use vacuum aspiration and the earliest possible removal of drains contribute to the rapid activation of patients in the postoperative period. Prolonged air leakage (PAL) after lung resection, on average, develops in 15 % of lung cancer patients, remaining one of the most common complications adversely affecting the rehabilitation of patients and leading to delayed discharge from the hospital. The incidence of empyema with prolonged air leakage is 10.4 % with air discharge for more than 7 days compared to 1 % with air leaks less than or equal to 7 days. PAL requires prolonged drainage of the pleural cavity, which increases postoperative pain, causing shallow breathing, difficulty coughing leads to an increased risk of pneumonia, decreased mobility is accompanied by a high risk of thromboembolic complications. In addition, the treatment of complications is associated with the need to perform additional invasive interventions such as chemical or mechanical pleurodesis. Prolonged air leakage is associated with an increase in hospital mortality. Patients with an air leak have a 3.4 times greater risk of death than patients without it. Active tactics in relation to PAL include preoperative prediction of a high risk of complications, intraoperative measures to prevent air leak from the lung parenchyma and postoperative treatment to reduce the duration of PAL. The urgency of the problem is due to the fact that prolonged air leakage in patients with lung cancer after organ-preserving operations is associated with an increased risk of infectious complications due to the need for prolonged drainage of the pleural cavity. In this review, the main attention is paid to two components of postoperative management of PAL: diagnosis with an accurate assessment of the intensity of air leak and treatment of alveolar-pleural fistulas.

ПРАКТИЧЕСКОЕ ПРИМЕНЕНИЕ МЕТОДОВ МАШИННОГО ОБУЧЕНИЯ НА ПРИМЕРЕ ОПРЕДЕЛЕНИЯ АКТИВНОСТИ ТУБЕРКУЛЕЗНОГО ПРОЦЕССА У ЛИЦ С МИНИМАЛЬНЫМИ ТУБЕРКУЛЕЗНЫМИ ИЗМЕНЕНИЯМИ, ВЫЯВЛЕННЫМИ НА РЕНТГЕНОГРАММЕ ОРГАНОВ ГРУДНОЙ КЛЕТКИ

Background: According to the World Health Organization (WHO), over 23% of the human population infected with tuberculosis bacilli – M.tuberculosis. For each infected person, the likelihood of a transition from a state of latent tuberculosis infection (LTBI) to active tuberculosis remains. WHO considers testing and treatment for LTBI in groups at high risk of reactivations as a necessary condition for tuberculosis elimination. Early detection of the transition of LTBI into active tuberculosis presents a certain difficulty due to the absence of clinically and radiographically distinguishable symptoms of the onset of the disease, therefore, immunodiagnostics, including the use of a skin test with a recombinant tuberculosis allergen, and methods of clinical laboratory diagnostics come to the aid of clinicians. The objective of our study was to demonstrate the possibilities of using an artificial intelligence system to identify the level of activity of tuberculosis infection in children with the presence of small tuberculosis changes in the respiratory organs, detected by X-ray. Material and methods The total number of patients registered in anti-tuberculosis institutions enrolled in the study was 489, including: the main group – a training sample consisting of patients with confirmed active tuberculosis (n1 = 369); the control group – a test sample of patients in whom the pathogen was in an inactive form (n2 = 120). As variables for calculations: anamnesis, laboratory parameters and X-ray data, were obtained by routine methods and used in accordance with current national standards of care and clinical guidelines, which did not require additional invasive interventions, equipment and material costs. The above survey results: age, gender, medical history, BCG vaccination, blood biochemical parameters in dynamics, X-ray signs, formalized according to the binary principle (presence / absence), were retrieved from patients files into the study database based on MS Excel spreadsheets for further processing. At the initial stage, the Wolfram Mathematica software package was used for calculations; six classical machine learning (ML) methods were carried out: Logistic Regression, Naive Bayes, Nearest Neighbors, Neural Network and Random Forest. Results: The results of the calculations based on combinations of categorical features did not suit us in terms of the quality of the forecast, and we proceeded to the search for a decision rule based on quantitative features. All spelled above methods predicted the presence of the disease significantly better than its absence. The Random Forest method showed the best results for both categorical and quantitative traits, however, interpretation of its results was not possible for clinical decision making. Convinced of the non-optimality of applying classical ML methods, it was decided to apply the author’s committee machine method with the possibility of minimal correction of conditions for significantly different cardinalities of the separable sets and subsequent geometric interpretation of the results. As a result of the application of the committee machine method, 7 most informative parameters were identified to create a decision rule that makes possible to distinguish patients with inactive pathogen and who do not require treatment in children with suspected tuberculosis. Conclusion: the committee machine method in a geometric formulation lead to localize areas in the feature space that correspond to sick and healthy patients from the training sample. That areas were unambiguously described in the form of a system of inequalities and could be easily explained to clinicians and allow moving from a geometric interpretation to a meaningful description of cause-and-effect relationships between the laboratory parameters in a certain area and the patient’s condition.

Spontaneous pneumomediastinum, pneumothorax, pneumoperitoneum and soft tissue emphysema as complication in patients with COVID-19, series of cases

Spontaneous pneumomediastinum, pneumothorax, pneumoperitoneum, and soft tissue emphysema have been recently described in several sources as possible complications in patients with severe COVID-19 and lung damage. This clinical case is dedicated to demonstrarte the development of these lesions in 3 male patients with comorbid conditions. The putative pathophysiological mechanism of these complications is air leakage due to extensive diffuse alveolar damage followed by rupture of the alveoli. All presented patients had a favorable outcome of the disease without lethal cases, their laboratory data and clinical dynamics were described.It should be noted that such conditions are not rare complications of COVID-19, and are observed mainly in male patients with severe form of the disease and the presence of comorbid conditions. Such complications are associated with long hospitalization and a severe prognosis. In some cases, with a mild course of the disease and positive dynamics in a decrease of the percentage of pulmonary lesions, the outcome is favorable, not requiring additional invasive interventions.

Spontaneous pneumomediastinum, pneumothorax, pneumoperitoneum and soft tissue emphysema as complication in patients with COVID-19, series of cases

Spontaneous pneumomediastinum, pneumothorax, pneumoperitoneum, and soft tissue emphysema have been recently described in several sources as possible complications in patients with severe COVID-19 and lung damage. This clinical case is dedicated to demonstrarte the development of these lesions in 3 male patients with comorbid conditions. The putative pathophysiological mechanism of these complications is air leakage due to extensive diffuse alveolar damage followed by rupture of the alveoli. All presented patients had a favorable outcome of the disease without lethal cases, their laboratory data and clinical dynamics were described.It should be noted that such conditions are not rare complications of COVID-19, and are observed mainly in male patients with severe form of the disease and the presence of comorbid conditions. Such complications are associated with long hospitalization and a severe prognosis. In some cases, with a mild course of the disease and positive dynamics in a decrease of the percentage of pulmonary lesions, the outcome is favorable, not requiring additional invasive interventions.

MultiPole pacing in non-responders to cardiac resynchronization therapy: Results from the QP ExCELs/MPP sub-study.

Multisite LV stimulation therapy allows for stimulation of two different left ventricular pacing vectors within a single LV lead and may improve responsiveness to cardiac resynchronization therapy (CRT). This study prospectively evaluated the safety and efficacy of the MultiPole Pacing (MPP) feature in CRT non-responder patients. CRT non-responders with a standard CRT-D indication were eligible for enrollment into the MPP Sub-Study. Patient status, NYHA classification, Patient Global Assessment (PGA), and adverse events were collected at follow-up. A clinical composite score (CCS) was determined at the 6 month follow-up visit. The primary objective was defined as the proportion of patients with an improved CCS. Safety was evaluated as freedom from MPP system related adverse events requiring additional invasive intervention to resolve. A total of 53 patients were enrolled across 26 U.S. centers. The cumulative follow-up duration was 24.1 years. CCS was improved in 35.6% of patients (p<.0001 when compared to a performance goal of 3%) after 6 months of MPP therapy. When incorporating patient feedback into a modified CCS, 60.0% of patients showed an improvement. Three patients (5.7%) experienced hospitalization for heart failure, and three patient deaths occurred over the follow-up period. No MPP system-related events were reported for an AE-free rate of 100% (95% CI 93.28% to 100.0%). The results of this small, non-randomized study suggest that the MPP feature is safe, and may be effective at converting a percentage of CRT non-responders to responders. Larger, randomized studies are needed to confirm this result.

Rates of reoperation and nonoperative intervention within 30 days of bariatric surgery

BackgroundComplications arising from laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are not insignificant and can necessitate additional invasive interventions or reoperations. ObjectivesIn this study, we identify early complications that result in nonoperative and operative interventions after LSG and LRYGB, the timeframe within which to expect them, and factors that influence the likelihood of their occurrence. SettingMulti-institutional database from across North America. MethodsData for this study were obtained from Metabolic and Bariatric Accreditation and Quality Improvement Program participant use files for 2015 and 2016. Statistical analysis was performed using STATA 15. Univariate analysis using Χ2 for categoric data and independent t test for continuous data was performed to determine between group differences. Multivariable logistic regression analysis was used to identify predictors of operative and nonoperative reinterventions. ResultsIn 2015 and 2016, 243,747 underwent LRYGB or LSG, of which 3013 (1.24%) required a second operative procedure and 1536 (0.63%) required an invasive but nonoperative intervention. Complications occurred in 5.48% of LRYGB patients and 2.28% of LSG patients, the most common of which was bleeding. LSG was associated with far fewer nonoperative and operative interventions (.85% versus 2.2%, respectively) than LRYGB (.67% versus 2.5%). Renal insufficiency, including dialysis dependency, was an important predictor of reoperations among bariatric surgery patients. This was also true of nonoperative interventions; however, history of pulmonary embolism, and use of therapeutic anticoagulation were marginally stronger predictors. ConclusionsIn a representative, multinational sample, operative and nonoperative interventions were half as likely among LSG patients compared with LRYGB; however, overall rates still remained low. These findings, in conjunction with new efficacy data demonstrating comparable long-term weight loss between LRYGB and LSG, provide further support for the safety, effectiveness, and cost efficiency of LSG.

DIFFICULTIES OF SYSTEMATIZATION OF POSTOPERATIVE COMPLICATIONS OF ENDOSCOPIC TREATMENT FOR UROLITHIASIS AND THE SOLUTION WAYS OF THE PROBLEM

Actuality. Classification of postoperative complications Clavien-Dindo is designed to monitor complications and compare data between different centers. But for an objective assessment of complications, for each method of surgical treatment, a generally accepted norm of postoperative course should be developed, taking into account the specifics of the intervention. The absence of such a norm in the endoscopic treatment of urolithiasis leads to mistakes in the evaluation of postoperative complications. Purpose of research . Critical assessment of Clavien-Dindo grading system for surgical complications and its adaptation for evaluation of postoperative complications of endoscopic surgery for urolithiasis. Materials and methods. Retrospectively evaluated 1027 patients with urolithiasis who were operated endoscopically. The average age was 38.9 ± 15.6 (4 to 84) years. From the position of endoscopic surgery patients with “simple” stone were 446 (43.4 %), with “complex” — 581 (56.6 %). In 765 (74.5 %) patients stones were located in PCS, in PCS and ureter — in 60 (5.8 %), only in the ureter — in 202 (19.7 %). Size of stones in 1027 arranged 30.3 ± 0.6 (3 to 150) mm; located only in the ureter — 14.4 ± 0.5 (3 to 55) mm. From 1027 cases in 948 stones were removed via PC access (in the prone position), in 79 - transurethral. Regardless of the type of access only pneumatic lithotripsy were performed, which made possible to objectively evaluate the effectiveness of treatment in different groups. For systematization of complications Clavien-Dindo (2004) grading system was used. Results . Based on many years of experience of the RSCU’s staff in the endoscopic treatment of urolithiasis, as well by determining the category of complexity urinary stones from the position of endoscopic surgery, a clear boundary was determined between the normal postoperative period and the complicated one. Deviations from the standard of the postoperative period were found in 195 (19.0 %) patients with 250 complications, which were systematized by the way of critical evaluation and correction of the ClavienDindo classification: I – 64 (6.2 %), II – 111 (10.8 %), IIIa – 33 (3.2 %), IIIb – 39 (3.8 %), Iva – 3 (0.3 %), IVb – 0, V – 0. Conclusions. In order to optimally adapt the classification of surgical complications Clavien-Dindo, in relation to endoscopic surgery for urolithiasis, it was necessary to develop indicators standard of normal postoperative course of endoscopic treatment for urolithiasis. In turn, standard course must be accepted by Urology society. And only thereafter it will be possible to objectively compare the results of treatment between different centers. According to adapted Clavien-Dindo classification 70 % of complications of endoscopic treatment of urolithiasis were I - II grade and they were eliminated by conservative therapy, 30 % — attributed to grade III-IV, and to eliminate them were required additional invasive interventions and intensive care.

ANALYSIS OF CAUSES, FREQUENCY AND SEVERITY OF ACUTE COMPLICATED PYELONEPHRITIS IN ENDOSCOPIC INTERVENTIONS FOR UROLITHIASIS

Introduction . Despite the improvement of endoscopic equipment and methods of percutaneous and transurethral interventions on urolithiasis, acute pyelonephritis remains one of the most frequent postoperative complications. Purpose of the study . Objective assessment of frequency, causes and severity of postoperative pyelonephritis in endoscopic surgery for urolithiasis, as well as additional interventions needed to manage this complication. Materials and methods . The results of 1027 endoscopic operations (percutaneous and transurethral) performed in Republican Specialized Center of Urology (RSCU, Tashkent, Uzbekistan) for kidney and upper urinary tract stones were analyzed. «Simple» stones were in 446 (43.4%) patients, «complex» – in 581 (56.6%) ones. The severity of postoperative pyelonephritis were assessed using Clavien-Dindo grading system according to the necessity of additional interventions. Results . Postoperative pyelonephritis developed in 115 (11.2%) patients. According to the systematization of postoperative complications patients with pyelonephritis were distributed as follows: I-0, II-95, IIIa-8, IIIb10, IVa-2, IVb-0, V-0. Conclusions . Patients with initial urinary tract infection (UTI) and complications arising during endoscopic interventions and in postoperative period should be considered as «patients with absolute risk of postoperative infectious and inflammatory complications development». Complicated pyelonephritis was eradicated conservatively in 82.6% of patients, additional invasive interventions and intensive therapy were required in 17.4% of patients.

Association of ICAM-1, VCAM-1, CYCLIN D1 and Cathepsin D with Clinicopathological Parameters in Breast Carcinoma; an Immunohistochemical Study.

Breast carcinoma is the most common malignant tumor detected in women. The hypothesis that increased levels of adhesion molecules and Cathepsin D affect cancerous cells moving away the primary tumor and contributes to migration of the cancerous cell and may cause remote organ metastases is defended. The aim of the present study was to search the association of intracellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), Cyclin D1, cathepsin D immunohistochemically with clinicopathological parameters in the patients diagnosed with invasive ductal breast carcinoma. The pathological slides of 153 patients diagnosed with invasive ductal carcinoma were evaluated retrospectively. Three groups were created. Group 1 consisted of patients with positive lymph node metastasis and extranodal tumor invasion; Group 2 consisted of patients with positive axillary lymph node metastasis and negative extranodal tumor invasion and Group 3 consisted of the patients with negative axillary lymph node metastasis. In all groups, 20 paraffin blocks belonging to the primary tumor in the breast were stained by ICAM-1, VCAM-1, Cyclin D1 and Cathepsin D. Findings were examined by comparing with clinicopathological parameters. The highest number of metastatic axillary lymph nodes and the highest rate of cathepsin D staining were statistically found in the cases with positive axillary lymph node metastasis and extranodal tumor invasion. CerbB2 was negative in the cases with negative ICAM-1 whereas estrogen receptor and progesterone receptor were positive in the cases with positive VCAM-1. The present study reveals significant results for the patients diagnosed with invasive ductal carcinoma through breast biopsy especially before mastectomy in terms of increased number of metastatic axillary lymph nodes and extranodal tumor invasion by immunohistochemical Cathepsin D stain without any additional invasive intervention. Results of the present study may contribute to monitoring and treatment of the patients in the future.

WITHIN NORMAL LIMITS

Figure: Frontal upright radiograph of the chest (left) shows a round metallic foreign object in the expected location of the proximal esophagus. Once magnified (right), the foreign body exhibits a double contour appearance (arrows). This corresponds to the shape of a button battery. Note regions of irregularity and lucency about the periphery of the button battery (arrowheads in 1b), which indicate corrosion of the battery itself.FigureFigureFigureAn 11-month-old girl was brought to the emergency department with a two-week history of pooling secretions and feeding intolerance. A chest radiograph was performed, and detected a button battery. ENT was consulted emergently, and the patient was taken to the operating room for a laryngoscopy. The battery was retrieved, and the patient was found to have erosion and perforation of the posterior esophageal wall, which was repaired. She was discharged home following a prolonged stay in the pediatric ICU. Six months later, the patient presented with cough and repeated bouts of emesis. An esophagram was performed, which showed focal high-grade narrowing in the proximal esophagus. This was an esophageal stricture that developed as a delayed complication of button battery ingestion and battery cell corrosion within the esophagus. Most cases of button battery ingestion result in spontaneous passage through the gastrointestinal tract, but impaction of the button battery in the esophagus can result in considerable morbidity and even mortality. This holds a high risk for severe injury to esophageal mucosa, including full-thickness erosion resulting in perforation. The mechanism for injury is only partially from pressure necrosis. The primary hazard of button batteries (as opposed to other foreign bodies of similar shape, like coins) lies in its ability to induce a current and hydrolyze tissue fluids to produce hydroxide, causing rapid tissue erosion and injury to the esophageal wall. Eventually, corrosion of the battery cell can result in the leakage of battery contents, which causes further injury and toxicity.Figure: Spot image from an esophagram (left) shows focal narrowing in the proximal esophagus (arrow). Magnification of the level of narrowing (right) better delineates the abrupt tapering of the esophagus, indicative of a stricture at this level and dilation of the more proximal esophagus and hypopharynx secondary to downstream obstruction.It was reasonable to conclude based on the radiographic evidence of battery cell corrosion that significant esophageal injury had already occurred. An emergent laryngoscopy showed a full-thickness injury resulting in perforation of the posterior esophageal wall. Button battery ingestion poses a risk for delayed complications such as tracheoesophageal fistula and esophageal stricture, in addition to an acute injury. Early diagnosis is key in managing ingested button batteries, and in cases of impaction within the esophagus, prompt retrieval is crucial not only to avoid acute injury but to prevent delayed complications that may necessitate additional invasive interventions. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

Interventions for necrotising pancreatitis.

Acute necrotising pancreatitis carries significant mortality, morbidity, and resource use. There is considerable uncertainty as to how people with necrotising pancreatitis should be treated. To assess the benefits and harms of different interventions in people with acute necrotising pancreatitis. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 4), MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers to April 2015 to identify randomised controlled trials (RCT). We also searched the references of included trials to identify further trials. We considered only RCTs performed in people with necrotising pancreatitis, irrespective of aetiology, presence of infection, language, blinding, or publication status for inclusion in the review. Two review authors independently identified trials and extracted data. We calculated the odds ratio (OR) and mean difference with 95% confidence intervals (CI) using Review Manager 5 based on an available-case analysis using fixed-effect and random-effects models. We planned a network meta-analysis using Bayesian methods, but due to sparse data and uncertainty about the transitivity assumption, performed only indirect comparisons and used Frequentist methods. We included eight RCTs with 311 participants in this review. After exclusion of five participants, we included 306 participants in one or more outcomes. Five trials (240 participants) investigated the three main treatments: open necrosectomy (121 participants), minimally invasive step-up approach (80 participants), and peritoneal lavage (39 participants) and were included in the network meta-analysis. Three trials (66 participants) investigated the variations in the main treatments: early open necrosectomy (25 participants), delayed open necrosectomy (11 participants), video-assisted minimally invasive step-up approach (12 participants), endoscopic minimally invasive step-up approach (10 participants), minimally invasive step-up approach (planned surgery) (four participants), and minimally invasive step-up approach (continued percutaneous drainage) (four participants). The trials included infected or sterile necrotising pancreatitis of varied aetiology.All the trials were at unclear or high risk of bias and the overall quality of evidence was low or very low for all the outcomes. Overall, short-term mortality was 30% and serious adverse events rate was 139 serious adverse events per 100 participants. The differences in short-term mortality and proportion of people with serious adverse events were imprecise in all the comparisons. The number of serious adverse events and adverse events were fewer in the minimally invasive step-up approach compared to open necrosectomy (serious adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study; adverse events: rate ratio 0.41, 95% CI 0.25 to 0.68; 88 participants; 1 study). The proportion of people with organ failure and the mean costs were lower in the minimally invasive step-up approach compared to open necrosectomy (organ failure: OR 0.20, 95% CI 0.07 to 0.60; 88 participants; 1 study; mean difference in costs: USD -11,922; P value < 0.05; 88 participants; 1 studies). There were more adverse events with video-assisted minimally invasive step-up approach group compared to endoscopic-assisted minimally invasive step-up approach group (rate ratio 11.70, 95% CI 1.52 to 89.87; 22 participants; 1 study), but the number of interventions per participant was less with video-assisted minimally invasive step-up approach group compared to endoscopic minimally invasive step-up approach group (difference in medians: 2 procedures; P value < 0.05; 20 participants; 1 study). The differences in any of the other comparisons for number of serious adverse events, proportion of people with organ failure, number of adverse events, length of hospital stay, and intensive therapy unit stay were either imprecise or were not consistent. None of the trials reported long-term mortality, infected pancreatic necrosis (trials that included participants with sterile necrosis), health-related quality of life at any time frame, proportion of people with adverse events, requirement for additional invasive intervention, time to return to normal activity, and time to return to work. Low to very low quality evidence suggested that the minimally invasive step-up approach resulted in fewer adverse events, serious adverse events, less organ failure, and lower costs compared to open necrosectomy. Very low quality evidence suggested that the endoscopic minimally invasive step-up approach resulted in fewer adverse events than the video-assisted minimally invasive step-up approach but increased the number of procedures required for treatment. There is currently no evidence to suggest that early open necrosectomy is superior or inferior to peritoneal lavage or delayed open necrosectomy. However, the CIs were wide and significant benefits or harms of different treatments cannot be ruled out. The TENSION trial currently underway in Netherlands is assessing the optimal way to perform the minimally invasive step-up approach (endoscopic drainage followed by endoscopic necrosectomy if necessary versus percutaneous drainage followed by video-assisted necrosectomy if necessary) and is assessing important clinical outcomes of interest for this review. Implications for further research on this topic will be determined after the results of this RCT are available.

Management strategies for pancreatic pseudocysts.

Management strategies for pancreatic pseudocysts.

Identification and management of a coronary sinus catheter fracture.

At facilities that offer cardiac surgery services, minimally invasive cardiothoracic surgery is fast becoming commonplace, particularly in aortic, tricuspid, and mitral valve procedures. Use of a coronary sinus catheter, a specialized central venous catheter, to monitor hypothermic depth and provide retrograde cardioplegia has been widely adopted at Tufts Medical Center. Complications of coronary sinus catheter insertion are considered rare but are well documented. In contrast, complications of catheter removal, such as the catheter fracture that we report here, are not well described in the literature. In this case, the catheter tip was retrieved without further patient harm or additional invasive interventions.

Evaluación de las características operativas de la escanografía de tórax de alta resolución: experiencia en el Hospital Universitario San Ignacio

Introducción: con respecto al valor clínico de la escanografía de tórax de alta resolución se ha considerado que algunos estudios pueden ofrecer descripciones radiológicas muy finas que derivan en muchas ocasiones en intervenciones diagnósticas adicionales e invasivas que al final no confirman la sospecha diagnóstica planteada inicialmente y tampoco asignan ningún significado a los hallazgos radiológicos descritos.Objetivos: el propósito del presente estudio es evaluar las características operativas de la escanografía de tórax al compararla con un patrón de oro combinado (biopsias, estudios de microbiología y seguimiento clínico), que permita evaluar su rendimiento diagnóstico. Así mismo evaluar la necesidad del TCAR en el abordaje diagnóstico del paciente con patología pulmonar, evaluando de esta forma el porcentaje de intervenciones diagnósticas invasivas adicionales que se realizaron por los hallazgos encontrados en la escanografía de tórax, y que al final tuvieron resultados no diagnósticos.Materiales y métodos: se realizó un estudio retrospectivo revisando las historias clínicas de 250 pacientes a quienes se les practicó TCAR en el Hospital Universitario San Ignacio (HUSI), en Bogotá, Colombia entre abril de 2008 y abril de 2010. El diagnóstico presuntivo sugerido por las imágenes y la descripción de los hallazgos semiológicos se compararon con un patrón de oro combinado; una vez establecido el diagnóstico definitivo según el patrón de oro combinado, los pacientes fueron clasificados en categorías etiológicas.Resultados: de los 250 casos revisados, se encontró que el 44,8% de los pacientes tenían enfermedades infecciosas, el 19,6% tenían patologías neoplásicas, el 17,12% enfermedades intersticiales, el 9,2% otras enfermedades pulmonares, el 4 % hallazgos indeterminados, el 3,2% patología infecciosa e intersticial simultáneamente, y finalmente 2% eran normales. La sensibilidad del TCAR para diagnosticar enfermedad pulmonar en la población general del estudio fue de 83,3% y la especificidad de 90,9%. Presentó un valor predictivo positivo del 99,5% y un valor predictivo negativo del 94.09%.Conclusiones: la escanografía de tórax de alta resolución es una herramienta útil para el abordaje del paciente con enfermedad pulmonar. Tiene una alta capacidad para detectar lesión pulmonar, proponer diagnósticos diferenciales y orientar el sitio más adecuado para tomar una biopsia. Es importante interpretar el estudio con información clínica que permita realizar un abordaje diagnóstico exitoso.

Preoperative cardiac risk assessment for noncardiac surgery

Coronary artery disease (CAD) represents an important risk in patients undergoing elective noncardiac surgical procedures, in whom the stress of surgery and postoperative recovery can represent a significant ischemic burden. Population considerations: Preoperative cardiac assessment should be based on the prevalence of CAD (if known) in the population undergoing the procedure and the institutional event rate for the procedure. Procedures considered high-risk are vascular, intra-abdominal or thoracic, major orthopedic, and any emergency procedures. Individual considerations: Clinical history: A history of angina, congestive heart failure, diabetes mellitus, prior myocardial infarction, ventricular ectopy, and/or elderly (age > 70) are clinical parameters of increased risk. Functional capacity: Good functional capacity is the ability of a 50–70-year-old patient to achieve 6–8 METS of activity without significant symptoms of dyspnea on exertion. Further noninvasive testing: Preoperative testing may include routine treadmill exercise testing, ambulatory ECG monitoring, echocardiographic stress testing with dobutamine or exercise, and/or thallium perfusion imaging. Strategy for high risk patients: Assessing the severity of an abnormality (e.g., with thallium) results in a small percentage of positive test results yielding a high positive predictive value for events. Therefore, more aggressive interventions should be reserved for the most abnormal noninvasive test results, and the severity of the risk assessment should impact the timing of any coronary revascularization procedure, not the decision to proceed to more invasive testing and therapies. In summary, it is important to realize that most of the patients being screened, even vascular surgery patients (with high prevalence of CAD and procedural risk), will be found suitable to go to surgery without additional invasive intervention and cardiac revascularization. Thus good functional capacity and absence of cardiac risk factors should direct 30–40% of this population to elective surgery without further evaluation. The finding of high-risk perfusion scan abnormalities appears to be limited to 15–20% of those patients being recommended for further noninvasive testing. Coronary artery disease (CAD) represents an important risk in patients undergoing elective noncardiac surgical procedures, in whom the stress of surgery and postoperative recovery can represent a significant ischemic burden. Population considerations: Preoperative cardiac assessment should be based on the prevalence of CAD (if known) in the population undergoing the procedure and the institutional event rate for the procedure. Procedures considered high-risk are vascular, intra-abdominal or thoracic, major orthopedic, and any emergency procedures. Individual considerations: Clinical history: A history of angina, congestive heart failure, diabetes mellitus, prior myocardial infarction, ventricular ectopy, and/or elderly (age > 70) are clinical parameters of increased risk. Functional capacity: Good functional capacity is the ability of a 50–70-year-old patient to achieve 6–8 METS of activity without significant symptoms of dyspnea on exertion. Further noninvasive testing: Preoperative testing may include routine treadmill exercise testing, ambulatory ECG monitoring, echocardiographic stress testing with dobutamine or exercise, and/or thallium perfusion imaging. Strategy for high risk patients: Assessing the severity of an abnormality (e.g., with thallium) results in a small percentage of positive test results yielding a high positive predictive value for events. Therefore, more aggressive interventions should be reserved for the most abnormal noninvasive test results, and the severity of the risk assessment should impact the timing of any coronary revascularization procedure, not the decision to proceed to more invasive testing and therapies. In summary, it is important to realize that most of the patients being screened, even vascular surgery patients (with high prevalence of CAD and procedural risk), will be found suitable to go to surgery without additional invasive intervention and cardiac revascularization. Thus good functional capacity and absence of cardiac risk factors should direct 30–40% of this population to elective surgery without further evaluation. The finding of high-risk perfusion scan abnormalities appears to be limited to 15–20% of those patients being recommended for further noninvasive testing.

Preoperative cardiac risk assessment for noncardiac surgery

Coronary artery disease (CAD) represents an important risk in patients undergoing elective noncardiac surgical procedures, in whom the stress of surgery and postoperative recovery can represent a significant ischemic burden. Population considerations: Preoperative cardiac assessment should be based on the prevalence of CAD (if known) in the population undergoing the procedure and the institutional event rate for the procedure. Procedures considered high-risk are vascular, intra-abdominal or thoracic, major orthopedic, and any emergency procedures. Individual considerations: A history of angina, congestive heart failure, diabetes mellitus, prior myocardial infarction, ventricular ectopy, and/or elderly (age > 70) are clinical parameters of increased risk. Functional capacity: Good functional capacity is the ability of a 50-70-year-old patient to achieve 6-8 METS of activity without significant symptoms of dyspnea on exertion. Further noninvasive testing: Preoperative testing may include routine treadmill exercise testing, ambulatory ECG monitoring, echocardiographic stress testing with dobutamine or exercise, and/or thallium perfusion imaging. Strategy for high risk patients: Assessing the severity of an abnormality (e.g., with thallium) results in a small percentage of positive test results yielding a high positive predictive value for events. Therefore, more aggressive interventions should be reserved for the most abnormal noninvasive test results, and the severity of the risk assessment should impact the timing of any coronary revascularization procedure, not the decision to proceed to more invasive testing and therapies. In summary, it is important to realize that most of the patients being screened, even vascular surgery patients (with high prevalence of CAD and procedural risk), will be found suitable to go to surgery without additional invasive intervention and cardiac revascularization. Thus good functional capacity and absence of cardiac risk factors should direct 30-40% of this population to elective surgery without further evaluation. The finding of high-risk perfusion scan abnormalities appears to be limited to 15-20% of those patients being recommended for further noninvasive testing.