Careful Perioperative Management Research Articles

Surgical Strategies in Total Colonic Aganglionosis: Primary Pullthrough-Pathway of Care

Background: Total colonic aganglionosis, as a rare variant of Hirschsprung Disease, still poses challenges to surgeons in terms of diagnosis and management. The optimal preparation for pullthrough is crucial for reconstructive surgery. This study aims to explore our surgical pathway for children with total colonic aganglionosis (TCA) and to describe the prehabilitation necessary to prepare for successful reconstructive pullthrough surgery. Methods: A prospective review of children with TCA receiving an abdominal surgical intervention between 1/22 and 4/24. The cohort included children receiving mapping +/− primary ileoanal pullthrough. An analysis of preoperative, perioperative, and postoperative data, and a short-term follow-up were performed. Results: A total of 18 children with TCA and no prior pullthrough received an abdominal intervention during the 29-month study period, and 5/18 (27.8%) were female. The children had a median of 4 (range 2–7) prior external surgeries; all had a stoma; 6 (33%) children received parental nutrition; 12 children underwent a mapping of the ganglia distribution and bowel length at a median age of 11 months (range 3–54), and in 10 of them, we relocated the stoma. There was a mean involvement of 15 (5–93) cm small bowel aganglionosis, with the remaining mean ganglionic small bowel having a length of 178 cm (110–254). A total of 11 children underwent straight primary ileoanal pullthrough of the stoma site at a median age of 16.7 months (10–133). Conclusions: The timely diagnosis of TCA still challenges the care team, and most children have a rough journey involving several surgeries until their diagnosis is established. The ensure bowel function with an adequate working stoma is the key to enabling enteral nutrition and growth, which are the baseline requirements to undertake a successful pullthrough procedure and restore continuity. Careful perioperative bowel management and parents’ active involvement supports children with Hirschsprung Disease achieving the best possible quality of life.

National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer.

Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission. All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest. Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32). AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.

Tracheostomy for the pediatric patient with fibrodysplasia ossificans progressiva: a case report

BackgroundFibrodysplasia ossificans progressiva (FOP) is an extremely rare connective tissue disease characterized by subsequent ossification of skeletal muscles, tendons, ligaments, and other fibrous tissues. The ossification of these tissues progresses during childhood and leads to limb and trunk deformities. Since any surgery may trigger subsequent ossification, it is relatively contraindicated for patients with FOP. In this report, we describe our experience in performing tracheostomy in a pediatric patient with FOP who developed a restrictive respiratory disorder due to progressive deformity of the trunk.Case presentationA 12-year-old boy, diagnosed with FOP at the age of one, was referred for a tracheotomy after requiring 2 months of oral intubation and mechanical ventilation due to severe deformity-induced dyspnea. After changing from oral intubation to nasal intubation, we carefully considered the indications and benefits of tracheostomy in patients with FOP. Eventually, tracheostomy was successfully performed using our surgical design: creating a skin incision at the level of the cricoid cartilage that can always be identified, creating inverted U-shaped incision on the anterior tracheal wall to make a flap, and suturing the entire circumference of the tracheotomy and skin. One month after the surgery, he regained normal breathing and pronunciation and returned to school. The patient showed no unfavorable postoperative outcomes over a 4-year follow-up period.ConclusionsTracheostomy in our pediatric case of FOP required careful perioperative management. However, it could effectively improve the patient’s quality of life.

Risk factors for anastomotic leakage after low anterior resection for obese patients with rectal cancer.

We aimed to analyze the risk factors for anastomotic leakage (AL) after low anterior resection (LAR) in obese patients (body mass index [BMI] ≥ 25kg/m2) with rectal cancer. Data were collected from four hundred two obese patients who underwent LAR for rectal cancer in 51 institutions. Forty-six (11.4%) patients had clinical AL. The median BMI (27kg/m2) did not differ between the AL and non-AL groups. In the AL group, comorbid respiratory disease was more common (p = 0.025), and the median tumor size was larger (p = 0.002). The incidence of AL was 11.5% in the open surgery subgroup and 11.4% in the laparoscopic surgery subgroup. Among the patients who underwent open surgery, the AL group showed a male predominance (p = 0.04) in the univariate analysis, but it was not statistically significant in the multivariate analysis. Among the patients who underwent laparoscopic surgery, the AL group included a higher proportion of patients with comorbid respiratory disease (p = 0.003) and larger tumors (p = 0.007). Comorbid respiratory disease and tumor size were risk factors for AL in obese patients with rectal cancer. Careful perioperative respiratory management and appropriate selection of surgical procedures are required for obese rectal cancer patients with respiratory diseases.

Assessment of the Physical Invasiveness of Peroral Endoscopic Myotomy during the Perioperative Period Based on Changes in Energy Metabolism.

A novel treatment method for achalasia of the esophagus and related disorders is known as peroral endoscopic myotomy (POEM). This study aimed to calculate the resting energy expenditure (REE) and evaluated the degree of physical invasiveness based on metabolic changes during the perioperative period of POEM. Fifty-eight patients who underwent POEM were prospectively enrolled; REE, body weight (BW), and basal energy expenditure were measured on the day of POEM, postoperative day 1 (POD 1), and three days after POEM (POD 3). The median REE/BW increased from 19.6 kcal/kg on the day of POEM to 24.5 kcal/kg on POD 1. On POD 3, it remained elevated at 20.9 kcal/kg. The stress factor on POD 1 was 1.20. Among the factors, including the Eckardt score, operation time, and the length of myotomy, the length of myotomy was associated with changes in REE/BW. During the perioperative period of POEM, the level of variation in energy expenditure was lower than that of esophageal cancer surgeries performed under general anesthesia. However, because the length of myotomy is a factor affecting changes in energy expenditure, careful perioperative management is desirable for patients with longer myotomy lengths.

Perioperative Management in Pulmonary Endarterectomy.

Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.

Sudden mode change of permanent pacemaker during living donor liver transplantation.

Pacemakers assist circulation by generating electrical impulses. Patients with pacemakers scheduled to undergo surgery are vulnerable to device-related complications. Therefore, careful perioperative management is required to prevent undesirable events. A 66-year-old man with alcohol-related hepatocellular carcinoma was referred for liver transplantation. The pacemaker was inserted preoperatively to manage sick sinus syndrome and paroxysmal atrial fibrillation. Overall liver transplantation was performed without any adverse events. However, the pacemaker suddenly failed to provide regular pacing rhythm during abdominal closure. Fortunately, the native heart rate was maintained above 70 beats per minute and blood pressure did not fluctuate after pacing failure. After retrospective analysis, the duration setting of preoperative pacemaker reprogramming (24 h) was revealed as the cause of unexpected pacing failure. Anesthesiologists should be alert in patients with pacemakers because minor errors may lead to inadvertent failure of pacing or severe hemodynamic instability.

The impact of standardized perioperative care management on improving outcomes in patients with peptic ulcer disease.

The present study investigated the impact of standardized perioperative nursing management on improving outcomes in patients with peptic ulcer disease. A total of 90 patients with peptic ulcers were admitted to the Wuhan Wuchang Hospital between July 2020 to July 2022. These patients were included in the present study. They were divided into 2 groups based on the nursing management that they received, with 45 patients classified into each group. The control group received routine nursing care, while the observation group received standardized perioperative nursing management. The improvement in clinical symptoms, recurrence rate, negative emotions and disease management capacity were compared between the 2 groups. The results demonstrated that the improvement rate of clinical symptom in the observation group was significantly higher as compared with the control group (P < .05). The recurrence rate in the observation group was significantly lower than in the control group (P = .026). Patients in the observation group had better psychological status, and better disease management capacity as compared with those in the control group (P < .05). The application of standardized perioperative nursing management for patients with peptic ulcer can help improve the patients' clinical symptoms, enhance their disease management capacity, reduce anxiety, and ensure the quality of nursing care.

Intraoperative Infusion of Dextran Confers No Additional Benefit after Carotid Endarterectomy but Is Associated with Increased Perioperative Major Adverse Cardiac Events

Intraoperative dextran infusion has been associated with reduction of an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions including anaphylaxis, hemorrhage, cardiac and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of intraoperative dextran infusion using a large multi-institutional dataset. Patients undergoing CEA between 2008 and 2022 from the Vascular Quality Initiative database were reviewed. Patients were categorized by use of intraoperative dextran infusion, and demographics, procedural data and in-hospital outcomes were compared. Logistic regression analysis was utilized to adjust for differences in patients while assessing the association between postoperative outcomes and intraoperative infusion of dextran. Of 140,893 patients undergoing CEA, 9,935 (7.1%) patients had intraoperative dextran infusion. Patients with intraoperative dextran infusion were older with lower rates of symptomatic stenosis (24.7% vs 29.3%; P<0.001) and preoperative use of antiplatelets, anticoagulants and statins. Additionally, they were more likely to have severe carotid stenosis (> 80%; 49% vs 45%; P<0.001) and undergo CEA under general anesthesia (96.4% vs 92.3%; P<0.001) with more frequent use of shunt (64.4% vs 49.5%; P<.001). After adjustment, multivariable analysis showed that intraoperative dextran infusion was associated with higher odds of in-hospital major adverse cardiac events (MACE) including myocardial infarction (MI; odds ratio [OR], 1.76, 95% confidence interval [CI]: 1.34-2.3, P<0.001), congestive heart failure (CHF; OR, 2.15, 95% CI: 1.67-2.77, P=0.001) and hemodynamic instability requiring vasoactive agents (OR, 1.08, 95% CI: 1.03-1.13, P=0.001). However, it was not associated with decreased odds of stroke (OR, 0.92, 95% CI: 0.74-1.16, P=0.489) or death (OR, 0.88, 95% CI: 0.58-1.35, P=0.554). These trends persisted even when stratified by symptomatic status and degree of stenosis. Intraoperative infusion of dextran was associated with increased odds of MACE including MI, CHF and persistent hemodynamic instability without decreasing the risk of stroke perioperatively. Given these results, judicious use of dextran in patients undergoing CEA is recommended. Furthermore, careful perioperative cardiac management is warranted in select patients receiving intraoperative dextran during CEA.

Biomarkers as predictors of inpatient mortality in fractured neck of femur patients

IntroductionHip fractures are common and it is estimated to cost the National Health Service (NHS) around £2 billion/year. The majority of these patients are elderly and they require careful perioperative management as morbidity and mortality are high. This study aims to look at routinely gathered biomarker data and baseline demographics to evaluate if they may be used to predict inpatient mortality. Patients and methodsThe study included 2158 patients from a single Centre over a 5-year period. Inclusion criteria: age>60, confirmed fractured neck of femur on radiological imaging. Exclusion criteria: pathological fractures, patients treated non-operatively, missing data. Univariate followed by multivariate analysis was conducted to identify the independent predictors of inpatient mortality. ResultsThe variables found to be independent predictors of inpatient mortality were: age > 85, sex (male), albumin < 35, lymphocytes < 1, American Society of Anesthesiologist (ASA) grade > 3. For the final derived multivariate logistic regression model, a receiver operator characteristic (ROC) curve was constructed to assess the ability of the included variables to predict inpatient mortality. The area under the curve was 0.794 which together with sensitivity of 63.2% and a specificity of 79.1% at a cut value of 0.1. ConclusionThis paper supports research previously conducted in this field, showing the prognostic value of both biomarker (albumin and lymphocytes), and non-biomarker data (ASA grade, age and gender) in predicting mortality in patients who have sustained a hip fracture.

Limb outcomes based on limb severity and anatomic complexity following infrapopliteal vein bypass for Japanese patients with chronic limb-threatening ischemia

ObjectiveThe 2019 Global Vascular Guidelines recommend a suitable initial revascularization method with reference to limb severity (wound, ischemia, and foot infection [WIfI] stage) and anatomic complexity (Global Limb Anatomical Staging System [GLASS] stage). However, limb outcomes after revascularization among WIfI and GLASS stages have not been investigated fully after infrapopliteal vein bypass. The purpose of this study was to assess the four Global Vascular Guideline-recommended limb outcomes after infrapopliteal vein bypass in cases with different WIfI and GLASS stages. MethodsPatients who underwent infrapopliteal vein bypass for chronic limb-threatening ischemia at a single center were analyzed retrospectively. Medium-term limb outcomes were compared among WIfI and GLASS stages. The primary end points were limb salvage rate and major to minor amputation ratio, and the secondary end points were wound healing rate and wound healing time. ResultsA total of 353 infrapopliteal vein bypasses were performed in 284 patients with tissue loss (male, 193 patients; median age, 77 years; diabetes, 71%; hemodialysis, 41%). A total of 111 limbs (31%) required only minor amputation and 38 limbs (11%) required major amputation. The major to minor amputation ratio was 0.34 with no significant differences among WIfI stages or GLASS stages. The 3-year limb salvage rate was 87%. This rate was significantly lower in WIfI stage 4 than in stage 2 (P = .049), but did not differ significantly among GLASS stages. The 12-month wound healing rate was 86%. This rate was also significantly lower in WIfI stage 4 than in stages 2 and 3 (both P < .001), but did not differ significantly among GLASS stages. The median wound healing time was 55 days (range, 32-110 days), and was significantly longer in WIfI stage 4 compared with stages 2 (P = .001) and 3 (P < .001), but showed no significant differences among GLASS stages. ConclusionsThe limb salvage rate, wound healing rate, and wound healing time were associated with limb severity (WIfI stage), but not with anatomic complexity (GLASS stage). These findings suggest that an appropriate preoperative strategy and careful perioperative management are important for patients with greater limb severity.

Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results

IntroductionEnhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery. Material and methodsA multidisciplinary group created the programme and the patient school (preoperative consultations where the patients’ surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D). ResultsOne hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively. ConclusionsThe ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.

471. OUTCOMES OF RETROSTERNAL RECONSTRUCTION ROUTE FOR ESOPHAGECTOMY IN ESOPHAGEAL CANCER PATIENTS IN OUR HOSPITAL

Abstract In cervical esophagogastric anastomosis after esophagectomy for esophageal cancer, the main reconstructive routes are retrosternal and posterior mediastinal. Since April 2019, the retrosternal route has been the standard procedure at our hospital. We report on the results of reconstruction by a retrosternal route at our hospital. This study included 38 patients with esophageal cancer (squamous cell carcinoma) who underwent resection and reconstructed by the retrosternal route between April 2019 and March 2021. We evaluated the short-term postoperative outcomes of these patients. All the reconstructed organs were the gastric tube. The anastomosis method was a Circular stapler: 33 cases and a Linear stapler: 5 cases. The median start of oral intake after surgery was 3 days, and the median postoperative length of stay was 16 days. Perioperative complications of Clavien-Dindo classification grade 3 or higher occurred in 4 cases: anastomotic leakage grade IIIa: 3 cases and grade IVa: 1 case. Complications within 1 month after the operation were anastomotic stenosis grade IIIa in 1 case, and within 6 months were anastomotic stenosis grade IIIa in 2 cases. In our department, anastomotic leakage of a retrosternal route reconstruction was about 10%, which was similar to the domestic data (all reconstruction route). The stylization of surgical techniques and instruments used contributes to the reduction of postoperative complications, especially anastomotic leakage. In addition to establishing surgical techniques, careful perioperative management including rehabilitation and nutritional management is also important for preventing complications.

Canine phaeochromocytoma: diagnosis and surgical management

Although pheochromocytomas are uncommon in dogs, awareness of this type of adrenal tumour is important because of the life-threatening consequences related to their functionality. Pheochromocytomas may periodically produce catecholamines, accounting for many of the intermittent clinical signs seen, the inconsistent nature of which can make pheochromocytomas challenging to diagnose. The treatment of choice is surgical excision and optimal outcome relies on careful perioperative medical management to decrease the anaesthetic risk associated with paroxysmal release of catecholamines during surgical manipulation. Both surgical and anaesthetic management can be extremely challenging in cases of pheochromocytoma. However, in cases in which metastasis has not occurred, good survival times are achievable.

The management of cataract surgery in diabetic patients.

A cataract in the eye is a major cause of vision loss in diabetic patients, which occurs earlier and develops faster than non-diabetic patients, and often requires surgery for treatment. However, diabetic patients undergoing cataract surgery have a higher risk of intraoperative and postoperative complications than non-diabetic patients. For diabetic patients undergoing any surgery, careful perioperative assessment and management are required to reduce postoperative complications and improve surgical outcomes. Better understanding of their needs may guide perioperative practitioners to manage their care appropriately. This article presents recent evidence and guidance associated with the preoperative, intraoperative and postoperative management of diabetic patients undergoing cataract surgery and to inform perioperative practitioners of the challenges and potential complications to provide the best care and improve sight.

Preoperative Risk Factors Affecting Outcome in Surgically Treated Pyogenic Spondylodiscitis.

Retrospective study. The primary aim of this study was to investigate the predictors of severe complications in patients following surgery for pyogenic spondylodiscitis (PS) using a surgeon-maintained database. The secondary aim was to investigate the predictors of early recovery. We introduced a surgeon-maintained database of prospectively collected multicenter data that mainly focused on perioperative complications in 2012. Our surgeon-maintained database allows the retrospective collection of detailed data. We analyzed 143 patients who underwent surgery for PS from the 19,056 patients in the prospective surgeon-maintained database at 27 affiliated institutions between 2013 and 2017. Data relating to preoperative patient factors, infection factors, surgical factors, and pre- and postoperative blood tests was retrospectively collected. We performed multivariate regression analysis to evaluate the predictors of postoperative severe complications and early recovery in patients with PS. High updated Charlson comorbidity index (uCCI), chronic pulmonary disease, diabetes, Gram-negative bacteria, pyogenic osteoarthritis, high preoperative white blood cell count, and low preoperative platelet count were significantly associated with severe complications in patients undergoing surgery for PS. A high uCCI was the sole independent negative predictor on early recovery. Careful perioperative management is necessary if surgery is performed on patients who are at a high risk of life-threatening events.

Laparoscopic splenectomy and devascularization for massive splenomegaly in portal hypertensive patients: a retrospective study of a single surgical team's experience with 6-year follow-up data.

BackgroundIn China, laparoscopic splenectomy and esophagogastric devascularization (LSED) are effective and safe tools that are used to treat esophageal-fundic variceal bleeding with portal hypertension (PHT) with minimal trauma; however, due to the increased difficulty of operation, their application in massive splenomegaly (MS) remains limited. This study sought to determine the efficacy and safety of LSED in treating MS patients with PHT.MethodsThe data of 124 patients who underwent LSED by a single surgical team at our department from January 2015 to December 2020 were retrospectively analyzed. The characteristics of the patients, perioperative parameters, and long-term follow-up data were examined.ResultsA total of 61 MS and 63 mild-to-moderate splenomegaly (MMS) patients underwent LSED. Much larger spleen and significant lower of white blood cells and platelets was found in MS group compared the MMS group preoperation (P<0.05). The MS group had a significantly longer operation time (P=0.009), more blood loss (P=0.003), and more abdominal drainage days (P=0.017) than the MMS group. Four patients in the MS group and 0 patients in the MMS group were converted to open surgery. No significant difference was found between the 2 groups in terms of postoperative complications. Nine patients in the MMS group and 10 in the MMS group experienced recurrent bleeding in the follow-up period, but no significant differences were observed in terms of recurrent bleeding and overall survival (OS) between the 2 groups.ConclusionsLSED can be used to treat MS patients with PHT under careful perioperative management. For experienced surgeons, LSED is a safe, feasible, and minimally invasive procedure with satisfactory long-term outcomes that can be used to treat MS patients with PHT.KeywordsLaparoscopic splenectomy (LS); massive splenomegaly (MS); devascularization; portal hypertension (PHT)

Analysis of Risk Factors for Perioperative Acute Kidney Injury and Management Strategies.

Acute kidney injury (AKI) is a serious clinical syndrome, and one of the common comorbidities in the perioperative period. AKI can lead to complications in surgical patients and is receiving increasing attention in clinical workup. In recent years, the analysis of perioperative risk factors has become more in-depth and detailed. In this review, the definition, diagnosis, and pathophysiological characteristics of perioperative AKI are reviewed, and the main risk factors for perioperative AKI are analyzed, including advanced age, gender, certain underlying diseases, impaired clinical status such as preoperative creatinine levels, and drugs that may impair renal function such as non-steroidal anti-inflammatory drugs (NASIDs), ACEI/ARB, and some antibiotics. Injectable contrast agents, some anesthetic drugs, specific surgical interventions, anemia, blood transfusions, hyperglycemia, and malnutrition are also highlighted. We also propose potential preventive and curative measures, including the inclusion of renal risk confirmation in the preoperative assessment, minimization of intraoperative renal toxin exposure, intraoperative management and hemodynamic optimization, remote ischemic preadaptation, glycemic control, and nutritional support. Among the management measures, we emphasize the need for careful perioperative clinical examination, timely detection and management of AKI complications, administration of dexmedetomidine for renal protection, and renal replacement therapy. We aim that this review can further increase clinicians' attention to perioperative AKI, early assessment and intervention to try to reduce the risk of AKI.

Giant occipital encephalocele: a case report, surgical and anesthetic challenge and review of literature

BackgroundAn encephalocele is a congenital neural tube defect characterized by herniation of cranial contents through a defect in the cranium and is caused by failure of the closure of the cranial part of the developing neural tube. An encephalocele is termed as “giant encephalocele” when the size of encephalocele is larger than the size of the head. They depend on size of the sac, percentage of neural tissue content, hydrocephalus, infection, and other associated pathologies for a favorable neurological outcome.Case presentationWe report a case of a four-month-old boy with a giant occipital encephalocele measuring 21 × 15 × 19 cm in size, which was a surgical and anesthetic challenge for us. Intubation was achieved in lateral position. Part of occipital and cerebellar parenchyma was present in the sac and bony defect was approximately 2.5 cm in occipital bone in midline. We performed surgical excision and repair with a good overall outcome.ConclusionPerioperative management of a giant occipital encephalocele is a challenge for both anesthesiologists and neurosurgeons. Managing such a case demands a search for other congenital abnormalities, expertise in handling airway, and proper intraoperative care. Careful planning and perioperative management are essential for a successful outcome.

Risk factors for prolonged ventilation after the modified Fontan procedure.

To investigate the risk factors associated with prolonged ventilation after Fontan surgery. Retrospective case series. Tertiary childrens hospital. We included 123 children who underwent Fontan surgery without delayed sternal closure or extracorporeal membrane oxygenation between 2011 and 2017. Fontan surgery. Prolonged ventilation was defined as intubation for more than 24 hours after surgery. Preoperative, intraoperative, and perioperative data were collected retrospectively from medical records. Multivariate logistic regression analysis was used to identify risk factors for prolonged ventilation. The median age and weight of patients were 2.2 years and 10.0 kg, respectively. Seventeen per cent of the patients (n = 21) received prolonged mechanical ventilation, and the median intubation period was 2.9 days. There were no 90-day or in-hospital deaths. The independent predictors of prolonged ventilation identified were fenestration (p < 0.01), low pulmonary artery index (p = 0.02), and advanced atrioventricular regurgitation (p < 0.01). The duration of ICU stay was significantly longer in the prolonged ventilation group than in the early extubation group (10 days versus 6 days, p < 0.01). Fenestration, low pulmonary artery index, and significant atrioventricular regurgitation are risk factors for prolonged ventilation after Fontan surgery. Careful preoperative and perioperative management that considers the risk factors for prolonged ventilation in each individual is important.