Complicated Perioperative Course Research Articles

Treatment of Esophageal Atresia in Germany: Analysis of National Hospital Discharge Data From 2016 to 2022

BackgroundEsophageal atresia (EA) is a complex malformation. Multidisciplinary management is necessary, with the operative repair being the most challenging step in the treatment algorithm. The complete care structure for children with EA in Germany has not been analyzed yet. MethodsIn the observed period 2016–2022, inpatient EA cases were analyzed 1) during the hospital stay of birth, and 2) during the hospital stay of corrective surgery in patients aged up to 365 days, both based on national hospital discharge data. Patients’ comorbidities, hospital caseload, treatment characteristics (e.g. surgical approach) and outcome parameters were analyzed. Results1) 1190 newborn EA cases were treated in 260 hospitals during the perinatal period. 54% had at least one additional malformation, and 16% had a birthweight below 1500 g. In-hospital mortality was 8.4%.2) 1475 corrective operations for EA were performed in 111 hospitals with a consistent median annual caseload of 2 (P25–P95 1–8) per hospital. At least one indicator for a complicated perioperative course was documented in 63.7% of cases. The use of bronchoscopy was coded in 50% of cases. Median ventilation time during the entire hospital stay was 176 h (P25–P95: 95–1759 h). ConclusionsNewborns with EA are complex and early postoperative complications are common. The care structure is decentralized, and there was no trend towards centralization in the observed period. The low documented use of bronchoscopy is noteworthy. Centralization of the highly complex and schedulable corrective surgery for EA is necessary to evaluate outcomes and might improve the quality of care and resource utilization. Category of the manuscript and type of studyoriginal article, observational cross-sectional study, secondary data analysis.

Index Admission Cholecystectomy for Biliary Colic Precludes the Risk of Readmissions with Biliary Complications and should be Standard Treatment

BackgroundEmergency biliary colic admissions can be managed with an index or elective laparoscopic cholecystectomy (LC). Opting to perform an elective LC may have significant repercussions such as the risk of readmissions before operation with further attacks or with biliary complications (e.g. cholecystitis, pancreatitis, choledocholithiasis). The risk of readmission and biliary complications in patients admitted with biliary colic but scheduled for elective surgery has never been investigated. The secondary aim was to compare rates of peri-operative morbidity between the index admission, elective and readmission LC cohorts.MethodAll patients admitted with a diagnosis of biliary colic over a 5-year period and proceeding to LC were included in the study (n = 441). The risk of being readmitted and suffering further morbidity whilst awaiting elective LC was investigated. Peri-operative morbidity was compared between the index admission, elective and readmitted LC groups using univariate and multivariate analysis.ResultsFollowing a biliary colic admission, the risk of readmission whilst awaiting elective LC is significant (2 months-25%; 10 months-48%). In this group, the risks of subsequent biliary complications (18.0%) and the requirement for ERCP (6.5%) were significant. Patients who are readmitted before LC, suffer a more complicated peri-operative course (longer total length of stay, higher post-operative complications, imaging and readmission).DiscussionIndex admission LC for biliary colic avoids the significant risk of readmission and biliary complications before surgery and should be the gold standard. Readmitted patients are likely to have higher rates of peri-operative adverse outcomes. Patients should be counselled about these risks.

Investigational study of the clinical characteristics of confirmed COVID-19 cases

ABSTRACT Background: The COVID-19 is an emerging infectious disease that impacted HealthCare System worldwide and patients undergoing elective surgical procedures is associated with a high mortality rate and a complicated perioperative course. Methods: A retrospective observational study, the research design was conducted utilizing the RedCap ACS COVID-19 Registry and Cerner EMR. The intent of this design is to create statistical information about confirmed COVID-19 cases admitted in an academic institution in Brooklyn, New York from March to May 2020. Results: A total of 1413 patients were included in the final analysis. Of the 1413 patients, 520 Expired, 40.5% were males, and 33% were females, p = 0.004. Male patients had high mortality at a rate that is statistically significant. For race of those ‘Expired’, 38.3% white, 34.2% Black, 28.2% Asian, and Unknown 43.6%, showing statistical significance at p = 0.050. The most common co-morbidities for those not-Expired versus Expired: DM, 44.6% expired versus 55.6% not-expired, HTN, 77.1% versus 22.9%, and CAD, 47.9% versus 52.1%. Comparing the data of COVID-19 patients without surgery and with those who had surgery, it was observed that 53% of those who did not have surgery went ‘Home’ versus 38.6%, of those with surgery who could not. Further examining those without surgery versus those with surgery: 3.4% versus 13.3% discharge to ‘Rehab’, for ‘Other discharge’ destinations 5.9% versus 14.5%, and for ‘Expired’ 37.1% versus 31.3%. Overall, the presence of surgery had a significant impact on COVID-19 patients discharge destinations at p = < 0.001. Conclusions: The implications of change in the setting of our current clinical practice therefore require forbearance, training, preparedness, and education to efficiently maintain our essential surgical services.

Postoperative Prescription of Low-dose Narcotics Yields Equivalent Pain Outcomes Compared to High-dose Narcotics in Opioid-naïve Patients Undergoing Spine Surgery.

Retrospective cohort study at a single institution. Patients undergoing specific, elective spinal procedures between 2012 and 2018. The aim of thi stsudy was to investigate the relationship between opioid prescriptions during the immediate, post-discharge period, and patient-reported pain outcomes. Medically prescribed opiates contribute to the opioid crisis, manifesting in significant mortality and economic burden. Although opioids are a mainstay of pain amelioration following spinal surgery, prescription practices are heterogeneous. Inclusion criteria included: patients who underwent one of 10 spinal procedures (Table 1); patients with preoperative, postoperative day (POD 1, and POD 30 pain scores reported on the visual analog scale (VAS); patients discharged without a complicated perioperative course. Opioids were converted to morphine milligram equivalents per day (MME/day) using a standard reference table. χ2, Kruskal-Wallis, and logistic regression were utilized to investigate associations between clinical variables and postoperative pain scores. Univariate and multivariable linear regression models with Stepwise selection (cut off: P = 0.05) were employed as appropriate on POD 30 VAS pain scores. Smoking status and postoperative LOS were associated with opioid prescription doses. Patients prescribed opioids <40 MME/day, equivalent to five tablets of 5 mg oxycodone/day, showed no significant difference in POD 30 VAS score (β coefficient: 0.095, P = 0.752) when compared to patients who received the highest-dose opioids (>80 MME/day-equivalent to 10 tablets of 5 mg oxycodone/day). Adjusted multivariable logistic regression analysis revealed that postoperative opioid dosage/prescription was not a significant predictor of patients reporting at least 50% pain improvement, suggesting that 40 MME/day is sufficient to maintain patient satisfaction. Patients receiving the lowest dosage of opioid prescriptions with sufficient nonopiate analgesics did not report worse pain relief at POD 30 compared to those receiving higher opioid prescriptions. In light of the opioid epidemic, this study supports initial dosing recommendations by the American Society for Addiction Medicine.Level of Evidence: 3.

Baseline Lung Allograft Dysfunction after Lung Transplantation is Not Associated with Donor Factors

Purpose After lung transplantation (LTx), lung function usually increases over the first 12 months. The peak forced expiratory volume (FEV1) reached within this first year serves as the baseline value for the further clinical course and for CLAD diagnosis. However, in a number of patients FEV1 fails to increase to adequate levels and remains below 65% of the predicted value, a condition termed baseline lung allograft dysfunction (BLAD). Risk factors of BLAD and how it impacts survival and CLAD diagnosis are still poorly understood. Methods We analyzed patients receiving primary double LTx between January 2010 and December 2018 at our center. Lobar LTx, pediatric patients and patients lost within the first 12 months were excluded. Post-transplant lung function trajectories were analyzed. Patients who failed to reach normal lung function (defined as FEV1>65% of the predicted value) formed a BLAD group. A control group consisted of patients who achieved adequate FEV1-values. Demographics and outcome factors including length of mechanical ventilation, PGD and graft survival were compared. A binary logistic regression analysis of donor parameters was performed to determine risk factors of BLAD. Results Of 598 patients included in the study, 77 (12.9%) did not reach an adequate lung function. Patients in group I reached their best FEV1 sooner (median 61 days; IQR: 15-282) compared to the control group (median 296 days; IQR: 113-613) (p 20pyrs and organ ischemic time) reached statistical significance. Conclusion Although BLAD may complicate the diagnosis of CLAD, it was not associated with impaired long-term outcomes. Donor quality was not associated with BLAD but affected patients had a complicated perioperative course more often than control patients.

New computed tomographic predictors of complicated perioperative course of 17.5F mini-percutaneous nephrolithotomy (mini-PNL)

PurposeRadiological parameters predicting a postoperative stone-free status (SFS) or a complicated perioperative course of mini-PNL, are scarce. Our aim was to identify such factors for prone 17.5F mini-PNL.MethodsA monocentric cohort of 103 cases was retrospectively analysed for factors predicting SFS and relevant complications, i.e. Clavien–Dindo (CD) ≥ 2. Parameters measured on preoperative supine CT included maximal stone diameter, skin-to-stone distance (SSD), ideal tract length (ITL), access angle, minimal T12—Lower Kidney Pole distance (T12LP) and minimal Iliac Crest—Lower Kidney Pole distance (ICLP). Infundibulopelvic angle (IPA) was measured on intraoperative pyelography.ResultsThe median maximal stone diameter was lower in cases with postoperative SFS [16 mm (Min. 10; Max. 35) vs. 20 mm (Min. 6; Max. 85), p = 0.0052]. CD ≥ 2 was more frequent in cases with a bigger stone burden [19 mm (Min. 13; Max. 85) vs. 16 mm (Min. 6; Max. 49), p = 0.0056] and with the ribs in the access angle [7/23 (30.43%) vs. 8/76 (10.53%); p = 0.0454]. T12LP significantly differed in cases with and without CD ≥ 2 [80.48 mm (± 21.31) vs. 90.43 mm (± 19.42), p = 0.0397]; however, it had no influence on SFS (p > 0.05). SSD, ITL, IPA and ICLP were significant regarding neither SFS nor CD ≥ 2 prevalence (p > 0.05). Using multivariate logistic regression, T12LP was confirmed as an independent predictor on CD ≥ 2 prevalence.ConclusionsPreoperative computed tomographic factors indicating elevated kidney position influence perioperative course of mini-PNL. T12LP and the presence of ribs in the access angle are, apart from stone diameter, the most useful indicators for cases at risk of CD ≥ 2.

Epidemiology and risk factors for invasive fungal disease in liver transplant recipients in a tertiary transplant center.

Invasive fungal disease (IFD) in liver transplant recipients causes significant morbidity and mortality. We aim to describe institutional epidemiology and risk factors for IFD in the liver transplant population. We conducted a retrospective cohort study of all adult liver transplant recipients in our institution from 2005 to October 2015 to describe the epidemiology of patients with proven and probable IFD according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. To determine risk factors for IFD, a case-control study was also conducted. Cases were defined as liver transplant recipients with proven or probable IFD, and controls were defined as liver transplant recipients without IFD. Each case was matched to two controls by age (±10years of age), gender, and time of transplant (within one year of the case). 28/554 (5.1%) patients developed IFD. Candidiasis (n=11; 39.3%), Aspergillosis (n=10; 35.7%), and Cryptococcosis (n=3; 10.7%) were the most common fungal infections in the proven and probable IFD groups. Mold infections occurred in 13 (46.4%) cases. Reoperation, roux-en-y anastomosis, and massive intraoperative transfusion of ≥40 units of cellular blood products were major risk factors for IFD in the multivariate analysis. Candida and Aspergillus are the most common causes of IFD in liver transplantation in our center. There is significant overlap in risk factors for such infections post-transplantation. In our cohort, critically ill patients with complicated perioperative course seem to predispose them to mold infections post-transplantation, but larger studies are required to better delineate risk factors for mold infection as well as determine the efficacy and optimal duration of mold prophylaxis in liver transplantation. With increasing echinocandin use for antifungal prophylaxis, it is also important to monitor for emerging antifungal resistance.

Long-term outcomes after intraoperative extracorporeal membrane oxygenation during lung transplantation

Over the past decade, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass (CPB) for cardiopulmonary support during lung transplantation at our institution. In this study, we present our experience using intraoperative ECMO in isolated lung transplantation and evaluate its impact on long-term graft function and survival. All patients undergoing isolated lung transplantation with or without ECMO support between January 2010 and June 2019 were evaluated. Patients transplanted using CPB were excluded. Peri-operative and follow-up results from our database and patient charts were analyzed. Follow-up continued until September 1, 2019 (median, 3.34 years). In total, 311 of 1,161 lung transplant recipients (27%) received intraoperative ECMO, with 24 (2%) patients further requiring CPB. None of the remaining 826 (71%) patients required intraoperative cardiopulmonary support. ECMO patients exhibited higher pre-transplant surgical risk profiles and endured more complicated early post-operative courses than those without ECMO (in-hospital mortality, 10.9% vs 2.3%; p < 0.001). Inevitably, this resulted in poorer overall graft survival among ECMO recipients (p = 0.0025). However, correcting for patients surviving to hospital discharge, no difference in survival between groups was observed (5-year survival, 71% vs 72%; p = 0.56). Similarly, freedom from chronic lung allograft dysfunction, biopsy-confirmed cellular rejection, or need for pulsed-steroid therapy did not differ between the groups (p = 0.99, p = 0.78, and p = 0.93, respectively). Compared with patients not requiring cardiopulmonary support, ECMO recipients endured a more complicated peri-operative and early post-operative course. However, among those surviving to hospital discharge, no differences in long-term complications or outcomes were observed.

What's Important: A Call for a Preoperative Psychiatric Risk-Assessment Metric for Orthopaedic Surgery.

What's Important: A Call for a Preoperative Psychiatric Risk-Assessment Metric for Orthopaedic Surgery.

The Unique Clinical Phenotype and Exercise Adaptation of Fontan Patients With Normal Exercise Capacity

BackgroundExercise limitation is almost universal among Fontan patients. Identifying unique clinical features in the small fraction of Fontan patients with normal exercise capacity (high-capacity Fontan [HCF]) provides potential to inform clinical strategies for those with low exercise capacity (usual Fontan). MethodsWe performed a retrospective chart review of all patients with single-ventricle physiology palliated with a Fontan operation who underwent incremental cardiopulmonary exercise testing at Cincinnati Children’s Hospital Medical Center from 2013 to 2018. Comparison was between patients with peak oxygen uptake < vs ≥ 80% predicted. ResultsA total of 22 of 112 patients were classified as HCF (68% were female; aged 18 ± 7 years). During incremental exercise, peak oxygen uptake (86.1% ± 6.1% vs 62% ± 12.2% predicted; P < 0.001) was greater in HCF vs usual Fontan despite similar chronotropic impairment, resulting in a greater oxygen pulse in HCF. Pulmonary function, breathing reserve, and ventilatory equivalent for CO2 output slope were not different between groups. Those in the HCF group were more likely to self-report exercise ≥ 4 days/week for at least 30 minutes (77% vs 10%, P < 0.001), have normal systolic function (95% vs 74%, P = 0.003), have fewer postoperative complications (8% vs 36%, P = 0.04), and have shorter post-Fontan length of stay (8 ± 2.8 vs 12.4 ± 0.9 days, P = 0.04). ConclusionsApproximately 1 in 5 Fontan patients who undergo cardiopulmonary exercise testing have normal exercise capacity despite chronotropic impairment. This implies a better preserved stroke volume, perhaps due to greater muscle pump-mediated preload. Additionally, a complicated perioperative Fontan course is associated with eventual impaired functional capacity.

Sublingual microcirculation in pancreatico-biliary surgery: An observational study.

An observational cohort study was conducted to identify potential sublingual microcirculation parameters as a target for goal-directed fluid therapy. Patients that were scheduled for an open elective pancreatico-biliary surgery in Erasmus Medical Center were included. All patients underwent sublingual microcirculatory measurement at three time points: one day before surgery (T0), within the first 24 hours after surgery (T1) and on the fourth day after surgery (T2). The following parameters were obtained: microvascular flow index (MFI (AU)), Total vessels density (TVD (mm/mm2/)), Perfused vessels density (PVD (mm/mm2)), and proportion of perfused vessels (PPV (%)). Sixteen patients were included in the final analysis. The differences between the time points T1 and T0 in patients without clinical significant complication and in patients with these complications gave a significant difference for PVD small vessels (PVDs) (delta PVDs mean -0.1 vs -8.2, p=0.01) and PPV small vessels (PPVs) (delta PPVs median 7.0 % vs -15.5 %, p=0.01). The most significant microcirculatory parameter for a perioperative complicated course is the change of PVD and PPV. In the first 24 hours after surgery, if these parameters decrease there is a high chance of a complicated perioperative course.

Case report: Life-saving pulmonary endarterectomy for a young female with primary antiphospholipid syndrome complicated by severe chronic thromboembolic pulmonary hypertension

Abstract Background: Prothrombotic state and impaired clot dissolution can contribute to the occurrence of chronic thromboembolic pulmonary hypertension in primary antiphospholipid syndrome. Pulmonary endarterectomy - the surgical removal of the organized thromboembolic material from the proximal pulmonary arteries - is the procedure of choice and potentially a curative option for patients with chronic thromboembolic pulmonary hypertension, including patients with antiphospholipid syndrome. We report an exceptionally severe and complicated case with favourable outcome. Case presentation: We present a case of a successful high risk pulmonary endarterectomy in a 29-year-old female with primary antiphospholipid syndrome and end-stage chronic thromboembolic pulmonary hypertension. Despite highly complicated perioperative course an impressive improvement in symptoms and functional status was achieved. Conclusion: We hope that this complicated but successfully managed case of a combination of two rare diseases will arouse earlier suspicion and timely diagnosis for such patients and will encourage physicians to promptly refer the suitable patients to a pulmonary endarterectomy team. It is important to remember that severe thrombocytopenia may occur in patients with antiphospholipid syndrome

Do seminoma germ cell elements affect perioperative outcomes following post-chemotherapy retroperitoneal lymph node dissection for metastatic testis cancer?

378 Background: Post-chemotherapy retroperitoneal lymph node dissections (PC-RPLND) performed at high-volume centers are safe and comparable in risk to primary RPLNDs. The desmoplastic reaction encountered during PC-RPLND in patients with seminoma components increases the complexity of surgical dissection. We examined whether the presence of seminoma at diagnosis was associated with more adverse events in the perioperative setting. Methods: A single institution review board approved retrospective review identified 108 patients undergoing PC−RPLND from 1992 to 2012. All patients had received at least first-line cisplatin-based induction chemotherapy. Of these, 11 patients undergoing redo PC-RPLNDs were excluded from analysis. Patients were divided into two groups; those with any seminoma element in their orchiectomy or retroperitoneal specimens and those without seminoma elements. We performed independent t-tests and Chi-squared analysis of the data. Results: Of 97 patients undergoing PC-RPLND, 33 had seminoma components in their diagnostic specimens. Using the Clavien classification system to stratify post-operative complications, the percentage of seminomatous elements (less than 50% compared to more than 50%) within the primary tumor did not correlate with a higher incidence of complications; even when examining only major complications (p=0.673). There was a trend towards higher nephrectomy rate for tumors with seminoma elements compared to those without (27% vs. 8.5%, p = .058). The nephrectomy rate did show a dependence on the pathologic size of the residual mass regardless of histology (31% for more than 10 cm, 6.8% for 5 to 10 cm, 0% for 0 to 5 cm p = 0.021). There was also a trend towards blood loss greater than one liter for patients with seminoma elements compared to those without (63% vs. 43%, p = 0.078), while the transfusion rate was similar between the two groups (p=0.785). Post−operative length of stay was independent of a patient’s histology (p=0.94). Conclusions: PC-RPLND remains a safe and necessary therapeutic procedure. The presence of seminoma germ cell elements in our patient cohort did not result in a more complicated perioperative course surrounding PC-RPLND.

Using Small-for-Size Grafts in Living Donor Liver Transplantation Recipients with High MELD Scores Should Not Be Considered a Contraindication

The model for end-stage liver disease (MELD) system is a good tool to predict short-term mortality among living donor liver transplantation (AALDLT) recipients and has also been suggested to prohibited live liver donation for recipients with MELD scores[25 [1]. A partial liver graft transplanted into an adult recipient is often defined as a small-for-size graft. It is generally accepted that such graft would be tolerated when the graft-to-body weight ratio (GBWR) is higher than 0.8. However, transplanted liver will suffer small-for-size syndrome (SFSS) and irreversible damage when GBWR \0.8. In AALDLT, graft size and pre-transplant MELD scores are important factors for patient post-transplant survival [2]. Here we evaluated the outcome of using a SFSG in AALDLT recipients with different MELD scores in a single liver transplant center. Clinical data of 118 patients who had right-lobe AALDLT from January 2004 to December 2011 were retrospectively analyzed. According to MELD, patients were divided into group L (MELD score B25, n = 102) and group H (MELD score [25, n = 16). To analyze the risk of the graft size, the patients were further stratified into group LS (MELD score B25, GBWR\0.8, n = 23), group LN (MELD score B25, GBWR C0.8, n = 79), group HS (MELD score [25, GBWR \0.8, n = 5), and group HN (MELD score [25, GBWR C0.8, n = 11). MELD scores between the two groups were significantly different. There was no significant difference in preoperative demographic data as well as postoperative liver function data. The length of ICU and hospital stay, graft loss, and mortality were similar in both groups. Complication rate was also similar between two groups (10.8 vs 6.3 %, P = 1.000). The 1and 3-year survival rate were similar between group L and group H (85.2 vs 74 %, 78.9 vs 74 %, P = 0.692). After stratified into groups LS, LN, HS, and HN, there were no significant differences among groups in 1and 3-year survival rate. Multivariate analysis revealed that accompanied hepatocellular carcinoma (HCC), GBWR, and MELD scores did not predict the 1and 3-year survival rate. Recipients with high MELD scores usually have worse preoperative conditions and experience a more complicated peri-operative course. However, there are still debates on this subject. Hayashi et al. [3] reported that there was no correlation between the 1-year survival rate and MELD scores. According to Yi et al. [4], the 1-year survival rate without HCC was found to be similar between those two groups as well as the rate of postoperative complications. In our report, the postoperative complication rate, ICU and hospital stay length after AALDLT did not differ between recipients. Pneumonia was still the first cause of death. We attributed these advanced results to a high level of perioperative intensive care for high MELD score recipients. When using a graft with GBWR less than 0.8 in AALDLT, recipients possibly suffer postoperative irreversible liver damage. However, Yi et al. [4] also reported that a high MELD score ([25) was not an important predictor of the 1-year survival rate in cases with an SFSG. Reconstruction of the MHV is well known as an important factor to reduce the incidence of graft failure in an SFSG. In our study, although there was no significant difference in survival rates among groups with versus without MHV, we might H. Li B. Li (&) Department of Liver and Vascular Surgery, Center of Liver Transplantation, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China e-mail: doclibo@126.com

Preoperative computed tomography of the chest in lung cancer patients: the predictive value of calcified lymph nodes for the perioperative outcomes of video-assisted thoracoscopic surgery lobectomy

To determine the predictive value of identifying calcified lymph nodes (LNs) for the perioperative outcomes of video-assisted thoracoscopic surgery (VATS). Fifty-six consecutive patients who underwent VATS lobectomy for lung cancer were included. We evaluated the number and location of calcified LNs on computed tomography (CT). We investigated clinical parameters, including percentage forced expiratory volume in 1 s (FEV1%), surgery duration, chest tube indwelling duration, and length of hospital stay. We performed linear regression analysis and multiple comparisons of perioperative outcomes. Mean number of calcified LNs per patient was 0.9 (range, 0-6), mostly located in the hilar-interlobar zone (43.8 %). For surgery duration (mean, 5.0 h), FEV1% and emphysema severity were independent predictors (P = 0.010 and 0.003, respectively). The number of calcified LNs was an independent predictor for chest tube indwelling duration (P = 0.030) and length of hospital stay (P = 0.046). Mean duration of chest tube indwelling and hospital stay was 8.8 days and 12.7 days in no calcified LN group; 9.2 and 13.2 in 1 calcified LN group; 12.8 and 19.7 in ≥2 calcified LNs group, respectively. The presence of calcified LNs on CT can help predict more complicated perioperative course following VATS lobectomy.

Low and “supranormal” central venous oxygen saturation and markers of tissue hypoxia in cardiac surgery patients: a prospective observational study

To characterize incidence of low, normal and "supranormal" central venous oxygen saturation (ScvO(2)) and the relation to markers of tissue hypoxia, course and outcome in cardiac surgery patients. Prospective, observational study in a university multidisciplinary 50-bed intensive care unit including 205 consecutive patients undergoing elective cardiac surgery. Data were split into training and test data sets and subjected to 50 replications of fivefold cross-validation to estimate lower and upper bounds of ScvO(2) indicative of impaired tissue oxygenation. Both low (≤ 60.8%) and supranormal (≥ 77.4%) ScvO(2) were associated with an unfavorable course, while the logistic EuroSCORE for risk adjustment was comparable between groups. Incidences of abnormal ScvO(2) were 13.2% low and 30.7% supranormal. Patients with low ScvO(2) and an uneventful course initially presented with normal lactate levels, whereas patients with supranormal ScvO(2) displayed consistently higher serum lactate levels. High ScvO(2) values were associated with the use of β-mimetics and signs of systemic inflammation. Mortality rates were comparable for patient populations presenting either low (14.8%) or supranormal ScvO(2) (7.9%) and higher than normals (0%, p < 0.001). Lactate was comparably increased in patients that ultimately died, irrespective whether they had low or supranormal ScvO(2) values. In contrast, neither low nor supranormal ScvO(2) was associated with altered gastric pCO(2.) High ScvO(2) is an under-recognized warning sign for impaired tissue oxygenation in the peri-operative period. Including values ≥ 77.4% as 'normal' impaired performance of ScvO(2) monitoring to predict a complicated perioperative course.

High-Risk Surgery

Surgical morbidity is a significant public health issue worldwide. It is estimated that >230 million surgical procedures are performed each year, with an estimated mortality of at least 0.4% and morbidity of between 3% and 17%. Furthermore, there are potentially far-reaching consequences of a complicated perioperative course, because perioperative morbidity is associated with reduced long-term survival. In this review, we examine the factors that are associated with surgical outcomes. Issues related to the delivery of health care, such as structure, process, and resource utilization, have been shown to vary within and between institutions, leading to differences in both morbidity and mortality after surgery. Patient-related factors, in particular comorbid illness, functional capacity, and cardiovascular health, are also related to perioperative risk, and may be assessed using risk stratification models, exercise testing, and biomarker assays. The strengths and weaknesses of each of these techniques are discussed. We also review the strengths and limitations of the measures used to assess outcome after surgery, including patient-centered variables such as mortality and morbidity scores, and patient-related outcome measures. Finally, we suggest the direction of future work, which should be aimed at improving the precision of tools for describing perioperative risk, and of the measures used to assess the outcomes and quality of surgical health care. These tools are the building blocks of high-quality clinical trials, epidemiological studies, and quality improvement programs.

A Case of Thyroid Storm With Underlying Thyroid Carcinoma

We describe a case of a young man with thyroid storm and an underlying papillary thyroid carcinoma. This case highlights the importance of prompt recognition and treatment of thyrotoxic crisis and importance of screening for concurrent thyroid carcinoma. An 18-year-old previously healthy man was admitted with fever and left retro-orbital abscess. A diagnosis of thyroid storm was made based on physical examination and laboratory investigations. Patient underwent an urgent decompression of abscess. Septic shock, shock liver, DIC and renal failure complicated perioperative course. The patient was managed with supportive treatment and multiple medications, including propylthiouracil. Patient later underwent thyroidectomy and the biopsy showed a background pattern of Graves disease, Hurthle cells adenoma, and multicentric subcentimeter of papillary thyroid carcinoma. A brief literature review of thyroid neoplasm in Graves disease is described.

Caring for the orphan's orphan: treatment of patients with portopulmonary hypertension

Patients with portopulmonary hypertension (PPHTN) are incredibly unfortunate. By definition, these patients have portal hypertension, leading to well-known life-threatening gastrointestinal, neurological, infectious, haematological and renal complications requiring liver transplantation for cure. If this were not enough, these patients also have pulmonary arterial hypertension (PAH). The coexistence of portal hypertension and PAH frequently makes patients with this rare (or “orphan”) condition medical “untouchables”. PPHTN patients with progressive hepatic dysfunction and other complications are often deemed to be too “high-risk” for placement of a transjugular intrahepatic portosystemic shunt or liver transplantation, making them destined for a poor outcome. Even those who may be acceptable candidates for liver transplantation commonly face a complicated perioperative course. The situation is not much better from the vantage of their lung disease, despite these patients having the third most common form of PAH in a recent population-based epidemiological study from France 1. While there is some evidence regarding medications which should be avoided in PPHTN 2, therapeutic approaches used to treat other forms of PAH have never been trialled in PPHTN, are potentially complicated by coexistent liver disease, and are used in PPHTN without the evidence base which now exists for other types of PAH. Many individuals with PPHTN have a history of (or are currently) using alcohol or illicit drugs, addictions commonly linked to the aetiology of their liver disease, and some have HIV infection, all accompanied by significant social stigma. These comorbidities often further limit access to specialised centres and available treatments. The sum of these burdens and the high toll of the disease have proved significant obstacles to successful advocacy on behalf of this patient group. Who can blame industry sponsors, scientific advisory committees and regulatory boards for excluding these patients from clinical trials of new therapies for PAH? It is against …

Different Profiles of Patients Who Require Dialysis After Cardiac Surgery

This study was aimed at evaluating the determinants of postoperative dialysis-requiring acute renal failure and at identifying eventual correlations between the different etiologic mechanisms and postoperative prognosis. We evaluated the preoperative and intraoperative features of the 69 out of 6,542 consecutive cardiac surgery patients who developed postoperative dialysis-requiring acute renal failure at our Institution during a 10-year period. Age, valvular and aortic surgery, hypertension, extracardiac vasculopathy, timing of surgery, cardiopulmonary bypass time, and preoperative creatinine level greater than 2.0 mg/dL were identified as predictors by multivariate analysis. In a second analysis, patients were divided in two groups according to the preoperative creatinine level: group A (preoperative creatinine 2.0 mg/dL or less; 38 cases) and group B (preoperative creatinine 2.1 mg/dL or more; 31 cases). The two groups significantly differed in preoperative and intraoperative characteristics and in postoperative outcome: group A patients were younger, had a lower incidence of cardiac and vascular risk factors and comorbidities, were mainly operated on urgent or emergent basis for valvular or aortic pathologies, had longer cardiopulmonary bypass and cross-clamp time, and worse in-hospital outcome but higher midterm survival. Group B patients were older, had a higher prevalence of comorbidities, required more often in-hospital or after-discharge dialysis, had lower in-hospital mortality, but reduced midterm survival. Postoperative dialysis-requiring acute renal failure can be the result of two different pathophysiological pathways: complicated perioperative course due to urgent-emergent surgery or main intraoperative technical complications in patients with preoperative normal renal function and uncomplicated perioperative course associated with reduced preoperative kidney function. The two patient groups significantly differ in baseline preoperative features, as well as in in-hospital and in midterm outcome.