Fourth Postoperative Day Research Articles

Brucellosis Spondylodiscitis

Brucellosis is neglected but important zoonotic disease when it comes about spondylodiscitis. Here, we are presenting rare case of 54 years old male with brucellosis spondylodiscitis which is diagnosed by serum agglutinin test and had undergone L5-S1 Level discectomy with L5 Partial coprpectomy with L4-L5-S1 Screw and rod fixation for the same. Postoperative period was uneventful and he was discharged on fourth postoperative day with complete neurological recovery. Due to atypical presentation and prevalence of spinal tuberculosis, diagnosis of brucellosis is challenging but with proper investigation battery and right treatment, patient can be saved from greater morbidity. Keywords: Brucellosis; Spondylodiscitis; Zoonotic disease.

Postoperative Pain Treatment With Continuous Local Anesthetic Wound Infusion in Patients With Head and Neck Cancer

Up to 80% of patients with head and neck cancer undergoing ablative surgery and neck dissection develop postoperative pain with detrimental effects on quality of life that also contributes to neuropathic and chronic postoperative pain. To investigate the association of continuous local anesthetic wound infusion with pain management after head and neck surgery. This prospective, longitudinal, nonrandomized clinical study carried out in a single tertiary referral center (December 1, 2015, to July 1, 2017) included 2 groups of 30 patients. Patients were consecutively enrolled and presented for ablative head and neck surgery including selective neck dissection and studied from the preoperative through the fourth postoperative day. The control group was treated according to a standardized escalating oral treatment protocol (ibuprofen, metamizole, opioids). The intervention group was treated with an intraoperatively applied pain catheter (InfiltraLong plus FuserPump, Pajunk, ropivacaine, 0.2%, 3 mL/h) that was removed 72 hours after operating. Average and maximum pain intensities on a numeric rating scale; quality of life using the acute version of the validated 36-Item Short Form Survey; and neuropathic pain using the validated 12-Item painDETECT questionnaire. Consumption of opioid and nonopioid analgesics and evaluation of catheter-associated complications. During postoperative days 1 through 4, patients of the intervention group (mean [SD] age, 63.2 [13.3 years; 9 [30%] women) experienced lower mean (SD) (1.6 [1.4] vs 2.7 [1.8]; η2p = 0.09 [0.01-0.21]) and maximum (2.4 [2.2] vs 4.2 [2.0]; η2p = 0.11 [0.01-0.24]) pain intensities compared with the control group (mean [SD] age, 62.5 [13.6] years; 5 [17%] women). The intervention group also reported less neuropathic pain (mean [SD], 5.4 [3.4] vs 7.6 [5.1]; η2p = 0.09 [0.004 - 0.22]) and higher quality of life regarding vitality (56.2 [21.5] vs 43.8 [20.9], r = 0.29; 95% CI, 0.01-0.52) and pain (66.8 [27.3] vs 49.5 [27.7], r = 0.31; 95% CI, 0.04-0.54). Patients from the intervention group requested nonopioid analgesics considerably less often (n = 17 [57% ]vs n = 29 [97%]; ϕ = 0.47; 95% CI, 0.30-0.67) associated with a noticeably lower need to escalate pain treatment (n = 3 [10%] vs n = 9 [30%]; mean [SD] ibuprofen dose: 500 [173] mg vs 1133 [650] mg; r = 0.64; 95% CI, 0.02-0.91). No catheter-associated complications were observed. Continuous anesthetic wound infusion is associated with reduced postoperative pain and decreased demand for analgesics. It therefore expands the treatment options for postoperative pain in head and neck cancer. German Clinical Trials Register: DRKS00009378.

Isolated upper vaginal wall laceration in an underage: a need to re-examine child sexual abuse in South-South Nigeria.

<p>Child sexual abuse includes any sexual act between a minor and an adult, or between two minors, when one exerts power over the other. It involves forcing, coercing or persuading a child to engage in any type of sexual act. It also involves non-contact acts such as exhibitionism, exposure to pornography, voyeurism, and communicating in a sexual manner by phone or internet. An eight-year-old girl was rushed to the gynaecological emergency unit of the Federal medical centre, Yenagoa with complaints of a three-hour history of sudden onset vaginal bleeding following a fall astride in their house. There was no injury to the vulva and the child and her relatives denied any form of sexual abuse by anyone within or outside their home. She had examination under anaesthesia in theatre and a 3 cm laceration was identified at the proximal one-third of the left lateral wall of the vagina, covered with a blood clot; not bleeding actively. Repair was done and she was subsequently discharged home on the fourth post-operative day after counselling of mother and child. Child sexual abuse is common in our environment. Education and bonding with children, education of the public via outreaches, social media campaigns and other means possible, and improvement in the socio-economic situation of people will help reduce the incidence of child sexual abuse and encourage reporting and early disclosure where they occur.</p>

Single dose of tranexamic acid effectively reduces blood loss and transfusion rates in elderly patients undergoing surgery for hip fracture: a randomized controlled trial.

The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day. Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture. Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J2021;103-B(3):442-448.

A case of synovial chondromatosis of knee joint treated with total knee arthroplasty

Synovial Chondromatosis is a rare disease of the synovial membrane characterised by formation of multiple loose bodies in a joint. Knee is the most common joint to be affected by this disease. Though, this disease can be managed by synovectomy and removal of loose bodies with a favourable functional outcome but in some cases where there is damage of articular cartilage, simple synovectomy might not be sufficient. Here, we present a case of right knee pain in a 53 year old male since 4 years with a established diagnosis of synovial chondromatosis. No other joint was affected. Pain was associated with a fixed flexion deformity and restriction of knee range of motion and multiple slipping bodies. Radiography showed multiple loose bodies in the tibio-femoral as well as in patello femoral compartment. MRI of knee revealed several damaged areas in the knee articular surface. As a result, decision was taken to perform total knee arthroplasty. Intraoperatively all the loose bodies were removed along with the affected synovium and arthroplasty was done. Patient was discharged in fourth post operative day with proper instructions and was called for follow up at 1 month, 3 month, 6 month, 1 year. Functional outcome was assessed by Tegner Lysholm knee score, Knee Society score and Visual Assessment Scale.

The diagnostic value of C-reactive protein for predicting pancreatic fistula following pancreatoduodenectomy

Introduction Pancreaticoduodenectomy is the preferred treatment of neoplasms in the pancreas and duodenum. Postoperative pancreatic fistula is a critical complication. A potential predictive marker is C-reactive protein. This retrospective study examined the predictive value of C-reactive protein as a marker for development of postoperative pancreatic fistulas. Methods All patients who had a pancreaticoduodenectomy from 1 January 2015 to 31 December 2019, were included. Levels of the biomarker and linear trajectory were determined for postoperative days one to four. Univariate analysis was used to identify predictive variables for a postoperative pancreatic fistula. Receiver operating characteristics curves, specificity, and sensitivity were calculated. Results Five hundred and fifty-two patients underwent pancreaticoduodenectomy. C-reactive protein level greater than 121.5mg/L on the third postoperative day and an increase in C-reactive protein level between the first and fourth postoperative days, greater than 21.7mg/L, seemed to be reliable predictors. For Grade C postoperative pancreatic fistulas, increases in C-reactive protein, greater than 40.6ml/L the first four postoperative days, had a sensitivity of 100%. White blood cell count did not have similar reliability in predicting postoperative pancreatic fistulas. Conclusion Our findings indicate that small rises in C-reactive protein during the first postoperative days after pancreaticoduodenectomy are associated with an increased risk of developing postoperative pancreatic fistula.

The Hardship of Recovering a Patient from Liver Failure after One Anastomosis Gastric Bypass

The one anastomosis gastric bypass (OAGB) was first described in 2001 as a safe and effective procedure that meets the criteria for the "ideal" weight loss operation. However, revisions for malnutrition and liver failure were reported. We report a patient who was transferred to our institution with protein calorie malnutrition and liver failure after undergoing OAGB. A 42-year-old morbidly obese female patient underwent a laparoscopic sleeve gastrectomy (LSG) in 2012 followed by conversion to OAGB in 2018 for weight regain at another institution. Nine months after conversion, she was transferred to our institution with dehydration, vomiting, dysphagia, generalized edema, and steatorrhea (7 times/day). She had become wheelchair bound. On examination, there was gross edema, protein-calorie malnutrition, dermatitis, and muscle wasting. She had anemia (8g/dl) reference range (11.5-15.5g/dl), bilirubin (1.8mg/dl) (0.2-1.2mg/dl), hypoalbuminemia (1.4g/dl) (3.5-5g/dl), and elevated international normalized ratio (INR). The patient was admitted to the hospital and was started on total parenteral nutrition (TPN), with thiamine, vitamins, iron injections, and trace mineral replacement. Her course was complicated by multiple episodes of line sepsis and bacteremia. After 6weeks, we succeeded in raising her albumin to 2.9g/dl and proceeded with surgery. Laparoscopic exploration started with identifying the anatomy and measuring the biliopancreatic limb (BPL = 430cm) and the common channel (CC = 380cm). First, we restored the continuity of the small bowel. Then the long gastric pouch was trimmed. Finally, the patient was converted to a Roux-en-Y gastric bypass (RYGB) with a 30cm BP limb and 70cm Roux limb. The patient had an uneventful recovery and was discharged home on the fourth postoperative day. At 3months of follow-up, her symptoms resolved, her laboratory work up normalized, and she regained mobility. Malnutrition and liver failure after OAGB are not uncommon. It is encountered with configurations of longer BP limb. BPL length of 150 to 200cm seems to reduce such complications. Preoperative nutritional optimization is key. Conversion to a proximal RYGB is a safe and feasible approach.

Laparoscopic Partial Cecal Resection With an Endoscopic Linear Stapler in Complicated Appendicitis: A Single Center Experiences

Introduction It can be challenging to perform an appendectomy laparoscopically in patients with complicated appendicitis with severe inflammation or perforation of the appendix base. This study aimed to introduce a simple alternative surgical treatment that can be used safely in difficult appendectomy cases. Case presentation We retrospectively reviewed the medical records of 14 patients who underwent laparoscopic partial resection of the cecum with a linear stapler between January 2015 and December 2016 in our hospital. Fourteen patients were included in this study, and no surgical complications were observed. Enteral feeding was resumed on the third or fourth postoperative day, and the average length of hospital stay was 7.6 days (range, 5 to 12 days). Conclusion The results suggest that laparoscopic partial cecal resection with an endostapler is a safe, simple surgical procedure that can be a good alternative in patients with complicated appendicitis.

Laparoscopic segment VII resection for hepatocellular carcinoma guided by 3D

Purpose: Laparoscopic segment VII hepatic resection remains one of the most difficult surgical techniques due to poor accessibility to the tumour and the difficulty of obtaining tumour-free resection margins. Laparoscopic approach in cirrhotic patients should be well planned, in order to preserve the largest possible liver remnant and assure favourable oncological results. We report a 3D-guided resection of segment VII. Methods: A 77-year-old woman, ASA 3, with CHILD-A cirrhosis, a suprahepatic pressure gradient of 8mmHg and thrombocytopenia of 133x10 ˆ 9 / L, was diagnosed by CT-scan of a 38mm hepatocellular carcinoma (HCC) located in segment VII. A 3D-guided laparoscopic atypical resection of segment VII was performed. Results: Operative time was 150 minutes, with an estimated blood loss of 100mL and a total Pringle manoeuvre of 26 minutes. Postoperative course was uneventful. The patient was discharged on the fourth postoperative day, and the drainage could be removed prior to discharge. The pathological analysis confirmed the diagnosis of hepatocellular carcinoma with negative resection margins (> 10mm in all axes). Conclusions: Implementation of 3D technology in order to plan hepatic resection allows the reduction of surgical time and decreases intraoperative bleeding, while oncological outcomes are preserved. 3D-guided laparoscopic approach should be a tool to be considered in patients with major comorbidities and high surgical-risk, to minimize surgical complications.

Isolated Giant Splenic Hydatid Cyst Treated with Spleen-Sparing Surgery

Isolated splenic hydatid cyst is a very rare parasitic infection. This case report presents the diagnosis and treatment process of giant splenic hydatid cyst treated with open spleen-sparing surgery. A 27-year-old female patient presented to the general surgery clinic with abdominal complaints. On computed tomography scan, she had a mass, 150 × 130 × 100 mm in size, at the medial side of the spleen. Spleen-sparing surgery was applied to the patient, who seemed to have a splenic hydatid cyst in the preoperative examinations. The patient was discharged without complications on the fourth postoperative day. Postoperative pathology was compatible with hydatid cyst. Albendazole treatment continued for two more months postoperatively.

Tailored laparoscopic approach for pancreatic tail resection for cancer

Laparoscopic resection is becoming the gold standard for distally located lesions of the pancreas. Changing the standard technique from the medial-to-lateral to lateral-to-medial approach can simplify the procedure in case of previous surgery, a known risk factor for conversion. We report the case of laparoscopic pancreatic tail resection with spleen preservation in a 79 y.o. woman affected by an 18 mm hypervascular lesion (Fig.1); the patient underwent to a left nephrectomy, trough a median laparotomy, thirty-three years before, for a clear cell renal carcinoma. The SUV at Ga68-DOTATOC-PET-CT was 14.9 and at F18-FDG-PET-CT was null. Operative technique: four trocar were positioned in L shape manner in the upper left quadrant of the abdomen, with patient in 30° right lateral position. We started lowering the colonic splenic flexure, exposing the tail of the pancreas and the tumor. The lesser sac was opened below the left gastroepiploic vessels. The body-tail were freed from retroperitoneal tissue, in a lateral-to-medial way. Finally, small arterial and venous branches of the splenic vessels were cut between clips. For parenchymal transection we used a 60 mm linear stapler, vascular cartridge; a suture of the stump was required to complete the hemostasis. The specimen was extracted by an endobag through the supraumbilical incision, and a drain was left close to the stump. After an uneventful postoperative course, the patient was discharged in the fourth postoperative day. The pathological report described a metastasis from clear cell renal carcinoma.

The Pre- and Postoperative Prevalence and Risk Factors of ASA Nonresponse in Vascular Surgery

BackgroundAn antiplatelet therapy with acetylsalicylic acid (ASA) is prescribed in the prevention of cardiovascular events, but around 24% of ASA takers are resistant to the treatment.AimIn this prospective, observational cohort study, we aimed to identify the prevalence and risk factors of ASA nonresponse in patients who underwent vascular surgery.MethodsThe study was conducted in the University hospital in Frankfurt am Main. In total, 70 patients were pre-treated with 100 mg of ASA per day and underwent either elective carotid thromboendarterectomy, femoral thromboendarterectomy or endovascular aneurysm repair of the abdominal aorta. The platelet function was measured on the first preoperative and the second or fourth postoperative day with the multiple electrode aggregometry by in-vitro stimulation with arachidonic acid (ASPItest) and thrombin receptor activating peptide 6 (TRAPtest). The primary end point was the in-vitro induced platelet aggregation in the ASPItest. If the ASPItest amounted ≥400 AU × min, the patients were categorized as ASA nonresponders.ResultsThe total prevalence of ASA nonresponse in our study was 20% preoperatively and 35.7% postoperatively (p = 0.005). As significant predictors for ASA nonresponse, we demonstrated the area under the aggregation curve in the TRAPtest preoperatively (p = 0.04) and postoperatively (p = 0.02), and the two comorbidities arterial hypertension (P < .001; rho 0.44) and diabetes mellitus (p = 0.04; rho 0.39), which are already well known to be associated with ASA nonresponse.ConclusionIn conclusion, data of the study indicate a high incidence of perioperative, laboratory ASA nonresponse in patients undergoing vascular surgery.

Living donor left lateral sectionectomy: Should the procedure still be performed open?

BackgroundThe chronic shortage of organs makes the option of living liver donation particularly appealing, and living donor LLS transplantation remains the most common procedure for pediatric liver transplantation in Russia. Laparoscopic living donor left lateral sectionectomy (lapLDLLS) was recently established as a new standard practice. PurposeThe present retrospective single center study aimed to achieve a greater understanding of when the conventional method could be suitably substituted with the laparoscopic approach and to review the potential advantages obtained. Herein, we describe our experience from the initial implementation to routinely use of the laparoscopic approach. MethodA retrospective review of 127 lapLDLLSs performed between May 2016 and August 2020 at the National Medical Research Center of Transplantation and Artificial Organs, Moscow, Russia was undertaken. A segmented line regression model and receiver operating characteristic analysis based on the operation time were used to determine the learning curve (LC) under the initial proctorship. Donors were divided into two groups: before and after attaining the LC, cases 1–37 and cases 38–127, respectively. The perioperative parameters of donors and recipients in post LC cases were compared to 154 open procedures with propensity score match 1:1. ResultsLC cutoff was determined to occur by the 37th case of lapLDLLS. Subsequently, for the lapLDLLS group compared to the open group, there were significant reductions in the operative time, estimated blood loss, visual analogue pain score on the first and fourth postoperative day, and length of hospital stay (p < 0.001 for each of the comparisons). There were no significant differences between the groups with respect to donor complication rates and recipient outcomes. ConclusionThe laparoscopic approach could be chosen for LLS living donors after achieving the LC, in circumstances where there is a well-developed and proctored program.

Hemostatic Spray; A Rescue to Severe Post-pancreaticoduodenectomy Hemorrhage - A Novel Technique to use

Pancreaticoduodenectomy (Whipple’s Procedure) being an immensely intricate procedure, is accompanied by morbidities out of which some can pose a considerable threat to human life. A morbidity worth discussing is post-pancreaticoduodenectomy hemorrhage. Being classified as early or late and mild, moderate or severe, PPH can be life threatening leading to hypovolemic shock and death if untreated. We describe a case of a 52 year old South-Asian female, who underwent pancreaticoduodenectomy with pancreatico-gastrostomy for a non metastatic periampullary tumor, experienced an intraluminal post pancreaticoduodenectomy hemorrhage on fourth postoperative day leading to hypovolemic shock, with no evidence of extraluminal bleed. Urgent upper gastrointestinal endoscopy showed ulcerated pancreaticogastric anastomosis and marginal ulcer at the site of anastomosis of small intestine and stomach. Hemostatic spray was applied and hemostasis was secured. After meticulous literature review, it became evident that hemostatic spray has been used for a variety of cases of upper gastrointestinal bleeding but has never been utilized for the post-pancreaticoduodenectomy hemorrhage as delineated in the concise discussion of the article.

Urgent Off-Pump Revascularisation in ACS and Cardiogenic Shock with Anomalous Origin of Right Coronary Artery from Left Anterior Descending Artery: A Case Report

A 55-year-old female known case of essential hypertension and diabetes was brought to the Emergency Department in a drowsy state with cardiogenic shock. At presentation systolic BP was 70 mm Hg, pulse rate was 44/min and random blood sugar was 239 mg/dl. Troponin I was 8.07. Electrocardiography showed junctional rhythm and bradycardia. Ejection Fraction (LVEF) was 15% - 20%. Coronary angiography was done which revealed single vessel disease in LAD with anomalous origin of RCA from midsegment of LAD. Patient was immediately taken up for Off-pump Coronary Artery Bypass Grafting (OPCAB). Right saphenous vein graft was harvested and anastomosed proximally to aorta and distally to LAD on beating heart using Medtronic Octopus heart stabilizer and coronary shunts. Wound closed in layers after achieving complete hemostasis. Patient was taken off ventilatory support on first post-operative day and discharged in a stable condition on fourth post-operative day. Post-operative Echocardiography showed LVEF increased from 15% - 20% at time of admission to 38% and 52% after 3 months and 12 months of surgery respectively.

Inframesocolic artery-first approach in laparoscopic ramps

Purpose: In 2003, Strasberg described the radical antegrade modular pancreatosplenectomy. This procedure is specifically designed for the surgical treatment of cancer of the body/tail of the pancreas. It primarily aims to achieve low rates of circumferential margin involvement and oncologically adequate lymphadenectomy. Recently, an adaptation of the surgical technique to the laparoscopic context has been described. This approach accesses the retroperitoneal plane as the first manoeuvre. This inframesenteric approach ensures oncologically adequate margins and allows to take full advantage of the vision and features of minimally invasive surgery. Method: A 52 year old female patient was diagnosed with body-tail junction pancreatic adenocarcinoma. CT scan revealed a focal lesion of approximately 19 mm in the pancreatic tail. The patient received 4 cycles of neoadjuvant chemotherapy with FOLFIRINOX regimen. Following, laparoscopic RAMPS was performed as follows: Five trocars were placed. After opening theomental bursa to rule out peritoneal disease, an inframesenteric approach of the SMA was performed. By means of a ligament of Treitz approach, the left renal vein and the left-superior aspect of the SMA were dissected; also, and dividing the SMV, retroperitoneal dissection was further dissected. This approach rules out tumor infiltration into the SMA and also allows the early determination of the posterior dissection plane. Then, extended lymphadenectomy is performed. After dividing the neck of the pancreas and splenic vein, the retroperitoenal space -previously developed- is entered. This facilitates the completion of the procedure thus ensuring a negative tangential margin. Results: Operation was completed without any intraoperative complication. Surgical time was 360 minutes. Blood loss was less than 50 mL. Patient was discharged on fourth postoperative day and no postoperative complications were observed. 17 lymph nodes were identified on the pathological report, none of them were affected by carcinoma. No vascular nor lymphatic invasion was documented. All resection margins were tumor-free. Conclusion: The inframesocolic artery-first approach in laparoscopic RAMPS is a feasible and safe procedure. It confirms resectability early in the procedure, ensures and facilitates tumor free-margins, may reduce blood loss and reproduce optimal oncological results.

Petersen's space hernia.

Petersen´s Space Hernia was first described in 1900 by Walther Petersen MD. It is an internal hernia, arising after any type of gastrojejunostomy, in particular, after Roux-en-Y anastomosis. A 49-years-old Caucasian woman was admitted to Emergency Room of our institution complaining of epigastric abdominal crampy pain and alimentary vomiting. Her past medical history highlighted Roux-Y Gastric Bypass for morbid obesity and weight loss of 60kg. Her abdominal physical examination revealed Blumberg sign. Vital signs were normal. White blood tests were in normal range. Body temperature was 36.2°C. CT scan demonstrated a “twist” in the mesentery with “whirlpool sign” of the jejunum. The patient was referred to operating theatre. We performed an exploratory laparotomy, disclosing an incarcerated Petersen´s space Hernia of the common limb, with obstruction of the jejunum. The incarcerated bowel was repositioned and there was no irreversible ischemia, no resection being required. The Petersen´s space was closed with a suture. The post-operative period was unremarkable and the patient was discharged at the fourth post-operative day.

Sebaceous carcinoma of the axilla

Sebaceous carcinoma is a rare cutaneous malignant neoplasm with an estimated incidence rate of approximately 1–2 per 1 000 000 per year. It rarely presents as an extra-ocular type and it affects patients in between the sixth and eighth decades of life. This is a case of a 31-year-old male with a 10-year history of a right axillary mass with an incisional biopsy of a sebaceous carcinoma. The mass was 10 × 6 cm in largest diameter, erythematous, non-tender and irregularly shaped. The patient underwent wide excision of the right axillary mass with negative margins confirmed by frozen section under general anesthesia. A parascapular fasciocutaneous flap was done in order to provide coverage for the defect. The patient was then discharged improved on the fourth postoperative day. Although there has been no established clinical protocol for the staging, medical and surgical management for extra-ocular sebaceous carcinoma, early diagnosis accompanied with the proper surgical intervention, such as oncologic wide excision with negative margins, were both adequate and paramount to the diagnosis, course and treatment of this patient, given its rarity.

Subacute post-operative atrial fibrillation after valvular surgery in patients undergoing cardiac rehabilitation: predictive factors

Abstract Background Postoperative atrial fibrillation (POAF) is the most frequent arrhythmic complication following cardiac surgery (occurring in up to one third of patients). It may develop between the second and fourth postoperative days (acute POAF) as well as later, within 30 days after surgery (subacute). Episodes of atrial fibrillation in the subacute phase (sPOAF) are associated with an increase in morbidity, length of hospital stay and several complications both in the mid- and long- term. Therefore, POAF is not just an acute event but it may impact on long term clinical outcomes. Aim of the study The aim of this study was to identify the clinical predictors of postoperative atrial fibrillation in the subacute phase (sPOAF) in patients performing Cardiovascular Rehabilitation (CR) after cardiac surgery. Materials and methods A retrospective study was conducted on 737 post-surgical valvular patients (median age 62 years; 55,4% male) hospitalised in our Unit for in-patient CR program. During all the hospital stay patients received continuous monitoring with 12-lead ECG telemetry. We evaluated the predictive value of anamnestic data, the type of cardiac surgery intervention, the clinical course in the Cardiac Surgery Unit and in the CR Unit, the 6 minutes-walking tests (6MWT) parameters and main blood tests on sPOAF onset. Results SPOAF was documented in 170 patients (23,1%). Those who developed sPOAF were older [median 66 (56–74) years vs median 61 (50–70) years; p&amp;lt;0,001), had a history of atrial fibrillation prior to surgery (29,4% vs 16,2%; p&amp;lt;0,001), had a worse functional result at the 6MWT at the admission in CR Unit [median 250 (180–320) vs median 275 (210–370); p=0,015], had higher values of neutrophil-lymphocite ratio at baseline [median 2,33 (1,84–3,27) vs median 2,17 (1,64 - 2,87); p=0,027] when compared to those who did not develop POAF. At the multivariable logistic regression analysis, the occurrence of POAF in the acute phase (OR 2,916; 95% CI 2,011–4,228; p&amp;lt;0,001), advanced age (OR 1,027; 95% CI 1,01–1,044; p=0,002), previous history of atrial fibrillation (OR 1,652; 95% CI 1,068–2,555; p=0,024), higher values of NLR at baseline (OR 1,144; 95% CI 1,028–1,272; p=0,013) and mitral valve surgery (OR 1,632, 95% CI 1,075–2,480; p=0,022) were found to be independent predictors of sPOAF after cardiac surgery. Conclusions Atrial fibrillation is a common complication after cardiac surgery with great clinical relevance. Advanced age, previous history of AF, higher values of NLR at baseline, mitral valve surgery and the occurrence of POAF in the acute phase were shown to be predictors of sPOAF in a cardiac surgery population during the rehabilitation period. Funding Acknowledgement Type of funding source: None

The Improved Mediastinal Drainage Strategy for the Enhanced Recovery System After Esophagectomy

The improved drainage strategy was the transperitoneal placement of a single mediastinal drainage tube after esophagectomy. This study aimed to explore its effect on the incidence of postoperative complications, pain scores, and hospital stay. Data from 108 patients who underwent minimally invasive esophagectomy were retrospectively analyzed. Patients were divided into 2 groups: those in group A were treated with transthoracic placement of mediastinal drain and those in group B were treated with transperitoneal placement. The incidence of postoperative complications, pain scores, and postoperative hospital stay were compared. The maximum pain scores in group B were significantly lower than those in group A from the first to the fourth postoperative days (PODs): POD1, 3.9 ± 0.7 vs 2.3 ± 0.7; POD2, 3.5 ± 0.8 vs 2.1 ± 0.7; POD3, 3.3 ± 0.8 vs 1.7 ± 0.8; and POD4, 3.1 ± 0.7 vs 1.7 ± 0.8 (all P<.001). Compared with group A, there were fewer postoperative analgesic drug users in group B (44.6% vs 17.9%; P= .005), fewer cases of pleural effusion (10.7% vs 0%; P= .045), and fewer cases of closed thoracic drainage due to pleural effusion or pneumothorax (14.3% vs 0%; P= .014). There were no significant differences in the incidence of anastomotic leakage, mediastinitis, major pulmonary complications, major abdominal complications, surgical site infection, and total postoperative complications, without statistical differences in postoperative hospital stay and 30-d mortality (all P > .05). The transperitoneal placement of a single mediastinal drain can reduce postoperative pain and the incidence of pleural effusion, without increasing the incidence of other major postoperative complications and postoperative hospital stay.