Fourth Postoperative Day Research Articles

Post-operative thrombocytopenia after sutureless biological aortic valve replacement: is it clinically relevant?

Introduction Postoperative thrombocytopenia (PTC) after aortic valve replacement by sutureless biological prosthesis (Perceval type) is described in the literature, however, its clinical relevance has not yet been established. • Primary objective: Description of platelet count after biological aortic valve replacement with Perceval® and Trifecta types. • Secondary objective: To compare need of transfusions (red blood cells (RBCs), Platelets, fibrinogen), re-explorations for bleeding in the first 48 hours, ICU stay, hospital stay and mortality at 30 days. Methods A retrospective comparative observational cohort study was conducted using data extracted from digital medical records, including data obtained by intraoperative thromboelastography (TEG) of patients undergoing aortic valve replacement with biological prosthesis Perceval and Trifecta, at our hospital. We performed consecutive non-randomized sampling from January 2018 to December 2018, including a total of 74 patients. 32 of them received Perceval®, 42 received Trifecta . Results We found a PTC after biological valve replacement that in both groups becomes severe, being in the Perceval group minimum values of 20 × 103 on the 4th postoperative day, while in the Trifecta group it was 50 × 103 also on the 4th postoperative day. We found no statistically significant differences in preoperative or postoperative platelet count except at hospital discharge, with Perceval presenting lower platelet count figures (median 133 × 103 interquartile range 108 - 203 × 103) than Trifecta® (median 230 × 103, interquartile range 167 - 220 × 103), (p = 0.018). Intraoperatively, we found statistically significant differences in the number of (RBCs) transfused, as follows in the Perceval group (mean: 1.06) versus Trifecta (mean: 0.31), (p = 0.005) We found no statistically significant differences in intra- or postoperative transfusion of blood products (platelets, fibrinogen), as well as in the need for re-explorations due to bleeding, ICU stay, hospital stay or mortality at 30 days. Discussion Biological valve replacement with Perceval and Trifecta causes postoperative thrombocytopenia, which, although it becomes severe on the fourth postoperative day in both groups, does not persist at hospital discharge. In our sample has not conditioned greater morbidity or mortality in patients. Larger sample studies will be necessary to corroborate the statistical significance.

Drain management after distal pancreatectomy based on a predictive model, including drainage fluid amylase and biochemical inflammatory markers: a preliminary study

Introduction Postoperative pancreatic fistula (POPF) is the Achilles’ heel of distal pancreatectomy. Surgeons use abdominal drains for early prediction, diagnosis, and timely management of POPF. The utility of drainage fluid in the prediction and diagnosis of POPF is a matter of debate. Patients and methods This is a retrospective cohort study of all patients who underwent distal pancreatectomy between January 2018 and January 2020. The present study aims to evaluate the association between drainage fluid amylase (DFA) and systemic inflammatory markers in the prediction of clinically relevant POPF. Results This study included 44 patients with a mean age of 40.3±16.3 years, and the female : male ratio was 2.7 : 1. POPF occurred in 11 (25%) patients. Of them, nine (20.5%) patients were managed by additional ultrasound-guided tube drainage. Higher drainage fluid amount and DFA-D1 were associated with a higher risk of POPF (P=0.036, and 0.009, respectively). The leukocytic count was significantly higher in POPF in the third postoperative day (POD) (P=0.032). POPF group had a significantly higher level of serum lactate dehydrogenase (LDH) on the fourth POD (P=0.001). Patients with high DFA-D1 (>330 IU/l), rising leukocytic count, and high serum LDH were significantly at higher risk of POPF (9/11 developed POPF, P=0.0001). Conclusion DFA-D1, rising leukocytic count, and high serum LDH level compromised a more robust predictive model for POPF. The cutoff value of DFA proposed by the ISGPF is applicable when combined with leukocytic count and serum LDH. Prospective large-scale studies are needed.

Differences in the prognostic impact of post-operative systemic inflammation and infection in colorectal cancer patients: Using white blood cell counts and procalcitonin levels

BackgroundSystemic inflammatory responses cause poor prognosis in cancer patients. However, post-operative systemic inflammatory response may occur owing to post-operative infection as well as cancer-related inflammation. This study aimed to identify the prognostic impact of cancer-related inflammation and infection for colorectal cancer. MethodsPatients who underwent curative surgery for colorectal cancer between January 2011 and March 2015 were enrolled. Procalcitonin (PCT) levels were measured on the fourth post-operative day; white blood cell (WBC) counts were measured daily until the fourth post-operative day. Patients were divided into groups according to the number of post-operative days required for the leukocyte count to decrease to <10,000/mm3 and PCT levels (0.5 ng/ml) as follows: group I, 0–3 days; group II, ≥4 days and high PCT; group III, ≥4 days and normal PCT. ResultsTotally, 248 patients were identified. A prolonged WBC normalization period was associated with poor disease-free survival (DFS). TNM stage III and IV and group III (hazard ratio [HR] 2.480, 95% confidence interval [CI] 1.137–5.410) were independently associated with poor DFS. In contrast, DFS was not significantly affected in group II. High PCT levels were significantly associated with post-operative infectious complications (odds ratio 10.579, 95% CI 4.182–26.764). Although infectious complication had no prognostic significance for DFS, it was an independently poor prognostic factor for overall survival (HR 3.728; 95% CI 1.291–10.766). ConclusionsThe increased post-operative systemic inflammatory response was associated with poor prognosis of colorectal cancer. Otherwise, post-operative infection affected overall mortality but was not associated with disease progression.

Utilization of the Falciform Ligament to Buttress the Pancreatic Transection Staple Line: A Novel Technique.

Postoperative pancreatic fistula (POPF) remains a common complication after distal pancreatectomy and is a major source of operative morbidity. Although various mechanical, biological, and synthetic aids have been used to reduce the risk of POPF, none have a proven benefit. The authors describe (and present a video, Supplemental Digital Content 1, http://links.lww.com/SLE/A256) a novel technique in which the autologous falciform ligament was harvested, wrapped around the pancreas at the site of proposed pancreatic transection, and secured with sutures to buttress the pancreatic transection staple line. The pancreas was then transected with a triple-row stapler. Two male patients aged 40 and 57 years each with a 4.3 and 4.2 cm solid mass in the body of the pancreas respectively underwent laparoscopic anterior radical antegrade modular pancreaticosplenectomy, the former patient underwent an en block transverse colectomy for suspected malignancy. Both patients had soft pancreata. They experienced no POPF, made an uneventful recovery, and were discharged from the hospital on the second and fourth postoperative days, respectively. No pancreatic complications were encountered at 5 and 6 months follow-up, respectively. The use of the falciform ligament to buttress the staple line at the time of pancreatic transection is a novel technique. Its potential benefit in reducing the risk of POPF warrants further assessment.

A double-blind placebo controlled trial on effectiveness of prophylactic dexamethasone for preventing post- dural puncture headache after spinal anesthesia for cesarean section

Aim To determine the effect of dexamethasone in reducing post-dural puncture headache (PDPH) after spinal anesthesia for cesarean section (CS). Methods A double blind placebo controlled randomized trial of parturients undergoing CS under spinal anesthesia was conducted. Participants (n = 192) were randomly (1:1 ratio) given either 2mls (8 mg) of dexamethasone (n = 96) intravenously or 2mls of normal saline (n = 96) intravenously as placebo after clamping the umbilical cord. Visual analogue scale was used to assess the incidence and severity of PDPH on the first and fourth post-operative days. The primary outcome measure was incidence of PDPH while the secondary outcome measure was incidence of nausea and vomiting. Analysis was by intention-to-treat. Results Baseline socio-demographic and clinical variables were similar between the two groups and none of the women was lost to follow up. The incidence of PDPH (8.3% vs 25.0%; p = .002) and nausea (11.5% vs 25.0%; p = .015) were significantly lower in dexamethasone group. The severity of headache in the control groups were statistically higher on the first (p < .001) and fourth (p < .001) post-operative days. . Conclusion Prophylactic dexamethasone reduces the incidence and severity of PDPH on both the first and fourth post-operative day after spinal anesthesia for CS. There was also an improvement on the incidence of nausea on the dexamethasone group compared to control.

Off-Label Treatment With Transfemoral Bare Stents for Isolated Aortic Arch Dissection

Aortic arch dissection is a catastrophic acute event involving the aorta. Its accurate diagnosis and treatment are mandatory to optimize patient outcome. We aimed to assess the efficacy and safety of endovascular treatment with transfemoral bare stents of isolated aortic arch dissection as a valid alternative in patients unsuitable for conventional surgery. In this case series, we report our experience with 3 patients affected by isolated aortic arch dissection treated with endovascular surgery from February 2019 to May 2019. All patients were associated with severe comorbidities emergently referred at our center. Vascular access was achieved by surgical exposure of the right common femoral artery performed under general anesthesia. All patients were observed for at least 3 months. All patients were treated in a hybrid operative room with transfemoral implantation of a bare metal Jotec E-XL stent released in the aortic arch. The postoperative period was uneventful, and all 3 patients were discharged or transferred on the fourth postoperative day. At follow-up, computed tomography scans showed good results in all patients. A purely endovascular approach to located aortic arch dissections, with bare stents, remains challenging, although it has been proven to be a valid alternative treatment in some off-label cases.

Preventing Functional Urinary Incontinence in Hip-Fractured Older Adults Through Patient Education: A Randomized Controlled Trial.

The purpose of this study was to evaluate whether an educational intervention would reduce the incidence of functional urinary incontinence (UI) in older adults with a fall-related hip fracture. The project was conducted as a multicenter randomized controlled trial (RCT). A total of 109 patients that had been admitted to six hospitals in Castilla-La Mancha (Spain) for acute treatment of hip fracture, previously continent and without cognitive impairment, were enrolled and randomly assigned to the experimental group (EG) or the control group (CG). Intervention (on EG): urinary habit training (Nursing Interventions Classifications taxonomy) was performed during hospital stay (second to fourth postoperative day), with a telephonic reinforcement 10 days after discharge. The CG received routine care. Primary outcome measure: incidence of UI. Follow-up: telephone assessment 3 and 6 months after discharge (blinded evaluation). The incidence of UI at 6 months was 49% (CG) versus 25.5% (EG) (relative risk = 0.52, 95% confidence interval [0.3, 0.9]; number necessary to treat = 4). The mean of UI episodes was 0.54 (EG) versus 1.8 (CG), p = .007. The educational intervention prevents the development of UI and decreases the number of episodes in case of appearance, in a statistically significant way.

Evaluation and comparison of anti-inflammatory properties of ibuprofen using two drug delivery systems after third molar surgery: using chitosan microspheres as a carrier for local drug delivery in to the third molar socket and through the oral route

We undertook this study to assess the analgesic and anti-inflammatory properties of ibuprofen when administered through two drug delivery systems after mandibular third molar surgery. The study was conducted on 100 patients who required the surgical removal of impacted mandibular third molars under local anaesthesia. The study subjects were divided into two groups of 50 patients each. Patients in the study group were given ibuprofen-incorporated chitosan-based microspheres, which were packed into the third molar sockets after removal of impacted teeth. Patients in the control group were prescribed with ibuprofen 400mg tablets that were to be administered orally after the removal of impacted mandibular third molars. All patients were assessed for pain, swelling, and trismus on the second, fourth, and seventh postoperative days, and wound healing was assessed on the seventh postoperative day. Patients in the study group had significantly less pain and comparatively better mouth opening on the second, fourth, and seventh postoperative days, which showed clinically and statistically significant results of p<0.05, respectively, while the assessment of swelling for the study group did not show statistically significant results on any of the three postoperative days. Among 50 patients in the study group, two had wound gaping, and among 50 patients in the control group, four presented with wound gaping and three patients developed dry socket. Ibuprofen-incorporated chitosan-based microspheres (study group) had comparatively better analgesic and anti-inflammatory properties with drastic reduction of pain, swelling, trismus, and also had a reliable wound healing property when compared with the orally-administered ibuprofen (control group) after mandibular third molar surgery.

Neonatal and infantile appendicitis still confuses minds: report of two cases

BackgroundAcute appendicitis is extremely rare in the neonatal and infantile periods. The number of cases published in the last century is just over 100. Mortality and morbidity are still high due to diagnostic problems because there are no specific clinical features and reliable investigation for the diagnosis. Herein, we present two patients to remind physicians that the diagnosis of neonatal and infantile appendicitis should always be kept in mind.Case presentationsA 30 3/7-week-old 740-g newborn girl was delivered by cesarean section because of preeclampsia. The newborn was followed in the neonatal intensive care unit and fed with an orogastric catheter. An abdominal distention developed on the 18th day of her life. While following up with a preliminary diagnosis of necrotizing enterocolitis, she was operated on the 4th day due to abdominal free air seen on X-ray. A perforated appendicitis was detected in the abdominal exploration and formal appendectomy was performed. Histology demonstrated marked transmural inflammation and necrosis at the perforated site and there was no evidence of Hirchsprung’s disease. The patient was started on breast milk on the third postoperative day and discharged home on day 98.A 3.5-month-old boy was admitted to our clinic because of abdominal distention, discomfort, and constipation which had been ongoing for 4 days. He was followed up as an outpatient basis for 4 days in another center with the diagnosis of infantile colic. An increase in echogenicity due to intense inflammation was observed in mesenteric plans using USG in the right lower quadrant of the abdomen. Following preoperative preparations, the patient underwent abdominal exploration and appendectomy. He had an uneventful recovery and pathologic examination demonstrated a necrotizing appendicitis with perforation. He was discharged on the fourth postoperative day without any problems.ConclusionIt is a fact that acute appendicitis in neonates and infants may not be diagnosed easily and quickly as in older children because there are no specific clinical features and reliable investigation for the diagnosis. Delay in diagnosis and treatment often results in appendicular perforation and peritonitis. The main safeguard against mortality and morbidity remains a high index of suspicion.

A Case Report and Literature Review: Grape Seeds Causing Meckel’s Diverticulitis, Perforation and Small Bowel Obstruction in a Young Adult Patient

Background: Meckel’s diverticulum is a true diverticulum consisting of a 3-layered outpouching of the bowel wall along the antimesenteric border. It is a remnant of the omphalomesenteric duct and the most common congenital gastrointestinal disorder. It has a male predilection and remains asymptomatic in the majority of cases. It constitutes a diagnostic challenge to physicians, as it can present with gastrointestinal bleeding in the pediatric population, and as an intestinal obstruction in adults. While the management of an asymptomatic Meckel’s diverticulum is on a case-by-case basis, when symptomatic, prompt surgical intervention is necessary, and a laparoscopic approach allows both in-situ diagnosis and treatment. Case Report: A 23-year-old previously healthy female patient, presented with diffuse abdominal pain, vomiting, and obstipation. Abdominal X-Ray and abdominopelvic Computed Tomography showed an intra-abdominal inflammatory process and evidence of bowel obstruction but were not conclusive. The patient was admitted to the hospital for management, and on the third day of hospitalization physical examination showed abdominal guarding suggestive of peritonitis. An urgent exploratory laparotomy identified a Meckel’s Diverticulum obstructed with phytobezoar grape seeds, and an inflamed and perforated bowel wall, with adhesive bands to proximal small bowel loops, necrosis, and resultant small bowel obstruction. We resected the Meckel’s diverticulum and the necrotic bowel and performed an end-to-end primary anastomosis of the small bowel. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. Conclusion: The diagnosis of Meckel’s diverticulum remains a challenge as it has a myriad of clinical presentation and radiological imaging sometimes fails to provide a definite diagnosis. It must be systematically included in the differential diagnosis of small bowel obstruction in adult patients, as it requires prompt surgical intervention for both diagnosis and treatment.

Early detection of infectious complications using C-reactive protein and the procalcitonin levels after laparoscopic colorectal resection: a prospective cohort study

PurposeThe predictive values of the C-reactive protein (CRP) and procalcitonin (PCT) levels for postoperative infectious complications were investigated in patients who underwent elective laparoscopic resection of colorectal cancer.MethodsA total of 154 consecutive patients who underwent elective laparoscopic resection for colorectal cancer (CRC) were prospectively studied. The CRP and PCT levels on the first postoperative day (POD1) and the fourth postoperative day (POD4) were measured. Any correlations between the CRP and PCT levels on POD1 and POD4 with the occurrence of infectious complications were examined.ResultsInfectious complications occurred in 18 (11.7%) patients. CRP on POD1 and CRP and PCT on POD4 were significantly higher in patients who developed infectious complications than in those who did not. The areas under the receiver operating characteristic curves of CRP on POD1 and CRP and PCT on POD4 were 0.597, 0.763 and 0.768, respectively. The cut-off values of CRP and PCT levels on POD4 were 14.33 mg/dl and 0,264 ng/ml, respectively. Whereas the positive predictive value of an elevated CRP level was high, the negative predictive value of an elevated PCT was high.ConclusionThe CRP and PCT levels on POD4 are both considered to be useful for the early detection of infectious complications after laparoscopic resection of CRC.

The Initial Experience on Thoracoscopic Sleeve Lobectomy: Continuous Suturing Technique of the Bronchial Anastomosis in 12 Cases.

Sleeve resection is a widely performed type of operation in the surgical treatment of non-small cell lung cancer. Video-assisted thoracoscopic surgery (VATS) is now used even in central tumor surgeries of the lung with the increasing technology and experience. Sleeve resection cases performed through VATS in our clinic in recent years were presented with demographic, surgical, pathologic, and survey characteristics. Twelve patients who underwent sleeve resection with VATS in our clinic between November 2015 and August 2019 were included in the study. Operative, pathologic, and postoperative characteristics of the patients were examined. A total of 12 patients, 3 female and 9 male individuals, were included in the study. The mean age of the patients was 61.7±12.9 years. According to the localization of the tumors, left upper lobectomy was performed in 4 patients and 8 patients underwent right upper lobectomy. During the sleeve anastomosis of the patients, 3/0 prolene sutures were used in 5 patients (36%) and 4/0 prolene sutures in 4 patients (36%), whereas 3/0 polydioxanone suture (PDS) was used in 3 patients (28%). The mean operation time was 288.2±77.1 (205 to 460) minutes and the mean anastomosis time was 70±18.5 (55 to 110) minutes. In the postoperative period, 1 patient who had acute myocardial infarction died on the fourth postoperative day. The mean postoperative drainage duration of the patients was 5.5±1.9 (3 to 10) days and the mean length of hospital stay was 6.4±1.9 (4 to 11) days. When the pathologic features were examined, the mean tumor diameter was found to be 2.5±1.2 (1 to 5.5) cm. The mean follow-up period was calculated as 26.1±15.6 months (2 to 47). Other than 1 patient who died, the follow-up of 11 patients still proceeds. VATS approach of sleeve resections, which is performed cautiously even by thoracotomy, is becoming more common. These operations, which could be performed in experienced centers, offer a postoperative period of less morbidity to the patients with the advantage of reduced postoperative pain, drainage time, and hospital stay.

Impact of immediate treatment within four days on prognosis in severe traumatic brain injury patients without vasospasm

Background and objectives: Traumatic brain injury (TBI) is associated with high mortality rate and long-term disability. Application of the Brain Trauma Foundation's ＂Guidelines for the management of severe traumatic brain injury＂ would reduce the prevalence of morbidity and mortality. However, the prevalence of some predictors of TBI have not been studied well with respect to the guidelines, for example, vasospasm. This study evaluated the correlation between the prognostic factors and outcome in patients without vasospasm. Materials and Methods: All patients were treated as per the aforementioned guidelines. Ten patients were prospectively recruited and nine were examined by computed tomography angiography (CTA). The cerebral perfusion pressure (CPP) was measured before and on the fourth postoperative day and was maintained at ≥ 60 mmHg. The results of Glasgow outcome scale (GOS) and Glasgow coma scale (GCS) were collected after four weeks, three months, one year, and two years after admission. Results: There was no vasospasm noted in any of the assessed patients. Current results showed that the elderly (≥ 65 years) had poor GOS (5/6, 83.3%), whereas the younger group had better GOS (3/3, 100%) (p ＜ 0.05). Lower GCS was associated with lower GOS. The subgroup with GCS ≤ 6 (p ＜ 0.05) had a lower GOS. We also observed a better outcome when GCS was higher than 9 (≥ 10) (5/5, 100%) on the fourth postoperative day (p ＜ 0.05). Conclusions: The use of CTA to evaluate vasospasm could be a reference while following the guidelines to manage patients with severe TBI. Aggressive treatment within the first four days could help in obtaining better brain resuscitation in severe TBI patients.

Reposição de volume orientada pela variação da pressão de pulso durante transplante renal: estudo randomizado controlado

PurposeKidney transplantation is the gold‐standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV‐guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. MethodsWe conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the PPV Group received fluids whenever PPV was higher than 12%, patients in the Free Fluid Group received fluids following our institutional standard care protocol for kidney transplantations (10mL.kg‐1.h‐1). ResultsUrinary output was similar at every time‐point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. ConclusionPPV‐guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.

Pulse pressure variation guided fluid therapy during kidney transplantation: a randomized controlled trial

PurposeKidney transplantation is the gold-standard treatment for end stage renal disease. Although different hemodynamic variables, like central venous pressure and mean arterial pressure, have been used to guide volume replacement during surgery, the best strategy still ought to be determined. Respiratory arterial Pulse Pressure Variation (PPV) is recognized to be a good predictor of fluid responsiveness for perioperative hemodynamic optimization in operating room settings. The aim of this study was to investigate whether a PPV guided fluid management strategy is better than a liberal fluid strategy during kidney transplantation surgeries. Identification of differences in urine output in the first postoperative hour was the main objective of this study. MethodsWe conducted a prospective, single blind, randomized controlled trial. We enrolled 40 patients who underwent kidney transplantation from deceased donors. Patients randomized in the “PPV” group received fluids whenever PPV was higher than 12%, patients in the “free fluid” group received fluids following our institutional standard care protocol for kidney transplantations (10 mL.kg-1. h-1). ResultsUrinary output was similar at every time-point between the two groups, urea was statistically different from the third postoperative day with a peak at the fourth postoperative day and creatinine showed a similar trend, being statistically different from the second postoperative day. Urea, creatinine and urine output were not different at the hospital discharge. ConclusionPPV guided fluid therapy during kidney transplantation significantly improves urea and creatinine levels in the first week after kidney transplantation surgery.

Sigmoid Volvulus in a Neonate with Anorectal Malformation: A Case Report

Background: Sigmoid volvulus in the neonate is an extremely rare condition needing emergency treatment. Sporadic cases of neonatal sigmoid volvulus and some in association with Hirschsprung’s disease have been documented. Sigmoid volvulus has been described only twice in the literature in association with anorectal malformation. However, newborns with anorectal malformations might be especially at risk for sigmoid volvulus due to increased intraluminal intestinal weight caused by bowel obstruction and its existence might be underreported. Case presentation: This is the case report of a full-term neonate with trisomy 21 who was diagnosed with anorectal malformation upon birth. An abdominal X-ray on his second day of life showed typical radiological findings of sigmoid volvulus as described by the radiologist. However, the findings were interpreted as a dilated rectosigmoid sling typical for anorectal malformation by the surgeon and a transverse loop colostomy was placed. On the fourth postoperative day sigmoid perforation occurred and led to meconium peritonitis and septic shock. An emergency laparotomy was performed and a perforation at the distal sigmoid colon was found. Conclusion: There is an urgent need to raise awareness as to the existence of sigmoid volvulus in the neonate with anorectal malformations. The distinct radiological findings of the “coffee bean sign”, the “northern exposure sign” and an empty rectum allow to distinguish the extremely rare sigmoid volvulus from the common finding of a dilated rectosigmoid in patients with anorectal malformations. Detorsion of sigmoid volvulus is vital to preventing sigmoid perforation.

Timing of hypocalcemia after total or near total thyroidectomy: a prospective observational study

Background: Hypocalcemia after thyroidectomy is the most common metabolic complication that prolongs the hospital stay. The aim of this study was to determine timing of hypocalcemia postoperatively and determine the safest day to discharge post-total or near-total thyroidectomy patients based on serum calcium level.Methods: From October 2012 to January 2017, the medical records of 117 consecutive patients who underwent a total or near-total, completion or redo thyroidectomy for benign and malignant thyroid diseases in two university hospitals were prospectively analyzed. The serum calcium was measured preoperatively, on the morning on the first, second, third and fourth postoperative days and the postoperative day on which hypocalcemia developed was identified.Results: Of the 117 patients who underwent a total or near thyroidectomy, 36 (30.7%) developed hypocalcemia, which was transient in 34 (29%) and permanent in two (1.7%) patients. The postoperative hypocalcemia was mild in 10 (8.5%) patients, and 26 (22.2%) patients developed significant postoperative hypocalcemia. Of the 36 patients who developed hypocalcemia postoperatively, the peak incidence of hypocalcemia (72.2%) was on the first postoperative day, and by the third day serum calcium measurement detected 97.3% of patients who developed hypocalcemia.Conclusions: Postoperative serial serum calcium levels may be useful for identifying patients suitable for early discharge following total/near total thyroid surgery in hospitals that lack the facilities. Hypocalcemia peaked on the first postoperative day. However, based on serum calcium levels alone, the third postoperative day is the crucial day for deciding whether to discharge the patients.

The results of a stepwise implementation of a fast-track program in total hip and knee replacement patients

BackgroundSeveral reports have shown that enhanced recovery or fast-track (FT) regime introduction in patients undergoing total knee replacement (TKR) and total hip replacement (THR) results in significant reduction in length of stay (LOS) with no associated increase of complications or readmission rate. Despite that, FT programs for arthroplasty have has not been uniformly recognized or accepted by many orthopaedic surgeons and there is still no consensus on the best implementation process. The aim of this study was to report the results of a stepwise implementation of a FT regime in TKR and THR patients in a general orthopaedic department. Material and methodsThis was a retrospective study of prospectively collected data (from 2014 to 2017) concerning all consecutive unselected patients who underwent TKR or THR on Monday morning. At stage 1 the rehabilitation and physiotherapy component was changed, at stage 2 and 3 a patient's blood management program and a pain management program were prospectively recorded (i.e. respectively Patients’ demographics, ASA classification, Charlson index, LOS, blood loss, transfusion rate, complications and 30 – day readmissions). ResultsFour hundred and thirty four patients underwent either TKR (n: 302) or THR (n:132) and were included in this study. A gradual reduction of mean LOS was found in THR patients from 5.7 days to 3.0 days and in TKR patients from 5.6 days to 3.4 days. Furthermore, no significant difference was found in complications or regarding the 30-day readmission rate at the different stages of implementation of the different FT components (i.e. at the final stage 96.7% of THR and 86.7% of TKR patients were discharged to home by the fourth post-operative day). ConclusionThe stepwise implementation of a FT program in an unelected population of THR and TKR patients was effective and safe, reducing the post-surgical recovery time and patients’ LOS with no major complications and no increase of 30-day re-admissions.

Subtotal Esophagectomy-Akiyama Procedure： In a Case with Esophageal Squamous Cell Carcinoma

Adenocarcinoma, typically in the distal third of the esophagus, and squamous cell carcinoma, typically in the proximal two thirds of the esophagus, each make up 49% of cases of esophageal cancer. The remaining cancers in this area include sarcoma (1%), lymphoma (0.5%), cylindroma (0.25%), and primary melanoma (0.25%). Case report We present patient S.G. 62 years old, male, with the following symptoms started 3 months from hospital admission: difficult swalloing mostly for the hard foods and eventually for the liquids too, chest burning, cough and vomiting, throat pain, weight loss. In the laboratory findings only a mild anemia was found, Hemoglobine 10.8 g/dl, and slightly high values of CRP. Patient was hospitalized in the First Clinic of General Surgery, University Hospital Center “Mother Teresa” Tirana, Albania and underwent an upper gastrointestinal tract endoscopy and 28 cm form the incisive teeth and esophageal narrowing was detected which could not allow the scope to go lower for further examination. Biopsy was taken through endoscopy. Patient was planned for a CT scan and tumor markers, CEA and CA 19-9, both later ones came in normal values. CT scan showed an irregular, asymmetric narrowing of the thoracic esophagus, thickening of the esophagus walls with 4 cm of extension without invasion of local periesophageal fat and regional lymphadenopathy. The biopsy resulted; esophageal squamous cell carcinoma G2. In these circumstances patient underwent a feeding jejunostomy and was sent to follow the protocol of neoadjuvant chemo and radiotherapy. Three months later the patient is returned in our clinic, where he underwent the surgical intervention. Postoperatively the patient was treated in the Intensive Care Unit. The next day after the operation, cervical drains were removed and in the fourth postoperative day the thoracic and abdominal drains were also removed. Patient comes in the surgery ward in the fifth postoperative day where is treated afterwards with an excellent postoperative course. In the tenth postoperative day the anastomosis integrity is verified by x-ray swallowing contrast gastrografin, and the next day he was discharged from the hospital. Keywords: Esophageal, squamous cell carcinoma, subtotal esophagectomy DOI: 10.7176/ALST/79-05 Publication date: March 31 st 2020

Physical Exercise Combined With CPAP in Subjects Who Underwent Surgical Myocardial Revascularization: A Randomized Clinical Trial.

Aerobic exercise and CPAP benefit patients in the postoperative period of cardiac surgery. To our knowledge, the association of aerobic exercise on an exercise bicycle with CPAP has not yet been demonstrated. Therefore, we aimed to evaluate the effectiveness of physical exercise on a cycle ergometer combined with CPAP in the postoperative period after coronary artery bypass graft surgery. This was a randomized clinical trial, with recruitment from May 2017 to December 2017 (registered in the Brazilian Clinical Trials Registry: RBR-69CDYF). The step group (n = 16 subjects) started rehabilitation in the immediate postoperative period with breathing exercises and passive mobilization in the sitting position, progressing to active exercises, ambulation, and stair training. For the intervention group (n = 15 subjects), dynamic exercises on a cycle ergometer combined with CPAP were added to the step program from the second to the fourth postoperative day in a single daily session. Functional capacity decreased in both groups, but this reduction was not significant in the intervention group (P = .11). The length of stay in ICU was lower in the intervention group (P = .050). In both groups there was a decrease in maximum inspiratory and expiratory pressure, as well as in the 1-min sit-to-stand test on the fourth postoperative day compared to the preoperative period. Physical exercise combined with CPAP promoted the maintenance of functional capacity and reduced the length of stay in the ICU.