High Risk Of Perioperative Complications Research Articles

The Beginning of a Paradigm Shift: Increase in Perioperative Complications Following Vaginal Hysterectomy Compared to Laparoscopic Hysterectomy Using the ACS-NSQIP 2016 - 2019 Database.

In this study, we compare perioperative outcomes following laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) between 2016 and 2019. A retrospective cohort study. National database study. The American College of Surgeons National Surgical Quality Improvement Program (ACS - NSQIP) database to identify patients underwent elective LH or VH between 2016 and 2019. Our primary outcome of interest was a composite incidence of perioperative complications. We generated a propensity score using a multiple logistic regression model to adjust for confounding factors and to reduce the selection bias between the two groups. We matched patients who underwent elective LH to patients who underwent elective VH on the logit of the propensity score. Of the 76,706 women in the cohort (2016-2019), 62,124 (80.9%) underwent LH and 14,582 (19.0%) underwent VH. After propensity matching (n=8,991 per group), results in the matched cohort revealed significant differences on the primary composite outcome. The composite risk of death, complications, reoperation, and readmission was lower among patients who underwent LH compared to VH, such that the primary composite outcome occurred in 5.62% of LH patients compared to 6.65% of VH patients (relative risk (RR) 0.845, 95% confidence interval (CI) 0.753 - 0.947, p = 0.004). In addition, the risk of both transfusion and readmission was higher among patients who underwent VH compared to LH (transfusion: RR 1.372, 95% CI 1.078 - 1.745, p =0.010; readmission: RR 1.546, 95% CI 1.216 - 1.966, p = 0.001). We have found that there is a lower 30-day composite morbidity for patients when undergoing LH compared to VH. These data demonstrate a higher risk of perioperative complications in women undergoing VH and should further inform surgeon's surgical considerations when deciding the optimal route of hysterectomy, depending on the expertise of the surgeon.

Концепция периоперационного риска: обзор литературы

INTRODUCTION: Perioperative risk refers to the likelihood of adverse events occurring during and after surgery. For the purpose of defining and classifying adverse events and predicting them, a comprehensive search of Pubmed and Lens.org was made according to the author expert opinion. OBSERVATIONS: Traditionally, two main types of postoperative adverse events have been investigated: complications and mortality. However, over the past decade, there has been a growing trend to expand the range of adverse events analyzed, from intraoperative critical events and the quality of recovery from anesthesia to the development of intensive care syndrome, assessing quality of life, disability, and survival over time. An important aspect associated with adverse events and outcomes is the provision of additional resources for a long-term stay for patients with acute respiratory viral infections and inpatient care after discharge, among other things. The review formulates its own concept of perioperative risk, based on a critical analysis of literature, with an emphasis on the need to create an ideal tool, such as a calculator, that must undergo external validation. This tool should include available, modifiable variables, and accurately determine the full range of adverse events and outcomes during the intra- and early postoperative periods, as well as delayed events. The concept shall also focus on identifying and characterizing patients with a high risk of perioperative complications.

Anaesthetic management of an infant with MEGD(H)EL syndrome undergoing cochlear implant

BackgroundThe syndrome has these features: 3-methylglutaconic aciduria (MEG), deafness(D), encephalopathy (E), Leigh-like syndrome (L). This disorder is caused by biallelic mutations in serine active site-containing protein 1 (SERAC1) gene. When these patients experience hepatopathy (H) in addition to the above manifestations, the syndrome is referred to as MEGD(H)EL. The pathology of this syndrome shares features with diverse types of inborn errors of metabolism.Case presentationWe discussed the anaesthetic management of an infant 2-year-old suffering from MEGD(H)EL syndrome undergoing cochlear implant. We discuss the pathology, genetics and significant aspects of this sporadic disease which is important for anaesthesiologist.ConclusionsThe usage of dexmedetomidine as the main anaesthetic drug might have the benefit of a non-triggering anaesthetic agent in patients with a mitochondrial disease. Mixture of dexmedetomidine and ketamine provide an effective combination for procedural sedation, predominantly in select populations who are at a high risk of perioperative complications due to underlying co-morbid conditions.

Algorithm for Managing Patients Hospitalized in the Surgical Wards Due to COVID-19-Related Acute Abdominal Pathology

AIM OF THE STUDY. Was to improve the outcomes of treatment of patients with COVID-19-related acute abdominal pathology by developing and implementing an algorithm for the diagnosis and treatment of those patients.MATERIAL AND METHODS. The study involved 200 patients who were randomized into two groups. This research was retrospective, based on the analysis of the medical histories of patients hospitalized with clinical manifestations of acute abdominal pathology that developed against the background of COVID-19. All medical histories in emergency departments and centers of the Republic of Uzbekistan were analyzed in the period from the beginning of the declaration of the pandemic (March 2020) to July 2022 inclusive.RESULTS. In the context of an infectious disease pandemic (COVID–19 as an example), it is very important to develop an algorithm for managing patients with acute surgical pathology. This algorithm should include a diagnostic component with the purpose of timely diagnosis of acute surgical pathology and hospitalization in the surgical department. The next step is to identify patients with a high risk of perioperative complications and adverse outcomes. The final component of the algorithm is the correction of possible risk factors for adverse outcomes.CONCLUSION. The duration of hospitalization of patients who underwent surgery for acute abdominal pathology was significantly longer during the pandemic compared to that of in the post-pandemic period (10.35±7.01 vs. 5.83±3.85 days, p<0.001), which may be due to both changes in the structure of the pathology and a larger number of complicated forms. The application of the developed algorithm will optimize the management of patients with COVID-19-related acute surgical pathology, guarantee rapid decision-making while minimizing the risk of infection, reduce the risk of complications and adverse outcomes.

215. MALNUTRITION AND VITAMIN DEFICIENCIES AFTER ONCOLOGICAL GASTRIC OR ESOPHAGEAL RESECTION

Abstract Background Patients receiving oncological esophagectomy or gastrectomy are known to be at high risk for vitamin and micronutrient deficiency before, during and after surgery. However, there are no clear guidelines for these cancer patients regarding postoperative vitamin supplementation. preoperative malnutrition has been shown to be associated with a higher risk of perioperative complications. In addition, malnutrition has shown to be an independent risk factor for reduced survival in cancer patients and early cancer recurrence. Methods This meta-analysis examines the prevalence of postoperative malnutrition, vitamin, and micronutrient deficiencies in patients who underwent gastrectomy or esophagectomy. A computer-based literature search was performed in several different databases with the The following search terms were used: vitamin, nutrition, deficienc*, malnutrition, osteoporos*, sarcopenia, esophagectom*, oesophagectom*, gastrectomy*, gastric, surg*, resect*, operat*, removal, excision, neoplas*, tumor, tumour, cancer, malign*adenocarcinom* squamous cell carcinom*. Out of 1611 studies, 42 documented relevant information, but only 17 provided 95% confidence intervals. After excluding seven studies due to insufficient data, the meta-analysis included 947 patients from 10 studies. Results The studies recorded vitamin and micronutrient blood levels from 3 months to 10 years post-surgery. The analysis found significant deficiencies in 25-OH Vitamin D3, Vitamin B12, and Serum Calcium levels. Patients had significantly lower Vitamin D3 levels compared to the healthy population, with mean levels in the lower normal range or lower. Serum Calcium levels were also significantly lower than the mean levels of the healthy population but stayed within the normal range. Mean Serum B12 levels were significantly lower than mean B12 levels in the standard population, but standard deviations stayed within the normal range. Serum albumin levels showed no signs of deficiency when compared to the healthy population. Similarly, no deficiency was detected in serum ferritin levels. Other vitamins and micronutrients studies included serum phosphorous, Vitamin A and Vitamin E, but data was insufficient for metanalysis. Discussion The study underscores the need for further research and guidelines to address postoperative nutritional deficiencies in these patients. Particularly, patients often develop a deficiency in Vitamin D3 after surgery, despite supplementation. Vitamin D3 insufficiency may increase perioperative risk and is concerning given the reduced calcium levels and bone marrow density. In conclusion there is a clear need for Vitamin D3 supplementation, both postoperatively and during the perioperative period. The study supports previous data indicating a high prevalence of postoperative micronutrient deficiency in esophagectomy patients. Given the high risk of malnutrition, screening should be a routine part of follow-up care. More data, particularly regarding deficiencies and supplementation after esophagectomy, is necessary.

Risk Factors for Perioperative Complications, Treatment Outcomes and Aggressive Behavior of the Tumor in Patients with Pheochromocytoma.

Pheochromocytomas are catecholamine-secreting tumors arising from chromaffin cells of the adrenal gland. Surgery is the only curative treatment with a high biochemical cure rate, low mortality and high risk of perioperative complications. To study the demographic characteristics of patients with pheochromocytoma and to identify the risk factors for perioperative complications, treatment outcomes, and aggressive behavior of the tumor. We retrospectively studied the data of pheochromocytoma patients registered from 2012 to 2022. In our study, a total of 30 patients with pheochromocytoma were included. The mean age of presentation was 35 ± 12.8 years. Fifty-six percent were females, and the sex ratio was 1.3:1. Pheochromocytoma spells (60%) was the most common complaint, followed by abdominal pain (53%), orthostatic complaints (10%) and incidentalomas (6%). The baseline mean 24-hour urinary total metanephrines was 2963.7 ± 2658 mcg/24 hours, and the mean tumor size was 7.3 ± 0.53 cm. Forty-three percent of patients underwent laparoscopic adrenalectomy, while the rest underwent open surgery. The mean Pheochromocytoma of Adrenal gland Scaled Score(PASS) was 3.41 ± 0.28, and 23% had a high risk for malignancy. Among perioperative complications, hypertensive crisis (17%) was the most common, followed by postoperative hypotension (13%), hypoglycemia (3%) and right-sided pneumothorax (3%). These patients with complications had higher metanephrine levels (5490 vs. 1880 mcg/24 hours, p = 0.001). Blood pressure normalized in 50%, and this was associated with male sex, younger age (29.5 vs. 40 years, p = 0.03), higher metanephrines (4619 vs. 1855 mcg/24 hours, p = 0.001) and smaller tumors (5.91 vs. 8.61 cm, p = 0.046). PASS score greater than or equal to 4 was associated with higher metanephrine levels (5104 vs. 2312 mcg/24 hours, p = 0.021) and larger tumors (9.28 vs. 6.68 cm, p = 0.024). Biochemical cure rate was achieved in 76% of patients after surgery and was associated with older age (37.7 years vs. 27.7 years, p = 0.047) and absence of pheochromocytoma spells (100% vs. 61%, p = 0.014). Young age, smaller tumor size and higher metanephrine concentrations were associated with normalization of blood pressure post-surgery. On the other hand, older patients and those without pheochromocytoma spells had better biochemical cure rates. Patients with higher baseline metanephrine levels had increased perioperative complications. More aggressive tumor behavior was associated with higher metanephrine levels and larger tumors. Sex, baseline blood pressure and mode of surgery did not have any influence on treatment outcomes.

Preoperative forced expiratory volume in one second and postoperative respiratory outcomes in nonpulmonary and noncardiac surgery: a retrospective cohort study

BackgroundAlthough the usefulness of pulmonary function tests has been established for lung resection and coronary artery bypass surgeries, the association between preoperative pulmonary function test and postoperative respiratory complications in nonpulmonary and noncardiac surgery is inconclusive. The purpose of this study was to determine the association between preoperative forced expiratory volume in one second (FEV1) on pulmonary function test and the development of postoperative respiratory failure and/or death in patients undergoing major nonpulmonary and noncardiac surgery.MethodsAdult patients aged ≥ 18 years and who underwent nonpulmonary and noncardiac surgery with expected moderate to high risk of perioperative complications from June 2012 to March 2019 were included. The primary exposure was preoperative FEV1 measured by pulmonary function test within six months before surgery. The primary outcome was respiratory failure (i.e., invasive positive pressure ventilation for at least 24 h after surgery or reintubation) and/or death within 30 days after surgery. A logistic regression model was used to adjust for the respiratory failure risk index, which is a scoring system that predicts the probability of postoperative respiratory failure based on patient and surgical factors, and to examine the association between preoperative FEV1 and the development of postoperative respiratory failure and/or death.ResultsRespiratory failure and/or death occurred within 30 days after surgery in 52 (0.9%) of 5562 participants. The incidence of respiratory failure and/or death in patients with FEV1 ≥ 80%, 70%– < 80%, 60%– < 70%, and < 60% was 0.9%, 0.6%, 1.7%, and 1.2%, respectively. Multivariable logistic regression analysis showed no significant association between preoperative FEV1 and postoperative respiratory failure and/or death (adjusted odds ratio per 10% decrease in FEV1: 1.01, 95% confidence interval: 0.88–1.17, P = 0.838). Addition of FEV1 information to the respiratory failure risk index did not improve the prediction of respiratory failure and/or death [area under the receiver operating characteristics curve: 0.78 (95% confidence interval: 0.72–0.84) and 0.78 (95% confidence interval: 0.72–0.84), respectively; P = 0.84].ConclusionWe found no association between preoperative FEV1 and postoperative respiratory failure and/or death in patients undergoing major nonpulmonary and noncardiac surgery.

A Meta-Analysis Comparing General Anesthesia, Deep Sedation, and Conscious Sedation for Catheter Ablation of Atrial Fibrillation

Background: The optimal anesthesia strategy during catheter ablation of atrial fibrillation (AF) remains controversial. This meta-analysis compared general anesthesia, deep sedation, and conscious sedation in terms of procedural time and complications. Methods: Literature searches were conducted in PubMed, EMBASE, and Web of Science databases. Mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using fixed- and random-effect models on the basis of the heterogeneity among studies, as assessed by I2 statistics. The random-effect model was used when the heterogeneity was high (I2 &gt; 50%). Publication bias was evaluated through funnel plots and Egger's tests. Results: Sixteen studies were included in this study. No significant difference was observed in procedural time between the general anesthesia and conscious sedation groups (MD: –8.1479 minutes, 95% CI: from –27.6836 to 11.3878, seven studies). Deep sedation was associated with procedural time (MD: 131.8436 minutes, 95% CI: 99.6540–164.0332, eight studies). The rate of serious intraprocedural complications was 1.5% (95% CI: 1.2%–1.9%) with deep sedation (seven studies). Conscious/analog sedation had 26%–29% higher odds of perioperative complications than general anesthesia (OR: 1.2622, 95% CI: 1.0273–1.5507, nine studies). Significant heterogeneity was present across studies. Conclusions: This meta-analysis found no significant difference in procedural time between general anesthesia and conscious sedation for AF ablation. Deep sedation was associated with longer procedural time. Conscious sedation appeared to have a higher risk of perioperative complications than general anesthesia. Further randomized trials are warranted to determine the optimal anesthesia strategy.

Drug-related problems in elective surgical inpatients: A retrospective study.

Patients with drug-related problems are at high risk for perioperative complications. The study aimed to determine the prevalence, number, characteristics, clinical significance and the involved drugs of drug-related problems in inpatients, who were admitted to elective surgery, as well as their burden of comorbidity. The study design was a retrospective, observational study across nine different surgical sites. Patients at admission for elective surgery with ≥ 1 drug-related problem, a hospital stay of ≥ 24 h and at age ≥ 18 years were included. The outcomes of interest were the prevalence and nature of drug-related problems, assessed by pharmacists at hospital admission. The Pharmaceutical Network Europe classification V9.1, the Hatoum scale of clinical significance, the Anatomical-Therapeutic-Chemical classification scheme of the World Health Organization were engaged to categorize drug-related problems and their clinical significance. The Charlson Comorbidity Index was applied to assess the comorbidity of participants. The final data set included 11,176 elective surgical inpatients. Of these, a sample of 284 (2.54%) patients was analysed. It was found that 9.89% of the patients showed at least one drug-related problem (average 1.43, SD 0.7). Major causes were drug-drug interactions (30.3%) and supra-therapeutic doses (18.0%). Most drug-related problems were referred to a prescriber for intervention (61.3%). Eighty-two percent of drug-related problems were rated as clinically significant. Cardiovascular drugs were of major concern. Participants' most common comorbidities were tumour diagnosis (34%), diabetes mellitus with end organ damage (26%) and peripheral vascular diseases (19%). Although the prevalence of drug-related problems in this diverse study population was low, drug-related problems were of great importance in terms of their cause and clinical significance. Patients with drug-related problems showed a moderate burden of physiological illness. Study results suggest a need to identify exposed patients with drug-related problems.

Perioperative management and outcomes for posterior spinal fusion in patients with Friedreich ataxia: A single-center, retrospective study.

Friedreich ataxia is a rare genetic disorder associated with progressive mitochondrial dysfunction leading to widespread sequelae including ataxia, muscle weakness, hypertrophic cardiomyopathy, diabetes mellitus, and neuromuscular scoliosis. Children with Friedreich ataxia are at high risk for periprocedural complications during posterior spinal fusion due to their comorbidities. To describe our single-center perioperative management of patients with Friedreich ataxia undergoing posterior spinal fusion. Adolescent patients with Friedreich ataxia presenting for spinal deformity surgery between 2007 and 2023 were included in this retrospective case series performed at the Children's Hospital of Philadelphia. Perioperative outcomes were reviewed along with preoperative characteristics, intraoperative anesthetic management, and postoperative medical management. Seventeen patients were included in the final analysis. The mean age was 15 ± 2 years old and 47% were female. Preoperatively, 35% were wheelchair dependent, 100% had mild-to-moderate hypertrophic cardiomyopathy with preserved systolic function and no left ventricular outflow tract obstruction, 29% were on cardiac medications, and 29% were on pain medications. Intraoperatively, 53% had transesophageal echocardiography monitoring; 12% had changes in volume status on echo but no changes in function. Numerous combinations of total intravenous anesthetic agents were used, most commonly propofol, remifentanil, and ketamine. Baseline neuromonitoring signals were poor in four patients and one patient lost signals, resulting in 4 (24%) wake-up tests. The majority (75%) were extubated in the operating room. Postoperative complications were high (88%) and ranged from minor complications like nausea/vomiting (18%) to major complications like hypotension/tachycardia (29%) and need for extracorporeal membrane oxygenation support in one patient (6%). Patients with Friedreich ataxia are at high risk for perioperative complications when undergoing posterior spinal fusion and coordinated multidisciplinary care is required at each stage. Future research should focus on the utility of intraoperative echocardiography, optimal anesthetic agent selection, and targeted fluid management to reduce postoperative cardiac complications.

Perioperative Considerations in Patients with Vein of Galen Malformation Undergoing Embolization–A Single-Institution Case Series

AbstractVein of Galen malformation (VOGM) is a congenital, intracranial vascular malformation, with an extracardiac shunt. Neonates can present with high output cardiac failure, pulmonary hypertension, or multiorgan failure and are at high risk of perioperative complications, especially in remote locations. We conducted a retrospective single-center analysis of the perioperative management of patients with VOGM presenting for embolization. Patients were identified by querying both the hospital billing dataset using International Classification of Diseases-10 diagnosis or billing code and the Neuro-interventional Radiology Database, from January 2011 to March 2020. As many as 14 patients were identified, 12 of which underwent definitive treatment. Six patients who underwent embolization in the neonatal period had pulmonary hypertension. Those children required varying degrees of hemodynamic and respiratory support preoperatively and experienced significant intraoperative events, including one intraoperative cardiac arrest. Caring for these critically ill patients in a remote location requires proper planning to prevent adverse outcomes.

Obesity and anesthesia.

Surgical procedures on obese patients are dramatically increasing worldwide over the past few years. In this review, we discuss the physiopathology of predominantly respiratory system in obese patients, the importance of preoperative evaluation, preoxygenation and intraoperative positive end expiratory pressure (PEEP) titration to prevent pulmonary complications and the optimization of airway management and oxygenation to reduce or prevent postoperative respiratory complications. Many patients are coming to preoperative clinic with medication history of glucagon-like-peptide 1 agonists ( GLP-1) agonists and it has raised many questions regarding Nil Per Os (NPO)/perioperative fasting guidelines due to delayed gastric emptying caused by these medications. American Society of Anesthesiologists (ASA) has come up with guiding document to help with such situations. Ambulatory surgery centers are doing more obesity cases in a safe manner which were deemed unsafe at one point . Quantitative train of four (TOF) monitoring, better neuromuscular reversal agents and gastric ultrasounds seemed to have made a significant impact in the care of obese patients in the perioperative period. Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.

Impact of Controlled Versus Uncontrolled mFI-5 Frailty on Perioperative Complications After Adult Spinal Deformity Surgery.

Retrospective review. We substratified the mFI-5 frailty index to reflect controlled and uncontrolled conditions and assess their relationship to perioperative complications. Risk assessment before adult spinal deformity (ASD) surgery is critical because the surgery is highly invasive with a high complication rate. Although frailty is associated with risk of surgical complications, current frailty measures do not differentiate between controlled and uncontrolled conditions. Frailty was calculated using the mFI-5 index for 170 ASD patients with fusion of ≥5 levels. Uncontrolled frailty was defined as blood pressure >140/90mm Hg, HbA1C >7% or postprandial glucose >180mg/dL, or recent chronic obstructive pulmonary disease (COPD) exacerbation, while on medication. Patients were divided into nonfrailty, controlled frailty, and uncontrolled frailty cohorts. The primary outcome measure was perioperative major and wound complications. Bivariate analysis was performed. Multivariable analysis assessed the relationship between frailty and perioperative complications. The cohorts included 97 nonfrail, 54 controlled frail, and 19 uncontrolled frail patients. Compared with nonfrail patients, patients with uncontrolled frailty were more likely to have age older than 60 years (84% vs. 24%), hyperlipidemia (42% vs. 20%), and Oswestry Disability Index (ODI) score >42 (84% vs. 52%) ( P <0.05 for all). Controlled frailty was associated with those older than 60 years (41% vs. 24%) and hyperlipidemia (52% vs. 20%) ( P <0.05 for all). On multivariable regression analysis controlling for hyperlipidemia, functional independence, motor weakness, ODI>42, and age older than 60 years, patients with uncontrolled frailty had greater odds of major complications (OR 4.24, P =0.03) and wound complications (OR 9.47, P =0.046) compared with nonfrail patients. Controlled frailty was not associated with increased risk of perioperative complications ( P >0.05 for all). Although patients with uncontrolled frailty had higher risk of perioperative complications compared with nonfrail patients, patients with controlled frailty did not, suggesting the importance of controlling modifiable risk factors before surgery. 3.

Impact of goal-directed hemodynamic therapy on perioperative outcomes in head and neck free flap surgery: A before-and-after pilot study.

Free flap reconstruction for head and neck cancer is associated with a high risk of perioperative complications. One of the modifiable risk factors associated with perioperative morbidity is intraoperative hypotension (IOH). The main aim of this pilot study is to determine if the intraoperative use of goal-directed hemodynamic therapy (GDHT) is associated with a reduction in the number of IOH events in this population. A before-and-after study design. The patients who had intraoperative GDHT were compared to patients from a previous period before the implementation of GDHT. The primary outcome was the number of IOH episodes defined as five or more successive minutes with a mean arterial pressure <65 mmHg. The secondary outcomes included major postoperative morbidity and 30-day mortality. A total of 414 patients were included. These were divided into two groups. The control group (n = 346; January 1, 2018, to December 31, 2019), and the monitored group (n = 68; January 1, 2020, to May 1, 2021). The median intraoperative administered fluid volume was similar between the control and monitored groups (2250 interquartile range[IQR][1607-3050] vs. 2210 IQR[1700-2807]mL). The monitored group was found to have an increased use of norepinephrine and dobutamine (respectively, 1.2% vs. 5.9% and 2.4% vs. 30.9%; p < 0.05). When adjusting for confounders (comorbidities, estimated blood loss,and duration of anesthesia) the incidence rate ratio (95% confidence interval) of number of IOH events was 0.94 (0.86-1.03), p = 0.24. The rate of postoperative flap and medical complications did not differ between the two groups. Even though the use of vasopressors/inotropes was higher in the monitored group, the number of IOH episodes and postoperative morbidity and mortality were similar between the two groups. Further change in hemodynamic management will require the use of specific blood pressure targets in the GDHT fluid algorithm.

Cardiovascular Disease in Total Knee Arthroplasty: An Analysis of Hospital Outcomes, Complications, and Mortality.

Cardiovascular comorbidities have been identified as a significant risk factor for adverse outcomes following surgery. The purpose of this study was to investigate its prevalence and impact on postoperative outcomes, hospital metrics, and mortality in patients undergoing total knee arthroplasty (TKA). Our hypothesis was that patients with cardiovascular comorbidities would have worse outcomes, greater postoperative complication rates, and increased mortality compared to patients without cardiovascular disease. In this retrospective study, data from the National Inpatient Sample database from 2011 to 2020 were queried for patients who underwent TKA with preexisting cardiac comorbidities, including congestive heart failure (CHF), coronary artery disease (CAD), valvular dysfunction, and arrhythmia. Multivariate logistic regression analyses compared hospital metrics (length of stay, costs, and adverse discharge disposition), postoperative complications, and mortality rates while adjusting for demographic and clinical variables. All statistical analyses were performed using R studio 4.2.2 and Stata MP 17 and 18 with Python package. A total of 385,585 patients were identified. Those with preexisting CHF, CAD, valvular dysfunction, or arrhythmias were found to be older and at higher risk of adverse outcomes, including prolonged length of stay, increased hospital charges, and increased mortality (p < 0.001). Additionally, all preexisting cardiac diagnoses led to an increased risk of postoperative myocardial infarction, acute kidney injury (AKI), and need for transfusion (p < 0.001). The presence of valvular dysfunction, arrhythmia, or CHF was associated with an increased risk of thromboembolic events (p < 0.001). The presence of CAD and valvular dysfunction was associated with an increased risk of urologic infection (p < 0.001). This study demonstrated that CHF, CAD, valvular dysfunction, and arrhythmia are prevalent among TKA patients and associated with worse hospital metrics, higher risk of perioperative complications, and increased mortality. As our use of TKA rises, a lower threshold for preoperative cardiology referral in older individuals and early preoperative counseling/intervention in those with known cardiac disease may be necessary to reduce adverse outcomes.

The Role of Invasive Hemodynamic Monitoring in Patients with Severe Mitral Regurgitation Undergoing Herniorrhaphy Operation

Background: Mitral regurgitation (MR) indeed presents challenges during noncardiac surgeries, especially as the severity of MR tends to increase with age and poses a higher risk of perioperative complications. Accurate hemodynamic monitoring becomes crucial in these cases to manage potential complications effectively. However, the standard monitoring in MR conditions during operation, such as TEE, is not always available, but there are other options for invasive monitoring, such as arterial lines, which provide accurate hemodynamic monitoring.&#x0D; Case presentation: A 64-year-old, male, presented with Reponible Lateral Inguinal Hernia with comorbid of severe mitral and tricuspid regurgitation alongside congestive heart failure. The patient was premedicated with fentanyl 25 mcg intravenously, followed by oxygen supplementation with 3 lpm nasal cannula and insertion of the arterial line. Anaesthesia was performed using a lumbar epidural technique, with the insertion of an epidural catheter in the L1-L2 intervertebral space, Reponible Lateral Inguinal Hernia. The local anesthesia agent chosen was plain bupivacaine with a concentration of 0.5% and a volume of 8 ml. The onset of action of epidural anesthesia is achieved within 20 minutes as long as the operation reaches a total blockade as high as T8. The patient is monitored with standard monitors and an artery line during surgery. There were no complaints of shortness of breath, chest heaviness, or chest pain felt by the patient during the operation.&#x0D; Conclusion: Epidural anesthesia technique can provide stable hemodynamics in patients with severe mitral-tricuspid regurgitation and congestive heart failure and hemodynamic monitoring plays an important role postoperatively to prevent further deterioration and maintain stability.

Lokalni nazolabijalni režanj u rekonstrukciji defekata dna usne šupljine

After an extensive tumor resection, a defect of the floor of the mouth is a significant reconstructive challenge. The main goal is to preserve the mobility of the tongue, which allows the restauration of mastication, deglutition, and articulation. Today, a standard method for reconstruction of floor of the mouth defects is free microvascular flaps, especially radial forearm free flap. Despite that, a potential problem is the high perioperative risk and high complication rate associated with the patient’s age and comorbidities. Current literature suggests that a local nasolabial flap is a reliable treatment option for reconstruction of this type of defect, with a low complication rate and excellent functional and aesthetic results. The aim of this case presentation is to show the use of a local nasolabial flap for reconstruction of the floor of the mouth and to determine the criteria for this type of reconstruction. We present a patient who underwent resection of a floor of the mouth tumor. Due to the patient’s age, medical condition, and comorbidities, the defect was reconstructed with a local nasolabial flap. There were no postoperative complications. Articulation, mastication, and deglutition were satisfactorily rehabilitated. Follow-up showed no signs of recurrent disease twelve months postoperatively. To conclude, a local nasolabial flap is still an important reconstructive choice for oral cavity defects, especially for elderly patients with multiple comorbidities who have a higher risk of perioperative complications.

Increased Risk of In-Hospital Complications and Costs After Total Hip Arthroplasty for Primary and Secondary Osteonecrosis

An increasing proportion of patients are undergoing total hip arthroplasty (THA) for osteonecrosis (ON). Comorbid conditions and surgical risk factors are known to be greater in ON patients compared with patients who have osteoarthritis (OA) alone. The purpose of our study was to quantify the specific in-hospital complications and resource utilization associated with patients undergoing THA for ON versus OA. A large national database was queried to identify patients undergoing primary THA from January 1, 2016 to December 31, 2019. A total of 1,383,880 OA, 21,080 primary ON, and 54,335 secondary ON patients were identified. Demographics, in-hospital complications, costs, lengths of stay, and discharge dispositions for primary and secondary ON cohorts were compared to OA only. Age, race, ethnicity, comorbidities, Medicaid, and income status were controlled with binary logistic regression analyses. The ON patients were often younger, African American or Hispanic, and had more comorbidities. Those undergoing THA for primary and secondary ON had a significantly higher risk of perioperative complications, including myocardial infarction, postoperative blood transfusion, and intraoperative bleeding. Total hospital costs and lengths of stay were significantly higher for both primary ON and secondary ON and both cohorts were less likely to be discharged home. While rates of most complications have decreased over recent decades in ON patients undergoing THA, the ON patients still have worse outcomes even when controlling for comorbidity differences. Bundled payment systems and perioperative management strategies for these different patient cohorts should be considered separately.

Novel treatment of gastric outlet obstruction secondary to incarcerated inguinal hernia: percutaneous endoscopic gastrostomy tube

Abstract A 93-year-old man presented with gastric outlet obstruction (GOO) secondary to a massive left inguinal hernia with incarcerated antrum. He reported a desire to avoid operative intervention, and given his comorbidities, such an operation carried high risk for perioperative complications. As such, we offered percutaneous endoscopic gastrostomy (PEG) tube placement, as this would allow intermittent decompression of the stomach to reduce the risk of obstruction and strangulation. He tolerated the procedure well and was discharged after several days of observation. He continues to do well at regular outpatient appointments. Although rare, GOO secondary to an incarcerated inguinal hernia is most likely to occur in a patient such as ours: elderly, comorbid and at high risk for perioperative complications. To our knowledge, this is the first documented case to be treated with a PEG tube, which can be a desirable and effective option in this subset of patients.

Operative Management of Thyroid Disease in Older Adults.

As the population ages, both domestically and globally, clinicians will increasingly find themselves navigating treatment decisions for thyroid disease in older adults. When considering surgical treatment, individualizing risk assessment is particularly important, as older patients can present with very different health profiles. While fit, independent individuals may benefit from thyroidectomy with minimal risk, those with multiple comorbidities and poor functional status are at higher risk of perioperative complications, which can have adverse health effects and detract from long-term quality of life. In order to optimize surgical outcomes for older adults, strategies for accurate risk assessment and mitigation are being explored. Surgical decision-making also should consider the characteristics of the thyroid disease being treated, given many benign thyroid disorders and some well-differentiated thyroid cancers can be appropriately managed nonoperatively without compromising longevity. Shared decision-making becomes increasingly important to respect the health priorities and optimize outcomes for older adults with thyroid disease. This review summarizes the current knowledge of thyroid surgery in older adults to help inform decision-making among patients and their physicians.