Low Operative Risk Research Articles

Efficacy and safety of Le Fort colpocleisis in the treatment of stage III-IV pelvic organ prolapse

BackgroundLe Fort colpocleisis is an obliterative surgery for the treatment of pelvic organ prolapse (POP). In this study, we aimed to investigate the efficacy and safety of Le Fort colpocleisis in the treatment of patients with stage III-IV POP.MethodsThe study was designed as a retrospective analysis of a single-center case series. Patients with stage III-IV POP treated with Le Fort colpocleisis were included. Perioperative indicators, subjective and objective outcomes and complications were assessed. The POP-Quantification (POP-Q) system was used for objective outcome evaluation. Pelvic Floor Distress Questionnaire (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) were used for subjective outcome evaluation.ResultsA total of 54 patients with complete pre- and postoperative data completed follow-up and were included in our study. The mean ± standard deviation of operative time, intraoperative blood loss, recovery activity time, postoperative hospitalization time and total hospitalization time were 146.85 ± 37.01 min, 92.04 ± 68.31 ml, 2.81 ± 0.85 days, 6.5 ± 2.11 days and 13.52 ± 4.78 days, respectively. Within the median follow-up period of 38.5 months, the objective cure rate of Le Fort colpocleisis reached 98.15% (53/54), and the subjective cure rate reached 92.59% (50/54). No serious complications were reported during the perioperative period and follow-up period.ConclusionLe Fort colpocleisis is an effective and safe procedure for the treatment of severe POP. Because of its lower operative risk, better subjective and objective outcomes, lower rates of prolapse recurrence and perioperative complications, Le Fort colpocleisis should be considered as the recommended procedure for elderly patients with severe POP (stage III-IV).

Cerebrovascular Events in Patients Undergoing Transcatheter Aortic Valve Replacement: A Review.

Cerebrovascular events (CVEs) are a dreaded complication of transcatheter aortic valve replacement (TAVR). They are associated with significant mortality, morbidity, and reduced quality of life and impose a significant burden to health care systems. Although the rates of clinical stroke have reduced since the advent of TAVR, it remains an important complication, particularly as TAVR is increasingly utilized. CVE may occur at the time of the TAVR, as a direct consequence of the procedure, or may occur later, related to thrombosis of the prosthetic valve, atrial fibrillation, and other comorbidities. Imaging of the brain has revealed a high prevalence of subclinical cerebral infarcts (68%-98%) associated with the TAVR procedure. Although their clinical significance has not been fully established, clinically evident CVE ranges between 3% and 5% in patients considered at high operative risk to between 1% and 3% in low operative risk patients. Periprocedural CVEs are largely the result of embolization of the thrombus and tissue derived from the valve, vasculature, or myocardium. Cerebral embolic protection devices have been studied in multiple trials, with some evidence supporting a reduction in new cerebral lesion volume, number, and potentially disabling strokes. However, thus far, there is no robust evidence that they reduce the overall stroke rate. The number and severity of comorbidities, in particular, new-onset atrial fibrillation, are associated with CVEs. Valve thrombosis diagnosed using computed tomography as areas of hypoattenuated leaflet thickening has been identified in 10% to 15% of patients. This is a dynamic process associated with an increase in CVEs, but that resolves with anticoagulation or sometimes without it. Routine use of anticoagulation compared with a single antiplatelet agent is associated with an increased risk of bleeding, without any additional alleviation in risk of thromboembolism. Future studies to improve risk stratification could facilitate the tailoring of preventive therapies to patients at high risk of CVE, who stand to gain the most benefit.

The impact of digitalization on operational risk: An organizational information processing perspective

Digitalization has emerged as a mitigation tool for business risks. However, digitalization has not been effectively utilized because the mechanism of digitalization mitigating risks is still in the dark box. Drawing upon organizational information processing theory, we propose that digitalization reduces operational risk through internal control systems and supply chain networks (SCN). Based on the data of Chinese public firms from 2010 to 2019, we confirm that both improving internal control system quality and reducing SCN centrality are effective vehicles to help digitalization combat operational risk. Specifically, a high degree of digitalization leads to high-quality internal control systems, which, in turn, leads to low operational risk. Inversely, digitalization increases SCN centrality, which, in turn, leads to high operational risk. Furthermore, the positive mediation effect of SCN centrality is significantly more substantial than the negative mediation effect of internal control system quality. Subsequent moderating effect analysis shows that diversification does not impact the mediation effect of internal control system quality but strengthens the mediation effect of SCN centrality. This study deepens the understanding of the risk mitigation effect of digitalization and offers meaningful metrics for managers to prevent firms from suffering unexpected risks.

Impact of Complex Anatomy and Patient Risk Profile in Minimally Invasive Mitral Valve Surgery

BackgroundWe aimed to assess the impact of complex mitral valve disease and patient risk profile on operative outcomes in the large cohort of the Mini-Mitral International Registry. MethodsPatients were assigned to categories of complex degenerative mitral valve regurgitation (DMR; bileaflet or anterior mitral leaflet prolapse/flail) and simple DMR (posterior mitral leaflet prolapse/flail). Subgroup analyses was performed in low-risk (EuroSCORE II <8%) and high-risk (EuroSCORE II >8%) cohorts. A logistic regression model was applied to investigate the impact of valve anatomy and patient risk factors on valve repair rate and operative risk. ResultsThe study cohort consisted of 4524 patients with DMR (complex DMR, 1296; simple DMR, 3228). Valve repair rate was 87.3% and 91% in complex DMR and simple DMR, respectively. Predictors of valve replacement were anterior leaflet prolapse/flail, bileaflet flail, female sex, age, and reoperation, whereas Barlow disease was protective. Clinical results were comparable between complex DMR and simple DMR. On subgroup analyses, high-risk patients showed less satisfactory outcomes with respect to both the valve repair and operative mortality rates. ConclusionsOur findings suggest that complex DMR can be satisfactorily addressed by minimally invasive techniques. However, whereas complex disease was associated with low operative risk, anterior leaflet lesions and bileaflet flail remain negative predictors of successful valve repair. Conversely, valve repair rate was less satisfactory in high-risk patients, regardless of DMR complexity.

Working Capital Behavior and Risk: Empirical Study of Manufacturing Companies in Indonesia

This study aims to examine empirically the aggressive behavior of investment in working capital. Empirically, the research was carried out for companies in industrial sectors listed on the Indonesia Stock Exchange. Data consist of panel data of 2012-2017 totaling 157 samples after screening for outliers and normality. Structural equation modeling (SEM) is employed to test the recursive model. The results reveal that investment aggressiveness is influenced by sales growth, that is, the higher the aggressiveness of working capital investment, the lower the risk of liquidity. Furthermore, the lower liquidity risk has an impact on the lower operational risk. The lower the operational risk, the lower the profitability, and the lower the value of the company or the higher the financial risk. The findings are supported by previous studies which show that the higher the liquidity risk, the lower the financial risk. In short, the aggressiveness of working capital does not create value for shareholders.

How safe and effective are paediatric virtual fracture clinics? A systematic review.

Virtual fracture clinics (VFC) involve a consultant-led multidisciplinary team meeting where cases are reviewed before a telephone consultation with the patient. VFCs have the advantages of reducing waiting times, outpatient appointments and time off school compared to face-to-face (F2F) fracture clinics. There has been a surge in VFC use since the COVID-19 pandemic but there are still concerns over safety in the paediatric population. Fractures make up a large burden of paediatric injuries, therefore research is required on the safety and efficacy of paediatric VFCs. This systematic review will look at the safety and effectiveness of paediatric VFCs, as well as determine the cost-effectiveness and parent preferences. As per the PRISMA guidelines two independent reviewers searched the following databases: Medline, Embase and Web of Science. Studies were included if children under 18 years old presented to A&E with a suspected or confirmed simple un-displaced fracture and were referred to a VFC. The primary outcomes assessed were effectiveness and safety, with the secondary outcomes of cost-effectiveness and parent satisfaction. Six studies met the inclusion criteria for this systematic review. There was a high rate of direct discharge from the VFC leading to reduced outpatient appointments. All patients were seen within 72 h of presentation. There were limited incidences of missed fractures and the rates of re-presentation were similar to that of F2F orthopaedic clinics. There were significant cost savings for the hospitals and high parent satisfaction. VFCs have shown to be safe and effective at managing most stable, low operative risk paediatric fractures. Safety must be ensured with a telephone helpline and an open return to fracture clinic policy. More research is needed into specific paediatric fracture types to be managed in the VFC. https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier: CRD42023423795.

Outcomes of Central Neck Dissection for Papillary Thyroid Carcinoma in Primary Versus Revision Setting.

Surgery in the central compartment after previous thyroidectomy involves an increased risk of injury to critical organs, including the parathyroids and recurrent laryngeal nerve. Contrastingly, primary central neck dissection involves a relatively low operative risk. This study aimed to compare the outcomes of central neck dissection in primary versus revision settings with respect to the lymph node yield and complication rates. This single-center prospective study included patients who underwent primary or revision neck dissection surgery for histologically confirmed thyroid malignancy between January 2018 and January 2022. We included 30 patients who underwent total thyroidectomy with primary central neck dissection and 29 patients who underwent central neck dissection following remote thyroidectomy with or without previous central dissection. There was no significant between-group difference in postoperative complications, including permanent hypocalcemia and recurrent laryngeal nerve injury. However, both groups showed a significant postoperative decrease in calcium levels even though calcium and parathyroid hormone levels were within reference range. Although many surgeons fear revision central neck dissection, it appears to have similar therapeutic outcomes and complication rates as primary neck dissection for papillary thyroid cancer. Specifically, there were no between-group differences in the lymph node yield, hypoparathyroidism, or recurrent laryngeal nerve paralysis. Patients with normocalcemia showed a significant postoperative reduction in calcium levels, suggesting subclinical parathyroid insufficiency.

Sternalsparing aortic valve replacement via right anterior minithoracotomy: An early experience.

This study aims to evaluate the perioperative outcomes of aortic valve replacement (AVR) via right anterior minithoracotomy (RAT) during the learning curve. It was a retrospective, observational, cohort study of patients who underwent RAT AVR from June 2015 to April 2022. Primary outcomes measured were 30-day morbidity and mortality. A total of 107 consecutive patients underwent elective RAT AVR. Our patients were mostly male (78.5%), elderly (mean 68.7 years), and obese (34.6%). A majority of the patients (93.5%) were of low operative risk. Median cross-clamp and bypass times were 95 and 123 minutes respectively. There was a statistically significant correlation between increase in number of cases and decrease in operative time. All patients had no paravalvular leak at discharge. There were no operative cardiovascular mortality or major morbidity including stroke, myocardial infarction, renal failure requiring dialysis, or vascular complication. No patient required intraoperative conversion to full sternotomy for completion of AVR. Our study demonstrated that RAT AVR can be safely introduced. The learning curve required in performing RAT AVR can be safely negotiated through training, previous experience in minimally invasive surgery, careful patient selection including use of preoperative computed tomography of the aorta, and introduction of sutureless/rapid deployment valves.

The value of mono-gender production in Atlantic salmon farming

Efforts to enhance production efficiency in the aquaculture industry are imperative to ensure its sustainable growth. The aim of this study is to investigate whether the usage of mono-gender smolt in Atlantic salmon farming can increase value of operations for salmon producers. Mono-male and mono-female smolt exhibit distinct biological characteristics, with males demonstrating accelerated growth rates, albeit being more exposed to the risk of sexual maturation, while females display reduced susceptibility to such maturation risks and grow at a comparatively slower pace. Despite the potential benefits of optimizing mono-gender smolt production, the economic viability of employing such strategies within a risk-reward framework has not been studied before In this paper, we compare the production efficiency and the operational risk of different compositions of mono-gender to the mixed-gender production plans. The study is performed by simulating multi-location productions of mono-gender and mixed-gender salmon based on actual production data. In all scenarios investigated, mono-gender production provides solutions with higher expected value and lower operational risk. The increased value of mono-gender production is driven by improved flexibility in the production planning and better utilisation of gender-specific biological properties, which outweighs the higher cost of mono-gender smolt. The optimal composition of genders is dependent on the quality downgrade factor, the cost of smolt and the risk preferences of the producer. Nevertheless, higher shares of all-female deployments are generally found to provide the best risk/reward profile. While providing valuable insights, the study's focus on gender-specific traits leaves out the consideration of market price uncertainty, suggesting a potential avenue for future research.

Performance-based contracting in the airline industry from the standpoint of risk-averse maintenance providers

Airline industry is a business characterized by its low profit and high operational risk. Sometimes contracting out aircraft maintenance is mandatory due to the lack of labor capacity or shortage of staff with specialized capabilities. It raises the challenge of negotiating an agreement through performance-based contracting (PBC) as an alternative to traditional on-call maintenance services, or time and material contracts (T &amp;MC), where no risk is transferred to the service provider. Due to the importance of risk transfer to contractors under PBC, the authors propose a model to determine the optimal contract price and the number of customers to serve when aircraft maintenance is outsourced to a risk-averse service provider offering two PBC options. To the best of the author’s knowledge, no quantitative studies for pricing contracts optimally when taking into account maintenance provider’s risk-aversion have been presented in the existing literature. For that purpose, the authors combine queuing, game, and modern portfolio theories in the proposed formulation.

Executives' horizon and trade credit

AbstractUsing executives' decision horizon as a measure of internal governance, this study examines the association between customer's internal governance and supplier's extension of trade credit. Suppliers may extend more trade credit to customers with strong internal governance because of their lower operational risk, higher firm performance, and better information environment. However, firms with better internal governance may have easier access to other sources of financing, and thus may need less trade credit. Using a sample of US listed firms between 1992 and 2021, we find that suppliers extend more trade credit to customers with strong internal governance. We also find that the association between internal governance and trade credit is more pronounced for financially, and informationally constrained firms. Our results are robust to alternative measures and specifications. Incremental to prior studies, we show that effectiveness of customers' internal governance affects suppliers' lending decisions.

Femoral or Axillary Cannulation for Extracorporeal Circulation during Minimally Invasive Heart Valve Surgery (FAMI): Protocol for a Multi-Center Prospective Randomized Trial.

Minimally invasive heart valve surgery via anterolateral mini-thoracotomy with full endoscopic 3D visualization (MIS) has become the standard treatment of patients with valvular heart disease and low operative risk over the past two decades. It requires extracorporeal circulation and cardioplegic arrest. The most established form of arterial cannulation for MIS is through the femoral artery and is used by most surgeons, but it is suspected to increase the risk of stroke through retrograde blood flow. An alternative route of cannulation is the axillary artery, producing antegrade blood flow during extracorporeal circulation. Femoral or axillary cannulation for extracorporeal circulation during minimally invasive heart valve surgery (FAMI) is a multicenter randomized controlled trial designed to determine whether axillary cannulation is superior to femoral cannulation for the outcome of a manifest stroke within 7 days postoperatively. The target sample size was 848 participants. Patients ≥ 18 years of age, with valvular regurgitation or stenosis scheduled for minimally invasive surgery via anterolateral mini-thoracotomy, were randomized to axillary cannulation (treatment group) or to femoral cannulation (standard care). Patients were followed up for seven days postoperatively. A CT scan was performed pre-operatively to screen patients for vascular calcifications and to assess the safety of femoral cannulation. The standard of care is femoral artery cannulation, but is performed only in patients without significant vascular calcifications or severe kinking of the iliac arteries and in patients with sufficient vessel diameter. The cannulation is performed via Seldinger's technique, and the vessel closed percutaneously using a plug-based vascular closure device. Only patients without significant vascular calcifications are considered for femoral cannulation, as an increased risk of stroke is assumed. In patients with vascular calcifications, axillary cannulation is the standard of care to avoid these risks. Retrospective studies have hinted that, even in patients without vascular calcifications, there may be a lower stroke risk with axillary cannulation compared to femoral cannulation. We present a protocol for a multi-center randomized trial to investigate this hypothesis. To date, evidence on the best access for peripheral artery cannulation during minimally invasive heart valve surgery has been scarce. Patients may benefit from axillary cannulation for extracorporeal circulation in terms of stroke risk and other neurological and vascular complications, though femoral cannulation is the gold standard. The aim of this study is to determine the risks of peri-operative stroke in a prospective randomized comparison of femoral vs. axillary cannulation.

Outcomes of aortic root replacement in patients with Marfan syndrome: the role of valve-sparing and valve-replacing approaches.

Marfan syndrome (MFS) is a heritable thoracic aortic disease with pervasive cardiovascular effects, including commonly, a dilated aortic root. Traditionally, the root is replaced using a mechanical composite valve graft (CVG); however, this valve-replacing (VR) approach necessitates a lifelong regimen of anticoagulation with a potential for late bleeding complications. In time, valve-sparing (VS) approaches were developed. Today, several options for aortic root replacement (ARR) exist; each has advantages and disadvantages that helps inform choice. The Aortic Valve Operative Outcomes in Marfan Patients (AVOMP) is a multi-center international registry to analyze clinical outcomes of ARR in MFS patients using either VR or VS techniques to better elucidate choice. We summarize outcomes of AVOMP and present our own experience. We performed 223 consecutive elective ARR [1991-2023] in patients with MFS; 15 such repairs were included in AVOMP. Repairs included 113 (51%) using a mechanical CVG, 62 (28%) using a VS approach, and 48 (22%) using a bioprosthetic root. Many patients underwent aortic arch repair (30% to 54% by type). The median patient age was 38 [29-52] years. In comparing VS and VR groups, patients were similar in age and rates of major comorbidities and symptoms. Patients with VR repair had a more complex aortic history. The rate of redo sternotomy was 24% (n=54). Operative death was uncommon [4% overall (10/223); ranging from 2% to 8% by type], and stroke was rare [1/223 (<1%)]. Late survival and reoperation differed by operative approach; survival was improved in patients who underwent VS repair. We found that repair in patients with MFS undergoing ARR resulted in low operative risk. Our late results were similar to those of AVOMP in that patients undergoing VS repair tended to experience greater rates of valvular-structural deterioration, although this did not appear to impact survival.

The effect of air pollution on cash holdings and financial leverage

PurposeThe purpose of this paper is to investigate whether air pollution has significant impact on corporate cash holdings and financial leverage.Design/methodology/approachThe data of 199 firms listed on Istanbul Stock Exchange during the period 2009–2020 is analyzed by using pooled ordinary least squares and two-step system generalized method of moments models.FindingsThe results indicate that firms in regions with high air pollution tend to increase cash level. In addition, the positive effect of air pollution on cash level is stronger and more significant for environmentally sensitive firms and firms with low operational and distress risk. The results also show insignificant effect of air pollution on financial leverage.Practical implicationsFirms in regions with high air pollution should conduct proactive environmental protection procedures and enhance their eco-efficiency instead of holding excess cash that could negatively affect financial performance. In this context, policymakers should provide financial facilities to firms located in regions with high air pollution and that have low ability to finance environmental investments. On the other hand, the environmental laws and regulations introduced by regulatory authorities can enhance the economic development and firm performance by decreasing the adverse influences of air pollution on corporate financial policies.Originality/valueTo the best of the author’s knowledge, this research is one of few that examines the impact of air pollution on corporate cash holdings and financial leverage in emerging markets.

P121 MITRAL VALVE STENOSIS ASSOCIATED WITH LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION: A TERRIBLE COMBINATION WITH A DIFFICULT TREATMENT

Abstract Case n. 1 A 77 year–old woman with obstructive hypertrophic cardiomyopathy who had undergone alcohol septal ablation with a reduction in dynamic left ventricular outflow tract (LVOT) gradient from 95 to 65 mmHg was hospitalized for pulmonary oedema. Echocardiography and cardiac catheterization confirmed the presence of obstructive hypertrophic cardiomyopathy with a dynamic gradient of 65 mmHg, and identified a severe calcific mitral stenosis (3D planimetric area= 0,9 cm2). There was severe postcapillary pulmonary hypertension (pulmonary artery mean pressure of 60 mmHg and pulmonary capillary wedge pressure of 26 mmHg). The patient underwent a combined surgical intervention of mitral valve replacement (Epic 27 mm bioprosthesis) and surgical septal myectomy via a mini–thoracotomic approach. After the intervention there were dehiscence and infection of the thoracotomy and right inguinal surgical wounds, septic shock, hyporexia (with marked cachexia), emotional instability and delirium. After 21 days of hospitalization in the ICU, the patient was transferred to a medical department and died seven days later. Case n. 2 A 82 year–old woman with severe mitral stenosis associated with marked left ventricular hypertrophy and LVOT obstruction was admitted for heart failure and worsening renal function. Her comorbidities included diabetic neuropathy and stage 4 chronic kidney disease. Cardiac catheterization excluded significant coronary artery disease; mitral valve area was 1 cm2, and LVOT gradient was 75 mmHg. Pulmonary artery mean pressure was 32 mmHg, pulmonary capillary wedge pressure was 25 mmHg, and right atrial mean pressure was 8 mmHg. She was deemed a high–risk surgical candidate. The patient therefore was treated initially with peritoneal dialysis. However she demonstrated persisting pulmonary congestion. An atrial septostomy inserting a 8–mm Atrial Flow Regulator was subsequently performed, with an immediate reduction of capillary wedge pressure to 18 mmHg. In the following 18 months the patient had no more hospitalizations for heart failure. Conclusion The association between mitral stenosis and LVOT obstruction is associated with elevated capillary wedge pressure and frequent episodes of heart failure. Surgical intervention remains the first therapeutical option. Nevertheless, in older patients, the association between atrial septostomy and peritoneal dialysis may represent a valuable solution, with a lower operative risk.

The Impact of Sustainable Supply-Chain Partnership on Bank Loans: Evidence from Chinese-Listed Firms

With the rapid development of economic globalization, keeping the global supply chains sustainable is becoming increasingly important in improving supply chain performance and firm value. To fully understand the role of the supply chain relationship, it is necessary to comprehensively assess different characteristics of supply chain partnership in achieving sustainability goals. This study explores the implication of concentrated supply-chain partnership on loan features. Using a sample of Chinese-listed firms, we find that concentrated customer or supplier bases positively influence loan features, including loan size, loan maturity, and loan cost. We propose that concentrated customer and supplier bases influence the loan features through different mediators. Through mediating analysis, concentrated customer bases affect loan features through better corporate governance and lower operational risk, and concentrated supplier bases through lower operational cost and longer accounts payable cycle. The benefit of a concentrated chain partnership is more pronounced when customers or suppliers have a greater certification role, less uncertainty, and stronger geographical advantage. The results are robust to instrumental variable analysis, propensity-matched analysis, and alternative measures of chain partnership concentration. Findings in this study have important implications for understanding the sustainable supply-chain partnership management and loan decisions of banks in an emerging market.

IMPACT OF EARLY POSTOPERATIVE IMMUNONUTRITION ON RENAL IMPAIRMENT IN LOW-RISK CARDIAC SURGERY PATIENTS

Rationale Cardiac surgeries with the use of cardiopulmonary bypass (CPB) lead to significant changes in homeostasis and a more or less pronounced immune response (1). Renal impairment is the most common clinically important complication in adult cardiac surgery patients, and is associated with increased mortality and morbidity (2). The aim of the study was to research the efficacy of early postoperative enteral immunonutrition on renal impairment after cardiac surgery. Methods A low operative risk adult patients, who underwent elective cardiac surgery, were included to the study. The patients were randomized into immunonutrition (IN) and control (C) groups. The IN group was supplemented with glutamine and antioxidants for five postoperative days. Creatinine levels were monitored in patients throughout the hospital stay - the worst parameters were recorded, analyzed and compared between the groups. Moreover renal impairment was assessed according to the RIFLE criteria. Student t-test and Mann–Whitney U test was used to compare differences between the groups. A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. Results Fifty-five patients were enrolled in the study, the mean age was 69.7±6.3 years, 28(50.9%) males, the median operative risk was 1.75%. Twenty-seven (49.1%) were in the IN group. A statistically significant decrease in postoperative creatinine clearance (worsening of renal function) was detected in the C group, accordingly 77,07 ± 23,90 vs 63,43 ± 23,31 (ml/min), p = 0,037. Based on RIFLE classification, our subjects were at risk of renal impairment in 11 cases (2 cases in the IN group and 9 cases in the C group, p = 0.023) and 5 patients had renal impairment (2 cases in the immunomodulatory group, 3 cases in the control group, p = 0.673). A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. The patients without glutamine and antioxidants supplementation had a 4.312-fold increased risk of kidney injury (p = 0,02). Conclusions Early postoperative immunonutrition has a positive effect on reducing risk of renal impairment in low-risk cardiac surgical patients. Cardiac surgeries with the use of cardiopulmonary bypass (CPB) lead to significant changes in homeostasis and a more or less pronounced immune response (1). Renal impairment is the most common clinically important complication in adult cardiac surgery patients, and is associated with increased mortality and morbidity (2). The aim of the study was to research the efficacy of early postoperative enteral immunonutrition on renal impairment after cardiac surgery. A low operative risk adult patients, who underwent elective cardiac surgery, were included to the study. The patients were randomized into immunonutrition (IN) and control (C) groups. The IN group was supplemented with glutamine and antioxidants for five postoperative days. Creatinine levels were monitored in patients throughout the hospital stay - the worst parameters were recorded, analyzed and compared between the groups. Moreover renal impairment was assessed according to the RIFLE criteria. Student t-test and Mann–Whitney U test was used to compare differences between the groups. A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. Fifty-five patients were enrolled in the study, the mean age was 69.7±6.3 years, 28(50.9%) males, the median operative risk was 1.75%. Twenty-seven (49.1%) were in the IN group. A statistically significant decrease in postoperative creatinine clearance (worsening of renal function) was detected in the C group, accordingly 77,07 ± 23,90 vs 63,43 ± 23,31 (ml/min), p = 0,037. Based on RIFLE classification, our subjects were at risk of renal impairment in 11 cases (2 cases in the IN group and 9 cases in the C group, p = 0.023) and 5 patients had renal impairment (2 cases in the immunomodulatory group, 3 cases in the control group, p = 0.673). A logistic regression model was developed to assess the relationship between immunonutrition and the risk of kidney injury. The patients without glutamine and antioxidants supplementation had a 4.312-fold increased risk of kidney injury (p = 0,02). Early postoperative immunonutrition has a positive effect on reducing risk of renal impairment in low-risk cardiac surgical patients.

Kawashima Procedure: The Impact of Age

BackgroundThe results of the Kawashima operation are incompletely defined. Furthermore, optimal timing of Kawashima operation, an important consideration when managing desaturated young infants awaiting surgery, remains unclear. We reviewed our outcomes of Kawashima operation, with a focus on the impact of age. MethodsWe conducted a retrospective review of patients who underwent Kawashima operation from 1990 to 2020. ResultsThirty patients underwent Kawashima operation at a median age of 11.7 months (interquartile range, 4.4-27.4). Left isomerism was present in 27 patients (90%). There were no early deaths. There were 2 patients (6.7%) who had Kawashima takedown, both attributed to hypoxia. Fontan completion was achieved in 25 patients (83%). Overall freedom from death and transplantation at 20 years was 67% (95% CI, 32%-87%). Freedom from death and transplantation at 10 years was 100% for children 3 to 6 months of age at the time of Kawashima, compared with 86.4% for older children (P = 1.0). However, children aged 3 to 6 months had longer ventilation time (P = .01), intensive care stays (P = .03), and hospital stays (P = .05). Freedom from death or transplantation at 20 years among those who had concomitant common atrioventricular valve repair was 33%, vs 79% for those who did not undergo common atrioventricular valve repair (P = .02). ConclusionsKawashima operation can be performed with low operative risk and acceptable long-term outcomes. Performing Kawashima operation on a patient aged less than 6 months does not affect survival, but is associated with increased morbidity. Need for common atrioventricular valve operation carries significant risk of mortality, and more effective techniques for atrioventricular valve repair are required.

Staged single-port thoracoscopic R2 sympathicotomy as a reproducible, safe and effective treatment option for debilitating severe facial blushing.

Our goal was to investigate the safety, feasibility, success rate, complication rate and side effects of staged single-port thoracoscopic R2 sympathicotomy in the treatment of severe facial blushing. Facial blushing is considered a benign condition; however, severe facial blushing can have a major impact on quality of life. When nonsurgical options such as medication and psychological treatments offer no or insufficient relief, surgical treatment with thoracoscopic sympathicotomy should be considered. All patients who underwent a staged thoracoscopic sympathicotomy at level R2 for severe facial blushing between January 2016 and September 2021 were included. Clinical and surgical data were prospectively collected and analysed. A total of 16 patients with low operative risk (American Society of Anesthesiologists class 1) were treated. No major perioperative complications were encountered. One patient experienced postoperative unilateral Horner's syndrome that resolved completely after 1 week. Two patients experienced compensatory hyperhidrosis. The success rate was 100%. One patient experienced a slight recurrence of blushing symptoms after 3 years that did not interfere with their quality of life. All patients were satisfied with the results and had no regrets of having undergone the procedure. Staged single-port thoracoscopic R2 sympathicotomy is a reproducible, safe and highly effective surgical treatment option with low compensatory hyperhidrosis rates and the potential to significantly improve quality of life in carefully selected patients suffering from severe facial blushing. We would like to increase awareness among healthcare professionals for debilitating facial blushing and suggest timely referral for surgical treatment.

Repair of Ruptured Sinus of Valsalva Aneurysm: 15 years of Single Center experience

Background and Aims: Ruptured sinus of Valsalva aneurysm is an uncommon cardiac anomaly, fatal if not treated in time. This study was designed to retrospectively analyze our 15‐year experience of the surgical repair for ruptured sinus of Valsalva aneurysm and to study the optimal surgical strategy, morbidity, mortality, and long-term surgical outcome.&#x0D; Methods: This study was conducted on 48 (36 Male, and 12 Female) patients of ruptured sinus of Valsalva aneurysm, operated at department of cardiac surgery, Shahid Gangalal National Heart Centre, Nepal, from January 2006 to December 2020 and followed up till March 2021. Follow‐up data were obtained from the outpatient department records and telephone calls.&#x0D; Results: Mean age was 30.17±11.5 (12-63) years. Rupture of the right coronary sinus into the right atrium was the most common anatomic type (52%). Preoperative aortic regurgitation equal to or greater than grade II were seen in 9 patients (19%) and ventricular septal defects in 6 cases (13%). Two patients had preoperative renal failure. One patient had associated aortic root dilatation and underwent modified Bentall’s procedure. Ruptured sinus of Valsalva aneurysm was repaired from single chamber approach in 9 patients, and dual chamber approach in 39. There was a single mortality (2.08%), two patients required permanent pacemaker placement for complete heart block, and two had wound infection. Follow‐up data were available for 36 patients (75%). With the mean follow up of 7.07±3.93 (range, 0.83-15) years, there was no recurrence present. All survivors were in New York Heart Association functional Class I or II. There was one late death, due to non-cardiac cause.&#x0D; Conclusion: Ruptured sinus of Valsalva aneurysm is rare, yet prompt diagnosis and optimal surgical management is crucial in reducing the deleterious effects. Surgical repair of ruptured sinus of Valsalva carries an acceptable low operative risk and can be performed with laudable long-term outcome, with low incidence of recurrence.