Major Surgery Research Articles

Impact of Intraoperative Colloid versus Crystalloid Administration on Postoperative Outcomes in Major Gastrointestinal Surgeries: An Interventional Study

Introduction: Colloids and crystalloids are frequently used for fluid resuscitation. However, their differing physiological properties may impact postoperative outcomes in distinct ways. Emerging evidence indicates that these variations could play a role in influencing surgical morbidity. Aim: To evaluate the impact on postoperative outcomes using crystalloids and colloids intraoperatively in patients undergoing major surgeries. Materials and Methods: This double-blinded, interventional study was conducted from July 2019 to December 2020 at Department of Anaesthesiology, Uttar Pradesh University of Medical Sciences (UPUMS), Saifai, Etawah, Uttar Pradesh, India. A total of 150 patients, aged 16-60 years, American Society of Anaesthesiologists (ASA) Grade I, II and III, undergoing elective major surgery were enrolled in the study and divided into three groups, with 50 patients per group: group RL (n=50), Group Hetastrach and Ringer’s Lactate (HS-RL) (n=50) and Group Tetrastarch and Ringer’s Lactate (TS-RL) (n=50). All patients received Ringer’s Lactate (RL) at a rate of 7.0 mL/kg/hour before induction. Intraoperatively, group RL received Ringer’s Lactate alone at a rate of 8.0 mL/kg/hour, group HS-RL received both Ringer’s Lactate and 6% hetastarch at a rate of 8.0 mL/kg/hour and group TS-RL received 6% tetrastarch and Ringer’s Lactate at a rate of 8.0 mL/kg/hour. The patients were observed for 8 days postoperatively for vital signs, Arterial Blood Gas (ABG) analysis, ambulation, Postoperative Nausea and Vomiting (PONV) and complications. The data were represented as mean standard deviations and percentages and analysed using the Statistical Package for Social Sciences (SPSS) version 20.0. A p-value of <0.05 was considered statistically significant. Results: Two patients were excluded from the study due to missing data in group RL (n=48). The demographic characteristics were statistically not significant among the groups (p-value>0.05). The proportion of patients who could ambulate independently or with assistance was higher in the HS-RL group 23 (46%) patients compared to the TS-RL group 16 (32%) patients, followed by patients in group RL (3 patients, 6.25%) (p-value <0.05). Intravenous fluids were administered to most patients for five days. Statistically, there was no significant difference among the groups (p-value=0.230). The data were represented as mean standard deviations and percentages and analysed using SPSS version 20.0. A p-value of <0.05 was considered statistically significant. Conclusion: Colloids are superior to crystalloids in terms of independent ambulation, ambulation with assistance, temperature regulation and reduction of nausea and vomiting. Overall, the present study concluded that colloids are able to effectively reduce postoperative complications more effectively than crystalloids without any serious side-effects.

Determinants of a longer length of stay in major head and neck cancer surgery: A national study based on the French hospital discharge database.

Determinants of a longer length of stay in major head and neck cancer surgery: A national study based on the French hospital discharge database.

Novel biological risk factors for 7-day postoperative kidney injury in elective major non-cardiac surgery: a retrospective observational study.

Few UK studies have explored the epidemiology of postoperative acute kidney injury after diverse types of elective major non-cardiac surgery. Fewer still have compared postoperative acute kidney injury risk factors with conditions such as peri-operative myocardial injury that might have similar pathophysiology. This study aimed to characterise postoperative acute kidney injury and its clinical consequences in elective major non-cardiac surgery, and to assess risk factors for postoperative acute kidney injury including those related to peri-operative myocardial injury. All elective major non-cardiac surgical episodes, occurring between 2015 and 2020, were identified retrospectively. Patients without measured peri-operative renal parameters were not studied. Our primary outcome was 7-day postoperative acute kidney injury rate, defined using Kidney Disease Improving Global Outcomes criteria. Multivariable logistic regression modelling was used to assess risk factors for postoperative acute kidney injury. Postoperative acute kidney injury occurred in 1334/13,790 (9.7%) episodes, with 663 (49.7%) occurring on day 1. Postoperative acute kidney injury was associated with increased peri-operative complications (OR 1.8, 95%CI 1.6-2.1, p < 0.001), unanticipated critical care admissions (OR 2.4, 95%CI 1.6-3.5, p < 0.001) and in-hospital mortality (OR 8.0, 95%CI 5.1-12.5, p < 0.001). Independent risk factors for postoperative acute kidney injury include: raised creatinine; hypertension; anaemia; platelet: lymphocyte ratio; heart rate; male sex: renin-angiotensin-aldosterone system blockade; and intra-abdominal surgery. Postoperative acute kidney injury is common and is associated with adverse outcomes. Prevalence peaks initially within the first 48 h, with a secondary rise seen from day 5 onwards, suggesting a different aetiology. It is determined by a combination of patient and surgical risk factors, with the former relating to physiological, rather than chronological, renal age. In common with peri-operative myocardial injury, postoperative acute kidney injury is independently associated with factors affecting autonomic tone and myeloid skewing.

Assessing the accuracy of Seismofit® as an estimate of preoperative maximal oxygen consumption in patients with hepato-pancreato-biliary, colorectal, and gastro-oesophageal cancer.

Assessing the accuracy of Seismofit® as an estimate of preoperative maximal oxygen consumption in patients with hepato-pancreato-biliary, colorectal, and gastro-oesophageal cancer.

Postoperative Movement-evoked Pain Trajectories in Abdominal Surgery Patients: A Retrospective Study.

Postoperative Movement-evoked Pain Trajectories in Abdominal Surgery Patients: A Retrospective Study.

Factors associated with readmission to index vs. non-index hospitals after major cancer surgery: Does centralization play a role?

11073 Background: While centralization of complex cancer surgery at regional referral centers improves perioperative outcomes, many vulnerable patients face barriers in accessing these hospitals. When these patients do manage to undergo surgery at referral centers, it remains unclear where they are readmitted to receive postoperative care when unplanned complications arise. Patients with cancer surgery who are readmitted to the hospital where the surgery was performed (index readmission) often have improved outcomes compared with those readmitted to a different hospital (non-index readmission). This study examined whether factors associated with readmission to index versus non-index hospitals differ for patients undergoing surgery at referral versus non-referral centers. Methods: We used data from the Pennsylvania Cancer Registry linked to all-payer statewide inpatient discharge records to identify patients who had surgery for bladder, brain, esophageal, liver, lung and pancreatic cancers between 2013-2019 and were subsequently readmitted within 90 days. We fit a multivariable logistic regression model to identify factors associated with 90-day readmission to an index versus non-index hospital. We included an interaction term between referral center status and cancer type in this model. We defined referral centers as National Cancer Institute-designated cancer centers or American College of Surgeons Commission on Cancer-accredited academic comprehensive cancer programs. Results: Of the 28,951 patients with major cancer surgery, 28% (N=8215) were readmitted within 90 days of cancer surgery. Of all patients readmitted, 57% (N=4671) were originally treated at referral centers and 78% (N=6388) were readmitted to the index hospital. On multivariable analysis, factors associated with lower odds of index versus non-index readmission included older age (≥70 years: odds ratio (OR)=0.61; 95% confidence interval (CI), 0.49-0.77, relative to &lt;55 years), high Elixhauser comorbidity scores (&gt;16: OR=0.74; 95% CI, 0.63-0.88; relative to &lt;8), longer travel times (&gt;60 minutes: OR=0.12; 95% CI, 0.10-0.15; relative to &lt;15 minutes), and Medicaid insurance (OR=0.68; 95% CI, 0.54-0.86; relative to commercial insurance). There was no significant difference in odds of index readmission when patients were treated at referral versus non-referral centers (OR=0.77; 95% CI, 0.50-1.20). When assessing interactions, patients with lung cancer had lower odds of index readmission when treated at referral versus non-referral centers, relative to other cancers (OR=0.59; 95% CI, 0.40-0.89). Conclusions: Ongoing centralization may be significantly increasing care fragmentation for patients with lung cancer surgery. Future interventions to improve care coordination after surgery should target patients with higher clinical complexity and greater travel burdens.

Effects of obstructive sleep apnea on postoperative outcomes following total shoulder arthroplasty: A matched cohort analysis.

Effects of obstructive sleep apnea on postoperative outcomes following total shoulder arthroplasty: A matched cohort analysis.

The 3-Minute Diagnostic Confusion Assessment Method severity score correlates with the Delirium Rating Scale-Revised-98 and with biomarkers of delirium.

The 3-Minute Diagnostic Confusion Assessment Method severity score correlates with the Delirium Rating Scale-Revised-98 and with biomarkers of delirium.

Development of the CAMUS Intra- and Postoperative Risk and Difficulty Estimation Indices Risk Prediction Tool for Estimating Peri- and Postoperative Outcomes, Including Surgical Difficulty, in Major Urological Surgery—A Protocol for a Delphi Study

Development of the CAMUS Intra- and Postoperative Risk and Difficulty Estimation Indices Risk Prediction Tool for Estimating Peri- and Postoperative Outcomes, Including Surgical Difficulty, in Major Urological Surgery—A Protocol for a Delphi Study

Race based disparities in clinical and financial outcomes associated with major elective and emergent surgery.

Race based disparities in clinical and financial outcomes associated with major elective and emergent surgery.

Current practice of targeted breathing exercises after abdominal and cardiothoracic surgery: a national multicentre observational study.

Current practice of targeted breathing exercises after abdominal and cardiothoracic surgery: a national multicentre observational study.

Perioperative iron deficiency and anaemia in scheduled gynaecological surgery: An update based on findings from the PERIOPES and CARENFER studies: Iron deficiency in gynaecological surgery.

Perioperative iron deficiency and anaemia in scheduled gynaecological surgery: An update based on findings from the PERIOPES and CARENFER studies: Iron deficiency in gynaecological surgery.

Temporal and regional mortality trends due to pulmonary embolism in female patients with genital cancers in the United States from 1999 to 2020.

5617 Background: The involvement of pulmonary vessels by tumor emboli has been described from different primary sites of malignancy. Pulmonary embolism (PE) is a severe and potentially fatal complication in patients with female genital cancers, including ovarian, cervical, uterine, and vulvar malignancies. These cancers, along with associated treatments such as major abdominal surgery, chemotherapy, and hormone therapy, significantly increase the risk of venous thromboembolism (VTE), including PE. While previous studies detail the advancements in cancer detection and treatment, temporal and regional trends of PE-related mortality among female genital cancer patients remain poorly characterized. Methods: This retrospective study analyzes national mortality data from the CDC WONDER database to assess mortality trends from 1999 to 2020 across different demographic subgroups in the United States. Patients with a known history of genital cancer were identified and PE related mortality data was retrieved. Age-adjusted mortality rates (AAMRs) per 100,000 individuals were calculated further stratified based on sex, age (15-64 years and &gt;64 years), race and census region. Rstudio was used to perform t-test and Mann Kendall test. Results: From 1999 to 2020, a total of 13,692 deaths were reported in female genital cancer associated pulmonary embolism in the US (AAPC: 0.421 (95% CI: 0.414-0.428)). The AAMR has risen from 0.363 in 1999 to 0.590 in 2020, indicating a worsening trend over the study period (τ: 0.680, p&lt;0.001). AAMR varied greatly by region, with the Northeast having the highest AAMR (9.928). This was followed by the West (0.488), Midwest (0.43) and South (0.366). Black females had consistently higher AAMR than white females, with rates of 0.763 vs. 0.329 in 1999 and 0.976 vs. 0.523 in 2020, respectively. Females older than 65 years demonstrated a much higher total AAMR (1.506) compared to females between the ages of 15 and 65 (0.212) (p&lt;0.001). Within the age group of 15-25 years, black females had higher AAMRs compared to white female (p&lt;0.001). Black females of the age group &gt;65 years demonstrated much higher mortality (total AAMR: 2.745) than white females of the same age group (1.419), and the highest AAMR overall (P&lt;0.001). Conclusions: The analysis of AAMR for female genital cancer associated pulmonary embolism highlights a concerning disparity in this dangerous cancer related complication, particularly after 2015. This underscores the need for greater attention to be directed towards reproductive health and cancer related complications faced by black women and to address systematic inequalities in intervention and healthcare access. This can improve early detection and timely interventions in order to reduce mortality and improve outcomes for these patients.

Evaluation of a Cost-Effective Virtual Reality Training System in Oral Maxillofacial Surgery: A Pilot Study.

Evaluation of a Cost-Effective Virtual Reality Training System in Oral Maxillofacial Surgery: A Pilot Study.

Erector spinae plane block for analgesia in children undergoing surgery: A systematic review, meta-analysis and trial sequential analysis.

Erector spinae plane block for analgesia in children undergoing surgery: A systematic review, meta-analysis and trial sequential analysis.

Trial in progress: A first-in-human (FIH) phase I study of PTX-912 in patients with locally advanced or metastatic solid tumors.

TPS2694 Background: High-dose IL-2 (HD IL-2) received FDA approval for metastatic melanoma (mM) and metastatic renal cell carcinoma (mRCC), but its use is limited by severe systemic toxicities. While PD-1 blockade has improved overall survival in 20–30% of cancer patients, resistance remains a significant challenge. Notably, HD IL-2 has shown durable anti-tumor effects in mM and mRCC patients who have progressed on anti-PD-1 therapy. Moreover, combining IL-2 with pembrolizumab in mRCC demonstrated a durable response rate of 70%, compared to objective response rates (ORR) of 20% and 33% with IL-2 and pembrolizumab monotherapy, respectively ( Chatzkel et al., Clin Genitourin Cancer(2022)) . These findings suggest that combining IL-2 receptor (IL-2R) activation with PD-1 blockade may be a promising strategy to overcome PD-1 resistance and enhance clinical outcomes. PTX-912 is a novel, first-in-class bifunctional PD-1-proIL-2v fusion protein designed to synergize PD-1 blockade with PD-1-cis-directed IL-2R agonism specifically within the tumor microenvironment (TME), reducing systemic toxicities typically associated with high dose IL-2 therapy. Methods: This first-in-human (FIH), multi-center Phase I study (NCT06190886) evaluates the safety, tolerability, and preliminary efficacy of PTX-912 in patients with locally advanced or metastatic solid tumors who have had disease progression on all available standard of care and/or refused available standard of care therapies that would confer clinical benefit. Eligible patients must have measurable disease per RECIST v1.1 and may have received any number of prior therapies. Key exclusions include immunodeficiency, unresolved toxicities &gt; Grade 1 per NCI CTCAE from prior therapy, active autoimmune disease, primary CNS or leptomeningeal involvement, history of transplant, recent major surgery, and significant cardiac or pulmonary dysfunction. The study includes dose escalation (Part 1a) and dose expansion (Part 1b) cohorts. In Part 1a, seven dose levels (DL1–7) will be tested, with DL1–3 following an accelerated titration design and DL4–7 using a standard 3+3 design. The primary objectives are to determine the maximum tolerated dose (MTD), optimal biological dose (OBD), and/or the recommended Phase II dose (RP2D) of PTX-912, assessed via dose-limiting toxicities (DLTs). Patients with melanoma, renal cell carcinoma (RCC), non-small cell lung cancer (NSCLC), or other populations identified based on Part 1a data will be enrolled in Part 1b. In Part 1a, patients will receive intravenous infusions of PTX-912 every two weeks (Q2W), followed by subsequent cycles with a 28-day DLT observation period. Study enrollment began in June 2024 in the United States at 3 centers. Cohorts 1 to 4 (6 patients) have been completed without DLT. Enrollment to cohort 5 is currently ongoing. Clinical trial information: NCT06190886 .

Anastomotic Strictures after Whipple Procedure: A Report of Two Cases

Whipple procedure is a major surgery performed for periampullary cancers. With improved surgical techniques and intensive care, perioperative mortality has become a rare event, occurring in less than 2% of cases; however, morbidity remains common, occurring in 30-50% of cases. Hereby, authors present a case report of two patients who were operated on for periampullary cancer and have now presented with anastomotic site strictures, hepatolithiasis and pancreatitis. Case 1 was a 58-year-old male who underwent the Whipple procedure with pancreaticojejunostomy 13 years ago for periampullary growth. The patient now presented with pancreatitis, dilated Main Pancreatic Duct (MPD), hepatolithiasis and a peptic ulcer with stricture at all three anastomotic sites. A lateral pancreaticojejunostomy, revision of hepaticojejunostomy with removal of calculi and redo gastrojejunostomy were performed using the same Roux limb. Case 2 was a 58-year-old male who underwent the Whipple procedure with pancreaticogastrostomy four years ago for a serous cystadenoma of the pancreas and presented with pancreatitis, dilated MPD and pleural effusion. The patient was diagnosed with pancreatitis due to anastomotic stricture at the pancreaticogastrostomy site and laparotomy with lateral pancreaticojejunostomy was performed. Both patients were discharged uneventfully. While individual anastomotic strictures and their management have been discussed in the literature following the Whipple procedure, Case 1, which presented with strictures at all three sites simultaneously and Case 2, which presented with pancreatitis, are noteworthy and unique. Surgery is the best approach to managing anastomotic strictures, as it offers a one-time solution.

Stellate ganglion block for preserving arteriovenous fistula in hemodialysis patients undergoing major lower limb orthopedic surgeries: randomized control trial

BackgroundMajor lower limb orthopedic surgeries can lead to hemodynamic alterations and increase the risk of arteriovenous (AV)fistula thrombosis. This study assessed the role of stellate ganglion block (SGB) in preserving the AV fistulas in hemodialysis (HD)patients undergoing major lower limb orthopedic surgeries.MethodsIn this randomized, controlled, double-blind trial, 50 chronic renal failure patients (ASA physical status III, aged 21–75 years) scheduled for major lower limb orthopedic surgeries were randomized into two groups: Group S received an ultrasound-guided SGB before spinal anesthesia, while Group C received a sham procedure. AVF function was assessed using Doppler ultrasonography on postoperative days 1 and 7. Primary outcome was AVF flow rate. Secondary outcomes included peak systolic velocity (PSV), end-diastolic velocity (EDV), resistive index (RI), thrombosis rate, and functional failure.ResultsGroup S demonstrated significantly higher AVF flow rates on both postoperative day 1 (276.96 ± 49.66 ml/min vs. 217.44 ± 46.73 ml/min) and day 7 (254.96 ± 49.38 ml/min vs. 204.56 ± 47.11 ml/min), with large effect sizes (Cohen’s d = 1.23 and 1.04, respectively; p < 0.001). PSV and EDV were significantly improved, and RI was significantly lower in Group S. Thrombosis (8% vs. 36%) and failure rates (32% vs. 64%) were significantly reduced compared to the control group (p < 0.05).ConclusionsPre-emptive stellate ganglion block was associated with significantly improved AVF flow rate postoperatively and reduced thrombosis and functional failure, suggesting its clinical benefit in maintaining AVF patency during major surgeries in HD patients.Trial registrationThis study was approved by the Ethical Committee of Aswan University Hospitals, Egypt (Institutional Review Board (IRB 900/2/24)) and registered on clinicaltrials.gov (ID: NCT06300658). The registration time of this experiment is 3/09/2024. The study protocol was designed and implemented in accordance with the CONSORT guidelines. The study protocol was conducted in compliance with the relevant guidelines and standards.

Ultrasonographic assessment of right internal jugular vein dimensions following passive legs elevation versus hepatic compression: a cross-sectional study

BackgroundCentral vein cannulation is a common invasive procedure performed in critically ill patients and during major surgeries. This study compares the right internal jugular vein’s diameters and cross-sectional area after passive legs elevation and hepatic compression, analyzing these based on age, gender, body mass index and fasting duration.MethodsA cross-sectional study of 184 elective surgery patients (84 males, 84 females) at B.P. Koirala Institute of Health Sciences, Nepal, included 18–75 years. Exclusions: patients on mechanical ventilation, history of right jugular cannulation, neck/abdominal swelling, raised intracranial pressure, lower extremity fracture and refusal of consent. Age, gender, fasting duration and body mass index were recorded. The 6–13 MHz linear probe identified the internal jugular vein by its compressibility and anechoic appearance. Short axis view of transverse and anteroposterior diameters and cross-sectional area were measured in short axis view at the cricoid level using electronic calipers. Maximum diameter and average cross-sectional area were measured in supine with the head rotated 15°- 30° left, after one minute of passive legs elevation at 45° and after hepatic compression for one minute with a 19.6 N force.ResultsHepatic compression increased transverse diameter by 1.64 (0.40) cm, p = 0.035 and cross-sectional area by 1.28 (0.54) cm2, p = 0.047. No gender differences were noted. The transverse diameter increased in underweight (p = 0.02) and overweight (p = 0.01) patients. The cross-sectional area increased in overweight (p = 0.03). Passive legs elevation matched hepatic compression for the fasting durations.ConclusionHepatic compression better optimizes transverse diameter and cross-sectional area of right internal jugular vein than passive legs elevation.

Preoperative carbohydrate loading reduces length of stay after major elective, non-cardiac surgery when compared to fasting: a systematic review and meta-analysis

Preoperative fasting is a worldwide routine even though the most recent Enhanced Recovery After Surgery (ERAS) Guidelines recommend preoperative carbohydrate loading instead of fasting, but with low quality of evidence. Our aim was to compare the effects of preoperative carbohydrate loading to fasting and placebo in patients undergoing elective major non-cardiac surgery under general anaesthesia. Our systematic search was conducted on 15th of October 2021 in five databases, Medline, Embase, Central, Web of Science and Scopus, and updated on November 12th, 2024. We included randomized controlled trials that compared the carbohydrate loading (CHO-group) with fasting or with placebo. Main outcomes were length of hospital stay (LOS), postoperative glucose levels on postoperative, postoperative insulin levels, and C-reactive protein (CRP) levels. Our search revealed 44 eligible articles for data extraction. LOS was shorter in the CHO group as compared to the No-CHO group (MD: − 0.56 [95% CI: − 1.10, − 0.02]). There were no clinically significant differences between the CHO and No-CHO groups regarding the postoperative glucose, insulin and CRP levels. This meta-analysis found that preoperative CHO-loading as compared to preoperative fasting or placebo shortened the length of hospital stay in patients undergoing major elective, non-cardiac surgery. Although several details are still to be unveiled, these data provide further support that preoperative carbohydrate loading could be beneficial in this patient population.