Perioperative Changes Research Articles

Association of Indoleamine 2,3-Dioxygenase (IDO) Activity with Outcome after Cardiac Surgery in Adult Patients.

Indoleamine 2,3-deoxygenase (IDO) plays an important role in the catabolism of the amino acid tryptophan. Tryptophan and its metabolites are key immune modulators. Increased IDO activity has been observed in various diseases and is associated with worse clinical outcomes. However, comprehensive research regarding its role in cardiac surgery remains limited. Therefore, we aimed to investigate perioperative changes in IDO activity and pathway metabolites, along with their impact on clinical outcomes in adult patients undergoing cardiac surgery. As an observational cohort study conducted at the Inselspital in Bern from January to December 2019, we retrospectively analyzed the data of prospectively collected biobank samples of patients undergoing cardiac surgery with the use of cardiopulmonary bypass. IDO pathway metabolite analysis was conducted by mass spectrometry. Perioperative dynamics were descriptively assessed and associated with pre-defined clinical outcome measures (30-day mortality, 1-year mortality, incidence of stroke and myocardial infarction, and length of hospital stay) through a multi-step exploratory regression analysis. A cohort of 192 adult patients undergoing cardiac surgery with the use of cardiopulmonary bypass were included (median age 67.0, IQR 60.0-73.0, 75.5% male). A significant perioperative decrease in the kynurenine/tryptophan (Kyn/Trp) ratio (-2.298, 95% CI -4.028 to -596, p = 0.009) and significant perioperative dynamics in the associated metabolites was observed. No association of perioperative changes in IDO activity and pathway metabolites with clinical outcomes was found. A significant decrease in the Kyn/Trp ratio among adult patients undergoing cardiac surgery indicates a perioperative downregulation of IDO, which stands in contrast to other pro-inflammatory conditions. Further studies are needed to investigate IDO in the setting of perioperative immunomodulation, which is a key driver of postoperative complications in cardiac surgery patients.

The association between changes in clinical pain severity and IL-6 reactivity among patients undergoing total knee Arthroplasty: The moderating role of change in insomnia

Knee osteoarthritis (KOA) is linked to an enhanced release of interleukin-6 (IL-6). Increased levels of IL-6 are associated with greater pain and insomnia. While total knee arthroplasty (TKA) typically results in the reduction of pain, for a subgroup of patients, pain does not improve. Understanding patients’ propensity to upregulate IL-6 may provide insight into variation in the clinical success of TKA for improving pain, and insomnia may play an important modulatory role. We investigated the association between pre- and post-surgical changes in clinical pain and IL-6 reactivity, and whether change in insomnia moderated this association.Patients (n = 39) with KOA came in-person before and 3-months after TKA. At both visits, patients completed validated measures of clinical pain and insomnia, as well as underwent quantitative sensory testing (QST). Blood samples were collected to analyze IL-expression both before and after QST procedures to assess changes in IL-6 in response to QST (IL-6 reactivity). Patients were categorized into two groups based on change in clinical pain from pre- to post-surgery: 1) pain decreased > 2 points (pain improved) and 2) pain did not decrease > 2 points (pain did not improve). Based on this definition, 49 % of patients had improved pain at 3-months. Among patients with improved pain, IL-6 reactivity significantly decreased from pre- to post-surgery, whereas there was no significant change in IL-6 reactivity among those whose pain did not improve. There was also a significant interaction between pain status and change in insomnia, such that among patients whose insomnia decreased over time, improved pain was significantly associated with a reduction in IL-6 reactivity. However, among patients whose insomnia increased over time, pain status and change in IL-6 reactivity were not significantly associated.Our findings suggest that the resolution of clinical pain after TKA may be associated with discernible alterations in pro-inflammatory responses that can be measured under controlled laboratory conditions, and this association may be moderated by perioperative changes in insomnia. Randomized controlled trials which carefully characterize the phenotypic features of patients are needed to understand how and for whom behavioral interventions may be beneficial in modulating inflammation, pain, and insomnia.

Intraoperative Oxygen Consumption and Postoperative Immune Response in Colorectal Oncological Surgery: A Prospective, Monocentric Pilot Study.

Surgical resection is the key treatment for colorectal cancer, but the extent of surgical trauma has been implied as a key factor for the oncologic outcome. The immune stress response to surgical trauma generates a cascade of immunological events implying neutrophils' perioperative change generating NETosis, N killer decrease, and platelets' activation that may influence postoperative surgical outcome, tumor cell growth, and future oncogenesis. The present study aimed to investigate the correlation between intraoperative oxygen consumption (VO2) and the dynamic variation of neutrophils, lymphocytes, and platelets in the perioperative period to identify an intraoperative tool that could predict the postoperative immune response. Twenty-six colorectal oncological surgical patients were enrolled in an observational, prospective, monocentric study, over 18 months. Serum neutrophils, lymphocytes, and thrombocytes values were collected in the preoperative period and on the third postoperative day, oxygen consumption was measured and recorded every 15 min during surgery using indirect calorimetry. We compared oxygen consumption measurements registered 30 min after induction of anesthesia (VO2a) and the first value registered after abdominal wall closure (VO2b) to perioperative variation of absolute neutrophils (VNC), lymphocytes (VLC), and platelets (VPC) count. Our results proved a significant correlation between VO2 variation and neutrophils' perioperative dynamic assessed by VNC (correlation coefficient = 0.547, p < 0.01, 95% confidence interval (CI) =0.175, 0.783). We also noticed a correlation between VPC and VO2 (correlation coefficient = -0.603, p < 0.01, 95% CI = -0.815, -0.248). No correlation could be shown between VO2 and VLC variation (p = 0.39). In conclusion, intraoperative VO2 variation measured by indirect calorimetry correlates well with perioperative neutrophils and platelets count dynamic variations and can be used as an early prognosis marker of postoperative immune response and surgical outcome in colorectal oncological surgery.

Impact of perioperative prognostic nutritional index changes on the survival of patients with stage II/III colorectal cancer.

To assess the impact of perioperative prognostic nutritional index (PNI) changes on prognosis and recurrence after colorectal cancer surgery. A total of 475 patients who underwent curative resection for primary colorectal adenocarcinoma and were diagnosed with pathological stage (pStage) II/III were retrospectively reviewed. The patients were divided into two groups: the high group (preoperative PNI ≤ postoperative PNI, n = 290) and the low group (preoperative PNI > postoperative PNI, n = 185). The low group exhibited significantly higher recurrence and mortality rates (all p < 0.001). Kaplan-Meier analysis showed worse overall and recurrence-free survival in the low group (all p < 0.001). Perioperative PNI changes predicted prognosis and recurrence independent of preoperative nutritional conditions. Subgroup analyses showed better overall survival and recurrence-free survival in the high group across various parameters, such as patient background, surgical outcomes, adjuvant chemotherapy, and pathological characteristics. Multivariate analysis revealed that the low group based on perioperative PNI changes (hazard ratio [HR]: 5.809, 95% confidence interval [CI]: 3.451-9.779, p < 0.001), pathological T stage (HR: 1.962, 95% CI: 1.184-3.253, p = 0.009), and pathological N stage (HR: 3.434, 95% CI: 1.964-6.004, p < 0.001) were identified as independent predictors of worse overall survival. Patients with pStage II/III colorectal cancer who demonstrate a lower postoperative PNI levels compared to preoperative had poorer overall survival and recurrence-free survival. Perioperative PNI changes can serve as useful biomarkers for predicting survival and recurrence.

Changes in and clinical utility of maximum phonation time and repetitive saliva swallowing test scores after esophagectomy.

Postoperative pneumonia in patients with esophageal cancer occurs due to swallowing dysfunction and aspiration. Recently, maximum phonation time (MPT) assessment and repetitive saliva swallowing test (RSST) have been focused on as swallowing function assessment methods that can identify patients as high risk for pneumonia. We aimed to evaluate the clinical utility of MPT assessment and RSST in patients undergoing oncological esophagectomy. In total, 47 consecutive patients who underwent esophagectomy for esophageal cancer between August 2020 and July 2023 were eligible. The perioperative changes in MPTs and RSST scores were examined. In addition, univariate and multivariate analyses were performed to identify the predictive factors of postoperative pneumonia. The median MPTs before surgery and on postoperative days (PODs) 3, 6, and 10 were 18.4, 7.2, 10.6, and 12.4s, respectively; postoperative MPTs were significantly lower than preoperative MPT. In addition, the MPT of POD 6 was significantly longer than that of POD 3 (P < 0.05). Meanwhile, there were no significant changes in perioperative RSST scores. Overall, 8 of 47 patients (17.0%) developed pneumonia postoperatively. A short MPT on POD 6 was one of the independent predictive factors for the incidence of postoperative pneumonia (odds ratio: 12.6, 95% confidence interval: 1.29-123, P = 0.03) in the multivariate analysis. The MPT significantly decreased after esophagectomy. However, the RSST score did not. The MPT on POD6 can be a predictor of postoperative pneumonia.

Dynamic change, not tonic activation, of the heart rate variability predicts onset of postoperative atrial fibrillation

Abstract Background and Aims Post-operative autonomic disturbances contribute to susceptibility to post-operative atrial fibrillation (POAF) but the nature of the autonomic disturbances and whether they precede POAF and can signal POAF onset is unclear. Methods In this prospective observational study, patients undergoing cardiac surgery were consecutively enrolled. Holter monitoring was undertaken 7 days before and after surgery with continuous heart rate variability (HRV) measurement. Cox regression was used to evaluate autonomic changes, and analyzed by restricted cubic spline (RCS) to explore individual risk levels. For the first episode of POAF, HRV indexes captured an hour before the onset of POAF were divided into six 10-minute epochs and analyzed by Friedman's Two-Way Analysis of Variance by Ranks. Results A total of 2306 patients known to have been without prior AF were enrolled and completed the study; POAF occurred in 718 (31.14%) patients. Based on univariate and multivariate analysis preoperative, tonic activation and perioperative HRV change were not significantly related to new POAF. However, in the postoperative phase, a marked increase or decrease of Δ Lg (LF/HF), Δ Lg (HF) and Δ Lg (LF) were associated with increased POAF risk. Further, examination of 10-minute epochs in the 30 minutes before the onset of POAF, revealed that progressive increase of HRV indexes. Conclusions POAF susceptibility is associated with postoperative dynamic HRV changes but not tonic autonomic state. Potentially the observation that POAF was preceded by progressive rise of HRV indexes may offer a promising signal for early warning of POAF, and permit preventive intervention.

Sex bias in prediction and diagnosis of cardiac surgery associated acute kidney injury

BackgroundFemale sex has been recognized as a risk factor for cardiac surgery associated acute kidney injury (CS-AKI). The current study sought to evaluate whether female sex is a risk factor for CS-AKI, or modifies the association of peri-operative change in serum creatinine with CS-AKI.MethodsObservational study of adult patients undergoing cardiac surgery between 2000 and 2019 in a single U.S. center. The main variable of interest was registered patient sex, identified from electronic medical records. The main outcome was CS-AKI within 2 weeks of surgery.ResultsOf 58526 patients, 19353 (33%) were female; 12934 (22%) incurred AKI based on ≥ 0.3 mg/dL or ≥ 50% rise in serum creatinine (any AKI), 3320 (5.7%) had moderate to severe AKI, and 1018 (1.7%) required dialysis within 2 weeks of surgery. Female sex was associated with higher risk for AKI in models that were based on preoperative serum creatinine (OR, 1.35; 95% CI, 1.29–1.42), and lower risk with the use of estimated glomerular filtration, (OR, 0.90; 95% CI, 0.86–0.95). The risk for moderate to severe CS-AKI for a given immediate peri-operative change in serum creatinine was higher in female compared to male patients (p < .0001 and p < .0001 for non-linearity), and the association was modified by pre-operative kidney function (p < .0001 for interaction).ConclusionsThe association of patient sex with CS-AKI and its direction was dependent on the operational definition of pre-operative kidney function, and differential outcome misclassification due to AKI defined by absolute change in serum creatinine.

The Role of the Glymphatic System in Perioperative Neurocognitive Disorders.

The glymphatic system plays a crucial role in clearing metabolic waste from the central nervous system and is most active during sleep. Patients with obstructive sleep apnea (OSA) have a dysfunctional glymphatic system that correlates with disease severity. In addition, these patients have worse outcomes after surgery. The status of the glymphatic system during the perioperative period is unclear and can be examined with magnetic resonance imaging (MRI)-based diffusion tensor imaging (DTI). This study assessed perioperative glymphatic system changes in OSA surgical patients and possible relationships with perioperative neurocognitive disorders. DTI data from 13 OSA patients having laparoscopic abdominal surgery with general anesthesia were acquired and analyzed using a 3.0-T MRI scanner. Diffusivity maps in the x-axis (Dxx), y-axis (Dyy), z-axis (Dzz), x-y axis (Dxy), y-z axis (Dyz), and x-z axis (Dxz) were calculated. Diffusion values for the projection and association fibers were extracted, and DTI analysis along the perivascular space (ALPS) was performed. The patients' cognition was assessed using the Montreal Cognitive Assessment tool. Evaluations were carried out within 5 days before surgery and within the first 48 hours after surgery. The ALPS index decreased after surgery, and this correlated with a decrease in general cognition scores and specific memory domains, including visuospatial and delayed recall. The glymphatic system in OSA patients is worsened after surgery and this may contribute to an increased risk for long-term postoperative cognitive disorders. This study suggest that the glymphatic system might play a role in the pathophysiology of perioperative neurocognitive disorders and be a potential therapeutic target.

Effectiveness of Segmental Thoracic Spinal Anaesthesia in Breast Surgery: An Observational Study

Effectiveness of Segmental Thoracic Spinal Anaesthesia in Breast Surgery: An Observational Study

Total mesorectal excision in MRI-defined low rectal cancer: multicentre study comparing oncological outcomes of robotic, laparoscopic and transanal total mesorectal excision in high-volume centres.

The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total mesorectal excision in MRI-defined low rectal cancer in expert laparoscopic, transanal and robotic high-volume centres. All MRI-defined low rectal cancer operated on between 2015 and 2017 in 11 Dutch centres were included. Primary outcomes were: R1 rate, total mesorectal excision quality and 3-year local recurrence and survivals (overall and disease free). Secondary outcomes included conversion rate, complications and whether there was a perioperative change in the preoperative treatment plan. Of 1071 eligible rectal cancers, 633 patients with low rectal cancer were identified. Quality of the total mesorectal excision specimen (P = 0.337), R1 rate (P = 0.107), conversion (P = 0.344), anastomotic leakage rate (P = 0.942), local recurrence (P = 0.809), overall survival (P = 0.436) and disease-free survival (P = 0.347) were comparable among the centres. The laparoscopic centre group had the highest rate of perioperative change in the preoperative treatment plan (10.4%), compared with robotic expert centres (5.2%) and transanal centres (2.1%), P = 0.004. The main reason for this change was stapling difficulty (43%), followed by low tumour location (29%). Multivariable analysis showed that laparoscopic surgery was the only independent risk factor for a change in the preoperative planned procedure, P = 0.024. Centres with expertise in all three minimally invasive total mesorectal excision techniques can achieve good oncological resection in the treatment of MRI-defined low rectal cancer. However, compared with robotic expert centres and transanal centres, patients treated in laparoscopic centres have an increased risk of a change in the preoperative intended procedure due to technical limitations.

Prognostic value of perioperative changes in the prognostic nutritional index in patients with surgically resected non-small cell lung cancer

PurposeThis single-institution retrospective cohort study was conducted to assess the prognostic significance of perioperative changes in the prognostic nutritional index (PNI) in patients who underwent surgery for non-small cell lung cancer (NSCLC).MethodsClinicopathological data were collected from 441 patients who underwent lobectomy for NSCLC between 2010 and 2016.The PNI ratio (postoperative PNI/preoperative PNI) was used as an indicator of perioperative PNI changes. Prognostic differences were investigated based on PNI ratios.ResultsThe optimal cut-off value of the PNI ratio for overall survival (OS) was set at 0.88 using a receiver operating characteristic curve. The PNI ratio was inversely related to a high smoking index, interstitial lung disease, and postoperative pulmonary complications. The 5-year OS rates for the high vs. low PNI ratio groups were 88.2% vs. 68.5%, respectively (hazard ratio [HR]: 3.04, 95% confidence interval [CI]: 1.90–4.86). Multivariable analysis revealed that a low PNI ratio was significantly associated with poor prognosis (HR: 2.94, 95% CI: 1.77–4.87). The PNI ratio was a more sensitive indicator than postoperative PNI status alone for identifying patients at high risk of mortality, particularly those with non-lung cancer causes.ConclusionThe perioperative PNI change is a significant prognostic factor for patients with NSCLC.

Self-reported dyspnoea and shortness of breathing deterioration in long-term survivors after segmentectomy or lobectomy for early-stage lung cancer.

The aim of this study was to assess the self-reported current dyspnoea and perioperative changes of dyspnoea in long-term survivors after minimally invasive segmentectomy or lobectomy for early-stage lung cancer. Cross-sectional telephonic survey of patients alive and disease-free as of March 2023, with pathologic stage IA1-2, non-small-cell lung cancer, assessed 1-5 years after minimally invasive segmentectomy or lobectomy (performed from January 2018 to January 2022). Current dyspnoea level: Baseline Dyspnoea Index score <10. Perioperative changes of dyspnoea were assessed using the Transition Dyspnoea Index. A negative Transition Dyspnoea Index focal score indicates perioperative deterioration in dyspnoea. Mixed effect models were used to examine demographic, medical and health-related correlates of current dyspnoea and changes in dyspnoea level. A total of 152 of 236 eligible patients consented or were available to respond to the telephonic interview(67% response rate): 90 lobectomies and 62 segmentectomies. The Baseline Dyspnoea Index score was lower (greater dyspnoea) in lobectomy patients (median 7, interquartile range 6-10) compared to segmentectomy (median 9, interquartile range 6-11), P = 0.034. 70% of lobectomy patients declared to have a current dyspnoea vs 53% after segmentectomy, P = 0.035. 82% of patients after lobectomy reported a perioperative deterioration in their dyspnoea compared to 57% after segmentectomy, P = 0.002. Mixed effect logistic regression analysis adjusting for patient-related factors and time elapsed from operation showed that segmentectomy was associated with a reduced risk of perioperative dyspnoea deterioration (as opposed to lobectomy) (Odds ratio (OR) 0.31, P = 0.004). Our findings may be valuable to inform the shared decision-making process by complementing objective data on perioperative changes of pulmonary function.

To Study Perioperative Changes in Plasma Phenytoin Levels in Patients with Brain Tumor Undergoing Craniotomy and Its Correlation with Postoperative Seizures

Abstract Introduction Phenytoin, although commonly used for postoperative seizure prophylaxis, exhibits variable results in mitigating seizure frequency following craniotomy. These discrepancies may be linked to a reduction in plasma phenytoin levels subsequent to the surgical intervention. Aims This prospective study aims to characterize changes in plasma phenytoin levels after craniotomy and their relationship with intraoperative blood loss. Methods Fifty consecutive patients were enrolled in this study after obtaining written informed consent. These patients had either been on oral phenytoin for at least 7 days or had received an intravenous loading dose before undergoing craniotomy. Serum phenytoin levels were measured 24 hours preoperatively, immediately before craniotomy (prior to skin incision), postcraniotomy (after skin closure), and 24 hours postcraniotomy. Additionally, intraoperative blood loss was calculated using a modified Gross formula. Results Immediately following craniotomy, there was a statistically significant mean decline of 28.16% in serum phenytoin levels. Furthermore, the analysis revealed a robust positive correlation between the decrease in phenytoin concentration level and several factors, including blood loss during surgery, the duration of the surgical procedure, intravenous fluids administered during surgery, and the occurrence of postoperative seizures. Conclusion This study underscores the potential utility of routinely measuring perioperative serum phenytoin levels in high-risk patients to prevent postcraniotomy seizures. Moreover, it suggests that patients with substantial intraoperative blood loss may benefit from an additional bolus dose of phenytoin toward the end of the surgical procedure.

Dynamics of the left ventricular ejection fraction after revascularization in patients with heart failure with preserved ejection fraction, association with the TRAIL protein

Aim. To study the association of dynamics of the ejection fraction (EF) of the left ventricle (LV) with the development of adverse cardiovascular events within 12 months after revascularization in patients with chronic heart failure with preserved LV EF (HFpEF), and to determine the value of TNF-related apoptosis-inducing ligand (TRAIL) in predicting changes of LVEF. Materials and methods. 52 patients with HFpEF hospitalized for coronary artery bypass grafting (CABG) were included in the prospective study. The levels of plasma NTproBNP (before CABG) and TRAIL protein (before CABG and 10 days after CABG) were determined. Echocardiography was performed for these patients at the time of enrollment in the study and after 12 months of follow-up. The patients were divided into 2 groups: group 1 (n=23) included patients with increased LVEF, group 2 (n=29) – with unchanged or reduced LVEF. The development of a combined endpoint (cardiovascular death, decompensated of HF, repeat unplanned revascularization) was studied. Results. LVEF before CABG was comparable in the studied groups. The frequency of the combined endpoint was 0 in the first group and 17.2% in the second group (p=0.02). There was an inverse correlation between change of LVEF one year after revascularization and the dynamics of the TRAIL protein in the perioperative period (r=-0.45, p=0.049). The area under the ROC for perioperative TRAIL changes and changes in LVEF during a follow-up was 0.79 (95% confidence interval 0.6–0.985; p=0.018). Conclusion. The increase of LVEF 12 months after CABG in patients with HFpEF is associated with a rarer development of cardiovascular events. The changes of LVEF after CABG can be predicted based on the analysis of the perioperative changes of the TRAIL protein.

Does delayed cord clamping result in higher maternal blood loss in primary cesarean sections? A retrospective comparative study.

The University Hospital Basel implemented delayed umbilical cord clamping of 30-60 s in all laboring women on April 1, 2020. This practice has been widely researched showing substantial benefit for the neonate. Few studies focused on maternal blood loss. The objective of our retrospective comparative study was to assess the impact of immediate vs. delayed cord clamping on maternal blood loss in primary scheduled cesarean sections. We analyzed data of 98 women with singleton gestations undergoing primary scheduled cesarean section at term. Data from procedures with early cord clamping (ECC) were compared to those after implementation of delayed cord clamping (DCC). Primary outcomes were perioperative change in maternal hemoglobin levels, estimated and calculated blood loss. Secondary outcomes included duration of cesarean section and neonatal data. There was a statistically significant difference in the mean perioperative decline of hemoglobin of 10.4 g/L (SD=7.92) and 18.7 g/L (SD=10.4) between the ECC and DCC group, respectively (p<0.001). The estimated (482 mL in ECC vs. 566 mL in DCC (p=0.011)) and the calculated blood loss (438 mL in ECC vs. 715 mL in DCC (p=0.002)) also differed significantly. Secondary outcomes showed no significant differences. In our study DCC resulted in a statistically significant higher maternal blood loss. In our opinion the widely researched neonatal benefit of DCC outweighs the risk of higher maternal blood loss in low-risk patients. However, maternal risks must be minimized, improvements to preoperative blood management and operative techniques are required.

Changes in Outcomes of Macular Optical Coherence Tomography Angiography Following Surgery for Optic Disc Pit Maculopathy.

we aimed to report on the optical coherence tomography angiography (OCTA) outcomes of eight patients with optic disc pit maculopathy (ODP-M) who were treated with 23-gauge pars plana vitrectomy (PPV). We examined sixteen eyes of eight patients-eight eyes with ODP-M and eight healthy fellow eyes. Fundus color photography, fundus autofluorescence, fundus fluorescein angiography, optical coherence tomography (OCT), and OCTA were performed. The vascular density, choriocapillaris blood flow (CCBF), and foveal avascular zone (FAZ) were analyzed using OCTA. Moreover, the correlation between the best-corrected visual acuity (BCVA) and macular OCTA parameters was assessed. Compared with the healthy fellow eyes, the eyes with ODP-M preoperatively were found to have decreased BCVA, superficial capillary plexus (SCP) vascular density (i.e., total, foveal, parafoveal, and perifoveal), deep capillary plexus (DCP) vascular density (i.e., total, parafoveal, and perifoveal), and CCBF but a significantly increased FAZ (p < 0.05). When the eyes with ODP-M were analyzed pre- and postoperatively at month 12 after surgery, the BCVA, SCP vascular density (i.e., perifoveal), and CCBF had significantly increased, and the FAZ had significantly decreased (p < 0.05). When the eyes with ODP-M were compared with the healthy fellow eyes postoperatively at month 12, the BCVA, SCP, and DCP vascular density parameters had increased, along with CCBF, and the FAZ had decreased in eyes with ODP-M, though not to the levels of the healthy fellow eyes (p < 0.05). Moreover, a positive correlation was found between the postoperative BCVA and SCP total vascular density (p < 0.05). The BCVA and macular OCTA parameters improved in eyes with ODP-M at month 12 following surgery. However, the BCVA and OCTA of the eyes operated on did not reach the levels of the healthy fellow eyes, possibly due to impaired choroidal blood flow (CBF) recovery and the presence of a larger FAZ. In summary, OCTA seems to be useful for assessing qualitative and quantitative perioperative microvascular changes.

Exploring the Preoperative Fasting and Perioperative Hemodynamic variability in Elective Surgery Under General Anesthesia

Background: It is usual practice all over the world to abstain from eating or drinking before surgery. Currently, the preferred protocol, according to the American Society of Anesthesiologists guidelines, is the 6-4-2 hour No Per Os protocol for solid, milk, and clear fluids respectively, although it is not universally applicable. Extended fasting may intensify negative outcomes including hemodynamic fluctuations. Hemodynamic stability stands as cornerstone in perioperative care as fluctuation can have serious consequences. This study aim was to explore current prevalence of preoperative fasting and hemodynamic fluctuations in elective surgery under general anesthesia. Methods: A six-month Cross-sectional comparative study was conducted on 200 patients at Mardan Medical Complex (MMC) approved by the Ethical Committee, Bacha Khan Medical College (BKMC) Mardan. The data was collected through patient interview in preoperative, medical records, and monitoring perioperatively. SPSS software statistical analysis was conducted using repeated measures ANOVA to assess perioperative changes in these parameters. Test statistics, including p-value were computed to determine the significance of hemodynamic variability. Results: All patients underwent prolonged fasting, with a mean fluid fasting time of 10.33 hours (SD=1.07) and an average solid fasting time of 10.34 hours (SD=1.11). There was a gradual minor drop-in heart rate (HR) from induction to the recovery phase, with statistical significance of 0.02, while no statistically significant variability in mean systolic and diastolic blood pressure was recorded. Conclusion: The study found that patients were undergoing midnight fasting, with a mean duration of 10.33 hrs. Perioperative hemodynamics showed minor decreases in heart rate from the induction to the recovery phase, with statistical significance of 0.02. Our study contributes to the ongoing discourse on preoperative fasting practices and perioperative hemodynamics.

The prognostic impact of perioperative dynamic changes in cachexia index in patients with hepatocellular carcinoma.

The cachexia index (CXI), which consists of skeletal muscle, inflammation, and nutritional status, has been associated with prognosis in patients with hepatocellular carcinoma (HCC). We hypothesized that dynamic changes in CXI might be associated with long-term outcomes in HCC. This study comprised 131 patients who had undergone primary hepatic resection for HCC between 2008 and 2019. Preoperative CXI (pre-CXI) and postoperative CXI (post-CXI) were calculated by the following formula: skeletal muscle index x serum albumin level / neutrophil-to-lymphocyte ratio. Pre- and post-CXI were classified into two groups (high vs. low). We retrospectively investigated the association of perioperative dynamic changes in CXI with disease-free and overall survival. In multivariate analyses, negative HBs-antigen (p = 0.02), high serum PIVKA-II level (p < 0.01), poor tumor differentiation (p = 0.02), multiple tumors (p < 0.01), microvascular invasion (p < 0.01), partial resection (p < 0.01), postoperative complications (p < 0.01), and low-pre-CXI (p < 0.01) were significant predictors of disease-free survival, while high ICGR15 (p = 0.01), poor tumor differentiation (p < 0.01), multiple tumors (p = 0.01), postoperative complications (p < 0.01), low-pre-CXI (p < 0.01), and low-post-CXI (p < 0.01) were significant predictors of overall survival. Low-post-CXI was associated with older age (p = 0.045), larger tumor (p < 0.01), longer operation time (p = 0.047), greater intraoperative bleeding (p < 0.01), and intraoperative blood transfusion (p < 0.01). Moreover, dynamic changes in CXI were associated with overall survival in each subgroup of patients with low-pre-CXI (p = 0.02) or high-pre-CXI (p = 0.03). Not only post-CXI but also dynamic changes in CXI from pre- to post-hepatectomy can be a prognostic indicator of HCC, providing a compelling rationale for aggressive perioperative nutritional and physical interventions to improve long-term outcomes.

Skin conductance algesimeter is unreliable during sudden perioperative temperature increases.

Pain assessment in anesthetized and non-communicative patients remains a challenge. Clinical signs such as tachycardia, hypertension, sweat and tears, have a low specificity for pain and should therefore ideally be replaced by more specific monitoring techniques. Skin conductance variability has been demonstrated to establish a patients' sensitivity to pain, but may be influenced by temperature changes that leads to profuse sweating. The aim of this pilot study was to test skin conductance changes during sudden temperature changes due to hyperthermic intraperitoneal chemotherapy (HIPEC) perfusation. We investigated skin conductance algesimeter (SCA) in ten consecutive patients undergoing cytoreductive surgery and HIPEC. Results from the SCA was compared to other standard physiological variables at seven time points during the surgical procedure, in particular during the period with hyperthermic intraabdominal perfusion leading to an increase in the patients core temperature. Nine out of ten patients had an increase in the SCA measurements during the HIPEC phase correlating the increase in temperature. SCA is unreliable to detect increased pain sensation during sudden perioperative temperature changes in adult patients.

Perioperative psychological distress in patients with intracranial tumors; a single center study.

Distress Thermometer (DT) was adopted to evaluate distress in neuro-oncology on a scale from 1 to 10. DT values above 4 indicate major distress and should initiate psycho(onco)logical co-therapy. However, data about peri-operative distress is scarce. Hence, we evaluated peri-operative distress levels in a neurosurgical patient cohort with various intracranial tumors using the DT. We conducted a retrospective study including inpatients with brain tumors who underwent surgery in our department between October 2015 and December 2019. Patients were routinely assessed for distress using the DT before or after initial surgery. A comparative analysis was performed via Wilcoxon rank-sum test. 254 patients were eligible. Mean DT value of the entire cohort was 5.4 ± 2.4. 44.5% (n = 114) of all patients exceeded DT values of ≥ 6. In our cohort, poor post-operative neurological performance and occurrence of motor deficits were significantly associated with major distress. When analysed for peri-operative changes, DT values significantly declined within the male sub-cohort (6.0 to 4.6, p = 0.0033) after surgery but remained high for the entire cohort (5.7 and 5.3, p = 0.1407). Sub-cohort analysis for other clinical factors revealed no further significant changes in peri-operative distress. Distress levels were high across the entire cohort which indicated a high need for psychological support. Motor deficits and poor post-operative neurological performance were significantly associated with DT values above 6. Distress levels showed little peri-operative variation.