Perioperative Characteristics Research Articles

Development and validation of machine learning model for mortality after curative gastrectomy for gastric cancer.

386 Background: The risk for postoperative complications can significantly impact perioperative planning. The aim of this study is to develop and validate a model based on various machine learning techniques to predict postoperative mortality (PM) after curative radical gastrectomy for gastric cancer. Methods: Data from a nationwide survey led by the Korean Gastric Cancer Association was used for the development set, which included 12,722 patients who underwent gastrectomy in 2019 across 68 institutions in South Korea. The validation set comprised 4,887 patients from 8 institutions between 2009 and 2017. PM was defined as all-cause death within 30 days after surgery or in-hospital death beyond 30 days. Five machine learning models (CatBoost, Gradient Boosting, Light GBM, Random Forest, XGBoost) were evaluated using perioperative clinical characteristics. Model performance was assessed using the area under the receiver operation characteristic curve (AUROC) with 5-fold cross-validation. Results: The PM rates were 0.83% and 1.04% in the development and validation set, respectively. In the development set, the Random Forest model demonstrated the highest discrimination capacity with an AUROC of 0.772, followed by Gradient Boosting at 0.767, CatBoost at 0.742, XGBoost at 0.732, and LightGBM at 0.717. However, in the validation set, CaBoost showed the highest AUROC at 0.747, while the AUROC for Random Forest decreased to 0.688. Conclusions: The CatBoost model demonstrated robust and consistent performance in predicting PM risk across both development and validation datasets. To further enhance the performance of the model and ensure stable clinical application, future research should focus on developing methods for quantitative measurement of perioperative factors such as surgical techniques.

P-2295. Risk Factors for and Impact of Enteric Gram-negative Infections on Lung Transplant Clinical Outcomes

Abstract Background Bacterial infections such as Pseudomonas aeruginosa (PsA) and S. aureus lead to increased morbidity post-lung transplant. Less is known about the impact of enteric gram-negative (GNR) infections. This study’s aim was to assess risk factors for developing GNR infections within 6-months of transplant and associated 1-year outcomes compared to lung transplant recipients (LTR) with other bacterial infections or uninfected LTR. Table 1 Characteristics and Outcomes of LTR with post-transplant GNR infections, other bacterial infections, and no infection Methods A single-center retrospective study of LTR between January 2017 and October 2023 was performed. Donor/recipient characteristics, microbiologic data, and 1-year clinical outcomes were analyzed. Results During the study period, 327 patients had a lung transplant with a greater than 30-day survival. 77 (23%) had GNR infections, 64 (20%) had either PsA, S. aureus, or Streptococcal infections (infect), and 186 (57%) did not have a bacterial infection within 6-months post-transplant. The GNR infections were: 18% Enterobacter cloacae complex, 16% E.coli, 25% Klebsiella sp., 7% Acinetobacter sp., 1% Serratia sp., 1% Citrobacter sp., 7% Burkholderia sp., 19% Stenotrophomonas sp., 6% others. Infections included: 19% bacteremia, 91% pneumonia, 5% empyema, 4% mediastinitis, 1% other. Donor, recipient, and perioperative characteristics were similar amongst the cohorts. A similar proportion of LTR donors were colonized with GNR, PsA, and S. aureus in the 3 cohorts pre-transplant. A greater proportion of the GNR cohort had delayed chest closure, required dialysis, mechanical ventilation, and/or ECMO for >48 hours, and had a longer ICU and index hospitalization compared to the other cohorts [Table 1]. The median time to infection was similar for the GNR and infect cohorts (52 and 51 days), but a greater proportion of the GNR cohort developed chronic kidney disease or respiratory failure. 6-month and 1-year survival were less in the GNR cohort but not statistically significant. Conclusion LTR with more complicated post-operative courses were more likely to develop enteric GNR infections which led to increased post-transplant morbidities. Pre-transplant GNR colonization was not a risk factor for GNR infection post-transplant. Strategies to minimize post-transplant enteric GNR infections need further study. Disclosures All Authors: No reported disclosures

Association between meningioma consistency and surgical outcomes.

Tumor consistency, or fibrosity, affects the ability to optimally resect meningiomas, especially with recent trends evolving toward minimally invasive approaches. The authors' team previously validated a practical 5-point scale for intraoperative grading of meningioma consistency. The impact of meningioma consistency on surgical management and outcomes, however, has yet to be explored. This study aimed to determine associations between meningioma consistency and presenting symptoms, tumor characteristics, and postoperative outcomes. A total of 209 surgically resected meningiomas were intraoperatively assigned a consistency grade according to a previously validated 5-point scale, ranging from extremely soft, suctionable tumors (grade 1) to firm/calcified tumors (grade 5). Presenting symptoms, tumor characteristics, postoperative complications, and surgical outcomes for these patients were prospectively collected. Tumor consistency was analyzed in three categories (grades 1 and 2, grade 3, and grades 4 and 5), using ANOVA, chi-square or Fisher's exact tests, and univariable logistic regression to evaluate associations between consistency and perioperative characteristics. The study cohort included 209 patients, of whom 48 (23%) were males with a mean age of 55.0 ± 13.7 years. Meningioma consistency distribution was as follows: grades 1 and 2 (n = 23, 11.0%), grade 3 (n = 88, 42.1%), and grades 4 and 5 (n = 98, 46.9%). The majority of meningiomas were skull base tumors (n = 144, 68.9%). Higher-consistency tumors were associated with lower rates of gross-total resection (OR 0.24, 95% CI 0.13-0.46; p < 0.001), increased invasiveness (OR 4.73, 95% CI 1.53-14.60; p = 0.007), tumor recurrence following resection (OR 3.30, 95% CI 1.25-8.66; p = 0.016), reoperation (OR 3.08, 95% CI 1.16-8.14; p = 0.024), and increased complication rates (OR 2.08, 95% CI 1.05-4.15; p = 0.037). No significant associations were identified with preoperative symptoms, tumor size (mean 4.04 ± 1.50 cm), or duration of surgery (mean 4.26 ± 1.60 hours) (all p > 0.05). Tumor consistency is associated with important meningioma characteristics and perioperative outcomes. A prior knowledge pertaining to meningioma consistency and tumor characteristics using advanced imaging is a priority and may provide surgeons with meaningful data to guide resection strategy and anticipate postoperative outcomes and complications.

Preoperative Oral Feeding in Infants with Congenital Heart Disease Within the First Month of Life is Associated with a Higher Likelihood of Freedom From Tube Feeding at Time of Postoperative Discharge.

Though several studies have demonstrated that preoperative oral feeding (PO) can be safe in patients with congenital heart disease, they are commonly prohibited from doing so, potentially precluding the development of such skills. We sought to determine whether preoperative oral feeding is associated with freedom from tube feeding at postoperative discharge. Single-center, observational study including patients in the first month of life (≤ 30days of age) who underwent a single cardiac surgery between 7/1/2017-6/30/2022 and survived to discharge. Preoperative PO was defined as any oral intake up to the day of cardiac surgery. General demographics and peri-operative characteristics were analyzed. A total of 235 patients were included of which 178 (78%) PO fed preoperatively, and 171 (73%) were discharged taking full PO. Those discharged without tube feeds received more preoperative oral feeds, were less likely to have a chromosomal abnormality/genetic syndrome, had lower STAT categories, and were less likely to have postoperative complications, vocal cord dysfunction or prolonged mechanical ventilation. Multivariate analysis found that any preoperative PO [odds ratio (OR) of 2.78 (CI 1.48, 5.24, p-value = 0.002)] and increasing amounts of PO were predictive of full PO intake at discharge [≤ 20ml/kg/day (OR 2.06, CI 1.03, 4.14, p-value = 0.042) and > 20ml/kg/day (OR 4.07, CI 1.88, 8.84, p-value = 0.004)]. Preoperative oral feeding is a strong predictor of discharging with full PO intake after cardiac surgery in the first month of life and that it may also improve with increasing volumes. Multi-institutional analyses are warranted.

Sarcopenia is a risk factor for postoperative delirium in geriatric hip fracture patients: a retrospective study.

Various factors contribute to postoperative delirium (POD) in elderly patients undergoing hip fracture surgeries. Sarcopenia was defined as the progressive loss of skeletal muscle mass and strength associated with aging. The aim of this study was to explore the prevalence of POD and sarcopenia in geriatric patients undergoing hip fracture surgeries and to investigate the correlation between preoperative sarcopenia and POD. After applying specific inclusion and exclusion criteria, the information of 234 patients were retrospectively collected. POD was screened for with 4A's Test and diagnosed with DSM-5 criteria. The incidences of POD and sarcopenia were calculated. The demographic and perioperative features as well as comorbidities of delirious and non-delirious patients were analyzed and the risk factors analysis for POD in elderly hip fracture patients were conducted through univariate analysis and multivariate regression analysis. 48.7% patients were diagnosed of POD, 78.95% of which were females. The average age of delirious and non-delirious patients were 84.75 years and 80.63 years, respectively. The incidence of sarcopenia was 41.02% for all the included patients with 60.53% for delirious patients and 20.55% for non-delirious patients. Results of univariate analysis showed that sarcopenia (OR:5.281, 95%CI 2.988-9.337, p = 0.000), age increase per year (OR:1.128, 95CI 1.070-1.190, p = 0.000), operation duration increase (OR:1.017, 95%CI 1.004-1.030, p = 0.011), intertrochanteric fracture (OR:2.571, 95%CI 1.517-4.358, p = 0.000), dementia (OR: 6.029, 95%CI 2.532-14.359, p = 0.000), ASA > 2 (OR: 6.955, 95%CI 3.461-13.976, p = 0.000), coronary heart disease (OR: 2.201, 95%CI 1.257-3.854, p = 0.006), renal insufficiency (OR: 2.215, 95%CI 1.187-4.133, p = 0.012) and COPD (OR: 2.554, 95%CI 1.414-4.615, p = 0.002) were risk factors for POD. Results of multivariate analysis identified sarcopenia (OR: 2.457, 95% CI 1.226-4.923, p = 0.011), ASA > 2 (OR: 3.968, 95% CI 1.805-8.722, p = 0.001), dementia (OR: 3.912, 95% CI 1.390-11.014, p = 0.010) and coronary heart disease (OR: 2.176, 95% CI 1.044-4.538, p = 0.038) as independent risk factors for POD in geriatric hip fracture patients. The incidences of POD and sarcopenia in geriatric hip fracture patients are high. Sarcopenia is an independent risk factor for POD in geriatric hip fracture patients.

Cushing Disease Clinical Phenotype and Tumor Behavior Vary With Age: Diagnostic and Perioperative Implications

Abstract Context Little is known about presenting clinical characteristics, tumor biology, and surgical morbidity of Cushing disease (CD) with aging. Objective Using a large multi-institutional data set, we assessed diagnostic and prognostic significance of age in CD through differences in presentation, laboratory results, tumor characteristics, and postoperative outcomes. Methods Data from the Registry of Adenomas of the Pituitary and Related Disorders (RAPID) were reviewed for patients with CD treated with transsphenoidal tumor resection at 11 centers between 2003 and 2023. Outcomes assessed included comorbidities, presenting features, preoperative endocrine evaluations, perioperative characteristics, postoperative endocrine laboratory values, and complications. Results Of the 608 patients evaluated, 496 (81.6%) were female; median age at surgery was 44 years (range, 10-78 years). Increasing age was associated with increasing comorbidities, frailty, rates of postoperative thromboembolic disease, Knosp grade, tumor size, and postoperative cortisol and adrenocorticotropin nadirs. Conversely, increasing age was associated with decreased hallmark CD features, preoperative 24-hour urinary free cortisol, Ki-67 indices, and arginine vasopressin deficiency. Younger patients presented more frequently with weight gain, facial rounding/plethora, abdominal striae, hirsutism, menstrual irregularities, dorsocervical fat pad, and acne. Obstructive sleep apnea and infections were more common with increasing age. Conclusion There are age-dependent differences in clinical presentation, tumor behavior, and postoperative outcomes in patients with CD. Compared to younger patients, older patients present with a less classic phenotype characterized by fewer hallmark features, more medical comorbidities, and larger tumors. Notably, age-related differences suggest a more indolent tumor behavior in older patients, potentially contributing to delayed diagnosis and increased perioperative risk. These findings underscore the need for tailored diagnostic and therapeutic approaches across age groups, with a focus on managing long-term comorbidities and optimizing surgical outcomes.

Feasibility and safety of hyperthermic intra-peritoneal chemotherapy in patients with ovarian cancer and chronic kidney disease.

This study aimed to compare perioperative outcomes and progression-free and overall survival in patients with chronic kidney disease (CKD) versus those without after hyperthermic intra-peritoneal chemotherapy (HIPEC) for ovarian cancer. This is a retrospective, single-institution cohort study of patients with ovarian cancer treated with HIPEC at the Cleveland Clinic from January 2009 to December 2022. All patients received HIPEC with cisplatin and renal protection with mannitol and furosemide. Patients with a documented pre-operative eGFR were included. CKD was defined as a pre-operative eGFR of <60 mL/min per 1.73 m2. Demographics, clinicopathological data, perioperative creatinine levels, surgical complexity, post-operative complications, and treatment characteristics were analyzed. Progression-free and overall survival were assessed using Cox right-censored univariate models. Of 171 patients, 16.4% (n = 28) had CKD. No significant differences were found in post-operative acute kidney injury (21.4% with CKD vs 13.3% in those without; p = .15), readmission rates (10.7% CKD vs 11.9% in those without; p = .99), or major complications such as death, venous thromboembolism, myocardial injury, and sepsis (10.7% with CKD vs 11.9% in those without; p = .95). Both groups had a median hospital stay of 5 days (p = .65). There was also no significant difference in survival, with median progression-free survival of 15.5 months in the group with CKD versus 16.8 months in those without (p = .79) and overall survival of 58.4 months in those with CKD versus 39.3 months in those without (p = .33). There was no significant difference in complication rates, progression-free survival, or overall survival between patients with CKD and those with normal kidney function receiving HIPEC for ovarian cancer.

Comparison of Da Vinci XI and Da Vinci SI Surgical Systems in Robot-Assisted Radical Prostatectomy

Introduction. Robot-assisted radical prostatectomy is considered to be the “gold standard” for the radical treatment of prostate cancer, achieving excellent oncological outcomes with a low incidence of complications.Aim. To analyze and compare the efficiency of Da Vinci Xi and Da Vinci Si surgical systems applied in performing robot-assisted radical prostatectomy. Materials and methods. 165 patients were divided into two groups: Xi-group (n = 77) and Si-group (n = 88). The perioperative characteristics and oncological outcomes were analyzed and compared.Results. The demographic, clinical, and oncological characteristics of the two patient groups appeared similar and comparable. Interventions involving the preservation of the neurovascular bundle, the pelvic fascia, and the puboprostatic ligament were performed using Xi system significantly more often. The surgery duration was significantly shorter in the Xi-group. The postoperative recovery time and the incidence of postoperative complications appeared to be identical across both groups. No differences were revealed in the rates of positive surgical margins or biochemical recurrence.Discussion. Reasons behind the reduced operative time were considered as follows: first, the docking of the Xi system is more user-friendly, resulting in decreased docking time; second, the operational efficiency of the Xi system had been enhanced, thereby leading to reduced workflow times; third, a number of collisions between robotic arms was significantly lower during the procedure, which accelerates the surgical process.Conclusion. A robot-assisted radical prostatectomy performed by an experienced professional, using the Da Vinci Xi or Da Vinci Si surgical systems, appears to be safe and feasible without an increased risk of serious complications. However, the Xi system ensures better perioperative outcomes with comparable oncological results.

Comparing Patient-Reported Outcomes in Patients Undergoing Lumbar Fusion for Degenerative Spondylolisthesis With Predominant Back Pain Versus Predominant Leg Pain Symptoms.

Retrospective review. This study aims to compare postoperative patient-reported outcome measures (PROMs) in predominant back pain (PBP) versus predominant leg pain (PLP) patients following lumbar fusion for degenerative spondylolisthesis (DS). Prior studies comparing PROMs in patients undergoing lumbar fusion with PBP versus PLP symptoms have included heterogeneous spinal pathology and restricted analysis to posterior fusion techniques. Demographics, perioperative characteristics, complications, and PROMs from a retrospective single-surgeon database were collected for primary, elective, and single-level lumbar fusion for DS. Preoperative/postoperative PROMs included visual analog scale (VAS)-back/leg pain (VAS-BP/VAS-LP), Oswestry disability index (ODI), 12-Item Short Form Physical and Mental Composite Score (SF-12 PCS/MCS), and Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF). Preoperative VAS-BP>VAS-LP established the PBP cohort and VAS-LP>VAS-BP established the PLP cohort. The average follow-up was 23.4±2.8 months. Improvement in PROMs (ΔPROM) at 6 weeks (ΔPROM-6W) and final follow-up (ΔPROM-FF) were calculated. χ2 and the Student t test analyzed categorical and continuous variables, respectively. Postoperative PROMs, ΔPROMs, and MCID achievement rates were compared between groups with multivariate linear or logistic regression. In total, 166 patients were selected with 108 in the PBP cohort. Both cohorts saw improvements in all PROM scores over time. The PBP cohort reported significantly greater ΔPROM-6W and ΔPROM-FF for VAS-BP (P<0.003). The PLP cohort reported greater ΔPROM-6W and ΔPROM-FF for VAS-LP and ΔPROM-FF for SF-12 PCS (P<0.014). MCID achievement rates for VAS-BP were higher in the PBP cohort, and VAS-LP MCID achievement rates were higher in the PLP cohort (P<0.015). Regardless of predominant pain location, patients-reported improvements in all PROs at the final follow-up. Patients with PLP-reported greater improvement in leg pain and physical function and patients with PBP-reported greater back pain improvement.

Perioperative outcomes in patients with symptomatic versus asymptomatic previous COVID-19 infection undergoing neurosurgical treatment (post–COVID-19 study)

Abstract Background and Aims: The long-term effects of coronavirus disease 2019 (COVID-19) infection (long-COVID) are being increasingly recognized. The long-COVID effects are more likely in individuals who were symptomatic than asymptomatic during their previous COVID-19 infection. The data on perioperative outcomes of patients undergoing elective neurosurgery long after their recovery from COVID-19 infection is lacking. The primary objective of this study was to compare the perioperative outcomes after elective neurosurgery between patients who were symptomatic and those who were asymptomatic during their previous COVID-19 infection. The secondary objectives were to compare the earlier COVID-19 characteristics and the perioperative pulmonary profile during current surgery between these groups. Material and Methods: This prospective observational study was performed in adult patients undergoing elective neurosurgery with history of previous COVID-19 infection. Data was collected regarding previous COVID-19 infection (symptoms, hospitalization, treatment, complications, etc.) and current perioperative characteristics (pulmonary profile, perioperative complications, hospital stay, mortality, etc.). Results: A total of 50 patients were recruited during the study period, of which 35 (73%) patients were symptomatic during previous COVID-19 infection (two patients were excluded). The mean duration between current surgery and previous COVID-19 infection was 7 months. Patients symptomatic during earlier COVID-19 infection were females, older, and had a lower oxygen level during current surgery. There was no difference between symptomatic and asymptomatic groups in adverse perioperative outcomes such as desaturation, pulmonary or extrapulmonary complications, or non-extubation. Conclusion: The perioperative outcomes of patients undergoing elective neurosurgery with previous mild to moderate symptomatic COVID-19 infection may not be different from those of patients with asymptomatic COVID-19 infection.

Perioperative outcomes in elderly patients undergoing pancreatoduodenectomy: a propensity-matched analysis.

To investigate perioperative outcomes of pancreatoduodenectomy in elderly patients. Data for 977 patients who underwent pancreatoduodenectomy from January 2018 to January 2023 were retrospectively analysed. Patients aged 75 years or older (n = 81) were matched with patients younger than 75 years (n = 896) using nearest neighbour propensity scores matching in a 1:1 ratio. After matching, there were no significant differences in perioperative characteristics between the old group (n = 80) and the young group (n = 80). Regarding perioperative outcomes, we observed a higher incidence of postpancreatectomy haemorrhage (13.8% vs. 3.8%; P = 0.025) and pulmonary infection (26.3% vs. 8.8%; P = 0.004) in the old group. The major morbidity (Clavien-Dindo ≥3), cardiovascular complications and length of stay were higher in the old group before matching, however, no difference was observed between the matched cohorts (P > 0.05). The multivariate analysis revealed ASA score ≥3 (OR = 3.672, 95% CI 1.367-9.863; P = 0.010) and longer operative time (OR = 1.006, 95% CI 1.000-1.011; P = 0.039) were independently identified as risk factors for major morbidity. Moreover, the subgroup analysis demonstrated that laparoscopic surgery significantly mitigated the incidence of major morbidity in elderly patients. With careful patient selection and perioperative management, elderly patients may achieve comparable short-term outcomes to those of their younger counterparts.

Comparing ambulatory to inpatient percutaneous nephrolithotomy: systematic review and meta-analysis.

To investigate the differences in perioperative characteristics and postoperative outcomes between inpatient and ambulatory percutaneous nephrolithotomy (PCNL) with a subgroup analysis of same-day discharge (SDD) patients, summarise published ambulatory pathways and compare cost and satisfaction data. This study was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered a priori with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023438692). Ambulatory PCNL was defined as patients who were discharged after an overnight stay (≤23 h) and SDD was considered a subgroup discharged on postoperative Day 0. A total of 25 studies were included in the systematic review, of which 12 comparative studies were utilised for meta-analysis. We had a pooled population of 2463 patients, of which 1956 (79%) ambulatory (747 [30%] SDD) and 507 (21%) inpatients. The ambulatory PCNL cohort had fewer overall complications (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.47-0.90; P = 0.010); however, there were no differences in major complications (i.e., Clavien-Dindo Grade ≥III; RR 0.46; 95% CI 0.17-1.21; P = 0.12), emergency department visits (RR 1.09, 95% CI 0.69-1.74; P = 0.71), 30-day readmission (RR 1.09, 95% CI 0.54-2.21; P = 0.81) or readmission at any point (RR 1.00, 95% CI 0.53-1.88; P = 0.99). The ambulatory PCNL cohort was more likely to be stone-free defined by imaging (RR 1.35, 95% CI 1.09-1.66; P = 0.005); however, when stone-free was inclusive of any definition there was no difference in stone-free rates (RR 1.10, 95% CI 0.98-1.23; P = 0.10). Subgroup analysis of SDD did not result in any significant differences. Cost savings ranged from $932.37 to a mean (standard deviation) $5327 (442) United States Dollars per case. No studies reported patient satisfaction data. Ambulatory PCNL seems to be a safe and efficacious model for select patients. Selection bias likely influenced ambulatory outcomes; however, this supports overall safety of current ambulatory inclusion criteria.

Association between early enteral nutrition and length of stay in neonates with congenital bowel obstruction: A retrospective cohort study.

The optimal feeding strategy for postoperative neonatal patients with congenital bowel obstruction is widely debated. This study aims to evaluate perioperative characteristics and postoperative nutrition practices for patients with congenital bowel obstruction. We hypothesized that earlier introduction of enteral nutrition (EN) is associated with shorter hospital stays and increased weight gain velocities. We performed a retrospective cohort study on neonatal patients (<30 days old) admitted to a pediatric referral hospital who underwent an operation for bowel obstruction between 2010 and 2020. Demographic information, clinical characteristics, and feeding characteristics were collected. Associations between early EN (EEN), defined as commencement of enteral feeding within 5 days of surgery, and perioperative characteristics were analyzed with SAS 9.4. Of the 97 neonates with congenital bowel obstruction, 36 patients received EEN. Sex, gestational age, and ethnicity were similar between groups. Patients receiving EEN were more likely to have a diagnosis of malrotation, anorectal malformation, or annular pancreas (P = 0.04). Patients receiving EEN weaned from parenteral nutrition earlier (9 vs 17 days, P = 0.005). Receiving EEN was associated with shorter median hospital stay (16 vs 29 days, P < 0.0001). Weight gain velocities at the 2-month follow-up were greater for patients receiving EEN (8.02 vs 7.00 g/kg/day, P = 0.04) with the difference dissipating at 6 months. EEN was more likely provided in patients with certain operative diagnoses and was associated with improved outcomes. Creating and implementing an EEN protocol in congenitally obstructed neonates may lead to shorter hospital stays and improved outcomes.

Surgical treatment and outcomes in aortic valve endocarditis and perivalvular abscesses

Patients with aortic root abscesses experience increased morbidity and mortality compared to those without abscess in aortic valve infective endocarditis. The superior intervention for patients with aortic root abscess is not determined. This research investigates the degree to which increased morbidity and mortality of aortic root abscess, and to describe perioperative characteristics and outcomes of root operations versus root-sparing repairs of aortic root abscess. All patients who underwent surgical treatment of active aortic valve endocarditis between 2011 and 2022 at a single institution were reviewed, yielding 218 patients, of whom 64 had perivalvular abscess. Patients were treated with either simple (root-sparing) or complex (root replacement) techniques. Patients with abscess demonstrated significantly higher rates of previous cardiac surgery, redo endocarditis surgery, aortocavitary fistula, heart block, and prosthetic valve endocarditis. One quarter of abscesses were not detected on preoperative imaging. Presence of abscess was a significant predictor of operative mortality. Prosthetic valve endocarditis was a significant predictor of complex repair in patients with abscess. Five-year survival was similar between simple and complex repair groups in patients with abscess. Aortic root abscess confers significant morbidity and mortality, and measures should be taken to ensure early detection and treatment of this condition.

Baseline American Society of Anesthesiologists classification predicts worse anxiety and pain interference following Lumbar Interbody Fusion

BackgroundThe American Society of Anesthesiologists (ASA) classifications allow physicians to briefly assess a patient’s risk for general anesthesia and surgical intervention. Although simple to calculate, a patient’s ASA score may correlate with differences in outcomes following spinal operations. The purpose of this study is to establish the effect of ASA score on Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes following Lateral Lumbar Interbody Fusion (LLIF). MethodsAll patient data was collected from a single spinal surgeon database. Patients were separated into cohorts of “Lower ASA” (ASA < 3) and “Higher ASA” (ASA ≥ 3). Demographics, perioperative characteristics, preoperative Patient-Reported Outcomes (PROs), and postoperative PROs at 6 weeks and final postoperative time points were compared statistically. These included Visual Analog Scales for back and leg pain (VAS-B, VAS-L), the Oswestry Disability Index (ODI), the 9-item Patient Health Questionnaire (PHQ-9), and PROMIS measures for Physical Function (PROMIS-PF), Sleep Disturbance (PROMIS-SD), Anxiety (PROMIS-A), and Pain Interference (PROMIS-PI). PRO improvements between preoperative and postoperative time points and Minimum Clinically Important Difference (MCID) were also compared. ResultsIn total, 154 patients were included (111 and 43 in the Lower and Higher ASA cohorts, respectively). Patient age, body mass index (BMI), presence of diabetes, and Charlson Comorbidity Index (CCI) score were significantly different between the two cohorts (Table 1, p < 0.004 for all). Primary vs. non-primary surgery, number of spinal levels fused, postoperative length of stay, and rates of isthmic spondylolisthesis and foraminal stenosis also significantly differed (Table 2, p < 0.05 for all). Patients with a higher ASA score were found to have higher PROMIS-A preoperatively (Table 3, p = 0.029). These patients also had higher PROMIS-A and PROMIS-PI at final postoperative evaluation (p values of 0.007 and 0.047, respectively). Score changes over time and MCID achievement did not seem to be impacted by baseline ASA score. ConclusionsPatients with a higher preoperative ASA score were found to have worse anxiety pre-operatively and worse anxiety and pain interference at the final postoperative evaluation. Clinical improvement over time was not significantly affected by the ASA score.

Transcatheter closure of paravalvular leakage through multiple approaches after surgical mechanical valve replacements: A retrospective study.

Transcatheter closure of percutaneous paravalvular leak (PVL) is a technically challenging procedure, especially after surgical mechanical valve replacements (SMVR), as the risk of interference with the prosthetic valve discs and the complex interventional techniques required for mitral PVL closure. Our study was designed to review the results with transcatheter closure of PVL after SMVR. From January 2018 through December 2023, a total of 64 patients with PVL after SMVR underwent transcatheter closure with the help of preoperative 3-dimensional printing model and simulator for image evaluation. We reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up was 28 (3-58) months. The procedure was successful in 60/64 (93.8%) patients. There were 36 aortic PVLs, 27 mitral PVLs, and 1 combined aortic and mitral PVL which were repaired by the transcatheter approach. A total of 24 patients had aortic valve replacements and 20 patients had mitral valve replacements, while 20 patients had previously combined aortic and mitral valve replacements. Procedural time was 35 to 300 (106.6±51.2) minutes. Fluoroscopic time was 8 to 50 (17.6±11.3) minutes. The hospital stay was 5 to 21 (8.1±3.5) days. A total of 47 (78.3%) patients improved by ≥1 New York Heart Association functional class at the 1-year follow-up. Complex catheter techniques were included in percutaneous closure of mechanical PVL. However, this minimally closure treatment could provide reliable outcomes and shorter hospital stays in selected patients.

An additional gastrojejunostomy may reduce the incidence of moderate and severe delayed gastric emptying after distal segmental duodenectomy for gastrointestinal stromal tumors

BackgroundTo investigate whether an additional gastrojejunostomy reduces the incidence of delayed gastric emptying (DGE) following a distal segmental duodenectomy for duodenal and proximal jejunal gastrointestinal stromal tumors (GIST).Materials and methodsThis retrospective review of the GIST database at Peking University Cancer Hospital included 50 patients who underwent distal segmental duodenectomies for primary GIST in the duodenum or proximal jejunum within 20 cm of Treitz’s ligament between January 2008 and December 2023. The patients were divided into two groups: non-bypass (without gastrojejunostomy) and bypass (with gastrojejunostomy and Braun’s jejunojejunostomy). Perioperative characteristics and postoperative complications were analyzed.ResultsAmong the 50 patients, 27 underwent duodenojejunostomies without gastrojejunostomies and 23 with gastrojejunostomies and Braun’s jejunojejunostomies. The incidence of grade B-C DGE was significantly lower in the bypass group (43.5% vs. 74.1%, p = 0.028). In addition, non-bypass surgery was an independent risk factor for increased grade B-C DGE (OR 3.67, 95% CI 1.07–12.64, p = 0.039). The bypass group showed a trend towards a shorter postoperative hospital stay (median: 14 days, range: 10–56) compared to the non-bypass group (median: 28 days, range: 6–75), but this difference did not reach statistical significance (p = 0.070). Operative time (min) was significantly longer in the multi-visceral resection group (381.0 ± 108.8 vs. 227.3 ± 87.6, p < 0.001), for tumors ≥ 6.3 cm compared to < 6.3 cm (337.0 ± 116.4 vs. 228.3 ± 99.8, p = 0.002), and in patients with positive preoperative symptoms versus asymptomatic patients (319.9 ± 118.0 vs. 210.2 ± 90.3, p = 0.031).ConclusionThe addition of gastrojejunostomy and Braun’s jejunojejunostomy in distal segmental duodenectomy can reduce the incidence of grade B-C DGE, potentially facilitating timely adjuvant imatinib therapy. Future multicenter studies are needed to confirm these findings.

Oncological safety of fertility preservation treatment in ovarian cancer: A Spanish multicenter study.

To assess the safety of fertility-sparing treatments for early-stage ovarian cancer in women younger than 40 years old. We performed a retrospective multicenter study including women aged 18-40 years diagnosed with early-stage (FIGO I-II) ovarian cancer in 55 Spanish hospitals, from January 2010 to December 2019. Benign and borderline tumors were excluded, as well as advanced stages (FIGO III-IV). All perioperative characteristics and follow-up data were collected and analyzed. Standard staging surgery (SSS) was compared with fertility-sparing surgery (FSS) in terms of oncological outcomes. In all, 366 women were included; 327 (89.3%) were stage I. Among all patients, 216 (59%) underwent SSS and 150 (41%) FSS. Up to 208 (56.8%) patients did not have children, but only 12 (3.2%) had oocyte preservation before treatment. Patients in the FSS group compared with the SSS group showed a non-significant difference in recurrences (8% vs. 9.3%, respectively; P < 0.711) and deaths (1.3% vs. 4.8%, respectively; P = 0.211) during the follow-up. No significant differences were found between epithelial and non-epithelial ovarian cancer both in recurrences (7.1% vs. 8.8%, respectively; P = 0.771) and in deaths (1.4% vs. 1.3%, respectively; P = 1) among patients who underwent FSS. FSS seems a safe option for treatment of early-stage ovarian cancer in patients who want to preserve fertility, either for epithelial and non-epithelial histology.

Aged hippocampal single-cell atlas screening unveils disrupted neuroglial system in postoperative cognitive impairment.

Glia-neuron interaction is a crucial feature in aged hippocampus during the occurrence of postoperative cognitive impairment. However, the regulatory effects of microglia, astrocytes, and oligodendrocytes in this glia-neuron interaction, the potential mechanisms and gene targets are still to be elucidated. Here, single-cell RNA sequencing was performed to detect the perioperative genomic expression characteristics of neuroglial system in the hippocampus of aged mice, and to investigate the potential cross-cellular mechanisms and valuable treatment options for glia-neuron interaction-related cognitive impairment. We found that postoperative neurons and glia cells exhibited protein dysmetabolism and mitochondrial electron misrouting. Impaired autophagy and circadian rhythm worsened microglia activation/neuroinflammation, and exacerbated these metabolic alterations. Reactive microglia also aggravated astrocyte and oligodendrocyte cytotoxicity through the PGD2/DP and complement pathways, altering glutamate level and synaptic function via the "tripartite synapses" model, and affecting neuronal myelination. Ligand-receptor communication also indicated these synaptic and axonal dysfunctions via enhanced MDK and PTN pathways. Additionally, we found that anesthetic dexmedetomidine hold therapeutic potential within the disrupted neuroglial system. It enhanced neuronal metabolic rebalance (Atf3-related) and reduced neuroinflammation from a multicellular perspective, therefore improving postoperative cognitive impairment. Together, our study proposes an aged hippocampal cell atlas and provides insights into the role of disrupted glia-neuron cycle in postoperative cognitive impairment. Our findings also elucidate the therapeutic potential and mechanism of dexmedetomidine intervention.

Modified kinematic alignment better restores plantar pressure distribution than mechanical alignment in total knee arthroplasty: a randomized controlled trial

Kinematic alignment (KA) in the short to medium term clinical outcomes is superior to the mechanical alignment (MA), but whether it will improve patients’ postoperative gait is still controversial. Understanding whether and how KA influences postoperative gait mechanics could provide insights into optimizing alignment philosophy to improve functional outcomes. To investigate the impact of KA versus MA in total knee arthroplasty (TKA) on the operated and contralateral native lower limbs by analyzing plantar pressure distribution during walking gait. This study was designed as a secondary analysis from a randomized controlled trial. Thirty-seven patients were included, nineteen underwent KA-TKA and eighteen underwent MA-TKA, each with a native knee in the contralateral limb. Pressure-sensitive insoles were used to collect plantar pressure distribution of both limbs simultaneously during walking defined as medial-lateral load ratio (MLR). Perioperative characteristics including radiographic metrics (Hip-Knee-Ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) and clinical outcomes (Oxford Knee Scores (OKS)) were compared between the two groups pre-operatively and 2-year postoperatively. Significant differences were found in postoperative radiographic metrics, with KA showing better OKS 1 year postoperatively (p = 0.021), lower mean HKA (p = 0.009) and mMPTA (p < 0.001). Other perioperative characteristics were similar between groups. In the pedobarographic analysis, the MA group demonstrated greater medial pressure distribution in forefoot compared to both the KA group (p < 0.001) and the contralateral native knee (p = 0.002). Besides, the MA group revealed a more lateral pressure distribution in rearfoot compared to the KA group (p = 0.007) and the contralateral native knee (p = 0.001). While there was no significant difference between KA and native group (p = 0.064 and p = 0.802, respectively). KA offered advantages over MA in restoring a more physiologic plantar pressure distribution at two years postoperatively. These results underscore the potential clinical benefits of adopting KA techniques in TKA procedures.