Perioperative Mortality Research Articles

Echocardiographic evaluation in patient candidate for liver transplant: from pathophysiology to hemodynamic optimization

AbstractCardiovascular complications are common in patients with severe liver disease and are an important cause of peri-operative and post-transplant morbidity and mortality. Cirrhotic cardiomyopathy (CCM), often found in advanced liver disease, is characterized by diastolic dysfunction, systolic dysfunction, and electrophysiological abnormalities. While CCM may not cause symptoms at rest, it can become evident during stressful activities, such as surgery. Liver transplantation, while being the definitive treatment for end-stage liver disease (ESLD), carries significant cardiovascular risks. Preoperative cardiac evaluation is essential for assessing these risks and planning appropriate management. Cardiac imaging, particularly echocardiography, plays a crucial role in evaluating liver transplant candidates, helping to identify conditions such as CCM, pulmonary hypertension, hepatopulmonary syndrome, and others. Currently, liver transplant anesthetists must acquire echocardiographic knowledge and skills to evaluate the cardiocirculatory conditions of the transplanted patient, especially in the pre-operative phase, but also intra-operatively and post-operatively.

HPB SO54 - Outcomes of Isolated Bile Duct Resection for Cholangiocarcinoma; More Than 15 Years Experience in a Single Tertiary HPB Centre

Abstract Background Cholangiocarcinoma of the extrahepatic biliary tree usually requires a major resection to achieve clear margins with adequate lymphadenectomy. For perihilar tumours this involves extended liver resection with bile duct resection whilst distal tumours require pancreaticoduodenectomy. Occasionally a combination of both (hepato-pancreaticoduodenectomy) is required. These procedures are associated with high morbidity and mortality. In a small number of patients, cholangiocarcinoma is confined to the extrahepatic bile duct with no involvement of the liver or pancreas and a bile duct resection alone is an option. We reviewed the outcomes of patients who underwent bile duct resection for cholangiocarcinoma in our unit. Method We identified all patients who underwent bile duct resection and hepaticojejunostomy for cholangiocarcinoma between June 2007 and June 2023 in our centre from a prospectively maintained database. Patient demographics, complications, histology, resection margin status, follow-up, recurrence, and survival were recorded. Time to recurrence and overall survival were analysed using Kaplan Meier analysis. Results Thirteen patients underwent bile duct resection and hepaticojejunostomy for cholangiocarcinoma. 12 (92%) were male and the median (range) age was 72 (41-82). No patients received neoadjuvant treatment. 3 (23%) patients developed postoperative complications with 1 (7.7%) perioperative mortality. R0 margin was achieved in 6 (46%). The median (range) postoperative stay was 7 (5-25) days. 8 (61.5%) patients received adjuvant chemotherapy. 7 patients (53.8%) developed recurrent disease at a median of 12 (IQR 8-54) months following surgery. The most common sites of recurrence were the liver (23.1%) followed by local recurrence (15.4%). The median survival was 38 (IQR 20-95) months. Conclusion Extrahepatic bile duct resection with hepaticojejunostomy is an option for patients with cholangiocarcinoma of the extrahepatic bile duct without macroscopic involvement of the liver or pancreas. In our series this procedure was associated with a low morbidity and perioperative mortality with acceptable recurrence rates and overall survival despite only modest R0 resection rates. Isolated bile duct resection with hepaticojejunostomy should be considered for tumours without macroscopic involvement of the liver or pancreas, especially in patients of borderline fitness for a more extensive resection.

EGS SO11 - A Retrospective Review of Perioperative Outcomes after Laparoscopic Cholecystectomy in Older Patients

Abstract Background Laparoscopic cholecystectomy is the definitive treatment for gallstone-related disease. With an increasingly aging population, a growing number of elderly patients are presenting acutely with gallstone pathology. However, rates of perioperative mortality and complications are significantly higher in elderly patients undergoing laparoscopic cholecystectomy (Kamarajah et al). We aim to evaluate peri-operative outcomes in elderly patients presenting with acute gallstone disease who have been clinically evaluated to be appropriate for emergency cholecystectomy, and explore the impact of frailty on these outcomes. Method A retrospective study was performed on patients over the age of 75 presenting acutely with gallstone disease over a 3-year period. Data on perioperative complications, mortality at 1 year, post-operative length of stay (LOS) and 90-day readmissions were collected and analysed. The patient’s pre-operative fitness was categorized using the ASA classification of physical status and the Clinical frailty score (CFS); a 9-point scale quantifying frailty based on function. Statistical significance was assessed to determine differences between the age or frailty score groups. Results 592 patients attended hospital with gallstone-related pathology; 99 patients underwent emergency laparoscopic cholecystectomy, 486 patients were managed conservatively, and 25 patients had cholecystostomies. The post-operative mortality rate was 4%, post-operative complication 19.2% and readmission rate 11.1%. Post-operative LOS was significantly longer in frailer patients (p=0.02299). There were no statistically significant differences in mortality or post-operative complications between the CFS3 or less and CFS4 or more groups, although a general trend towards higher rates of complications and mortality was noted with increasing frailty. Conclusion Patients over 75 years of age should be carefully considered before proceeding with surgical management. Although older and frailer patients exhibited increased rates of complications and mortality post-operatively, these didn't reach statistical significance, reflecting the role of clinical decision-making regarding surgical fitness. Even for a pre-selected patient group, there is statistically significant prolonged post-operative LOS in frailer patients. This suggests a need for comprehensive preoperative assessment in this population, and a combination of CFS and ASA may be key determinants. Further studies assessing frailty and non-operative outcomes are required to substantiate these findings and guide clinical management in this population.

HPB SO32 - Outcomes Following Surgical Resection for Duodenal Adenocarcinoma – A Single Centre Experience

Abstract Background Duodenal adenocarcinomas are rare cancers and their clinico-oncological management pathways tend to follow that of small bowel tumours. The aim of this study was to determine the outcomes of patients undergoing surgical resection for duodenal adenocarcinoma. Method Retrospective data of all patients who underwent surgical resection for duodenal adenocarcinoma between January 2008 to December 2023 were included. Collated data included demographics, clinico-pathological features and survival outcomes. Results Thirty-one patients were included, with a mean age of 65.7 (± 9.6) years and a greater proportion were male patients (58.1%). The predominant site of the primary tumour was at D2 section of the duodenum (58.1%). The majority of patients required a pancreatico-duodenectomy (80.6%) and 58.1% experienced minor morbidity (Clavien-Dindo I-II) while 22.6% experienced major morbidity (Clavien-Dindo III-V). There were 4 (12.9%) peri-operative mortalities. Results The median post-operative follow-up was 29.7 (IQR 61.5) months. Only 37.0% of patients received adjuvant chemotherapy while 13 patients (48.1%) experienced disease recurrence. The 3- and 5-year overall survival was 44.3% and 33.3%, respectively, while the disease-free survival at 3 and 5 years were 37.0% and 29.6%, respectively. Patients who received adjuvant chemotherapy had a trend towards improved mean overall survival in comparison to patients who did not receive chemotherapy following surgery [80.3 vs 51.2 months; log rank 1.857, p=0.173]. Nevertheless, the median disease-free survival was similar between both groups [24.0 vs 26.0 months, log rank 0.016, p=0.901]. Patients who experienced major morbidity (Clavien-Dindo III-V) were significantly more likely to have a poorer median overall survival compared to patients with minor morbidity (Clavien-Dindo I-II) [72.1 vs 3.4 months; log rank 16.860, p<0.001]. Conclusion Major morbidity (Clavien-Dindo III-V) following surgery is associated with poorer overall survival. Patients who received adjuvant chemotherapy following surgical resection for duodenal adenocarcinoma may have a trend towards improved overall survival.

Abstract 4138248: Outcomes of Patients with Radiation-Associated Cardiac Disease Undergoing Cardiothoracic Surgery: Development of a Disease Specific Risk Score

Background: Radiation-associated cardiac disease (RACD) has significant long-term mortality and morbidity, often requiring cardiac surgery(CS). Hypothesis: We sought to study factors associated with longer-term survival in RACD patients and develop a specific risk score associated with 5-year survival following CS. Methods: This was an observational cohort study of 351 patients with documented RACD (252 [72%] had mantle radiation for lymphoma at a mean of 18 years prior), who underwent CS at a tertiary care center between 1991-2018. Clinical characteristics were collected, and Society of Thoracic Surgeons (STS) score was calculated. The primary endpoint was mortality. Multivariable analysis for 5-year mortality was performed using age, sex, history of lymphoma, New York Heart Association class, prior cardiac surgery, atrial fibrillation, constriction, chronic pulmonary disease, serum creatinine, left ventricular ejection fraction, right ventricular systolic pressure and valvular surgery(aortic, mitral or tricuspid). Results: Clinical characteristics are shown in Figure 1. Mean follow-up was 6.2±4.6 years&5-year mortality occurred in 123 (35%) patients (7 [2%] in-hospital deaths). Cox 5-year survival analysis results are shown in Figure 2A. A receiver operator curve analysis for 5-year mortality showed an area under curve of 0.70 (95% confidence interval 0.64-76, p<0.001). Subsequently, a 5-year risk score (0-7 points) was generated (Figure 2 A); with an increasing risk of mortality at 5 years, based on increasing risk score (Figure 2C). Cardiac reoperation was not associated with worse outcomes. Conclusion: RACD patients undergoing CTS have a high rate of 5-year mortality, despite a low baseline STS score&perioperative mortality. A novel RACD-specific risk score (incorporating higher age, abnormal renal/pulmonary, constrictive pericarditis&need for concomitant mitral valve surgery) provides good discrimination for 5-year survival&could be used for shared-decision making.

Abstract 4138620: Assessment of the Accuracy of the Perioperative Mortality Risk in Adults with Congenital Heart Disease (PEACH) Score

INTRODUCTION: Previous mortality risk scores for adult cardiac surgery patients did not include adult congenital heart disease (ACHD) patients. Development of ACHD specific mortality risk scores include the procedure-specific ACHS score and recently derived PEACH score. While validated in Europe, further evaluation of the PEACH score in additional settings is necessary. RESEARCH QUESTION: We assessed the efficacy of the PEACH score to predict mortality in ACHD patients undergoing congenital cardiac surgery at our institution. We compared the PEACH score to the ACHS and STS scores and assessed for additional risk factors which may further augment the PEACH score. Methods: A retrospective cohort study was conducted of patients who underwent congenital cardiac surgery at the University of Colorado Hospital and Children’s Hospital Colorado between 2010-2022. Patients were identified by the institutional STS congenital cardiac surgery database and were eligible if 18 years or older and underwent congenital cardiac surgery. Components of the PEACH score and additional postulated risk factors were evaluated by univariate analysis. A receiver operating characteristic (ROC) curve was used to compare the PEACH score to existing risk models. Logistic regression analysis determined additional risk factors to augment the PEACH score. Results: A total of 516 patients were included with a median age of 30 (IQR 23-42) and 51% were male. There were nine deaths overall. The PEACH score was predictive of mortality (OR: 2.09, p<0.001) with a score of 0: 0 deaths/240 patients (0%); 1-2: 6 deaths/229 patients (2.6%); 3+: 3 deaths/41 patients (7.3%). Of additional risk factors tested, platelets less than 184,000 per mcL (OR: 8.36, p=0.01) was significantly associated with mortality. Comparison of the models revealed PEACH score AUC 0.832 (95% CI: 0.740,0.924), ACHS score AUC 0.869 (95% CI: 0.806, 0.932), and STAT AUC 0.769 (95% CI: 0.616, 0.922, Figure 1). The addition of platelet level improved the predictive ability of the PEACH score (AUC 0.881). Conclusion: In this single-center analysis, the PEACH score provided strong predictive ability for peri-operative mortality. The addition of platelet levels may further augment this score.

Risk Factors and Management of Portal Vein Thrombosis after Hepatectomy: A Single-Center Experience

Objective: This study investigated the risk factors and management of portal vein thrombosis (PVT) after hepatectomy. Background: PVT after hepatectomy can cause liver dysfunction and portal hypertension, and may be fatal. However, it has not been sufficiently investigated. Methods: The study included 1403 consecutive patients who underwent elective hepatectomy at our department from January 2010 to July 2022. The patients were divided into PVT and non-PVT groups based on the presence or absence of PVT, and relevant risk factors were analyzed. The management and prognosis of patients with PVT were investigated. Results: Among the 1403 patients, PVT occurred in 33 cases, giving a frequency of 2.4%. In univariate analyses, female sex (P = 0.03), portal vein reconstruction (P = 0.01), and left lateral sectionectomy (P < 0.001) were significant risk factors for PVT. On multivariate analysis, portal vein reconstruction (P = 0.01) and left lateral segmentectomy (P < 0.001) remained significant risk factors for PVT. The management options for PVT were thrombectomy, antithrombotic therapy, and observation. With antithrombotic therapy, 96.4% of patients achieved PVT resolution. Among patients who underwent hepatectomy with portal vein reconstruction, the PVT site was the main trunk of the portal vein in all 3 cases, and thrombectomy was performed in 2 cases. No perioperative mortality was observed. Conclusions: In the present study, portal vein reconstruction and left lateral sectionectomy were identified as risk factors for PVT after hepatectomy. As PVT can be fatal, early detection and appropriate treatment according to the status of PVT are important.

Abstract 4137869: Ross Procedure for Correction of Congenitally Unicuspid Aortic Valve: A Paradigm Shift?

Case 1: A 54-yr-old man reported exertional dyspnea for 3 months, with a systolic murmur on exam. TTE noted severe aortic stenosis, moderate insufficiency and possible bicuspid valve morphology. Coronary angiogram showed no obstructive disease. CT chest showed a 5-cm ascending aortic aneurysm. CT surgery evaluation was sought, and patient had a Ross procedure with aortic hemiarch repair. Intra-operative TEE confirmed a congenitally unicommissural, unicuspid aortic valve (UAV). A 7-month follow-up TTE showed a normal aortic and pulmonic prosthetic gradient. Case 2: A 46-yr-old lady reported progressive exercise intolerance, with a systolic murmur and faint S2 noted on exam. TTE showed severe aortic stenosis. MR angiogram showed a unicuspid valve and a mildly dilated aortic root. The patient was evaluated by CT surgery and underwent Ross procedure. TTE 4 years later showed a normal aortic and a moderately elevated pulmonic prosthetic gradient. Patient continues to exercise without limitations. Discussion: UAV is a rare entity with an incidence of 0.02%. It has a bimodal distribution, in infants and adults, with the unicommissural type more common in adults. Due to rapid progression of valvular disease, the mean age at diagnosis is 42 years. Concurrent aortic dilatation is present in 48% patients. Management of UAV is a matter of ongoing investigation. Classically, young patients with aortic valve disease underwent mechanical AVR. Ross procedure was under-utilized due to concerns about the surgical complexity and potential need for re-operation of the aortic and pulmonic grafts. However, recent studies show promising results. Patients with UAV have lower reoperation rates after a Ross procedure compared to a repair alone. Furthermore, a Ross procedure confers mortality benefit over mechanical AVR with no significant difference in immediate perioperative complications and mortality, although, this needs further investigation in a UAV cohort. Our cases support the feasibility of a Ross procedure for UAV, in providing a durable solution while avoiding anticoagulation in young patients. As Ross procedure is performed in limited centers, patients with UAV should be referred to such centers for definitive management.

The effect of comorbidity on 28-day perioperative mortality rate among non-cardiac surgical patients in Northwest Ethiopia: a prospective cohort study using propensity score matching

The effect of comorbidity on 28-day perioperative mortality rate among non-cardiac surgical patients in Northwest Ethiopia: a prospective cohort study using propensity score matching

Predictors of In-hospital and Short-term Outcomes of Thoracic Endovascular Aortic Repair for Aortic Aneurysm and Aortic Syndrome: A Single-Center Experience

BACKGROUND: Endovascular technique has replaced open repair as primary treatment for different aortic disease indications and was associated with low perioperative mortality and acceptable short-, mid-, and long-term survival. Locally, thoracic endovascular aortic repair (TEVAR) was not widely practiced until year 2017. This study aims to determine the predictors of in-hospital and short-term outcomes of patients who underwent TEVAR for aortic aneurysm and aortic syndrome in a single center and how it compares with local and international data. METHODS: This study is a retrospective analysis of 52 adult patients who underwent TEVAR for the treatment of aortic aneurysm and aortic syndrome. Demographic and clinical data, diagnostic imaging, and procedural details were obtained via inpatient charts at the medical records section and hospital system database archiving. Outcomes at 30 days and 1 year postprocedure were obtained through telephone follow-up after attaining verbal consent. Gathered data were analyzed as to association of different variables with or without the presence of complications. Outcomes reported included in-hospital mortality rate, presence of major adverse events (MAEs), 30-day and 1-year survival rates, and rate of freedom from reintervention. RESULTS: The overall in-hospital mortality was 7.69% (n = 4/52), and complication rate was 32% (n = 20/52), with a survival rate of 92.31% and 87.76% at 30 days and 1 year, respectively. The rates of overall freedom from reintervention were 83.33% and 100% at 30 days and 1 year, respectively. The independent predictors for in-hospital mortality and development of MAEs were increasing weight (odds ratio [OR], 1.0588; 95% confidence interval [CI], 1.003–1.208), preexisting chronic kidney disease (OR, 10.33; 95% CI, 1.1069–96.462), and TEVAR with debranching done as a single procedure (OR, 3.6667; 95% CI, 1.1154–12.054), whereas an estimated glomerular filtration rate of 49.05 ± 19.25 (OR, 0.9402; 95% CI, 0.9019–0.9801) and TEVAR with debranching done as a staged procedure (OR, 0.1624; 95% CI, 0.0321–0.8225) statistically decrease the risk for development of in-hospital mortality and MAEs (P = 0.001 and P = 0.028, respectively). CONCLUSIONS: In this single-center study, indications for TEVAR were fusiform and saccular aneurysm, high-risk intramural hematoma and penetrating aortic ulcer, complicated acute type B dissection, chronic complicated type B dissection with high-risk feature, and aortic rupture. The outcome of this study shows comparable results with other international studies with an acceptable in-hospital mortality rate, complication rate, short-term survival rate, and rate freedom from reintervention at 30 days and 1 year. Increasing weight, preexisting chronic kidney disease, and TEVAR with debranching done as a single setting are independent predictors for developing in-hospital mortality and MAEs, whereas a normal estimated glomerular filtration rate and TEVAR with debranching done as a staged procedure decrease the risk; hence, careful planning and scheduling of procedure among elective and amenable cases could further reduce complication rates of future TEVAR procedures.

Can Novel Biomarkers Effectively Predict Acute Kidney Injury in Liver or Kidney Transplant Recipients?

Acute kidney injury (AKI) constitutes a common complication associated with liver or kidney transplantation, which may significantly impact the graft condition and perioperative mortality. Current AKI diagnostic criteria based on serum creatinine (sCr) and urine output alterations are widely utilized in routine clinical practice. However, the diagnostic value of sCr may be limited by various confounding factors, including age, sex, reduced or increased muscle mass, and pre-existing chronic kidney disease (CKD). Furthermore, sCr is rather a late indicator of AKI, as its concentration tends to increase only when the severity of the injury is enough to decrease the estimated glomerular filtration rate (eGFR). Recent expertise highlights the need for novel biomarkers in post-transplantation AKI diagnosis, prediction of event-associated mortality, or evaluation of indications for renal replacement treatment (RRT). Over the last decade, the diagnostic performance of various AKI biomarkers has been assessed, among which some showed the potential to outperform sCr in AKI diagnosis. Identifying susceptible individuals, early diagnosis, and prompt intervention are crucial for successful transplantation, undisturbed graft function in long-term follow-up, and decreased mortality. However, the research on AKI biomarkers in transplantation still needs to be explored. The field lacks consistent results, rigorous study designs, and external validation. Considering the rapidly growing prevalence of CKD and cirrhosis that are associated with the transplantation at their end-stage, as well as the existing knowledge gap, the aim of this article was to provide the most up-to-date review of the studies on novel biomarkers in the diagnosis of post-transplantation AKI.

Short-term outcome after isolated tricuspid valve surgery: prognostic role of right ventricular strain

Abstract Objectives To assess the incremental prognostic value of right ventricular free wall longitudinal strain over conventional risk scores in predicting the peri-operative mortality in patients with severe tricuspid regurgitation (TR) undergoing isolated tricuspid valve (TV) surgery. Methods We retrospectively enrolled 110 consecutive patients with severe TR who underwent isolated TV surgery between November 2016 and July 2022 at San Raffaele Hospital, Milan, Italy. Exclusion criteria were previous TV surgery, urgent surgery, complex congenital heart disease, active endocarditis and inadequate acoustic window. Baseline clinical data were included, as well as laboratory tests and clinical risk score, as TRI-SCORE and MELD-XI. The clinical outcome was peri-operative mortality, defined as all-cause mortality within 30 days. Results The final cohort included 79 patients. The endpoint occurred in 7 patients (9%), who died within 30-days after isolated TV surgery. ROC curves analysis showed that, among parameters of right ventricular function, right ventricular free wall longitudinal strain was the best parameter to predict peri-operative mortality (AUC: 0.854, 95% CI 0.74–0.96, p = 0.005, sensitivity 68%, specificity 100%) At univariable analysis, left ventricular ejection fraction, diabetes mellitus, creatinine, estimated glomerular filtration rate, serum sodium, MELD-XI, TRI-SCORE, right ventricular areas, right ventricular global longitudinal strain, right ventricular free wall longitudinal strain, fractional area change and the ratio between right ventricular free wall longitudinal strain/pulmonary arterial systolic pressure were significantly associated with the endpoint. The combination of TRI-SCORE and right ventricular Strain, evaluating right ventricular systolic function with speckle-tracking echocardiography, outperformed classic TRI-SCORE in outcome prediction (AUC 0.874 vs 0,787, p value=0.05). Conclusion Right ventricular free wall longitudinal strain has an incremental prognostic value over conventional parameters and significantly improves the ability of clinical scores to predict peri-operative mortality in patients undergoing isolated TV surgery.

Endo-Aortic Clamp for Minimally Invasive Redo Mitral Valve Surgery: Early Outcome

Objective: Redo mitral valve surgery still represents a challenging and high-risk procedure in cardiac surgery. The incidence of cardiac structural injuries during re-sternotomy remains consistent and is reported to be an independent risk factor for hospital mortality. Minimally invasive cardiac surgery with retrograde femoral arterial perfusion and endo-aortic clamping avoids re-entry injuries and reduces the requirement for dissection of adhesions and the risk of damage to cardiac structures. The aim of this study is to analyze redo patients undergoing mitral valve surgery with retrograde arterial perfusion and endo-aortic clamping setting. Methods: A retrospective analysis was performed on patients undergoing surgery from 2006 to 2022. Exclusion criteria were more than mild aortic regurgitation, moderate-to-severe peripheral vascular disease, dilated ascending aorta, and a lack of preoperative vascular screening. The primary outcome was perioperative mortality. Results: Two hundred eighty-five patients were analyzed. Mean age was 63.8 ± 13.3 years, mean EuroSCORE was 16.5 ± 14.5%, and one quarter of the patients had undergone two or more previous procedures via sternotomy. Perioperative mortality was 3.9% (11/285). Stroke was reported in six (2.1%) patients. Median intensive care unit and hospital length of stay were 1 and 8 days, respectively. Conclusions: Endo-aortic clamping setting in redo MV surgery avoids re-entry injuries and allows the surgeon to clamp the aorta and deliver the cardioplegia with minimal dissection of adhesions. In high-volume and experienced centers, this approach can be applied safely and effectively and may in the near future become the standard of care for redo mitral valve surgery.

Robotic Versus Thoracoscopic Minimally Invasive Mitral Valve Surgery: A Systematic Review and Meta-Analysis of Matched Studies.

Mitral regurgitation is the most prevalent form of valvular heart disease, impacting over 24 million people globally. Robotic and thoracoscopic minimally invasive mitral valve repair (MIMR) techniques have emerged as viable alternatives to traditional open-heart surgery. However, the comparative effectiveness and safety of these 2 approaches remain underexplored. This systematic review and meta-analysis, conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, aimed to compare robotic and thoracoscopic MIMR outcomes. A literature search was performed across PubMed, Scopus, and Embase databases to identify studies comparing these 2 surgical techniques. Eligible studies included randomized controlled trials and cohort studies. Six propensity score-matched studies and 1 retrospective cohort study, involving 11,823 patients, were included, with 5851 undergoing robotic mitral valve repair and 5972 receiving thoracoscopic MIMR. No significant differences were found in perioperative mortality [risk ratio (RR): 0.97, 95% confidence interval (CI): 0.65-1.45] or pump/clamp times. Robotic surgery was associated with longer operative times (mean difference: 33.01 minutes) and higher intraoperative transfusion rates (RR: 1.53, 95% CI: 1.07-2.18), but a lower risk of atrial fibrillation (RR: 0.89, 95% CI: 0.83-0.95). In conclusion, robotic and thoracoscopic MIMR show comparable mortality and overall safety profiles. However, robotic surgery may require longer operative times and increased transfusion needs, while reducing the risk of atrial fibrillation. Further high-quality, randomized studies are warranted to validate these findings.

Outcomes and Perioperative Complications of Surgical Resection on Canine Carotid Paragangliomas (21 Cases): A Veterinary Society of Surgical Oncology Study.

Carotid body paragangliomas represent an uncommon neoplasm in dogs. The objective of this study was to report outcomes and complications associated with surgical excision of carotid body paragangliomas in 21 dogs. Cases were recruited retrospectively via medical record review from 9 veterinary speciality centres. The perioperative complication rate was 52% (11/21). Complications encountered in this cohort related to removal of carotid body tumour included airway obstruction, aspiration pneumonia, megaesophagus, unilateral laryngeal paralysis, coughing and Horner's syndrome. The overall perioperative mortality rate was 4.7% (1/21 dogs) and median survival time was 554 days for the six patients with known dates of death. One- and two-year survival rates were 61% and 42%, respectively. This is the largest collection of carotid body paraganglioma cases reported in veterinary literature. Based on these results, surgical resection of carotid body paragangliomas was associated with low perioperative mortality and long survival times.

Long-term treatment outcomes of complicated acute diverticulitis in immunocompromised patients

PurposeThe main aim of this study was to determine the short- and long-term outcomes of the non-operative management of acute left-sided complicated diverticulitis (ALCD) in severely immunocompromised patients (IMS group) and compare them with immunocompetent patients (IC group). The secondary aim was to assess the necessity of an elective surgery following a successful prior non-operative management in the IMS group after a non-operative management of the first episode of ALCD.MethodsPatients presented with their first episode of ALCD between 2012 and 2018 were retrospectively reviewed. Only severely immunosuppressed patients were considered for the analysis, including the following: long-term oral or intravenous steroid intake, current malignancy undergoing chemotherapy, chronic kidney disease on hemodialysis, or solid organ transplant with immunosuppressive medication. For each group, demographic data, severity of the episode, management decisions (conservative or operative), and short- and long-term outcomes were recorded and compared. A sub-analysis of patients with ALCD associating and abscess (modified Hinchey classification Ib/II) was performed.ResultsA total of 290 patients were included in the study: 50 among the IMS and 240 among the IC group. The rate of emergent surgery was higher in the IMS group (50.0% vs. 22.5%, p < 0.001) and was associated with increased morbidity (72.4% vs. 50.0%, p = 0.041) and mortality (24.1% vs. 4.3%, p = 0.003). The duration of the hospital stay was significantly longer in the IMS group (15 vs. 8 days, p < 0.001). The final stoma rate was significantly higher in the IMS group (82.1% vs. 22.9, p < 0.001), with a median follow-up of 51.4 months. A total of 141 patients presented ALCD with an abscess; 25 in the IMS and 116 in the IC group. There was a higher rate of surgical intervention among the IMS group as the initial treatment approach (24.0% vs. 5.2%, p = 0.002), even though the conservative treatment had a similar rate of success (81.3% vs. 92.0%, p = 0.178). The recurrence rate following a non-operative approach was similar (IMS: 31.2% vs. 35.4% in the IC group, p = 0.169). Furthermore, 81.2% of non-operatively managed IMS patients (13 out of 16) did not require a surgical intervention at the end of the follow-up, with similar findings in the IC group (78/96, 81.2%, p = 0.148).ConclusionMedical treatment of immunosuppressed patients during their first ALCD episode associated with an abscess is feasible, with a high success rate and results comparable with the IC group. Moreover, taking into account the readmission rates, the need for emergent surgery of the recurrence, and the perioperative mortality and morbidity in the IMS group, conservative management with no differed scheduled surgery seems to be a safe option in this subgroup of patients.

Impact of neoadjuvant therapy on prognosis in renal cell carcinoma with inferior vena cava thrombus

BackgroundThe standard treatment for non-metastatic renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is complete surgical resection; however, this procedure is complex and carries high complication rates and perioperative mortality. Previous studies have explored preoperative multimodal therapy to reduce surgical difficulty, but limited evidence prevents guideline recommendations. This study aimed to investigate the impact of neoadjuvant therapy on the prognosis of patients with RCC and IVC thrombus without distant metastasis. MethodsData from 2006 to 2024 on RCC patients with IVC thrombus undergoing radical nephrectomy plus IVC thrombus resection were collected. Patients received neoadjuvant therapy, including tyrosine kinase inhibitors or immune checkpoint inhibitors, followed by surgery. Tumor size and thrombus height were assessed by computed tomography. Disease-free survival (DFS) and overall survival (OS) were calculated using Kaplan-Meier curves. Multivariate analysis was used to identify factors predicting DFS. ResultsThirty-one patients who did not receive neoadjuvant chemotherapy therapy (NAC-Naive group) and 19 patients who received neoadjuvant chemotherapy therapy (NAC group) were analyzed. The NAC group showed significant reductions in primary renal tumor size and neutrophil-to-lymphocyte ratio compared to the NAC-Naive group just before nephrectomy. The NAC group had significantly improved DFS and OS. Median DFS and OS were not reached in the NAC group compared to 26.3 months and 73.5 months, respectively, in the NAC-Naive group. The NAC group had a 2-year recurrence-free survival rate of 70.9% compared to 50.6% in the NAC-Naive group. Multivariate analysis identified a preoperative tumor size of 10 cm or larger and lack of neoadjuvant therapy as poor prognostic factors for DFS. ConclusionNeoadjuvant therapy significantly improves the prognosis of RCC patients with IVC thrombus. This therapy reduces surgical invasiveness and has a mid- to long-term preventive effect on recurrence. These findings support the potential benefit of neoadjuvant systemic therapy in improving outcomes for this patient population.

Error traps in patients with congenital heart disease undergoing noncardiac surgery.

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes.

Comparison Between Billroth II and Billroth II + Braun Anastomosis in Gastrectomy for Gastric Cancer

IntroductionDistal gastrectomy remains the predominant therapeutic approach for gastric cancer, with digestive tract reconstruction as an integral procedure. The implementation of Braun anastomosis following Billroth II anastomosis is common in distal gastrectomy. This retrospective cohort study evaluated the clinical utility of Braun anastomosis by comparing the outcomes and quality of life between Billroth II (B-II) and Billroth II with Braun (B-IIB) anastomosis in the treatment of gastric cancer. MethodsA retrospective cohort study examined clinical and pathological data from 377 patients who underwent distal gastrectomy for gastric cancer treatment at The Affiliated Lihuili Hospital, Ningbo University, from October 2016 to October 2021.185 patients received B-II anastomosis, while the other 192 received B-IIB anastomosis, forming the B-II and B-IIB groups, respectively. Baseline characteristics, perioperative variables, short-term and long-term complications, and nutritional indicators at 1 mo and 1 y postsurgery were compared across both groups. Additionally, gastric endoscopy results at 6 mo and 1 y postsurgery were evaluated. Quality of life at 1 y postsurgery was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. ResultsBaseline characteristics between the two groups revealed no statistically significant differences (all P > 0.05), confirming their equivalence. All 377 patients successfully underwent curative distal gastrectomy for gastric cancer without intraoperative procedural modifications. No intraoperative complications or perioperative mortality occurred. Notable differences included extended operative time (222.1 ± 41.0 vs. 199.4 ± 24.9 min, P < 0.001), reduced postoperative nasogastric tube removal time (1.8 ± 0.9 vs. 2.2 ± 1.1 d, P < 0.001), decreased average gastric drainage volume (100.7 ± 35.2 vs. 112.2 ± 32.0 mL, P = 0.001), and increased incidence of internal hernia and ileus (4.7% vs. 1.1% and 8.3% vs. 3.2%, P = 0.038 and P = 0.035) in the B-IIB group compared to the B-II group. No significant differences were observed in estimated blood loss, lymph node dissection, postoperative flatus time, transition to a semiliquid diet, length of hospital stay, or short-term and long-term complications (all P > 0.05). Nutritional assessments conducted 1 mo and 1 y postsurgery indicated no statistically significant differences in body mass index, total protein, and serum albumin levels between the two groups (all P > 0.05). Gastric endoscopy evaluations at 6 mo and 1 y postsurgery, including food residue grade, gastritis severity, extent of gastritis, and bile reflux, demonstrated no significant discrepancies between the groups (all P > 0.05). At the 1-y follow-up, neither group exhibited tumor recurrences, deaths from tumor-related diseases, postoperative complications, or other diseases. Additionally, quality of life assessments using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core revealed no significant differences across various domains or items between the groups (all P > 0.05). ConclusionsA comparative analysis between B-II and B-IIB anastomosis demonstrated no notable variations in intraoperative parameters, postoperative nutritional outcomes, gastric endoscopic results, or postoperative quality of life. Nevertheless, incorporating Braun anastomosis can extend the duration of surgery and may elevate the likelihood of postoperative internal hernia.

Comparison of 4.54% hypertonic saline and 20% mannitol for brain relaxation during auditory brainstem implantation in pediatric patients: a single-center retrospective observational cohort study

BackgroundMannitol is frequently utilized to achieve intracranial brain relaxation during the retrosigmoid approach for auditory brainstem implantation (ABI). Hypertonic saline (HS) is an alternative for reducing intracranial pressure; however, its application during ABI surgery remains under-investigated. We aimed to compare the efficacy and safety between HS and mannitol for maintaining brain relaxation.MethodsThis single-center retrospective cohort study included pediatric patients undergoing ABI surgery from September 2020 to January 2022 who received only 4.54% HS or 20% mannitol for brain relaxation. The analysis involved initial doses, subsequent doses, and dosing intervals of the two hyperosmolar solutions, as well as the time elapsed from meningeal opening to the first ABI electrode placement attempt. Additionally, the analysis encompassed electrolyte testing, hemodynamic variables, urine output, blood transfusion, second surgeries, adverse events, intensive care unit length of stay, and 30-day mortality.ResultsWe analyzed 68 consecutive pediatric patients; 26 and 42 in the HS and mannitol groups, respectively. The HS group exhibited a reduced rate of supplementary use (7.7% vs. 31%) and lower total urine volume. Perioperative outcomes, mortality, and length of intensive care unit stay did not exhibit significant between-group differences, despite transient increases in blood sodium and chloride observed within 2 h after HS infusion.ConclusionsIn pediatric ABI surgery, as an osmotherapy for cerebral relaxation, 4.54% HS demonstrated a lower likelihood of necessitating additional supplementation than 20% mannitol. Furthermore, the diuretic effect of HS was weak and the increase in electrolyte levels during surgery was temporary and slight.