Postoperative Day Research Articles

Surgical Outcome in Retroperitoneal Sarcoma Surgery: Accuracy of P-POSSUM, ACS-NSQIP, and Inflammatory Biomarkers Prognostic Index (IBPI) Risk-Calculators for Prediction of Severe and Overall Morbidity.

Retroperitoneal sarcoma often requires comprehensive resection, leading to severe postoperative morbidity. The lack of disease-procedure specific tools for morbidity risk and the questionable accuracy of existing tools (ACS-NSQIP and P-POSSUM) in RPS surgery drove this study to assess these calculators' accuracy. Retrospective analysis of primary RPS cases undergoing surgery at two sarcoma-referral centers was conducted. Predicted morbidity/mortality rates at 90days postsurgery, classified by Clavien-Dindo (CD) and Comprehensive Complication Index (CCI), were compared with observed data. Accuracy was assessed by Brier Score and area under the curve (AUC). Inflammatory Biomarkers Prognostic Index (IBPI) also was tested. A total of 567 patients (median age 62years; 53.6% male) with a median of four resected organs were included. 59% experienced surgical complications by 90 days postoperation, graded CD ≥ 3 in 30.5%, median CCI 20.9, with a mortality rate of 1.6% (8/567). Reoperation was required in 68 of 567 patients (12%). Thirty-day mortality was 1.1%. Severe complications occurred after 30th postoperative day in 3.5% cases. ACS-NSQIP predicted below-average complication for 65.1%, average for 16.9%, and above-average for 18% of patients. P-POSSUM predicted a 66% rate of morbidity and 4% mortality. None of the prediction tools were accurate, with Brier scores ranging 0.155-0.231 and no AUC ≥ 0.7. IBPI accuracy for predicting severe infective complication was low (AUC 0.58, Brier 0.161). The significant morbidity burden after MVR necessitates reliable evaluation, especially in frail patients. Given the limitations of ACS-NSQIP and P-POSSUM, a dedicated prediction tool for perioperative events in RPS candidates for MVR needs urgent development.

Preoperative Acetaminophen For Microsuspension Laryngoscopy Reduces Postoperative Opioid Use.

The opioid crisis has prompted consideration of analgesic prescriptions. This study explored the value of preoperative acetaminophen for pain control following microsuspension laryngoscopy (MSL) and compared the results with a previous study of pain and opioid use following MSL (Tsang et al.). A prospective open-label clinical trial was conducted in patients undergoing MSL. All patients were administered preoperative acetaminophen. Short-form McGill Pain Questionnaire (SF-MPQ), pain visual analogue scale (VAS), and present pain intensity (PPI) scores were collected preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. Statistical analysis identified variables associated with opioid use or increased pain scores, and compared outcomes with Tsang et al. RESULTS: Eighty-nine patients were included (mean age 52.8 ± 17.3 years, 40 males). All patients received preoperative 1 g acetaminophen (77 (86.5%) orally) with no adverse effects. On POD1, opioid usage was 10%. Median [IQR] pain scores were 5 [2-11], 21 [12.3-56.8], and 3 [2-3.3] on SF-MPQ, VAS, and PPI, respectively. Post-Anesthesia Care Unit (PACU) opioid requirements significantly correlated with POD1 opioid consumption (τb = 0.214; p ≤ 0.05), and significant associations with PACU opioid administration were found for total anesthesia time (OR (95%CI) = 1.271 (1.043-1.548), p = 0.017) and total laryngoscope suspension time (OR (95%CI) = 0.791 (0.651-0.962, p = 0.019)). This cohort demonstrated reduced opioid usage on POD1 compared with Tsang et al (23%). Preoperative acetaminophen is a safe intervention, resulting in decreased postoperative opioid use following MSL. Anesthesia time correlated with need for postoperative opioids. 4 Laryngoscope, 134:4625-4635, 2024.

The Inter-Laennec Approach for Liver Tumors in Contact with Hepatic Veins in Laparoscopic Liver Resection.

Patients with liver tumors that are in contact with the major hepatic veins may require hepatic vein resection to achieve an adequate surgical margin; however, the potential for venous congestion and impaired remnant liver function must be considered. We introduce the anatomy of the hepatic vein related to Laennec's capsule as well as the surgical techniques to overcome these limitations in the laparoscopic approach.1,2 PATIENTS AND METHODS: A patient with hepatocellular carcinoma underwent resection of the paracaval portion of the caudate lobe. A 4.5-cm tumor was located on the hepatic hilum, compressing the middle and right hepatic veins (MHV and RHV). The Laennec's capsule around the hepatic veins consists of cardiac and hepatic layers. In the inter-Laennec approach, the hepatic veins and inferior vena cava were continuously exposed from the root side, during entry into the space between the hepatic and cardiac Laennec's capsules.3,4 Hence, the cardiac Laennec's capsule was preserved on the venous side, and the strength of the hepatic vein walls was maintained without exposing the tumor. Parenchymal transection was performed while preserving the MHV and RHV. The operative time was 331 min, with minimal estimated blood loss. The patient was discharged on postoperative day 6 without complications. A pathological examination revealed the presence of focal capsular invasion; however, the surgical margin was maintained by leaving the hepatic Laennec's capsule on the tumor side. Understanding the structure of the Laennec's capsule can contribute to the establishment of safe and feasible liver resection techniques.

The Effect of Obesity on Postoperative Analgesia Practices and Complications Following Endoscopic Sinus Surgery: A Propensity Score-Matched Cohort Study.

Despite growing concern regarding over-prescription of narcotic pain medication following ambulatory surgery, little is known about the analgesic prescribing practices following endoscopic sinus surgery (ESS) in obese patients in comparison to non-obese patients. To compare the rates of opioid versus non-opioid prescriptions, the need for steroids, and post-operative adverse events between obese and non-obese adult patients undergoing ESS. Using TriNetX Live database, we identified all patients aged ≥18 years who underwent ESS (n = 1303) between 2014 and 2022 across several healthcare institutions across the state of Tennessee. We 1:1 propensity score-matched obese (BMI ≥ 30 kg/m2) and non-obese (18.5 kg/m2 ≤ BMI < 30 kg/m2) cohorts for age, gender, race, and comorbidities including asthma, nicotine dependence, and sleep apnea. Rates of prescriptions and post-operative adverse events between cohorts were analyzed using risk ratios (RR) and confidence intervals (CI). A toal of 532 obese patients were compared to 532 propensity score-matched non-obese patients in the first 14 post-operative days following ESS. The obese cohort was significantly more likely to be prescribed analgesics generally (RR = 1.72; 95% CI = 1.20-2.47), non-opioid analgesics (RR = 1.73; 95% CI = 1.19-2.50), and opioid analgesics (RR = 1.64; 95% CI = 1.14-2.36) than non-obese patients. There was no difference in rates of antibiotic or antiemetic prescription, prednisone/methylprednisolone, dexamethasone, ED visits, critical care service, epistaxis, transfusion, anemia, revision sinus surgery, mechanical ventilation, CPAP, or inhalation airway treatments. Obese patients undergoing ESS were significantly more likely to be prescribed non-opioid and opioid analgesia in the first 14 days post-operatively compared to non-obese patients. There were no differences in post-operative adverse events or other prescriptions. Otolaryngologists should be aware that obese patients are at increased risk of opioid induced airway obstruction and steroid induced hyperglycemia, especially in patients with comorbid sleep apnea or diabetes. Emphasis on non-opioid analgesics and multimodal pain management should be advocated for this population.

Utilizing a modified-Postoperative Morbidity Survey for assessing morbidity after laparoscopic or robot-assisted radical prostatectomy: a retrospective observational study

BackgroundCompared with open radical prostatectomy (RP), laparoscopic or robot-assisted RP have shown a notable decrease in the incidence of organ dysfunction or potentially life-threating complications after surgery. However, despite advances, the postoperative length of hospital stay (LOS) remains longer than desired in many cases. The Postoperative Morbidity Survey (POMS) is a simple approach to detect complications capable of prolonging LOS. The primary objective of this study was to outline the incidence and type of early morbidity following laparoscopic or robot-assisted RP using modified POMS(m-POMS). The secondary objective was to investigate the correlation between m-POMS and postoperative LOS.MethodsA retrospective study of the electronic health records was performed for all eligible patients undergoing laparoscopic or robot-assisted RP over a one-year period (August 1, 2022 to July 31, 2023). Morbidity as defined by m-POMS was collected on postoperative day 1 (POD1), POD3, POD5 and POD8. Poisson regression models were employed to assess the correlation between positive m-POMS and postoperative LOS.ResultsA total of 121 patients were included. Morbidity, as measured by m-POMS, occurred on POD1 (19.01%, 95% CI [13.01%, 26.91%]), POD3 (18.81%, 95% CI [12.39%, 27.52%]), POD5 (30.23%, 95% CI [18.60%, 45.10%]) and POD8 (35.29%, 95% CI [17.31%, 58.70%]). Two prevalent domains with positive m-POMS scores were infectious and pulmonary. The occurrence of morbidity as indicated by m-POMS was correlated with longer median (IQR) postoperative LOS on POD1 7 (5, 9) versus 4 (4, 6), POD3 7 (6, 11) versus 5(4, 6), and POD5 11 (6.5, 11) versus 7(6, 9) (p < 0.05) compared with patients who did not encounter m-POMS-assessed morbidity. Regression analysis showed that m-POMS-defined morbidity was correlated with longer postoperative LOS on POD1 and POD3.ConclusionsThe incidence of early morbidity, as defined by m-POMS following radical prostatectomy, was approximately 20%, with infectious and pulmonary complications being the most prevalent. Short-term morbidity assessed by m-POMS was significantly associated with prolonged LOS.

Model of superior semicircular canal dehiscence: asymmetrical vestibular dysfunction induces reversible balance impairment

BackgroundSuperior semicircular canal dehiscence (SSCD) is a vestibular-cochlear disorder in humans in which a pathological third mobile window of the otic capsule creates changes to the flow of sound pressure energy through the perilymph/endolymph. The primary symptoms include sound-induced dizziness/vertigo, inner ear conductive hearing loss, autophony, headaches, and visual problems. We have developed an animal model of this human condition in the Mongolian Gerbil that uses surgically created SSCD to induce the condition. A feature that is unique in this model is that spontaneous resurfacing of the dehiscence occurs via osteoneogenesis without a subsequent intervention. In this study, we completed our assessment of this model to include reversible asymmetrical vestibular impairments that interfere with balance.MethodsAdult Mongolian gerbils (N = 6) were trained to complete a balance beam task. They were also trained to perform a Rotarod task. After 10 days of training, preoperative ABR and c+VEMP testing was followed by a surgical fenestration of the left superior semicircular canal. Balance beam testing recommenced at postoperative day 6 and continued through postoperative day 15 at which point final ABR and c+VEMP testing was carried out.ResultsBehavioral comparison of preoperative and postoperative performance show a significant decrease in Rotarod performance, increased rates of falling, and an increase in time to cross the balance beam. Impairments were the most significant at postoperative day 7 with a return toward preoperative performance by postoperative day 14. This behavioral impairment was correlated with residual impairments to auditory thresholds and vestibular myogenic amplitudes at postoperative day 14.ConclusionThese results confirm that aberrant asymmetric vestibular output in our model of SSCD results in reversible balance impairments. The level of these behavioral impairments is directly correlated with severity of the vestibular dysfunction as we have previously reported for peripheral ear physiology and cognition.

Factors influencing hospital stay duration in an elective cardiac surgery cohort

Abstract Cardiac surgery has become more complex in recent years, with increases in patient age, complexity, and associated costs. The use of a multidisciplinary strategy to analyze and standardize patient management offers significant benefits. The development of Enhanced Recovery After Surgery (ERAS) programs has proven useful in various types of surgery, recently including cardiac surgery, yielding good results. One of the primary objectives of ERAS programs is the reduction of the Inpatients' length of stay (LOS), with the subsequent improvement in the patient experience and a reduction in costs. The aim of this study is to analyze preoperative and postoperative factors related to the LOS reduction in a cohort of elective cardiac surgery patients included in the Cardiac ERAS program at our hospital. All patients included in the ERAS program, corresponding to elective cardiac surgery, were included in the analysis. 138 patients were divided into four quartiles based on the inpatient’s LOS. An extensive search was conducted in our quality control database, which contains 470 variables on the factors more strongly associated with LOS. The results were analyzed using Chi-Square test for categorical and the Kruskal-Wallis test for continuous variables, generally of non-normal distribution. The results are summarized in the table. Age, poor mobility, surgery other than coronary bypass, and reoperation were the non-modifiable factors most associated with a prolonged LOS. Lower preoperative hemoglobin and albumin levels were associated with an increase in LOS. A class 3 or 4 NYHA functional class, chronic pulmonary disease, and anticoagulation use were associated with higher LOS. Classic cardiovascular risk factors, such as dyslipidemia, hypertension, and tobacco use, were not associated with differences in hospitalization duration. Postoperative and intraoperative factors associated with higher LOS included extubation in the operating room or within six hours, ICU stay duration, mobilization on postoperative days one and two, time to oral food tolerance and gut motility recovery, hyperglycemia on postoperative day one, the duration of arterial, venous, and urinary catheters, the amount of fluids on postoperative day one and the opioid use in POD 2. The complications most associated with a prolonged duration were any infectious complication, any respiratory complication, reoperation, readmission to intensive care, transfusion after 12 hours or at any time during hospitalization, prolonged postoperative sedation, and any rhythmic complication. Conclusion In our cohort of elective patients for cardiac surgery, factors traditionally addressed by ERAS programs were identified as being associated with a longer inpatient’s length of stay. Pre-operative nutritional and anemia optimization, early extubation and mobilization, and the prevention of respiratory and infectious complications should be targeted to improve hospital stay duration.

Prevalence and prognostic value of thrombocytopenia in aortic valve replacement surgery: bioprosthesis versus mechanical prosthesis

Abstract Background Thrombocytopenia is a frequent complication of valve surgery, and is associated with different postoperative outcomes. Concern has recently arisen about thrombocytopenia following aortic valve replacement (AVR), as some authors have reported increased postoperative thrombocytopenia with certain biological aortic valves. In adittion, it is unclear whether thrombocytopenia predicts mortality in this type of surgery. Purpose The aim of this study was to determine the prevalence and prognostic value of thrombocytopenia in biological and mechanical aortic valve replacement. Methods The study was an observational analysis of patients undergoing AVR with or without associated coronary artery bypass grafting (CABG) at a single center between October 2014 and October 2023. Cardiac Surgery database was computerized and prospectively completed. Preoperative and first 4 days postoperative platelet counts were analyzed. Thrombocytopenia was defined as platelet count &amp;lt; 100 × 10³/mm³. To obtain comparable populations, a propensity score matching analysis was performed. Results A total of 1,197 patients underwent AVR with (n = 494) or without CABG (n = 703). Patients received either a mechanical prosthesis (n = 320), or a biological prosthesis (n = 877). The mean population age was 68 years (SD 6), with the majority being male (68%). Univariate analysis of the baseline characteristics of both groups of patients showed that they were not comparable. A risk-adjusted subanalysis was performed according to a propensity score (n=278). The nadir of bioprostheses was on the third postoperative day with an average of 93.8 × 10³/mm³, while in mechanical prostheses was also on the same day but with an average of 114.7 × 10³/mm³ (p: 0.001). (Figure 1) Bioprosthesis implantation was significantly associated with a higher prevalence of thrombocytopenia (72.7% vs. 45.3%, p&amp;lt;0.001). The presence of postoperative thrombocytopenia has been associated with higher in-hospital mortality (6.7% vs. 0.9%, p=0.019); but not with other postoperative complications. (Figure 2) Conclusions Patients undergoing AVR with bioprostheses had a significantly higher prevalence of thrombocytopenia, and also lower platelet counts than mechanical prothesis within the first 4 postoperative days. Thrombocytopenia was associated with higher in-hospital mortality in a risk score-adjusted population.Platelet counts after AVROutcomes according to platelet count

Patient-reported outcomes, postoperative pain and pain relief after day case surgery (POPPY): methodology for a prospective, multicentre observational study.

In the UK, approximately 70% of surgical procedures are undertaken as day-cases. Little information exists about recovery from day-case surgery, yet international data highlights patients are at risk of developing significant longer-term health problems including chronic post-surgical pain and persistent postoperative opioid use. The Patient-reported Outcomes, Postoperative Pain and pain relief after daY case surgery (POPPY) study was a national prospective multicentre observational study, measuring short- and longer-term patient-reported outcomes, postoperative pain and pain relief after day-case surgery. This was a collaborative project led by resident anaesthetists under the Research and Audit Federation of Trainees umbrella. Adult day-case surgical patients were recruited on the day of surgery. Baseline data including patient characteristics; procedure details; pre-operative analgesic use; pre-existing pain; and quality of life scores were recorded. Patients were followed up through automated short message service messages. Short-term (postoperative days 1, 3 and 7) outcomes included: quality of recovery; pain severity; impact of pain on function; and analgesic use. Longer-term outcomes (postoperative day 97) included: quality of life; analgesic use; incidence of chronic post-surgical pain; and incidence persistent postoperative opioid use. Additional outcomes were completed by those patients with chronic post-surgical pain and persistent postoperative opioid use, with 30 patients recruited to a qualitative semi-structured interview study exploring postoperative expectations, recovery, postoperative pain and opioid use. An embedded pilot study at four sites recruited 129 patients. Responses to the automated short message service were gained from 129 patients (100%) at day 1; 116 (89.9%) at day 3; 108 (83.7%) at day 7; and 77 (59.7%) at day 97 postoperatively. The pilot enabled refinement of the methods and processes before the national roll out. This paper outlines the methods for the POPPY study, the largest UK multicentre prospective observational study considering short- and longer-term outcomes following day-case surgery.

The effect of afterload on right ventricular pacing-induced left ventricular dysfunction: a translational study

Abstract Introduction Right ventricular (RV) pacing (RVP) impairs left ventricular (LV) function. Nevertheless, the interaction between arterial afterload and RVP-associated LV dysfunction has not been investigated yet. Purpose We sought to examine the effect of afterload on RVP-evoked LV hemodynamic changes in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) as well as in a small animal model of sustained LV pressure overload (PO). Methods Thirty-five patients with AS and a previously implanted pacemaker underwent detailed echocardiographic examination immediately before TAVI and also on the second postoperative day. The ultrasound measurements were carried out during intrinsic, narrow QRS rhythm and during frequency-matched RVP as well. Global myocardial work index (GMWI) was calculated to assess LV contractility. In parallel, LV pressure-volume analysis was performed in Wistar rats with transverse aortic constriction (TAC) or sham operation (Sham) during intrinsic narrow QRS rhythm (termed as TAC-Vsense and Sham-Vsense) as well as during RVP (termed as TAC-Vpace and Sham-Vpace). RVP was achieved in rats by an octopolar electrophysiology catheter placed in the RV. Results RVP decreased LV contractility in AS patients before and after TAVI as well. Nevertheless, the extent of RVP-evoked LV dysfunction was alleviated following pressure unloading (ΔGMWI: -37±7 vs. -25±8%, before TAVI vs. after TAVI, P&amp;lt;0.05). Similarly, although RVP was associated with reduced LV contractility in both the TAC (the slope of the maximum rate of LV pressure rise-end-diastolic volume relation [dPdtmax-EDV]: 92±8 vs. 53±6mmHg/s/µl, TAC-Vsense vs. TAC-Vpace; P&amp;lt;0.05) and Sham groups (dPdtmax-EDV: 74±5 vs. 60±9 mmHg/s/µl, Sham-Vsense vs. Sham-Vpace; P&amp;lt;0.05), the negative inotropic effect of RVP was found to be stronger in the TAC compared to the Sham group (ΔdPdtmax-EDV: -42±4 vs. -19±6%; TAC vs. Sham, P&amp;lt;0.01). Furthermore, reduction of the maximal rate of LV pressure decrease (ΔdPdtmin: -20±3 vs. -5±5%, TAC vs. Sham, P&amp;lt;0.01) and prolongation of the active relaxation time constant (Δτ: 22±3 vs. 6±3%, TAC vs. Sham, P&amp;lt;0.01) also occurred to a greater extent in case of sustained LV PO, indicating augmented diastolic dysfunction. Conclusion Our translational results indicate that RVP-induced LV dysfunction might be afterload dependent.

Major bleeding complications and antithrombotic treatment after isolated surgical bioprosthetic aortic valve replacement

Abstract Background Despite advancements in surgical techniques and perioperative care, post-operative bleeds and stroke remain significant concerns after bioprosthetic surgical aortic valve replacement (SAVR). Purpose We assessed the incidence of short-term (30d) and long-term major bleeds and strokes and their relations to antithrombotic treatment after isolated bioprosthetic SAVR. Methods The CAREAVR study included 721 patients who underwent isolated SAVR at four Finnish university hospitals between 2002 and 2014. The day-to-day information on short-term antithrombotic treatment was available from a subgroup including 227 patients, of whom 138 (60.7%) had preoperative aspirin. Preoperative aspirin was usually discontinued the day before the index surgery. Enoxaparin 1mg/kg twice daily and vitamin K antagonist (VKA) were routinely initiated on the first postoperative day, and enoxaparin continued until the INR remained at a therapeutic level ≥ 2.0 for two days. The routine duration of VKA treatment after surgery was 3 months. Results The median follow-up time was 4.9 (interquartile range 3.0–7.0) years. During the short-term 30-day period, 31 (4.3%) patients had a major bleed, and 13 (1.8%) patients experienced a major stroke. A vast majority of the bleeding (80.6%) occurred within two days after the surgery, and the tail effect of preoperative aspirin (5-7d) was present in 51.6% of episodes, indicating unintentional triple antithrombotic therapy. During the long-term follow-up (&amp;gt;30d after the index surgery), 40 (5.5%) major bleeding episodes occurred, and 47 (6.5%) patients experienced a major stroke. Overall, 23 (57.5%) of the patients with major bleeding were on OAC during the event. In addition, 13 (27.7%) of the patients experiencing major stroke during the long-term follow-up were on OAC during the event. Conclusions Compared to major strokes, the incidence of perioperative major bleeds was over twofold, the majority occurring during the tail effect of preoperative aspirin. During the long-term follow-up, the risks of stroke and bleeding were equal, and the majority of bleeding episodes appeared during anticoagulation treatment.

Molybdenum temporary epicardial pacing wires: function and biodegradation

Abstract Cardiac pacing with temporary epicardial pacing wires (TEPW) is used to treat rhythm disturbances after cardiac surgery. Wires typically begin to fail around postoperative day four and are extracted. Occasionally, TEPW cannot be mechanically removed, have to stay in the thorax and may rarely cause serious complications like migration and infection. We aim to develop novel, bioresorbable TEPW which will dissolve over time, even if postoperative removal is unsuccessful. We manufactured prototypical braided molybdenum (Mo) leads (16 Mo wires of 40 µM diameter each, length 18 cm for ex vivo, 7.5 cm for in vivo experiments) coated with the biodegradable polymers poly(lactide-co-glycolic acid) (PLGA, inner coating) and polycaprolactone (PCL, outer coating) for shaping and electrical insulation. Mo electrodes showed similar pacing and sensing properties to conventional steel electrodes (Osypka) in Langendorff-perfused rat hearts, even with somewhat lower stimulation thresholds. In artificial body fluid at 37°C, the polymer-coated Mo electrodes dissolved at a rate of 1.6 ± 0.3 µg/cm2·d (n = 5) compared to uncoated electrodes with 30.3 ± 0.8 µg/cm2·d (n = 4, p &amp;lt; 0.001). Assessing apoptosis and necrosis in human cardiomyocytes and cardiac fibroblasts, we detected no toxicity at Mo concentrations up to 0.52 mM. To test the in vivo properties of Mo TEPW, we sutured them epicardially onto the anterior wall of the heart of female Wistar rats, led them out of the thorax through an intercostal space and placed them in a subcutaneous pocket. We tested electrophysiological properties directly after implantation and after different time periods. Mo TEPW showed similar pacing and sensing properties directly upon implantation and after 2 weeks, with only impedance and slew rate of the sensed R-wave decreasing time-dependently. After one month, all but one pair of Mo electrodes were mechanically broken at their exit from the thorax, the site of assumedly highest mechanical stress. Progressive Mo degradation led to multiple fragmentation of the Mo TEPW after 6 months. The conventional steel TEPW we used as control had similar electrical properties directly after implantation, after 2 weeks and one month without signs of broken electrodes. After 6 months, all but one pair of steel electrodes were mechanically broken at their thorax exit site. Comparing urinary Mo concentration of Mo TEPW treated rats to controls, we saw similar values of 1.9 ± 1.9 µM (n = 6) vs. 0.6 ± 0.2 µM (n = 5, n.s.) after one week. In contrast, we saw a significant increase of 12.1 ± 9.7 µM (n = 5) vs. 1.0 ± 0.9 µM (n = 5, p &amp;lt; 0.001) after 6 months, reflecting the degradation progress. We demonstrate that Mo TEPW are a feasible option for epicardial pacing in vivo for up to 2 weeks and observed the progress of Mo degradation up to 6 months. These findings represent an important step in the development of bioresorbable TEPW as a novel and even safer approach to temporary epicardial pacing.Graphical AbstractIn Vivo Degradation Progress

Stapler-induced vascular injury during uniportal VATS lobectomy: lessons learned from a rare complication case

BackgroundDue to advances in video-assisted thoracic surgery (VATS), the majority of lung resections can be performed safely via VATS with low morbidity and mortality. However, pulmonary artery (PA) bleeding often requires emergency conversion to thoracotomy, potentially leading to a life-threatening situation. We report a case of pulmonary artery injury caused by an unexpected stapler-tissue interaction during uniportal VATS lobectomy, highlighting the importance of recognizing and managing such rare complications to improve patient outcomes.Case presentationA 63-year-old man underwent uniportal VATS left upper lobectomy for a suspected primary lung cancer. During the procedure, unexpected bleeding occurred from the third branch of the pulmonary artery (A3) after withdrawal of an unfired stapler. The protruding staple of the A3 stump was inadvertently hooked and stretched by the groove of the staple anvil. Although the bleeding was controlled by compression with the lung, the injured A3 stump required repair. Due to the extensive intimal injury near the central part of the left main pulmonary artery and the potential risk of fatal postoperative complications, we converted to open thoracotomy for definitive vascular repair by suturing. The patient had no postoperative complications and was discharged on postoperative day 8.ConclusionsThis case report provides valuable lessons regarding the rare stapler-related vascular injury during uniportal VATS lobectomy. It is important to note that even during non-vascular dissection, unexpected stapler-tissue interactions can lead to bleeding. To prevent the vessel stump entanglement with stapler components, maintaining separation between the stapler and staple stumps is crucial. In uniportal VATS, manipulation during stapler insertion is one of the most challenging phases for instrument interference, requiring increased caution to prevent complications such as the vascular injury described in this case. Thorough preoperative planning, specific intraoperative precautions, and adapted safety protocols that address the limitations of uniportal VATS are essential for effective management of potential complications. Although techniques for thoracoscopic vascular control exist, they are not always feasible and conversion to open thoracotomy should be considered when necessary to ensure patient safety.

Mandibular third molar coronectomy in older adults and its effects on oral health-related quality of life.

The purpose of this study was to investigate the effect of coronectomy on postoperative quality of life in older adults. Coronectomy is an alternative to complete surgical removal of a mandibular third molar that lies close to the inferior alveolar nerve. This prospective study included patients >60 years old who had an indication for coronectomy of a mandibular third molar. Patients were asked to complete the Dutch version of the Oral Health Impact Profile-14 (OHIP-14) daily during the first postoperative week. Postoperative pain, swelling, limited mouth opening, chewing ability and infection were also recorded. Furthermore, the effect of the impaction pattern, state of eruption, presence of preoperative pathology, patient health status according to the American Society of Anaesthesiologists score, gender, smoking on the postoperative OHIP-14 and pain scores were investigated. Thirty patients (16 males, 14 females) with a mean age of 71.2 (SD 8.3, range 60-91) years were included in the study. OHIP-14 and pain scores were highest on the first postoperative day and gradually declined during the first postoperative week. Patients who underwent coronectomy of a fully impacted mandibular third molar had significantly higher OHIP-14 scores on the first postoperative day than those who underwent coronectomy on a (partially) erupted mandibular third molar. We did not observe any postoperative complications up to 1 year after the surgery. Mandibular third molar coronectomy seems to present a valid treatment option in older adults.

Impenetrable Abdomen: A Case Report of Endoscopic Sleeve Gastroplasty Performed in Patient with Huge Paramedian Laparocele.

Bariatric surgical techniques have demonstrated scientific efficacy and interventional safety; however, these approaches are not universally appropriate for all patients. The term "impenetrable abdomen" refers to the inability to achieve surgical access to the abdominal cavity, a condition that may arise from several underlying factors. Endoscopic sleeve gastroplasty (ESG) is proposed as a safe and effective technique in this subgroup of patients with obesity. A 56-year-old Caucasian woman with an impenetrable abdomen due to the presence of a large left paramedian laparocele underwent ESG (Fig. 1) to our unit. An abdominal computed tomography (CT) scan revealed a substantial laparocele in the left paramedian region, involving the tenuous loops, mesentery, and part of the transverse colon. The patient body mass index (BMI) at presentation was 47.15 kg/m2 (116 kg per 1.57 m). Comorbidities included obstructive sleep apnea syndrome (OSAS), requiring nocturnal continuous positive airway pressure (CPAP) therapy, hepatic steatosis, hypertension, hypertriglyceridemia, and hypovitaminosis D. The case was discussed with our multidisciplinary board team (MDT), who agreed to proceed with the ESG. The endoscopic procedure was performed in the supine position, using the Overstitch device and lasted 58 min. No intraprocedural or post-procedural complications/adverse events have been observed. The patient resumed a liquid diet on the first postoperative day and was discharged from the hospital 24 h after the procedure in good clinical condition. Regular outpatient follow-up visits showed significant reduction of the BMI at 6 months post-procedure with a value of 34.9 kg/m2 compared with the initial value of 47.1 kg/m2. Additionally, the patient's use of nocturnal CPAP for OSAS was successfully discontinued suggesting an improvement in her respiratory condition as a result of weight loss. Moreover, there was a notable reduction in the pharmacological management required for arterial hypertension. These outcomes underscore the positive impact of selecting the most appropriate therapeutic strategy for each patient with obesity through a multidisciplinary team approach. In our experience, we confirm that endoscopic sleeve gastroplasty is both feasible and safe in patients presenting with an impenetrable abdomen. Despite the minimally invasive approach, this technique has proven effective in terms of body weight loss and reduction of obesity related compared with bariatric surgery.

Driving pressure during general anesthesia for minimally invasive abdominal surgery (GENERATOR)—study protocol of a randomized clinical trial

BackgroundIntraoperative driving pressure (ΔP) has an independent association with the development of postoperative pulmonary complications (PPCs) in patients receiving ventilation during general anesthesia for major surgery. Ventilation with high intraoperative positive end–expiratory pressure (PEEP) with recruitment maneuvers (RMs) that result in a low ΔP has the potential to prevent PPCs. This trial tests the hypothesis that compared to standard low PEEP without RMs, an individualized high PEEP strategy, titrated to the lowest ΔP, with RMs prevents PPCs in patients receiving intraoperative protective ventilation during anesthesia for minimally invasive abdominal surgery.Methods“DrivinG prEssure duriNg gEneRal AnesThesia fOr minimally invasive abdominal suRgery (GENERATOR)” is an international, multicenter, two–group, patient and outcome–assessor blinded randomized clinical trial. In total, 1806 adult patients scheduled for minimally invasive abdominal surgery and with an increased risk of PPCs based on (i) the ARISCAT risk score for PPCs (≥ 26 points) and/or (ii) a combination of age > 40 years and scheduled surgery lasting > 2 h and planned to receive an intra–arterial catheter for blood pressure monitoring during the surgery will be included. Patients are assigned to either an intraoperative ventilation strategy with individualized high PEEP, titrated to the lowest ΔP, with RMs or one with a standard low PEEP of 5 cm H2O without RMs. The primary outcome is a collapsed composite endpoint of PPCs until postoperative day 5.DiscussionGENERATOR will be the first adequately powered randomized clinical trial to compare the effects of individualized high PEEP with RMs versus standard low PEEP without RMs on the occurrence of PPCs after minimally invasive abdominal surgery. The results of the GENERATOR trial will support anesthesiologists in their decisions regarding PEEP settings during minimally invasive abdominal surgery.Trial registrationGENERATOR is registered at ClinicalTrials.gov (study identifier: NCT06101511) on 26 October 2023.

Outcome of Centenarians with Hip Fracture: An Analysis of the Registry for Geriatric Trauma (ATR-DGU)

Background/Objectives: Outcomes for hip fracture patients have improved over the years, yet the population of older patients (≥80 years) continues to grow. By 2100, the global centenarian population is projected to exceed 25 million, but data on hip fracture outcomes in this group are rare and often derived from small samples. This study aimed to analyze outcomes for centenarian hip fracture patients in specialized geriatric trauma centers and compare them with those of patients under 80. Methods: We conducted a retrospective analysis of the AltersTraumaRegister DGU® from 2016 to 2022, including all proximal femur fracture data. Patients were categorized into two groups: under 80 years and centenarians. The primary outcome was in-hospital mortality, with secondary outcomes including quality of life, walking ability on postoperative day seven, length of hospital stay, readmission rates, and changes in living situations. Results: Among 14,521 patients, 316 were over 99 years old. In-house mortality was significantly higher in centenarians (15.44% vs. 3.58%; p &lt; 0.001), with more discharged to nursing homes. After matching by the Geriatrics at Risk (GeRi) score, mortality differences diminished. Conclusions: While age is a risk factor for mortality, centenarian hip fracture patients’ outcomes do not significantly differ from those aged ≤80 when considering other risk factors.

Triple-console robotic telesurgery: first impressions and future impact.

Telesurgery has been recently gaining momentum as a natural evolution of robotic surgery. Besides providing expert surgical care to patients who cannot geographically access it, telesurgery can also facilitate surgical collaboration between surgeons who might need urgent assistance or coaching experts. The idea of having two consoles, with one remote and one local, has been the ideal setup for such ecosystems. However collaborations can take on many forms and might require more than one remote surgeon, depending on procedure complexity and surgeon availability. The objective of the study was to describe our perspectives and experience performing telesurgery on one patient, using three surgeon consoles for three surgeons, operating from three separate cities. In November 2023, a triple-console, robot-assisted radical prostatectomy (RARP) was performed in a collaborative effort among three surgeons in three separate locations employing telesurgery using the Kangduo Endosopic Surgical Robot (KD-SR-01, Sagebot Medical). The furthest distance between participants was approximately 2600km between Beijing and Hainan. We described and illustrated the applications and outcomes of this procedure to treat a single patient with prostate cancer. The local surgeon, along with the operating room team, and the patient were in Hainan, while the other two surgeons were in Beijing and Hunan Telesurgery command centers. The procedure lasted approximately 120min and there were no intra- or postoperative complications. Estimated blood loss was 100ml. The patient was ambulating 4h after surgery and remained in the hospital for 2days secondary to the postoperative care protocol followed by the local team taking care of the patient. The Foley catheter was removed on postoperative day 7 without complication. The final pathology was ISUP Grade Group 4 (Gleason score 4 + 4 = 8) T2cN0 with negative surgical margins. Our experience shows that telesurgery involving multiple surgeons at multiple remote locations is possible and can be completed safely with low-latency connections via available telecommunication networks.

Bilateral total knee arthroplasty-analysis of risk factors for blood loss and blood transfusion

Background: Total knee arthroplasty in general is a safe and successful surgical procedure for end stage arthritis of the knee joint to relieve pain, correct the deformity and restore function in the joint. However, it is often associated with significant blood loss. In such cases, blood transfusion is not uncommon. Methods: 100 patients who underwent simultaneous bilateral TKA from April 2022 to December 2022 at Sant Parmanand Hospital, New Delhi were taken up for the study. Results: In this study among 100 patients who underwent simultaneous bilateral total knee replacement, 9% of the cases required blood transfusion. Preoperative haemoglobin (&lt;12.64 gm/dl) continues to be a predictor in blood transfusions. A haemoglobin level of less than 10.34 gm/dl preoperatively, a postoperative haemoglobin day 1 level of less than 8.56gm/dl and a postoperative day 3 level of less than 7.49 gm/dl increases the necessity for blood transfusion in simultaneously performed bilateral TKAs. Conclusions: Asthma, Diabetes mellitus and patients on blood thinners are three major comorbidities than can cause increased blood loss. Age, gender, BMI and comorbidities are not related to the need for blood transfusion. Patients on blood thinners are at an increased risk for blood transfusion if they have a lower preoperative haemoglobin. Checking haemoglobin values on postoperative day 1 and day 3 are significant in terms of the need for blood transfusion.

Postoperative Innate Immune Dysregulation, Proteomic, and Monocyte Epigenomic Changes After Colorectal Surgery: A Substudy of a Randomized Controlled Trial.

Colorectal surgery is associated with moderate-to-severe postoperative complications in over 25% of patients, predominantly infections. Monocyte epigenetic alterations leading to immune tolerance could explain postoperative increased susceptibility to infections. This research explores whether changes in monocyte DNA accessibility contribute to postoperative innate immune dysregulation. Damage-associated molecular patterns (DAMPs) and ex vivo cytokine production capacity were measured in a randomized controlled trial (n = 100) in colorectal surgery patients, with additional exploratory subgroup proteomic (proximity extension assay; Olink) and epigenomic analyses (Assay for Transposase-Accessible Chromatin [ATAC sequencing]). Monocytes of healthy volunteers were used to study the effect of high-mobility group box 1 (HMGB1) and heat shock protein 70 (HSP70) on cytokine production capacity in vitro. Plasma DAMPs were increased after surgery. HMGB1 showed a mean 235% increase from before- (preop) to the end of surgery (95% confidence interval [CI] [166 - 305], P < .0001) and 90% increase (95% CI [63-118], P = .0004) preop to postoperative day 1 (POD1). HSP70 increased by a mean 12% from preop to the end of surgery (95% CI [3-21], not significant) and 30% to POD1 (95% CI [18-41], P < .0001). Nuclear deoxyribonucleic acid (nDNA) increases by 66% (95% CI [40-92], P < .0001) at the end of surgery and 94% on POD1 (95% CI [60-127], P < .0001). Mitochondrial DNA (mtDNA) increases by 370% at the end of surgery (95% CI [225-515], P < .0001) and by 503% on POD1 (95% CI [332-673], P < .0001). In vitro incubation of monocytes with HSP70 decreased cytokine production capacity of tumor necrosis factor (TNF) by 46% (95% CI [29-64], P < .0001), IL-6 by 22% (95% CI [12-32], P = .0004) and IL-10 by 19% (95% CI [12-26], P = .0015). In vitro incubation with HMGB1 decreased cytokine production capacity of TNF by 34% (95% CI [3-65], P = .0003), interleukin 1β (IL-1β) by 24% (95% CI [16-32], P < .0001), and IL-10 by 40% (95% CI [21-58], P = .0009). Analysis of the inflammatory proteome alongside epigenetic shifts in monocytes indicated significant changes in gene accessibility, particularly in inflammatory markers such as CXCL8 (IL-8), IL-6, and interferon-gamma (IFN-γ). A significant enrichment of interferon regulatory factors (IRFs) was found in loci exhibiting decreased accessibility, whereas enrichment of activating protein-1 (AP-1) family motifs was found in loci with increased accessibility. These findings illuminate the complex epigenetic modulation influencing monocytes' response to surgical stress, shedding light on potential biomarkers for immune dysregulation. Our results advocate for further research into the role of anesthesia in these molecular pathways and the development of personalized interventions to mitigate immune dysfunction after surgery.