Postoperative Decline Research Articles

Early and long-term cognitive outcome after conventional cardiac valve surgery.

Adverse cognitive outcome is well recognized after coronary artery bypass grafting (CABG) while little is known about the extent and duration of decline after cardiac valve surgery. We investigated changes in cognitive function following conventional cardiac valve surgery over up to 4 years. Among 36 patients (65.2 ± 9.2 years, 36% women) who received valve surgery, we assessed serial cognitive function with a battery of 11 standardized tests across 3-4 years. Cognitive function was analysed to identify: (1) cognitive decline (i.e. within-patient changes in test scores) and (2) cognitive deficit (i.e. drop of score ≥1 SD in ≥3 tests). Diffusion-weighted magnetic resonance imaging (DW-MRI) was applied pre- and post-procedure to detect ischaemic brain injury. Data were compared to a historical cohort of 39 patients undergoing CABG. After both valve surgery and CABG, a significant decline at discharge was detected in 7 of 11 cognitive tests. The rate of patients with a cognitive deficit after valve surgery vs CABG was 39% vs 56% at discharge, 14% vs 23% at 3 months, and 16% vs 26% at 3-4 years (not significant, [n.s.]). After valve surgery, DW-MRI identified 19 (53%) patients with evidence of 50 new focal ischaemic lesions (CABG: 20 [51%] patients with 42 lesions, n.s.). Cumulative cerebral ischaemic load per patient was not significantly different between the valve surgery group and CABG group (503 ± 485 mm 3 vs 415 ± 234 mm 3 ). After correction for multiple potential risk factors in both groups, reduced verbal memory at discharge could be identified as a predictor of long-term cognitive impairment in CABG patients only ( P = 0.04). For both the valve surgery and CABG group, no association between cognitive impairment and new ischaemic cerebral lesions was found. The course of cognitive performance after valve surgery and CABG was similar with early postoperative decline followed by subsequent recovery. Although silent small brain infarcts were present in about half of all patients, they did not impact cognitive performance neither at early nor during long-term follow-up.

Brain Microstructural White and Gray Matter Alterations after Cardiopulmonary Bypass: Anatomical Distribution and Corresponding Neurocognitive Deficit

Background: We sought to detect microstructural brain injury after coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) and to define its anatomical distribution. Analyses were performed to determine possible correlation with postoperative neurocognitive deficit.Methods: Seven patients undergoing CPB-CABG were assigned for serial cerebral designated diffusion tensor (DTI)-magnetic resonance imaging (MRI) examinations, preoperatively, on postoperative day (POD) 1 and 5. Levels of mean diffusivity (MD) and fractional anisotropy (FA) were analysed to assess gray and white matter injury. BBBdisruption and microembolic load were concomitantly evaluated by dynamic contrast enhancement (DCE)-MRI and diffusion-weighted imaging (DWI)-MRI methods, respectively. Neuropsychological tests were performed one day preoperatively and on POD 5.Results: Increase in MD and decrease in FA were evident on POD 1 in gray matter structures including the hippocampus (MD, 0.000768 mm2/s ± 0.0000347 versus 0.000804 mm2/s ± 0.0000267, p<0.01; FA, 0.180 ± 0.03 mm2/s versus 0.163 mm2/s ± 0.032, p<0.01), middle frontal gyrus (MD, 0.000989 mm2/s ± 0.0000487 versus 0.001068 mm2/s ± 0.0000553, p<0.01), orbital gyrus (MD, 0.000867 mm2/s ± 0.0000374 versus 0.000908 mm2/s ± 0.0000356, p<0.01) and in the following white matter structures: Superior longitudinal fasciculus (MD, 0.000836 mm2/s ± 0.0000384 versus 0.000874 mm2/s ± 0.0000359, p<0.01; FA, 0.324 mm2/s ± 0.018 versus 0.305 mm2/s ± 0.022, p<0.01), frontal white matter (FA, 0.277 mm2/s ± 0.031 versus 0.26 mm2/s ± 0.033, p<0.01) internal capsule (MD, 0.000772 mm2/s ± 0.0000648 versus 0.000803 mm2/s ± 0.0000601, p<0.01; FA,0.364 mm2/s ± 0.032 versus 0.343 mm2/s ± 0.029, p<0.01) and corticospinal tract (MD, 0.000759 mm2/s ± 0.0000557 versus 0.00078 mm2/s ± 0.0000591, p<0.01; FA, 0.440 mm2/s ± 0.023 versus 0.411 mm2/s ± 0.023, p<0.01). Corticospinal tract fibre tracing showed significant decrease in postoperative fibre number. DTI findings persisted through POD 5 without spontaneous regression. BBB-disruption reflected by increased K^trans was detected in five patients (71%) on POD 1, mainly in frontal lobes and spontaneously restored by POD 5. Postoperative global cognitive score was reduced in all patients (98.2 ± 12 vs. 95.1 ± 11, p=0.032), predominantly in executive function and attention (91.8 ± 13 vs. 86.9±12, p=0.042). Postoperative FA decline significantly correlated with delta K^trans (R=0.6) and with postoperative decline in attention and Go-no-Go response inhibition tests (R=0.66 and 0.63, respectively).Conclusion: CABG using CPB elicits gray and white matter microstructure injury in the above-mentioned anatomical distribution. These alterations are associated with transient BBB-disruption and may account for postoperative neurocognitive dysfunction.

Forbidden word entropy of cerebral oximetric values predicts postoperative neurocognitive decline in patients undergoing aortic arch surgery under deep hypothermic circulatory arrest.

Purpose:Up to 53% of cardiac surgery patients experience postoperative neurocognitive decline. Cerebral oximetry is designed to detect changes in cerebral tissue saturation and therefore may be useful to predict which patients are at risk of developing neurocognitive decline.Methods:This is a retrospective analysis of a prospective study originally designed to determine if treatment of cerebral oximetry desaturation is associated with improvement in postoperative cognitive dysfunction in patients undergoing aortic reconstruction under deep hypothermic circulatory arrest. Cognitive function was measured, preoperatively and 3 months postoperatively, with 15 neuropsychologic tests administered by a psychologist; the individual test scores were summed and normalized. Bilateral cerebral oximetry data were stored and analyzed using measures of entropy. Cognitive decline was defined as any decrease in the summed normalized score from baseline to 3 months.Results:Seven of 17 (41%) patients suffered cognitive decline. There was no association between baseline cerebral oximetry and postoperative cognitive dysfunction. Nor were changes in oximetry values associated with cognitive decline. However, cognitive decline was associated with loss of forbidden word entropy (FwEn) (correlation: Rho ρ = 0.51, P = 0.037 for left cerebral oximetry FwEn and ρ = 0.54, P = 0.025 for right cerebral oximetry FwEn).Conclusion:Postoperative cognitive decline was associated with loss of complexity of the time series as shown by a decrease in FwEn from beginning to end of the case. This suggests that regulation of cerebral oximetry is different between those who do and those who do not develop cognitive decline.

Surgical treatment for male prolactinoma: A retrospective study of 184 cases.

A total of 184 cases of surgically treated male prolactinoma were analyzed retrospectively to summarize the outcome of this surgical intervention. We analyzed the general characteristics, clinical manifestations, hormone levels, imaging features, preoperative treatments, surgical outcomes, pathology results, and follow-up records for all included patients. The most common clinical manifestations included sexual dysfunction (47.4%), headache (55.9%), and visual disturbance (46.7%). Serum prolactin levels ranged from 150 to 204,952 ng/mL. Tumor size varied from 6 to 70 mm. Pituitary adenomas grew in a parasellar pattern with visual deficits occurring 40.7% of the time. After surgical therapy, 88.6% of patients achieved symptom relief, and 98.4% experienced an immediate postoperative decline in prolactin level. Fifty-seven patients (31.0%) achieved initial remission, and 26 patients (45.6%) experienced recurrence. Hence, our results suggest that in male prolactinoma characterized by a large pituitary diameter and high serum prolactin level, tumor size predicts the degree of gross resection. The prognostic predictors included preoperative tumor growth pattern and Ki-67 index.Citation: Yi-jun S, Mei-ting C, Wei L, Bing X, Yong Y, Ming F, Ren-zhi W. (2016) Surgical treatment for male prolactinoma: a retrospective study of 184 cases

Carbon Dioxide Insufflation During Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

Despite the widespread use of carbon dioxide insufflation (CDI) in cardiac surgery, there is still paucity of evidence to prove its benefit in terms of neurologic protection. Therefore, we conducted a meta-analysis of available randomized controlled trials comparing CDI vs standard de-airing maneuvers. Electronic searches were performed to identify relevant randomized controlled trials. Primary outcomes investigated were postoperative stroke, neurocognitive deterioration, and in-hospital mortality. Risk difference (RD) was used as summary statistic. Pooled estimates were obtained by means of random-effects model to account for possible clinical diversity and methodological variation between studies. Eight studies were identified with 668 patients randomized to CDI (n = 332) vs standard de-airing maneuvers (n = 336). In-hospital mortality was 2.1% vs 3.0% in the CDI and control group, respectively (RD 0%; 95% confidence interval [CI] -2% to 2%; P = 0.87; I2 = 0%). Incidence of stroke was similar between the 2 groups (1.0% vs 1.2% in the CDI and control group, respectively; RD 0%; 95% CI -1% to 2%; P = 0.62; I2 = 0%). Neurocognitive deterioration rate was 12% vs 21% in the CDI and control group, respectively, but this difference was not statistically significant (RD: -7%; 95% CI -0.22% to 8%; P = 0.35; I2 = 0%). The present meta-analysis did not find any significant protective effect from the use of CDI when compared with manual de-airing maneuvers in terms of clinical outcomes, including postoperative neurocognitive decline.

Comprehensive Analysis of Factors Affecting Post-partial Nephrectomy Renal Global Function

To explore new factors that are predictive of post-partial nephrectomy (PN) renal global function, we analyzed various clinico-pathological factors with a special focus on renal volume measured via three-dimensional imaging technology and histopathological parameters in non-neoplastic parenchyma. Estimated glomerular filtration rate (eGFR) and computed tomography (CT) scan were examined pre- and 6 months. post-operatively in 52 patients treated by PN. The post-operative percent eGFR decline was employed as the measure of global renal functional deterioration. The novel factors analyzed included the percent renal parenchymal volume decline of the diseased side, contralateral and bilateral sides and the global glomerulosclerosis (GS) extent in non-neoplastic parenchyma. Renal parenchymal volumetry by CT scan was performed using SYNAPSE VINCENT (Fujifilm). Additional factors analyzed included patient demographics and comorbidities, surgical factors and tumor pathology. All factors demonstrating significant tendencies (P < 0.1) in univariate analyses were subjected to multivariate logistic regression analysis. Two groups were categorized according to the degree of eGFR decline. Groups A and B were categorized as less than 15% and greater than 15% decline, respectively. Pre-operative eGFR was significantly lower in group B than in group A. Greater than 10% global GS extent in non-neoplastic parenchyma, male gender and proteinuria were significantly more frequent in in group B than in group A. The renal volume change was not statistically significant. In multivariate logistic regression analysis, greater than 10% global GS extent in non-neoplastic parenchyma was the sole independent affecting factor for Group B. Our study suggested that host factors rather than surgical factors may be useful for the prediction of post-PN renal global function. The evaluation of the global GS extent in non-neoplastic parenchyma is a promising biomarker of post-PN renal global function.

Activations in temporal areas using visual and auditory naming stimuli: A language fMRI study in temporal lobe epilepsy

ObjectiveVerbal fluency functional MRI (fMRI) is used for predicting language deficits after anterior temporal lobe resection (ATLR) for temporal lobe epilepsy (TLE), but primarily engages frontal lobe areas. In this observational study we investigated fMRI paradigms using visual and auditory stimuli, which predominately involve language areas resected during ATLR. MethodsTwenty-three controls and 33 patients (20 left (LTLE), 13 right (RTLE)) were assessed using three fMRI paradigms: verbal fluency, auditory naming with a contrast of auditory reversed speech; picture naming with a contrast of scrambled pictures and blurred faces. ResultsGroup analysis showed bilateral temporal activations for auditory naming and picture naming. Correcting for auditory and visual input (by subtracting activations resulting from auditory reversed speech and blurred pictures/scrambled faces respectively) resulted in left-lateralised activations for patients and controls, which was more pronounced for LTLE compared to RTLE patients.Individual subject activations at a threshold of T>2.5, extent >10 voxels, showed that verbal fluency activated predominantly the left inferior frontal gyrus (IFG) in 90% of LTLE, 92% of RTLE, and 65% of controls, compared to right IFG activations in only 15% of LTLE and RTLE and 26% of controls. Middle temporal (MTG) or superior temporal gyrus (STG) activations were seen on the left in 30% of LTLE, 23% of RTLE, and 52% of controls, and on the right in 15% of LTLE, 15% of RTLE, and 35% of controls.Auditory naming activated temporal areas more frequently than did verbal fluency (LTLE: 93%/73%; RTLE: 92%/58%; controls: 82%/70% (left/right)). Controlling for auditory input resulted in predominantly left-sided temporal activations.Picture naming resulted in temporal lobe activations less frequently than did auditory naming (LTLE 65%/55%; RTLE 53%/46%; controls 52%/35% (left/right)). Controlling for visual input had left-lateralising effects. ConclusionAuditory and picture naming activated temporal lobe structures, which are resected during ATLR, more frequently than did verbal fluency. Controlling for auditory and visual input resulted in more left-lateralised activations. We hypothesise that these paradigms may be more predictive of postoperative language decline than verbal fluency fMRI.

Comparison of early postoperative decline of serum antiMüllerian hormone levels after unilateral laparoscopic ovarian cystectomy between patients categorized according to histologic diagnosis

ObjectiveTo evaluate the change of ovarian reserve after unilateral laparoscopic ovarian cystectomy (LOC) in the early postoperative period between patients divided according to histologic diagnosis of cyst type. Materials and MethodsSixty-five patients who were undergoing unilateral LOC for benign ovarian disease were included in this study. All participants were divided into three groups according to histologic diagnosis: endometrioma (n=26), mature teratoma (n=24), and other benign cyst (n=15). Serum samples were collected preoperatively and 3-days postoperatively and assayed for antiMüllerian hormone (AMH) levels, and the changes between the two samples were analyzed. ResultsPreoperative AMH levels were not significantly different between the three groups. On postoperative Day 3 AMH levels of all three groups were significantly reduced compared with preoperative AMH levels. The rates of decline of AMH levels after LOC in patients with endometrioma (26.37±20.70%) and in those with teratoma (28.25±22.16%) were both significantly higher than those with other benign cyst (12.03±18.56%). No statistically significant differences were found in the rate of decline of AMH levels between patients with endometrioma and teratoma. Decline of AMH after LOC was not significantly correlated with age, body mass index, the size of cyst, or preoperative AMH levels. ConclusionOur results suggest that ovarian reserve is reduced after unilateral LOC in the early postoperative period, and that the postoperative decline of AMH levels after LOC is similar between patients with endometrioma and those with mature teratoma.

Corneal endothelial cell loss after pars plana vitrectomy and combined phacoemulsification–vitrectomy surgeries

ObjectiveTo compare postoperative corneal endothelial cell density (ECD) loss in eyes undergoing pars plana vitrectomy (PPV), or combination of cataract extraction (using phacoemulsification) and intraocular lens implantation with vitrectomy (CE/IOL-PPV) surgeries. MethodsInstitutional setting. Best-corrected visual acuity (BCVA) and ECD by specular microscopy were measured preoperatively and 3 months postoperatively in both groups. Relative postoperative ECD loss was the primary outcome measure. Change in BCVA was the secondary outcome measure. ResultsForty eyes of 40 patients undergoing PPV and 46 eyes of 46 patients undergoing CE/IOL-PPV were included in the final analysis. Postoperative ECD was decreased slightly more in the CE/IOL-PPV group compared with the PPV group (13.9% ± 15.5% vs 9.0% ± 14.6%), although this was not statistically significant (p = 0.10). The improvement in the logMAR BCVA was, however, statistically more significant in the CE/IOL-PPV group compared with the PPV group (−56.6% ± 24.3% vs −38.6% ± 45.5%, p = 0.04). ConclusionsPPV and the combination CE/IOL-PPV surgeries lead to modest and statistically similar postoperative decline in ECD. The combination surgery may lead to slightly more postoperative cells loss, but also more improvement in visual acuity.

Perioperative changes in serum CA125 levels: a prognostic factor for disease-specific survival in patients with ovarian cancer.

ObjectiveIn patients with advanced stage epithelial ovarian cancer (EOC) the volume of residual tumor after debulking is known as prognostic factor for survival. We wanted to examine the relationship between postoperative decline in serum CA125 and residual disease after cytoreductive surgery and evaluate perioperative changes in serum CA125 levels as predictor for disease-specific survival.MethodsA retrospective study was conducted of patients with FIGO stage IIb-IV EOC treated with cytoreductive surgery, followed by chemotherapy between 1996 and 2010 in three hospitals in the Southeastern region of the Netherlands. Data were analyzed with the use of multilevel linear regression and Cox-proportional hazard regression models.ResultsA postoperative decline in serum CA125 level of ≥80% was associated with complete primary cytoreduction (p=0.035). Univariate analyses showed favorable associations with survival for both the degree of decline in serum CA125 and residual tumor after primary cytoreduction. In multivariate analyses the decline in serum CA125 but not the outcome of surgery remained significantly associated with better survival (HR50%–79%=0.52 [95% CI: 0.28–0.96] and HR≥80%=0.26 [95% CI: 0.13–0.54] vs. the serum CA125 decline of <50% [p<0.001]).ConclusionThe current study, although hampered by possible biases, suggests that the perioperative decline in serum CA125 is an early biomarker that predicts disease-specific survival in patients who underwent primary cytoreductive surgery for advanced stage EOC. If confirmed prospectively, the perioperative change in serum CA125 could be a better marker for residual tumor volume after primary cytoreductive surgery (and therewith disease-specific survival) than the surgeons’ estimation of residual tumor volume.

Microembolization is associated with transient cognitive decline in patients undergoing carotid interventions

ObjectiveCarotid interventions are important in helping to reduce the risk of stroke for patients with high-grade carotid artery stenosis; however, subclinical cerebral microemboli can occur during these procedures. Associations have been found between the incidence of microemboli and postoperative decline in memory. We therefore sought to determine whether this decline persisted long-term and to assess changes in other cognitive domains. MethodsPatients were prospectively recruited under an Institutional Review Board-approved protocol at a single academic center. Neuropsychological testing was administered preoperatively and at 1-month and 6-month intervals postoperatively. Cognitive domains that were evaluated included verbal memory, visual memory, psychomotor speed, dexterity, and executive function. Diffusion-weighted magnetic resonance imaging sequencing was performed preoperatively and ≤48 hours postoperatively to identify procedure-related microemboli. Univariate and multivariate regression models were used to identify relationships among microembolization, demographics, and cognition. ResultsIncluded were 80 male patients with an average age of 69 years. Forty patients underwent carotid artery stenting and 40 underwent carotid endarterectomy. Comorbidities included diabetes in 45%, coronary artery disease in 50%, and prior neurologic symptoms in 41%. New postoperative microemboli were found in 45 patients (56%). Microembolization was significantly more common in the carotid artery stenting cohort (P < .005). Univariate analysis demonstrated that patients with procedurally related embolization showed decline 1 month postoperatively in verbal memory and Trail Making A measures. Multivariate analysis demonstrated that procedurally related embolization (odds ratio [OR], 2.8; P = .04) and preoperative symptomatic stenosis (OR, 3.2; P = .026) were independent predictors of decline for the Rey Auditory Verbal Learning Test Short Delay measure at 1 month. At 6 months, no significant relationship was found between emboli and decline on Rey Auditory Verbal Learning Test Short Delay, but age (OR, 1.1, P = .005) and chronic obstructive pulmonary disease (OR, 7.1, P = .018) were significantly associated with decline at 6 months after the intervention. ConclusionsMicroembolization that is associated with carotid artery intervention predicts short-term cognitive decline. However, some of these cognitive deficits persist at 6 months after the intervention, and further investigation is warranted to determine individual patient risk factors that may affect recovery.

Preoperative Falls Predict Postoperative Falls, Functional Decline, and Surgical Complications

BackgroundFalls are common and linked to morbidity. Our objectives were to characterize postoperative falls, and determine whether preoperative falls independently predicted postoperative falls (primary outcome), functional dependence, quality of life, complications, and readmission. MethodsThis prospective cohort study included 7982 unselected patients undergoing elective surgery. Data were collected from the medical record, a baseline survey, and follow-up surveys approximately 30days and one year after surgery. ResultsFall rates (per 100 person-years) peaked at 175 (hospitalization), declined to 140 (30-day survey), and then to 97 (one-year survey). After controlling for confounders, a history of one, two, and ≥three preoperative falls predicted postoperative falls at 30days (adjusted odds ratios [aOR] 2.3, 3.6, 5.5) and one year (aOR 2.3, 3.4, 6.9). One, two, and ≥three falls predicted functional decline at 30days (aOR 1.2, 2.4, 2.4) and one year (aOR 1.3, 1.5, 3.2), along with in-hospital complications (aOR 1.2, 1.3, 2.0). Fall history predicted adverse outcomes better than commonly-used metrics, but did not predict quality of life deterioration or readmission. ConclusionsFalls are common after surgery, and preoperative falls herald postoperative falls and other adverse outcomes. A history of preoperative falls should be routinely ascertained.

Extended Suboccipital Retrosigmoid Surgical Approach Is Effective for Resection of Petrous Apex Meningioma.

The aim of this study was to evaluate the clinical features, treatment strategies, and outcomes of patients presented with petrous apex meningiomas. In this retrospective clinical study, 17 patients with petrous apex meningiomas were treated microsurgically via an extended suboccipital retrosigmoid approach. Data regarding the general characteristics of the patients, surgical management, and surgery-related outcomes were obtained by reviewing patients' medical records. In the authors' study, the authors report that the use of an extended suboccipital retrosigmoid approach and careful microneurosurgical technique can be used to achieve improved surgical and functional outcomes. This was evidenced by gross tumor resection, which was confirmed in 12 (70.6%) patients, and by partial tumor resection, achieved in the remaining 5 patients. Using this surgical approach, the petrosal vein was preserved in 15 (88.2%) patients. In the remaining 2 (11.8%) patients, this vein was sacrificed. Postsurgical improvement of neurological deficits was consequently observed in 12 (70.6%) patients. Though 3 patients (17.6%) demonstrated a postoperative decline in neurological function, 1 patient significantly recovered facial function at follow-up. One patient with sacrificed petrosal vein experienced loss of functional hearing surgery with no recovery during the follow-up period. No operative mortality was observed. Total resection of petrous apex meningiomas is achievable using an extended suboccipital retrosigmoid approach without permanent surgery-associated neurological deficits in a majority of patients. Our primary surgical goal was to achieve maximal tumor resection while maintaining or improving neurological function. Intraoperative protection of the petrosal vein should also be a surgical focus to avoid postoperative complications. Finally, stereotactic radiosurgery can also be useful as a supplemental treatment for postoperative tumor residuals.

Disruption of desmin-mitochondrial architecture in patients with regurgitant mitral valves and preserved ventricular function

ObjectiveRecent studies have demonstrated improved outcomes in patients receiving early surgery for degenerative mitral regurgitation (MR) rather than adhering to conventional guidelines for surgical intervention. However, studies providing a mechanistic basis for these findings are limited. MethodsLeft ventricular (LV) myocardium from 22 patients undergoing mitral valve repair for American Heart Association class I indications was evaluated for desmin, the voltage-dependent anion channel, α-B-crystallin, and α, β-unsaturated aldehyde 4-hydroxynonenal by fluorescence microscopy. The same was evaluated in 6 normal control LV autopsy specimens. Cardiomyocyte ultrastructure was examined by transmission electron microscopy. Magnetic resonance imaging with tissue tagging was performed in 55 normal subjects and 22 MR patients before and 6 months after mitral valve repair. ResultsLV end-diastolic volume was 1.5-fold (P < .0001) higher and LV mass-to-volume ratio was lower in MR (P = .004) hearts versus normal hearts and showed improvement 6 months after mitral valve surgery. However, LV ejection fraction decreased from 65% ± 7% to 52% ± 9% (P < .0001) and LV circumferential (P < .0001) and longitudinal strain decreased significantly below normal values (P = .002) after surgery. Hearts with MR had a 53% decrease in desmin (P < .0001) and a 2.6-fold increase in desmin aggregates (P < .0001) versus normal, along with substantial, intense perinuclear staining of α, β-unsaturated aldehyde 4-hydroxynonenal in areas of mitochondrial breakdown and clustering. Transmission electron microscopy demonstrated numerous electron-dense deposits, myofibrillar loss, Z-disc abnormalities, and extensive granulofilamentous debris identified as desmin-positive by immunogold transmission electron microscopy. ConclusionsDespite well-preserved preoperative LV ejection fraction, severe oxidative stress and disruption of cardiomyocyte desmin-mitochondrial sarcomeric architecture may explain postoperative LV functional decline and further supports the move toward earlier surgical intervention.

The natural history of renal function after surgical management of renal cell carcinoma: Results from the Canadian Kidney Cancer Information System

Introduction and objectivePatients who undergo surgical management of renal cell carcinoma (RCC) are at risk for chronic kidney disease and its sequelae. This study describes the natural history of renal function after radical and partial nephrectomy and explores factors associated with postoperative decline in renal function. MethodsThis is a multi-institutional cohort study of patients in the Canadian Kidney Cancer Information System who underwent partial or radical nephrectomy for RCC. Estimated glomerular filtration rate (eGFR) and stage of chronic kidney disease were determined preoperatively and at 3, 12, and 24 months postoperatively. Linear regression was used to determine the association between postoperative eGFR and type of surgery (radical vs. partial), duration of ischemia, ischemia type (warm vs. cold), and tumor size. Results and limitationsWith a median follow-up of 26 months, 1,379 patients were identified from the Canadian Kidney Cancer Information System database including 665 and 714 who underwent partial and radical nephrectomy, respectively. Patients undergoing radical nephrectomy had a lower eGFR (mean = 19ml/min/1.73m2 lower) at 3, 12, and 24 months postoperatively (P<0.001). Decline in renal function occurred early and remained stable throughout follow-up. A lower preoperative eGFR and increasing age were also associated with a lower postoperative eGFR (P<0.01). Ischemia type and duration were not predictive of postoperative decline in eGFR (P>0.05). Severe renal failure (eGFR<30ml/min/1.73m2) developed postoperatively in 12.5% and 4.1% of radical and partial nephrectomy patients, respectively (P<0.001). ConclusionsAfter the initial postoperative decline, renal function remains stable in patients undergoing surgery for RCC. Patients undergoing radical nephrectomy have a greater long-term reduction in renal function compared with those undergoing partial nephrectomy. Ischemia duration and type are not predictive of postoperative renal function when adhering to generally short ischemia durations.

Early improvement in obstructive sleep apnea and increase in orexin levels after bariatric surgery in adolescents and young adults

BackgroundObstructive sleep apnea (OSA) associated with obesity is known to improve after bariatric surgery, but little is known about early changes in this condition after surgery. ObjectivesTo study the clinical course of OSA after bariatric surgery SettingChildren’s hospital in the United States MethodsAdolescents and young adults with obstructive sleep apnea undergoing vertical sleeve gastrectomy (n = 6) or gastric bypass (n = 1) were enrolled in this prospective study. Participants underwent formal polysomnography before and at 3 and 5 weeks after bariatric surgery. Anthropometric measurements and assay for orexin and leptin were also performed at study visits. Thirty-one adolescents who underwent 2 polysomnography studies that were 4 weeks apart served as control patients. ResultsBaseline mean (range) age of participants was 17.8 (15.4–20.7) years, 71% were male, with body mass index of 55.2 (41.3–61.6) kg/m2 and had a median apnea hypopnea index (AHI) of 15.8 (7.1–23.8) events/hour. Differences in least-square means from longitudinal analysis did not show significant differences in AHI in the control group but showed significant postoperative decline in AHI relative to baseline. AHI declined postoperatively from baseline by 9.2 events/hour (95% confidence interval: 3.8 to 14.5) at 3 weeks (P = .002) and 9.1 events/hour (95% confidence interval: 3.8 to 14.5) at 5 weeks (P = .002); there was no significant change from 3 to 5 weeks in AHI. Leptin decreased and orexin levels increased significantly by 3 weeks postoperatively. ConclusionsThese observations suggest that OSA responds early and out of proportion to weight loss after metabolic and or bariatric surgery, thus weight independent factors may at least in part be responsible for early improvement in OSA postoperatively.

Influence of Tumor Location and Other Variables on Predictive Value of Intraoperative myogenic Motor-Evoked Potentials in Spinal Cord Tumor Surgery

To study the influence of tumor location (cervical vs. thoracic; extramedullary vs. intramedullary) on predictive value of intraoperative myogenic motor-evoked potentials (iMEP) changes in patients undergoing surgery for spinal cord tumors. Three hundred patients retrospective data (91 intramedullary) and 209 (intradural extramedullary) with successful iMEP recordings were analyzed. Responses to transcranial electrical stimulation were recorded from the lower limb muscles. Preoperative clinical variables, iMEPs changes, and postoperative neurologic deficits were noted. Associations between categorical variables and outcome were analyzed with the Fisher exact test. Of the 300 patients 28 (9.3%) had significant intraoperative worsening of iMEPs. New postoperative deficits occurred in 23 of these 28 patients. False-positive decreases in iMEPs were observed in 5 patients. There was a significant association between changes in iMEP and postoperative new motor deficits (P ≤ 0.0001). Multivariate analysis showed that patients with changes in iMEP undergoing surgery for thoracic segment tumors, with longer duration of symptoms (>12 months) and older age (≥21.5 years) were more likely to suffer postoperative neurological decline (odds ratio 4.1, P ≤ 0.001 and odds ratio 5.4 P ≤ 0.0001, respectively). The sensitivity of iMEPs was 100% and specificity 98.2%. The positive and negative predictive values were 82% and 100%; however, the sensitivity and specificity is similar in thoracic intramedullary (TIM) (n= 53) and cervical intramedullary tumors (n= 38) (both were 100% and 97%). The positive predictive value was significantly greater for TIM tumors (93% vs. 50%). A strong association was observed between worsening of iMEPs and postoperative new neurological deficits in patients with TIM tumor.

Editorial Comment

Mamut et al demonstrate that among patients undergoing radical nephrectomy (RN), preoperative glomerular filtration rate (GFR) and diabetes mellitus (DM) were independent predictors for postoperative renal function decline and chronic kidney disease (CKD), whereas hypertension and cardiovascular disease were not found to be independent risk factors. 1 Mamut A.E Violette P.D Rowe N.E Cui F. Luke P. Measuring the impact of medical chronic kidney disease and diabetes mellitus on renal functional decline following surgical management of renal masses. Urology. 2016; https://doi.org/10.1016/j.urology.2015.12.081 Abstract Full Text Full Text PDF Scopus (9) Google Scholar

Hippocampus Sparing Resections within the Temporal Lobe in Adolescents with Epilepsy: Impact on Cognition and Remaining Hippocampal Volume

Background/Purpose: Resections within the language dominant temporal lobe including hippocampectomy bear the risk of postoperative verbal memory decline. Thus, there has been a tendency toward tailored resections, sparing the hippocampus if clinically indicated.

Thrombin-Based Hemostatic Agent in Primary Total Knee Arthroplasty.

The present meta-analysis pooled the results from randomized controlled trials (RCTs) to identify and assess the efficacy and safety of thrombin-based hemostatic agent in primary total knee arthroplasty (TKA). Potential academic articles were identified from the Cochrane Library, Medline (1966-2015.5), PubMed (1966-2015.5), Embase (1980-2015.5), and ScienceDirect (1966-2015.5). Relevant journals and the recommendations of expert panels were also searched by using Google search engine. RCTs assessing the efficacy and safety of thrombin-based hemostatic agent in primary TKA were included. Pooling of data was analyzed by RevMan 5.1 (The Cochrane Collaboration, Oxford, UK). A total of four RCTs met the inclusion criteria. The meta-analysis revealed significant differences in postoperative hemoglobin decline (p < 0.00001), total blood loss (p < 0.00001), drainage volume (p = 0.01), and allogenic blood transfusion (p = 0.01) between the treatment group and the control group. No significant differences were found regarding incidence of infection (p = 0.45) and deep vein thrombosis (DVT; p = 0.80) between the groups. Meta-analysis indicated that the application of thrombin-based hemostatic agent before wound closure decreased postoperative hemoglobin decline, drainage volume, total blood loss, and transfusion rate and did not increase the risk of infection, DVT, or other complications. Therefore, the reviewers believe that thrombin-based hemostatic agent is effective and safe in primary TKA.