Postoperative Decrease Research Articles

Clinical Utility and Cost of Postoperative Hemoglobin Level Testing Following Robotic-assisted Hysterectomy for Endometrial Cancer.

Our aim was to assess the clinical utility of postoperative hemoglobin testing following hysterectomy. We carried out a retrospective cohort study of patients who underwent robotic surgery at an academic center during a 44-month study period. Data included demographics and perioperative outcomes. The mean postoperative decrease in hemoglobin level was evaluated using numerical and categorical variables. A total of 201 women were included. A total of 45 (22.4%) developed symptoms suggestive of hemodynamic compromise. When compared to asymptomatic patients, these patients were no different in operative time, estimated blood loss, pre- or post-operative hemoglobin levels, or the change in hemoglobin levels. Symptomatic patients did receive less fluid intraoperatively (1.2 vs. 1.5 l; p<0.0001). Perioperative outcomes were not associated with a greater postoperative decrease in hemoglobin (Hb). Postoperative anemia was associated with preoperative anemia (0% vs. 45%; p<0.0001). Patients with postoperative anemia were also more likely to be re-admitted within 30 days after surgery (7% vs. 23%; p=0.025). Of the three patients who received blood transfusions postoperatively, all three had preoperative Hb<9.5 g/dl, compared to 2.5% of those who were not transfused (p<0.0001). Using Institutional charges and Medicare reimbursement rates for blood hemoglobin testing, savings were estimated to be $3,629 and $1,236, respectively, during the study period. Postoperative Hb testing may be safely avoided unless starting Hb is less <10 g/dl. Clinical practice change can reduce healthcare costs without hindering patient care.

Liposomal Bupivacaine in Adductor Canal Blocks Before Total Knee Arthroplasty Leads to Improved Postoperative Outcomes: A Randomized Controlled Trial

BackgroundThis study compares the use of liposomal bupivacaine (Exparel) versus ropivacaine in adductor canal blocks (ACB) before total knee arthroplasties (TKAs). MethodsFrom the months of April 2020 to September 2021, 147 patients undergoing unilateral primary TKA were asked to participate in this prospective, double-blinded randomized controlled trial. Each patient received an iPACK block utilizing ropivacaine and was additionally randomized to receive an ACB with Exparel or Ropivacaine. For each patient, demographic information, inpatient hospital information, postoperative opioid use, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire scores were collected. ResultsOverall, 100 patients were included (50 in each cohort). The Exparel group had a lower hospital length of stay compared to the Control group (36.3 vs 49.7 hours, P < .01). Patients in the Exparel group reported an increased amount of Numerical Rating Scale pain score improvement at all postoperative timepoints. These patients also used a lower amount of inpatient opioids (40.9 vs 47.3 MME/d, P = .04) but a similar amount of outpatient opioids (33.4 vs 32.1 MME/d, P = .351). Finally, the Exparel group had increased improvements in all WOMAC subscores and total scores at most timepoints compared to the Control group (P < .05). ConclusionExparel peripheral regional nerve blocks lead to decreases in pain levels, shorter hospital lengths of stay, inpatient opioid usage, and improved WOMAC scores. Exparel can be safely used in ACB blocks before TKA to help in controlling postoperative pain and decrease length of stay.

Consequences of Stapes Surgery on Tongue Morphological Characteristics in Narrow Band Imaging, Gustatory Function and General Sensation: A Prospective Tertiary Center Study

(1) Background: Chorda tympani (CT) manipulation during stapes surgery affects its functions. We hypothesized that this alters tongue morphology and sensory functions. (2) Methods: Patients undergoing stapes surgery were tested 1 day preoperatively, 1 and 6 months postoperatively. Narrow band imaging contact endoscopy (NBI) was used to determine the number of fungiform papillae (Npapillae) and the total score of blood vessel morphology (NBItotal). The taste was tested with taste strips. General sensation was tested with a static two-point discrimination. Tests were performed on ipsilateral and contralateral side of the tongue. (3) Results: 52 otosclerosis patients were included in the study. There was a statistically significant decrease of NBItotal (p = 0.005), Npapillae (p = 0.009), sensation of sweet (p = 0.003), salty (p = 0.035), sour (p = 0.036), and bitter taste (p = 0.013) within the test side during the follow-up. A statistically significant impact on presence of dysgeusia for sweet was found 1 month postoperatively (p &lt; 0.005). Postoperative decrease in two-point discrimination score did not reach a statistical significance (p = 0.056). (4) Conclusions: CT manipulation affects fungiform papillae density, vascular patterns and taste sensation. The general sensation of the tongue is not influenced by CT manipulation.

Evaluation of Carhart’s Notch in Patients with Serous Otitis Media

Objective: To investigate the changes in bone-conduction and air-bone gap in patients with serous otitis media and to evaluate the presence of Carhart’s notch. Material and Methods: Patients with unilateral serous otitis media were included in the study. Audiometric evaluation comprised air-conduction and bone-conduction hearing thresholds, and air-bone gap values. The preoperative and postoperative pure tone audiometry results of 45 patients were compared in terms of the air-bone gap and bone-conduction thresholds. Results: Carhart’s notch was present in 17 (37.8%) patients preoperatively. For pure tone audiometry, there was a statistically significant decrease in air-bone gap at all frequencies postoperatively. The postoperative decrease in the bone-conduction thresholds was statistically significant only at 2 kHz. In the postoperative period, a 4.7 dB improvement was observed in the bone-conduction threshold at 2 kHz for patients with Carhart’s notch. Conclusion: Carhart’s notch may be present in patients with serous otitis media. It is not specific to otosclerosis.

EFFECT OF SUBMUCOSAL INJECTION OF DEXAMETHASONE ON POSTOPERATIVE SEQUELAE FOLLOWING SURGICAL REMOVAL OF IMPACTED THIRD MOLARS: A CLINICAL STUDY.

Background and Objectives: Impacted third molar surgery is one of the most common procedures performed by maxillofacial surgeons in the outpatient setting. Since the region of surgery is highly vascularized and constituted mostly by loose connective tissue that contains blood and lymph vessels, a series of functional and structural alterations occur after extraction which is expressed as pain, swelling and trismus. These sequelae can have a serious impact on the patient's quality of life; therefore, a reduction of postoperative complications seems a logical goal, particularly if healing is not compromised. Method:A hospital-based case-control study with a study population of 50 patients was done to assess the efcacy of submucosal injection of 8mg dexamethasone on reducing the post-operative sequelae such as oedema, pain and trismus following surgical removal of impacted third molars. The study was conducted in patients with bilaterally impacted mandibular third molars where one side is randomly selected and 8mg dexamethasone is administered submucosally and the other side is selected as control. All the patients selected for the study were followed up on rst, third and seventh post-operative day. Result: The submucosal injection of dexamethasone showed signicant improvement in oedema and trismus on all postoperative days but decrease in postoperative pain was not signicant on rst and third days but signicant on seventh day. Submucosal injection of dexamethasone 8 mg is an effective therapeutic strategy for improving the quality of life after surgical removal of impacted lower third molars.

Pharmacist-led standardization of total parenteral nutrition improves postoperative nutritional status in colorectal cancer patients.

BackgroundTotal parenteral nutrition (TPN) is an essential treatment for patients who undergo abdominal surgery. Due to the gap of knowledge background between clinicians and pharmacists, the participation of the latter may improve TPN standardization. However, the impact on clinical outcome is unknown. In this study, we evaluated the impact of appropriacy and efficacy of TPN prescription, after a pharmacist-led TPN standardization program introduced.MethodsA pharmacist-led TPN standardization program was introduced in the Zhejiang Cancer Hospital and the clinical outcomes were assessed. The TPN standardization program includes a pre-established standard multidisciplinary evaluation standard, a computerized TPN management system and regular evaluations of TPN prescription performed by pharmacists. Any concerns were identified and improved via discussed with doctors. To evaluate the effect of pharmacists’ intervention in nutritional status and postoperative complications, an observational before-and-after cohort study was performed. All patients admitted in hospital with colorectal cancer (CRC) and receiving abdominal surgery in June 2019 (pre-intervention cohort) and June 2020 (post-intervention cohort) were retrospectively analyzed. Nutritional status of patients was evaluated using the levels of postoperative serum albumin, prealbumin, total protein, and their decrease extent. Surgical or TPN-related complications and recovery time were collated as the clinical outcomes.ResultsThere were no significant differences in the basic clinical information of the two cohorts, suggesting that the two groups are comparable. The average postoperative prealbumin levels were elevated in 2020 compared to 2019 (192.3±5.5 mg/L for 2019 and 229.5±4.8 mg/L for 2020, P<0.001). In addition, the post-intervention cohort showed a lower postoperative infection rate (11.6% vs. 18.2%), shorter duration of infection (9.4±1.4 vs. 7.7±1.0 days), lower incidence of postoperative albumin decrease (25.2% vs. 76.7%), prealbumin decrease (71.5% vs. 78.9%), and total protein decrease (25.2% vs. 72.2%), and lower incidence of TPN-related hypoglycemia (5.4% vs. 15.3%).ConclusionsPharmacist-led TPN standardization improved the postoperative clinical outcomes in patients with colorectal cancer (CRC).

Can Color Doppler Ultrasound Challenge the Paradigm in Percutaneous Nephrolithotomy?

Objectives: Compare color Doppler (Color) ultrasound-guided puncture with common type-B (Type-B) ultrasound-guided puncture in reducing the incidence of hemorrhagic complications of percutaneous nephrolithotomy (PCNL). Materials and Methods: A total of 348 patients who received PCNL from September 2017 to December 2018 were divided into Color (231 cases) and Type-B groups (117 cases). The avascular area of the target fornix was pinpointed in the Color group, whereas the middle of the target fornix was the default puncture point in the Type-B group. Tract bleeding, nephrostomy tract creation time, operation time, postoperative hemoglobin (Hb) values and serum creatine (Scr) concentrations, and stone-free rates were analyzed. Results: Color Doppler imaging revealed that 35.1% of the cases in the Color group (81/231) had variable artery positioning in the target fornix. Tract bleeding and postoperative Hb reduction in the Color group were significantly lower than the Type-B group (10.8% vs 24.8%, p = 0.0007, and 4.87 ± 8.58 g/L vs 7.70 ± 8.90 g/L, p = 0.0044, respectively). The postoperative hospitalization of the Color group was also shortened (8.3 ± 5.9 days vs 9.7 ± 3.0 days, p < 0.0001). Although working channel creation took longer in this group (4.2 ± 0.3 minutes vs 3.6 ± 0.2 minutes, p < 0.0001), there were no significant differences in the total operation time between the two groups (39.2 ± 15.2 minutes vs 36.4 ± 16.5 minutes, p = 0.1097) or postoperative Scr and stone-free rates. Conclusion: Vascular variation of the fornix is very common. Consistent puncture of the avascular area of the target fornix significantly lowered tract bleeding and postoperative Hb decrease compared with traditional procedures. Color Doppler ultrasound-guided puncture is, thus, useful to reduce the incidence of severe hemorrhagic complications of PCNL.

Intraoperative and postoperative outcomes of thulium laser enucleation versus bipolar resection in the transurethral treatment of benign prostatic hyperplasia: a meta-analysis.

To compare the intraoperative and postoperative outcomes of thulium laser enucleation of the prostate (ThuLEP) vs bipolar transurethral resection of the prostate (B-TURP) in treating patients with benign prostatic hyperplasia (BPH). Clinical trials of ThuLEP and B-TURP in treating BPH were searched systematically by using PubMed, Cochrane Library databases, and EMBASE (until May 2021). The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was followed. The datum was calculated by Review Manager version 5.3.0. Four articles including 782 patients were studied in this analysis. The analysis discovered that there was no significant difference in operative time and percentage of tissue removed between ThuLEP and B-TURP. But the intraoperative irrigated volume and postoperative hemoglobin (Hb) decrease in the ThuLEP group was significantly less compared with the B-TURP group. The catheterization time and hospitalization duration in the B-TURP group was significantly longer than that in the ThuLEP group. Compared with those before treatment, the micturition indexes of the two groups improved significantly. But no significant difference was identified between ThuLEP and B-TURP for the variation of international prostate symptom score, quality of life, maximum flow rate, and post-void residual. By analyzing the postoperative complications, there were no significant discrepancies between ThuLEP and B-TURP in the incidence of blood transfusion, recatheterization, transient incontinence, bladder neck contracture, and urethral stricture. The micturition indexes and clinical symptoms were significantly improved after ThuLEP and B-TURP for patients with BPH. However, ThuLEP was more effective than B-TURP in terms of intraoperative irrigated volume, postoperative Hb decrease, catheterization time, and hospitalization duration.

Long-Term Follow-Up of Corneal Endothelial Cell Changes After Iris-Fixated Phakic Intraocular Lens Explantation.

The purpose of this study was to evaluate long-term corneal endothelial cell changes and visual outcomes after iris-fixated phakic intraocular lens (pIOL) explantation in patients with endothelial damage and to investigate potential predictors of endothelial injury. Consecutive patients undergoing pIOL explantation with corneal endothelial cell density (ECD) <2000 cells/mm 2 at the time of the procedure were retrospectively reviewed in a single tertiary center. All patients were treated between April 2016 and October 2020 at a high-volume referral-based tertiary hospital. The primary outcome was the change in corneal endothelial parameters, including ECD, over long-term follow-up. Secondary outcomes included changes in corrected distance visual acuity and analysis of prognostic factors. This study included 44 eyes from 28 patients with an average age of 42.5 ± 7.8 years (range: 27-63). Mean ECD before explantation was 1375.4 ± 468.2 cells/mm 2 (range: 622-1996), and the average duration of follow-up after explantation was 20.5 months (6-58.2). Two years after explantation, ECD had significantly decreased by more than 25% to 1019.6 ± 368.6 (608-1689; P < 0.01). However, there was no significant change in corrected distance visual acuity (20/23-20/22, P = 0.59). Longer operation duration (odds ratio, 1.004; P = 0.04) was the only significant factor weakly associated with postoperative decreases in ECD. Although ECD continuously decreased despite pIOL explantation on a long-term follow-up, patients did not experience any discomfort or showed decreases in visual acuity. Therefore, a careful follow-up is required for possible endothelial injury after pIOL explantation.

Effect of intraoperative theophylline use on acute kidney injury in paediatric cardiac surgery.

This study aimed to examine the effects of theophylline use in preventing renal dysfunction in patients undergoing CHD surgery. A total of 94 patients aged 1-60 months were included in the study. Patients in the theophylline group were enrolled according to a pre-defined protocol for treatment administration, while controls were selected retrospectively from patients without theophylline treatment during the same period - who were matched according to critical baseline characteristics. The incidence of acute kidney injury was similar between the two groups (p = 1.000). Higher urinary output and lower fluid balance were found intraoperatively and also postoperatively in the theophylline group (all, p < 0.050). Postoperative decrease in urinary output and estimated glomerular filtration rate were higher in the theophylline group (p < 0.050). Lower postoperative urea and creatinine levels were shown in theophylline recipients (p < 0.050). Urea levels increased significantly in the non-theophylline group during surgery (p < 0.001), and no significant change was observed in theophylline group (p = 0.136). Postoperative increase in creatinine and lactate levels was demonstrated in theophylline group (p < 0.050), and lactate levels were higher in the non-theophylline group during and after cardiopulmonary bypass (p = 0.010). Multiple linear regression analysis revealed less reduction in estimated glomerular filtration rate with higher age and in the presence of theophylline use (p < 0.050). Although we demonstrated a similar incidence of acute kidney injury in the both groups, we revealed an important decrease in serum creatinine, urea and lactate levels, accompanied by improved estimated glomerular filtration rate, increased urine output and decreased fluid overload, with theophylline treatment, suggesting that renal functions significantly improved with the use of theophylline.

Surgical correction of nasal obstruction in obstructive sleep apnea improves CPAP outcomes and compliance.

Although continuous positive airway pressure (CPAP) therapy curtails most of the negative impacts of obstructive sleep apnea (OSA), its efficacy is limited by its low long-term adherence. Nasal obstruction contributes to OSA pathophysiology and necessitates high CPAP titration pressures which reduce CPAP compliance. This study aims at elucidating the outcomes of surgical correction of nasal obstruction in patients intolerant to CPAP therapy. Forty-nine patients with severe OSA intolerant to CPAP secondary to surgically correctable nasal obstruction were operated upon. Patients were evaluated preoperatively and at least 3months after the surgical intervention. Subjective assessment entailed the Nasal Obstruction Symptom Evaluation score (NOSE) and the Epworth Sleepiness Scale (ESS). Objectively the patients were assessed by acoustic rhinometry and standard polysomnography. Nasal surgical intervention resulted in an a statistically significant decrease in the mean NOSE score, ESS and optimal CPAP titration pressure. In addition, theminimalcross-sectional area (MCA1&2) increased significantly postoperatively. There was a positive correlation between the improvement in NOSE score as well as the MCA1& 2 and the postoperative decrease in CPAP titration pressure. Surgical correction of nasal obstruction improved CPAP outcomes and compliance in all patients. Nasal surgery in OSA objectively assessed by acoustic rhinometry improved nasal obstruction with a resultant decrease in the CPAP pressure requirements. Given that lower CPAP pressures improve adherence to CPAP therapy, surgical alleviation of nasal obstruction should be considered a crucial intervention in the management armamentarium of OSA.

The effect of suprarenal graft fixation during endovascular aneurysm repair on short- and long-term renal function

ObjectiveThe effect of suprarenal fixation (SR) compared with infrarenal fixation (IR) on renal function during endovascular aneurysm repair (EVAR) remains controversial. This study aims to compare the renal outcomes between fixation types in short- and long-term follow-up. MethodsPatients undergoing EVAR for infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. The estimated glomerular filtration rate (eGFR) was measured at baseline and during a follow-up of 5 years. A decline in renal function was defined as a 20% or greater decrease in the eGFR. Changes in the eGFR were compared between SR and IR groups at 1 to 7 days, 30 days, and 1 to 5 years postoperatively. Preoperative renal insufficiency was defined as an eGFR of less than 60 mL/min/1.73 m2, and those patients were included in the subanalyses. ResultsA total of 358 patients were included. Among these, 267 (74.6%) had SR and 91 (25.4%) had IR fixation. A decrease in renal function occurred more commonly after SR than after IR in 1 to 7 days postoperatively (P = .009), but no difference was noticed at 30 days and 1 to 5 years. Regardless of the fixation method, renal function steadily decreased steadily over time after EVAR (estimate –3.13 per a year; 95% confidence interval, –3.40 to –2.85; P < .001). Patients with preexisting renal insufficiency were included in subgroup analyses, and those with SR were more often found to have a decline in eGFR 5 years postoperatively than their counterparts with IR (59.5% vs 20.0%; P = .036). ConclusionsAn immediate postoperative decrease in renal function was seen more often after SR fixation than IR fixation but this difference was transient. SR fixation is a safe method for patients with normal renal function. Long-term results seems to favor IR over SR in patients with preexisting renal insufficiency.

Association of First Metatarsal Pronation with Patient-Reported Outcomes and Recurrence Rates in Hallux Valgus

Category:BunionIntroduction/Purpose:Hallux valgus (HV) is a triplanar deformity of the first metatarsal in which the first metatarsal adducts, dorsiflexes, and pronates with an average increase in pronation between 2° and 8° compared with normal patients (Kimura JBJS, Campbell FAI). Despite these radiographic changes of the first metatarsal in patients with HV, no correlation between postoperative two-dimensional radiographic parameters and patient-reported outcomes has been reported (Thordarson FAI). The purpose of this study was to determine if a postoperative decrease in first metatarsal pronation (1MTPronation) was associated with changes in patient-reported outcomes as measured by the PROMIS physical function, pain interference, and pain intensity domains or recurrence rates in patients with HV who undergo a first tarsometatarsal fusion (modified Lapidus procedure).Methods:This study included thirty-nine consecutive HV patients who underwent a modified Lapidus procedure, had preoperative and >=2-year postoperative PROMIS scores, and had 1MTPronation measured using the previously described triplanar angle of pronation (FAI, in press) on preoperative and at least 5-month postoperative weightbearing CT scans.Multivariable regression analyses were used to investigate differences in the change in PROMIS domains preoperatively and 2-years postoperatively between patients with 'no change/increased 1MTPronation' and 'decreased 1MTPronation.' No differences in preoperative radiographic parameters or patient characteristics found between two groups. A secondary analysis using multivariable regression modeling was performed to determine if patients with a decrease in 1MTPronation between 2°-8° ('moderate pronation change') had greater improvements in PROMIS scores compared with 'minimal pronation change' (<2°) and 'substantial pronation change' (>8°) groups. A log-binomal regression analysis was performed to identify if a decrease in 1MTPronation was associated with recurrence of the HV deformity (postoperative HVA>=20°Results:The decreased 1MTPronation group (n=26) had a statistically significant greater improvement in the PROMIS physical function scale by 7.2 points (95% confidence interval (CI) 2.1-12.3, P=0.007) compared to the no change/increased 1MTPronation group (n=13). There were no statistically significant differences in PROMIS pain interference (P=0.380) or pain intensity (P=0.443) scores between the two groups. The secondary analysis found that patients in the moderate pronation change group (n=15) had significantly better improvements in the PROMIS physical function and pain intensity domains than the minimal pronation change group (n=14) (Table 1). The moderate pronation change group also had greater improvements in the PROMIS pain interference and pain intensity domains than the substantial pronation (n=10) change group (Table 1). Recurrence rates were significantly lower in the decreased 1MTPronation pronation group when compared to the no change/increased 1MTPronation group (11.5% and 46.2%, respectively; risk ratio 0.25, 95% CI 0.07-0.84, P=0.025).Conclusion:In patients undergoing a modified Lapidus procedure for correction of their HV deformity, a postoperative decrease in pronation of the first metatarsal, especially between 2° and 8°, was associated with improvement in PROMIS scores at two- years postoperatively and a lower recurrence rate. These results suggest that the rotational component of the hallux valgus deformity may play an important role in outcomes following surgery, and consequently, surgeons should consider addressing but not overcorrecting the first metatarsal pronation deformity when performing a surgical procedure for the treatment of hallux valgus.

Low Tibial Valgization Osteotomy for More Severe Varus Ankle Arthritis

Category:Ankle ArthritisIntroduction/Purpose:Low tibial valgization osteotomy with medial opening wedge (LTO) is generally indicated for ankle arthritis with a small talar tilt (TT). We addressed the following research questions: the efficacy of LTO for more significant varus ankle arthritis, the effect of additional inframalleolar correction followed by LTO, and the preoperative or operation related factors influencing postoperative TT decrease.Methods:We retrospectively reviewed the radiographic and clinical findings of 31 patients with more significant varus ankle arthritis (>=8 degrees) who underwent LTO or LTO plus inframalleolar correction. We grouped the included patients according to combination with inframalleolar correction and postoperative decreased TT. Furthermore, a binary logistic regression analysis was performed to determine the factors influencing postoperative TT decrease.Results:Even though the mean TT was unchanged postoperatively (from 12.1 to 9.9 degrees, P =.052), clinical parameters were significantly increased. In the group with concomitant inframalleolar correction, we found that TT was more corrected (3.9 vs 1.8 degrees, P =.023) with a greater lateralization of the talar center and a greater correction of the hindfoot alignment to valgus. The results of the binary logistic regression analysis showed a significant relationship between postoperative decreased TT and preoperative talar center migration (P =.016), hindfoot alignment angle (P =.033), hindfoot moment arm (P =.041), and hindfoot alignment ratio (P =.016).Conclusion:LTO in more significant varus ankle arthritis could result in clinical improvement, although TT was not significantly changed. We recommend adding inframalleolar correction after LTO for the patients with more significant varus ankle arthritis.

The Modified Norwood Procedure at Necker Hospital: Stage I and II for Hypoplastic Left Heart Syndrome

We describe a modified Stage I neonatal surgical palliation for hypoplastic left heart syndrome inspired by both the Norwood and hybrid procedures. This new technique consists in: (1) replacement of the patent ductus arteriosus and aortic arch plasty with a pulmonary homograft, (2) banding of both the right and left pulmonary arteries (PA), (3) atrial septectomy, and (4) reimplantation of the Aorta (when needed). This surgery is performed under cardio-pulmonary bypass without aortic cross clamping, except when the ascending Aorta is atretic and needs to be reimplanted. Stage II consists in the division of the pulmonary bifurcation, PA branch plasty (with debanding), bidirectional cavopulmonary shunt and Damus-Kaye-Stansel anastomosis. This new surgical procedure allowed us to obtain hemodynamically stable postoperative patients and decrease by twice our mortality rate after Stage I palliation in hypoplastic left heart syndrome but with frequent left PA stenosis or hypoplasia. We describe a modified Stage I neonatal surgical palliation for hypoplastic left heart syndrome inspired by both the Norwood and hybrid procedures. This new technique consists in: (1) replacement of the patent ductus arteriosus and aortic arch plasty with a pulmonary homograft, (2) banding of both the right and left pulmonary arteries (PA), (3) atrial septectomy, and (4) reimplantation of the Aorta (when needed). This surgery is performed under cardio-pulmonary bypass without aortic cross clamping, except when the ascending Aorta is atretic and needs to be reimplanted. Stage II consists in the division of the pulmonary bifurcation, PA branch plasty (with debanding), bidirectional cavopulmonary shunt and Damus-Kaye-Stansel anastomosis. This new surgical procedure allowed us to obtain hemodynamically stable postoperative patients and decrease by twice our mortality rate after Stage I palliation in hypoplastic left heart syndrome but with frequent left PA stenosis or hypoplasia. Commentary: Norwoodized Hybrid from NeckerOperative Techniques in Thoracic and Cardiovascular SurgeryVol. 27Issue 3PreviewThe mortality associated with the Hypoplastic Left Heart Syndrome (HLHS) remains the highest among all congenital heart defects. One-year transplant-free survival for the conventional surgical palliation, the Norwood procedure, stagnates at around 70%.1 The Hybrid palliation, offers a less invasive approach with bilateral pulmonary artery banding with/out subsequent stenting of the PDA, omitting the use of cardiopulmonary bypass (CPB) in the neonatal period. Although reserved for high-risk patients with multiple risk factors who are not deemed to undergo the Norwood procedure in most centers, the Hybrid approach yields excellent outcomes in dedicated centers for allcomers. Full-Text PDF

Plasma Concentration of the Lipid Peroxidation (LP) Biomarker 4-Ηydroxynonenal (4-HNE) in Benign and Cancer Patients.

The present study investigated the plasma concentration of the lipid peroxidation (LP) biomarker 4-hydroxynonenal (4-HNE) in benign and cancer patients having the rectus sheath block (RSB) analgesia after midline laparotomy. Plasma concentrations of catalase (CAT) and malondialdehyde (MDA) were used as a reference. This study assessed three LP biomarkers; CAT, MDA and 4-HNE and compared the plasma levels to the patient satisfaction 24 h postoperatively (SFS24; 0=fully unsatisfied; 10=fully satisfied); the overall pain at rest (NRSr) and when pressing the wound at 20 Newton force (NRSp) were surveyed and filed on a 11-point numeric rating scale at 24 h following surgery (NRS; 0=no pain; 10=worst pain). There were 56 patients in the study, of whom 12 were excluded due to missing plasma samples. The final study cohort consisted of 15 patients with benign disease and 29 patients with cancer. The RSB analgesia enhanced significantly the SFS24 scores in the study groups (p=0.001). The plasma 4-HNE decreased immediately after operation (POP1) and the postoperative decrease between the preoperative and the POP1 values in the 4-HNE marker were statistically significant (p<0.001). The individual plasma 4-HNE and MDA concentration correlated significantly in benign and cancer patients (r=0.413, p<0.001). The present study confirms the applicability of the plasma biomarker 4-HNE to cast further light on the postoperative pain in midline laparotomy patients.

Outcomes of post-mi vsr surgical repair in-patients operated in different time periods upon acute myocardial infarction evolvement

Aim: The article highlights problematic issues of surgical treatment of mechanical complications of acute myocardial infarction (AMI), specifically, post-myocardial infarction ventricular septum rupture (post-MI VSR). Based on the study of the results of surgical treatment of post-MI VSR in patients with different terms of surgical intervention upon AMI evolvement, the most rational approach to ventricular septum defect (VSD) repair in such patients has been determined. Specifically, subject to hemodynamic stability in patients with post-MI VSR within the first two weeks after AMI evolvement, given the risk of mortality (42.1%), the wait-and-see tactics of surgical treatment is deemed a wise measure. Since the third week after AMI the stabilization of operative mortality rate (up to 10.5-15.8%) has been observed this lays the grounds for active surgical treatment tactics. Notably, analysis of the dynamics of echocardiographic characteristics and changes in the degree of tolerance to physical activity (PA) in patients with post-MI VSR who underwent surgery in different periods after AMI evolvement have been particularly addressed. It has been found that the probability of achievement the most favourable clinical condition corresponding to class I by New York Heart Association (NYHA) classification (χ2 (2, n=65) = 20,791; p&lt;0,001) increases when patients performed are operated on in later periods after AMI. Thus, given the risk of mortality in the early post myocardial infarction period, the most appropriate measure in the tactics of managing patients with post-MI VSR is surgical intervention aimed at VSD repairing 2 weeks after AMI. Nonetheless, the decision on the necessity of emergency surgery patients with post-MI VSR must be also based on the potential stabilization of systemic hemodynamic system characteristics using drug therapy and endovascular practices. Material and Methods: In the study we have presented the retrospectively analysis of data of 90 ischemic heart disease (IHD) patients with post-MI VSR complications. The age of post-MI VSR in-patients ranged from 29 to 81 (60.0 ± 9.6). Among such patients men prevailed (72.3%). Duration of hospitalization of those post-MI VSR from AMI onset varied from 1 to 462 days (n=90). Depending on the time of surgery to be performed after AMI suffered, all patients were divided into groups: group 1 – up to 28 days (n=28); group 2 – from 29 to 56 days n=26); group 3 – from 57 days (n=36). Among the 90 patients who participated in the study, the surgical treatment of post-MI VSR was used in 93.3% (n=84) of patients. LV aneurysm repair according to W. M. Dagget’s technique (14) was performed in 54.8% of patients (n=46), according to T. E. David’s technique (7) – in 36.9% of patients (n=31). Results: Overall surgical mortality among 84 patients has been observed in 22.6% (n=19). In patients of group 1 there occurred 10 lethal cases, in group 2 there were 5, and in group 3 – there were 4 deaths ( n=84)observed. Starting from the 3rd week after AMI onset, significant decrease in operative mortality from 42.1% to 10.5-15.8% has been observed. Study of the dynamics of echocardiography characteristics show less marked changes in LVESV and LVEDV in group 1 compared to groups 2 and 3 testify, in the latter, in favor of completed post-infarction "heart remodeling" with LV aneurysm formed. Conclusion: 1. When planning the scope of surgical intervention at a later date from AMI evolvement, account must be taken of individual dynamics of post-myocardial infarction "cardiac remodeling". 2. Postoperative decrease in ECHO values of LVESV, LVEDV and LVSV in patients with post-MI VSR speaks for the effectiveness of surgical intervention aimed at repairing VSD and restoring LV geometry. 3. The probability of achieving the most favorable NYHA class I clinical state increases when surgery is performed in patients at the later time after AMI suffered.

Pre-emptive 600 mg oral gabapentin reduces morphine requirements and postoperative pain following non-obstetric lower abdominal surgery.

Postoperative pain following lower abdominal surgery is one of the most common complications reported by patients. Gabapentin given two hours before surgery as pre-emptive analgesia has been reported to reduce postoperative pain and decrease postoperative analgesia requirements. The aim of this study was to determine the effectiveness of 600 mg oral gabapentin as a pre-emptive analgesia to reduce postoperative pain and morphine requirements following nonobstetric lower abdominal surgery. A double-blind randomized clinical trial was conducted with 72 subjects acquired by consecutive sampling from November 2019 to February 2020 at Tangerang District Hospital. Eligible subjects were randomized to two groups: placebo or 600 mg oral gabapentin two hours before skin incision. The total morphine requirements, visual analogue scale (VAS) score, first-time analgesic demand, and side effects were assessed during the first 24 hours postoperatively. The first 24-hour postoperative total morphine was higher in the placebo group (5.33 ± 1.97 mg vs. 2.47 ± 1.90 mg; P < 0.001). The pain scale at rest and movement during recovery, two hours postoperatively, and 24 hours postoperatively were significantly different between the two groups (P < 0.05). The Mann-Whitney test showed a significant difference in the first-time morphine required as rescue analgesia between the gabapentin group (161.5 [25-990] minutes) and placebo group (67.5 [10-371] minutes; P < 0.001). No significant difference was found in adverse events between the groups. Following nonobstetric lower abdominal surgery, 600 mg oral gabapentin as a pre-emptive analgesia attenuates postoperative pain and reduces morphine requirements.

Cystine and Theanine as Stress-Reducing Amino Acids-Perioperative Use for Early Recovery after Surgical Stress.

Perioperative nutritional therapy requires the consideration of metabolic changes, and it is desirable to reduce stress aiming at early metabolic normalization. Glutathione (GSH) is a tripeptide composed of glutamic acid, cysteine, and glycine. It is one of the strongest antioxidants in the body and important for adjusting immune function. Cystine and theanine (γ-glutamylethylamide) provide substrates of GSH, cysteine and glutamic acid, promoting the synthesis of GSH. It has been reported that the ingestion of cystine (700 mg) and theanine (280 mg) exhibits inhibitory effects against excess inflammation after strong exercise loads in athletes, based on which its application for invasive surgery has been tried. In patients undergoing gastrectomy, ingestion of cystine (700 mg) and theanine (280 mg) for 10 days from 5 days before surgery inhibited a postoperative increase in resting energy expenditure, promoted recovery from changes in interleukin-6, C-reactive protein, lymphocyte ratio, and granulocyte ratio and inhibited an increase in body temperature. In a mouse small intestine manipulation model, preoperative 5-day administration of cystine/theanine inhibited a postoperative decrease in GSH in the small intestine and promoted recovery from a decrease in behavior quantity. Based on the above, cystine/theanine reduces surgical stress, being useful for perioperative management as stress-reducing amino acids.

Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis.

Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL. We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis. A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate. These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.