Preoperative Impairment Research Articles

Geriatric co-management leads to safely performed cytoreductive surgery in older women with advanced stage ovarian cancer treated at a tertiary care cancer center

ObjectiveTo assess fitness and outcomes in older women undergoing cytoreductive surgery for advanced ovarian cancer (OC). MethodsA prospective study of OC patients referred to Geriatrics Clinic for preoperative evaluation. All completed the electronic Rapid Fitness Assessment (eRFA) and were followed by Geriatrics Service during inpatient postoperative course, co-managed by Surgical Service. Outcomes were 30-day Intensive Care Unit (ICU) admission, emergency room (ER) visit, readmission, mortality, adverse surgical events. Descriptive statistics were used. ResultsForty-two women (median age 79, range 74–88), 38 with newly diagnosed advanced OC, 4 with recurrent OC, underwent cytoreductive surgery between 5/2015 and 1/2018. Preoperative age-related impairments per eRFA: high level of distress (71%), functional dependency (59%), limited social activity (59%), depression (57%), slow Time Up and Go (54%), Karnofsky Performance Score (KPS) ≤ 80 (41%), poor social support (43%), polypharmacy (35%), weight loss>10 lbs. (25%), fall history (244%), cognitive impairment (13%). Median number of comorbid conditions = 3.Among 38 newly diagnosed women, 26 (68%) had stage IIIC, 11 (29%) stage IV. Sixteen (42%) underwent primary debulking surgery, 22 (58%) neoadjuvant chemotherapy followed by interval debulking surgery. Median duration of surgery = 245.5 min (range 95–621); median hospital length of stay = 6 days (range 0–22). Optimal debulking rate = 97%, complete gross resection rate = 63%. One patient was admitted to ICU, 26% had 30-day ER visit, 10% were readmitted. Any complication, minor complication, major complication occurred in 58%, 55%, 8%, respectively. Median time from surgery to postoperative chemotherapy = 34.5 days (range 19–66). Median follow-up = 15.7 months (range 3.7–38.0), 12-month survival = 93.3%. There was no 180-day mortality. ConclusionCytoreductive surgery among older women with advanced OC and frailty can be performed safely in a tertiary care center with preoperative/postoperative geriatric and surgical co-management.

Compound Muscle Action Potential Amplitude Predicts the Severity of Cubital Tunnel Syndrome

Cubital tunnel syndrome has a spectrum of presentations ranging from mild paresthesias to debilitating numbness and intrinsic atrophy. Commonly, the classification of severity relies on clinical symptoms and slowing of conduction velocity across the elbow. However, changes in compound muscle action potential (CMAP) amplitude more accurately reflect axonal loss. We hypothesized that CMAP amplitude would better predict functional impairment than conduction velocity alone. A retrospective cohort of patients who underwent a surgical procedure for cubital tunnel syndrome over a 5-year period were included in the study. All patients had electrodiagnostic testing performed at our institution. Clinical and electrodiagnostic variables were recorded. The primary outcome was preoperative functional impairment, defined by grip and key pinch strength ratios. Multivariable regression identified which clinical and electrodiagnostic variables predicted preoperative functional impairment. Eighty-three patients with a mean age of 57 years (75% male) were included in the study. The majority of patients (88%) had abnormal electrodiagnostic studies. Fifty-four percent had reduced CMAP amplitude, and 79% had slowing of conduction velocity across the elbow (recorded from the first dorsal interosseous). On bivariate analysis, older age and longer symptom duration were significantly associated (p < 0.05) with reduced CMAP amplitude and slowing of conduction velocity across the elbow, whereas body mass index (BMI), laterality, a primary surgical procedure compared with revision surgical procedure, Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, and visual analog scale (VAS) scores for pain were not. Multivariable regression analysis demonstrated that reduced first dorsal interosseous CMAP amplitude independently predicted the loss of preoperative grip and key pinch strength and that slowed conduction velocity across the elbow did not. Reduced first dorsal interosseous amplitude predicted preoperative weakness in grip and key pinch strength, and isolated slowing of conduction velocity across the elbow did not. CMAP amplitude is a sensitive indicator of axonal loss and an important marker of the severity of cubital tunnel syndrome. It should be considered when counseling patients with regard to their prognosis and determining the necessity and timing of operative intervention. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Oxygenation impairment in patients with acute aortic dissection is associated with disorders of coagulation and fibrinolysis: a prospective observational study.

Stanford type-A acute aortic dissection (AAD) is typically accompanied by oxygenation impairment before surgery. In addition, inflammation, coagulation and fibrinolysis also impair blood oxygenation. However, our understanding of the concentration of these factors in bronchoalveolar lavage fluid (BALF) has not been reported. The objective of the study was to investigate the impact of preoperative acute lung injury (ALI) on postoperative oxygenation impairment and to explore the effect of coagulation and fibrinolysis in blood and BALF. This investigation utilized a prospective observational study design, which was registered at www.clinicaltrials.gov (identifier NCT01894334). The study included 53 patients undergoing surgery for Stanford type-A AAD at an academic hospital in China between October 2013 and July 2014. Preoperative ALI was identified according to the oxygenation index calculated by the PaO2/FiO2 ratio. The subjects were divided into the ALI group (oxygenation index ≤300 mmHg) or the control group (oxygenation index >300 mmHg). The primary outcome was patient oxygenation index, while secondary outcomes were concentrations of tissue factor (TF), tissue factor pathway inhibitor (TFPI), and plasminogen activator inhibitor-1 (PAI-1) in serum and BALF. The incidence of preoperative ALI for Stanford type-A AAD patients was 41.5%. Stanford type-A AAD patients with preoperative ALI had a lower postoperative oxygenation index (104.6±31.7 vs. 248.7±48.0 mmHg, P<0.001), higher concentrations of TF in serum and BALF (F=133.67, P<0.001; F=68.14, P<0.001), higher concentrations of TFPI in serum and BALF (F=31.98, P<0.001; F=45.58, P<0.001), and higher concentrations of PAI-1 in serum and BALF (F=213.88, P<0.001; F=107.95, P<0.001) when compared with those without preoperative ALI. Type-A AAD patients also showed a greater loss of blood (1,524±458 vs. 1,175±327 mL, P=0.040), longer mechanical ventilation time in the ICU (27.24±8.37 vs. 17.33±7.36 h, P<0.001), longer total stay in the ICU (42.27±10.85 vs. 33.45±9.05 h, P=0.002), and longer total hospital stay (17.77±5.00 vs. 13.48±3.97 days, P=0.001). Multivariate linear regression analysis indicated that preoperative PAI-1 in BALF, and TF in both serum and BALF were significantly associated with preoperative oxygenation impairment in patients with Stanford type-A AAD. Preoperative ALI caused more serious postoperative oxygenation impairment for Stanford type-A AAD, and coagulation and fibrinolysis appear to play critical roles in this process. Preoperative PAI-1 in BALF and TF in both serum and BALF were significant factors related to the occurrence of preoperative oxygenation impairment for Stanford type-A AAD.

Speech intelligibility in patients with oral cancer: An objective baseline evaluation of pretreatment function and impairment.

This study seeks to identify those factors that influence the pre-therapeutic speech intelligibility in patients with oral squamous cell carcinoma (OSCC). A group of 172 patients (125 males, 47 females, mean age = 61 ± 11 a) with different OSCC stages ranging from T1 to T4 and N0 to N2 was examined for their speech intelligibility using a computerized measuring tool, and compared to a healthy reference group (30 males, 10 females, mean age = 59 ± 12 a). It was found that the pre-therapeutic speech intelligibility in patients with OSCC is decreased when compared to a healthy collective. Two demographic factors that influence speech intelligibility could be identified: sex and age. It was determined that the only disease-related factor that influences speech intelligibility before therapy is the location of the tumor. The results of this study reveal that a preoperative speech intelligibility impairment in patients suffering from OSCC occurs independent of tumor stage, size of the tumor and infiltration status.

The Computerized General Neuropsychological INPH Test revealed improvement in idiopathic normal pressure hydrocephalus after shunt surgery.

The Computerized General Neuropsychological INPH Test (CoGNIT) provides the clinician and the researcher with standardized and accessible cognitive assessments in patients with idiopathic normal pressure hydrocephalus (INPH). CoGNIT includes tests of memory, executive functions, attention, manual dexterity, and psychomotor speed. Investigations of the validity and reliability of CoGNIT have been published previously. The aim of this study was to evaluate CoGNIT's sensitivity to cognitive change after shunt surgery in patients with INPH. Forty-one patients with INPH (median Mini-Mental State Examination score 26) were given CoGNIT preoperatively and at a postoperative follow-up 4 months after shunt surgery. Scores were compared to those of 44 healthy elderly control volunteers. CoGNIT was administered by either a nurse or an occupational therapist. Improvement after shunt surgery was seen in all cognitive domains: memory (10-word list test, p < 0.01); executive functions (Stroop incongruent color and word test, p < 0.01); attention (2-choice reaction test, p < 0.01); psychomotor speed (Stroop congruent color and word test, p < 0.01); and manual dexterity (4-finger tapping, p < 0.01). No improvement was seen in the Mini-Mental State Examination score. Preoperative INPH test scores were significantly impaired compared to healthy control subjects (p < 0.001 for all tests). In this study the feasibility for CoGNIT to detect a preoperative impairment and postoperative improvement in INPH was demonstrated. CoGNIT has the potential to become a valuable tool in clinical and research work.Clinical trial registration no.: NCT01618500 (clinicaltrials.gov).

Do preoperative patient-reported outcomes predict hospital length of stay for surgically-treated end-stage ankle osteoarthritis patients?

BackgroundEnd-stage ankle arthritis is often debilitating, associated with diminished mobility, pain, and reduced health related quality of life. Direct hospital costs of AA and TAA differ, with hospital length of stay being a major contributor. The objective of this study is to test the association between four patient-reported outcome measures with hospital length of stay, potentially important for preoperative planning and care. MethodsThis study is based on a prospective cohort of patients scheduled for AA or TAA for end-stage ankle arthritis in the Vancouver Coastal Health authority, Canada. Participants completed a condition-specific instrument, the AOS, and three generic instruments, the PHQ-9, PEG and EQ-5D(3L) shortly after being scheduled for surgery. Multivariate mixed-effects Poisson regression models were used to measure the association between preoperative patient-reported outcome measures and length of stay. ResultsAmong the 183 patients eligible to participate, the participation rate was 48.5%. There were 89 participants. Participants reported a high level of preoperative ankle impairment and pain. The adjusted results found no relationship between the AOS, EQ-5D(3L) VAS or PHQ-9 values and participants’ LOS. Participants with at least one chronic health condition and lowest SES category had longer LOS. ConclusionsThis study found no evidence of an association between four PROs collected prior to AA or TAA with hospital LOS. This finding suggests collecting these PROs preoperatively may not help with discharge planning.

Evaluation of Parotid Gland Function Before and After Endoscopy-Assisted Stone Removal

To quantify gland function before and after endoscopy-assisted lithectomy for patients with parotid stones and to analyze correlations among different evaluation modalities. This study investigated 58 patients (27 men and 31 women) with a stone larger than 5mm or multiple parotid stones who underwent successful endoscopy-assisted surgery at the authors' center from August 2007 through September 2017. Meticulous postoperative manipulations were administered routinely for 3 to 6months to promote functional recovery of the affected gland. Glandfunction was evaluated preoperatively and 6 to 36months (mean, 12months) postoperatively by sialography, scintigraphy, and sialometry. Statistical analyses were conducted to quantify gland function recovery and to distinguish correlations among the 3 objective tests. Preoperative sialograms exhibited ductal ectasia at the stone site with ductal stenosis anterior to the stone (n=53) or duct interruption at the stone site (n=5). Postoperative sialograms of 45 patients without stones were categorized as approximately normal (type I; n=17); showing ectasia or stenosis of the main duct without persistent contrast on the functional film (type II; n=16); showing ectasia or stenosis of the main duct with mild contrast retention (type III; n=6); or showing poor ductal shape with evident contrast retention (type IV; n=6). Scintigraphy of 23 preoperative and 12 postoperative patients and sialometry of 24 preoperative and 12 postoperative patients indicated severe preoperative impairment and postoperative improvement of gland function. Postoperatively, although no relevant differences in saliva flow rate were found between the 2 sides, scintigraphy showed lower function of the affected gland compared with the control side. Statistical data showed positive correlations among the 3 methods. Sialography intuitively reflected the ductal shape, whereas sialometry and scintigraphy were more sensitive for evaluating gland function. For patients with parotid stones, minimally invasive endoscopic surgery and meticulous postoperative manipulations help preserve the glands and facilitate recovery of gland function. The 3 evaluating modalities have certain positive correlations.

Trochlear Nerve Repair during Retrosigmoid Suprameatal Approach for Petrotentorial Meningioma: Operative Video.

When operating on difficult skull base lesions, it is essential to be able to handle unexpected intraoperative findings or troubles, while achieving maximal lesion removal and minimal functional deficit. This video demonstrates a case of trochlear nerve repair that was performed during the retrosigmoid suprameatal approach for treatment of a petrotentorial meningioma, extending into the Meckel's cave. The patient is a 47-year-old woman with a right petrotentorial meningioma, extending into the Meckel's cave. The retrosigmoid suprameatal approach was performed with preservation of the superior petrosal vein. However, a divided trochlear nerve was incidentally found during tumor resection. We hence carefully dissected both nerve ends from the tumor without shortening their lengths, and repaired them by end-to-end anastomosis, using fibrin glue without any graft materials. The tumor was removed completely and the patient's preoperative facial sensory impairment disappeared after the surgery. The patient's facial sensory impairment disappeared completely, but she had transient diplopia after the surgery. However, the newly developed diplopia resolved completely, and she had no neurological deficits or tumor recurrence during the follow-up period of 1-year. The link to the video can be found at: https://youtu.be/g-B-w_zDudg .

Factors influencing early postoperative complications following surgery for symptomatic spinal metastasis: a single-center series and multivariate analysis.

Patients presenting with neurological deficits and/or pain due to spinal metastasis usually require immediate or subacute surgical treatment. Nevertheless, it is unclear whether or not side effects of primary cancer location might influence postoperative complication rate. We therefore analyzed our spinal database to identify factors influencing early postoperative complications after surgery for symptomatic spinal metastases. From 2013 to 2017, 163 consecutive patients suffering from symptomatic spinal metastases were treated at our department. Early postoperative complications were defined as any postoperative event requiring additional medical or surgical treatment within 30days of spinal surgery. A multivariate regression analysis was performed to identify independent predictors for postoperative complications after surgery for spinal metastasis. Overall, 39 of 163 patients who underwent spinal surgery for spinal metastasis developed early postoperative complications throughout the treatment course (24%). Preoperative ASA score ≥ 3 (p = 0.003), preoperative C-reactive protein level > 10mg/l (p = 0.008), preoperative Karnofsky Performance Score < 60% (p = 0.03), radiation treatment within 2months of surgery (p = 0.01), presence of diabetes mellitus (p = 0.008), and preoperative complete neurological impairment (p = 0.04) were significant and independent predictors for early postoperative complications in patients with surgery for spinal metastasis. The ability to preoperatively predict postoperative complication risk is valuable to select critically ill patients at higher risk requiring special attention. Therefore, the present study identified several significant and independent risk factors for the development of early postoperative complication in patients who underwent surgery for spinal metastasis.

Assessment of the Cerebral Hemodynamic Benefits of Carotid Artery Stenting for Patients with Preoperative Hemodynamic Impairment Using Cerebral Single Photon Emission Computed Tomography (SPECT) and Carbon Dioxide Inhalation.

BackgroundThe aim of this study was to evaluate the effects of carotid artery angioplasty and carotid artery stenting (CAS) on cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) in patients with preoperative cerebrovascular hemodynamic impairment.Material/MethodsSeventeen patients with unilateral severe internal carotid artery (ICA) stenosis and ipsilateral CVR impairment underwent CAS. CBF and CVR were measured by single photon emission computed tomography (SPECT) with inhalation of carbon dioxide (CO2) one week before and three months after CAS. Sixty-eight ROIs in the middle cerebral artery (MCA) territory were analyzed in 17 patients.ResultsBefore CAS, CVR was impaired in all ROIs. CBF was impaired in 16 ROIs (23.5%). The percentage of ROIs with impaired CBF was significantly increased in patients with ≥90% carotid artery stenosis (p=0.047) without collateral flow through the circle of Willis (p=0.005). CAS significantly increased CVR in ROIs with a normal preoperative CBF and impaired CVR, indicating mild hemodynamic impairment (0.9±6.7% vs. 4.9±8.6%) (p=0.014). CAS significantly increased CBF in ROIs with preoperative impaired CBF and impaired CVR, indicating severe hemodynamic impairment (79.1±7.5% vs. 86.7±10.0%) (p<0.001). Following CAS, ROIs with normal CBF and impaired CVR had a significantly increased percentage of improved CVR (p=0.047); ROIs with impaired CBF and impaired CVR had a significantly increased percentage of improved CBF (p=0.027).ConclusionsThe severity of preoperative hemodynamic impairment, which is related to the degree of carotid artery stenosis and cerebral collateral flow, may influence hemodynamic benefits by CAS.

P32. Improved reliabilty of intraoperative language mapping through preoperative nTMS and baseline linguistic scores

Objective Repetitive navigated transcranial magnetic stimulation (rnTMS) and direct cortical stimulation (DCS) during awake surgery are complementary tools to locate speech functional areas of the brain. However, patients show inter-individual differences in their preoperative linguistic capabilities, which can impact the validity of intraoperative DSC mapping. We developed a standardized approach which utilizes preoperative aphasia scores and rnTMS to screen patients for their capability to perform reliable object naming during awake surgery. Methods We prospectively included 18 patients with language-eloquent brain tumors, scheduled for awake surgery. Aachen Aphasia Score (AAS), Demtect Score (DS) and Berlin Aphasia Score (BAS) were used to evaluate linguistic eloquence of each patient preoperatively. Moreover, all patients underwent 3 runs of naming all objects without rnTMS (baseline run), from which only promptly and correctly named objects were retained for later rnTMS mapping. These selected objects were also used for the intraoperative baseline testing and DCS mapping under level 2 of Ramsay Sedation Score. Results The degree of preoperative language impairment significantly correlated with the incidence of errors during preoperative as well as intraoperative baseline errors (AAT p = 0.01, BAS p = 0.001, DS = 0.001). Patients with significant aphasia (BAS >=2, AAT >=1) and cognitive impairment (DS >=2) committed over 50% of incorrect or delayed namings in the preoperative baseline (p = 0.001). Despite utilizing only the images retained after preoperative baseline naming, these patients still made significantly more mistakes during intraoperative baseline naming than patients with less severe aphasia. Moreover, the dosage of anaesthetic medication significantly correlated with the incidence of errors during intraoperative baseline naming (propofol p = 0.028, remifentanil p = 0.036), despite stopping all systemic analgetic and sedative medication at least 8 min before testing. Conclusion Patients with significant aphasia (BAS >=2, AAT >=2) and cognitive impairment (DS >=2) are not able to perform reliable intraoperative object naming and are therefore not suited for this procedure. In addition, dosages of analgetic and sedative medication during craniotomy should be kept as low as possible to allow for reliable intraoperative cognitive testing.

Lower Extremity Motor Function Following Complex Adult Spinal Deformity Surgery: Two-Year Follow-up in the Scoli-RISK-1 Prospective, Multicenter, International Study.

Background:The reported neurologic complication rate following surgery for complex adult spinal deformity (ASD) is variable due to several factors. Most series have been retrospective with heterogeneous patient populations and use of nonuniform neurologic assessments. The aim of this study was to prospectively document lower extremity motor function by means of the American Spinal Injury Association (ASIA) lower extremity motor score (LEMS) before and through 2 years after surgical correction of complex ASD.Methods:The Scoli-RISK-1 study enrolled 272 patients with ASD, from 15 centers, who had undergone primary or revision surgery for a major Cobb angle of ≥80°, corrective osteotomy for congenital spinal deformity or as a revision procedure for any type of deformity, and/or a complex 3-column osteotomy.Results:One of 272 patients lacked preoperative data and was excluded from the analysis, and 62 (22.9%) of the remaining 271 patients, who were included, lacked a 2-year postoperative assessment. Patients with no preoperative motor impairment (normal LEMS group; n = 203) had a small but significant decline from the mean preoperative LEMS value (50) to that at 2 years postoperatively (49.66 [95% confidence interval = 49.46 to 49.85]; p = 0.002). Patients who did have a motor deficit preoperatively (n = 68; mean LEMS, 43.79) had significant LEMS improvement at 6 months (47.21, p < 0.001) and 2 years (46.12, p = 0.003) postoperatively. The overall percentage of patients (in both groups combined) who had a postoperative LEMS decline, compared with the preoperative value, was 23.0% at discharge, 17.1% at 6 weeks, 9.9% at 6 months, and 10.0% at 2 years.Conclusions:The percentage of patients who had a LEMS decline (compared with the preoperative score) after undergoing complex spinal reconstructive surgery for ASD was 23.0% at discharge, which improved to 10.0% at 2 years postoperatively. These rates are higher than previously reported, which we concluded was due to the prospective, strict nature of the LEMS testing of patients with these challenging deformities.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Complications in Posterior Spinal Fusion Surgery for Neuromuscular Scoliosis.

Introduction Patients with neuromuscular disorders sometimes show progressive spinal scoliosis. The surgery for neuromuscular scoliosis (NMS) has high rates of complications. In this study, we elucidated the perioperative complications in patients with NMS. Methods We included 83 patients with NMS (58 boys and 25 girls; 61 with muscular dystrophy, 18 with spinal muscular atrophy, and 4 others) who had undergone posterior fusion surgery for scoliosis. We evaluated the perioperative complications (within 3 months), age at time of surgery, operative time, blood loss, preoperative %VC and FEV1.0 (%) for pulmonary function, and preoperative ejection fraction (EF) for cardiac function. Results There were 5 (6%) major complications, including pneumonia and a cardiovascular complication requiring intensive care unit (ICU) care, and 15 (18%) minor complications including viral enteritis and a urinary tract infection. Overall, there were 20 (24%) complications. Three of the 5 major complications were pulmonary. The mean age at the time of surgery was 13.7 y, operative time was 304 min, and blood loss was 1530 ml. The mean preoperative %VC was 41%, FEV1.0 was 91%, and EF was 60%. When we separated the patients into a group with major complications (n = 5) and a group without major complications (n = 78), the preoperative %VC in the group with major complications (23%) was significantly lower than that in the group without (42%) (p < 0.05). However, operative time, blood loss, preoperative FEV1.0 (%) and EF between the two groups were not significantly different (p > 0.05). Conclusions Compared with the previous findings of the perioperative complication rate (45%-74%) for NMS, the complication rate was remarkably low in this case series. Because of advances in medical skills, including anesthesia and surgical instruments, surgery for NMS appears to be safe. However, patients with NMS with complications demonstrated severe restrictive ventilatory impairment preoperatively. Therefore, we should be vigilant for perioperative pulmonary complications especially in patients with NMS and preoperative severe restrictive ventilatory impairment.

Mapping of Arithmetic Processing by Navigated Repetitive Transcranial Magnetic Stimulation in Patients with Parietal Brain Tumors and Correlation with Postoperative Outcome.

Preserving functionality is important during neurosurgical resection of brain tumors. Specialized centers also map further brain functions apart from motor and language functions, such as arithmetic processing (AP). The mapping of AP by navigated repetitive transcranial magnetic stimulation (nrTMS) in healthy volunteers has been reported. The present study aimed to correlate the results of mapping AP with functional patient outcomes. We included 26 patients with parietal brain tumors. Because of preoperative impairment of AP, mapping was not possible in 8 patients (31%). We stimulated 52 cortical sites by nrTMS while patients performed a calculation task. Preoperatively and postoperatively, patients underwent a standardized number-processing and calculation test (NPCT). Tumor resection was blinded to nrTMS results, and the change in NPCT performance was correlated to resected AP-positive spots as identified by nrTMS. The resection of AP-positive sites correlated with a worsening of the postoperative NPCT result in 12 cases. In 3 cases, no AP-positive sites were resected and the postoperative NPCT result was similar to or better than preoperatively. Also, in 3 cases, the postoperative NPCT result was better than preoperatively, although AP-positive sites were resected. Despite presenting only a few cases, nrTMS might be a useful tool for preoperative mapping of AP. However, the reliability of the present results has to be evaluated in a larger series and by intraoperative mapping data.

Oxygenation impairment after total arch replacement with a stented elephant trunk for type-A dissection

ObjectiveTo study the risk factors of oxygenation impairment in patients with type-A acute aortic dissection who underwent total arch replacement with a stented elephant trunk. MethodsIn this study, 169 consecutive patients were enrolled who were diagnosed with type-A acute aortic dissection and underwent a total arch replacement procedure at the Qilu Hospital of Shandong University between January 2015 and February 2017. Postoperative oxygenation impairment was defined as arterial oxygen partial pressure/inspired oxygen fraction ≤ 200 with positive end expiratory pressure ≥ 5 cm H2O that occurred within 72 hours of surgery. Perioperative clinical characteristics of all patients were collected and univariable analyses were performed. Risk factors associated with oxygenation impairment identified by univariable analyses were included in the multivariable regression analysis. ResultsThe incidence of postoperative oxygenation impairment was 48.5%. Postoperative oxygenation impairment was associated with prolonged mechanical ventilation time, intensive care unit stay, and hospital stay. Multivariable regression analysis demonstrated that body mass index (odds ratio [OR], 1.204; 95% confidence interval [CI], 1.065-1.361; P = .003), preoperative oxygenation impairment (OR, 9.768; 95% CI, 4.159-22.941; P < .001), preoperative homocysteine (OR, 1.080; 95% CI, 1.006-1.158; P = .032), circulatory arrest time (OR, 1.123; 95% CI, 1.044-1.207; P = .002), and plasma transfusion (OR, 1.002; 95% CI, 1.001-1.003; P = .002) were significantly associated with postoperative oxygenation impairment. ConclusionsPostoperative oxygenation impairment is a common complication of surgery for type-A acute aortic dissection. Body mass index, preoperative oxygenation impairment, preoperative homocysteine, circulatory arrest time, and plasma transfusion were independent risk factors for oxygenation impairment after a total arch replacement procedure.

Quality of Life After Craniovertebral Junction Meningioma Resection: Shaping the Real Neurologic and Functional Expectancies About These Surgeries in a Contemporary Large Multicenter Experience.

Craniovertebral junction (CVJ) meningiomas are one of the most surgically complex conditions in neuro-oncologic surgery. The aim of this work is to correlate our data with clinical outcome to outline factors leading to a worse functional prognosis. We analyzed sex, age, clinical presentation, topography, surgical approach, Simpson grade resection, postoperative lower cranial nerve deficits, consistency, histology, site of origin, presence of a capsule, and radiologic and clinical follow-up at 1, 6, and 12 months of 61 patients affected by CVJ meningiomas, operated on in our institution from 1992 to2014. 78.7% of patients were women (mean age, 52.85 years); the onset symptom was pain in 65.5% of cases. The mean preoperative Nurick grade of the sample was 3.78; the most frequent histologic type was endotheliomatous (42.8%). We treated 22 patients with a posterior median approach (5 with lateral and 17 with posterolateral axial topography); in 39 cases (30 anterolateral and 9 anterior) we performed a posterolateral approach. Gross total removal was achieved in 85.2% of cases. We recorded a final follow-up step overall neurologic improvement in the cohort (average preoperative Nurick grade, 3.81, and at 12 months, 2.13). Twenty-nine patients presented with lower cranial nerve deficit (permanent or transient) and no statistically significant association was found between surgical approach and temporary or permanent postoperative complications. We selected, in our experience, some predictors of worse outcome: preoperative sphincter impairment, absence of a capsule, cranial site of origin, a poor preoperative functional status, and firm consistency of the tumor.

Lateral supraorbital approach for microsurgical resection of olfactory groove meningiomas

Objective To investigate the safety and efficacy of the application of lateral supraorbital (LSO) approach for microsurgical resection of olfactory groove meningiomas. Methods Between January 2013 and December 2016, 20 patients with olfactory groove meningiomas underwent surgery through LSO approach at Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine. Their clinical data, surgical treatment and outcomes were analyzed retrospectively. Neuroradiological findings, improvement of symptoms and some relevant evaluation scales were used to assess the efficacy and safety of LSO for resection of olfactory groove meningiomas. Results Six patients had Simpson grade Ⅰ resection, 12 had Simpson grade Ⅱ grade resection and 2 had Simpson grade Ⅳ resection. The mean operation time was 204.8±77.4 min and the mean intraoperative blood loss was 192.5±109.2 ml. Four patients developed fever post operation, 1 had psychiatric symptoms, 1 had disturbance of consciousness, 1 had cerebral edema, and 1 developed seizure. No incision infection or cerebrospinal fluid rhinorrhea occurred. Post surgery, 2 out of 8 patients with preoperative impairment of olfactory function obtained symptomatic improvement. Among the 4 patients with vision impairment, 2 achieved improvement, 1 remained the same and 1 reported aggravation. During the follow-up of 19 patients lasting 3-40 months with an average of 16.4±9.7 months, favorable outcomes were reported in 16 cases, severe disability in 1 and tumor recurrence in 2. There was no death. Conclusion Microsurgery through LSO approach demonstrates advantages in resection of olfactory groove meningiomas including shorter operative duration, less invasiveness, and low morbidity and mortality, which is thus worthy of recommendation. Key words: Meningioma; Microsurgery; Lateral supraorbital approach; Treatment outcome

Predictive Role of Serum Cytokine Profiles in Acute Kidney Injury after Living Donor Liver Transplantation.

Introduction Previous studies have shown that a higher serum interleukin- (IL-) 6 level is associated with a higher risk of acute kidney injury (AKI) development after major nontransplant surgery. Our study investigated the potential association of preoperative serum cytokine profiles with new AKI development in patients who underwent living donor liver transplantation (LDLT). Methods Serum levels of cytokines IL-2, IL-6, IL-10, IL-12, and IL-17, interferon-γ, and tumor necrosis factor- (TNF-) α were measured in 226 LDLT recipients preoperatively and analyzed retrospectively. Recipients with a preoperative functional impairment of the kidney were excluded. AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Results In a univariate regression model, IL-6, IL-17, and TNF-α levels showed an association with AKI development after LDLT. Multivariate analysis showed an independent association of the preoperative serum IL-6 level with AKI development after LDLT and a significant relationship between higher serum IL-6 levels and a greater likelihood of developing AKI. Serum IL-6 levels were higher in patients with stage 3 AKI than in patients who did not develop AKI. Conclusions Our results support the need for further investigations of IL-6 as a predictor of AKI development in patients undergoing LDLT.

Improvement in Cognitive Status and Depressive Symptoms Three Months after Cataract Surgery.

Background:Cataract induced vision impairment can lead to loss of older people’s independence and self-esteem and limit their daily activities. Moreover it has comorbid cognitive impairment and depression. Cataract surgery may be one way to attenuate these comorbidities. The aim of this study was to compare pre-operative and postoperative depressive symptoms and cognitive impairments of patients who underwent cataract surgery.Methods:This study was a before - after clinical trial. Participants completed the following validated surveys one day before and again three months after surgery. Dependent variables were preoperative to postoperative within-patient difference in Geriatric Depression Scale (GDS) and Mini-Mental State Examination (MMSE) scores. Independent variable was improvement of visual acuity.Results:Mean age was 71.77±8.08, 54% were females. Mean postoperative visual acuity improvement was 0.7720±0.1758, mean GDS score difference was -1.49±1.72 and mean MMSE score difference was 0.28±0.88. Postoperative improvement of visual acuity, GDS and MMSE scores were statistically significant (p=0.001). The mean visual acuity improvement in the participants with age over 80 years was lower than the younger subjects; while improvement in MMSE scores in this age group was significantly higher than them. There were no significant relationship between visual acuity, GDS and MMSE scores before and after surgery based on BMI and educational level.Conclusions:It was concluded that cataract surgery is effective for relieving depressive symptoms in the elderly. Improved visual acuity at older ages has far more effects on reducing cognitive impairment.

Efficacy of intraoperative epidural triamcinolone application in lumbar microdiscectomy: a matched-control study.

OBJECTIVE The purpose of this study was to investigate whether the intraoperative application of an epidural steroid (ES) on the decompressed nerve root improves short- and midterm subjective and objective clinical outcomes after lumbar microdiscectomy. METHODS This study was a retrospective analysis of a 2-center database including consecutive cases in which patients underwent lumbar microdiscectomy. All patients who received ES application (40 mg triamcinolone, ES group) were matched by age and sex to patients who had not received ES application (control group). Objective functional impairment (OFI) was determined using age- and sex-adjusted T-scores of the Timed Up and Go (TUG) test. Back and leg pain (visual analog scale), functional impairment (Oswestry Disability Index [ODI], Roland-Morris Disability Index [RMDI], and health-related quality of life (hrQoL; 12-Item Short Form Health Survey [SF-12] physical component summary [PSC] score and EuroQol [EQ-5D index]) were measured at baseline, on postoperative day 3, and at postoperative week 6. RESULTS Fifty-three patients who received ES application were matched with 101 controls. There were no baseline demographic or disease-specific differences between the study groups, and preoperative pain, functional impairment, and hrQoL were similar. On postoperative day 3, the ES group had less disability on the RMDI (mean 7.4 vs 10.3, p = 0.003) and higher hrQoL as determined by the SF-12 PCS (36.5 vs 32.7, p = 0.004). At week 6, the ES group had less disability on the RMDI (3.6 vs 5.7, p = 0.050) and on the ODI by trend (17.0 vs 24.4, p = 0.056); better hrQoL, determined by the SF-12 PCS (44.3 vs 39.9, p = 0.018); and lower OFI (TUG test T-score 100.5 vs 110.2, p = 0.005). The week 6 responder status based on the minimum clinically important difference (MCID) was similar in the ES and control groups for each metric. The rates and severity of complications were similar, with a 3.8% and 4.0% reoperation rate in the ES group and control group, respectively (p = 0.272). There was a tendency for shorter hospitalization in the ES group (5.0 vs 5.8 days, p = 0.066). CONCLUSIONS Intraoperative ES application on the decompressed nerve root is an effective adjunct treatment that may lower subjective and objective functional impairment and increase hrQoL in the short and intermediate term after lumbar microdiscectomy. However, group differences were lower than the commonly accepted MCIDs for each metric, indicating that the effect size of the benefit is limited. ■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: retrospective cohort trial; evidence: Class II.