Risk Of Severe Complications Research Articles

Cellular Bone Matrix in Spine Surgery - Are They Worth the Risk: A Systematic Review.

Systematic Review. To review the literature for complications and outcomes after the implantation of cellular bone matrix (CBM) during spine fusion. The PubMed database was queried from inception to January 31, 2023 for any articles that discussed the role of and identified a specific CBM in spinal fusion procedures. Adverse events, reoperations, methods, and fusion rates were collected from all studies and reported. Six hundred articles were identified, of which 19 were included that reported outcomes of 7 different CBM products. Seven studies evaluated lumbar fusion, 11 evaluated cervical fusion, and 1 study reported adverse events of a single CBM product. Only 4 studies were comparative studies while others were limited to case series. Fusion rates ranged from 68% to 98.7% in the lumbar spine and 87% to 100% in the cervical spine, although criteria for radiographic fusion was variable. While 7 studies reported no adverse events, there was no strict consensus on what constituted a complication. One study reported catastrophic disseminated tuberculosis from donor contaminated CBM. The authors of 14 studies had conflicts of interest with either the manufacturer or distributor for their analyzed CBM. Current evidence regarding the use of cellular bone matrix as an osteobiologic during spine surgery is weak and limited to low-grade non-comparative studies subject to industry funding. While reported fusion rates are high, the risk of severe complications should not be overlooked. Further large clinical trials are required to elucidate whether the CBMs offer any benefits that outweigh the risks.

Evaluation of a stabilized RSV pre-fusion F mRNA vaccine: Preclinical studies and Phase 1 clinical testing in healthy adults

Human respiratory syncytial virus (RSV) causes a substantial proportion of respiratory tract infections worldwide. Although RSV reinfections occur throughout life, older adults, particularly those with underlying comorbidities, are at risk for severe complications from RSV. There is no RSV vaccine available to date, and treatment of RSV in adults is largely supportive. A correlate of protection for RSV has not yet been established, but antibodies targeting the pre-fusion conformation of the RSV F glycoprotein play an important role in RSV neutralization. We previously reported a Phase 1 study of an mRNA-based vaccine (V171) expressing a pre-fusion-stabilized RSV F protein (mDS-Cav1) in healthy adults. Here, we evaluated an mRNA-based vaccine (V172) expressing a further stabilized RSV pre-fusion F protein (mVRC1). mVRC1 is a single chain version of RSV F with interprotomer disulfides in addition to the stabilizing mutations present in the mDS-Cav1 antigen. The immunogenicity of the two mRNA-based vaccines encoding mVRC1 (V172) or a sequence-optimized version of mDS-Cav1 to improve transcriptional fidelity (V171.2) were compared in RSV-naïve and RSV-experienced African green monkeys (AGMs). V172 induced higher neutralizing antibody titers than V171.2 and demonstrated protection in the AGM challenge model. We conducted a Phase 1, randomized, placebo-controlled, clinical trial of 25 μg, 100 μg, 200 μg, or 300 μg of V172 in healthy older adults (60–79 years old; N = 112) and 100 μg, 200 μg, or 300 μg of V172 in healthy younger adults (18–49 years old; N = 48). The primary clinical objectives were to evaluate the safety and tolerability of V172, and the secondary objective was to evaluate RSV serum neutralization titers. The most commonly reported solicited adverse events were injection-site pain, injection-site swelling, headache, and tiredness. V172 was generally well tolerated in older and younger adults and increased serum neutralizing antibody titers, pre-fusion F-specific competing antibody titers, and RSV F-specific T-cell responses.

Prognostic assessment of liver cirrhosis and its complications: current concepts and future perspectives.

Liver cirrhosis is an irreversible stage of chronic liver disease with varying clinical course. Acute decompensation of liver cirrhosis represents a watershed in prognosis and is characterized by the occurrence of clinical complications such as ascites, jaundice, hepatic encephalopathy, infections, or portal-hypertensive hemorrhages. Emergent data indicate that an acute decompensation can be subdivided into stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre-acute-on chronic liver failure (pre-ACLF) and acute-on chronic liver failure (ACLF), while the mortality risk varies greatly between the respective subgroups. ACLF is the most severe form of acutely decompensated cirrhosis and characterized by the development of organ failure(s) and a high short-term mortality. Due to the dynamic disease course of acute decompensation, it is paramount to detect patients at particular risk for severe complications those at high risk for developing ACLF as early as possible in order to initiate optimal management. This review describes new concepts and perspectives in the definition and classification of decompensated cirrhosis and provides on overview on emerging predictive scoring systems, non-invasive measurement methods and new biomarkers, which allow an early identification of patients with acute decompensation at risk.

Robotic management of isolated endometriosis of sciatic nerve: a reproducible approach that can guide through the labyrinth of pelvic neuroanatomy

To present the robotic, standardized, and reproducible surgical technique we routinely use in our center to manage isolated endometriosis of the sciatic nerve. Surgical video article. Tertiary referral center. A 36-year-old woman suffering from left-sided sciatica pain was diagnosed with an isolated endometriotic nodule of the left sciatic nerve at preoperative assessment. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus), and other applicable sites. Complete removal of the isolated endometriotic nodule of the sciatic nerve may be performed through a stepwise robotic approach. The surgery starts laterally with the opening of the iliolumbar space between the external iliac vessels and the psoas muscle, as well as the identification of the genitofemoral and obturator nerves. The lumbosacral trunk and emergence of the sciatic nerve were then identified medially and caudally to the obturator nerve. The surgery moves medially with the anterograde dissection of both the internal iliac artery and vein, which allows a safe approach to the posterior and medial limits of the nodule. Ligation of branches of internal iliac vessels directed toward the nodule may be necessary during this step. Isolation and ligation of obturator vessels are frequently required to obtain a bloodless dissection of the lateral limit of the nodule from the lateral pelvic wall. The complete removal of the nodule was then achieved using an alternating approach to all limits of the nodule previously identified, with subsequent release of the sciatic nerve. Description of the relevant pelvic neuroanatomy and the evaluation of robotic routes in the field of pelvic neurosurgery. The use of standardized techniques together with the advantages of a robotic route can make the radical excision of isolated endometriosis of the sciatic nerve reproducible, feasible, and safe. Because of the complexity of neuroanatomy and the risk of severe complications, this surgery remains challenging, and patients affected by deep infiltrating endometriosis involving retroperitoneal neural structures should be referred to multidisciplinary management in expert centers.

Post-viral idiopathic purpura fulminans is associated with inherited thrombophilia and anti-cardiolipin antibodies.

Idiopathic purpura fulminans (IPF) is a rare and severe coagulation disorder, associated with transient anti-protein S (anti-PS) antibodies in the context of post-viral infection such as varicella. Anti-protein S antibodies are frequently found in the context of varicella, in contrast with the rarity of IPF. Other factors such as anti-phospholipid antibodies (APL) and inherited thrombophilia may be associated with severe vascular complication. This is an ancillary study of a French multicenter retrospective series and systematic review of literature. We analyzed patients who were tested for inherited thrombophilia, namely antithrombin, protein C, protein S deficiency; prothrombin gene G20210A polymorphism (FII:G20210A),Factor V R506Q polymorphism (FV:R506Q); and/or for APL (lupus anticoagulant (LA), anti-cardiolipin antibodies (ACL), or anti-beta 2-GPI antibodies (Aβ2GP1). Among the 25 patients tested for inherited thrombophilia, 7 (28%) had positive results. Three had FV R506Q, two FII:G20210A, one compound heterozygote FV:R506Q associated to FII:G20210A, and one protein C deficiency. APL testing was performed in 32 patients. It was positive in 19 patients (59%): 17 ACL (53%), 5 LA (16%), 4 Aβ2GP1 (13%). The risk of severe complications was not associated with presence of inherited thrombophilia or APL presence, with RR: 0.8 [95% CI: 0.37-1.71], p = 1 and RR: 0.7 [95% CI: 0.33-1.51], p = 0.39, respectively. We found a high prevalence of inherited thrombophilia or APL in a population of patients with IPF. However, we do not find an association with the occurrence of severe vascular complications or venous thromboembolism.

DAA - directly acting antivirals - as a new, more efficient solution of the chronic hepatitis C treatment and theirs various application.

Introduction Cirrhosis is a condition in which the liver becomes fibrotic following damage to the liver and transforms the architecture of the organ into regenerative nodules. The disease is caused 30% by HCV infection, resulting in a risk of severe complications and death. Since the use of direct-acting antivirals ( DAAs) for the treatment of chronic HCV, sustained virological response (SVR) rates have begun to increase, even in treatment-resistant cases. Studies have also shown that DAAs may have applications in other viral diseases and even In the treatment of breast cancer. Aim of the study The purpouse of our study was to review scientific articles to show the efficiency and potential use of DAAs in the treatment of chronic HCV, and to identify possible directions for further research. Methods and materials We reviewed the English literature in the PubMed, using the key words: "simeprevir" ; "sofosbuvir" ; "velpatasvir" ; "telaprevir" ; "chronic hepatitis C". Results Studies have shown that the therapeutic regimens currently being designed with (DAAs) offer the possibility of treating almost the entire population with hepatitis C, while reducing side effects of interferon therapy such as increased AST, ALT activities, diarrhoea, vomiting, nausea and depression. They remain effective and tolerable, regardless of the stage of cirrhosis and associated serious co-morbidities. Analysis of studiem shows, that DAAs also show efficacy against other disease such as breast cancer, MRSA infections, SARS-CoV-2 or flavivirus infection. Conclusion All (DAAs) are effective in the treatment of patients with HCV, including cirrhosis. They result in significant improvements in prognosis and clinical outcomes. Promising results have been obtained in published data on the effect of DAAs against disease entities other than HCV, suggesting the rationale for future clinical trials to further the hypothesis of the increased potential of these drugs.

P216 Oral Budesonide and low serum albumin levels at surgery are associated with a higher risk of postoperative intra-abdominal septic complications after primary ileocecal resection for Crohn’s disease: a retrospective analysis of 853 consecutive patients treated in a tertiary centre.

Abstract Background Patients undergoing ileocecal resection for Crohn’s disease (CD) are at high risk of postoperative intra-abdominal septic complications (IASC). The associated risk factors are still debated. The aim of the study was to identify the variables associated with IASC in patients treated for primary CD of the terminal ileum. Methods Retrospective single-centre study including consecutive patients undergoing ileocecal resection for CD between 2004-2021 and managed before surgery in a multidisciplinary IBD unit. Outcomes to identify the variables associated with IASC (primary aim) and severe complications, classified as Clavien-Dindo grade 3 and higher (secondary aim). The potential independent predictors of each outcome were evaluated using logistic regression. To reduce overfitting, all models were built including only the variables that were significant at univariate analyses, except for age, gender and history of cardiovascular diseases, that were included a priori. Standard diagnostic procedures were adopted to check all models validity: influential observation analysis (Dbeta, change in Pearson chi-square), Hosmer-Lemeshow test for the goodness of fit and C statistic (area under the Receiving Operator Curve). Results A total of 853 patients were included. Overall sample characteristics are shown in Table 1. Table 2 and Table 3 reported the comparison according to the primary (IASC) and secondary (severe complications) outcomes, respectively. Table 4 showed the multivariate analyses of the potential predictors of IASC and severe complications. The onset of IASC was associated with lower serum albumin level (OR 1.81, 95% CI 1.15-2.94, p=0.011) and the use of oral budesonide at time of surgery (OR 2.07, 95% CI 1.12-3.83, p= 0.021). The risk of severe complications was associated with a history of cardiovascular disease (OR 2.91, 95% CI 1.08-7.84, p=0.03) and lower serum albumin level (OR 1.58, 95% CI 1.02-2.50, p=0.04). Conclusion The present study analysed a large population of patients affected by CD of the terminal ileum who were treated homogeneously before surgery in a multidisciplinary setting and confirmed the significant impact of preoperative nutritional status on the risk of severe postoperative complications and IASC. The latter, however, was also associated with the use of oral budesonide at the time of surgery. This finding has not been previously reported in the literature. Based on the present evidence, oral budesonide should be discontinued or tapered to the lowest dose before surgery.

Factors Affecting the Complication Rate of Septoplasty: Analysis of 1,506 Consecutive Cases of Single Surgeon.

Based on the analysis of a single surgeon's consecutive cases, we present the incidence of septoplasty complications and factors that contribute to the increased risk of complications. We retrospectively reviewed the medical records from 1,506 patients diagnosed with deviated nasal septum who underwent septoplasty by a single surgeon from January 2003 until May 2020. The incidence of different complications was investigated. Predisposing factors for specific complications were examined with univariate analysis. The average age of patients was 35 (11-76) years. Out of 1,506 patients, 1,252 were male, and 254 were female. The most frequent complication was insufficient correction (78 cases, 5.2%), and revision septoplasty was performed in 21 cases. We also reported 59 (3.9%), 55 (3.7%), 33 (2.2%), 20 (1.3%), and 18 (1.2%) cases of olfactory dysfunction, hematoma, synechia, abscess, and septal mucosal defect, respectively. Additionally, there were nine (0.6%), six (0.4%), five (0.3%), four (0.3%), and four (0.3%) cases of septal perforation, postoperative bleeding, saddle nose, chondritis, empty nose syndrome, respectively. The proportion of insufficient correction was higher in revision cases than in primary cases. Hematoma formation, abscess formation, and septal mucosal defect occurred more frequently in the bilateral flap elevation group. Olfactory dysfunction was significantly more frequent when the bony batten was inserted, while hematoma, abscess formation, and septal mucosal defect were more frequent when the cartilage batten was used. Septoplasty was associated with the risk of several complications, while complication rates were influenced by choice of surgical techniques and approaches.

Secretome of Mesenchymal Stromal Cells as a Possible Innovative Therapeutic Tool in Facial Nerve Injury Treatment.

Facial nerve palsy is a serious neurological condition that strongly affects patient everyday life. Standard treatments provide insufficient improvement and are burdened with the risk of severe complications, e.g., facial synkinesis. Mesenchymal stromal cell-based therapies are a novel and extensively developed field which offers new treatment approaches with promising results in regards to the nervous tissue regeneration. The potential of mesenchymal stromal cells (MSCs) to aid the regeneration of damaged nerves has been demonstrated in several preclinical models, as well as in several clinical trials. However, therapies based on cell transplantation are difficult to standardize in the manner similar to that of routine clinical practices. On the other hand, treatments based on mesenchymal stromal cell secretome harness the proregenerative features of mesenchymal stromal cells but relay on a product with measurable parameters that can be put through standardization procedures and deliver a fully controllable end-product. Utilization of mesenchymal stromal cell secretome allows the controlled dosage and standardization of the components to maximize the therapeutic potential and ensure safety of the end-product.

Side effects following COVID-19 vaccination in pediatric patients with sickle cell disease.

Vulnerable patient populations have seen decreased rates of vaccination against SARS-CoV2-19 (COVID-19) due to hesitancies and distrust, magnified by a paucity of data for certain populations. The rate of COVID-19 vaccination in children with sickle cell disease (SCD) remains low despite the risk for severe complications, resulting in continued infections and hospitalizations from COVID-19. We sought to describe vaccine reactions, including vaso-occlusive crises, emergency department visits, and hospitalizations, in children with SCD. Our findings will start to provide the necessary vaccine side effect data to inform patients, caregivers, and clinicians considering the COVID-19 primary vaccination series.

Open Abdominal Management Among Non-Trauma Patients: The Appropriate Duration and a New Clinical Index

Purpose: Despite widespread adoption of open abdominal management (OAM), there is currently no threshold criterion for OAM duration for non-trauma patients. Moreover, there is a positive relationship between morbidity and the duration of OAM, but an uncertain relationship with patients’ age. Therefore, a novel clinical index for the duration of open abdominal management (IDOM) was developed based on the patient’s age and risk of severe complications following OAM to indicate the maximum tolerable number of days of OAM based on the individual’s age. The utility of this new index was evaluated.Methods: This retrospective study included 65 non-trauma patients managed with an open abdomen (OA) from August 2015 to August 2018. The IDOM was developed based on the patient’s age. The result indicated the maximum number of OA days. Patients’ demographic and operative variables were examined and patient data was assigned to one of two groups according to whether the actual number of OA days was above or below the calculated IDOM. Prevalence of complications between these groups was compared. Measures of validity were employed to assess the utility of the IDOM for patient complications.Results: Sixty-five patients were included. The above-the calculated IDOM group exhibited a significantly longer OA and higher rates of wound complications and postoperative respiratory complications compared with the below the calculated IDOM group. The IDOM predicted the incidence of OA-related complications with a sensitivity of 72.4%, and a specificity of 80.6%.Conclusion: The IDOM is a potentially useful tool for appropriate duration at the outset of OA.

Necrotizing enterocolitis in preterm infants: state of the intestinal barrier, features of vitamin D metabolism and their regulation

The priority of the national health policy is to preserve the life and a high level of quality of life for every premature baby. The clinical focus is on children born with ELBW. Among this category of children, NEC makes the main contribution to the structure of infant mortality. Based on the analysis of the literature, the authors conclude that the study of cell markers that characterize different depths of damage to enterocytes allows: to assess the likelihood of developing NEC in infants with ELMT; conduct early diagnosis of NEC; rule out NEC in neonates with similar symptoms; predict the course of NEC; propose and substantiate personalized approaches to correcting the low supply of 25(OH)D; to analyze the influence of candidate genes on the implementation of NEC, its outcomes, and 25(OH)D metabolism. To assess damage at the level of the enterocyte, the authors selected the intestinal fraction of fatty acid binding protein (I-FABP) for literature analysis. To determine the depth of damage to intercellular junctions of the intestine - the expression of transmembrane (claudin-2, claudin-3, claudin-4, occludin) and cytoplasmic (zonulin) tight junction proteins. Analysis of the results of studies on the expression of fecal calprotectin, lipocalin-2 (LCN2) and eosinophilic neurotoxin, showing the activity of local inflammation, was carried out in order to assess both the risk of NEC and its course. Intestinal damage is associated with impaired 25(OH)D metabolism, and metabolic bone disease in preterm infants with damage to the intestinal barrier up to NEC is recorded ten times more often at the stage of nursing in the NICU. A huge number of studies have shown a decrease in survival, an increase in the risk of severe complications against the background of a low supply of 25(OH)D in the preterm population. The authors analyze the relationship between 25(OH)D availability, taking into account the influence of exogenous and endogenous factors, the nature of damage to the intestinal wall and the implementation of NEC, and focus on the existing preventive and therapeutic approaches to prescribing various doses of vitamin D in preterm infants with NEC.

Associations between smoking and clinical outcomes after total hip and knee arthroplasty: A systematic review and meta-analysis.

Smoking increases risk of several complications after total hip or knee arthroplasty (THA/TKA), so we systematically reviewed and meta-analyzed the literature to take into account all relevant evidence, particularly studies published since 2010. The PubMed, Ovid Embase, Web of Science, and EBSCOHost databases were searched and studies were selected and analyzed according to MOOSE recommendations. Methodological quality of included studies was assessed using the Newcastle-Ottawa Scale. Data were qualitatively synthesized or meta-analyzed using a random-effects model. A total of 40 studies involving 3,037,683 cases were included. Qualitative analysis suggested that smoking is associated with worse patient-reported outcomes within one year after surgery, and meta-analysis showed that smoking significantly increased risk of the following outcomes: total complications (OR 1.41, 95% CI 1.01-1.98), wound complications (OR 1.77, 95% CI 1.50-2.10), prosthetic joint infection (OR 1.84, 95% CI 1.52-2.24), aseptic loosening (OR 1.62, 95% CI 1.12-2.34), revision (OR 2.12, 95% CI 1.46-3.08), cardiac arrest (OR 4.90, 95% CI 2.26-10.60), cerebrovascular accident (OR 2.22, 95% CI 1.01-4.85), pneumonia (OR 2.35, 95% CI 1.17-4.74), acute renal insufficiency (OR 2.01, 95% CI 1.48-2.73), sepsis (OR 4.35, 95% CI 1.35-14.00), inpatient mortality (OR 12.37, 95% CI 4.46-34.28), and persistent opioid consumption (OR 1.64, 95% CI 1.39-1.92). Smoking patients undergoing THA and TKA are at increased risk of numerous complications, inpatient mortality, persistent opioid consumption, and worse 1-year patient-reported outcomes. Pre-surgical protocols for these outcomes should give special consideration to smoking patients.

S3344 The Hunt for the Lost Intragastric Balloon and Its Complications

Introduction: Obesity is a global pandemic on the rise, affecting about 40% of adults in the United States. There is a need for minimally invasive methods to aid current standard of care practices. The intragastric balloon (IGB) is a temporary therapy for weight loss, with the FDA approving several devices including the ObalonⓇ in the recent years. In 2021, AGA published clinical practice guidelines on Intragastric Balloons in the management of obesity. Serious adverse events are relatively rare in patients receiving IGB treatment, and include injury to the gastrointestinal (GI) tract, such as perforation (0.3%), esophageal mucosal injury (0.8%), gastric ulcer/bleeding (0.76%), and gastric outlet/bowel obstruction (0.12%). Case Description/Methods: A 47-year-old female with a medical history including two intragastric balloon placements (ObalonⓇ) one year ago, presented with severe acute abdominal pain. Patient’s BMI was 28 kg/m2. Routine labs were unremarkable and vitals were stable. Initial CT Abdomen/pelvis with contrast showed gastric and duodenal thickening; however, imaging failed to comment on a foreign object and location. A gastroscopy was performed subsequently showing one Obalon balloon found in the gastric fundus. The balloon was cut with a needle knife, collapsed and withdrawn with rat tooth forceps. To locate the second balloon, repeat imaging showed dilated bowel loops with a deflated ObalonⓇ lodged in the distal ileum, 7 centimeters proximal to ileocecal valve, resulting in mechanical small bowel obstruction. A colonoscopy was deferred due to concern for risk of perforation given the small bowel obstruction. Subsequently, the patient underwent laparoscopic enterectomy with approximately 5 cm of bowel on either side of the enterotomy with creation of anastomosis and foreign object retrieval. (Figure) Discussion: Intragastric balloons are a minimally invasive therapy for weight loss in conjunction with lifestyle modifications in the war against obesity. We present a rare, yet crucial case report of IGB complication resulting in small bowel obstruction and subsequent need for surgical intervention. IGBs are meant to be a short term, temporary tool for weight loss in obese patients generally BMI ≥ 30. This case highlights the importance of a timely removal, risk of severe complications, and emphasis on the importance of assessing proper indication for placement.Figure 1.: (A) Coronal view of CT scan showing dislodged Intragastric Balloon in the distal ileum (red arrow); (B) XR Abdomen showing radiopaque density overlying the left hemisacrum (red arrow) and dilated small bowel loops; (C) XR Abdomen Complete w/ Decub/Erect showing radiopaque foreign body in the right mid abdomen and second foreign body in the stomach (red arrows).

THE AGE FACTOR IN THE DEVELOPMENT OF PERIOPERATIVE COMPLICATIONS DURING THE SURGICAL TREATMENT OF CALCULOUS CHOLECYSTITIS

Summary. Elderly and senile patients in surgery are associated with numerous concomitant diseases, reduced functional reserve and high anesthetic risk.
 Aim. To assess the frequency and nature of perioperative complications in elderly and senile patients after laparoscopic cholecystectomy for acute or chronic calculous cholecystitis.
 Materials and methods. We analyzed the qualitative and quantitative characteristics of intraoperative and postoperative complications in 180 patients aged 60 to 90 years (elderly and senile) after laparoscopic cholecystectomy for acute or chronic calculous cholecystitis. The comparison group consisted of 200 patients aged 25 to 44 years. The procedure of choice in all patients was laparoscopic cholecystectomy.
 Results. In elderly and senile patients, intraoperative complications occurred more often (p<0.05) than in patients under 44 years of age. No significant differences were observed only in the frequency of intraoperative bleeding from the gallbladder artery, in the intrahepatic localization of the gallbladder, in the frequency of local peritonitis and gallbladder hydrops. In 20 (11.1 %) cases, there was a need for conversion (p=0.0002). Complications occurred in 29.4 % of cases, against 10.5 % in young patients (p<0.001). The difference in the number of minor complications: Clavien Dindo-1, Clavien Dindo-2 and Clavien Dindo-2a was improbable. Clavien Dindo-2b (5.0 %) (p<0.05), Clavien Dindo-3 (5.0 %) (p<0.05) and Clavien Dindo-4 (4.4 %) (p<0.05) complications occurred more often.
 Conclusions. Patients over 60 years of age are more likely (p<0.05) to have intraoperative problems during laparoscopic cholecystectomy and have a higher (p<0.05) risk of severe complications that require invasive procedures or may cause patient death.

Evaluation of the Factors Influencing on Intraoperative Difficulty Scores of Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair.

Background: Inguinal hernias are the leading surgical diseases in the world. There are different surgical procedures reported for the treatment. Some problems are thought to be encountered when performing laparoscopic surgery in these patients, such as risk of severe complications and the prolonged operative duration. Aim: The objective of this study was to specify the complexity of the transabdominal preperitoneal (TAPP) procedure by using an intraoperative scoring system and examine the scores with these patients' predictive factors. Materials and Methods: A prospective study was conducted in patients who underwent inguinal hernia surgery with TAPP. Previous lower abdominal surgery, previous (open) hernia surgery, body mass index (BMI), type of hernia, duration of the surgery, scoring the difficulty of the operation in five various stages using the visual analog scale (VAS) score (1. Mobilizing the peritoneum/dissection of the inferior peritoneal flap. 2. Dissection of internal ring or vas deference or hernia sac. 3. Visualization of Cooper's ligament. 4. Mesh placement. 5. Peritoneal closure.) and the time of discharge were recorded. Results: In this study, 137 patients were included. "BMI" and "previous lower abdominal surgery" have significantly higher scores, time of surgery, and hospital stay compared with other risk factors (P < .005). Conclusion: This study showed that patient's BMI and previous lower abdominal surgery could create technical difficulty with the TAPP procedure, but it is not necessary to avoid this laparoscopic technique because of these situations and can be performed safely.

Successful pregnancy in an end-stage renal disease woman on chronic hemodialysis

Successful conception in a female patient on hemodialysis (HD) is considered a high-risk pregnancy and associated with maternal and fetal complications. Thus, most such pregnancies lead to abortion or termination to preserve maternal health. Here, we report a successfully-delivered case of a 19th-week-diagnosed pregnancy in a 35-year-old mother with end-stage renal disease (ESRD). We present the case of a 35-year-old female with ESRD, diagnosed 10 years ago secondary to glomerulonephritis. The patient underwent the deceased–donor renal transplantation once, which unfortunately was rejected. During the initial tests for second-time kidney transplantation, a human chorionic gonadotropin-beta (beta-hCG) positive with a level of 9953 mIU/mL was reported, suggesting the pregnancy. The transvaginal ultrasonography confirmed the pregnancy at an approximate gestational age of 19 weeks. As a result, the patient underwent four and half hours of intensive HD five times a week and continued until 36 weeks of pregnancy. At 36 weeks, the patient presented to Shariati hospital, Tehran, Iran, with low- back pain. Consequently, a cesarean section (C/S) was performed, and the baby boy was born with a nine of ten Apgar score. Although successful pregnancy is possible for women with ESRD, it requires special multidisciplinary care. Intensive HD and regular fetal monitoring have improved the pregnancy outcome in this population. However, the risk of severe complications is still for the health of the mother and her offspring.

Rates of severe complications in patients undergoing colorectal surgery for deep endometriosis-a retrospective multicenter observational study.

Surgical experience and hospital procedure volumes have been associated with the risk of severe complications in expert centers for endometriosis in France. However, little is known about other certified units in Central European countries. This retrospective observational study included 937 women who underwent surgery for colorectal endometriosis between January 2018 and January 2020 in 19 participating expert centers for endometriosis. All women underwent complete excision of colorectal endometriosis by rectal shaving, discoid or segmental resection. Postoperative severe complications were defined as grades III-IV of the Clavien-Dindo classification system including anastomotic leakage, fistula, pelvic abscess and hematoma. Surgical outcomes of centers performing less than 40 (group 1), 40-59 (group 2) and≥60 procedures (group 3) over a period of 2 years were compared. The overall complication rate of grade III and IV complications was 5.1% (48/937), with rates of anastomotic leakage, fistula formation, abscess and hemorrhage in segmental resection, discoid resection and rectal shaving, respectively, as follows: anastomotic leakage 3.6% (14/387), 1.4% (3/222), 0.6% (2/328); fistula formation 1.6% (6/387), 0.5% (1/222), 0.9%; (3/328); abscess 0.5% (2/387), 0% (0/222) and 0.6% (2/328); hemorrhage 2.1% (8/387), 0.9% (2/222) and 1.5% (5/328). Higher overall complication rates were observed for segmental resection (30/387, 7.8%) than for discoid (6/222, 2.7%, P=0.015) or shaving procedures (12/328, 3.7%, P=0.089). No significant correlation was observed between the number of procedures performed and overall complication rates (rSpearman =-0.115; P=0.639) with a high variability of complications in low-volume centers (group 1). However, an intergroup comparison revealed a significantly lower overall severe complication rate in group 3 than in group 2 (2.9% vs 6.9%; P=0.017) without significant differences between other groups. A high variability in complication rates does exist in centers with a low volume of activity. Major complications may decrease with an increase in the volume of activity but this effect cannot be generally applied to all institutions and settings.

Acute Traumatic Spinal Cord Injury: Implementation of a Multidisciplinary Care Pathway.

Management of acute traumatic spinal cord injuries is complex, and patients are at risk for severe complications while inpatient. Performance review revealed opportunities for improvement in the care of patients with acute traumatic spinal cord injury at our institution. To compare mortality, failure-to-rescue, and health care utilization of patients with acute traumatic spinal cord injury after implementation of a revised multidisciplinary care pathway. Using a pre- and post-between-subjects study design, a retrospective cross-sectional analysis of consecutive patients admitted to our Level I trauma center with acute traumatic spinal cord injury was performed. An updated care pathway for all patients who presented with acute traumatic spinal cord injury was implemented in July 2020. This pathway includes a revised order set in the electronic medical record, distribution of a "best practice" guide to inpatient providers, a formal twice-daily respiratory evaluation, and weekly clinical nurse specialist-led patient rounds. One hundred and eight patients were included in analysis (prepathway: n = 52, postpathway: n = 56). Total mean hospital length of stay was 15.2 (14.0) and 21.5 (24.8) days for the pre- and postpathway groups. Eleven patients (21%) compared with six patients (11%) died, and failure-to-rescue occurred in six patients (60%) compared with zero patient in the pre- and postpathway groups, respectively. In addition, 10 (20%) postpathway patients were discharged to home compared with one (2%) in the prepathway group. Following implementation of the updated acute traumatic spinal cord injury pathway, overall inpatient mortality decreased, and fewer patients died after experiencing a complication. Results highlight the need for continued review of care practices and multidisciplinary review in quality improvement initiatives.

Preoperative and postoperative complications of cerebrospinal fluid drainage in descending thoracic and thoraco-abdominal aortic aneurysm surgery: a single-center retrospective study.

Cerebrospinal-fluid drainage (CSFD) has been performed to prevent paraplegia in descending thoracic or thoraco-abdominal aortic aneurysm (DTA/TAAA) surgery; however, CSFD itself has a risk of severe complications. We retrospectively investigated the incidence rates of CSFD-related preoperative and postoperative complications. Patients who underwent DTA/TAAA surgery with a CSFD catheter that was inserted on the day before surgery were enrolled. The incidence rates of complications from spinal puncture until DTA/TAAA surgery were investigated as preoperative CSFD complications, and the incidence rates from DTA/TAAA surgery to postoperative day 7 were investigated as CSFD-related postoperative complications. Preoperative CSFD complications were analyzed in 123 cases. DTA/TAAA surgery was postponed due to bloody cerebrospinal fluid (2.5%) and due to meningitis (1.7%). The incidence rate of mild preoperative complications was 32.4%. Postoperative CSFD complications were analyzed in 108 cases. Intracranial hemorrhage occurred in 3.9% of cases in open surgery and other postoperative severe CSFD complications did not occur. The incidence rates of moderate/mild complications in open surgery were 2.6%/14.3% and those in TEVAR were 3.2%/19.4%. Bloody cerebrospinal fluid and meningitis, which are severe complications associated with spinal puncture, occurred within 1 day after spinal puncture. The incidence rates of moderate/mild complications were high in both the preoperative and postoperative periods. These results showed that CSFD catheter insertion and management should be performed carefully with consideration given to the risks and benefits of CSFD.