Surgical Insult Research Articles

Rex Shunt for Portal Vein Thrombosis After Pediatric Living Donor Liver Transplantation

BackgroundPortal vein thrombosis (PVT) after pediatric liver transplantation (LT) is a common but grave complication which could eventually result in life-threatening portal hypertension. A “Rex” shunt between the superior mesenteric vein and the Rex recess of the liver has been reported to be a treatment option for extrahepatic portal vein obstruction; however, its application to living donor liver transplantation (LDLT) is limited due to the availability of appropriate vein grafts. In this study, we retrospectively evaluated the effectiveness of Rex shunt as an option for the treatment of PVT after pediatric LDLT.Case ReportThree children underwent the Rex shunt for early (n=2) and late (n=1) PVT after LDLT using the greater saphenous vein (n=2) and the external iliac vein (n=1) from the parents who previously donated their livers.Two of the 3 children are free from symptoms with patent shunt grafts at 14 years after the procedures. One child died at 30 days after LDLT due to repeated episodes of PVT, which finally led to hepatic infarction.ConclusionsThe Rex shunt is feasible to treat PVT after LDLT. However, additional surgical insults to the living donor need further discussion.

Acceleration of orthodontic tooth movement and root resorption with near and distant surgical insults: An in-vivo study on a rat model

The purpose of this study was to determine the effects of alveolar decortications (AD) closer and farther from the tooth on Orthodontic tooth movement (OTM) and root resorption. Twenty-four Wistar rats (age 17 weeks) were used in the study. Three groups were formed by randomly dividing the rats into: 1) Control Group (N=8): OTM (14 days) without any surgical insult; 2) Near Group (N=8) OTM (14 days)+Alveolar Decortications (AD) adjacent to roots of the maxillary first molar; 3) Far Group (N=8) OTM (14 days)+AD 5mm away from the roots of the maxillary first molar. OTM was performed using a closed coil Nickel-Titanium (NiTi) spring to apply a mesial force on maxillary first molars of 8-10 grams. AD was performed with high-speed quarter round bur on the palatal aspect of alveolar bone. The rats were euthanized after 2 weeks of OTM and microfocus computed tomography and histological analysis were performed. Near-AD and Far-AD groups exhibited significantly increased OTM and reduction of Bone volume fraction compared to control. The root volume was significantly decreased (increased root resorption) in the Near-AD group. Histological analysis showed no statistically significant difference between the groups. Alveolar decortications lead to a significant increase in the rate of OTM. Increased root resorption was observed when the alveolar decortications were performed close to the maxillary molar.

Predilection for developing a hematogenous orthopaedic implant-associated infection in older versus younger mice

BackgroundThe pathogenesis of hematogenous orthopaedic implant-associated infections (HOIAI) remains largely unknown, with little understanding of the influence of the physis on bacterial seeding. Since the growth velocity in the physis of long bones decreases during aging, we sought to evaluate the role of the physis on influencing the development of Staphylococcus aureus HOIAI in a mouse model comparing younger versus older mice.MethodsIn a mouse model of HOIAI, a sterile Kirschner wire was inserted retrograde into the distal femur of younger (5–8-week-old) and older (14–21-week-old) mice. After a 3-week convalescent period, a bioluminescent Staphylococcus aureus strain was inoculated intravenously. Bacterial dissemination to operative and non-operative legs was monitored longitudinally in vivo for 4 weeks, followed by ex vivo bacterial enumeration and X-ray analysis.ResultsIn vivo bioluminescence imaging and ex vivo CFU enumeration of the bone/joint tissue demonstrated that older mice had a strong predilection for developing a hematogenous infection in the operative legs but not the non-operative legs. In contrast, this predilection was less apparent in younger mice as the infection occurred at a similar rate in both the operative and non-operative legs. X-ray imaging revealed that the operative legs of younger mice had decreased femoral length, likely due to the surgical and/or infectious insult to the more active physis, which was not observed in older mice. Both age groups demonstrated substantial reactive bone changes in the operative leg due to infection.ConclusionsThe presence of an implant was an important determinant for developing a hematogenous orthopaedic infection in older but not younger mice, whereas younger mice had a similar predilection for developing periarticular infection whether or not an implant was present. On a clinical scale, diagnosing HOIAI may be difficult particularly in at-risk patients with limited examination or other data points. Understanding the influence of age on developing HOIAI may guide clinical surveillance and decision-making in at-risk patients.

Pharmacological treatment to reduce pulmonary morbidity after esophagectomy.

Esophagectomy for esophageal cancer is one of the most invasive procedures in gastrointestinal surgery. An invasive surgical procedure causes postoperative lung injury through the surgical procedure and one‐lung ventilation during anesthesia. Lung injury developed by inflammatory response to surgical insults and oxidative stress is associated with pulmonary morbidity after esophagectomy. Postoperative pulmonary complications negatively affect the long‐term outcomes; therefore, an effort to reduce lung injury improves overall survival after esophagectomy. Although significant evidence has not been established, various pharmacological treatments for reducing lung injury, such as administration of a corticosteroid, neutrophil elastase inhibitor, and vitamins are considered to have efficacy for pulmonary morbidity. In this review we survey the following topics: mediators during the perioperative periods of esophagectomy and the efficacy of pharmacological therapies for patients with esophagectomy on pulmonary complications.

Crucial involvement of catecholamine neurotransmission in postoperative nausea and vomiting: Whole-transcriptome profiling in the rat nucleus of the solitary tract.

The genetic mechanisms of postoperative nausea and vomiting (PONV) and the involvement of the catecholamine system in the brain have not been elucidated. Eating kaolin clay as a type of pica has been examined as an alternative behavior to emesis. Here, we evaluated changes in whole-transcriptome analysis in the nucleus of the solitary tract (NTS) in a rat pica model as a surrogate behavior of PONV to elucidate the molecular genetic mechanisms of the development of PONV and the involvement of the catecholamine system in the NTS. First, kaolin pica behaviors were investigated in 71 female Wistar rats following isoflurane anesthesia, surgical insult or morphine administration. Multiple linear regression analysis showed that 3mg/kg morphine increased kaolin intake by 2.8g (P=0.0002). Next, total RNA and protein were extracted from the dissected NTS, and whole-transcriptome sequencing (RNA-seq) was performed to identify PONV-associated genes and to verify the involvement of the catecholamine system. The gene expression levels of tyrosine hydroxylase and dopamine beta-hydroxylase in the catecholamine biosynthesis pathway decreased significantly in the PONV model. Release of noradrenaline, a catecholamine pathway end product, may have increased at the synaptic terminal of the NTS neuron after pica behavior. Systematic administration of α2 adrenergic receptor agonists after surgery reduced kaolin intake from 3.2g (control) to 1.0g (P=0.0014). These results indicated that catecholamine neurotransmission was involved in the development of PONV in the NTS.

New diagnosis of myasthenia gravis presenting as myasthenic crisis after radical thymectomy: a case report

: Myasthenia gravis (MG) is a well-known paraneoplastic syndrome associated with thymomas. It occurs secondary to the production of autoantibodies against acetylcholine receptors (AChR). This results in the reduced delivery of action potentials that generate muscular contractions. In its most extreme form, MG can present as a crisis resulting in respiratory failure requiring invasive ventilatory support. There are several known risk factors for patients with known MG to develop a post-operative crisis after thymectomy. It is recommended that patients diagnosed with thymoma be evaluated for MG prior to resection. However, most guidelines do not make any recommendations regarding screening with AChR antibody tests if there are no signs or symptoms of MG. In this case report, we present a patient with an incidental finding of a large anterior mediastinal thymoma with no signs or symptoms of MG. The patient subsequently develops bulbar symptoms and dyspnea necessitating readmission to hospital 2 weeks after surgery. This eventually culminated in cardiorespiratory arrest. This was confirmed to be secondary to a myasthenic crisis via AChR autoantibody testing. The patient was treated with intravenous immunoglobulin (IVIG), pyridostigmine and prednisone with good effect. The onset of myasthenic crisis after a surgical insult in known MG patients has been well documented. However, the development of myasthenic crisis in an asymptomatic patient with no history of MG has not previously been shown. This case report illustrates the need for more sensitive screening tools to detect MG in patients with thymoma. The routine use of AChR autoantibody testing as a screening tool in patients with thymoma even when asymptomatic and/or deemed low risk may help clinicians better prepare for possible MG flairs. Furthermore, surgeons should have a low threshold to suspect MG in patients after thymectomy regardless of time elapsed since surgery.

The Effect of Remote Ischemic Preconditioning on Serum Creatinine in Patients Undergoing Partial Nephrectomy: A Randomized Controlled Trial.

Renal function declines after partial nephrectomy due to ischemic reperfusion injury induced by surgical insult or renal artery clamping. The effect of remote ischemic preconditioning (RIPC) on reducing renal injury after partial nephrectomy has not been studied regarding urinary biomarkers. Eighty-one patients undergoing partial nephrectomy were randomly assigned to either RIPC or the control group. RIPC protocol consisted of four cycles of five-min inflation and deflation of a blood pressure cuff to 250 mmHg. Serum creatinine levels were compared at the following time points: preoperative baseline, immediate postoperative, on the first and third days after surgery, and two weeks after surgery. The incidence of acute kidney injury, other surgical complication rates, and urinary biomarkers, including urine creatinine, β-2 microglobulin, microalbumin, and N-acetyl-beta-D-glucosaminidase were compared. Split renal functions measured by renal scan were compared up to 18 months after surgery. There was no significant difference in the serum creatinine level on the first postoperative day (median (interquartile range) 0.87 mg/dL (0.72–1.03) in the RIPC group vs. 0.92 mg/dL (0.71–1.12) in the control group, p = 0.728), nor at any other time point. There was no significant difference in the incidence of acute kidney injury. Secondary outcomes, including urinary biomarkers, were not significantly different between the groups. RIPC showed no significant effect on the postoperative serum creatinine level of the first postoperative day. We could not reveal any significant difference in the urinary biomarkers and clinical outcomes. However, further larger randomized trials are required, because our study was not sufficiently powered for the secondary outcomes.

Platelet TLR4-ERK5 Axis Facilitates NET-Mediated Capturing of Circulating Tumor Cells and Distant Metastasis after Surgical Stress.

Surgical removal of malignant tumors is a mainstay in controlling most solid cancers. However, surgical insult also increases the risk of tumor recurrence and metastasis. Tissue trauma activates the innate immune system locally and systemically, mounting an inflammatory response. Platelets and neutrophils are two crucial players in the early innate immune response that heals tissues, but their actions may also contribute to cancer cell dissemination and distant metastasis. Here we report that surgical stress-activated platelets enhance the formation of platelet-tumor cell aggregates, facilitating their entrapment by neutrophil extracellular traps (NET) and subsequent distant metastasis. A murine hepatic ischemia/reperfusion (I/R) injury model of localized surgical stress showed that I/R promotes capturing of aggregated circulating tumor cells (CTC) by NETs and eventual metastasis to the lungs, which are abrogated when platelets are depleted. Hepatic I/R also increased deposition of NETs within the lung microvasculature, but depletion of platelets had no effect. TLR4 was essential for platelet activation and platelet-tumor cell aggregate formation in an ERK5-GPIIb/IIIa integrin-dependent manner. Such aggregation facilitated NET-mediated capture of CTCs in vitro under static and dynamic conditions. Blocking platelet activation or knocking out TLR4 protected mice from hepatic I/R-induced metastasis with no CTC entrapment by NETs. These results uncover a novel mechanism where platelets and neutrophils contribute to metastasis in the setting of acute inflammation. Targeted disruption of the interaction between platelets and NETs holds therapeutic promise to prevent postoperative distant metastasis. SIGNIFICANCE: Targeting platelet activation via TLR4/ERK5/integrin GPIIb/IIIa signaling shows potential for preventing NET-driven distant metastasis in patients post-resection.

Foot and ankle trauma management during the COVID-19 pandemic: Experiences from a major trauma unit

The COVID-19 pandemic has resulted in a paradigm shift in clinical practice, particularly in ways in which healthcare is accessed by patients and delivered by healthcare practitioners. Many of these changes have been serially modified in adaptation to growing service demands and department provision capacity. We evaluated the impact of the pandemic on the foot and ankle service at our trauma unit, assessing whether these adaptations to practice were justifiable, successful and sustainable for the future. This was a single-centre, retrospective cohort study analysing the patient care pathway from admission to discharge, for two pre-defined timeframes: Phase 0 (pre-lockdown phase) and Phase 1 (lockdown phase). Patients were split into stable and unstable injuries depending on their fracture pattern. The follow-up modality and duration were evaluated. Trauma throughput for the equivalent timeframe in 2019 was also analysed for comparison. There were 106 unstable fractures and 100 stable fractures in 2020.78 interventional procedures were performed on 72 patients with unstable fractures in Phase-1. Close contact casting was performed on 13 patients at presentation in the ED. Selective patients underwent partial fixation in theatre, which still provided adequate stability. 35% of patients with a stable fracture were discharged directly from the ED with written advice from a review letter. The treatment modality in selective patients, particularly the vulnerable should be carefully assessed. Interventions performed at presentation often negate the need for admission. Partial fixation reduces intraoperative time and surgical insult. Integrating telemedicine into the care pathway, particularly for stable ankle fractures reduces the need for physician-patient contact and eases follow-up burden. Many of our recommended changes are easily replicated in other clinical settings. Should these adaptations demonstrate long-term sustainability, it is likely they will remain incorporated into future clinical practice.

Wnt/-Catenin Signaling and Liver Regeneration: Circuit, Biology, and Opportunities.

The liver is uniquely bestowed with an ability to regenerate following a surgical or toxicant insult. One of the most researched models to demonstrate the regenerative potential of this organ is the partial hepatectomy model, where two thirds of the liver is surgically resected. The remnant liver replenishes the lost mass within 1014 days in mice. The distinctive ability of the liver to regenerate has allowed living donor and split liver transplantation. One signaling pathway shown to be activated during the process of regeneration to contribute toward the mass and functional recovery of the liver is the Wnt/-catenin pathway. Very early after any insult to the liver, the cellmolecule circuitry of the Wnt/-catenin pathway is set into motion with the release of specific Wnt ligands from sinusoidal endothelial cells and macrophages, which, in a paracrine manner, engage Frizzled and LDL-related protein-5/6 coreceptors on hepatocytes to stabilize -catenin inducing its nuclear translocation. Nuclear -catenin interacts with T-cell factor family of transcription factors to induce target genes including cyclin D1 for proliferation, and others for regulating hepatocyte function. Working in collaboration with other signaling pathways, Wnt/-catenin signaling contributes to the restoration process without any compromise of function at any stage. Also, stimulation of this pathway through innovative means induces liver regeneration when this process is exhausted or compromised and thus has applications in the treatment of end-stage liver disease and in the field of liver transplantation. Thus, Wnt/-catenin signaling pathway is highly relevant in the discipline of hepatic regenerative medicine.

Perioperative Precedex: Whole New Ball Game or Whole New Ball of Wax?

Perioperative Precedex: Whole New Ball Game or Whole New Ball of Wax?

Risk of Dependency Following Microsurgical Clipping in Good Grade Patients With Ruptured Anterior Circulation Aneurysms

Background and Aim: Most good grade (WFNS I and II) patients who undergo microsurgical clipping achieve a favorable outcome. However, some independent patients before surgery face unfavorable outcomes after the operation, signifying the impact of microsurgical clipping. This study aimed to identify the risk of developing dependency in patients without previous neurological deficits. Methods and Materials/Patients: We reviewed 50 consecutive good grade patients with ruptured anterior circulation aneurysms who underwent microsurgical clipping between May 2017 and May 2020 in the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan. The clinical outcome at discharge and three months follow-up was assessed using the Glasgow Outcome Scale (GOS). Results: In this study, seven patients (14%) became dependent (GOS II and III) following clipping. Of whom, five patients (10%) suffered surgical insult in the form of intraoperative rupture (4%), post-op infarct (4%), and direct brain damage (2%). Conclusion: Patients without neurologic deficit pre-operatively still suffer unfavorable outcomes mainly due to operative complications. Vascular injuries remain the main cause of morbidity-producing dependency. Therefore, all surgical techniques must minimize the risk to vessels, both during dissection and at clip placement.

Efficacy of L-Ascorbic acid in the healing of extraction site after trans alveolar extraction of third molar teeth

Wound healing monitoring after every surgery is the most vital concern to deal with. The surgical removal of the teeth involves guttering of overlying bone, splitting the tooth (odontectomy), delivery of the tooth, irrigation of the socket, achieving haemostasis and closure of the soft tissue flap. This leads to big surgical insults resulting in post-operative inflammatory response like pain and swelling, difficulty in mouth opening, fever, etc. In some cases, other rare complications, including infection, nerve damage, have also been reported. The objective of this study is to evaluate the effects of submucosal injection of vitamin c (L-Ascorbic Acid) in wound healing after trans alveolar extraction of teeth. Thirty patients requiring trans alveolar extraction of teeth were included in this study. Patients were divided into two groups, Group S (Vit c) and Group B (Control). Healing of extraction socket was observed on 3rd and 7th post-operative days. The study group (Vitamin C) had better healing indices than the controls at 7th post-op day. There was no significant difference in 3rd post-op day. There was no significant reduction in pain on 3rd and 7th post-operative days. L-Ascorbic acid injection provides satisfactory post-operative healing following trans alveolar extraction of teeth. But it does not decrease the post-operative pain following surgery.

The effect of differential force system and minimal surgical intervention on orthodontic tooth movement and root resorption.

The primary objective of this study was to quantify the orthodontic tooth movement (OTM) and orthodontically induced root resorption (OIRR) with differential force system in conjunction with minimal surgical insult. 15-week-old, 48 male Wistar rats were used in the research and were randomly divided into six groups: 1. Group 1 (8 Wistar rats): OTM for 14 days with 8-g force; 2. Group 2 (8 Wistar rats): OTM for 14 days with 25-g force; 3. Group 3 (8 Wistar rats): OTM for 14 days with 100-g force; 4. Group 4 (8 Wistar rats): OTM for 14 days with 8-g force and alveolar decortications (ADs); 5. Group 5 (8 Wistar rats): OTM for 14 days with 25-g force and ADs; 6. Group 6 (8 Wistar rats): OTM for 14 days with 100-g force and ADs. A nickel-titanium spring was used to protract the molar mesially using maxillary incisors as an anchorage. ADs (minimal surgical insult) were done using a hand piece and a round bur, adjacent to the left first maxillary molar on the palatal alveolar bone. After 14 days of OTM, Wistar rats were killed and microfocus computed tomography and histological analysis were performed. The 100-g group showed significant increase (P < 0.05) in OTM. However, with ADs, the OTM was significantly higher (P < 0.05) in 8 and 100 g. In addition, with ADs, there is significant increase (P < 0.05) in OIRR and significant decrease (P < 0.05) in bone volume fraction. Histological quantification of tartrate-resistant acid phosphatase indicated a significant increase (P < 0.05) in the number of osteoclasts with ADs when compared without ADs. Light force in conjunction with ADs are optimal to accelerate the OTM. Additionally, ADs increases the OIRR.

Priority Setting in Damage Control Surgery for Multiple Abdominal Trauma Following Resuscitative Endovascular Balloon Occlusion of the Aorta

Damage control surgery (DCS) is an abbreviated laparotomy procedure that focuses on controlling bleeding to limit the surgical insult. It has become the primary treatment modality for patients with exsanguinating truncal trauma. Herein, we present the case of a 47-year-old woman with liver, kidney, and superior mesenteric vein (SMV) injuries caused by a motor vehicle collision. The patient underwent DCS following resuscitative endovascular balloon occlusion of the aorta (REBOA). In this case report, we discuss the importance of priority setting in DCS for the treatment of multisystem damage of several abdominal organs, particularly when the patient has incurred a combination of major vascular injuries. We also discuss the implications of damage control of the SMV, perihepatic packing, and right-sided medial visceral rotation. Further understanding of DCS, along with REBOA as a novel resuscitation strategy, can facilitate the conversion of uniformly lethal abdominal injuries into rescuable injuries.

Reoperation in Zygomatico-orbital Trauma: A Review of Patients With Suboptimal Outcomes Following Initial Repair.

Treatment to restore anatomy, function, and aesthetics after trauma should involve as little surgical insult as possible. As such, repeated procedures may suggest failed initial management. To date, no predictive factors for failure of primary surgery have been identified. The aim of this review was to identify factors affecting the requirement for reoperation following treatment of zygomatico-orbital injuries. A retrospective review of patients undergoing surgery for zygomatico-orbital fractures between 2011 and 2019 in a single UK major trauma center was undertaken. All operative notes and imaging were reviewed independently by 2 authors to classify the fracture patterns for both zygomatic and orbital components of the injury. For all cases, the mode of preoperative imaging the grade of operating surgeon, materials used for fixation, and the surgical approaches were recorded. Coding data identified 432 patients who underwent surgery for zygomatico-orbital fractures. In total, 116 cases were treated with closed reduction and 316 with open reduction and internal fixation; 20 cases required reoperation. There were no significant differences identified between cases requiring reoperation and those who did not. A need for repeated surgery is rare. However, this review identified an increased risk of infection of fixation when an intraoral approach was used and highlights the potential benefits that can be achieved by open reduction and internal fixation when more conservative approaches fail to achieve the desired outcome.

Microalbuminuria assessment after thoracic surgery: Early identification of complication risks.

Microalbuminuria (MA) is considered a reflection of systemic capillary leak and an early marker of acute stress reaction to the surgical insult, proportional to the severity of the initiating condition and predictive of the individual response to surgical stress. We conducted a prospective study to assess for the variation of MA within 4 days after thoracic surgery. We correlated observed MA levels with both their respective PaO2 /FiO2 respiratory ratio and the onset of postoperative complications. This single-centre study enrolled 255 consecutive patients having an American Society of Anaesthesiologists (ASA)score≤3. The mean age was 62 years with 67% male. All patients were scheduled for elective pulmonary resection. MA was measured in urine samples as the albumin-to-creatinine ratio (A/C), prior to, at and after extubation up to 96 hours. PaO2 /FiO2 was measured at extubation and on the first postoperative day. Overall, preoperative A/C levels resulted normal, with a significant average increase at extubation which peaked 6 hours later (P<0.001). Larger postoperative A/C increases were observed in patients who developed postoperative complications, compared to those without these complications (P<0.019). Moreover, patients undergoing major open pulmonary resections had larger postoperative A/C increases, compared to those undergoing minor video-assisted thoracic surgeryresections (P<0.006). At the time of extubation, A/C was inversely related to the PaO2 /FiO2 ratio (r=-0.25; P=0.038). Peak A/C > 61mg/g (P=0.0003) was associated with postoperative cardio-pulmonary complications (OR 3.85; P=0.003). Within 6 hours after extubation, MA assessment may be a rapid and relatively inexpensive method for better predicting perioperative risk in an ASA score ≤3 population.

Gastrointestinal injurious insults in gynecological surgical procedures at El Sahel Hospital

Background: Gastrointestinal surgical insults during operative gynecologic procedures varies considerably according to the procedure. Prognostic tools and risk factors should be elucidated by further research efforts to enhance management levels of those cases category Aim of the work: To investigate the risk factors, impact and severity as regards gastrointestinal injuries during gynecological and obstetrical operations Methodology: A retrospective case-control research study performed on cases who have underwent gynecologic surgery in the period between 2014 and 2019. Results: Risk factors for gastrointestinal injuries in which past history of abdominal operation , pelvic adhesions, previous pelvic operation have shown to be statistically significant risk factors for GIT injuries (p values = 0.007, 0.019, consecutively) Conclusions and Recommendations: Innovation of a surgical prognosis algorithm based on statistical analysis is considered the cornerstone of enhancement of surgical management of gynecologically challenging cases aiding in reducing gastrointestinal surgical insults within gynecological surgical practice.

Three-Year Effect of Phakic Intraocular Lenses on the Corneal Endothelial Cell Density.

PurposeTo compare the effect of three different phakic intraocular lenses (pIOLs) on the corneal endothelial cell density (ECD).Patients and MethodsThis was a prospective observational cohort study that included 60 eyes (30 patients) with axial myopia of −6.50 to −22.00 diopters (D). The Verisyse anterior chamber (AC) rigid iris fixated pIOL, the Veriflex (AC) flexible iris fixated pIOL, and the Visian posterior chamber (PC) implantable collamer lens (ICL) were implanted in three equal groups of patients. The effect of the three pIOLs on the ECD was compared over a follow-up period of one week, and one, three, and six months, and one, two, and three years. Specular microscopy was done to evaluate the cornea before the surgery and throughout the study. Changes were statistically analyzed and compared.ResultsIn the first three postoperative months, Verisyse and Veriflex pIOLs induced almost the same amount of endothelial cells loss of 10.3% and 10.6%, respectively, while ICLs showed endothelial cells loss of 3.5%. At the end of the three-year study, Veriflex pIOLs induced the highest rate of endothelial cell loss of 25%, while Verisyse and ICL lenses showed endothelial cells loss of 15.7% and 13.4%, respectively. The main effect of time and type of lens was statistically significant (p<0.001).ConclusionAll pIOLs cause a decrease in ECD. The AC pIOLs tend to be associated with more cell loss than PC pIOLs. Surgical insult is the important factor responsible for the early endothelial cell loss, while the material from which the pIOL is made may be an important factor for the continuous corneal endothelial cell loss over a long time.

Impact of enhanced recovery after surgery on open and laparoscopic liver surgery: A single center cohort study.

Background: Enhanced recovery after surgery (ERAS) protocols are designed to improve postoperative recovery. ERAS has shown to reduce hospital stay and improve post operative outcomes. The aim of this study is to investigate the impact of ERAS on liver surgery and assess whether impact differs when applied in laparoscopic vs open liver surgery. Methods: All liver resections performed in a single center, between January, 1 2008 and December 31, 2016 were identified and clinical data were collected. ERAS was implemented in May 2013 and carried out throughout the study period. Patients treated according to ERAS were compared with patients treated before implementation of ERAS. The primary endpoint was hospital stay. Multivariable linear regression was performed to account for confounders. Results: Overall, 787 patients were included (375 ERAS and 412 pre-ERAS). The mean age was 64±14 years and 415 (53%) were female. A total of 405 (52%) resections were considered major and 439 (56%) of the entire cohort were performed laparoscopically. Hospital stay was shorter after implementation of ERAS in t open liver surgery (7 (5-9) days vs 7 (6-12) days in ERAS and pre-ERAS, respectively, P=0.006). This difference was not seen in laparoscopic resections. In multivariable analysis both ERAS (β= -0.88, P=0.03) and the laparoscopic approach (β= -3.74, P<0.001) were independently associated with a shorter hospital stay. Sensitivity analysis of the subgroups open and laparoscopic surgery revealed that the impact of ERAS on hospital stay was seen in open liver surgery (β= -2.75, P=0.003) but not in laparoscopic liver surgery (β= 0.25, P=0.44). Conclusions: As in other surgical fields, ERAS reduces hospital stay in liver surgery. However, the impact is only seen in open liver surgery. It is possible that the laparoscopic approach itself, leading to a reduced surgical insult, has a greater impact on hospital stay than ERAS.