Timing Of Surgery In Patients Research Articles

Increasing reoperation rates and inferior outcome with prolonged symptom duration in lumbar disc herniation surgery — a prospective cohort study

BACKGROUND CONTEXTLumbar disc herniation (LDH) is associated with great morbidity and significant socioeconomic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients in whom pain and disability are unacceptable, surgical intervention provides effective clinical relief. Currently, there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome. PURPOSEThe aim of this study is to evaluate if prolonged symptom duration is correlated with less favorable outcome following surgery for LDH. STUDY DESIGN/SETTINGConsecutive series of patients from a single-center, multisurgeon, tertiary spine practice. PATIENT SAMPLEConsecutive series of patients who underwent surgery for LDH. OUTCOME MEASURESOswestry Disability Index (ODI), EuroQol-5D (EQ-5D), and Visual Analog Scale (VAS) for back and leg pain (0–100). METHODSPatients with a first-episode LDH were included. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their preoperative self-reported duration of leg pain: <3 months, 3 to 12 months, and >12 months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. Statistical significance level was set at p value <.01. RESULTSThere were 2,144 patients included in the study, with complete 1-year follow-up on 1,694 patients (79%) and a reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain; however, this did not reach statistical significance (p=.039). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) 1 year after surgery (p=.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=.008) of increasing incidence of reoperation was found with increasing length of symptom duration. CONCLUSIONSDelayed surgical intervention results in inferior outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved significantly better outcome 1 year after surgery when compared to the other groups.

Initial medical and surgical management of inflammatory bowel disease in the biologic era: A comparison between the United States and China.

Background and AimsWe compared the initial medical and surgical management of Crohn's disease (CD) and ulcerative colitis (UC) between the United States and China, with aims to better characterize the global variation in the treatment patterns of inflammatory bowel disease (IBD).MethodsParticipants from the United States and China completed a questionnaire on demographic and clinical characteristics, medications (biologics, immunomodulators, aminosalicylates, steroids), and IBD‐related surgical history. Patients diagnosed in 2006 and later were eligible. Analysis was restricted to treatment patterns within 1 year of diagnosis. Multivariable logistic regressions examined differences by country.ResultsWe recruited 202 CD (US: 49%, China: 51%) and 133 UC (US: 63%, China: 37%) participants. Median age at survey was 31 years (range: 18–76) and at diagnosis was 28 years (range: 12–70). Biologics were commonly used in the United States for CD (66%) and UC (28%) and less commonly in China for CD (19%) and UC (0%). On regression, US CD participants were more likely to receive biologics (odds ratio [OR] 23.82 [95% confidence interval [CI] 8.98–63.14]), aminosalicylates (OR 4.93 [2.00–12.15]), and steroids (OR 4.36 [1.87–10.16]). US UC participants were more likely to receive immunomodulators (OR 3.45 [1.09–10.90]) and steroids (OR 3.31 [1.55–7.06]). There existed minimal differences regarding undergoing surgery for CD (US: 16%, China: 16%) and UC (US: 5%, China: 2%). A proportion (US: 12%, China: 19%) underwent IBD‐related surgery prior to diagnosis (median: 5 years; range: 1–39).ConclusionUS, relative to Chinese, participants were more likely to report early biologic use. There were no differences between countries in undergoing early surgery. Evaluating global practice variation is integral to optimizing early pharmacological therapy and timing of surgery for patients with IBD.

Impact of Radicality Versus Timing of Surgery in Patients with Advanced Ovarian Cancer (Stage III C) Undergoing CRS and HIPEC-a Retrospective Study by INDEPSO.

HIPEC in addition to interval CRS has shown a survival benefit of 12months compared to CRS alone. However, there are many controversial issues pertaining to CRS itself which should be addressed first. To compare NACT and primary CRS approaches when CRS is categorized according to the extent of resection. To evaluate the feasibility of performing HIPEC at these two time points. A retrospective analysis of patients with stage III C ovarian cancer undergoing primary and interval CRS + HIPEC was performed. The surgical approach for interval CRS was classified as (1) resection of sites of residual disease alone or (2) resection of sites involved before NACT. The morphological response was divided into different categories, and surgeons had to state what they consider residual disease and what they do not. From January 2013 to December 2017, 54 patients were included (18-primary; 36-interval). Median PCI 11 vs 6.5 (p = 0.07); CC-0 was obtained in 77.7%. Three surgeons resected previously involved sites; three sites of residual disease only. All surgeons resected areas of scarring. Twenty percent patients had residual disease in "normal-looking" peritoneum. Morbidity (p = 0.09), median OS (p = 0.71), and median DFS (p = 0.54) were similar in the two groups. Early recurrence occurred in 50% with resection of residual disease alone compared to 16.6% when previous disease sites were resected (p = 0.07). Interval CRS should be performed to resect sites involved prior to NACT and not just sites of residual disease. HIPEC can be performed in both primary/interval settings with acceptable morbidity.

The role of parents in delayed surgery of undescended testis

Aim: Undescended testis (UDT) is the most common congenital urinary system disease. Delayed treatment increases the risk of infertility or malignancy. The aim of this study was to evaluate the effect of educational status and geographical location of the parents (rural vs. urban) on the timing of surgery in patients with UDT.Material and Methods: The retrospective study included 248 patients that underwent surgery due to UDT between 2014 and 2018. The patients were divided into two groups based on age at surgery: (I) >1 year and (II) ≤1 year. Data regarding the educational status and geographical location of the parents were obtained via telephone interviews. Results: Of the 248 patients, 67% (n=166) of them were aged over 1 year (Group I) and 33% (n=82) of them were aged below 1 year (Group II). Mean age at surgery was 48.98±29.25 months in Group I and 9.68±1.98 months in Group II. The educational status of the parents was higher in the patients aged below 1 year than in patients aged over 1 year. In addition, the patients living in urban areas admitted to the hospital earlier than those living in rural areas. Conclusion: Both the parental educational status and the geographical location of the parents had a significant effect on the timing of surgery in UDT patients. Keywords: Undescended testis; education status; geographical location

ОЦЕНКА ЭФФЕКТИВНОСТИ ИСПОЛЬЗОВАНИЯ ПРИСПОСОБЛЕНИЯ ДЛЯ УСТАНОВКИ ДРЕНАЖЕЙ ПРИ ЛАПАРОСКОПИЧЕСКИХ ВМЕШАТЕЛЬСТВАХ У ПАЦИЕНТОВ С ОСТРЫМ НЕКРОТИЗИРУЮЩИМ ПАНКРЕАТИТОМ

Background. Drainage of the abdominal cavity is an important final stage of many surgeries, and sometimes also the main method of surgical intervention. The installation of drainage under pneumoperitoneum conditions may cause certain difficulties. Objective. To conduct a clinical assessment of the effectiveness of using the device for the installation of drainage during laparoscopic interventions on the abdominal organs. Material and methods. The device we developed has a form of a metal rod with a handle on one end and a circularshaped thickening on the other. A movable cone-shaped sleeve is installed on the rod, allowing the tight closing of the proximal end of the drainage tube and preventing the leakage of carbon dioxide from the abdominal cavity. The use of the suggested tool stiffens the drainage tube for its installation in the abdominal cavity in specified location and position. The tool has been used in 20 surgeries, with 3 drainage tubes installed during each of them.Results. The use of the suggested tool allowed us to reduce the average surgery time for patients in the main group by more than 12 minutes as compared with the control group. Reducing the duration of the operation lowered the patient's need for respiratory support in the early postoperative period. Conclusions. The suggested device strongly facilitates the installation of drainage tubes during video-laparoscopic surgeries, can significantly reduce surgery time and be successfully used in abdominal surgery.

Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications

IntroductionDirect oral anticoagulation agents (DOACs) are increasingly prescribed to older adults. Concerns for perioperative blood loss dictate cessation of anticoagulation treatment and postponement of surgery until the coagulation system returns to normal state. The goal of this study is to compare the estimates of perioperative blood loss and mortality between patients using DOACs and patients receiving no anticoagultaion, in order to challenge the existing policy and question the need for surgery deferral. Materials and methodsThis is a retrospective cohort of patients (age > 65) with proximal hip fractures treated with either closed reduction internal fixation (CRIF, n = 1143; DOAC use n = 60) or hemiarthroplasty (HA, n = 571; DOAC use n = 29). Baseline patient characteristics included age, gender, ASA score, socioeconomic level, type of surgica#1: In general a l treatment, duration of surgery and time from admission to surgery. The effect of anticoagulant prescription on percentage of hemoglobin change, odds of receiving blood transfusions and one-month and one-year mortality was evaluated separately for CRIF and HA patients. ResultsPatients receiving DOACs had similar perioperative hemoglobin change, transfusion rates and mortality, compared to subjects without anticoagulants in both CRIF and HA cohorts. DOAC patients undergoing CRIF had a longer delay to surgery (40.2 ± 26.9 vs 31.2 ± 22.2, p = 0.003) and higher mortality rates at one year postoperatively (26.7% vs 16.1%, p = 0.015). ConclusionsDOAC use was not associated with an increased perioperative blood loss or mortality compared to controls. However, they had to wait longer for surgery, which itself was an independent predictor of mortality. It may be safe to shorten waiting time for surgery in patients using anticoagulation, with the goal to minimize surgery delay.

Ulnar Nerve Enlargement at the Medial Epicondyle Negatively Correlates With Nerve Conduction Velocity in Cubital Tunnel Syndrome.

Background: In cubital tunnel syndrome (CuTS), chronic compression often occurs at the origin of the flexor carpi ulnaris at the medial epicondyle. Motor nerve conduction velocity (NCV) across the elbow is assessed preoperatively to corroborate the clinical impression of CuTS. The purpose of this study was to correlate preoperative NCV to the direct measurements of ulnar nerve size about the elbow at the time of surgery in patients with clinical and/or electrodiagnostic evidence of CuTS. Methods: Data from 51 consecutive patients who underwent cubital tunnel release over a 2-year period were reviewed. Intraoperative measurements of the decompressed nerve were taken at 3 locations: at 4 cm proximal to the medial epicondyle, at the medial epicondyle, and at the distal aspect of Osborne fascia at the flexor aponeurotic origin. Correlation analysis was performed comparing nerve size measurements to slowing of ulnar motor nerve conduction velocities (NCV) below the normal threshold of 49 m/s across the elbow. Results: Enlargement of the ulnar nerve at the medial epicondyle and nerve compression at the flexor aponeurotic origin was a consistent finding. The mean calculated cross-sectional area of the ulnar nerve was 0.21 cm2 above the medial epicondyle, 0.30 cm2 at the medial epicondyle, and 0.20 cm2 at the flexor aponeurotic origin (P < .001). There was an inverse correlation between change in nerve diameter and NCV slowing (r = -0.529, P < .001). Conclusions: For patients with significantly reduced preoperative NCV and clinical findings of advanced ulnar neuropathy, surgeons can expect nerve enlargement, all of which may affect their surgical decision-making.

Friday, September 28, 2018 3:00 PM–4:00 PM abstracts: optimizing lumbar disc surgery: 217. Increasing reoperation rates and inferior outcome with prolonged symptom duration in lumbar disc herniation surgery

BACKGROUND CONTEXT Lumbar disc herniation (LDH) is associated with great morbidity and significant socio-economic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients where pain and disability is unacceptable, surgical intervention provides effective clinical relief. Currently there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome. PURPOSE The aim of this study is to evaluate if patients with prolonged preoperative symptom duration will have less favorable outcome following surgery for LDH. STUDY DESIGN/SETTING Consecutive series of patients from a single-center, multisurgeon, teritiary spine practice. PATIENT SAMPLE Consecutive series of patients scheduled for spine surgery. OUTCOME MEASURES Oswestru Disability Index (ODI), EuroQol-5D (EQ-5D) and Visual Analog Scale (VAS) for back and leg pain (0–100). METHODS Patients with first episode LDH were included in a single-center study. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their self-reported duration of leg pain prior to enrollment into the registry: <3-months, 3-12 months and >12-months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. RESULTS A total of 1,834 patients were included in the study, with complete 1-year follow-up on 1,448 patients (79%) and an overall reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain, however, this did not reach statistical significance (p=.028). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) 1 year after surgery (p=.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=.009) of increasing incidence of reoperation was found with increasing length of symptom duration. CONCLUSIONS Delayed surgical intervention results in inferior clinical outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved the best outcome 1 year after surgery. Lumbar disc herniation (LDH) is associated with great morbidity and significant socio-economic impact in many parts of the world. Studies have shown that most LDH can be treated effectively with nonoperative management. However, for some patients where pain and disability is unacceptable, surgical intervention provides effective clinical relief. Currently there is little consensus in the medical community on the timing of surgery for patients suffering from radicular pain due to LDH. Multiple studies suggest that prolonged symptom duration adversely affects clinical outcome. The aim of this study is to evaluate if patients with prolonged preoperative symptom duration will have less favorable outcome following surgery for LDH. Consecutive series of patients from a single-center, multisurgeon, teritiary spine practice. Consecutive series of patients scheduled for spine surgery. Oswestru Disability Index (ODI), EuroQol-5D (EQ-5D) and Visual Analog Scale (VAS) for back and leg pain (0–100). Patients with first episode LDH were included in a single-center study. Data were prospectively collected in DaneSpine, the Danish National Spine Registry. Subjects were divided into three groups based on their self-reported duration of leg pain prior to enrollment into the registry: <3-months, 3-12 months and >12-months. Associations between patient-reported outcomes (PROs), perioperative complications and duration of symptoms were evaluated. A total of 1,834 patients were included in the study, with complete 1-year follow-up on 1,448 patients (79%) and an overall reoperation rate of 8.4%. Incidence of surgical complications, specifically dural tears, was higher with increasing duration of leg pain, however, this did not reach statistical significance (p=.028). Prolonged preoperative symptoms adversely influenced all PROs (EQ-5D, ODI, VAS) 1 year after surgery (p=.001). Furthermore, reoperation rates increased with longer duration of preoperative symptoms. A statistically significant trend (p=.009) of increasing incidence of reoperation was found with increasing length of symptom duration. Delayed surgical intervention results in inferior clinical outcomes and increased reoperation rates. Patients who had surgery within the first 3 months of leg pain achieved the best outcome 1 year after surgery.

Timing of surgery in ulcerative colitis in the biologic therapy era-the patient's perspective.

There is no general consensus regarding the ideal timing of surgery in patients with refractory ulcerative colitis (UC). Decision-making and timing of restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is influenced by treating physicians and patients themselves. The aim of this study was to determine whether or not patients would have preferred the operation to be performed earlier, at the same time, or at a later point of time and to determine the reasons for their preference. Clinical data of 193 patients with UC who have undergone IPAA were documented in a prospective database at our institution between 2004 and 2015. From this database, 190 patients were identified and a standardized custom-made questionnaire was mailed for follow-up survey. Patients who did not respond were called by telephone and encouraged to complete the questionnaire. One hundred nine questionnaires were eligible for analysis (57.4%). Average time between diagnosis and surgery was 11.2 ± 10.8years (mean ± SD). Indications for surgery were refractory disease (70.6%), colitis-associated colorectal cancer (11.0%), high-grade dysplasia or stenosis (11.9%), and septic complications of UC (6.4%); 39 of 77 patients (50.6%) with refractory UC reported to have preferred their operation to be carried out earlier as it was actually performed (16.8 ± 11.9months). Refractory course of the disease was identified as a predictor for a retrospectively desired earlier surgical approach (p= 0.014). A substantial proportion of patients felt that they should have undergone surgery earlier than actually performed. It appears that timing of the decision to undergo surgery is suboptimal. This situation may be improved by earlier surgical consultation in the course of the disease.

The predictive value of left ventricular myocardium mechanics evaluation in asymptomatic patients with aortic regurgitation and preserved left ventricular ejection fraction. A long-term speckle-tracking echocardiographic study.

The management of asymptomatic patients with aortic regurgitation (AR) and preserved left ventricular (LV) ejection fraction (LVEF) remains challenging. The purpose of the study was to assess the early changes of LV mechanics by 2D speckle-tracking echocardiography (2D-STE) in order to predict a decrease in LVEF. Sixty-seven patients (age, 47±15years) with asymptomatic moderate (n=27) and severe AR (n=40) with preserved LVEF were prospectively followed for about 5years. Sixty healthy age-matched controls were included in the study. Standard echocardiography and 2D-STE were performed at the baseline and follow-up. The primary endpoint was a deterioration of the LVEF (≤50%). At baseline, global LV longitudinal peak systolic strain (GLS) and strain rate (GLSRs) were decreased in patients with severe AR compared to controls (-18.9±2.4 vs 20.0±2.1%; -1.05±0.19 vs -1.18±0.15 1/s, P<.05, respectively). In the moderate AR group, GLS was not different from that of the control group, but GLSRs was significantly lower than in controls. The primary endpoint was reached in 12 patients with severe AR, while this was not observed in patients with moderate AR. In multivariate analysis, GLS was an independent predictor of LVEF. According to ROC curve analysis, probability of primary endpoint occurrence was significantly greater in patients with GLS values ≥-18.5% (AUC: 0.89, P<.01). The reduction of LV longitudinal deformation is a sign of early subclinical LV dysfunction. GLS is a prognostic predictor of LV dysfunction and may be potentially useful for optimal timing of surgery for patients with significant AR.

Myocardial Strain in Prediction of Outcomes After Surgery for Severe Mitral Regurgitation

ObjectivesWe investigated whether global longitudinal strain (GLS) is a better predictor of clinical events after surgery for mitral regurgitation (MR) than conventional parameters. BackgroundThe optimal timing for surgery is guided by left ventricular (LV) dimension or left ventricular ejection fraction (LVEF), even though normal LVEF can mask depressed LV systolic function in severe mitral MR. MethodsFrom 2006 to 2016, 506 patients (age 58.5 ± 13.7 years, 54.3% male) with severe primary MR who underwent mitral valve surgery were included. We measured GLS and global circumferential strain. Cardiac events included admission for worsening heart failure (HF), reoperation for failure of MV surgery, and cardiac death. ResultsDuring a median follow-up period of 3.5 years, 56 (11.1%) patients died, 41 (8.1%) were hospitalized for HF, and 10 (2.0%) underwent reoperation. In univariate analysis, LVEF, atrial fibrillation, left atrial dimension, age, previous ischemia, concomitant coronary artery bypass graft, and both GLS and global circumferential strain were predictive of cardiac events. On multivariate Cox models, age (hazard ratio [HR]: 1.429, 95% confidence interval [CI]: 1.116 to 1.831; p = 0.005), left atrial dimension (HR: 1.034, 95% CI: 1.006 to 1.063; p = 0.019) and GLS (HR: 1.229, 95% CI: 1.135 to 1.331; p < 0.001) were independent predictors of cardiac events. In subgroup analysis, LV GLS was a significant predictor of cardiac outcome, regardless of the presence of LV dysfunction, the presence of atrial fibrillation, and the type of surgery. Impaired GLS was associated with all-cause mortality (HR: 1.068, 95% CI: 1.003 to 1.136; p = 0.040). ConclusionsGLS appears to be a better predictor of cardiac events all-cause death than conventional parameters. Measuring preoperative GLS is helpful to predict post-operative outcome and determine optimal timing for surgery in patients with severe primary MR.

Thirty-day mortality in patients undergoing laparotomy for small bowel obstruction

Small bowel obstruction (SBO) is a common indication for emergency laparotomy. There are currently variations in the timing of surgery for patients with SBO and limited evidence on whether delayed surgery affects outcomes. The aim of this study was to evaluate the impact of time to operation on 30-day mortality in patients requiring emergency laparotomy for SBO. Data were collected from the National Emergency Laparotomy Audit (NELA) on all patients aged 18 years or older who underwent emergency laparotomy for all forms of SBO between December 2013 and November 2015. The primary outcome measure was 30-day mortality, with date of death obtained from the Office for National Statistics. Patients were grouped according to the time from admission to surgery (less than 24 h, 24-72 h and more than 72 h). A multilevel logistic regression model was used to explore the impact of patient factors, primarily delay to surgery, on 30-day mortality. Some 9991 patients underwent emergency laparotomy requiring adhesiolysis or small bowel resection for SBO. The overall mortality rate was 7·2 per cent (722 patients). Within each time group, 30-day mortality rates were significantly worse with increasing age, ASA grade, Portsmouth POSSUM score and level of contamination. Patients undergoing emergency laparotomy more than 72 h after admission had a significantly higher risk-adjusted 30-day mortality rate (odds ratio 1·39, 95 per cent c.i. 1·09 to 1·76). In patients who require an emergency laparotomy with adhesiolysis or resection for SBO, a delay to surgery of more than 72 h is associated with a higher 30-day postoperative mortality rate.

Surgical timing of anterior cruciate ligament reconstruction to prevent associated meniscal and cartilage lesions.

The purpose of this study was to analyze the association between the prevalence of meniscal and chondral lesions and the timing of surgery in patients undergoing primary anterior cruciate ligament (ACL) reconstruction to determine a safe time for surgery. This retrospective study involved 226 patients (91 females and 135 males; median age, 29 years) undergoing primary ACL reconstruction. Time interval from ACL injury to surgery (median, 4 months; range, 1-420 months) and concomitant meniscal and cartilage lesions in ACL reconstruction were reviewed. Receiver operating characteristic (ROC) curve analysis was used to determine the precise threshold interval to surgery to prevent meniscal or cartilage lesions. The risk of lesion occurrence after each cutoff period was determined using odds ratio (OR). The incidences of medial meniscus (MM), lateral meniscus (LM), and cartilage lesions were 43.8%, 32.7%, and 27.4%, respectively. ROC analysis revealed that patients who waited for more than 6, 4, and 5 months for ACL reconstruction had a significantly greater risk of associated MM, LM, and chondral lesions, respectively. Patients who underwent ACL reconstruction ≥7 months after injury had OR of 4.1 (p<0.001) for the presence of MM lesion as compared with those who underwent reconstruction within 6 months. Similarly, patients who underwent ACL reconstruction ≥5 months after injury had OR of 1.9 (p=0.023) for the presence of LM lesion as compared with those who underwent reconstruction within 4 months, and patients who underwent ACL reconstruction ≥6 months after injury had OR of 2.9 (p<0.001) for chondral lesion as compared with those who underwent reconstruction within 6 months. ACL reconstruction should be performed within approximately 6 months after the injury to prevent associated meniscal or chondral lesions.

Impact of Preoperative Neurological Events on Outcome and Timing of Surgery in Patients with Infective Valve Endocarditis

Impact of Preoperative Neurological Events on Outcome and Timing of Surgery in Patients with Infective Valve Endocarditis

Soft tissue complications and timing of surgery in patients with a tongue-type displaced intra-articular calcaneal fracture: An international retrospective cohort study

IntroductionTongue-type displaced intra-articular calcaneal fractures (DIACF) are associated with a specific pattern of fracture displacement in contrast to joint depression fractures. This may result in tension of soft tissue in the posterior part of the heel. Tension-induced ischemia can result in skin necrosis. The objectives of this study were to investigate whether patients with tongue-type calcaneal fractures exert a higher risk of complications, especially of the posterior soft tissues, than joint depression type fractures. Also, late interventions (e.g., antibiotics, debridements, and amputations) and the effect of timing of surgery on the complication rate was assessed. MethodsIn this international retrospective cohort study, data of adult patients with a DIACF in the period January 1, 2005–December 31, 2015 were extracted from patients’ medical files. Descriptive, univariate, and multivariable analyses were performed in SPSS. ResultsA total of 560 patients with 632 DIACF were included (295 tongue-type and 337 non-tongue-type fractures). At hospital presentation, 20.3% of the patients with a tongue-type fracture had compromised posterior soft tissue versus 12.8% with non-tongue-type fractures (p = 0.032). However, corrected for potential confounders the risk was no longer statistically significant (OR 1.497; 95% CI 0.831–2.696). Patients with a TT-DIACF had a 1.2–3.4-fold higher rate of any local wound complication (deep infections, and full thickness lesions, p < 0.03). In addition they had 2.0–8.0-fold more intravenous antibiotics, debridements, soft tissue coverage procedures and amputations (p < 0.03). Patients who underwent surgery within two days after trauma had a higher risk to develop any complication, in particular superficial infections, when compared to surgery between 3–7 days, but no significant difference between 3 and 7 and ≥8 days could be demonstrated. ConclusionDespite the fact that patients with a tongue-type fracture developed posterior skin and soft tissue compromise nearly twice as often, this difference disappeared after correction for confounders. The overall complication risk was increased in patients with tongue-type calcaneal fractures as compared to patients with a non-tongue-type fracture. Whether or not patients with tongue-type fractures require immediate surgery cannot be concluded from the data.

Spontaneous Spinal Epidural Hematoma in a Patient on Rivaroxaban: Case Report and Literature Review

BackgroundSpinal hematomas (SHs) are rare yet potentially debilitating causes of acute back pain. Although spontaneous SHs have been described in the setting of anticoagulation with warfarin or enoxaparin, few cases of spontaneous SH on direct oral anticoagulants (DOACs) have been reported. Case ReportWe report a case of spontaneous spinal epidural hematoma in a patient on rivaroxaban. A 72-year-old man on rivaroxaban and aspirin presented with a 4-day history of nontraumatic back pain. In the emergency department he developed lower-extremity weakness and numbness, followed by urinary incontinence. Magnetic resonance imaging revealed spinal epidural hematoma at T11–L2. The patient underwent emergent decompression and hematoma evacuation and was discharged home 8 days later with complete resolution of symptoms. Why Should an Emergency Physician Be Aware of This?Early recognition and surgical intervention for SHs with neurologic compromise is key to favorable outcome. Optimal timing of surgery in patients on DOACs requires an assessment of the risk of intraoperative or postoperative bleeding, an assessment of the patient's symptom progression, as well as an understanding of the pharmacokinetics of the DOAC used and possible reversal options available. We also review all published cases of spontaneous SHs in patients on DOACs and report on their management and outcomes.

Regional audit of timing of surgery in patients receiving short course pre-operative radiotherapy (SCPRT) for rectal cancer

Regional audit of timing of surgery in patients receiving short course pre-operative radiotherapy (SCPRT) for rectal cancer

The interaction between preoperative platelet count and function and its relationship with postoperative bleeding in cardiac surgery

Platelet function tests (PFTs) before cardiac surgery are predictive of postoperative bleeding and can guide a correct timing of surgery in patients under P2Y12 inhibitors. Thrombocytopenia affects PFT and may determine postoperative bleeding. The present study aims to investigate the relationship between platelet count and function, and its role in determining postoperative bleeding in cardiac surgery patients pre-treated with P2Y12 inhibitors. The study includes 589 consecutive cardiac surgery patients, tested before surgery with platelet count and multiple electrode aggregometry (MEA) ADPtest (investigating P2Y12 receptor platelet reactivity) and TRAPtest (investigating the thrombin-dependent platelet reactivity). Platelet function was linearly associated (P = 0.001) with platelet count at the ADPtest and the TRAPtest, demonstrating a positive association in the whole spectrum of platelet count. The ADPtest (P = 0.001) and platelet count (P = 0.001) were negatively associated with postoperative bleeding, whereas the TRAPtest was not. At a multivariable analysis, the ADPtest (P = 0.026) and platelet count (P = 0.006) remained independent predictors of postoperative bleeding. The platelet transfusion rate was 5.7% in patients with ADPtest ≥30 U and platelet count ≥150 000 cells/µL, 14.3% in patients with ADPtest ≥30 U and platelet count <150 000 cells/µL, 38.9% in patients with ADPtest <30 U and platelet count ≥150 000 cells/µL, and 50% in patients with ADPtest <30 U and platelet count <150 000 cells/µL (P = 0.001).Platelet function at MEA is dependent on the platelet count not only in the case of thrombocytopenia, but also in the whole range of platelet count; preoperative platelet count and function are determinants of postoperative bleeding, with a larger effect on platelet transfusions attributable to a poor P2Y12-dependent platelet function.

Does Concomitant Tricuspid Valve Repair Elevate the Operative Risk Due to Prolonged Time of Surgery in Patients with Minimally Invasive Mitral Valve Repair?

Does Concomitant Tricuspid Valve Repair Elevate the Operative Risk Due to Prolonged Time of Surgery in Patients with Minimally Invasive Mitral Valve Repair?

Effects of Decreased Annular Height and Annular Saddle-Shaped Non-Planarity in Degenerative Severe Mitral Regurgitation with Normal Left Ventricular Ejection Fraction: Real-Time 3D Transesophageal Echocardiography.

BackgroundThe extent of mitral annular (MA) remodeling and dysfunction is correlated with the severity of mitral regurgitation (MR) as well as left atrial (LA) and left ventricular (LV) dilation. MA dysfunction may be a useful prognostic factor for operative timing and MR recurrence after successful mitral valve (MV) repair. The aim of this study was to evaluate additive prognostic factors of MA non-planarity using real-time 3D transesophageal echocardiography (RT3D-TEE) analysis in patients with chronic severe MR and preserved LV systolic function.MethodsForty-seven patients with chronic severe MR and preserved LV systolic function scheduled for MV repair were prospectively enrolled. Echocardiographic studies were performed before surgery and postoperatively within 2 weeks and at least 6 months after surgery. RT3D-TEE was performed before the operation and immediately post-operative.ResultsMean age was 55.4 ± 15.1 years and 24 were male. Annulus height/body surface area (BSA) obtained via RT3D-TEE was correlated with the degree of postoperative LA remodeling. Patients were divided into two groups by average baseline annulus height/BSA. Patients with normal annular height had a smaller postoperative LV end-diastolic dimension, LV end-systolic dimension and LA volume index than patients with decreased annular height. Preoperative annulus height/BSA values strongly predicted postoperative LA remodeling.ConclusionMA height may be a useful prognostic factor for determining the timing of surgery in patients with chronic primary MR. Annulus height/BSA assessed via RT3D-TEE may provide additional information predictive of postoperative LA remodeling after successful MV repair.