Timing Of Surgery In Patients Research Articles

Platelet function recovery after ticagrelor withdrawal in patients awaiting urgent coronary surgery.

Dual antiplatelet therapy with ticagrelor and aspirin is associated with an increased risk of perioperative bleeding complications. Current guidelines recommend therefore discontinuation of ticagrelor 5 days before surgery to allow sufficient recovery of platelet function. It is not known how the time to recovery varies between individual patients after discontinuation of ticagrelor. Twenty-five patients accepted for urgent coronary artery bypass surgery and treated with ticagrelor and aspirin were included in a prospective observational study. Platelet aggregation was evaluated with impedance aggregometry at five timepoints 12-96 h after discontinuation of ticagrelor. In a subset of patients ( n = 15), we also tested the ex vivo efficacy of platelet concentrate supplementation on platelet aggregation. There was a gradual increase in mean adenosine diphosphate-induced platelet aggregation after discontinuation of ticagrelor. After 72 h, mean aggregation was 38 ±23 aggregation units (U), which is above a previously suggested cut-off of 22 U, when patients can be operated without increased bleeding risk. However, there was a large interindividual variability (range 4‒88 U at 72 h) and 6/24 patients (25%) had <22 U after 72 h. Ex vivo administration of platelet concentrate did not improve adenosine diphosphate-induced aggregation at any timepoint after ticagrelor discontinuation. Adenosine diphosphate-induced aggregation was acceptable after 72 h in the majority of patients but with a large interindividual variability. Due to the large variability, platelet function testing may prove to be a valuable tool in timing of surgery in patients with ongoing or recently stopped ticagrelor treatment. Adenosine diphosphate-induced aggregation was not improved by addition of platelet concentrate.

Is pulmonary artery pressure a trigger of adverse outcome in mitral regurgitation?

Mitral regurgitation (MR) is an important cause of morbidity and mortality in developed countries (1,2). The most common cause of MR is degenerative with an age-related epidemiological burden consisting of a peak incidence in patients over 70 years of age (1). Open surgical correction, using mitral valve repair or replacement, is currently accepted as the standard treatment of MR. Congestive heart failure symptoms or left ventricular (LV) dysfunction (EF 40 or >45 mm according to ACC/AHA and ESC guidelines, respectively) are the suggested Class-I triggers for surgery (3,4). However, surgical treatment based on Class-I triggers may be characterized by a suboptimal postoperative outcome. Due to its long standing asymptomatic clinical course, the selection of optimal timing for surgery remains an important challenge (5-7). Due to the absence of randomized studies, current guidelines are based on the inference from observational studies or expert opinions. An ESC-position paper supports the organization of specialized valve clinics attempting optimal and individualized MR management (8). In the last few decades, the wide application of mitral valve repair has progressively changed the timing for surgery in patients with MR. Targeting valve lesion treatment, independent of symptoms and LV deterioration signs, mitral valve repair challenges the more conservative valve replacement approach, leading to early surgery in order to achieve an optimal postoperative outcome. The key points to consider are the predictability of repair using the best surgical strategy based on the functional mechanism of MR, the evaluation of MV repair efficacy before closing the chest, prediction and management of complications, and radicalization of MR treatment to achieve a durable repair without longterm recurrence or lesion progression. Mitral valve repair has been proposed for the treatment of MR without Class-I triggers when functional mitral anatomy matched with an experienced surgical team predicts a 95% rate of successful and durable repair with an expected surgical mortality <1%. Unlike the ACC/AHA statement, decision-making based on surgical reparability alone is not considered beneficial in the ESC recommendations (Class IIb). Although repair feasibility is considered a key point for early surgery in the real world the ultimate repair of degenerative MR is around 60%, with great inter-hospital variability related to team experience and intervention volume rate. The use of three-dimensional imaging may improve communication with surgeons, enabling them to predict a surgical strategy that might help close the gap between valve reparability and ultimate repair. New onset atrial fibrillation or resting pulmonary hypertension (PH) may be the facilitators of decision-making to perform mitral repair in asymptomatic MR with preserved LV function (Class IIa).

Does Early Surgical Decompression in Cauda Equina Syndrome Improve Bladder Outcome?: Comments on a Recent Study by Srikandarajah et al.

This study by Srikandarajah et al is a retrospective cohort study of 200 CES patients. Although parts of the study appear to be well done we identified serious problems that impacted their conclusions. There is strong consensus that patients with incomplete cauda equina syndrome (CESI) should be operated upon expeditiously to prevent progression to CES with urinary retention (CESR). There is controversy concerning optimal timing of surgery in patients who have entered CESR. Some studies conclude urgent surgery for CESR does nothing to improve chance of recovery; others conclude surgery should be done within a 48 or 24-hours window after onset of bladder paralysis. Srikandarajah et al concluded that in CESI patients, decompressive surgery within 24 hours of onset of autonomic symptoms reduces bladder dysfunction at follow-up. In CESR patients, "no statistically significant difference in outcome was observed" regarding timing of surgery. We analyzed the methods used by Srikandarajah et al to collect and analyze their data. The primary problem with their study is that it does not consider deterioration to CESR that occurs in CESI patients over time. We also found serious problems with the methods, implementation (including numeric errors), and interpretation of the statistical analysis. The authors' conclusion that in CESR patients, "no statistically significant difference in outcome was observed" regarding timing of surgery is not justified as a representation of their findings, because absence of statistical significance does not mean acceptance of the null hypothesis of "no effect". Their numeric results do show elevated risk of delay. We do not want to detract from the basic importance of this study, because it emphasizes the importance of operating expeditiously on patients with CESI. However, the authors' conclusions are compromised by the methodological problems. N/A.

Endothelial dysfunction of internal thoracic artery graft in patients with chronic kidney disease

ObjectivesThe present study was designed to evaluate the association between chronic kidney disease and the endothelial function of internal thoracic artery (ITA) grafts in patients undergoing coronary bypass surgery. An isometric tension study was performed in ITA strips obtained during surgery. Concentration-response curves for acetylcholine (ACh) and sodium nitroprusside were constructed in ITA strips partially precontracted with phenylephrine under the inhibition of cyclooxygenase. The integrity of the endothelium was verified histologically by en-face staining of the luminal surface with the use of silver nitrate solution. ResultsIn endothelium-intact ITA strips, ACh produced a concentration-dependent relaxation in patients with glomerular filtration rate (GFR, mL/min/1.73 m2) > 60. A concentration-dependent relaxation response also was observed in patients with GFR 30 to 60, but it was reduced significantly compared with those with GFR > 60. In both groups, removal of endothelium or treatment with nitric oxide (NO) synthase inhibitors almost abolished the ACh-induced relaxation. On the other hand, in patients with GFR < 30, mild contraction rather than relaxation was induced at a high concentration of ACh, which was modified neither by treatment with NO synthase inhibitors nor by removal of the endothelium. Vasodilator responses to sodium nitroprusside were comparable among the 3 groups. The relaxation of endothelium-intact strips to a peak ACh concentration correlated positively with GFR. This relationship held true in a multiple linear regression model, and interaction terms between GFR and other risk factors were not statistically significant. ConclusionsEndothelial function of ITA grafts to release NO is impaired at the time of surgery in patients with chronic kidney disease.

Timing of surgical intervention in patients of infected necrotizing pancreatitis not responding to percutaneous catheter drainage

BackgroundThe timing of surgery in patients not responding to percutaneous catheter drainage (PCD) in infected pancreatic necrosis remains challenging. Materials and methodsA randomized controlled trial was designed to establish the optimal timings of surgery following PCD in patients with infected pancreatic necrosis (IPN). Patients who did not improve by day 10 after PCD insertion were included in the present study and were randomized to group A (step-up approach as a bridge to surgery) or group B (step-up approach with intention to avoid surgery). Weekly inflammatory and nutritional markers were monitored in both groups (clinical trials. gov identifier NCT-01527084). ResultsFrom July 2011 to December 2012, 40 patients underwent treatment with PCD. The first 8 patients were randomized into two groups. The trial was stopped prematurely because of difficulty in accrual and poor progress. All subsequent patients were managed with step-up approach with the intention to avoid surgery. Of 35 patients, 24 patients were managed by PCD alone while 11 patients required surgery. In patients who did not require surgery; levels of serum high sensitivity C-reactive protein (hsCRP), interleukin-6(IL6) and prealbumin showed a falling trend. This group also had higher baseline albumin and higher albumin at 4 weeks. ConclusionDuring the present study, randomization into surgery at a predetermined time in step-up approach was discontinued due to poor progress. Step-up approach with the intention to avoid surgery led to a success rate of 68.5%. The present study failed to predict the optimal timing of surgery after PCD. Patients who needed surgery were sicker at the time of admission, had higher incidence of organ failure, and spent more time in the ICU compared to patients who did not need surgery. In future, inflammatory and nutritional markers may be useful to identify patients who are unlikely to respond to PCD and may help determine the timing of surgery.

Does surgical treatment within 4 hours after trauma have an influence on neurological remission in patients with acute spinal cord injury?

BackgroundThe proper timing for surgery in patients with acute spinal cord injury is controversial. This study was conducted to detect if there is an advantage in early (within the first 4 hours after trauma) compared to late (between 4 and 24 hours after trauma) surgery on neurological outcome.MethodsIn this single institution prospective cohort study, data were analyzed from 51 spinal cord injured patients with an average age of 43.4 (±19.2) years. The influence of early (29 patients within the first 4 hours) as opposed to late (22 patients between 4 and 24 hours) decompression was evaluated by comparing data for neurological outcome. Patients of the study collectively suffered acute spinal fractures from C2 to L3 (cervical 39.2%, thoracic 29.4%, and lumbal 21.6%) or nonosseous lesions (9.8%). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades were assessed at time of admission and 6 months after trauma or longer depending on the time of release. Surgical treatment included early stabilization and decompression within 24 hours.ResultsNo significant difference between improved neurological function, measured with the AIS, and an early or late surgery time can be seen (P=0.402). Furthermore, binary logistic regression shows no significant difference between sex or age, and AIS improvement as possible confounders.ConclusionIn our study, all patients with spinal cord injury were treated with spine stabilization and decompression within the first 24 hours after trauma. Surgical decompression within the first 4 hours after trauma was not associated with improved neurological outcome compared to treatment between 4 and 24 hours. In a clinical context, this indicates that there is a time frame of at least 1 day in which optimal care is possible.

Can applied external fixators be sterilized for surgery? A prospective cohort study of orthopaedic trauma patients

BackgroundTemporary external fixators are often used to stabilize fractures when definitive fracture surgery must be delayed. Sometimes, external fixators are left in place during repeat operations, including definitive internal fixation of tibial pilon and tibial plateau fractures. It is unknown how well current surgical preparation sterilizes these devices, which become part of the surgical field. Our hypothesis was that our institution’s standard surgical preparation creates a low rate of culture-positive environments on external fixators at the time of surgical skin incision. MethodsWe prospectively consented and enrolled patients to obtain cultures (48 patients, 55 external fixators, 165 sets of culture data). After standard preparation and immediately before incision, cultures were obtained from three sites on each external fixator: 1) most distal pin 1cm from pin-skin interface, 2) most distal bar at midpoint between pin and clamp connectors, and 3) most distal clamp at bar-clamp interface. Our standard preparation for patients with external fixation in place is to don sterile gloves and wipe down all components of the external fixator with 70% alcohol-soaked sterile 4×4in gauze sponges before skin preparation. The skin and external fixator are then prepped in the usual fashion with ChloraPrep for closed wounds or with povidone iodine scrub and paint for open wounds. Swabs were processed and organisms from cultures identified. Clinicians were blinded to study results until study completion. ResultsTwo of 165 cultures (1.2%; 95% confidence interval [CI]: 0–2.9%) were positive for common pathogens sometimes observed in surgical site infection. Four cultures (2.4%; 95% CI: 0–4.8%) had pathogens that are rarely associated with surgical site infection, and four (2.4%; 95% CI: 0–4.8%) had nonpathogenic organisms. ConclusionUsing 70% alcohol on external fixators plus either ChloraPrep for closed wounds or povidone iodine for open wounds seems to result in a low rate of positive cultures. Most species that were isolated are infrequently identified as sources of surgical site infections. This preparation protocol might be effective at producing a relatively clean environment at the time of surgery for patients with external fixators already in place.

Invited Commentary

Surgical reexploration to control blood loss is a serious complication of cardiac surgery and is, per se, a marker of severe postoperative bleeding. Patients who require this procedure invariably experience an increased morbidity and mortality rate. There are many possible explanations for this association. Severe bleeding is a determinant of bad outcomes, either directly (as a factor leading to hemodynamic instability and acute anemia) or indirectly (as a determinant of massive blood transfusions); additionally, surgical reexploration may increase the risk for infections. The study from Fröjd and Jeppsson [1Fröjd V. Jeppsson A. Reexploration for bleeding and its association with mortality after cardiac surgery.Ann Thorac Surg. 2016; 102: 109-117Google Scholar] is confirmative of previous findings, actually showing that surgical reexploration doubles the early and even the medium-long term mortality risk. Even if this information is not new, this study offers some interesting points of discussion. The first one is related to the decision-making process for the surgical reexploration and its timing. As the authors admit, their surgical reexploration rate is considerable (6.0%) as a consequence of their aggressive policy of early reexploration in actively bleeding patients. Certainly, delaying a necessary surgical reexploration means burdening the patient with the weight of ongoing hemodynamic instability, poor systemic oxygen delivery, and transfusions; conversely, an inappropriate surgical approach to patients affected by disorders of the hemostatic system adds risks to a risky clinical condition. This conundrum is still unsolved in the daily clinical practice, even if point-of-care coagulation tests may probably offer a useful piece of information. The second important point is the identification of 2 theoretically modifiable risk factors: preoperative low levels of fibrinogen and dual antiplatelet therapy <5 days before surgery. It is difficult to hypothesize that preoperative fibrinogen supplementation is a viable option (unless in presence of very low, presently not established, fibrinogen levels) as a recent study from the same group has demonstrated [2Jeppsson A. Waldén K. Roman-Emanuel C. Thimour-Bergström L. Karlsson M. Preoperative supplementation with fibrinogen concentrate in cardiac surgery: A randomized controlled study.Br J Anaesth. 2016; 116: 208-214Crossref Scopus (45) Google Scholar]. Conversely, the correct timing of surgery in patients under dual antiplatelet therapy is probably an issue that may benefit from a preoperative assessment of platelet function with one of the existing point-of-care tests [3Ferraris V.A. Saha S.P. Oestreich J.H. et al.2012 update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations.Ann Thorac Surg. 2012; 94: 1761-1781Abstract Full Text Full Text PDF PubMed Scopus (234) Google Scholar]. This last option will probably gain a wider popularity once the new generation of antiplatelet agents (acting on the powerful platelet thrombin receptor) will enter the clinical scenario. Reexploration for Bleeding and Its Association With Mortality After Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 102Issue 1PreviewExcessive bleeding after cardiac surgical procedures sometimes necessitates reexploration. This study described the associations between reexploration for bleeding and morbidity and mortality after cardiac surgical procedures. In addition, independent predictors of reexploration were identified. Full-Text PDF

Unanticipated 30-day readmission following rectosigmoid resection at the time of cytoreductive surgery in patients with advanced-stage ovarian cancer

Unanticipated 30-day readmission following rectosigmoid resection at the time of cytoreductive surgery in patients with advanced-stage ovarian cancer

Prolonged Medical Therapy Increases the Risk of Surgical Complications in Patients with Severe Ulcerative Colitis

Aims: To determine the risk factors of surgical complications and the optimal timing of surgery for patients with severe ulcerative colitis (UC). Methods: One hundred one UC patients who had undergone surgery for a severe indication were retrospectively reviewed. Indications included severe disease unresponsive to medical therapy, massive bleeding, toxic megacolon, and colon perforation. Outcomes were compared based on the occurrence or absence of surgical complications. Patients with severe disease unresponsive to medical therapy were investigated separately to determine the optimal timing of surgery. Results: There was no significant difference regarding the use of rescue therapy. The duration of all medical therapy for a severe attack was the only significant factor associated with a surgical complication (p = 0.032). In patients with severe disease unresponsive to medical therapy, the receiver operating characteristic curve analysis showed that 30.5 days was the length of medical therapy after which the risk of surgical complications significantly increased. Conclusions: In patients with severe UC, rescue therapy itself was not related to an increased risk of surgical complications. However, prolonged medical therapy increased the risk of surgical complications. Patients should undergo surgery within 30 days from the institution of medical therapy for a severe attack.

Prognostic Importance of Exercise Brain Natriuretic Peptide in Asymptomatic Chronic Organic Severe Mitral Regurgitation: An Observational Study.

BackgroundThe optimal timing of surgery in patients with chronic organic severe mitral regurgitation (MR) continues to be debated, especially for those who are asymptomatic. The aim of the study was to determine independent and additive prognostic value of exercise brain natriuretic peptide (eBNP) in patients with severe asymptomatic MR and normal left ventricular ejection fraction (LVEF).MethodsTwo hundred twenty-three consecutive patients with severe MR defined by effective regurgitant orifice (ERO) area ≥ 40 mm2 and/or residual volume ≥ 60 mL, LVEF > 60%, and normal LV end-systolic diameter < 40 mm underwent symptom limited exercise treadmill test (TMT). Echocardiography was done immediately after exercise. Data were obtained within 3 minutes of peak exercise. BNP levels were assessed before echo (after 30 minutes of supine rest) and at exercise (i.e., within the 3 minutes of the end of effort). Patients were followed up every 3 months up to 15 months for major adverse cardiac events (MACEs) (cardiovascular death, need for mitral valve surgery and hospitalization for acute pulmonary edema or heart failure).ResultsMean age was 31.2 ± 9 years (range: 18 - 40) with majority being male (n = 153; 68%). Etiologies were rheumatic (n = 201; 90%), mitral valve prolapse (n = 17; 7.6%) and hypertrophic cardiomyopathy (n = 5; 2.4%). BNP level significantly increased from rest (65.24 ± 43.92 pg/mL; median: 43.5 pg/mL) to exercise (100.24 ± 98.24 pg/mL; median: 66.5 pg/mL; P < 0.001). Patients were divided into three tertiles according to eBNP levels (T1 = 15 - 44; T2 = 45 - 104; T3 = 105 - 400). There was trend for significantly lower exercise time in T3. During TMT, 66 (29.5%) stopped exercise due to dyspnea. They had similar resting BNP level compared with others but had significantly higher eBNP level (136 ± 109.7 pg/mL vs. 84.88 ± 90.2 pg/mL; P < 0.001). During follow-up (15 months), MACE occurred in 83 patients (37.2%): mitral valve replacement (MVR) in 59 patients (symptomatic: 43; LV dilatation or dysfunction: 9; both symptoms and dilatation/dysfunction: 7), 17 hospitalizations for congestive heart failure, five patients developing acute pulmonary edema and atrial fibrillation in remaining two patients. This was 7.6%, 35% and 69% in T1, T2 and T3, respectively and had significantly higher eBNP level than without any event (165 ± 119 pg/mL vs. 57 ± 48 pg/mL; P < 0.001). Using receiver operating characteristic curve analysis, the best cut-off value of eBNP level to predict cardiac events was 90 pg/mL (sensitivity: 75%; specificity: 88.6%; positive predictive value: 79%; negative predictive value: 83.9%).ConclusionIn asymptomatic patients, eBNP level provides incremental prognostic value beyond echocardiographic data and those with elevated eBNP should be considered at high risk for reduced event-free survival and might be considered for early MVR.

Time to Surgery and Outcomes in Cauda Equina Syndrome: An Analysis of 45 Cases

The objective of this study is to analyze time to surgery as both a continuous and discrete variable to determine its association with outcomes in cauda equina syndrome (CES). Patients at a single center whose medical record allowed precise calculation of time to surgery were included. CES was defined as at least four of the following: bladder dysfunction, saddle anesthesia, lower extremity weakness, lower extremity sensory disturbance, bowel dysfunction, or acute lower back or leg pain. Time to surgery was analyzed as a continuous variable using logistic and ordered logistic regression, and as a discrete variable by comparing patients treated before and after set thresholds. Forty-five patients were identified. Analysis of time as a continuous variable did not reveal any significant association with outcomes. A parsimonious model with adjustment for age, sex, race, acute onset of CES, saddle anesthesia, motor deficit, and bowel dysfunction at presentation was used to analyze the continuous influence of time to surgery on bladder dysfunction and an aggregate outcome of symptoms. Neither time to surgery nor any of the covariates were significantly associated with either outcome. Discrete analysis of outcomes across thresholds of 12, 24, 36, 48, 60, and 72 hours did not reveal prognostic time points. In this single-center CES series, time to surgery did not have a convincing continuous or discrete relationship with outcome. Future prospective studies are needed to determine the best timing for surgery in patients with CES.

Optimal timing for early surgery in infective endocarditis: a meta-analysis.

To systematically review early surgery and the optimal timing of surgery in patients with infective endocarditis (IE), a search for foreign and domestic articles on cohort studies about the association between early surgery and infective endocarditis published from inception to January 2015 was conducted in the PubMed, EMBASE, Chinese Biomedical Literature (CBM), Wanfang and Chinese National Knowledge Infrastructure (CNKI) databases. The studies were screened according to the inclusion and exclusion criteria, the data were extracted and the quality of the method of the included studies was assessed. Then, the meta-analysis was performed using the Stata 12.0 software. Sixteen cohort studies, including 8141 participants were finally included. The results of the meta-analysis revealed that, compared with non-early surgery, early surgery in IE lowers the incidence of in-hospital mortality [odds ratio (OR) = 0.57, 95% confidence interval (CI) (0.42, 0.77); P = 0.000, I(2) = 73.1%] and long-term mortality [OR = 0.57, 95% CI (0.43, 0.77); P = 0.001, I(2) = 67.4%]. Further, performing operation within 2 weeks had a more favourable effect on long-term mortality [OR = 0.63, 95% CI (0.41, 0.97); P = 0.192, I(2) = 39.4%] than non-early surgery. In different kinds of IE, we found that early surgery for native valve endocarditis (NVE) had a lower in-hospital [OR = 0.46, 95% CI (0.31, 0.69); P = 0.001, I(2) = 73.0%] and long-term [OR = 0.57, 95% CI (0.40, 0.81); P = 0.001, I(2) = 68.9%] mortality than the non-early surgery group. However, for prosthetic valve endocarditis (PVE), in-hospital mortality did not differ significantly [OR = 0.83, 95% CI (0.65, 1.06); P = 0.413, I(2) = 0.0%] between early and non-early surgery. We concluded that early surgery was associated with lower in-hospital and long-term mortality compared with non-early surgical treatment for IE, especially in NVE. However, the optimal timing of surgery remains unclear. Additional larger prospective clinical trials will be required to clarify the optimal timing for surgical intervention and determine its efficacy in PVE.

Abstract 17048: Prognostic Implication of Enlarged Left Ventricle in Patients Who Underwent Valve Surgery due to Mitral Valve Prolapse or Flail Mitral Valve: Volume versus Dimension

Introduction: Left ventricular end-systolic dimension (LVESD) has been being used to guide the optimal timing of surgery in patients with mitral valve prolapse (MVP) or flail mitral valve (FMV). We sought to evaluate whether LVES volume (LVESV) measured by echocardiography can provide additive prognostic information. Methods: Of patients who underwent MV surgery due to MVP or FMV from 2000 to 2014, after exclusion of patients whose rhythm was atrial fibrillation or who needed concomitant maze procedure, aortic valve or coronary bypass surgery, a total of 648 patients (age 51±14 years; ejection fraction 64±7%; LVESD 38±6 mm; LVESV 60±26 mL; repair/replacement = 612/36) was selected. Clinical outcomes included cardiovascular (CV) death, admission due to heart failure (HF) and development of LV dysfunction (EF &lt;45% at the last follow-up). Results: During median follow up of 4.2 years (interquartile range, 1.8-6.6 years), 5 patients died of CV death, 36 admitted for HF, and 38 developed LV dysfunction. Increased LVESD (≥45mm) could not predict CV death. But patients with enlarged LVESV index (LVESV/ body surface area ≥50 ml/m 2 , n=64, 10%) showed higher rate of CV death (p=0.04), HF admission (p=0.04) and composite clinical events (p&lt;0.001). In multivariate regression analysis, enlarged LVESV index was the only independent variable associated with composite clinical events (hazard ratio 2.67, 95% confidence interval 1.39-5.13, p=0.003). Conclusions: In the modern era of MV repair surgery for MVP and FMV, LV volume provides more robust prognostic information than LV dimension.

Evaluation of risk factors affecting anastomotic leakage after repair of esophageal atresia.

Background:Anastomotic leak are reported among neonates who underwent esophageal atresia. Aim: To find risk factors of anastomotic leakage in patients underwent esophageal repair. Methods: All cases with esophageal atresia were included. In this case control study, patients were classified in two groups according to presence or absence of anastomotic leaks. Duration of study was 10 years. Results: Sixty-one cases were included. Mean±SD age at time of surgery in patients with leakage and without leakage was 9.50±7.25 and 8.83±6.93 respectively (p=.670). Blood transfusion and two layer anastomosis had significant correlation with anastomotic leakage. Conclusion: Blood transfusion and double layer anastomosis are associated with higher rate of anastomotic leakage.

Transplant Rejection Following Endothelial Keratoplasty and Penetrating Keratoplasty in the United Kingdom: Incidence and Survival

To investigate the incidence and outcome of cornea transplant rejection following endothelial keratoplasty (EK) and penetrating keratoplasty (PK) for Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK). Multicenter cohort study. Patients registered on the United Kingdom Transplant Registry (UKTR) who had an EK or PK for FED or PBK between April 1, 2005 and March 31, 2011 were included. Data were collected from UKTR forms at 1 and 2 years. Postoperative steroid use varies between surgeons and cannot be captured in this reporting system. Rejection events were identified as those recorded as endothelial rejection. A total of 3486 corneal transplants were undertaken: 1973 for FED, 1513 for PBK. For FED, 2-year rejection-free survival was 93% (95% confidence interval [CI] 90%-94%) for PK and 94% (95% CI 92%-96%) for EK (P= .3). In transplants that had a rejection episode, 50% of PKs (17) and 60% of EKs (15) subsequently failed. For PBK, 2-year rejection-free survival for PK was 88% (95% CI 86%-90%) and 90% (95% CI 86%-92%) for EK (P= .6). In transplants that had a rejection episode, 85% of PKs (41) and 76% of EKs (22) subsequently failed. Inflammation (ie, conjunctival injection, presence of keratic precipitates and intraocular signs) at the time of surgery for patients with FED was significant for developing rejection: 3.5 times greater compared with those with no inflammation (P= .02). There is no significant difference in rejection-free survival between EK and PK for FED or PBK. The presence of inflammation is an important risk factor, and attention to its control before and following surgery is important.

466 Indications and timing of revision surgery in patients having had multiple artificial urinary sphincters

466 Indications and timing of revision surgery in patients having had multiple artificial urinary sphincters

Précipités rétro-cornéens annulaires

To investigate the incidence and outcome of cornea transplant rejection following endothelial keratoplasty (EK) and penetrating keratoplasty (PK) for Fuchs endothelial dystrophy (FED) and pseudophakic bullous keratopathy (PBK).Multicenter cohort study.Patients registered on the United Kingdom Transplant Registry (UKTR) who had an EK or PK for FED or PBK between April 1, 2005 and March 31, 2011 were included. Data were collected from UKTR forms at 1 and 2 years. Postoperative steroid use varies between surgeons and cannot be captured in this reporting system. Rejection events were identified as those recorded as endothelial rejection.A total of 3486 corneal transplants were undertaken: 1973 for FED, 1513 for PBK. For FED, 2-year rejection-free survival was 93% (95% confidence interval [CI] 90%–94%) for PK and 94% (95% CI 92%–96%) for EK (P = .3). In transplants that had a rejection episode, 50% of PKs (17) and 60% of EKs (15) subsequently failed. For PBK, 2-year rejection-free survival for PK was 88% (95% CI 86%–90%) and 90% (95% CI 86%–92%) for EK (P = .6). In transplants that had a rejection episode, 85% of PKs (41) and 76% of EKs (22) subsequently failed. Inflammation (ie, conjunctival injection, presence of keratic precipitates and intraocular signs) at the time of surgery for patients with FED was significant for developing rejection: 3.5 times greater compared with those with no inflammation (P = .02).There is no significant difference in rejection-free survival between EK and PK for FED or PBK. The presence of inflammation is an important risk factor, and attention to its control before and following surgery is important.

Timing of surgical decompression for traumatic cervical spinal cord injury.

Although there have been numerous studies aimed at determining the effects and safety of early vs. late surgical decompression for traumatic cervical spinal cord injury, controversies still exist regarding the optimal timing of surgery for this serious spinal trauma. This study was conducted to evaluate the effectiveness and safety of early vs. late surgical decompression for lower cervical spine trauma associated with spinal cord injury. A retrospective review of was performed on consecutive patients who underwent surgical decompression for lower cervical (C3-C7) spine trauma associated with spinal cord injury at six institutions across China from January 2007 to January 2012. These patients were analysed according to the timing of surgical intervention. The early group comprised patients who underwent surgery within the first 72 hours after being injured, whilst the late group comprised patients who underwent surgery after the first 72 hours. For analysis of neurologic improvement, patients who had completed a follow-up of at least six months were assessed. Other outcomes analysed were hospitalisation periods, complications and mortality. A total of 595 patients were identified (456 men and 139 women at an average age of 41.4 years), with 212 in the early group and 383 in the late group. Patients in both groups had made a significant neurologic improvement in the final follow-up, but no statistically significant difference was noted between groups. Patients in the early group had a significantly shorter hospital stay (15.4 vs. 18.3 days, p <0.001) but realised no benefits in terms of intensive care unit length of stay and ventilator days. No significant differences were identified between groups with regards complications (pneumonia, pulmonary embolism, wound infection, sepsis and urinary tract infection). Compared with the late group, the early group had a significantly higher incidence of postoperative neurological deterioration (6.6 vs. 0.7 %, p <0.001) and mortality (7.1 vs. 2.1 %, p = 0.003). The timing of surgery for patients sustaining traumatic lower cervical spine injury with neurological involvement did not affect neurological recovery. Early surgical intervention was associated with a higher incidence of mortality and neurological deterioration compared with late surgical intervention, indicating that surgery after the first 72 hours might be relatively safe.

Graft choice and timing of coronary bypass surgery in patients with vasculitis syndromes: A report of two cases

Polyarteritis nodosa (PAN) is a multisystem disease with necrotizing vasculitis of middle and small sized arteries. Takayasu arteritis (TA) is a rare nonspecific inflammatory disease with unknown cause, predominantly affecting the aorta and its main branches. There has not yet been a consensus on graft choice for patients with vasculitis syndromes. Here, we report one case with PAN and the other with TA undergoing coronary revascularization surgery.