Hirschsprung-Associated Enterocolitis at a Referral Institution: A Retrospective Review

BackgroundHirschsprung-associated enterocolitis (HAEC) is the most common cause of morbidity and mortality amongst patients with Hirschsprung disease (HD); rectal Botulinum toxin (Botox) has been reported a possible prevention strategy. We aimed to evaluate our institution's historic cohort of HD patients, first to determine our incidence of HAEC and second to begin assessing the effect of Botox on HAEC incidence.MethodsPatients with HD seen at our institution between 2005 and 2019 were reviewed. Incidence of HD and frequencies of HAEC and Botox injections were tallied. Associations between initial Botox treatment or transition zone and HAEC incidence were evaluated.ResultsWe reviewed 221 patients; 200 were included for analysis. One hundred thirteen (56.5%) patients underwent primary pull-through at a median age of 24 days (IQR 91). Eighty-seven (43.5%) patients with initial ostomy had their intestinal continuity reestablished at a median of 318 days (IQR 595). Ninety-four (49.5%) experienced at least one episode of HAEC and 62 (66%) experienced multiple episodes of HAEC. Nineteen (9.6%) patients had total colonic HD and had an increased total incidence of HAEC compared to patients without total colonic HD (89% vs 44%, p < 0.001). Six (2.9%) patients received Botox injections at the time of pull-through or ostomy takedown; one experienced an episode of HAEC (versus 50.7% of the patients who were confirmed to have not received Botox injections at their surgery, p = 0.102).ConclusionFurther prospective study on Botox's effect on Hirschsprung-associated enterocolitis is required and is the next step in our investigation.Level of evidenceLevel III.     

Remote Ischaemic Pre-Conditioning Reduces Intestinal Ischaemia Reperfusion Injury in a Newborn Rat

ObjectiveRemote ischaemic conditioning (RIC) has been shown to reduce ischaemia-reperfusion injury(IRI) in multiple organ systems. IRI is seen in multiple bowel pathologies in the newborn, including NEC. We investigated the potential of RIC as a novel therapy for various intestinal pathologies in the newborn.MethodsWe used an established intestinal IRI model in rat pups which results in similar intestinal injury to necrotising enterocolitis (NEC). Animals were randomly allocated to IRI only(n = 14), IRI + RIC(n = 13) or sham laparotomy(n = 10). The macroscopic extent of intestinal injury is reported as a percentage of total small bowel. Injury severity was measured using Chiu-Park scoring. Neutrophil infiltration/activation was assayed by myeloperoxidase activity. Immunohistochemistry was used to assess the expression of hypoxia-inducible factor alpha (HIF-1α). Data are median (interquartile range).ResultsAnimals that underwent RIC showed a decreased extent of macroscopic injury from 100%(85–100%) in the IRI only group to 58%(15–84%, p = 0.003) in the IRI + RIC group. Microscopic injury score was significantly lower in animals that underwent RIC compared to IRI alone (3.5[1.25–5] vs 5.5[4–6], p = 0.014). Intestinal myeloperoxidase activity in animals exposed to IRI was 3.4 mU/mg of tissue (2.5–3.7) and 2.1 mU/mg(1.5–2.8) in the IRI + RIC group(p = 0.047). HIF-1α expression showed a non-significant trend towards reduced expression in the IRI + RIC group.ConclusionsRIC reduces the extent and severity of bowel injury in this animal model, supporting the hypothesis that RIC has therapeutic potential for intestinal diseases in the newborn.     

Partial warfarin reversal prior to hip fracture surgical intervention in geriatric trauma patients effects on blood loss and transfusions

BackgroundWarfarin reversal is typically sought prior to surgery for geriatric hip fractures; however, patients often proceed to surgery with partial warfarin reversal. The effect of partial reversal (defined as having an international normalized ratio [INR] > 1.5) remains unclear.MethodsThis was a retrospective cohort study. Geriatric patients (≥65 y/o) admitted to six level I trauma centers from 01/2014-01/2018 with isolated hip fractures requiring surgery who were taking warfarin pre-injury were included. Warfarin reversal methods included: vitamin K, factor VIIa, (a)PCC, fresh frozen plasma (FFP), and the “wait and watch” method. An INR of ≤ 1.5 defined complete reversal. The primary outcome was the volume of blood loss during surgery; other outcomes included packed red blood cell (pRBC) and FFP transfusions, and time to surgery.ResultsThere were 135 patients, 44% partially reversed and 56% completely reversed. The median volume of blood loss was 100 mL for both those completely and partially reversed, p = 0.72. There was no difference in the proportion of patients with blood loss by study arm, 95% vs. 95%, p > 0.99. Twenty-five percent of those completely reversed and 39% of those partially reversed had pRBCs transfused, p = 0.08. Of those completely reversed 5% received an FFP transfusion compared to 14% of those partially reversed, p = 0.09. There were no statistically significant differences observed for the volume of pRBC or FFP transfused, or for time to surgery.ConclusionsPartial reversal may be safe for blood loss and blood product transfusions for geriatric patients with isolated hip fractures. Complete warfarin reversal may not be necessary prior to hip fracture surgery, especially for mildly elevated INRs.     

Single-center comparison of outcomes between laparoscopic appendectomy and transumbilical laparoscopic assisted appendectomy

PurposeAppendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical laparoscopic assisted appendectomy (TULAA) for 1154 uncomplicated patients across 5 years at a single institution. Primary outcomes include length of stay (LOS), post-operative complications, pain score, and operating room (OR) time.MethodsDemographic and clinical data was collected for 1154 eligible patients treated for uncomplicated appendicitis between August 2014–October 2019, with 830 patients in the LA group, and 324 in the TULAA group. Mixed effects modeling procedure using logistic and linear regression examined the effect of surgery type on the four primary outcomes after adjustment for potential clustering effect of surgeon and confounding factors.ResultsOf 1154 patients, 62.7% were male, and mean (SD) age was 10.9 (3.6) years. Median [IQR] LOS was 28.0 h [22.0, 36.0], mean (SD) OR time was 29.0 (10.0) minutes, and median [IQR] pain at maximum level was 5.5 (2.7). The complication rate overall was <5.0% and did not differ between TULAA and LA groups (p > 0.05). OR time was reduced by an average of 5.2 min in the TULAA group (p < 0.001), pain did not differ between groups overall (p > 0.05), and patients were more likely to be discharged within 24 h in patients who underwent TULAA (OR = 5.3 [1.6, 17.4], p = 0.007).ConclusionRetrospective analysis of 1154 pediatric appendectomies, found no difference in complications between single- and three-incision laparoscopic procedures (TULAA vs. LA). Findings suggest TULAA is a safe procedure for acute appendicitis in pediatrics.Level of EvidenceIV.     

Comparison of Trauma and Burn Evaluations in a Pediatric Emergency Department During Pre,Early and Late COVID-19 Pandemic

BackgroundPediatric trauma epidemiology altered during early COVID-19 pandemic period but the impact of the ongoing pandemic is unknown.ObjectivesTo compare pediatric trauma epidemiology between the pre, early and late pandemic periods and to evaluate the association of race and ethnicity on injury severity during the pandemic.MethodsWe performed a retrospective study of trauma consults for an injury/burn in children ≤16 years between January 1, 2019 and December 31, 2021. Study period was categorized into pre (January 1, 2019–February 28, 2020), early (March 1, 2020–December 31, 2020), and late (January 1, 2021–December 31, 2021) pandemic. Demographics, etiology, injury/burn severity, interventions and outcomes were noted.ResultsA total of 4940 patients underwent trauma evaluation. Compared to pre-pandemic, trauma evaluations for injuries and burns increased during both the early (RR: 2.13, 95% CI: 1.6–2.82 and RR: 2.24, 95% CI: 1.39–3.63, respectively) and late pandemic periods (RR: 1.42, 95% CI: 1.09–1.86 and RR: 2.44, 95% CI: 1.55–3.83, respectively). Severe injuries, hospital admissions, operations and death were higher in the early pandemic but reverted to pre-pandemic levels during late pandemic. Non-Hispanic Blacks had an approximately 40% increase in mean ISS during both pandemic periods though they had lower odds of severe injury during both pandemic periods.ConclusionsTrauma evaluations for injuries and burns increased during the pandemic periods. There was a significant association of race and ethnicity with injury severity which varied with pandemic periods.Level of evidenceRetrospective comparative study, Level III.     

The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk

BackgroundThe optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion.MethodsA retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression.Results102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48–39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20–85) vs. those who did not (median 9 mg/dL, IQR 7–13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737).ConclusionWe demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO.Level of evidenceLevel III cohort study.     

Influence of bacteriobilia on postoperative complications in patients with periampullary tumors

BackgroundPeriampullary tumours (PAT) may cause obstruction of distal choledochus. The bile stasis is a risk factor for microbial colonisation of bile (bacteriobilia), cholangitis, hepatic insufficiency and coagulopathy. PAT obstruction can be managed surgically or non-operatively - by inserting a biliary drain or stent (BDS). Although BDS allows for adequate bile drainage, liver function restitution and coagulopathy, increased bacteriobilia has been reported and this is associated with an increased incidence of postoperative complications.MethodsA monocentric, prospective, comparative study including 100 patients operated with PAT. The effects of bacteriobilia and the presence of a drain in the biliary tract on the development of postoperative complications were evaluated.ResultsPositive microbial findings in bile were found in 67% of patients. It was 98% in the biliary drain group vs. 36% in non-drained patients (p = 0.0001). In 68% 2 or more different bacterial strains were simultaneously present (p = 0.0001). Patients with a positive microbial finding in bile had more frequent incidence of infectious complications 40.2% (27) vs. 9.1% (3); p = 0.0011. The most frequent infectious complication was wound infection 29.8% (20) vs. 3.03% (1); p = 0.0014. Similarly, a higher incidence of postoperative infectious complications occurred in patients with BDS - 36% (18) vs. 24% (12); p = 0.2752.ConclusionThe presence of a drain or stent in the biliary tract significantly increases the microbial colonisation of bile. It is associated with a significant increase in infectious complications, especially infections in the wound.     

Impact of Covid-19 pandemic on arthroplasty services and early experience after resuming surgeries at a ‘non Covid’ center

BackgroundThe aim of this study is to assess the impact of Covid-19 crisis on hip and knee joint replacement surgeries at a high volume tertiary care hospital in the Indian National Capital Region and to evaluate the early experience of resumption of arthroplasty services.MethodsInstitutional records of the arthroplasty cases, operated between 1st March to 31 August of 2019 (Group A, pre-Covid) and 2020 (Group B, pandemic year) were compared retrospectively over numerous parameters including the complications within six weeks of surgery.ResultsThere was a significant drop (by 82.53 %) in the total number of arthroplasty surgeries in Group B (62) as compared with Group A (355). Average number of arthroplasties per month were 59.17 ± 12.93 and 10.67 ± 13.29 in Group A and Group B respectively (p < 0.001). There was a significant increase in postoperative complication rate 7/355 (1.97 %) in Group A vs 7/62 (11.29 %) in Group B during pandemic (p < 0.002), along with a higher 30-days mortality rate 2/355 (3.22 %) vs 2/62 (0.56 %). Pandemic year also saw an increased readmission rate (4.83 %) vs (0.56 %) and postoperative ICU transfer rate (1.61 %) vs (0.56 %) in comparison with pre-Covid year.ConclusionIn the pandemic, arthroplasty services got severely affected at our center. With nearly six fold increase in complication rates, higher 30-days mortality and increased readmission rates, caution is advised in resuming arthroplasty surgeries without robust evaluation of cases. Whether undetected Covid-19 infection or poor pre-existing disease control due to lockdown can be linked to these results is a matter of further research with larger multicenter studies.     

Hirschsprung-associated inflammatory bowel disease: A multicenter study from the APSA Hirschsprung disease interest group

Background/PurposeA small number of Hirschsprung disease (HD) patients develop inflammatory bowel disease (IBD)-like symptoms after pullthrough surgery. The etiology and pathophysiology of Hirschsprung-associated IBD (HD-IBD) remains unknown. This study aims to further characterize HD-IBD, to identify potential risk factors and to evaluate response to treatment in a large group of patients.MethodsRetrospective study of patients diagnosed with IBD after pullthrough surgery between 2000 and 2021 at 17 institutions. Data regarding clinical presentation and course of HD and IBD were reviewed. Effectiveness of medical therapy for IBD was recorded using a Likert scale.ResultsThere were 55 patients (78% male). 50% (n = 28) had long segment disease. Hirschsprung-associated enterocolitis (HAEC) was reported in 68% (n = 36). Ten patients (18%) had Trisomy 21. IBD was diagnosed after age 5 in 63% (n = 34). IBD presentation consisted of colonic or small bowel inflammation resembling IBD in 69% (n = 38), unexplained or persistent fistula in 18% (n = 10) and unexplained HAEC >5 years old or unresponsive to standard treatment in 13% (n = 7). Biological agents were the most effective (80%) medications. A third of patients required a surgical procedure for IBD.ConclusionMore than half of the patients were diagnosed with HD-IBD after 5 years old. Long segment disease, HAEC after pull through operation and trisomy 21 may represent risk factors for this condition. Investigation for possible IBD should be considered in children with unexplained fistulae, HAEC beyond the age of 5 or unresponsive to standard therapy, and symptoms suggestive of IBD. Biological agents were the most effective medical treatment.Level of EvidenceLevel 4     

Safety and Cost Savings Using Polymeric Clips in Appendectomies in the Pediatric Population: Single-Center Experience

IntroductionAlthough laparoscopic appendectomy is standard management for appendicitis, management of the appendiceal stump remains debated. Even though most surgeons can agree on the safety and effectiveness of various closure methods for the appendiceal stump, such as the surgical stapler (SS) or the Endoloop, the cost of these methods should also be considered. A relatively new alternative method, the polymeric clips (PC), has been gaining acceptance in the surgical community as it has repeatedly proven to be as safe as other methods, while being significantly cheaper.MethodsFor the period of January 2019 to December 2021, we performed a retrospective chart review of a single surgeon's laparoscopic appendectomies in children 18 years or younger for acute, non-complicated appendicitis and grouped the cases by appendiceal stump management (SS or PC). Demographics collected included gender, age, BMI percentile, race, and ASA score. Surgical variables included length of stay, surgical time, and anesthesia time. Outcomes were number of intra- and post-operative complications, reoperations, ER visits within 30 days, and total implant cost. Mann–Whitney U tests were performed to test for differences between SS and PC groups in surgical variables. Chi-square or Fisher's exact tests were performed to test differences in demographics and outcome variables.ResultsThere were 107 patients identified. The PC group represented 16% (n = 17) of our study population. The PC group was significantly younger than the SS group at 10 years (2.8) vs 12 years (3.5) p = 0.04. No differences were observed in length of stay and anesthesia time between the two groups. However, a significantly longer length of surgery was observed in the PC group at 33.5 min [30.0–43.3] when compared to the SS group at 28.0 min [23.0–36.0] (p = 0.003). No significant differences were seen in post-op complications, post-op ED visits and reoperations within 30 days. The median total implant cost of the PC closure method was significantly lower than the SS method ($35.36 vs. $375.67 p = <0.001).ConclusionThere were no significant differences in clinical outcomes. However, the significant difference in the implant cost between the 2 methods could favor the use of PC for selected cases. The increase in length of surgery can be attributed to the learning curve associated with a new device.Level of Evidence3.     

Improved Outcomes of Reimplantation vs Remodeling in Marfan Syndrome: A Propensity-Matched Study

BackgroundValve-sparing root replacement (VSRR) has excellent outcomes when performed in experienced centers in well-selected patients. It is suggested that reimplantation of the aortic valve may have better durability than remodeling in patients with Marfan syndrome (MFS), although long-term comparative data are limited.MethodsBetween 1988 and 2018, 194 patients with MFS underwent VSRR at our institution. From these, we derived a propensity-matched cohort of 68 patients (44 who underwent reimplantation and 24 who had remodeling). Early outcomes included death and perioperative complications. Late outcomes were survival, probability of aortic insufficiency, and reintervention up to 20 years of follow-up. Median follow-up was 17.8 years (interquartile range, 12.0-20.6 years) for the entire matched cohort.ResultsBaseline variables were similar between reimplantation and remodeling patients after matching: age (39 ± 12 vs 40 ± 13 years, P = .75) and male sex (28 [64%] vs 15 [63%], P = 1.0). Similar 20-year survival was observed after reimplantation compared with remodeling (82% vs 72%, P = .20), whereas the probability of developing greater than mild aortic insufficiency at 20 years was increased after remodeling (5.8% vs 13%, P = .013). More patients underwent reoperation on the aortic valve after a remodeling procedure than after reimplantation of the aortic valve (18% vs 0%, P = .018).ConclusionsVSRR provides excellent long-term survival and freedom from valve-related complications outcomes in patients with MFS. Reimplantation of the aortic valve was associated with a lower risk of aortic valve reoperation and aortic insufficiency than the remodeling procedure after 2 decades of follow-up.     

Randomized phase II study to determine the optimal dose of 3-week cycle nab-paclitaxel in patients with metastatic breast cancer

BackgroundChemotherapy-induced peripheral neuropathy is commonly observed in patients treated with nanoparticle albumin–bound paclitaxel (nab-PTX). We conducted a multicenter randomized controlled study to evaluate the optimal dose of nab-PTX.MethodsWe compared three different doses of q3w nab-PTX (Standard: 260 mg/m² [SD260] vs Medium: 220 mg/m² [MD220] vs Low: 180 mg/m² [LD180]) in patients with HER2-negative metastatic breast cancer (MBC). Primary endpoint was progression-free survival (PFS). Grade 3/4 neuropathy rates in the three doses were estimated using the logistic regression model. The optimal dose was selected in two steps. Initially, if the hazard ratio (HR) for PFS was <0.75 or >1.33, the inferior dose was excluded, and we proceeded with the non-inferior dose. Then, if the estimated incidence rate of grade 3/4 neurotoxicity exceeded 10%, that dose was also excluded.ResultsOne hundred forty-one patients were randomly assigned to SD260 (n = 47), MD220 (n = 46), and LD180 (n = 48) groups, and their median PFS was 6.66, 7.34, and 6.82 months, respectively. The HRs were 0.73 (95% confidence interval [CI]: 0.42–1.28) in MD220 vs SD260, 0.77 (95% CI 0.47–1.28) in LD180 vs SD260, and 0.96 (95% CI 0.56–1.66) in LD180 vs MD220. SD260 was inferior to MD220 and was excluded. The estimated incidence rate of grade 3/4 neurotoxicity was 29.5% in SD260, 14.0% in MD220, and 5.9% in LD180. The final selected dose was LD180.ConclusionsIntravenous administration of low-dose nab-PTX at 180 mg/m² q3w may be the optimal therapy with meaningful efficacy and favorable toxicity in patients with MBC.     

Outcomes after endovascular versus open thoracoabdominal aortic aneurysm repair: A population-based study

ObjectiveWe sought to determine the early and late outcomes of endovascular versus open thoracoabdominal aortic aneurysm repair.MethodsWe performed a multicenter population-based study across the province of Ontario, Canada, from 2006 to 2017. The primary end point was mortality. Secondary end points were time to first event of a composite of mortality, permanent spinal cord injury, permanent dialysis, and stroke, the individual end points of the composite, patient disposition at discharge, hospital length of stay, myocardial infarction, and secondary procedures at follow-up.ResultsA total of 664 adults undergoing surgical repair of a thoracoabdominal aortic aneurysm (endovascular: n = 303 [45.5%] vs open: n = 361 [54.5%]) were identified using an algorithm of administrative codes validated against the operative records. Propensity score matching resulted in 241 patient pairs. Endovascular repairs increased during the study and currently comprise more than 50% of total repairs. In the matched sample, open repair was associated with a higher incidence of in-hospital death (17.4% vs 10.8%, P = .04), complications (26.1% vs 17.4%, P = .02), discharge to rehabilitation facilities (18.7% vs 10.0%, P = .02), and longer length of stay (12 [7-21] vs 6 [3-13] days, P < .01). Long-term mortality was not significantly different (hazard ratio, 1.09; 95% confidence interval, 0.78-1.50), nor were the other secondary end points, with the exception of secondary procedures, which were higher in the endovascular group (hazard ratio, 2.64; 95% confidence interval, 1.54-4.55). At 8 years, overall survival was 41.3% versus 44.6% after endovascular and open repair (P = .62).ConclusionsEndovascular repair was associated with improved early outcomes but higher rates of secondary procedures after discharge. Long-term survival after thoracoabdominal aortic aneurysm repair is poor and independent of repair technique.     

Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: A multi-institutional validation study

PurposeEmerging data suggest that higher radiation doses in post-mastectomy radiotherapy may be associated with an increased risk of reconstruction complications. This study aimed to validate previous findings regarding the impact of radiation dose on complications among women with breast cancer using a multi-center dataset.MethodsFifteen institutions participated, and women with breast cancer who received radiotherapy after either autologous or prosthetic breast reconstruction were included. The primary endpoint was major post-radiation therapy complications requiring re-operation for explantation, flap failure, or bleeding control.ResultsIn total, 314 patients were included. Radiotherapy was performed using both conventional fractionation and hypofractionation in various schedules. The range of the radiation therapy dose in Equivalent Dose in 2 Gy fractions (EQD2; α/β = 3.5) varied from 43.4 to 71.0 Gy (median dose: 48.6 Gy). Boost radiation therapy was administered to 49 patients. Major post-radiation therapy complications were observed in 24 (7.6%) patients. In multivariate analysis, an increasing EQD2 per Gy (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.26–1.98; p < 0.001), current smoking status (OR: 25.48, 95% CI: 1.56–415.65; p = 0.023), and prosthetic breast reconstruction (OR: 9.28, 95% CI: 1.84–46.70; p = 0.007) were independently associated with an increased risk of major complications.ConclusionA dose-response relationship between radiation dose and the risk of complications was validated in this multi-center dataset. In this context, we hypothesize that the use of hypofractionated radiotherapy (40 Gy in 15 fractions) may improve breast reconstruction outcomes. Our multi-center prospective observational study (NCT03523078) is underway to further validate this hypothesis.     

The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery

BackgroundCorticosteroids have a negative impact on the human immune system’s ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine.MethodsA retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment.Results26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024).ConclusionLong-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.     

Effects of a Preoperative Carbohydrate Load on Postoperative Recovery in Children: A Randomised,Double-Blind,Placebo-Controlled Trial

BackgroundNausea and vomiting are common causes for prolonged postoperative length of hospital stay (LOS) in children. A preoperative carbohydrate load may reduce postoperative nausea and vomiting by improving the perioperative metabolic state. The aim of this study was to determine if a preoperative carbohydrate-containing drink would lead to an improvement in the perioperative metabolic state and consequently reduce the incidence of postoperative nausea, vomiting and LOS in children undergoing day-case surgical procedures.MethodRandomised, double-blind, placebo-controlled trial involving children aged 4 to 16-years undergoing day-case surgical procedures. Patients were randomised to receive a carbohydrate-containing drink or a placebo. During the induction of anaesthesia, a venous blood gas, and blood glucose and ketone levels were measured. Postoperatively, the incidence of nausea, vomiting, and LOS were documented.Results120 patients were randomised with 119/120 (99.2%) undergoing analysis. Blood glucose level was higher in the carbohydrate group; 5.4 mmol/L [3.3–9.4] versus 4.9 mmol/L [3.6–6.5] (p = 0.01). Blood ketone level was lower in the carbohydrate group; 0.2 mmol/L versus 0.3 mmol/L (p = 0.003). The incidence of nausea and vomiting was not different (p > 0.9 and p = 0.8, respectively). LOS in the carbohydrate group was 26 min shorter than the placebo group (p = 0.02).ConclusionAlthough a preoperative carbohydrate load may provide a more stable metabolic state at the induction of anaesthesia, we did not find a reduction in postoperative nausea and vomiting. A preoperative carbohydrate load has also minimal effects on the postoperative LOS.Type of studyRandomised clinical trial.Level of evidenceI.     

Renal perfusion with histidine-tryptophan-ketoglutarate compared with Ringer's solution in patients undergoing thoracoabdominal aortic open repair

ObjectiveThe objective of this study was to compare the efficacy of renal perfusion with Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany) versus enriched Ringer's solution for renal protection in patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair.MethodsNinety consecutive patients scheduled for elective open TAAA repair were enrolled between 2015 and 2017 in a single-center, phase IV, prospective, parallel, randomized, double-blind trial (the CUstodiol versus RInger: whaT Is the Best Agent [CURITIBA] trial), and randomized to renal arteries perfusion with 4°C Custodiol (Dr Franz-Kohler Chemie GmbH, Bensheim, Germany; n = 45) or 4°C lactated Ringer's solution (n = 45). The incidence of acute kidney injury (AKI) in patients undergoing TAAA open surgery using Custodiol renal perfusion versus an enriched Ringer's solution was the primary end point.ResultsNinety patients completed the study (45 patients in each group). The incidence of postoperative AKI was significantly lower in the Custodiol group (48.9% vs 75.6%; P = .02). In the multivariable model, only the use of Custodiol solution resulted as protective from the occurrence of any AKI (odds ratio, 0.230; 95% confidence interval, 0.086-0.614; P = .003), whereas TAAA type II extent was associated with the development of severe AKI (odds ratio, 4.277; 95% confidence interval, 1.239-14.762; P = .02). At 1-year follow-up, serum creatinine was not significantly different from the preoperative values in both groups.ConclusionsThe use of Custodiol during open TAAA repair was safe and resulted in significantly lower rates of postoperative AKI compared with Ringer's solution. These findings support safety and efficacy of Custodiol in this specific setting, which is currently off-label.     

Initial Outcomes Using Cryoablation in Surgical Management of Slipping Rib Syndrome

IntroductionMinimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE.MethodsA retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected.ResultsA total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy.ConclusionIntercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes.Level of evidenceIII.