Does experience with laparoscopic colorectal surgery influence intraoperative outcomes?

Background  This study aimed to define the management and risk factors for intraoperative complications (IOC) and conversion in laparoscopic colorectal surgery, and to assess whether surgeon experience influences intraoperative outcomes. Methods  Consecutive patients undergoing laparoscopic colorectal procedures from 1991 to 2005 were analyzed from a longitudinal prospectively collected database. All patients referred to the four surgeons involved in this study were offered a minimally invasive approach. Patient characteristics, perioperative variables, and surgeon experience data were analyzed and compared. Results  A total of 991 consecutive laparoscopic colorectal procedures were studied. The majority of operations were performed for malignant disease (n = 526, 53%), and most frequently consisted of segmental colonic resections (n = 718, 72%). A total of 85 patients (8.6%) had an IOC. Patients experiencing an IOC had a significantly higher median body weight (75 versus 68 kg, p = 0.0047) and had a higher proportion of previous abdominal surgery (31% versus 20%, p = 0.029). Only 39% of patients suffering an IOC required conversion to open surgery. A total of 126 (13%) cases were converted to open surgery. On multivariable analysis, previous abdominal surgery [odds ratio (OR) 3.40, 95% confidence interval (CI) 1.39–8.35, p = 0.0076] was independently associated with having an IOC and a conversion to open within the same procedure. With increasing experience, individual surgeons were found to operate on heavier patients (p = 0.025), and on patients who had a higher rate of previous intra-abdominal surgery (p < 0.0001). Despite these risk factors, the early and late experience demonstrated no significant difference in terms of IOCs (p = 0.54) and conversion to open surgery (p = 0.40). Conclusions  The majority of IOCs can be managed laparoscopically. With increasing experience surgeons can perform laparoscopic colorectal surgery on a patient population with a greater proportion of previous abdominal surgery and a higher mean body weight without adversely affecting their rates of intraoperative complications or conversion. Oral presentation at the Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons, April 12th, 2008, Philadelphia, PA.     

Do patients with haemophilia undergoing cardiac surgery have good surgical outcomes?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with haemophilia undergoing cardiac surgery have good surgical outcomes. Haemophilia A and haemophilia B are sex-linked recessive inherited diseases affecting males only, with females acting as carriers. The conditions result in various degrees of factor VIII or factor IX deficiency, respectively. The life expectancy of haemophilia patients is increasing and now approaches that of the general male population, and they are confronted with age-related co-morbidity, including ischaemic cardiovascular disease. Replacement of the deficient factor (VIII for haemophilia A and IX for haemophilia B) is the cornerstone of treatment; other therapeutic options include tranexamic acid, desmopressin and aprotinin. Recently, the advent of recombinant factor VIII and IX has eliminated the infective risk of using factor concentrates, such as prothrombin complex concentrate or fresh frozen plasma. A total of 84 papers were found using the reported search criteria, and out of this 25 papers, selected with reference to a more modern date range, provided the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results were tabulated. We conclude that there is lack of good-quality evidence and that, in all probability, these papers are subject to publication bias as poor outcomes are unlikely to have been reported. However, all the reported series showed that good outcomes are possible in this specific subgroup of patients given the correct approach. The data accrued from these studies (a total of 30 adults and three children) suggest that routine cardiac surgery can be performed safely in patients with haemophilia, with minimal morbidity and mortality. We identified the following key points to achieve this result: a team approach, a factor replacement protocol and perioperative monitoring of factor levels. Intraoperative plasma factor levels can be easily measured before heparin and after protamine sulphate administration, whereas during cardiopulmonary bypass this will require a chromogenic method. Exposure to factor concentrates early in the life might predispose a patient with severe haemophilia to the development of inhibitors. Moreover, the absence of inhibitors should be confirmed before any surgical procedure.     

Does primary brachial plexus surgery alter palliative tendon transfer surgery outcomes in children with obstetric paralysis?

Background  

The surgical management of obstetrical brachial plexus palsy can generally be divided into two groups; early reconstructions in which the plexus or affected nerves are addressed and late or palliative reconstructions in which the residual deformities are addressed. Tendon transfers are the mainstay of palliative surgery. Occasionally, surgeons are required to utilise already denervated and subsequently reinnervated muscles as motors. This study aimed to compare the outcomes of tendon transfers for residual shoulder dysfunction in patients who had undergone early nerve surgery to the outcomes in patients who had not.     

Primary cardiac tumours: when is surgery necessary?

OBJECTIVE: Primary cardiac tumours are rare. The literature predominantly contains series on myxomas in adults and only a few long-term series that involve the very different primary cardiac tumours in early childhood. As foetal ultrasonography has continued to improve, cardiac tumours are increasingly detected early before significant symptoms develop. It is a challenge for paediatric cardiologists and surgeons to ascertain which patients need surgery and which will benefit from conservative follow-up. METHODS: A retrospective review of a 10-year period revealed 51 tumours in 26 children (median age: 1 month). Analysis was by presentation, location, associated findings, interventions, histological findings, and clinical course. RESULTS: The most common tumours were rhabdomyomas (29), fibromas (nine), teratomas (two), and haemangiomas (two). The tumour location was the right ventricle in 24 and the left ventricle in 22 patients. The symptoms varied between abnormal heart murmur (20), arrhythmia and conduction abnormalities (ten), obstruction of the outflow tract >30 mmHg (nine), severe cyanosis (three) and congestive heart failure (two). Fourteen children with haemodynamic compromises underwent surgery. There was one post-operative death and one heart transplantation after bridging with an assist device. There was no tumour recurrence even when resection was incomplete. Nine of 13 children with rhabdomyomas had spontaneous tumour regression without intervention. CONCLUSIONS: Most of the cardiac tumours in children are benign. Spontaneous regression is possible not only in rhabdomyoma. Surgical intervention is only required for children who develop relevant clinical symptoms. Total resection of the tumour is not the only therapeutic aim; more important is the restoration of the best possible heart function.     

Does more than a single chest tube for mediastinal drainage affect outcomes after cardiac surgery?

Background

The use of 1 or more mediastinal chest tubes has traditionally been routine for all cardiac surgery procedures to deal with bleeding. However, it remains unproven whether multiple chest tubes offer a benefit over a single chest tube.

Methods

All consecutive patients undergoing cardiac surgery (2005–2010) received at least 1 chest tube at the time of surgery based on surgeon preference. Patients were grouped into those receiving a single chest tube (SCT) and those receiving multiple chest tubes (MCT). The primary outcome was return to the operating room for bleeding or tamponade.

Results

A total of 5698 consecutive patients were assigned to 2 groups: 3045 to the SCT and 2653 to the MCT group. Patients in the SCT group were older, more often female and less likely to undergo isolated coronary artery bypass graft than those in the MCT group. Unadjusted outcomes for SCT and MCT, respectively, were return to the operating room for bleeding or tamponade (4.7% v. 5.0%; p = 0.50), intensive care unit stay longer than 48 hours (25.5% v. 27.9%; p = 0.041, postoperative stay > 9 days (31.5% v. 33.1%; p = 0.20) and mortality (3.8% v. 4.6%; p = 0.16). Logistic regression analysis, adjusted for clinical differences between groups, showed that the number of chest tubes was not associated with return to the operating room for bleeding or tamponade.

Conclusion

The use of multiple mediastinal chest tubes after cardiac surgery confers no advantage over a single chest tube in preventing return to the operating room for bleeding or tamponade.     

Is bariatric surgery safe in patients with history of cardiac revascularization?

BackgroundThe number of patients undergoing bariatric surgery with prior cardiac revascularization (CR) is rising. However, scarce data exist regarding the safety of bariatric procedures in these patients.ObjectivesThe aim of this study is to compare postoperative cardiovascular and noncardiovascular outcomes among patients with different CR procedures.SettingAcademic hospital, United States.MethodsWe retrospectively reviewed 2884 patients undergoing bariatric surgery from 2009–2018. Patients with prior CR were included and stratified into groups: coronary artery bypass graft (CABG), percutaneous coronary intervention with stent (PCI), and CABG + PCI. We described patient demographic characteristics, co-morbidities, smoking status, history of myocardial infarction, type of bariatric surgery, number of vessels grafted/stents, time from CR to bariatric surgery, length of stay, and cardiovascular and noncardiovascular 30-day outcomes. A control group composed of patients without prior CR undergoing bariatric surgery was used to compare the rate of complications to the total patients with prior CR. For continuous and categorical variables, t test and χ² tests were performed, respectively.ResultsWe identified 76 patients with prior CR undergoing bariatric surgery. The mean patient age was 61.4 ± 7.9 years, the mean body mass index was 41.7 ± 6.5 kg/m², and male sex was predominant (71.1%). Among these, 50% (n = 38) had PCI, 39.4% (n = 30) had CABG, and 10.5% (n = 8) had CABG + PCI. Early cardiovascular complications rate included ST-segment-elevation myocardial infarction (n = 2), pulmonary embolism (n = 1), supraventricular arrhythmia (n = 2), ventricular arrhythmia (n = 1), and pacemaker/defibrillator-insertion (n = 1). The overall rate of cardiovascular and noncardiovascular complications was 9.2% (n = 7) and 10.5% (n = 8) during the 30 days. Mortality rate was 0%. Comparison of rate of complications between groups did not show any statistical difference; no significant difference was found when comparing patients with prior CR to the 76 patients in the control group (P > .05).ConclusionsAlthough revascularized individuals have severe co-morbidities and are high-risk patients, bariatric surgery remains safe in this population when outcomes are compared with bariatric patients without prior CR.     

Can soluble urokinase plasminogen receptor predict outcomes after cardiac surgery?

Open in a separate window OBJECTIVESSoluble urokinase plasminogen activator receptor (suPAR) is a biomarker that has been implicated in several cardiac pathologies and has been shown to be elevated in critically ill populations. We measured plasma suPAR in a cohort of cardiac surgical patients to evaluate its ability to predict prolonged intensive care unit (ICU) and hospital length of stay and development of complications following surgery. We compared suPAR against EuroSCORE II and C-reactive protein (CRP).METHODSNinety patients undergoing cardiac surgery were recruited with samples taken preoperatively and on postoperative days 1, 2 and 3. suPAR was measured using enzyme-linked immunosorbent assay. Area under the receiver operator curve (AUROC) was used to test predictive capability of suPAR. Comparison was made with EuroSCORE II and CRP.RESULTSsuPAR increased over time (P < 0.001) with higher levels in patients requiring prolonged ICU and hospital stay, and prolonged ventilation (P < 0.05). suPAR was predictive for prolonged ICU and hospital stay, and prolonged ventilation at all time points (AUROC 0.66–0.74). Interestingly, this association was also observed preoperatively, with preoperative suPAR predicting prolonged ICU (AUROC 0.66), and hospital stay (AUROC 0.67) and prolonged ventilation (AUROC 0.74). The predictive value of preoperative suPAR compared favourably to EuroSCORE II and CRP.CONCLUSIONSsuPAR increases following cardiac surgery and levels are higher in those who require prolonged ICU stay, prolonged hospital stay and prolonged ventilation. Preoperative suPAR compares favourably to EuroSCORE II and CRP in the prediction of these outcomes. suPAR could be a useful biomarker in predicting outcome following cardiac surgery, helping inform clinical decision-making.Clinical registrationWest of Scotland Research Ethics Committee Reference: 12/WS/0179 (AM01).     

Long-term outcomes comparing metabolic surgery to no surgery in patients with type 2 diabetes and body mass index 30–35

BackgroundWe previously conducted a randomized study comparing metabolic surgery with medical weight management in patients with type 2 diabetes (T2D) and body mass index (BMI) 30 to 35 kg/m². At 3-year follow-up, surgery was very effective in T2D remission; furthermore, in the surgical group, those with a higher baseline soluble receptor for advanced glycation end products had a lower postoperative BMI.ObjectivesTo provide long-term follow-up of this initial patient cohort.SettingUniversity Hospital.MethodsRetrospective chart review was performed of the initial patient cohort. Patients lost to follow-up were systematically contacted to return to clinic for a follow-up visit. Data were compared using 2-sample t test, Fisher’s exact test, or analysis of variance when applicable.ResultsOriginally, 57 patients with T2D and BMI 30 to 35 kg/m² were randomized to metabolic surgery (n = 29) or medical weight management (n = 28). Ten patients in the medical weight management group crossed over to surgery. Five-year follow-up data were available in 43 of 57 (75%) patients. Baseline mean BMI and glycated hemoglobin were 32.6 kg/m² and 7.8%, respectively. Median follow-up was 79 and 88 months in the surgical group and nonsurgical group, respectively. Compared with the nonsurgical group, the surgical patients had significantly lower rate of T2D (62% versus 100%; P = .008), lower insulin use (10% versus 50%; P = .0072), lower glycated hemoglobin (6.93% versus 8.26%; P = .012), lower BMI (25.8 versus 28.6 kg/m²; P = .007), and higher percent weight loss (21.4% versus 10.3%; P = .025). Baseline soluble receptor for advanced glycation end products was not associated with long-term outcomes.ConclusionsMetabolic surgery in T2D patients with BMI 30 to 35 kg/m² remains effective long term. Baseline soluble receptor for advanced glycation end products are most likely predictive of early outcomes only.     

Are patients with Werlhof's disease at increased risk for bleeding complications when undergoing cardiac surgery?

BACKGROUND: It is generally assumed, that patients with Werlhof's disease (WD) are at increased risk for bleeding complications when undergoing cardiac surgery with extracorporeal circulation. Therefore we performed this case control study to estimate the real risk for bleeding complications of these patients. METHODS: Between 05/95 and 07/98, ten patients with WD (eight males, two females) underwent cardiac surgery employing extracorporeal circulation (WD-group). Five of these patients with platelet counts below 80/nl were treated by immunoglobulins preoperatively. Each patient with WD was matched to five patients without WD (no-WD-group) using diagnosis, age, gender, ejection fraction, number of distal anastomosis and body-mass-index as matching criteria. RESULTS: Mean number of platelet counts were significant lower in the WD-group than in the no-WD-group despite a significant increase of platelet counts after immunoglobulin treatment (54/nl-->112/nl, P=0.018). On the day before, directly after and on the first day after surgery they were 141/nl vs. 215/nl (P=0.012), 75/nl vs. 147/nl (P=0.001) and 93/nl vs. 136/nl (P=0.009). Accordingly, patients of the WD-group received significantly more platelet concentrates than patients of the no-WD-group (mean number of platelet concentrates: 2.3 versus 0.7, P=0.007). Total drainage loss via the mediastinal chest tubes was almost identical (1197 ml in the no-WD-group and 1140 ml in the WD-group). One patient of each group suffered from a bleeding complication requiring reexploration. Three patients of the no-WD-group (6%) and one patient of the WD-group (10%) expired postoperatively unrelated to WD. CONCLUSIONS: Patients with WD may possibly undergo cardiac surgery without a markedly enhanced risk for bleeding complications despite a more than usual transfusion requirement and significantly lower platelet counts perioperatively.     

Is replacement of albumin in major abdominal surgery useful?

Study Objective

To evaluate retrospectively serum albumin concentrations as well as morbidity and mortalitiy of abdominal surgical patients who -if hypoalbuminemic- did not receive human albumin solutions versus those who did receive such solutions.

Design

Retrospective observational study.

Setting

Academic community hospital.

Measurements

The records of 76 consecutive patients who had undergone elective abdominal surgery were reviewed. Preoperative and postoperative serum albumin concentrations up to the seventh day after surgery were recorded. Morbidity and mortality were followed until the time of discharge from the hospital.

Results

38 patients who received albumin replacement if they were hypoalbuminemic versus 38 patients who did not receive albumin replacement showed no significant difference in cumulative (P < 0.52) or individual postoperative complications (infections P < 0.35, cardiovascular complications P < 1.0, organ failure P < 0.67, thromboembolic incidents P < 0.26), and mortality (P < 0.47).

Conclusions

Postoperative serum albumin concentration had no correlation with postoperative morbidity. There is no justification for perioperative albumin replacement in abdominal cancer surgical patients.     

In cardiac surgery patients does Voluven(R) impair coagulation less than other colloids?

Hydroxyethyl starch (HES) solutions are commonly used for volume replacement in cardiac surgery patients. The degree of impairment of the haemostatic system depends on the molecular weight and substitution degree of HES solutions. It is claimed that as HES 130/0.4 (Voluven(?)) exhibits a lower in vitro molecular weight and a lower degree of hydroxyethyl substitution than HES 200/0.5 (HAES-steril(?)) therefore it has less impact on haemostasis. A best evidence topic in cardiac surgery was written according to a structured protocol to verify this statement. The question addressed was: in cardiac surgery patients does volume replacement with Voluven(?) impair coagulation less than other colloids? Using the reported search 12 papers, three in vitro and nine clinical studies, were found to represent the best evidence to answer the clinical question. The nine clinical studies were all randomised controlled trials. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The in vitro studies suggest that HES 130/0.4 has no significant effect on platelet variables, shows a faster clot formation process and a better clot retraction as compared with the other HES solutions. On the other hand, current best available evidence (level 1b) from clinical studies, limited by heterogeneity predominantly in terms of dosage of HES 130/0.4 administered and the sample size of individual trials, overwhelmingly suggests that HES 130/0.4 compared with HES 200/0.5 or gelatin-based volume replacement fluid affects coagulation to the same extent resulting in similar degree of blood loss. It can be concluded that contrary to in vitro studies HES 130/0.4 in clinical practice has comparable effects on blood loss after cardiac surgery.     

Does treatment sequence affect outcomes in patients with metaplastic breast cancer?

IntroductionWe compared characteristics and outcomes by treatment sequence among patients with metaplastic breast cancer (MBC), an aggressive subtype.MethodsWomen ≥18 years old with newly diagnosed Stage I-III MBC from 2003 to 2018 who received any treatment in our health system were identified. Unadjusted overall survival (OS) was estimated with the Kaplan-Meier method; the log-rank test was used to compare survival differences between recipients of neoadjuvant (NACT) and adjuvant chemotherapy (ACT).ResultsOf the 91 MBC patients identified, 60 received chemotherapy. NACT recipients (n = 20, median age 46.5 y) were younger than ACT recipients (n = 40, median age 60.5 y, p < 0.001) but similar with regards to race and radiation receipt. There was no significant OS difference between NACT and ACT recipients (log-rank p = 0.15), which remained true when patients were stratified by age (≥50 y vs < 50 y).ConclusionsAmong MBC patients, NACT recipients were younger than ACT recipients, but there was no survival difference by treatment sequence.     

Is brain natriuretic peptide a marker for adverse postoperative outcomes in patients undergoing cardiac surgery?

A best evidence topic (BET) was constructed according to a structured protocol. The question addressed was 'Is brain natriuretic peptide (BNP) a marker for adverse postoperative outcomes in patients undergoing cardiac surgery?' Nearly 200 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. BNP levels have been shown by several prospective observational cohort studies to be a marker for cardiac dysfunction and adverse outcome in patients undergoing cardiac surgery. BNP levels can be used to guide the therapy of patients with heart failure which may reduce adverse cardiac events. Whether BNP-guided therapy can be applied to patients undergoing cardiac surgery is unknown. We conclude that preoperative and postoperative measurement of natriuretic peptides could help predict postoperative cardiac dysfunction and adverse outcome in patients undergoing cardiac surgery. Furthermore, they may improve the ability of commonly used risk assessment tools to predict outcome.     

Does previous abdominal surgery affect the course and outcomes of laparoscopic bariatric surgery?

Background

Global experiences in general surgery suggest that previous abdominal surgery may negatively influence different aspects of perioperative care. As the incidence of bariatric procedures has recently increased, it is essential to assess such correlations in bariatric surgery.