Monitoring of skeletal muscle oxygenation using near-infrared spectroscopy during abdominal aortic surgery

Purpose. To examine the utility of near-infrared spectroscopy (NIRS) in assessing lower-leg perfusion, NIRS was performed on the calf muscles of patients who underwent abdominal aortic surgery. Methods. Thirty patients undergoing elective infrarenal abdominal aortic surgery for abdominal aortic aneurysm (AAA group; n = 16) and aorto-occlusive disease (AOD group; n = 14) were studied. Before induction of anesthesia, NIRS probes were placed over both calf muscles, and muscle oxygen saturation (S_tO2) was continuously monitored throughout the surgery. Results. The preoperative S_tO2 value was significantly lower in the AOD group (57.0 ± 11.2%) than in the AAA group (68.7 ± 7.0%). In both groups, S_tO2 significantly decreased after aortic cross-clamping; the maximal ischemic value of S_tO2 in the AAA group (17.8 ± 7.2%) was significantly lower than that in the AOD group (46.7 ± 17.1%). The time taken to reach maximal ischemia was significantly longer in the AAA group (30 ± 12 min) than in the AOD group (19 ± 12 min). After release of the aortic clamp, the decreased S_tO2 returned to the preoperative level in the AAA group, whereas it increased above the preoperative value in the AOD group. Conclusion. NIRS performed on the calf muscles is a useful method for assessing the changes in lower-leg perfusion during and after abdominal aortic surgery. Received: June 6, 2001 / Accepted: December 5, 2001     

Low skeletal muscle mass is associated with increased hospital costs in patients with cirrhosis listed for liver transplantation–a retrospective study

Low skeletal muscle mass (sarcopenia) is associated with increased morbidity and mortality in liver transplant candidates. We investigated the association between sarcopenia and hospital costs in patients listed for liver transplantation. Consecutive patients with cirrhosis listed for liver transplantation between 2007 and 2014 in a Eurotransplant centre were identified. The skeletal muscle index (SMI, cm²/m²) was measured on CT performed within 90 days from waiting list placement. The lowest sex‐spe cific quartile represented patients with sarcopenia. In total, 224 patients were included. Median time on the waiting list was 170 (IQR 47–306) days, and median MELD score was 16 (IQR 11–20). The median total hospital costs in patients with sarcopenia were €11 294 (IQR 3570–46 469) compared with €6878 (IQR 1305–20 683) in patients without sarcopenia (P = 0.008). In multivariable regression analysis, an incremental increase in SMI was significantly associated with a decrease in total costs (€455 per incremental SMI, 95% CI 11–900, P = 0.045), independent of the total time on the waiting list. In conclusion, sarcopenia is independently associated with increased health‐related costs for patients on the waiting list for liver transplantation. Optimizing skeletal muscle mass may therefore lead to a decrease in hospital expenditure, in addition to greater health benefit for the transplant candidate.     

血管平滑肌细胞凋亡在腹主动脉瘤发病中的作用

目的：探讨腹主动脉瘤（AAA）中膜血管平滑肌细胞（VSMC）密度降低的机制。方法：选取人体肾下AAA及正常腹主动脉组织（NA）标本,采用免疫组化及原位末端DNA标记技术,测定中膜VSMC,凋亡细胞及其相关蛋白,计算机图像分析并计算VSMC密度及凋亡指数。结果：与NA相比,AAA中膜VSMC密度降低,VSMC凋亡指数及其相关蛋白P53,P21明显增加,而bcl-2无显变化。结论：VSMC凋亡在细胞水平参与腹主动脉结构损伤与重构,促进AAA形成。     

Coated prostheses are associated with prolonged inflammation in aortic surgery: a cost analysis

Abstract:  This prospective study was conducted to compare inflammatory responses between patients receiving coated and uncoated vascular prostheses, and to examine their effect on length of stay and cost of patients undergoing abdominal aortic aneurysmectomy. Patients undergoing elective vascular reconstruction of an abdominal aortic aneurysm were assigned randomly to coated-graft or uncoated-graft groups ( n  = 20, for each group). Interleukin (IL)-6, granulocyte elastase, white blood cell count, C-reactive protein (CRP), and body temperature (BT) were prospectively recorded preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. In-hospital stay and hospitalized costs were also analyzed. IL-6 and CRP concentrations in the coated-graft group were higher than those in the uncoated-graft group ( P  = 0.01 and 0.05). BT was more frequently elevated >37°C at POD 14 in the coated-graft group than in the uncoated-graft group ( P  =0.03). Discharge was delayed, and overall hospitalization cost was higher in the coated-graft group than in the uncoated group (17.6 vs. 13.5 days, and 2 010 000 vs. 1 780 000 yen, P  = 0.006 and P  = 0.002, respectively). Coated vascular prosthesis demonstrated more profound inflammatory reaction than noncoated prosthesis, postoperatively.       

手术治疗腹主动脉瘤205例远期疗效分析

目的评价手术治疗肾下型腹主动脉瘤的围手术期和远期效果。方法回顾性分析205例肾下型腹主动脉瘤切除术的临床资料,总结围手术期并发症和远期生存率,评价手术治疗腹主动脉瘤的安全性和远期疗效。结果30 d围手术期死亡率为1．0％;手术时间3-6 h,平均(3．8±1．4)h;ICU恢复时间中位数为16 h。围术期主要并发症包括心功能不全18例,呼吸功能不全10例,急性心肌梗塞2例,急性脑梗塞2例,急性肾功能衰竭4例;寿命表分析1、3、5年生存率分别为96．2％,83．1％,75．8％,随访中未发现与人工血管移植有关的死亡病例和并发症。结论手术仍是腹主动脉瘤的标准治疗方法。术前全身系统风险的评估和围手术期的谨慎管理在提高手术治疗效果中起重要作用。     

Posttherapeutic skeletal muscle mass recovery predicts favorable prognosis in patients with advanced urothelial carcinoma receiving first-line platinum-based chemotherapy

Objectives

Sarcopenia, decreased skeletal muscle mass (SMM), is an adverse prognostic factor in patients with advanced urothelial carcinoma (aUC). Given that SMM is variable depending on disease and patient conditions, changes in SMM over the course of treatments may be also prognostic. We investigated the prognostic role of posttherapeutic SMM recovery (PSR) in patients with aUC receiving first-line platinum-based chemotherapy.

Deep and organ/space infections in patients undergoing elective colorectal surgery: incidence and impact on hospital length of stay and costs

Background

The reported incidence of infection complicating elective colorectal surgery (ECS) is 11% to 26%. We evaluated length of stay (LOS) and expense associated with such infections, which heretofore remain unexplored.

Methods

We reviewed 1127 ECS procedures from October 2005 to may 2007 to identify infected case subjects (n = 46). Data were obtained by way of chart abstraction and administrative database review. A case-control study evaluated LOS and actual accounting costs for case subjects versus uninfected control subjects (n = 46). Logistic regression determined risk factors for infection.

Results

Infection incidence was 4.1%. Mean ± SD LOS and costs were greater for case than control subjects: 21 ± 15 days compared with 6 ± 4 days (P < .001) and $42,516 ± 39,972 compared with $10,999 ± $7,122 (P < .001). Procedure type, infection, chronic obstructive pulmonary disease, increased age, and nonsmoking status predicted greater LOS and costs. Infection risk factors included duration of procedure ≥3 hours, male sex, higher American Society of Anesthesiologists (ASA) score, low baseline hematocrit, and indication for surgery of regional enteritis/ulcerative colitis.

Comments

Infection development after ECS is infrequent in our population, but it results in significantly poorer outcomes. Vigilant adherence to preventive guidelines, including those for antibiotic prophylaxis, is warranted.     

Short-term and long-term outcome in low body mass index patients undergoing cardiac surgery

Objective  We sought to assess the effect of low body mass index (BMI) on short- and long-term outcomes following cardiac surgery. Methods  This is a retrospective review of a prospectively collected departmental database over a 6-year period. Patients were eligible for the study if the BMI was <25 kg/m². All morbidities, length of hospital stay, and short- and long-term mortality were reviewed. Results  There were 704 patients divided into low (n = 71) and normal (n = 633) BMI. Postoperative pulmonary complications were higher in the low BMI group compared to the normal BMI group (24% vs. 11%, P < 0.001) with a higher incidence of in-hospital mortality (10% vs. 5%). Using multiple logistic regression, low BMI was an independent risk factor for in-hospital mortality. The 1-, 3-, and 5-year survivals for the low group were 90%, 78%, and 70% compared to 94%, 86%, and 81% in the normal BMI group. Conclusion  Low BMI is associated with increased morbidity and mortality following cardiac surgery. Risk scoring systems should utilize the BMI in the preoperative risk assessment with special attention to low BMI. This study was presented in poster form at the 7th international congress on coronary artery disease, Venice, Italy, October 2007.     

A randomised controlled trial of prehabilitation in patients undergoing elective cardiac surgery

The feasibility, safety and efficacy of prehabilitation in adult patients awaiting elective cardiac surgery are unknown. A total of 180 participants undergoing elective cardiac surgery were allocated randomly to receive either standard pre-operative care or prehabilitation, consisting of pre-operative exercise and inspiratory muscle training. The primary outcome was change in six-minute walk test distance from baseline to pre-operative assessment. Secondary outcomes included change in inspiratory muscle strength (maximal inspiratory pressure); sarcopenia (handgrip strength); quality of life and compliance. Safety outcomes were pre-specified surgical and pulmonary complications and adverse events. All outcomes were assessed at baseline; at pre-operative assessment; and 6 and 12 weeks following surgery. Mean (SD) age was 64.7 (10.2) years; 33/180 (18%) were women. In total, 65/91 (71.4%) participants who were allocated to prehabilitation attended at least four of eight supervised in-hospital exercise classes; participants aged > 50 years were more likely than younger participants to attend (odds ratio (95%CI) of 4.6 (1.0–25.1)). Six-minute walk test was not significantly different between groups (mean difference (95%CI) -7.8 m (-30.6–15.0), p = 0.503) in the intention-to-treat analysis. Subgroup analyses based on tests for interaction indicated improvements in six-minute walk test distance were larger amongst sarcopenic patients in the prehabilitation group (p = 0.004). Change in maximal inspiratory pressure from baseline to all time-points was significantly greater in the prehabilitation group, with the greatest mean difference (95%CI) observed 12 weeks after surgery (10.6 cmH₂O (4.6–16.6) cmH₂O, p < 0.001). There were no differences in handgrip strength or quality of life up to 12 weeks after surgery. There was no significant difference in postoperative mortality (one death in each group), surgical or pulmonary complications. Of 71 pre-operative adverse events, six (8.5%) were related to prehabilitation. The combination of exercise and inspiratory muscle training in a prehabilitation intervention before cardiac surgery was not superior to standard care in improving functional exercise capacity measured by six-minute walk test distance pre-operatively. Future trials should target patients living with sarcopenia and include inspiratory muscle strength training.     

Preoperative expiratory and inspiratory muscle weakness to predict postoperative outcomes in patients undergoing elective cardiac surgery

Background: Few studies have evaluated preoperative respiratory muscle strength as a risk factor for postoperative morbidity and mortality. The objective of this study was to evaluate the association of preoperative inspiratory muscle weakness (IMW) and preoperative expiratory muscle weakness (EMW) with duration of mechanical ventilation, length of stay in the intensive care unit (ICU), incidence of postoperative pulmonary complications (PPCs), and mortality in patients undergoing elective cardiac surgery. Materials and methods: This was a prospective observational study. Patients admitted for elective cardiac surgery were recruited. Maximal inspiratory and expiratory pressure were measured before surgery. A multivariate regression model was used to adjust for possible confounding variables and test the association of IMW and EMW with the duration of mechanical ventilation, length of stay in the ICU, PPCs, and hospital mortality. Results: Two hundred and fifty-five patients were included in this study. The presence of IMW was associated with an increase in the duration of mechanical ventilation (P = .012). The presence of EMW was associated with a reduction in the incidence of PPCs (P = .005). IMW had no significant association with length of stay in the ICU, PPCs, or hospital mortality. EMW had no significant association with the duration of mechanical ventilation, length of stay in the ICU, or hospital mortality. Conclusions: In patients undergoing elective cardiac surgery, preoperative IMW is associated with the duration of mechanical ventilation while preoperative EMW is associated with a decrease in PPCs.     

腹主动脉瘤腔内修复术中特殊远端锚定区的处理经验

目的探讨腹主动脉瘤腔内修复术中特殊远端锚定区的处理方法以及并发症。方法自1997年5月至2006年12月在150例包括髂总动脉瘤、髂内动脉瘤、髂动脉狭窄、严重成角等特殊远端锚定区的腹主动脉瘤腔内修复术中,根据情况选择不同的处理方式,术后观察内漏、缺血并发症、髂动脉瘤形态以及旁路血管的通畅性。结果围手术期死亡率4％（6／150）,总死亡率42．5％（51／120）。6例原发性远端I型内漏,5例自愈,1例转化为持续性内漏;3例髂内动脉返流引起的Ⅱ型内漏随访中均自愈。7例单臂支架型血管,股股旁路手术2年通畅率为86％;4例髂内动脉旁路手术2年通畅率为100％。11例栓塞单侧髂内动脉出现臀肌缺血症状,平均症状消失时间42 d（5-90 d）。结论结合传统外科技术以及腔内技术,并选择合适的产品处理腹主动脉瘤特殊远端锚定区可取得满意疗效。中远期结果仍需观察。     

Long-term follow-up of passive containment surgery in patients with aortic regurgitation

The goal of this case-control study was to evaluate the long-term effects on cardiac dimensions, cardiac function and coronary circulation in patients with aortic regurgitation (AR) and left ventricular dilatation undergoing aortic valve replacement and application of the Acorn CorCap cardiac support device Of 10 patients with AR and ventricular dilatation who had a mechanical aortic valve implanted, 5 in addition received the cardiac support device. Cardiac dimensions and cardiac function were measured by echocardiography preoperatively and 1, 5 and 10 years postoperatively. The coronary circulation was assessed by computed tomography angiography. After aortic valve replacement, there was a rapid and sustained decrease in cardiac dimensions. This result did not differ after application of the cardiac support device. Improvement in cardiac function remained unchanged in both groups at the 10-year follow-up. None of the patients had developed any signs of coronary artery disease. Application of the Acorn CorCap cardiac support device in patients with AR and left ventricular dilatation did not add to the reversed remodelling or cardiac function at the long-term follow-up compared to aortic valve replacement alone.     

东乡族成人低骨量与肌少症相关的肌肉质量下降的相关性研究

目的 分析甘肃省东乡族成人骨量与骨骼肌量变化规律,探讨骨量降低与肌少症相关的肌肉质量下降之间的关系。方法 对甘肃省东乡族432例(男性198例,女性234例)成人骨密度、骨强度及四肢骨骼肌量进行测量及数据分析,不同年龄段多组比较采用单因素方差分析,组间两两比较采用LSD法,相关性分析采用Pearson相关分析。结果 (1)东乡族成年男性骨强度指数及骨骼肌质量指数峰值出现在40～岁、女性出现在20～岁年龄组。(2)东乡族成人不同年龄段均出现低骨量与肌少症相关的肌肉质量下降情况。(3)骨量减少会导致骨强度指数及骨骼肌质量指数降低。(4)骨量异常情况下肌少症相关的肌肉质量下降明显。(5)骨量降低与年龄、骨强度指数、骨骼肌质量指数显著相关。结论 骨量减少与肌少症相关的肌肉质量下降显著相关,骨量异常是肌少症前期发生的一个危险因素。     

全髋关节置换术患者延迟出院的危险因素分析

目的分析全髋关节置换术患者延迟出院的危险因素。方法回顾性分析2015年1月至2018年7月择期行单侧全髋关节置换术患者的临床资料,包括性别、年龄、BMI、ASA分级、手术时间、麻醉方式、术中失血量、术中输液量、术中阿片类药物用量、术中血管活性药物用量、PACU停留时间、术后随访静息疼痛评分、术前住院时间、术前合并症、术后并发症及转归情况。根据术后住院时间将患者分为两组:正常出院组(术后住院时间≤14 d)和延迟出院组(术后住院时间>14 d),采用单因素和多因素Logistic回归分析影响延迟出院的因素。结果共纳入908例患者。单因素分析显示,与正常出院组比较,延迟出院组的年龄明显偏高,术中失血量明显增多,手术时间、PACU停留时间、术前住院时间明显延长,术前合并症、术后并发症明显增多(P<0.05)。Logistic回归分析显示,年龄≥70岁(OR=2.075,95%CI 1.287~3.346,P=0.003)、手术时间>3 h(OR=1.997,95%CI 1.181~3.375,P=0.010)、术中失血量≥800 ml(OR=2.898,95%CI 1.449~5.794,P=0.003)、PACU时间>60 min(OR=1.745,95%CI 1.064~2.859,P=0.027)、术前住院时间≥7 d(OR=1.805,95%CI 1.114~2.924,P=0.016)、术前有合并症≥2个(OR=2.912,95%CI 1.513~5.825,P=0.003)是导致患者延迟出院的独立危险因素。结论患者年龄、术中失血量、手术时间、PACU停留时间、术前住院时间及术前合并症是全髋关节置换术后出院延迟的独立危险因素,针对危险因素进行有效干预是缩短住院时间改善患者预后的重要策略。     

Abdominal aortic surgery in patients with human immunodeficiency virus infection

PURPOSE: Human immunodeficiency virus (HIV) infection is known to cause acquired immune deficiency syndrome, which has been associated with a wide array of cardiovascular pathologies. This report examined the clinical outcome of patients infected with HIV who underwent abdominal aortic reconstruction for aneurysm or occlusive disease. METHODS: Hospital and clinic records of all patients with HIV infection who underwent an abdominal aortic operation were reviewed during an 11-year period. Relevant risk factors and clinical variables were assessed for surgical outcome. RESULTS: Forty-eight HIV patients (mean age 54 +/- 13 years) were identified who underwent abdominal aortic bypass grafting during the study period. Indications for aortic operation included aneurysm (n = 20) and aortoiliac occlusive disease (n = 28). All patients underwent successful aortic reconstructions without intraoperative mortality. Postoperative complications and in-hospital mortality occurred in 16 patients (33%) and 7 patients (15%), respectively. The mean follow-up period was 41 months. Life-table survival rates in aneurysm and occlusive patients at 60 months were 43.2% +/- 5.3% and 46.3% +/- 7.4% (not significant), respectively. Multivariate analysis showed that low CD4 lymphocyte counts (< 200/microL, P <0.05) and hypoalbuminemia (<3.5 g/dL, P <0.05) were risk factors for postoperative complications. CONCLUSION: Perioperative morbidity and mortality rates are high in HIV patients undergoing an abdominal aortic operation. Low CD4 lymphocyte counts and hypoalbuminemia are associated with poor clinical outcomes in HIV patients undergoing abdominal aortic reconstruction.     

A structured bowel management program for patients with severe functional constipation can help decrease emergency department visits,hospital admissions,and healthcare costs

Background

Published health-care costs related to constipation in children in the USA are estimated at $3.9 billion/year. We sought to assess the effect of a bowel management program (BMP) on health-care utilization and costs.

Increased hsCRP is associated with higher risk of aortic valve replacement in patients with aortic stenosis

Objective To investigate relations between inflammation and aortic valve stenosis (AS) by measuring high-sensitivity C-reactive protein, at baseline (hsCRP₀) and after 1 year (hsCRP₁) and exploring associations with aortic valve replacement (AVR). Design We examined 1423 patients from the Simvastatin and Ezetimibe in Aortic Stenosis study. Results During first year of treatment, hsCRP was reduced both in patients later receiving AVR (2.3 [0.9–4.9] to 1.8 [0.8–5.4] mg/l, p?<?0.001) and not receiving AVR (1.90 [0.90–4.10] to 1.3 [0.6–2.9] mg/l, p?<?0.001). In Cox-regression analyses, hsCRP₁ predicted later AVR (HR?=?1.17, p?<?0.001) independently of hsCRP₀ (HR?=?0.96, p?=?0.33), aortic valve area (AVA) and other risk factors. A higher rate of AVR was observed in the group with high hsCRP₀ and an increase during the first year (AVR_{highCRP0CRP1inc?}=_?47.3% versus AVR_{highCRP0CRP1dec?}=_?27.5%, p?<?0.01). The prognostic benefit of a 1-year reduction in hsCRP was larger in patients with high versus low hsCRP₀ eliminating the difference in incidence of AVR between high versus low hsCRP₀ (AVR_{highCRP0CRP1dec?}=_?27.5% versus AVR_{lowCRP0CRP1dec?}=_?25.8%, p?=?0.66) in patients with reduced hsCRP during the first year. Conclusions High hsCRP₁ or an increase in hsCRP during the first year of follow-up predicted later AVR independently of AVA, age, gender and other risk factors, although no significant improvement in C-statistics was observed.     

Impaired skeletal muscle mitochondrial function in morbidly obese patients is normalized one year after bariatric surgery

BackgroundObesity and type 2 diabetes are associated with impaired skeletal muscle mitochondrial metabolism. As an intrinsic characteristic of an individual, skeletal muscle mitochondrial dysfunction could be a risk factor for weight gain and obesity-associated co-morbidities, such as type 2 diabetes. On the other hand, impaired skeletal muscle metabolism could be a consequence of obesity. We hypothesize that marked weight loss after bariatric surgery recovers skeletal muscle mitochondrial function.MethodsSkeletal muscle mitochondrial function as assessed by high-resolution respirometry was measured in 8 morbidly obese patients (body mass index [BMI], 41.3±4.7 kg/m²; body fat, 48.3%±5.2%) before and 1 year after bariatric surgery (mean weight loss: 35.0±8.6 kg). The results were compared with a lean (BMI 22.8±1.1 kg/m²; body fat, 15.6%±4.7%) and obese (BMI 33.5±4.2 kg/m²; body fat, 34.1%±6.3%) control group.ResultsBefore surgery, adenosine diphosphate (ADP)-stimulated (state 3) respiration on glutamate/succinate was decreased compared with lean patients (9.5±2.4 versus 15.6±4.4 O₂ flux/mtDNA; P<.05). One year after surgery, mitochondrial function was comparable to that of lean controls (after weight loss, 12.3±5.5; lean, 15.6±4.4 O₂ flux/mtDNA). In addition, we observed an increased state 3 respiration on a lipid substrate after weight loss (10.0±3.2 versus 14.0±6.6 O₂ flux/mtDNA; P< .05).ConclusionWe conclude that impaired skeletal muscle mitochondrial function is a consequence of obesity that recovers after marked weight loss.