Association between preoperative prealbumin level and postoperative mortality and morbidity after hepatic resection for hepatocellular carcinoma: A multicenter study from a HBV-endemic area

BackgroundPrealbumin is a more sensitive serum biomarker in reflecting liver function and nutritional status than albumin, because of its shorter half-life and its characteristics that could hardly be affected by supplemental venous infusion of albumin or blood transfusion. This study aimed to identify whether preoperative prealbumin level was associated with postoperative mortality and morbidity after hepatic resection for patients with hepatocellular carcinoma (HCC).MethodsFrom a Chinese multicenter database, patients who underwent hepatic resection for HCC were divided into the low and normal prealbumin groups by using 17 mg/dL as the cut-off level for serum prealbumin taken within a week before surgery. Using univariable and multivariable logistic regression analyses, independent predictors associated with postoperative 30-day and 90-day mortality, 30-day overall and major morbidity, and postoperative hepatic insufficiency were identified.ResultsAmong 1356 patients, 409 (30.2%) had a low preoperative prealbumin level. Postoperative 30-day and 90-day mortality, and 30-day overall and major morbidity in the low prealbumin group were significantly higher than the normal prealbumin group (2.9% vs. 0.5%, 5.1% vs. 1.5%, 35.7% vs. 18.4%, and 14.4% vs. 6.5%, respectively, all P < 0.001). Multivariable analyses identified that preoperative prealbumin level, but not albumin level, was independently associated with postoperative 30-day mortality (OR: 3.486, 95% CI: 1.184–10.265), 90-day mortality (2.504, 1.219–5.145), 30-day overall morbidity (1.727, 1.302–2.292), 30-day major morbidity (1.770, 1.155–2.711) and postoperative hepatic insufficiency (1.967, 1.119–3.427).ConclusionsPreoperative prealbumin level could be used to predict postoperative morbidity and mortality for patients treated with hepatic resection for HCC.     

Outcomes of open repairs of chronic distal aortic dissection anatomically amenable to endovascular repairs

ObjectiveTo review short-term outcomes and long-term survival and durability after open surgical repairs for chronic distal aortic dissections in patients whose anatomy was amenable to thoracic endovascular aortic repair (TEVAR).MethodsBetween February 1991 and August 2017, we repaired chronic distal dissections in 697 patients. Of those patients, we enrolled 427 with anatomy amenable to TEVAR, which included 314 descending thoracic aortic aneurysms (DTAAs) and 105 extent I thoracoabdominal aortic aneurysms (TAAAs). One hundred eighty-five patients (44%) had a history of type A dissection, and 33 (7.9%) had a previous DTAA/TAAA repair. Variables were assessed with logistic regression for 30-day mortality and Cox regression for long-term mortality. Time-to-event analysis was performed using Kaplan-Meier methods.ResultsThirty-day mortality was 8.4% (n = 36). In all, 22 patients (5.2%) developed motor deficit (paraplegia/paraparesis), and 17 (4.0%) experienced stroke. Multivariable analysis identified low estimated glomerular filtration rate (eGFR; <60 mL/min/1.73 m²), previous DTAA/TAAA repair, and chronic obstructive pulmonary disease (COPD) as associated with 30-day mortality. Patients without all 3 risk factors had a 30-day mortality rate of 2.6%. During a median follow-up of 6.5 years, 160 patients died. The survival rate was 81% at 1 year and 61% at 10 years. Cox regression analysis identified preoperative aortic rupture, eGFR <60 mL/min/1.73 m², previous DTAA/TAAA repair, COPD, and age >60 years as predictive of long-term mortality. Forty-five patients required subsequent aortic procedures, including 8 reinterventions to the treated segment. Freedom from any aortic procedures was 85% at 10 years, and aortic procedure-free survival was 45% at 10 years. Hereditary aortic disease was the sole predictor for any aortic interventions (hazard ratio, 3.2; P = .004).ConclusionsOpen surgical repair provided satisfactory low neurologic complication rates and durable repairs in chronic distal aortic dissection. Patients without low eGFR, redo, and COPD are the low-risk surgical candidates and may benefit from open surgical repair at centers with similar experience to ours. Patients with hereditary aortic disease warrant close surveillance.     

Differences Among Clinical Trials and Registries on Surgical and Percutaneous Coronary Interventions

BackgroundA need exists for systematic evaluation of the differences in baseline characteristics and early outcomes between patients enrolled in randomized controlled trials (RCTs) and clinical practice for coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).MethodsSystematic searches were conducted to identify RCTs comparing CABG vs PCI and CABG or PCI registries. Sixteen predefined baseline characteristics and 30-day mortality were extracted from the included studies. Pooled proportion and mean with 95% CI were calculated for binary and continuous outcomes, respectively, by using the random effects model.ResultsFourteen RCTs and 10 registries including more than 2 million patients were included. Registry patients who underwent CABG had a higher prevalence of hypertension, smoking, reduced left ventricular ejection fraction, and prior myocardial infarction, but a lower prevalence of single-vessel disease when compared with CABG-treated patients included in RCTs. Regarding PCI, hypertension, hyperlipidemia, left main coronary artery disease, triple-vessel coronary disease, and NYHA functional class <IV were significantly more prevalent among patients in RCTs, whereas age, reduced left ventricular ejection fraction, and smoking were more represented among PCI registry patients. Thirty-day mortality was higher in registries for both PCI-treated and CABG-treated patients.ConclusionsThere were significant differences in baseline characteristics and 30-day mortality between patients enrolled in RCTs comparing CABG vs PCI and CABG and PCI registries. However, results were mixed, and the discrepancy was less than seen in other fields.     

Safety and feasibility of esophagectomy following combined immunotherapy and chemoradiotherapy for esophageal cancer

ObjectivesWe sought to determine the safety and feasibility of esophagectomy after neoadjuvant immunotherapy and chemoradiotherapy in clinical trial patients with locally advanced esophageal cancer.MethodsWe retrospectively identified patients who were treated with neoadjuvant immunotherapy and chemoradiotherapy (n = 25) or chemoradiotherapy alone (n = 143) at our institution between 2017 and 2020. The primary end point was risk of 30-day major complications (Clavien-Dindo classification system grade ≥ 3), which was assessed between groups using a multivariable log-binomial regression model to obtain adjusted relative risk ratios. Secondary end points were interval to surgery, 30-day readmission rate, and 30-day mortality.ResultsAll included patients successfully completed neoadjuvant therapy and underwent esophagectomy with negative margins. Age, sex, performance status, clinical stage, histologic subtype, procedure type, and operative approach were similar between groups. Neoadjuvant immunotherapy was not associated with a statistically significantly increased risk of developing a major pulmonary (relative risk, 1.43; 95% confidence interval, 0.53-3.84; P = .5), anastomotic (relative risk, 1.34; 95% confidence interval, 0.45-3.94; P = .6), or other complication (relative risk, 1.29; 95% confidence interval, 0.26-6.28; P = .8). Median (interquartile range) interval to surgery was 54 days (47-61 days) in the immune checkpoint inhibitor group versus 53 days (47-66 days) in the control group (P = .6). Minimally invasive approaches were successful in 72% of cases, with only 1 conversion. Thirty-day mortality and readmission rates were 0% and 17%, respectively, in the immune checkpoint inhibitor group and 1.4% and 13%, respectively, in the control group.ConclusionsOn the basis of our preliminary experience, esophagectomy appears to be safe and feasible following combined neoadjuvant immunotherapy and standard chemoradiotherapy for locally advanced esophageal cancer.     

First intention vertebroplasty in fractures within an ankylosed thoracolumbar spinal segment

PurposeTo evaluate the outcome of percutaneous vertebral cementoplasty (PVC) as the first-line treatment for traumatic thoracolumbar fractures within an ankylosed spinal segment.Materials and methodsThirty-one patients (15 men, 16 women; mean age: 79.2 ± 11 [SD] years; age range: 66–95 years) with thoracolumbar fractures within an ankylosed spine segment without neurological impairment treated with PVC were retrospectively evaluated. All patients were controlled at six weeks and one year after PVC. Ankylosing conditions, fractures sites and types, radiological consolidation, spinal complications were assessed. Anterior/posterior vertebral height ratios were measured before and after PVC. Postoperative pain relief and treatment success (radiological fracture consolidation) rates were considered.ResultsThe 31 patients had a total of 39 fractures (19 stable [49%], 20 unstable [51%]) treated with PVC. Primary success rate of PVC (initial fracture consolidation without complication) was 61% (19/31). Seven patients (7/31; 23%) exhibited new fractures, and the secondary success rate of PVC (global fracture consolidation one year after repeat PVC) was 87% (34/39). Global consolidation rates of unstable fractures were 85% (17/20) of treated levels. Pain score was null in 84% patients (26/31) one year after PVC. There were no significant differences between pre-PVC (0.62 ± 0.18 [SD]; range: 0.22–0.88) and post-PVC (0.60 ± 0.18 [SD]; range: 0.35–0.88) vertebral height ratios (P = 0.94).ConclusionPVC conveys a high overall success rate and effectively controls pain in patients with vertebral fractures within ankylosed spine segments.     

Outcomes of transapical mitral valve repair with neochordae implantation

ObjectiveTransapical off-pump beating-heart neochord implantation (NC) has shown encouraging early results in patients with degenerative mitral regurgitation. The aim of this study was to evaluate clinical and echocardiographic 5-year outcomes of patients who underwent NC.MethodsAll patients who underwent NC at our institution from November 2013 to March 2016 were included. Indications were severe symptomatic degenerative mitral regurgitation due to leaflet prolapse/flail. Patients were classified as having favorable anatomy (FA) and unfavorable anatomy (UA) on the basis of the extent and severity of mitral valve disease. All patients underwent clinical and echocardiographic follow-up at 1, 3, 6, and 12 months, and annually thereafter. Data were prospectively collected and retrospectively analyzed. Outcomes were on the basis of the Mitral Valve Academic Research Consortium guidelines.ResultsOne hundred consecutive patients were included in the analysis (FA: 81%; UA: 19%). Median age was 66 years (interquartile range, 58-76) and median European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 1.4% (interquartile range, 0.7-2.3). Technical and procedural success were 98% and 94%, respectively. Thirty-day mortality was 2%. Device success was 94%, 92%, and 78%, at 30 days, 1-year, and 5 years, respectively. Patient success at 1 year was 92%. Median follow-up was 5.1 years. At 5 years, overall survival was 83% with no difference between FA and UA patients. Cumulative incidence of severe mitral regurgitation recurrence at 5 years was 14% (95% CI, 6.5%-22.8%) in FA patients and 63% (95% CI, 39.7%-86.2%) in UA patients, respectively (P < .001). Patients with FA compared with UA had a lower incidence of reintervention (14.7% vs 43.4%; P < .001).ConclusionsTransapical off-pump beating heart NC might represent an acceptable option in patients with degenerative mitral valve disease and FA.     

Asymptomatic degenerative mitral regurgitation repair: Validating guidelines for early intervention

IntroductionMitral repair for asymptomatic (New York Heart Association [NYHA] class I) degenerative mitral regurgitation (MR) is supported by the guidelines, but is not performed often. We sought to determine outcomes for asymptomatic patients when compared with those with symptoms.MethodsBetween 2004 and 2018, 1027 patients underwent mitral replacement (22) or repair with or without other cardiac surgery (1005), the latter being grouped by NYHA class: I (n = 470; 47%), II (n = 408; 40%), or III/IV (n = 127; 13%). Statistical analyses included propensity score matching and weighting, and multistate models.ResultsThe proportion of patients designated as NYHA class I undergoing surgery increased steadily during this period (P < .001). Overall, 30-day mortality was 0.4%, and zero for patients designated NYHA class I. Unadjusted 10-year survival was significantly greater in patients designated NYHA class I compared with II and III/IV (P < .001). Freedom from reoperation at 10 years was 99.8% overall, and 100% for patients designated NYHA class I. In patients designated as NYHA class I, predischarge and 10-year moderate MR were 0.7% and 20.1%, whereas more than moderate was zero and 0.6%. Preoperative ejection fraction less than 60% was associated with late mortality (P = .025). After covariate-adjustments, freedom from MR and tricuspid regurgitation were not statistically significantly different by NYHA class. However, overall survival was significantly worse in patients with NYHA class III/IV, compared with class II.ConclusionsMitral repair in asymptomatic patients is safe and durable. Careful monitoring until class II symptoms is appropriate. However, repair before ejection fraction decreases below 60% is important for late overall survival.     

Efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) created using covered stents of different diameters: A systematic review and meta-analysis

PurposeThe purpose of this study was to make a systematic review and meta-analysis to determine the stent diameter (8 mm vs. 10 mm) that conveys better safety and clinical efficacy for transjugular intrahepatic portosystemic shunt (TIPS).Materials and methodsFour databases were used to identify clinical trials published from inception until March 2020. Data were extracted to estimate and compare one-year and three-year overall survivals, hepatic encephalopathy, variceal rebleeding, and shunt dysfunction rates between patients with 8 mm covered stents and those with 10 mm covered stents.ResultsFive eligible studies were selected, which included 489 patients (316 men, 173 women). The 8 mm covered stent group had higher efficacy regarding one-year or three-year overall survival (odds ratio [OR], 2.88; P = 0.003) and (OR, 1.81; P = 0.04) and lower hepatic encephalopathy (OR, 0.69; P = 0.04) compared with 10 mm covered stent group. There were no significant differences in variceal rebleeding rate (OR 0.80; P = 0.67). However, shunt dysfunction was lower in 10 mm covered stent group (OR, 2.26; P = 0.003).ConclusionsOur results suggest that the use of 8 mm covered stents should be preferred to that of 10 mm covered stents for TIPS placement when portal pressure is frequently monitored.     

CT-guided infiltration of greater occipital nerve for refractory craniofacial pain syndromes other than occipital neuralgia

PurposeThe purpose of this study was to evaluate the effectiveness of computed tomography (CT)-guided infiltration of greater occipital nerve (GON) for the treatment of refractory craniofacial pain syndromes other than occipital neuralgia.Materials and methodsFifty-six patients suffering from refractory craniofacial pain syndromes were included between 2011 and 2017. There were 33 women and 23 men with a mean age of 50.7 years ± 13.1 (SD) (range: 27–74 years). CT-guided infiltration was performed at the intermediate site of the GON with local anesthetics and cortivazol. Twenty-six (26/56; 46%) patients suffered from chronic migraine, 14 (14/56; 25%) from trigeminal neuralgia and 16 (16/56; 29%) from cluster headaches. Clinical success at 1, 3, and 6 months was defined by a decrease of at least 50% of pain as assessed using visual analog scale (VAS).ResultsMean overall VAS score before infiltration was 8.7 ± 1.3 (SD) (range: 6 - 10). Mean overall VAS scores after infiltration were 2.3 ± 3 (SD) (range: 0 - 10) (P < 0.01) at one month, 3.5 ± 3.3 (SD) (range: 0 - 10) (P < 0.01) at three months and 7.6 ± 1.3 (SD) (range: 1–10) (P < 0.01) at six months. After infiltration, clinical success was achieved in 44 patients (44/56; 78.5%) at 1 month, 37 patients (37/56; 66%) at 3 months and 13 patients (13/56; 23%) at 6 months. Clinical success according to the clinical presentation were as follows: 88% (23/26) at one month, 73% (19/26) at 3 months, and 23% (6/26) at 6 months in patients with chronic migraine, 81% (13/16), 69% (11/16) and 31% (5/16) in those with cluster headaches and 57% (8/14), 50% (7/14) and 14% (2/14) in those with trigeminal neuralgia. No major complications due to CT-guided GON infiltration were reported in any patient.ConclusionCT-guided infiltration at the intermediate site of the GON appears as an effective treatment of craniofacial pain syndromes especially in patients with chronic migraine and those with cluster headaches.     

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis

BackgroundReconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.MethodsSeven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.ResultsNinety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).ConclusionThis meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.Review registrationRegistered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.     

Safety and oncologic efficacy of percutaneous MRI-guided cryoablation of intraparenchymal renal cancers

PurposeThe purpose of this study was to evaluate the safety and oncologic efficacy of percutaneous magnetic resonance imaging (MRI)-guided cryoablation of intraparenchymal renal cancer.Materials and methodsBetween February 2009 and August 2019, 31 consecutives patients with 31 entirely intraparenchymal biopsy-proven renal cancers were treated with cryoablation under MRI-guidance in our institution, and were retrospectively included. There were 20 men and 11 women with a mean age of 68.5 ± 12.5 (SD) (range: 40–91 years). Patient, tumor- and procedure-related, and follow-up data were retrospectively collected and analyzed. Local recurrence free (LRFS), metastasis free (MFS), disease free (DFS), cancer specific (CSS), and overall survivals (OS) were calculated.ResultsPrimary and secondary technical efficacy rates were 94% and 100%, respectively. Median follow-up was 27 months. Seven (7/31; 23%) minor complications were noted in 7 patients. Patients showed a significant decline of the estimated glomerular filtration rate (eGFR) between baseline and nadir (mean basal eGFR 65.9 ± 22.4 [SD] mL/min/1.73 m² vs. mean nadir eGFR 52.8 ± 26.0 [SD] mL/min/1.73 m²; P < 0.001), but only two showed a clinically significant renal function decline. Three-year estimates of primary and secondary LRFS, MFS, and DFS were 64% (95% confidence interval [CI]: 47–87%), 89% (95% CI: 78–99%), 83% (95% CI: 77–98%), and 45% (95% CI: 28–73%), respectively. No patients died due to renal cancer evolution (three-year CSS of 100%; 95% CI: 100–100%). One patient died 52 months after the percutaneous treatment due to cryoablation-unrelated causes (three-year OS of 100%; 95% CI: 100–100%).ConclusionMRI-guided percutaneous cryoablation for intraparenchymal renal cancer offers good oncologic outcomes with acceptable complication rates and renal function worsening.     

Durability and clinical experience using a bovine pericardial prosthetic aortic valve

ObjectivesTo report the implant experience and long-term outcomes from a large tertiary care referral center on surgical aortic valve replacement (SAVR) with a contemporary stented pericardial bioprosthesis with anticalcification treatment.MethodsPatients underwent SAVR using the Trifecta valve at a single institution. Endpoints included procedural outcomes, adverse events, prosthesis–patient mismatch (PPM), long-term survival, and valve durability. Follow-up included 30-day, 6-month, and annual assessments. Treatment for structural valve deterioration (SVD) included surgical explant and valve-in-valve (V-in-V) transcatheter aortic valve implantation (TAVI).ResultsSAVR was performed in 1241 patients (median age, 73.5 ± 6.4 years; 54% male; median logistic EuroSCORE, 7.8) with concomitant procedures in 713 cases (57.5%). Intraprocedural mortality was 1.4%, and 30-day mortality was 6.0%. At hospital discharge, 68 patients (5.5%) had moderate PPM, and no patients had severe PPM. Adverse events included cardiac arrhythmias (44.7%, mostly atrial fibrillation), respiratory failure (22.9%), acute renal failure requiring temporary renal replacement therapy (12.9%), and low cardiac output syndrome (3.3%). Follow-up data were available over a total of 5469 patient-years (median duration of follow-up, 4.7 years). Freedom at 8 years from all-cause mortality, valve-related mortality, reoperation for SVD (redo SAVR or V-in-V TAVI), and endocarditis were 78.4%, 98.0%, 93.3%, and 96.5%, respectively. Of the 30 patients with SVD, 17 were treated by V-in-V TAVI and 13 underwent surgical explant.ConclusionsOutcomes from this large single-center cohort at increased surgical risk demonstrate excellent long-term durability of the Trifecta valve for SAVR and feasibility of treating SVD by V-in-V TAVI.     

Prediction of overall survival in patients with hepatocellular carcinoma treated with Y-90 radioembolization by imaging response criteria

PurposeTo evaluate the potential of imaging criteria in predicting overall survival of patients with hepatocellular carcinoma (HCC) after a first transcatheter arterial yttrium-90 radioembolization (TARE)Materials and methodsFrom October 2013 to July 2017, 37 patients with HCC were retrospectively included. There were 34 men and 3 women with a mean age of 60.5 ± 10.2 (SD) years (range: 32.7–78.9 years). Twenty-five patients (68%) were Barcelona Clinic Liver Cancer (BCLC) C and 12 (32%) were BCLC B. Twenty-four primary index tumors (65%) were > 5 cm. Three radiologists evaluated tumor response on pre- and 4–7 months post-TARE magnetic resonance imaging or computed tomography examinations, using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1, modified RECIST (mRECIST), European Association for Study of the Liver (EASL), volumetric RECIST (vRECIST), quantitative EASL (qEASL) and the Liver Imaging Reporting and Data System treatment response algorithm. Kaplan–Meier survival curves were used to compare responders and non-responders for each criterion. Univariate and multivariate Cox proportional hazard ratio (HR) analysis were used to identify covariates associated with overall survival. Fleiss kappa test was used to assess interobserver agreement.ResultsAt multivariate analysis, RECIST 1.1 (HR: 0.26; 95% confidence interval [95% CI]: 0.09–0.75; P = 0.01), mRECIST (HR: 0.22; 95% CI: 0.08–0.59; P = 0.003), EASL (HR: 0.22; 95% CI: 0.07–0.63; P = 0.005), and qEASL (HR: 0.30; 95% CI: 0.12–0.80; P = 0.02) showed a significant difference in overall survival between responders and nonresponders. RECIST 1.1 had the highest interobserver reproducibility.ConclusionRECIST and mRECIST seem to be the best compromise between reproducibility and ability to predict overall survival in patients with HCC treated with TARE.     

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.     

Interhospital failure to rescue after coronary artery bypass grafting

ObjectiveWe evaluated whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue.MethodsAn observational study was conducted among 83,747 patients undergoing isolated coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals. Failure to rescue was defined as operative mortality among patients developing complications. Complications included the Society of Thoracic Surgeons 5 major complications (stroke, surgical reexploration, deep sternal wound infection, renal failure, prolonged intubation) and a broader set of 19 overall complications. After creating terciles of hospital performance (based on observed:expected mortality), each tercile was compared on the basis of crude rates of (1) major and overall complications, (2) operative mortality, and (3) failure to rescue (among major and overall complications). The correlation between hospital observed and expected (to address confounding) failure to rescue rates was assessed.ResultsMedian Society of Thoracic Surgeons predicted mortality risk was similar across hospital observed:expected mortality terciles (P = .831). Mortality rates significantly increased across terciles (low tercile: 1.4%, high tercile: 2.8%). Although small in magnitude, rates of major (low tercile: 11.1%, high tercile: 12.2%) and overall (low tercile: 36.6%, high tercile: 35.3%) complications significantly differed across terciles. Nonetheless, failure to rescue rates increased substantially across terciles among patients with major (low tercile: 9.1%, high tercile: 14.3%) and overall (low tercile: 3.3%, high tercile: 6.8%) complications. Hospital observed and expected failure to rescue rates were positively correlated among patients with major (R² = 0.14) and overall (R² = 0.51) complications.ConclusionsThe reported interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals, including early recognition and management of complications.     

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

8 out of 10 patients do well after surgery for tarsal coalitions: A systematic review on 1284 coalitions

BackgroundThe primary aim was to determine the clinical success rate after treatment for talocalcaneal (TCC) and calcaneonavicular coalitions (CNC). The secondary aim was to evaluate the complication, recurrence and revision rate.MethodsA search was carried out in MEDLINE, EMBASE and Cochrane Library. Methodological quality was assessed using the Methodological Index for Non-Randomised Studies (MINORS) criteria. The primary outcome was the clinical success rate and was pooled per type of coalition and treatment modality. 95% Confidence Intervals (CI) of the success rates were calculated. Secondary outcomes included complication rates, coalition recurrence rates, revision rates and pain improvement using the Visual Analogue Scale (VAS). A sub-analysis on interposition material was performed.Results43 articles comprising of 1284 coalitions were included, with a pooled mean follow-up of 51 months. Methodological quality was fair. The overall pooled success rate for TCCs was 79% (95% CI, 75%?83%). Conservative treatment, open resection and arthroscopic resection of TCCs resulted in success rates of 58% (95% CI, 42%?73%), 80% (95% CI, 76%?84%) and 86% (95% CI, 71%?94%), respectively. CNCs have an overall success rate of 81% (95% CI, 75%?85%), with 100% (95% CI, 34%?100%), 80% (95% CI, 74%?85%) and 100% (95% CI, 65%?100%) for conservative treatment, open resection and arthroscopic resection, respectively. Pooled complication rates of 4% (95% CI, 3%?7%) for TCCs and 6% (95% CI, 4%?11%) for CNCs were found. The success rates of resection with and without interposition material for TCCs were 83% (95% CI, 78%?87%) and 79% (95% CI, 65%?88%), and for CNCs 81% (95% CI, 76%?86%) and 69% (95% CI, 44%?85%), respectively.ConclusionTreatment of tarsal coalitions can be considered good to excellent as well as safe, with an overall clinical success rate of 79% for TCCs and 81% for CNCs. Arthroscopic resection of the coalition appears to be non-inferior to open resection of TCCs and CNCs.Level of evidenceLevel IV, Systematic Review.     

Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation

BackgroundRisk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR).MethodsA novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately.ResultsEvent rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4746; 8.88%), and CONV (n = 3399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (interquartile range: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality.ConclusionsThis etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.     

Thrombosis and infections of peripherally inserted central catheters in burn patients: A 3-year retrospective study and a systematic review

AimsPeripherally inserted central catheters (PICCs) are becoming common and effective in acute and critical care settings recently. Burn patients need special considerations because of restricted insertion sites, burn wounds, hyper coagulation, high infection rates and others. However, the safety of PICCs in burn patients are not well elucidated and no related protocol has been formed. This study aims to investigate the thrombosis and infections of PICCs in burn patients.MethodsThis was a single center retrospective study and a systematic review. All the burn patients with PICCs between January 1, 2018 and December 31, 2020 were included. A systematic search of Medline, PubMed, EMBASE and Web of Science was performed from inception to 4 June 2021 following PRISMA guidelines. Upper extremity vein thrombosis (UEVT) and central line-associated bloodstream infection (CLABSI) were the main outcome.ResultsA total of 85 successful PICCs in 78 patients were included. Most patients were male (79.5%), adults(80.8%) and injured by flame(74.4%). The mean TBSA was 50.3% and 76.9% of patients had TBSA more than 30%. Most PICCs were punctured once (60.0%) and inserted less than 30 days after injury (80.0%) through basilar vein (70.6%). The overall line days were 2195 days and the mean line days was 25.8 ± 18.3 days. Six PICCs were complicated by UEVT (7.1%) in 21.2 ± 17.3 days after insertion. Patients with UEVT had significantly higher rate of bacteremia and later insertions than those without UEVT. One patient developed CLABSI and the CLABSI rate was 1.2% and 0.5 per 1000 line days. Six PICCs had catheter colonization. No significant risk factors were identified. Five articles involving 293 patients and 319 PICCs were ultimately evaluated in systematic review. The overall incidence of UEVT was 3.2% and CLABSI was 6.9% in burn populations.ConclusionPICCs in burn patients had acceptable incidence of UEVT and CLABSI with relative long line durations. A standardized PICC guideline for burn patients is required to further improve the feasibility and safety of PICCs.     

Covid-19 Pandemic Strategy for Treatment of Acute Uncomplicated Appendicitis with Antibiotics- Risk Categorization and Shared Decision-Making

BackgroundDuring the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by our department on antibiotics treatment for Acute Uncomplicated Appendicitis (AUA). Our study aimed to determine the feasibility and safety of non-operative treatment (NOT), compared to upfront laparoscopic appendectomy (LA), for AUA in children during the pandemic.MethodOur prospective comparative study was conducted from May 1, 2020 to January 31, 2021. Patient selection criteria included: age ≥5 years, abdominal pain duration ≤48 h, ultrasound (US)/Computered Tomography scan confirmation of AUA, US appendiceal diameter 6–11 mm with no features of perforation/abscess collection and no faecolith. For NOT patients, intravenous antibiotics were administered for 24–48 h followed by oral for 10-day course. Comparison was performed between patients whose parents preferred NOT to those who opted for up-front appendectomy. Primary outcomes were NOT success at index admission, early and late NOT failure rates till 27 months. Secondary outcomes were differences in complication rate, hospital length of stay (LOS) and cost between groups.Results77 patients were recruited: 43 (55.8%) underwent NOT while 34 (44.2%) patients opted for LA. Success of NOT at index admission was 90.7% (39/43). Overall, NOT failure rate at 27 months’ follow-up was 37.2% (16/43). Of the NOT failures, 1 appendix was normal on histology while only 1 was perforated. There were no significant differences in secondary outcomes between both groups except for LOS of late NOT failure. Cost for upfront LA was nearly thrice that of NOT.ConclusionOur stringent COVID protocol together with shared decision-making with parents is a safe and feasible treatment option during a crisis situation.Level of EvidenceTreatment study, Level II.