Predictors and outcome of gastrointestinal complications after cardiac surgery.

AIM: Gastrointestinal (GI) complications following cardiac surgery are uncommon but may be life-threatening. The aim of this prospective study is to determine the incidence, independent risk factors, and outcomes following GI complications after cardiac surgery. METHODS: Between March 2006 and February 2011, postoperative GI complications were diagnosed in 35 of 7175 consecutive patients who underwent cardiac surgery. Preoperative, intraoperative, and postoperative predictors of complication and death were identified and compared with a control group. We also sought to compare the incidence of GI complications in patients undergoing on-pump and off-pump cardiac surgery. RESULTS: GI complications occurred in 35 (0.48%) patients including upper GI bleeding (29, 82.8%), intestinal ischemia (3, 8.5%) perforated duodenal ulcer (1, 2.8%), volvulus of sigmoid (1, 2.8%), and also one patient (2.8%) had upper GI bleeding because of gastric tumor. Patients in the GI group were an average of 5 years older than patients in the control group (P=0.011). In the on-pump group, 32 (91.4%) patients experienced GI complications, compared with 3(8.6%) in the off-pump group (P=0.011). The incidence per type of procedure was as follows: coronary artery bypass grafting (CABG) (51.4%), single or multiple valve surgery (17.1%), congenital disease (14.2%), combined CABG and valve (8.6%), aortic surgery (5.7%) and the pulmonary artery embolectomy (2.8%). By logistic multivariate analysis, twelve parameters were identified that predicted GI complications: age greater than 65 years, low left ventricular ejection fraction (EF<30%), preoperative creatinine>1.5 mg/dL, on pump operation, prolonged time of cardiopulmonary bypass (CPB), prolonged time of aortic cross clamp, congenital heart disease, aortic dissection, use of intraaortic balloon pump (IABP), blood transfusion, hypotension, and sodium bicarbonate use. Surgical treatment was used in 7 patients (20%) with GI complication. The mortality rate in the surgical group was 85.7% and was the highest in patients who had intestinal ischemia (42.8%). The overall hospital mortality among patients with GI complications was 62.8% (N.=22) compared with a mortality rate of 2.9% (N.=10) in patients without postoperative GI complications (P=0.000). CONCLUSION: GI complications are an infrequent, but serious consequence of cardiac surgery and high index of suspicious is required for their detection. Furthermore, successful outcome can be enhanced by improving cardiac output, prompt diagnosis and early surgical intervention.

Early outcomes of intra-aortic balloon pump in cardiac surgery.

AIM: As the proportion of high-risk patients for cardiac surgery increases, use of intraaortic balloon pump (IABP) has increased, especially for acute heart failure following cardiac surgery. The aim of this prospective study was to determine risk factors of early mortality and IABP complications in patient who underwent cardiac surgery. METHODS: From March 2008 through February 2011, 106 (2.36%) patients received preoperative (N.=19) and postoperative IABP (N.=87). They included 68 (64.2%) men and 38 (35.8%) women, with a mean age 59 ± 9.6 years. Most of patients only had coronary disease. (N.=73) Prospective data collection obtained. RESULTS: Fifty nine patients (59.7%) were successfully weaned from IABP support and survived to hospital discharge. Hospital mortality was 44.3%. Risk factors for hospital death were age, urgent procedure, cardiopulmonary bypass (CPB) time, and incomplete revascularization. The overall mortality between patients with preoperative IABP insertion and patients with postoperative IABP did not significantly differ (6/19 vs. 41/87, P=0.163). Early vascular complications occurred in 4 patients (3.8%) that were not significant. CONCLUSION: The use of IABP is a safe option to support heart failure in cardiac surgery. Improved IABP technology and better surveillance have lead to increased use with lower complication rates.

Non-operative management of blunt trauma in abdominal solid organ injuries: a prospective study to evaluate the success rate and predictive factors of failure.

AIM: Over the past several years, non-operative management (NOM) has increasingly been recommended for the care of selected blunt abdominal solid organ injuries. No prospective study has evaluated the rate of NOM of blunt abdominal trauma in the northwest of Iran. The objective of our study was to evaluate the success rate of this kind of management in patients who do not require emergency surgery. METHODS: This prospective study was carried out in Imam Khomeini Hospital (as a referral center of trauma) at Tabriz University of Medical Sciences, Iran, between 20 March 2004 and 20 March 2007. All trauma patients who had suffered an injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis, using the Student's t test or the c2 test. RESULTS: During the three years of the study, 98 patients (83 males and 15 females) with blunt trauma were selected to NOM for renal, hepatic and splenic injuries. Mean age was 26.1+/-17.7 years (range, 2 to 89) and mean injury severity score (ISS) was 14.5+/-7.4. The success rate of NOM was 93.8%. Fifty-one patients (43 males, 8 females; mean ISS, 14.2+/-5.8) underwent NOM of splenic trauma; 38 patients (33 males, 5 females; mean ISS, 12.9+/-8.2) hepatic trauma, and nine patients (7 males, 2 females; mean ISS, 22.2+/-7.6) renal trauma. Six patients underwent laparotomy due to the failure of NOM. The success rates of this treatment were 94.1%, 94.7% and 88.8% for the spleen, liver and kidney injuries, respectively. Age, female gender and ISS were significant predictors of the failure of NOM (P<0.05). CONCLUSION: According to the authors NOM can be successfully performed for the hemodynamically stable patients with solid organ blunt trauma. The study indicates that the rates of NOM vary in relation to the severity of the organ injury. This suggests trauma centers should use this approach.

Mucormycotic pseudoaneurysm of the common carotid artery with tracheal involvement.

Mucormycosis is an emerging and fatal fungal infection. A high index of suspicion and the knowledge of its potential manifestations are essential for early diagnosis. We describe a patient with acute lymphoblastic leukaemia (L2 subtype) who developed a neck mass following a course of induction chemotherapy. Doppler ultrasonography and angiography of the neck revealed a pseudoaneurysm of the right common carotid artery. The patient then developed haemoptysis. Surgical exploration revealed a necrotic right common carotid artery with anteromedial pseudoaneurysm and adjacent tracheal wall perforation. Local debridement and tracheal repair were performed. Nonseptate hypheal invasion (mucormycosis) was found on the microscopic examination of the excised arterial wall. A subsequent recurrence of pseudoaneurysm was treated with local surgical debridement and intravenous amphotericin B (Fungizone) administration. Although rare, clinicians should be aware of these possible presenting features of mucormycosis as early diagnosis and treatment may potentially improve the survival.