Vascular Surgery Procedures Performed By Residents. A Narrative Review On The Impact In 30-Day Outcomes.

INTRODUCTION: Worldwide, there is an increase in scrutiny after surgical treatment of a vast array of pathologies. Doing so, a large body of evidence clearly supports centralisation, such as teaching hospitals, where a larger caseload enables optimal outcomes. These institutions have a strong presence of surgical residents seeking training in both technical and non-technical skills. Inevitably, as part of training, they will be involved in the surgical treatment of those patients, even as the primary operator. We sought to investigate the impact of trainee performed procedures in outcomes of common vascular procedures of different technical complexity. METHODS: A non-systematic MEDLINE and Scopus databases review on the outcomes of resident performed common vascular procedures was performed. RESULTS: Specific evidence in many procedures (venous disease, aortic aneurysms, peripheral artery disease) is lacking. After carotid endarterectomy (CEA), resident performed procedures seem to have similar cranial nerve palsy and stroke when compared to expert surgeons. Generally, resident-performed primary radiocephalic and elbow arteriovenous fistula (AVF) presents similar primary and secondary patency. As with CEA, AVF procedures performed by residents took longer. On aortic aneurysms, although no specific comparison has been performed, resident involvement (irrespective of surgeon or assistant) in these procedures does not seem associated with increased adverse events. CONCLUSION: In most vascular surgery procedures, little is known about resident performance and their impact on outcomes. Notwithstanding, resident-performed CEA and primary AVF seem free of major compromise to patients. Further research is warranted to clarify this topic.

Autologous mesenchymal stem cell transplantation for spinal fusion: 10 years follow-up of a phase I/II clinical trial.

Posterolateral spinal fusion is the standard surgical approach for patients with degenerative disc disease. In our previously published article, we reported a 5-years follow-up of a phase I/II clinical trial in patients undergoing spinal fusion with autologous mesenchymal stem cells (MSCs) embedded in tricalcium phosphate. In the current manuscript, we have updated the results with a 10-year follow-up, the longest reported to date in this setting. After clinical and radiological evaluation, safety of the procedure was further confirmed in all 11 treated patients, with no evidence of tumor, infection, inflammatory reaction, or heterotopic ossification related to the administration of MSCs. Regarding clinical efficacy, low back pain and radicular pain (both assessed by the visual analogue scale-VAS), and the Owestry Disability Index remained significantly lower compared to pre-intervention. Radiologic evaluation demonstrated spinal fusion in all cases, improving over time. Finally, quality of life improved significantly also during follow-up. In summary, the use of tricalcium phosphate-embedded autologous MSCs with lumbar posterolateral arthrodesis is safe and potentially provides long-term benefits for 10 years.

Long-Term Results of a Phase I/II Clinical Trial of Autologous Mesenchymal Stem Cell Therapy for Femoral Head Osteonecrosis.

(1) Background: Osteonecrosis of the femoral head (ONFH) is characterized by impaired vascularization with ischemia resulting in bone cell death, leading to the deterioration of the hip joint. Mesenchymal stem/stromal cells (MSCs) are an attractive potential therapeutic approach in this setting. The aim of this study is to evaluate the clinical improvement in terms of pain and quality of life, as well as the safety of the procedure during the follow-up of patients. (2) Methods: A Phase I-II Open-Label Non-Randomized Prospective clinical trial was conducted. Eight patients with idiopathic ONFH and stage < IIC in the ARCO classification were included. Four weeks before therapy, 40 mL of autologous bone marrow was obtained, and MSCs were expanded under Good-Manufacturing-Practice (GMP) standards. Study medication consisted of a suspension of autologous BM-derived MSCs (suspended in a solution of 5-10 mL of saline and 5% human albumin) in a single dose of 0.5-1 × 106 cells/kg of the patient, administered intraosseously with a trocar and under radioscopic control. Per-protocol monitoring of patients included a postoperative period of 12 months, with a clinical and radiological assessment that included the visual analog scale (VAS), the Harris scale, the SF-36, and the radiological evolution of both hips. In addition, all patients were further followed up for eight years to assess the need for long-term total hip replacement (THR) surgery. (3) Results: Median age of patients included was 48.38 ± 7.38 years, and all patients were men. Autologous MSCs were expanded in all cases. There were no adverse effects related to cell administration. Regarding efficacy, both VAS and ODI scores improved after surgery. Radiologically, 12.5% of patients improved at the end of follow-up, whereas 50% improved clinically. No adverse effects related to the procedure were recorded, and none of the patients needed THR surgery within the first year after MSC therapy. (4) Conclusions: The use of autologous MSCs for patients with ONFH disease is feasible, safe in the long term, and potentially effective.

Lower estimated glomerular filtration rate at admission is associated with a worse outcome in older patients with hip fracture who undergo surgical treatment.

BACKGROUND: We assessed the relationship of estimated glomerular filtration rate values at hospital admission on the outcome of surgically treated older adults who had suffered a hip fracture. METHODS: Prospective study that included patients > 65 years of age, surgically treated for primary hip fracture, with no pathologic or high-energy trauma aetiology admitted to a tertiary teaching hospital between 2018 and 2019. We stratified patients based on their estimated glomerular filtration rate at admission and examined its association to demographic and clinical variables, including 90-day post-discharge mortality. RESULTS: The study included 942 hip fracture patients. Lowered estimated glomerular filtration rate was significantly associated to a worsening of the functional status, higher incidence of medical postoperative complications, higher postoperative renal dysfunction, and greater number of blood transfusions. Mortality displayed a staircase pattern, increasing with decreasing estimated glomerular filtration rate. Patients with estimated glomerular filtration rate <60 had significantly higher mortality at 90 days after discharge. In-hospital mortality rate was 10.7% in hip fracture patients with chronic kidney disease who experienced a significant variation in the estimated glomerular filtration rate (>5 mL/min/1.73m2) on admission in comparison to baseline values. CONCLUSION: Older adult patients treated for hip fracture with lower glomerular filtration rate values have poorer functional status and worse prognosis. A significant clinical variation of estimated glomerular filtration rate upon hospital admission for hip fracture may be associated with increased in-hospital mortality of chronic kidney disease patients.

Total Knee Arthroplasty for the Oldest Old.

The present study describes and compares the early functional results after total knee arthroplasty (TKA) of the oldest-old population (aged over 84 years) and a randomly matched younger septuagenarian cohort so treated. We aimed to evaluate the early functional outcomes after patients' rehabilitation and the yearly requirements for hospital readmission and emergency room visits after TKA. We noted a similar length of hospital stay for octogenarian and septuagenarian patients, and we determined that both groups of patients were improving ROM (both flexion and extension) after the rehabilitation program (p < 0.05, in all cases), but there were no significant differences between octogenarian and septuagenarian improvement of the knee function (p > 0.05, in all cases). Patients from both age groups behaved similarly in terms of mobility before starting rehabilitation and after completion of the rehabilitation program. We noted that older octogenarian patients showed a higher one-year hospital readmission rate than younger septuagenarian patients, but similar early emergency room visits for both age groups. The findings of this study allow us to conclude that advanced age in itself should not be a contraindication for TKA.