Lumen-apposing metal stents for anastomosis creation throughout the gastrointestinal tract: A large single-center experience.

Objectives: The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound. This study aims to evaluate the efficacy and safety of LAMS in creating an endoscopic ultrasound-guided anastomosis between two segments of the gastrointestinal (GI) tract. Methods: Data from all consecutive LAMS procedures for anastomosis creation between two segments of the GI, conducted between October 2019 and February 2024, were retrospectively analyzed for technical success (defined as correct deployment of the LAMS in the target), clinical success (defined as achievement of the intended clinical goal), and adverse events. Results: A total of 145 LAMS procedures were performed in 136 patients. Indications for LAMS procedures included the need for endoscopic access to or reversal of surgically excluded segments of the GI tract (n = 73, 50.3%), and the alleviation of any GI outflow obstruction (n = 72, 49.7%). The overall technical and clinical success rates were very high (97.2% and 95.2%, respectively). Adverse events were observed in 20/145 (13.8%) cases, including 11 (7.6%) minor events (AGREE <3) and nine (6.2%) major events (AGREE ≥3). Major events included stent migration (n = 1), persisting fistula (n = 3), and bleeding (n = 4). All adverse events were successfully managed, and there were no procedure-related deaths. Loss of LAMS patency occurred in 4/145 (2.8%) cases and could be endoscopically managed in all cases. Conclusions: The creation of anastomoses with LAMS between two segments of the GI tract appears to be effective and safe, with a low reintervention rate due to loss of LAMS patency.

Biliopancreatic limb obstruction after one-anastomosis gastric bypass; a very rare and fatal event: A case report and literature review.

The biliopancreatic limb (BPL) obstruction occurrence after one-anastomosis gastric bypass (OAGB) has not been well described in the literature. A 65-year-old female with a history of OAGB surgery presented with acute weight loss and abdominal pain. Imaging studies revealed a bezoar in the duodenal diverticulum obstructing the small bowel. An urgent laparoscopic intervention was performed to remove the bezoar and alleviate the obstruction. The patient experienced postoperative complications, including gastrostomy drainage and subsequent biliobezoar migration. additional surgeries were required to address these complications. This is a rare condition, and it is usually seen in patients with predisposing factors like DM, previous surgery, and duodenal diverticulum. CT scan study is the useful diagnostic modality, and laparoscopic intervention is the choice treatment; this case highlights the importance of recognizing and managing bezoars as a potential complication following bariatric surgery.

Two-stage hybrid strategy for multivessel coronary artery disease and functional ischemic mitral regurgitation: A case series.

The optimal treatment strategy of high surgical risk patients with multivessel coronary artery disease (CAD) and functional mitral regurgitation (MR) remains controversial. We present two cases in which two-stage hybrid treatment with prior transcatheter mitral valve edge-to-edge repair (TEER) followed by off-pump coronary artery bypass grafting (OPCAB) was successfully performed in patients with CAD and functional ischemic MR. In both cases, the patient showed good hemodynamic stability during OPCAB without an increase in MR. A two-stage hybrid strategy with prior TEER followed by OPCAB may be an ideal treatment option for high surgical risk patients with multivessel CAD and functional ischemic MR. Learning objective: To recognize the effectiveness of a two-stage hybrid approach with transcatheter edge-to-edge repair and off-pump coronary artery bypass grafting in high surgical risk patients with multivessel coronary artery disease and functional mitral regurgitation.

Goal-directed perfusion to reduce acute kidney injury after pediatric cardiac surgery.

BACKGROUND: Although the goal-directed perfusion (GDP) during cardiopulmonary bypass (CPB) has been discussed a lot in adult studies, no pediatric indexed oxygen delivery (DO2i) thresholds are universally accepted, and no pediatric randomized controlled trial (RCT) is reported until now. This study aimed to determine whether the GDP initiative (maintaining DO2i ≥ 360 mL/min/m2 during CPB) could reduce the incidence of acute kidney injury (AKI) after pediatric cardiac surgery and improve clinical outcomes. METHODS: This single-center RCT enrolled 312 pediatric patients, who were randomized to receive either the GDP strategy or a conventional perfusion strategy during CPB. The primary outcome was the rate of postoperative AKI. Secondary outcomes included major postoperative complications, all-cause mortality within 30 days and short-term clinical outcomes after surgery. RESULTS: AKI occured in 43 patients (28.1%) in the GDP group and in 65 patients (42.2%) in the control group (relative risk, 0.67; 95% confidence interval, 0.49-0.91; P = 0.010). In the subgroup analysis, The GDP group had a lower AKI rate compared with the control group among patients with age less than 1 year, with nadir temperature greater than 32°C and nadir hemoglobin less than 8 g/L during CPB, with preoperative cyanosis, and with CPB duration from 60 to 120 minutes. CONCLUSIONS: The GDP strategy aimed at maintaining DO2i ≥ 360 mL/min/m2 during CPB is effective in reducing the risk of AKI after pediatric cardiac surgery.

The discussion of the relationship between cardiopulmonary bypass and postoperative thyroid function changes in pediatric congenital heart disease, and the analysis of oral thyroid hormone therapy and cardiac prognosis.

OBJECTIVE: This study aims to investigate the relationship between CPB factors and changes in TH levels in postoperative patients and the effect of oral levothyroxine sodium tablets on outcomes in patients with postoperative TF abnormalities. METHODS: Select patients who underwent CHD surgery between September 2017 and September 2023 and were aged 13 years or younger. The relationship between CPB and postoperative TF changes and the influencing factors were analyzed. In addition, patients with different diseases and ages were divided into the medication group and the non-medication group. The primary outcome was postoperative ejection fraction (EF), and the secondary outcomes were PICU hospitalization days and total hospital cost. RESULTS: Seven hundred 53 patients were included. The longer the CPB time and ACC time, the lower the postoperative triiodothyronine (T3) and thyroxin (T4) levels (p < 0.001 and p < 0.001). The longer the CPB time, the more pronounced the postoperative T3 level abnormality (p < 0.001). The longer the CPB time, ACC time, and DHCA time, the more pronounced the postoperative T4 level abnormalities (p < 0.001 and p < 0.001 and p = 0.046). The postoperative EF of patients in the medication group was slightly higher than that of the non-medication group, and the EF before discharge was significantly higher than that of the non-medication group (p = 0.021, p = 0.015, and p = 0.024). Postoperative PICU days in the medication group [3.0 (2.0,7.0) versus4.0 (2.0,10.0), p = 0.020] were shorter than the non-medication group, and the proportion of ≤ 5 days was more [154 (66.1%) versus304 (58.5%), p = 0.047]. The total hospitalization cost was slightly lower in the medication group (p < 0.05). CONCLUSION: The duration of CPB, ACC, and DHCA in the open surgery process for CHD affects patients' thyroid function in the postoperative period. In our study, we found that oral levothyroxine sodium tablets are beneficial to the children's postoperative recovery.

Subjective improvement of reflux symptoms after conversion of sleeve gastrectomy to Roux-en-Y gastric bypass and concomitant repair of hiatal hernia.

BACKGROUND: Symptoms of reflux after sleeve gastrectomy (SG) are common and may be refractory to medical treatment. OBJECTIVES: To assess outcomes of conversion of SG to Roux-en-Y gastric bypass (RYGB) with concomitant repair of hiatal hernias on symptoms of reflux. SETTING: Tertiary community hospital. METHODS: We reviewed data from all consecutive patients (2018-2021) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and postoperative proton pump inhibitor (PPI) use were compared with McNemar statistical test. Data are reported as mean ± standard deviation. RESULTS: In total, 64 patients (92% female; 48 ± 10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4 ± 3 years after the index SG. A hiatal hernia was detected preoperatively in 57 of 64 patients (89%) by either upper gastrointestinal contrast studies, computed tomography scan, or esophagogastroduodenoscopy. At 29 ± 14 months postconversion to RYGB, percent total body weight loss was 14 ± 9% and percent excess weight loss was 37 ± 29%, and body mass index decreased from 37 ± 7 to 32 ± 6 kg/m2. Symptoms of reflux and use of PPI improved during the early follow-up period (median: 14 months; P < .001) and was sustained at late follow-up (median: 32 months; P < .01). Improvement of nausea and dysphagia reached statistical significance at late follow-up (median: 32 months; P < .01). Vomiting and abdominal pain decreased with time but did not reach statistical significance. Postoperative complications were deep surgical-site infection (n = 3), pulmonary embolism (n = 1), bleeding (n = 5), reoperation (n = 3), and 30-day readmission (n = 6). CONCLUSIONS: Conversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss.

[Rehabilitation potential of patients with ischemic heart disease who underwent autovenous coronary artery bypass surgery in the evaluation of rehabilitation treatment effectiveness]. / Reabilitatsionnyi potentsial patsientov s ishemicheskoi bolezn'yu serdtsa, perenesshikh autovenoznoe aortokoronarnoe shuntirovanie, v otsenke effektivnosti vosstanovitel'nogo lecheniya.

The search for methods to assess the rehabilitation potential (RP) of patients with ischemic heart disease (IHD) who underwent coronary artery bypass surgery (CABS), which will allow to personalize approaches to the administration of necessary for the certain patient treatment complexes, increasing their effectiveness and reducing the probability of complications, remains relevant. OBJECTIVE: To develop a method for RP evaluation in patients with IHD who underwent CABS and to assess its role in predicting the effectiveness of therapeutic activities in the early rehabilitation period. MATERIAL AND METHODS: The study consisted of two parts. A method for RP assessment in 118 patients with IHD aged 36-85 years (mean age 62.3±2.0 years) who underwent CABS was developed in the 1st part based on the analysis of hospital discharge reports using mathematical modeling methods. The results of rehabilitation activities were analyzed in the 2nd part of the study in patients who were transferred to the cardiovascular department of the Angara Clinical Resort after the cardiovascular surgery department for the second stage of rehabilitation. The multidisciplinary team evaluated the effectiveness of patients' treatment after the rehabilitation completion using integral indicators characterizing clinical condition of the patient who underwent CABS. RESULTS: A methodological algorithm was created in the 1st part of the study, namely a formalized patient chart was formed, the evidence base was represented by 99 indicators. The values of linear classification functions' coefficients were assigned to certain indicators, according to which the patient was classified into one of four groups: the 1st group - without RP; the 2nd group - with medium RP; the 3rd group - with high RP and the 4th group - with low RP. The values of RP were determined in the second part of the study for predicting the effectiveness of therapeutic measures in the early rehabilitation period (the second stage of medical rehabilitation). It has been found that the greatest effect was observed in subjects of the 3rd group with high RP in the patients' testing after treatment at the health resort. The lesser effect has been noted in patients of the 2nd group and especially of the 4th group. CONCLUSIONS: The use of RP assessment method based on mathematical modeling in patients who underwent CABS allows to predict the results of patients' medical rehabilitation at the second stage in the health resort conditions.

Safety and efficacy of surgical revascularization with percutaneous ventricular assist device for acute myocardial infarction complicated by cardiogenic shock: Japanese national registry study.

BACKGROUND: This study aims to assess the safety of coronary artery bypass grafting (CABG) with percutaneous ventricular assist device (PVAD) in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). METHODS: A retrospective analysis was conducted on 1198 patients with AMI-CS from the J-PVAD registry, who underwent PVAD support using Impella® (Abiomed Inc., Danvers, MA) and subsequent revascularization between February 2020 and December 2021. Patients were divided into two groups based on the method of coronary revascularization: percutaneous coronary intervention (PCI, n = 1084) and CABG (n = 114). The study assessed short-term all-cause and cardiac-related mortality. RESULTS AND CONCLUSION: The CABG group exhibited significantly lower short-term all-cause mortality compared with the PCI group (30-day: 26.2% vs. 39.9%, 90-day: 45.5% vs. 58.4%, log-rank p = 0.004). Short-term cardiac-related mortality was similar toward low in the CABG group compared with the PCI group (30-day: 18.7% vs. 25.6%, 90-day: 29.4% vs. 35.5%, log-rank p = 0.084). Multivariable analysis using the Cox proportional hazard model did not identify revascularization strategy as a risk factor for both all-cause mortality (Hazard ratio (HR): 0.743, 95% confidence intervals (CI): 0.457-1.208, p = 0.231) and cardiac-related mortality (HR: 0.762, 95% CI: 0.390-1.490, p = 0.427). These results were not attenuated even in subgroup analyses separately comparing CABG alone and hybrid therapy with PCI after propensity score matching. Thus, CABG can be a treatment option with feasible short-term outcomes in patients with AMI-CS under PVAD support.

Safety and Efficacy of Lumen-Apposing Metal Stents for Management of Late Refractory Gastro-jejunal Structures in Patients with Roux-en-Y Gastric Bypass (with Video).

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) related late gastro-jejunal (GJ) strictures are often resistant to endoscopic balloon dilations. Lumen-apposing metal stents (LAMSs) have been used to treat benign strictures with favorable results. However, the data remains limited to justify LAMS use for management of post-RYGB late GJ strictures. We aim to evaluate the safety and efficacy of LAMS placement for the management of late GJ strictures that are refractory to balloon dilations in post-RYGB patients. METHODS: This was a single center retrospective study that included all post-RYGB patients who underwent LAMS placement for management of late GJ strictures that had previously failed balloon dilations. Primary outcomes were technical and clinical success, and secondary outcomes were LAMS-related adverse events. RESULTS: A total of 28 patients underwent LAMS placement for management of GJ strictures. Median age was 60.5 (IQR 50.5, 67.0) years and majority were females (27, 96.4%). Median interval between surgery and first diagnosis of GJ stricture was 13 years (IQR 7, 17.5). 20 × 10 mm LAMS was the most used stent (n = 24, 85.7%). The median procedure time was 23.5 (IQR 14.5, 32.0) minutes. Technical and short-term clinical success of LAMS placement was 100% (95% CI 87.9-100.0). Long-term success was achieved in 19 out of 25 patients (76.0%, 95% CI 56.6-88.5) that had over 3 months follow-up after LAMS removal. Stent migration was noted in 2 (7.1%) patients, and 1 (3.6%) patient each experienced pain and minor bleeding without the need for additional interventions. No patient in our cohort required surgical revision of GJ anastomosis. CONCLUSION: Placement of LAMS is safe, technically feasible, and associated with a high clinical success rate in patients with late GJ strictures after RYGB who have failed prior balloon dilations. Placement of LAMS can be considered early in patients requiring multiple balloon dilations.

Autoregulatory dysfunction in adult Moyamoya disease with cerebral hyperperfusion syndrome after bypass surgery.

Cerebral hyperperfusion syndrome (CHS) is a serious complication after bypass surgery in Moyamoya disease (MMD), with autoregulatory dysfunction being a major pathogenesis. This study investigated the change of perioperative autoregulation and preoperative prognostic potentials in MMD with postoperative CHS. Among 26 hemispheres in 24 patients with adult MMD undergoing combined bypass, 13 hemispheres experienced postoperative CHS. Arterial blood pressure and cerebral blood flow velocity were perioperatively measured with transcranial Doppler ultrasound during resting and the Valsalva maneuver (VM). Autoregulation profiles were discovered in both the CHS and non-CHS groups using mean flow index (Mxa), VM Autoregulatory Index (VMAI), and a new metric termed VM Overshooting Index (VMOI). The CHS group had inferior autoregulation than the non-CHS group as indicated by VMOI on preoperative day 1 and postoperative 3rd day. Deteriorated autoregulation was observed via Mxa in the CHS group than in the non-CHS group on the postoperative 3rd and discharge days. Postoperative longitudinal autoregulation recovery in the CHS group was found in a logistic regression model with diminished group differences over the time course. This work represents a step forward in utilizing autoregulation indices derived from physiological signals, to predict the postoperative CHS in adult MMD.

The effect of spironolactone in reducing the risk of postoperative atrial fibrillation in patients undergoing coronary artery bypass graft surgery: randomized single-blind placebo-controlled study.

BACKGROUND: Postoperative atrial fibrillation (POAF), one of the most common cardiac arrhythmias following coronary artery bypass graft (CABG) surgery is associated with unfavorable outcomes. OBJECTIVES: This study investigated the effect of spironolactone administered two weeks before surgery on the incidence of POAF in patients undergoing CABG. METHODS: This randomized single-blind placebo-controlled study was conducted on 130 CABG patients. All patients were randomly divided into intervention and control groups including 65 cases for each group. In the intervention group, patients received 50 mg of spironolactone orally daily for 2 weeks before surgery, and in the control group patients received placebo daily from 2 weeks before surgery. All patients were continuously monitored for the occurrence of POAF for two weeks postoperatively. RESULTS: The mean age of the patients in the intervention and control groups was 61.7 ± 5.4 and 60 ± 6.7 years, respectively. The incidence of POAF in the intervention and control groups was 7.7% and 20%, respectively (Odds Ratio = 0.33, P = 0.042). All demographic and clinical variables were similar in patients with and without POAF (all P > 0.05). CONCLUSIONS: Our findings revealed that in comparison to placebo, the use of spironolactone is associated with reduced incidence of POAF in CABG candidates.

Sanguineous cardiopulmonary bypass prime accelerates the inflammatory response during pediatric cardiac surgery.

BACKGROUND: The inflammatory response to cardiopulmonary bypass (CPB) in pediatric patients remains an unresolved challenge. Sanguineous CPB prime, composed of allogenic blood products, is one potentially important stimulus. This study aims to identify specific inflammatory mediators active in sanguineous CPB prime and their impact on the inflammatory response at CPB initiation. METHODS: In a post-hoc analysis of a prospective observational cohort study (NCT05154864), where pediatric patients undergoing cardiac surgery with CPB were enrolled after informed consent, patients were grouped by CPB prime type (sanguineous vs crystalloid). Arterial samples were collected post-sternotomy as a baseline and again at CPB initiation from all patients. In the sanguineous group, CPB prime samples were also collected after buffered ultrafiltration but before CPB initiation. Luminex® measured concentrations of 24 inflammatory mediators for comparison between groups. Statistical analyses were by Mann-Whitney test and Wilcoxon signed-rank test. Data are presented as median [IQR]. RESULTS: Forty consecutive pediatric patients participated. The sanguineous group (n = 26) was younger (4.0 [0.2 - 6.0] vs 48.5 [39.0 - 69.5] months; p = 2.6 × 10-7) and smaller (4.9 [34 - 6.6] vs 17.2 [14.9 - 19.6] kg; p = 2.6 × 10-7) than the crystalloid group (n = 14). Despite this, baseline concentrations of 20 complement and cytokine concentrations were comparable between groups (p > 0.05) while four showed differences between groups (p < 0.05). The sanguineous prime contained supraphysiologic concentrations of complement mediators: C2, C3, C3a, C3b, and C5a. Correspondingly, upon CPB initiation, patients receiving sanguineous prime exhibited a significantly larger burden of C2, C3, C3b, C5, and C5a (p < 0.001) relative to the crystalloid group. Cytokine and chemokine mediators were present at trace levels in the sanguineous prime. CONCLUSIONS: Sanguineous prime contains activated complement that accelerates the inflammatory response at CPB initiation in neonates and infants. Immunomodulatory interventions targeting complement during CPB prime preparation could offer substantial benefits for these vulnerable patients.

One anastomosis gastric bypass in a patient with situs inversus totalis and severe obesity.

INTRODUCTION: Obesity is a widespread health concern, and bariatric surgery has shown promise as an effective treatment for addressing this issue. The increasing global prevalence of obesity has led to a rise in the occurrence of obesity alongside rare conditions such as situs inversus totalis (SIT). One of the most effective bariatric surgeries, one-anastomosis gastric bypass (OAGB), has gained popularity in recent years. MATERIALS AND SURGICAL TECHNIQUE: We report a successful case of OAGB in a patient with a body mass index (BMI) of 51.48 kg/m2 and SIT. DISCUSSION: It is worth noting that in skilled hands, OAGB can be both effective and safe for patients with anatomical abnormalities like SIT.

Impella™-assisted left main coronary artery intervention via aortofemoral bypass graft limb: a case report.

Aortofemoral graft limbs are a rarely used and understudied option for large-bore access for mechanical support due to a risk of downstream vascular events. Here we present a case of left main coronary artery percutaneous intervention utilizing an aortofemoral bypass graft limb for large-bore access for mechanical support with successful hemostasis utilizing a widely available suture-based closure device.

[Box: see text].

Potentially Risk Factors for New Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting: A Retrospective Cohort Study.

Objective: Our study evaluated the risk factors for new postoperative atrial fibrillation (POAF) by analyzing the data collected from patients who underwent first coronary artery bypass grafting (CABG). Methods: Our study retrospectively collected data from January 2021 to December 2023 at Changzhi People's Hospital. The perioperative period data were collected, and logistic regression was used to analyze the independent predictors of the occurrence of POAF after CABG and the related predictive values of risk factors were analyzed by using the subjects' work characteristic curve (ROC). Results: A total of 169 patients were included, and there are 45 patients in the POAF group, with an incidence of 26.6%, and 124 in the non-POAF group. The POAF group was significantly higher than the non-POAF group in terms of age (69.2±8.8 years vs 62.3±9.3 years) and preoperative LAD (42.7±7.2mm vs 36.8±5.5mm), and the difference was significant (P<0.05). Preoperative HDL-C in the POAF group were lower than non-POAF group (1.0±0.5 mmol/l vs 1.4±0.7 mmol/l, P<0.05). The logistic regression analysis revealed a significant correlation between age, LAD, HDL-C and the occurrence of POAF (P<0.05). According to the ROC curve analysis, age >64.5 years, LAD >41mm, and HDL-C <0.9 mmol/l were the cut-off values for predicting the occurrence of POAF (AUC1=0.733; AUC2=0.741; AUC3=0.647, P < 0.05). The combined age + LAD + HDL-C (AUC = 0.755; P < 0.05) had a higher diagnostic value and high sensitivity. Conclusion: The age, LAD, and HDL-C are independent risk factors for the POAF after CABG, and clinicians should assess these risk factors as much as possible when managing patients in the perioperative period and make corresponding measures to prevent the development of POAF.

Open Heart Dual Valve Surgery Without Blood Transfusion: A Case Report.

In Nepal, rheumatic heart disease (RHD) is alarmingly prevalent, marked by presentations like migratory joint arthritis, carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea. This condition can progress to instigate valvular defects. Although these patients are first approached medically, they may require surgery for severe cases. Refusal for blood transfusion might not be a major issue for other general surgeries; however, in cardiac surgery, where there is massive blood loss, it's quite a challenge. This challenge becomes even more pronounced in a developing country that lacks advanced facilities like a cell saver for autotransfusion. Herein, we report a case of a 22-year-old female, a Jehovah's Witness, suffering from RHD, severe mitral regurgitation, severe tricuspid regurgitation, and severe pulmonary artery hypertension. She underwent mitral valve replacement and tricuspid repair surgery (modified DeVega) by avoiding any form of blood product transfusion.