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Background: To investigate the impact of Cryo Nerve Block with cryoICE™ device utilization, on post-operative pain in patients undergoing isolated coronary artery bypass grafting (CABG) through left thoracotomy. Methods: All consecutive patients undergoing isolated CABG through left thoracotomy between July 2021 and July 2022 from a single surgeon were included in the study. Patients using the cryoICE™ device for nerve block were compared for baseline demographics and pre-operative characteristics with those that did not use the cryoICE™ device. A propensity-adjusted analysis was used to compare the two groups. The primary outcome was degree of incisional pain and numbness. Results: A total of 103 patients underwent isolated CABG through left thoracotomy. After matching, the cryoICE™ device was used for nerve block in 60 patients while the control group included 43 patients. Mean follow-up was 5.7 months. The cryoICE™ device group had a mean value of incisional pain at hospital discharge was 1.5 (scale 0-10) while at follow-up was 0.69 (scale 0-10). Mean values of skin numbness at hospital discharge were 1 (scale 0-10) and 0.57 (scale 0-10) at follow-up. After univariate analysis comparison of cryoICE™ device group (60 patients) versus non-cryoICE™ device group (43 patients), the total in-hospital morphine use was 49% lower in the cryoICE™ versus the non-cryoICE™ cohort (73.8 + 79.37 mg vs 144.1 + 118.99 mg). Conclusions: Good clinical outcomes were observed in patients undergoing isolated left thoracotomy CABG with cryoICE™ utilization, including a very low incidence of post-operative pain, numbness, and hypersensitivity for all comers.
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BACKGROUND: Permanent pacemaker implantation (PPI) is a common complication after transcatheter aortic valve implantation (TAVI). The cusp-overlap view (COV) was adopted to reduce PPI risk after TAVI with self-expandable valves (SEVs); however, the evidence remains scarce. We performed a systematic review with meta-analysis comparing COV and the standard coplanar view (CPV) technique to evaluate their effectiveness and safety. METHODS: Following the PRISMA statement, data were extracted from studies published by August 2022 and found in PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, and Google Scholar. The primary outcome of interest was post-procedural PPI and the secondary outcomes were new left bundle branch block (LBBB), moderate/severe paravalvular leak (PVL), valve dislocation (pop-out); need of second transcatheter heart valve, 30-day mortality, stroke, conversion to surgery, coronary obstruction, implantation depth (mm), and post-TAVI mean gradients (mmHg). RESULTS: Eleven studies met our eligibility criteria and included 1464 patients in the COV group and 1743 patients in the CPV group. Patients who underwent TAVI with COV had lower risk of PPI (odds ratio 0.48; 95% confidence interval [CI] 0.33-0.70; p = 0.001) and higher implantation depths with COV (mean difference -0.83; 95% CI -1.2 to -0.45; p < 0.001). We did not observe any statistically significant differences in the rates of new LBBB, moderate/severe PVL, valve dislocation, need of second transcatheter heart valve, 30-day mortality, stroke, conversion to surgery, coronary obstruction, and post-TAVI mean gradients (mmHg). CONCLUSION: In TAVI with SEVs, the application of COV is associated with lower risk of PPI compared with the standard CPV without increasing risk for adverse outcomes.
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Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/complicaciones , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Arritmias Cardíacas/etiología , Bloqueo de Rama/etiología , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugíaRESUMEN
BACKGROUND: Permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is associated with higher risk of mortality and rehospitalization for heart failure. Efforts to prevent conduction abnormalities (CA) requiring PPI after TAVI should be made. The membranous septum (MS) length and its interaction with implantation depth (ID-ΔMSID) could provide useful information about the risk of CA/PPI following TAVI. OBJECTIVES: To identify MS length and ΔMSID as predictors of CA/PPI following TAVI. METHODS: Study-level meta-analysis of studies published by September 30, 2022. RESULTS: Eighteen studies met our eligibility including 5740 patients. Shorter MS length was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: odds ratio [OR] 1.60, 95% confidence interval [CI] 1.28-1.99, p < 0.001). Similarly, lower ΔMSID was associated with a significantly higher risk of CA/PPI (per 1 mm decrease: OR 1.75, 95% CI 1.32-2.31, p < 0.001). Meta-regression analyses revealed a statistically significant modulation of the effect of shorter MS length and lower ΔMSID on the outcome (CA/PPI) by balloon postdilatation (positive regression coefficients with p < 0.001); with increasing use of balloon postdilatation, the effect of shorter MS length and lower ΔMSID on the outcome increased. MS length and ΔMSID demonstrated excellent discriminative abilities, with diagnostic ORs equaling 9.49 (95% CI 4.73-19.06), and 7.19 (95% CI 3.31-15.60), respectively. CONCLUSION: Considering that short MS length and low ΔMSID are associated with higher risk of CA and PPI, we should include measurement of MS length in the pre-TAVI planning with MDCT and try to establish optimal ID values before the procedure to avoid CA/PPI.
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Estenosis de la Válvula Aórtica , Prótesis Valvulares Cardíacas , Marcapaso Artificial , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Factores de Riesgo , Resultado del Tratamiento , Tomografía Computarizada por Rayos X , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugíaRESUMEN
BACKGROUND: Over the last 20 years, the prevalence of severe obesity (body mass index ≥ 35 kg/m2) has almost doubled. This condition increases the challenge of laparoscopic adrenalectomy (LA) by creating problems with instrument reach, adequate exposure, and visualization. The aim was to compare perioperative outcomes of laparoscopic versus robotic adrenalectomy (RA) in severely obese patients. METHODS: This was an institutional review board-approved retrospective study. Prospectively collected clinical parameters of patients who underwent LA versus RA between 2000 and 2021 at a single center were compared using Mann-Whitney U, ANOVA, Chi-square, and multivariate regression analysis. Continuous data are expressed as median (interquartile range). RESULTS: For lateral transabdominal (LT) adrenalectomies, skin-to-skin operative time (OT) [164.5 (71.0) vs 198.8 (117.0) minutes, p = 0.006] and estimated blood loss [26.2 (15.0) vs 72.6 (50.0) ml, p = 0.010] were less in RA versus LA group, respectively. Positive margin rate, hospital stay and 90-day morbidity were similar between the groups (p = NS). For posterior retroperitoneal (PR) approach, operative time and perioperative outcomes were similar between LA and RA groups. Multivariate analysis demonstrated robotic versus laparoscopic technique (p = 0.006) to be an independent predictor of a shorter OT. CONCLUSION: There was a benefit of robotic over the laparoscopic LT adrenalectomy regarding OT and estimated blood loss. Although limited by the small sample size, there was no difference regarding perioperative outcomes between RA and LA performed through a PR approach.
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Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Humanos , Procedimientos Quirúrgicos Robotizados/métodos , Adrenalectomía/métodos , Estudios Retrospectivos , Laparoscopía/métodos , Obesidad/cirugía , Neoplasias de las Glándulas Suprarrenales/cirugíaRESUMEN
BACKGROUND: Post-operative pain relief after abdominal operations is critical for patient satisfaction and rapid recovery. Narcotics have been a traditional part of postoperative analgesia, with transversus abdominis plane (TAP) block introduced recently. The aim of this study is to assess the efficacy of laparoscopic TAP block on postoperative pain control in patients undergoing minimally invasive adrenalectomy. METHODS: This was an institutional review board-approved retrospective study. Parameters related to postoperative pain control were compared between patients who underwent robotic transabdominal lateral adrenalectomy with (after December 2018) or without laparoscopic TAP block (control group) (before December 2018) by one surgeon. Statistics were performed using Mann Whitney U and Chi-square tests. RESULTS: There were 86 patients in the TAP and 83 patients in the control group. Groups were similar regarding demographic and clinical parameters. Despite the availability of intravenous acetaminophen to a higher percentage of patients in the control (31.3%) versus the TAP group (8.1%), 0-24 h lowest postoperative pain scores were significantly lower in the TAP group (P < 0.0001). In TAP versus control group, percentage of patients requiring narcotics and amount of narcotics used was lower (P = 0.04 vs P = 0.0004, respectively). Mainly due to less pain-related over-stay, percentage of patients requiring more than a day of hospital stay was less in the TAP (12%) versus control group (18%) (P = 0.01). CONCLUSION: To our knowledge, the utility of TAP block in patients undergoing minimally invasive adrenalectomy has not been reported in the past. This study shows that there may be benefits of laparoscopic TAP block in reducing post-operative narcotic usage while improving pain control in these patients.
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Laparoscopía , Narcóticos , Músculos Abdominales , Acetaminofén/uso terapéutico , Adrenalectomía , Analgésicos Opioides/uso terapéutico , Humanos , Narcóticos/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Estudios RetrospectivosRESUMEN
BACKGROUND: Data regarding changes in cortisol axis after adrenalectomy for non-cortisol secreting tumors and their correlation with adrenal insufficiency are limited. Our aim was to analyze these changes and their clinical correlations to guide management after adrenalectomy for non-Cushing's tumors. METHODS: Following IRB approval, postoperative cortisol axis changes were analyzed in patients who underwent unilateral adrenalectomy for non-Cushing's tumors. A morning serum cortisol of ≥ 10 µg/dl was accepted as a sufficient adrenal response. RESULTS: 223 adrenalectomies were analyzed. In 63% of patients, POD1 serum cortisol was ≥ 10 µg/dl and in 37% < 10 µg/dl. No patient with a POD1 cortisol ≥ 10 µg/dl developed AI symptoms, whereas symptoms of AI were observed in 4% of those with < 10 µg/dl. In patients with a POD1 cortisol of < 10 µg/dl, the rate of steroid replacement therapy initiation was 100%, 8%, and 25% when the decision was based on serum cortisol, clinical symptoms, and serum cortisol plus ACTH stimulation test results, respectively. In 90% of asymptomatic patients, hypocortisolemia resolved uneventfully within a week on repeat morning cortisol testing. 75% of patients with hypocortisolemia on POD1 demonstrated an adequate cortisol response to ACTH stimulation test. CONCLUSION: Although postoperative hypocortisolemia was observed in 37% of patients undergoing unilateral adrenalectomy for non-cortisol secreting tumors, majority did not develop symptoms of adrenal insufficiency. All three steroid initiation approaches appeared safe, with management based on clinical symptoms or selective ACTH stimulation testing sparing more patients from steroids compared to steroid initiation based on POD 1 cortisol levels alone.
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Neoplasias de las Glándulas Suprarrenales , Insuficiencia Suprarrenal , Neoplasias de las Glándulas Suprarrenales/complicaciones , Neoplasias de las Glándulas Suprarrenales/patología , Neoplasias de las Glándulas Suprarrenales/cirugía , Insuficiencia Suprarrenal/diagnóstico , Insuficiencia Suprarrenal/etiología , Insuficiencia Suprarrenal/cirugía , Adrenalectomía , Hormona Adrenocorticotrópica , Humanos , HidrocortisonaRESUMEN
BACKGROUND: Recent studies have reported the feasibility of indocyanine green fluorescence imaging of adrenal tumors to guide dissection. Although the adrenal has been reported to concentrate the dye more than surrounding tissues, the amount of tissue distinction and how this compares with conventional vision has not been quantified before. The aim of this study is to quantify this distinction using color analysis. METHODS: This was an institutional review board-approved retrospective study. By excluding adrenal cortical carcinoma, metastasis and pheochromocytoma, video recordings of 50 patients who underwent robotic transabdominal lateral adrenalectomy with indocyanine green (ICG) imaging for adrenocortical tumors between August 2015 and May 2018 were reviewed. Using a color analysis software, the pixel intensity of adrenal tumors versus adjacent retroperitoneal tissues was calculated for conventional red, green and blue, as well as indocyanine green (ICG) scales. Statistical analysis was performed using ANOVA. RESULTS: A total of 50 patients underwent unilateral robotic transabdominal lateral adrenalectomy. All procedures were completed robotically without a conversion to laparoscopy or open. Morbidity was 4%. Measured pixel intensity of adrenal tumors was higher than adjacent retroperitoneal tissues for all conventional color and ICG modes (p < 0.0001), with the gradient being more pronounced for ICG green versus conventional red, green and blue modes. CONCLUSIONS: To our knowledge this is the first study attempting to encode tissue planes in robotic adrenalectomy. The results show that the visual contrast distinction observed between adrenal and adjacent retroperitoneal tissues can be quantified using pixel intensity. ICG enabled the distinction of tissue planes with a wider gradient compared to conventional RGB view, quantifying its subjective benefits reported in prior studies.
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Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Neoplasias de las Glándulas Suprarrenales/diagnóstico por imagen , Neoplasias de las Glándulas Suprarrenales/patología , Neoplasias de las Glándulas Suprarrenales/cirugía , Adrenalectomía/métodos , Humanos , Verde de Indocianina , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/métodosRESUMEN
Over the last decade, sutureless valves (Perceval, LivaNova PLC) were brought to the market as an alternative to stented valves for patients requiring surgical aortic valve replacement (SAVR). However, Perceval demands special steps for implantation, among which we can mention specific training for the surgical team members. Sternal-sparing cardiac procedures are conceived to limit surgical trauma, but the technical requirements and preoperative planning are more challenging than those for conventional sternotomy. SAVR is frequently carried out through an upper hemisternotomy, but the right anterior thoracotomy (RAT) represents an even less traumatic, technical advancement. In the context of SAVR with RAT, Perceval has been considered the "perfect marriage." In patients with bicuspid aortic valve (BAV), some surgeons initially avoided the Perceval valve but, with growing experience, the prosthesis has been used for a wide variety of indications. According to an international consensus statement recently published, there are 3 BAV types: the fused BAV, the 2-sinus BAV and the partial-fusion BAV, each with specific phenotypes. The 2-sinus BAV has 2 cusps, roughly equal in size and shape, each cusp occupying 180° of the annular circumference, with only 2 aortic sinuses, resulting in a 2-sinus/2-cusp valve without raphe and with 180° commissural angles. Since the elliptic aortic annulus in BAV patients poses a challenge for sutureless valves and the RAT approach has been increasingly adopted for minimally invasive SAVR, our description of the surgical technique focuses on the specific procedural details in the scenario of 2-sinus BAV laterolateral phenotype.
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Estenosis de la Válvula Aórtica , Enfermedad de la Válvula Aórtica Bicúspide , Enfermedades de las Válvulas Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Humanos , Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Estenosis de la Válvula Aórtica/cirugía , Válvula Mitral/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Enfermedad de la Válvula Aórtica Bicúspide/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Robotic-assisted coronary artery bypass grafting (CABG) outcomes in patients with a high society of thoracic surgery (STS) score in urgent settings remain hindered. PRESENTATION OF CASE: A high-risk female patient presented with dyspnea and low ejection fraction (EF = 15%) and was diagnosed with pulmonary edema post myocardial infarction. She was medically stabilized with intraaortic balloon pump and the heart-team decided to intervene with off-pump robotic hybrid coronary revascularization (HCR). The patient had the planned with left internal mammary artery (LITA) anastomosis to the left anterior descending artery (LAD) and the postoperative recovery was uneventful and patients discharged after few days at home. DISCUSSION: CABG has proven to be superior to percutaneous coronary intervention (PCI) even when guided by fractional flow rate and using the last generation stents according to fractional flow reserve versus angiography for multivessel evaluation 3 clinical trial. In moderate SYNTAX score patients that have been historically (SYNTAX trial) treated with multivessels PCI, robotic CABG has been shown to offer the advantage of LITA-LAD in combination with stent for non-LAD territory. CONCLUSION: High-risk, fragile patients, with low EF and high STS score that undergo urgent CABG can benefit from heart-team collaboration, and HCR is an important tool in the armamentarium.
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Enfermedad de la Arteria Coronaria , Reserva del Flujo Fraccional Miocárdico , Intervención Coronaria Percutánea , Procedimientos Quirúrgicos Robotizados , Humanos , Femenino , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/diagnóstico , Resultado del TratamientoRESUMEN
BACKGROUND: Off-pump coronary artery bypass (OPCAB) previously demonstrated its potential benefits in women; however, robotic-assisted OPCAB was scarcely studied. OBJECTIVES: To investigate whether robotic-assisted OPCAB could further improve the outcomes in women and the potential impact of hybrid approaches with stents and completeness of revascularization on the late outcomes. METHODS: Women who underwent robotic-assisted or conventional OPCAB (with sternotomy) between May 2005 and January 2021 at Lankenau Heart Institute were included. Propensity score matching was used to match 273 pairs on 27 characteristics. RESULTS: In the intraoperative period, women who underwent robotic-assisted OPCAB presented longer operative times (6.00 vs. 5.38 h; p < 0.001), higher rates of extubation in the operating room (83.9% vs. 75.5%; p = 0.019) and lower rates of blood transfusion (13.2% vs. 32.2%; p < 0.001). In the postoperative period, women who underwent robotic-assisted OPCAB presented lower rates of new onset atrial fibrillation (16.8% vs. 25.6%; p = 0.016), need of blood transfusion (33.0% vs. 54.9%; p < 0.001), shorter intensive care unit (ICU) (46.1 vs. 49.8 h; p = 0.006) and hospital length of stay (5.0 vs. 6.0 days; p < 0.001). We observed no statistically significant differences in the rates of operative death between the groups (1.47% vs. 1.47%; p = 0.771). In the follow-up, we observed no differences in terms of overall survival regardless of hybrid procedures with stents and completeness of revascularization. CONCLUSIONS: Robotic-assisted OPCAB in women is as safe as conventional OPCAB and may further improve outcomes. Hybrid coronary revascularization was a valuable adjunct in the robotic scenario and completeness of revascularization did not play a role in this setting.
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Puente de Arteria Coronaria Off-Pump , Procedimientos Quirúrgicos Robotizados , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria Off-Pump/métodos , Femenino , Humanos , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Outcomes of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with aortic stenosis and bicuspid aortic valve (BAV) must be better investigated. METHODS: A meta-analysis including studies published by January 2022 reporting immediate outcomes (in-hospital death, stroke, acute kidney injury [AKI], major bleeding, new permanent pacemaker implantation [PPI], paravalvular leakage [PVL]), mortality in the follow-up (with Kaplan-Meier curves for reconstruction of individual patient data). RESULTS: Five studies met our eligibility criteria. No statistically significant difference was observed for in-hospital death, stroke, AKI, and PVL. TAVI was associated with lower risk of major bleeding (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.12-0.69; p = .025), but higher risk of PPI (OR: 2.00; 95% CI: 1.05-3.77; p = .041). In the follow-up, mortality after TAVI was significantly higher in the analysis with the largest samples (HR: 1.24, 95% CI: 1.01-1.53, p = .043), but no statistically significant difference was observed with risk-adjusted populations (HR: 1.06, 95% CI: 0.86-1.32, p = .57). Landmark analyses suggested a time-varying risk with TAVI after 10 and 13 months in both largest and risk-adjusted populations (HR: 2.13, 95% CI: 1.45-3.12, p < .001; HR: 1.7, 95% CI: 1.11-2.61, p = .015, respectively). CONCLUSION: Considering the immediate outcomes and comparable overall survival observed in risk-adjusted populations, TAVI can be used safely in selected BAV patients. However, a time-varying risk is present (favoring SAVR over TAVI at a later timepoint). This finding was likely driven by higher rates of PPI with TAVI.
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Lesión Renal Aguda , Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Accidente Cerebrovascular , Reemplazo de la Válvula Aórtica Transcatéter , Lesión Renal Aguda/etiología , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Mortalidad Hospitalaria , Humanos , Válvula Mitral/cirugía , Factores de Riesgo , Accidente Cerebrovascular/etiología , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
OBJECTIVES: To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD). METHODS: We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD. RESULTS: Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025). CONCLUSION: The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Humanos , Implantación de Prótesis Vascular/métodos , Resultado del Tratamiento , Enfermedad Aguda , Estudios Retrospectivos , Disección Aórtica/cirugía , Reoperación , Aneurisma de la Aorta Torácica/cirugía , Factores de Riesgo , Aorta Torácica/cirugíaRESUMEN
BACKGROUND: Recently, efficacy of laparoscopic posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma and malignancy has been questioned. Although robotic technique using wristed instruments may improve limitations of laparoscopic PRA, the worldwide experience with robotic PRA is limited. This study aimed to describe patient characteristics, surgical technique, and long-term outcomes of robotic PRA from a 12-year single-center experience. METHODS: This analysis was an institutional review board-approved retrospective study. In this study, PRA was performed robotically, with intraoperative ultrasound and indocyanine green imaging guidance. Long-term outcomes and predictors of operative time (OT) were assessed using descriptive and regression analyses. Using OT as a surrogate for difficulty of procedure, receiver operating characteristic curve analysis was performed to quantify anthropometric thresholds that would predict a more challenging procedure. RESULTS: Altogether, 112 robotic PRA procedures were performed. Three cases (3%) were converted to a lateral approach, and one case (1%) was converted to open surgery. The morbidity rate was 2%. Microscopic capsular disruption occurred for one patient. No patient experienced persistent disease or local recurrence from pheochromocytoma or malignant adrenal tumors during the follow-up period (median, 48 months). Operating time was independently predicted by perirenal fat thickness, with 18.5 mm as the critical threshold. CONCLUSION: In this study, favorable PRA outcomes were achieved with careful patient selection and meticulous surgical technique that used robotic articulation guided by intraoperative imaging.
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Neoplasias de las Glándulas Suprarrenales , Laparoscopía , Procedimientos Quirúrgicos Robotizados , Neoplasias de las Glándulas Suprarrenales/diagnóstico por imagen , Neoplasias de las Glándulas Suprarrenales/cirugía , Adrenalectomía , Humanos , Recurrencia Local de Neoplasia , Selección de Paciente , Estudios RetrospectivosRESUMEN
BACKGROUND: Contrast-enhanced computed tomography (CT) with washout has emerged as an option to distinguish lipid-poor adenomas from non-adenomas. OBJECTIVE: The aim of this study was to assess the utility of CT washout in characterizing indeterminate lipid-poor adrenal incidentalomas. METHODS: From an Institutional Review Board-approved database, patients with adrenal incidentalomas who had adrenal protocol CT scans with a 15-min washout between 2003 and 2019 were identified. Non-contrast CT attenuation and washout patterns of different tumor types were compared. RESULTS: Overall, 156 patients with 175 adrenal lesions were included. Average tumor size was 3.0 cm, non-contrast CT density was 24.7 Hounsfield units (HU), and absolute washout was 52.6%. In 102 lesions (58.3%), CT washout was ≥ 60%; 94 (92.2%) of these were benign adrenocortical adenomas, 7 (6.9%) were pheochromocytomas, and 1 (0.9%) was an adrenal hematoma. Furthermore, in 73 tumors (41.7%), CT washout was < 60%; diagnosis was benign adrenocortical adenoma in 45 (61.6%) lesions, pheochromocytoma in 8 (11%) lesions, metastasis in 9 (12.3%) lesions, adrenocortical cancer in 6 (8.2%) lesions, and 'others' in 5 (6.9%) lesions. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of > 60% absolute CT washout for detecting an adrenal adenoma was 67.6%, 77.8%, 92.2%, 38.4%, and 69.7%, respectively. CONCLUSION: CT washout should be incorporated into the management algorithm of indeterminate adrenal incidentalomas with a high non-contrast CT attenuation to 'rule-in' benign tumors. For small tumors with mild elevation of plasma metanephrines, it should be kept in mind that adenomas and pheochromocytomas may have similar imaging and washout characteristics.
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Neoplasias de la Corteza Suprarrenal , Neoplasias de las Glándulas Suprarrenales , Neoplasias de la Corteza Suprarrenal/diagnóstico por imagen , Neoplasias de las Glándulas Suprarrenales/diagnóstico por imagen , Diagnóstico Diferencial , Humanos , Lípidos , Estudios Retrospectivos , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: The aim of this study is to assess the effect of tumor versus ablation-algorithm dependent parameters on local recurrence (LR) after microwave ablation (MWA) of liver malignancies. METHODS: This was an institutional review board-approved study of patients who underwent laparoscopic or open MWA of malignant liver tumors. The impact of ablation algorithm (stepwise or direct heating, single or overlapping ablations, and ablation margin) and tumor-dependent (type, size, location, and blood vessel proximity) parameters on LR was analyzed using Kaplan-Meier and Cox proportional hazards. RESULTS: A total of 179 patients with 602 liver tumors underwent 200 MWA procedures. Colorectal liver metastasis (CLM) was the most frequent tumor type followed by neuroendocrine liver metastasis (NELM), other metastatic tumors, and hepatocellular cancer (HCC). For patients followed at least a year with imaging, LR rate was 8.8% per lesion and 13.1%,1.3%, 11.7%, and 12.6%, for CLM, NELM, HCC, and other tumor types, respectively. On multivariate analysis, independent predictors of LR included tumor type, tumor size, and ablation margin. CONCLUSION: LR after MWA for malignant liver tumors is predicted by both tumor and surgeon-dependent factors. Variations in the ablation algorithm did not affect LR, leaving the ablation margin as the only parameter that could be modified to optimize local tumor control.
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Algoritmos , Carcinoma Hepatocelular/cirugía , Ablación por Catéter/mortalidad , Neoplasias Hepáticas/cirugía , Microondas/uso terapéutico , Ablación por Radiofrecuencia/mortalidad , Carcinoma Hepatocelular/patología , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Hepáticas/patología , Masculino , Márgenes de Escisión , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Intraoperative near-infrared imaging (NIFI) of parathyroid glands (PG) by first-generation technology had limited image quality and depth penetration. Second-generation NIFI has recently been introduced. Our aim was to compare (1) capability to detect PG and (2) image quality between older and newer technologies. METHODS: Accurately detecting PG, as well as, quality of autofluorescence (AF) was compared between an older charge-coupled device (CCD) camera and a newer complementary metal-oxide semiconductor (CMOS). χ2 , t test, and analysis of variance were used for analysis. RESULTS: There were 300 patients who underwent parathyroidectomy (PTX) and/or thyroidectomy (THY) with NIFI, 200 with CCD, and 100 with CMOS. Although both NIFI technologies detected >94% of PG, CMOS was superior to CCD. Comparing AF quality, mean pixel intensity of PG compared with the background was higher with CMOS compared with CCD. When comparing PG detected by NIFI before visual identification by a surgeon, both CCD and CMOS had similar results (25% vs. 22%; p = .3). CONCLUSION: Both NIFI cameras were excellent at detecting PG. Second-generation NIFI (CMOS) displayed higher detection rates and AF intensity. Although surgeons identified majority of PG before NIFI detection, 25% of PG were identified with NIFI first, suggesting future advancements of this technology may expand its applications during parathyroid/thyroid operations.
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Imagen Óptica/métodos , Enfermedades de las Paratiroides/patología , Glándulas Paratiroides/patología , Semiconductores , Espectroscopía Infrarroja Corta/métodos , Femenino , Humanos , Masculino , Metales/química , Persona de Mediana Edad , Enfermedades de las Paratiroides/diagnóstico por imagen , Enfermedades de las Paratiroides/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Glándulas Paratiroides/cirugía , Paratiroidectomía , Pronóstico , Estudios ProspectivosRESUMEN
BACKGROUND: Compared with conventional thyroidectomy, hypocalcemia rate was reported to be lower after total thyroidectomy (TT) utilizing near infrared fluorescence imaging (NIFI). The aim of this study is to evaluate the impact of NIFI on postoperative parathyroid function after TT. METHODS: This was a retrospective institutional review board-approved study comparing 100 patients who underwent TT with NIFI guidance and 200 patients without, by the same surgeon. Clinical parameters were compared using χ2 and t test. RESULTS: Average number of parathyroid glands identified intraoperatively was similar between two groups. However, rate of incidental parathyroidectomy was higher in conventional (14%) versus NIFI group (6%) (P = .039), despite similar (4% vs 6%, respectively) autotransplantation rates (P = .562). Incidences of transient (6.5% vs 5.0%) and permanent (0.5% vs 0%) hypocalcemia were not statistically different between conventional and NIFI groups (P = NS). CONCLUSION: The use of NIFI during thyroidectomy may decrease the rate of incidental parathyroidectomy by increasing the ability of the surgeon to recognize parathyroid glands with fluorescent contrast distinction. Nevertheless, in contrary to recent reports in literature, postoperative hypocalcemia rate was not altered compared with conventional technique, suggesting that preservation of parathyroid vasculature, rather than an augmented ability to detect the glands, may dominantly affect postoperative function.
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Bocio/cirugía , Enfermedad de Graves/cirugía , Glándulas Paratiroides/diagnóstico por imagen , Glándulas Paratiroides/fisiología , Neoplasias de la Tiroides/cirugía , Calcio/sangre , Femenino , Bocio/sangre , Bocio/diagnóstico por imagen , Enfermedad de Graves/sangre , Enfermedad de Graves/diagnóstico por imagen , Humanos , Hipocalcemia/etiología , Masculino , Persona de Mediana Edad , Imagen Óptica/métodos , Paratiroidectomía/efectos adversos , Paratiroidectomía/métodos , Estudios Retrospectivos , Neoplasias de la Tiroides/sangre , Neoplasias de la Tiroides/diagnóstico por imagen , Tiroidectomía/efectos adversos , Tiroidectomía/métodosRESUMEN
Background: Arterial stiffness causes cardiovascular disease and target-organ damage. Carotid-femoral pulse wave velocity is regarded as a standard arterial stiffness metric. However, the prognostic value of cardio-ankle vascular index (CAVI), which is mathematically corrected for blood pressure, remains understudied. Objectives: The purpose of this study was to determine the association of CAVI with cardiovascular and kidney outcomes. Methods: PubMed, Scopus, and Web of Science were searched until May 6, 2023, for longitudinal studies reporting the association of CAVI with mortality, cardiovascular events (CVEs) (including death, acute coronary syndromes, stroke, coronary revascularization, heart failure hospitalization), and kidney function decline (incidence/progression of chronic kidney disease, glomerular filtration rate decline). Random-effects meta-analysis was performed. Studies were assessed with the "Quality in Prognostic Studies" tool. Results: Systematic review identified 32 studies (105,845 participants; follow-up range: 12-148 months). Variable cutoffs were reported for CAVI. The risk of CVEs was higher for high vs normal CAVI (HR: 1.46 [95% CI: 1.22-1.75]; P < 0.001; I2 = 41%), and per SD/unit CAVI increase (HR: 1.30 [95% CI: 1.20-1.41]; P < 0.001; I2 = 0%). Among studies including participants without baseline cardiovascular disease (primary prevention), higher CAVI was associated with first-time CVEs (high vs normal: HR: 1.60 [95% CI: 1.15-2.21]; P = 0.005; I2 = 65%; HR per SD/unit increase: 1.28 [95% CI: 1.12-1.47]; P < 0.001; I2 = 18%). There was no association between CAVI and mortality (HR = 1.31 [0.92-1.87]; P = 0.130; I2 = 53%). CAVI was associated with kidney function decline (high vs normal: HR = 1.30 [1.18-1.43]; P < 0.001; I2 = 38%; HR per SD/unit increase: 1.12 [95% CI: 1.07-1.18]; P < 0.001; I2 = 0%). Conclusions: Higher CAVI is associated with incident CVEs, and this association is present in the primary prevention setting. Elevated CAVI is associated with kidney function decline.
RESUMEN
OBJECTIVE: This study sought to identify periprocedural risk predictors that affect long-term prognosis in patients with chronic obstructive pulmonary disease (COPD) undergoing isolated coronary artery bypass grafting (CABG). METHODS: All consecutive 4,871 patients undergoing isolated CABG between May 2005 and June 2021 were included. Patients with and without COPD were compared for baseline demographics and preoperative characteristics. A propensity-matched analysis was used to compare the 2 groups. The primary outcome was long-term incidence of all-cause death. RESULTS: After matching, 767 patients each were included in the COPD and non-COPD groups; mean age was 71.6 and 71.4 years (P = .7), respectively; 29.3% and 32% (P = .2) were women, respectively. Intraoperatively, median (IQR) operating room time was higher in the COPD group than in the non-COPD group (5.9 [5.2-7.0] hours vs 5.8 [5.1-6.7] hours, respectively; P = .01). Postoperatively, intensive care unit stay (P = .03), hospital length of stay (P = .0004), and fresh frozen plasma transfusion units (P = .012) were higher in the COPD group than in the non-COPD group. Thirty-day mortality was not different between groups (1.3% in the COPD group vs 1% in the non-COPD group; P = .4). Median follow-up time was 4.0 years. The rate of all-cause death was higher in the COPD group than in the non-COPD group (138 patients [18.3%] vs 109 patients [14.5%], respectively; P = .042). Periprocedural risk predictors for all-cause death in patients with COPD were atrial fibrillation, diabetes, male sex, dialysis, ejection fraction less than 50%, peripheral vascular disease, and Society of Thoracic Surgeons Predicted Risk of Mortality score greater than 4%. CONCLUSION: Patients with COPD undergoing isolated CABG had a significantly higher incidence of all-cause death than those without COPD. Herein, risk predictors are provided for all-cause death in patients undergoing isolated CABG.
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Enfermedad de la Arteria Coronaria , Enfermedad Pulmonar Obstructiva Crónica , Humanos , Masculino , Femenino , Resultado del Tratamiento , Transfusión de Componentes Sanguíneos , Plasma , Puente de Arteria Coronaria/efectos adversos , Pronóstico , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Enfermedad Pulmonar Obstructiva Crónica/diagnóstico , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/cirugía , Factores de Riesgo , Estudios RetrospectivosRESUMEN
OBJECTIVES: The aim of this study was to compare long-term prognosis after isolated coronary artery bypass grafting between white and black patients and to investigate risk factors for poorer outcomes among the latest. METHODS: All consecutive 4766 black and white patients undergoing isolated coronary artery bypass grafting between May 2005 and June 2021 at our institution were included. Primary outcomes were long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events in black versus white patients. A propensity-matched analysis was used 2 compare groups. RESULTS: After matching, 459 patients were included in each black and white groups while groups were correctly balanced. The mean age was 70.4 vs 70.6 years old (P = 0.7) in black and white groups, respectively. Intraoperatively, mean operating room time and blood product transfusion, were higher in the black group while incidence of extubation in the operating room was higher in the white one. Postoperatively, hospital length of stay was higher in the black cohort. Thirty-day all-cause mortality was not different among groups. The median follow-up time was 4 years. Primary outcome of all-cause death was higher in the black versus the white, respectively. Major adverse cardiovascular and cerebrovascular events incidence was twice higher in the black compared to the white cohort (7.6% vs 3.7%, P = 0.013). Risk predictors for all-cause death and major adverse cardiovascular and cerebrovascular events in blacks were creatinine level, chronic obstructive pulmonary disease, ejection fraction <50% and preoperative atrial fibrillation. CONCLUSIONS: Racial disparities persist in a high-volume centre. Despite no preoperative difference, black minority has a higher incidence of major adverse cardiovascular and cerebrovascular events.