Defining and understanding the "extra-corporeal membrane oxygenation gap" in the veno-venous configuration: Timing and causes of death.

In-hospital mortality of adult veno-venous extracorporeal membrane oxygenation (V-V ECMO) patients remains invariably high. However, little is known regarding timing and causes of in-hospital death, either on-ECMO or after weaning. The current review aims to investigate the timing and causes of death of adult patients during hospital admittance for V-V ECMO, and to define the V-V ECMO gap, which is represented by the patients that are successfully weaned of ECMO but still die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-V ECMO patients from January 2006 to December 2020 were screened. Studies that did not report on at least on-ECMO mortality and discharge rate were excluded from analysis as they could not provide the required information regarding the proposed V-V ECMO-gap. Mortality rates on-ECMO and after weaning, as well as weaning and discharge rates, were analyzed as primary outcomes. Secondary outcomes were the causes of death and complications. Initially, 35 studies were finally included in this review. Merely 24 of these studies (comprising 975 patients) reported on prespecified V-V ECMO outcomes (on-ECMO mortality and discharge rate). Mortality on V-V ECMO support was 27.8% (95% confidence interval (CI) 22.5%-33.2%), whereas mortality after successful weaning was 12.7% (95% CI 8.8%-16.6%, defining the V-V ECMO gap). 72.2% of patients (95% CI 66.8%-77.5%) were weaned successfully from support and 56.8% (95% CI 49.9%-63.8%) of patients were discharged from hospital. The most common causes of death on ECMO were multiple organ failure, bleeding, and sepsis. Most common causes of death after weaning were multiorgan failure and sepsis. Although the majority of patients are weaned successfully from V-V ECMO support, a significant proportion of subjects still die during hospital stay, defining the V-V ECMO gap. Overall, timing and causes of death are poorly reported in current literature. Future studies on V-V ECMO should describe morbidity and mortality outcomes in more detail in relation to the timing of the events, to improve patient management, due to enhanced understanding of the clinical course.

Understanding the "extracorporeal membrane oxygenation gap" in veno-arterial configuration for adult patients: Timing and causes of death.

Timing and causes of hospital mortality in adult patients undergoing veno-arterial extracorporeal membrane oxygenation (V-A ECMO) have been poorly described. Aim of the current review was to investigate the timing and causes of death of adult patients supported with V-A ECMO and subsequently define the "V-A ECMO gap," which represents the patients who are successfully weaned of ECMO but eventually die during hospital stay. A systematic search was performed using electronic MEDLINE and EMBASE databases through PubMed. Studies reporting on adult V-A ECMO patients from January 1993 to December 2020 were screened. The studies included in this review were studies that reported more than 10 adult, human patients, and no mechanical circulatory support other than V-A ECMO. Information extracted from each study included mainly mortality and causes of death on ECMO and after weaning. Complications and discharge rates were also extracted. Sixty studies with 9181 patients were included for analysis in this systematic review. Overall mortality was 38.0% (95% confidence intervals [CIs] 34.2%-41.9%) during V-A ECMO support (reported by 60 studies) and 15.3% (95% CI 11.1%-19.5%, reported by 57 studies) after weaning. Finally, 44.0% of patients (95% CI 39.8-52.2) were discharged from hospital (reported by 60 studies). Most common causes of death on ECMO were multiple organ failure, followed by cardiac failure and neurological causes. More than one-third of V-A ECMO patients die during ECMO support. Additionally, many of successfully weaned patients still decease during hospital stay, defining the "V-A ECMO gap." Underreporting and lack of uniformity in reporting of important parameters remains problematic in ECMO research. Future studies should uniformly define timing and causes of death in V-A ECMO patients to better understand the effectiveness and complications of this support.

The Relationship Between Tachycardia After Laparoscopic Sleeve Gastrectomy and the Development of Postoperative Complications.

BACKGROUND: Bariatric surgery can be associated with severe complications. Tachycardia is an important indicator of certain complications, such as anastomotic leak and hemorrhage. Our aim was to examine the relationship between tachycardia following sleeve gastrectomy and the appearance of associated complications. METHODS: Patients who underwent sleeve gastrectomy over a 2-year period were included in the study. Participants were divided into two groups: the first included patients who suffered from postoperative tachycardia and the second patients with normal postoperative heart rates. Complications in both groups were examined. Other parameters that predict the onset of complications were also reviewed. RESULTS: A total of 457 patients were included. Postoperative tachycardia was measured in 181 (39.6%) patients; 17 (3.7%) suffered from bleeding and 4 (1%) from staple line leakage. Postoperative bleeding was more common among patients with tachycardia than among those without (14 (7.7%) vs. 3 (1.1%), respectively). Patients in the tachycardia group had more staple line leakages than those in the normal heart rate group (3 (2%) vs. 1 (0%), respectively); tachycardia was also attributed to postoperative pain or other minor complications in 160 (88%) patients. Age ≥ 40 years was found to be predictive factor for postoperative complications. CONCLUSIONS: The most common causes of tachycardia postoperatively were pain and minor complications. Tachycardia is an essential indicator of postoperative minor and major complications, mainly staple line leakage and bleeding. This should prompt immediate medical intervention in order to avoid serious adverse events.

Postpancreatoduodenectomy Hemorrhage: Association between the Causes and the Severity of the Bleeding.

INTRODUCTION: Of the complications following pancreatoduodenectomy (PD), postpancreatoduodenectomy hemorrhage (PPH) is the least common, but severe forms can be life-threatening without urgent treatment. While early PPH is mostly related to surgical hemostasis, late PPH is more likely due to complex physiopathological pathways secondary to different etiologies. The understanding of such etiologies could therefore be of great interest to help guide the treatment of severe, potentially life-threatening, late PPH cases. OBJECTIVE: The aim of this retrospective study was to assess the causes of PPH as a complication and explore a possible association between the causes and the severity of late PPH. METHODS: A retrospective study was performed at the HPB and Surgical Oncology Unit, Rambam Health Care Campus, Haifa, Israel. The charts of all patients submitted for PD were reviewed, and all patients with PPH were included. The timing, cause, and severity of PPH as well as other information were collected. A statistical analysis on the possible association between cause and severity of late PPH was performed. RESULTS: A total of 347 patients underwent PD, 18 of whom (5.18%) developed PPH. Early PPH was reported in 1 patient (5.6%) with severe bleeding from the gastric staple line. Late PPH was reported in 17 patients (94.4%). The most common causes of late PPH were bleeding from a vascular pseudoaneurysm (PSA) reported in 6 patients, 1 with mild and 5 with severe hemorrhage, and bleeding from a gastroenteric anastomosis marginal ulcer reported in 6 patients, all with mild hemorrhage. No etiology was found in 5 patients with mild hemorrhage. A significant association was found between the severity of late hemorrhage and vascular PSA as the cause of the bleeding (p = 0.001). All PSA bleeding occurred in cases complicated by a postoperative pancreatic fistula (POPF), with a significant statistical association (p < 0.001). CONCLUSIONS: The most common cause of PPH was bleeding from a vascular PSA; the majority of these cases involved severe bleeding with late presentation, and all were associated with a POPF formation. In such cases, early detection by computed tomography angiography is mandatory, thereby promoting urgent treatment by angiography of vascular bleeding complications following PD.