Pathological findings associated with the updated European Society of Cardiology 2022 guidelines for preoperative cardiac testing: an observational cohort modelling study.

BACKGROUND: In 2022, the European Society of Cardiology updated guidelines for preoperative evaluation. The aims of this study were to quantify: (1) the impact of the updated recommendations on the yield of pathological findings compared with the previous guidelines published in 2014; (2) the impact of preoperative B-type natriuretic peptide (NT-proBNP) use for risk estimation on the yield of pathological findings; and (3) the association between 2022 guideline adherence and outcomes. METHODS: This was a secondary analysis of MET-REPAIR, an international, prospective observational cohort study (NCT03016936). Primary endpoints were reduced ejection fraction (EF<40%), stress-induced ischaemia, and major adverse cardiovascular events (MACE). The explanatory variables were class of recommendations for transthoracic echocardiography (TTE), stress imaging, and guideline adherence. We conducted second-order Monte Carlo simulations and multivariable regression. RESULTS: In total, 15,529 patients (39% female, median age 72 [inter-quartile range: 67-78] yr) were included. The 2022 update changed the recommendation for preoperative TTE in 39.7% patients, and for preoperative stress imaging in 12.9% patients. The update resulted in missing 1 EF <40% every 3 fewer conducted TTE, and in 4 additional stress imaging per 1 additionally detected ischaemia events. For cardiac stress testing, four more investigations were performed for every 1 additionally detected ischaemia episodes. Use of NT-proBNP did not improve the yield of pathological findings. Multivariable regression analysis failed to find an association between adherence to the updated guidelines and MACE. CONCLUSIONS: The 2022 update for preoperative cardiac testing resulted in a relevant increase in tests receiving a stronger recommendation. The updated recommendations for TTE did not improve the yield of pathological cardiac testing.

Risk assessment for major adverse cardiovascular events after noncardiac surgery using self-reported functional capacity: international prospective cohort study.

BACKGROUND: Guidelines endorse self-reported functional capacity for preoperative cardiovascular assessment, although evidence for its predictive value is inconsistent. We hypothesised that self-reported effort tolerance improves prediction of major adverse cardiovascular events (MACEs) after noncardiac surgery. METHODS: This is an international prospective cohort study (June 2017 to April 2020) in patients undergoing elective noncardiac surgery at elevated cardiovascular risk. Exposures were (i) questionnaire-estimated effort tolerance in metabolic equivalents (METs), (ii) number of floors climbed without resting, (iii) self-perceived cardiopulmonary fitness compared with peers, and (iv) level of regularly performed physical activity. The primary endpoint was in-hospital MACE consisting of cardiovascular mortality, non-fatal cardiac arrest, acute myocardial infarction, stroke, and congestive heart failure requiring transfer to a higher unit of care or resulting in a prolongation of stay on ICU/intermediate care (≥24 h). Mixed-effects logistic regression models were calculated. RESULTS: In this study, 274 (1.8%) of 15 406 patients experienced MACE. Loss of follow-up was 2%. All self-reported functional capacity measures were independently associated with MACE but did not improve discrimination (area under the curve of receiver operating characteristic [ROC AUC]) over an internal clinical risk model (ROC AUCbaseline 0.74 [0.71-0.77], ROC AUCbaseline+4METs 0.74 [0.71-0.77], ROC AUCbaseline+floors climbed 0.75 [0.71-0.78], AUCbaseline+fitnessvspeers 0.74 [0.71-0.77], and AUCbaseline+physical activity 0.75 [0.72-0.78]). CONCLUSIONS: Assessment of self-reported functional capacity expressed in METs or using the other measures assessed here did not improve prognostic accuracy compared with clinical risk factors. Caution is needed in the use of self-reported functional capacity to guide clinical decisions resulting from risk assessment in patients undergoing noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT03016936.

Secondary tracheal distortion in an adult patient after therapy for diphtheria at childhood.

We report a rare case of difficult intubation because of trachea deformation after therapy for diphtheria and subsequent tracheostomy at childhood. The patient was admitted to be subjected to a Bentall procedure, because of ascending aorta dilatation. With a detailed preanesthetic assessment and simulation for intubation by using three-dimensional technology, he was successfully intubated and the operation was accomplished uneventfully. 3D-printed models of the difficult airway enhance imaging of difficult anatomy, assist in simulation and management of potentially problematic intubation, and can be a valuable tool when dealing with airways with potential anatomical malformations.

Critical Illness Polyneuropathy (CIP): a multicenter study on functional outcome.

OBJECTIVES: To describe the functional recovery of consecutive inpatients with Critical Illness Polyneuropathy (CIP) at the time-point of the discharge from rehabilitation units according to Barthel Index scores. To examine whether age, gender, pre-ICU admission diagnosis, tracheostomy performance, heterotopic ossification development and duration of neuro-rehabilitation treatment are among the prognostic factors that can predict the functional outcome in studied patients. METHODS: A retrospective observational clinical study from January 2010 to December 2014 in three rehabilitation units in Greece. RESULTS: Sixteen subjects (57.1%) had >60 BI discharge scores, showing a prospect in gaining further independence. Females presented a tendency for better functional outcome vs males (73.8 ± 12.6 vs 58.6 ± 23.4, p=0.082). Respiratory, septic and neurologic patients demonstrated better rates of functional improvement after the rehabilitation process vs cardiac patients (p minor than 0.001, p=0.009 and p=0.019, respectively vs p=0,072). Heterotopic ossification development proved to be an adverse independent prognostic factor of functional outcome (47.8 ± 25.7 vs 68.8 ± 17.7, p=0.023). CONCLUSIONS: A proportion of included patients experienced severe disability with poor prospect of further functional development and return to work at the discharge from the rehabilitation units. According to the present study, which is the first that focuses only on CIP and its outcome, specific prognostic factors can be defined. Our results can be used as pilot data for larger studies, so that firmer conclusions can be drawn.

Resection of abdominal inferior vena cava without graft interposition: Considerations in preserving renal function.

The management of tumors involving or infiltrating the inferior vena cava (IVC) constitutes a great surgical challenge, since radical resection affords patients the only possibility for long-term survival. These tumors can be resected without graft interposition, provided that there is adequate collateral circulation and that the renal function can be secured. Meanwhile, ligation of the left renal vein may be possible due to the existence of collateral circulation through the adrenal and gonadal veins. We briefly present our experience on renal outflow preservation through implantation of the right renal vein into the IVC stump or through diversion of the left renal vein into the inferior mesenteric vein.

A retrospective comparison of inhaled milrinone and iloprost in post-bypass pulmonary hypertension.

During cardiac operations, weaning from cardiopulmonary bypass (CPB) may prove challenging as a result of superimposed acute right ventricular dysfunction in the setting of elevated pulmonary vascular resistance (PVR). The aim of this study was to retrospectively evaluate the effect of inhaled milrinone versus inhaled iloprost in patients with persistent pulmonary hypertension following discontinuation of CPB. Eighteen patients with elevated PVR post-bypass were administered inhaled milrinone at a cumulative dose of 50 µg kg-1. These patients were retrospectively matched with 18 patients who were administered 20 µg of inhaled iloprost. Both drugs were administered through a disposable aerosol-generating jet nebulizer device and inhaled for a 15-min period. Hemodynamic measurements were performed before and after cessation of the inhalation period. Both inhaled milrinone and inhaled iloprost induced significant reductions in mean pulmonary artery pressure and PVR and significant increases in cardiac index in patients with post-CPB pulmonary hypertension. The favorable effect of both agents on the pulmonary vasculature was confirmed by echocardiographic measurements. Both agents were devoid of systemic side effects, since mean arterial pressure and systemic vascular resistance were not affected. A decrease in intrapulmonary shunt by inhalation of both agents was also demonstrated. Pulmonary vasodilatation attributed to iloprost seems to be of greater magnitude and of longer duration as compared to that of inhaled milrinone. Both substances proved to be selective pulmonary vasodilators. The greater magnitude and of longer duration vasodilatation attributed to iloprost may be due to its longer duration of action.

Ultrasonographic evaluation of abdominal organs after cardiac surgery.

BACKGROUND: Disturbances of the hepatosplanchnic region may occur after cardiac operations. Experimental studies have implicated impairment of splanchnic blood supply in major abdominal organ dysfunction after cardiopulmonary bypass (CPB). We investigated the impact of the cardiac operation and CPB on liver, kidney, and renal perfusion and function by means of ultrasonography and biochemical indices in a selected group of cardiac surgery patients. MATERIALS AND METHODS: Seventy five patients scheduled for a major cardiac operation were prospectively included in the study. Criteria for selection were moderate or good left ventricular ejection fraction and absence of previous hepatic or renal impairment. Ultrasound examination of the hepatic and renal vasculature and examination of biochemical parameters were performed on the day preceding the operation (T0), on the first postoperative day (T1), and on the seventh postoperative day (T2). RESULTS: Portal vein velocity and flow volume increased significantly, whereas hepatic artery velocity and flow volume decreased at T1 in comparison with T0. Hepatic vein indices remained unaffected throughout the observation period. Renal artery velocity and flow decreased, whereas renal pulsatility index and renal resistive index increased at T1 as compared with T0. Aspartate aminotransferase and alanine aminotransferase values were increased as compared with baseline values 24 h postoperatively. All parameters displayed a trend to approach preoperative levels at T2. Strong negative correlations between alanine aminotransferase values at T1 and hepatic artery velocity and flow volume at the same time point were also demonstrated (R = 0.638, P < 0.001 and r = 0.662, P < 0.001, respectively). CONCLUSIONS: The increase in portal vein flow and velocity and the decrease in hepatic artery flow and velocity in the period after CPB might be attributed to the hypothermic bypass technique and the hepatic arterial buffer response, respectively. The decrease in renal blood flow and velocity and the parallel increase in Doppler renal pulsatility index and renal resistive index could be considered as markers of kidney hypoperfusion and intrarenal vasoconstriction. Maintaining a high index of suspicion for the early diagnosis of noncardiac complications in the period after CPB and institution of supportive care in case of compromised splanchnic perfusion are warranted.

How does an undergraduate pain course influence future physicians' awareness of chronic pain concepts? A comparative study.

OBJECTIVE: Pain is one of the most undertreated medical complaints, with barriers to effective pain management lying in poor education of health professionals and misconceptions regarding patients in pain. The aim of this study was to assess whether an elective undergraduate course on chronic pain offered in Greek medical schools influences knowledge and attitudes of medical undergraduates about chronic pain and helps them clarify pain-related concepts. METHODS: An electronic questionnaire with 6 demographic and 21 pain-related items was uploaded on SurveyMonkey. The questionnaire was open to medical students in every Greek medical school for 1 month. Students were asked to respond to questions regarding various aspects of pain taught in the aforementioned course. In specific, they were asked to respond to questions regarding the definition, types, and adequacy of treatment of chronic cancer and non-cancer pain. They were queried about their knowledge of pain clinics, health practitioners who run them, and types of treatment available there. There were also questions about opioid use in cancer and non-cancer chronic pain patients and regarding the likelihood of opioid addiction. RESULTS: According to their responses, medical students had good knowledge about the definition and consequences of pain, and those who attended the pain course had greater knowledge regarding the adequacy of treatment of chronic pain and were more familiar with the recent classification of types of pain. Students who did not have exposure to the undergraduate pain course had little information regarding pain clinics and had poor knowledge regarding the use of opioids in cancer and in nonmalignant chronic pain. All students expressed concerns regarding addiction to opioids. CONCLUSIONS: Although students enter medical school with little knowledge about pain issues, pain awareness can be positively influenced by education. A curriculum about pain should not only teach the basic science of pain but also present treatment strategies available and address the socio-emotional dimensions of pain. Additionally, if misconceptions about opioid use and addiction are properly elucidated early in medical education, the future health practitioners will be one step forward in achieving the goal of alleviating suffering patients' pain.

Carotid endarterectomy in a young symptomatic patient with B-thalassemia major.

ß-Thalassemia major promotes atherosclerotic process, although the debating literature concerning the lipidic profile of young patients; it is well accepted that there is early vascular destruction in these homozygous patients either as a direct consequence of the genetic disorder per se or because of the repeated transfusions and the iron overload. Despite the potential of the disease for local brain thrombotic events, accelerated atheromatosis can lead to early thromboembolic events. We present an interesting case of a 36-year-old man with unilateral embolic infarcts (repeated transient ischemic attacks) originated from a near occlusion right carotid stenosis with additional peripheral thrombus. The patient underwent a successful carotid endarterectomy with primary arterial closure with uneventful postoperative course, confirmed by a clear postoperative angiography; he remains asymptomatic 18 months later. To the best of our knowledge, this is the first case of a young symptomatic patient with ß-thalassemia major who underwent carotid repair.

Cystic fibrosis and pregnancy: counseling, obstetrical management and perinatal outcome.

The progress in research of in vitro fertilization and fetal-maternal medicine allows more women and men, with fertility problems due to cystic fibrosis, to have a baby. In the majority of cases, pregnancy in women with cystic fibrosis results in favorable maternal and fetal outcomes. However, the incidence of preterm delivery, intrauterine growth restriction, caesarean section and deterioration of the maternal health are increased. Pre-pregnancy counseling is a crucial component of overall obstetric care, especially in women with poor pulmonary function. Additionally, closer monitoring during pregnancy with a multidisciplinary approach is required. The value of serial ultrasound scans and fetal Doppler assessment is important for the control of maternal and fetal wellbeing, as well as for the definition of the appropriate timing of delivery. In this article, clinical issues of pregnant women with cystic fibrosis are reviewed; counseling, obstetrical management and perinatal outcomes are being discussed.

Preoperative biliary drainage of severely jaundiced patients increases morbidity of pancreaticoduodenectomy: results of a case-control study.

BACKGROUND: Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in patients suffering from obstructive jaundice before surgery. The severity of jaundice that mandates PBD has yet to be defined. Our aim was to investigate whether PBD is truly justified in severely jaundiced patients before pancreaticoduodenectomy. The parameters evaluated were overall morbidity, length of hospital stay, and total in-hospital mortality. METHODS: From January 2000 to December 2012, a total of 240 patients underwent pancreaticoduodenectomy for periampullary tumors. Group A comprised 76 patients with preoperative serum bilirubin ≥15 mg/dl who did not undergo PBD before surgery. Group B comprised another 76 patients, matched for age and tumor localization (papillary vs. pancreatic head) who underwent PBD 2-4 weeks before pancreaticoduodenectomy and were identified from the same database. RESULTS: Less operative time was required in the 'no PBD' group compared with the 'PBD' group (210 vs. 240 min). Total intraoperative blood loss and blood transfusions were also significantly less in the 'no PBD' group. There was no difference detected in the rate of pancreatic fistula or biliary fistula formation. Group A patients demonstrated significantly lower morbidity than group B (24 vs. 36 %, respectively) and therefore required briefer hospitalization (11 vs. 16 days). Mild infectious complications appear to be the main factor that enhanced morbidity in the PBD group. However, total in-hospital mortality was not significantly different between the two groups. CONCLUSIONS: Even severe jaundice should not be considered as an indication for PBD before pancreaticoduodenectomy, as PBD increases infections and postoperative morbidity, therefore delaying definite treatment.

Postoperative pain after major abdominal surgery: is it gender related? An observational prospective study.

OBJECTIVES: Gender may be associated with postoperative pain. This study aimed to assess pain intensity and postoperative analgesic requirements in female and male patients scheduled for major abdominal surgery. METHODS: Sixty-five patients, 31 men and 34 women, scheduled for major abdominal surgery were recruited. Anesthesia and intraoperative analgesics were standardized in all patients. Postoperatively, all patients had access to a 60 mL PCA pump containing 1 mg/mL morphine and 50 µg/mL droperidol. Morphine consumption and VAS scores at rest and after cough were recorded 2, 4, 8, 24, and 48 hours postoperatively. RESULTS: Of the 65 patients recruited for the study, 30 women and 30 men aged 65 ± 8.9 and 66 ± 9.0 years, respectively, were included in the analysis. Morphine consumption was examined 2, 4, 8, 24, and 48 hours after surgery and did not differ in women vs. men (mean ± standard deviation, 4.4 ± 3.2 vs. 5 ± 4.8, 7.2 ± 4.8 vs. 8.7 ± 6.9, 10.4 ± 7.1, vs. 12.5 ± 8.5, 22.9 ± 11.6 vs. 25.6 ± 14.5, and 36.2 ± 15.7 vs. 39.7 ± 21.7 mg, P = 0.384). Cumulative morphine consumption was not significantly different in women vs. men when normalized for body mass index (mean ± standard deviation, 0.17 ± 0.13, 0.28 ± 0.20, 0.40 ± 0.30, 0.88 ± 0.46, and 1.38 ± 0.59 mg/kg(/) m(2) in women and 0.18 ± 0.18, 0.31 ± 0.25, 0.46 ± 0.32, 0.95 ± 0.54, and 1.47 ± 0.81 mg/kg/m(2) in men at 2, 4, 8, 24, and 48 hours postoperatively (P = 0.567). Both genders exhibited similar VAS pain scores (mm) at rest and after cough (P = 0.476, P = 0.378, respectively). CONCLUSIONS: Postoperative morphine requirements did not differ between female and male patients undergoing major abdominal surgery. Pain intensity reported at rest and after cough did not differ between the 2 groups.

Non-functioning pancreatic endocrine tumors: eleven-year experience in a single institute.

PURPOSE: Non-functioning pancreatic endocrine tumors (NF-PETs) comprise the majority of pancreatic endocrine tumors. We present our experience from the management of 18 patients with NF-PET. METHODS: From May 2002 to June 2013, 18 patients were admitted in our hospital for the management of NF-PETs. We analyzed their clinical presentation, preoperative evaluation, surgical and postoperative management and the outcome. RESULTS: The tumor was located in the pancreatic head in 13 (72%) patients and in the body and tail of the pancreas in the remaining 5 (28%). Four patients (22%) had stage IIIa, 7 (39%) stage IIIb and 7 (39%) stage IV. Twelve (67%) patients with pancreatic head tumor underwent pancreatoduodenectomy (PD). In one case (5%), the tumor was deemed unresectable and the remaining 5 (28%) patients underwent distal pancreatectomy and splenectomy (DPSP). Four (22%) patients with unilobar metastatic liver disease underwent hemihepatectomy or segmentectomy. Perioperative mortality was 0%. Postoperatively, all stage IV patients received peptide receptor radionuclide treatment (PRRT). The 5-year overall survival rate was 61%, with a median survival of 71 months, whereas the 5-year overall survival rate after diagnosis of hepatic metastases was 45%. CONCLUSION: Surgical resection is the gold standard for the treatment of NF-PETs. A formal resection appears to be the standard procedure when malignancy is verified or suspected. Aggressive surgery should be undertaken in patients with locally advanced or metastatic NF-PETs, as it may prolong survival. In stage IV patients, intra-arterial PRRT, after super-selective catheterization of the hepatic artery, is a promising therapeutic modality.

Atrial and brain natriuretic peptide changes in an experimental model of intra-abdominal hypertension.

BACKGROUND: Intra-abdominal hypertension (IAH) can have a profound impact on the cardiovascular system. We hypothesized that natriuretic peptides (Nt-pro-ANP and Nt-pro-BNP) are produced in response to the cardiovascular changes observed in an experimental model of IAH. MATERIALS AND METHODS: Eleven female pigs were enrolled in this study. Four experimental phases were created: a baseline phase for instrumentation (T1); two subsequent phases (T2 and T3), in which helium pneumoperitoneum was established at 20 and 35 mm Hg, respectively; and the final phase (T4), in which abdominal desufflation took place. Hemodynamic parameters and concentrations of Nt-pro-ANP and Nt-pro-BNP were measured. RESULTS: Central venous pressure and pulmonary capillary wedge pressure increased significantly during the elevation of intra-abdominal pressure (IAP) and returned to baseline after abdominal desufflation. Right and left transmural pressures remained unaffected by the elevation of IAP. Cardiac output decreased in phases T2 and T3 and was restored to baseline levels after abdominal desufflation. Systemic and pulmonary vascular resistances increased significantly with IAH and decreased after abdominal desufflation. Nt-pro-ANP did not change significantly in comparison to baseline. Nt-pro-BNP increased significantly in comparison to baseline at T3 and T4. Peak Nt-pro-BNP levels at T3 (peak IAP) correlated positively with indices of afterload at this time point, that is, systemic vascular resistance and pulmonary vascular resistance (r(2) = 0.38, P = 0.042 and r(2) = 0.55, P = 0.009, respectively). A strong negative correlation between Nt-pro-BNP and cardiac output at T3 was also demonstrated (r(2) = 0.58, P = 0.006). CONCLUSIONS: IAH resulted in cardiovascular compromise. The unchanged Nt-pro-ANP concentrations might reflect unaltered atrial stretch with IAH, despite the elevation of right atrial filling pressure. The significant increase of Nt-pro-BNP in response to high levels of IAP may reflect left ventricular strain and dysfunction due to the severe IAH and provide an alternative marker in the monitoring of IAH.

Should diaphragmatic involvement preclude resection of large hepatic tumors?

BACKGROUND: Treatment of peripherally located liver tumors with diaphragmatic invasion is technically demanding but does not preclude resection for cure. The aim of the present study was to compare patients undergoing combined liver and diaphragmatic resection with those submitted to hepatectomy alone so as to evaluate the safety, effectiveness, and value of this complex surgical procedure. METHODS: From January 2000 to September 2011, 36 consecutive patients underwent en bloc liver-diaphragm resection (group A). These were individually matched for age, gender, tumor size, pathology, and co-morbitidies with 36 patients who underwent hepatectomy alone during the same time (group B). Operative time, warm ischemia time, blood loss, required transfusions, postoperative complications, and long-term survival were evaluated. RESULTS: Mean operative time was significantly longer in group A than in group B (165 vs 142 min; P = 0.004). The two groups were comparable regarding warm ischemia time, intraoperative blood loss, required transfusions, and postoperative laboratory value fluctuations. Some 33 % of group A patients developed complications postoperatively as opposed to 23 % of group B patients (P = 0.03). The mortality rate was 2.8 % in group A compared to 0 % in group B. Postoperative follow-up demonstrated 60 % 1-year survival for group A patients as opposed to 80 % 1-year survival for group B patients, a difference that is practically eliminated the longer the follow-up period is extended (35 vs 40 % 3-year survival and 33 vs 37 % 5-year survival for group A and group B patients, respectively). CONCLUSIONS: En bloc diaphragmatic and liver resection is a challenging but safe surgical procedure that is fully justified when diaphragmatic infiltration cannot be ruled out and the patient is considered fit enough to undergo surgery.

Hemodynamic effects of combination therapy with inhaled nitric oxide and iloprost in patients with pulmonary hypertension and right ventricular dysfunction after high-risk cardiac surgery.

OBJECTIVE: The purpose of this study was to evaluate the hemodynamic effects of inhaled nitric oxide (NO) plus aerosolized iloprost in patients with pulmonary hypertension/right ventricular dysfunction after cardiac surgery. DESIGN: A retrospective study. SETTING: A single center. PARTICIPANTS: Eight consecutive patients with valve disease and postextracorporeal circulation (ECC) pulmonary hypertension/right ventricular dysfunction. INTERVENTION: The continuous inhalation of nitric oxide (10 ppm) and iloprost, 10 µg, in repeated doses. MEASUREMENTS AND MAIN RESULTS: The hemodynamic profile was obtained before inhalation, during the administration of inhaled NO alone (prior and after iloprost), and after the first 2 doses of iloprost. Tricuspid annular velocity and tricuspid annular plane systolic excursion were estimated at baseline and before and after adding iloprost. At the end of the protocol, there were significant decreases in pulmonary vascular resistance (p < 0.001), the mean pulmonary arterial pressure (p < 0.001), and the mean pulmonary artery pressure/mean arterial pressure ratio (p = 0.006). Both tricuspid annular velocity (p < 0.001) and tricuspid annular plane systolic excursion (p < 0.001) increased. The cardiac index (p < 0.001) and venous blood oxygen saturation (p = 0.001) increased throughout the evaluation period. Each iloprost dose was associated with further decreases in pulmonary vascular resistances/pressure. By comparing data at the beginning of inhaled NO with those after the second dose of iloprost, the authors noticed decreases in pulmonary vascular resistances (p = 0.004) and the mean pulmonary artery pressure (p = 0.017) and rises in tricuspid annular velocity (p < 0.001) and tricuspid annular systolic plane systolic excursion (p < 0.001). CONCLUSIONS: Inhaled NO and iloprost significantly reduced pulmonary hypertension and contributed to the improvement in right ventricular function. Inhaled NO and iloprost have additive effects on pulmonary vasculature.

Resuscitation after hemorrhagic shock: the effect on the liver--a review of experimental data.

The liver is currently considered to be one of the first organs to be subjected to the hypoxic insult inflicted by hemorrhagic shock. The oxidative injury caused by resuscitation also targets the liver and can lead to malfunction and the eventual failure of this organ. Each of the various fluids, vasoactive drugs, and pharmacologic substances used for resuscitation has its own distinct effect(s) on the liver, and the anesthetic agents used during surgical resuscitation also have an impact on hepatocytes. The aim of our study was to identify the specific effect of these substances on the liver. To this end, we conducted a literature search of MEDLINE for all types of articles published in English, with a focus on articles published in the last 12 years. Our search terms were "hemorrhagic shock," "liver," "resuscitation," "vasopressors," and "anesthesia." Experimental studies form the majority of articles found in bibliographic databases. The effect of a specific resuscitation agent on the liver is assessed mainly by measuring apoptotic pathway regulators and inflammation-induced indicators. Apart from a wide range of pharmacological substances, modifications of Ringer's Lactate, colloids, and pyruvate provide protection to the liver after hemorrhage and resuscitation. In this setting, it is of paramount importance that the treating physician recognize those agents that may attenuate liver injury and avoid using those which inflict additional damage.

Efficiency of the Robotic Platform in Improving the Rate of Sphincter Preservation in Patients With Mid and Low Rectal Cancer.

Background: The aim of this study was to investigate whether the robotic platform can have a positive impact on the rate of sphincter preservation in patients with rectal tumors, undergoing robotic total mesorectal excision (TME), in comparison with laparoscopic or open TME. We also analyzed and compared short-term outcomes. Methods: A prospectively collected robotic database was reviewed and compared with the trust and national data. Three groups were designed according to the surgical technique: open, laparoscopic and robotic. This includes all resections for mid and low rectal cancer which were performed with the robotic platform, over a period of 4 years, versus the trust data for the same period. Results: Two hundred ninety-seven patients with mid and low rectal cancers were analyzed. Demographics for the groups (gender, age, and body mass index) were similar but distance from anal verge was shorter in the robotic group (7 vs. 8.5 cm, P < 0.001). The percentage of abdominoperineal resection (APR) rate was significantly lower in the robotic group (13.5% vs. 39.6% vs. 52.4% for the open group, P < 0.001). Median length of stay, complication rate, and positive circumferential resection margin (CRM) rate for the robotic group were also statistically significantly lower than those for both laparoscopic and open groups. Conclusion: Robotic surgery for mid and low rectal cancer is safe and feasible, and could help surgeons perform ultra-low anterior resections, rather than APRs and save patients' sphincters. Positive CRM is low, which could lead to improved oncological outcomes.