Effects of Concomitant CABG on Outcomes in Veterans Who Require Surgery for Endocarditis.

BACKGROUND: Infective Endocarditis (IE) is a complicated disease frequently accompanied by coronary artery disease (CAD) though no clear guidelines exist for when concomitant revascularization should be undertaken once valve surgery is indicated. Data on this topic within the United States (US) Veteran population, who have unique healthcare needs when compared to the civilian population, is sparse. We investigated the impact of concomitant coronary artery bypass grafting (CABG) on morbidity and mortality in US Veterans requiring surgical management of IE. METHODS: We identified 489 patients who underwent surgical management of IE between January 1 2010 and December 31 2020 at any of 43 Veterans Affairs (VA) cardiac surgery centers in the US. Patients were stratified based on who underwent concomitant CABG at the time of operation. Primary outcomes included the occurrence of postoperative myocardial infarction (MI), stroke, or mortality. Continuous variables were compared using independent t-tests or Mann Whitney U tests, and categorical variables were compared using the Chi square test. Cox proportional-hazard models were used to calculate risk for primary outcomes based on group. RESULTS: 61 patients (12.5%) underwent concomitant CABG for CAD. After adjusting for significant covariates, patients who underwent CABG had a higher long-term risk of MI (adjusted hazard ratios (aHR) 2.37, 95% CI: 1.29-4.35, p = 0.005) and higher risk of MI at 30-days (aHR 2.34, 95% CI: 1.06-5.19, p = 0.035). Concomitant CABG was not associated with long-term stroke or death, 30-day stroke or death, or perioperative complications. On sub-analysis of patients with moderate to severe CAD, rates of MI were higher in the CABG group at 30 days (25.9 vs. 3.4%, p = 0.016) and 1 year (33.3 vs. 3.4%, p = 0.004), though not long-term. The mean number of grafts was 1.51 ± 0.76, with only one graft performed in 65.6% (40/61) of patients. CONCLUSIONS: Concomitant CABG at the time of operation for IE was associated with increased risk of MI at 30-day and long-term, though most CABGs involved a low number of grafts. It was not associated with 30-day stroke or death, long term stroke or death, or perioperative complications. The optimal treatment of CAD noted during preoperative evaluation for veterans undergoing surgery for IE remains unclear.

A nutritional screening threshold for optimal outcomes after Hartmann's reversal.

PURPOSE: Determining is nutritionally replete enough for Hartmann's reversal (HR) can be controversial and multifactorial. While there are many preoperative nutritional screening tools, the impact of malnourishment on HR has not been evaluated. The study aims to clarify how often patients undergoing HR are high risk for malnourishment at the time of surgery and how this impacts postoperative outcomes. METHODS: From 2012-2019, all elective HRs were identified in ACS-NSQIP. Patients were categorized in a malnourished group if they met one of the following criteria: (1) BMI < 18.5 kg/m2, (2) albumin < 3.5 g/dL, or (3) > 10% body weight loss in the last 6 months. Bivariate associations of preoperative demographics and postoperative outcomes were analyzed. Multivariable logistic regression was performed to identify independent predictors for 30-day mortality and organ space wound infection. RESULTS: 8878 procedures were evaluated (well-nourished = 7116 and malnourished = 1762). The malnourished group had higher mortality (p < 0.001), shorter operating time (p < .001), longer length of stay (p = 0.016), and higher rates of infection (p = 0.011), reintubation (p = 0.002), bleeding (p < 0.001), sepsis (p = 0.001), and reoperation (p = 0.018). In multivariate regression models, malnourishment was an independent predictor for mortality (OR = 2.72, p < 0.001) and wound infection (OR = 1.19, p = 0.028). CONCLUSION: A large percentage of patients undergoing HR were classified as being high-risk for malnutrition. Malnourishment was associated with some worse postoperative compilations including death and wound infection. Surgeons should routinely use preoperative screening for malnutrition to identify and attempt to optimize nutritional status prior to undergoing Hartmann's Reversal.

Risk factors for cerebrovascular accident after isolated coronary artery bypass grafting in Veterans.

BACKGROUND: Cerebrovascular accident (CVA) after coronary artery bypass grafting (CABG) is a devastating complication. Patient comorbidities and intraoperative elements contribute to the risk of CVA. The aim of this study is to identify risk factors for CVA in Veterans undergoing CABG. METHODS: Veterans undergoing isolated CABG from 2008 to 2019 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Thirty-day postoperative outcomes were observed. Univariate analysis followed by multivariable logistic regression identified independent risk factors for postoperative CVA. Receiver operating characteristic diagnostics identified optimal inflection points between continuous risk factors and odds of CVA. RESULTS: Twenty-eight thousand seven hundred fifty-seven patients met inclusion criteria. Incidence of CVA was 1.1% (310 cases). In multivariate analysis, preoperative cerebrovascular disease had the strongest association with postoperative CVA (adjusted odds ratio = 2.29; p < .001). There was an inverse relationship between CVA incidence and ejection fraction (EF), with EF of 35%-39% conferring a 2.11 times higher risk compared to EF >55% (p < .001). CVA incidence was not different in on-pump versus off-pump cases; however, after 104 min or more on bypass patients had a 55% greater adjusted odds of CVA (p < .001). Other risk factors included poor kidney function, prior myocardial infarction, and intra-aortic balloon pump use. CONCLUSION: The risk of CVA after CABG is multifactorial and involves multiple organ systems, including cardiac disease, poor renal function, and cerebrovascular disease, which was the strongest contributing risk factor. Optimization of these comorbidities and time on bypass may help improve clinical outcomes and lower the risk of this devastating complication.

Lymphovascular Invasion and Perineural Invasion Negatively Impact Overall Survival for Stage II Adenocarcinoma of the Colon.

BACKGROUND: Lymphovascular invasion and perineural invasion are histopathological features associated with higher-risk colon cancer. OBJECTIVE: The purpose of this study was to quantify the impact of lymphovascular and perineural invasion on overall survival after diagnosis and to determine the protective effect of adjuvant chemotherapy for early adenocarcinoma with high-risk factors. DESIGN: This was a retrospective database review of the 2010-2014 National Cancer Database for colon cancer. SETTINGS: Individuals diagnosed with invasive adenocarcinoma of the colon (histology code 8140) with primary surgical resection with >12 nodes harvested and no positive nodes on pathological examination were included. PATIENTS: A total of 32,493 patients underwent surgical resection for stage II adenocarcinoma of the colon. INTERVENTIONS: The study involved multivariate Cox regression analysis of the impact of lymphovascular and perineural invasion and adjuvant chemotherapy on overall survival after a diagnosis of stage II adenocarcinoma of the colon. MAIN OUTCOME MEASURES: Survival after a diagnosis of stage II adenocarcinoma of the colon was measured. RESULTS: Five-year survival after diagnosis and surgical resection without adjuvant chemotherapy was lower for patients with lymphovascular (60.0%), perineural (56.9%), and lymphovascular and perineural invasion (55.8%) compared with double-negative disease (66.1%). Log-rank testing confirmed that adjuvant chemotherapy improved 5-year survival after diagnosis for lymphovascular (85.5%), perineural (83.6%), and lymphovascular and perineural invasion (74.3%). After controlling for differences in cohorts, Cox regression analysis showed an increased HR for mortality of 14.0% for lymphovascular (HR = 1.141 (95% CI, 1.060-1.228)), 32.1% for perineural (HR = 1.321 (95% CI, 1.176-1.483)), and 41.0% for lymphovascular and perineural invasion (HR = 1.409 (95% CI, 1.231-1.612)) compared with having neither. Chemotherapy showed a 43% reduction in hazard for mortality (HR = 0.570 (95% CI, 0.513-0.633)). LIMITATIONS: The study was limited by its retrospective review and observational bias. CONCLUSIONS: Lymphovascular and perineural invasion have a detrimental effect on survival after diagnosis of stage II adenocarcinoma of the colon. Chemotherapy may be protective specifically when lymphovascular and perineural invasion are present. See Video Abstract at http://links.lww.com/DCR/A786.

Safety of robotic surgical management of non-elective colectomies for diverticulitis compared to laparoscopic surgery.

Non-elective minimally invasive surgery (MIS) remains controversial, with minimal focus on robotics. This study aims to evaluate the short-term outcomes for non-elective robotic colectomies for diverticulitis. All colectomies for diverticulitis in ACS-NSQIP between 2012 and 2019 were identified by CPT and diagnosis codes. Open and elective cases were excluded. Patients with disseminated cancer, ascites, and ventilator-dependence were excluded. Procedures were grouped by approach (laparoscopic and robotic). Demographics, operative variables, and postoperative outcomes were compared between groups. Covariates with p < .1 were entered into multivariable logistic regression models for 30 day mortality, postoperative septic shock and reoperation. 6880 colectomies were evaluated (Laparoscopic = 6583, Robotic = 297). The laparoscopic group included more preoperative sepsis (31.6% vs. 10.8%), emergency cases (32.3% vs. 6.7%), and grade 3/4 wound classifications (53.3% vs. 42.8%). There was no difference in mortality, anastomotic leak, SSI, reoperation, readmission, or length of stay. The laparoscopic group had more postoperative sepsis (p = 0.001) and the robotic group showed increased bleeding (p = 0.011). In a multivariate regression model, increased age (OR = 1.083, p < 0.001), COPD (OR = 2.667, p = 0.007), dependent functional status (OR = 2.657, p = 0.021), dialysis (OR = 4.074, p = 0.016), preoperative transfusions (OR = 3.182, p = 0.019), emergency status (OR = 2.241, p = 0.010), higher ASA classification (OR = 3.170, p = 0.035), abnormal WBC (OR = 1.883, p = 0.046) were independent predictors for mortality. When controlling for confounders, robotic approach was not statistically significantly associated with septic shock or reoperation. When controlling for confounders, robotic approach was not a predictor for mortality, reoperation or septic shock. Robotic surgery is a feasible option for the acute management of diverticulitis.

Racial Disparities in 30-Day Outcomes After Colorectal Surgery in an Integrated Healthcare System.

BACKGROUND: Racial disparities in colorectal surgery outcomes have been studied extensively in the USA, and access to healthcare resources may contribute to these differences. The Veterans Health Administration (VHA) is the largest integrated healthcare network in the USA with the potential for equal access care to veterans. The objective of this study is to evaluate the VHA for the presence of racial disparities in 30-day outcomes of patients that underwent colorectal resection. METHODS: Colon and rectal resections from 2008 to 2019 were reviewed retrospectively using the Veterans Affairs Surgical Quality Improvement Program database. Patients were categorized by race and ethnicity. Multivariable analysis was used to compare 30-day outcomes. Cases with "unknown/other/declined to answer" race/ethnicity were excluded. RESULTS: Thirty-six-thousand-nine-hundred-sixty-nine cases met inclusion criteria: 27,907 (75.5%) Caucasian, 6718 (18.2%) African American, 2047 (5.5%) Hispanic, and 290 (0.8%) Native American patients. There were no statistically significant differences in overall complication incidence or mortality between all cohorts. Compared to Caucasian race, African American patients had longer mean length of stay (10.7 days vs. 9.7 days; p < 0.001). Compared to Caucasian race, Hispanic patients had higher odds of pulmonary-specific complications (adjusted odds ratio with 95% confidence interval = 1.39 [1.17-1.64]; p < 0.001). CONCLUSIONS: The VHA provides the benefits of integrated healthcare and access, which may explain the improvements in racial disparities compared to existing literature. However, some racial disparities in clinical outcomes still persisted in this analysis. Further efforts beyond healthcare access are needed to mitigate disparities in colorectal surgery. CLASSIFICATIONS: [Outcomes]; [Database]; [Veterans]; [Colorectal Surgery]; [Morbidity]; [Mortality].

Wireless, fully implantable cardiac stimulation and recording with on-device computation for closed-loop pacing and defibrillation.

Monitoring and control of cardiac function are critical for investigation of cardiovascular pathophysiology and developing life-saving therapies. However, chronic stimulation of the heart in freely moving small animal subjects, which offer a variety of genotypes and phenotypes, is currently difficult. Specifically, real-time control of cardiac function with high spatial and temporal resolution is currently not possible. Here, we introduce a wireless battery-free device with on-board computation for real-time cardiac control with multisite stimulation enabling optogenetic modulation of the entire rodent heart. Seamless integration of the biointerface with the heart is enabled by machine learning-guided design of ultrathin arrays. Long-term pacing, recording, and on-board computation are demonstrated in freely moving animals. This device class enables new heart failure models and offers a platform to test real-time therapeutic paradigms over chronic time scales by providing means to control cardiac function continuously over the lifetime of the subject.

The outcomes of two robotic platforms performing transanal minimally invasive surgery for rectal neoplasia: a case series of 21 patients.

Colorectal cancer remains the third most common cancer effecting adults. Surgical guidelines recommend transanal excision of early rectal neoplasia up to 8 cm from the anal verge. A retrospective review of two novel approaches for transanal robotic local excision with R0 resections of rectal cancers which was, on average, higher than 8 cm. Twenty-one cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) were reviewed. The first 10 cases performed with the da Vinci® Si robotic platform between 2013 and 2016, and the first 11 cases performed using the Flex® Medrobotics platform between August 2017 and August 2018. The average distance from the anal verge was 11.1 cm and 9.5 cm for the da Vinci® Si and Flex® Colorectal Drive, respectively. The average operative time was 167.6 min for the da Vinci® Si and 110.1 min for the Flex® Colorectal Drive; the average EBL was 37.5 cc and 9.1 cc for the da Vinci® Si and Flex® Colorectal Drive. In the da Vinci® series, four cases required intraoperative conversion. In the Flex® series, one case was aborted due to unfavorable robotic positioning. All margins were histologically negative when surgically complete with no recurrences to date. Transanal robotic surgery may provide a method to address rectal lesions farther from the anal verge than previously described. The Flex® Colorectal Drive platform may provide superior ability to navigate the nonlinear anatomy of the rectum and distal sigmoid colon.

Barriers to bariatric surgery: Factors influencing progression to bariatric surgery in a U.S. metropolitan area.

BACKGROUND: Bariatric surgery is an effective and durable treatment for obesity. However, the number of patients that progress to bariatric surgery after initial evaluation remains low. OBJECTIVES: The purpose of this study was to identify factors influencing a qualified patient's successful progression to surgery in a U.S. metropolitan area. SETTING: Academic, university hospital. METHODS: A single-institution retrospective chart review was performed from 2003 to 2016. Patient demographics and follow-up data were compared between those who did and did not progress to surgery. A follow-up telephone survey was performed for patients who failed to progress. Univariate analyses were performed and statistically significant variables of interest were analyzed using a multivariable logistic regression model. RESULTS: A total of 1102 patients were identified as eligible bariatric surgery candidates. Four hundred ninety-eight (45%) patients progressed to surgery and 604 (55%) did not. Multivariable analysis showed that patients who did not progress were more likely male (odds ratio [OR] 2.2 confidence interval [CI]: 1.2-4.2, P < .05), smokers (OR 2.4 CI: 1.1-5.4, P < .05), attended more nutrition appointments (OR 2.1 CI: 1.5-2.8, P < .0001), attended less total preoperative appointments (OR .41 CI: .31-.55, P < .0001), and resided in-state compared with out of state (OR .39 CI: .22-.68, P < .05). The top 3 patient self-reported factors influencing nonprogression were fear of complication, financial hardship, and insurance coverage. CONCLUSIONS: Multiple patient factors and the self-reported factors of fear of complication and financial hardship influenced progression to bariatric surgery in a U.S. metropolitan population. Bariatric surgeons and centers should consider and address these factors when assessing patients.

Robotic transanal microsurgery for high early rectal neoplasia (T0-T1, N0 lesions), case series of 10 patients.

PURPOSE/BACKGROUND: In 2017, an estimated 39 910 people will receive a new diagnosis of rectal cancer. Current surgical guidelines limit transanal excision of early rectal neoplasia to 8 cm from the anal verge. We report that R0 resection of higher rectal cancers is possible using transanal robotic microsurgery. METHODS/INTERVENTIONS: Ten cases of robotic assisted transanal surgery for early stage disease (T0-T1, N0) between 2013 and 2016 were reviewed. RESULTS/OUTCOMES: All cases were diagnosed preoperatively with colonoscopy, and the average distance from the anal verge was 11.1 cm. The average operative time was 167 minutes, and the average blood loss was 37.5 cc. Four cases required intraoperative conversion; one conversion required robotic abdominal access to repair a proctotomy. All margins were histologically negative, and 6-month follow-up showed no recurrences. CONCLUSION/DISCUSSION: Transanal robotic surgery may provide the colorectal surgeon a method to address rectal lesions farther from the anal verge.

A case report of successful management of clostridium difficile colitis with antegrade Fidaxomicin through a mucous fistula obviating the need for subtotal colectomy.

INTRODUCTION: Clostridium difficile is the most common cause of healthcare-associated infections and can have devastating morbidity and mortality. Traditional treatment algorithms involve intravenous metronidazole and enteric metronidazole or vancomycin. Fidaxomicin (DificidR) targets "switch regions" within RNA polymerases and effectively kills clostridium difficile bacteria and is typically administered orally primarily or through a naso/oro-gastric conduit. PRESENTATION OF CASE: 55-year-old with a recent elective surgical procedure was hospitalized with multifocal pneumonia and subsequently developed clostridium difficile colitis. This patient failed the standard medical therapy for clostridium difficile colitis, decompensated and required surgical exploration, partial colectomy and mucous fistula creation. Following her surgery, her clinical condition improved and her colitis resolved with the antegrade administration of fidaxomicin through her mucous fistula. DISCUSSION: Fidaxomicin is a newer to market therapeutic agent that has been shown to be effective in the treatment of clostridium difficile colitis. Previously studies have shown benefit of oral fidaxomicin therapy for fulminant clostridium difficile but our study case report describes the index case of topical fidaxomicin through a mucous fistula. CONCLUSION: In our case of fulminant clostridium difficile colitis, Fidaxomicin administered in an antegrade fashion through a mucous fistula may have reduced the need for total colectomy in the treatment of fulminant clostridium difficile colitis.