Mesenteric Malperfusion Syndromes in Type A Aortic Dissection: Current Management Strategies.

Acute type A aortic dissection is a surgical emergency associated with high mortality and morbidity. When complicated with mesenteric malperfusion, its management carries a very high mortality. Many innovations in the field of vascular and cardiothoracic surgery in the last two decades have been tried in the continuous efforts to improve on the surgical outcomes. Although some reports have documented better mortality rates with reperfusion-first strategies, there is still room for improvement in the absence of a general consensus on its management.

Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy.

OBJECTIVE: To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS). SUMMARY BACKGROUND DATA: LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other. METHODS: A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes. RESULTS: A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18-0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27-0.76), wound occurrences (OR: 0.37, 95% CI: 0.11-0.79), and sepsis (OR: 0.52, 95% CI: 0.26-0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS. CONCLUSIONS: LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patient's clinical status.

Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study.

BACKGROUND: Preoperative anaemia is associated with adverse outcomes after cardiac surgery but outcomes after non-cardiac surgery are not well established. We aimed to assess the effect of preoperative anaemia on 30-day postoperative morbidity and mortality in patients undergoing major non-cardiac surgery. METHODS: We analysed data for patients undergoing major non-cardiac surgery in 2008 from The American College of Surgeons' National Surgical Quality Improvement Program database (a prospective validated outcomes registry from 211 hospitals worldwide in 2008). We obtained anonymised data for 30-day mortality and morbidity (cardiac, respiratory, CNS, urinary tract, wound, sepsis, and venous thromboembolism outcomes), demographics, and preoperative and perioperative risk factors. We used multivariate logistic regression to assess the adjusted and modified (nine predefined risk factor subgroups) effect of anaemia, which was defined as mild (haematocrit concentration >29-<39% in men and >29-<36% in women) or moderate-to-severe (≤29% in men and women) on postoperative outcomes. FINDINGS: We obtained data for 227,425 patients, of whom 69,229 (30·44%) had preoperative anaemia. After adjustment, postoperative mortality at 30 days was higher in patients with anaemia than in those without anaemia (odds ratio [OR] 1·42, 95% CI 1·31-1·54); this difference was consistent in mild anaemia (1·41, 1·30-1·53) and moderate-to-severe anaemia (1·44, 1·29-1·60). Composite postoperative morbidity at 30 days was also higher in patients with anaemia than in those without anaemia (adjusted OR 1·35, 1·30-1·40), again consistent in patients with mild anaemia (1·31, 1·26-1·36) and moderate-to-severe anaemia (1·56, 1·47-1·66). When compared with patients without anaemia or a defined risk factor, patients with anaemia and most risk factors had a higher adjusted OR for 30-day mortality and morbidity than did patients with either anaemia or the risk factor alone. INTERPRETATION: Preoperative anaemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery. FUNDING: Vifor Pharma.

Subpleural block is less effective than thoracic epidural analgesia for post-thoracotomy pain: a randomised controlled study.

CONTEXT: Thoracic epidural and paravertebral blocks provide adequate analgesia for postoperative thoracotomy pain. Both procedures are usually performed percutaneously with considerable failure rates. A subpleural catheter placed in the space posterior to the parietal pleura and alongside the paravertebral area may provide superior postoperative pain relief. OBJECTIVE: To compare subpleural analgesia with thoracic epidural analgesia in patients undergoing thoracotomy. DESIGN: Randomised, double-blind study. SETTING: A tertiary care University Medical Centre between 26 June 2008 and 21 March 2011. PATIENTS: Forty-two patients scheduled for elective posterolateral thoracotomy. Patients with American Society of Anesthesiologists physical status ≥4, with a previous history of thoracotomy, on chronic pain medications or with a contraindication to receiving local anaesthetics or thoracic epidural block were excluded from the study. INTERVENTIONS: Patients were randomised to receive either subpleural analgesia or thoracic epidural analgesia for 24-h post-thoracotomy pain control. MAIN OUTCOME MEASURES: A visual analogue scale was used to assess pain at rest and on coughing during the first 24 h postoperatively and the incidence of hypotension was recorded. RESULTS: Patients who received subpleural analgesia had higher visual analogue scores at rest and on coughing than those who received thoracic epidural analgesia. Seven patients who started with subpleural analgesia were treated with thoracic epidural analgesia at a mean (SD) of 3.9 (4.8) h. The remaining 14 patients had a median (IQR [range]) visual analogue score of 5 cm (4-5 [3-6]) at rest and were maintained on subpleural analgesia until the end of the study. The visual analogue score at rest was <7 cm in all 21 patients who received thoracic epidural analgesia and none was switched to subpleural analgesia during the study. None of the patients in the subpleural analgesia group experienced hypotension compared with five of the 21 patients in the thoracic epidural analgesia group (P=0.047). CONCLUSION: Thoracic epidural analgesia is superior to subpleural analgesia in relieving post-thoracotomy pain.

Current status in decision making to treat acute type A dissection: limited versus extended repair.

Acute type A aortic dissection remains one of the most challenging conditions in aortic surgery. Despite the advancements in the field, the mortality rate still remains high. Though there is a general consensus that the ascending aorta should be replaced, the distal extension of the surgery still remains a controversy. Few surgeons argue for a conservative approach to reduce operative and postoperative morbidity while others considering the problems associated with "downstream problems" support an aggressive approach including a frozen elephant trunk. The cohort in the Indian subcontinent and APAC is far different from the western world. Many factors determine the decision for surgery apart from the pathology of the disease. Economy, availability of the suitable prosthesis, the experience of the surgeon, ease of access to the medical facility all contribute to the decision making to treat acute type A dissection.

Prophylactic amiodarone versus lidocaine for prevention of reperfusion ventricular fibrillation after release of aortic cross-clamp.

BACKGROUND AND OBJECTIVE: Ventricular fibrillation is common after aortic cross-clamp release in patients undergoing open-heart surgeries. The aim of the study was to evaluate the efficacy of the prophylactic administration of 150 mg amiodarone by way of the pump 2 min before release of aortic cross-clamp in preventing ventricular fibrillation. METHODS: The present study is a prospective, randomized, controlled and blinded study performed at a teaching university hospital where 120 patients undergoing coronary bypass graft surgery were randomly assigned to three groups. Each group received either 150 mg of amiodarone or 100 mg lidocaine or isotonic saline by way of pump 2 min before release of the aortic cross-clamp. The frequency of occurrence of ventricular fibrillation and the subsequent required defibrillation counter shocks were determined in all groups. RESULTS: The frequency of occurrence of ventricular fibrillation was significantly higher in both the amiodarone (48%) and the control group (45%) as compared with the lidocaine group (20%) with no statistically significant difference between the amiodarone and the control groups. Furthermore, when ventricular fibrillation occurred, the percentage of patients requiring defibrillation counter shocks was significantly higher in both the amiodarone (58%) and control (61%) groups as compared with the lidocaine group (13%) with no difference between the amiodarone and the control groups, despite a significant decrease in the defibrillation counter shocks energy requirements in the amiodarone group. CONCLUSION: The present study showed no difference between amiodarone (150 mg) and placebo in preventing ventricular fibrillation after release of aortic cross-clamp. In addition, the use of lidocaine was able to reduce the incidence of ventricular fibrillation as compared with both amiodarone and placebo.

Thoracic splenosis mimicking thoracic schwannoma: case report and review of the literature.

BACKGROUND: Thoracic splenosis is a rare entity. It occurs sometime after splenic and diaphragmatic injury, and it is rarely symptomatic. CASE DESCRIPTION: We report a case of left upper thoracic paraspinal splenosis 25 years after a thoracoabdominal penetrating trauma that required a splenectomy. The pathology was suspected on a routine chest x-ray and it mimicked a schwannoma on magnetic resonance imaging. Less than 40 cases of thoracic splenosis were described in the literature, but few were misinterpreted as schwannoma. CONCLUSION: Alertness to the possibility of thoracic splenosis can lead to confirmation of the diagnosis with technetium Tc 99m-tagged red blood cell radionuclide scanning based on a previous history of traumatic splenectomy.

Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery.

IMPORTANCE: The effects of smoking on postoperative outcomes in patients undergoing major surgery are not fully established. The association between smoking and adverse postoperative outcomes has been confirmed. Whether the associations are dose dependent or restricted to patients with smoking-related disease remains to be determined. OBJECTIVE: To evaluate the association between current and past smoking on the risk of postoperative mortality and vascular and respiratory events in patients undergoing major surgery. DESIGN: Cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We obtained data on smoking history, perioperative risk factors, and 30-day postoperative outcomes. We assessed the effects of current and past smoking (>1 year prior) on postoperative outcomes after adjustment for potential confounders and effect mediators (eg, cardiovascular disease, chronic obstructive pulmonary disease, and cancer). We also determined whether the effects are dose dependent through analysis of pack-year quintiles. SETTING AND PARTICIPANTS: A total of 607,558 adult patients undergoing major surgery in non-Veterans Affairs hospitals across the United States, Canada, Lebanon, and the United Arab Emirates during 2008 and 2009. MAIN OUTCOMES AND MEASURES: The primary outcome measure was 30-day postoperative mortality; secondary outcome measures included arterial events (myocardial infarction or cerebrovascular accident), venous events (deep vein thrombosis or pulmonary embolism), and respiratory events (pneumonia, unplanned intubation, or ventilator requirement >48 hours). RESULTS: The sample included 125,192 current (20.6%) and 78,763 past (13.0%) smokers. Increased odds of postoperative mortality were noted in current smokers only (odds ratio, 1.17 [95% CI, 1.10-1.24]). When we compared current and past smokers, the adjusted odds ratios were higher in the former for arterial events (1.65 [95% CI, 1.51-1.81] vs 1.20 [1.09-1.31], respectively) and respiratory events (1.45 [1.40-1.51] vs 1.13 [1.08-1.18], respectively). No effects on venous events were observed. The effects of smoking mediated through smoking-related disease were minimal. The increased adjusted odds of mortality in current smokers were evident from a smoking history of less than 10 pack-years, whereas the effects of smoking on arterial and respiratory events were incremental with increased pack-years. CONCLUSIONS AND RELEVANCE: Smoking cessation at least 1 year before major surgery abolishes the increased risk of postoperative mortality and decreases the risk of arterial and respiratory events evident in current smokers. These findings should be carried forward to evaluate the value and cost-effectiveness of intervention in this setting. Our study should increase awareness of the detrimental effects of smoking-and the benefits of its cessation-on morbidity and mortality in the surgical setting.

Mammary myocutaneous-glandular flap for reconstruction of oncological defects of the anterior midline chest wall.

We describe a mammary myocutaneous-glandular flap, which is a simple, convenient, reliable, and speedy reconstructive technique applicable for women that combines little or no morbidity with excellent cosmetic outcome and provides a simple solution to an extremely difficult problem.

Mitral valve repair or replacement in elderly people.

PURPOSE OF REVIEW: Much has been published so far to describe and praise the benefits of mitral valve repair, and to compare it with valve replacement. Now, with mitral valve surgery in elderly people gaining greater acceptance worldwide, repair or replacement remains a controversial issue. This is especially true in the ageing population, in whom many of the complications associated with a mechanical valve can be avoided by using a bioprosthesis. This review will try to assess the latest views in the field and come up with possible answers to this ongoing question. RECENT FINDINGS: The causes of mitral regurgitation in this age group are separately reviewed and discussed in the light of our better understanding of the pathophysiology of the disease. Mitral surgery is recommended when the effective regurgitant orifice reaches 40 mm. Repair in degenerative disease seems to be feasible, with good long-term results. In chronic ischaemic regurgitation, the concept of a tethered 'normal valve' is changing. The 'poor' ventricle may be able to withstand surgery as long as the subvalvular apparatus is preserved; on the other hand, repair and replacement seem to have the same survival advantage in high-risk patients. SUMMARY: Mitral valve surgery is well tolerated in elderly people. Early intervention leads inevitably to better outcome. The majority of valvular disorders in this age group are amenable to repair, with good reproducible results. Replacement with a bioprosthesis remains a viable option for complex regurgitant jets.