Perioperative corticosteroids for reducing postoperative complications following esophagectomy: an updated systematic review and meta-analysis.

BACKGROUND: This updated systematic review and meta-analysis aims to evaluate the efficacy and safety of perioperative corticosteroid administration versus placebo for esophageal cancer patients following scheduled esophagectomy. METHODS: We searched databases through June 30, 2023. We included articles on randomized controlled trials (RCTs) comparing perioperative corticosteroid administration with placebo in esophageal cancer patients with esophagectomy. The outcomes were the death rate during hospitalization, length of hospital stay, and short-term complications. Risk ratios (RRs) and corresponding 95% confidence interval (CIs) for each estimated effect size were applied for dichotomous outcomes, and the mean difference (MD) and corresponding 95% CIs for each estimated effect size were applied for continuous outcomes. We used GRADE to evaluate the quality of each of the outcome and the level of recommendations. RESULTS: Nine RCTs with 508 participants were included in this study. Severe outcomes, including the length of hospital stay, leakage, mortality during the hospitalization period in the corticosteroid group was comparable to that in the control group, but positive effects of corticosteroid administration were observed on the length of intensive care unit stay (MD -3.1, 95% CI - 5.43 to - 0.77), cardiovascular disorders (RR 0.44, 95% CI 0.21-0.94) and other general complications (RR 0.49, 95% CI 0.29-0.85). CONCLUSIONS: Peri-operative intravenous corticosteroid administration may reduce cardiovascular disorders, other general complications and the length of ICU stay without carrying severe outcomes. More high quality RCTs are warranted to further investigate the effects of corticosteroids on postoperative mortality and complications for esophageal cancer patients with esophagectomy. SYSTEMATIC REVIEW REGISTRATION: Cochrane, registration number: 196.

A Modified Technique for Valve Regurgitation After Partial Atrioventricular Septal Defect Repair.

Given its complex pathologic anatomy, recurrent left atrioventricular valve regurgitation after partial atrioventricular septal defect repair remains a challenge for surgical correction. Here, we introduce a modified bridging technique by shortening the anteroposterior leaflet distance in selected patients with inadequate coaptation to compensate for the short leaflet height, specifically that of the anterior leaflet.

Inflammatory indicator levels in patients undergoing aortic valve replacement via median sternotomy with preoperative anxiety and postoperative complications: a prospective cohort study.

OBJECTIVE: This study was performed to evaluate the association of preoperative anxiety with inflammatory indicators and postoperative complications in patients undergoing scheduled aortic valve replacement surgery. METHODS: A prospective cohort study was performed. The Hamilton Anxiety Scale was used to assess preoperative anxiety. The serum white blood cell (WBC) count and concentrations of C-reactive protein, interleukin (IL)-6, and IL-8 were measured 1 day preoperatively and 3 and 7 days postoperatively. Postoperative complications were also recorded. RESULTS: Seventy-three patients were included. The incidence of preoperative anxiety was 30.1% (22/73). The payment source was the only independent risk factor for preoperative anxiety. The incidence of postoperative complications was lowest in the mild anxiety group. The WBC count 3 days postoperatively was significantly lower in the mild than moderate-severe anxiety group. The IL-8 concentration 1 day preoperatively was highest in the no anxiety group. CONCLUSIONS: Mild preoperative anxiety might help to improve clinical outcomes. However, further investigations with more patients are warranted. Patients with different degrees of anxiety may have different levels of inflammatory cytokines.

Results of surgery on adults with functional single ventricle without prior cardiac surgery in childhood.

OBJECTIVES: Patients with unoperated functional single ventricle (FSV) rarely survive into adulthood with good functional status and there are few reports about surgical results of adult patients with FSV. This study retrospectively reviews our experience with surgery in adult patients with FSV. METHODS: From January 2008 to September 2017, 65 adult patients with FSV underwent surgery in our hospital. Twenty underwent Blalock-Taussig shunt or bidirectional Glenn procedures in other hospitals prior, and four were lost to follow-up. Finally, 41 patients were included in this study. RESULTS: The early postoperative mortality was 7.3% (3/41). Postoperative systemic arterial oxygen saturation (SpO2 , 83.7% ± 4.8%) was significantly higher than preoperative SpO2 (77.9% ± 10.1%, P < .01). The mean follow-up time was 3.9 ± 3.1 years (range 1-11 years). There was only one case of late mortality and massive hemoptysis was the cause of death. Right ventricular morphology and severe atrioventricular valve regurgitation (AVVR) were the risk factors of postoperative death for patients with pulmonary stenosis(PS). There was no death case in patients who received Fontan procedure. In a follow-up, we found the grade of AVVR was reduced and the grade of heart function (New York Heart Association) was improved. CONCLUSIONS: Adult patients with FSV can also undergo surgery. The mortality was acceptable and late results were satisfactory. After surgery, oxygen saturations increased, grades of AVVR decreased and the heart functions improved. Right ventricular morphology and severe AVVR were risk factors for patients with PS.

Assessing the impact of total extracorporeal circulation on hemodynamics in an ovine fetal model.

The present study aimed to evaluate the impact of total extracorporeal circulation on hemodynamics and placental function in an ovine fetal model. Mid-term ovine fetuses (n=6) underwent extracorporeal circulation (30 min), cardioplegic arrest (20 min) and monitoring (120 min). The ascending aorta and umbilical cords of the fetuses were occluded during the bypass and an extracorporeal membrane oxygenator was used as the oxygen source. Biventricular intracardiac pressures, echocardiographic data, blood gas levels and placental function variables were recorded, and statistical analysis was performed using the repeated-measure analysis of variance test. The data indicated that fetal heart rate and blood pressure at 30, 60, 90 and 120 min following the bypass were stable relative to pre-arrest baseline (pre-bypass) values (P>0.05). However, end diastolic pressures in the ovine right ventricles post-bypass were significantly increased at 30, 60, 90 and 120 min relative to pre-bypass pressures (P<0.05). The pulsatility index also increased at 30 min post-bypass relative to the pre-bypass score (0.91±0.06 vs. 0.61±0.14; P=0.007). The mean resistivity index at all time points post-bypass was consistent with the pre-bypass score (P>0.05), while the mean Tei index values for the left and right ventricles post-bypass were significantly higher at all time points relative to pre-bypass values (P<0.05). The pre-bypass fetal blood pH, SaO2, base excess and lactate values were maintained during arrest (P>0.05). Fetal hemodynamics and placental function additionally remained stable for up to 2 h upon reperfusion following total extracorporeal circulation and cardioplegic arrest. Collectively these data suggest that the reproducible ovine fetal model may be useful in the evaluation of fetal cardiac surgery.

[Effects of different arterial oxygen partial pressures on serum protein S100ß and neuron specific enolase during cardiopulmonary bypass in infants with cyanotic congenital heart disease].

OBJECTIVE: A prospective study was conducted to probe into the relationship between arterial oxygen partial pressure (PaO2) and brain injury during cardiopulmonary bypass (CPB) in infants with cyanotic congenital heart disease (CHD). METHOD: Enrolled in the study were 45 cyanotic infants, who were less than three years old and underwent corrective cardiac surgery from August 1(st), 2010 to January 31(st), 2011 at Guangdong General Hospital. All the infants had a pulse oxygen saturation (SpO2) lower than 85% and were randomly allocated into three groups by a specific computer program. In controlled group 1 (G1 group), PaO2 levels were controlled at 80 - 120 mm Hg (1 mm Hg = 0.133 kPa) during CPB; in controlled group 2 (G2 group), PaO2 levels at 120 - 200 mm Hg during CPB; while in uncontrolled group (G3 group), PaO2 levels were at 200 - 400 mm Hg during CPB. Blood samples were collected just before starting CPB, at the end of CPB, and at 3 h, 5 h, and 24 h after CPB (T1, T2, T3, T4, T5) for the determination of serum concentrations of protein S100ß, neuron specific enolase (NSE), and adrenomedullin (ADM) by ELISA. RESULT: Protein S100ß rose significantly after starting CPB. In group G3, it reached a peak of (699 ± 139) ng/L by the end of CPB, significantly higher than those in groups G1 and G2 [(528 ± 163) ng/L and (585 ± 155) ng/L], and was positively correlated with PaO2 levels (r = 0.526, P < 0.01). NSE levels of group G1 were continuously rising after starting CPB and reached significantly high levels at 3 h or 5 h after CPB [(12.2 ± 3.4) µg/L and (12.3 ± 3.7) µg/L], while those of group G2 rose significantly during CPB [(10.9 ± 4.8) µg/L] and even higher at 3 h or 5 h after CPB [(12.6 ± 5.1) µg/L and (13.2 ± 5.4) µg/L]. NSE levels of group G3 rose significantly during CPB and maintained at a high level [(12.2 ± 5.7) µg/L] afterwards. There was no significant difference in serum ADM concentrations among different time points in each group and among these three groups. All the infants were discharged from the hospital without any obvious nervous symptom and sign. CONCLUSION: High PaO2 during CPB in infants with CHD might cause an increase of serum protein S100ß and NSE, indicating that brain injury might become worse with a higher PaO2 and might be positively correlated with PaO2 during CPB.

A fetal goat model of cardiopulmonary bypass with cardioplegic arrest and hemodynamic assessment.

OBJECTIVE: Increasing evidence shows that some cardiac defects may benefit from fetal interventions, including fetal cardiac surgery. We attempted to develop an in vivo animal model of fetal cardiopulmonary bypass with cardioplegic arrest. METHODS: Operations were performed on 14 pregnant goats. The extracorporeal circulation circuit consisted of a centrifugal pump, silicone tubings with an inner diameter of 6 mm, a roller pump, and a reservoir. The placenta was the sole oxygenator. Cardiopulmonary bypass was maintained at a mean flow rate of 344 ± 68 mL/kg/min, including 30 minutes of cardiac arrest and 15 minutes of reperfusion. Mean arterial blood pressure and heart rate were monitored. Arterial blood samples were analyzed. The pulse index and resistance index of the fetal umbilical artery were monitored. RESULTS: Experiments were completed in 11 cases (79%), with the fetuses weighing 0.65 to 1.8 kg. Fetal mean arterial blood pressure and heart rate remained stable throughout the experiments. A decrease in partial pressure of oxygen with concomitant increase in carbon dioxide partial pressure was noted, but trends were relatively stable. Metabolic acidosis was recognized during and after cardiac bypass. The pulse index and resistance index of the umbilical artery increased significantly after 2 hours off bypass. CONCLUSIONS: We confirmed the technical feasibility of establishing an in vivo model of fetal cardiac bypass with cardioplegic arrest. This fetal goat model provides reproducible data and is suitable to study clinically relevant problems related to fetal cardiopulmonary bypass, myocardial protection, and hemodynamics.

Palliative arterial switch for transposition of the great arteries, ventricular septal defect, and pulmonary vascular obstructive disease: midterm outcomes.

OBJECTIVE: Our objective was to evaluate the early and midterm outcomes of palliative arterial switch operation in which a ventricular septal defect was not closed or repaired with a fenestrated patch in patients with transposition of the great arteries, ventricular septal defect, and severe pulmonary vascular obstructive disease. METHODS: Between March 2000 and September 2009, the palliative arterial switch operation was performed in 21 patients with a mean age of 3.7 years (range, 0.5-15). Mean preoperative values for systolic pulmonary arterial pressure and systemic arterial oxygen saturation were 91 mm Hg and 69%, respectively. Eighty-one percent of the patients were in New York Heart Association functional class III or IV preoperatively. RESULTS: Early mortality was 14.3%. Mean follow-up was 4.0 years (maximum 9.5 years). Regression of pulmonary arterial pressure occurred in 8 patients (44% of the early survivors). Three of the 8 fenestrations were closed interventionally. Mean postoperative systemic arterial oxygen saturation increased significantly to 93% (P < .001). One late death occurred 3 months after surgery. All the long-term survivors (n = 17) were in New York Heart Association functional class I or II (P < .001). CONCLUSIONS: The palliative arterial switch operation significantly improved the quality of life and possibly life expectancy in patients with transposition of the great arteries, ventricular septal defect, and severe pulmonary vascular obstructive disease. Postoperative pulmonary vascular resistance might be reversible in some patients. Closing the ventricular septal defect with a fenestrated patch, which can be easily closed nonsurgically later on, might contribute to a safer postoperative recovery.

[The application of bidirectional Glenn procedure on 68 pediatric cases with functional univentricle heart].

OBJECTIVE: To analyze 68 pediatric cases with functional univentricle heart who underwent bidirectional Glenn procedure during from April 1998 to December 2005. METHODS: There were 47 males and 21 females in this group, aged from 5 months to 14 years old and weighed from 6.7 to 30.0 kg. Among them, 39 cases were received bidirectional Glenn procedure on the right side, 13 cases on the left side and 16 cases on both sides. Three cases had the pulmonary artery banded; one case had the pulmonary artery ligated;one case had the original A-P shunt cut off; six cases had the PDA ligated; four cases had the MAPCAs cut off; one case had TAPVC corrected contemporarily; two cases of PAPVC were also corrected; four cases had the atrial-ventricular valve repaired. RESULTS: Three cases died. The mortality was 4.4%. The mean post-operative pressure of super vena cava was (15.9 +/- 2.4) mm Hg (1 mm Hg = 0.133 kPa), higher than the pre-operative one (8.3 +/- 1.8) mm Hg (P < 0.01). The mean post operative SpO(2) was (89.3 +/- 4.2)%, higher than the pre-operative one (78.4 +/- 6.0)% (P < 0.01). CONCLUSIONS: Bidirectional Glenn procedure is of satisfied effect on surgical treatment for functional univentricle heart. The persistent forward flow from pulmonary artery should be reserved in bidirectional Glenn procedure.

[Treatment with oral sildenafil in patients with severe pulmonary hypertension after open heart operations].

OBJECTIVE: To evaluate the clinical effects of treatment with oral sildenafil on severe pulmonary hypertension after cardiac surgery. METHODS: From September 2002 to January 2005, oral sildenafil was added to the treatment regime in 27 cases of severe pulmonary hypertension after cardiac surgery. All these cases were given general treatments including intravenous prostaglandin E1 and inhalation of nitric oxide before the use of sildenafil, which did not show obvious effects on decreasing pulmonary pressure. Then a combined treatment [general treatment plus oral sildenafil (1-2 mg/kg, q8h; Pfizer Ltd)] was instituted. Pulmonary artery pressure, systolic pulmonary artery pressure/systolic systemic blood pressure (Pp/Ps) were measured before and every hour after adding sildenafil. RESULTS: One hour after adding sildenafil, the patients' pulmonary artery pressure decreased remarkably (P < 0.01) with no adverse effects on systematic artery pressure. SO(2) and PaO(2) of all cases improved respectively (P < 0.05). One or two days later, the patients' hemodynamics were stable and some patients stopped inhaling nitric oxide and the dosage of prostaglandin E1 decreased. 25 cases stopped use of ventilator and were discharged safely. 2 cases died of multiple organ dysfunction. CONCLUSION: Sildenafil is a highly selective and effective pulmonary hypertension vasodilator, which can be given for the treatment of pulmonary hypertension after cardiac surgery.