Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management.

This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.

Risk Prediction Models for Renal Function Decline After Cardiac Surgery Within Different Preoperative Glomerular Filtration Rate Strata.

BACKGROUND: Our goal was to create a simple risk-prediction model for renal function decline after cardiac surgery to help focus renal follow-up efforts on patients most likely to benefit. METHODS AND RESULTS: This single-center retrospective cohort study enrolled 24 904 patients who underwent cardiac surgery from 2012 to 2019 at Fuwai Hospital, Beijing, China. An estimated glomerular filtration rate (eGFR) reduction of ≥30% 3 months after surgery was considered evidence of renal function decline. Relative to patients with eGFR 60 to 89 mL/min per 1.73 m2 (4.5% [531/11733]), those with eGFR ≥90 mL/min per 1.73 m2 (10.9% [1200/11042]) had a higher risk of renal function decline, whereas those with eGFR ≤59 mL/min per 1.73 m2 (5.8% [124/2129]) did not. Each eGFR stratum had a different strongest contributor to renal function decline: increased baseline eGFR levels for patients with eGFR ≥90 mL/min per 1.73 m2, transfusion of any blood type for patients with eGFR 60 to 89 mL/min per 1.73 m2, and no recovery of renal function at discharge for patients with eGFR ≤59 mL/min per 1.73 m2. Different nomograms were established for the different eGFR strata, which yielded a corrected C-index value of 0.752 for eGFR ≥90 mL/min per 1.73 m2, 0.725 for eGFR 60-89 mL/min per 1.73 m2 and 0.791 for eGFR ≤59 mL/min per 1.73 m2. CONCLUSIONS: Predictors of renal function decline over the follow-up showed marked differences across the eGFR strata. The nomograms incorporated a small number of variables that are readily available in the routine cardiac surgical setting and can be used to predict renal function decline in patients stratified by baseline eGFR.

Diaphragmatic dysfunction is associated with postoperative pulmonary complications and phrenic nerve paresis in patients undergoing thoracic surgery.

PURPOSE: We aimed to quantify perioperative changes in diaphragmatic function and phrenic nerve conduction in patients undergoing routine thoracic surgery. METHODS: A prospective observational study was performed in patients undergoing esophageal resection or pulmonary lobectomy. Examinations were carried out the day prior to surgery, 3 days and 10-14 days after surgery. Endpoints for diaphragmatic function included ultrasonographic measurements of diaphragmatic excursion and thickening fraction. Endpoints for phrenic nerve conduction included baseline-to-peak amplitude, peak-to-peak amplitude, and transmission delay. Measurements were assessed on both the surgical side and the non-surgical side of the thorax. RESULTS: Forty patients were included in the study. Significant reductions in diaphragmatic excursion were seen on the surgical side of the thorax for all excursion measures (posterior part of the right hemidiaphragm, p < 0.001; hemidiaphragmatic top point, p < 0.001; change in intrathoracic area, p < 0.001). Significant changes were seen for all phrenic nerve measures (baseline-to-peak amplitude, p < 0.001; peak-to-peak amplitude, p < 0.001; transmission delay, p = 0.041) on the surgical side. However, significant changes were also seen on the non-surgical side for all phrenic nerve measures (baseline-to-peak amplitude, p < 0.001; peak-to-peak amplitude, p < 0.001; transmission delay, p = 0.022). A postoperative reduction in posterior diaphragmatic excursion of more than 50% was significantly associated with postoperative pulmonary complications (coefficient: 2.69 (95% CI [1.38, 4.01], p < 0.001). CONCLUSION: Thoracic surgery caused a significant unilateral reduction in diaphragmatic excursion on the surgical side of the thorax, which was accompanied by significant changes in phrenic nerve conduction. However, phrenic nerve conduction was also significantly affected on the non-surgical side to a lesser extent, which was not mirrored in diaphragmatic excursion. Our findings suggest that phrenic nerve paresis plays a role in postoperative diaphragmatic dysfunction, which may be a contributing factor in the pathogenesis of postoperative pulmonary complications. CLINICAL TRIALS REGISTRATION NUMBER: NCT04507594.

Single-channel qEEG characteristics distinguish delirium from no delirium, but not postoperative from non-postoperative delirium.

OBJECTIVE: This exploratory study examined quantitative electroencephalography (qEEG) changes in delirium and the use of qEEG features to distinguish postoperative from non-postoperative delirium. METHODS: This project was part of the DeltaStudy, a cross-sectional,multicenterstudy in Intensive Care Units (ICUs) and non-ICU wards. Single-channel (Fp2-Pz) four-minutes resting-state EEG was analyzed in 456 patients. After calculating 98 qEEG features per epoch, random forest (RF) classification was used to analyze qEEG changes in delirium and to test whether postoperative and non-postoperative delirium could be distinguished. RESULTS: An area under the receiver operatingcharacteristic curve (AUC) of 0.76 (95% Confidence Interval (CI) 0.71-0.80) was found when classifying delirium with a sensitivity of 0.77 and a specificity of 0.63 at the optimal operating point. The classification of postoperative versus non-postoperative delirium resulted in an AUC of 0.50 (95%CI 0.38-0.61). CONCLUSIONS: RF classification was able to discriminate delirium from no delirium with reasonable accuracy, while also identifying new delirium qEEG markers like autocorrelation and theta peak frequency. RF classification could not distinguish postoperative from non-postoperative delirium. SIGNIFICANCE: Single-channel EEG differentiates between delirium and no delirium with reasonable accuracy. We found no distinct EEG profile for postoperative delirium, which may suggest that delirium is one entity, whether it develops postoperatively or not.

Functional Disorders of the Ileal-Anal Pouch: A Systematic Review.

BACKGROUND: The IPAA is a boon to patients needing proctocolectomy but maintains per anal function through anatomic and physiologic compromises. The state of pouch function is hard to define because pouch anatomy is not normal and pouch physiology is a distortion of normal defecation. Patients with pouches develop multiple symptoms: some are expected, some are disease related, and some are the result of surgical complications. It is important to understand the cause of pouch-related symptoms so that appropriate management is offered. OBJECTIVES: The study aimed to review pouch symptoms and discuss their likely cause, review the literature on pouch function and dysfunction, and provide clarity to clear the confusion. DATA SOURCES: PubMed and Cochrane databases were searched using the terms "ileoanal pouch function" and "ileoanal pouch dysfunction." STUDY SELECTION: From 1983 to 2023, 553 articles related to "ileoanal pouch function" and 178 related to "ileoanal pouch dysfunction" were reviewed. Nine studies appeared under both headings. Case studies, duplicate publications, and articles concerning pouch diseases were excluded. MAIN OUTCOME MEASURES: Definitions of pouch function and dysfunction, methods of describing and scoring symptoms, and understanding of expected changes in pouch function given the nature of the surgery. RESULTS: Twenty-seven studies were reviewed from the ileoanal pouch dysfunction search and 38 from ileoanal pouch function. Three studies tried to define normal pouch function, 10 attempted to measure pouch function, and 4 aimed to score pouch function. Only 3 studies addressed pouch physiology. LIMITATIONS: A full discussion of pouch dysfunction is limited by the lack of studies focussing on the anatomic and physiologic consequences of turning the terminal ileum into an organ of storage. CONCLUSIONS: Most studies of pouch function and dysfunction do not consider expected changes in the physiology of defecation that follow restorative proctocolectomy. Thus, most studies of pouch function produce conclusions that lack an important dimension. See video from symposium.

Abordaje abierto versus laparoscópico para la reconstitución del tránsito luego de la cirugía de Hartmann: resultados de una experiencia de 10 años / Open versus laparoscopic approach for Hartmann's reversal: results of a 10-year retrospective cohort study

Resumen Objetivo: El objetivo de este estudio es comparar los resultados perioperatorios del abordaje abierto (AA) con el abordaje laparoscópico (AL) para la reconstitución de tránsito (RT), y determinar factores de riesgo asociados a morbilidad posoperatoria. Material y Métodos: Se estudiaron pacientes consecutivos sometidos a RT entre enero de 2007 y diciembre de 2016 en nuestro centro. Se excluyeron aquellos con grandes hernias incisionales que requirieran reparación abierta simultánea. Se consignaron variables demográficas y perioperatorias, y se compararon ambos grupos. Además, se realizó una regresión logística para la identificación de factores de riesgo asociados a morbilidad posoperatoria en la serie. Resultados: Se realizaron 101 RT en el período. Se excluyeron 14 casos por hernia incisional, por lo que se analizaron 87 casos (46 AA y 41 AL). Diez pacientes en el grupo AL (24,4%) requirieron conversión, principalmente por adherencias. La morbilidad total de la serie fue de 36,8%, siendo mayor en el AA (50% vs 21,9%, p = 0,007). Hubo una filtración anastomótica en cada grupo. La estadía posoperatoria fue de 5 (3-52) días para el AL y 7 (4-36) días para el AA (p < 0,001). En la regresión logística, sólo el AA fue un factor de riesgo independientemente asociado a morbilidad posoperatoria (OR 2,89, IC 95% 1,11-7,49; p = 0,029). Conclusión: El abordaje laparoscópico se asocia a menor morbilidad y estadía posoperatoria que el abordaje abierto para la reconstitución del tránsito pos-Hartmann. En nuestra serie, el abordaje abierto fue el único factor independientemente asociado a morbilidad posoperatoria.

Introduction: Hartmann's reversal (HR) is considered a technically demanding procedure and is associated with high morbidity rates. Aim: The aim of this study is to compare the perioperative results of the open approach (OA) with the laparoscopic approach (LA) for HR, and to determine the risk factors associated with postoperative morbidity. Material and Methods: Consecutive patients undergoing HR between January 2007 and December 2016 at a university hospital were included. Patients with large incisional hernias that required an open approach a priori were excluded from the analysis. Demographic and perioperative variables were recorded. Analytical statistics were carried out to compare both groups, and a logistic regression was performed to identify risk factors associated with postoperative morbidity in the series. Results: A hundred and one HR were performed during the study period. Fourteen cases were excluded due to large incisional hernias, so 87 cases (46 OA and 41 LA) were analyzed. Ten patients in the LA group (24.4%) required conversion, mainly due to adhesions. The total morbidity of the series was 36.8%, being higher in the OA group (50% vs. 21.9%, p = 0.007). There was one case of anastomotic leakage in each group. The length of stay was 5 (3-52) days for LA and 7 (4-36) days for OA (p < 0.001). In the logistic regression, the OA was the only independent risk factor associated with postoperative morbidity in HR (OR 2.89, IC 95% 1.11-7.49; p = 0.029). Conclusion: A laparoscopic approach is associated with less morbidity and a shorter length of stay compared to the open approach for Hartmann's reversal. An open approach was the only factor independently associated with postoperative morbidity in our series.

Renoprotective Effect of Intraoperative Dexmedetomidine in Renal Transplantation.

BACKGROUND: Renal dysfunction after kidney transplantation may be influenced by many reasons. This study was designed to evaluate whether the administration of dexmedetomidine (Dex) could ameliorate renal function and prognosis after kidney transplantation. METHODS: A total of 65 patients were divided into Dex group (n = 33) and Con group (Con, n = 32). Dex group intravenously received an initial loading dose of 0.6 µg/kg Dex for 15 min before anaesthesia induction, followed by a rate of 0.4 µg/kg/h until 30 min after kidney reperfusion. By contrast, Con group received saline. The concentration of urinary kidney injury molecule-1 (KIM-1), serum creatinine (Cr), blood urea, urine output, ß2 microglobulin (ß2-MG), Cystatin C (CysC), and estimated glomerular filtration rate (eGFR) was recorded and compared between two groups during the course of the hospitalization or follow-up. Mean arterial pressure (MAP) and heart rate (HR), vasoactive drugs, and anaesthetics were recorded during the operation. Pain degree was evaluated using a visual analogue scale (VAS) after operation. Delayed graft function (DGF), graft loss, length of hospital stay, and mortality were compared between groups. RESULTS: The concentration of KIM-1 in Dex group was lower than Con group at 2 h (P = 0.018), 24 h (P = 0.013), 48 h (P < 0.01), and 72 h (P < 0.01) after reperfusion. MAP of Dex group after tracheal intubation (P = 0.012) and incision (P = 0.018) and HR after intubation (P = 0.021) were lower than that of Con group. The dosage of sufentanil during operation in Dex group was less than Con group (P = 0.039). Patients that used atropine in Dex group were more than Con group (P = 0.027). Patients who received Dex presented with lower VAS scores at 6 h (P = 0.01) and 12 h (P = 0.002) after operation. Concentration of serum Cr and blood urea had no significant differences between groups before operation and on postoperative day 1 to 6. Urine output was recorded for 6 days after operation and had no differences between groups. Also, no differences were identified between two groups in urea, Cr, ß2-MG, CysC, and eGFR in the first 3 months after operation. Incidence of DGF after operation was detected no difference between groups, while length of hospital stay in Dex group was less than Con group (P = 0.012). CONCLUSION: Dex can decrease kidney injury marker level, attenuate perioperative stress, relieve the dosage of sufentanil and postoperative pain, and reduce length of hospital stay. However, Dex is not associated with changes in prognosis in the first 3 months after transplantation.

Autonomic Neuromodulation for Atrial Fibrillation Following Cardiac Surgery: JACC Review Topic of the Week.

Autonomic neuromodulation therapies (ANMTs) (ie, ganglionated plexus ablation, epicardial injections for temporary neurotoxicity, low-level vagus nerve stimulation [LL-VNS], stellate ganglion block, baroreceptor stimulation, spinal cord stimulation, and renal nerve denervation) constitute an emerging therapeutic approach for arrhythmias. Very little is known about ANMTs' preventive potential for postoperative atrial fibrillation (POAF) after cardiac surgery. The purpose of this review is to summarize and critically appraise the currently available evidence. Herein, the authors conducted a systematic review of 922 articles that yielded 7 randomized controlled trials. In the meta-analysis, ANMTs reduced POAF incidence (OR: 0.37; 95% CI: 0.25 to 0.55) and burden (mean difference [MD]: -3.51 hours; 95% CI: -6.64 to -0.38 hours), length of stay (MD: -0.82 days; 95% CI: -1.59 to -0.04 days), and interleukin-6 (MD: -79.92 pg/mL; 95% CI: -151.12 to -8.33 pg/mL), mainly attributed to LL-VNS and epicardial injections. Moving forward, these findings establish a base for future larger and comparative trials with ANMTs, to optimize and expand their use.

The burden of perioperative hypertension/hypotension: A systematic review.

STUDY OBJECTIVE: Our goal is to review the outcomes of acute hypertensive/hypotensive episodes from articles published in the past 10 years that assessed the short- and long-term impact of acute hypertensive/hypotensive episodes in the perioperative setting. METHODS: We conducted a systematic peer review based upon PROSPERO and Cochrane Handbook protocols. The following study characteristics were collected: study type, author, year, population, sample size, their definition of acute hypertension, hypotension or other measures, and outcomes (probabilities, odds ratio, hazard ratio, and relative risk) and the p-values; and they were classified according to the type of surgery (cardiac and non-cardiac). RESULTS: A total of 3,680 articles were identified, and 66 articles fulfilled the criteria for data extraction. For the perioperative setting, the number of articles varies by outcome: 20 mortality, 16 renal outcomes, 6 stroke, 7 delirium and 34 other outcomes. Hypotension was reported to be associated with mortality (OR 1.02-20.826) as well as changes from the patient's baseline blood pressure (BP) (OR 1.02-1.36); hypotension also had a role in the development of acute kidney injury (AKI) (OR 1.03-14.11). Postsurgical delirium was found in relation with BP lability (OR 1.018-1.038) and intra- and postsurgical hypotension (OR 1.05-1.22), and hypertension (OR 1.44-2.34). Increased OR (37.67) of intracranial hemorrhage was associated to postsurgical systolic BP >130 mmHg. There was a wide range of additional diverse outcomes related to hypo-, hypertension and BP lability. CONCLUSIONS: The perioperative management of BP influences short- and long-term effects of surgical procedures in cardiac and non-cardiac interventions; these findings support the burden of BP fluctuations in this setting.

Degree of change in right ventricular adaptation measures during axillary Impella support informs risk stratification for early, severe right heart failure following durable LVAD implantation.

Risk assessment for early, severe right heart failure (RHF) after LVAD implantation remains imperfect. We sought to define the differences in RV adaptation and load after axillary Impella support between patients who experienced RHF and those who did not. Seventeen of 18 patients included were deemed intermediate or high risk for RHF by EUROMACS-RHF score. Before Impella insertion, RV adaptation parameters (RAP, RAP:PCWP, PAPi) were worse in the non-RHF group compared to the RHF group. In both groups, RV load parameters (effective pulmonary arterial elastance, pulmonary vascular resistance, and pulmonary vascular compliance) improved after Impella insertion. Lesser improvements in RV adaptation were seen in the RHF group. Moreover, load-to-adaptation relationships (EA/RAP and EA/RAP:PCWP) worsened to a greater degree. In patients at intermediate or high risk for RHF after LVAD, assessment of RV adaptation and load during axillary Impella support may improve risk stratification.

Effect of Combined Thoracic Paravertebral Block and General Anesthesia vs General Anesthesia Alone on Postoperative Stress and Pain in Patients Undergoing Laparoscopic Radical Nephrectomy.

BACKGROUND This single-center study compared the effect of combined thoracic paravertebral block (TPVB) and general anesthesia vs general anesthesia alone on postoperative stress and pain in patients undergoing laparoscopic radical nephrectomy. MATERIAL AND METHODS Patients undergoing laparoscopic radical nephrectomy were selected and randomized into a study group given TPVB combined with general anesthesia (n=43) and a reference group (n=43) given general anesthesia. The perioperative clinical indicators, blood pressure, pulse rate, visual analog scale (VAS) score, and adverse reactions were compared. RESULTS Perioperative clinical indicators of the study group (other than operation duration) were superior to those of the reference group (P<0.05). At 90 min in the operation, systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate were lower than before anesthesia (t=7.691, 10.017, and 7.728, P<0.05). SBP, DBP, and pulse rate at 90 minutes during operation were significantly lower in the study group than in the reference group (t=7.582, 8.754, and 6.682, P<0.01). The study group had lower VAS scores both during activity and at rest 48 h after the operation than in the reference group (t=5.171 and 6.025, P<0.001). The total incidence of adverse reactions in the study group was lower than in the reference group (χ²=5.018, P=0.024). CONCLUSIONS The findings from this study from a single center showed that TPVB combined with general anesthesia for patients undergoing laparoscopic radical nephrectomy significantly reduced postoperative pain and stress.

Oblique Lateral Interbody Fusion with Anterolateral Screw Fixation Is as Effective as with Posterior Percutaneous Pedicle Screw Fixation in Treating Single-Segment Mild Degenerative Lumbar Diseases.

BACKGROUND Oblique lateral interbody fusion (OLIF) is a new and minimally invasive surgery. This study aimed to compare the clinical efficacy and safety of oblique lateral interbody fusion with anterolateral screw fixation and with posterior percutaneous screw fixation in treating single-segment mild degenerative lumbar diseases. MATERIAL AND METHODS A retrospective analysis was performed on 51 patients with single-segment mild degenerative lumbar diseases who received OLIF from April 2017 to January 2020 in Hong Hui Hospital, Xi'an Jiao Tong University; 24 and 27 patients received OLIF with anterolateral screw fixation (OLIF+AF) and OLIF with posterior percutaneous screw fixation (OLIF+PF), respectively. Anesthesia time, operation time, intraoperative blood loss, intraoperative fluoroscopy number, hospital stay, postoperative complications, Visual Analog Scale (VAS) score, Oswestry Disability Index (ODI) score, anterior and posterior disc heights, foraminal height, and fusion rate of the 2 groups were compared to assess clinical and radiological outcomes. RESULTS Anesthesia time, operation time, intraoperative blood loss, number of intraoperative fluoroscopy, and VAS score in the OLIF+AF group were significantly better than those in the OLIF+PF group (P<0.05). There were no significant differences in ODI score, anterior and posterior disc heights, foraminal height, fusion rate, and incidence of complications between the 2 groups (P<0.05). CONCLUSIONS OLIF+AF in treating single-segment mild degenerative lumbar diseases produces a satisfactory clinical effect. Moreover, OLIF+AF does not invade the paraspinal muscle group, thereby reducing trauma, postoperative residual low back pain, operation time, bleeding, and frequency of fluoroscopy. Thus, OLIF+AF is a feasible treatment method for single-segment mild degenerative lumbar diseases.

Low left ventricular ejection fraction, complication rescue, and long-term survival after coronary artery bypass grafting.

OBJECTIVES: To evaluate the association between low left ventricular ejection fraction (LVEF), complication rescue, and long-term survival after isolated coronary artery bypass grafting. METHODS: National cohort study of patients who underwent isolated coronary artery bypass grafting (2000-2016) using Veterans Affairs Surgical Quality Improvement Program data. Left ventricular ejection fraction was categorized as ≥35% (n = 55,877), 25%-34% (n = 3893), or <25% (n = 1707). Patients were also categorized as having had no complications, 1 complication, or more than 1 complication. The association between LVEF, complication rescue, and risk of death was evaluated with multivariable Cox regression. RESULTS: Among 61,477 patients, 6586 (10.7%) had a perioperative complication and 2056 (3.3%) had multiple complications. Relative to LVEF ≥35%, decreasing ejection fraction was associated with greater odds of complications (25%-34%, odds ratio, 1.30 [1.18-1.42]; <25%, odds ratio, 1.65 [1.43-1.92]). There was a dose-response relationship between decreasing LVEF and overall risk of death (≥35% [ref]; 25%-35%, hazard ratio, 1.46 [1.37-1.55]; <25%, hazard ratio, 1.68 [1.58-1.79]). Among patients who were rescued from complications, there were decreases in 10-year survival, regardless of LVEF. Among those rescued after multiple complications, LVEF was no longer associated with risk of death. CONCLUSIONS: While decreasing LVEF is associated with post-coronary artery bypass grafting complications, patients rescued from complications have worse long-term survival, regardless of left ventricular function. Prevention and timely treatment of complications should remain a focus of quality improvement initiatives, and future work is needed to mitigate their long-term detrimental impact on survival.

Prevention and management of spinal cord ischemia following aortic surgery: A survey of contemporary practice.

OBJECTIVE: Spinal cord ischemia (SCI) is a devastating complication of thoracoabdominal aortic aneurysm repair. We aim to characterize current practices pertaining to SCI prevention and treatment across Canada. METHODS: Two questionnaires were developed by the Canadian Thoracic Aortic Collaborative and the Canadian Cardiovascular Critical Care Society targeting aortic surgeons and intensivists. A list of experts in the management of patients at risk of SCI was developed, with representation from each of the Canadian centers that perform complex aortic surgery. RESULTS: The response rate was 91% for both intensivists (21/23), and from cardiac and vascular surgeons (39/43). Most surgeons agreed that staging is important during endovascular repair of extent II thoracoabdominal aortic aneurysm (60%) but not for open repair (34%). All of the surgeons felt prophylactic lumbar drains were effective in reducing SCI, whereas only 66.7% of intensivists felt that lumbar drains were effective (P < .001). There was consensus among surgeons over when to employ lumbar drains. A majority of surgeons preferred to keep the hemoglobin over 100 g/L if the patient demonstrated loss of lower-extremity function, whereas most intensivists felt a target of 80 g/L was adequate (P < .001). Management of perioperative antihypertensives, use of intraoperative adjuncts, and management of venous thromboembolism prophylaxis in the presence of a lumbar drain, were highly variable. CONCLUSIONS: We observed some consensus but considerable variability in the approach to SCI prevention and management across Canada. Future studies focused on the areas of variability may lead to more consistent and improved care for this high-risk population.

Functional and Cognitive Decline Among Older Adults After High-risk Surgery.

OBJECTIVE: The aim of this study was to determine whether older adults are at higher risk of lasting functional and cognitive decline after surgery, and the impact of decline on survival and healthcare use. SUMMARY BACKGROUND DATA: Patient-centered outcomes after surgery are poorly characterized. METHODS: Using data from the Health and Retirement Study linked with Medicare, we matched older adults (≥65 years) who underwent one of 163 high-risk elective operations (ie, inpatient mortality of ≥1%) with nonsurgical controls between 1992 and 2012. Functional decline was defined as an increase in the number of activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs) requiring assistance from baseline. Cognitive decline was defined by worse response to a test of memory and mental processing from baseline. Using logistic regression, we examined whether surgery was associated with functional and cognitive decline, and whether declines were associated with poorer survival and increased healthcare use. RESULTS: The matched cohort of patients who did not undergo surgery consisted of 3591 (75%) participants compared to 1197 (25%) who underwent surgery. Patients who underwent surgery were at higher risk of functional and cognitive declines [adjusted odds ratio (aOR) 1.52, 95% confidence interval (CI): 1.23-1.87 and aOR 1.32, 95% CI: 1.03-1.71]. Declines were associated with poorer long-term survival [hazard ratio (HR) 1.67, 95% CI: 1.43-1.94 and HR 1.35, 95% CI: 1.15-1.58], and were significantly associated with nearly all measures of increased healthcare utilization (P < 0.001). CONCLUSION: Older adults undergoing high-risk surgery are at increased risk of developing lasting functional and cognitive declines.

Autograft remodeling after the Ross procedure by cardiovascular magnetic resonance imaging: Aortic stenosis versus insufficiency.

BACKGROUND: Studies suggest that patients undergoing the Ross procedure for aortic insufficiency are at greater risk of autograft dilatation than those with aortic stenosis. By using a tailored Ross technique to mitigate autograft dilatation in patients with aortic insufficiency, we aimed to compare the biomechanical and morphologic remodeling of the autograft at 1 year between patients with aortic insufficiency and patients with aortic stenosis. METHODS: A total of 210 patients underwent a Ross procedure (2011-2016). Of those, 86 patients (mean age 43 ± 13 years; 32% were female) completed preoperative and postoperative cardiovascular magnetic resonance imaging. A total of 71 studies were suitable for analysis: 41 patients with aortic stenosis and 30 patients with aortic insufficiency. Nine healthy adults were used as controls. Autograft root dimensions, individual sinus volumes, and distensibility were measured using cardiovascular magnetic resonance. RESULTS: At 1 year, there was no difference in autograft root dimensions between patients with aortic stenosis (mean annulus 25.1 ± 3.1 mm and sinus diameters 35 ± 4.1 mm) and patients with aortic insufficiency (26.6 ± 3 mm and 37.1 ± 3.5 mm; P = .12 and .06, respectively). Relative sinus of Valsalva volumes were symmetrical in the aortic stenosis (right 34.8% ± 4%, left 33.7% ± 3.5%, noncoronary 31.4% ± 3.2%) and aortic insufficiency groups (34.8% ± 3.9%, 33.8% ± 2.8%, 31.3% ± 3.7%, P = .85, .92, and .82), and similar to those of healthy adults. Aortic root distensibility was reduced in both groups compared with healthy adults (P = .003), but was similar between aortic stenosis (3.12 ± 1.58 × 10-3 mm Hg-1) and aortic insufficiency (3.04 ± 1.15 × 10-3 mm Hg-1; P = .9). CONCLUSIONS: Using a tailored technique, there were no differences in the morphologic or biomechanical remodeling of the autograft root 1 year after the Ross procedure between patients with aortic stenosis and patients with aortic insufficiency. However, autograft roots are stiffer than native aortic roots.

Feasibility Study of Transanal Irrigation Using a Colostomy Irrigation System in Patients With Low Anterior Resection Syndrome.

BACKGROUND: Low anterior resection syndrome has a negative impact on quality of life. Intestinal irrigation is a method of lavage consisting of a scheduled evacuation. OBJECTIVE: This study aims to evaluate functional and quality-of-life outcomes in patients with low anterior resection syndrome after transanal irrigation using a colostomy irrigation system. DESIGN: This was a prospective case series. SETTINGS: This study presents a single-center experience at a tertiary oncological center in an upper-middle-income country. PATIENTS: Patients classified as having minor or major low anterior resection syndrome 12 months after their operation were selected. INTERVENTIONS: Transanal irrigation was performed using an ostomy irrigation kit. Questionnaires assessing patients' bowel function (low anterior resection syndrome and Wexner score) and quality of life (Short Form-36 questionnaire) were applied before and after treatment. MAIN OUTCOME MEASURES: The primary outcomes were low anterior resection syndrome score and quality-of-life improvement after a 12-month treatment. RESULTS: Of the 22 patients included, 20 had major and 2 had minor low anterior resection syndrome, with a median score of 39, especially high rates of incontinence for liquid stool (21; 95.5%), clustering (21; 95.5%), and urgency (17; 77.3%). All patients successfully completed the 3-day training, and there were no complications during the treatment. After the 12-month period, the median score was 8, with 90% of the patients classified as having "no syndrome" and great improvement in all domains of this score. The most improved quality-of-life sections were patient vitality (p = 0.025) and physical (p = 0.002), social (p = 0.001), and emotional aspects (p = 0.001). LIMITATIONS: The study was limited by its small sample size and the limited follow-up period. CONCLUSIONS: This study presents a safe implementation protocol of an ostomy irrigation device for transanal irrigation. It also adds to the literature that transanal irrigation is a safe, effective, and easily implemented procedure for patients with low anterior resection syndrome with a significant improvement in quality of life. See Video Abstract at http://links.lww.com/DCR/B563.ESTUDIO DE FACTIBILIDAD DE LA IRRIGACIÓN TRANSANAL UTILIZANDO EL SISTEMA DE IRRIGACIÓN PARA COLOSTOMÍA EN PACIENTES CON SÍNDROME DE RESECCIÓN ANTERIOR BAJAANTECEDENTES:El síndrome de resección anterior baja tiene un impacto negativo en la calidad de vida de los pacientes. La irrigación intestinal es un método de lavado que consiste en evacuaciones programadas.OBJETIVOS:Evaluar los resultados de la funcionalidad e impacto en la calidad de vida de los pacientes con síndrome de resección anterior y baja posterior a la irrigación transanal utilizando un sistema de irrigación de colostomía.DISEÑO:Es estudio prospectivo de una serie de casos.ESCENARIO:En este estudio se muestra la experiencia de un centro oncológico de tercer nivel en un país en vías de desarrollo.PACIENTES:Aquellos clasificados como síndrome con afección en menor o mayor grado doce meses después de la cirugía.METODO:Se efectuó irrigación transanal utilizando un equipo de irrigación de estomas. Se aplicaron cuestionarios para valorar la función intestinal de los pacientes (síndrome de resección anterior baja y la escala de Wexner) y para calidad de vida (Cuestionario Corto-36) antes y después del tratamiento.EVALUACION DE LOS RESULTADOS PRINCIPALES:Los principales resultados se obtuvieron de la escala del síndrome de resección baja y la mejoría en la calidad vida doce meses después de tratamiento.RESULTADOS:De los veintidós pacientes incluidos, veinte presentaron manifestaciones mayores del síndrome de resección baja y dos, manifestaciones menores. Con una media de treinta y nueve, se encontraron, especialmente, altos índices de incontinencia a líquidos (21; 95'5%) hiperdefecación "clustering" (21; 95'5%) y urgencia (17; 77'3%). Todos los pacientes completaron en forma satisfactoria el entrenamiento de tres días sin presentarse complicaciones durante el tratamiento. Al término del mes doce la media fue de ocho, con el 90% de los pacientes clasificados como "sin síndrome" y se observó una mejoría substancial en todos los puntos de la evaluación. Las secciones de calidad de vida que mostraron una mejoría significativa fueron: la vitalidad del paciente (p = 0'025), física (p = 0'002), social (p = 0'001) y emocional (p = 0'001).LIMITACIONES:El tamaño de la muestra es pequeño y el tiempo de seguimiento corto.CONCLUSIONES:Este estudio muestra la implementación de un protocolo seguro para la irrigación de estomas mediante un dispositivo transanal. Además contribuye con el concepto en la literatura de que la seguridad de la irrigación transanal es seguro, efectivo y facilmente reproducible para pacientes con síndrome de resección anterior baja con una mejoría significativa en la calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B563. (Traducción-Dr. Miguel Esquivel-Herrera).

Glial cell-derived neurotrophic factor decrease may mediate learning, memory and behavior impairments in rats after neonatal surgery.

Patients who have surgery during the first few years of their lives may have an increased risk of behavioral abnormality. Our previous study has shown a role of glial cell-derived neurotrophic factor (GDNF) in neonatal surgery-induced learning and memory impairment in rats. This study was designed to determine whether neonatal surgery induced hyperactive behavior in addition to learning and memory impairment and whether GDNF played a role in these changes. Postnatal day 7 male and female Sprague-Dawley rats were subjected to right common carotid arterial exposure under sevoflurane anesthesia. Their learning, memory and behavior were tested from 23 days after the surgery. GDNF was injected intracerebroventricularly at the end of surgery. Surgery reduced GDNF expression in the hippocampus. Surgery impaired learning and memory and induced a hyperactive behavior as assessed by Barnes maze, fear conditioning and open field tests. In addition, surgery reduced dendritic arborization and spine density. The effects were attenuated by GDNF injection. These results suggest that surgery induces a hyperactive behavior pattern, impairment of learning and memory, and neuronal microstructural damage later in the lives in rats. GDNF reduction may mediate these surgical effects.