Locoregional Anaesthesia for Laparotomy: A Literature Review and Subsequent Case Series Highlighting the Potential of an Alternative Anaesthetic Technique.

Laparotomy is a surgical incision utilised in both emergency and elective scenarios to gain access to abdominal surgery. General anaesthesia is usually necessitated due to the substantial insult of the approach and to facilitate organ relaxation and paralysis. However, this brings with it the need for an assessment of the suitability of the anaesthetic technique, with a large number of patients having comorbidities significant enough to exclude them from surgery. Locoregional anaesthesia, provided via spinal, epidural, or a combined approach offers a means of providing anaesthesia that places a reduced level of strain on patients' cardiorespiratory function. We review the existing literature on the topic of so-called "awake laparotomy" performed with locoregional anaesthesia and present a case series including both elective and emergency procedures.

Complete Spontaneous Regression of Colorectal Cancer: A Report of Two Cases.

Spontaneous regression of cancer is rare, and rarer still in colorectal cancer. We present a report of two cases of spontaneous regression of histologically proven proximal colonic cancers described in detail, alongside endoscopic, histological, and radiological images. We discussed the potential mechanisms by reviewing previous literature.

Under-reporting of gastrointestinal bleeding associated with anticoagulant use using the UK Yellow Card Scheme.

BACKGROUND: The Yellow Card Scheme was created in 1964 to oversee new and existing medicines and medical devices, and act as an early warning system for unexpected adverse drug reactions (ADRs). Under-reporting within the system is a known issue, estimated to be as high as 94% in a 2006 systematic review. Anticoagulants are often prescribed in the UK to prevent stroke in patients with atrial fibrillation but can be associated with gastrointestinal bleeding as a common ADR. AIM: The study aimed to investigate the incidence of suspected DOAC-related GI bleeds at a North-West England hospital and explore the volume of these incidents reported through the MHRA Yellow Card Scheme, over a 5-year period. METHOD: Hospital coding data was used to identify patient records with GI bleeding and cross-referenced with electronic prescribing records for anticoagulant usage. Additionally, pharmacovigilance reporting activity for the Trust was obtained from the MHRA Yellow Card Scheme. RESULTS: For the period investigated, the Trust recorded 12,013 GI bleed related emergency admissions. Of these admissions, 1058 patients were taking a DOAC. During the same time period, a total of 6 DOAC-related pharmacovigilance reports were made by the trust. CONCLUSION: Utilisation of the Yellow Card System for reporting potential ADR is poor, leading to under-reporting of ADRs.

Human Milk Oligosaccharides Are Associated with Lactation Stage and Lewis Phenotype in a Chinese Population.

BACKGROUND: Human milk oligosaccharides (HMOs) are the third most abundant component of human milk. Various factors may affect the concentration of HMOs, such as the lactation period, Lewis blood type, and the maternal secretor gene status. OBJECTIVES: The purpose of this study is to investigate factors associated with HMO concentrations in Chinese populations. METHODS: A sub-sample of 481 was randomly selected from a large cross-sectional study in China (n = 6481) conducted in eight provinces (Beijing, Heilongjiang, Shanghai, Yunnan, Gansu, Guangdong, Zhejiang, and Shandong) between 2011 and 2013. HMO concentrations were determined by a high-throughput UPLC-MRM method. Various factors were collected through face-to-face interviews. Anthropometric measurement was conducted by trained staff. RESULTS: Median total HMO concentration was 13.6 g/L, 10.7 g/L, and 6.0 g/L for colostrum, transitional milk, and mature milk, respectively. HMO concentration decreased significantly as the lactation period increased (p < 0.0001). There were significant differences of average total HMO concentration between secretor mothers and non-secretor mothers (secretor 11.3 g/L vs. non-secretor 5.8 g/L, p < 0.0001). There were significant differences of average total HMO concentrations among three Lewis blood types (p = 0.003). Comparing with the concentration of total oligosaccharides of Le+ (a-b+), average of total oligosaccharides concentrations increased by 3.9 (Le+ (a+b-), p = 0.004) and 1.1 g/L (Le- (a-b-), p = 0.049). The volume of breast milk expressed and the province the mother came from affected the concentration of total oligosaccharides (all p < 0.0001). Maternal BMI (p = 0.151), age (p = 0.630), prematurity (p = 0.850), mode of delivery (p = 0.486), infants' gender (p = 0.685), maternal education level (p = 0.989), maternal occupation (p = 0.568), maternal allergic history (p = 0.370), maternal anemia (p = 0.625), pregnancy-induced hypertension (p = 0.739), gestational diabetes (p = 0.514), and parity (p = 0.098) were not significantly correlated with the concentration of milk oligosaccharides. The concentrations of 2'-fucosyllactose (2'-FL), lacto-N-neotetraose (LNnT), sialyllacto-N-tetraose c (LSTc), lacto-N-fucopentaose I (LNFP-I), disialylated lacto-N-tetraose (DSLNT), difucosyl-para-lacto-N-neohexaose (DFpLNnH), difucosyl-lacto-N-hexaose (DFLNH[a]), and 3-sialyllactose (3'-SL) showed a gradual downward trend, while the concentration of 3-fucosyllactose (3-FL) showed a gradual upward trend among three lactation stages (p < 0.05). CONCLUSIONS: The concentration of HMOs changes throughout lactation, and it varies between different HMOs. HMO concentrations differed between lactation stage, maternal secretor gene status, Lewis blood type, volume of breast milk expressed, and the province the mother came from. Prematurity, mode of delivery, parity, infants' gender, and maternal characteristics did not affect the HMO concentration. Geographical region may be not associated with HMOs concentration in human milk. There may be a mechanism for co-regulation of the secretion of some of the oligosaccharides such as 2'FL vs. 3FL, 2'FL vs. LNnT, and lacto-N-tetraose (LNT).

Hernioscopy: A Description of an Adjunct Technique in Emergency Femoral Hernia Surgery.

Femoral hernias commonly present as an emergency with a large proportion strangulated or with contents that are threatened. Many surgical options are available including minimally invasive surgery and multiple open approaches. A low approach allows a relatively simple repair of the hernia and has a long-established history of safety with reproducible outcomes and low recurrence rates. It is technically less challenging than a high approach but does not allow easy assessment or management of hernia sac contents. We highlight and describe a technique that can be used when the hernia reduces spontaneously at induction, or when the surgeon cannot be confident that the contents are viable. Hernioscopy is the technique of utilizing a laparoscope inserted via the hernia sac to either examine the abdominal contents or facilitate the safe creation of pneumoperitoneum and further insertion of ports transabdominally when the patient has pelvic adhesions. We describe the operative steps taken to make this a feasible approach and reduce the need for unnecessary laparotomies and the associated morbidity.

The Utility of Minimally Invasive Surgery in the Emergency Management of Femoral Hernias: A Systematic Review.

Background: Femoral hernias are a relatively rare type of hernia but have a high complication rate, with a high proportion either presenting as an emergency or requiring emergency management. Minimal access surgery has been shown to be safe, with good results, in an elective setting, but there is little published evidence of its utility in an emergency. Methods: A systematic review was conducted searching PubMed, OVID, Embase, and Cochrane reviews for ((Femoral hernia) AND (laparoscop* OR minimal access OR robotic)) AND (strangulat* OR obstruct* OR incarcerat*). Results: 286 manuscripts were identified of which 33 were relevant. 24 were individual case reports, 3 case series, 4 cohort studies or case control series, and 2 high level reviews of National registers. Conclusion: Minimal access surgery can avoid an unnecessary laparotomy for the assessment of hernial contents, especially via a TAPP approach. Minimal access repair of femoral hernias as an emergency is feasible and can be done safely with results similar to open surgery but good quality evidence is lacking.

Management of a Pediatric Patient With a Left Ventricular Assist Device and Symptomatic Acquired von Willebrand Syndrome Presenting for Orthotopic Heart Transplant.

We present the successful perioperative management of an 11-year-old patient presenting for heart transplant with a left ventricular assist device, symptomatic acquired von Willebrand syndrome, and recent preoperative intracranial hemorrhage. A brief review of the pathophysiology of acquired von Willebrand syndrome is included. As the number of pediatric patients supported with ventricular assist devices continues to increase, the management of symptomatic acquired von Willebrand syndrome during the perioperative period is an important consideration for anesthesiologists.

Perforated necrotic appendix in Amyand's hernia treated with appendicectomy and simple suture repair of the inguinal hernia.

A 50-year-old man was referred to the emergency department by his general practitioner with a tender right-sided irreducible inguinal hernia (previously reducible), right-sided testicular pain and scrotal swelling. Clinical examination revealed a non-reducible, tender right inguinal-scrotal hernia and swollen right scrotum. Blood tests showed raised inflammatory markers. The patient went on to have a CT scan which was reported to show an indirect right inguinal-scrotal hernia possibly containing terminal ileum and small bowel mesentery. The scan also showed increased infiltrate changes within the hernia sac suggesting incarceration with possible early strangulation but no obvious evidence of bowel obstruction. The patient was taken to the operating theatre and found to have a large right inguinal-scrotal hernia containing pus and a perforated necrotic appendix. He went to have an appendicectomy and sutured repair of the hernia. Postoperatively, the patient made a good recovery and was discharged 2 days postsurgery.

Perfusion Methods and Modifications to the Cardiopulmonary Bypass Circuit for Midline Unifocalization Procedures.

Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs) is a rare form of congenital heart disease. The midline unifocalization procedure has been developed for the treatment of PA/VSD/MAPCAs. These are complex and very lengthy procedures that require an entirely different method of perfusion. The purpose of this study was to review our perfusion modifications to support these unifocalization procedures. Sixty-four unifocalization procedures have been performed at our institution during the past 3 years. The median age was 4.1 months (range 1 month-3.5 years) and the median weight at surgery was 4.5 kg (range 3.5-19 kg). The median duration of cardiopulmonary bypass was 352 minutes (range 128-629 minutes), and the median duration of cross-clamp was 24 minutes (range 14-72 minutes). The conduct of surgery included cooling to a rectal perfusion temperature of 25° and a flow rate of 100 mL/kg/min. A pH-stat strategy and del Nido cardioplegia were used. Modifications to the cardiopulmonary bypass circuit include upsizing the oxygenator, reservoir, cannulae, vent catheter, and tubing. All circuits were modified to include the capability of performing an intraoperative flow study. This study is used to determine whether the VSD can be closed during surgery. A collateral flow study circuit is also set up for first-time operations to measure the residual collateral flow after all of the MAPCAs have been harvested. Patients who require midline unifocalization will invariably require very lengthy periods of support on cardiopulmonary bypass. We have adapted our perfusion circuitry to prepare for the demands on the bypass circuit to meet the requirements of this patient population. Our institution has developed a systematic approach for the conduct of perfusion to best serve our patients presenting with PA/VSD/MAPCAs.

Measurement of Residual Collateral Flow in Pulmonary Atresia With Major Aortopulmonary Collaterals.

BACKGROUND: Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (MAPCAs) is a rare form of congenital heart disease characterized by the entirety of pulmonary blood flow originating from systemic vessels. This study measured the residual collateral flow after harvesting of the MAPCAs for surgical repair. METHODS: The study enrolled 32 patients with pulmonary atresia with ventricular septal defect and MAPCAs who were undergoing their first surgical procedure. The median age was 6.8 months, and median weight was 5.7 kg. The patients had a mean of 4.2 ± 0.7 MAPCAs. The cardiopulmonary bypass circuit was modified to contain a diversion loop in the left ventricular vent system to accurately measure residual collateral flow. During the period of aortic cross-clamp (for ventricular septal defect repair), the diversion loop was opened for 1-minute intervals, and the residual collateral flow collected. The systemic perfusion temperature was 25° and flow rate was 100 mL · kg-1 · min-1. RESULTS: The mean residual collateral flow was 5.5 mL · kg-1 · min-1 (range, 0.8 to 15.2 mL · kg-1 · min-1). The corresponding calculated pulmonary blood flow-to-systemic blood flow ratio values ranged from 1.01 to 1.36. There was a significant correlation between residual collateral flow and preoperative saturation (p < 0.05). CONCLUSIONS: The data demonstrate a wide range of residual collateral flow values after harvesting of the MAPCAs. The amount of residual collateral flow was correlated with preoperative saturation. These results suggest that some patients at the higher end of this spectrum may require adjustments in pump flow to assure adequate systemic perfusion.

Utilization of Del Nido Cardioplegia in Adult Coronary Artery Bypass Grafting　- A Retrospective Analysis.

BACKGROUND: Studies assessing the safety and effectiveness of Del Nido cardioplegia for adult cardiac surgery remain limited. We investigated early outcomes after coronary artery bypass grafting (CABG) using single-dose Del Nido cardioplegia vs. conventional multi-dose blood cardioplegia. Methods and Results: The 81 consecutive patients underwent isolated CABG performed by a single surgeon. The initial 27 patients received anterograde blood cardioplegia, while the subsequent 54 patients received anterograde Del Nido cardioplegia. There were no differences in the baseline characteristics of each group nor any differences in the 30-day incidences of myocardial infarction, all-cause death, and readmission following surgery. The use of Del Nido cardioplegia was associated with shorter cardiopulmonary bypass time (98 vs. 115 min, P=0.011), shorter cross-clamp time (74 vs. 87 min, P=0.006), and decreased need for intraoperative defibrillation (13.0% vs. 33.3%, P=0.030) compared with blood cardioplegia. To control for the difference in cross-clamp time, we performed propensity score matching with a logistical treatment model and confirmed that Del Nido cardioplegia provided similar outcomes as blood cardioplegia and also reduced the need for defibrillation independent of cross-clamp time. CONCLUSIONS: Compared with conventional blood cardioplegia, Del Nido cardioplegia provided excellent myocardial protection with reduced need for intraoperative defibrillation, shorter bypass and cross-clamp times, and comparable early clinical outcomes for adult patients undergoing CABG.

Epoprostenol Therapy for a Pediatric Patient With Subacute Heparin-Induced Thrombocytopenia and a Ventricular Assist Device Undergoing Heart Transplant: A Case Report.

Concerns remain regarding the use of direct thrombin inhibitors for cardiopulmonary bypass anticoagulation in pediatric patients with heparin-induced thrombocytopenia undergoing complex cardiac surgery. We describe the safe and effective use of epoprostenol sodium as an alternative therapy before heparin exposure for a pediatric patient with subacute heparin-induced thrombocytopenia and a ventricular assist device undergoing heart transplant.

Characteristics of deposits and pump exchange in the Berlin Heart EXCOR ventricular assist device: Experience with 67 cases.

Pump exchanges are frequently required in the Berlin Heart EXCOR VAD. We intended to describe the characteristics of pump deposits in a larger patient series and evaluate if changes in our exchange procedure over time have led to increased complications. We reviewed all EXCOR pump exchanges in our institution from July 2004 to October 2014. We gathered data on size and location of pump deposits and exchange procedures. EXCOR devices were implanted in 38 children. Support was LVAD only in 22, BiVAD in 13, and SVAD in 3 cases. Sixty-seven pumps were exchanged. The incidence of pump exchanges per month was higher for smaller pumps and for RVADs vs LVADs. Indications were visible pump deposit in 55, stroke without visible deposit in 5, incorporation of membrane oxygenator in 3, pump size change in 2, and sepsis in 1 case, respectively. Deposits were located in the outflow valve in 73%, inflow valve in 22%, pump body in 3%, and outflow cannula in 3%. EXCOR pumps are predominantly exchanged for deposits, which are most frequently located in the outflow valves. The procedure is now carried out without sedation at the bedside. No major complications were observed during exchanges.

Long-Term Pediatric Ventricular Assist Device Therapy: A Case Report of 2100+ Days of Support.

Ventricular assist devices (VADs) have been placed as destination therapy in adults for more than 20 years, but have only recently been considered an option in a subset of pediatric patients. A 2016 report from the Pediatric Interagency Registry for Mechanical Circulatory Support revealed only eight pediatric patients implanted with a VAD as destination therapy. Herein, we report the case of an adolescent male with Becker muscular dystrophy who underwent VAD placement in 2011 as bridge to candidacy. He subsequently decided to remain as destination therapy and so far has accrued more than 2100 days on VAD support, the longest duration of pediatric VAD support reported in the literature to date.

Temporary Circulatory Support in U.S. Children Awaiting Heart Transplantation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has long served as the standard of care for short-term mechanical circulatory support in pediatrics. It is unknown whether newer-generation temporary circulatory support (TCS) devices afford children a meaningful survival advantage over ECMO. OBJECTIVES: This study sought to determine whether bridge-to-heart transplant survival with a TCS device is superior to ECMO after adjusting for patient differences. METHODS: All children ≤21 years of age listed for heart transplant from 2011 to 2015 who received a TCS device or ECMO as a bridge to transplant were identified using Organ Procurement and Transplantation Network data. Children supported with a TCS device were compared with a propensity score (PS)-matched cohort of children supported with ECMO as a bridge to transplant. The primary endpoint was Kaplan-Meier survival to transplant. RESULTS: The number of TCS devices implanted in children increased from ≤3 per year before 2011 to 50 in 2015. Overall, 93 patients implanted with TCS devices were included for analysis (59% left ventricular assist devices, 23% right ventricular assist devices, 18% biventricular assist devices). The most commonly used device was the CentriMag-PediMag system (65%), followed by TandemHeart (18%), Rotaflow (6%), and Impella (5%). Among 164 PS-matched patients, support duration was longer for the TCS cohort (median 19 days vs. 6 days; p < 0.001), and was longest for the CentriMag-PediMag (24 days vs. 6 days; p < 0.001) with 27% supported for >60 days. Compared with the ECMO cohort, the PS-matched TCS cohort had longer survival to transplant (hazard ratio: 0.49; 95% confidence interval: 0.30 to 0.79) and longer overall survival (hazard ratio: 0.61; 95% confidence interval: 0.39 to 0.96), with 90-day mortality before transplant that was modestly reduced (from 45% with ECMO to 39% with TCS). CONCLUSIONS: The use of TCS devices in children as a bridge to transplant has risen rapidly in recent years, led by the growth of magnetically levitated centrifugal flow pumps. Compared with conventional ECMO, TCS durations are longer, and more importantly, patient survival is superior.

Cerebral oxygen metabolism during total body flow and antegrade cerebral perfusion at deep and moderate hypothermia.

The aim of this study is to evaluate the effect of temperature on cerebral oxygen metabolism at total body flow bypass and antegrade cerebral perfusion (ACP). Neonatal piglets were put on cardiopulmonary bypass (CPB) with the initial flow rate of 200mL/kg/min. After cooling to 18°C (n=6) or 25°C (n=7), flow was reduced to 100mL/kg/min (half-flow, HF) for 15min and ACP was initiated at 40mL/kg/min for 45min. Following rewarming, animals were weaned from bypass and survived for 4h. At baseline, HF, ACP, and 4 h post-CPB, cerebral blood flow (CBF) was measured using fluorescent microspheres. Cerebral oxygen extraction (CEO(2) ) and cerebral metabolic rate of oxygen (CMRO(2) ) were monitored. Regional cranial oxygen saturation (rSO(2) ) was continuously recorded throughout the procedure using near-infrared spectroscopy. At 18°C, CBF trended lower at HF and ACP and matched baseline after CPB. CEO(2) trended lower at HF and ACP, and trended higher after CPB compared with baseline. CMRO(2) at ACP matched that at HF. Cranial rSO(2) was significantly greater at HF and ACP (P<0.001, P<0.001) and matched baseline after CPB. At 25°C, CBF trended lower at HF, rebounded and trended higher at ACP, and matched baseline after CPB. CEO(2) was equal at HF and ACP and trended higher after CPB compared with baseline. CMRO(2) at ACP was greater than that at HF (P=0.001). Cranial rSO(2) was significantly greater at HF (P=0.01), equal at ACP, and lower after CPB (P=0.03). Lactate was significantly higher at all time points (P=0.036, P<0.001, and P<0.001). ACP provided sufficient oxygen to the brain at a total body flow rate of 100mL/kg/min at deep hypothermia. Although ACP provided minimum oxygenation to the brain which met the oxygen requirement, oxygen metabolism was altered during ACP at moderate hypothermia. ACP strategy at moderate hypothermia needs further investigation.

Case report: a thrombus in the venous reservoir while using bivalirudin in a patient with heparin-induced thrombocytopenia undergoing heart transplantation.

Direct thrombin inhibitors are heparin alternatives for anticoagulation during cardiopulmonary bypass in patients with heparin-induced thrombocytopenia. We report a case of a large thrombus forming in the venous reservoir while using bivalirudin. We suggest that blood stasis associated with the full venous reservoir maintained in this case led to formation of a large thrombus at the top of the venous canister. Furthermore, activated clotting times may not accurately reflect the magnitude of anticoagulation when using direct thrombin inhibitors.

Does a delay in performing an activated clotting (ACT) test really matter? A study in nonheparinized blood and a single ACT machine.

Activating clotting time (ACT) is a point-of-care, blood clotting test used to monitor anticoagulation. Recently, institutional requirements have required that ACT testing be completed outside the operating room with trained, certified personnel other than anesthesia staff. For this reason, in this study, we looked at whether a delay in processing an ACT makes a significant difference to the ACT results. Twenty patients between 18 and 65 years of age consented to the study, each undergoing non-cardiac surgery, with no intraoperative administration of heparin. The study was approved by our Institutional Review Board. A blood sample was taken from the patient's arterial line in the operating room. Immediately afterward, 1 mL was placed into each of two ACT cartridges and the measurement was done in a Medtronic ACT2 machine. The first ACT value was 126.9 +/- 14.5 seconds. The ACT value at approximately 30 minutes was 108.3 +/- 20.3 seconds (p < .0001). The time between the first and last measurements was 29.4 +/- 3.0 minutes. The results suggest that the ACT values decrease over time between sampling all measurements. At approximately 30 minutes, the ACT values average 15% less than the control measurements. Therefore, it would seem prudent to determine ACT values immediately in the operating room without any delay, using point-of-care testing.