Decreasing length of stay in bariatric surgery: The power of suggestion.

OBJECTIVE: Enhanced recovery has been utilized to decrease length of stay and cost in bariatric surgery. We have recently focused efforts on pre-operative education with regards to discharge on the first post-operative day. The aim of this study was to determine the effectiveness of pre-operative education on discharge timing and readmission rates. METHODS: A retrospective review was conducted after revising discharge expectation education. Patients undergoing first time bariatric operations were included. Early group education focused on average patient stay of 2 postoperative days. Revised education informed patients they could go home on the first post-operative day. RESULTS: A total of 125 patients met inclusion criteria. Implementation of preoperative education was associated with a decrease in mean LOS and greater percentage of patients discharged on post-operative day one. There was no difference in readmission and complication rates. CONCLUSION: Effective pre-operative education can decrease length of stay in first time laparoscopic bariatric surgery.

Extended pharmacologic thromboprophylaxis in oncologic liver surgery is safe and effective.

Essentials The risk for venous thromboembolism after liver surgery remains high in the modern era. We evaluated the safety/efficacy of extended anticoagulation in liver surgery. This protocol reports zero venous thromboembolism events in 124 liver surgery patients. Extended anticoagulation after oncologic liver surgery is safe and effective. SUMMARY: Background The incidence of venous thromboembolism (VTE) after liver surgery remains high. Objective To evaluate the safety and efficacy of extended pharmacologic thromboprophylaxis after liver surgery for the prevention of VTE. Patient/Methods From August 2013 to April 2015, 124 patients who underwent liver resection for malignancy were placed on an extended pharmacologic thromboprophylaxis protocol. Intraoperative VTE prophylaxis included thromboembolic deterrent hoses and sequential compression devices. Once hemostasis had been ensured following hepatectomy, daily anticoagulant VTE prophylaxis was initiated for the duration of hospitalization. After hospital discharge, the large majority of patients (114, 91.9%) continued to receive anticoagulant thromboprophylaxis (enoxaparin) to complete a total course of 14 days after minor/minimally invasive hepatectomy or 28 days after major hepatectomy or a history of VTE. Results The cohort included 39 (31.2%) major hepatectomies and 38 (31.5%) minor/minimally invasive approaches. The intraoperative, postoperative and overall transfusion rates were 5.6%, 8.1%, and 10.5%, respectively. Pharmacologic thromboprophylaxis was started on postoperative day (POD) 0 for 40 (32.3%) patients and on POD 1 for 84 (67.7%) patients. During 90 days of follow-up, no postoperative symptomatic deep vein thrombosis or pulmonary embolic events were diagnosed. Standard-protocol computed tomography scans of the chest, abdomen and pelvis that were obtained for 112 (90.3%) study patients showed no pulmonary emboli, or other thoracic, splanchnic or ileofemoral vein thromboses. Two (1.6%) patients had minor bleeding events that resolved after discontinuation of enoxaparin, requiring neither blood transfusion nor reoperation. The severe complication rate was 5.6%, with no 90-day mortalities. Conclusions These preliminary data suggest that extended pharmacologic thromboprophylaxis for liver surgery patients is safe and effective.

Incidence and impact of postoperative atrial fibrillation after minimally invasive esophagectomy.

Atrial fibrillation (AF) following open esophagectomy has been associated with increased rates of pulmonary and anastomotic complications, and mortality. This study seeks to evaluate effects of AF after minimally invasive esophagectomy (MIE). A retrospective review of patients consecutively treated with MIE for esophageal carcinoma, dysplasia. and benign disease from November 2006 to November 2011 was performed. One hundred twenty-one patients underwent MIE. Median age was 65 years (range 26-88) with 85% being male. Thirty-eight (31.4%) patients developed AF postoperatively. Of these 38 patients, 7 (18.4%) had known AF preoperatively. Patients with postoperative AF were significantly older than those without postoperative AF (68.7 vs. 62.8 years, P = 0.008) and more likely to be male (94.7% vs. 80.7%, P = 0.04). Neoadjuvant chemoradiation showed a trend toward increased risk of AF (73.7% vs 56.6%, P = 0.07). Sixty-day mortality was 2 of 38 (5.3%) in patients with AF and 4 of 83 (6.0%) in the no AF cohort (P = 1.00). The group with AF had increased length of hospitalization (13.4 days vs. 10.6 days P = 0.02). No significant differences in rates of pneumonia (31.6% vs. 21.7% P = 0.24), stricture (13.2% vs. 26.5% P = 0.10), or leak requiring return to operating room (13.2% vs. 8.4% P = 0.51) were noted between groups. We did not find an increased rate of AF in our MIE cohort compared with prior reported rates in open esophagectomy populations. AF did result in an increased length of stay but was not a predictor of other short-term morbidities including anastomotic leak, pulmonary complications, stenosis, or 60-day mortality.

Geographical variability in life-history traits of a midslope dogfish: the brier shark Deania calcea.

Deania calcea (n = 420) were collected from the catch of deep-water trawlers in the southern and eastern scalefish and shark fishery in southern Australia during the years 2008-2011. The total length (LT ) range varied between sexes, females being larger (n = 264; 280-1530 mm) than males (n = 156; 310-921 mm). The reproductive cycle in this population is non-continuous and asynchronous. The estimated LT at which 50% of males are mature is 807 mm and is 914 mm for females. Populations of D. calcea in higher latitudes appear to mature at a larger size than conspecifics in lower latitudes, in both the northern and southern hemispheres. Litters ranged from three to 10 embryos with a 1:1 sex ratio, but litter size does not increase with maternal LT . Deania calcea shows geographical variability in its biological parameters and gathering information on life-history traits of populations is vital to understand the trade-offs made by this species in response to environmental conditions and to predict intraspecific spatial differences. Such information is a basis for specific spatial management to protect populations from excessive fishing.

Reproductive biology of the greeneye spurdog Squalus chloroculus (Squaliformes, Squalidae).

The reproduction of the greeneye spurdog Squalus chloroculus was studied based on animals caught in the multispecies and multi-gear southern and eastern scalefish and shark fishery on the upper continental slope off southern Australia. One hundred and ninety-nine females (502-990 mm, total length, LT ) and 189 males (515-810 mm LT ) were examined. The female reproductive cycle, based on 41 breeding animals, is continuous and triennial, with the pregnancy period estimated to be 31-34 months, seasonal and synchronous with the ovarian cycle; a third of the breeding female population is estimated to give birth between September and December each year. The estimated LT at which 50% of females are mature is 799 mm (95% c.i.: 794, 804), whereas the LT at which 50% are maternal is 825 mm (95% c.i.: 817-833), but these estimates are probably biased by the phenomenon of apparent change of LT at maternity and LT at maturity following severe length-selective fishing mortality. Litters ranged from four to 15 embryos with a 1:1 sex ratio, and litter size increased with maternal length. The breeding cycle of males is neither seasonal nor synchronous with the female cycle. The estimated LT of males where 50% are mature was 629 mm (95% c.i.: 603, 645).

Prevalence of variants in methylenetetrahydrofolate reductase and the severity of pulmonary vascular disease.

Pulmonary hypertension is a serious disease associated with constriction, cellular proliferation, inflammation, and in situ thrombosis of the small vessels of the lung. Some studies suggest that homozygous 677TT variants and compound heterozygous 677CT/1298AC variants in methylenetetrahydrofolate reductase may increase the risk for systemic vascular disease. We sought to determine the prevalence of variants in methylenetetrahydrofolate reductase in patients with pulmonary hypertension, and whether homozygous or compound heterozygous variants are associated with an increased severity of disease. The medical records of patients with pulmonary hypertension were retrospectively reviewed to identify 105 patients who were evaluated for variants in methylenetetrahydrofolate reductase. The frequency of the minor allele 677C > T was 0.352 and the frequency of the minor allele 1298A > C was 0.295. The number of patients who were homozygous 677TT, homozygous 1298CC or compound heterozygous 677CT/1298AC was similar to the number of control patients with corresponding variants in a meta-analysis of studies. Patients with homozygous or compound heterozygous variants had a significantly higher ratio of pulmonary to systemic vascular resistance (0.75 ± 0.07 vs. 0.56 ± 0.04, p = 0.019) during baseline heart catheterization. Twenty-five of 61 patients without, and 28 of 44 patients with, homozygous or compound heterozygous variants had moderate to severe disease (p = 0.030). Variants in methylenetetrahydrofolate reductase are common in the general population and in patients with pulmonary hypertension. It is unlikely that these variants cause pulmonary vascular disease; however, they may influence the progression or severity of disease.

Parameterization of European perch Perca fluviatilis length-at-age data using stochastic Gompertz growth models.

Three stochastic versions of the Gompertz growth model were used to parameterize total length (L(T) )-at-age data for perch Perca fluviatilis, an important target species for commercial and recreational fishers and a food species for predatory fishes and aquatic birds. Each model addresses growth heterogeneity by incorporating random parameters from a specific positive distribution: Weibull, gamma or log-normal. The modelling outputs for each version of the model provide L(T) distributions for selected ages and percentiles of L(T) at age for both males and females. The results highlight the importance of using a stochastic approach and the logistic-like growth pattern for analysing growth data for P. fluviatilis in Curonian Lagoon (Lithuania). Outputs from this modelling can be extended to a stochastic analysis of fish cohort dynamics, incorporating all length-based biological relationships, and the selectivity-related interactions between fish cohorts and fishing gear.

Using rapid assessment and demographic methods to evaluate the effects of fishing on Heterodontus portusjacksoni off far-eastern Victoria, Australia.

A rapid semi-quantitative ecological risk assessment method (productivity and susceptibility analysis) indicated that, despite its low biological productivity, the Port Jackson shark Heterodontus portusjacksoni is at low risk to all fishing methods in far-eastern Victoria, Australia, under the present fishing practices, because of its low catch susceptibility. The risk to this population, however, would increase if the shark gillnet fishery operating in the region were to retain the species as a by-product. Demographic analysis indicated that the species has medium intrinsic population growth rate and potential rebound in comparison with other chondrichthyan species, juveniles have higher elasticity than mature females and both juvenile and mature females have higher elasticities than hatchlings. Because of its low biological productivity and moderate resilience to the effects of fishing, cautious management measures will be necessary to ensure the sustainable use of H. portusjacksoni if its marketing increases in the future. Information on the dynamics of a population that is valuable to provide management advice can be obtained through demographic methods, but rapid assessment methods can also provide complementary information on the effects of fishing by considering the catch susceptibility of the population to each fishing method.

Childhood leukaemia in Belarus, Russia, and Ukraine following the Chernobyl power station accident: results from an international collaborative population-based case-control study.

BACKGROUND: There is little evidence regarding the risk of leukaemia in children following exposure to radionuclides from the Chernobyl Nuclear Power Plant explosion on April 26, 1986. METHODS: This population-based case-control study investigated whether acute leukaemia is increased among children who were in utero or <6 years of age at the time of the Chernobyl accident. Confirmed cases of leukaemia diagnosed from April 26, 1986 through December 31, 2000 in contaminated regions of Belarus, Russia, and Ukraine were included. Two controls were matched to each case on sex, birth year, and residence. Accumulated absorbed radiation dose to the bone marrow was estimated for each subject. RESULTS: Median estimated radiation doses of participants were <10 mGy. A significant increase in leukaemia risk with increasing radiation dose to the bone marrow was found. This association was most evident in Ukraine, apparent (but not statistically significant) in Belarus, and not found in Russia. CONCLUSION: Taken at face value, these findings suggest that prolonged exposure to very low radiation doses may increase leukaemia risk as much as or even more than acute exposure. However the large and statistically significant dose-response might be accounted for, at least in part, by an overestimate of risk in Ukraine. Therefore, we conclude this study provides no convincing evidence of an increased risk of childhood leukaemia as a result of exposure to Chernobyl radiation, since it is unclear whether the results are due to a true radiation-related excess, a sampling-derived bias in Ukraine, or some combination thereof. However, the lack of significant dose-responses in Belarus and Russia also cannot convincingly rule out the possibility of an increase in leukaemia risk at low dose levels.

Cerebral blood flow velocity acutely decreases in newborns who respond to inhaled nitric oxide.

Regional cerebral blood flow is directly proportional to the Doppler velocity time integral of flow in corresponding cerebral arteries. This study was performed to determine whether an acute change in the velocity time integral of cerebral blood flow occurs in newborns with pulmonary hypertension who experience an acute improvement in pulmonary hemodynamics and gas exchange at the onset of inhaled nitric oxide therapy. Twenty-two newborns with lung disease and an oxygenation index >25 were treated with 10 to 20 parts per million inhaled nitric oxide. Measurements of heart rate, blood pressure, arterial blood gases, right and left ventricular planimetry, and Doppler ultrasonography were performed before and after 30 to 60 minutes of therapy. Nitric oxide inhalation was associated with a significant acute change in arterial blood pressure, pH, arterial carbon dioxide tension, arterial oxygen tension, proportion of right-to-left ductal shunt, estimated systolic pulmonary arterial pressure, and right ventricular diastolic and systolic areas. In the middle cerebral artery, peak systolic flow velocity (49+/-5 vs. 41+/-4, cm/sec), diastolic flow velocity (21+/-3 vs. 14+/-3, cm/sec), and the velocity time integral (10.3+/-1.1 vs. 7.9+/-1.1, cm) all decreased (p<0.05). These changes only occurred in a subgroup of 17 patients who experienced an improvement in arterial oxygen tension > or =10 mm Hg. The velocity time integral of flow in the middle cerebral artery is acutely decreased in newborns with pulmonary hypertension who experience an acute increase in oxygenation after the onset of inhaled nitric oxide.

Successful pediatric stenting of a nonthrombotic coronary occlusion as a complication of radiofrequency catheter ablation.

This is a case of a right coronary artery occlusion complicating a RF catheter ablation of a posteroseptal accessory connection in an 8-year-old boy. After multiple balloon angioplasty attempts in the occluded vessel, only transient patency was achieved. The occlusion was successfully treated with placement of an intracoronary stent.

Can Doppler systemic venous flow indices predict central venous pressure in children?

Tricuspid valve, superior vena cava (SVC), and hepatic vein Doppler patterns may be abnormal in right heart anomalies and have been used to predict high central venous pressure (CVP) in adults. The purpose of this study was to evaluate the relationship of these systemic venous flow indices to CVP in children. Children undergoing cardiac catheterization were studied prospectively using simultaneous recordings of mean CVP with pulsed-Doppler tracings of SVC, hepatic vein, and tricuspid valve flow. Systemic venous Doppler measurements included peak velocities and velocity time integrals for ventricular systole (S), ventricular diastole (D), and ventricular systole (B), and atrial systole (A). Tricuspid inflow Doppler E and A waves were recorded also. Patients with significant tricuspid stenosis or regurgitation, systemic venous obstruction, and nonsinus rhythm were excluded. The 42 patients ranged in age from 0.2 to 21.0 years and in weight from 3.0 to 68.0 kg. Mean CVPs ranged from 1 to 17 mmHg. Catheterization indications included hemodynamic evaluation (25 patients), transplant biopsy, (11 patients), and interventional procedures (6 patients). No SVC or tricuspid valve Doppler measurement correlated with CVP. Hepatic vein peak D, peak B, and peak A significantly correlated with CVP (r = 0.34 - 0.55; P < 0.05, linear regression). For all correlations, the r values were low with significant overlap among patients. Thus, in children, only hepatic vein peak velocities correlate with CVP. Because of the low r values and significant overlap among patients, the currently used Doppler indices have a low sensitivity for predicting CVP in this age group.

Randomized controlled study of inhaled nitric oxide after operation for congenital heart disease.

BACKGROUND: Inhaled nitric oxide selectively decreases pulmonary vascular resistance. This study was performed to determine whether inhaled nitric oxide decreases the incidence of pulmonary hypertensive crises after corrective procedures for congenital heart disease. METHODS: Patients with a systolic pulmonary arterial pressure of 50% or more of the systolic systemic arterial pressure during the early postoperative period were randomized to receive 20 parts per million inhaled nitric oxide (n = 20) or conventional therapy alone (n = 20). Acute hemodynamic and blood gas measurements were performed at the onset of therapy. The efficacy of sustained therapy was determined by comparing the number of patients in each group who experienced a pulmonary hypertensive crisis. RESULTS: In comparison to controls, there were no significant differences in the baseline and 1-hour measurements of patients who were treated with nitric oxide. Four patients in the control group and 3 patients in the nitric oxide group experienced a pulmonary hypertensive crisis. CONCLUSIONS: Nitric oxide did not substantially improve pulmonary hemodynamics and gas exchange immediately after operation for congenital heart disease. Nitric oxide also failed to significantly decrease the incidence of pulmonary hypertensive crises.

Growth of children with a functionally single ventricle following palliation at moderately increased altitude.

The bidirectional Glenn and Fontan procedures are empirically performed as interim and definitive procedures in children with a functionally single ventricle. The optimal stage of palliation, nonetheless, remains unknown. During childhood, growth is a fundamental measure of response to therapy. Growth may be influenced by the degree of cyanosis, the volume load on the ventricle, and cardiac performance. Thus, the weight and stature of children with a functionally single ventricle who underwent a bidirectional Glenn procedure or a Fontan procedure were studied to determine the effect of each intervention on growth. Z scores for weight and stature were retrospectively determined prior to palliation, at yearly intervals for 4 years, and from long-term measurements until 18 years of age in all patients with at least 2 years of observation following palliation. Growth was evaluated in 54 patients with a bidirectional Glenn procedure, and 65 patients with a Fontan procedure. The Z scores for weight were improved after each method of surgical palliation. Stature, however, was improved only following the bidirectional Glenn procedure. Growth was impaired in patients who developed protein losing enteropathy. Weight improved only during the initial 2 years after the Fontan procedure in patients who had a surgical fenestration. Over the long-term, patients who underwent a Fontan procedure were more likely to have a Z score less than -2.0 for weight and stature than patients who underwent only a bidirectional Glenn procedure. Late mortality and the incidence of heart transplantation were increased in patients who experienced a decrease in their rate of growth, defined as a negative change of more than one Z score in weight or stature, following the Fontan procedure. In conclusion, at moderately increased altitude, children with a functionally single ventricle grow more appropriately following the bidirectional Glenn procedure than following the Fontan procedure. A decrease in the rate of growth is associated with a poor prognosis following the Fontan procedure.

Septal cystic mass in the right atrium: echocardiographic evaluation.

Right atrial masses rarely are seen in children and are usually benign. Clinical manifestations mainly depend on the location of the mass and whether it alters blood flow. This report describes the clinical course, echocardiographic findings, pathology, and serial follow-up of an unusual cystic mass with a mixture of tissue common to the atrioventricular septum located in the posteroinferior right atrium.

Right ventricular size is acutely decreased by inhaled nitric oxide in newborns with pulmonary hypertension.

The pressure and volume demands of the right and left ventricles may dramatically change following selective pulmonary vasodilation in newborns with pulmonary hypertension. Thus, ventricular planimetry was performed by two-dimensional echocardiography in 35 newborns with lung disease and increased pulmonary vascular resistance who were treated with inhaled nitric oxide to determine the influence of therapy on right and left ventricular size and function. The end-diastolic and end-systolic areas of each ventricle were measured from apical 4-chamber images before, and 30 to 60 minutes after, the onset of 20 parts per million inhaled nitric oxide. Estimates of ventricular function were determined by the systolic decrease in ventricular area, (diastolic area - systolic area) x 100/diastolic area. Heart rate, systemic blood pressure, and left ventricular areas did not change. However, the oxygenation index, the proportion of right-to-left ductal shunt (nonrestrictive ductus arteriosus, n = 22), the systolic pulmonary arterial pressure (closed or restrictive ductus arteriosus, n = 13), and the right ventricular diastolic and systolic areas were decreased after nitric oxide inhalation. The baseline systolic decrease in left ventricular area was lower in a subgroup of patients who developed an increase in left ventricular diastolic area following nitric oxide inhalation. Thus, nitric oxide improves pulmonary hemodynamics and decreases right ventricular size in newborns with lung disease and pulmonary hypertension. However, newborns may develop an increase in left ventricular size if left ventricular function is decreased prior to therapy.

Late results and reintervention after aortic valvotomy for critical aortic stenosis in neonates and infants.

BACKGROUND: Many centers have adopted balloon valvuloplasty for treatment of infants with critical aortic stenosis because of historically poor early results and a lack of long-term results with surgical valvotomy. We evaluated our results with open aortic valvotomy over the past decade, specifically examining factors influencing survival and reintervention in the current era. METHODS: From 1986 to 1996, 37 infants in the first 3 months of life underwent open aortic valvotomy for critical aortic stenosis. All patients underwent cardiopulmonary bypass, valvotomy, and valve debridement under direct vision with standard techniques. RESULTS: Early mortality was 11% (4 of 37, 70% confidence limit 7% to 20%) and all early deaths were in neonates less than 2 weeks of age. Late death occurred in 6 patients a mean of 10 +/- 12 months (range, 2 to 36 months) after valvotomy. Actuarial survival, including operative deaths was 92% +/- 6% at 1 month, 78% +/- 9% at 1 year, and 73.4% +/- 10% at 10 years. In a multifactorial regression analysis, the best predictors of death were the presence of endocardial fibroelastosis and small body surface area and the best predictor of the need for late reintervention was preoperative aortic annular size. Thirteen patients required reintervention: repeat operation in 7 patients, balloon valvuloplasty in 3 patients, and both balloon valvuloplasty and reoperation in 3 patients. Actuarial freedom from reintervention postoperatively is 97% +/- 3% at 1 month, 73% +/- 9% at 1 year, and 55% +/- 11% at 10 years. Reintervention was for recurrent left ventricular outflow obstruction in 9 patients and mixed aortic stenosis and aortic insufficiency in 4. Echocardiography 4.3 +/- 2.5 years after aortic valvotomy in survivors who have not required reintervention (n = 20) revealed a Doppler peak instantaneous systolic gradient of 37 +/- 14 mm Hg and mild or less aortic regurgitation in 16 patients and moderate aortic regurgitation in 4 patients. CONCLUSIONS: Current surgical results with critical aortic stenosis in the neonate and young infant are acceptable in terms of both late survival, reintervention, and functional results in the majority of patients. Newer interventions, such as balloon valvuloplasty, should be carefully evaluated for long-term results and should be compared more appropriately to current surgical results to determine the best treatment modality for the neonate and infant with critical aortic stenosis.