Colombian surgical outcomes study insights on perioperative mortality rate, a main indicator of the lancet commission on global surgery - a prospective cohort study.

Background: Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia. Methods: A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions. Findings: 3807 patients were included with a median age of 48 (IQR 32-64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien-Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68-12.76) and any complication (31.6%, 30.09-33.07). POMR stood at 1.9% (1.48-2.37), with elective and emergency surgery mortalities at 0.7% (0.40-1.23) and 3% (2.3-3.89) respectively. Interpretation: The POMR was higher than the ratio reported in previous national studies, even when patients had a low-risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care. Funding: This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017.

Open Surgical Repair in a Patient With Loeys-Dietz Syndrome and Extensive Vascular Compromise: A Case Report and Literature Review.

Loeys-Dietz syndrome (LDS) has been associated with multiple vascular abnormalities involving the entire arterial tree. However, limited reports regarding compromise in the aortoiliac and femoral bifurcation are available. Further, recommendations for optimal approach, thresholds for diameter at the time of surgery, and surveillance are also limited. We present a case of a 67-year-old male patient with LDS and aneurysmal aortoiliac and enlarging common femoral arteries aneurysms, who underwent open surgical repair. His past surgical history included multiple vascular interventions for lower extremity claudication and bilateral hip replacements. The right hip arthroplasty was previously removed due to infection. From the vascular standpoint, the patient underwent staged endovascular left hypogastric artery embolization and open aorto-bi-profunda bypass with a Rifampin-soaked Dacron graft. At 5-month follow-up, he remains asymptomatic with healed incisions and patent bypasses. This case highlights the challenges in managing peripheral aneurysms in LDS patients, emphasizing the need for tailored treatment strategies. While open repair is preferred, endovascular options may be considered in selected cases. Surveillance remains critical with annual cross-sectional imaging. Surgical planning is intricate due to comorbidities, anatomical complexities, and previous surgical infection. Surveillance of these patients must be strict as multiple vascular and non-vascular complications may arise. Therefore, collaborative decision-making is essential for optimal outcomes in this known high-risk population with connective tissue disorders.

Clinical characterization of patients with cardiac amyloidosis in a referral center of Colombia.

Objective: The objective of the study is to describe the characteristics of our first cohort of amyloidosis in a Latin America cardiovascular reference center in Colombia. Methods: This is a historic cohort study and data were taken from the electronic records of the Fundación Cardioinfantil-Instituto de cardiología; adult patients with a diagnosis of cardiac amyloidosis were included and a descriptive analysis was presented. Results: A total of 31 patients with amyloidosis were included. 17 were Transthyretin Amyloidosis (ATTR) subtype and 14 were AL subtype. An overall mortality of 25% was found. The mean age at diagnosis was 74 years, male sex predominant. More frequent comorbidities were hypertension and atrial fibrillation. The most frequent clinical presentation was congestive heart failure (75%), with mildly reduced ejection fraction (41.94%), followed by reduced ejection fraction (32.26%), and preserved ejection fraction (25.81%). In the ATTR subtype, a reduced ejection fraction was found at 41.18% and a mildly reduced ejection fraction at 35.29%. Conclusion: These results provide information on the most frequent type of amyloidosis and the late timing to diagnose in our historic cohort study, we present some of the baseline characteristics and most frequent approaches to diagnose Cardiac Amyloidosis that represents all challenges in clinical practice. Improvements are needed in the diagnosis and early treatment of these patients.

Objetivo: Describir las características de nuestra primera cohorte de amiloidosis en un centro de referencia cardiovascular de Latinoamérica en Colombia. Métodos: Los datos fueron tomados de los registros electrónicos de la Fundación Cardioinfantil- Instituto de cardiología; Se incluyeron pacientes adultos con diagnóstico de amiloidosis cardíaca y se presenta un análisis descriptivo. Resultados: Se incluyeron un total de 31 pacientes con amiloidosis. 17 eran ATTR y 14 eran AL. Se encontró una mortalidad global del 25%. La edad media al diagnóstico fue de 74 años, predominando el sexo masculino. Las comorbilidades más frecuentes fueron Hipertensión y Fibrilación auricular. La presentación clínica más frecuente fue insuficiencia cardíaca congestiva (75%), con fracción de eyección levemente reducida (41.94%), seguida de fracción de eyección reducida (32.26%) y fracción de eyección preservada (25.81%). En el subtipo ATTR, la fracción de eyección reducida se encontró en el 41.18% y la fracción de eyección levemente reducida en el 35.29%. Conclusión: Estos resultados brindan información sobre el tipo de amiloidosis más frecuente y el momento del diagnóstico, el cual fue tardío en nuestra cohorte, su prevalencia en el sexo masculino (61.29%), edad promedio al diagnóstico de 74 años, principal presentación clínica y abordaje más frecuente, mostrando el desafío que representa en la práctica clínica llegar al diagnóstico. Se necesitan mejoras en el diagnóstico y tratamiento precoz de estos pacientes.

Challenges in prompt identification and surgical correction of Marfan Syndrome aortic disease in a middle-income country: a case series study.

BACKGROUND: Marfan Syndrome is an autosomal dominant disease caused by pathogenetic variants in the FBN1 gene. The progressive dilatation of the aorta and the potential risk of acute aortic syndromes influence the prognosis of these patients. We aim to describe population characteristics, long-term survival, and re-intervention patterns in patients who underwent aortic surgery with a previously confirmed clinical diagnosis of Marfan Syndrome in a middle-income country. METHODS: A retrospective single-center case series study was conducted. All Marfan Syndrome patients who underwent aortic procedures from 2004 until 2021 were included. Qualitative variables were frequency-presented, while quantitative ones adopted mean ± standard deviation. A subgroup analysis between elective and emergent procedures was conducted. Kaplan-Meier plots depicted cumulative survival and re-intervention-free. Control appointments and government data tracked out-of-hospital mortality. RESULTS: Fifty patients were identified. The mean age was 38.79 ± 14.41 years, with a male-to-female ratio of 2:1. Common comorbidities included aortic valve regurgitation (66%) and hypertension (50%). Aortic aneurysms were observed in 64% without dissection and 36% with dissection. Surgical procedures comprised elective (52%) and emergent cases (48%). The most common surgery performed was the David procedure (64%), and the Bentall procedure (14%). The in-hospital mortality rate was 4%. Complications included stroke (10%), and acute kidney injury (6%). The average follow-up was 8.88 ± 5.78 years. Survival rates at 5, 10, and 15 years were 89%, 73%, and 68%, respectively. Reintervention rates at 1, 2.5, and 5 years were 10%, 14%, and 17%, respectively. The emergent subgroup was younger (37.58 ± 14.49 years), had the largest number of Stanford A aortic dissections, presented hemodynamic instability (41.67%), and had a higher requirement of reinterventions in the first 5 years of follow-up (p = 0.030). CONCLUSION: In our study, surveillance programs played a pivotal role in sustaining high survival rates and identifying re-intervention requirements. However, challenges persist, as 48% of the patients required emergent surgery. Despite not affecting survival rates, a greater requirement for reinterventions was observed, emphasizing the necessity of timely diagnosis. Enhanced educational initiatives for healthcare providers and increased patient involvement in follow-up programs are imperative to address these concerns.

One-stage or two-stage elective coronary artery bypass graft surgery and abdominal aortic aneurysm open repair in low and moderate cardiac surgical risk patients.

OBJECTIVES: Coronary artery disease (CAD) and abdominal aortic aneurysm (AAA) are common arterial pathologies that might occur simultaneously; however, there is not enough evidence about the optimal strategy for patients with concomitant indications of coronary artery bypass grafting (CABG) and open repair of the AAA (AAOR). This study aims to present the outcomes in low and moderate cardiac surgical risk patients who underwent one-stage or two-stage elective CABG and AAOR in a middle-income country. METHODS: An observational, retrospective case series study was conducted. Patients who had low and moderate cardiac surgical risk (less than 8% mortality risk on the STS score) and had the concomitant indication for CABG and AAOR between December 2005 and August 2021 were included. Patients were assigned to one of three strategies: Group 1 underwent one-stage surgery for CABG and AAOR, Group 2 underwent two-stage surgery within the same in-patient stay, and Group 3 underwent two-stage surgery in a new in-patient stay within 6 months. RESULTS: Twenty seven, patients with simultaneous requirements of CABG and AAOR were identified, with a mean age of 69.5 ± 6.1 years and 92.6% were male. The most common comorbidities were hypertension at 77.8% and dyslipidemia at 55.6%. The average mortality risk calculated by the STS score was 2.09% ± 1.53%. In Group 1 (n = 9), 1/9 had in-hospital mortality and no reinterventions were needed. In Group 2 (n = 10), 1/10 had in-hospital mortality, and the most common postoperative complication was acute kidney injury 2/10. Furthermore, 2/10 required a reintervention. In Group 3 (n = 8), no in-hospital mortality was present, however, complications such as sepsis, atrial fibrillation, and acute kidney injury occurred in 2/8 patients each, and 2/8 required a reintervention. CONCLUSION: Patients with CAD and AAA that need a concomitant surgical correction with CABG and an AAOR are uncommon in contemporary practice, given the advances in endovascular therapy. When indicated, one-stage surgery can be performed in patients with low cardiac surgical risk, proper patient selection plays a fundamental role and might be performed in experienced centers. However, two-staged surgeries at the same or different inpatient stay may be considered for asymptomatic AAA with close monitoring during the postoperative period. These findings can hold significance for addressing sociodemographic barriers in low and middle-income countries. More robust and extensive studies are needed to make clear comparisons between the different strategies.

Inferior Vena Cava Filter Long Term Complications and Retrieval Techniques: A Case Series and Literature Review.

INTRODUCTION AND IMPORTANCE: Long-term mechanical complications after inferior vena cava (IVC) filter placement include embedded or tilted filters, erosion of the vena cava, filter thrombosis. In the setting of caval thrombosis, patients may subsequently develop venous hypertension and post-thrombotic syndrome (PTS). Here we present three unique cases of IVC filter complications and surgical management. CASE PRESENTATION: A 30-year-old female presented with acute abdominal pain, revealing a duodenal perforation caused by an IVC filter eroding into her duodenum. A 42-year-old female with an IVC filter in place for 20 years due to a prior pulmonary embolism underwent laser-assisted retrieval of the filter due to concerns of caval adherence. A 48-year-old male with a history of DVT, venous stasis ulcer, and an IVC filter presented for filter retrieval. CLINICAL FINDINGS AND INVESTIGATIONS: The surgical techniques described in this report include complicated IVC filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis resulting in PTS. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. INTERVENTION AND OUTCOMES: The surgical techniques described in this report include complicated inferior vena cava filter retrieval, performed in cases of filter complications including migration, fracture, duodenal perforation and IVC thrombosis. One case, requiring open retrieval, is explained and the surgical technique is provided. There are images and videos of these procedures to enrich the learning experience. RELEVANCE AND IMPACT: Endovascular retrieval of long-term complicated IVC filters is challenging, but it can be a safely performed in many patients. However, open surgery may be necessary in selected patients.

Emergent hybrid surgical approaches for non-dissecting ruptured Kommerell's aneurysm: a case report series.

BACKGROUND: Kommerell's aneurysm is a saccular or fusiform dilatation found in 3-8% of Kommerell's diverticulum cases. A non-dissecting rupture rate of 6% has been reported. If ruptured, emergent surgical correction is usually granted. However, evidence regarding the optimal surgical approach in this acute setting is scarce. In this case report series, we aim to describe our experience managing type-1 non-dissecting ruptured Kommerell's aneurysm with hybrid emergent surgical approaches. CASES PRESENTATION: From January 2005 to December 2020, three cases of type-1 non-dissecting ruptured Kommerell's aneurysm requiring emergent surgical repair were identified. The mean age was 66.67 ± 7.76 years, and 3/3 were male. The most common symptoms were atypical chest pain, dyspnoea, and headache (2/3). The mean aneurysm's diameter was 63.67 ± 5.69 mm. Frozen Elephant Trunk was the preferred surgical approach (2/3). The Non-Frozen Elephant Trunk patient underwent a hybrid procedure consisting of a supra-aortic debranching and a zone-2 stent-graft deployment. We found a mean clamp time of 140 ± 60.75 min, cardiac arrest time of 51.33 ± 3.06 min, and a hospital stay of 13.67 ± 5.51 days. The most common complications were surgical-site infection and shock (2/3). Only one patient died (1/3). CONCLUSION: Evidence of management for non-dissecting ruptured Kommerell's aneurysms is scarce. Additional, robust, and more extensive studies are required. The selection of the appropriate surgical approach is challenging, and each patient should be individualized. Frozen Elephant Trunk was feasible for patients requiring emergent surgical repair in our centre. However, other hybrid or open procedures can be performed.

Nefroprotección en frío para reparo de ectasia aórtica y aneurismas ilíacos bilaterales ante la presencia de riñón ectópico pélvico / Cold nephroprotection for repair of aortic ectasia and bilateral iliac aneurysms in the presence of pelvic ectopic kidney

Resumen Los riñones ectópicos pélvicos solitarios asociados a degeneración aneurismática de las arterias ilíacas y la aorta abdominal son eventos muy raros. Los enfoques quirúrgicos para la corrección de aneurismas con compromiso renal son un desafío por la falta de consenso actual, en especial cuando cursan con riñones ectópicos pélvicos solitarios funcionales asociados. Por tal motivo, una de las estrategias que ha demostrado buenos resultados a corto y mediano plazo es la nefroprotección en frío, la cual puede ser usada con seguridad en estos pacientes. En el caso que se presenta, se evidenció una ectasia aórtica con aneurismas ilíacos bilaterales asociados con un riñón ectópico pélvico solitario en un paciente masculino de 75 años, con hipertensión arterial y dislipidemia. Se realizó una reconstrucción aortoilíaca bilateral y una reconstrucción de la arteria hipogástrica, además de reimplante de la arteria renal ectópica bajo irrigación renal en frío, sin complicaciones y preservación de la función renal.

Abstract Solitary pelvic ectopic kidneys associated with aneurysmal degeneration of the iliac arteries and abdominal aorta are very rare events. Surgical approaches for the correction of aneurysms with renal involvement are challenging due to the lack of current consensus, especially when they are associated with functional solitary pelvic ectopic kidneys. For this reason, one of the strategies that has shown good results in the short and medium term is cold nephroprotection, which can be used safely in these patients. In the present case, aortic ectasia with bilateral iliac aneurysms associated with a solitary pelvic ectopic kidneys was evidenced in a 75-year-old male patient with arterial hypertension and dyslipidemia. Bilateral aortoiliac reconstruction was performed with hypogastric artery reconstruction and reimplantation of the ectopic renal artery under cold renal irrigation, without complications and preservation of renal function.

Perioperative mortality in Colombia: perspectives of the fourth indicator in The Lancet Commission on Global Surgery - Colombian Surgical Outcomes Study (ColSOS) - a protocol for a multicentre prospective cohort study.

INTRODUCTION: Death following surgical procedures is a global health problem, accounting for 4.2 million deaths annually within the first 30 postoperative days. The fourth indicator of The Lancet Commission on Global Surgery is essential as it seeks to standardise postoperative mortality. Consequently, it helps identify the strengths and weaknesses of each country's healthcare system. Accurate information on this indicator is not available in Colombia, limiting the possibility of interventions applied to our population. We aim to describe the in-hospital perioperative mortality of the surgical procedures performed in Colombia. The data obtained will help formulate public policies, improving the quality of the surgical departments. METHODS AND ANALYSIS: An observational, analytical, multicentre prospective cohort study will be conducted throughout Colombia. Patients over 18 years of age who have undergone a surgical procedure, excluding radiological/endoscopic procedures, will be included. A sample size of 1353 patients has been projected to achieve significance in our primary objective; however, convenience sampling will be used, as we aim to include all possible patients. Data collection will be carried out prospectively for 1 week. Follow-up will continue until hospital discharge, death or a maximum of 30 inpatient days. The primary outcome is perioperative mortality. A descriptive analysis of the data will be performed, along with a case mix analysis of mortality by procedure-related, patient-related and hospital-related conditions ETHICS AND DISSEMINATION: The Fundación Cardioinfantil-Instituto de Cardiología Ethics Committee approved this study (No. 41-2021). The results are planned to be disseminated in three scenarios: the submission of an article for publication in a high-impact scientific journal and presentations at the Colombian Surgical Forum and the Congress of the American College of Surgeons. TRIAL REGISTRATION NUMBER: NCT05147623.

Small Diameter Cell-Free Tissue-Engineered Vascular Grafts: Biomaterials and Manufacture Techniques to Reach Suitable Mechanical Properties.

Vascular grafts (VGs) are medical devices intended to replace the function of a blood vessel. Available VGs in the market present low patency rates for small diameter applications setting the VG failure. This event arises from the inadequate response of the cells interacting with the biomaterial in the context of operative conditions generating chronic inflammation and a lack of regenerative signals where stenosis or aneurysms can occur. Tissue Engineered Vascular grafts (TEVGs) aim to induce the regeneration of the native vessel to overcome these limitations. Besides the biochemical stimuli, the biomaterial and the particular micro and macrostructure of the graft will determine the specific behavior under pulsatile pressure. The TEVG must support blood flow withstanding the exerted pressure, allowing the proper compliance required for the biomechanical stimulation needed for regeneration. Although the international standards outline the specific requirements to evaluate vascular grafts, the challenge remains in choosing the proper biomaterial and manufacturing TEVGs with good quality features to perform satisfactorily. In this review, we aim to recognize the best strategies to reach suitable mechanical properties in cell-free TEVGs according to the reported success of different approaches in clinical trials and pre-clinical trials.

Early preoperative progressive pneumoperitoneum for a symptomatic giant abdominal incisional hernia.

INTRODUCTION AND IMPORTANCE: Early preoperative progressive pneumoperitoneum (PPP) is a technique that helps large eventrations with loss of domain to reintroduce protruded organs. However, a standardized technique has not been developed. This technique has been proved in elective patients, but the evidence is scarce in patients with a high risk of incarceration/strangulation. CLINICAL FINDINGS AND INVESTIGATIONS: We present a 61-year-old patient with history of a thoracoabdominal aneurysm repair, developed a massive incisional hernia with loss of domain. At admission, he presented with abdominal pain and inability to reduce the hernia by himself, however it reduced after clinical examination. Aortic syndromes were excluded. INTERVENTIONS AND OUTCOME: After a multidisciplinary meeting, early PPP was initially performed. Later he was taken to surgery and admitted in the ICU to prevent abdominal hypertension. Medical complications resolved within 14 days. The patient did not report long-term complications. RELEVANCE AND IMPACT: PPP is a technique that pursues the prevention of abdominal hypertension syndrome in patients with large hernias with loss of domain electively. For patients with high risk of hernia complications, the evidence is limited regarding the applicability of early PPP. A multidisciplinary team can improve decision making and therefore reduce the risk of long-term complications. We show a case where PPP was performed in an acute painful, reducible hernia with a high risk of incarceration, showing that this approach can be an option for acutely ill patients.