Indications and Safety of the Zygomatic Osteotomy in Middle Cranial Fossa Surgery: A Retrospective Cohort Review.

Background Zygomatic osteotomy, an adjunct to middle cranial fossa (MCF) surgical approaches, improves the superior-inferior angle of approach and minimizes temporal lobe retraction. However, a decision-making algorithm for selective use of the zygomatic osteotomy and the impact of the zygomatic osteotomy on surgical complications have not been well documented. Objective We described an algorithm for deciding whether to use a zygomatic osteotomy in MCF surgery and evaluated complications associated with a zygomatic osteotomy. Methods A retrospective review of MCF cases over 11 years at our academic tertiary referral center was conducted. Demographic variables, tumor characteristics, surgical details, and postoperative complications were extracted. Results Of the 87 patients included, 15 (17%) received a zygomatic osteotomy. Surgical trajectory oriented from anterior to posterior (A-P) was significantly correlated with the use of the zygomatic osteotomy. Among the cases approached from A-P, we found (receiver-operating characteristic curve) that the cut-off tumor size that predicted a zygomatic osteotomy was 30 mm. Of the 87 cases included, 15 patients had a complication. The multivariate logistic regression model failed to reveal any significant correlation between complications and zygomatic osteotomies. Conclusions We found that the most important factor determining the use of a zygomatic osteotomy was anticipated trajectory. A-P approaches were most highly correlated with zygomatic osteotomy. Within those cases, a lesion size cut-off of 30 mm was the secondary predicting factor of zygomatic osteotomy use. The odds of suffering a surgical complication were not significantly increased by use of zygomatic osteotomy.

Is Fulminant Hepatic Failure the Nemesis for Liver Transplant Centers? A Two Decade Psychosocial and Long-Term Outcome Study.

Long-term outcomes in liver transplantation for acute liver failure (ALF) are poorly studied. The aim of the study was to identify psychosocial variables that affect adherence and late survival. Retrospective review of ALF liver transplant (LTx) patients between 1997 and 2017 (n = 47) was conducted. Psychosocial history, life stressors, and ability to participate in transplant were recorded. Survival was calculated using Kaplan-Meier and logistic regression. Eleven patients (31.5%) had poor adherence, four died, all from graft failure. Of 13 with fair and 12 with good adherence, two died, no adherence related. Poor adherence was associated with higher mortality (P = 0.04), but by Kaplan-Meier, their five- and 10-year survival was 78 and 54 per cent, versus fair and good adherence (five years, 83% P = 0.3). Participating in transplant decision improved survival (five years, 80%) versus not participating (five years, 61%; P = 0.03). Of 10 early deaths, three were neurologic and five of sepsis. Overall, one- and five-year survival was 78 and 69 per cent. ALF represents the nemesis of LTx programs. Psychosocial aspects pre-LTx, stressors, and poor adherence affected survival in this series. No improvement over two decades of ALF LTxs was observed. The ethics of transplanting these high-risk patients will be the subject of our future research.

Outcomes of abdominal surgeries in cirrhotic patients performed by liver transplant surgeons: Are these safe?

BACKGROUND: Elective abdominal surgeries in patients with cirrhosis have been discouraged due to the high risk of complications. This study investigates the outcomes and safety of surgeries for hernias, and laparoscopic cholecystectomies in cirrhotic patients. METHODS: A retrospective cohort study that compared 91 cirrhotic patients to a control group of non-cirrhotic patients operated by liver transplant surgeons was conducted between 2009 and 2015. RESULTS: No statistical significance found in re-admission rates or complication rates (p = 0.21). Hernia recurrent rates were similar (p = 0.27). Survival rates among cirrhotic versus non cirrhotic group was 93.4% and 98.9% respectively (p = 0.0539). Amongst the 91 cirrhotic patients, there was a 100% survival rate for both ventral herniorrhaphies and laparoscopic cholecystectomy. Survival in umbilical and inguinal herniorrhaphies was 88.2% and 89.5% respectively. Mortality rate for umbilical and inguinal hernias was 11.7% and10.5% respectively. Mortality by Child-Pugh (CP) class were; 8.8% for CP B and 10.7% for CP class C. All CP class A patients survived. CONCLUSIONS: Our study indicates that elective operations could be performed safely with acceptable mortality in cirrhotic patients.

Echocardiography fails to detect left ventricular noncompaction in a cohort of patients with noncompaction on cardiac magnetic resonance imaging.

BACKGROUND: Left ventricular noncompaction (LVNC) is a rare disorder characterized by increased left ventricular trabeculation, deep intertrabecular recesses, and a thin compacted myocardial layer with associated clinical sequelae. Cardiac imaging with echocardiogram and cardiac magnetic resonance (CMRI) can detect variable myocardial morphology including excessive trabeculations. Multiple CMRI and echocardiographic criteria have been offered that attempt to identify LVNC morphology. The aim of this study was to assess the utility of echocardiogram in identifying LVNC in a cohort of patients with LVNC detected on CMRI. HYPOTHESIS: Echocardiography fails to identify LVNC morphology in a large proportion of patients with LVNC/hypertrabeculation detected on CMRI. METHODS: There were 1060 CMRI studies collected from 2009 to 2015 at 2 institutions. The patients included in this study (n = 37) met the criteria for LVNC on CMRI and had complete CMRI and echocardiogram images Clinical and imaging data were retrospectively reviewed. RESULTS: Of the 37 patients with LVNC on CMRI, only 10 patients (27%) had LVNC identified on echocardiogram (P < 0.0001, 95% confidence interval: 25.7%-66.2%). Echocardiography and CMRI were also significantly different in terms of identification of distribution of LVNC. Although 21 of 37 patients (57%) had evidence of LVNC in either the anterior or lateral walls on CMRI, there were 0 patients with LVNC detected in the anterior or lateral walls on echocardiogram (P = 0.019). CONCLUSIONS: Echocardiogram fails to detect LVNC morphology/hypertrabeculation in a significant number of a cohort of patients with LVNC on CMRI. LVNC may be missed if echocardiogram is the only imaging modality performed in a cardiac evaluation.