Flexible single-incision surgery: a fusion technique.

INTRODUCTION: The development of natural orifice transluminal endoscopic surgery has led to other techniques, such as single-incision surgery. The use of the flexible endoscope for single-incision surgery paves the way for further refinement of both surgical methods. OBJECTIVE: To describe a new, single-incision surgical technique, namely, flexible single-incision surgery. PATIENTS AND METHODS: Assessment of the safety and effectiveness of endoscopic cholecystectomy in a series of 30 patients. This technique consists of a single umbilical incision through which a flexible endoscope is introduced and consists of 2 parallel entry ports that provide access to nonarticulated laparoscopic instruments. RESULTS: The technique was applied in all patients for whom it was prescribed. No general or surgical wound complications were noted. Surgical time was no longer than usual for single-port surgery. CONCLUSIONS: Flexible single-incision surgery is a new single-site surgical technique offering the same level of patient safety, with additional advantages for the surgeon at minimal cost.

Short-term outcomes in premature neonates adhering to the philosophy of supportive care allowing for weight gain and organ maturation prior to cardiac surgery.

BACKGROUND: Prematurity is a recognized risk factor for morbidity and mortality following cardiac surgery. The purpose of this study was to examine short-term outcomes following cardiac surgery in premature neonates adhering to our institutional philosophy of supportive care allowing for weight gain and organ maturation. METHODS: Retrospective review of all neonates undergoing cardiac surgery from January 2002 to May 2008. A total of 810 neonates (<30 days of age) were identified. Prematurity defined as less than 36 weeks of gestation. Neonates undergoing ductus arteriosus ligation alone were excluded. In all, 63 neonates comprised the premature group. Term group comprised 244 randomly selected term neonates in a 1:4 ratio. Outcome variables were compared between the 2 groups. RESULTS: Median gestation 34 weeks, range 24 to 35 weeks. Defects: 2 ventricle, normal arch (41% premature vs 44% term; P = .7), 2 ventricle, abnormal arch (24% vs 22%; P = .8), single ventricle, normal arch (21% vs 15%; P = .2), single ventricle, abnormal arch (14% vs 19%; P = .4). Premature neonates were older and smaller at surgery. Cardiopulmonary bypass procedures were performed less frequently in premature neonates (49% vs 69%; P = .004). Length of mechanical ventilation at our institution (6 days [0.5-54) vs 4 days [0.5-49); P = .06); postoperative hospital stay at our institution (17 days [1-161) vs 15 days [0-153); P = .06); and mortality (16% vs 11%; P = .2) was not different between the 2 groups. CONCLUSION: Early outcome seems independent of weight, prematurity, cardiopulmonary bypass, and type of first intervention. Importantly, there was no statistical difference in mortality between the 2 groups, regardless of how they were treated. Further long-term follow-up is needed in this patient population.

Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250).

BACKGROUND AND STUDY AIMS: Natural orifice transluminal endoscopic surgery (NOTES) is a technique still in experimental development whose safety and effectiveness call for assessment through clinical trials. In this paper we present a three-arm, noninferiority, prospective randomized clinical trial of 1 year duration comparing the vaginal and transumbilical approaches for transluminal endoscopic surgery with the conventional laparoscopic approach for elective cholecystectomy. PATIENTS AND METHODS: Sixty female patients between the ages of 18 and 65 years who were eligible for elective cholecystectomy were randomized in a ratio of 1:1:1 to receive hybrid transvaginal NOTES (TV group), hybrid transumbilical NOTES (TU group) or conventional laparoscopy (CL group). The main study variable was parietal complications (wound infection, bleeding, and eventration). The analysis was by intention to treat, and losses were not replaced. RESULTS: Cholecystectomy was successfully performed on 94% of the patients. One patient in the TU group was reconverted to CL owing to difficulty in maneuvering the endoscope. After a minimum follow-up period of 1 year, no differences were noted in the rate of parietal complications. Postoperative pain, length of hospital stay, and time off from work were similar in the three groups. No patient developed dyspareunia. Surgical time was longer among cases in which a flexible endoscope was used (CL, 47.04 min; TV, 64.85 min; TU, 59.80 min). CONCLUSIONS: NOTES approaches using the flexible endoscope are not inferior in safety or effectiveness to conventional laparoscopy. The transumbilical approach with flexible endoscope is as effective and safe as the transvaginal approach and is a promising, single-incision approach.

[Incorporation of the flexible endoscope in gastrointestinal surgery]. / Integración del endoscopio flexible en cirugía digestiva.

The flexible endoscope has not traditionally figured among the tools used by the surgeon. Intra-operative flexible endoscopy may be one of the techniques available in the operating room in the near future. On analysing the development of minimally invasive surgery and flexible endoscopy, it can be seen that they are converging and losing ground to gastrointestinal endoscopy on the one hand, and gaining it with the flexible endoscope, on the other. The technical development of «hybrid¼ NOTES has shown how some tools not usually available in theatre may be very useful. Flexible endoscopy is probably the technique to enter into the surgical area that offers improved performance. Surgeons need to work closely with the gastroenterologists, while they are trained in these techniques for future «hybrid¼ specialists.

Prolonged cardiopulmonary resuscitation and low flow state are not contraindications for extracorporeal support.

Outcomes of out-of-hospital cardiac arrest are poor irrespective of the patient age group and circumstances. Survival to discharge after out-of-hospital arrest in children is less than 10%. Use of extracorporeal cardiopulmonary resuscitation is increasing and has been shown to improve outcomes in some situations. However, the candidacy for such augmentation is based on patient selection, institutional practices, and availability of an extracorporeal membrane oxygenation center. Often, duration of resuscitation, low flow state, presenting pH, and circumstances of arrest dictate candidacy for extracorporeal membrane oxygenation. We present a case of extremely prolonged resuscitation for out-of-hospital arrest in a pediatric patient, and we describe the use of mechanical compression device and transition to extracorporeal membrane oxygenation. We present the case outcome as well as brief discussion about controversies in extracorporeal cardiopulmonary resuscitation. We hope the case provides an opportunity for further discussion regarding opportunities to improve selection, use of extracorporeal cardiopulmonary resuscitation, and impact outcomes.

Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy: analysis of a prospective clinical series.

INTRODUCTION: Natural orifice transluminal endoscopic surgery (NOTES) makes it possible to perform intraperitoneal surgical procedures with a minimal number of access points in the abdominal wall. It is not yet possible to perform these interventions without the help of abdominal wall entryways, so these procedures are hybrids, a fusion of minilaparoscopy and transluminal endoscopic surgery. In this paper we present a prospective clinical series of 15 patients who underwent transvaginal hybrid cholecystectomy for cholelithiasis. METHODS: This was a prospective clinical series of 15 consecutive female patients, nonrandomly chosen and without a control group, who underwent a fusion transvaginal NOTES and minilaparoscopy procedure with two entryways for cholelithiasis. One was umbilical and measured 5 mm in diameter, and the other was in the right upper quadrant and measured 3 mm in diameter. RESULTS: The scheduled surgical intervention was performed on the 15 patients in whom it had been indicated. There were no intraoperative complications. One patient had mild hematuria that resolved in less than 12 h; there were no other complications after average follow-up of 124 days. Nine patients were discharged in 24 h, and two were discharged less than 12 h after the procedure. DISCUSSION: Hybrid transvaginal cholecystectomy is a good surgical model for minimally invasive surgery, a combination of NOTES and minilaparoscopy. It can be performed in surgical settings where laparoscopy is practised regularly, using the instruments normally used for endoscopy and laparoscopic surgery. Owing to the reproducibility of the intervention and the ease of vaginal closure, hybrid transvaginal cholecystectomy will permit further development of NOTES in the future.

Polymyxin B for Gram Negative Multidrug Resistant Bacteria in a Hispanic Population.

OBJECTIVE: This study intends to determine the prevalence of multidrug resistant (MDR) infections by A. baumannii, K. pneumoniae and P. aeruginosa in a tertiary care teaching hospital intensive care unit (ICU) in San Juan, PR, estimate the mortality rate and compare the morbidity and mortality differences among those treated with and without polymyxin B. METHODS: We selected adults patients admitted to the ICU who had positive cultures from January 2012 to June 2013. Sample consisted of 25 patients with age ranges from 27-78 years, 13 women and 12 men. RESULTS: The median age at death was 60 years. Polymyxin B nephrotoxicity was identified on 15% of the patients. Variables related to higher survival were younger age, female sex, use of polymyxin B, and the use of daptomycin. The use of vancomycin and vasopressors were associated with worse outcome. Mortality associated to single MDR bacteria was 88% for A. baumannii, 84% for K. pneumoniae and 67% for P. aeruginosa. All patients with more than one MDR infection died in the ICU. CONCLUSION: The use of polymyxin B was associated with an ICU mortality reduction. Unexpectedly we found a significantly improved survival in patients who received polymyxin B in combination with daptomycin, which awaits prospective confirmation.

Idiopathic infantile arterial calcification: a case report of successful extracorporeal membrane oxygenation support.

Idiopathic infantile arterial calcification is a rare cause of infantile ischemic cardiac failure with extremely poor prognosis. We present the first case report of successful extracorporeal membrane oxygenation support and outcome in a child with idiopathic infantile arterial calcification (IIAC). This 6-week-old infant presented with cardiogenic shock and circulatory collapse. The patient underwent extracorporeal cardiopulmonary resuscitation, allowing stabilization, diagnosis, and treatment with etidronate, followed by successful discharge to home.

Cost-utility analysis of salvage cardiac extracorporeal membrane oxygenation in children.

BACKGROUND: Indications for extracorporeal membrane oxygenation therapy have expanded to include cardiopulmonary arrest and support after congenital heart surgery. Data from a national registry have reported that cardiac patients have the poorest survival of all extracorporeal membrane oxygenation recipients. Concerns have been raised about the appropriateness of such an aggressive strategy, especially in light of the high costs and potential for long-term neurologic disability. We reviewed our experience with salvage cardiac extracorporeal membrane oxygenation to determine the cost-utility, which accounts for both costs and quality of life. METHODS: Medical records of patients with congenital heart disease receiving salvage cardiac extracorporeal membrane oxygenation between January 2000 and May 2004 were reviewed. Charges for all medical care after the institution of extracorporeal membrane oxygenation were determined and converted to costs by published standards. The quality-of-life status of survivors was determined with the Health Utilities Index Mark II. RESULTS: Salvage cardiac extracorporeal membrane oxygenation was instituted in 32 patients (18 for cardiopulmonary arrest and 14 for cardiac failure after heart surgery) at a median age of 2.0 months (range, 4 days to 5.1 years). Congenital heart disease was present in 27 (84%). The mean duration of extracorporeal membrane oxygenation support was 5.1 +/- 4.1 days. Survival to hospital discharge was 50%, including 1 patient bridged to heart transplantation. Survival to 1 year was 47%. The mean score of the Health Utilities Index for the survivors was 0.75 +/- 0.19 (range, 0.41-1.0). The median cost for hospital stay after the institution of extracorporeal membrane oxygenation was USD 156,324 per patient. The calculated cost-utility for salvage extracorporeal membrane oxygenation in this population was USD 24,386 per quality-adjusted life-year saved, which would be considered within the range of accepted cost-efficacy (< USD 50,000 per quality-adjusted life-year saved). CONCLUSIONS: Salvage cardiac extracorporeal membrane oxygenation results in reasonable survival and is justified on a cost-utility basis.

Nesiritide in infants and children with congestive heart failure.

OBJECTIVES: Nesiritide (synthetic B-type natriuretic peptide) has been shown to be effective in the management of acute decompensated heart failure in adults. The role of nesiritide in pediatric heart failure has not been examined. In the present study, we reviewed our initial experience with nesiritide in children with primary heart failure or low cardiac output after heart surgery. METHODS: Nesiritide was administered in an open-label fashion to patients with heart failure who were already receiving inotropic and diuretic therapy. Between July 2003 and August 2004, 30 patients aged 5 days to 16.7 yrs (median age, 4.6 months) received nesiritide therapy. Diagnoses included single-ventricle congenital defect (n = 5), two-ventricle congenital defect (n = 13), heart transplant (n = 5), and dilated cardiomyopathy (n = 7). Sixteen patients were started on nesiritide within 2 wks of corrective or palliative heart surgery. The majority of subjects (n = 24) received an initial bolus dose. Continuous infusion dosage ranged between 0.005 and 0.02 microg.kg.min. Nesiritide was discontinued for possible side effects in two patients (arrhythmia and hypotension). Duration of therapy ranged from 1 to 24 days (median, 4 days). RESULTS: Administration of nesiritide was associated with improvement in fluid balance from positive 0.8 +/- 1.9 mL.kg.hr at baseline to negative 0.3 +/- 1.8 mL.kg.hr after 24 hrs of therapy (p = .02). There was a nonsignificant trend toward a reduction in right atrial pressure (9.2 +/- 3.9 vs. 11.2 +/- 4.1, p = .08). CONCLUSIONS: Nesiritide is well tolerated in children with heart failure and is associated with improved diuresis. Further prospective studies will be needed to compare nesiritide with other vasoactive agents and examine the cost-efficacy of this therapy.

Early experience with a modified Norwood procedure using right ventricle to pulmonary artery conduit.

BACKGROUND: A recent modification to the Norwood procedure involves the use of a right-ventricle (RV) to pulmonary artery (PA) conduit to provide pulmonary blood flow for patients with hypoplastic left heart syndrome (HLHS). This modification is thought to provide more stable hemodynamics by avoiding the diastolic "run-off" that occurs with a Blalock-Taussig shunt. METHODS: We reviewed our experience with the first 11 patients undergoing the RV-PA conduit modification of the Norwood operation and compared their outcomes with those of the preceding 22 patients who underwent a conventional Norwood procedure. RESULTS: Between July 1999 and March 2002, 33 patients with HLHS underwent the Norwood procedure at a median age of 5 days (range 1 to 31 days). Aortic atresia was present in 28 (85%). No significant difference was noted between the RV-PA (n = 11) and conventional Norwood (n = 22) groups with respect to measures of morbidity such as duration of mechanical ventilation or hospital stay. Patients who underwent the conventional Norwood procedure did have significantly lower diastolic blood pressure in the early postoperative period (38.4 +/- 4.4 mm Hg versus 49.5 +/- 4.3 mm Hg, p = 0.001). The operative and 1-year survival rates were 81% and 81%, respectively, for patients with the RV-PA modification, which was not significantly different from those of patients who underwent the conventional procedure, 81% and 73% (p = 1.00 and p = 0.36). Two patients developed a pseudoaneurysm of the RV infundibulum after placement of RV-PA conduit. Four sudden deaths occurred after hospital discharge, all occurring in the conventional Norwood group. CONCLUSIONS: The RV-PA conduit modification of the Norwood procedure results in excellent early survival. By avoiding low diastolic blood pressure this modification may provide superior perfusion to the coronary vascular bed and potentially reduce the risk of sudden unexpected death.

Low-weight infants are at increased mortality risk after palliative or corrective cardiac surgery.

BACKGROUND: Low weight is an established risk factor for mortality after congenital cardiac surgery. Given the advances in the care of neonates and infants after surgery, we sought to examine the effect of low weight on outcomes in the current era. METHODS: From 2002 to 2012, 2051 infants aged 90 days or less underwent cardiac surgery including 534 (26.0%) with single-ventricle pathology. Regression models examined the effect of low weight (≤ 2.5 kg; n = 274, 13.4%) on early and late outcomes. RESULTS: Overall, the incidence of prematurity, associated chromosomal/extracardiac abnormalities was higher in infants who weighed 2.5 kg or less than in those who weighed more than 2.5 kg; the incidence of single-ventricle pathology was comparable between the 2 groups. In addition, infants who weighed 2.5 kg or less underwent more palliation and had a higher proportion of STAT (Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery) risk category 4 and 5 procedures. Adjusted regression models showed that low weight (≤ 2.5 kg) did not increase unplanned reoperation (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.48-1.67; P = .73) or extracorporeal membrane oxygenation requirement (OR, 1.23; 95% CI, 0.68-2.22; P = .49), however it was associated with significant increase in hospital mortality (OR, 2.15; 95% CI, 1.33-3.50; P = .002). In addition, there was a significant association between low weight and increased duration of postoperative mechanical ventilation and intensive care unit and hospital stays. Adjusted hazard analysis showed that weight equal to or less than 2.5 kg was associated with diminished late survival (hazard ratio, 1.89; 95% CI, 1.39-2.55; P < .001) and that was evident in all patients subgroups (P < .001 for all). CONCLUSIONS: In a large single-center series, low weight continues to be associated with increased early mortality risk and resource utilization after palliative and corrective cardiac surgery. The hazard of death in low-weight patients continues beyond the perioperative period for at least 1 year before normalizing. Strategies to improve outcomes for this high-risk population must address perioperative care, outpatient surveillance, and management.

NOTES, MANOS, SILS and other new laparoendoscopic techniques.

A new way of opening a body cavity can be a revolution in surgery. In 1980s, laparoscopy changed how surgeons had been working for years. Natural orifice translumenal endoscopic surgery (NOTES), minilaparoscopy-assisted natural orifice surgery (MANOS), single incision laparoscopic surgery (SILS) and other new techniques are the new paradigm in our way of operating in the 21(st) century. The development of these techniques began in the late 90s but they have not had enough impact to develop and evolve. Parallels between the first years of laparoscopy and NOTES can be made. Working for an invisible surgery, not only for cosmesis but for a less invasive surgery, is the target of NOTES, MANOS and SILS performed by surgeons and endoscopists over the last 10 years. The future flexible endoscopic platforms and the fusion between laparoscopic instruments and devices and robotic surgery will be a great advance for "scarless surgery".

[Non-randomised, comparative, prospective study of transvaginal endoscopic cholecystectomy versus transparietal laparoscopic cholecystectomy]. / Estudio comparativo, prospectivo y no aleatorizado de la colecistectomía endoscópica transvaginal frente a la colecistectomía laparoscópica transparietal.

INTRODUCTION: We present a non-randomised comparative study of two patients series followed up prospectively, in which convention laparoscopic cholecystectomy is compared with transvaginal cholecystectomy, a hybrid transluminal endoscopic procedure, with the objective of assessing the clinical safety of the procedures and its efficacy in the resolution of cholelithiasis. PATIENTS AND METHOD: A non-randomised prospective clinical series of 40 female patients, operated on for cholelithiasis using endoscopic surgery, 20 with a conventional laparoscopic approach and 20 using a transvaginal endoscopic approach. Surgical wound infection, urinary infection, evisceration, eventration, mortality and other complications. RESULTS: Scheduled operations were performed on the 40 patients as indicated. There were no complications during the operations. There was no mortality associated with the procedures and there was only one post-surgical complication, a urinary tract infection in one patient operated on by the transvaginal approach. The mean follow up was the same in both groups (9 months). The mean hospital stay was less than 0.8 days in both groups. The duration of the surgery was longer in the transvaginal approach group, with a mean of 69.5 min, compared to 46.2 min in the laparoscopy group. CONCLUSIONS: Although the cosmetic benefit is obvious, no differences were found as regards parietal problems in this series. The duration of the transvaginal surgery is higher than that of the transparietal, but the times of both are acceptable. In this study, the non-inferiority in the safety and efficacy of the transvaginal approach is able to be assessed.

Do neonates with genetic abnormalities have an increased morbidity and mortality following cardiac surgery?

INTRODUCTION: Genetic abnormalities occur in approximately 20% of children with congenital heart disease. The purpose of this study was to evaluate the effect of genetic abnormalities on short-term outcomes following neonatal cardiac surgery. METHODS: Retrospective review of all neonates (n = 609) undergoing cardiac surgery from January 2003 to December 2006. Genetic abnormalities were identified in 93 neonates (15%). Genetic abnormalities identified were 22q11.2 deletion (23), chromosomal abnormalities including various monosomies, trisomies, deletions, duplications, and inversions (17), dysmorphic undefined syndrome without recognized chromosomal abnormality (27), Down syndrome (9), laterality sequences (9), recognixed syndromes and genetic etiology including Mendelian (i.e. Alagille, CHARGE) (8). RESULTS: Neonates with genetic abnormalities had lower birth weights and were older at time of surgery. There was no difference in operative variables, duration of mechanical ventilation or ICU length of stay between the two groups. There was an increase in total hospital length of stay and postoperative complications in the neonates with genetic abnormalities. Importantly, in hospital mortality was not different. CONCLUSION: Neonates with genetic abnormalities have a higher risk of postoperative complications and a longer hospital length of stay. However, there is no increase in hospital mortality. This information may aid in patient management decisions and parental counseling. Longer-term studies are needed for understanding the total impact of genetic abnormalities on neonates with congenital heart disease.

Hemodynamic effects and safety of nesiritide in neonates with heart failure.

OBJECTIVE: Evaluate effects and safety of nesiritide (Natrecor, Scios Inc.) human B-type natriuretic peptide, in neonates with heart failure. METHODS: Seventeen neonates, not responding to conventional therapy, treated with nesiritide were retrospectively reviewed. RESULTS: Average age 16 + 8 days; weight 3.2 + 0.6 kg. Fifteen treated with concomitant inotropic therapy; all with diuretics. Twelve received loading dose; followed by continuous infusions of 0.005 mcg/kg/min (2); 0.01 mcg/kg/min (12); 0.02 mcg/kg/min (3). Length of therapy 5 + 4 days. No change in heart rate or blood pressure between baseline, 1 hour or 24 hours of nesiritide infusion. Decrease central venous pressure (CVP) 24 hours after infusion (p = 0.03). Ins-out ratio improved in 29%. No difference in pre and post therapy BUN and creatinine (Cr). 18% had hypotension requiring intervention. CONCLUSIONS: Nesiritide use in neonates may improve hemodynamics as demonstrated by reduction in CVP. All patients tolerated bolus dosing, however, transient hypotension occurred in 18% of neonates with continuous infusion.

B-type natriuretic peptide in the emergency diagnosis of critical heart disease in children.

OBJECTIVE: The initial presentation of congenital and acquired heart disease in children can present a diagnostic challenge. We sought to evaluate B-type natriuretic peptide as a marker of critical heart disease in children at presentation in the acute care setting. METHODS: A cohort of 33 pediatric patients with newly diagnosed congenital or acquired heart disease had B-type natriuretic peptide levels obtained on hospital admission after evaluation in an acute care setting. Patients were admitted from March 2005 through February 2007. A noncardiac cohort of 70 pediatric patients who presented with respiratory or infectious complaints had B-type natriuretic peptide levels obtained during emergency department evaluation. A comparison of B-type natriuretic peptide results was performed. RESULTS: Cardiac diagnoses included cardiomyopathy (14), left-sided obstructive lesions (12), anomalous left coronary artery from the pulmonary artery (4), total anomalous pulmonary venous return (2), and patent ductus arteriosus (1). Cardiac cohort mean age at presentation was 33.6 months. The 33 patients with new cardiac diagnoses had a mean B-type natriuretic peptide level of 3290 pg/mL (SD: +/-1609; range: 521 to >5000 pg/mL). The 70 noncardiac patients' mean age at presentation was 23.1 month, and mean B-type natriuretic peptide level was 17.4 pg/mL (SD: +/-20; range: <5 to 174 pg/mL). CONCLUSIONS: B-type natriuretic peptide levels were markedly elevated at presentation in the acute care setting for all patients in this cohort of children with newly diagnosed congenital or acquired heart disease. B-type natriuretic peptide levels from noncardiac patients were significantly lower, with no overlap to the cardiac disease group. B-type natriuretic peptide level can be useful as a diagnostic marker to aid in the recognition of pediatric critical heart disease in the acute care setting.

Does preoperative mechanical ventilation affect outcomes in neonates undergoing cardiac surgery?

OBJECTIVE: To review, in retrospective fashion, the effect of preoperative mechanical ventilation on neonatal outcomes after cardiac surgery. METHODS: We studied 114 newborns less than 15 days old admitted to the cardiac intensive care unit for cardiac surgery. Of the newborns, 71 (62%) were mechanically ventilated at the referring hospital before transport to our institution. Of the 71 ventilated patients, 14 were extubated and breathing spontaneously before cardiac surgery. We compared variable haemodynamics and outcomes between the 57 patients mechanically ventilated at time of cardiac surgery, and the 57 patients breathing spontaneously at this time. RESULTS: Newborns mechanically ventilated before cardiac surgery had increased preoperative haemodynamic compromise, increased postoperative sepsis (p equal to 0.02) and mortality (p equal to 0.005) compared with those breathing spontaneously before cardiac surgery. CONCLUSION: Newborns requiring preoperative mechanical ventilation had greater risk of postoperative morbidity and mortality. Heightened vigilance is warranted in this population of patients at high risk.