Validation of Perioperative Troponin Levels for Predicting Postoperative Mortality and Long-Term Survival in Patients Undergoing Surgery for Hepatobiliary and Pancreatic Cancer

Background: Hepatopancreato and biliary (HPB) tumors represent some of the leading cancer-related causes of death worldwide, with the majority of patients undergoing surgery in the context of a multimodal treatment strategy. Consequently, the implementation of an accurate risk stratification tool is crucial to facilitate informed consent, along with clinical decision making, and to compare surgical outcomes among different healthcare providers for either service evaluation or clinical audit. Perioperative troponin levels have been proposed as a feasible and easy-to-use tool in order to evaluate the risk of postoperative myocardial injury and 30-day mortality. The purpose of the present study is to validate the perioperative troponin levels as a prognostic factor regarding postoperative myocardial injury and 30-day mortality in Greek adult patients undergoing HPB surgery. Method: In total, 195 patients undergoing surgery performed by a single surgical team in a single tertiary hospital (2020-2022) were included. Perioperative levels of troponin before surgery and at 24 and 48 h postoperatively were assessed. Model accuracy was assessed by observed-to-expected (O:E) ratios, and area under the receiver operating characteristic curve (AUC). Survival at one year postoperatively was compared between patients with high and normal TnT levels at 24 h postoperatively. Results: Thirteen patients (6.6%) died within 30 days of surgery. TnT levels at 24 h postoperatively were associated with excellent discrimination and provided the best-performing calibration. Patients with normal TnT levels at 24 h postoperatively were associated with higher long-term survival compared to those with high TnT levels. Conclusions: TnT at 24 h postoperatively is an efficient risk assessment tool that should be implemented in the perioperative pathway of patients undergoing surgery for HPB cancer.

Appraisal of the clinical practice guidelines on thromboprophylaxis in orthopaedic procedures; Do we AGREE (II)?

OBJECTIVE

Optimal thromboprophylaxis in orthopaedic procedures is crucial in an attempt to lower the risk of venous thromboembolism, including deep vein thrombosis and pulmonary embolism. We aim to: 1) identify clinical practice guidelines (CPGs) and recommendations (CPRs) on thromboprophylaxis in adult patients undergoing orthopaedic procedures, and 2) assess the methodological quality and reporting clarity of these guidelines.

METHODS

The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered on the international prospective register of systematic reviews (PROSPERO) under the registration number (CRD42023406988). An electronic search was conducted using Medline, Embase, Cochrane, Web of Science, Google Scholar and medRxiv. The search terms used were ""adults", "orthopedic surgery", "orthopedic surgeries", "orthopedic surgical procedure", "orthopedic surgical procedures" "english language", "venous thromboembolism", in all possible combinations (January 2013 to March 2023). The eligible studies were evaluated by four blind raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool.

RESULTS

The literature research resulted in 931 studies. Finally, a total of 16 sets of guidelines were included in the current analysis. There were 8 national and 8 international CPGs. Eight CPGs made specific recommendations for orthopaedic surgery and referred mostly to joints; one guideline focused on pelvi-acetabular trauma, while the rest were more inclusive and non-specific. Four guidelines, one from the American Society of Hematology (ASH), two from the United Kingdom (UK) and one from India were found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. Inter-rater agreement was very good with a mean Cohens Kappa 0.962 (95 % CI, 0.895-0.986) in the current analysis. So, the reliability of the measurements can be interpreted as good to excellent.

CONCLUSION

Optimal thromboprophylaxis in orthopaedic procedures is crucial. The available guidelines were found to be mostly of high methodological quality and inter-rater agreement was very good, according to our study.

Perioperative management of antithrombotics in elective intracranial procedures: systematic review, critical appraisal

PURPOSE

Perioperative management of patients medicated with antithrombotics requiring elective intracranial procedures is challenging. We ought to (1) identify the clinical practice guidelines (CPGs) and recommendations (CPRs) on perioperative management of antithrombotic agents in elective intracranial surgery and (2) assess their methodological quality and reporting clarity.

METHODS

The study was conducted following the 2020 PRISMA guidelines for a systematic review and has been registered (PROSPERO, CRD42023415710). An electronic search was conducted using PubMed, Scopus, and Google Scholar. The search terms used were "adults," "antiplatelets," "anticoagulants," "guidelines," "recommendations," "english language," "cranial surgery," "brain surgery," "risk of bleeding," "risk of coagulation," and "perioperative management" in all possible combinations. The search period extended from 1964 to April 2023 and was limited to literature published in the English language. The eligible studies were evaluated by three blinded raters, by employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool.

RESULTS

A total of 14 sets of guidelines were evaluated. Two guidelines from the European Society of Anaesthesiology and one from the American College of Chest Physicians found to have the highest methodological quality and reporting clarity according to the AGREE-II tool. The interrater agreement was good with a mean Cohens Kappa of 0.70 (range, 46.5-94.4%) in the current analysis.

CONCLUSION

The perioperative management of antithrombotics in intracranial procedures may be challenging, complex, and demanding. Due to the lack of high quality data, uncertainty remains regarding the optimal practices to balance the risk of thromboembolism against that of bleeding.

Femoral-Obturator-Sciatic (FOS) Nerve Block as an Anesthetic Triad for Arthroscopic ACL Reconstruction: Is This the Magic Trick We Were Missing?

Arthroscopic anterior cruciate ligament (ACL) reconstruction with hamstring grafting is a common orthopedic procedure that is associated with moderate-to-severe pain. Peripheral nerve blockade as an anesthetic technique is an appealing option in the era of modern anesthesia. The aim of this narrative review is to document the efficacy and safety of the combination of femoral, obturator, and sciatic (FOS) nerve blocks as an exclusive method for anesthesia in patients undergoing ACL reconstruction. An electronic search of the literature published up to October 2023 was conducted in the Medline, Embase, Cochrane, Web of Science, and Google Scholar databases to find studies on ACL reconstruction and peripheral obturator nerve block. Overall, 8 prospective studies-with a total of 315 patients-published between 2007 and 2022 were included in this review. Ultrasound-guided peripheral FOS nerve blockade is an effective anesthetic technique for ACL reconstruction, offering good perioperative pain management, minimal opioid consumption, and an excellent safety profile. Further well-designed prospective studies are needed to determine the best approach for obturator nerve blockade and the appropriate type and dosage of local anesthetic.

Predicting the Outcome of Patients with Severe COVID-19 with Simple Inflammatory Biomarkers: The Utility of Novel Combined Scores-Results from a European Tertiary/Referral Centre

Background: The clinical significance of combinations of inflammatory biomarkers in severe COVID-19 infection is yet to be proved. Although several studies have evaluated the prognostic value of biomarkers in patients with COVID-19, there are limited data regarding the value of the combination scores that could take full advantage of the prognostic value of several biomarkers and that could account for the heterogeneity of patients with severe COVID-19. We investigated the prognostic value of combination scores of admission values of inflammatory biomarkers in adults with severe COVID-19. Methods: Adults admitted to the Department of Respiratory Medicine of the UHL with severe COVID-19 (April-September 2021, NCT05145751) were included. Demographics, medical history, laboratory tests and outcome (high-flow nasal cannula (HFNC), admission to Intensive Care Unit (ICU) or death) were recorded. The optimal cut-off points of on admission values of C-reactive protein (CRP), CRP to lymphocyte ratio (CLR), lymphocyte to neutrophil ratio (LNR) and derived variation of neutrophil to lymphocyte ratio (dv-NLR (neutrophil/white blood count-lymphocyte)) for the predetermined outcome were defined. Based on the cut-off of CRP, LNR, dv-NLR and CLR, which were found to be predictors for HFNC, 3 scores were defined: CRP and LNR (C-CRP #1), CRP and dv-NLR (C-CRP #2), CRP and CLR (C-CRP #3). Likewise, based on the cut-off of CRP and CLR, which were found to be predictors for death, the score of CRP and CLR (C-CRP #3*) was defined. The combination scores were then classified as: 2 points (both biomarkers elevated); 1 point (one biomarker elevated) and 0 points (normal values). None of the biomarkers was predictive for the ICU admission, so no further analysis was performed. Binomial logistic regression analysis was used to establish the predictive role for each biomarker. Results: One hundred and fifteen patients (60% males, mean age 57.7 years) were included. Thirty-seven (32.2%) patients required HFNC, nine (7.8%) died and eight (7%) were admitted to ICU, respectively. As far as HFNC is concerned, the cut-off point was 3.2 for CRP, 0.231 for LNR, 0.90 for dv-NLR and 0.004 for CLR. Two points of C-CRP #1 and 2 points of C-CRP #3 predicted HFNC with a probability as high as 0.625 (p = 0.005) and 0.561 (p < 0.001), respectively. Moreover, 1 point of C-CRP #2 and 2 points of C-CRP #2 predicted HFNC with a probability of 0.333 and 0.562, respectively. For death, the optimal cut-off point for CRP was 1.11 and for CLR 3.2*1033. Two points of C-CRP #3* with an accuracy of 0.922 predicted mortality (p = 0.0038) in severe COVID-19. Conclusions: The combination scores of CRP and inflammatory biomarkers, based on admission values, are promising predictors for respiratory support using HFNC and for mortality in patients suffering from severe COVID-19 infection.

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

BACKGROUND

Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

METHODS

This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

RESULTS

The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

CONCLUSION

Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Predictors of 30-Day Postoperative Outcome after Elective Endovascular Abdominal Aortic Aneurysm Repair: A Tertiary Referral Center Experience

BACKGROUND

We evaluated the 30-day postoperative outcome after elective endovascular aneurysm repair (EVAR) and the possible predictors for the 30-day postoperative outcome.

MATERIALS

Demographics, medical history, laboratory values, intensive care unit (ICU) admission and 30-day complications classified as major (major adverse cardiovascular events (MACEs), acute kidney injury (AKI) and death of any cause) and minor (postimplantation syndrome (PIS), postoperative delirium (POD), urinary tract infection (UTI) and technical graft failure) were documented (March 2016 to February 2019).

RESULTS

We included 322 patients. The majority were managed under general anesthesia (83%) with femoral cutdown (98.1%). Overall, 121 (37.5%) complications, mostly minor (n = 103, 31.9%), were recorded. In total, 11 patients (3.4%) developed MACEs, 5 (1.6%) experienced AKI and 2 (0.6%) died in the ICU. Moreover, 77 patients (23.9%) suffered from PIS, 11 from POD, 11 from UTI and 4 from technical graft failure. The multivariate logistic regression analysis revealed that aneurysm diameter (p = 0.01) and past smoking (p = 0.003) were predictors for complications. PAD was an independent predictor of MACEs (p = 0.003), preoperative neutrophil to lymphocyte ratio (NLR) of AKI (p = 0.003) and past smoking of PIS (p = 0.008), respectively.

CONCLUSIONS

Our study showed that the 30-day morbidity after EVAR exceeded 35%. However, the majority of complications were minor, and the associated mortality was low. Aneurysm diameter and past smoking were independent predictors for postoperative outcome.

The Emerging Role of "Failure to Rescue" as the Primary Quality Metric for Cardiovascular Surgery and Critical Care

We conducted a thorough literature review on the emerging role of failure to rescue (FTR) as a quality metric for cardiovascular surgery and critical care. For this purpose, we identified all original research studies assessing the implementation of FTR in cardiovascular surgery and critical care from 1992 to 2023. All included studies were evaluated for their quality. Although all studies defined FTR as mortality after a surgical complication, a high heterogeneity has been reported among studies regarding the included complications. There are certain factors that affect the FTR, divided into hospital- and patient-related factors. The identification of these factors allowed us to build a stepwise roadmap to reduce the FTR rate. Recently, FTR has further evolved as a metric to assess morbidity instead of mortality, while being also evaluated in the context of interventional cardiology. All these advances are further discussed in the current review, thus providing all the necessary information to surgeons, anesthesiologists, and physicians willing to implement FTR as a metric of quality in their establishment.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Complete Vascular Replacement of the Infrarenal Inferior Vena Cava and Abdominal Aorta during Post-Chemotherapy Retroperitoneal Lymph Node Dissection for a Non-Seminomatous Germ Cell Tumor

Testicular germ cell tumors (TGCTs) are the leading cause of cancer-related death in males between the ages of 20 and 40. In the advanced stages, the combination of cisplatin-based chemotherapy and surgical excision of the remaining tumor can cure many of these patients. Vascular procedures may be required during retroperitoneal lymph node dissection (RPLND) in order to achieve the complete excision of all residual retroperitoneal masses. Careful assessment of pre-operative imaging and the identification of patients who could benefit from additional procedures are important for minimizing peri- and postoperative complications. We report on a case of a 27-year-old patient with non-seminomatous TGCT, who successfully underwent post-chemotherapy RPLND with additional infrarenal inferior vena cava (IVC) and complete abdominal aorta replacement using synthetic grafts.

Sex disparities in left ventricular assist device implantation outcomes: A systematic review and meta-analysis of over 50 000 patients

BACKGROUND

Left ventricular assist devices (LVAD) represent an important therapeutic option for patients progressing to end-stage heart failure. Women have been historically underrepresented in LVAD studies, and have been reported to have worse outcomes despite technological optimisation. We aimed to systematically explore the evidence on sex disparities in the use and outcomes of LVAD implantation.

METHODS

A systematic database search with meta-analysis was conducted of comparative original articles of men versus women undergoing LVAD implantation, in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to July 2022. Primary outcomes were stroke (haemorrhagic and ischaemic) and early/overall mortality. Secondary outcomes were LVAD thrombosis, right VAD implantation, major bleeding, kidney dysfunction, and device/driveline infection.

RESULTS

Our search yielded 137 relevant studies, including 22 meeting the inclusion criteria with a total of 53 227 patients (24.2% women). Overall mortality was higher in women (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.05-1.62, p = 0.02), as was overall stroke (OR 1.32, 95%CI 1.06-1.66, p = 0.01), including ischemic (OR 1.80, 95%CI 1.22-2.64, p = 0.003) and haemorrhagic (OR 1.72, 95%CI 1.09-2.70, p = 0.02). Women had more frequent right VAD implantation (OR 2.11, 95%CI 1.24-3.57, p = 0.006) and major bleeding (OR 1.40, 95%CI 1.06-1.85, p = 0.02). Kidney dysfunction, LVAD thrombosis, and device/driveline infections were comparable between sexes.

CONCLUSIONS

Our analysis suggests that women face a greater risk of adverse events and mortality post-LVAD implantation. Although the mechanisms remain unclear, the difference in outcomes is thought to be multifactorial. Further research, that includes comprehensive pre-operative characteristics and post-operative outcomes, is encouraged.

Differences in long-term survival outcomes after coronary artery bypass grafting using single vs multiple arterial grafts: a meta-analysis with reconstructed time-to-event data and subgroup analyses

OBJECTIVE

We reviewed the available literature on patients with coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) with either single (SAG) or multiple arterial grafting (MAG).

METHODS

Original research studies that evaluated the long-term survival of MAG versus SAG were identified, from 1995 to 2022. The median overall survival (OS) and event-free OS were the primary endpoints. Comparison of median OS between the right internal mammary artery (RIMA) and radial artery (RA) as a second arterial conduit was the secondary endpoint. Subgroup analyses were performed regarding patients older than 70 years, with diabetes mellitus, and females. A sensitivity analysis was performed with the leave-one-out method.

RESULTS

Forty-four studies were included in the qualitative and thirty-nine in the quantitative synthesis. After pooling data from 180 to 459 patients, the MAG group demonstrated a higher OS (HR, 0.589; 95% CI, 0.58-0.60; p < 0.0001) and event-free OS compared with the SAG group (HR, 0.828; 95% CI, 0.80-0.86; p < 0.0001). In addition, RITA was associated with superior OS compared with RA as a second arterial conduit (HR, 0.936; 95% CI, 0.89-0.98; p = 0.009). MAG was also superior to SAG in patients over 70 years, females, and patients with diabetes mellitus. Sensitivity analysis demonstrated a small-size study effect on the female subgroup analysis.

CONCLUSION

The present meta-analysis indicates that MAG is associated with enhanced survival outcomes compared to SAG for patients undergoing isolated CABG.

In-depth bioinformatic study of the cadherin 5 interactome in patients with thoracic aortic aneurysm unveils 8 novel biomarkers

OBJECTIVES

Thoracic aortic aneurysm (TAA) is characterized by the dilation of the aorta and is associated with poor prognosis if not diagnosed and treated early. In this context, the identification of biomarkers regarding the TAA diagnosis, monitoring and prognosis is crucial. The purpose of the current study was to investigate the differential gene expression profile of the cadherin 5 (CDH5 or VE-Cadherin) gene network in patients with TAA, to propose novel biomarkers.

METHODS

In silico techniques were used to construct the interactome of the CDH5 network, identify the differentially expressed genes (DEGs) in TAA as compared to healthy controls, and uncover the related molecular functions and the regulating miRNAs.

RESULTS

Transcriptomic data of one microarray dataset were included, incorporating 43 TAA and 43 control samples. Eight DEGs were identified; 7 were up-regulated and 1 was down-regulated. A molecular signature of 8 genes (CDH5; Calcitonin Receptor-Like Receptor-CALCRL; Activin A Receptor-Like Type 1-ACVRL1, Tryptophanyl-TRNA Synthetase 1-WARS; Junction Plakoglobin-JUP, Protein Tyrosine Phosphatase Receptor Type J-PTPRJ, Purinergic Receptor P2X 4-P2RX4, Kinase Insert Domain Receptor-KDR) were identified as biomarkers associated with TAA. PTPRJ was associated with excellent discrimination and calibration in predicting TAA presentation. Positive correlations were reported regarding the expression of CDH5-CALCRL, CDH5-ACVRL1, CDH5-WARS and CDH5-PTPRJ. Finally, gene set enrichment analysis indicated the molecular functions and miRNA families (hsa-miR-296-5p, hsa-miR-6836-5p, hsa-miR-6132, hsa-miR-27a-5p and hsa-miR-6773-5p) relevant to the 8 biomarkers.

CONCLUSIONS

These outcomes propose an 8-gene molecular panel associated with TAA.

Introducing the "Bleeding Team": Urgent Reconstruction of an Open Fracture in a Patient Receiving Acenocoumarol: A Case Report

CASE

An elderly, polytrauma patient receiving vitamin K antagonist (VKA) for atrial fibrillation required immediate surgery for open distal tibial fracture. As the initial reversal with vitamin K and fresh frozen plasma by the trauma team was ineffective, the "Bleeding Team" was convened and administrated the appropriate four-factor prothrombin complex regimen, reversing the VKA in a timely manner. Surgery was performed under peripheral nerve blockade subsequently. The postoperative course of the patient was uneventful.

CONCLUSION

The individualized approach and the multidisciplinary experts' team guidance is of outmost importance in patients who are treated with anticoagulants and present for nonelective surgery.

Soaking of autografts with vancomycin is highly effective on preventing postoperative septic arthritis in patients undergoing ACL reconstruction with hamstrings autografts

PURPOSE

To evaluate the impact of local soaking of the autografts with vancomycin during anterior cruciate ligament (ACL) reconstruction on postoperative infection rates.

METHODS

Between 2003 and 2014 (first study period), 1,242 patients underwent ACL reconstruction using autografts, without soaking them in vancomycin solution, while between 2014 and 2019 (second study period) all ACL autografts in 593 patients were soaked in a 5-mg/ml vancomycin solution, in a territory University Hospital. The same standard treatment of perioperative IV antibiotics was applied in both groups.

RESULTS

Postoperative septic arthritis occurred in seven out of 1,242 patients (0.56%) during the first study period. Bone patellar tendon bone autograft was used in 311 (25%) patients, and hamstring tendon autograft was used in the rest 931 (75%) of the study population during this period. All infected cases were male and had a hamstrings graft implanted. There were no postoperative infections (0%) in 593 ACL reconstructions during the second study period. Bone patellar tendon bone autograft was used in 178 (30%) patients while hamstring tendon autograft was used in the rest 415 (70%) of the study population, during this period. Statistical analysis revealed a significantly reduced postoperative infection rate (p = 0.018) between the two reported periods, with the main impact referring to the use of hamstrings autograft (p = 0.031) for the first study period.

CONCLUSIONS

Septic arthritis following ACL reconstruction can be significantly reduced (or even eliminated) by soaking ACL autografts in a 5 mg/ml vancomycin solution. Of note, this strategy seems to be more effective in the setting of hamstring tendon autograft use, since the risk of postoperative knee infection is significantly higher when this type of graft is used.

Translation and cultural adaptation of the Greek version of the confusion assessment method diagnostic algorithm and the nursing delirium screening scale and their inter-rater reliability: A prospective cohort study

AIM

The lack of standardized tools limits the diagnosis οf postoperative delirium (POD) in the Greek population. Our aim was the translation and the cultural adaptation of the confusion assessment method (CAM) diagnostic algorithm and the nursing delirium screening scale (nu-DESC) in the Greek surgical population, and the determination of their inter-rater reliability.

METHODS

After Ethical approval and registration as a clinical trial (NCT04154176), a prospective cohort study was conducted in the Department of Anesthesiology, University Hospital of Larissa, Greece. Patients at least 60 years old, undergoing elective non-cardiac surgery, under general anesthesia were included.

RESULTS

Data from 60 patients, 180 records in total, were analyzed. There was an "almost perfect agreement" between the raters with the use of CAM (Cohen's Kappa estimate: 0.960; 95 % CI: 0.905-1.000) and nu-DESC (Cohen's Kappa estimate: 0.981; 95 % CI: 0.944-1.000). The agreement on each specific question of CAM and nu-DESC ranged from "substantial" to "almost perfect agreement". Based on the CAM, the sensitivity and specificity of nu-DESC were 0.97 (95 % CI: 0.82-1.00) and 0.99 (95 % CI: 0.96-1.00), respectively. The Greek versions of CAM and nu-DESC showed a high inter-rater agreement.

CONCLUSION

With the translation, the cultural adaptation, and the determination of their inter-rater agreement, the CAM diagnostic algorithm and the nu-DESC may serve as reliable instruments for the detection of POD in the Greek population. HIPPOKRATIA 2020, 24(1): 8-14.

Results of Arthroscopic Bankart Repair in Recreational Athletes and Laborers: A Retrospective Study With 5 to 14 Years of Follow-up

Background:

Arthroscopic Bankart repair is the most common procedure for anterior shoulder instability management. However, the long-term efficacy of the procedure is questionable, and the results are different among different populations. Few studies have focused on specific populations, such as recreational athletes and laborers.

Hypothesis:

Good to excellent long-term results, with a low recurrence rate, can be achieved using arthroscopic Bankart repair in recreational athletes and laborers suffering from anterior shoulder instability.

Study Design:

Case series; Level of evidence, 4.

Methods:

A specific group of laborers and recreational athletes were included in this study. A total of 52 patients (52 shoulders) with anterior-inferior traumatic shoulder instability underwent arthroscopic Bankart repair and met our strict criteria for study inclusion. The recurrence rate was recorded. Patients were evaluated at a minimum follow-up of 5 years using the American Shoulder and Elbow Surgeons (ASES) score, the Rowe score, the Constant score, and a visual analog scale (VAS) for pain. A radiological evaluation for arthritis was also performed according to the Samilson-Prieto classification.

Results:

The mean follow-up was 105.4 months (range, 65-164 months). Our overall recurrence rate was 11.5% (6/52 patients). All patients were able to return to their previous job status with minimum limitations, and 76.7% of our study population reported returning to their preinjury sporting activities. Postoperatively, all scores were improved, with statistically significant increases from preoperative values (P < .001). At the last radiographic follow-up, 9 patients (18.8%) had mild arthritis, while 2 patients (4.2%) had moderate arthritis.

Conclusion:

Arthroscopic soft tissue Bankart repair may provide good to excellent long-term clinical results with an acceptable recurrence rate in medium-demand patients (recreational athletes and laborers).

Superior perioperative analgesia with combined femoral-obturator-sciatic nerve block in comparison with posterior lumbar plexus and sciatic nerve block for ACL reconstructive surgery

PURPOSE

The purpose of this randomized controlled study is to compare and evaluate the intraoperative and post-operative outcome of PLPS nerve block and that of femoral, obturator and sciatic (FOS) nerve block as a method of anaesthesia, in performing ACL reconstruction.

METHODS

Patients referred for elective arthroscopic ACL reconstruction using hamstring autograft were divided in two groups. The first group received combined femoral-obturator-sciatic nerve block (FOS Group) under dual guidance, whereas the second group received posterior lumbar plexus block under neurostimulation and sciatic nerve block (PLPS Group) under dual guidance.

RESULTS

The two groups were comparable in terms of age, sex, BMI and athletic activity. The time needed to perform the nerve blocks was significantly shorter for the FOS group (p < 0.005). Similarly, VAS scores during tourniquet inflation and autograft harvesting were significantly higher (p < 0.005) in the PLPS group and this is also reflected in the intraoperative fentanyl consumption and conversion to general anaesthesia. Finally, patients in this group also reported higher post-operative VAS scores and consumed more morphine.

CONCLUSIONS

Peripheral nerve blockade of FOS nerve block under dual guidance for arthroscopic ACL reconstructive surgery is a safe and tempting anaesthetic choice. The success rate of this technique is higher in comparison with PLPS and results in less peri- and post-operative pain with less opioid consumption. This study provides support for the use of peripheral nerve blocks as an exclusive method for ACL reconstructive surgery in an ambulatory setting with almost no complications.

LEVEL OF EVIDENCE

I.

Effect of interscalene brachial plexus block on heart rate variability

Background

Interscalene brachial plexus block (ISB) may be followed by cardiovascular instability. Until date, there is no clear picture available about the underlying mechanisms of ISB. In this study, we aimed to determine the changes in heart rate variability (HRV) parameters after ISB and the differences between right- and left-sided ISBs.

Methods

We prospectively studied 24 patients operated for shoulder surgery in sitting position and divided them into two respective groups: R (right-sided block = 14 pts) and L (left-sided block = 10 pts). HRV data were taken before and 30 min after the block. Ropivacaine without ephedrine was used for the ISB through an insulated block needle connected to a nerve stimulator. Statistical analysis implemented chi-square, Student's and t-paired tests. Skewed distributions were analyzed after logarithmic transformation.

Results

All the studied patients had successful blocks. Horner's syndrome signs were observed in 33.3% of the patients (R = 5/14, L = 3/10; [P = 0.769]). There were no significant differences in pre-block HRV between the groups. The application of ISB had differential effect on HRV variables: R-blocks increased QRS and QTc durations and InPNN50, while a statistical decrease was seen in InLF. L-blocks did not show any significant changes. These changes indicate a reduced sympathetic and an increased parasympathetic influence on the heart's autonomic flow after R-block.

Conclusions

Based on the obtained results we conclude that ISB, possibly through extension of block to the ipsilateral stellate ganglion, alters the autonomic outflow to the central circulatory system in a way depending on the block's side.

Management of sigmoid volvulus avoiding sigmoid resection

Acute sigmoid volvulus is typically caused by an excessively mobile and redundant segment of colon with a stretched mesenteric pedicle. When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation. A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness. The patient had tympanitic percussion tones and no bowel sounds. She was diagnosed with acute sigmoid volvulus. Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression. Controversy exists on the decision of the time, the type of definitive treatment, the strategy and the most appropriate surgical technique, especially for teenagers for whom sigmoid resection can be avoided.

Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial

BACKGROUND

Cardiac surgery is a major consumer of blood products, and hemodilution increases transfusion requirements during cardiac surgery under CPB. As intraoperative parenteral fluids contribute to hemodilution, we evaluated the hypothesis that intraoperative fluid restriction reduces packed red-cell (PRC) use, especially in transfusion-prone adults undergoing elective cardiac surgery.

METHODS

192 patients were randomly assigned to restrictive (group A, 100 pts), or liberal (group B, 92 pts) intraoperative intravenous fluid administration. All operations were conducted by the same team (same surgeon and perfusionist). After anesthesia induction, intravenous fluids were turned off in Group A (fluid restriction) patients, who only received fluids if directed by protocol. In contrast, intravenous fluid administration was unrestricted in group B. Transfusion decisions were made by the attending anesthesiologist, based on identical transfusion guidelines for both groups.

RESULTS

137 of 192 patients received 289 PRC units in total. Age, sex, weight, height, BMI, BSA, LVEF, CPB duration and surgery duration did not differ between groups. Fluid balance was less positive in Group A. Fewer group A patients (62/100) required transfusion compared to group B (75/92, p < 0.04). Group A patients received fewer PRC units (113) compared to group B (176; p < 0.0001). Intraoperatively, the number of transfused units and transfused patients was lower in group A (31 u in 19 pts vs. 111 u in 62 pts; p < 0.001). Transfusions in ICU did not differ significantly between groups. Transfused patients had higher age, lower weight, height, BSA and preoperative hematocrit, but no difference in BMI or discharge hematocrit. Group B (p < 0.005) and female gender (p < 0.001) were associated with higher transfusion probability. Logistic regression identified group and preoperative hematocrit as significant predictors of transfusion.

CONCLUSIONS

Our data suggest that fluid restriction reduces intraoperative PRC transfusions without significantly increasing postoperative transfusions in cardiac surgery; this effect is more pronounced in transfusion-prone patients.

TRIAL REGISTRATION

NCT00600704, at the United States National Institutes of Health.