The Italian Unitary Society of Colon-proctology (SIUCP: Società Italiana Unitaria di Colonproctologia) guidelines for the management of anal fissure

INTRODUCTION

The aim of these evidence-based guidelines is to present a consensus position from members of the Italian Unitary Society of Colon-Proctology (SIUCP: Società Italiana Unitaria di Colon-Proctologia) on the diagnosis and management of anal fissure, with the purpose to guide every physician in the choice of the best treatment option, according with the available literature.

METHODS

A panel of experts was designed and charged by the Board of the SIUCP to develop key-questions on the main topics covering the management of anal fissure and to performe an accurate search on each topic in different databanks, in order to provide evidence-based answers to the questions and to summarize them in statements. All the clinical questions were discussed by the expert panel in different rounds through the Delphi approach and, for each statement, a consensus among the experts was reached. The questions were created according to the PICO criteria, and the statements developed adopting the GRADE methodology.

CONCLUSIONS

In patients with acute anal fissure the medical therapy with dietary and behavioral norms is indicated. In the chronic phase of disease, the conservative treatment with topical 0.3% nifedipine plus 1.5% lidocaine or nitrates may represent the first-line therapy, eventually associated with ointments with film-forming, anti-inflammatory and healing properties such as Propionibacterium extract gel. In case of first-line treatment failure, the surgical strategy (internal sphincterotomy or fissurectomy with flap), may be guided by the clinical findings, eventually supported by endoanal ultrasound and anal manometry.

Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes-a prospective non-randomized controlled trial

Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.

Clinics and pathology of Krukenberg tumor: a systematic review and meta-analysis

INTRODUCTION

Krukenberg tumor (KT) is defined as a secondary neoplasm of the ovary. While ovarian metastases account for about 30% of ovarian tumors, KTs are rare, accounting for about 1-2% of the total. The rarity of KT is at least in part responsible for the lack of a precise clinic-pathological characterization of these tumors. Clinically, KT may have a subtle clinical presentation, with few symptomatic manifestations and nonspecific clinical signs, even though in literature there is disagreement about the clinical presentation of these patients; such difficulties in the diagnostic framework often leads to a delayed diagnosis with serious consequences on the patient outcome. We aimed to provide a clinico-pathological characterization of Krukenberg Tumor (KT) through a systematic review and meta-analysis to improve the diagnosis and management of KT.

EVIDENCE ACQUISITION

Electronic databases were searched for all studies assessing clinico-pathological features of KT series. Pooled prevalence of each clinical or pathological factor was calculated according to the random-effect model.

EVIDENCE SYNTHESIS

Forty-eight studies with 3025 KT patients were included; 39.7% of patients were ≥50 and 39.8% were postmenopausal. The most common primary tumor sites were stomach (42.5%), colon-rectum (26.1%), breast (9.3%), and appendix (5%); 48.7% of KTs were synchronous with the primary tumor, 64.3% were bilateral, 40.5% had a diameter ≥10 cm; 55.3% showed extraovarian extent and 49% showed peritoneal involvement. The most common presenting symptoms were ascites (51.7%), palpable mass (31.3%), pain (29.3%), abdominal distention (28.7%), irregular bleeding (9.1%), asymptomatic (11.2%).

CONCLUSIONS

KT shows a highly variable presentation. Understanding the prevalence of clinico-pathological factors may be helpful to improve the diagnosis and management of KT.

Intraoperative use of indocyanine green fluorescence imaging in rectal cancer surgery: The state of the art

Indocyanine green (ICG) fluorescence imaging is widely used in abdominal surgery. The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems. In that setting, ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow. The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery. Each type of use has been separately addressed and the evidence was investigated. During rectal resection, ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks. In addition, ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury. This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed. This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature. Although further studies are need to investigate the real clinical benefits, these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.

Surgical stress and metabolic response after totally laparoscopic right colectomy

No clear consensus on the need to perform an intracorporeal anastomosis (IA) after laparoscopic right colectomy is currently available. One of the potential benefits of intracorporeal anastomosis may be a reduction in surgical stress. Herein, we evaluated the surgical stress response and the metabolic response in patients who underwent right colonic resection for colon cancer. Fifty-nine patients who underwent laparoscopic resection for right colon cancer were randomized to receive an intracorporeal or an extracorporeal anastomosis (EA). Data including demographics (age, sex, BMI and ASA score), pathological (AJCC tumour stage and tumour localization) and surgical results were recorded. Moreover, to determine the levels of the inflammatory response, mediators, such as C-reactive protein (CRP), tumour necrosis factor (TNF), interleukin 1β (IL-1β), IL-6, IL-10, and IL-13, were evaluated. Similarly, cortisol and insulin levels were evaluated as hormonal responses to surgical stress. We found that the proinflammatory mediator IL-6, CRP, TNF and IL-1β levels, were significantly reduced in IA compared to EA. Concurrently, an improved profile of the anti-inflammatory cytokines IL-10 and IL-13 was observed in the IA group. Relative to the hormone response to surgical stress, cortisol was increased in patients who underwent EA, while insulin was reduced in the EA group. Based on these results, surgical stress and metabolic response to IA justify advocating the adoption of a totally laparoscopic approach when performing a right colectomy for cancer.

This trial is registered on ClinicalTrials.gov (ID: NCT03422588).

Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis

Purpose

To evaluate safety and efficacy of a mesh reinforcement following stoma reversal to prevent stoma site incisional hernia (SSIH) and differences across the prostheses used.

Methods

A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Cochrane databases was conducted to identify comparative studies until September 2020. A meta-analysis of postoperative outcomes and a network meta-analysis for a multiple comparison of the prostheses with each other were performed.

Results

Seven studies were included in the analysis (78.4% ileostomy and 21.6% colostomy) with a total of 1716 patients with (n = 684) or without (n = 1032) mesh. Mesh placement was associated with lower risk of SSIH (7.8%vs18.1%, OR0.266,95% CI 0.123–0.577, p < 0.001) than no mesh procedures but also with a longer operative time (SMD 0.941, 95% CI 0.462–1.421, p < 0.001). There was no statistically significant difference in terms of Surgical Site infection (11.5% vs 11.1%, OR 1.074, 95% CI 0.78–1.48, p = 0.66), seroma formation (4.4% vs 7.1%, OR 1.052, 95% CI 0.64–1.73, p = 0.84), anastomotic leakage (3.7% vs 2.7%, OR 1.598, 95% CI 0.846–3.019, p = 0.149) and length of stay (SMD − 0.579,95% CI − 1.261 to 0.102, p = 0.096) between mesh and no mesh groups. Use of prosthesis was associated with a significant lower need for a reoperation than no mesh group (8.1% vs 12.1%, OR 0.332, 95% CI 0.119–0.930, p = 0.036). Incidence of seroma is lower with biologic than polypropylene meshes but they showed a trend towards poor results compared with polypropylene or biosynthetic meshes.

Conclusion

Despite longer operative time, mesh prophylactic reinforcement at the site of stoma seems a safe and effective procedure with lower incidence of SSIH, need for reoperation and comparable short-term outcomes than standard closure technique. A significant superiority of a specific mesh type was not identified.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02393-w.

Risk of appendiceal neoplasm after interval appendectomy for complicated appendicitis: A systematic review and meta-analysis

BACKGROUND

Non-operative management is often the treatment of choice in cases of complicated appendicitis and routine interval appendectomy is not usually recommended. Actually, recent studies show an alarming number of appendiceal neoplasms following interval appendectomy. The aim of this study is to evaluate the prevalence of appendiceal neoplasms and their histological types after interval appendectomy for complicated appendicitis in adults.

METHODS

A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement. Studies reporting appendiceal neoplasm rates after interval appendectomy and histopathological characteristics were included. The most recent World Health Organization (WHO) classification of malignant tumours was considered. A pooled prevalence analysis for both prevalence and pathology was performed.

RESULTS

A total of eight studies was included: seven retrospective series and one randomized controlled trial. The pooled prevalence of neoplasms after interval appendectomy was 11% (95% CI 7-15; I² = 37.5%, p = 0.13). Appendiceal mucinous neoplasms occurred in 43% (95% CI 19-68), adenocarcinoma in 29% (95% CI 6-51), appendiceal neuroendocrine neoplasm in 21% (95% CI 6-36), globet cell carcinoma in 13% (95% CI -2-28), adenoma or serrated lesions in 20% (95% CI -0-41) of cases.

CONCLUSION

The risk of appendiceal neoplasm in patients treated with interval appendectomy for complicated appendicitis is 11%; mucinous neoplasm is the most common histopathological type. Further studies should investigate this association in order to clarify the biological pathway and clinical implications.

Risk of anastomotic bleeding after left colectomy with preservation of inferior mesenteric artery for diverticular disease: preliminary results

BACKGROUND

The inferior mesenteric artery (IMA) preservation in elective laparoscopic left colectomy for diverticular disease may reduce the risk of anastomotic leakage. However, an increased risk of bleeding is assumed. The aim of this study was to investigate the risk of colorectal anastomosis bleeding when IMA is resected or preserved during left colectomy.

METHODS

A retrospective study of a prospectively collected database was performed. All patients who underwent elective left colectomy, from December 2018 to September 2020 were included. Patients' data and clinical information were collected and analyzed. Patients were categorized in two groups: IMA resected (IMA-R) and IMA preserving (IMA-P) left colectomy. Perioperative outcomes between the two groups were compared.

RESULTS

Sixty-three consecutive patients who underwent left colectomy over a period of three years were enrolled: 42 in IMA-R group and 22 in the IMA-P group. There were no significant differences in demographic and intraoperative characteristics between the two groups, except for patients' age and primary disease. Six patients (9.37%) developed anastomotic bleeding during recovery, more frequently in the IMA-P than IMA-R group, although the difference is not statistically significative (13.6% and 7.3%; P=0.406). All bleedings were self-limited and only one needed red blood cells transfusion. Using the bioabsorbable staple line reinforcement (BSLR) has proved to be advantageous in preventing anastomotic bleeding in the IMA-P group.

CONCLUSIONS

IMA preserving left colectomy seems to be associated with a higher risk of mostly self-limited anastomotic bleeding during recovery. BSLR seems to be effective in this group of patients.

Risk of anastomotic bleeding after left colectomy with preservation of inferior mesenteric artery for diverticular disease: preliminary results

BACKGROUND

The inferior mesenteric artery (IMA) preservation in elective laparoscopic left colectomy for diverticular disease may reduce the risk of anastomotic leakage. However, an increased risk of bleeding is assumed. The purpose of this study is to investigate the risk of colorectal anastomosis bleeding, when IMA is resected or preserved during left colectomy.

METHODS

A retrospective review of a prospectively collected database was performed. All patients who underwent elective left colectomy, from December 2018 to September 2020, were included. Patients' data and clinical information were collected and analyzed. Patients were categorized in two group: IMA resected (IMAR) and IMA preserving (IMA-P) left colectomy. Perioperative outcomes between the two groups were compared.

RESULTS

Sixty-three consecutive patients who underwent left colectomy over a period of three years were enrolled: 42 in IMA-R group and 22 in the IMA-P group. There were no significant differences in demographic and intraoperative characteristics between the two groups, except for patients' age and primary disease. Six patients (9.37%) developed anastomotic bleeding during recovery, more frequently in the IMA-P than IMA-R group, although the difference is not statistically significative (13.6% and 7.3%; p=0.406). All bleedings were self-limited and only one needed red blood cells transfusion. Using the bioabsorbable staple line reinforcement (BSLR) has proved to be advantageous in preventing anastomotic bleeding in the IMA-P group.

CONCLUSIONS

IMA preserving left colectomy seems to be associated with a higher risk of mostly selflimited anastomotic bleeding during recovery. BSLR seems to be effective in this group of patients.

Laparoscopic segmental resection for tumours of the Angle of Treitz: a challenging but feasible surgical option. Results from a retrospective case-series analysis

Tumours of the small intestine are rare and account for about 5% of gastrointestinal tract neoplasms. The angle of Treitz (AT) could be defined as the intestinal loop comprised between the third duodenal portion and the first 10 cm of jejunum. A gold standard surgical treatment for AT neoplasm has not yet been well defined. This paper is focused on a very rare disease and at the best of our knowledge this is the largest case series in the literature about the Laparoscopic Segmental Resection (LSR) of AT tumours. Using a prospectively collected database, all data of consecutive patients, from January 2007 to May 2019, who underwent LSR for AT tumours at two different institutions were analysed. Patients’ demographics, intra and post-operative data, 30-day mortality and overall survival were collected. A total of 16 patients were retrieved from our database. The mean operative time was 206,5 ± 79 min. Conversion to open surgery was needed in two cases due to tumor size and, respectively, invasion of the transverse colon which required a multivisceral resection. The mean distal and proximal resection margins were 7.4 ± 2.2 and 3.9 ± 1.2 cm. The median number of harvested nodes was 9 ± 3. Pathological diagnosis was GIST in 11 cases, adenocarcinoma in 4 and sarcoma in 1 case. In conclusion, in experienced hands, LSR appears to be a safe and effective treatment option for tumours of the AT. Prospective studies are needed to confirm these findings.

Serum biomarkers for sepsis in children with febrile neutropenia and cancer

The National Institute for Health and Care Excellence (NICE) defines febrile neutropenia or "neutropenic sepsis" as a patient with an absolute neutrophil count (ANC) less than 0.5 x 109/L and temperature >38°C or signs and symptoms of sepsis.

Laparoscopic drainage of a recurrent psoas abscess

BACKGROUND

Many Authors suggest that psoas abscess should initially undergo an antibiotic therapy, with or without percutaneous drainage. In their opinion, surgical drainage should be done in case of failure or complicated recurrences. Herein we report a laparoscopic drainage of a recurrent and multilocular psoas abscess.

METHODS

A 43-year-old woman presented to our department with a 4-week history of fever, anorexia, difficulty in walking, and pain in her right flank, lower back and hip. She had a 20-year history of recurrent lower back pain and fever treated with cyclic antibiotic therapy. Abdominal CT scan showed a complex multilocular right psoas abscess and a 17 mm hypodense area in the sixth liver segment. A drainage of the abscess through a laparoscopic access with intraoperative laparoscopic ultrasound of the liver was decided.

RESULTS

The patient was discharged on the 3 th postoperative day. Her white blood cell count was normal and she was symptom free. At 1-, 6-, 12- and 24-months-follow-up, neither fever nor lower back pain were reported.

CONCLUSIONS

According to our experience, laparoscopic drainage of iliopsoas abscess is safe and effective. However, further studies comparing laparoscopic drainage with open drainage and percutaneous drainage are required in order to define the specific indications of laparoscopic drainage.

Short and long term results of the laparoscopic Heller-Dor myotomy. The influence of age and previous conservative therapies

AIMS

To evaluate the long-term outcome and quality of life (QoL) data, and to assess the potential influence of age and different conservative procedures on laparoscopic surgery.

BACKGROUND

Current therapies for achalasia can palliate dysphagia, but other symptoms may persist, making it difficult to quantify and compare. To understand if they could influence results, we analyzed short- and long-term results and correlated them to age and previous conservative treatments using a specific QoL test.

METHODS

Functional examinations (endoscopy, 24-hr pH manometry, upper GI X-rays) and the gastrointestinal quality of life index (GIQLI) were used before and after a laparoscopic Heller-Dor myotomy. Data were analyzed by the Mann-Whitney U test, Wilcoxon signed rank test, and Spearman's rho coefficient for bivariate correlations (p < 0.05).

RESULTS

From January 1996 to January 2004, 31 consecutive patients out of 35 diagnosed with achalasia, in clinical stages I-III, were operated on by laparoscopy . Two groups were identified using the break point of 70 years of age, (20 younger and 15 older) and two subgroups according to the conservative therapy performed (20, none; 15, some). Patients underwent a clinical manometry evaluation at six and 12 months, and then yearly, and pH-metry at six, 24, and 60 months. In 78% of patients dysphagia disappeared and the incidence of reflux was 13%. Age and previous treatments did not influence surgical outcome. Patients completed a GIQLI questionnaire before surgery, six months after surgery, and then yearly (for five years). The median preoperative GIQLI score was 78 (range 38-109) out of a theoretical maximum score of 144. At a median follow-up of 49 months (range 24-72 months), the score had significantly improved to 115 (range 71-140). There was no significant statistical difference between the groups.

CONCLUSIONS

Laparoscopic Heller-Dor myotomy is an effective palliation for achalasia; the long-term outcome is not significantly affected by preoperative conservative treatments or by the age of the patients. The GIQLI questionnaire is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL before and after surgery.

[Timing and results of the surgical treatment of the diverticular disease of the colon]

AIMS

To evaluate retrospectively the outcome of the curative open and laparoscopic surgical approach to the diverticular disease according to timed steps based on the pathologic stage.

PATIENT AND MATERIAL

From 1989 83 out of 242 outpatients underwent surgery in emergency or after medical failure and at least two acute attacks requiring hospital admittance, or complicated diverticulitis. Modified Hinchey classification staged the disease. Clinic and instrumental criteria, surgical procedures, early and late complications were statistically evaluated (Students t-test and exact Fischer test, p < 0.05) in comparison with the different steps of therapeutic strategy.

RESULTS

Twenty nine patients were classified as Hinchey 0, 26 as I, 14 as II, 11 as III, 3 as IV. Clinical characteristics of the lap and open groups overlapped, with higher rate of earlier age in first and advanced stages in the second group. 16 patients (19.3%) underwent surgery at the first attack in emergency or in delayed emergency (5 TC-guided drainages). 30 open and 53 lap procedures were done: 21 two-stage: 18 primary resections + ileostomy and 3 Hartmann; 61 single stage: 49 sigmoidectomy, 12 left colectomy. 4 conversions (7.5%), 12 early (14.5%) and 10 late (12.1%) complications were observed.

DISCUSSION

Complications rate was higher in the open group including more advanced stages. Elective surgery performed following conservative therapy, 4 weeks from the first acute attack in younger people (age < 55yrs.) and after two attacks in elder (age > 55yrs.) showed a significant lower complications' incidence (p < 0.05) compared to the 8 weeks delayed operations.

CONCLUSION

Surgery of diverticulitis must follow standardized criteria. The laparoscopic approach could be performed in more severe stages, provided that conditions of delayed emergency were achieved.

Multimedia article. Laparoscopic treatment of chronic sigmoid volvulus in a young adult

INTRODUCTION

Sigmoid volvulus is responsible for 8% of all intestinal obstructions. The most frequent presentation is in the elderly, with it occurring exceptionally in young people. Surgical resection is mandatory to prevent recurrence. Laparoscopic maneuvers in the long and distended bowel are difficult, and not much experience with these procedures has been reported.

MATERIALS AND METHODS, AND RESULTS

A 21-year-old man with antecedents of constipation had two episodes of rectal prolapse, and one episode of acute volvulation treated with decompressive endoscopy. A laparoscopic exploration was performed for definitive treatment. Transanal intubation with a large-bore tube permitted deflation of the bowel. A deep Douglas's pouch was observed with a mobile sigmoid loop that intussuscepted the rectum. A proctosigmoidectomy including the 5 cm of the upper rectum was performed without incident.

CONCLUSION

Laparoscopic management of suboclusive colonic volvulus is feasible. Intraopertive transanal intubation permits deflation the loop and facilitates manipulation.

Oesophageal achalasia in elderly people: results of the laparoscopic Heller-Dor myotomy

AIMS

To assess the outcome of laparoscopic Heller-Dor myotomy for oesophageal achalasia in two groups of patients identified by age (under and over 70 years) using functional and clinical instruments.

BACKGROUND

Current therapies for achalasia can't restore normal motility but can palliate dysphagia. Many other symptoms may persist difficult to quantify and to compare. In order to understand if age is a factor that influences the therapeutic outcome we tested the reliability of a specific QoL instrument for comparing outcomes of surgery for achalasia.

METHODS

Functional examinations and the Gastrointestinal Quality of Life Index (GIQLI) were used before and after laparoscopic Heller-Dor myotomy.

RESULTS

Starting in January 1996, 28 consecutive patients of 32 diagnosed (instrumental evidences) achalasia were operated on laparoscopically for various clinical stages of achalasia. In 78% of patients dysphagia disappeared, the incidence of gastro-oesophageal reflux was of 11%. The patients completed a GIQLI questionnaire preoperatively and after a minimum postoperative follow-up of 1 year. Median preoperative GIQLI score was 78(range 38-109) out of a theoretical maximum score of 144. At a median follow-up of 35 months (range 18-72), the score had significantly improved to 115 (range 71-140). All the items assessing gastrointestinal symptoms and physical, social, and emotional function were significantly improved. There is no difference between the two groups identified.

CONCLUSIONS

The laparoscopic Heller-Dor myotomy is an effective palliation for acalasia, the medium-term outcome is not affected by the age of the patients. The GIQLI is a reliable instrument to compare the impact of achalasia symptoms on health-related QoL.

Hematocrit value on intensive care unit entry influences the frequency of Q-wave myocardial infarction after coronary artery bypass grafting. The Institutions of the Multicenter Study of Perioperative Ischemia (McSPI) Research Group

OBJECTIVES

No data exist regarding "the best" hematocrit value after coronary artery bypass graft surgery. Transfusion practice varies, because neither an optimal hematocrit value nor a uniform transfusion trigger criterion has been determined.

METHODS

To investigate the optimal hematocrit value, we studied 2202 patients undergoing coronary bypass. The hematocrit value on entry into the intensive care unit (IHCT) was categorized into three groups: high (> or = 34%), medium (25% to 33%), and low (< or = 24%). Characteristics and adverse events (outcomes) were compared, and the effect of IHCT on the risk of myocardial infarction was determined by logistic regression.

RESULTS

High IHCT (> or = 34%) was associated with an increased rate of myocardial infarction (8.3% vs 5.5% vs 3.6%; p < or = 0.03, high, medium vs low) and with more severe left ventricular dysfunction (11.7% vs 7.4% and 5.7%; p=0.006, high, medium vs low). Mortality rate increased with higher IHCT when all the high-risk subgroups were combined (8.6% vs 4.5% vs 3.2%; p < 0.001, high, medium vs low). By multivariate analysis, IHCT remained the most significant predictor of adverse outcomes (relative risk high vs low 2.22, 95% confidence interval: 1.04 to 4.76). No characteristic, event, medication, or transfusion therapy confounded the relationship between IHCT and outcome.

CONCLUSION

High IHCT is associated with a higher rate of myocardial infarction and is an independent predictor of infarction. On the basis of the risk of myocardial infarction, there is no rationale for transfusion to an arbitrary level after coronary artery bypass grafting.

Restoration of the normal coagulation process: advances in therapies to antagonize heparin

A number of naturally occurring anticoagulants exist that preserve normal blood fluidity and limit blood clot formation to vascular injury sites, thus acting as regulators of hemostasis. The protein C/protein S pathway is one system that acts to modulate thrombin formation. The activation of protein C by thrombin is accelerated more than 1,000-fold at the endothelial surface by thrombomodulin localized on the endothelial cell. Activated protein C then binds to its co-factor, protein S, and the protein C/protein S complex exerts its antithrombotic function by inactivating the coagulation factors Va and VIIIa. Patients deficient in protein C and protein S may be particularly vulnerable to thrombotic events after cardiac surgery. In addition, several studies suggest that reductions in protein C and protein S concentrations, as well as thrombomodulin, occur during cardiopulmonary bypass (CPB). The possibility of a low anticoagulant potential when heparinization is reversed may be an important factor in the subsequent morbidity associated with thrombotic complications. Aprotinin is a serine protease inhibitor that in vitro binds competitively with the serine protease-activated protein C. However, aprotinin in the clinical setting has not been reported to alter levels of protein C in patients undergoing CPB. Reversal of the heparinization needed for CPB is almost universally performed with protamine. However, protamine has many deleterious effects. Recombinant platelet factor 4 (rPF4) has been proposed as an alternative to protamine. We investigated the effective heparin neutralization dose of rPF4 vs. the standard agent protamine in human blood activated through exposure to the CPB circuit. Activated clotting time (ACT) measurements suggested a 2:1 (w/w) reversal ratio for rPF4 and protamine. The first human open-label phase 1 trial of rPF4 reported no serious side effects and no important hemodynamic effects. Doses of 2.5 and 5.0 mg/kg were uniformly effective in reversing the anticoagulant effect of heparin and reducing the ACT to <200 s by 5 min after administration. Repeated monitoring of the ACT did not detect a rebound effect of heparin.

Is intraoperative echocardiography a useful monitor in the operating room?

Few cardiac surgeons or anesthesiologists would argue with the view that intraoperative echocardiography, both transesophageal and epicardial, has become an important diagnostic tool. Specific diagnostic applications primarily involve valve reconstruction and replacement, as well as complex congenital heart disease repairs. Routine echocardiographic monitoring in cardiac operations is, however, controversial. Three specific modalities may benefit from this technology. Aortic root scanning before cannulation/proximal coronary anastomoses using surface echocardiography is one. Areas with significant atherosclerosis can be identified and manipulation avoided. Another is quantification of global left-ventricular function using transesophageal echocardiography. This method may have specific relevance to patients requiring mechanical circulatory assistance. Using echocardiography to monitor ischemic regional wall-motion abnormalities and using the findings to predict an unfavorable outcome is a third suggested use for perioperative monitoring in cardiac surgery.