The effect of cold crystalloid versus warm blood cardioplegia on the myocardium during coronary artery bypass grafting

Background: The optimal cardioplegic solution is still debated. The objective of this study was to compare the effect of cold crystalloid versus warm blood cardioplegia on the myocardial injury during coronary artery bypass grafting. Methods: The study included 34 consecutive patients who underwent elective primary on-pump isolated coronary artery bypass grafting from 2016 to 2019. We randomly assigned the patients into two groups. Group (ICCC) (n= 17) received intermittent antegrade cold crystalloid cardioplegia and Group (IWBC) (n= 17) received intermittent antegrade warm blood cardioplegia. Results: There was no difference in the preoperative and operative variables between groups. The time taken by the heart to regain normal sinus rhythm was significantly longer in the cold crystalloid group (7.06 ± 1.8 vs. 2.17 ± 0.8 minutes, p<0.001) with a higher rate of reperfusion ventricular arrhythmia (35% versus 6%; p=0.03) compared to the warm blood cardioplegia group. Both coronary sinus acid production and lactate level were significantly higher in the warm blood group than in the cold crystalloid group (p< 0.001 and 0.043, respectively). The ischemic ECG changes and the severity of new segmental wall motion abnormalities were non-significantly different between both groups (p= 0.68 and 0.67, respectively). Postoperative CK-MB and cTnI levels in all-time points were not significantly different between groups (p= 0.46 and 0.37, respectively). ICU (2.29 ± 0.77 vs. 2.41 ± 0.87 days, p= 0.68) and hospital stay (9.28 ± 0.76 vs. 9.42 ± 0.88 days, p= 0.62) were non-significantly different between both groups. Conclusion: Intermittent antegrade cold crystalloid cardioplegia was associated with attenuated myocardial metabolism. However, it was associated with a longer time to regain normal sinus rhythm and more reperfusion ventricular arrhythmias. We did not find differences in the clinical and echocardiographic outcomes and cardiac enzymes between cold crystalloid and warm blood cardioplegia

Hepatobiliary manifestations following two-stages elective laparoscopic restorative proctocolectomy for patients with ulcerative colitis: A prospective observational study

BACKGROUNDHepatobiliary manifestations occur in ulcerative colitis (UC) patients. The effect of laparoscopic restorative proctocolectomy (LRP) with ileal pouch anal anastomosis (IPAA) on hepatobiliary manifestations is debated.AIMTo evaluate hepatobiliary changes after two-stages elective laparoscopic restorative proctocolectomy for patients with UC.METHODSBetween June 2013 and June 2018, 167 patients with hepatobiliary symptoms underwent two-stage elective LRP for UC in a prospective observational study. Patients with UC and having at least one hepatobiliary manifestation who underwent LRP with IPAA were included in the study. The patients were followed up for four years to assess the outcomes of hepatobiliary manifestations.RESULTSThe patients' mean age was 36 +/- 8 years, and males predominated (67.1%). The most common hepatobiliary diagnostic method was liver biopsy (85.6%), followed by Magnetic resonance cholangiopancreatography (63.5%), Antineutrophil cytoplasmic antibodies (62.5%), abdominal ultrasonography (35.9%), and Endoscopic retrograde cholangiopancreatography (6%). The most common hepatobiliary symptom was Primary sclerosing cholangitis (PSC) (62.3%), followed by fatty liver (16.8%) and gallbladder stone (10.2%). 66.4% of patients showed a stable course after surgery. Progressive or regressive courses occurred in 16.8% of each. Mortality was 6%, and recurrence or progression of symptoms required surgery for 15%. Most PSC patients (87.5%) had a stable course, and only 12.5% became worse. Two-thirds (64.3%) of fatty liver patients showed a regressive course, while one-third (35.7%) showed a stable course. Survival rates were 98.8%, 97%, 95.8%, and 94% at 12 mo, 24 mo, 36 mo, and at the end of the follow-up.CONCLUSIONIn patients with UC who had LRP, there is a positive impact on hepatobiliary disease. It caused an improvement in PSC and fatty liver disease. The most prevalent unchanged course was PSC, while the most common improvement was fatty liver disease

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

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 (beta 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

MDCT signs predicting internal hernia and strangulation in patients presented to emergency department with acute small bowel obstruction

Objective: We prospectively evaluate multidetector computed tomography (MDCT) criteria of internal hernia, and related complication as intestinal strangulation. Methods: 27 patients presented to emergency department with acute small bowel obstruction (ASBO) and diagnosed with MDCT as IH were included. Validity of different MDCT criteria in diagnosing IH was compared with surgical diagnosis. Results: Surgical diagnosis was 22 patients with IH (14 paraduodenal and 8 transmesenteric hernia) and 5 false positive cases. There was excellent agreement between MDCT and surgery in diagnosing paraduodenal hernia (k = 1), and good agreement in diagnosing transmesenteric hernia (k = 0.624). Significant MDCT criteria include the following: cluster of small-bowel (p < 0.0001); mass effect to surrounding (p = 0.009); crowding of mesenteric vessels (Swirl's sign) (p = 0.01). Sensitivity, specificity, PPV, NPV and accuracy of MDCT in diagnosing strangulation were 83%, 100%, 100%, 95%, and 96% respectively. MDCT signs for detecting strangulation were statistically significant and varied from highly significant for bowel-wall thickening and mesenteric vessel engorgement (p < 0.001) to significant for abnormal bowel-wall enhancement, mesenteric infiltrate and mesenteric fluid with p value = 0.001. Conclusion: MDCT helps in early diagnosis of IH and strangulation, which accounts for appropriate management of such emergent cases

Bipartite Laparoscopic Cholecystectomy: New Technique for Avoiding Bile Duct Injury in Difficult Cases

The incidence of bile duct injury in laparoscopic cholecystectomy (LC) is still two times greater compared to classic open surgery. This study offers new procedure to avoid this complication during LC. The gall bladder was divided into two parts above the Hartmann pouch and all contents were aspirated. Then, the distal part was dissected for short distance. The proximal part was dissected dome down until reaching to cystic duct which was tied or clipped and cut. J-vac drain was put in peritoneal cavity. Between September 2012 and October 2013, overall 77 patients (53 females and 24 males) with mean age of 49 years (between 23 and 67 years) underwent bipartite laparoscopic cholecystectomy. The mean operative time was 60 minutes (between 40 and 90 minutes). The dissection of both parts of gall bladder was safe and easy as close as possible from its wall. No biliary tract injuries were recorded during or after procedure and also at follow-up period (20 months). Bipartite laparoscopic cholecystectomy is safe, easy to do, and can avoid all complications especially bile duct injuries in difficult cases

Propionic and Methylmalonic Acidemias: Initial Clinical and Biochemical Presentation

PA and MAA have numerous nonspecific presentations, potentially leading to delayed diagnosis or misdiagnosis. In this paper, we present the clinical and biochemical characteristics of MMA and PA patients at initial presentation. Results. This is a retrospective review of 20 patients with PA (n=10) and MMA (n=10). The most observed symptoms were vomiting (85%) and refusing feeding (70%). Ammonia was 108.75±9.3 μmol/l, showing a negative correlation with pH and bicarbonate and positive correlation with lactate and anion gap. Peak ammonia did not correlate with age of onset (r=0.11 and p=0.64) or age at diagnosis (r=0.39 and p=0.089), nor did pH (r=0.01, p=0.96; r=−0.25, p=0.28) or bicarbonate (r=0.07, p=0.76; r=−0.22, p=0.34). There was no correlation between ammonia and C3 : C2 (r=0.1 and p=0.96) or C3 (r=0.23 and p=0.32). The glycine was 386±167.1 μmol/l, and it was higher in PA (p=0.003). There was a positive correlation between glycine and both pH (r=0.56 and p=0.01) and HCO3 (r=0.49 and p=0.026). There was no correlation between glycine and ammonia (r=−0.435 and p=0.055) or lactate (r=0.32 and p=0.160). Conclusion. Clinical presentation of PA and MMA is nonspecific, though vomiting and refusing feeding are potential markers of decompensation. Blood gas, lactate, and ammonia levels are also good predictors of decompensation, though increasing levels of glycine may not indicate metabolic instability

International Variations in Surgical Morbidity and Mortality Post Gynaecological Oncology Surgery: A Global Gynaecological Oncology Surgical Outcomes Collaborative Led Study (GO SOAR1)

Simple Summary Little is known about factors contributing to early post-operative morbidity and mortality in low and middle income countries with a paucity of data limiting global efforts to improve gynaecological cancer care. In this multicentre, international prospective cohort study of women undergoing gynaecological oncology surgery, we show that low and middle versus high income countries were associated with similar post-operative major morbidity. Capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention.Abstract Gynaecological malignancies affect women in low and middle income countries (LMICs) at disproportionately higher rates compared with high income countries (HICs) with little known about variations in access, quality, and outcomes in global cancer care. Our study aims to evaluate international variation in post-operative morbidity and mortality following gynaecological oncology surgery between HIC and LMIC settings. Study design consisted of a multicentre, international prospective cohort study of women undergoing surgery for gynaecological malignancies (NCT04579861). Multilevel logistic regression determined relationships within three-level nested-models of patients within hospitals/countries. We enrolled 1820 patients from 73 hospitals in 27 countries. Minor morbidity (Clavien-Dindo I-II) was 26.5% (178/672) and 26.5% (267/1009), whilst major morbidity (Clavien-Dindo III-V) was 8.2% (55/672) and 7% (71/1009) for LMICs/HICs, respectively. Higher minor morbidity was associated with pre-operative mechanical bowel preparation (OR = 1.474, 95%CI = 1.054-2.061, p = 0.023), longer surgeries (OR = 1.253, 95%CI = 1.066-1.472, p = 0.006), greater blood loss (OR = 1.274, 95%CI = 1.081-1.502, p = 0.004). Higher major morbidity was associated with longer surgeries (OR = 1.37, 95%CI = 1.128-1.664, p = 0.002), greater blood loss (OR = 1.398, 95%CI = 1.175-1.664, p <= 0.001), and seniority of lead surgeon, with junior surgeons three times more likely to have a major complication (OR = 2.982, 95%CI = 1.509-5.894, p = 0.002). Of all surgeries, 50% versus 25% were performed by junior surgeons in LMICs/HICs, respectively. We conclude that LMICs and HICs were associated with similar post-operative major morbidity. Capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention