The value of pericardial window in preventing pericardial effusion after cardiac surgery

Background: Pericardial window (PW) is a technique that allows the passage of fluid from the pericardial to the pleural cavity to reduce the postoperative pericardial effusion. The purpose of this study was to evaluate the effectiveness of the pericardial window in decreasing pericardial effusions after cardiac surgery. Methods: The study included 400 adult patients who underwent cardiac surgery from 2017 to 2020. Patients were randomly assigned into two groups; the pericardial window (PW) group included 200 patients who underwent posterior pericardiotomy, and the control group included 200 patients who did not undergo this procedure. Results: Preoperative data were comparable between both groups. More patients in the PW group had chest tube drainage more than 500 cc/ 24 hours (40 (20%) vs. 5 (2.5%), respectively; p=0.005). The drainage of 500 cc/24 hours or more in the mediastinal tube was lower in the PW group (10 (5%) vs. 40 (20%) patients in the PW and control groups, respectively; p<0.001). Early pericardial collection occurred in 6 patients in the PW group (3%) vs. 46 (23%) in the control group (p<0.001), and no patient had late effusion in the PW group vs. 26 (13%) in the control group (p< 0.001). Six patients in the PW group (3%) had postoperative atrial fibrillation and 12 patients (6%) in the control group (p= 0.23). Pulmonary complications were nonsignificantly higher in the PW group (Lung collapse: 40 (20%) vs. 26 (13%); p=0.08 and pleural effusion: 34 (17%) vs. 26 (13%); p= 0.3, in the PW vs. control groups, respectively). Conclusion: Posterior pericardiotomy is a simple technique that could reduce postoperative pericardial effusion, atrial fibrillation, and the pericardial tamponade. The technique did not increase the postoperative complications compared to the standard method

Right mini-thoracotomy versus median sternotomy for mitral valve replacement

Background: The advantages of minimally invasive mitral valve surgery over the conventional approach is still debated. This study aimed to evaluate early outcomes after mitral valve replacement (MVR) using the right mini-thoracotomy (RMT) versus median sternotomy (MS). Methods: We prospectively included 60 patients who had MVR from May 2015 to June 2017. We classified patients into two groups; Group A (n= 30) had RMT, and Group B (n= 30) had MS. Postoperative pain score, wound satisfaction, and clinical and echocardiographic outcomes were compared between both groups. Results: The mean age was 39.90 ± 12.34 years in Group A and 45.75 ± 13.10 years in Group B (p= 0.08). Preoperative and echocardiographic data showed no statistical significance difference between the groups. Group A had longer aortic cross-clamp (118.85 ± 40.56 vs. 70.75 ± 24.81 minutes, p<0.001) and cardiopulmonary bypass times (186.70 ± 67.44 vs. 104.65 ± 42.60 minutes, p<0.001).  Group B had more blood loss (565 ± 344.3 vs. 241.5 ±89.16 ml/24 hours, p<0.001). The median pain score was 1 (range: 1- 3) in Group A and 4 (2- 8) in Group B (p<0.001), and the median wound satisfaction was 1.5 (1- 4) in Group A and 4 (1- 7) in Group B (p<0.001).  Wound infection occurred in 1 (3.3%) patient in Group A and 6 (20%) patients in Group B (p=0.04). Conclusion: Mitral valve replacement through the right mini-thoracotomy could be a safe alternative to median sternotomy. The right mini-thoracotomy was associated with longer operative times but better pain and wound satisfaction scores and lower wound infection

The relation between the timing of coronary angiography and renal function post coronary artery bypass grafting

Background: Acute kidney injury is a serious complication after coronary artery bypass grafting (CABG). This work aimed to assess the impact of the timing of coronary angiography on kidney function after on-pump coronary artery bypass grafting.   Methods: We included 60 patients who underwent elective isolated on-pump coronary artery bypass grafting from 2017 to 2018 at the National Heart Institute and Benha University Hospital. We divided the patients into two groups; group І included 30 patients with coronary angiography performed less than seven days prior to CABG, and Group ІІ included 30 patients who had coronary angiography more than seven days prior to CABG. Postoperative acute kidney injury was defined according to the consensus kidney disease: Improving Global Outcomes Definition and Staging criteria. Results: The mean body mass index was significantly higher in group I (35.89±5.15 Kg/ m² vs. 31.72±4.99 Kg/ m², P = 0.002). The mean preoperative hemoglobin was higher in group II (12.7 ± 1.5 g/dl vs. 13.9 ± 1.5 g/dl, P = 0.004). The frequency of acute kidney damage was higher in patients who had coronary angiography less than seven days before CABG but did not reach a significant level (46.7 % vs. 30%, P =0.184). There was no difference in the creatinine postoperatively between both groups (1.2 ±0.5 vs. 1 ±0.3 mg/dl; p= 0.214). Conclusions: We found no association between the timing of coronary angiography before on-pump coronary artery bypass graft surgery and postoperative acute kidney injury

A Clinical Score to Predict Acute Renal Failure after Cardiac Surgery in Egypt

Background: Acute Kidney Injury (AKI) after cardiac surgery is a serious complication. AKI could occur in 30% of patients, and 1-5% develop severe kidney injury. The present study aimed to evaluate the use of the Cleveland Clinic Score (CCS) to identify patients at higher risk of AKI after cardiac surgery. Methods: This study included 100 patients, 83 were males, and the mean age was 52.47±11.3 years. All patients had elective operations; 30% had isolated valve surgery, 64% had isolated coronary artery bypass grafting (CABG), and 6% had combined CABG and valve operation. Results: Creatinine serum level ranged between 0.5-2 mg/dL with a mean of 0.98±0.32 mg/dL. Seventy-four patients had good renal function postoperatively, and their CCS was 1.45±0.36, while 26 patients had renal impairment, and their CCS was 12.5±0.44 (P= 0.001). Patients who had AKI were older (62.87±8.7 vs. 49.9±13.9; P<0.001) and had higher preoperative creatinine (1.1±0.32 vs. 0.94±0.31; P= 0.03). AKI was more common in diabetics (23 (88.5%) vs. 28 (37.85, P<0.001) and patients with COPD (6 (23.1%) vs. 3 (4.1%); P= 0.004). CCS score was significantly higher among the different degrees of severity of AKI. Conclusion: Cleveland Clinic Score could be good for predicting acute kidney injury after cardiac surgery

Mortality Predictors in Patients with Infective Endocarditis Undergoing Surgery

Background: Infective endocarditis (IE) is considered a series disorder with high in-hospital mortality, so early detection and therapy can improve outcomes. Diagnosis relies upon consistent history and manifestations like persistent bacteremia, fungemia or active valvulitis. Surgical treatment in infective endocarditis is considered as a part of management rather than a consequence of medical treatment failure.Objectives: To assess the risk factors influencing the early outcome of surgical intervention in patients with IE. Patients and methods: This prospective cohort study was conducted on sixty patients diagnosed with infective endocarditis and underwent cardiac surgery. We tested preoperative, intraoperative and postoperative factors that may act as prospective predictors of mortality.Results: Rheumatic heart was found to be the most common underlying fundamental issue among most of the cases. Mitral valve regurgitation was the frequent lesion found (61.7%). The mean EuroScore II in non-survivor group was 25.69 ± 8.13. The hospital mortality was 21.7% (13 patient), while the 6-month mortality was 12.8% (6 patients). Congestive heart failure, embolization, and periannular extension of infection are the most significant predictors of hospital mortality and 6 month mortality also.Conclusion: Surgery for IE keeps on being challenging. EuroScore II was found to have a very good capability to anticipate mortality in IE surgery. Also favorable outcomes could be acquired with valve repair techniques even in cases of IE

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Geospatial model for allocating favorable plots for groundwater-dependent cultivation activities in Egypt

Moving towards horizontal expansion in the vast barren lands to alleviate overpopulation along the Nile River is imperative to Egypt’s 2030 sustainable development strategy. Accordingly, a mega reclamation project was advocated with a key goal of achieving food self-sufficiency. Solar-powered groundwater pumping system was adopted as the main water supply. Planning efforts are therefore inevitable to help locate the most favourable sites for such extensive cultivation activities. Herein, a multicriteria decision analysis was conducted to facilitate the zoning of potential rural communities across the northern portions of the Western Desert of Egypt. For this purpose, data of groundwater exploration, soil characterization, terrestrial accessibility, insolation intensity, and terrain information were fused to produce a high-resolution suitability map. The analytical hierarchy process approach was adopted to set the weighted importance of adopted criteria. The study area was categorized into Best, Good, Moderate, Fair, Poor, and Restricted classes at 1.7%, 13%, 42.6%, 26%, 10%, and 3%, respectively, of the entire region, while the constrained plots were masked out. The implemented and proposed wells fields within the underway national rural development project extend over agriculturally suitable pixels affirming the validity of the developed geospatial model. About 1.5 million ha, representing 7.2% of the undeveloped area, were found to be highly suitable for future expansion of agribusiness activities. The generated priority map will assist the decision-makers in the planning procedures for ongoing reclamation activities throughout Egypt

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research