Performancevergleich berechneter GFR mit gemessener Kreatinin-Clearance in einer herzchirurgischen Population

Hintergrund und Zielgrößen: Die schnelle und richtige Ermittlung der Nierenfunktion ist im klinischen Alltag von großer Bedeutung. Ziel dieser Arbeit war es, die Performance verschiedener Formeln für die Berechnung der Nierenfunktion bei herzchirurgischen PatientInnen zu testen. Die untersuchten Formeln waren die Cockcroft-Gault (CGF), die Modification of Diet in Renal Disease (MDRD) und die Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) Formel. Die Ergebnisse der Formeln wurden an der gemessenen Kreatinin Clearance (ClCr) validiert. Methoden: In dieser prospektiven Observations-Kohortenstudie wurden die Nierenfunktionen von 96 herzchirurgischen PatientInnen, davon 34 weiblich, zu drei Zeitpunkten (prä-, intra- und postoperativ) mittels ClCr bestimmt und mittels CGF, MDRD und CKDEPI berechnet. Es wurden Blut- und Harn-Proben präoperativ, intraoperativ und postoperativ am ersten postoperativen Tag entnommen. Die Performance der Formeln wurde anhand von T-Tests und Korrelationsanalysen nach Spearmans Rho mit der ClCr verglichen. Die Analysen erfolgten für das Gesamtkollektiv und zusätzlich getrennt für beide Geschlechter, sowie getrennt für Gruppen mit unterschiedlicher Nierenfunktion. Ergebnisse: 55,2% erhielten eine Klappenoperation, 16,7% einen koronararteriellen Bypass und 28,1% eine Kombination beider Eingriffe. Das mittlere Alter lag bei 67,411,3 Jahren. Serum-Kreatinin (SCr) und ClCr zeigten perioperativ keine signifikanten Veränderungen. Der Vergleich der Mittelwerte zeigte perioperativ zunehmend signifikante Unterschiede bei gleichzeitiger Verstärkung der Korrelation. Bei männlichen Patienten waren die Mittelwerte aller Formeln signifikant divergent zu ClCr, die CGF korrelierte am stärksten (r = 0,795). Im weiblichen Kollektiv zeigten nur die Mittelwerte der CKDEPI (68,431; 82,131,4; 96,152,8 ml/min) keine signifikanten Abweichungen, diese hatte auch die beste Korrelation (r = 0,873). Die Nierenfunktion wurde bei PatientInnen mit hoher- oder stark eingeschränkter glomerulärer Filtrationsrate durch Berechnung signifikant unter- bzw. überschätzt. Diskussion: Die Messung der ClCr ist der Berechnung der Nierenfunktion vorzuziehen. Trotz kürzerer Sammelzeit zeigt die intraoperative ClCr valide Ergebnisse. Die Streuung der Formel-Ergebnisse zeigt die Unfähigkeit der Formeln, extreme Nierenfunktionen darzustellen. Es besteht die Gefahr der Missklassifikation und folgend falscher Therapieentscheidungen bei Anwendung der Formeln. Eine Berechnung der Nierenfunktion bei PatientInnen mit stark eingeschränkter Nierenfunktion führt, ungeachtet welche Formel verwendet wird, zu falsch hohen Ergebnissen und sollte vermieden werden.Background and Objectives: The fast and correct determining of the renal function is highly relevant in clinical practice. In this study, we compared the performance of different glomerular filtration rate equations in cardiac surgical patients. The analysis concerned the Cockcroft-Gault (CGF), the Modification of Diet in Renal Disease (MDRD), and the Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) formula. All calculated results for renal function were validated in relation to measured Creatinine-Clearance (ClCr). Methods: In this prospective observational cohort study, we analysed the renal function of 96 patients (34 females) undergoing cardiac surgery at three different junctures (pre-, intra- and postoperative), by measuring the ClCr and calculation through CGF, MDRD, and CKDEPI. Urine- and blood-samples were collected preoperatively, intraoperatively, and postoperatively at the first day after surgery. We performed T-tests and rank-correlations (Spearmans Rho) to compare the performance of these three equations with measured ClCr. All analyses were conducted separately for both genders and groups with distinct renal function. Results: Valve replacement was performed in 55,2%, coronary artery bypass graft in 16,7%, and a combination of both procedures in 28,1% of all patients. The mean age was 67,411,3 years. There were no significant changes in SCr and ClCr perioperatively. We assessed progression in the differences perioperatively next to simultaneously increasing correlations. In male patients, all means of all formulas showed significant deviation compared to ClCr. The CGF displayed the highest correlation amongst men (r = 0,795). In female patients, the highest correlation was found with CKDEPI (r = 0,873), also CKDEPI (68,431; 82,131,4; 96,152,8 ml/min) indicated no significant derivation of ClCr exclusively. Through the calculation, the renal function of patients with increased or severely decreased glomerular filtration rate was under-, respectively overestimated. Conclusion: The measured ClCr should be preferred for assessing the renal function. Despite the short urine collection, the intraoperative ClCr revealed valid results. Due to the variation of the calculated results, we assume the inability of the formulas to display extreme renal function. There is a risk of misclassification, followed by false treatment, when solely using the calculated glomerular filtration rate. The findings of this study advise against the application of the formulas for patients with severely compromised renal function, because it results in false high values.Abweichender Titel laut Übersetzung der Verfasserin/des VerfassersArbeit an der Bibliothek noch nicht eingelangt - Daten nicht geprüftMedizinische Universität Wien, Diplomarb., 2019(VLID)446548

Prepectoral versus subpectoral implant-based breast reconstruction: a systemic review and meta-analysis

Background: Implant-based breast reconstruction (IBBR) remains the standard and most popular option for women undergoing breast reconstruction after mastectomy worldwide. Recently, prepectoral IBBR has resurged in popularity, despite limited data comparing prepectoral with subpectoral IBBR. Methods: A systematic search of PubMed and Cochrane Library from January 1, 2011 to December 31, 2021, was performed following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) reporting guidelines, data were extracted by independent reviewers. Studies that compared prepectoral with subpectoral IBBR for breast cancer were included. Results: Overall, 15 studies with 3,101 patients were included in this meta-analysis. Our results showed that patients receiving prepectoral IBBR experienced fewer capsular contractures (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.32–0.92; P = 0.02), animation deformity (OR, 0.02; 95% CI, 0.00–0.25; P = 0.002), and prosthesis failure (OR, 0.58; 95% CI, 0.42–0.80; P = 0.001). There was no significant difference between prepectoral and subpectoral IBBR in overall complications (OR, 0.83; 95% CI, 0.64–1.09; P = 0.19), seroma (OR, 1.21; 95% CI, 0.59-2.51; P = 0.60), hematoma (OR, 0.76; 95% CI, 0.49–1.18; P = 0.22), infection (OR, 0.87; 95% CI, 0.63–1.20; P = 0.39), skin flap necrosis (OR, 0.70; 95% CI, 0.45–1.08; P = 0.11), and recurrence (OR, 1.31; 95% CI, 0.52–3.39; P = 0.55). Similarly, no significant difference was found in Breast-Q scores between the prepectoral and subpectoral IBBR groups. Conclusions: The results of our systematic review and meta-analysis demonstrated that prepectoral, implant-based, breast reconstruction is a safe modality and has similar outcomes with significantly lower rates of capsular contracture, prosthesis failure, and animation deformity compared with subpectoral, implant-based, breast reconstruction

Preoperative Phase Angle as a Risk Indicator in Cardiac Surgery—A Prospective Observational Study

Background: The phase angle (PhA) can be used for prognostic assessments in critically ill patients. This study describes the perioperative course of PhA and associated risk indicators in a cohort of elective cardiac surgical patients. Methods: The PhA was measured in 168 patients once daily until postoperative day (POD) seven. Patients were split into two groups depending on their median preoperative PhA and analyzed for several clinical outcomes; logistic regression models were used. Results: The PhA decreased from preoperative (6.1° ± 1.9°) to a nadir on POD 2 (3.5° ± 2.5°, mean difference −2.6° (95% CI, −3.0°; −2.1°; p < 0.0001)). Patients with lower preoperative PhA were older (71.0 ± 9.1 vs. 60.9 ± 12.0 years; p < 0.0001) and frailer (3.1 ± 1.3 vs. 2.3 ± 1.1; p < 0.0001), needed more fluids (8388 ± 3168 vs. 7417 ± 2459 mL, p = 0.0287), and stayed longer in the ICU (3.7 ± 4.5 vs. 2.6 ± 3.8 days, p = 0.0182). Preoperative PhA was independently influenced by frailty (OR 0.77; 95% CI 0.61; 0.98; p = 0.0344) and cardiac function (OR 1.85; 95%CI 1.07; 3.19; p = 0.028), whereas the postoperative PhA decline was independently influenced by higher fluid balances (OR 0.86; 95% CI 0.75; 0.99; p = 0.0371) and longer cardiopulmonary bypass times (OR 0.99; 95% CI 0.98; 0.99; p = 0.0344). Conclusion: Perioperative PhA measurement is an easy-to-use bedside method that may critically influence risk evaluation for the outcome of cardiac surgery patients

Characteristics of Interleukin-6 Signaling in Elective Cardiac Surgery—A Prospective Cohort Study

Interleukin-6 (IL-6) can cause pro- and anti-inflammatory effects via different signaling pathways. This prospective study investigated the perioperative kinetics of IL-6, soluble IL-6 receptor (sIL-6R), and soluble glycoprotein 130 (sgp130) in elective patients undergoing cardiopulmonary bypass (CPB). IL-6, sIL-6R, and sgp130 were measured simultaneously and consecutively at 19 timepoints until the 10th postoperative day (POD). The proportion of pro- and anti-inflammatory pathways were determined by calculating sIL-6R/IL-6 and sIL-6R/sgp130 ratios. We analyzed 93 patients. IL-6 increased during surgery with reaching a plateau two hours after CPB and peaking on POD 1 (188.5 pg mL−1 (IQR, 126.6; 309.2)). sIL-6R decreased at the beginning of the surgical procedure, reaching a nadir level on POD 2 (26,311 pg mL−1 (IQR, 22,222; 33,606)). sgp130 dropped immediately after CPB initiation (0.13 ng mL−1 (IQR, 0.12; 0.15)), followed by a continuous recovery until POD10. The sIL-6R/IL-6 ratio decreased substantially at the beginning of the procedure, reaching a nadir on POD 1 (149.7 (IQR, 82.4; 237.4)), while the sIL-6R/sgp130 ratio increased simultaneously until 6 h post CPB (0.219 (IQR 0.18; 0.27)). In conclusion, IL-6 exhibited high inter-individual variability reflecting an inhomogeneous inflammatory response. Pro-inflammatory effects and overwhelming inflammation were rare and predominantly anti-inflammatory effects were found

Surgical Technique for Weight Regain After Roux-En-Y Gastric Bypass: Pouch-Resizing and the Minimizer® Gastric Ring

Laparoscopic Roux-en-Y Gastric Bypass (RYGB) is a commonly used method in bariatric surgery that leads to sufficient long-term weight loss and consequently to improvement or resolution of obesity-associated diseases. The nadir weight is commonly reached between six months and two years after surgery. Despite this initially good weight loss, weight regain is observed in up to 20% of the patients. Besides intensive dietological evaluation, bariatric re-operation can be an option in these cases. Before the surgical reintervention, an intensive evaluation of the esophagus, pouch, anastomosis, and adjacent small bowel using upper GI-endoscopy and radiological examinations (X-ray and/or 3D-CT volumetry) is mandatory. In patients with a dilated pouch, pouch-resizing with a MiniMIZER® Gastric Ring (Bariatric Solutions GmbH, Stein am Rhein, Switzerland) could be an option to reestablish restriction in the long term. Currently, there is no gold standard for the choice of the weight regain procedure or for the technique used in the procedure itself. This article focuses on the standardized procedure of pouch resizing with implantation of a MiniMIZER® Gastric Ring for the surgical therapy of weight regain due to pouch dilatation and/or dilatation of the gastrojejunostomy and the adjacent small bowel (usually approximately the first 20cm), resulting in a huge neo-stomach after RYGB, as performed at the Medical University of Vienna. Further, indications for revisional surgery for weight regain, mandatory examinations, and recommended conservative therapy options prior to surgery will be described. Next, the fast-track concept and its advantages are explained. Lastly, the surgical procedure, including positioning of the patient, placement of trocars, the intraoperative process, and special advice, is presented. Exact planning of the procedure and postoperative follow-up are indispensable for a further long-term success after weight regain surgery. In conclusion, pouch-resizing and implantation of the MiniMIZER® Gastric Ring represent a practical and effective solution in patients with dilated pouch/anastomosis/adjacent small bowel with weight regain after RYGB, if conservative therapy, including dietitian counseling and new drugs (e.g., Semaglutide), has failed

Surgical Technique of Single Anastomosis Duodeno-Ileal Bypass With Sleeve Gastrectomy (Sadi-S)

Laparoscopic Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) is a bariatric/metabolic procedure that has been gaining popularity in recent years. SADI-S strongly affects the secretion of various gut hormones, adipocytokines and incretins. From a mechanistic point of view, the operation combines malabsorption and restriction, and has been shown to have a long-lasting and significant impact on weight loss and remission of comorbidities. With regard to the technique, first, a Sleeve is created and then the duodenum is tran-sected approximately 3-4cm after the pylorus at the level of the gastroduodenal artery (GDA). Next, 250-300cm of small bowel is measured from the caecum and a hand-sewn duo-deno-ileal anastomosis is performed. The length of the biliopancreatic limb is variable in this procedure. Because of the standardized common limb length in all patients, weight loss is very precise within a low range. Nevertheless, due to the complex hand-sewn anastomosis and the delicacy necessary when handling the duodenum, this procedure should be reserved for experienced bariatric surgeons in specialized centers. This article provides an overview of the standard surgical technique at the Department of Visceral Surgery at the Medical University of Vienna, as well as information about patient selection and pre- and postoperative care

Rapid improvement of hepatic steatosis and liver stiffness after metabolic/bariatric surgery: a prospective study

Abstract Metabolic dysfunction-associated steatotic liver disease (MASLD) and related steatohepatitis (MASH) are common among obese patients and may improve after metabolic/bariatric surgery (MBS). 93 Patients undergoing MBS in 2021–2022 were prospectively enrolled. Liver stiffness measurement (LSM; via vibration-controlled transient elastography [VCTE], point [pSWE] and 2D [2DSWE] shear wave elastography) and non-invasive steatosis assessment (via controlled attenuation parameter [CAP]) were performed before (baseline [BL]) and three months (M3) after surgery. 93 patients (median age 40.9 years, 68.8% female, median BL-BMI: 46.0 kg/m2) were included. BL-liver biopsy showed MASLD in 82.8% and MASH in 34.4% of patients. At M3 the median relative total weight loss (%TWL) was 20.1% and the median BMI was 36.1 kg/m2. LSM assessed by VCTE and 2DSWE, as well as median CAP all decreased significantly from BL to M3 both in the overall cohort and among patients with MASH. There was a decrease from BL to M3 in median levels of ALT (34.0 U/L to 31 U/L; p = 0.025), gamma glutamyl transferase (BL: 30.0 to 21.0 U/L; p < 0.001) and MASLD fibrosis score (BL: − 0.97 to − 1.74; p < 0.001). Decreasing LSM and CAP, as well as liver injury markers suggest an improvement of MASLD/MASH as early as 3 months after MBS