Background
Three-dimensional (3D) imaging has been suggested to improve learning and performance of laparoscopy. We sought to investigate whether 3D imaging could improve the outcomes after ...laparoscopic cholecystectomy.
Materials and methods
Two-hundred and forty-one consecutive patients underwent elective or urgent laparoscopic cholecystectomy using 2D (
n
= 111) and 3D (
n
= 130) imaging equipments from March 2017 to March 2019 at the Kainuu Central Hospital, Finland. The main outcomes of this study were biliary tract injury, conversion to open procedure and procedure duration.
Results
In the overall series, there were 5 cases of biliary tract injury (2.1%). When compared to 3D imaging, 2D was associated with increased risk of biliary tract injury in the overall series (0% in 3D vs. 4.7% in 2D,
p
= 0.026) in addition to a subgroup of acute cholecystitis patients operated by senior surgeons (
n
= 92), 0% in 3D group (
n
= 60) vs. 10.0% in 2D group (
n
= 32),
p
= 0.037 in univariate analysis. The rates of conversion to open surgery did not differ between the groups in the overall series (5.3 vs 5.7%,
p
= 0.909) or any of the subgroups. Duration of surgery with 3D vs. 2D imaging were comparable in the elective (57.0 ± 16.3 vs. 54.1 ± 18.9 min,
p
= 0.228) and urgent setting (66.9 ± 15.1 vs. 67.4 ± 16.6 min,
p
= 0.805). Such differences were not significant in multivariate analysis.
Conclusions
The present study suggests that the use of 3D imaging is significantly associated with a reduced risk of intraoperative biliary tract injury during laparoscopic cholecystectomy especially in acute cholecystitis.
Background The aim of this meta-analysis was to evaluate the safety and efficacy of vascular closure devices (VCDs). Methods This meta-analysis was performed in accordance with the Cochrane Handbook ...for Systematic Reviews. Results The literature search yielded 31 prospective, randomized studies including 7,528 patients who were randomized to VCDs or manual/mechanical compression after diagnostic angiography and/or endovascular procedures. Most of these studies have excluded patients at high risk of puncture site complications. Meta-analysis showed similar results in the study groups in terms of groin hematoma, bleeding, pseudoaneurysm, and blood transfusion. Lower limb ischemia and other arterial ischemic complications (0.3% vs 0%, P = .07) as well as need of surgery for vascular complications (0.7% vs 0.4%, P = .10) were somewhat more frequent with arterial puncture closure devices. The incidence of groin infection was significantly more frequent with VCDs (0.6% vs 0.2%, P = .02). The use of VCD was uniformly associated with a significantly shorter time to hemostasis. Such differences where more evident in patients undergoing percutaneous coronary intervention, whereas these methods were associated with similar rates of adverse events among patients undergoing diagnostic coronary angiography. Conclusions The use of VCDs is associated with a significantly shorter time to hemostasis and thus may shorten recovery. However, the use of VCDs is associated with a somewhat increased risk of infection, lower limb ischemia/arterial stenosis/device entrapment in the artery, and need of vascular surgery for arterial complications. Further studies are needed to get more conclusive results, particularly in patients at high risk of femoral puncture-related complications.
The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) has been recently developed to improve the performance of the original EuroSCORE. Herein we evaluated its discriminatory ...ability in predicting the immediate and late outcome after coronary artery bypass grafting (CABG).
Complete data on 1,027 patients who underwent isolated CABG were available for validation of EuroSCORE II and to compare its discriminatory ability with the original EuroSCORE and its Finnish modified version.
EuroSCORE II performed somewhat better (area under the curve AUC 0.852, Brier score 0.031) than the original logistic EuroSCORE (AUC 0.838, Brier score 0.034) and its Finnish modified version (AUC 0.825, Brier score 0.034) in predicting operative mortality. The overall expected-to-observed operative mortality ratio for the original logistic EuroSCORE was 1.8, for its Finnish modified version was 0.6, and for EuroSCORE II was 1.2. EuroSCORE II showed expected-to-observed ratios ranging from 1.05 to 1.17 in its highest third quintiles. The best cutoff of EuroSCORE II in predicting operative postoperative mortality was 10% (21.5% vs 1.6%, p<0.0001; sensitivity 91.5%, specificity 60.5%, negative predictive value 98.4%, accuracy of 90.3%). The EuroSCORE II was predictive of de novo dialysis (AUC 0.805), prolonged use of inotropes (AUC 0.748), and intensive care unit stay 5 days or greater (AUC 0.793). The risk of late mortality significantly increased across increasing quintiles of EuroSCORE II (p<0.0001).
The EuroSCORE II performs better than its original version in predicting operative mortality and morbidity after isolated CABG. Its ability to predict 30-day mortality in high-risk patients is of particular importance. The EuroSCORE II is also a good predictor of late postoperative survival.
Background
The current prognosis of esophageal perforation and the efficacy of available treatment methods are not well defined.
Methods
We performed a systematic review of esophageal perforations ...published from January 2000 to April 2012 and subjected a proportion of the retrieved data to a meta-analysis. Meta-regression was performed to determine predictors of mortality immediately after esophageal perforation.
Results
Analysis of 75 studies resulted in a pooled mortality of 11.9 % 95 % confidence interval (CI) 9.7–14.3: 75 studies with 2,971 patients with a mean hospital stay of 32.9 days (95 % CI 16.9–48.9: 28 studies with 1,233 patients). Cervical perforations had a pooled mortality of 5.9 %, thoracic perforations 10.9 %, and intraabdominal perforations 13.2 %. Mortality after esophageal perforation secondary to foreign bodies was 2.1 %, iatrogenic perforation 13.2 %, and spontaneous perforation 14.8 %. Treatment started within 24 h after the event resulted in a mortality rate of 7.4 % compared with 20.3 % in patients treated later (risk ratio 2.279, 95 % CI 1.632–3.182). Primary repair was associated with a pooled mortality of 9.5 %, esophagectomy 13.8 %, T-tube or any other tube repair 20.0 %, and stent-grafting 7.3 %.
Conclusions
Results of recent studies indicate that mortality after esophageal perforation is high despite any definitive surgical or conservative strategy. Stent-grafting is associated with somewhat lower mortality rates, but studies may be biased by patient selection and limited experience.
A few studies recently reported controversial results with transfemoral transcatheter aortic valve replacement (TF-TAVR) versus transapical transcatheter aortic valve replacement (TA-TAVR), often ...without adequate adjusted analysis for baseline differences. Data on patients who underwent TF-TAVR and TA-TAVR from the Observational Study of Effectiveness of avR–tavI procedures for severe Aortic stenosis Treatment study were analyzed with propensity score 1-to-1 matching. From a cohort of 1,654 patients (1,419 patients underwent TF-TAVR and 235 patients underwent TA-TAVR), propensity score matching resulted in 199 pairs of patients with similar operative risk (EuroSCORE II: TF-TAVR 8.1 ± 7.1% vs TA-TAVR, 8.4 ± 7.3%, p = 0.713). Thirty-day mortality was 8.0% after TA-TAVR and 4.0% after TF-TAVR (p = 0.102). Postoperative rates of stroke (TA-TAVR, 2.0% vs TF-TAVR 1.0%, p = 0.414), cardiac tamponade (TA-TAVR, 4.1% vs TF-TAVR 1.5%, p = 0.131), permanent pacemaker implantation (TA-TAVR, 8.7% vs TF-TAVR 13.3%, p = 0.414), and infection (TA-TAVR, 6.7% vs TF-TAVR 3.6%, p = 0.180) were similar in the study groups but with an overall trend in favor of TF-TAVR. Higher rates of major vascular damage (7.2% vs 1.0%, p = 0.003) and moderate-to-severe paravalvular regurgitation (7.8% vs 5.2%, p = 0.008) were observed after TF-TAVR. On the contrary, TA-TAVR was associated with higher rates of red blood cell transfusion (50.0% vs 30.4%, p = 0.0002) and acute kidney injury (stages 1 to 3: 44.4% vs 21.9%, p <0.0001) compared with TF-TAVR. Three-year survival rate was 69.1% after TF-TAVR and 57.0% after TA-TAVR (p = 0.006), whereas freedom from major adverse cardiovascular and cerebrovascular events was 61.9% after TF-TAVR and 50.4% after TA-TAVR (p = 0.011). In conclusion, TF-TAVR seems to be associated with significantly higher early and intermediate survival compared with TA-TAVR. The transfemoral approach, whenever feasible, should be considered the route of choice for TAVR.
Objective This study was planned to evaluate the outcome of patients ≥80 years old undergoing isolated conventional aortic valve replacement (AVR). Methods Systematic review of the literature and ...meta-analysis of data on octogenarians and nonagenarians who underwent isolated AVR were performed. Results The literature search yielded 48 observational studies reporting on 13 216 patients ≥80 years old. Pooled proportion of immediate postoperative mortality was 6.7 % (95% CI 5.8-7.5, 47 studies, 13,092 patients), and it was 5.8% (95% CI 4.8-6.9) in 18 studies with a mid-date from 2000 to 2006 and 7.5% (95% CI 6.8-8.2) in 30 studies with a mid-date from 1982 to 1999 ( P = .004). Pooled proportion of postoperative stroke was 2.4% (95% CI 2.1-2.7, 21 studies, 8,436 patients), that of postoperative dialysis was 2.6% (95% CI 1.6-3.8, 10 studies, 1,945 patients), and that of postoperative implantation of a pacemaker was 4.6% (95% CI 3.6-5.8, 6 studies, 1,470 patients). Pooled survival rates at 1, 3, 5, and 10 years after isolated AVR were 87.6%, 78.7%, 65.4%, and 29.7%, respectively. Conclusions Immediate postoperative mortality and morbidity after isolated AVR in patients ≥80 years old are rather low. Postoperatively mortality decreased even further in the most recent series. Importantly, isolated AVR in these high-risk patients was associated with good late survival. These findings suggest that advanced age alone cannot be considered as a contraindication to conventional isolated AVR and that any new valve prosthesis implanted in these patients should be durable enough to guarantee the results so far offered by conventional surgery.
Increased glycated hemoglobin (HbA1c) has been shown to increase the risk of mortality, myocardial infarction, and stroke after cardiac surgery, whereas its impact on the development of sternal wound ...infection (SWI) is less clear. A systematic review and meta-analysis were performed to evaluate the impact of preoperative HbA1c levels on the occurrence of SWI after adult cardiac surgery. Fourteen studies including 17,609 patients fulfilled the inclusion criteria and were included in this analysis. Diagnostic test meta-analysis of studies evaluating baseline HbA1c cut-off values ranging from 6% to 7% DCCT units (42–53 mmol/mol IFCC units) showed that the diagnostic odds ratio for deep SWI was 3.02 (95% confidence interval CI 2.10–4.35), while the diagnostic odds ratio for any SWI was 2.81 (95% CI 2.02–3.93). Binary meta-analysis confirmed that baseline HbA1c cut-off values ranging from 6% to 7% increased the risk for deep SWI (pooled incidence 2.7% vs 0.8%, risk ratio RR 3.01, 95% CI 2.32–3.90, I2 0%). Six studies included only diabetics and their pooled RR for deep SWI was 2.94 (1.59–5.45, I2 0%). Nine studies evaluated an HbA1c cut-off value of 7% and their RR for deep SWI was 3.22 (95% CI 2.38–4.37, I2 0%). The RR for any SWI was 2.92 (95% CI 2.42–3.53, I2 0%). This pooled analysis showed that the risk of SWI is substantially increased when preoperative HbA1c levels are over 6–7%. Future studies should evaluate whether postponing surgery for optimization of the glycemic control can reduce the risk of SWI in patients with increased levels of HbA1c.
Bleeding after cardiac surgery requiring surgical reexploration and blood component transfusion is associated with increased morbidity and mortality. Although prothrombin complex concentrate (PCC) ...has been used satisfactorily in bleeding disorders, studies on its efficacy and safety after cardiopulmonary bypass are limited.
Between January 2005 and December 2013, 3454 consecutive cardiac surgery patients were included in an observational study aimed at investigating the efficacy and safety of PCC as first-line coagulopathy treatment as a replacement for fresh frozen plasma (FFP). Starting in January 2012, PCC was introduced as solely first-line treatment for bleeding following cardiac surgery.
After one-to-one propensity score-matched analysis, 225 pairs of patients receiving PCC (median dose 1500 IU) and FFP (median dose 2 U) were included. The use of PCC was associated with significantly decreased 24-h post-operative blood loss (836 ± 1226 vs. 935 ± 583 ml, p < 0.0001). Propensity score-adjusted multivariate analysis showed that PCC was associated with significantly lower risk of red blood cell (RBC) transfusions (odds ratio OR 0.50; 95% confidence interval CI 0.31-0.80), decreased amount of RBC units (β unstandardised coefficient -1.42, 95% CI -2.06 to -0.77) and decreased risk of transfusion of more than 2 RBC units (OR 0.53, 95% CI 0.38-0.73). Patients receiving PCC had an increased risk of post-operative acute kidney injury (AKI) (OR 1.44, 95% CI 1.02-2.05) and renal replacement therapy (OR 3.35, 95% CI 1.13-9.90). Hospital mortality was unaffected by PCC (OR 1.51, 95% CI 0.84-2.72).
In the cardiac surgery setting, the use of PCC compared with FFP was associated with decreased post-operative blood loss and RBC transfusion requirements. However, PCC administration may be associated with a higher risk of post-operative AKI.
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