Summary
Tracheal tubes are routinely used in adults undergoing elective surgery. The size of the tracheal tube, defined by its internal diameter, is often generically selected according to sex, with ...7–7.5 mm and 8–8.5 mm tubes recommended in women and men, respectively. Tracheal diameter in adults is highly variable, being narrowest at the subglottis, and is affected by height and sex. The outer diameter of routinely used tracheal tubes may exceed these dimensions, traumatise the airway and increase the risk of postoperative sore throat and hoarseness. These complications disproportionately affect women and may be mitigated by using smaller tracheal tubes (6–6.5 mm). Patient safety concerns about using small tracheal tubes are based on critical care populations undergoing prolonged periods of tracheal intubation and not patients undergoing elective surgery. The internal diameter of the tube corresponds to its clinical utility. Tracheal tubes as small as 6.0 mm will accommodate routinely used intubation aids, suction devices and slim‐line fibreoptic bronchoscopes. Positive pressure ventilation may be performed without increasing the risk of ventilator‐induced lung injury or air trapping, even when high minute volumes are required. There is also no demonstrable increased risk of aspiration or cuff pressure damage when using smaller tracheal tubes. Small tracheal tubes may not be safe in all patients, such as those with high secretion loads and airflow limitation. A balanced view of risks and benefits should be taken appropriate to the clinical context, to select the smallest tracheal tube that permits safe peri‐operative management.
Systemic inflammation is pivotal in the pathogenesis of cardiovascular disease. As inflammation can directly cause cardiomyocyte injury, we hypothesised that established systemic inflammation, as ...reflected by elevated preoperative neutrophil-lymphocyte ratio (NLR) >4, predisposes patients to perioperative myocardial injury.
We prospectively recruited 1652 patients aged ≥45 yr who underwent non-cardiac surgery in two UK centres. Serum high sensitivity troponin T (hsTnT) concentrations were measured on the first three postoperative days. Clinicians and investigators were blinded to the troponin results. The primary outcome was perioperative myocardial injury, defined as hsTnT≥14 ng L−1 within 3 days after surgery. We assessed whether myocardial injury was associated with preoperative NLR>4, activated reactive oxygen species (ROS) generation in circulating monocytes, or both. Multivariable logistic regression analysis explored associations between age, sex, NLR, Revised Cardiac Risk Index, individual leukocyte subsets, and myocardial injury. Flow cytometric quantification of ROS was done in 21 patients. Data are presented as n (%) or odds ratio (OR) with 95% confidence intervals.
Preoperative NLR>4 was present in 239/1652 (14.5%) patients. Myocardial injury occurred in 405/1652 (24.5%) patients and was more common in patients with preoperative NLR>4 OR: 2.56 (1.92–3.41); P<0.0001. Myocardial injury was independently associated with lower absolute preoperative lymphocyte count OR 1.80 (1.50–2.17); P<0.0001 and higher absolute preoperative monocyte count OR 1.93 (1.12–3.30); P=0.017. Monocyte ROS generation correlated with NLR (r=0.47; P=0.03).
Preoperative NLR>4 is associated with perioperative myocardial injury, independent of conventional risk factors. Systemic inflammation may contribute to the development of perioperative myocardial injury.
NCT01842568.
The clinical efficacy and safety of bariatric surgery trials were systematically reviewed. MEDLINE, EMBASE, CENTRAL were searched to February 2009. A basic PubCrawler alert was run until March 2010. ...Trial registries, HTA websites and systematic reviews were searched. Manufacturers were contacted. Randomized trials comparing bariatric surgeries and/or standard care were selected. Evidence-based items potentially indicating risk of bias were assessed. Network meta-analysis was performed using Bayesian techniques. Of 1838 citations, 31 RCTs involving 2619 patients (mean age 30-48 y; mean BMI levels 42-58 kg/m²) met eligibility criteria. As compared with standard care, differences in BMI levels from baseline at year 1 (15 trials; 1103 participants) were as follows: jejunoileal bypass MD: −11.4 kg/m², mini-gastric bypass −11.3 kg/m², biliopancreatic diversion −11.2 kg/m², sleeve gastrectomy −10.1 kg/m², Roux-en-Y gastric bypass −9.0 kg/m², horizontal gastroplasty −5.0 kg/m², vertical banded gastroplasty −6.4 kg/m², and adjustable gastric banding −2.4 kg/m². Bariatric surgery appears efficacious compared to standard care in reducing BMI. Weight losses are greatest with diversionary procedures, intermediate with diversionary/restrictive procedures, and lowest with those that are purely restrictive. Compared with Roux-en-Y gastric bypass, adjustable gastric banding has lower weight loss efficacy, but also leads to fewer serious adverse effects.
Background
Fundoplication and medical management are current mainstays for management of Barrett’s esophagus (BE), however our understanding of differences in outcomes between these two treatments is ...limited. The aim of this study was to perform a systematic review and meta-analysis to evaluate the efficacy of these interventions on BE disease regression and progression.
Methods and procedures
A comprehensive search in MEDLINE, EMBASE, Scopus, Web of Science, and Cochrane Library databases was performed on February 22, 2021. Inclusion criteria were studies with both medical and surgical management comparators, BE diagnosis prior to treatment, patients aged ≥ 18 years, and studies with greater than five patients. Primary outcomes of interest included evaluating changes in histopathologic BE regression and disease progression between interventions. Meta-analysis was performed using a Mantel–Haenszel random-effects model (RevMan 5.4.1).
Results
A total of 7231 studies were retrieved after initial search with nine studies (1 randomized trial, 7 prospective cohorts, 1 retrospective cohort) meeting final inclusion criteria. Of included studies, 890 (65%) patients received medical management while 470 (35%) received surgical management. Medical management included proton pump inhibitors (
n
= 807, 91%; 6 studies), H2-receptor blockers (
n
= 40, 4% patients; 3 studies), and combination therapy (
n
= 43, 5%; 1 study). Nissen fundoplication was the most commonly performed type of fundoplication (
n
= 265, 93%). Median length of follow-up ranged from 1.5–7 years. Meta-analysis revealed that fundoplication was associated with improved histopathologic regression of metaplasia/low-grade dysplasia (OR 4.38; 95% CI 2.28–8.42;
p
< 0.00001) and disease progression to dysplasia/adenocarcinoma (OR 0.34; 95% CI 0.12–0.96;
p
= 0.04) compared to medical therapy.
Conclusion
Fundoplication is superior to medical therapy with regards to improved odds of histopathologic BE disease regression and disease progression. Additional randomized trials which directly compare medical management and surgical intervention are required to delineate the optimal delivery and timing of these interventions.
Abstract
Objectives
Current gold standard investigations to determine the pathology of ineffective esophageal motility (IEM) are invasive and resource-intensive. Marshmallow barium swallow ...esophagogram (MBSE) is emerging as a more feasible modality; however, our understanding of its role in the clinical setting is limited. Our aim was to appraise the current literature and describe the effectiveness and limitations of MBSE as a potential diagnostic tool when investigating the pathological cause of IEM.
Methods
A search in PubMed was conducted on May 23, 2021. Search terms included “marshmallow” AND “barium.” We included all studies which examined MBSE in the context of esophageal disease. The primary outcome of interest was to characterize the use of MBSE in current literature.
Results
A total of 12 studies were retrieved after initial search with 9 studies meeting final inclusion criteria. A total of 375 patients were included, with 296 patients (79%) having a relevant diagnosis or symptom prompting investigation with MBSE. The most common diagnoses included referral to a gastroenterology clinic for a barium swallow (44%), post-Angelchik insertion (23%), and dysphagia (13%). Esophageal disease was identified in both the MBSE and other screening tests in 63% participants, whereas in 27% participants abnormalities were only seen using the MBSE.
Conclusion
There is currently limited high-quality evidence on the use of MBSE to diagnose IEM. Further large-scale studies comparing its use in patients with different pathologic causes of IEM and of older age are required to further delineate the optimal delivery of this emerging diagnostic modality.
Systemic arterial pulse pressure (systolic minus diastolic pressure) ≤53 mm Hg in patients with cardiac failure is correlated with reduced stroke volume and is independently associated with ...accelerated morbidity and mortality. Given that deconditioned surgical and heart failure patients share similar cardiopulmonary physiology, we examined whether lower pulse pressure is associated with excess morbidity after major surgery.
This was a prospective observational cohort study of patients deemed by their preoperative assessors to be at higher risk of postoperative morbidity. Preoperative pulse pressure was calculated before cardiopulmonary exercise testing. The primary outcome was any morbidity (PostOperative Morbidity Survey) occurring within 5 days of surgery, stratified by pulse pressure threshold ≤53 mm Hg. The relationship between pulse pressure, postoperative morbidity, and oxygen pulse (a robust surrogate for left ventricular stroke volume) was examined using logistic regression analysis (accounting for age, sex, BMI, cardiometabolic co-morbidity, and operation type).
The primary outcome occurred in 578/660 (87.6%) patients, but postoperative morbidity was more common in 243/ 660 patients with preoperative pulse pressure ≤53 mm Hg{odds ratio (OR): 2.24 95% confidence interval (CI): 1.29–3.38; P<0.001). Pulse pressure ≤53 mm Hg OR:1.23 (95% CI: 1.03–1.46); P=0.02 and type of surgery were independently associated with all-cause postoperative morbidity (multivariate analysis). Oxygen pulse <90% of population-predicted normal values was associated with pulse pressure ≤ 53 mm Hg OR: 1.93 (95% CI: 1.32–2.84); P=0.007.
In deconditioned surgical patients, lower preoperative systemic arterial pulse pressure is associated with excess morbidity. These data are strikingly similar to meta-analyses identifying low pulse pressure as an independent risk factor for adverse outcomes in cardiac failure. Low preoperative pulse pressure is a readily available measure, indicating that detailed physiological assessment may be warranted.
ISRCT registry, ISRCTN88456378.
Osteoarthritis is a common progressive disease leading to joint pain and severe disability. It is a complex multifactorial disease leading to damage of cartilage, deposition of subchondral bone ...matrix and release of pro‐inflammatory cytokines. Obesity is an emerging epidemic and also an important risk factor for osteoarthritis. Weight loss has been shown to improve pain and function in hip and knee joints with osteoarthritis. Bariatric surgery currently is the only evidence‐based approach to marked weight loss in obese individuals. However, there is currently limited literature to evaluate the role of bariatric surgery in hip and knee osteoarthritis. The objective of the present study was to systematically review the literature regarding the effectiveness of bariatric surgery in obese adult patients in improving large weight‐bearing joint (hip and knee) osteoarthritis. Published English‐language manuscripts were considered for review inclusion. A comprehensive search of electronic databases using broad search terms was completed. From a total of 400 articles, eight articles were identified. A total of six studies were included for qualitative analysis. A general trend was identified indicating improved hip and knee osteoarthritis following marked weight loss secondary to bariatric surgery. This systematic review demonstrates that bariatric surgery may benefit obese patients with hip or knee osteoarthritis. However, this review identifies the need for randomized controlled trials to clarify the role and indications for bariatric surgery.
Enhanced recovery, in part, aims to reduce postoperative gastrointestinal dysfunction (PGID). Acquired – or established- vagal dysfunction may contribute to PGID, even for surgery not involving the ...gastrointestinal tract. However, direct evidence for this is lacking. We hypothesized that chewing gum reduces morbidity (including PGID) by preserving efferent vagal neural activity postoperatively after elective orthopaedic surgery.
In a two-centre randomized controlled trial (n=106), we explored whether patients randomized to prescribed chewing gum for five days postoperatively sustained less morbidity (primary outcome, defined by the Postoperative Morbidity Survey), PGID and faster time to become morbidity free (secondary outcomes). In a subset of patients (n=38), cardiac parasympathetic activity was measured by serial Holter monitoring and assessed using time and frequency domain analyses.
Between September 2011 and April 2014, 106 patients were randomized to chewing gum or control. The primary clinical outcome did not differ between groups, with similar morbidity occurring between patients randomized to control (26/30) and chewing gum (21/28; absolute risk reduction (ARR):13% (95%C I:− 6–32); P=0.26). However, chewing gum reduced PGID (ARR:20% (95% CI: 1–38); P=0.049). Chewing gum reduced time to become morbidity-free (relative risk (RR): 1.62 (95% CI: 1.02–2.58); P=0.04) and was associated with a higher proportion of parasympathetic activity contributing to heart rate variability (11% (95% CI: 1–20); P=0.03).
Chewing gum did not alter overall morbidity, but reduced PGID. These data show for the first time that prescription of sham feeding preserves vagal activity in surgery not directly involving the gastrointestinal tract.
ISRCTN20301599.
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