METHODS: 10 010 high-risk noncardiac surgical patients were randomized aspirin or placebo and clonidine or placebo. Neuraxial block was defined as intraoperative spinal anaesthesia, or thoracic or lumbar epidural anaesthesia. Postoperative epidural analgesia was defined as postoperative epidural local anaesthetic and/or opioid administration. We used logistic regression with weighting using estimated propensity scores.
RESULTS: Neuraxial block was not associated with the primary outcome [7.5% vs 6.5%; odds ratio (OR), 0.89; 95% CI (confidence interval), 0.73-1.08; P=0.24], death (1.0% vs 1.4%; OR, 0.84; 95% CI, 0.53-1.35; P=0.48), myocardial infarction (6.9% vs 5.5%; OR, 0.91; 95% CI, 0.74-1.12; P=0.36) or stroke (0.3% vs 0.4%; OR, 1.05; 95% CI, 0.44-2.49; P=0.91). Neuraxial block was associated with less clinically important hypotension (39% vs 46%; OR, 0.90; 95% CI, 0.81-1.00; P=0.04). Postoperative epidural analgesia was not associated with the primary outcome (11.8% vs 6.2%; OR, 1.48; 95% CI, 0.89-2.48; P=0.13), death (1.3% vs 0.8%; OR, 0.84; 95% CI, 0.35-1.99; P=0.68], myocardial infarction (11.0% vs 5.7%; OR, 1.53; 95% CI, 0.90-2.61; P=0.11], stroke (0.4% vs 0.4%; OR, 0.65; 95% CI, 0.18-2.32; P=0.50] or clinically important hypotension (63% vs 36%; OR, 1.40; 95% CI, 0.95-2.09; P=0.09).
CONCLUSIONS: Neuraxial block and postoperative epidural analgesia were not associated with adverse cardiovascular outcomes among POISE-2 subjects.
METHODS: Case report.
RESULTS: The use pre-operative halo-ring traction for a duration of 6 weeks in this case lead to improvement in cobb angle from 123.3°, kyphotic angle 87.1° to cobb angle of 78.0°, kyphotic angle 57.2° (on bending and stress films). The operation was completed in 150 min, blood loss 1050 ml (25 ml/kg), and cell salvage of 490 ml. He was immediately extubated post correction, but monitored in ICU for a day. Total length of stay was 8 days without any perioperative morbidity or allogeneic blood transfusion. Final post-operative radiograph showed a cobb angle of 44.2°, kyphotic angle 22.8°. Follow up at 27 months showed solid union with no significant loss of correction.
CONCLUSION: From this case experience, pre-operative halo traction is a useful surgical strategy in patients with Fontan circulation with severe kyposcoliosis to achieve adequate correction without additional osteotomies to minimize the risk of surgical correction.
OBJECTIVE: This analysis is a subset of a larger systematic review. The objective of this study is to determine the effects of MDO on feeding and GERD.
DATA SOURCES: The databases searched included PubMed, Embase, Scopus, Web of Knowledge and grey literature sources.
STUDY SELECTION: The inclusion criterion included studies in children with clinical evidence of micrognathia/Pierre Robin Sequence (PRS) who have failed conservative treatments, including both syndromic (sMicro) and non-syndromic (iPRS) patients. 21 studies relevant to feeding and 4 studies relevant to GERD outcomes were included. All studies included were case series and case reports.
RESULTS: MDO leads to a significant improvement in feeding, with 82% of children feeding exclusively orally after surgery. The overall percentage of children with iPRS who were feeding orally was 93.7% compared with only 72.9% in the sMicro group (p<0.004). A growth decline within the first six weeks after surgery was observed in multiple studies. Overall, out of 70 patients with pre-operative GERD, only four had evidence of GERD after surgery.
CONCLUSIONS: Considering the limitations of this systematic review, this study found that successful relief of airway obstruction by MDO leads to improvement of feeding and improvement in symptoms of GERD in children with upper airway obstruction secondary to micrognathia. Clinicians need to be aware of the risk of growth decline in the initial post-operative period.
OBJECTIVE: To determine if surgically leveling the upper thoracic spine in patients with adolescent idiopathic scoliosis results in level shoulders postoperatively.
SUMMARY OF BACKGROUND DATA: Research has shown that preoperatively tilted proximal ribs and T1 tilt are more correlated with trapezial prominence than with clavicle angle.
METHODS: Prospectively collected Lenke 1 and 2 cases from a single center were reviewed. Clinical shoulder imbalance was measured from 2-year postoperative clinical photos. Lateral shoulder imbalance was assessed utilizing clavicle angle. Medial imbalance was assessed with trapezial angle (TA), and trapezial area ratio (TAR). First rib angle, T1 tilt, and upper thoracic curve were measured from 2-year radiographs. Angular measurements were considered level if ≤ 3° of zero. TAR was considered level if ≤ 1 standard deviation of the natural log of the ratio. Upper thoracic Cobb at 2-years was categorized as at or below the mean value (≤ 14°) versus above the mean.
RESULTS: Eighty-four patients were identified. There was no significant difference in the percentage of patients with a level clavicle angle or TAR based on first rib being level, T1 tilt being level, or upper thoracic Cobb being at/below versus above the mean (P
METHODS: Forty-seven patients underwent this newly modified PG technique between February 2012 and August 2016. Demographics, histopathological findings, type of surgery performed, perioperative parameters, postoperative length of stay, postoperative complications and interventional procedures, follow-up, and mortality data were collected and analyzed. Clavien-Dindo classification was used to grade the complications' severity.
RESULTS: Postoperative mortality was 4.25%, unrelated to POPF, and postoperative morbidity was 44.68%. Thirteen patients had severe (>Grade IIIa) complications, according to Clavien-Dindo classification. As classified in accordance to the International Study Group of Pancreatic Fistula, 24 (51.06%) patients developed Grade A POPF, and no occurrence of Grade B/C POPF was noted. All patients recovered uneventfully with successful treatment interventions.
CONCLUSION: The reported PG anastomotic technique is a safe and dependable reconstruction procedure with acceptable morbidity and mortality.
METHODS: A systematic review of randomized controlled trials (RCTs) was undertaken using the PRISMA guidelines to investigate the postoperative impact on diabetes resolution following LVSG versus LRYGB.
RESULTS: Seven RCTs involving a total of 732 patients (LVSG n = 365, LRYGB n = 367) met inclusion criteria. Significant diabetes resolution or improvement was reported with both procedures across all time points. Similarly, measures of glycemic control (HbA1C and fasting blood glucose levels) improved with both procedures, with earlier improvements noted in LRYGB that stabilized and did not differ from LVSG at 12 months postoperatively. Early improvements in measures of insulin resistance in both procedures were also noted in the studies that investigated this.
CONCLUSIONS: This systematic review of RCTs suggests that both LVSG and LRYGB are effective in resolving or improving preoperative type 2 diabetes in obese patients during the reported 3- to 5-year follow-up periods. However, further studies are required before longer-term outcomes can be elucidated. Areas identified that need to be addressed for future studies on this topic include longer follow-up periods, standardized definitions and time point for reporting, and financial analysis of outcomes obtained between surgical procedures to better inform procedure selection.
Objective: To determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality).
Design, Setting, and Participants: Prospective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013.
Exposures: Patients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement.
Main Outcomes and Measures: A modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality.
Results: Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.
Conclusions and Relevance: Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.
MATERIAL AND METHODS: RCTs comparing postoperative comorbid disease resolution such as hypertension, dyslipidemia, obstructive sleep apnea, joint and musculoskeletal conditions, gastroesophageal reflux disease, and menstrual irregularities following LVSG and LRYGB were included for analysis. The studies were selected from PubMed, Medline, EMBASE, Science Citation Index, Current Contents, and the Cochrane database and reported on at least one comorbidity resolution or improvement. The present work was undertaken according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA). The Jadad method for assessment of methodological quality was applied to the included studies.
RESULTS: Six RCTs performed between 2005 and 2015 involving a total of 695 patients (LVSG n = 347, LRYGB n = 348) reported on the resolution or improvement of comorbid disease following LVSG and LRYGB procedures. Both bariatric procedures provide effective and almost comparable results in improving or resolving these comorbidities.
CONCLUSIONS: This systematic review of RCTs suggests that both LVSG and LRYGB are effective in resolving or improving preoperative nondiabetic comorbid diseases in obese patients. While results are not conclusive at this time, LRYGB may provide superior results compared to LVSG in mediating the remission and/or improvement in some conditions such as dyslipidemia and arthritis.
OBJECTIVE: The aim of this study was to determine and evaluate the trajectory of surgical wound pain from day 1 to day 14 after posterior spinal fusion (PSF) surgery in patients with adolescent idiopathic scoliosis (AIS).
SUMMARY OF BACKGROUND DATA: Information regarding how the postoperative pain improves with time offers invaluable information not only to the patients and parents but also to assist the clinician in managing postoperative pain.
METHODS: AIS patients who were planned for elective PSF surgery from September 2015 to December 2015 were prospectively recruited into this study. All patients underwent a similar pain management regimen with patient-controlled anesthesia (PCA) morphine, acetaminophen, celecoxib, and oxycodone hydrochloride.
RESULTS: A total of 40 patients (36 F:4 M) were recruited. The visual analogue score (VAS) pain score was highest at 12 hours postoperation (6.0 ± 2.3). It reduced to 3.9 ± 2.2 (day 4), 1.9 ± 1.6 (day 7), and 0.7 ± 1.1 (day 14). The total PCA usage in all patients was 12.4 ± 9.9 mg (first 12 hours), 7.1 ± 8.0 mg (12 to 24 hours), 5.6 ± 6.9 (24-36 hours), and 2.1 ± 6.1 mg (36-48 hours). The celecoxib capsules usage was reducing from 215.0 ± 152.8 mg at 24 hours to 55.0 ± 90.4 mg on day 14. The acetaminophen usage was reducing from 2275 ± 1198 mg at 24 hours to 150 ± 483 mg at day 14. Oxycodone hydrochloride capsules consumption rose to the peak of 1.4 ± 2.8 mg on day 4 before gradually reducing to none by day 13.
CONCLUSION: With an adequate postoperation pain regimen, significant pain should subside to a tolerable level by postoperative day 4 and negligible by postoperative day 7. Patient usually can be discharged on postoperative day 4 when the usage of PCA morphine was not required.
LEVEL OF EVIDENCE: 2.