Life-Threatening Mediastinal Teratoma of Infant Requiring Emergency Surgical Removal

Background Teratoma is a tumor derived from fetal germ cells with aberrant differentiation. Case Description A 3-month-old infant with a mediastinal tumor was referred to our heart center. She presented with progressive dyspnea, cyanosis, and the need to be manually ventilated. The computed tomography scan displayed a huge tumor restricting the distal trachea including the bifurcation. An emergent operation was performed and the tumor was completely removed. Histological examination confirmed a mature teratoma. Conclusion In such life-threatening situation, the early detection and the immediate operation are very important for the management of rapidly-progressing mediastinal teratomas compressing the respiratory tract.

Impact of COVID-19 pandemic on surgical care of patients with acute aortic conditions

Background The outbreak of COVID-19 pandemic catastrophically interrupted medical care systems causing substantial decrease in the admission of patients and consecutively a sharp decline in the number of surgeries and interventions. In several European countries, the nationwide lockdown severely restricted movement which may have contributed to this phenomenon on top of anxiety of patients to contract COVID-19 when admitted to hospital. Purpose The aim of this analysis was to evaluate the impact of the COVID-19 pandemic onto acute and elective thoracic aortic surgeries and interventions and to compare the data with the same period in 2019 in a single aortic centre. Methods Information on admission and surgery/intervention was extracted from hospital electronic record system. Patients who were admitted for treatment of aortic conditions between January 1st to June 30th both in 2019 and 2020 were identified and selected for this analysis. The time from referral to admission and surgery/intervention was noted for service delay analysis. Aortopathies were classified as type A aortic dissection, type B aortic dissection, aortic aneurysm and others. In a daily central hub meeting, urgency was defined as emergent (operation required before the next working day), urgent (operation needed within 48 hours), and elective. Patients' condition and comorbidities were represented by ACEF II score. Results Total case volume of 81 in 2019 reference period was reduced to 70 in 2020 (−14%). Elective cases significantly declined from 59 (72.8%) in 2019 to 30 (42.8%) in 2020 (−49%). Urgent and emergent cases were performed more frequently in 2020 with 40 cases versus 22 in 2019 (+45%). The ACEF II score showed no difference for patients in both periods (2.1±1.9 vs. 2.5±2.1, p=0.221), however, a trend to higher ACEF II score in 2020 consistent with a higher proportion of urgent and emergent cases. The overall in-hospital delay (from admission to surgery) was not significant affected with 1 (IQR 1–2) versus 1 (IQR 0–2); p=0.991. However, with the official declaration of a pandemic and introduction of restrictions, no in-hospital delay was documented. In-hospital mortality was observed lower in 2019 as compared in 2020 (6.1% vs 11.4%, P=0.251). Conclusion The first wave of COVID-19 pandemic disrupted the aortic service, however, acute care for urgent thoracic aortic conditions and subsequent procedures even increased compared to 2019 as a result of both centralised allocation system and decline of elective cases. Acute aortic syndromes were managed despite COVID-19 according to current guidelines. FUNDunding Acknowledgement Type of funding sources: None. Impact of COVID on aortic case load

Closed Gastroschisis: A Rare Abdominal Wall Defect

Gastroschisis is a rare congenital abdominal wall defect characterized by intestinal evisceration to the right of the umbilical stalk. In less than 6% of cases, the fascial defect closes around the herniated viscera in utero. The mechanism of fascial closure in these cases is unknown; however, the tourniquet effect on the mesenteric vasculature is thought to lead to intestinal atresia and midgut infarction. We report a case of a female neonate with a prenatal diagnosis of gastroschisis who was found to have a closed defect at the time of delivery. She required emergent operation for symptoms of intestinal obstruction and bowel ischemia.

Prehospital shock index outperforms hypotension alone in predicting significant injury in trauma patients

BackgroundThe American College of Surgeons Resources for Optimal Care of the Injured Patient recommends using hypotension, defined as systolic blood pressure ≤90 mm Hg, as an indicator of a full team trauma activation. We hypothesized that an elevated shock index (SI) predicts significant traumatic injuries better than hypotension alone.MethodsThis is a retrospective cohort study analyzing full team trauma activations between February 2018 and January 2020, excluding transfers and those who had missing values for prehospital blood pressure or heart rate. We reviewed patients’ demographics, prehospital and emergency department vitals, injury pattern, need for operation, and clinical outcomes. The primary outcome was rate of significant injury defined as identified injured liver, spleen, or kidney, pelvis fracture, long bone fracture, significant extremity soft tissue damage, hemothorax, or pneumothorax.ResultsAmong 544 patients, 82 (15.1%) had prehospital hypotension and 492 had normal blood pressure. Of the patients with prehospital hypotension, 34 (41.5%) had a significant injury. There was no difference in age, gender, medical history, or injury pattern between the two groups. There was no difference between the two groups in rate of serious injury (41.5% vs. 46.1%, NS), need for emergent operation (31.7% vs. 28.1%, NS) or death (20.7% vs. 18.8%, NS). On the other hand, SI ≥1 was associated with increased rate of serious injury (54.6% vs. 43.4%, p=0.04). On a logistic regression analysis, prehospital hypotension was not associated with significant injury or need for emergent operation (OR 0.83, 95% CI 0.51 to 1.33 and OR 1.32, 95% CI 0.79 to 2.25, respectively). SI ≥1 was associated with both increased odds of significant injury and need for emergent operation (OR 1.57, 95% CI 1.01 to 2.44 and OR 1.64, 95% CI 1.01 to 2.66).DiscussionSI was a better indicator and could replace hypotension to better categorize and triage patients in need of higher level of care.Level of evidencePrognostic and epidemiologic, level III.

Relationship of Surgeon Experience and Outcomes of Surgery for Degenerative Mitral Valve Disease

Objective: To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. Methods: We reviewed all patients who had surgery for degenerative mitral valve disease between 2011-2016. Experienced surgeon was defined as performing  25 mitral valve operations/year. Patient characteristics and outcomes were compared. Multivariable analysis was performed to identify factors associated with MR recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional Hazard method. Results: There were 575 patients treated by 9 surgeons for severe mitral regurgitation caused by degenerative mitral valve disease between 2011-2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (P=0.001). Experienced surgeons were more likely to attempt repair (P=0.024), to succeed in repair (94.7% vs 87%, P=0.001), had shorter cross-clamp times (P=0.001), and achieved higher repair rate (81.3% vs 69.7%, P=0.005). Experienced surgeons were more likely to use neochordae (P=0.001) and less likely to use chordae transfer (P=0.001). Surgeon experience was not associated with recurrence (moderate or higher MR) within the first two years after surgery but was an independent risk factor for mortality (HR= 2.64, P=0.002). Conclusions: Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

Neutrophil-to-lymphocyte ratio has limited predictive value for determining outcomes in perforated colon cancer: a retrospective study.

Background: The neutrophil-to-lymphocyte ratio (NLR) is a significant prognostic marker in resectable colorectal cancer; however, there are no equivalent findings for perforated colon cancer. Using our colorectal cancer database, we retrospectively analyzed the data from 1995 to 2015 to determine if preoperative NLR was associated with survival outcomes in patients with perforated colon cancer. Methods: One-to-one propensity score matching (PSM) was applied to minimize the difference between the higher- (>5) and lower- (≤5) NLR groups. Clinicopathological factors, long-term overall survival (OS), and disease-free survival (DFS) were analyzed and compared between the two groups. The main outcome measures were OS and DFS. Results: Before PSM, the higher-NLR group had significantly higher prevalence of leukocytosis (lower- vs. higher-NLR groups: 12 [12.9%] vs. 46 [59.7%], p<0.001), lower serum albumin levels (lower- vs. higher-NLR groups: 30 [32.3%] vs. 42 [54.5%], p=0.003), and higher emergent operation rate (lower- vs. higher-NLR groups: 5 [5.4%] vs. 20 [26.0%], p<0.001). After one-to-one PSM, the groups comprised 41 patients each; none of the parameters were significantly different. The mean follow-up period was 76.3 months. Five-year OS and DFS were not significantly different (OS: p=0.637; DFS: p=0.827) between the higher- and lower-NLR groups. Conclusion: NLR have limited predictive value for outcomes in patients with perforated colon cancer.

Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies

SUMMARY Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient’s condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.

Endotracheal intubation with video laryngoscope at semilateral decubitus position: a case report of a pediatric patient with a back stab wound

Background: Endotracheal intubation is routinely performed in a supine position. However, this position might be difficult for some emergent patients. Although several alternative positions have been suggested for adult patients, such studies on pediatric patients are rare. Case presentation: We present a case of a female pediatric patient with a pencil stab wound to the back requiring an emergent operation under general endotracheal anesthesia. Placing her in supine position would have been inappropriate because of the protruding pencil. The patient was moved to a semilateral decubitus position for intubation. The endotracheal tube was inserted with a video laryngoscope. Her vital signs and oxygen saturation were stable during operation. The patient was discharged without complications. Conclusion: Semilateral intubation in pediatric patients using a video laryngoscope may be feasible under some specific conditions that make it inappropriate to place patients in a supine position.

P5600Surgical reconstruction of type A aortic dissection in octogenarians

Introduction Because the population is aging, the indication for surgical reconstruction in older patients will increase. Japan is especially facing the most aging society worldwide. However, surgical reconstruction of type A aortic dissection (AADA) in patients who are octogenarians is not often performed because of the decision of the patient or surgeon. We examined the outcome of surgical reconstruction of AADA in octogenarians. Method Over 4 years, 132 cases of surgical reconstruction of AADA were analyzed. Twenty-five consecutive octogenarians with AADA were retrospectively reviewed. In our institution, we recommend an emergent operation to the patient or family in all generations unless they reject it for some reason. Results Operative factors in octogenarians with AADA were not significantly different compared with those in patients aged younger than 79 years (n=107) (operation: 238±11 vs. 246±5 min, p=0.54; cardiopulmonary bypass: 147±7.4 vs. 154±3.5 min, p=0.42; aortic-clamp: 114±6.0 vs. 120±2.8 min, p=0.36; hypothermic-arrest: 43±2.7 vs. 42±1.3 min, p=0.81). The overall mortality rate was 24.0% (n=6). The mortality rate was no difference between younger patients and octogenarians (OR: 2.7, 95% CI: 0.86–8.21, p=0.08). Furthermore, MACE (Major Adverse Cardiac Event) and the postoperative stroke rate were not significantly different between the two groups (OR: 1.5, 95% CI: 0.52–3.93, p=0.42; OR: 0.77, 95% CI: 0.16–2.59, p=0.69, respectively). Conclusion In AADA, the outcome of emergent surgical reconstruction in octogenarians is acceptable. Even with the risk of aging, surgeons should consider aggressive surgical reconstruction in octogenarians.