Corneal epithelial defects following vitreoretinal surgery: incidence and outcomes from the DISCOVER study

AIM: To investigate the incidence, risk factors, clinical course, and outcomes of corneal epithelial defects (CED) following vitreoretinal surgery in a prospective study setting. METHODS: This was a post-hoc analysis of all participants in DISCOVER intraoperative optical coherence tomography study. Subjects with CED 1d after surgery without intraoperative corneal debridement was defined as the postoperative CED group. Subjects who underwent intraoperative debridement were defined as intraoperative debridement group. Eyes were matched 2:1 with controls (eyes without postoperative CED) for comparative assessment. The primary outcomes were the incidence of CED on postoperative day one and the incidence of required intraoperative debridement. Secondary outcomes included time to defect closure, delayed healing (>2wk), visual acuity (VA) and presence of scarring at one year and cornea consult. RESULTS: This study included 856 eyes that underwent vitreoretinal surgery. Intraoperative corneal debridement was performed to 61 (7.1%) subjects and postoperative CED developed spontaneously in 94 (11.0%) subjects. Significant factors associated with postoperative CED included prolonged surgical duration (P=0.003), diabetes mellitus (P=0.04), postoperative ocular hypotension (P<0.001). Prolonged surgical duration was associated with intraoperative debridement. Delayed defect closure time (>2wk) was associated with corneal scar formation at the end of the 1y in all epithelial defect subjects (P<0.001). The overall rate of corneal scarring for all eyes undergoing vitrectomy was 1.8%. CONCLUSION: Prolonged duration of surgery is the strongest factor associated with both intraoperative debridement and spontaneous postoperative CED. Delayed defect closure is associated with a greater risk of corneal scarring at one year. The overall rate of corneal scarring following vitrectomy is low at <2%.

Cross-sectional Analysis of Risk Factors for Surgical Site Infection Secondary to Spinal Internal Fixation via the Posterior Approach

Backgroud: The aim of this study was to investigate the risk factors related to surgical site infection (SSI) secondary to spinal internal fixation via the posterior approach.Methods: Patients who had undergone spinal internal fixation via the posterior approach at the spinal center of our hospital from January 2004 to December 2019 were selected in this cross-sectional study. Information about age, sex, body mass index (BMI), fused segment, hemoglobin concentration, serum albumin concentration, surgical duration, surgery beginning time, allogeneic blood transfusion, combined diabetes, peak blood glucose 72 h postoperatively ≥12 mmol/L, smoking history, and blood loss were included. The factors related to SSI were analyzed using univariate and multivariate analyses. P < 0.05 was considered to indicate statistical significance.Results: Among the 4,350 patients, 66 had SSI, with an infection prevalence of 1.5%. The subjects included 37 men and 29 women (age range, 22–84 y; average age, 47.4 ± 12.8 y). Univariate analysis showed that sex, BMI, fused segment, surgery beginning time, allogeneic blood transfusion, and smoking history were not correlated to infection (P > 0.05). However, age >60 y, surgical duration >3 h, serum albumin concentration <30 g/L, hemoglobin concentration <80 g/L, combined diabetes, peak blood glucose 72 h postoperatively ≥12 mmol/L, and blood loss >1,000 mL were correlated with infection (P < 0.05). Multivariate logistic regression analysis demonstrated that age >60 y, surgical duration >3 h, hemoglobin concentration <80 g/L, serum albumin concentration <30 g/L, combined diabetes, and blood loss >1,000 mL were significantly correlated with SSI secondary to spinal internal fixation via the posterior approach.Conclusion: This study provides information on SSI secondary to spinal internal fixation via the posterior approach. We found that age >60 y, surgical duration >3 h, hemoglobin concentration <80 g/L, serum albumin concentration <30 g/L, combined diabetes, and blood loss >1,000 mL are directly correlated with SSI secondary to spinal internal fixation via the posterior approach. These findings may contribute to discussions and actions that may help to reduce SSI secondary to spinal internal fixation via the posterior approach in the short or medium term.

The Safety and Feasibility of Laryngeal Mask Airway (LMA) Management in Non-intubated Subxiphoid-subcostal Thoracoscopic Thymectomy: Preliminary Results

Intubated general anesthesia and single-lung ventilation are considered mandatory for conventional thoracoscopic surgery. Non-intubated thoracoscopic thymectomy is technically challenging. The aim of this article was to present the initial results of non-intubated subxiphoid-subcostal thoracoscopic thymectomy (NI-STT) under LMA management for patients with thymic tumor or myasthenia gravis (MG) and to investigate the feasibility and safety of the procedure. A retrospective analysis of patients undergoing NI-STT for thymic tumor or MG at our department from January 2017 to January 2020 was performed. The clinical characteristics and perioperative outcomes of the patients were reviewed and analyzed. A total of 61 patients were received NI-STT in this analysis, of which 19 patients with MG undergone an extended thymectomy and the rest (n=42) undergone a partial thymectomy. The anesthetic induction duration, surgical duration and global operating room duration were 24.83±12.27 min, 118.75±32.49 min and 173.51±41.80 min, respectively. The lowest SpO2 and peak EtCO2 during operation were 96.15±2.93 mmHg and 41.79±7.53 mmHg, respectively. The mean duration of chest drainage and postoperative hospital stays were 1.87 days, and 2.91 days, respectively. Three cases had sore throat and irritable cough and two cases suffered nausea and vomiting occurred. one patient suffered from an atrial fibrillation, two patients experienced pneumonia, and one patient suffered wound infection, respectively. There were no phrenic nerve paralysis and mortality occurred in the study group. The postoperative pain was low on 1,3, 7, 14, 30, 90 and 180 postoperative days. NI-STT was a technically safe and feasible approach for treating thymic tumors or MG. It could be an alternative to intubated single-lung ventilation for thymectomy in selected patients.

LONG VERSUS SHORT PROXIMAL FEMORAL NAIL IN THE MANAGEMENT OF UNSTABLE INTERTROCHANTERIC FRACTURES IN ELDERLY POPULATION

INTRODUCTION: Intertrochanteric fractures constitute a vast majority of geriatric orthopedic trauma having highest postoperative morbidity and mortality of surgically treated fractures. Use of cephalomedullary nails for treatment of highly unstable intertrochanteric fractures is now more common as plate xation is associated with higher risk of implant breakage and screw cutout. However, choice of length of these nails remains surgeon dependent. AIM: to compare the functional outcome and complications associated with the use of Long and Short PFN for the treatment of unstable intertrochanteric fractures (AO/OTAtype 31A1 and 31A2) in elderly population. METHOD: A prospective interventional study comprising of 58 patients distributed in two groups in which one group (n=25) was treated with long PFN while other group (n=33) was operated with short PFN. Parameters compared between these two groups included demographic data, intraoperative blood loss and surgical duration as well as analysis of radiological and clinical progression of union and postoperative complications in the form of hip pain, anterior thigh pain and failure rate. Functional assessment was done using Harris hip score. RESULT:This study included only AO/OTAtype 31A1 and 31A2 fracture types in elderly patients above 60 years of age. We found no statistically signicant difference with regard to age, sex as well as fracture type among two groups. Long PFN group had a shorter union time (11.4 weeks) and was associated with lesser postoperative complication and failure rate as compared to short PFN. Also, functional outcome evaluated using Harris hip score shown better scores in long PFN group. However, intraoperative blood loss and surgical duration was found to be signicantly lesser in short PFN group. CONCLUSION: use of cephalomedullary nails either short or long for xation of unstable intertrochanteric fractures particularly AO/OTA type 31A1 and 31A2 provides good results. However, longer nails should be preferred over short nails as these are associated with less postoperative complication such as hip pain or anterior thigh pain owing to excessive curvature of femur in Indian population with lesser union time and better functional outcome as compared to short PFN. Shorter nails may be used in cases of sick and polytrauma patients where shorter operative time with minimal blood loss is desirable

Development and validation of a novel predictive model and web calculator for evaluating transfusion risk after spinal fusion for spinal tuberculosis: a retrospective cohort study

Objectives The incidence and adverse events of postoperative blood transfusion in spinal tuberculosis (TB) have attracted increasing attention. Our purpose was to develop a prediction model to evaluate blood transfusion risk after spinal fusion (SF) for spinal TB. Methods Nomogram and machine learning algorithms, support vector machine (SVM), decision tree (DT), multilayer perceptron (MLP), Naive Bayesian (NB), k-nearest neighbors (K-NN) and random forest (RF), were constructed to identified predictors of blood transfusion from all spinal TB cases treated by SF in our department between May 2010 and April 2020. The prediction performance of the models was evaluated by 10-fold cross-validation. We calculated the average AUC and the maximum AUC, then demonstrated the ROC curve with maximum AUC. Results The collected cohort ultimately was consisted of 152 patients, where 56 required allogeneic blood transfusions. The predictors were surgical duration, preoperative Hb, preoperative ABL, preoperative MCHC, number of fused vertebrae, IBL, and anticoagulant history. We obtained the average AUC of nomogram (0.75), SVM (0.62), k-NM (0.65), DT (0.56), NB (0.74), MLP (0.56) and RF (0.72). An interactive web calculator based on this model has been provided (https://drwenleli.shinyapps.io/STTapp/). Conclusions We confirmed seven independent risk factors affecting blood transfusion and diagramed them with the nomogram and web calculator.

A Retrospective Comparative Study of Local Anesthesia Only and Local Anesthesia with Sedation for Percutaneous Endoscopic Lumbar Discectomy

The purpose of this study was to compare surgical experience and clinical outcomes of lumbar disk herniation (LDH) patients treated with percutaneous endoscopic lumbar discectomy (PELD) using local anesthesia only and local anesthesia with sedation. Ninety-two consecutive LDH patients were divided into four groups: control group (Con Group), dexmedetomidine group (Dex Group), oxycodone group (Oxy Group), and dexmedetomidine + oxycodone group (Dex + Oxy Group). Mean arterial pressure (MAP), heart rate (HR), Ramsay score and VAS score were compared before anesthesia (T1), working cannula establishment (T2), nucleus pulposus removal (T3), and immediately postoperative (T4). Surgical duration, hospitalization and MacNab criteria were evaluated. In control group, MAP and HR at T2 and T3 were higher than T1 (P < 0.05). In Dex, Oxy, and Dex + Oxy groups, MAP and HR at T2, T3, T4 were lower than T1, but Ramsay scores at T2, T3, T4 were higher than T1 (P < 0.05). VAS scores in all groups were improved postoperative (p>0.05). The clinical outcomes have no significant differences among the four groups (P > 0.05). We concluded that the combination of dexmedetomidine and oxycodone under local anesthesia is an effective method to improve surgical experience and reduce anxiety in suitable LDH patients.

The hemodynamic effects of intravenous paracetamol (acetaminophen) in patients with chronic liver disease undergoing liver transplantation: a pilot study

Objective We performed a single-center double-blinded, randomized trial to investigate the hemodynamic effects of IV paracetamol in patients with chronic liver disease (CLD) undergoing liver transplantation surgery. Patients with CLD are particularly susceptible to hemodynamic derangements given their low systemic vascular resistance state. Accordingly, hypotension is common in this setting. The hemodynamic effects of IV paracetamol in patients undergoing elective liver transplantation are unknown, therefore we evaluated whether the intraoperative administration of IV paracetamol in patients with chronic liver disease undergoing liver transplantation results in adverse hemodynamic effects. The primary end point was a change in systolic blood pressure 30-min after the preoperative infusion. Results Twenty-four participants undergoing liver transplantation surgery were randomly assigned to receive a single bolus of IV paracetamol (1 g paracetamol + 3.91 g mannitol per 100 mL) (n = 12) or placebo (0.9% Saline 100 mL) (n = 12). All participants completed their study intervention, and there were no breaches or violations of the trial protocol. Baseline characteristics were similar in both groups. There were no significant differences regarding surgical duration, intraoperative use of fluids, and intraoperative noradrenaline use. After the administration of paracetamol there were no significant differences observed in blood pressure or other hemodynamic parameters when compared to placebo.

Pancreaticoduodenectomy: Impact of Volume on Outcomes at a Tertiary Care Center. Our Experience in Single Institute of Nepal.

BackgroundPancreaticoduodenectomy is a complex high risk surgical procedure usually done for malignant disease carrying significant postoperative morbidity and mortality. An audit and analysis of rate of postoperative morbidity and mortality and the impact of case volume can provide information about the lacunas in patient care and methods to improve it for safe and early discharge of patients. This study was conducted to find out demographic profile, the rate of perioperative morbidities, mortality and impact of case volume on patients undergoing pancreaticoduodenectomy for malignant disease which may serve as a guide to uplift the patient care in our center.MethodsRetrospective analysis of prospectively collected data of patients undergoing pancreaticoduodenectomy from 2015 to 2019 was performed. A total of 62 patients were included in the study. Patients clinic-demographic details, intraoperative and postoperative events were recorded. Rate of various postoperative morbidities and mortality and year wise trend of these factors were analyzed.ResultsMost of the patients were in sixth decade of life (38.7%) with male preponderance (61.3%). Pancreatic cancer was most commonly seen followed by cholangiocarcinoma (46.8%). SSI (32.3%), intraabdominal collection (25.8%), anastomotic leak (14.5%), pancreatic fistula (22.6%), postpancreatectomy hemorrhage (8.1% ) were the major postoperative events. Mortality was found in 12.9% patients. ConclusionThere has been a decrease in rate of all these postoperative adverse events and improvement in the intraoperative blood loss and surgical duration with advancing years and increasing number of cases.