cT1N0M0 Esophageal Squamous Cell Carcinoma Invades the Muscularis Mucosa or Submucosa: Comparison of the Results of Endoscopic Submucosal Dissection and Esophagectomy

Background: Endoscopic submucosal dissection (ESD) combined with selective adjuvant chemoradiotherapy may be a new treatment option for cT1N0M0 esophageal squamous cell carcinoma (ESCC) invading muscularis mucosa or submucosa (pT1a-M3/pT1b). We aim to report the effectiveness of this treatment by comparing the results of esophagectomy. Methods: This retrospective single-center study included 72 patients with pT1a-M3/pT1b ESCC who received ESD combined with selective adjuvant chemoradiotherapy (n = 40) and esophagectomy (n = 32). The main outcome comparison was overall survival (OS). The secondary outcomes were treatment-related events, including operation time, complication rate, and length of hospital stay. Disease-specific survival (DSS) and progression-free survival (PFS) were also evaluated. Results: There were no significant differences in the rates of OS, DSS, and PFS between the two groups (median follow-up time: 49.2 months vs. 50.9 months); these were also the same in the subgroup analysis of pT1b ESCC patients. In the ESD group, the procedure time, overall complication rates, and length of hospital stay were significantly reduced. However, the metachronous recurrence rate was significantly higher. In a multivariate analysis, tumor depth and R0 resection were the independent factors associated with OS. Conclusions: ESD combined with selective adjuvant chemoradiotherapy can be an alternative treatment to esophagectomy for cT1N0M0 ESCC invading muscularis mucosa or submucosa.

Risk Factors for Early and Late Complications after Laparoscopic Sleeve Gastrectomy in One-Year Observation

Background: Although laparoscopic sleeve gastrectomy (LSG) is considered a safe bariatric procedure in the treatment of obesity, it still involves a risk of developing postoperative complications. Knowledge of risk factors for possible complications would allow appropriate preoperative planning, optimization of postoperative care, as well as early diagnosis and treatment. The aim of this study was to evaluate risk factors for complications after laparoscopic sleeve gastrectomy. Methods: A retrospective study of 610 patients who underwent LSG at a tertiary institution were included in the study through retrospective analysis of the medical data. Complications were categorized as early (<30 days) and late (≥30 days) and evaluated according to the Clavien–Dindo Classification. Results: Early complications were observed in 35 patients (5.74%) and late complications occurred in 10 patients (1.64%). Independent risk factors of early complications after laparoscopic sleeve gastrectomy included hypercholesterolemia (OR 3.73; p-value = 0.023) and smoking (OR = 274.66, p-value < 0.001). Other factors that may influence the postoperative course are length of hospital stay and operation time. Smoking, peptic ulcer diseases and co-existence of hiatal hernia were found to be an independent predictors of late complications. Conclusions: Smoking is associated with the higher risk of both, early and late complications, while hypercholesterolemia with only <30 days complications after laparoscopic sleeve gastrectomy.

Observational study of changes in utilization and outcomes in mechanical ventilation in COVID-19

Background The role of non-invasive ventilation (NIV) in severe COVID-19 remains a matter of debate. Therefore, the utilization and outcome of NIV in COVID-19 in an unbiased cohort was determined. Aim The aim was to provide a detailed account of hospitalized COVID-19 patients requiring non-invasive ventilation during their hospital stay. Furthermore, differences of patients treated with NIV between the first and second wave are explored. Methods Confirmed COVID-19 cases of claims data of the Local Health Care Funds with non-invasive and/or invasive mechanical ventilation (MV) in the spring and autumn pandemic period in 2020 were comparable analysed. Results Nationwide cohort of 17.023 cases (median/IQR age 71/61–80 years, 64% male) 7235 (42.5%) patients primarily received IMV without NIV, 4469 (26.3%) patients received NIV without subsequent intubation, and 3472 (20.4%) patients had NIV failure (NIV-F), defined by subsequent endotracheal intubation. The proportion of patients who received invasive MV decreased from 75% to 37% during the second period. Accordingly, the proportion of patients with NIV exclusively increased from 9% to 30%, and those failing NIV increased from 9% to 23%. Median length of hospital stay decreased from 26 to 21 days, and duration of MV decreased from 11.9 to 7.3 days. The NIV failure rate decreased from 49% to 43%. Overall mortality increased from 51% versus 54%. Mortality was 44% with NIV-only, 54% with IMV and 66% with NIV-F with mortality rates steadily increasing from 62% in early NIV-F (day 1) to 72% in late NIV-F (>4 days). Conclusions Utilization of NIV rapidly increased during the autumn period, which was associated with a reduced duration of MV, but not with overall mortality. High NIV-F rates are associated with increased mortality, particularly in late NIV-F.

Cost of tuberculosis-related aeromedical retrievals in the Torres Strait, Australia

Tuberculosis (TB) remains a disease of public health significance at the Australia / Papua New Guinea (PNG) international border. In the remote Torres Strait Islands, aeromedical evacuation is a necessary but costly component of TB management and patients with critical care needs require support to prevent onward TB transmission. A detailed costing of an exemplar TB patient from PNG who presented to a Queensland Health facility in the Torres Strait and required urgent aeromedical evacuation was performed. Data were drawn from patient charts, financial and clinical information systems used within Queensland Health and the Torres and Cape Hospital and Health Service. The total cost of aeromedical evacuation was AUD 124,280; 54% of the cost was attributed to travel. Between 2016 and 2019, 19 patients diagnosed with TB were medically evacuated from an outer Torres Strait Island with a median length of hospital stay of 57 days. Aeromedical evacuation and medical management costs require adequate budget allocation.

The Incidence and Causes of Unplanned Reoperations as a Quality Indicator in Pediatric Surgery

Background: Unplanned return to the operating room (uROR) within the 30-day postoperative period can be used as a quality indicator in pediatric surgery. The aim of this study was to investigate and evaluate uROR as a quality indicator. Methods: The case records of pediatric patients who underwent reoperation within the 30-day period after primary surgery, from 1 January 2018 to 31 December 2020 were retrospectively reviewed. The primary outcome of the study was the rate of uROR as a quality indicator in pediatric surgery. Secondary outcomes were indications for primary and secondary surgery, types and management of complications, factors that led to uROR, length of hospital stay, duration of surgery and anesthesia, and starting time of surgery. Results: A total of 3982 surgical procedures, under general anesthesia, were performed during the three-year study period (2018, n = 1432; 2019, n = 1435; 2020, n = 1115). Elective and emergency surgeries were performed in 3032 (76.1%) and 950 (23.9%) patients, respectively. During the study period 19 (0.5%) pediatric patients, with the median age of 11 years (IQR 3, 16), underwent uROR within the 30-day postoperative period. The uROR incidence was 6 (0.4%), 6 (0.4%), and 7 (0.6%) for years 2018, 2019, and 2020, respectively (p = 0.697). The incidence of uROR was significantly higher in males (n = 14; 73.7%) than in females (n = 5; 26.3%) (p = 0.002). The share of unplanned reoperations in studied period was 4.5 times higher in primarily emergency surgeries compared to primarily elective surgeries (p < 0.001). The difference in incidence was 0.9% (95% CI, 0.4–1.4). Out of children that underwent uROR within the 30-day period after elective procedures, 50% had American Society of Anesthesiologists (ASA) score three or higher (p = 0.016). The most common procedure which led to uROR was appendectomy (n = 5, 26.3%) while the errors in surgical technique were the most common cause for uROR (n = 11, 57.9%). Conclusion: Unplanned reoperations within the 30-day period after the initial surgical procedure can be a good quality indicator in pediatric surgery. Risk factors associated with uROR are emergency surgery, male gender, and ASA score ≥3 in elective pediatric surgery.

Expert Opinions on the Debate of Pericardial Reconstruction in Cardiovascular Surgery: To Close or Not to Close?

Background: As of 2019, pericardial closure was performed in only a small portion of the over 320,000 cardiac surgeries performed annually. However, evidence regarding the benefits of pericardial closure or reconstruction has been accruing, particularly with the publication of the RECON study in 2019. Methods: This group of authors convened to try to arrive at consensus expert opinion regarding pericardial reconstruction. Structured topic questions initially were used to stimulate discussion. Subsequently, a survey of proposed expert opinion statements was conducted among the authors. Based on that survey, consensus expert opinion statements and recommendations were compiled. Results: The expert opinions encompass various topics relating to pericardial reconstruction, including definitions, benefits/risks, and technique. Observed benefits include reductions in: (1) adhesions; (2) postoperative pericardial effusion, atrial fibrillation, and bleeding; and (3) readmissions and length of hospital stay. Expert opinion recommendations regarding surgical technique are compiled into a single chart. Complete pericardial reconstruction should be performed, using native pericardial tissue if available and viable; if not feasible, a patch may be used. Patches that stimulate the formation of site-specific tissue in situ (such as natural extracellular matrix) may have additional benefits (including bioregenerative properties and lack of inflammatory response). Closure should be taut, but tension-free. Adequate drainage of the closed pericardium must be ensured. Conclusions: Based on available data and collective surgical experience, we endorse pericardial reconstruction as standard approach in appropriately selected patients. We also endorse adoption of standardized pericardial reconstruction techniques to optimize patient outcomes and improve evidence quality in future studies.

Caloric adequacy of parenteral nutrition and its influence on the clinical outcome of hospitalised patients

Background: The adaptation of Parenteral Nutrition (PN) to actual energy requirements of hospitalised patients is essential, since excessive and insufficient nutritional intake have been associated with poor clinical outcomes. Aim: To evaluate the adaptation of prescribed PN to the estimated nutritional requirements using three predictive equations and the influence of excessive/insufficient nutrient intake on patient clinical outcomes (nutritional parameters, metabolic and infectious complications). Methods: Prospective, observational study in hospitalised patients nutritionally assessed. Data was collected the first and fifth/sixth day of PN with clinical (infection, length of hospital stay), biochemical (visceral proteins, cholesterol, glucose, triglycerides, lymphocytes, CRP) and anthropometric parameters (skin folds, height, weight). Theoretical requirements were calculated using Harris-Benedict (HB), Mifflin-St Jeor (MF) and 25 Kcal/Kg/day formulas. The HB formula was used to compare estimated and provided requirements. Results: A total of 94 patients (mean: 72 ± 13.7 years old) were included with initial mean weight and height of 69.2 Kg and 162.8 cm, respectively (mean BMI: 26.1 Kg/m2). No statistically significant differences were found between the actual (1620 Kcal/day) and estimated caloric mean calculated with HB (1643 Kcal/day) and MF (1628 Kcal/day). When comparing with the caloric estimation, 31.9% of patients were underfed, while 14.9% were overfed. Intergroup analysis demonstrated significant variations in albumin, prealbumin, glucose, cholesterol, triglycerides and MUAC, with a significant increase of hyperglycaemia (+37.86; p < 0.05) and hypertriglyceridemia (+63.10; p < 0.05), being higher in overfed patients. Conclusion: In our study, inadequate nutrient intake was associated with a higher degree of hyperglycaemia and hypertriglyceridemia, without positive impact on anthropometric parameters.

Local anesthesia versus general anesthesia for evacuation of chronic subdural hematoma in elderly patients above 70 years old

Background: The aim of this study was to assess the safety and efficacy of chronic subdural hematoma (CSDH) evacuation by two burr-hole craniostomies under local versus general anesthesia (GA) in elderly patients over 70 years. Methods: This retrospective study included 45 patients with CSDH aged over 70 years old treated from March 2018 to April 2020. The cases were subdivided into Group A (n = 22) that underwent evacuation under local anesthesia and Group B (n = 23) that was treated under GA. Patients’ demographics and history of comorbidities were recorded. Variables including pre- and post-operative neurological status and Markwalder’s score, complication rate, operative time, and length of hospital stay were evaluated. Results: The mean and standard deviation of patients’ age of groups (A) and (B) were 74.3 ± 2.5 and 73.2 ± 1.7 years, respectively. Postoperative Glasgow Coma Scale of group (A) was statistically higher than Group B at postoperative day 1 (P = 0.01). Operative time was statistically shorter in Group A than B (P < 0.0001). The length of hospital stay was found to be longer in group (B) than (A) (P = 0.0001). The complication rate was found to be higher in group (B) than (A) (P = 0.044). Conclusion: Evacuation of CSDH under local anesthesia in elderly patients over 70 years is effective, safe, and economic with less complication rate than the traditional technique with GA.

Protecting brains and saving futures guidelines: A prospective, multicenter, and observational study on the use of telemedicine for neonatal neurocritical care in Brazil

Background Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs. Methods A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up. Discussion The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring. Trial registration NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1.