Perioperative outcomes in minimally invasive lumbar spine surgery: A systematic review

AIM: To compare minimally invasive(MIS) and open techniques for MIS lumbar laminectomy, direct lateral and transforaminal lumbar interbody fusion(TLIF) surgeries with respect to length of surgery, estimated blood loss(EBL), neurologic complications, perioperative transfusion, postoperative pain, postoperative narcotic use, and length of stay(LOS).METHODS: A systematic review of previously published studies accessible through Pub Med was performed. Only articles in English journals or published with English language translations were included. Level of evidence of the selected articles was assessed. Statistical data was calculated with analysis of variance with P < 0.05 considered statistically significant.RESULTS: A total of 11 pertinent laminectomy studies, 20 direct lateral studies, and 27 TLIF studies were found. For laminectomy, MIS techniques resulted in a significantly longer length of surgery(177.5 min vs 129.0 min, P = 0.04), shorter LOS(4.3 d vs 5.3 d, P = 0.01) and less perioperative pain(visual analog scale: 16 ± 17 vs 34 ± 31, P = 0.04). There is evidence of decreased narcotic use for MIS patients(postoperative intravenous morphine use: 9.3 mg vs 42.8 mg), however this difference is of unknown significance. Direct lateral approaches have insufficient comparative data to establish relative perioperative outcomes. MIS TLIF had superior EBL(352 mL vs 580 mL, P < 0.0001) and LOS(7.7 d vs 10.4 d, P < 0.0001) and limited data to suggest lower perioperative pain.CONCLUSION: Based on perioperative outcomes data, MIS approach is superior to open approach for TLIF. For laminectomy, MIS and open approaches can be chosen based on surgeon preference. For lateral approaches, there is insufficient evidence to find noninferior perioperative outcomes at this time.

Comparison of perioperative outcomes between laparoscopic and open partial splenectomy in children and adolescents

BACKGROUND In order to avoid consequences of total splenectomy,partial splenectomy(PS)is increasingly reported.The purpose of this study was to compare perioperative outcomes of laparoscopic PS(LPS)and open PS(OPS)in children and adolescents.AIM To compare perioperative outcomes of patients with LPS and OPS.METHODS After institutional review board approval,a total of 26 patients that underwent LPS or OPS between January 2008 and July 2018 were identified from the database of our tertiary referral center.In total,10 patients had LPS,and 16 patients underwent OPS.Blood loss was calculated by Mercuriali’s formula.Pain scores,analgesic requirements and complications were assessed.The Wilcoxon rank sum test was used for comparison.To compare categorical variables,Fisher’s exact test was applied.RESULTS LPS was performed in 10 patients;16 patients had OPS.Demographics(except for body mass index and duration of follow-up),indicating primary disease,preoperative spleen size and postoperative spleen volume,perioperative hematological parameters,postoperative pain scores,analgesic requirements,adverse events according to the Clavien-Dindo classification and the comprehensive complication index,median time from operation to initiation of feeds,median time from operation to full feeds,median time from operation to mobilization and median length of hospital stay did not differ between LPS and OPS.Median(range)operative time(min)was longer in LPS compared to the OPS group[185(135-298)vs 144(112-270),respectively;P=0.048].Calculated perioperative blood loss(mL of red blood cell count)was higher in the LPS group compared to OPS[87(-45-777)vs-37(-114-553),respectively;P=0.039].CONCLUSION This is the first study that compared outcomes of LPS and OPS.Both operative approaches had comparable perioperative outcomes.LPS appears to be a viable alternative to OPS.

Subsequent total joint arthroplasty: Are we learning from the first stage?

BACKGROUND With the increasing incidence of total joint arthroplasty(TJA),there is a desire to reduce peri-operative complications and resource utilization.As degenerative conditions progress in multiple joints,many patients undergo multiple proce-dures.AIM To determine if both physicians and patients learn from the patient’s initial arth-roplasty,resulting in improved outcomes following the second procedure.METHODS The institutional database was retrospectively queried for primary total hip arth-roplasty(THA)and total knee arthroplasty(TKA).Patients with only unilateral THA or TKA,and patients undergoing same-day bilateral TJA,were excluded.Patient demographics,comorbidities,and implant sizes were collected at the time of each procedure and patients were stratified by first vs second surgery.Outcome metrics evaluated included operative time,length of stay(LOS),disposition,90-d readmissions and emergency department(ED)visits.RESULTS A total of 642 patients,including 364 undergoing staged bilateral TKA and 278 undergoing bilateral THA,were analyzed.There was no significant difference in demographics or comorbidities between the first and second procedure,which were separated by a mean of 285 d.For THA and TKA,LOS was significantly less for the second surgery,with 66%of patients having a shorter hospitalization(P<0.001).THA patients had significantly decreased operative time only when the same sized implant was utilized(P=0.025).The vast majority(93.3%)of patients were discharged to the same type of location following their second surgery.However,when a change in disposition was present from the first surgery,patients were significantly more likely to be discharged to home after the second procedure(P=0.033).There was no difference between procedures for post-operative readmissions(P=0.438)or ED visits(P=0.915).CONCLUSION After gaining valuable experience recovering from the initial surgery,a patient’s perioperative outcomes are improved for their second TJA.This may be the result of increased confidence and decreased anxiety,and it supports the theory that enhanced patient education pre-operatively may improve outcomes.For the surgical team,the second procedure of a staged THA is more efficient,although this finding did not hold for TKA.

Is bactibilia a predictor of poor outcome of pancreaticoduodenectomy?

BACKGROUND:Although bile infection has been proposed to increase infective complications following pancreaticoduodenectomy,its association with infective complications and non-infective complications like pancreatic fistula is still controversial.METHODS:Seventy-six patients who had undergone pancreaticoduodenectomy between July 2007 and December 2008 were included in a prospective database and their data analyzed.In all patients intraoperative bile from the bile duct was cultured.Preoperative,intra-operative,and post-operative variables were recorded and analyzed.RESULTS:Bile culture showed positive growth in 35 patients and negative growth in 41.Twenty patients in the positive group underwent ERCP and stenting.The patients with a positive bile culture had a higher incidence of infective complications including intra-abdominal abscess (n=8),wound infection (n=27),bacteremia (n=10),and renal insufficiency (n=9).There was no increase in the rate of non-infective complications of pancreaticoduodenectomy including pancreatic fistula (n=7),delayed gastric emptying (n=9),and post-operative hemorrhage (n=3).The hospital stay was significantly prolonged in the patients with a positive bile culture (P=0.0002).CONCLUSIONS:Pre-operative biliary drainage is significantly associated with bile infection,and bile infection increases the overall rates of infective complications and renal insufficiency.Because of the high incidence of complications is associated with infected bile,routine intra-operative bile culture is recommended in patients undergoing pancreaticoduodenectomy.Pre-operative prophylaxis is dependent on sensitivity of cases to perioperative antibiotics and intraoperative bile culture report.Because of its significant association with infected bile,biliary stenting should be used in strictly selected cases.

Circulating biomarkers in perioperative management of cancerpatients

Owing to the advances in surgical technology,most solid tumours can be controlled by surgical excision.The priority should be tumour control,while some routine perioperative management might influence cancer progression in an unnoticed way.Moreover,it is increasingly recognized that effective perioperative management should include techniques to improve postoperative outcomes.These influences are elucidated by the different functions of circulating biomarkers in cancer patients.Here,circulating biomarkers with two types of clinical functions were reviewed:(i)circulating biomarkers for cancer progression monitoring,for instance,those related to cancer cell malignancy,tumour microenvironment formation,and early metastasis,and(i)circulating biomarkers with relevance to postoperative outcomes,including systemic inflammation,immunosuppression,cognitive dysfunction,and pain management.This review aimed to provide new perspectives for the perioperative management of patients with cancer and highlight the potential clinical translation value of circulating biomarkers in improving outcomes.

Loss of bifurcation patency after cross-over stenting of ostial lesions in superficial femoral artery： possible causes, prevention and reintervention

Background Crossover stenting across the origin of the profunda femoral artery （PFA） and occasionally into the common femoral artery （CFA） is commonly used after suboptimal balloon angioplasty of ostial occlusive lesions of the superficial femoral artery （SFA） involving the bifurcation. Late stent occlusion at the bifurcation is not rare and results in severe lower extremity ischemia. Therefore, we tried to assess its possible causes, prevention and reintervention. Methods Using a prospectively maintained single-center database, 12-month femoral bifurcation patency was retrospectively compared and lesion and procedural predictors of stent occlusion were determined among 63 patients （64 lesions） who between July 2011 and February 2013 underwent crossover （36 non-jailed and 15 jailed SFA, and 12 distal and 1 complete CFA） stenting of de novo ostial SFA lesions. Results Twelve-month overall patency rate at the femoral bifurcation was 88%, with no significant difference between jailed-ostial SFA （80%） and distal CFA （67%） stenting （P=0.731）, and significant differences between either and non-jailed ostial stenting （100%,P=0.035 and 0.002）. When PFA ostium was jailed by the stent, patients with preexisting CFA or PFA lesions had a 12-month bifurcation patency rate of 20%, significantly lower than those with simple ostial SFA lesions （83%, P=0.015）. Stent induced intimal hyperplasia caused bifurcation occlusion in 6 surgical reintervention cases. Conclusions In crossover stenting of ostial lesions in SFA, bifurcation patency loss was significantly higher in distal CFA and jailed ostial SFA stenting than non-jailed ostial SFA stenting. Preexisting CFA or PFA lesion is a significant risk factor for bifurcation patency loss when PFA ostium is jailed by crossover stenting.