Surgical risk for patients with Chagasic achalasia and its correlation with the degree of esophageai dilation

AIM： To analyze the risk of cardiovascular complications in patients with indication for surgical treatment of Chagasic esophageal achalasia and to correlate the surgical risks with the degree of esophageal dilation, thereby proposing a risk scale index. METHODS： One hundred and twenty-four patients with Chagasic esophageal achalasia, who received surgical treatment at the Hospital das Clinicas of the Federal University of Goiás, were included in this study. The patients were mostly related to the postoperative complications due to the cardiovascular system. All the patients were submitted to： （1） clinical history to define the cardiac functional class （New York Heart Association）; （2） conventional 12-lead electrocardiogram at rest; and （3） contrast imaging of the esophagus to determine esophageal dilatation according to Rezende＇s classification of Chagasic megaesophagus. RESULTS： An assessment of the functional classification （FC） of heart failure during the preoperative period determined that 67 patients （54.03%） were assigned functional class Ⅰ （FC Ⅰ）, 46 patients （37.09%） were assigned functional class Ⅱ （FC Ⅱ）, and 11 patients （8.87%） were assigned functional class Ⅲ （FC Ⅲ）. None of the patients were assigned to functional class Ⅳ （FC Ⅳ）. There was a positive correlation between the functional class and the postoperative complications （FC Ⅰ×FC Ⅱ： P〈0.001; FC Ⅰ×FC Ⅲ： P〈0.001）. The ECG was normal in 44 patients （35.48%） and presented abnormalities in 80 patients （64.52%）. There was a significant statistical correlation between abnormal ECG （arrhythmias and primary change in ventricular repolarization） and postoperative complications （P〈0.001）. With regard to the classification of the Chagasic esophageal achalasia, the following distribution was observed： group Ⅱ, 53 patients （42.74%）; group Ⅲ, 37 patients （29.83%）; and group Ⅳ, 34 patients （27.41%）. There was a positive correlation between the degree of esophageal dilation and the increase in postoperative complications （grade Ⅱ×grade Ⅲ achalasia： P〈0.001; grade Ⅱ×grade Ⅳ achalasia： P〈0.001; and grade Ⅲ×grade Ⅳ achalasia： P = 0.017）. Analyzing these results and using a multivariate regression analysis associated with the probability decision analysis, a risk scale was proposed as follows： up to 21 points （mild risk）; from 22 to 34 points （moderate risk）; and more than 34 points （high risk）. The scale had 82.4% accuracy for mild risk patients and up to 94.6% for the high risk cases. CONCLUSION： The preoperative evaluation of the cardiovascular system, through a careful anamnesis, an ECG and contrast imaging of the esophagus, makes possible to estimate the surgical risks for Chagas＇ disease patients who have to undergo surgical treatment for esophageal achalasia.

A meta-analysis of 1-year outcomes of transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis

Background Transcatheter aortic valve replacement(TAVR)for the treatment symptomatic severe aortic stenosis(AS)is indicated in patients with intermediate or higher surgical risk.Latest trials showed TAVR,and surgical aortic valve replacement(SAVR)perform similarly at 1-year for the composite outcomes of mortality,stroke and rehospitalization.We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients.Methods Pub Med,Embase,and Cochrane central were searched for all the randomized controlled trials(RCTs)that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement(SAVR).Our conclusions are based upon the random-effects model using Der Simonian-Laird estimator.Results Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality,cardiovascular mortality,and atrial fibrillation compared to SAVR at 1-year follow-up(P<0.05 for all).Also,TAVR was also associated with a significantly higher risk of permanent pacemaker implantation and moderate-severe paravalvular leak(P<0.05).Conclusions The latest randomised trial data demonstrates that in short-term,TAVR is safe and effective in reducing all-cause mortality or stroke.Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.

Efficacy and safety of conversion of percutaneous cholecystostomy to endoscopic transpapillary gallbladder stenting in high-risk surgical patients

Background:Endoscopic transpapillary gallbladder stenting(ETGBS)has been used as an alternative to percutaneous cholecystostomy in patients with acute cholecystitis who are considered unfit for surgery.However,there are few data on the efficacy and safety of ETGBS replacement of percutaneous cholecystostomy in high-risk surgical patients.This study aimed to evaluate the feasibility,efficacy,and safety of ETGBS to replace percutaneous cholecystostomy in high-risk surgical patients.Methods:This single center retrospective study reviewed the data of patients who attempted ETGBS to replace percutaneous cholecystostomy between January 2017 and September 2019.The technical success,clinical success,adverse events,and stent patency were evaluated.Results:ETGBS was performed in 43 patients(24 male,mean age 80.7±7.4 years)to replace percutaneous cholecystostomy due to high surgical risk.The technical success rate and clinical success rate were 97.7%(42/43)and 90.5%(38/42),respectively.Procedure-related adverse events and stent-related late adverse events occurred in 7.0%(3/43)and 11.6%(5/43),respectively.Of the patients who successfully underwent ETGBS(n=42),only one had recurrent acute cholecystitis during follow-up.The median stent patency was 415 days(interquartile range 240–528 days).Conclusions:ETGBS,as a secondary intervention for the purpose of internalizing gallbladder drainage in patients following placement of a percutaneous cholecystostomy,is safe,effective,and technically feasible.Thus,conversion of percutaneous cholecystostomy to ETGBS may be considered as a viable option in high-risk surgical patients.

Adjustable muscle plication:a new surgical technique for strabismic patients with high risk for anterior segment ischemia

【正】INTRODUCTION Anterior ciliary arteries provide 70%of the vascular supply of the anterior segment.A significant interruption of the vascular flow of these arteries increases the risk for anterior ischemia.Although the frequency of this special condition is low after strabismus surgery(1:13 000)[1],its effects may involve substantial visual problems[2].We report the successful outcome of a new surgical approach for strabismus management in a case of high risk for anterior ischemia.Specifically,we show the correction of the horizontal ocular deviation by means of an adjustable muscle

Risk factors and strategy for surgical incision infection in department of abdominal surgery

Objective To study the risk factors of surgical wound infection among the patients in department of abodominal surgery. Methods The factors on surgical wound infection were investigated by retrospective study. The diagnosis standard was based on Diagnosis Standard of Hospital Infection published by Ministry of Health.

Prediction of surgical complications in the elderly:Can we improve outcomes?

As the number of Americans aged 65 years and older continues to rise,there is projected to be a corresponding increase in demand for major surgeries within this population.Consequently,it is important to utilize accurate preoperative risk stratification techniques that are applicable to elderly individuals.Currently,commonly used preoperative risk assessments are subjective and often do not account for elderly-specific syndromes that may pose a hazard for geriatric patients if not addressed.Failure to accurately risk-stratify these patients may increase the risk of postoperative complications,morbidity,and mortality.Therefore,we aimed to identify and discuss the more objective and better-validated measurements indicative of poor surgical outcomes in the elderly with special focus on frailty,patient optimization,functional status,and cognitive ability.

Transcatheter aortic valve implantation in very elderly patients： immediate results and medium term follow-up

Objective To evaluate immediate transcatheter aortic valve implantation （TAVI） results and medium-term follow-up in very elderly pa- tients with severe and symptomatic aortic stenosis （AS）. Methods This multicenter, observational and prospective study was carried out in three hospitals. We included consecutive very elderly （〉 85 years） patients with severe AS treated by TAVI. The primary endpoint was to evaluate death rotes from any cause at two years. Results The study included 160 consecutive patients with a mean age of 87 ± 2.1 years （range from 85 to 94 years） and a mean logistic EuroSCORE of 18.8% ± 11.2% with 57 （35.6%） patients scoring 〉 20%. Procedural success rate was 97.5%, with 25 （15.6%） patients experiencing acute complications with major bleeding （the most frequent）. Global mortality rate during hospitalization was 8.8% （n = 14） and 30-day mortality rate was 10% （n = 16）. Median follow up period was 252.24± 232.17 days. During the follow-up period, 28 （17.5%） patients died （17 of them due to cardiac causes）. The estimated two year overall and cardiac survival rates using the Kaplan-Meier method were 71% and 86.4%, respectively. Cox proportional hazard regression showed that the variable EuroSCORE ≥ 20 was the unique vari- able associated with overall mortality. Conclusions TAVI is safe and effective in a selected population of very elderly patients. Our findings support the adoption of this new procedure in this complex group of patients.

The Institute of Urology, Peking University prostatectomy score： a simple preoperative classification of prostate cancer for predicting surgical difficulty and risk

Traditional laparoscopic radical prostatectomy is a treatment choice in many developing countries and regions for most patients with localized prostate cancer; however, no system for predicting surgical difficulty and risk has been established. This study aimed to propose a simple and standard preoperative classification system of prostate cancer using preoperative data to predict surgical difficulty and risk and to evaluate the relationship between the data and postoperative complications. We collected data from 236 patients and divided them into three groups to evaluate and validate the relationships among preoperative, operative, and postoperative data. This new scoring system is based on the body mass index, ultrasonic prostate volume, preoperative prostate-specific antigen level, middle lobe protrusion, and clinical stage. In the scoring group, we classified 89 patients into two groups： the low-risk group （score of 〈4） and high-risk group （score of ~4）, and then compared the postoperative data between the two groups. The positive surgical margin rate was higher in the high-risk group than low-risk group. The results in validation Groups A and B were similar to those in the scoring group. The focus of our scoring system is to allow for preliminary assessment of surgical difficulty by collecting the patients＇ basic information. Urologists can easily use the scoring system to evaluate the surgical difficulty and predict the risks of a positive surgical margin and urinary incontinence in patients undergoing laparoscopic radical prostatectomy.

How to select elderly colorectal cancer patients for surgery: a pilot study in an Italian academic medical center

Objective: Cancer is one of the most common diagnoses in elderly patients. Of all types of abdominal cancer, colorectal cancer(CRC) is undoubtedly the most frequent. Median age at diagnosis is approximately 70 years old worldwide. Due to the multiple comorbidities affecting elderly people, frailty evaluation is very important in order to avoid over- or undertreatment. This pilot study was designed to investigate the variables capable of predicting the long-term risk of mortality and living situation after surgery for CRC.Methods: Patients with 70 years old and older undergoing elective surgery for CRC were prospectively enrolled in the study. The patients were preoperatively screened using 11 internationally-validated-frailty-assessment tests. The endpoints of the study were long-term mortality and living situation. The data were analyzed using univariate Cox proportional-hazard regression analysis to verify the predictive value of score indices in order to identify possible risk factors.Results: Forty-six patients were studied. The median follow-up time after surgery was 4.6 years(range, 2.9-5.7 years) and no patients were lost to follow-up. The overall mortality rate was 39%. Four of the patients who survived(4/28, 14%) lost their functional autonomy. The preoperative impaired Timed Up and Go(TUG), Eastern Cooperative Group Performance Status(ECOG PS), Instrumental Activities of Daily Living(IADLs), Vulnerable Elders Survey(VES-13) scoring systems were significantly associated with increased long term mortality risk.Conclusion: Simplified frailty-assessing tools should be routinely used in elderly cancer patients before treatment in order to stratify patient risk. The TUG, ECOG-PS, IADLs and VES-13 scoring systems are potentially able to predict long-term mortality and disability. Additional studies will be needed to confirm the preliminary data in order to improve management strategies for oncogeriatric surgical patients.