Category: Surgeries & Procedures

Categories : Cardiovascular Disease Surgeries & ProceduresTags :

Post-operative AF Linked to Risk of Hospitalisation for Heart Failure

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Associations between post-operative atrial fibrillation and incident heart failure hospitalisations. Credit: European Heart Journal

A study of over three million patients found that people who develop an atrial fibrillation (AF) after undergoing surgery have an increased risk of subsequent hospitalisation for heart failure.

The study, which is published in the European Heart Journal, showed that the risk of hospitalisation for heart failure among patients who developed AF after surgery increased regardless of whether or not the surgery was for a heart condition.

Among 76 536 patients who underwent heart surgery, 18.8% developed post-operative AF and the risk of hospitalisation for heart failure increased by a third compared to patients who did not develop AF. Among 2 929 854 patients without a history of heart disease who had surgery for non-heart-related conditions, 0.8% developed AF and the risk of hospitalisation for heart failure doubled.

The study’s first author, Dr Parag Goyal, Associate Professor of Medicine at Weill Cornell Medicine, said: “Our study, which to our knowledge is the largest study to date, shows that post-operative atrial fibrillation is associated with future heart failure hospitalisations. This could mean that atrial fibrillation is an important indicator of underlying but not yet detected heart failure; or it could mean that atrial fibrillation itself contributes to the future development of heart failure. While this study could not specifically address which of these mechanisms are at play, our hope is that this study will inspire future work into exploring the underlying mechanism seen in our important findings.

“Regardless of the mechanism, our study shows that post-operative atrial fibrillation is clearly an important entity that merits attention and incorporation into decision making. Most importantly, patients and doctors need to be more vigilant about heart failure symptoms among patients who develop post-operative atrial fibrillation. Those who do develop the condition may require more aggressive treatments for other risk factors for heart failure, such as high blood pressure, diabetes and narrowing of the arteries.”

Post-operative AF occurs in up to 40% of patients undergoing heart surgery and 2% of patients undergoing non-cardiac surgery. Doctors have tended to view it as a benign event, triggered by the stress of the surgery – but evidence is emerging that post-operative AF is linked to longer term problems such as stroke and death from any cause. Until now, there has been limited evidence regarding its association with subsequent heart failure.

For the current, retrospective study, the researchers collected data on hospital health claims from 2016 to 2018, adjusting for factors that could affect the results such as age, sex, race, insurance status, medical history and body mass index.

Study limitations include its observational nature which can only establish association, not causation. The study relies on administrative claims data and medical codes to identify medical conditions; it lacks more detailed information like management strategies for post-operative AF, and on the function and size of the left ventricle, which could affect the likelihood of developing AF.

The researchers hope to conduct further studies to understand the underlying mechanism and to investigate ways of preventing future hospitalisations for heart failure among patients who develop post-operative AF.

The researchers wrote in the conclusion that “In the meantime, clinicians should be aware that POAF [post-operative AF] may be a harbinger of HF.”

In an accompanying editorial, Dr Melissa Middeldorp and Professor Christine Albert, both from the Smidt Heart Institute at Cedars-Sinai, California, USA, write: “These data add to a growing body of literature suggesting that POAF is not just a transient response to surgery but may be reflective of underlying atrial and myocardial structural changes that not only predispose to the acute AF event but to other potentially related adverse cardiovascular events, such as HF hospitalisation.”

They write that further studies are needed for a better understanding of the mechanisms involved in placing people at greater risk of AF and post-operative heart failure is needed in order to reduce hospitalisation and deaths after surgery.

“With a greater understanding of patients’ full risk factor profile, we may advocate for early aggressive intervention at the initial manifestation of POAF, to improve outcomes and reduce rehospitalisation following cardiac and non-cardiac surgery,” they concluded.

Source: European Society of Cardiology

Categories : Surgeries & ProceduresTags :

AI-enabled Kidney Surgery Makes it Easier for Novice Surgeons

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Anatomic model of a kidney
Photo by Robina Weermeijer on Unsplash

Percutaneous nephrolithotomy (PCNL) is an efficient surgical intervention for removing large kidney stones. However, it is a challenging procedure that requires years of training to perform. To address this, a group of scientists from the Nagoya City University, developed and trialled an artificial intelligence (AI)-enabled robotic device for assisting surgeons in PCNL.

Creating a renal access from the skin on the back to the kidney is a crucial yet challenging step in PCNL. A poorly performed renal access can lead to severe complications including massive bleeding, thoracis and bowel injuries, renal pelvis perforation, or even sepsis. This procedure takes years of training to master. The two main renal access methods for PCNL – X-ray guidance and ultrasound (US) guidance deliver similar postoperative outcomes but require experience-based expertise.

Many technologies are being developed to bridge this skill gap. This inspired a Nagoya University research team to question if artificial intelligence (AI)-powered robotic devices could be used for improved guidance compared with conventional US guidance. Specifically, they wanted to see if the AI-powered device called the Automated Needle Targeting with X-ray (ANT-X), which was developed by the Singaporean medical start-up, NDR Medical Technology, offers better precision in percutaneous renal access along with automated needle trajectory.

The team performed a randomised, single-blind, controlled trial comparing their robotic-assisted fluoroscopic-guided (RAF) method with US-guided PCNL. The results of this trial were detailed in the The Journal of Urology. “This was the first human study comparing RAF with conventional ultrasound guidance for renal access during PCNL, and the first clinical application of the ANT-X ,” said Dr Kazumi Taguchi, Assistant Professor at NCU.

The trial was conducted with 71 patients—36 in the RAF group and 35 in the US group. The primary outcome of the study was single puncture success, with stone-free rate (SFR), complication rate, parameters measured during renal access, and fluoroscopy time as secondary outcomes.

The single puncture success rate was ~34 and 50% in the US and RAF groups, respectively. Fewer needle punctures were needed in the RAF group (1.82 times) as opposed to the US group (2.51 times). In 14.3% of US-guided cases, the resident was unable to obtain renal access due to procedural difficulty, prompting a surgeon change. However, none of the RAF cases faced this issue. The median needle puncture duration was also significantly shorter in the RAF group (5.5 minutes vs 8.0 minutes). No significant differences in the other secondary outcomes was found.

Multiple renal accesses during PCNL are directly linked to postoperative complications including, decreased renal function. Therefore, the low needle puncture frequency and shorter puncture duration, as demonstrated by the ANT-X, may provide better long-term outcome for patients. While the actual PCNL was performed by residents in both RAF and US groups, the renal access was created by a single, novice surgeon in the RAF group, using ANT-X. This demonstrates the safety and convenience of the novel robotic device, which could possibly reduce surgeons’ training load and allow more hospitals to offer PCNL procedures.

Dr Taguchi commented, “The ANT-X simplifies a complex procedure, like PCNL, making it easier for more doctors to perform it and help more number of patients in the process. Being an AI-powered robotic technology, this technique may pave the way for automating similar interventional surgeries that could shorten the procedure time, relieve the burden off of senior doctors, and perhaps reduce the occurrence of complications.”

Source: Nagoya City University

Categories : Cancer Surgeries & ProceduresTags :

Bariatric Surgery Reduces Cancer Risks with Obesity

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Obesity
Image source: Pixabay CC0

A study published in JAMA shows that weight loss through bariatric surgery for adults with obesity was associated with a 32% lower risk of developing cancer and a 48% lower risk of cancer-related death compared with those who did not have the surgery.

Rising obesity numbers are being seen all over the world. The International Agency for Research on Cancer describes 13 types of cancer as obesity-associated cancers such as endometrial cancer, postmenopausal breast cancer, and cancers of the colon, liver, pancreas, ovary and thyroid.

Lead author of the study, Ali Aminian, MD, at Cleveland Clinic, said that bariatric surgery is currently the most effective treatment for obesity. “Patients can lose 20 to 40% of their body weight after surgery, and weight loss can be sustained over decades. The striking findings of this study indicate that the greater the weight loss, the lower the risk of cancer,” said Dr Aminian.

From 2004 and 2017, the SPLENDID (Surgical Procedures and Long-term Effectiveness in Neoplastic Disease Incidence and Death) study matched a group of 5053 adult patients with obesity who had bariatric surgery 1:5 to a control group of 25 265 patients with obesity who did not undergo the surgery.

After 10 years, 2.9% of patients in the bariatric surgery group and 4.9% of patients in the non-surgical group developed an obesity-associated cancer.

After 10 years, 0.8% of patients in the surgery group and 1.4% of patients in the non-surgical group died from cancer, indicating that bariatric surgery is associated with a 48% lower cancer mortality risk.

Researchers noted that the benefits of bariatric surgery were seen in a wide range of study participants in terms of age, sex and race. In addition, benefits were similarly observed after both gastric bypass and gastric sleeve operations.

“According to the American Cancer Society, obesity is second only to tobacco as a preventable cause of cancer in the United States,” said the study’s senior author, Steven Nissen, MD, Chief Academic Officer of the Heart, Vascular and Thoracic Institute. “This study provides the best possible evidence on the value of intentional weight loss to reduce cancer risk and mortality.”

Numerous studies have shown the health benefits of bariatric or weight-loss surgery in patients with obesity. The Cleveland Clinic-led STAMPEDE study showed that following bariatric surgery, significant weight loss and control of type 2 diabetes last over time. The SPLENDOR study showed that in patients with fatty liver, bariatric surgery decreases the risk of the progression of liver disease and serious heart complications.

The SPLENDID study adds important findings to the literature focused on the link between obesity and cancer. Given the growing epidemic of obesity worldwide, these findings have considerable public health implications.

“Based on the magnitude of benefit shown in our study, weight loss surgery can be considered in addition to other interventions that can help prevent cancer and reduce mortality,” said Jame Abraham, M.D., chairman of the Hematology and Medical Oncology Department at Cleveland Clinic. “Further research needs to be done to understand the underlying mechanisms responsible for reduced cancer risk following bariatric surgery.”

Source: Cleveland Clinic

Categories : Obstetrics & Gynaecology Surgeries & ProceduresTags :

Audit Finds Women are Uninformed of Common Anaesthetic’s Effect on Contraception

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Women undergoing operations are not being routinely informed that a common anaesthetic may reduce their contraception’s effectiveness, putting them at risk of an unplanned pregnancy, suggests new research which is being presented at Euroanaesthesia, the annual meeting of the European Society of Anaesthesiology and Intensive Care (ESAIC).

The drug sugammadex is widely used in anaesthesia.  Administered towards the end of the operation, ahead of waking the patient up, it reverses the action of the neuromuscular blocking drugs rocuronium and vecuronium given earlier in the procedure to relax the patient’s muscles.

Sugammadex is known to interact with progesterone, possibly reducing the effectiveness of hormonal contraceptives, including the progesterone-only pill (mini-pill), combined pill, vaginal rings, implants and intra-uterine devices.

Current guidance is to inform women of child-bearing age (WCBA) that they have received the drug and, due to increased risk of contraceptive failure, advise those taking oral hormonal contraceptives to follow the missed pill advice in the leaflet that comes with their contraceptives and advise those using other types of hormonal contraceptive to use an additional non-hormonal means of contraception for seven days.

However in the experience of the authors, robust methods for identifying at-risk patients and informing them of the associated risk of contraceptive failures is not common practice across anaesthetic departments within the UK, and likely further afield. 

To find out more, Dr Neha Passi, Dr Matt Oliver and colleagues at the University College London Hospitals NHS Foundation Trust surveyed anaesthetists at their hospital trust on their use of sugammadex and carried out a retrospective audit of sugammadex use in the Trust.

A seven-question survey was sent to all anaesthetists at the Trust.  Including consultants, junior doctors and physician assistants, this numbered almost 150 professionals.

Of the 82 anaesthetists who responded, 94% said they were aware of the risk of contraceptive failure – but 70% of respondents reported they do not routinely discuss sugammadex with patients who received it.

During the audit, 65 WCBA patients were given sugammadex, and 48 of these should have received advice on the risks of contraceptive failure.  There was no record of it, however, in the medical notes of any of the 48 women. (The other 17’s medical history meant they weren’t at risk of pregnancy and so not eligible for the advice.)

Dr Passi said: “It is concerning that we are so seldom informing patients of the risk of contraceptive failure following sugammadex use.

“Use of sugammadex is expected to rise as it becomes cheaper in the future and ensuring that women this receiving medicine are aware it may increase their risk of unwanted pregnancy must be a priority.”

Dr Oliver added: “We only studied one hospital trust but we expect the results to be similar in elsewhere in the UK.”

Dr Passi adds: “It is important to note, however, that most patients receiving an anaesthetic do not need a muscle relaxant2 and that sugammadex is one several drugs available to reverse muscle relaxation.”

In response to their findings, the study’s authors have created patient information leaflets and letters and programmed the Trust’s electronic patient record system to identify ‘at-risk’ patients and deliver electronic prompts to the anaesthetists caring for them in the perioperative period.

Sugammadex is the only anaesthetic drug known to have this effect.

Source: EurekAlert!

Categories : Ageing Surgeries & ProceduresTags :

Progressive Exercise Programme Improves Outcomes after Hip Surgery

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Carers help an old man to walk
Photo by Kampus Productions on Pexels

A study published in the Journal of the American Geriatrics Society shows that a 12-month home-based supervised exercise programme can help to improve physical performance and functioning after patients undergo hip fracture surgery.

Hip fracture is a major health problem among older people, often resulting in long-term, sometimes persistent, functional impairments such as poor mobility and reduced independence in daily activities. Sedentary behaviour and low level of physical activity are also common among patients recovering from surgical repair of a hip fracture.

Standard care post-discharge care does not seem to meet the requirements of effective rehabilitation, as many patients with hip fractures do not reach their pre-fracture level of functioning. Growing evidence shows that multidisciplinary and well-coordinated rehabilitation started at the hospital and continued after discharge enhances the recovery of patients with hip fractures. Multicomponent rehabilitation in particular, which includes individualised and progressive resistance training, has improved functioning and mobility and decreased dependency in everyday activities. Longer lasting exercise programs of 6 to 12 months duration have reduced or reversed incident disability after hip fractures.

For the study, 121 patients aged 60 years and older were randomised to either an exercise group or a usual care group as a control. Home-based exercise sessions were delivered by physiotherapists twice a week and included strength, balance, mobility, and functional components as well as brief counselling on physical activity and nutrition.

Compared with patients in the usual care group, patients in the exercise group saw more improvements over the course of a year in their physical performance, their handgrip strength, and their ability to complete certain activities of daily living.

“It is worthwhile to invest in rehabilitation exercise for older people after hip fracture. Better functioning benefits the individual and also society,” said lead author Paula K. Soukkio, MSc, of the South Karelia Social and Health Care District (Eksote), in Finland.

Source: Wiley

Categories : Surgeries & ProceduresTags :

Earlier Valve Replacement Surgery Recommended in Aortic Stenosis

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Source: Pixabay CC0

Valve replacement surgery should be performed earlier than conventionally thought for people with aortic stenosis, as shown by new research published in the journal Open Heart.

Aortic stenosis is a common valvular disorder, especially in the elderly population, causing left ventricular outflow obstruction. Aetiologies include congenital (bicuspid/unicuspid), calcific, and rheumatic disease. Symptoms such as exertional dyspnoea or fatigue gradually develop after a long asymptomatic latent period of about 10 to 20 years. But many patients with aortic stenosis do not have symptoms even when they have severe narrowing of the valve and are thus not eligible for valve replacement.

The findings from this study show that these patients would benefit by undergoing a valve replacement – before they suffer irreversible heart muscle damage.

Lead researcher Prof Vassilios Vassiliou, from UEA’s Norwich Medical School, said: “The heart has four valves, which allow the blood to flow in one direction efficiently. With increasing age, one of the valves, the aortic valve, becomes increasingly narrowed or ‘stenosed’.

“A lot of patients with severe aortic stenosis do not have symptoms and therefore are not eligible for valve replacement according to the current guidelines.

“For these patients without symptoms, the guidelines suggest a ‘watchful waiting’ approach and intervention is recommended only when they show symptoms or develop pump failure.

“We wanted to know if it would be better to perform surgery and replace the valve sooner rather than later.”

In a systematic review, researchers compared early intervention versus conservative management in patients with asymptomatic severe aortic stenosis.

They then analysed data from all the available studies which involved a total of 3798 patients, out of which 302 were included in the two largest randomised controlled trials and 3496 in the observational studies.

Prof Vassiliou said: “We found that early intervention, before patients have symptoms, is associated with lower risk of death and hospitalisation for heart failure.

“By the time the patients develop symptoms, there has likely been irreversible damage to the muscle of the heart. This in turn may preclude a worse prognosis and adverse outcomes even after successful intervention.

“The timing of aortic valve intervention is crucial.

“We hope that our findings may herald the beginning of a change in the management of aortic stenosis patients, enabling the intervention to take place more commonly whilst the patients are asymptomatic.

“Ongoing trials investigating this high-risk population are anticipated to shed more light into the matter and in the identification of the optimal time of intervention,” he added.

Source: University of East Anglia

Categories : Surgeries & ProceduresTags :

20 Years of Data Proves Safety of Islet Cell Transplantation

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A 3D map of the islet density routes throughout the healthy human pancreas. Credit: MariusOrion/Wikimedia Commons

In a paper published in The Lancet Diabetes & Endocrinology, researchers report that their long-running islet cell transplant programme has shown that is safe and helps control diabetes for up to 20 years.

The researchers reported on patient survival, graft survival, insulin independence and protection from life-threatening hypoglycaemia for 255 patients who have received a total of more than 700 infusions of islets at the University of Alberta Hospital over the past two decades.

“We’ve shown very clearly that islet transplantation is an effective therapy for patients with difficult-to-control Type 1 diabetes,” said Professor James Shapiro at the University of Alberta. “This long-term safety data gives us confidence that we are doing the right thing.”

In Type 1 diabetes, the immune system mistakenly destroys the cells within the insulin-producing islets so patients have to take insulin by injection. Patients with hard-to-control diabetes face dangerous hypo- or hyperglycaemia and long-term complications.

Between March 1999 and October 2019, 255 patients received islet transplants by infusion into their livers. Seventy per cent of the grafts survived for a median time of nearly six years. The researchers reported that a combination of two anti-inflammatory medications given during the first two weeks following transplant significantly increased long-term islet function.

The transplant recipients have to take lifelong immunosuppression drugs, which in some cases lead to skin cancer or infection, but most such complications were not fatal during the study period.

After two or more islet infusions and a median time of 95 days following the first transplant, 79% of the recipients could go off insulin. A year later, 61% remained insulin-independent, 32% at five years and 8% after 20 years, the researchers reported. Even though most patients had to start taking insulin again, doses were generally much smaller and diabetes control was improved.

“Being completely free of insulin is not the main goal,” said Prof Shapiro. “It’s a big bonus, obviously, but the biggest goal for the patient — when their life has been incapacitated by wild, inadequate control of blood sugar and dangerous lows and highs — is being able to stabilise. It is transformational.”

With trials ongoing in other countries, Prof Shapiro will continue to focus on finding a more plentiful supply of islet cells to replace the current reliance on deceased donors. Human trials have already shown success using stem cells programmed to produce insulin. Trials have just started to transplant cells that have been gene edited to make them invisible to the immune system.

“Islet transplant as it exists today isn’t suitable for everybody, but it shows very clear proof of concept that if we can fix the supply problem and minimize or eliminate the anti-rejection drugs, we will be able to move this treatment forward and make it far more available for children and adults with Type 1 and Type 2 diabetes in the future,” said Shapiro.

Source: University of Alberta

Categories : Surgeries & ProceduresTags :

In Finger Osteoarthritis, Lipofilling Reduces Pain, Improves Function

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Hand osteoarthritis
Source: Pixabay CC0

For patients with painful finger osteoarthritis, lipofilling  a nonsurgical procedure where a patient’s fat is transferred into the arthritic joints, may result in lasting improvements in hand function and especially pain, according to a study in Plastic and Reconstructive Surgery.

Researchers reported their experience with 18 patients undergoing fat transfer procedures for finger osteoarthritis.

“Even over a long-term follow-up, the transfer of fatty tissue to arthritic fingers joints appears to provide a safe and minimally invasive alternative to conventional surgery for patients with osteoarthritis,” commented the study’s lead author Max Meyer-Marcotty, MD, PhD.

In the lipofilling procedure, a sample of the patient’s own fatty tissue was obtained by liposuction from another part of the body: the upper thigh or hip area. Tiny volumes of lipid cells (< 1mL) were injected into the arthritic finger joints. For recovery, patients wore a splint around the treated finger and took pain relievers for a week. No infections or other complications were recorded.

The researchers analysed follow-up outcomes in a total of 25 finger joints treated by lipofilling. Hand function, pain scores, and patient satisfaction were evaluated an average of 44 months (maximum 50 months) after treatment.

Assessment showed a “highly significant clear improvement” in pain score: from a median of 6 points (on a 10-point scale) before treatment to 0.5 points at follow-up. “We believe that for our patients the reduction of pain represents the most striking and important result, which also has the most pronounced and highly significant effect,” Dr Meyer-Marcotty et al. wrote.

On functional evaluation, pinch grip strength of the treated fingers increased from a median of 2.0kg before lipofilling to 4.3kg at follow-up. Non-significant improvements were seen in fist closure force and score on a standard assessment of hand function during everyday tasks.

In severe cases of osteoarthritis, surgery is effective in relieving arthritis pain, but is associated with potential complications and lengthy recovery time.

Fat transfer procedures have been introduced in recent years for a growing range of purposes in plastic and reconstructive surgery. Animal studies have suggested that mesenchymal stromal cells found in fatty tissues can regenerate tissue in arthritic joints.

“The chance to preserve the joint with a minimally invasive procedure is of particular interest in the early, albeit painful, phases of finger osteoarthritis,” Dr. Meyer-Marcotty added. “Since the lipofilling procedure is nondestructive, conventional joint surgery can still be performed later, if needed.”

Larger long-term follow-up studies are needed to further corroborate these initial positive findings, the researchers said.

Source: EurekAlert!

Categories : Surgeries & ProceduresTags :

Smartphone Pics of Post-surgical Wounds for Spotting Infections

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Photo by Daniel Romero on Unsplash

Researchers have shown that smartphone pictures of post-surgical wounds taken by patients and then assessed by clinicians help spot infections early on.

These ‘surgery selfies’ were associated with a reduced number of GP visits and improved access to advice among patients who took them. This practice could help manage surgical patients’ care while they recover.

Death within 30 days of surgery is the third largest cause of mortality globally. More than a third of postoperative deaths are associated with surgical wound infections.

In the study, published in NPJ Digital Medicine, University of Edinburgh researchers conducted a randomised clinical trial involving 492 emergency abdominal surgery patients to determine if photos from smartphones and questions on symptoms of infection could be used to diagnose wound infections early.

One group of 223 patients were contacted on days three, seven and 15 after surgery and directed to an online survey, where they were asked about their wound and any symptoms they were experiencing. Then they were asked to take a picture of their wound and upload it.

A surgical team member assessed the photographs and patients’ responses were assessed for signs of wound infection. They followed up with patients 30 days after surgery to find out if they had been subsequently diagnosed with an infection.

A second group of 269 received standard care and were contacted 30 days after surgery to find out if they had been diagnosed with an infection.

No significant difference between groups was seen in the overall time it took to diagnose wound infections in the 30-days after surgery.

However, the smartphone group was nearly four times more likely to have their wound infection diagnosed within seven days of their surgery compared to the routine care group. They also had fewer GP visits and reported a better experience of trying to access post-operative care.

The research team is now conducting a follow-up study to determine how this can be best put into practice for surgical patients around the country. Artificial intelligence will also be used to help the clinical team in assessing the possibility of wound infection.

Professor Ewen Harrison, Professor of Surgery and Data Science, who led the research said: “Our study shows the benefits of using mobile technology for follow-up after surgery. Recovery can be an anxious time for everybody. These approaches provide reassurance – after all, most of us don’t know what a normally healing wound looks like a few weeks after surgery. We hope that picking up wound problems early can result in treatments that limit complications.”

Dr. Kenneth McLean, who co-led the research said: “Since the COVID-19 pandemic started, there have been big changes in how care after surgery is delivered. Patients and staff have become used to having remote consultations, and we’ve shown we can effectively and safely monitor wounds after surgery while patients recover at home – this is likely to become the new normal.”

Source: University of Edinburgh