bluuebunny/crossref_metadata_2025_split huggingface dataset:
Milestones in Surgical Complication Reporting – Twenty years of Clavien-Dindo Classification & ten years of Comprehensive Complication Index (CCI®)
Authors: Abbassi F , Pfister M , Domenghino A , Lucas K L , Puhan M A , Clavien P A 
Published: May 2024

Abstract

Background
Standardized outcome reporting is key for proper assessment of surgical procedures. A recent consensus conference recommended the Clavien-Dindo classification (CDC) and the Comprehensive Complication Index (CCI®) for assessing postoperative morbidity. However, their use in randomized controlled trials (RCTs) has not been assessed, and several challenging scenarios for grading complications require consensus-based guidance.

Aims
The aim of this study was to assess the use of the CDC and CCI® in RCTs and to provide guidance on their standardized and consistent application.

Methods
We identified all RCTs that used the CDC or CCI® as a primary or secondary outcome.
In addition, we asked 163 international surgeons to independently grade complications of 20 clinical cases covering seven challenging scenarios. Finally, a core group of five experts used this information do develop consistent recommendations.

Results
Up to July 2023, 1424 RCTs used the CDC or CCI® to assess postoperative morbidity. Annual use was steadily increasing with now over 200 new RCTs per year.
Eighty-nine (55%) surgeons completed the survey. Complications requiring multiple interventions, complications of complications, complications occurring prior to referral, and expected and unrelated complications should all be counted as separate complications and included in the CCI®. Invasive diagnostics without findings should not be considered as a complication since purely diagnostic.

Conclusion
We observed an extensive and steadily increasing use of CDC and CCI® in RCTs, highlighting the importance of their consistent application. Provided by the original developers of the CDC and CCI® and based on an international survey of their frequent users, the current consensus offers much-needed guidance for challenging scenarios. This will further improve the consistency and accuracy of complication reporting, leading to higher quality RCTs, improved cost estimations, and better quality control, ultimately benefiting all stakeholders.
Air-Leak-Management Supported by Ventilation-SPECT/CT: A New Perspective on a Long-Known Problem
Authors: Gelpke H , Guglielmetti L , Nagel H , Klaeser B , Zehnder A 
Published: May 2024

Abstract

Background
Prolonged air leakage (PAL) is a common problem after lung surgery. Localization of air leaks (AL) remains challenging in some cases especially in minimally invasive surgery. Ventilation-SPECT/Computertomography (vSPECT/CT) has been reported as potential aid to identify and localize AL.

Aims
To evaluate vSPECT/CT as potential aid for the localization of AL and explore its use as support for PAL management.

Methods
Retrospective analysis of a case series of seven patients with PAL after minimally invasive thoracic surgery at our institution in 2023 for which vSPECT/CT was applied.

Results
Six patients underwent oncologic lung resections, one patient underwent thymectomy for a thymoma. In 5/7 cases an AL was spotted with vSPECT/CT (maximal AL ranged from 40-2000 ml/min). In the remaining two cases (with a maximal AL of 1900ml/min for 1 day, and 10 ml/min after more than 4 weeks and continuous clinical signs of PAL), the AL could neither be localized during revision surgery.
Nevertheless, the AL ceased in all patients after revision surgery. In two cases the detected AL supported the continuance of conservative treatment as it confirmed a leak within the prior resection site (maximal AL 40ml/min and 200ml/min). These results are depicted in the attached visual abstract.

Conclusion
The use of vSPECT/CT for localizing ALs proved to be precise in all instances where an imaging spot was observed (5/5 cases). Additionally, in the two cases where no spot was detected, no AL was found during subsequent revision surgery. These initial results are promising and support further prospective studies of a broader group of cases, reinforcing the role of vSPECT/CT as valuable aid in managing PAL.
Loco-Regional Ropivacaine Analgesia Via a Surgically Placed Intercostal Catheter after Anatomic Lung Resection: Prospective, Placebo-Controlled, Double-Blind; Randomized Superiority Trial
Authors: Hojski A , Krämer M , Gecas P , Bolliger D , Lampart A , Lardinois D 
Published: May 2024

Abstract

Background
Even after minimally invasive anatomic lung resection, pain remains a burden for patients. Current guidelines recommend the surgical placement of intercostal catheters at the end of the surgery to promote faster recovery after lung surgery.

Aims
The aim of this trial was to investigate the analgesic efficacy of continuous loco-regional application of ropivacaine via an intercostal catheter and to establish this method as a possible standard of care in postoperative analgesia management.

Methods
Between December 2021 and October 2023, we evaluated the efficacy of surgically inserted intercostal catheters. Patients were eligible when undergoing anatomic VATS lung resection under general anesthesia for confirmed or suspected stage I lung cancer (UICC, 8th edition). Patients received ropivacaine at a concentration of 2 mg/ml or a placebo through an elastomer pump, flow rate of 6-8 ml/h for 72 hours after surgery. The sample size was calculated to find an NRS (numerical rating scale) difference associated with a pain reduction of 1.5 points.

Results
14 patients were randomly included in the ropivacaine group and 18 in the placebo group. The patients’ characteristics and preoperative pain scores were similar in both groups.
Between the observed groups there was no statistically significant difference in postoperative pain scores and morphine consumption. The NRS score for cough 24 hours postoperatively was 4.9 (±2.2) in the ropivacaine group and 4.3 (±2.4); p=0.474 in the placebo group. In addition, we were unable to determine any influence of the pain management on the relative postoperative pulmonary function.

Conclusion
Our results suggest that the analgesic efficacy of continuous loco-regionally applied ropivacaine administered through a surgically placed intercostal catheter after surgery does not have a positive effect on postoperative pain scores or morphine requirements. Instead, local analgesia started at the beginning of the procedure and covering several intercostal spaces should be considered.
Potential Advantage of Magnetic Resonance Imaging in Detecting Thoracic Wall Infiltration in Pleural Mesothelioma. A Retrospective Single Center Analysis.
Authors: Barreto I , Franckenberg S , Frauenfelder T , Opitz I , Lauk O 
Published: May 2024

Abstract

Background
Thoracic wall infiltration in pleural mesothelioma (PM) can be an important prognostic factor when determining the extent of resection. Currently, standardized imaging for restaging after neoadjuvant systemic therapy comprises contrast enhanced Computed Tomography (CT) or Positron Emission Tomography (PET/CT) scan.

Aims
However, thoracic Magnetic Resonance Imaging (MRI) could be a better discriminator of chest wall infiltration prior to surgery. To increase the preoperative staging accuracy, we introduced a MRI protocol at our center.

Methods
A retrospective analysis of this prospective new imaging protocol was performed from 07/2018 to 08/2023, including descriptive analysis for patient`s sex, age, nicotine consumption, asbestos exposure, histological subtype, TNM-stage, RECIST criteria and number of neoadjuvant therapy cycles. Preoperative restaging included routine imaging and MRI. After histological diagnosis of PM, neoadjuvant therapy was conducted, followed by partial pleurectomy or extended pleurectomy/decortication, with intraoperative biopsies of suspicious chest wall lesions. The CT/MRI results were compared to the intraoperative biopsies. Sensitivity and specificity of both modalities were analyzed.

Results
Twenty-five patients (mean age 65.4, 12% female) with possible chest wall infiltration were included out of the 35 patients with PM treated during the observation period. Of the 10 patients with actual chest wall infiltration, 9 (90%) had a T-Stage of 3 or higher, 9 (90%) had PM of epithelioid histologic subtype and 4 (40%) a R2-Resection. The mean overall survival of all patients was 18.88 months (8-58).
In our study, thoracic MRI showed a high sensitivity (90%) and specificity (100%) for the detection of chest wall infiltration, especially when compared to the CT scan (sensitivity of 10%).

Conclusion
With the adjunctive use of thoracic MRI we demonstrated a higher sensitivity for detection of chest wall infiltration compared to conventional imaging prior to surgery. This may facilitate the preoperative assessment of the extent of resection. Nevertheless, larger studies are required to confirm these results.
Association Between Documented Intraoperative and Postoperative Adverse Events: An Analysis of Over 100,000 Surgical Trauma Cases
Authors: Mittlmeier A , Canal C , Dell-Kuster S , Pape H C , Neuhaus V 
Published: May 2024

Abstract

Background
Intraoperative adverse events (iAEs) are common during surgical procedures. However, structured and comparable documentation often depends on the physician’s subjective assessment of each iAE.

Aims
The aim of this study was to validate the hypothesis that iAEs during surgical interventions are clearly associated with further postoperative complications and prolonged hospital stays.

Methods
We performed a retrospective analysis comparing surgical patients with and without any iAEs regarding postoperative outcomes during the hospitalization. We analyzed more than 100,000 patients with surgically treated injuries between January 2012 and December 2022 from over 70 institutions across Switzerland. Outcome parameters were further compared using a 1:1 case-control matching method, while controlling for same age, gender, main diagnosis and procedure.

Results
Regarding outcomes, patients with iAEs had a significantly longer duration of surgery (131 vs. 77 minutes), a prolonged length of hospital stay (10 vs. 8 days), a significantly higher need for an intensive care unit (ICU) stay of more than one day (7% vs. 3%), and a significantly higher rate of postoperative and procedure-associated complications (28% vs. 7%) than those without iAEs. The prolonged duration of surgery, length of stay, and postoperative and procedure-associated complications in the iAE group were also confirmed in the matched-pair analysis to be associated with poorer patient outcomes while controlling for significant characteristics.

Conclusion
In line with the current literature, our data show a clear relevance of iAEs as crucial factors for patient outcomes, manifesting in significantly longer durations of surgery, prolonged lengths of stay, and more postoperative complications, in a broad spectrum of surgical trauma procedures. We propose the mandatory documentation of iAEs through a standardized classification system, such as ClassIntra, and in accordance with the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) guidelines for clinical practice and surgical research.
Endovascular Arch Repair of Anastomotic Aneurysm and Pseudoaneurysm in Patients after Open Repair of the Ascending Aorta and Aortic Arch: A Case Series
Authors: Becker D , Stana J , Prendes C F , Konstantinou N , Öz T , Pichlmaier M , Peters S , Tsilimparis N 
Published: May 2024

Abstract

Background
Endovascular techniques have provided new options in the treatment of arch pathologies. Multiple studies have reported good results after endovascular treatment of aortic arch aneurysms and it has developed to be a considerable approach, especially in patients who are unfit for open surgery. In treatment of progressing distal pathologies after open ascending aorta and/or aortic arch replacement, the endovascular arch repair has shown promising results.

Aims
Aim of study was to investigate the outcomes of endovascular arch repair (b-TEVAR) with a custom-made double or triple branched arch endograft in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement.

Methods
Retrospective analysis was conducted of all consecutive patients with anastomotic aneurysms after open surgical repair involving the ascending aorta and/or aortic arch treated with b-TEVAR. All patients were treated with a custom-made double or triple inner-branched arch endograft. Study endpoints were technical success, 30-day and follow up mortality/ morbidity and re-interventions.

Results
Between 2018 and 2022, ten patients were treated with custom-made double or triple branched TEVAR due to anastomotic aneurysms after open ascending aorta and/or proximal aortic arch replacement. Eight patients received a triple and two a double arch branched endograft. Eight cases were performed electively and two urgently for contained rupture. Technical success was achieved in nine cases (90%). All elective patients survived. Two patients treated due to contained ruptures expired. Within 30 postoperative days, one transient ischemic attack occurred. No early endograft-related re-interventions were necessary. Median follow-up was 20 months. One patient died two months after discharge due to sepsis caused by pneumonia. No further deaths or endograft-related re-interventions were observed.

Conclusion
Endovascular aortic arch repair with double or triple inner-branched arch endograft for anastomotic aneurysms after open ascending and/or proximal arch replacement is technically feasible and a promising alternative in a patient cohort unfit for surgery.
Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards
Authors: Wyss T , Sörelius K 
Published: May 2024

Abstract

Background
There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm.

Aims
The aim of this study was to establish this by performing a consensus study.

Methods
The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two-week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five-point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting “strongly agree” or “agree” on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient &gt; .80.

Results
All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items.

Conclusion
This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge.
PERCUTANEOUS LEFT STELLATE GANGLION BLOCK TO INCREASE VENTRICULAR FIBRILLATION THRESHOLD AND DEFIBRILLATION SUCCESS RATE IN ACUTE FULMINANT MYOCARDITIS WITH ELECTRICAL STORM
Authors: Morena A , Gravinese C , Frea S , Angelini F , Boretto P , Gallone G , De Lio G , Bocchino P , Zanierato M , Tore D , Barreca A , Raineri C , Pidello S , De Ferrari G , Dusi V 
Published: May 2024

Abstract

Introduction
Acute fulminant myocarditis represents a predisposing substrate for life–threatening ventricular arrhythmias (VAs). Percutaneous left stellate ganglion block (PLSGB) usage has been reported for the prevention of recurrent VAs, but clinical data on its acute effect on ongoing ventricular fibrillation (VF) are missing.

Case
A 57–years–old man suffering gastroenteritis and fever in the past week presented in the ED with typical chest pain. ECG depicted infero–lateral ST–segment elevation, cardiac ultrasound showed a mildly reduced LVEF and coronary angiography ruled out coronary lesions. In the following hours the patient developed frequent premature ventricular complexes with R on T phenomenon triggering short coupled torsade de pointes with rapid degeneration into VF. VAs episodes, initially responsive to single DC shock, kept recurring despite intravenous (iv) amiodarone, iv lidocaine and iv correction of potassium and magnesium. The patient was therefore treated with deep sedation, intubation and ECMO VA placement; still, he reached a status of persistently ongoing VF, refractory even to DC shocks (n=20). Therefore, ultrasound–guided PLSGB using a local bolus of lidocaine 150 mg + ropivacaine 50 mg was performed. After 5 minutes, a single DC shock was delivered, effective in achieving a stable sinus rhythm at 35 bpm with no more recurrences. Despite electrical stabilization, the patient developed a severe cardiogenic shock due to bradycardia and severe biventricular disfunction, treated with vasopressin and dobutamine. In the next 48 hours we observed a significant improvement, resumption of biventricular contractility and absence of VAs recurrences, so the patient was slowly weaned off ECMO and vasopressors. Immunological tests showed Enterovirus IgM positivity, while endomyocardial biopsy was negative for inflammatory infiltrates in the analyzed sections. Cardiac MRI (performed 10 days after onset) showed edema and non–ischemic LGE in the antero–lateral and infero–lateral basal subepicardial regions of the left ventricle, LVEF was 55%. After 15 days from admission, despite ongoing amiodarone and bisoprolol, the patient developed a run of monomorphic VA of 30 beats at 170 bpm, therefore he underwent sICD implantation.

Conclusion
PLSGB played a key role for the acute management of refractory VF unresponsive to DC shocks, allowing for acute stabilization. More clinical data are needed on acute neuromodulation for electrical storm.
CARDIONEUROABLATION: CASE SERIES
Authors: Valenti N , Di Monaco A , Romanazzi I , Quadrini F , Vitulano N , Troisi F , Grimaldi M 
Published: May 2024

Abstract

The aim of our prospective
Non–randomized study was to evaluate the efficacy and safety of Cardioneuroablation (CNA) in patients with recurrent cardioinhibitory vaso–vagal syncope (VVS) or functional bradyarrhythmias. From September 2022 to June 2023, a total of 10 ablation procedures were performed on 10 patients who met the inclusion criteria (30% female, mean age 51.9 years, range 19–81 years). In 5 cases the CNA was guided by HFS with documentation of vagal response, while in the other 5 cases it was performed with an anatomical approach. In 3 cases the ablation was performed only on the GPs of the right atrium, while in the remaining 70% of cases biatrial lesions were performed.
As regards the acute endpoints, we observed an increase in sinus heart, a shortening of the PQ interval, a reduction in TRNSc, a shortening of the AH interval and an increase in PW. During follow–up, a single patient, due to persistence of symptoms and bradyarrhythmic disorder, underwent definitive pacemaker implantation. No other patient had a recurrence of syncope and all reported being persistently asymptomatic. As regards the secondary endpoints, we highlighted a persistence of the increase in the minimum and average heart rate, a shortening of the PQ interval, a reduction in time and frequency domain parameters in the HRV analysis on the Holter ECG performed at follow–up. An increasing trend was also highlighted for maximum heart rate, although not significant. There were no significant changes in the QTc interval and no patient developed arrhythmic episodes.

Discussion
Cardioneuroablation is a relatively recent and still developing technique that aims to promote persistent cardiac vagal denervation through endocardial ablation of parasympathetic ganglia. In our prospective study of patients without structural heart disease suffering from recurrent cardioinhibitory VVS or symptomatic functional bradyarrhythmias, CNA was effective in reducing the syncopal burden and other symptoms complained of by patients before the procedure, and safety (only one case of pericardial effusion that did not require any therapy; low rate of exposure to ionizing radiation; not any increase in arrhythmic risk related to a prevalent sympathetic activity; no patient reported discomfort in feeling an average higher heart rate), with a notable improvement in the quality of life.
REPOLARIZATION GRADIENT CAUSES LOCAL DEPOLARIZATION ABNORMALITIES IN BRUGADA SYNDROME
Authors: Garibaldi S , Tirabasso D , Latrofa S , Hartwig V , Nesti M , Panchetti L , Mirizzi G , Startari U , Morelli M , Passino C , Emdin M , Piacenti M , Giannoni A , Rossi A 
Published: May 2024

Abstract

Background
Transmural voltage gradient in RVOT induces ECG–phenotype in Brugada syndrome(BrS). Moreover,RVOT depolarization abnormalities have been described as contributors to BrS phenotype and arrhythmogenesis.

Purpose
To investigate the effect of ajmaline administration on J–elevation of RVOT unipolar signals in BrS patients. Moreover,we wanted to assess whether ajmaline–induced unipolar J–point elevation variations induced local depolarization abnormalities.

Methods
21 BrS patients with spontaneous type–1 ECG pattern were enrolled. Due to the absence of BrS ECG pattern at the study, patients underwent RV endocardial mapping with the CARTO3 system, before (PRE) and after (POST) ajmaline administration. The data were exported from CARTO and converted into Matlab format using OpenEP. J–elevation for each point was calculated as the amplitude of the unipolar signal at J wave with respect to baseline. Activation time (AT) of each point was defined as the difference between local depolarization (minimum dV/dt of the unipolar signal) and surface ECG depolarization(time of the minimum signal on V2). With an automatic algorithm, corresponding PRE and POST points were selected. The difference between POST and PRE of each parameter was calculated to obtain the differential values delta–J and delta–AT. Differential values were then interpolated on the mesh of each subject to obtain 3D maps. The deltaJ map was divided into four intervals based on quartiles. We then selected a ROI ‘IN‘ on a region with the greatest deltaJ variation, and a second ROI ‘OUT‘ on the zone of lowest variation. The same ROIs were applied to the deltaAT map. The mean value of the respective differential parameters was extracted in each ROI.

Results
Greatest delta–J values were found in the RVOT/anterior wall. delta–J in the ROI ‘IN‘ was greater than in the ROI ‘OUT‘ (1.68 [1.11–2.28] vs 0.56 [0.38–0.93] mV, p&lt;0.001). delta–AT in the ROI ‘IN’ was greater than in the ROI ‘OUT’ (27.96 [20.39–44.89] vs 7.62 [4.24–16.69] ms, p&lt;0.001). A good correlation was found between delta–J and delta–AT, considering the data for the two ROIs together (Spearman R coefficient=0.71, p&lt;0.001). Conclusions: Our study shows that the repolarization gradient, evaluated by localized delta–J increase in RVOT, justifies BrS ECG phenotype and local depolarization abnormalities. A strong correlation was present in these RVOT areas between J–elevation variation and slow conducting zones.