Yen-Yi Juo

Does left atrial appendage ligation during coronary bypass surgery decrease the incidence of postoperative stroke

Objective The study objective was to evaluate the association between surgical left atrial appendage ligation and in‐hospital stroke incidence after coronary artery bypass grafting among patients with atrial fibrillation. Methods A retrospective cohort study was performed by using the Nationwide Inpatient Sample between 2008 and 2014. All atrial fibrillation patients who underwent coronary artery bypass graft were included and categorized as left atrial appendage ligation or control group. Propensity score–weighted regression analyses were performed to assess the impact of left atrial appendage ligation on stroke incidence. Results A total of 234,642 patients were identified, among whom 20,664 (8.81%) received concomitant left atrial appendage ligation. The national postoperative stroke incidence was 0.92%. Results of the propensity‐weighted regression analysis showed no significant association between LAA ligation and control with regard to postoperative stroke (odds ratio [OR], 0.83; confidence interval [CI], 0.57‐1.22; P = .35), pericardial complications (OR, 1.15; CI, 0.88‐1.49; P = .31), hemorrhage and/or hematoma (OR, 1.08; CI, 0.99‐1.17; P = .07), mortality (OR, 1.29; CI, 0.99‐1.68; P = .06), and length of stay (coefficient −0.21; CI, −0.44‐0.02; P = .08). There was no specific CHA2DS2VASC score cutoff above which left atrial appendage ligation was demonstrated to have lower postoperative stroke incidence. Conclusions The postoperative stroke risk after coronary artery bypass grafting was low at approximately 1% among patients with atrial fibrillation in the United States. Concomitant left atrial appendage ligation was not associated with lower postoperative stroke risk.

Incidence of Myocardial Infarction After High-Risk Vascular Operations in Adults

Importance Advances in perioperative cardiac management and an increase in the number of endovascular procedures have made significant contributions to patients and postoperative myocardial infarction (POMI) risk following high-risk vascular procedures. Whether these changes have translated into real-world improvements in POMI incidence remain unknown. Objective To examine the temporal trends of myocardial infarction (MI) following high-risk vascular procedures. Design, Setting, and Participants A retrospective cohort study was performed using data collected from January 1, 2005, to December 31, 2013, in the American College of Surgeons National Surgery Quality Improvement Program database, to which participating hospitals across the United States report their preoperative, operative, and 30-day outcome data. A total of 90 303 adults who underwent a high-risk vascular procedure—open aortic surgery or infrainguinal bypass—during the study period were identified. Patients were divided into cohorts based on their year of operation, and their baseline cardiac risk factors and incidence of POMI were compared. Cases from 2005 to 2014 in the database were eligible for inclusion if one of their Current Procedural Terminology codes matched any of the operations identified as a high-risk vascular procedure. Data analysis took place from August 1, 2016, to November 15, 2016. Exposures The main exposure was the year of the operation. Other variables of interest included demographics, comorbidities, and other risk factors for MI. Main Outcomes and Measures Primary outcome of interest was the incidence of POMI. Results Of the 90 303 patients included in the study, 22 836 (25.3%) had undergone open aortic surgery and 67 467 (74.7%) had had infrainguinal bypass. The open aortic cohort comprised 16 391 men (71.9%), had a mean (SD) age of 69.1 (11.5) years, and was predominantly white (18 440 patients [80.8%] self-identified as white race/ethnicity). The infrainguinal bypass cohort included 41 845 men (62.1%), had a mean (SD) age of 66.7 (11.7) years, and had 51 043 patients (75.7%) who self-identified as white race/ethnicity. During the study period, patients who underwent open aortic procedures were more likely to be classified as American Society of Anesthesiologists class IV (7426 patients [32.6%] vs 15 683 [23.3%] for the infrainguinal bypass cohort) or class V (1131 [5.0%] vs 206 [0.3%]; P < .001) and to undergo emergency procedures (4852 [21.3%] vs 4954 [7.3%]; P < .001). The open aortic procedure cohort also experienced significantly higher actual incidence of POMI (464 [3.0%] vs 1270 [1.9%]; P < .001). From 2009 to 2014, the incidence of POMI demonstrated no substantial temporal change (2.7% in 2009 to 3.1% in 2014; P = .64 for trend). Postoperative MI was consistently associated with poor prognosis, with a 3.62-fold (95% CI, 2.25-5.82) to 11.77-fold (95% CI, 6.10-22.72) increased odds of cardiac arrest and a 3.01-fold (95% CI, 2.08-4.36) to 6.66-fold (95% CI, 4.66-9.52) increased odds of mortality. Conclusions and Relevance The incidence of MI did not significantly decrease in the past decade and has been consistently associated with worse clinical outcomes. Further inquiry into why advanced perioperative care did not reduce cardiac complications is important to quality improvement efforts.

Efficacy of Distal Perfusion Cannulae in Preventing Limb Ischemia During Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis.

To date, no consensus exists regarding indication, technique, or efficacy of distal perfusion cannulae (DPC) in preventing limb ischemia among patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aim to examine the available literature and report association between DPC and risk of limb ischemia. PubMed/Medline, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, and bibliographies of included studies were searched from database inception until August 2016. Original studies describing the DPC placement technique and incidence of limb ischemia following DPC placement among VA-ECMO patients were included for systematic review. Studies with a comparison group of patients without DPC were included for meta-analysis. Two authors independently screened title/abstracts, reviewed full texts, and extracted data from the eligible studies. Meta-analysis was performed using the Mantel-Haenszel method under a random-effects model. Statistical heterogeneity was examined with the I2 statistic (RevMan Version 5.3). Of 542 title/abstracts screened, 62 full text articles were selected for review, yielding 22 retrospective observational studies, for a total of 779 patients with 132 limb ischemia events. There was significant variation in DPC indication, cannula type, and placement technique among the studies. Compared to no DPC, the presence of a DPC was associated with at least a 15.7% absolute reduction in the incidence of limb ischemia (9.74 vs. 25.42%; risk ratio 0.41; 95% confidence interval 0.26-0.65, P < 0.01; heterogeneity statistic I2 = 28%). There was no statistically significant difference in mortality in the pooled dataset comparing DPC versus no DPC. In adults treated with VA-ECMO, DPC placement was associated with a lower incidence of limb ischemia. Currently no consensus guidelines exist regarding indication for DPC placement. Given the association described in this analysis, future prospective trials are warranted to establish a causal relationship and optimal technique for the use of DPC in patients treated with VA-ECMO.

Cost analysis and risk factors for interval cholecystectomy after bariatric surgery: a national study

BACKGROUND Besides rate and extent of weight loss, little is known regarding demographic factors predicting interval cholecystectomy (IC) after bariatric surgery and its incremental costs. OBJECTIVES We aim to identify risk factors predicting IC after bariatric surgery and quantify its associated costs. SETTING Nationally representative sampling of acute care hospitals across the United States. METHODS A retrospective cohort study was performed using the National Readmission Database 2010 to 2014. Cox proportional hazard analyses were used to identify risk factors for IC. Linear regression models were constructed to examine associations between cholecystectomy timing and cumulative hospitalization costs. RESULTS An estimated national total of 553,658 patients received bariatric surgery during the study period. Of these, 3.3% received concomitant cholecystectomy (CC). After adjusting for bariatric procedure type, age, sex, complication, and length of stay, CC was independently associated with a US

Evolution of Surgical Aortic Valve Replacement in the Era of Transcatheter Valve Technology

1589 increase in hospitalization cost (95% confidence interval US

Artificial palpation in robotic surgery using haptic feedback

1021-2158, P<.01). Of patients that received no CC, only .6% underwent IC during the up to 1-year follow-up. Age<35 (P<.01), female sex (P<.01), and high preoperative body mass index (P = .03) were all risk factors for IC. IC was independently associated with a US

Incidence and trends of cardiac complications in major abdominal surgery

1499 higher cumulative hospitalization cost than CC (P<.01, 95% confidence interval US

Readmission and resource utilization after orthotopic heart transplant versus ventricular assist device in the National Readmissions Database, 2010–2014

844-2154). CONCLUSIONS Despite the higher absolute cost of IC, its low incidence does not financially justify a routine prophylactic CC approach. In addition, no significant reduction in cholecystectomy-related complications was achieved by performing CC. An individualized approach taking identified risk factors for IC into consideration is recommended when deciding whether to perform prophylactic CC.

Mixed-Method Evaluation of a Cadaver Dissection Course for General Surgery Interns: An Innovative Approach for Filling the Gap Between Gross Anatomy and the Operating Room

Author(s): Mantha, Aditya; Juo, Yen-Yi; Morchi, Ravi; Ebrahimi, Ramin; Ziaeian, Boback; Shemin, Richard J; Benharash, Peyman

Obesity Is Associated with Early Onset of Gastrointestinal Cancers in California

BackgroundThe loss of tactile feedback in minimally invasive robotic surgery remains a major challenge to the expanding field. With visual cue compensation alone, tissue characterization via palpation proves to be immensely difficult. This work evaluates a bimodal vibrotactile system as a means of conveying applied forces to simulate haptic feedback in two sets of studies simulating an artificial palpation task using the da Vinci surgical robot.MethodsSubjects in the first study were tasked with localizing an embedded vessel in a soft tissue phantom using a single-sensor unit. In the second study, subjects localized tumor-like structures using a three-sensor array. In both sets of studies, subjects completed the task under three trial conditions: no feedback, normal force tactile feedback, and hybrid vibrotactile feedback. Recordings of correct localization, incorrect localization, and time-to-completion were used to evaluate performance outcomes.ResultsWith the addition of vibrotactile and pneumatic feedback, significant improvements in the percentage of correct localization attempts were detected (p = 0.0001 and p = 0.0459, respectively) during the first experiment with phantom vessels. Similarly, significant improvements in correct localization were found with the addition of vibrotactile (p = 2.57E−5) and pneumatic significance (p = 8.54E−5) were observed in the second experiment involving tumor phantoms.ConclusionsThis work demonstrates not only the superior benefits of a multi-modal feedback over traditional single-modality feedback, but also the effectiveness of vibration in providing haptic feedback to artificial palpation systems.