Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes.

INTRODUCTION: Hemodynamic Depression (HD) characterized by hypotension and bradycardia is a complication of carotid surgery due to direct autonomic stimulation in the carotid sinus. The authors believe the incidence of HD is high and possibly related to major cardiac complications. METHODS: Analysis of patient records during admissions for carotid surgery between January 2014 and December 2018 in two hospitals. HD was defined as bradycardia or hypotension in the first 24 postoperative hours. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure < 90 mmHg, continuous use of vasopressors, or a drop in SBP > 20% compared to preoperative values. Myocardial infarction, stroke, and cardiovascular death were defined as adverse events. RESULTS: Overall, 237 carotid surgeries (178 endarterectomies, 59 angioplasties) were studied, and the global incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0%, and hypotension and bradycardia in 6.8%). The independent predictors of HD were asymptomatic carotid stenosis (OR = 1.824; 95% CI 1.014-3.280; p = 0.045), endovascular surgery (OR = 3.319; 95% CI 1.675-6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR = 2.144; 95% CI 1.222-3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor independently associated with adverse cardiovascular events (OR = 5.504; 95% CI 1.729-17.529; p = 0.004). DISCUSSION/CONCLUSION: Incidence of Hemodynamic Depression after carotid surgery is high and independently associated with surgical technique, symptomatic repercussion of the carotid stenosis, and intraoperative hypotension or bradycardia. Hypotension requiring the continuous infusion of vasopressors was independently associated with the occurrence of MACE.

One-step Endovascular Aortic Aneurysm Repair With CO2 contrast and Robotic Partial Nephrectomy for Renal Cell Carcinoma: Case Report.

INTRODUCTION: Although rare, as the population ages, abdominal aortic aneurysm synchronous to abdominal malignancies, as renal cell carcinoma, is expected to become more prevalent. There are only two case reports of minimally invasive surgeries to treat these synchronous diseases, with endovascular aortic repair and laparoscopic nephrectomy, but they were performed in two stages, with iodinated contrast and without robotic assistance. CASE REPORT: We herein present a case of a 71-year-old patient with chronic kidney disease, a 6.4 cm infra-renal abdominal aortic aneurysm associated and a suspicious 6 cm solid-cystic expansile lesion in the right kidney, successfully treated at one stage with endovascular aortic repair using carbon dioxide as a contrast medium and with robotic right partial nephrectomy, aiming to preserve the renal function as much as possible. The patient's postoperative course was free of complications with hospital discharge on the fifth postoperative day, with a serum creatinine of 0.84 mg/dL. CONCLUSION: single-stage minimally invasive surgical treatment of AAA and RCC can be a safe and feasible approach. Combining a robot-assisted laparoscopic partial nephrectomy with an EVAR using carbon dioxide as a contrast medium was safe and successfully preserved renal function.

Hemodynamic depression after carotid surgery: Incidence, risk factors and outcomes

Abstract Introduction: Hemodynamic Depression (HD) characterized by hypotension and bradycardia is a complication of carotid surgery due to direct autonomic stimulation in the carotid sinus. The authors believe the incidence of HD is high and possibly related to major cardiac complications. Methods: Analysis of patient records during admissions for carotid surgery between January 2014 and December 2018 in two hospitals. HD was defined as bradycardia or hypotension in the first 24 postoperative hours. Bradycardia was defined as heart rate < 50bpm; hypotension as systolic blood pressure < 90 mmHg, continuous use of vasopressors, or a drop in SBP > 20% compared to preoperative values. Myocardial infarction, stroke, and cardiovascular death were defined as adverse events. Results: Overall, 237 carotid surgeries (178 endarterectomies, 59 angioplasties) were studied, and the global incidence of HD was 54.4% (hypotension in 50.2%, bradycardia in 11.0%, and hypotension and bradycardia in 6.8%). The independent predictors of HD were asymptomatic carotid stenosis (OR = 1.824; 95% CI 1.014 −3.280; p = 0.045), endovascular surgery (OR = 3.319; 95% CI 1.675−6.576; p = 0.001) and intraoperative hypotension or bradycardia (OR = 2.144; 95% CI 1.222−3.762; p = 0.008). Hypotension requiring continuous vasopressor infusion was the only factor independently associated with adverse cardiovascular events (OR = 5.504; 95% CI 1.729-17.529; p = 0.004). Discussion/conclusion: Incidence of Hemodynamic Depression after carotid surgery is high and independently associated with surgical technique, symptomatic repercussion of the carotid stenosis, and intraoperative hypotension or bradycardia. Hypotension requiring the continuous infusion of vasopressors was independently associated with the occurrence of MACE.

Long-term results of the treatment of primary hyperhidrosis with oxybutynin: follow-up of 1,658 cases.

BACKGROUND: Hyperhidrosis (HH) is characterized by exaggerated sweating in a specific region due to hyperfunction of the sweat glands. In the late 2000s, we started treating patients with an anticholinergic, oxybutynin, that was not being used until then. OBJECTIVES: To present, after 12 years of utilizing this medication in our service, the substantial experience obtained with the use of oxybutynin as an initial treatment of HH in a large series of 1,658 patients. METHODS: We analyzed 1,658 patients treated with oxybutynin for HH from May 2006 to June 2018. The patients were divided into four groups according to the main site of HH: the plantar group, the axillary group, the facial group, and the palmar group. To measure the degree of satisfaction, a quality of life (QoL) questionnaire was used. RESULTS: Pre-treatment QoL was poor or very poor in more than 94% of the cases, and the palmar group had the worst quality of life. After treatment, we observed an improvement in the quality of life in 77% of patients. More than 70% of the patients in all groups present moderate or optimal subjective clinical improvement in sweating after treatment. The group with the best result was the facial group. Intense dry mouth was reported in 24.9% of all patients in all groups. CONCLUSIONS: This study included a large number of patients followed for a long period and demonstrated the good effectiveness of treatment with oxybutynin for hyperhidrosis in the main sites of sweating.

Late neurological deficit after attempted PICC insertion in the arm.

INTRODUCTION:: Insertion of central catheters in peripheral vessels is a common procedure performed for a variety of indications, including parenteral nutrition. Hyperemesis gravidarum may require parenteral nutrition in exceptional situations. Although globally safe, insertion of peripherally inserted central catheters (PICCs) can lead to complications. CASE REPORT:: We describe a case of a pregnant woman who required parenteral nutrition and underwent an unsuccessful PICC insertion attempt resulting in arterial puncture, and who 34 days later presented with right upper limb paresthesia. A pseudoaneurysm with nerve compression was diagnosed and treated by open surgery, without maternal or fetal complications. CONCLUSION:: We recommend active surveillance ultrasound (e.g. in the first 24-48 h) of unsuccessful PICC insertion attempts, because late complications may occur and require invasive procedures for treatment.

Long-term results of the use of oxybutynin for the treatment of plantar hyperhidrosis.

BACKGROUND: Plantar hyperhidrosis is a common illness with significant impact on quality of life. Oxybutynin presents good short-term results, but longer follow-up results are lacking. We evaluated oxybutynin effectiveness in patients who were not surgically treated and who had at least six months of follow-up. METHODS: From September 2007 to September 2013, 85 consecutive patients were enrolled in our institutional protocol for the "pharmacological-first" treatment of primary plantar hyperhidrosis with oxybutynin. Eight patients were lost to follow-up, 15 patients have not yet been under treatment for six months, and data were available for 39 patients (all female) treated for at least six months. Data at the start of the protocol, six weeks after beginning treatment, and at their final visit were analyzed. RESULTS: Twenty-three of the 77 patients (29.87%) did not improve after pharmacological therapy. From the 39 patients with more than six months of follow-up (median 16.9 months, range 9-71), 79.5% reported moderate/great improvement in excessive plantar sweating after six weeks of treatment, and this rate increased to 84.7% in the last follow-up visit; 82.85% showed improvement in other sites presenting hyperhidrosis. Dry mouth was the most common side effect; 51.6% of patients reported it to be moderate/severe at the last visit. CONCLUSION: In patients with good initial response to oxybutynin, more than 82% presented moderate or great improvement in plantar and other sites' excessive sweating; dry mouth was the most common side effect but was tolerable and did not lead any patient to interrupt treatment.

Long-Term Efficacy of Oxybutynin for Palmar and Plantar Hyperhidrosis in Children Younger than 14 Years.

Oxybutynin for treating hyperhidrosis in children has been evaluated only in short-term studies. We aimed to investigate the long-term effects of oxybutynin in treating children with palmar and plantar hyperhidrosis who had not undergone surgery and who were monitored for at least 6 months (median 19.6 mos). A cohort of 97 patients was evaluated retrospectively, with particular attention to 59 children (ages 4-14 yrs) who were treated for longer than 6 months. Their quality of life (QOL) was evaluated using a validated clinical questionnaire before and after 6 weeks of pharmacologic therapy. A self-assessment of hyperhidrosis was performed after 6 weeks and after the last consultation. By their final office visit, more than 91% of the children with hyperhidrosis treated with oxybutynin experienced moderate or great improvement in their level of sweating and 94.9% experienced improvement in QOL. More than 90% of children reported improvement of hyperhidrosis at other sites. Dry mouth was the most common side effect. Oxybutynin appears to be an effective treatment option for children with hyperhidrosis, and positive results are maintained over the long term (median 19.6 mos).

Quality of life before hyperhidrosis treatment as a predictive factor for oxybutynin treatment outcomes in palmar and axillary hyperhidrosis.

BACKGROUND: Studies have suggested that quality of life (QOL) evaluation before video-assisted thoracoscopic sympathectomy for patients with hyperhidrosis may serve as a predictive factor for positive postoperative outcomes. Our study aims to analyze if this tendency is also observed in patients treated with oxybutynin for palmar and axillary hyperhidrosis. METHODS: Five hundred sixty-five patients who submitted to a protocol treatment with oxybutynin were retrospectively analyzed between January 2007 and January 2012 and were divided into 2 groups according to QOL assessment before treatment. The groups consisted of 176 patients with "poor" and 389 patients with "very poor" QOL evaluation before oxybutynin treatment. Outcomes involving improvements in QOL and clinical progression of hyperhidrosis were evaluated using a validated clinical questionnaire that was specifically designed to assess satisfaction in patients with excessive sweating. RESULTS: Improvements in hyperhidrosis after oxybutynin were observed in 65.5% of patients with very poor pretreatment QOL scores and in 75% of patients with poor pretreatment QOL scores, and the only adverse event associated with oxybutynin treatment was dry mouth, which was observed with greater intensity in patients with very poor initial QOL evaluation. CONCLUSION: Improvements in hyperhidrosis after oxybutynin treatment were similar in both groups, suggesting that QOL before treatment is not a predictive factor for clinical outcomes, contrasting with surgical results that disclose significantly better results in patients with initially poorer QOL analysis.

Severe protein-calorie malnutrition after bariatric procedures.

BACKGROUND: Serious nutritional complications after Roux-en-Y gastric bypass (RYGBP) are infrequent. In a retrospective study of patients operated during a 68-month period, malnutrition was investigated to analyze circumstances associated with nutritional failure. METHODS: In 236 consecutive RYGBPs, 11 patients with severe malnutrition were identified (4.7%) with age 45.1 +/- 10.6 years (10 females/1 male) and initial BMI 54.6 +/- 8.4 kg/m(2). RESULTS: In these 11 patients, the derangement was diagnosed 17.9 +/- 15.8 months after RYGBP, following defined events in 63.6% (gastric stenosis, associated diseases ) or mostly exaggeration of expected symptoms in 36.4% (vomiting without endoscopic abnormalities). BMI then was 31.4 +/- 8.6 kg/m(2) (42.5 +/- 9.9% total reduction, or 2.4 +/- 2.1% decrease/month), and serum albumin and hemoglobin were 24.0 +/- 8.2 g/L and 97.0 +/- 23.0 g/L respectively. Edema was present in 45.4% (5/11), hospitalization was required in 54.5% (6/11), and 18.2% (2/11) eventually died. CONCLUSIONS: Serious malnutrition was unusual but not exceedingly rare in this series. Exogenous precipitating factors were clearly identified in 63.6% of the patients. Careful clinical and nutritional follow-up is recommended to prevent these uncommon but potentially dangerous complications.