Observational Study on the Risk of Surgical Site Infection in Patients Undergoing Common Femoral Endarterectomy in Conjunction With an Endovascular Procedure Compared With Common Femoral Endarterectomy Alone.

Objective: A hybrid approach is being employed increasingly in the management of peripheral arterial disease. This study aimed to assess the surgical site infection (SSI) incidence of hybrid revascularisation (HR) compared with common femoral endarterectomy (CFEA) alone. Methods: This was a retrospective review of consecutive patients who underwent CFEA or HR alongside CFEA between 2017 and 2021 including one year of follow up. The primary outcome was SSI incidence. Secondary outcomes included length of surgery, duration of admission, further revascularisation surgery, limb salvage, and death. Differences in outcomes were assessed with the Student's unpaired t test, chi square test, and Fisher's exact test. Results: A total of 157 groin incisions from 155 patients were included: 78 had CFEA procedures and 79 had HR procedures. No statistical difference was found between groups for age, sex, and indication for surgery. Surgical site infection occurred in five of the CFEA patients (6%) compared with seven of the HR patients (9%) (p = 0.77). The HR procedures took significantly longer, with an average of 299 minutes compared with 220 minutes for CFEA (p < 0.001). No statistically significant difference was identified for length of admission: median stay five days for CFEA vs. four days for HR (p = 0.44). Major amputation was performed within one year in five of the CFEA procedures (6%) and five of the HR procedures (6%) (p = 1.0). Further revascularisation surgery was attempted in two patients in the HR group and six patients in the CFEA group (p =. 17). No statistically significant difference was found in the one year mortality rate: eight CFEA (10%) and seven HR (9%) (p = 0.77). Conclusion: Patients who underwent HR alongside CFEA did not have a statistically significantly increased incidence of SSI, despite increased surgical time. Using HR techniques enabled patients to have multilevel disease treated in one stage without an increased incidence of SSI.

A systematic scoping review protocol to summarise and appraise the use of artificial intelligence in the analysis of digital videos of invasive general surgical procedures.

Background: Intraoperative video recordings are a valuable addition to operative written documentation. However, the review of these videos often requires surgical expertise and takes considerable time. While a large amount of work has been undertaken to understand the role of artificial intelligence (AI) in healthcare more generally, the application of these techniques to automate the analysis of surgical videos is currently unclear. In this systematic scoping review, we sought to give a contemporary overview of the use of AI research in the analysis of digital videos of invasive general surgical procedures. We will describe and summarise the study characteristics, purpose of the applications and stage of development, to ascertain how these techniques might be applied in future research and to identify gaps in current knowledge (e.g. uncertainties about the study methods). Methods: Systematic searches will be conducted in OVID Medline and Embase, using terms related to 'artificial intelligence', 'surgery' and 'video' to identify all potentially relevant studies published since 1st January 2012. All primary studies where AI has been applied to the analysis of videos (recorded by conventional digital cameras or laparoscopic or robotic-assisted technology) of general surgical procedures will be included. Data extraction will include study characteristics, governance, details of video datasets and AI models, measures of accuracy, validation and any reported limitations. Ethics and dissemination: No ethical approval is required as primary data will not be collected. The results will be disseminated at relevant conferences, on social media and published in a peer-reviewed journal.

Developing balloon dilatation sizing guidance for anastomotic stricture dilatation following oesophageal atresia repair.

PURPOSE: To develop guidance for the selection of balloon catheter size when performing an oesophageal dilatation for a stricture post oesophageal atresia repair. METHODS: This was a single centre retrospective study at a paediatric tertiary centre. Dilatations were performed between 2015 and 2020. All dilatations were performed under general anaesthesia using balloon catheters under fluoroscopic guidance. Outliers were excluded using ROUT method and descriptive analysis was calculated to 1SD or IQR depending on the normality of data distribution. RESULTS: 97 patients underwent 341 dilatations. Median age was 19 months (37 weeks corrected gestation-17 years), median weight was 10.7 kg (2.6-72 kg). Balloon catheter sizes ranged from 6-8 mm to 18-20 mm. There was strong correlation between weight and balloon size (r = 0.8, p < 0.0001). There were 2 perforations (0.6%), both diagnosed intra-operatively and treated conservatively. From the results, weight recommendations were created for each balloon size. CONCLUSION: Fluoroscopic balloon dilatation is a safe and effective method to treat anastomotic stricture following oesophageal atresia repair. Previous studies have shown correlation between patient weight and oesophageal diameter. We propose guidance for using an appropriate balloon size based on patient's weight with the aim to reduce complication.

Development of a Semiautomated Database for Patients With Adult Congenital Heart Disease.

BACKGROUND: Databases for Congenital Heart Disease (CHD) are effective in delivering accessible datasets ready for statistical inference. Data collection hitherto has, however, been labour and time intensive and has required substantial financial support to ensure sustainability. We propose here creation and piloting of a semiautomated technique for data extraction from clinic letters to populate a clinical database. METHODS: PDF formatted clinic letters stored in a local folder, through a series of algorithms, underwent data extraction, preprocessing, and analysis. Specific patient information (diagnoses, diagnostic complexity, interventions, arrhythmia, medications, and demographic data) was processed into text files and structured data tables, used to populate a database. A specific data validation schema was predefined to verify and accommodate the information populating the database. Unsupervised learning in the form of a dimensionality reduction technique was used to project data into 2 dimensions and visualize their intrinsic structure in relation to the diagnosis, medication, intervention, and European Society of Cardiology classification lists of disease complexity. Ninety-three randomly selected letters were reviewed manually for accuracy. RESULTS: There were 1409 consecutive outpatient clinic letters used to populate the Scottish Adult Congenital Cardiac Database. Mean patient age was 35.4 years; 47.6% female; with 698 (49.5%) having moderately complex, 369 (26.1%) greatly complex, and 284 (20.1%) mildly complex lesions. Individual diagnoses were successfully extracted in 96.95%, and demographic data were extracted in 100% of letters. Data extraction, database upload, data analysis and visualization took 571 seconds (9.51 minutes). Manual data extraction in the categories of diagnoses, intervention, and medications yielded accuracy of the computer algorithm in 94%, 93%, and 93%, respectively. CONCLUSIONS: Semiautomated data extraction from clinic letters into a database can be achieved successfully with a high degree of accuracy and efficiency.

Defining a Safe Corridor of Cervical Branch Preservation in Lateral Platysmaplasty Surgery During Facial Rejuvenation Surgery.

BACKGROUND: During rhytidectomies, the cervical branch of the facial nerve (CBFN) can easily be encountered, and potentially injured, when releasing the cervical retaining ligaments in the lateral neck. This nerve has been shown to occasionally co-innervate the depressor anguli oris muscle, and damage to it can thus potentially compromise outcomes with a postoperative palsy. OBJECTIVES: The authors sought to examine the lateral cervical anatomy specific to the CBFN to ascertain if the position of the nerve can be predicted, thereby enhancing safety of the platysmal flap separation and dissection from this lateral zone of adhesion. METHODS: Eleven cadaveric hemifaces were dissected, and the distance between the medial border of sternocleidomastoid muscle (SCM) and the CBFN was measured at 3 key points: (1) superior: the distance between the SCM and the nerve at the level of the angle of the mandible in neutral; (2) narrowest: the narrowest distance measurable between the superior and inferior points as the CBFN descends into the neck medial to the SCM; and (3) inferior: the distance at the most distal part of the cervical nerve identified before its final intramuscular course. RESULTS: The average distances (in mms) were as follows: superior = 12.1 (range, 10.1-15.4), narrowest = 8.8 (range, 5.6-12.2), and inferior = 10.9 (range, 7.9-16.7). CONCLUSIONS: There is a narrow range between the nerve and the anterior border of SCM. We thus propose a safe corridor where lateral deep-plane dissection can be performed to offer cervical retaining ligament release, with reduced risk of endangering the CBFN.

C-reactive protein accurately predicts severity of acute pancreatitis in children.

INTRODUCTION: Predicting severity of acute pancreatitis enables optimization of care, reducing morbidity and length of stay. Modified adult scoring systems have not been able to adequately predict severity in children. METHODS: This was a retrospective study of children presenting with a first episode of acute pancreatitis from 2002 to 2020 in a single tertiary paediatric surgical centre. Serum markers including CRP at 48 h of admission were analysed. Promising biomarkers underwent ROC (Receiver Operating Curve) analysis, and these were compared to the modified Glasgow Pancreas Score. An AUC (Area Under Curve) > 0.90 was taken as an excellent predictor of severity. RESULTS: Data of 59 children were analysed, median age 13 years. 22 patients (37%) had a severe episode. ROC analysis demonstrated CRP as the best predictor of severity giving an AUC of 0.92. Optimum cut off value for CRP was 107.5 mg/L (p < 0.0001) producing sensitivity of 91%, specificity of 84%. This was superior to the modified Glasgow Pancreas score, which produced a sensitivity of 36% and specificity of 100%. CONCLUSION: We have shown that a CRP value of > 108 mg/L within 48 h of admission can be used to predict severity of acute pancreatitis in children with greater accuracy than current scoring systems. TYPE OF STUDY: Diagnostic test. LEVEL OF EVIDENCE: Level I.

Late gadolinium enhancement and adverse outcomes in a contemporary cohort of adult survivors of tetralogy of Fallot.

OBJECTIVE: Myocardial fibrosis has been associated with poorer outcomes in tetralogy of Fallot, however only a handful of studies have assessed its significance in the current era. Our aim was to quantify the amount of late gadolinium enhancement in both the LV and RV in a contemporary cohort of adults with surgically repaired tetralogy of Fallot, and assess the relationship with adverse clinical outcomes. DESIGN: Single centre cohort study SETTING: National tertiary referral center Patients: One hundred fourteen patients with surgically repaired tetralogy of Fallot with median age 29.5 years (range 17.5-64.2). Prospective follow-up for mean 2.4 years (SD 1.29). INTERVENTIONS: Cardiovascular magnetic resonance was performed, and late gadolinium enhancement mass was estimated for the LV using the 5-SD remote myocardium method, and for the RV using a segmental scoring system. Cohort characterization was determined through the use of a computerized database. OUTCOME MEASURES: Survival analysis from time of scan to first adverse event, defined as an episode of atrial arrhythmia, sustained ventricular arrhythmia, hospitalization with heart failure, or implantable cardioverter-defibrillator insertion. RESULTS: Eleven patients experienced an adverse outcome in the follow-up period, although there were no deaths. LV late gadolinium enhancement was associated with adverse outcomes in a univariate model (P = .027). However, when adjusted for age at scan the significant variables included NYHA class (P = .006), peak oxygen uptake (P = .028), number of prior sternotomies (P = .044), and higher indexed RV and LV end diastolic volumes (P = .002 and P < .001), but not RV or LV late gadolinium enhancement. CONCLUSIONS: Formal quantification of late gadolinium enhancement is not currently as helpful in ascertaining prognosis compared to other, more easily assessed parameters in a contemporary cohort of tetralogy of Fallot survivors, however assessment particularly of the LV holds promise for the future.

Biomarkers in congenital heart disease.

The population of adults with congenital heart disease (CHD) now exceeds the population of children with CHD. The long-term management of these patients relies on sequential assessment of anatomy and physiology and integration with symptoms, all targeted toward decision making around intervention. The advances in technology have vastly improved our assessment of anatomy and function. However, while the assessment of chronic heart failure in acquired heart disease has been revolutionized by the proven utility of cardiac biomarkers, their use in adult CHD is still being assessed.

Keeping track of congenital heart disease--is it time for a national registry?

Considerable improvements have been made in care and provision for patients with congenital heart disease in the United Kingdom. However, delayed presentation of adult patients with sequelae of known childhood cardiac defects reflects the current situation that there is no national registry of patients with congenital heart disease, and this "lost cohort" of patients is difficult to trace. Maintaining regular follow-up for selected patients with congenital heart disease can be challenging for a variety of reasons, but remains particularly important as emerging therapies and treatment strategies continue to alter management. Despite recent calls from a variety of organisations to establish a national registry of patients with congenital heart disease, progress has been slow. Faced with competition for resources, the costs of such a venture may be cited as a likely hurdle, but the potential advantages for patients and healthcare providers alike justify calls to integrate a registry as part of the ongoing reorganisation of congenital heart services in the United Kingdom.

Beneficial effects of phosphodiesterase 5 inhibition in pulmonary hypertension are influenced by natriuretic Peptide activity.

BACKGROUND: Phosphodiesterase type 5 (PDE5) inhibitors (eg, sildenafil) are a novel, orally active approach to the treatment of pulmonary arterial hypertension. The role of natriuretic peptides in the response to sildenafil was examined in mice lacking NPR-A, a guanylyl cyclase-linked natriuretic peptide receptor, in which pulmonary hypertension was induced by hypoxia. METHODS AND RESULTS: Mice homozygous for NPR-A (NPR-A+/+) and null mutants (NPR-A-/-) were studied. Sildenafil inhibited the pressor response to acute hypoxia in the isolated perfused lungs of both genotypes. This effect was greater in the presence of atrial natriuretic peptide in the perfusate in NPR-A+/+ mice but not NPR-A-/- animals. In vivo, NPR-A mutants had higher basal right ventricular (RV) systolic pressures (RVSPs) than did NPR-A+/+ mice, and this was not affected by 3 weeks of treatment with sildenafil (25 mg x kg(-1) x d(-1)). Both genotypes exhibited a rise in RVSP and RV weight with chronic hypoxia (10% O2 for 21 days); RVSP and RV weight were reduced by continuous sildenafil administration in NPR-A+/+ mice, but only RVSP showed evidence of a response to the drug in NPR-A-/- mice. The effect of sildenafil on hypoxia-induced pulmonary vascular muscularization and cyclic GMP levels was also blunted in NPR-A-/- mice. CONCLUSIONS: The natriuretic peptide pathway influences the response to PDE5 inhibition in hypoxia-induced pulmonary hypertension, particularly its effects on RV hypertrophy and vascular remodeling.