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Objectives: According to the conventional postoperative procedure after total ankle arthroplasty (TAA), mobilization and weight-bearing is currently started after completion of wound healing. Recently, early mobilization for dorsiflexion after TAA with modified antero-lateral approach was reported to be feasible and safe. To investigate the further possibility of expediting rehabilitation, this study evaluated the feasibility and safety of early full weight-bearing and gait exercise after cemented TAA. Materials and Methods: This retrospective, observational study investigated 23 consecutive ankles (OA: 14 ankles, RA: 9 ankles) that had received cemented TAA with a modified antero-lateral approach. These ankles were divided into three groups 1. conventional postoperative protocol, 2. early dorsiflexion protocol, 3. early dorsiflexion+full weight-bearing protocol. Postoperative wound complications were observed and recorded. Number of days for hospitalization was also evaluated. Results: No postoperative complications related to wound healing were observed even after early full weight-bearing and gait exercise. Days for hospitalization was significantly shortened in early full weight-bearing and gait exercise group (group 3) from 35-38 days to 24 days. Conclusions: Within this small number of cases, early full weight-bearing and gait exercise from 7 days after cemented TAA was feasible and safe with the modified antero-lateral approach. Combination of early dorsiflexion mobilization and weight-bearing/gait exercise contributed to shortening the hospitalization day. Innovations in postoperative procedures for rehabilitation after TAA can be expected. [ABSTRACT FROM AUTHOR]

Context Transgender and gender diverse (TGD) individuals have greater access to genital surgery (GS) with improved insurance coverage and access to trained surgeons and interdisciplinary gender-affirming providers. Objective To determine perioperative medical and behavioral health outcomes in transfeminine (TF) individuals undergoing GS, with use of a specific gender-affirming hormone therapy (GAHT) algorithm based on individualized risk factor assessment. Methods In this retrospective observational cohort study, we collected preoperative and postoperative data from 183 TF individuals at a single tertiary referral center from 2017 to 2022, grouping patients by those who continued estradiol (Group 1) vs those who had temporarily discontinued estradiol for 2 to 6 weeks preoperatively (Group 2). Data included clinical and biochemical assessment, GAHT regimens, validated behavioral health measures, and postoperative complications. Main outcomes included venous thromboembolism (VTE) incidence, non-VTE postoperative complication incidence, and change in behavioral health assessments. Results The majority of individuals continued estradiol perioperatively (Group 1; 138 [75.4%]). Individuals who temporarily held estradiol preoperatively (Group 2; 45 [24.6%]) were statistically older (P <.01), had higher incidence of cardiometabolic comorbidities (P <.01), and higher Caprini scores (P <.01). Group 1 was statistically more likely to use oral estradiol (P <.01). One episode (0.05%) of VTE occurred (Group 1). There was no significant difference in postoperative complications or behavioral health measures between groups. Conclusion An individualized algorithm for preoperative hormone management for TF GS resulted in perioperative continuation of GAHT for the majority of individuals without significantly increasing the risk for postoperative surgical complications, while maintaining stable behavioral health measures perioperatively. [ABSTRACT FROM AUTHOR]

Background: The ventral and distal aspects of the corpora cavernosa are the thinnest, increasing the likelihood of cylinder extrusion or crossover complications pertaining to inflatable penile prosthesis procedures. A double distal corporal anchoring double stitch can be used to robustly secure impending lateral extrusions and crossovers of implant cylinders. It is a novel, effective corrective measure for the uncommon complication of migrated cylinders in inflatable penile prosthesis placement. Aim: To describe the surgical indications and technique for the double distal corporal anchoring fixation stitch for lateral penile implant cylinder extrusion. Methods: We discuss a double-stitch technique that is performed following corporoplasty and capsulotomy. A lateral incision is made subcoronally on the affected side to identify the crossover or lateral extrusion. The cylinder is repositioned properly within the native corpora to prevent further cylinder migration. Two 2-0 Ethibond sutures are threaded through the distal cylinder eyelet, and each suture is delivered through the glans with a Keith needle and tied off. An incision is made in the glans, and 1 arm of each suture is tied with the other to create a bridge between the sutures that can be positioned deep within the skin of the glans. Outcomes: Over the past 4 years, 66 patients with lateral cylinder extrusion underwent the double distal corporal anchoring fixation stitch procedure, with overall improved satisfaction (97%). Only 2 patients had surgical complications. One patient experienced repeated lateral extrusion of the penile implant cylinders 6 weeks following the double-anchoring stitches procedure. The second patient developed a painful suture granuloma that necessitated excision, which resolved this issue, and the penile implant cylinder remained in the proper position over a year later. Clinical Implications: This technique ensures the secure fixation of the affected cylinders in the surgical capsule by creating a bridge between 2 sutures holding each repositioned cylinder in place, and the ensuing fibrotic reaction helps to fixate the extruded cylinder within the midglandular tissue. Strength and Limitations: This surgical technique describes the double distal corporal anchoring stitch for lateral penile implant cylinder extrusion. Further studies are warranted to validate long-term outcomes and satisfaction. Conclusion: The double distal corporal anchoring fixation stitch is a safe and efficacious method to secure cylinders in the proper surgical capsule during revision procedures to correct distal crossovers or laterally extruded penile prosthesis implants. [ABSTRACT FROM AUTHOR]

Left ventricular assist devices (LVADs) are gaining increasing importance as therapeutic strategy in advanced heart failure (HF), not only as bridge to recovery or to transplant but also as destination therapy. Even though long-term LVADs are considered a precious resource to expand the treatment options and improve clinical outcome of these patients, these are limited by peri-operative and post-operative complications, such as device-related infections, haemocompatibility-related events, device mis-positioning, and right ventricular failure. For this reason, a precise pre-operative, peri-operative, and post-operative evaluation of these patients is crucial for the selection of LVAD candidates and the management LVAD recipients. The use of different imaging modalities offers important information to complete the study of patients with LVADs in each phase of their assessment, with peculiar advantages/disadvantages, ideal application, and reference parameters for each modality. This clinical consensus statement sought to guide the use of multimodality imaging for the evaluation of patients with advanced HF undergoing LVAD implantation. [ABSTRACT FROM AUTHOR]

Background Pretransplant respiratory virus (RV) infections have been associated with negative transplant outcomes in adult hematopoietic cell transplantation (HCT) recipients. In the era of HCT delay because of high-risk RVs, we examined the impact of pretransplant RV detection on transplant outcomes in pediatric HCT recipients. Methods This retrospective cohort study included pediatric myeloablative allogeneic HCT recipients from 2010 to 2019. All patients were screened for RV at least once within 90 days before HCT using reverse transcriptase polymerase chain reaction (PCR), regardless of symptoms. Posttransplant outcomes included days alive and out of hospital and progression to lower respiratory tract infection (LRTI). Results Among 310 patients, 134 had an RV detected in the 90 days before HCT. In univariable analysis, transplant factors including younger age, total body irradiation, umbilical cord blood transplantation, lymphocyte count <100/mm3, HCT comorbidity index score ≥3, and viral factors including symptomatic infection, human rhinovirus as a virus type, and symptomatic pretransplant upper respiratory tract infection were associated with fewer days alive and out of hospital. In multivariable analysis, transplant factors remained significant, but not viral factors. There was a higher incidence of progression to posttransplant LRTI with the same pretransplant RV if the last positive PCR before HCT was ≤30 days compared with >30 days (P =.007). Conclusions In the setting of recommending HCT delay for high-risk RVs, symptomatic upper respiratory tract infection, including human rhinovirus infections, may lead to increased duration of hospitalization and early progression to LRTI when transplantation is performed within 30 days of the last positive PCR test. [ABSTRACT FROM AUTHOR]

Background Compared with primary transplantation, ipsilateral renal re-transplantation is associated with an increased risk of surgical complications and inferior graft outcomes. This study investigates whether an ipsilateral re-transplantation approach per se is an independent risk factor for surgical complications and early graft loss. Methods In this retrospective, single-centre analysis, surgical complications and early graft outcomes of ipsilateral kidney re-transplantations from January 2007 to December 2017 were compared with primary transplantations and contralateral re-transplantations. Univariate and multivariate binary logistic regression analyses were performed to identify risk factors for surgical complications requiring surgical revision and graft loss within the first year after transplantation. Results Of the 1489 kidney transplantations, 51 were ipsilateral, 159 were contralateral re-transplantations and 1279 were primary transplantations. Baseline characteristics did not differ between the ipsilateral and contralateral re-transplant recipients except for current and highest panel reactive antibody levels. Major complications requiring surgical revision were significantly more frequent in ipsilateral re-transplantations (P = .010) than in primary transplantations but did not differ between ipsilateral and contralateral re-transplantations (P = .217). Graft loss within the first year after transplant was 15.7% in the ipsilateral versus 8.8% in the contralateral re-transplant group (P = .163) versus 6.4% in the primary transplantation group (P = .009). In a multivariate regression model, ipsilateral re-transplantation was not identified as an independent risk factor for complications requiring surgical revision or first-year graft loss. Conclusions Ipsilateral renal re-transplantation is not a risk factor for inferior outcomes. Graft implantation into a pre-transplanted iliac fossa is a feasible and valid therapeutic option. [ABSTRACT FROM AUTHOR]

Stump appendicitis, a rare postoperative complication of appendicectomy, is inflammation of the remnant appendix tissue due to incomplete removal of the appendix at the index operation. Due to a past surgical history of appendicectomy, there is often a diagnostic delay. This delay can result in increased morbidity and mortality for patients. This series seeks to describe two cases encountered in a London district general hospital to elucidate the diagnostic, management, and operative challenges of stump appendicitis. Our case series demonstrates the importance of recognition of stump appendicitis as a differential for patients presenting with abdominal pain and previous appendicectomy. Active exclusion of this differential diagnosis in a patient with previous appendicectomy who presents with right iliac fossa pain is vital. Early identification and treatment can prevent morbidity in the patient population. We highlight that complete operative documentation and access to medical records are useful for this diagnosis. [ABSTRACT FROM AUTHOR]

Standard posterior cervical fusion is a common surgical technique that utilizes lateral mass screws and rods for fixation. A relatively new, minimally invasive technique involving interfacet decortication and placement of spacers has shown promise in terms of outcomes. We sought to determine fusion rates and complications of this new technique at our institution to bolster current literature. We retrospectively reviewed all patients that underwent a 3-level or less minimally invasive posterior cervical fusions by a single surgeon. Patients were evaluated to determine fusion rates and postoperative complications. Twenty-eight patients underwent minimally invasive posterior cervical fusion. Twenty-seven demonstrated fusion (96%). One patient that underwent the procedure for juxta-fusional disease required additional surgery for pseudoarthrosis. The minimally invasive posterior cervical technique results in favorable fusion rates and has low complication rates. Our study strengthens current literature that this minimally invasive technique is a safe and effective alternative. [ABSTRACT FROM AUTHOR]

Background: Resection of non-functioning pancreatic neuroendocrine tumours (NF-PanNETs) is curative in most patients. The potential benefits of neoadjuvant treatments have, however, never been explored. The primary aim of this study was to evaluate the safety of neoadjuvant 177Lu-labelled DOTA0-octreotate (177Lu-DOTATATE) followed by surgery in patients with NF-PanNETs. Methods: NEOLUPANET was a multicentre, single-arm, phase II trial of patients with sporadic, resectable or potentially resectable NF-PanNETs at high-risk of recurrence; those with positive 68Ga-labelled DOTA PET were eligible. All patients were candidates for neoadjuvant 177Lu-DOTATATE followed by surgery. A sample size of 30 patients was calculated to test postoperative complication rates against predefined cut-offs. The primary endpoint was safety, reflected by postoperative morbidity and mortality within 90 days. Secondary endpoints included rate of objective radiological response and quality of life. Results: From March 2020 to February 2023, 31 patients were enrolled, of whom 26 completed 4 cycles of 177Lu-DOTATATE. A partial radiological response was observed in 18 of 31 patients, and 13 patients had stable disease. Disease progression was not observed. Twenty-four R0 resections and 4 R1 resections were performed in 29 patients who underwent surgery. One tumour was unresectable owing to vascular involvement. There was no postoperative death. Postoperative complications occurred in 21 of 29 patients. Severe complications were observed in seven patients. Quality of life remained stable after 177Lu-DOTATATE and decreased after surgery. Conclusion: Neoadjuvant treatment with 177Lu-DOTATATE is safe and effective for patients with NF-PanNETs. Lay Summary: Surgical removal of non-functioning pancreatic neuroendocrine tumours (NF-PanNETs) can often cure patients. However, it is not known whether treating patients before surgery provides additional benefits. The main aim of the study was to investigate safety of treatment called peptide receptor radionuclide therapy with 177Lu-labelled DOTA0-octreotate (177Lu-DOTATATE) before surgery in patients with NF-PanNETs. The NEOLUPANET study was conducted from March 2020 to February 2023 across multiple centres. Patients with NF-PanNETs that were at high risk of recurrence after surgery were included. All patients received 177Lu-DOTATATE before surgery. The main measure of success was safety, reflected by complications or death within 90 days after surgery. The study enrolled 31 patients and 26 completed four cycles of 177Lu-DOTATATE. Tumours shrank partially in 18 patients, and in 13 patients the tumour remained the same. No tumours increased in size. The entire tumour was removed in 28 of 29 patients. No patients died, but 72% had some complications (severe in 7 patients). The study found that using 177Lu-DOTATATE before surgery is safe and useful for treating patients with NF-PanNETs. NEOLUPANET was a multicentre, single-arm, phase II trial, conducted between March 2020 and February 2023 at eight Italian institutions. Patients with histologically confirmed sporadic, resectable or potentially resectable, well differentiated non-functioning pancreatic neuroendocrine tumours (NF-PanNETs) at high risk of recurrence, with positive uptake on 68Ga-labelled DOTA PET, were included, and underwent neoadjuvant 177Lu-labelled DOTA0-octreotate (177Lu-DOTATATE) therapy followed by surgical resection. Neoadjuvant treatment with 177Lu-DOTATATE in patients with NF-PanNETs at high risk of recurrence resulted in an acceptable complication rate, with no postoperative death. The majority of patients had a partial response without any progressive disease. [ABSTRACT FROM AUTHOR]

Introduction Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. Materials and Methods This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. Results There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. Conclusions Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system. [ABSTRACT FROM AUTHOR]

Objective The Food and Drug Administration approved the MRI-compatible wireless SCOUT localization system in April 2022. The purpose of this study was to evaluate feasibility of SCOUT localization under MRI guidance. We present our initial experience adopting MRI-guided SCOUT localization and compare it to MRI-guided wire localization. Methods Electronic medical records and imaging were retrospectively reviewed for all patients who underwent MRI-guided SCOUT or wire localization at our institution between October 2022 and July 2023. Statistical analysis was performed using 2-sample proportion and Wilcoxon rank-sum tests. Results There were 14 MRI-guided SCOUT and 23 MRI-guided wire localization cases during the study period. All SCOUTs were placed without complication and were considered to be in adequate proximity to the target. There was no significant difference in complication rate (P = .25) or days lapsed from MRI-detected abnormality to surgery (P = .82) between SCOUT and wire cases. SCOUT was placed at time of biopsy for 71% (10/14) of cases. 57% (8/14) of SCOUT cases were used for breast conservation surgery (BCS) compared to 100% (23/23) of wire cases (P <.01), with all 6 SCOUTs not used for BCS placed at time of biopsy. Conclusion MRI-guided SCOUT localization is feasible and offers an alternative to MRI-guided wire localization, with no SCOUT complications reported. SCOUT placement at time of biopsy obviates the need for an additional procedure, but predicting appropriateness is challenging, with 60% (6/10) of SCOUTs placed at time of MRI-guided biopsy not used for subsequent localization surgery. [ABSTRACT FROM AUTHOR]

Background Mechanical ventilation, as an important respiratory support, plays an important role in general anesthesia and it is the cornerstone of intraoperative management of surgical patients. Different from spontaneous respiration, intraoperative mechanical ventilation can lead to postoperative lung injury, and its impact on surgical mortality cannot be ignored. Postoperative lung injury increases hospital stay and is related to preoperative conditions, anesthesia time, and intraoperative ventilation settings. Method Through reading literature and research reports, the relationship between perioperative input parameters and output parameters related to mechanical ventilation and ventilator-related complications was reviewed, providing reference for the subsequent setting of input parameters of mechanical ventilation and new ventilation strategies. Results The parameters of inspiratory pressure rise time and inspiratory time can change the gas distribution, gas flow rate and airway pressure into the lungs, but there are few clinical studies on them. It can be used as a prospective intervention to study the effect of specific protective ventilation strategies on pulmonary complications after perioperative anesthesia. Conclusion There are many factors affecting lung function after perioperative mechanical ventilation. Due to the difference of human body, the ventilation parameters suitable for each patient are different, and the deviation of each ventilation parameter can lead to postoperative pulmonary complications. Inspiratory pressure rise time and inspiratory time will be used as the new ventilation strategy. [ABSTRACT FROM AUTHOR]

OBJECTIVES Patients undergoing thoracic surgery experience high complication rates. It is uncertain whether preoperative health-related quality of life (HRQOL) measurements can predict patients at higher risk for postoperative complications. The objective of this study was to determine the association between preoperative HRQOL and postoperative complications among patients undergoing thoracic surgery. METHODS This was a retrospective cohort study of prospectively collected data. Consecutive patients undergoing elective thoracic surgery at a Canadian tertiary care centre between January 2018 and January 2019 were included. Patient HRQOL was measured using the Euroqol-5 Dimension (EQ-5D) survey. Complications were recorded using the Ottawa Thoracic Morbidity and Mortality system. Uni- and multivariable analysis were performed. RESULTS Of 515 surgeries performed, 133 (25.8%) patients experienced at least 1 postoperative complication; 345 (67.0%) patients underwent surgery for malignancy. A range of 271 (52.7%) to 310 (60.2%) patients experienced pain/discomfort at each timepoint. On multivariable analysis, lower preoperative EQ-5D visual analogue scale scores were significantly associated with postoperative complications (adjusted odds ratio 0.97, 95% confidence interval 0.95–0.99; P  =   0.01). Presence of malignancy was not independently associated with complications (P  =   0.68). CONCLUSIONS Self-reported preoperative HRQOL can predict incidence of postoperative complications among patients undergoing thoracic surgery. Assessments of preoperative HRQOL may help identify patients at higher risk for developing complications. These findings could be used to direct preoperative risk-mitigation strategies in areas of HRQOL where patients suffer most, such as pain. The full perioperative trajectory of patient HRQOL should be discerned to identify subsets of patients who share common risk factors. [ABSTRACT FROM AUTHOR]

OBJECTIVES Prior studies have associated morbidity following anatomic lung resection with prolonged postoperative length of stay; however, each complication's individual impact on length of stay as a continuous variable has not been studied. The purpose of this study was to determine the risk-adjusted increase in length of stay associated with each individual postoperative complications following anatomic lung resection. METHODS Patients who underwent anatomic lung resection cataloged in the prospectively collected American College of Surgeons National Surgical Quality Improvement Program participant use file, 2005–2018, were targeted. The association between preoperative characteristics, postoperative complications and length of stay in days was tested. A negative binomial model adjusting for the effect of preoperative characteristics and 18 concurrent postoperative complications was used to generate incidence rate ratios. This model was fit to generate risk-adjusted increases in length of stay by complication. RESULTS Of 32 133 patients, 5065 patients (15.8%) experienced at least one post-operative complication. The most frequent complications were pneumonia (n  = 1829, 5.7%), the need for transfusion (n  = 1794, 5.6%) and unplanned reintubation (n  = 1064, 3.3%). The occurrence of each of the 18 individual complications was associated with significantly increased length of stay. This finding persisted after risk-adjustment, with the greatest risk-adjusted increases being associated with prolonged ventilation (+17.4 days), followed by septic shock (+17.2 days), acute renal failure (+16.5 days) and deep surgical site infection (+13.2 days). CONCLUSIONS All 18 postoperative complications studied following anatomic lung resection were associated with significant risk-adjusted increases in length of stay, ranging from an increase of 17.4 days with prolonged ventilation to 2.6 days following the need for transfusion. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of this study is to demonstrate the ability of the Versius surgical system to successfully and safely complete a range of thoracic procedures aligned with Stage 2a (Development) of the Idea, Development, Exploration, Assessment and Long-term follow-up framework for surgical innovation. METHODS This prospective study included the first 30 consecutive patients who underwent robotic surgery with Versius by 2 surgeons without prior robotic experience between 1 April 2023 and 30 December 2023 [25 lung resections (wedge, segmentectomy and lobectomy) and 5 thymectomies]. There were no specific predetermined selection criteria for each case. The primary outcome was safe completion of the procedure without unplanned conversion. Secondary outcomes included intraoperative and postoperative complications, intraoperative device-related outcomes and pathology results. RESULTS Twenty-eight (93.3%) cases were completed without conversion. Both conversions were to thoracoscopy, one due to a 'console alarm' and the other due to pulmonary artery bleeding. In lung resections, median console time was 103 (90–129) min. Five (20%) patients experienced postoperative complications, most frequent was persistent air leak (16%). Median length-of-stay was 3 (2–4) days. Neither readmissions nor mortality was observed. In thymectomies, no intraoperative or postoperative complications, readmissions, reinterventions or mortality were observed. Median console time was 77 (75–89) min and median length of stay was 1 (1–1) day. CONCLUSIONS This phase 2a IDEAL-D study confirms lung resections and thymectomies are feasible with the use of Versius system, laying the foundation for larger phase 2b and 3 clinical studies within the IDEAL-D framework. [ABSTRACT FROM AUTHOR]

Objective The surgical population is ageing and often frail. Frailty increases the risk for poor post-operative outcomes such as delirium, which carries significant morbidity, mortality and cost. Frailty is often measured in a binary manner, limiting pre-operative counselling. The goal of this study was to determine the relationship between categorical frailty severity level and post-operative delirium. Methods We performed an analysis of a retrospective cohort of older adults from 12 January 2018 to 3 January 2020 admitted to a tertiary medical center for elective surgery. All participants underwent frailty screening prior to inpatient elective surgery with at least two post-operative delirium assessments. Planned ICU admissions were excluded. Procedures were risk-stratified by the Operative Stress Score (OSS). Categorical frailty severity level (Not Frail, Mild, Moderate, and Severe Frailty) was measured using the Edmonton Frail Scale. Delirium was determined using the 4 A's Test and Confusion Assessment Method-Intensive Care Unit. Results In sum, 324 patients were included. The overall post-operative delirium incidence was 4.6% (15 individuals), which increased significantly as the categorical frailty severity level increased (2% not frail, 6% mild frailty, 23% moderate frailty; P  < 0.001) corresponding to increasing odds of delirium (OR 2.57 [0.62, 10.66] mild vs. not frail; OR 12.10 [3.57, 40.99] moderate vs. not frail). Conclusions Incidence of post-operative delirium increases as categorical frailty severity level increases. This suggests that frailty severity should be considered when counselling older adults about their risk for post-operative delirium prior to surgery. [ABSTRACT FROM AUTHOR]

Background A proportion of patients undergoing midline laparotomy will develop surgical site infections after surgery. These complications place considerable financial burden on healthcare economies and have negative implications for patient health and quality of life. The prophylactic application of negative pressure wound therapy devices has been mooted as a pragmatic strategy to reduce surgical site infections. Nevertheless, further availability of multicentre randomized clinical trial data evaluating the prophylactic use of negative pressure wound therapy following midline laparotomy is warranted to definitely provide consensus in relation to these closure methods, while also deciphering potential differences among subgroups. The aim of this study is to determine whether prophylactic negative pressure wound therapy reduces postoperative wound complications in patients undergoing midline laparotomy. Methods PROPEL-2 is a multicentre prospective randomized clinical trial designed to compare standard surgical dressings (control arm) with negative pressure wound therapy dressings (Prevena™ and PICO™ being the most commonly utilized). Patient recruitment will include adult patients aged 18 years or over, who are indicated to undergo emergency or elective laparotomy. To achieve 90% power at the 5% significance level, 1006 patients will be required in each arm, which when allowing for losses to follow-up, 10% will be added to each arm, leaving the total projected sample size to be 2013 patients, who will be recruited across a 36-month enrolment period. Conclusion The PROPEL-2 trial will be the largest independent multicentre randomized clinical trial designed to assess the role of prophylactic negative pressure wound therapy in patients indicated to undergo midline laparotomy. The comparison of standard treatment to two commercially available negative pressure wound therapy devices will help provide consensus on the routine management of laparotomy wounds. Enrolment to PROPEL-2 began in June 2023. Registration number: NCT05977816 (http://www.clinicaltrials.gov). [ABSTRACT FROM AUTHOR]

Background Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. Methods A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. Results Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. Conclusion The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer. [ABSTRACT FROM AUTHOR]

Background: Prostate biopsies are mainly performed through transrectal or perineal approaches, while ultrasound probes are located in the rectum for guidance. However, reports on the use of perineal ultrasound-guided transperineal prostate biopsy (PG-TPPB) are few. Methods: A retrospective case-control study was designed. A total of 111 patients who underwent PG-TPPB from February 2019 to December 2020 were investigated retrospectively. Simultaneously, 188 patients who underwent transrectal prostate biopsy (TRPB) were included as control. The prostate cancer detection rates (PCDR), complication rates, and application values were compared between the 2 groups. Results: The overall PCDR in the PG-TPPB and TRPB groups were 33.3% (37/111) and 39.9% (75/188), respectively (P = .258). There was no significant difference in the PCDR between the 2 groups under each prostate-specific antigen level (all P > .05). The single-needle PCDR in the PG-TPPB and TRPB groups were 21.5% (277/1 287) and 24.0% (513/2 134), respectively (P = .091). The incidence of complications in the PG-TPPB group was significantly lower than that in the TRPB group (8.1% vs 21.3%, P = .003). Conclusions: The PCDRs of PG-TPPB and TRPB were the same. However, the postoperative complication rate of PG-TPPB was significantly lower than that of TRPB. Moreover, PG-TPPB required simpler equipment and did not require enema administration, which is suitable for patients with rectal contraindications. Advances in knowledge: The reports on PG-TPPB are few. Our study indicated that PG-TPPB reduced the postoperative complication rate. Moreover, PG-TPPB required simpler equipment. Importantly, PG-TPPB is suitable for patients with rectal contraindications. [ABSTRACT FROM AUTHOR]

Background Adjunctive lung resection is recommended for select patients with nontuberculous mycobacteria (NTM) pulmonary disease (PD). However, data are limited on long-term recurrence rates in patients infected with major pathogens, including Mycobacterium avium complex (MAC) and Mycobacterium abscessus (MABC). Methods In this prospective observational study, we retrospectively analyzed data from 125 patients with MAC-PD (n = 90) or MABC-PD (n = 35) who underwent adjunctive lung resection. We evaluated microbiological response, postoperative complications, recurrence, and all-cause mortality over a median 80-month follow-up. Results Persistent culture positivity (64%) was the most common indication for surgery, followed by hemoptysis, recurrent pneumonia, or radiologic deterioration. Postoperative complications occurred in 18 (14%) patients, with no surgery-related deaths. Treatment outcomes did not significantly differ between the MAC- and MABC-PD groups. Cure with culture conversion was achieved in 112 (90%) patients. Recurrence occurred in 37 (33%) of 112 patients, of which 18 (49%) cases were attributed to reinfection by different NTM species or subspecies. The MAC group had higher recurrence rates than the MABC group (Kaplan-Meier curve, log-rank test, P =.043) and was significantly associated with recurrence in the multivariable analysis (adjusted hazard ratio, 2.71; 95% CI, 1.23–5.99). However, mortality was higher in the MABC-PD group than the MAC-PD group (7/35 vs 4/90, P =.006). Conclusions Adjunctive lung resection with antibiotics helps to reduce bacterial burden and manage symptoms in patients with NTM-PD. However, it does not prevent recurrence, which is mostly caused by reinfection. [ABSTRACT FROM AUTHOR]

Skin-to-skin care (SSC) is an important part of parent and infant care during the neonatal period and into infancy. SSC should be initiated immediately after birth and practiced as a standard of care in all settings, as well as in the home. There is strong evidence that SSC has a positive effect on breastfeeding and human milk feeding in both term and preterm infants, as well as on mortality, cardiopulmonary stability, and thermoregulation. SSC reduces pain and infant stress, enhances parent–infant bonding, has neurodevelopmental benefits, and has positive effects on parental mental health. The safety and feasibility of providing SSC has been established in term and preterm infants, and SSC is recommended as best practice for all infants. The benefits of SSC outweigh the risks in most situations, and despite challenges, care providers should implement procedures and accommodations to ensure that SSC occurs as a safe and positive experience for the parent, family, infant, and health care team. This statement includes all families as defined and determined by themselves, and recognizes that health communication, language, and terminology must be individualized to meet specific family needs by the health care team. [ABSTRACT FROM AUTHOR]

OBJECTIVES Thoracoscopic segmentectomy is the recommended treatment option for small peripheral pulmonary nodules. To assess the ability of preoperative three-dimensional (3D) reconstruction computed tomography (CT) to shorten the operative time and improve perioperative outcomes in thoracoscopic segmentectomy compared with standard chest CT, we conducted this randomized controlled trial. METHODS The DRIVATS study was a multicentre, randomized controlled trial conducted in 3 hospitals between July 2019 and November 2023. Patients with small peripheral pulmonary nodules not reaching segment borders were randomized in a 1:1 ratio to receive either 3D reconstruction CT or standard chest CT before thoracoscopic segmentectomy. The primary end-point was operative time. The secondary end-points included incidence of postoperative complications, intraoperative blood loss and operative accident event. RESULTS A total of 191 patients were enrolled in this study: 95 in the 3D reconstruction CT group and 96 in the standard chest CT group. All patients underwent thoracoscopic segmentectomy except for 1 patient in the standard chest CT group who received a wedge resection. There is no significant difference in operative time between the 3D reconstruction CT group (median, 100 min [interquartile range (IQR), 85–120]) and the standard chest CT group (median, 100 min [IQR, 81–140]) (P  =   0.82). Only 1 intraoperative complication occurred in the standard chest CT group. No significant difference was observed in the incidence of postoperative complications between the 2 groups (P  =   0.52). Other perioperative outcomes were also similar. CONCLUSIONS In patients with small peripheral pulmonary nodules not reaching segment borders, the use of 3D reconstruction CT in thoracoscopic segmentectomy was feasible, but it did not result in significant differences in operative time or perioperative outcomes compared to standard chest CT. [ABSTRACT FROM AUTHOR]

Background Chronic hip pain is one of the most common and difficult-to-treat causes of disability. Our study's primary aim was to investigate the effects of ultrasound and fluoroscopy-guided radiofrequency thermocoagulation of the femoral and obturator nerve articular branches on chronic hip pain, and the secondary aim was to determine its effects on hip function and quality of life. Methods Fifty-three patients with hip pain lasting more than three months were enrolled in the study. VPS scale and WOMAC, SF-12 questionnaires were applied to the patients before and in the first, third, and sixth months following the procedure. Results Of the patients, 60.4% were female, and 39.6% were male. Hip pain was caused by osteoarthritis in 77.1%, postoperative hip pain in 12.5%, malignancy in 8.3%, and avascular necrosis in 2.1%. The VPS scores were 8.9 ± 1.1 (mean±SD) in the baseline period, 2.4 ± 2.5 in the first postoperative week, 3.8 ± 2.5 in the first month, 5.1 ± 2.8 in the third month, and 5.8 ± 2.7 in the sixth month, with a significant decrease in VPS score (P  < .001). One patient developed a motor deficit that improved spontaneously. Conclusions We concluded that radiofrequency thermocoagulation application to the articular branches of the femoral and obturator nerves provides pain relief, hip function improvement, and better quality of life (better physical component scores but no improvement in mental component scores in SF-12) for up to 6 months in chronic hip pain. [ABSTRACT FROM AUTHOR]

Duodenal stump fistula (DSF) is a dangerous complication after gastrectomy. There is no consensus on the management of DSF. Sometimes, emergency surgery may be necessary. We present the case who underwent subtotal gastrectomy with Roux-en-Y reconstruction for advanced gastric cancer. After that surgery, we diagnosed DSF due to pancreatic fistula, and performed reoperation because of hemodynamic instability due to diffuse peritonitis and sepsis. We resected the stump and closed with handsewn suturing and inserted three intra-abdominal drainage tubes, including a dual drainage tube around the duodenal stump. Although there was a recurrence of DSF, because of the continuous and absolute drainage, the patient improved and discharged on postoperative Day 59. From this experience, diligent debridement and a continuous suction dual drainage system, intraluminal drain of the duodenum, and biliary diversion may be an effective surgical management for DFS. [ABSTRACT FROM AUTHOR]

Paragangliomas (PGLs) located around the pancreas are rare and challenging to diagnose preoperatively. Tumor resection with pancreatectomy is often performed for peripancreatic PGL. However, pancreas-sparing tumor resection can be indicated with an accurate preoperative diagnosis. Six patients with pathologically diagnosed peripancreatic PGL were included. The clinical data were retrospectively collected from medical records. Five of them were suspected of peripancreatic PGL on imaging studies due to the fat plane identified between the tumor and pancreas, and subsequently diagnosed with PGL preoperatively based on elevated urinary catecholamine levels and/or metaiodobenzylguanidine scintigraphy without biopsy. All patients underwent pancreas-sparing tumor resection with negative surgical margins, and they did not develop postoperative complications related to potential damage to the pancreas. A fat plane between the tumor and pancreas on imaging studies and hormone levels are key findings for obtaining an accurate preoperative diagnosis of peripancreatic PGL, which can be managed with pancreas-sparing tumor resection. [ABSTRACT FROM AUTHOR]

Background It remains unclear whether the incidence of post-operative acute kidney injury (PO-AKI) has been reduced despite the recent emphasis on its early recognition and prevention in clinical practice. We aimed to investigate the trend in the incidence of PO-AKI and to identify the associated factors affecting its changes. Methods We gathered clinical data from patients who underwent non-cardiac major surgeries at three referral hospitals from 2005 to 2020. PO-AKI was defined as KDIGO AKI criteria within 7 days after surgery. Severe PO-AKI (S-PO-AKI) was defined as stage 2 or 3 AKI. The temporal change of PO-AKI was evaluated by joinpoint regression analysis and multivariable logistic regression based on a 3-year interval. Results Among 138 235 patients, 8156 (5.9%) PO-AKI and 1127 (0.8%) S-PO-AKI occurred, respectively. The patients enrolled in recent years were older and more were women. They had more comorbidities and a higher PO-AKI risk compared with those included in past years. As time passed, the PO-AKI incidence decreased from 8.6% in 2005–07 to 5.1% in 2017–20, whereas S-PO-AKI incidence did not change (0.8% to 0.9%). In joinpoint analysis, PO-AKI incidence tended to decrease with annual percentage change (APC) of –4.2% per year [95% confidence interval (CI) –5.5% to –2.8%, P -value <.001), although S-PO-AKI did not (APC 0.9%, 95% CI –1.1 to 2.9%, P -value = .347). Similarly, the overall PO-AKI incidence decreased but S-PO-AKI did not, even after adjusting covariables. Conclusion The incidence of PO-AKI has decreased recently despite the increase in known risk factors; however, the incidence of S-PO-AKI has not decreased in recent years. Trial registration information ClinicalTrials.gov Identifier: NCT05986474. Name of registry: Development of Synthetic Medical Data Generation Technology to Predict Postoperative Complications. URL: https://classic.clinicaltrials.gov/ct2/show/NCT05986474. Date of registration: 14 August 2023. Date of enrollment of the first participant to the trial: 27 September 2022, retrospectively registered. [ABSTRACT FROM AUTHOR]

Background Postoperative cognitive dysfunction (POCD) manifests as a subtle decline in cognition, potentially leading to unfavourable postoperative outcomes. We explored the impact of POCD on physical function, length of hospital stay (LOS), dementia and mortality outcomes. Methods PubMed and Scopus were searched until May 2023. All studies of major surgical patients that assessed POCD and outcomes of interest were included. POCD effects were stratified by surgery type (cardiac and noncardiac) and time of POCD assessment (<30 and ≥30 days postsurgery). Results Of 2316 studies, 20 met the inclusion criteria. POCD was not associated with functional decline postsurgery. Patients who experienced POCD postcardiac surgery had an increased relative risk (RR) of death of 2.04 [(95% CI: 1.18, 3.50); I 2 = 0.00%]. Sensitivity analyses showed associations with intermediate-term mortality among noncardiac surgical patients, with an RR of 1.84 [(95% CI: 1.26, 2.71); I 2 = 0.00%]. Patients who developed POCD <30 days postcardiac and noncardiac surgeries experienced longer LOS than those who did not [mean difference (MD) = 1.37 days (95% CI: 0.35, 2.39); I 2 = 92.38% and MD = 1.94 days (95% CI: 0.48, 3.40); I 2 = 83.29%, respectively]. Postoperative delirium (POD) may contribute to the heterogeneity observed, but limited data were reported within the studies included. Conclusions Patients undergoing cardiac and noncardiac surgeries who developed POCD <30 days postsurgery had poorer outcomes and an increased risk of premature death. Early recognition of perioperative neurocognitive disorders in at-risk patients may enable early intervention. However, POD may confound our findings, with further studies necessary to disentangle the effects of POD from POCD on clinical outcomes. [ABSTRACT FROM AUTHOR]

Aims To assess pericoronary adipose tissue (PCAT) density on coronary computed tomography angiography (CCTA) as a marker of inflammatory disease activity in coronary allograft vasculopathy (CAV). Methods and results PCAT density, lesion volumes, and total vessel volume-to-myocardial mass ratio (V/M) were retrospectively measured in 126 CCTAs from 94 heart transplant patients [mean age 49 (SD 14.5) years, 40% female] who underwent imaging between 2010 and 2021; age- and sex-matched controls; and patients with atherosclerosis. PCAT density was higher in transplant patients with CAV [ n = 40; −73.0 HU (SD 9.3)] than without CAV [ n = 86; −77.9 HU (SD 8.2)], and controls [ n = 12; −86.2 HU (SD 5.4)], P < 0.01 for both. Unlike patients with atherosclerotic coronary artery disease (n = 32), CAV lesions were predominantly non-calcified and comprised of mostly fibrous or fibrofatty tissue. V/M was lower in patients with CAV than without [32.4 mm3/g (SD 9.7) vs. 41.4 mm3/g (SD 12.3), P < 0.0001]. PCAT density and V/M improved the ability to predict CAV from area under the receiver operating characteristic curve (AUC) 0.75–0.85 when added to donor age and donor hypertension status (P < 0.0001). PCAT density above −66 HU was associated with a greater incidence of all-cause mortality {odds ratio [OR] 18.0 [95% confidence interval (CI) 3.25–99.6], P < 0.01} and the composite endpoint of death, CAV progression, acute rejection, and coronary revascularization [OR 7.47 (95% CI 1.8–31.6), P = 0.01] over 5.3 (SD 2.1) years. Conclusion Heart transplant patients with CAV have higher PCAT density and lower V/M than those without. Increased PCAT density is associated with adverse clinical outcomes. These CCTA metrics could be useful for the diagnosis and monitoring of CAV severity. [ABSTRACT FROM AUTHOR]

Aims To compare the novel 2D multi-velocity encoding (venc) and 4D flow acquisitions with the standard 2D flow acquisition for the assessment of paravalvular regurgitation (PVR) after transcatheter aortic valve replacement (TAVR) using cardiac magnetic resonance (CMR)-derived regurgitant fraction (RF). Methods and results In this prospective study, patients underwent CMR 1 month after TAVR for the assessment of PVR, for which 2D multi-venc and 4D flow were used, in addition to standard 2D flow. Scatterplots and Bland–Altman plots were used to assess correlation and visualize agreement between techniques. Reproducibility of measurements was assessed with intraclass correlation coefficients. The study included 21 patients (mean age ± SD 80 ± 5 years, 9 men). The mean RF was 11.7 ± 10.0% when standard 2D flow was used, 10.6 ± 7.0% when 2D multi-venc flow was used, and 9.6 ± 7.3% when 4D flow was used. There was a very strong correlation between the RFs assessed with 2D multi-venc and standard 2D flow (r = 0.88, P < 0.001), and a strong correlation between the RFs assessed with 4D flow and standard 2D flow (r = 0.74, P < 0.001). Bland–Altman plots revealed no substantial bias between the RFs (2D multi-venc: 1.3%; 4D flow: 0.3%). Intra-observer and inter-observer reproducibility for 2D multi-venc flow were 0.98 and 0.97, respectively, and 0.92 and 0.90 for 4D flow, respectively. Conclusion Two-dimensional multi-venc and 4D flow produce an accurate quantification of PVR after TAVR. The fast acquisition of the 2D multi-venc sequence and the free-breathing acquisition with retrospective plane selection of the 4D flow sequence provide useful advantages in clinical practice, especially in the frail TAVR population. [ABSTRACT FROM AUTHOR]

Objective To conduct a meta-analysis to assess the efficacy of intravascular ultrasound (IVUS) during transjugular intrahepatic portosystemic shunt (TIPS) creation. Methods MEDLINE and Embase databases were queried until July 2022 for comparative studies reporting procedure metrics for TIPS creation with or without IVUS guidance. Meta-analysis was performed with random-effects modelling for total procedural time, time to portal venous access, fluoroscopy time, iodinated contrast volume use, air kerma, dose area product, and number of needle passes. Intraoperative procedure-related complications were also reviewed. Results Of 95 unique records initially identified, 6 were eligible for inclusion. A total of 194 and 240 patients underwent TIPS with and without IVUS guidance. Pooled analyses indicated that IVUS guidance was associated with reduced total procedure time (SMD −0.76 [95% CI −1.02, −0.50] P  < .001), time to portal venous access (SMD −0.41 [95% CI −0.67, −0.15] P  = .002), fluoroscopy time (SMD, −0.54 [95% CI −1.02, −0.07]; P  = .002), contrast volume use (SMD, −0.89 [95% CI −1.16, −0.63]; P  < .001), air kerma (SMD, −0.75 [95% CI −1.11, −0.38]; P  < .001) and dose area product (SMD, −0.98 [95% CI −1.77, −0.20]; P  = .013). A total of 4.2 and 7.8 needle passes were required in the IVUS and non-IVUS group, respectively (SMD, −0.60 [95% CI −1.42, 0.21]; P  = .134). Pooled complication rates were 15.2% (12/79) and 21.4% (28/131), respectively. Conclusion IVUS guidance during TIPS creation improves procedural metrics including procedural time, contrast usage, and radiation exposure. Advances in Knowledge (1) The use of IVUS during TIPS is associated with shorter procedural time, lower contrast usage, and radiation exposure. (2)The use of IVUS is not associated with higher complication rates. [ABSTRACT FROM AUTHOR]

The article discusses the use of stented aortic matrices for tracheal reconstruction in advanced thyroid cancer. The study reports on the outcomes of 12 patients who underwent this procedure and found it to be a safe and effective treatment option for previously unresectable malignancies. The patients had favorable long-term results with no tracheal recurrence and a good quality of life. However, the study acknowledges limitations such as a small sample size and a lack of comparison to non-surgical methods. The authors plan to conduct a larger, randomized trial in the future. [Extracted from the article]

Background Postoperative acute kidney injury (AKI) is a common condition after surgery, however, the available data about nationwide epidemiology of postoperative AKI in China from large and high-quality studies are limited. This study aimed to determine the incidence, risk factors and outcomes of postoperative AKI among patients undergoing surgery in China. Methods This was a large, multicentre, retrospective study performed in 16 tertiary medical centres in China. Adult patients (≥18 years of age) who underwent surgical procedures from 1 January 2013 to 31 December 2019 were included. Postoperative AKI was defined by the Kidney Disease: Improving Global Outcomes creatinine criteria. The associations of AKI and in-hospital outcomes were investigated using logistic regression models adjusted for potential confounders. Results Among 520 707 patients included in our study, 25 830 (5.0%) patients developed postoperative AKI. The incidence of postoperative AKI varied by surgery type, which was highest in cardiac (34.6%), urologic (8.7%) and general (4.2%) surgeries. A total of 89.2% of postoperative AKI cases were detected in the first 2 postoperative days. However, only 584 (2.3%) patients with postoperative AKI were diagnosed with AKI on discharge. Risk factors for postoperative AKI included older age, male sex, lower baseline kidney function, pre-surgery hospital stay ≤3 days or >7 days, hypertension, diabetes mellitus and use of proton pump inhibitors or diuretics. The risk of in-hospital death increased with the stage of AKI. In addition, patients with postoperative AKI had longer lengths of hospital stay (12 versus 19 days) and were more likely to require intensive care unit care (13.1% versus 45.0%) and renal replacement therapy (0.4% versus 7.7%). Conclusions Postoperative AKI was common across surgery type in China, particularly for patients undergoing cardiac surgery. Implementation and evaluation of an alarm system is important for the battle against postoperative AKI. [ABSTRACT FROM AUTHOR]

Background Pancreatoduodenectomy is associated with an increased incidence of surgical-site infections, often leading to a significant rise in morbidity and mortality. This trend underlines the inadequacy of traditional antibiotic prophylaxis strategies. Hence, the aim of this meta-analysis was to assess the outcomes of antimicrobial prophylaxis, comparing piperacillin/tazobactam with traditional antibiotics. Methods Upon registering in PROSPERO, the international prospective register of systematic reviews (CRD42023479100), a systematic search of various databases was conducted over the interval 2000–2023. This inclusive search encompassed a wide range of study types, including prospective and retrospective cohorts and RCTs. The subsequent data analysis was carried out utilizing RevMan 5.4. Results A total of eight studies involving 2382 patients who underwent pancreatoduodenectomy and received either piperacillin/tazobactam (1196 patients) or traditional antibiotics (1186 patients) as antibiotic prophylaxis during surgery were included in the meta-analysis. Patients in the piperacillin/tazobactam group had significantly reduced incidences of surgical-site infections (OR 0.43 (95% c.i. 0.30 to 0.62); P < 0.00001) and major surgical complications (Clavien–Dindo grade greater than or equal to III) (OR 0.61 (95% c.i. 0.45 to 0.81); P = 0.0008). Subgroup analysis of surgical-site infections highlighted significantly reduced incidences of superficial surgical-site infections (OR 0.34 (95% c.i. 0.14 to 0.84); P = 0.02) and organ/space surgical-site infections (OR 0.47 (95% c.i. 0.28 to 0.78); P = 0.004) in the piperacillin/tazobactam group. Further, the analysis demonstrated significantly lower incidences of clinically relevant postoperative pancreatic fistulas (grades B and C) (OR 0.67 (95% c.i. 0.53 to 0.83); P = 0.0003) and mortality (OR 0.51 (95% c.i. 0.28 to 0.91); P = 0.02) in the piperacillin/tazobactam group. Conclusion Piperacillin/tazobactam as antimicrobial prophylaxis significantly lowers the risk of postoperative surgical-site infections, major surgical complications (complications classified as Clavien–Dindo grade greater than or equal to III), clinically relevant postoperative pancreatic fistulas (grades B and C), and mortality, hence supporting the implementation of piperacillin/tazobactam for surgical prophylaxis in current practice. [ABSTRACT FROM AUTHOR]

Background The potential benefits of robotic-assisted compared with laparoscopic surgery for locally advanced cancer have not been sufficiently proven by prospective studies. One factor is speculated to be the lack of strict surgeon criteria. The aim of this study was to assess outcomes for robotic surgery in patients with locally advanced rectal cancer with strict surgeon experience criteria. Methods A criterion was set requiring surgeons to have performed more than 40 robotically assisted operations for rectal cancer. Between March 2020 and May 2022, patients with rectal cancer (distance from the anal verge of 12 cm or less, cT2–T4a, cN0–N3, cM0, or cT1–T4a, cN1–N3, cM0) were registered. The primary endpoint was the rate positive circumferential resection margin (CRM) from the pathological specimen. Secondary endpoints were surgical outcomes, pathological results, postoperative complications, and longterm outcomes. Results Of the 321 registered patients, 303 were analysed, excluding 18 that were ineligible. At diagnosis: stage I (n = 68), stage II (n = 84) and stage III (n = 151). Neoadjuvant therapy was used in 56 patients. There were no conversions to open surgery. The median console time to rectal resection was 170 min, and the median blood loss was 5 ml. Fourteen patients had a positive CRM (4.6%). Grade III-IV postoperative complications were observed in 13 patients (4.3%). Conclusion Robotic-assisted surgery is feasible for locally advanced rectal cancer when strict surgeon criteria are used. [ABSTRACT FROM AUTHOR]

Background Total mesorectal excision (TME) is the standard surgery for low/mid locally advanced rectal cancer. The aim of this study was to compare three minimally invasive surgical approaches for TME with primary anastomosis (laparoscopic TME, robotic TME, and transanal TME). Methods Records of patients undergoing laparoscopic TME, robotic TME, or transanal TME between 2013 and 2022 according to standardized techniques in expert centres contributing to the European MRI and Rectal Cancer Surgery III (EuMaRCS-III) database were analysed. Propensity score matching was applied to compare the three groups with respect to the complication rate (primary outcome), conversion rate, postoperative recovery, and survival. Results A total of 468 patients (mean(s.d.) age of 64.1(11) years) were included; 190 (40.6%) patients underwent laparoscopic TME, 141 (30.1%) patients underwent robotic TME, and 137 (29.3%) patients underwent transanal TME. Comparative analyses after propensity score matching demonstrated a higher rate of postoperative complications for laparoscopic TME compared with both robotic TME (OR 1.80, 95% c.i. 1.11–2.91) and transanal TME (OR 2.87, 95% c.i. 1.72–4.80). Robotic TME was associated with a lower rate of grade A anastomotic leakage (2%) compared with both laparoscopic TME (8.8%) and transanal TME (8.1%) (P = 0.031). Robotic TME (1.4%) and transanal TME (0.7%) were both associated with a lower conversion rate to open surgery compared with laparoscopic TME (8.8%) (P < 0.001). Time to flatus and duration of hospital stay were shorter for patients treated with transanal TME (P = 0.003 and 0.001 respectively). There were no differences in operating time, intraoperative complications, blood loss, mortality, readmission, R0 resection, or survival. Conclusion In this multicentre, retrospective, propensity score-matched, cohort study of patients with locally advanced rectal cancer, newer minimally invasive approaches (robotic TME and transanal TME) demonstrated improved outcomes compared with laparoscopic TME. [ABSTRACT FROM AUTHOR]

Background Major emergency abdominal surgery is associated with a high risk of morbidity and mortality. Given the ageing and increasingly frail population, understanding the impact of frailty on complication patterns after surgery is crucial. The aim of this study was to evaluate the association between clinical frailty and organ-specific postoperative complications after major emergency abdominal surgery. Methods A prospective cohort study including all patients undergoing major emergency abdominal surgery at Copenhagen University Hospital Herlev, Denmark, from 1 October 2020 to 1 August 2022, was performed. Clinical frailty scale scores were determined for all patients upon admission and patients were then analysed according to clinical frailty scale groups (scores of 1–3, 4–6, or 7–9). Postoperative complications were registered until discharge. Results A total of 520 patients were identified. Patients with a low clinical frailty scale score (1–3) experienced fewer total complications (120 complications per 100 patients) compared with patients with clinical frailty scale scores of 4–6 (250 complications per 100 patients) and 7–9 (277 complications per 100 patients) (P < 0.001). A high clinical frailty scale score was associated with a high risk of pneumonia (P = 0.009), delirium (P < 0.001), atrial fibrillation (P = 0.020), and infectious complications in general (P < 0.001). Patients with severe frailty (clinical frailty scale score of 7–9) suffered from more surgical complications (P = 0.001) compared with the rest of the cohort. Severe frailty was associated with a high risk of 30-day mortality (33% for patients with a clinical frailty scale score of 7–9 versus 3.6% for patients with a clinical frailty scale score of 1–3, P < 0.001). In a multivariate analysis, an increasing degree of clinical frailty was found to be significantly associated with developing at least one complication. Conclusion Patients with frailty have a significantly increased risk of postoperative complications after major emergency abdominal surgery, especially atrial fibrillation, delirium, and pneumonia. Likewise, patients with frailty have an increased risk of mortality within 90 days. Thus, frailty is a significant predictor for adverse events after major emergency abdominal surgery and should be considered in all patients undergoing major emergency abdominal surgery. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE) is a serious but rare complication of aesthetic surgery, with an incidence of 0.017% for liposuction and 0.01%–0.02% for augmentation mammoplasty. Despite the low incidence and appropriate patient selection, we present two cases of VTE in low-risk patients without hypercoagulability undergoing aesthetic procedures. In the first case, a 45-year-old woman with a history of anemia developed bilateral pulmonary embolism after ultrasound-assisted liposuction. In the second case, a 33-year-old woman with a history of oral contraceptive use developed deep vein thrombosis in the right upper extremity after augmentation mammoplasty. The patients were treated early and fully recovered after 12 months. This report highlights the importance of early diagnosis and treatment of VTE in aesthetic surgery, even in low-risk patients. [ABSTRACT FROM AUTHOR]

Objective: We retrospectively reviewed the records of rheumatoid arthritis (RA) patients who underwent orthopaedic surgery to examine the influence of the perioperative use of Janus kinase (JAK) inhibitors on early postoperative complications. Patients and Methods: Thirty-two patients with RA under disease control with JAK inhibitors who underwent 49 orthopaedic procedures were included in the study. Patient records after surgery were investigated for surgical site infection (SSI), delayed wound healing (DWH), a flare-up of the disease, preoperative and postoperative absolute lymphocyte counts (ALCs), venous thromboembolism, and other postoperative complications. Results: JAK inhibitors were continued during the perioperative period in 31 procedures. In the remaining 18 procedures, JAK inhibitors were discontinued perioperatively with a mean discontinuation period of 2.4 days. No instances of SSI were identified in any patient during at least 90 days' follow-up, while DWH was seen in one patient. Disease flare-up was noted in two patients after 3 and 9 days of discontinuation of JAK inhibitors, respectively. The ALCs significantly decreased on postoperative Day 1 (P < .0001), and there was a significant correlation between pre- and post-one-day ALCs (r = 0.75, P < .0001). Conclusion: JAK inhibitors seem to be safe during the perioperative period of orthopaedic surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVES Robotic thymectomy has been suggested and considered technically feasible for thymic tumours. However, because of small-sample series and the lack of data on long-term results, controversies still exist on surgical and oncological results with this approach. We performed a large national multicentre study sought to evaluate the early and long-term outcomes after robot-assisted thoracoscopic thymectomy in thymic epithelial tumours. METHODS All patients with thymic epithelial tumours operated through a robotic thoracoscopic approach between 2002 and 2022 from 15 Italian centres were enrolled. Demographic characteristics, clinical, intraoperative, postoperative, pathological and follow-up data were retrospectively collected and reviewed. RESULTS There were 669 patients (307 men and 362 women), 312 (46.6%) of whom had associated myasthenia gravis. Complete thymectomy was performed in 657 (98%) cases and in 57 (8.5%) patients resection of other structures was necessary, with a R0 resection in all but 9 patients (98.6%). Twenty-three patients (3.4%) needed open conversion, but no perioperative mortality occurred. Fifty-one patients (7.7%) had postoperative complications. The median diameter of tumour resected was 4 cm (interquartile range 3–5.5 cm), and Masaoka stage was stage I in 39.8% of patients, stage II in 56.1%, stage III in 3.5% and stage IV in 0.6%. Thymoma was observed in 90.2% of patients while thymic carcinoma occurred in 2.8% of cases. At the end of the follow-up, only 2 patients died for tumour-related causes. Five- and ten-year recurrence rates were 7.4% and 8.3%, respectively. CONCLUSIONS Through the largest collection of robotic thymectomy for thymic epithelial tumours we demonstrated that robot-enhanced thoracoscopic thymectomy is a technically sound and safe procedure with a low complication rate and optimal oncological outcomes. [ABSTRACT FROM AUTHOR]

Introduction Post-operative delirium (POD) is a common complication in older patients, with an incidence of 14–56%. To implement preventative procedures, it is necessary to identify patients at risk for POD. In the present study, we aimed to develop a machine learning (ML) model for POD prediction in older patients, in close cooperation with the PAWEL (patient safety, cost-effectiveness and quality of life in elective surgery) project. Methods The model was trained on the PAWEL study's dataset of 878 patients (no intervention, age ≥ 70, 209 with POD). Presence of POD was determined by the Confusion Assessment Method and a chart review. We selected 15 features based on domain knowledge, ethical considerations and a recursive feature elimination. A logistic regression and a linear support vector machine (SVM) were trained, and evaluated using receiver operator characteristics (ROC). Results The selected features were American Society of Anesthesiologists score, multimorbidity, cut-to-suture time, estimated glomerular filtration rate, polypharmacy, use of cardio-pulmonary bypass, the Montreal cognitive assessment subscores 'memory', 'orientation' and 'verbal fluency', pre-existing dementia, clinical frailty scale, age, recent falls, post-operative isolation and pre-operative benzodiazepines. The linear SVM performed best, with an ROC area under the curve of 0.82 [95% CI 0.78–0.85] in the training set, 0.81 [95% CI 0.71–0.88] in the test set and 0.76 [95% CI 0.71–0.79] in a cross-centre validation. Conclusion We present a clinically useful and explainable ML model for POD prediction. The model will be deployed in the Supporting SURgery with GEriatric Co-Management and AI project. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to conduct a systematic and comprehensive review of qualitative research to examine the physical and psychological needs, as well as work experiences, of patients undergoing total knee replacement and total hip replacement surgeries during their process of returning to work. Methods A systematic review and meta-synthesis of qualitative literature was conducted. A systematic search was conducted across 8 databases to identify qualitative or mixed-methods research on the needs and experiences of individuals with total knee replacement and total hip replacement who have returned to work. The search period extended from the inception of each database to March 2023. Two researchers independently utilized a predetermined search strategy to retrieve relevant English-language studies published in any year. The included studies were assessed for quality using the Critical Appraisal Skills Program appraisal tool. Findings from the studies were then summarized and integrated using the pooled integration method. Results There were 10 studies in total. Three key themes were identified from the original research: needs during the return to work process and rehabilitation training, faith and support to return to work, and constraints and challenges at work. Conclusion Health care professionals and employers should conscientiously consider the physical and psychological requirements of patients who have undergone total knee replacement and total hip replacement when they are resuming work, taking into account the specific constraints and challenges that may arise in the workplace. To ensure a seamless transition back to work, it is essential to develop tailored occupational interventions, implement comprehensive return to work programs, and offer patients sufficient understanding and support. Impact The findings of this study offer valuable insights into the physical and psychological needs, as well as the work experiences, of patients who have undergone total knee replacement and total hip replacement during their reintegration into the workforce. These findings have the potential to assist health care professionals and employers in providing enhanced support to facilitate successful return-to-work outcomes for patients. [ABSTRACT FROM AUTHOR]

Background: Gender-affirming colovaginoplasty (GACv) presents excellent postoperative results. However, neovaginal spasms, reported as painful cramps, can affect the sexual life of patients. Aim: The study sought to describe an innovative surgical technique and evaluate its impact on the prevention and treatment of neovaginal spasms. Methods: This was a single-center prospective observational study with 2 series of patients: (1) patients who underwent GACv with double myotomy (DM) for spasm prevention (series A), in which longitudinal myotomies were performed across the defunctionalized colon, transecting the taenias, and resecting 2 strips of the intestinal muscle layer of approximately 1- to 2-mm wide and tall, leaving intact colonic tissue between strips; and (2) patients who reported neovaginal spasms in whom intravaginal-DM was performed as treatment surgery (series B), in which the posterior wall of the neovagina was dissected from the rectum and transected by longitudinal myotomies, resecting 2 strips of endoluminal mucosa and submucosal muscle of approximately 1- to 2-mm wide and tall, and the colonic mucosa was subsequently closed. Outcomes: Patient-reported outcomes and neovaginal examination were performed following standardized protocols. Results: In series A, 177 patients underwent GACv with the DM technique and were prospectively followed for a median time of 18 months (interquartile range, 13-60 months). No patients reported neovaginal spasms. In series B, 18 patients who reported neovaginal spasms after GACv were treated with intravaginal DM. After a median time of 35 months (interquartile range, 26-45 months), 83% (n = 15 of 18) reported remission of symptoms. Clinical implications: Double longitudinal myotomy performed on the derived portion of the colon in colovaginoplasty is an easy-to-perform and safe technique that may prevent and treat postoperative neovaginal spasms. Strengths and limitations: Our results presented certain limitations, mainly associated with a low prevalence of neovaginal spasms, which, being of personal perception, can be underdiagnosed. To the same extent, the fact that it is a monocentric experience limits the possibility of extrapolating it to other centers. Moreover, a more trained surgical team may be the cause of fewer postoperative complications. On the other hand, the fact of being a reference center for gender-affirming surgery, having our procedures protocolized, and the prospective nature of the study allowed us to obtain a certain homogeneity and granularity of the results. Conclusion: DM is a safe procedure and appears to be highly effective for the prevention and treatment of neovaginal spasms after GACv. Routine use of this technique does not increase the operating time or postoperative complications. Multicenter, prospective studies are required to validate our results. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To assess the feasibility and safety of uniportal video-assisted thoracoscopic pulmonary segmentectomy compared with lobectomy by studying early postoperative outcomes. METHODS We included all patients who underwent uniportal segmentectomy and lobectomy between 2017 and 2022 at Karolinska University Hospital. Early clinical outcomes were compared between the uniportal segmentectomy and lobectomy groups. Differences in baseline characteristics were addressed using inverse probability of treatment weighting. RESULTS A total of 833 patients (232 segmentectomy, 601 lobectomy) were included. The number of uniportal operations increased during the study period. Patients in the segmentectomy and lobectomy groups, respectively, had stage I lung cancer in 65% and 43% of the cases; 97% and 94% had no postoperative complications, the median number of lymph node stations sampled was 4 vs 5, and non-radical microscopic resection occurred in 1.7% vs 1.8%. The drains were removed on postoperative day 1 in 75% vs 72% of the patients following segmentectomy and lobectomy, respectively, and 90% vs 89% were discharged directly home. CONCLUSIONS Uniportal video-assisted segmentectomy was performed with similar early postoperative clinical results compared with uniportal lobectomy in patients with benign, metastatic or early-stage lung cancer. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES To investigate the postoperative outcomes of lung resection in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and determine the optimal timing of surgery. METHODS This retrospective, single-centre cohort study included patients who underwent lung resection between June 2021 and June 2022. Patients were divided into the coronavirus disease 2019 (COVID-19) and non-COVID-19 groups based on their preoperative SARS-CoV-2 infection history, and postoperative outcomes were compared. Logistic regression analysis was conducted to identify the risk factors of complications after lung resection surgery. RESULTS In total, 1194 patients were enrolled, of whom, 79 had a history of SARS-CoV-2 infection. In the COVID-19 group, 66 patients (90.4%) had received at least 1 vaccination dose. The average interval between infection and surgery was 67 days, with no significant impact on postoperative outcomes. Regarding postoperative outcomes, there were no significant differences in major complication rate (6.3% vs 5.4%, P = 0.613), respiratory complication rate (19.0% vs 12.2%, P  = 0.079) or length of stays (4.9 ± 3.4 vs 5.0 ± 5.6, P  =   0.992) between the 2 groups. Multivariate logistic regression analysis revealed that age, male sex, poor pulmonary function test, open surgery and extensive lung resection were risk factors for postoperative complications, while preoperative COVID-19 infection status was not a statistically significant risk factor. CONCLUSIONS In the post-vaccination era, lung resection surgery can be safely performed shortly after SARS-CoV-2 infection, even within 4 weeks of infection. [ABSTRACT FROM AUTHOR]

OBJECTIVES Lung volume reduction surgery (LVRS) is an established therapeutic option for advanced emphysema. To improve patients' safety and reduce complications, an enhanced recovery protocol (ERP) was implemented. This study aims to describe and evaluate the short-term outcome of this ERP. METHODS This retrospective single-centre study included all consecutive LVRS patients (1 January 2017 until 15 September 2020). An ERP for LVRS was implemented and stepwise optimised from 1 August 2019, it consisted of changes in pre-, peri- and postoperative care pathways. Patients were compared before and after implementation of ERP. Primary outcome was incidence of postoperative complications (Clavien-Dindo), and secondary outcomes included chest tube duration, incidence of prolonged air leak (PAL), length of stay (LOS) and 90-day mortality. Lung function and exercise capacity were evaluated at 3 and 6 months post-LVRS. RESULTS Seventy-six LVRS patients were included (pre-ERP: n =41, ERP: n =35). The ERP cohort presented with lower incidence of postoperative complications (42% vs 83%, P =0.0002), shorter chest tube duration (4 vs 12 days, P <0.0001) with a lower incidence of PAL (21% vs 61%, P =0.0005) and shorter LOS (6 vs 14 days, P <0.0001). No in-hospital mortality occurred in the ERP cohort versus 4 pre-ERP. Postoperative forced expiratory volume in 1 s was higher in the ERP cohort compared to pre-ERP at 3 months (1.35 vs 1.02 l) and at 6 months (1.31 vs 1.01 l). CONCLUSIONS Implementation of ERP as part of a comprehensive reconceptualisation towards LVRS, demonstrated fewer postoperative complications, including PAL, resulting in reduced LOS. Improved short-term functional outcomes were observed at 3 and 6 months. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The optimal surgical strategy for primary spontaneous pneumothorax remains a matter of debate and variation in surgical practice is expected. This variation may influence clinical outcomes, such as postoperative complications and length of stay. This national population-based registry study provides an overview and extent of variability of current surgical practice and outcomes in the Netherlands. METHODS To identify national patterns of care and between-hospital variability in the treatment of primary spontaneous pneumothorax, patients who underwent surgical pleurodesis and/or bullectomy between 2014 and 2021, were identified from the Dutch Lung Cancer Audit—Surgery database. The type of surgical intervention, postoperative complications, length of stay and ipsilateral recurrences were recorded. RESULTS AND CONCLUSIONS Out of 4338 patients, 1851 patients were identified to have primary spontaneous pneumothorax. The median age was 25 years (interquartile range 20–31) and 82% was male. The most performed surgical procedure was bullectomy with pleurodesis (83%). The overall complication rate was 12% (Clavien–Dindo grade ≥III 6%), with the highest recorded incidence for persistent air leak >5 days (5%). Median postoperative length of stay was 4 days (interquartile range 3–6) and 0.7% underwent a repeat pleurodesis for ipsilateral recurrence. Complication rate and length of stay differed considerably between hospitals. There were no differences between the surgical procedures. In the Netherlands, surgical patients with primary spontaneous pneumothorax are preferably treated with bullectomy plus pleurodesis. Postoperative complications and length of stay vary widely and are considerable in this young patient group. This may be reduced by optimization of surgical care. [ABSTRACT FROM AUTHOR]

Introduction Interspinous process devices (IPDs) were developed as minimally invasive alternatives to open decompression surgery for spinal stenosis. However, given high treatment failure and reoperation rates, there has been minimal adoption by spine surgeons. This study leveraged a national claims database to characterize national IPD usage patterns and postoperative outcomes after IPD implantation. Method Using the PearlDiver database, we identified all patients who underwent 1- or 2-level IPD implantation between 2010 and 2018. Univariate and multivariable logistic regression was performed to identify predictors of the number of IPD levels implanted and reoperation up to 3 years after the index surgery. Right-censored Kaplan-Meier curves were plotted for duration of reoperation-free survival and compared with log-rank tests. Results Patients (n  = 4865) received 1-level (n  = 3246) or 2-level (n  = 1619) IPDs. Patients who were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.01–1.03, P  < .001), male (aOR 1.31, 95% CI 116–1.50, P  < .001), and obese (aOR 1.19, 95% CI 1.05–1.36, P  < .01) were significantly more likely to receive a 2-level IPD than to receive a 1-level IPD. The 3-year reoperation rate was 9.3% of patients when mortality was accounted for during the follow-up period. Older age decreased (aOR 0.97, 95% CI 0.97–0.99, P  = .0039) likelihood of reoperation, whereas 1-level IPD (aOR 1.37, 95% CI 1.01–1.89, P  = .048), Charlson Comorbidity Index (aOR 1.07, 95% CI 1.01–1.14, P  = .018), and performing concomitant open decompression increased the likelihood of reoperation (aOR 1.68, 95% CI 1.35–2.09, P  = .0014). Conclusion Compared with 1-level IPDs, 2-level IPDs were implanted more frequently in older, male, and obese patients. The 3-year reoperation rate was 9.3%. Concomitant open decompression with IPD placement was identified as a significant risk factor for subsequent reoperation and warrants future investigation. [ABSTRACT FROM AUTHOR]

Aims Atrial fibrillation (AF) symptom relief is a primary indication for catheter ablation, but AF symptom resolution is not well characterized. The study objective was to describe AF symptom documentation in electronic health records (EHRs) pre- and post-ablation and identify correlates of post-ablation symptoms. Methods and results We conducted a retrospective cohort study using EHRs of patients with AF (n = 1293), undergoing ablation in a large, urban health system from 2010 to 2020. We extracted symptom data from clinical notes using a natural language processing algorithm (F score: 0.81). We used Cochran's Q tests with post-hoc McNemar's tests to determine differences in symptom prevalence pre- and post-ablation. We used logistic regression models to estimate the adjusted odds of symptom resolution by personal or clinical characteristics at 6 and 12 months post-ablation. In fully adjusted models, at 12 months post-ablation patients, patients with heart failure had significantly lower odds of dyspnoea resolution [odds ratio (OR) 0.38, 95% confidence interval (CI) 0.25–0.57], oedema resolution (OR 0.37, 95% CI 0.25–0.56), and fatigue resolution (OR 0.54, 95% CI 0.34–0.85), but higher odds of palpitations resolution (OR 1.90, 95% CI 1.25–2.89) compared with those without heart failure. Age 65 and older, female sex, Black or African American race, smoking history, and antiarrhythmic use were also associated with lower odds of resolution of specific symptoms at 6 and 12 months. Conclusion The post-ablation symptom patterns are heterogeneous. Findings warrant confirmation with larger, more representative data sets, which may be informative for patients whose primary goal for undergoing an ablation is symptom relief. [ABSTRACT FROM AUTHOR]

Purpose Cobalt metallosis is a rare but dangerous complication of total joint arthroplasty resulting from deterioration of the joint leading to metal-on-metal friction and breakdown. Potential manifestations vary in severity and include dilated cardiomyopathy, thyroid dysfunction, cognitive disturbances, neuropathy, fatigue, and weakness. The therapeutic role of N -acetylcysteine in metallosis has been investigated due to its ability to chelate with heavy metal ions, such as cobalt and chromium. Summary Here we report the case of a 71-year-old female who presented with suspected metallosis diagnosed in the outpatient setting due to symptoms of significant weight loss and failure to thrive. This metallosis was secondary to the hardware breakdown of a left knee revision roughly 6 years previously. The patient was not a surgical candidate due to her poor nutrition status and was started on nasojejunal tube feeds along with N -acetylcysteine 600 mg by mouth twice daily for 45 days. The patient's serum cobalt levels decreased from 61.7 µg/L on admission to 16.2 µg/L prior to her undergoing proper revision of the left knee roughly 2 months after admission to the hospital. The patient tolerated treatment well and was able to be discharged the day after surgery, with no further complaints or complications. Conclusion This case report contributes to the body of literature suggesting that administration of N -acetylcysteine can reduce serum cobalt concentrations, without notable adverse effects, in the context of prosthetic knee–associated metallosis. [ABSTRACT FROM AUTHOR]

Background It has previously been reported that there are similar reoperation rates after elective colorectal surgery but higher failure-to-rescue (FTR) rates in low-volume hospitals (LVHs) versus high-volume hospitals (HVHs). This study assessed the effect of hospital volume on reoperation rate and FTR after reoperation following elective colorectal surgery in a matched cohort. Methods Population-based retrospective multicentre cohort study of adult patients undergoing reoperation for a complication after an elective, non-centralized colorectal operation between 2006 and 2017 in 11 hospitals. Hospitals were divided into either HVHs (3 hospitals, median ≥126 resections per year) or LVHs (8 hospitals, <126 resections per year). Patients were propensity score–matched (PSM) for baseline characteristics as well as indication and type of elective surgery. Primary outcome was FTR. Results A total of 6428 and 3020 elective colorectal resections were carried out in HVHs and LVHs, of which 217 (3.4%) and 165 (5.5%) underwent reoperation (P < 0.001), respectively. After PSM, 142 patients undergoing reoperation remained in both HVH and LVH groups for final analyses. FTR rate was 7.7% in HVHs and 10.6% in LVHs (P = 0.410). The median Comprehensive Complication Index was 21.8 in HVHs and 29.6 in LVHs (P = 0.045). There was no difference in median ICU-free days, length of stay, the risk for permanent ostomy or overall survival between the groups. Conclusion The reoperation rate and postoperative complication burden was higher in LVHs with no significant difference in FTR compared with HVHs. [ABSTRACT FROM AUTHOR]