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Purpose: To evaluate the effect of continuous perioperative clopidogrel treatment on the osseointegration of titanium implants. Materials and Methods: A total of 32 New Zealand rabbits were randomly divided between two groups: a clopidogrel group (n = 16) and a control group (n = 16). For 1 week prior to the surgical placement of a titanium implant in their medial femoral condyle, rabbits in the clopidogrel group received 3 mg/kg of clopidogrel daily, and the control group received only the vehicle. This treatment was continued for another 6 weeks postoperatively. At 6 weeks, the rabbits were euthanized and postmortem histologic and histomorphometric evaluation of the implants was performed. Results: The surgical procedures and postoperative period were uneventful and well tolerated by all animals without any surgical wound dehiscence, signs of infection, or other complication. No implant failure was observed in any of the groups. Histomorphometric analysis showed that bone-to-implant contact (BIC) was 48.77% for the clopidogrel group and 34.65% for the control group, with statistically significant difference between them (P < .001). Moreover, clopidogrel group had significantly greater bone tissue density (40.52% vs 28.74%, respectively; P <.001) and mean trabecular thickness (284.7 μm vs 180.7 μm, respectively; P < .001) in proximity to the implant surface than the control group, while the mean trabecular number had no difference between groups (1.56 vs 1.60, respectively; P = .961). Conclusions: The present study showed that continuous clopidogrel treatment does not negatively affect osseointegration, but rather promotes it in terms of BIC and bone density around the titanium implants. Further studies on the effect of the P2Y12 receptor and its antagonists on peri-implant bone homeostasis may provide useful information or applications for long-term success of dental implant therapy. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Across specialties, surgeons over-prescribe opioids to patients after surgery. We aimed to develop and implement an evidence-based calculator to inform post-discharge opioid prescription size for gynecologic oncology patients after laparotomy. METHODS: In 2021, open surgical gynecologic oncology patients were called 2-4 weeks after surgery to ask about their home opioid use. This data was used to develop a calculator for post-discharge opioid prescription size using two factors: 1) age of the patient, 2) oral morphine equivalents (OME) used by patients the day before hospital discharge. The calculator was implemented on the inpatient service from 8/21/22 and patients were contacted 2-4 weeks after surgery to again assess their opioid use at home. RESULTS: Data from 95 surveys were used to develop the opioid prescription size calculator and are compared to 95 post-intervention surveys. There was no difference pre- to post-intervention in demographic data, surgical procedure, or immediate postoperative recovery. The median opioid prescription size decreased from 150 to 37.5 OME (p

BACKGROUND: Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. METHODS: Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. RESULTS: Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4 h before and 24 h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24 h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24 h, hourly neurologic assessments for at least 12 h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. CONCLUSIONS: In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the role of continuous electroencephalography in postoperative moyamoya care, optimal perioperative blood pressure and hemoglobin targets, and the role of supplemental oxygen for treatment of suspected postoperative ischemia.

Background: Research indicates that prehabilitation is effective in optimizing physical status before surgery, although this method may be considered "aggressive" for frail elderly patients. This study aimed to evaluate whether multimodal prehabilitation decreases postoperative complications and improves functional recovery in frail elderly patients undergoing gastric cancer surgery, in comparison to usual clinical care. Methods: This study was a single-center, single-blind, randomized controlled trial. Patients over 65 years old with a Fried Frailty Index of 2 or higher, scheduled for gastric cancer surgery, were considered for inclusion. Eligible participants were randomized in a 1:1 ratio to either the intervention or control group. The intervention group underwent a 3-week multimodal prehabilitation program prior to surgery, in addition to perioperative care guided by ERAS protocols. The control group received only the latter. The primary outcome was the comprehensive complications index (CCI) measured at 30 days after surgery. Secondary outcomes included 30-day overall complications, functional walking capacity as assessed by 6-minute walking distance (6MWD) at 4 weeks postoperatively, and 3-month postoperative quality of life. This study was registered at ClinicalTrials.gov (No. NCT06510088). Results: Among the 112 eligible patients, the median age was 74 years, with 58 (52.7%) being female. No between-group difference was found in the primary outcome measure, 30-day CCI. The Median (Q1-Q3) CCI for the intervention and control groups was 0 (0-12.2) and 0 (0-22.6) (P = 0.082), while the mean (SD) CCI was 6.1 (15.8) and 9.8 (12.7), respectively (P = 0.291). Notably, the incidence of severe complications (CCI > 20) was significantly lower in the intervention group compared to the control group (11.1% vs. 25.9%, P = 0.046), particularly in terms of medical complications (12.3% vs. 29.3%, P = 0.025). Preoperatively, 27 patients (47.4%) in the intervention group exhibited an increase in the 6MWD of at least 20 m, compared to 16 patients (27.6%) in the control group (P = 0.028). At 4 weeks postoperatively, more patients in the intervention group returned to their baseline 6MWD levels (63.2% vs. 43.1%, P = 0.031). Secondary parameters of functional capacity in the postoperative period generally favored the multimodal prehabilitation approach. Conclusions: In frail elderly patients undergoing elective gastric cancer surgery, a prehabilitation program did not affect the 30-day postoperative complication rate or CCI but reduced severe complications and improved perioperative functional capacity. Trial registration: [ClinicalTrials.gov], [NCT06510088], [07/15/2024], [Retrospectively registered] [ABSTRACT FROM AUTHOR]

This study aimed to assess the safety and feasibility of the Robocare nursing model in patients undergoing da Vinci robot-assisted radical gastrectomy for gastric cancer. A total of 68 patients who underwent da Vinci robot-assisted radical gastrectomy for gastric cancer in our department from January 2022 to June 2022 were enrolled in this study and were assigned to a control group (n = 34) and an intervention group (n = 34). The control group received standard perioperative nursing care, while the intervention group received the Robocare model along with standard care. We compared the differences in postoperative hospital stay length, the incidence of postoperative complications, readmission rates within one month after discharge, and satisfaction with nursing care between the two groups. Compared to the control group, patients in the intervention group exhibited a significantly shorter postoperative hospital stay (mean 8.94 days vs. 9.76 days, P < 0.05) without an increase in the incidence of postoperative complications (26.5% vs. 29.4%, P > 0.05). In addition, there was no significant difference in readmission rates within 1 month after discharge between the two groups (14.7% vs. 5.9%, P > 0.05). Patient satisfaction was significantly higher in the intervention group compared to the control group (96.34% vs. 91.96%, P < 0.05). The implementation of the Robocare nursing model for patients undergoing da Vinci robot-assisted radical gastrectomy for gastric cancer may reduce the length of postoperative hospital stays without increasing the incidence of postoperative complications, while also enhancing patient satisfaction with nursing care. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsConclusionsA chronic subdural haematoma (cSDH) is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway.Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care.We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across eight major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery.We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care. [ABSTRACT FROM AUTHOR]

The increasing incidence of surgical site infections (SSIs) following caesarean sections highlights the necessity for updated protocols that address risk factors throughout the preoperative, intraoperative, and postoperative stages. Negative Pressure Wound Therapy (NPWT) and hydrocolloid dressings have demonstrated potential for improving wound management and reducing complications, particularly by enhancing dressing integrity. Nevertheless, the application of NPWT requires careful consideration and adherence to local trust guidelines to ensure both its safety and efficacy. [ABSTRACT FROM AUTHOR]

Background: There is a need for improved methodologies on how to longitudinally analyze, interpret and learn from the Surveys on Patient Safety Culture™ (SOPS), developed by the Agency for Healthcare Research and Quality (AHRQ). Typically, SOPS quantify results by the percentage of positive responses, but this approach may miss insights from neutral or negative feedback. Study design: The SOPS were distributed every two years from 2011 to 2022 to all hospital staff at one academic institution from perioperative services. Differences between rates of "positive" and "negative" scores ("Delta"), and "neutral" responses over time were calculated. The coefficient of determination (R 2) was used to assess the correlation strength of the positive scores as the primary outcomes provided by the SOPS and Delta values over time. Finally, we evaluated patterns (crossing and converging [indicating "worrisome" patterns] vs. diverging [suggesting "desirable" pattern] vs. stable [suggesting "neutral" pattern]) of the longitudinal scores. Results: A total of 1,035 responses were analyzed [51 and 40 survey items for SOPS v1 and v2 (2022 only), respectively]. Comparing the R 2 values of the positive only scores to the Delta scores demonstrated a change in effect size for "Nonpunitive Response to Error" (R 2 = 0.290 vs. 0.420). Of the 13 specific categories measured through SOPS, plotting negative vs. positive values elucidated 2 crossing, 2 converging and 2 diverging patterns indicating both a decrease in positive responses and an increase in negative responses rather than neutral. Conclusion: Longitudinal analysis of the SOPS using the directional measures, Delta and pattern trends can provide organizations with additional key insights regarding culture of patient safety. [ABSTRACT FROM AUTHOR]

Background: This paper evaluates endoscopic stapedotomy from the perspectives of a group of 3 surgeons, each of whose experience in endoscopic and microscopic stapedotomy is 3 years and more than 12 years, respectively. Methods: Thirty-four patients clinically diagnosed with stapedial otosclerosis were alternately assigned for unilateral, microscope- and endoscope-assisted stapedotomy following the selection criteria given. Results were evaluated with predetermined epidemiologic, preoperative, perioperative, and postoperative outcome parameters. Results: The microscope group had 12 ears with otosclerosis and the endoscope-assisted group 14. Ears found to have conditions other than otosclerosis at surgery, and patients lost to follow-up were excluded. Apart from the operative time, the difference in the results of none of the parameters was statistically significant in the two groups. The average operative times for microscope- and endoscope-assisted stapedotomy were 63 minutes and 86.5 minutes, respectively, the difference being statistically significant (P <.001). Conclusions: From the perspectives of otologists in differential positions in the learning curve for microscope- and endoscope-assisted stapedotomy, there were no statistically significant differences between the two procedures in the execution of the steps to achieve "adequate surgical exposure" and in postoperative outcomes, except for operative time. [ABSTRACT FROM AUTHOR]

Background: Distal femoral varus osteotomy (DFVO) is an established surgical procedure for addressing valgus malalignment across various knee conditions. However, the effect of DFVO on stress distribution within the femorotibial joint has not been explored through in vivo studies. Purpose: To (1) explore the distribution pattern of subchondral bone density across the proximal tibia in nonarthritic knees without arthritis and in those of patients with valgus knees, (2) assess changes in the pattern of bone density distribution in patients with valgus knees before and after medial closing-wedge (MCW) DFVO, and (3) determine the correlation between leg alignment and changes in bone density distribution. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively analyzed clinical and radiographic data from 14 patients (14 knees; mean age, 44 years; 3 men, 11 women) treated with MCW-DFVO for lateral compartment osteoarthritis (OA) due to valgus malalignment, alongside a control group of 18 patients (18 knees; mean age, 21 years; 4 men, 14 women) without OA. The distribution patterns of subchondral bone density distribution on the femorotibial articular surface of the tibia were examined both preoperatively and >1 year postoperatively using computed tomography osteoabsorptiometry. Quantitative analyses were conducted on the locations and percentages of the high-density areas (HDAs) on the articular surface. The mean time between surgery and the postoperative radiograph and computed tomography absorptiometry imaging was 13.6 months (range, 11-19 months). The mean length of clinical follow-up was 28.7 months (range, 14-62 months) after surgery. Results: The mean proportion of HDA in the lateral compartment relative to the total HDA (lateral ratio) was significantly greater in the preoperative OA group (58.8%) compared with the control group (41.1%) (P <.001). After MCW-DFVO, the mean lateral ratio in the OA group notably declined to 45.3% (P <.001). The lateral ratio exhibited a significant correlation with the hip-knee-ankle angle in both the control (r = 0.630; P =.011) and OA (r = 0.537; P =.047) groups. Moreover, the alteration in the lateral ratio after MCW-DFVO showed a significant relationship with changes in the hip-knee-ankle angle (r = 0.742; P =.002) and the mechanical lateral distal femoral angle (r = −0.752; P =.002). Within the lateral compartment, HDAs in the 3 lateral regions of the 4 lateral subregions diminished after MCW-DFVO, whereas in the medial compartment, HDAs in the 3 lateral subregions saw an increase. Conclusion: The mean lateral ratio was significantly greater in the preoperative OA group compared with the control group. MCW-DFVO resulted in a redistribution of HDA from the lateral to the medial compartment of the proximal tibial articular surface. The extent of alignment correction after MCW-DFVO was closely linked to the shifts in HDA distribution, reflecting changes in stress distribution. [ABSTRACT FROM AUTHOR]

Background: Osteochondral allograft transplantation (OCAT) has become a standard-of-care treatment option for patients with large symptomatic articular defects. Recent advances in allograft science and OCAT protocols have been reported to result in consistently robust outcomes after OCAT in the knee. However, only short-term comparisons have been reported, and analyses are lacking for treatment failure risk factors that account for confounding variables. Hypothesis: Midterm functional graft survival rate would exceed 80% for all OCATs combined, with consideration of risk factors for lower survivorship including older patient age, higher body mass index (BMI), tibiofemoral bipolar OCAT, and nonadherence to prescribed postoperative rehabilitation protocols. Study Design: Case series; Level of evidence, 4. Methods: Patients with outcome data available at ≥5 years after primary OCAT using high chondrocyte–viability (HCV) osteochondral allografts were analyzed according to 2 clinically relevant definitions: (1) initial treatment failure, defined by revision or arthroplasty surgery performed for the primary OCAT at any time point during the study period; and (2) functional graft failure, defined by documented conversion to arthroplasty after primary or revision OCAT at any time point during the study period. Analyses were used to assess outcomes for each definition, separately for age group, sex, obesity status, tobacco use, type of OCAT surgery, osteotomy status, concurrent ligament surgery status, and adherence to postoperative protocols. Kaplan-Meier analyses were used to assess differences in survival rates, and Cox proportional hazards models were used to assess risk factors and multivariable relationships with survival. Patient-reported outcome measures for pain, function, mobility, and satisfaction were also analyzed. Results: Analysis included 137 primary knee OCATs performed in 134 patients with a mean follow-up of 66 months (59 female, 75 male; mean age, 37.8 years; mean BMI, 28.5). The midterm (5- to 8-year) functional graft survival rate for patients undergoing primary OCAT in the knee using HCV grafts was 82% for all cases combined, ranging from 69% for tibiofemoral bipolar HCV OCATs to 89% for patellofemoral bipolar, 94% for multisurface unipolar, and 97% for single-surface unipolar. Initial treatment failure rates (revision or arthroplasty after primary OCAT) and OCAT nonsurvival rates (arthroplasty after primary or revision OCAT) were greater for older patient age, concurrent ligament reconstruction, tibiofemoral bipolar OCAT, and nonadherence to the prescribed postoperative rehabilitation protocols. When adjusted for patients' age, BMI, and tobacco use status, different surgery types did not demonstrate an increased risk for failure, while concurrent ligament reconstruction and nonadherence did. Patients who experienced functional graft survival after primary OCAT reported significantly greater improvements in PROMIS Physical Function and Mobility (Patient-Reported Outcomes Measurement Information System), International Knee Documentation Committee questionnaire, and Single Assessment Numeric Evaluation scores such that they were significantly higher at final follow-up as compared with patients who required arthroplasty. Patient-reported improvements in pain, function, and mobility exceeded minimal clinically important differences for ≥5 years after primary OCAT. When asked if they were satisfied with primary OCAT surgery, 76.2% of patients were very satisfied or satisfied with their results, while 8.5% were neutral and 15.4% were unsatisfied or very unsatisfied. Conclusion: With use of HCV osteochondral allografts, midterm (5- to 8-year) functional graft survival rates for patients undergoing primary OCAT in the knee were notably higher than previously reported midterm rates for traditional OCATs. When adjusted for patient characteristics, risk factors for nonsurvival included concurrent ligament reconstruction for knee instability and nonadherence to the prescribed postoperative rehabilitation protocols. Patients who experienced functional graft survival for ≥5 years after primary OCAT reported statistically significant and clinically meaningful improvements in pain, function, and mobility. [ABSTRACT FROM AUTHOR]

Introduction A dilation and evacuation (D&E) is a safe and effective option for patients undergoing a second trimester abortion. Recent legislation and geographic restrictions threaten patients' access to this surgical procedure, prompting a call to action to strengthen abortion training. This quality improvement project aimed to assess if a standardized lecture and checklist would improve military trainee knowledge and comfort with performing D&Es. Materials and Methods Using society recommendations and incorporating available level I to III evidence, a standardized checklist for D&Es was created to include necessary equipment, procedural steps, perioperative considerations, and potential complications. The checklist and associated lecture were presented to gynecology residents from seven of the nine military training programs. Residents completed a six-question assessment regarding comfort and knowledge in performing D&Es prior to and following the intervention. Responses were ranked on a five-point Likert scale and analyzed with the Wilcoxon sign-rank test. This project was deemed exempt by the Institutional Review Board. The standard Plan, Do, Study, Act (PDSA) methodology was used for ongoing assessment of the efficacy of this quality improvement project. Results There were 67 trainees that completed the pre-intervention assessment and 44 who completed it post-intervention, with 27 responses paired for statistical analysis. All trainees self-reported improved comfort and knowledge in all procedural aspects of D&Es, with the largest improvement observed in equipment knowledge (mean difference 1.44, P <0.001), performing procedural steps (mean difference 1.26, P <0.001), and managing complications (mean difference 1.33, P <0.001). Conclusions Use of an evidence-based checklist significantly improves resident knowledge and comfort with performing second trimester D&Es. In a post Dobbs environment, the military is an appropriate proxy for larger society and training programs need to develop alternatives and adjuncts to clinical training. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations. [ABSTRACT FROM AUTHOR]

Approximately 20% of patients sustaining a fragility femur fracture use an anticoagulant, and over 30% use an antiplatelet medication, both of which can result in surgical delay. Previously confined to fractures of the proximal femur, performance assessment, outcome and surgical delay is now assessed for all fractures of the femur in older patients, including those involving implants. This narrative review draws together all literature pertaining to anticoagulation and antiplatelet management in older patients with a fracture of the femur to address 5 key points: prevalence of anticoagulant and antiplatelet use; analysis of management protocols; collation of national guidelines; comparison of perioperative management; timing of surgery and perioperative outcomes. Our review found that the prevalence of fragility femur fracture patients taking anticoagulant and antiplatelet medication ranges from 20–40% and 25–35% respectively. More anticoagulated patients are taking direct oral anticoagulants compared to vitamin k antagonists with growing implications for variation in practice and delays to surgery. Several national guidelines exist although these are characterised by marked variation, there is little standardisation, and none are generalised across all fragility femur fractures. Expedited surgery within 36 hours of admission in patients taking an anticoagulant or antiplatelet medication is safe and has been demonstrated in fractures of the proximal femur across many small number studies although no such evidence exists in non-proximal femur fractures despite this population sharing similar characteristics. There is a need for all fractures of the femur in older people to be considered when researching and assessing performance in this population to prevent needless variation and delay. [ABSTRACT FROM AUTHOR]

Background: Symptomatic intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide. In patients undergoing endovascular treatment for ICAS, in-stent restenosis (ISR) is associated with ischemic stroke recurrence. Objective: Intracranial drug-eluting self-expanding stent systems (COMETIU; Sinomed Neurovita Technology Inc., CHN) are new devices for treating ICAS. This study evaluated the perioperative experience and medium-term outcomes of COMETIU in 16 patients. Methods: We prospectively analyzed 16 patients with ICAS (≥ 70% stenosis) who underwent intravascular therapy between September 4, 2022, and February 1, 2023. The primary outcome was the incidence of ISR at 6 months postoperatively. The secondary efficacy outcomes were device and technical success rates. The secondary safety outcomes included stroke or death within 30 days after the procedure and the cumulative annual rate of recurrent ischemic stroke in the target-vessel territory from 31 days to 6 months and 1 year. Results: A total of 16 patients with 16 intracranial atherosclerotic lesions were treated with 16 COMETIUs. All procedures were performed under general anesthesia with 100% device and technical success rates, with no cases of periprocedural stroke or death. The mean radiographic follow-up duration was at least 6 months postoperatively, and all patients presented for radiographic and clinical follow-up. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for all patients revealed no cases of ISR. Conclusion: COMETIU is safe and effective for treating ICAS, with minimal risk during the procedure and a low rate of ISR during medium-term follow-up. [ABSTRACT FROM AUTHOR]

Objective: To explore the decision-making factors for defunctioning ileostomy (DI) after rectal cancer surgery and to analyze the impact of the DI on perioperative outcomes. Methods: A retrospective case–control study was conducted that included rectal cancer patients who underwent low anterior resection from January 2013 to December 2023. Among them, 33 patients did not undergo DI but with anastomotic leakage (AL) after surgery, and 1030 patients were without AL. Preoperative, operative and tumor factors between these two groups were compared to explore the decision-making factors for DI. Meanwhile, the differences of perioperative outcomes between the DI group of 381 cases and non-DI group of 701 cases were compared. Results: For preoperative factors, the proportions of male patients and preoperative chemoradiotherapy (CRT) in the AL with non-DI group were greater than those in the non-AL group (p < 0.05); for operative factors, the proportion of patients in the AL with non-DI group with a surgical time > 180 min were greater (p < 0.05); for tumor factors, the proportion of T3-4 stage was higher in the AL with non-DI group (p < 0.05). Multiple regression analysis revealed that male sex and preoperative CRT were the independent risk factors affecting DI. For perioperative outcomes, the DI did not reduce the incidence of all and symptomatic AL and non-AL postoperative complications (p > 0.05) but with 12.07% stoma-related complications, and increase hospitalization costs (p < 0.05); however, it can shorten the postoperative hospital stay, pelvic drainage tube removal time, and reduce the anal tube placement rate and readmission rate (all p < 0.05). Conclusion: Male patients and preoperative CRT were the independent risk factors affect the decision of DI in our study, and DI can shorten the postoperative hospitalization, pelvic drainage tube removal time, and decrease the anal tube placement rate and readmission rate during the perioperative period but with a higher economic cost. [ABSTRACT FROM AUTHOR]

Introduction: Vitamin c can relieve the pain after other diseases, but there are no studies on whether vitamin C can relieve the pain after hip replacement. The purpose of this paper is to study whether vitamin C can relieve the pain after total hip replacement. Purpose: In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients receiving THA at our hospital were randomly assigned to vitamin c or control groups. During the operation, the vitamin C group will receive intravenous injection of 3 g vitamin C, and the control group will receive 3 g placebo. If the patient has postoperative pain, 10 ml subcutaneous injection of morphine will be required as a rescue analgesic. The primary outcome was the amount of postoperative injection of morphine as a rescue analgesic and expression of inflammatory factors, and the secondary outcome was postoperative pain and hip recovery as assessed by visual analog scale (VAS). Results: The dosage of subcutaneous injection of morphine was significantly reduced in vitamin C group. VAS pain scores at rest and exercise were lower in the vitamin C group 24 h after surgery, and hip motion was better 24 h after surgery, but there was no significant difference between the two groups 24 h after surgery.Nonetheless, the overall changes in morphine usage and VAS scores did not surpass the established minimal clinically important differences (10 mg for morphine consumption; 1.5 at rest and 1.8 during movement for VAS scores). Conclusion: Adding intravenous vitamin c to multimodal analgesia significantly improved morphine consumption, VAS pain score, and functional recovery. However, it is recommended that single intravenous administration of vitamin C during the perioperative period may achieve better pain relief for patients after THA. [ABSTRACT FROM AUTHOR]

Surgeons could improve patient optimisation, shared decision making and team-working to improve overall care and outcomes for patients. [ABSTRACT FROM AUTHOR]

Background: Treatment with opioids is a mainstay in perioperative pain management. While the leading treatment paradigm has been procedure‐specific pain management, efforts regarding personalized pain treatment are increasing. The OPI•AID project aims to develop personalized algorithms for perioperative pain management, taking demographic, surgical, and anaesthesiologic factors into account. We will undertake five parallel reviews to illuminate current evidence on different aspects of individual responses to perioperative opioid treatment. Methods: Inclusion of adult populations in English‐written studies. Review‐specific searches are developed for the following databases: CENTRAL, MEDLINE, Embase, clinicaltrials.gov, and clinicaltrial.eu. Two authors will independently screen citations, extract data, and assess the risks of bias in each review (QUIPS, PROBAST and RoB2, as relevant). Conclusion: These reviews will evaluate various aspects of perioperative opioid treatment, including individualized treatment strategies, selection of specific opioids, and individual patient responses. These will guide future development of a personalized perioperative opioid treatment algorithm (OPI•AID) that will be validated and tested clinically against standard of care. [ABSTRACT FROM AUTHOR]

Objectives: Previous evidence suggests that bisphosphonates (BPs) may lower the risk of recurrent fractures and enhance functional recovery in patients with fractures. However, there has been controversy regarding the optimal timing of treatment initiation for patients with fragility fractures. We conducted a meta-analysis to evaluate the available evidence on the use of BPs during the perioperative period and compared it to both non-perioperative periods and non-usage. Methods: Electronic searches were performed using PubMed, EMBASE, Web of Science and the Cochrane Library published before February 2023, without any language restrictions. The primary outcomes included fracture healing rate, healing time, and new fractures. We also examined a wide range of secondary outcomes. Random effects meta-analysis was used. Results: A total of 19 clinical trials involving 2543 patients were included in this meta-analysis. When comparing patients with non-perioperative BPs use in 4-6 weeks and approximately 10-12 weeks post-surgically, the overall risk ratios (RRs) of perioperative BPs use for healing rate were 1.06 (95% CI: 0.81, 1.38, p=0.69) and 1.02 (95% CI: 0.94, 1.11, p=0.65), respectively, suggesting no difference in healing rate between perioperative and non-perioperative BP initiation. For healing time, the overall mean difference between perioperative and non-perioperative periods was -0.19 week (95% CI: -1.03, 0.64, p=0.65) at approximately 10-12 weeks, indicating no significant impact of perioperative BP initiation on healing time. In terms of new fractures, the overall RR with BP use was 0.35 (95% CI: 0.17-0.73, p=0.005), when compared to patients without BPs use. This suggests a protective impact of BP use against new fractures compared to patients without BP use. Perioperative BP use was associated with a markedly higher likelihood of having adverse experiences, including fever (RR: 23.78, 95% CI: 8.29, 68.21, p< 0.001), arthralgia (RR: 10.20, 95% CI: 2.41, 43.16, p=0.002), and myalgia (RR: 9.42, 95% CI: 2.54, 34.87, p< 0.001), compared with non-BPs use. Conclusions: Treatment with BP during the perioperative period does not affect the healing process and has positive effects on therapy for patients with fragility fractures. These compelling findings underscore the potential efficacy of BP use during the perioperative period as a viable treatment option for patients with fragility fractures. [ABSTRACT FROM AUTHOR]

• Comprehensive evidence-based guidelines for cesarean hysterectomy for PAS are based primarily on observational studies. • Outcomes in planned cesarean hysterectomy for PAS may be improved with a standardized hospital protocol and delivery at a high-volume center. • Several gaps in the literature were identified, including structure and organization of hospital protocols for cesarean hysterectomy. In this systematic review, we aim to propose evidence-based management for perioperative care to improve outcomes at the time of planned cesarean hysterectomy for placenta accreta spectrum, a procedure associated with significant maternal and neonatal morbidity. We conducted a literature search for studies published in MEDLINE (via Ovid), Embase, CINAHL, and Cochrane/CENTRAL up until February 25, 2022. The search included free-text and controlled-vocabulary terms for cesarean section, cesarean delivery, and hysterectomy. We included randomized controlled trials, prospective cohort, retrospective cohort, and case-control studies published in English that reported on a perioperative intervention in the performance of a planned CH for PAS. Studies must have included a comparator group. Of the 8,907 studies screened in this systematic review, 79 met the inclusion criteria. Articles examining each step or intervention of the CH were grouped together and reviewed qualitatively as a group. Evidence levels and recommendations were made by consensus of all authors according to the terminology of the United States Preventive Services Task Force (USPSTF). We synthesized the results of 79 articles, and provided 28 recommendations. Based on USPSTF criteria, 21.4 % of the recommendations were level B (n = 6), 39.3 % were C (n = 11), 10.7 % were D (n = 3) and 28.6 % were I (n = 8). The interventions with the highest level of recommendation included delivery at a hospital with high cesarean hysterectomy volume, implementation of a standardized hospital protocol, delivery via a planned procedure, neuraxial anesthesia, and transverse skin incision (all level B recommendations by USPSTF criteria). Development of a standardized hospital protocol, delivery at a center with high CH surgical volume, and utilization of neuraxial anesthesia garnered B evidence levels. Recommendations were limited due to the lack of prospective trials. Further research into the technical aspects of this high-risk procedure is warranted. [ABSTRACT FROM AUTHOR]

Depression and delirium are common and serious problems for surgical patients, particularly in high-risk groups such as older adults. Screening for depression in peri-operative settings has gained more focus as clinicians recognize the importance of identifying and addressing barriers to recovery. A meta-analysis of nearly 5 million patients from five continents found that patients with depression are at double the risk of postoperative delirium compared to those without depression. However, the effectiveness of traditional medications for depression in preventing delirium is uncertain. The causal relationship between depression and delirium is complex and may involve multiple factors, making it difficult to determine the exact cause. Despite this, depression can be a predictor of delirium and offers an opportunity for diagnosis and treatment in the peri-operative period to improve patients' quality of life. The peri-operative period is seen as an opportunity to optimize patients' health conditions and implement interventions to improve long-term outcomes. While more research is needed to determine the efficacy and safety of interventions for depression and delirium, the association between the two conditions provides motivation to improve peri-operative care. [Extracted from the article]

Patient–physician communication is an integral part of daily anaesthetic practice. Although it is an undeniably powerful means of building a solid therapeutic alliance, several of its fundamental aspects are often overlooked, which can hinder successful communication in the preoperative period. We outline these underexploited elements by analysing the various phases of preoperative patient–physician interactions to provide the practising anaesthesiologist with a useful framework for achieving thoughtful and patient-centred communication. [ABSTRACT FROM AUTHOR]

There is a lack of qualitative data on the negative effects of workplace stressors on the well-being of healthcare professionals in hospitals in Africa. It is unclear how well research methods developed for high-income country contexts apply to different cultural, social, and economic contexts in the global south. We conducted a qualitative interview-based study including 64 perioperative healthcare professionals across all provinces of Rwanda. We used an iterative thematic analysis and aimed to explore the lived experience of Rwandan healthcare professionals and to consider to what extent the Maslach model aligns with these experiences. We found mixed responses of the effects on individuals, including the denial of burnout and fatigue to the points of physical exhaustion. Responses aligned with Maslach's three-factor model of emotional exhaustion, decreased personal accomplishment, and depersonalisation, with downstream effects on the healthcare system. Other factors included strongly patriotic culture, goals framed by narratives of Rwanda's recovery after the genocide, and personal and collective investment in developing the Rwandan healthcare system. The Rwandan healthcare system presents many challenges which can become profoundly stressful for the workforce. Consideration of reduced personal and collective accomplishment, of moral injury, and its diverse downstream effects on the whole healthcare system may better represent the costs of burnout Rwanda. It is likely that improving the causes of work-based stress will require a significant investment in improving staffing and working conditions. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate if implementation of the 2019 Society of Interventional Radiology (SIR) guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy is associated with increased haemorrhagic adverse events, change in pre-procedural blood product utilization, and evaluation of guideline compliance rate at a single academic institution. Methods: Ultrasound guided percutaneous liver biopsies from (January 2019-January 2023) were retrospectively reviewed (n = 504), comparing biopsies performed using the 2012 SIR pre-procedural coagulation guidelines (n = 266) to those after implementation of the 2019 SIR pre-procedural guidelines (n = 238). Demographic, preprocedural transfusion, laboratory, and clinical data were reviewed. Chart review was conducted to evaluate the incidence of major bleeding adverse events defined as those resulting in transfusion, embolization, surgery, or death. Results: Implementation of the 2019 SIR periprocedural guidelines resulted in reduced guideline non-compliance related to the administration of blood products, from 5.3% to 1.7% (P =.01). The rate of pre-procedural transfusion remained the same pre and post guidelines at 0.8%. There was no statistically significant change in the incidence of bleeding adverse events, 0.8% pre guidelines versus 0.4% post (P = 1.0). Conclusion: Implementation of the 2019 SIR guidelines for periprocedural management of bleeding risk in patients undergoing percutaneous ultrasound guided liver biopsy did not result in an increase in bleeding adverse events or pre-procedural transfusion rates. The guidelines can be safely implemented in clinical practice with no increase in major adverse events. [ABSTRACT FROM AUTHOR]

Patients with congenital heart disease are living longer due to improved medical and surgical care. Congenital heart disease encompasses a wide spectrum of defects with varying pathophysiology and unique anesthetic challenges. These patients often present for noncardiac surgery before or after surgical repair and are at increased risk for perioperative morbidity and mortality. Although there is no singular safe anesthetic technique, identifying potential error traps and tailoring perioperative management may help reduce morbidity and mortality. In this article, we discuss five error traps based on the collective experience of the authors. These error traps can occur when providing perioperative care to patients with congenital heart disease for noncardiac surgery and we present potential solutions to help avoid adverse outcomes. [ABSTRACT FROM AUTHOR]

Objective: Venous aneurysms are rare vascular abnormalities associated with venous thromboembolism. In this study, we presented our experience in managing thrombosed lower extremity venous aneurysms and evaluate the impact of vitamin D deficiency and genetic thrombophilic risk factors on patient management and outcomes. Methods: A single-center retrospective observational analysis was conducted on ten patients with thrombosed lower limb venous aneurysms who underwent surgical procedures at our hospital from July 2014 to February 2023. Collected data included venous duplex ultrasonographic imaging and laboratory tests including genetic thrombophilic risk factors and assessments of vitamin D levels. Results: There were 5 males and 5 females. The mean age was 46.6 ± 12.1 years. The aneurysms were located in the popliteal vein in three patients, the great saphenous vein in six, and the small saphenous vein in one. Venous duplex imaging revealed saccular aneurysms in eight patients and fusiform aneurysms in two, with a mean diameter of 37.2 ± 10.6 mm, ranging from 23 to 52 mm. Laboratory tests indicated vitamin D deficiency in all of the patients, and genetic thrombophilic risk factors were identified in two cases. Surgical interventions consisted of tangential excision with lateral venorrhaphy in three patients and total excision and ligation in seven patients. The postoperative period was favorable for all patients. Conclusions: Surgical treatment of thrombosed venous aneurysms in the lower extremities is essential to prevent complications such as thromboembolism. A comprehensive approach, including knowledge of genetic risk factors and vitamin D levels, may improve patient outcomes. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice. [ABSTRACT FROM AUTHOR]

Copyright of Environmental & Social Management Journal / Revista de Gestão Social e Ambiental is the property of Environmental & Social Management Journal and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Simple Summary: Perioperative FLOT (5-fluorouracil, oxaliplatin and docetaxel) is a standard of care for patients with locally advanced gastro-oesophageal adenocarcinoma (GEA) in Western guidelines, but its use is limited in Asian patients. The aim of our retrospective study was to assess the safety and efficacy of perioperative FLOT in Asian patients from a single centre with routine granulocyte colony-stimulating factor (GCSF) prophylaxis. We demonstrate similar tolerability and efficacy for FLOT to that reported in Western populations but with lower rates of grade 3 to 4 neutropenia. Elderly patients ≥ 65 years old had similar outcomes to those under 65. However, patients of lower socioeconomic status were more likely to experience severe AEs, highlighting the need to proactively support vulnerable groups during treatment. Background: Perioperative FLOT (5-fluorouracil, oxaliplatin and docetaxel) is a standard of care for patients with locally advanced gastro-oesophageal adenocarcinoma (GEA) in Western guidelines, but its use is limited in Asian patients. We report outcomes from a single Asian centre of perioperative FLOT with concomitant granulocyte colony-stimulating factor (GCSF) prophylaxis. Methods: A retrospective analysis of all 56 stage II to III GEA patients treated with perioperative FLOT at the National Cancer Centre Singapore between June 2017 and February 2024 was performed. All patients were discussed at a multidisciplinary tumour board, underwent preoperative laparoscopic staging, and received prophylactic GCSF with perioperative FLOT. Surgery was performed across four partner institutions. The primary endpoints were the tolerability of FLOT and pathological complete response (pCR). A univariate analysis of factors associated with survival and adverse events was also performed. Results: Overall, 33 patients (58.9%) completed eight cycles of pre- and postoperative FLOT, and 92.9% underwent resection. The commonest grade 3 to 4 adverse events (AEs) were diarrhoea (10.7%) and neutropenia (5.6%). The 30- and 90-day postoperative mortality rates were 0% and 1.9%, respectively. In resected tumours, the pCR was 15.4%. The median DFS was 27.5 months, but the median OS was not reached. The values for 1-, 2-, and 3-year DFS were 74.6%, 61.0%, and 46.5%, respectively. The values for 1-, 2-, and 3-year OS were 85.0%, 67.4%, and 61.0%, respectively. In the univariate analysis of patients who underwent resection, an ECOG status of 0 was associated with better DFS, while ypN0, R0 resection, and pathological stages 0-II were associated with better DFS and OS. Patients ≥ 65 years benefited from FLOT similarly to those <65 years in terms of DFS (HR 1.03; p = 0.940) and OS (HR 1.08; p = 0.869), with similar rates of grade 3 to 4 AEs. Patients with a higher housing index (HI) were less likely to experience ≥grade 3 AEs compared to those with a lower HI (OR 0.16, p = 0.029). Conclusions: This study presents a unique real-world Asian experience of perioperative FLOT with prophylactic GCSF use, with low rates of G3 to 4 neutropenia. The tolerability of FLOT was similar to that reported in Western populations. Furthermore, similar survival and rates of grade 3 to 4 AEs were observed in elderly patients. Patients of lower socioeconomic status were more likely to experience severe AEs, highlighting the need to proactively support vulnerable groups during treatment. [ABSTRACT FROM AUTHOR]

In the era of minimally invasive surgery, esophagectomy remains a highly invasive procedure with a high rate of postoperative complications. Preoperative risk assessment is essential for planning esophagectomy in patients with esophageal cancer, and it is crucial to implement evidence‐based perioperative management to mitigate these risks. Perioperative support from multidisciplinary teams has recently been reported to improve the perioperative nutritional status and long‐term survival of patients undergoing esophagectomy. Intraoperative management of anesthesia and fluid therapy also significantly affects short‐term outcomes after esophagectomy. In this narrative review, we outline the recent updates in the perioperative management of esophagectomy, focusing on preoperative risk assessment, intraoperative management, and perioperative support by multidisciplinary teams to improve operative outcomes. [ABSTRACT FROM AUTHOR]

Copyright of Cirugía y Cirujanos is the property of Publicidad Permanyer SLU and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Objective: To assess the association between provider type (primary care provider [PCP] or perioperative provider) and excessive preoperative testing. Study Design: Cross‐sectional study. Setting: Academic medical center. Methods: Electronic medical records of adult patients who obtained an outpatient preoperative assessment and underwent surgery in the Department of Otolaryngology–Head and Neck Surgery during the first 2 weeks of January 2019 (n = 94) were reviewed. Patients receiving preoperative tests beyond those recommended by the guidelines were deemed to have had excessive testing. Descriptive statistics were used to characterize the study population. Simple and multivariate logistic regression were used to analyze the association between the outcome and the predictor variables. Results: Overall, 44.7% of preoperative evaluations had excessive testing. Patients who had their preoperative evaluation performed by a perioperative provider had 89% lower odds of having excessive preoperative testing compared to those evaluated by a PCP (odds ratio = 0.11, 95% confidence interval: [0.03, 0.37], P <.001). Female sex, younger age, and higher risk of major adverse cardiac events were associated with greater odds of excessive testing. Conclusion: Excessive preoperative testing is more commonly performed by PCPs compared to perioperative providers. These results give preliminary evidence in support of a potential shift in the clinical responsibility of preoperative evaluation from PCPs to perioperative providers in order to reduce excessive testing and promote high‐value health care. The next steps include validating these findings, identifying reasons for differential guideline concordance, and intervening accordingly. [ABSTRACT FROM AUTHOR]

Background: The implementation of ERAS represents a promising solution to improve treatment efficiency and facilitate patient involvement. This innovative care model aims to optimize recovery processes following surgeries by adopting a holistic, interprofessional approach. At our hospital, ERAS was implemented in minimally invasive heart valve surgery, offering two distinct ERAS models. Additionally, there is also the standard of care without ERAS. The objective of the study is to gain insight into patient satisfaction and perceived differences across these various care models. Methods: Patients were interviewed using semi-structured interviews approximately two to three months after undergoing surgery. The data were analysed using qualitative content analysis in accordance with the methodology proposed by Kuckartz. Four main categories were established: Preoperative care, postoperative care and communication, patient participation and involvement, and rehabilitation and post-clinical course. Results: Comprehensive preoperative education and seamless communication throughout the perioperative care journey were identified as fundamental to patient satisfaction and optimal care processes. Patients in the ERAS + model reported higher overall satisfaction with their care compared to patients in the standard of care and ERAS groups. Conclusion: Preoperative education establishes the foundation for patients' subsequent behaviours and expectations regarding their treatment. Physical activity, nutrition, and mental health are significant aspects. The active involvement and participation of patients and their families in the treatment process facilitated superior postoperative care, intensive physiotherapy, mental support, and faster recovery. A functional flow of information throughout the entire care process is vital. Moreover, having a dedicated point of contact had a beneficial impact on patients´ well-being. The integration of innovative ERAS concepts, which encompass interprofessional preoperative patient education and psychosomatic support, represents a promising approach from a patient perspective, offering benefits to a broad spectrum of cardiac surgical patients. [ABSTRACT FROM AUTHOR]

A Core Measures Set (CMS) is an agreed standardized group of measures that should be assessed and reported in research for a specific condition or clinical area. This study undertook the development of a CMS for Patient Safety through a two-round, web-based Delphi consensus approach, in the context of the "Improving quality and patient SAFEty in surgical care through STandardisation and harmonization of perioperative care in Europe" (SAFEST) project—a collaborative, patient-centered and evidence-based European Union-funded project that aims to generate action-oriented evidence in perioperative care. We developed an Initial List of Measures via an umbrella review following the deployment of an e-Delphi method with an inclusive panel of experts to prioritize measures towards a consensualized Final List of Measures. All measures were rigorously assessed for both importance and feasibility. After the two rounds of the e-Delphi consensus method we observed 13 preoperative measures (40.6% of the initial number), 24 intraoperative measures (66.7%), 25 postoperative measures (20.3%) and 23 mixed period measures (41.1%) met consensus criteria for both importance and feasibility. Higher scores were detected in importance ratings compared to feasibility across all groups of measures. Importantly, numeric averages regarding pain-related measures differed in the assessment of patients when compared to that of Healthcare Professionals (HCPs). This work not only informs future SAFEST iterations but also sets a precedent for research into valid, patient-centered, and action-oriented perioperative safety measures. [ABSTRACT FROM AUTHOR]

Background: Thymoma is a primary tumor of the thymus, commonly located in the anterior mediastinum. Most thymomas are benign or low‐grade malignant, but they can invade surrounding organs or metastasize. The primary treatment for thymoma is surgical resection. Traditional methods involve open thoracotomy, but it is traumatic, with slow recovery and many complications. In recent years, with the development of thoracoscopic techniques, thoracoscopic total thymectomy has gradually become the preferred method for small size thymomas due to its minimally invasive, safe, and effective. Methods: This paper introduces a thoracoscopic extend thymectomy technique, the subxiphoid video–assisted thoracoscopic extend thymectomy with sternal suspension. This method involves placing hooks at the upper and lower ends of the sternum to suspend the sternum upward, increasing the thoracic cavity space and facilitating thoracoscopic operations. This research reviews the clinical data of 59 patients with early‐stage thymomas treated with this technique at our center since 2020 and analyzes the perioperative therapeutic efficacy and safety. It also compares the outcomes with those of 17 patients who underwent thoracoscopic approaches. Results: The results show that subxiphoid video–assisted thoracoscopic total thymectomy with sternal suspension is an innovative and effective surgical method, achieving the same tumor eradication as other thoracic surgeries. The flexible switching of observation ports provides a more comprehensive surgical field, reduces surgical trauma and complications, and improves the surgical outcomes and quality of life for patients. [ABSTRACT FROM AUTHOR]

Background/Objectives: Enhanced recovery after surgery (ERAS) protocols optimize perioperative care and improve recovery. This study evaluated the effectiveness of ERAS in one- or two-level posterior lumbar fusion surgeries, focusing on perioperative medication use, pain management, and functional outcomes. Methods: Eighty-eight patients undergoing lumbar fusion surgery between March 2021 and February 2022 were allocated into pre-ERAS (n = 41) and post-ERAS (n = 47) groups. Outcomes included opioid and antiemetic consumption, pain scores (numerical rating scale (NRS)), functional recovery (Oswestry Disability Index (ODI) and EuroQol 5 Dimension (EQ-5D)), and complication rates. Pain was assessed daily for the first four postoperative days and at 6 months. Linear Mixed Effects Model analysis evaluated pain trajectories. Results: The post-ERAS group showed significantly lower opioid (p = 0.005) and antiemetic (p < 0.001) use. No significant differences were observed in NRS pain scores in the first 4 postoperative days. At 6 months, the post-ERAS group reported significantly lower leg pain (p = 0.002). The time:group interaction was not significant for back (p = 0.848) or leg (p = 0.503) pain. Functional outcomes at 6 months, particularly ODI and EQ-5D scores, showed significant improvement in the post-ERAS group. Complication rates were lower in the post-ERAS group (4.3% vs. 19.5%, p = 0.024), while hospital stay and fusion rates remained similar. Conclusions: The ERAS protocol significantly reduced opioid and antiemetic use, improved long-term pain management and functional recovery, and lowered complication rates in lumbar fusion patients. These findings support the implementation of ERAS protocols in spinal surgery, emphasizing their role in enhancing postoperative care. [ABSTRACT FROM AUTHOR]

A host of anti-hyperglycemic agents are currently available and widely prescribed for diabetes and weight loss management. In patients undergoing surgery, use of these agents poses a clinical challenge to surgeons, anesthesiologists, and other perioperative care providers with regard to optimal timing of discontinuation and resumption of use, as well as possible effects of these agents on physiology and risk of postoperative complications. Here, we provide a comprehensive review of anti-hyperglycemic medications' effects on physiology, risks/benefits, and best practice management in the perioperative setting. Additionally, we report an illustrative case of small bowel obstruction in a patient taking semaglutide for 6 months prior to an otherwise uncomplicated laparoscopic hysterectomy and bilateral salpingo-oophorectomy. This review is meant to serve not as a replacement of, but rather as a consolidated complement to, various society guidelines regarding perioperative anti-hyperglycemic agent management. [ABSTRACT FROM AUTHOR]

Pancreatic surgery is complex and associated with higher rates of morbidity and mortality compared to other abdominal surgeries. Over the past decade, the introduction of new technologies, such as minimally invasive approaches, improvements in multimodal treatments, advancements in anesthesia and perioperative care, and better management of complications, have collectively improved patient outcomes after pancreatic surgery. In particular, the adoption of Enhanced Recovery After Surgery (ERAS) recommendations has reduced hospital stays and improved recovery times, as well as post-operative outcomes. The aim of this narrative review is to highlight the surgeon's perspective on the ERAS program for pancreatic surgery, with a focus on its potential advantages for perioperative functional recovery outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Perioperative dysglycemia is associated with negative surgical outcomes, including increased risk of infections and longer hospital stays. Continuous glucose monitoring (CGM) provides real-time glucose data, potentially improving glycemic control during surgery. However, the performance of CGM in the intraoperative environment has not been well established. This scoping review aimed to evaluate the performance of CGM systems during the intraoperative period, focusing on their technical reliability, accuracy, adverse device effects, and efficacy. Inclusion criteria: Studies that assessed intraoperative CGM performance, focusing on technical reliability, accuracy, adverse effects, or efficacy, were included. No restrictions were placed on the study design, surgical type, participant demographics, or publication date. Methods: A comprehensive literature search was performed using PubMed, EMBASE, and the Cochrane Library, covering publications up to 12 June 2024. Two independent reviewers screened and selected the studies for inclusion based on predefined eligibility criteria. Data extraction focused on the study characteristics, CGM performance, and outcomes. Results: Twenty-two studies were included, the majority of which were prospective cohort studies. CGM systems demonstrated a high technical reliability, with sensor survival rates above 80%. However, the accuracy varied, with some studies reporting mean or median absolute relative differences of over 15%. The adverse effects were minimal and mainly involved minor skin irritation. One randomized trial found no significant difference between CGM and point-of-care glucose monitoring for glycemic control. Conclusions: Although CGM has the potential to improve intraoperative glycemic management, its accuracy remains inconsistent. Future research should explore newer CGM technologies and assess their impact on surgical outcomes. [ABSTRACT FROM AUTHOR]

Background: Neurosurgery performed in the semi-sitting position provides advantages for certain procedures. However, this approach is associated with potential complications, particularly venous air embolism. Due to typically negative venous pressure at the wound site, air can be drawn into the veins. This risk is especially high in patients presenting with an intra- or extracardiac right-to-left-shunt. Transoesophageal echocardiography can be used to detect a patent foramen ovale or other possible pulmonary-systemic shunt before placing the patient in the sitting position. Case presentation: In this report, we present two young patients undergoing scheduled microsurgical vestibular schwannoma removal in a semi-sitting position who were diagnosed with congenital heart defects during routine perioperative assessment to detect possible intracardiac right-to-left shunts, using pre- and intraoperative transesophageal echocardiography (TEE) and additionally conducting an agitated saline bubble study under Valsalva manoeuvre. Patient A was diagnosed with a persistent left superior vena cava and Patient B with an unroofed coronary sinus (UCS). These findings confronted the anesthesiological and surgical teams with difficult individual decisions regarding further perioperative management. Conclusions: Perioperative transesophageal echocardiography is a diagnostic tool to both detect intraoperative position-related air embolisms and to rule out intracardiac right-to-left shunts, e.g. a patent foramen ovale, in order to decide for or against a (semi-)sitting position. Depending on the surgical circumstances a semi-sitting positioning of patients presenting with an intracardiac right-to-left-shunt, e.g. a PFO, can be feasible in individual cases if there is an implemented therapeutic algorithm to immediately terminate significant venous air entry. However, since certain other intra- or extracardiac right-to-left-shunts, such as here presented PLSVC or UCS, are rare, there is no definitive way of estimating the amount of entered air through detected shunts or anomalous vessels. Therefore, it is recommended to avoid a (semi-)sitting position in favour of a lateral or prone position for a patient undergoing intracranial surgery, once the perioperative TEE shows air bubbles in the left atrium or ventricle whose origins cannot be defined solely through TEE for certain in order to ensure patient safety by minimizing the risk of intraoperative paradoxical air embolisms. [ABSTRACT FROM AUTHOR]

Introduction: Cancer, malnutrition, and surgery negatively impact patient's immune system. Despite standardized surgical technique and the development of new perioperative care protocols, morbidity after cystectomy remains a serious challenge for urologists. Most common postoperative complications, such as infections and ileus, often lead to longer length of stay and worse survival. The immune system and its interaction with the gut microbiota play a pivotal role in cancer immunosurveillance and in patient's response to surgical stress. Malnutrition has been identified as an independent and modifiable risk factor for both mortality and morbidity. Immunonutrition (IN) may improve the nutritional status, immunological function, and clinical outcome of surgical patients. Aims of the study are (1) to evaluate the impact of IN on morbidity and mortality at 30 and 90 days after cystectomy and (2) to determine immune and microbiota signature that would predict IN effect. Methods: This is a randomized, multicentric, controlled, pragmatic, parallel-group comparative study, supported by the Swiss National Science Foundation. A total of 232 patients is planned to be enrolled between April 2023 and June 2026. Three participating centers (Lausanne, Bern, and Riviera-Chablais) have been selected. All patients undergoing elective radical and simple cystectomy will be randomly assigned to receive 7 days of preoperative IN (Oral Impact®, Nestlé, Switzerland) versus standard of care (control group) and followed for 90 days after surgery. For the exploratory outcomes, blood, serum, urine, and stool samples will be collected in patients treated at Lausanne. In order to determine the impact of IN on immune fitness, patients enrolled at Lausanne will be vaccinated against influenza and the establishment of the vaccine-specific immune response will be followed. Analysis of the microbiota and expression of argininosuccinate synthetase 1 as potential biomarker will also be performed. Discussion and conclusion: Strengths of the INCyst study include the randomized, multicenter, prospective design, the large number of patients studied, and the translational investigation. This study will challenge the added value of preoperative IN in patients undergoing cystectomy, assessing the clinical effect of IN on the onset of postoperative morbidity and mortality after cystectomy. Furthermore, it will provide invaluable data on the host immune response and microbiota composition. Trial registration: ClinicalTrials.gov NCT05726786. Registered on March 9, 2023. [ABSTRACT FROM AUTHOR]

Aim Method Results Conclusion Patients undergoing surgery experience perioperative anxiety and pain. Music has been shown to reduce perioperative anxiety, pain and medication requirement. This study assessed the feasibility and effectiveness of implementing a perioperative music intervention.A prospective pre‐ and post‐implementation pilot study was conducted to assess adherence to the intervention and the initial effect of music on postoperative pain scores (Numerical Rating Scale, 0–10) compared to a control group. Secondary outcomes encompassed pain scores throughout hospital admission, anxiety levels, medication usage, complications and hospital stay length.Adherence to the music intervention was preoperative 95.2%, intraoperative 95.7%, postoperative 31.9% and overall 29.7%. The intervention did influence postoperative pain. Patient's willingness to receive music was high (73%), they appreciated the intervention (median 8.0, interquartile range 7.0–9.0) and healthcare professionals were willing to apply the intervention. Music significantly reduced postoperative anxiety (2.0 vs. 3.0, p = 0.02) and the consumption of benzodiazepines on the first postoperative day (number of patients: zero [0%] vs. five [10%], p = 0.04).Implementation of music resulted in reduced postoperative anxiety and decreased consumption of benzodiazepines, and the strategy was feasible, but adjustments are needed to improve postoperative adherence. Both patients and healthcare professionals had a positive attitude towards the intervention. [ABSTRACT FROM AUTHOR]

ABSTRACT Aims Design Data Sources Methods Results Conclusions Implications for the Profession and/or Patient Care Impact Reporting Method To identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries.Systematic review.Five databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023.Two reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions.The initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full‐text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions.Local consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented.Advancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals.These findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives.This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines.No patient or public contribution.Trial Registration: CRD42023413817 [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Enhanced recovery after surgery (ERAS) programs have demonstrated efficacy in optimizing perioperative care and improving patient outcomes in various surgeries. However, their implementation and outcomes in resource‐limited settings remain underexplored. This study aimed to assess the implementation of an ERAS protocol for laparoscopic cholecystectomy in such a setting.This prospective non‐randomized controlled trial involved 100 patients undergoing laparoscopic cholecystectomy at the University Teaching Hospital of Kigali, Rwanda. The first 50 patients on the ERAS pathway were prospectively evaluated and retrospectively compared to the last 50 patients operated on before ERAS implementation. Data on demographics, preoperative information, intraoperative compliance, postoperative events, and patient feedback were collected and analyzed.ERAS implementation resulted in a significant reduction in hospital length of stay (LOS) (p < 0.001) without increase in complications. Compliance with ERAS principles, including preoperative education and perioperative management, was more than 90%. ERAS also reduced costs due to quicker recovery and shorter hospital LOS.The implementation of ERAS for laparoscopic cholecystectomy in a limited‐resource setting is feasible and safe, suggesting the possibility of its potential adoption in other abdominal procedures. A high level of adherence to the ERAS pathway can be achieved with effective patient education and the dedication of healthcare providers. [ABSTRACT FROM AUTHOR]

Introduction: Endothelial dysfunction (ED) promotes the development of atherosclerosis, and studies suggest an association with age-related neurocognitive disorders. It is currently unclear whether ED is also associated with the risk of perioperative neurocognitive disorders. Method: We included 788 participants aged ≥ 65 years of the BioCog study. Patients were scheduled to undergo elective surgery with expected duration > 60 min. Blood was collected before surgery for measurement of 5 biomarkers of ED: asymmetric and symmetric dimethylarginine (ADMA; SDMA), intercellular and vascular adhesion molecule (ICAM-1, VCAM-1), and von Willebrand factor (vWF). Patients were monitored for the occurrence of postoperative delirium (POD) daily until the 7th postoperative day. 537 (68.1%) patients returned for a 3-month follow-up. Post-operative cognitive dysfunction (POCD) was defined from the change in results on a battery of 6 neuropsychological tests between baseline and 3 months, compared to the change in results of a control group during the 3-month interval. The associations of each of the 5 ED biomarkers with POD and POCD respectively were determined using multiple logistic regression analyses with adjustment for age, sex, surgery type, pre-morbid IQ, body mass index, hypertension, diabetes, HbA1C, triglyceride, total and HDL cholesterol. Results: 19.8% of 788 patients developed POD; 10.1% of 537 patients had POCD at 3 months. Concentrations of ED biomarkers were not significantly associated with a POD. A higher VCAM-1 concentration was associated with a reduced POCD risk (adjusted odds ratio 0.55; 95% CI: 0.35–0.86). No further statistically significant results were found. Conclusion: Pre-operative concentrations of ED biomarkers were not associated with POD risk. We unexpectedly found higher VCAM-1 to be associated with a reduced POCD risk. Further studies are needed to evaluate these findings. [ABSTRACT FROM AUTHOR]

Aim Method Results Conclusion Patients requiring a beyond total mesorectal excision (bTME) procedure for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) will probably benefit from enhanced recovery after surgery (ERAS) protocols. However, implementation of ERAS protocols in such groups of patients is considered challenging. The aims of this study were to evaluate ERAS‐related outcomes of patients with LARC or LRRC undergoing bTME and to investigate the possibility of designing a tailored ERAS protocol.This study was divided into four phases. Phase one consisted of a literature study to compare functional recovery and postoperative outcomes in patients undergoing bTME. In phase two, outcomes on ERAS care elements in bTME were retrospectively evaluated. In phase three, differences in ERAS‐related outcomes and compliance of the colorectal ERAS protocol in patients who had undergone bTME were studied. In phase four, multidisciplinary team meetings were held to develop an ERAS protocol for bTME patients.Seven studies reported on ERAS‐related outcomes in patients undergoing bTME. Median length of hospital stay was 9–19 days, median stay in the intensive care unit was 2–4 days and 30‐day postoperative major complication rates were 22.6%–61.3%. Seventy‐five bTME patients were included for retrospective analysis. In these patients, length of stay was 9.0 days and major postoperative complications were observed in 40.0%. The overall ERAS compliance was 44.4%. Compared with the colorectal ERAS protocol, the largest differences in management were observed in the use of epidural anaesthesia, the postoperative use of urethral catheters, oral intake and mobilization.Patients undergoing bTME for LARC or LRRC are substantially different from patients treated with the colorectal ERAS protocol, regarding ERAS‐related outcomes. A tailored, multimodal ERAS protocol with specific modifications was developed by an expert multidisciplinary team for patients undergoing bTME for LARC or LRRC. [ABSTRACT FROM AUTHOR]

Objective: The lifetime risk of stroke is one in four people. As the population aged over 60 constantly expands, the impact of stroke on perioperative care is of increasing concern. This study investigates the effect of preoperative stroke on short- and long-term outcomes, hypothesizing that it decreases both 1-year mortality and days alive and at home up to 30 days after surgery (DAH30). Methods: This cohort study investigated 290,306 adult patients with (7214) and without (283,092) preoperative stroke undergoing major non-cardiovascular, non-ambulatory surgery at 23 hospitals in Sweden between 2007 and 2014. Data were pre- and postoperatively matched with quality registers. Using logistic regression, significant independent risk factors influencing the risk of 1-year mortality and impeded DAH30 were identified with adjusted odds ratios calculated. Results: Preoperative stroke was associated with higher 1-year mortality and lower DAH30, even after full adjustment for other co-morbid and surgical factors. Conclusions: This large cohort showed preoperative stroke to impact both the patient-centered short-term outcome DAH30 and 1-year mortality. These findings should be considered in perioperative planning. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the implications of frailty as a predictive factor for outcomes among patients with oral and maxillofacial space infection. Methods: A retrospective cohort study was conducted to analyze 348 medical records, gathering data on several key aspects. These included the etiology of infection, the location of inflamed areas, the treatment administered, and the ultimate treatment outcomes. Additionally, the study collected information on the Symptom Severity (SS) score, frailty score, age, gender, the presence of systemic diseases, alcohol consumption, and smoking history. Results: A total of 155 patients were classified as frailty, while 193 patients were classified as non-frailty. We found a significantly different in age, BMI, hospitalization expenses, length of hospital stay, SS, fibrinogen and admission to ICU between the frail group and the non- frail group. Conclusions: Frailty serves as a valuable predictor of outcomes among patients with oral and maxillofacial space infections. By identifying high-risk patients, frailty can be employed as a clinical tool to guide perioperative care, ultimately optimizing patient outcomes. Notably, frail patients often require more ICU treatment. [ABSTRACT FROM AUTHOR]

Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly performed orthopedic procedures. This study aimed to evaluate the impact of COVID-19 status on postoperative complications and mortality in patients undergoing THA and TKA. Methods: A total of 110,186 underwent either THA or TKA. Patients were grouped based on their COVID-19 status, gathered from the National COVID-19 Cohort Collaborative (N3C) in the 12 weeks preceding surgery and compared for various variables, including age, sex, BMI, and Charlson Comorbidity Index (CCI) scores. COVID-19 status was defined as a positive test result that was closest to the date of surgery regardless of testing positive previously. Postoperative complications such as venous thromboembolism (VTE), sepsis, surgical site infection, bleeding, acute kidney injury (AKI), 30-day, and 1-year all-cause mortality were examined. To compare the variables, an odds ratio with a 95% confidence interval was calculated with a significant level set at P < 0.05. Logistic regression using R programming was utilized for these calculations. Results: Univariate analysis was performed and rates of VTE (1.02% vs. 3.35%), 30-day mortality (0.25% vs. less than 5%), and 1-year mortality (1.42% vs. 5.43%) were higher in the COVID-19-positive group for THA patients (P < 0.001). For TKA patients, only 30-day mortality was significantly higher in the COVID-19-positive group (P = 0.034). Multivariate logistic regression revealed that a positive COVID-19 diagnosis within two weeks of surgery and a CCI score > 3 were significant predictors of postoperative complications and mortality for both TKA and THA. Conclusions: Patients with a positive COVID-19 diagnosis within 12 weeks of THA or TKA carried a significantly higher risk for postoperative complications and mortality. In addition, a CCI score > 3 is also a significant risk factor. These findings emphasize the importance of vigilant preoperative screening and risk stratification in the era of COVID-19. [ABSTRACT FROM AUTHOR]