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The care of children with primary surgical diagnoses in acute care units often involves a shared surgical and medical model ("comanagement"). There are no formal guidelines for how such programs should be structured or care provided. We used a modified Delphi process, including national experts in pediatrics and pediatric medical subspecialties, pediatric surgical specialties, and pediatric anesthesiology, to develop recommendations for best practices for comanagement programs in community and tertiary care settings. [ABSTRACT FROM AUTHOR]

Introduction: Canceling scheduled surgeries on the day of surgery places a heavy burden on healthcare providers and has psychological, social, and financial consequences on patients and their families. This study aimed to investigate the main reasons for cancellations of elective procedures and provide appropriate recommendations to reduce the rate of such avoidable cancellations. Methods: Data were collected retrospectively from all consecutive elective cases scheduled for various elective surgeries from January 1, 2020 to March 31, 2022 at Namazi Teaching Hospital, a major referral center in southern Iran with a capacity of 938 beds. Daily data were collected on the number of planned electives, cancellations, and reasons for cancellations. Surgical cancellation reasons were categorized as patient-related, surgeon-related, hospital/system-related, and anesthesia-related. Data were expressed as frequency (percentage) and analyzed with SPSS version 19 software. Results: The cancellation rate on surgery day for elective procedures in all fields was 6.3%. The highest cancellation rate was related to minor surgeries (19%), followed by urology (8%), pediatrics (7%), and plastic surgery (7%). The most common reasons for cancellation were patients not suitable for the procedure (37%), followed by patients who did not follow instructions (10%), lack of time (10.5%), and equipment/supplies problems (10%), and refusal to consent (6%). Conclusions: According to this study, patients' unsuitability for surgery, non-compliance with instructions, lack of time, and problems with equipment/supplies are the main reasons for canceling surgery. Proper preoperative assessment and preparation of patients and improved communication between medical teams and patients reduce the cancellation of booked surgeries. [ABSTRACT FROM AUTHOR]

Background There is limited evidence about the role and effectiveness of intraoperative angiography (IOA) during neurosurgical procedures with patients in prone, three-quarters prone, and park-bench positions. Objective To carry out a systematic review and metaanalysis of the literature to evaluate the safety and efficacy of IOA during neurosurgical procedures. Methods We reviewed (between January 1960 and July 2022) all studies in which IOAs were performed during neurosurgical procedures with patients in either prone, three-quarters prone, or park-bench positions. Additionally, a cohort of patients from our institutional experience was included. Efficacy outcomes were the rate of successful angiography and the rate of surgical adjustment/revision after IOA. Safety outcomes were the rate of angiography-related complications and mortality. Data were analyzed using a random-effects metaanalysis of proportions, and statistical heterogeneity was assessed. Results A total of 26 studies with 142 patients plus 32 subjects from our institution were included in the analysis. The rate of successful intraoperative angiography was 98% (95% CI 94% to 99%; I²=0%). The rate of surgical adjustment/revision was 18% (95% CI 12% to 28%; I²=0%). The rate of complications related to the angiography was 1% (95% CI 0% to 5%; I²=0%). There were no deaths associated with IOA. Conclusion We found that IOA performed with patients in prone, three-quarters prone, and park-bench positions is feasible and safe with a non-negligible rate of intraoperative post-angiographical surgical adjustment/revision. Our findings suggest that the performance of IOA to complement vascular neurosurgical procedures might have a valuable role in favoring patient outcomes. [ABSTRACT FROM AUTHOR]

The concept of performance excellence in surgery has been difficult to fully articulate. Similarly, the precise definition of a hyperperformer can be debated, but commonly involves elements of excellent problem [...]

Cancellation of elective total shoulder arthroplasty (TSA) is an expected occurrence. The typical cost of canceled elective surgeries is estimated to be $3000 per patient and can lead to hospital losses of nearly $1 million per year. With the growing interest of same-day TSA, understanding and minimizing unexpected same-day cancellation will reduce impact on patients, surgeons, and health care system. The purpose of the study is to identify the frequency and causes of unexpected same-day cancellations in TSA and determine which treatment path those patients take following their cancellation. A consecutive series of 1189 TSA (anatomic and reverse) patients operated at a single-academic institution across two tertiary care hospitals from 2010 to 2020 were reviewed. All patients who were scheduled for TSA and subsequently canceled were identified. The etiology of cancellation, time to rescheduling, date of actual TSA procedure, and subsequent work-up were recorded. Descriptive statistics of the canceled patient cohorts were analyzed. Univariate analysis, chi-square test, and analysis of variance were used to compare patients who canceled on the day of surgery (DOS) to prior to surgery. Of the 1189 TSA patients, 964 were TSA for primary glenohumeral osteoarthritis or cuff tear arthropathy. Ninety-eight (10.2%) TSA had cancellations, of which 49.0% were on the DOS. Most common causes of DOS cancellations were due to medical reasons (45.8%) and anesthesia-related complications (27.1%). Infection (40.9%) was the most frequent medical reasons for cancellations. Fifty-four percent of the anesthesia-related complication cancellations underwent additional diagnostic and therapeutic intervention, despite 100 % of those patients receiving preoperative clearance. DOS cancellations in TSA are unavoidable, but there are modifiable factors that can minimize the risk of cancellation. Contrary to studies that attributed cancellations to inadequate cardiovascular-related medical clearance, our study found that the majority of these cancellations are due to infection-related issues. A higher proportion of patients with inadequate medical clearance will cancel prior to the DOS. Despite preoperative optimization, certain patient risk factors need additional diagnostic and therapeutic interventions prior to undergoing shoulder arthroplasty. Through coordination and planning, health care providers and patients can identify those factors and address these issues early on to avoid cancellation and ultimately proceed with a TSA. [ABSTRACT FROM AUTHOR]

Aim: The aims of the study are to audit the default rate of the provisional date of elective surgery in pediatric urology private practice and to study the factors involved in the postponement of elective operation dates by patients. Patients and Methods: The audit involved analysis of reasons behind patients defaulting from elective pediatric urology procedures between January 2019 and December 2019 at a tertiary private teaching hospital in South India. The details were obtained from the outpatient register kept for elective booking. The details of actual procedures performed were obtained from OT records. From the defaulters, the reasons for postponement were obtained through personal/telephonic interview. Results: A total of 289 patients were given dates for elective procedures. Among this, 72 (24.9%) defaulted, leaving 217 patients who underwent elective surgery. Among those who underwent surgery, 90 (41%) were elective day case (DC) procedures, whereas 127 (59%) were inpatient (IP) procedures. The default rate was 26/116 (22.4%) for DC procedures, whereas 46/173 (26.6%) for IP procedures, with no significant difference between them (P = 0.64). Among the 72 defaulters, the reasons for cancellation were as follows: financial factors (FFs) 22 (30.6%), lack of family support 19 (26.4%), function/grievance in house 10 (13.9%), respiratory illness 14 (19.4%), and treatment at a different center 7 (9.7%). FF (insurance denial) was significantly higher (P = 0.001) in crucial IP procedures at 19/46 (41%) compared to DC procedures at 3/26 (12%). The various diagnoses denied insurance were UPJO (7), VUR (6), hypospadias (4), UDT (3), and PUV (2). Conclusions: FFs were mainly responsible for parents postponing their children's elective pediatric urology procedures in India. Universal insurance coverage for congenital anomalies might help overcome this most important cause of cancellations. [ABSTRACT FROM AUTHOR]

Background: Prevalence trends and reasons for pediatric surgery cancellation in Japan during the coronavirus disease 2019 (COVID‐19) pandemic have not previously been reported. This study aimed to compare the prevalence and reasons for cancellation of pediatric surgeries in Japan before and during the COVID‐19 pandemic. Methods: This single‐center retrospective cohort study reviewed the reasons for surgery cancellations scheduled for patients aged <18 years between the prepandemic period (September 2017–December 2019) and the COVID‐19 pandemic period (January 2020–April 2022). The cancellation reasons were classified into four major categories: medical, surgical, patient‐related, and administrative. Results: Of the 3395 and 3455 surgeries scheduled before and during the COVID‐19 pandemic, 305 (9.0%) and 319 (9.2%) surgeries were canceled (p = 0.737), respectively. The proportion of cancellations due to infections or fever in medical reasons decreased from 67.9% to 56.1% (p = 0.003) and that due to patient‐related reasons increased from 6.6% to 15.1% (p = 0.001). Further, the proportion of cancellations due to staff shortages in staff administrative reasons increased from 0.3% to 3.1% (p = 0.011). There was no significant difference in the proportion of surgeries canceled due to surgical reasons between the two periods. Conclusions: The proportion of cancellations due to infections or fever decreased during the COVID‐19 pandemic, while that due to staff shortages increased. Infection prevention is an important measure to address the staff shortages. Implementation of national or regional policies and additional strategic interventions may be required to prepare for disasters like the COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Hospital Pharmacy / Journal Canadien de la Pharmacie Hospitalière is the property of Canadian Society of Hospital Pharmacists 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.)

Background: Cancellations of elective surgeries adversely affect the patient, hospital staff, facility, and health system. Cancellations potentially result in hospital financial losses, theatre inefficiency, and substandard patient care. A common benchmark for the cancellation rate of elective surgeries is less than five percent, and most operating rooms fall short of this standard. There is a paucity of data on the rates and causes of elective surgical cancellations in rural, resource-limited settings. This study aimed to determine the prevalence of elective surgery cancellations, the causes for such cancellations, and the surgical disciplines most affected at Nelson Mandela Academic Hospital (NMAH). Methodology: This was an observational, descriptive, cross-sectional review of operating theatre records from January 2019 to July 2019. The prevalence and main causes of elective case cancellations were determined. The causes were classified, and the most affected surgical departments and patient characteristics were identified. Results: The prevalence of elective surgical case cancellations was 14.4% in our hospital, higher than the international benchmark of 5%. Patient-, facility-, and surgical-related factors were the leading causes of cancellations, and avoidable cancellations were mostly surgical- and anaesthetic-related. Ophthalmology was the most affected, followed by gynaecology and general surgery, with plastic surgery being the least affected. The most common patient-related factors were nonattendance and uncontrolled medical conditions, while overbooking was the most common surgical reason. Abnormal investigatory results and unfit status were the most common anaesthetic reasons. Facility-related issues included the lack of theatre time, equipment scarcity or malfunction, and staff unavailability. Most cancellations were unavoidable, but with careful planning, could be avoided. Conclusion and recommendations: This study identified challenges with theatre efficiency in a rural, resource-limited setting that call for the cooperation of multidisciplinary teams of surgeons, anaesthetists, nursing staff, and health care policymakers. [ABSTRACT FROM AUTHOR]

Background: Women are at risk of postoperative nausea and vomiting (PONV) after laparoscopic gynaecological surgery. Traditionally, patients who undergo laparoscopic gynaecological surgery are only allowed to initiate oral intake after return of bowel function, including bowel sounds or passage of flatus or stool. The present study was designed to assess the effect of liberal oral intake immediately after discharge from the post‐anaesthesia care unit (PACU) on PONV incidence in patients who underwent elective laparoscopic gynaecological surgery. Methods: In total, 174 patients (aged 20–64 years) were randomly assigned to the traditional and liberal groups. In the traditional group, patients were allowed to initiate oral intake 6 h after discharge from the PACU. In the liberal group, patients were allowed oral intake immediately after discharge from the PACU. The primary outcome was the incidence of PONV 48 h after surgery. Secondary outcomes included ileus incidence, total dose of postoperative opiate (sufentanil) use, time to postoperative first flatus (FFL), first out‐of‐bed mobilisation and the duration of postoperative hospitalisation stay. Results: Incidence of PONV was not significantly different between both groups (32.18% vs. 33.33%, p = 0.872). Time to FFL in the liberal group was significantly shorter than that in the traditional group (14.82 ± 0.91 h vs. 17.50 ± 0.96 h, p = 0.024). The postoperative pain score at 48 h after surgery was significantly lower in the liberal group than that in the traditional group (2.48 ± 0.17 vs. 3.20 ± 0.19, p = 0.008) without an increase in sufentanil use (89.32 ± 1.02 µg vs. 89.92 ± 1.16 µg, p = 0.702). No ileus occurred in either group. When considering the time of actually return to regular diet, initiating regular diet no more than 6 h after discharge from PACU significantly shortened the time to first out‐of‐bed mobilisation (11.18 ± 1.01 h vs. 15.05 ± 0.70 h, p = 0.003). Conclusions: Our results indicate that liberal oral intake after discharge from the PACU in patients aged 20–64 years who underwent gynaecological surgery is safe and beneficial and supports the rationale for a more liberal diet regime postoperatively. Key points: Women are at risk of postoperative nausea and vomiting (PONV) after laparoscopic gynaecological surgery. This single‐centre randomised controlled trial was designed to assess the effect of liberal oral intake immediately after discharge from post‐anaesthesia care unit (PACU) on PONV incidence in patients who underwent elective laparoscopic gynaecological surgery. Liberal oral intake after discharge from the PACU in patients aged 20–64 years who underwent gynaecological surgery is safe and beneficial and supports the rationale for a more liberal diet regime postoperatively. [ABSTRACT FROM AUTHOR]

Considering the gap observed in studies on health costs, this article aims to propose a cost calculation model for surgical hospitalization. A systematic literature review using PRISMA was conducted to map cost drivers adopted in similar studies and provide theoretical background. Based on the review, an integrated model considering real patient flow was developed using CHEERS guidelines. The micro-costing top-down method was adopted to develop the cost model allowing a balance between the accuracy of the information and the feasibility of the cost estimate. The proposed model fills two gaps in the literature: the standardization of a cost model and the ability to assess a vast number of different surgery costs in the same hospital. Flexibility stands out as an important advantage of the proposed model, as its application enables evaluation of elective and urgent surgeries of medium and high complexity performed in public and private hospitals. As a limitation, the hospital should have hospital information and cost systems implemented. The proposed cost model can provide important information that can result in better decision making. This becomes more relevant in public health, especially in low- and middle-income countries, which faces a lack of resources and whose positive effects can improve healthcare. [ABSTRACT FROM AUTHOR]

The complete absence of keratinized attached gingiva on the buccal surface of a tooth can make the area more susceptible to gingival recession. The modified apically repositioned flap (MARF) technique is an effective procedure to increase the dimensions of attached gingiva in areas that present with some existing keratinized tissue. The objective of this case report is to present long-term clinical and histologic evidence that the MARF technique can be used to create attached gingiva in areas that lack keratinized tissue. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has produced massive procedural backlogs in many parts of the developed world, with a disproportionate impact on the elderly. Whereas it is well-known that such a backlog would cause undue morbidity and mortality in thousands of patients, it is still unclear how jurisdictions plan on catching up on their missed surgeries and screening tests. In this comparative review therefore, we examine existing literature to quantify the backlog and thereafter summarize the solutions that have been proposed to clear it. Searches were performed on Google, Google Scholar, PubMed, Ovid MEDLINE®, and Ovid Embase® to identify literature from Canada, the United Kingdom, and the United States of America. We report our findings with a focus on three representative types of procedures including cataract surgery, colorectal screening, and hip and knee replacement surgery. Common themes of potential solutions included leveraging more advanced technology, ensuring preventative care, training an appropriate allied health workforce, and innovating in the operating room to improve efficiency and surgical capacity. Although no single solution emerges to be universally applicable, a combination of proposed solutions can be considered after an individualized assessment of the hospital or clinic context, the type of surgery required, and the availability of equipment, facility, and staff. [ABSTRACT FROM AUTHOR]

Introduction: Thousands of elective day-case procedures are cancelled in the National Health Service (NHS) annually on the day of surgery resulting in significant financial loss. The aim of this study is to determine the rate of cancellations and identify contributing factors in order to minimise and the number of cancellations Methods: Hospital data were collated on all patients undergoing elective-day case surgery across all surgical specialties at our institution over a 2-year period from September 2015 to August 2017. Reasons for cancellation were categorised as due to patient factors, hospital, administration/organisational factors. Results: Over this time period, a total of 1,692 cases were cancelled, giving a cancellation rate of approximately 8.0%. The majority of these were Orthopaedic (32.1%, n=543/1,692), Ophthalmology (26.4%, n=446/1,692) and General Surgery cases (14.9%, n=252/1,692). The median number of cancellations were 75 cases per month. Cancellations appeared to be lower in the summer months of July and August (112 and 134 respectively, p=0.03). The majority of patients were cancelled due to patient reasons (49.1%, n=831/1,692). A further 33.4% (n=565/1,692) were due to medical reasons and 17.5% (n=296/1,692) were due to hospital/ administrative reasons. Conclusions: The majority of same-day cancellations are due to patient factors, although a substantial proportion is due to hospital and medical reasons which can and should be pre-empted. Robust measures are required to address the multi-factorial nature of the problem and although internationally there is substantial variation in healthcare systems, sharing experiences can provide insight and enhance quality improvement strategies that could be locally adapted. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this article was to review the current literature with regard to the efficacy and effectiveness of flapless surgery for endosseous dental implants. The available data were evaluated for short- and long-term outcomes. Materials and Methods: A MEDLINE search was conducted on studies published between 1966 and 2008. For the purpose of this review, only clinical (human) studies with five or more subjects were included, and clinical opinion papers were excluded. Clinical studies or reports were further rated in terms of the level or weight of evidence using criteria defined by the Oxford Center for Evidence-Based Medicine in 2001. Results: The available data on flapless technique indicate high implant survival overall. The prospective cohort studies demonstrated approximately 98.6% (95% CI: 97.6 to 99.6) survival, suggesting clinical efficacy, while the retrospective studies or case series demonstrated 95.9% (95% CI: 94.8 to 97.0) survival, suggesting effective treatment. Six studies reported mean radiographic alveolar bone loss ranging from 0.7 to 2.6 mm after 1 year of implant placement. Intraoperative complications were reported in four studies, and these included perforation of the buccal or lingual bony plate. Overall, the incidence of intraoperative complications was 3.8% of reported surgical procedures. Conclusion: Flapless surgery appears to be a plausible treatment modality for implant placement, demonstrating both efficacy and clinical effectiveness. However, these data are derived from short-term studies with a mean interval of 19 months, and a successful outcome with this technique is dependent on advanced imaging, clinical training, and surgical judgment. [ABSTRACT FROM AUTHOR]

Summary: What is known and objectives: Inadequate management of chronic medication puts patients at risk and causes unnecessary suspension of surgical procedures. The objective of the study was to calculate the rate of cancellation of elective surgical procedures due to inadequate management of chronic medications and to analyse the underlying causes of cancellation. Methods: We designed an analytic, observational, retrospective study of all elective surgical procedures performed from July to October 2017 in a tertiary hospital. The main variable was the percentage of surgeries cancelled owing to inadequate management of chronic medications. Other variables recorded included demographic characteristics, time between the preanaesthesia evaluation and surgery, drug involved, and the reason for incorrect management of the medication. Results: During the study period, 5415 surgical procedures were programmed, and 793 (14.6%) were cancelled. Cancellations due to inadequate patient preparation accounted for 5.3% (42 cases), and 19 were related to incorrect medication management (2.4% of the total number of cancellations). The 19 patients, who were mostly men (73.7%), had a median age of 76 years (IQR 68‐81). The drugs involved were acenocoumarol (6), enoxaparin (4), clopidogrel (4), direct‐acting oral anticoagulants (2), acetylsalicylic acid (1), tocilizumab (1) and leflunomide (1). The reasons for drug mishandling were poor understanding of the anaesthesiology recommendations (15) and lack of a preanaesthesia evaluation (4). What is new and conclusion: Inadequate management of chronic medications (2.4%) is not the most frequent reason for cancellation, although it is one of the easiest to avoid. Based on our results, starting in October 2017, the Pharmacy Department began to offer a pharmaceutical service to patients with doubts about the preoperative management of chronic medications. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to determine the accuracy of three-dimensional endoanal ultrasound scan (3D-EAUS) in the pre-operative assessment of fistula-in-ano in identifying the fistula tract and comparing with findings at surgery in a South Asian cohort. A retrospective analysis of 87 patients with suspected fistula-in-ano who underwent pre-operative 3D-EAUS between January 2009 and January 2016 was carried out. All patients subsequently had surgical exploration under anaesthesia (EUA), irrespective of 3D-EAUS findings. The 3D-EAUS results were compared with the surgical findings to determine the accuracy of 3D-EAUS. Results: A total of 86 (98.9%) patients (male = 75) were subsequently shown to have a fistula at surgical exploration and of them, 3D-EAUS detected a fistula in 79 (92%) patients. In this cohort, 3D-EAUS correctly predicted the surgical findings in (n = 61, 70.9%) patients with the highest accuracy being for transphincteric fistulae (87.1%). However, the overall concordance in our study was low with a kappa coefficient of 0.318. Additional findings such as sphincter defects were detected by the 3D-EAUS in 37 patients (internal sphincter defects-21, external sphincter defects-7, both-9) which were not evident at EUA. Therefore, 3D-EAUS had a good accuracy in selected types of fistulae and particularly useful in identifying sphincter defects before surgery. [ABSTRACT FROM AUTHOR]

The objective of this retrospective analysis was to describe the development and implementation of an anesthesiologist‐led multidisciplinary committee to evaluate high‐risk surgical patients in order to improve surgical appropriateness. The study was conducted in an anesthesia preoperative evaluation clinic at an academic comprehensive cancer center. One hundred sixty‐seven high‐risk surgical patients with cancer‐related diagnoses were evaluated and discussed at a High‐Risk Committee (HRC) meeting to determine surgical appropriateness and optimize perioperative care. The HRC is an anesthesiologist‐led model for multidisciplinary review of high‐risk patients developed at Roswell Park Comprehensive Cancer Center. The group of high‐risk patients in which surgery was not performed had, on average, a greater percentage of hypertension, smoking history, dyspnea, heart failure, chronic obstructive pulmonary disease, diabetes, renal failure, and sleep apnea than the group in whom surgery was performed. Only one of 107 high‐risk patients who had surgery died within the first 30 days after surgery. A smaller percentage of patients died in the group that had surgery versus the group in which surgery was canceled. For all patients discussed by the HRC, the mortality was less than 2% within the first 30 days after the HRC. [ABSTRACT FROM AUTHOR]

Background With the increasing use of the robotic platform in general surgery, whether 8-mm ports should be closed comes into question. We sought to characterize the incidence of port-site hernias (PSHs) among patients undergoing robotic-assisted general surgery. Methods A retrospective chart review of a single institutional database identified patients who underwent robotic-assisted general surgery from July 2010 to December 2016. For each patient, the number, type, location, and size of all ports were collected. Twelve-millimeter port sites were routinely closed, whereas 5-mm and 8-mm port sites were not. PSH was detected on review of documented physical examination and of postoperative cross-sectional imaging, when available, in which case it was defined as a disruption of the fascia with or without eventration of tissue at a site of prior port placement. Results One hundred and seventy-eight patients underwent robotic-assisted general surgery, with 725 total ports: 433 8-mm working ports, 72 12-mm working ports, 178 12-mm camera ports, and 42 5-mm assistant ports. Ninety-four percent of the patients were men, the mean age was 63 ± 12, body mass index was 29 ± 7 kg/m 2 , and the median American Society of Anesthesiologists score was 3. Types of cases included 68 rectal (38.2%), 36 colon (20.2%), 25 hepatopancreatobiliary (14.0%), 21 inguinal hernia (11.8%), and 28 “other” (15.7%) operations. At a median follow-up of 193 d, there were three PSHs through 8-mm port sites (0.7%), two PSHs through 12-mm port sites (0.8%), and no PSH through 5-mm port sites. Two of the three 8-mm PSHs occurred in the early postoperative period and required emergent repair due to small bowel incarceration. Conclusions PSHs through 8-mm robotic port sites occur infrequently but can cause significant morbidity. Further investigation with longer follow-up is warranted to better understand the true incidence of robotic PSH. [ABSTRACT FROM AUTHOR]

The quality of clinical research in surgery has long attracted criticism. High-quality randomised trials have proved difficult to undertake in surgery, and many surgical treatments have therefore been adopted without adequate supporting evidence of efficacy and safety. This evidence deficit can adversely affect research funding and reimbursement decisions, lead to slow adoption of innovations, and permit widespread adoption of procedures that offer no benefit, or cause harm. Improvement in the quality of surgical evidence would therefore be valuable. The Idea, Development, Exploration, Assessment, and Long-term Follow-up (IDEAL) Framework and Recommendations specify desirable qualities for surgical studies, and outline an integrated evaluation pathway for surgery, and similar complex interventions. We used the IDEAL Recommendations to assess methodological progress in surgical research over time, assessed the uptake and influence of IDEAL, and identified the challenges to further methodological progress. Comparing studies from the periods 2000-04 and 2010-14, we noted apparent improvement in the use of standard outcome measures, adoption of Consolidated Standards of Reporting Trials (CONSORT) standards, and assessment of the quality of surgery and of learning curves, but no progress in the use of qualitative research or reporting of modifications during procedure development. Better education about research, integration of rigorous evaluation into routine practice and training, and linkage of such work to awards systems could foster further improvements in surgical evidence. IDEAL has probably contributed only slightly to the improvements described to date, but its uptake is accelerating rapidly. The need for the integrated evaluation template IDEAL offers for surgery and other complex treatments is becoming more widely accepted. [ABSTRACT FROM AUTHOR]

This article describes an innovative workflow that incorporates the prescription drug monitoring program (PDMP) into a suggested workflow for managing pain in elective surgery patients. Using the PDMP and working with the patient's pain management provider, clinicians can make sure that patients on chronic opioid therapy are identified before admission so that their care can be individualized, a plan developed to manage postoperative pain, and the patient can be transitioned seamlessly back to outpatient pain management. [ABSTRACT FROM AUTHOR]

Aim: The purpose of this literature review was to establish the scope of the literature about clinical handover from the operating room to Post Anaesthesia Care Unit (PACU) published in the last ten years and identify relevant key sources, theories, concepts and ideas. Method: The literature included in this review is divided into policy framework, practice, theoretical and primary research literature. Findings: This literature review demonstrates that either clinicians perceive clinical handover as informal, unstructured and inconsistent or transfer of information in handover as incomplete or unclearly expressed. Anaesthetists and PACU nurses differed in expectations of content and timing of information transfer. Conclusion: There is a need to develop training and educational strategies to improve clinical handover practice, particularly in a way that encourages collaboration. [ABSTRACT FROM AUTHOR]

Purpose: The Short Physical Performance Battery (SPPB) is a test used to assess physical function; however, the minimal clinically important difference (MCID) in patients after cardiac surgery is unknown. The aim of this study was to determine the MCID of the SPPB after cardiac surgery. Methods: Seventy-two participants performed the SPPB at 4 weeks and 3 months postoperatively. The Short Form-36 version 2 was used to assess physical function and the Global Rating of Change (GRC) scale was used to assess patient's perceived change. Distribution-based methods were used to determine the MCID. Results: The mean (95% confidence intervals [CIs]) change of the SPPB between testing time points was 11.04 (0.67-1.42) points. Ninety-eight percent of patients rated their function as "changed" on the GRC scale. The MCID calculated using distribution-based methods ranged from 0.44 points (95% CI [0.191, 0.613]) for the effect size-based estimate to 1.35 points for the standard error of measurement-based estimate. No participants scored 0/12; however, 45% and69% of participants scored 12/12 at 4 weeks and 3 months postoperatively, respectively. Conclusion: The MCID for SPPB is estimated to be between 0.44 and 1.35 points out of 12 for patients in the early postoperative period. Nearly half of the participants scored the maximum score at 4 weeks, increasing to two-thirds at 3 months meaning that the SPPB may be too easy as time from surgery increases and patients recover. Further research is required to confirm the MCID in patients closer to surgery where the ceiling effect is likely to be lower. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study was to compare the effectiveness of laparoscopic with that of open surgery up to 2 years after intervention in patients with rectal cancer. Methods: This is a prospective cohort study of patients with rectal cancer who underwent surgery (laparoscopic or open) between June 2010 and December 2012 in 22 acute hospitals. Main outcomes were mortality, complications, reoperation, readmission, and patient-reported outcome measures (PROMs), as measured using the EuroQol-5D (EQ-5D), European Organisation for Research and Treatment of Cancer (EORTC) QLQ-Q30 and Q29, the Barthel Index (BI), and the Duke-UNC Functional Social Support Questionnaire at baseline, 1 year, and 2 years after surgery. Multivariable multilevel logistic regression and generalized linear models were used in the analyses after adjusting for specific propensity scores developed for each outcome and time point. Results: In the multivariable analysis, rates of some medical complications after surgery during admission (renal failure and paralytic ileus) and infectious (urinary tract infection, septic shock, and localized intra-abdominal infection) and at 1 year (renal and heart failure) were higher among patients who underwent open surgery than among those who underwent laparoscopic surgery. There were no differences between the two surgical approaches in all other parameters assessed at the different time points or in all PROMs evaluated. Conclusions: Laparoscopic surgery and open surgery provide quite similar results in patients with rectal cancer up to 2 years after intervention in most outcomes, though the rates of certain medical and infectious complications at admission and up to 1 year after the intervention were higher in open surgery. [ABSTRACT FROM AUTHOR]

Introduction: Comparison of elective laparoscopic repair of axial vs paraesophageal hiatal hernias reveals relevant differences in both the patient collectives and the complexity of the procedures.Materials and Methods: The present uni- and multivariable analysis of data from the Herniamed Registry compares the outcome for 2047 (67.3%) (type I) axial with 996 (32.7%) (types II-IV) paraesophageal primary hiatal hernias following laparoscopic repair.Results: Compared with the patients with axial hiatal hernias, patients with paraesophageal hiatal hernia were nine years older, had a higher ASA score (ASA III/IV: 34.8 vs 13.7%; p < 0.001), and more often at least one risk factor (38.8 vs 21.4%; p < 0.001). This led in the univariable analysis to significantly more general postoperative complications (6.0 vs 3.0%; p < 0.001). Reflecting the greater complexity of the procedures used for laparoscopic repair of paraesophageal hiatal hernias, significantly higher intraoperative organ injury rates (3.7 vs 2.3%; p = 0.033) and higher postoperative complication-related reoperation rates (2.1 vs 1.1%; p = 0.032) were identified. Univariable analysis did not reveal any significant differences in the recurrence and pain rates on one-year follow-up. Multivariable analysis did not find any evidence that the use of a mesh had a significant influence on the recurrence rate.Conclusion: Surgical repair of paraesophageal hiatal hernia calls for an experienced surgeon as well as for corresponding intensive medicine competence because of the higher risks of general and surgical postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Major abdominal oncology surgery is associated with substantial postoperative loss of functional capacity, and exercise may be an effective intervention to improve outcomes. The aim of this study was to assess efficacy, feasibility and safety of a supervised postoperative exercise programme.Methods: We performed a single-blind, parallel-arm, randomized trial in patients who underwent major abdominal oncology surgery in a tertiary university hospital. Patients were randomized to an early mobilization postoperative programme based on supervised aerobic exercise, resistance and flexibility training or to standard rehabilitation care. The primary outcome was inability to walk without human assistance at postoperative day 5 or hospital discharge.Results: A total of 108 patients were enrolled, 54 into the early mobilization programme group and 54 into the standard rehabilitation care group. The incidence of the primary outcome was nine (16.7%) and 21 (38.9%), respectively (P=0.01), with an absolute risk reduction of 22.2% [95% confidence interval (CI) 5.9-38.6] and a number needed to treat of 5 (95% CI 3-17). All patients in the intervention group were able to follow at least partially the exercise programme, although the performance among them was rather heterogeneous. There were no differences between groups regarding clinical outcomes or complications related to the exercises.Conclusions: An early postoperative mobilization programme based on supervised exercises seems to be safe and feasible and improves functional capacity in patients undergoing major elective abdominal oncology surgery. However, its impact on clinical outcomes is still unclear.Clinical trial registration: NCT01693172. [ABSTRACT FROM AUTHOR]

Background. The use of total parenteral nutrition can affect liver function, causing a series of problems such as cholestasis. The aim of this meta-analysis was to compare structured triglyceride- (STG-) based lipid emulsions with physical medium-chain triglyceride (MCT)/long-chain triglyceride (LCT) mixtures in patients who had undergone liver surgery to identify any differences between these two types of parenteral nutrition. Methods. We searched the databases of PubMed, the Cochrane Library, Web of Science, EMBASE, and Chinese Biomedicine Database from January 2007 to March 2017 and included studies that compared STG-based lipid emulsions with physical MCT/LCT mixtures for surgical patients with liver disease. Conclusion. The STG was more beneficial than physical MCT/LCT on recovery of liver function and immune function. Therefore, STGs may represent a promising alternative to other types of lipid emulsions for hepatic surgery patients. [ABSTRACT FROM AUTHOR]

The article reports on the results of a feasibility study in 15 patients who had piezoelectric device for bone work in endoscopic anterior skull base surgery. Endoscopic transsphenoidal pituitary surgery has become the norm in the surgical treatment of most pituitary lesions. Despite excellentresults and postoperative CSF-leaks and skull base reconstructionsare still considerable issues.

The article discusses the approach of the researcher to revision stapes surgery and the outcomes from 49 procedures at a UK tertiary center. Revision stapes surgery are perceived to be difficult. Cases may harbor factors which include failure of primary surgery and including advanced otosclerotic disease and additional pathology such as lateral ossicular chain fixation, or difficult access due to anatomy.

Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet, these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social, and spiritual well-being and quality of life. To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. The objective of this article was to describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. We propose a research agenda to address these gaps and provide a road map for future investigation. [ABSTRACT FROM AUTHOR]

Objective: The geometry of the proximal femur has gained very much attention in the last decade. Many radiological measures have been introduced to help radiologists and orthopaedic surgeons to evaluate surgeries, diagnose diseases and plan for surgical interventions. The main purpose of this study was to assess the validity of a novel radiological land marks and angles to help in Dynamic Hip screw (DHS) application surgery in the proximal femur. Method: 200 true hip anteroposterior radiographs were obtained for patients between ages 50 to 80 years. We have developed the lesser trochanteric fovea capitis angle (LTFCA) and the lesser trochanteric lateral cortex angle (LTLFCA). Patients were divided into two groups, the male group (n=100) and the female group (n=100). The LTFCA + LTLFCA were assessed in the left and right hips in both genders. Results: In male population, the average LTFCA + LTLFCA values for the right and left hip joints were (133.2°±5.27, 134.5°±4.92) respectively. There was no statistical difference between both sides, p= 0.74. Whereas in female population, the average LTFCA + LTLFCA values for the right and left hip joints were (134.8°±6.13, 135.6°±5.45) respectively. No statistical significance was detected between the two sides, p=0.37. Conclusions: The LTFCA is an easy method that can facilitate trustable radiological land marks for surgeons for proper DHS insertion. Further studies should be conducted to evaluate the sensitivity and specificity of the lesser trochanteric fovea capitis angle (LTFCA) and its validity in proximal femoral surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVE To describe the learning curve for veterinary surgery residents performing hemilaminectomy surgeries in dogs. DESIGN Retrospective case review and learning curve evaluation. SAMPLE 13 individuals who completed a 3-year surgery residency program at a university teaching hospital and who had no prior experience performing hemilaminectomies. PROCEDURES The 13 residents performed hemilaminectomies on 399 dogs between July 2006 and July 2013. Medical records were reviewed, and operative time was recorded. Data were examined with a linear mixed-effects model to quantify fixed and random effects, a curve-fitting technique to find the best-fit curve, and a segmented 2-phase linear model to describe the domains and learning rates for 2 phases of learning. RESULTS The linear mixed-effects model indicated that increasing patient body weight and increasing surgical complexity (graded on the basis of number and contiguity of hemilaminectomy sites) were associated with longer operative times and that increasing exposure number was associated with shorter operative times. The monoexponential and biexponential parametric curves were of similar quality in modeling the data. The segmented 2-phase linear model showed an early phase of learning during which operative time decreased rapidly and a late phase when operative time decreased more gradually. CONCLUSIONS AND CLINICAL RELEVANCE The learning curve for the residents suggested that for early exposures, instruction in the form of direct supervision provided substantial benefit. By the tenth exposure, the benefit of instruction diminished and ongoing improvement was primarily a result of refinement. If validated by further study, this understanding of a 2-phase learning curve may inform the design of training programs in veterinary surgery. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Midurethral slings (MUS) are the mainstay of treatment for stress urinary incontinence, but the definition of success varies widely amongst studies. The King's Health Questionnaire (KHQ) was designed to evaluate the impact of urinary incontinence on the quality of life. We hypothesised that the KHQ could be useful for postoperative quantitative assessment of subjective outcomes. Materials and methods: This is a retrospective analysis of 204 patients who underwent incontinence surgery with transobturator MUS between 2004 and 2013. Follow-up was planned at 6, 12 and 24 months and success was evaluated using the cough stress test (objective cure) and the KHQ global score (subjective outcomes). Statistical analysis included receiver operating characteristic (ROC) curves to calculate a cut-off value for the KHQ global score to define subjective cure. The minimal clinically important difference was calculated with a distribution-based method (effect size) to estimate subjective improvement. Results: Objective cure rates were 97 % and 95 % at 6 and 24 months respectively. ROC curves established the cut-off score at ≤ 31 for subjective cure, with sensitivity of 63-100 % and specificity of 82-88 %. Subjective cure rates were 80 % and 85 % at 6 and 24 months respectively. The minimal clinically important difference was set at 10 and an improvement of ≥ 10 points was defined as subjective improvement. Rates varied between 10 and 13 %. Conclusions: This study showed the value of the KHQ as an evaluation tool after UI surgery and determined clinically relevant threshold scores to define subjective outcomes. [ABSTRACT FROM AUTHOR]

Background Standard setting allows educators to create benchmarks that distinguish between those who pass and those who fail an assessment. It can also be used to create standards in clinical and simulated procedural skill. The objective of this review was to perform a systematic review of the literature using absolute standard-setting methodology to create benchmarks in technical performance. Methods A systematic review was conducted by searching MEDLINE, Embase, PsycINFO and the Cochrane Database of Systematic Reviews. Abstracts of retrieved studies were reviewed and those meeting the inclusion criteria were selected for full-text review. The quality of evidence presented in the included studies was assessed using the Medical Education Research Study Quality Instrument ( MERSQI), where a score of 14 or more of 18 indicates high-quality evidence. Results Of 1809 studies identified, 37 used standard-setting methodology for assessment of procedural skill. Of these, 24 used participant-centred and 13 employed item-centred methods. Thirty studies took place in a simulated environment, and seven in a clinical setting. The included studies assessed residents (26 of 37), fellows (6 of 37) and staff physicians (17 of 37). Seventeen articles achieved a MERSQI score of 14 or more of 18, whereas 20 did not meet this mark. Conclusion Absolute standard-setting methodologies can be used to establish cut-offs for procedural skill assessments. [ABSTRACT FROM AUTHOR]

Albutrepenonacog alfa (Idelvion), a fusion protein that genetically fuses recombinant factor IX (rFIX) with recombinant human albumin (rAlbumin), is indicated in the treatment of haemophilia B. This narrative review discusses the pharmacological properties and clinical data related to the use of this novel fusion protein, hereafter referred to as rIX-FP. The fusion of rFIX to rAlbumin prolongs the elimination half-life of rIX-FP in the circulation, allowing routine prophylaxis to be administered once every 7-14 days. In the pivotal phase 3 clinical trials in previously treated patients with moderately severe to severe haemophilia B, routine rIX-FP prophylaxis (administered once every 7 days in children, and once every 7-14 days in adolescents and adults) was associated with low annualized spontaneous, total and joint bleeding rates, and was associated with significantly fewer bleeding episodes than on-demand treatment. rIX-FP was also effective in controlling bleeding episodes when used as on-demand treatment and in maintaining haemostasis in the perioperative setting. rIX-FP was well tolerated in the clinical trials, with no reports of inhibitor development. In conclusion, rIX-FP provides an effective, well-tolerated option for the treatment and management of haemophilia B that, by virtue of its extended half-life, is less burdensome than conventional FIX products. [ABSTRACT FROM AUTHOR]

Objective To determine the relationship between the severity of stenosis graded using both surgeons' visual assessment of spinal stenosis as well as measurement of dural cross-sectional area on magnetic resonance imaging (MRI), with the patient's disability. Methods Seven fellowship-trained spine surgeons reviewed MRI studies retrospectively of 30 symptomatic consecutive patients with lumbar stenosis and graded stenosis in the central canal, the lateral recess, and the foramen at T12-L1 to L5-S1 as none, mild, moderate, or severe. Dural cross-sectional area was measured at each level from T12-L1 to L5-S1. All patients completed the questionnaires for Oswestry Disability Index (ODI), Short Form 36 (SF-36), and recorded Visual Analog Scale scores for leg and back pain, and symptom severity scale of the Zurich claudication questionnaire. Results There was positive correlation between the right leg pain Visual Analog Scale score and the mean surgeon grades for central and lateral recess stenosis at L4-L5 and lateral recess stenosis at L5-S1. Except for a positive correlation between role physical score and surgeon grade for lateral recess stenosis at L5-S1, we found no correlation between the surgeons' grading of stenosis at any level with the ODI or SF-36. We found no correlation between the dural cross-sectional area with the ODI or SF-36. We did not find any correlation between the Zurich symptom severity scale and surgeons' grading of stenosis at any level. Conclusions Although surgeons rely on visual assessment of the severity of stenosis while making surgical decisions, we found that objective and subjective imaging parameters to grade severity of stenosis did not consistently indicate the patient's disability level. [ABSTRACT FROM AUTHOR]

This paper argues for the inclusion of surgery within the canon of performance science. The world of medicine presents rich, complex but relatively under-researched sites of performance. Performative aspects of clinical practice are overshadowed by a focus on the processes and outcomes of medical care, such as diagnostic accuracy and the results of treatment. The primacy of this "clinical" viewpoint--framed by clinical professionals as the application of medical knowledge--hides resonances with performance in other domains. Yet the language of performance is embedded in the culture of surgery--surgeons "perform" operations, work in an operating "theater" and use "instruments." This paper asks what might come into view if we take this performative language at face value and interrogate surgery from the perspective of performance science. [ABSTRACT FROM AUTHOR]

Importance: Trisomy 13 and 18 are genetic diagnoses with characteristic physical features, organ anomalies, and neurodevelopmental disability. Most children with these disorders die shortly after birth, although limited data suggest some children survive longer. Surgeries are controversial, and little evidence is available about outcomes.Objective: To describe survival and utilization of any type of surgery among children with trisomy 13 and 18 born over a 21-year period in Ontario, Canada.Design, Setting, and Participants: This retrospective cohort study used linked health administrative databases to identify children born in Ontario between April 1, 1991, and March 31, 2012, with a diagnosis code for trisomy 13 or 18 on a hospital record in the first year of life. Survival was calculated from birth and death dates; children living on March 31, 2013, were censored at their last clinical encounter.Exposures: All procedures classified as occurring in an operating room through March 31, 2013, were categorized as major, intermediate, or minor surgeries.Main Outcomes and Measures: Survival and surgical procedure utilization.Results: The cohorts included 174 children with trisomy 13 (mean [SD] birth weight, 2.5 [0.7] kg; 98 [56.3%] female); and 254 children with trisomy 18 (mean birth weight, 1.8 [0.7] kg; 157 [61.8%] female), with follow-up times of 0 to more than 7000 days. Median (interquartile range [IQR]) survival times were 12.5 (2-195) days for trisomy 13 and 9 (2-92) days for trisomy 18. Mean 1-year survival for trisomy 13 was 19.8% (95% CI, 14.2%-26.1%) and 12.6% (95% CI, 8.9%-17.1%) for trisomy 18. Ten-year survival for trisomy 13 was 12.9% (95% CI, 8.4%-18.5%) and 9.8% (95% CI, 6.4%-14.0%) for trisomy 18. Survival did not change over the study period. Forty-one children (23.6%) with trisomy 13 and 35 children (13.8%) with trisomy 18 underwent surgeries, ranging from myringotomy to complex cardiac repair. Median age at first surgery for trisomy 13 was 92 (IQR, 30.5-384.5) days and for trisomy 18, it was 205.5 (IQR, 20.0-518.0) days. Kaplan-Meier curves showed 1-year survival after first surgery of 70.7% (95% CI, 54.3%-82.2%; n = 23) for trisomy 13 and 68.6% (95% CI, 50.5%-81.2%; n = 29) for trisomy 18.Conclusions and Relevance: Among children born with trisomy 13 or 18 in Ontario, early mortality was the most common outcome, but 10% to 13% survived for 10 years. Among children who underwent surgical interventions, 1-year survival was high. [ABSTRACT FROM AUTHOR]

Background Transcatheter aortic valve implantation (TAVI) is often associated with conduction disturbances, followed by permanent pacemaker (PPM) implantation. Because of the potential reversibility of these conduction disorders, controversy exists regarding the right timing of PPM implantation. TAVI is routinely performed under dual-antiplatelet and antithrombotic therapy, which poses an additional hemorrhagic risk on a same-day procedure. The aim of the present study was to evaluate the safety and effectiveness of same-day PPM implantation in patients undergoing TAVI. Methods Consecutive patients undergoing TAVI with Medtronic Corevalve bioprosthesis (Medtronic Inc., Minneapolis, MN, USA) in a tertiary center were divided into two study groups. Group A included patients undergoing PPM implantation the same day with TAVI, and Group B patients were implanted with a PPM later after TAVI and before hospital discharge. The two study groups were compared for all complications associated with PPM implantation. Results In total, 168 patients were included in the study. PPM was implanted in 65 patients (38.7%). In 23 patients, a PPM was implanted the same day with TAVI (Group A) and in 42 patients PPM implantation was postponed at least 1 day (Group B). Cephalic vein was the access used for the leads in the majority of cases. There was only one case of pneumothorax in Group B. There were no differences in the incidence of pocket hematomas between the study groups. Conclusions Same-day PPM implantation after TAVI is safe and feasible. Strategies reducing pocket hematomas are essential in such patients of high hemorrhagic risk. [ABSTRACT FROM AUTHOR]

Aim: Clinical evaluation of the safety and effectiveness of compression anastomosis with ColonRing™ for large-bowel end-to-end anastomosis for rectal cancer and explanation of the procedure and the device itself since this device is used for the first time in our clinic. Material and methods: In November, 2012, a team of surgeons from our clinic attended the Clinical practice workshop in Belgrade, Serbia which was organized by the World Congress of Compression Anastomosis (WCCA) and held by its President Prof. Dr. Steven Wexner from Cleveland Clinic in USA. On this workshop, all aspects of technical point of view were obtained and surgeons were certified for the technique. A total of 25 patients have been scheduled for elective colorectal surgery with subsequent compression anastomosis using ColonRing. All patients were operated for high and mid rectal cancers excluding the low rectal cancers, since those patients are usually diverted with decompressive ileostomy. Patients, who are diverted, are at higher risk of retaining the ring, after its dislodgement, in the ampulla of the rectum since they do not have natural excretion of stool via the anus. All patients were followed for anastomotic leak, anastomotic bleeding, stricture formation, device (ColonRing) handling in general and time of expulsion of the ring via anus. Results: We used this technique for the first time in 2013 and since then a total of 25 patients underwent anterior resection of the rectum with subsequent colorectal compression anastomosis using ColonRing. Of all patients, 9 were female while 16 were male with median age of 64 years. All patients were operated for rectal cancers. The mean length of hospital stay was 7.4 days (range 5 to 9 days). None of the patients developed anastomotic bleeding or dehiscence. To date none of the patients developed anastomotic stricture, although some patients were followed for almost two years. The average day of expulsion from the body could not be calculated since despite, and although all patients were given instruction on how to check for ring expulsion, 21 of them did not report this event. Only 2 patients brought the ring to us. In two cases after 2 week of the initial operation, the ring was find and palpated on digital rectal examination, free in the ampulla of the rectum and was easily removed via the anus during the examination. Misfiring was reported in 1 patient (first patient) and reanastomosis was employed using another ColonRing, No perioperative mortality was observed in this patient population. Conclusion: End-to end colorectal anastomosis with the ColonRing is feasible and safe procedure with fast learning curve. To date, this type of anastomosis is possible in left sided colon lesions where anastomosis is contemplated below the promontory. We find the device easy to use with high level of confidence. Further prospective studies including comparison between the ColonRing device and the conventional staplers evaluating long-term anastomotic complications (i.e., leak or stricture) are needed to evaluate the benefits and limitations of this device. [ABSTRACT FROM AUTHOR]

Background: The lung is the most common site of extrahepatic metastasis from hepatocellular carcinoma (HCC). The aim of this study was to evaluate the significance and long-term outcomes of pulmonary metastasectomy for HCC, especially in patients with multiple nodules or repeated pulmonary recurrence. Methods: We retrospectively analyzed 19 patients who underwent pulmonary metastasectomy for HCC at our institution from 1993 to 2013. Results: No in-hospital mortality occurred. The 19 patients included 14 men. The median age was 61 (range 20-76) years. Eight patients (42 %) had single pulmonary metastatic lesions, whereas 4 (21 %) had >10 lesions. Median follow-up after pulmonary metastasectomy was 23.1 (6.3-230) months. Twelve patients died, and the cause of death was HCC progression in nine. The 1-, 3-, 5-, and 10-year overall survival rates after pulmonary metastasectomy were 89, 48, 48, and 21 %, respectively. Seven patients developed pulmonary recurrence after initial pulmonary metastasectomy. Five of the seven underwent repeat metastasectomy, with a median survival time of 65 months, and 2- and 3-year survival rates of 100 and 67 %, respectively. The 2- and 3-year survival rates in the four patients with >10 pulmonary nodules were 75 and 50 %, respectively. Conclusions: Surgical resection is a safe and effective treatment in selected patients with pulmonary metastasis from HCC, even in those with multiple nodules. Repeated locoregional therapy for lung recurrence might help to improve survival in these patients. [ABSTRACT FROM AUTHOR]

Background: Pulmonary metastasectomy is increasingly performed in selected patients by video-assisted thoracic surgery (VATS) on the base of thin-slice high-resolution CT-Scan (HRCT). This study determines the overall survival and ipsilateral recurrence rate and of patients undergoing after VATS lung metastasectomy. Patients and method: Retrospective single institution study of all patients who underwent VATS pulmonary metastasectomy on the base of HRCT with curative intent between 2005 and 2014. Results: Seventy-seven patients (41 males, 36 females) underwent VATS pulmonary metastasectomy for solitary ( n = 63) or multiple ( n = 14) lung metastases in the context of colorectal carcinoma ( n = 26), sarcoma ( n = 17), melanoma ( n = 16), or other primaries ( n = 18). Nine patients had bilateral lung metastases and underwent synchronous ( n = 4) or sequential ( n = 5) VATS resections. Preoperative CT-guided hook wire localization of the lesions was performed in 65 patients (84 %). The postoperative mortality and morbidity rates were 0 and 5.2 %, respectively. During a mean follow-up time of 24 months (range 1-120 months), tumor progression occurred in 46 patients. Twenty-three patients (30 %) had pulmonary recurrence only, of them, eight patients (10 %) in the operated lungs. Seven of eight patients with recurrence in the operated lungs underwent a second metastasectomy by VATS ( n = 5) or thoracotomy ( n = 2). The overall 5-year survival rate was 54 % and without difference between patients without tumor recurrence and those with pulmonary recurrence treated by re-metastasectomy. Conclusion: Ipsilateral recurrence remains low after VATS pulmonary metastasectomy guided by preoperative HRCT and can be efficiently treated by re-metastasectomy. [ABSTRACT FROM AUTHOR]

Background: The association between surgical extent and prognosis in papillary thyroid carcinoma originating in the isthmus is unclear. Methods: We included 233 patients with early-stage, node-negative papillary thyroid cancer originating in the isthmus; 126 were treated by lobectomy plus isthmusectomy with ipsilateral central neck dissection and 97 were treated by total thyroidectomy with bilateral central neck dissection. Subgroup analysis was performed according to tumor size (≤1 vs. >1 cm) to evaluate whether tumor size had a significant impact on determining the optimal extent of surgery in our cohort. Results: Total thyroidectomy patients had longer recurrence-free survival (RFS) than those treated by lobectomy plus isthmusectomy. Subgroup analysis showed that this was true only for tumors >1 cm. In multivariate analysis, total thyroidectomy was an independent risk factor for RFS only for tumors >1 cm. Conclusions: Lobectomy plus isthmusectomy may be optimal for early-stage, node-negative papillary thyroid carcinoma originating in the isthmus for tumors ≤1 cm; total thyroidectomy might be better for tumors >1 cm. [ABSTRACT FROM AUTHOR]

Background: A totally extraperitoneal (TEP) approach is currently the technique of choice for the laparoscopic repair of bilateral inguinal hernias in our institution. Most other surgeons use two meshes for the TEP repair, one for each side. We prefer a large single mesh when possible since it allows for easier correct placement of the mesh in one stage. We compared our long-term results of both techniques in terms of late complications and recurrence rates. Methods: This study retrospectively evaluated the medical records of 108 patients who underwent bilateral laparoscopic TEP repair in our institution between January 2002 and December 2003. Excluded were patients who had a conversion to a transabdominal preperitoneal or open approach. A total of 73 (67 %) patients fulfilled study entrance criteria and were enrolled: 39 had undergone single mesh repair and 34 had undergone double mesh repair. Results: There were no significant group differences in demographics, operating time, postoperative morbidity, or hospital stay. Likewise, after a median follow-up of 102 months (range 94-115 months), there were no significant group differences between the single and double mesh groups in persistent pain (5.8 vs 2.5 %, respectively; p = 0.476) and recurrence (7.6 vs 8.8 %, respectively; p = 0.55). Conclusion: The use of a large single mesh is an effective and safe alternative technique for TEP repair of bilateral inguinal hernias, and is technically easy to perform. [ABSTRACT FROM AUTHOR]

Background: Appendectomy is considered a safe operation, the related complications being minor. Negative exploration is an accepted procedure to avoid complications of appendicitis. Treatment with antibiotics is under debate as a primary treatment for appendicitis. The aim of this study was to collect and analyze detailed information on complications and morbidity related to appendectomy using the information of the nationwide Patient Insurance Association (PIA) database and to study the incidence of patient claims and compensated injuries related to appendectomy in Finland. Methods: Patients' claims from 1990 to 2010 were collected from the PIA register. Complications were classified using the accordion severity grading system. Severe complications were selected for more detailed analyses. Laparoscopic and open surgeries were compared. Factors related to compensated claims were assessed. For statistical analysis, Fisher's exact test, logistic multivariate regression, and the Mann-Kendall function were used. Results: Appendectomy complications leading to a patient insurance claim in Finland are rare (0.2 %). The rate of patients' claims after laparoscopic surgery was higher than after open surgery ( p < 0.001), but the rate of compensated claims was equal. During the study period, complications after laparoscopic procedures more often led to additional surgery or organ failure ( p = 0.03). Of the patients with a compensated injury, only 57 % had appendicitis. Preoperative computed tomography was used in only 6 % of these cases. Conclusions: Patient injuries and claims regarding severe complications after appendectomy are rare. The complications related to laparoscopic appendectomy were more severe than those of open surgery. [ABSTRACT FROM AUTHOR]

Unplanned general surgery represents a major workload and requires comprehensive evaluation with appropriate outcomes. This study aimed to summarize current reporting of patient-reported outcomes (PROs) in randomized clinical trials (RCTs) in unplanned general surgery. A systematic review identified RCTs reporting PROs in the commonest six areas of unplanned general surgery. Details of the PRO measures were examined using the CONSORT extension for PRO reporting in RCTs. Extracted information about each PRO domain included the reporting of baseline PROs, rationale for PRO selection and whether PRO findings were used in conjunction with clinical outcomes to inform treatment recommendations. The internal validity of included studies was assessed using the Cochrane risk of bias tool. 12,519 abstracts were screened and 20 RCTs containing data from 2037 patients included. Included studies used 14 separate PRO measures covering 35 different health domains. A visual analogue assessment of pain was most frequently reported ( n = 13). Reporting of baseline PRO data was uncommon (11/35 PRO domains). The rationale for PRO data collection and a PRO-specific hypothesis were provided for 9 (25.7 %) and 5 (14.3 %) domains, respectively. Seventeen RCTs (85.0 %) used the PRO data alongside clinical outcomes to inform treatment recommendations. Of the 116 risk of bias assessments, 77 (66.0 %) were judged as high or unclear. There is a lack of well designed, and conducted RCTs in unplanned general surgery that include PROs. Future work to define relevant PROs and methods for optimal assessment are needed to inform health care decision-making. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study is to analyze whether the trend towards operating on patients with less severe primary hyperparathyroidism (pHPT) than earlier is reflected in a change of preoperative presentation and surgical outcome. Methods: In this longitudinal cohort study, patients with pHPT subjected to first time surgery were compared in three time periods: 1989-1994, 1995-2000, and 2001-2006 in this longitudinal cohort study. Results: There were 404 patients. Median levels of preoperative ionized calcium were lower in 2001-2006 compared to 1989-1994; 1.45 versus 1.50 versus 1.45 mmol/L; p < 0.001. Preoperative parathyroid hormone levels in patients with parathyroid adenoma were lower in 2001-2006 than in 1989-1994; 10.0 versus 11.6 pmol/L; p 0.04. Median preoperative bone mineral density, BMD, in the whole cohort did not differ between time periods. Median pre- and postoperative glomeruli filtration rate, GFR, and 25-hydroxy-vitamin D remained unchanged between period 1 and period 3. Adenoma weight was lower in 2001-2006 than 1989-1994; 0.70 versus 0.50 g; p 0.04. Cure rate did not change during observation time. There was no evidence for differences in change of BMD (femoral neck) after surgery between period 2 and 3 1995-2000 and 2001-2006, 0.798 versus 0.795 g/cm; p 0.67. GFR did not change significantly between 1989-1994 and 2001-2006, 74 versus 77 mL/min; p 0.43. Conclusions: A significant change towards operating patients with smaller adenomas and lower preoperative calcium levels was evident throughout the observation period, but this did not correlate with differences in preoperative renal or skeletal function. We found no evidence for a change of postoperative renal function or skeletal function during observation time. [ABSTRACT FROM AUTHOR]