American Society Of Anesthesiologists Score Research Articles

EGS SO26 - Back Under the Knife: Unveiling the Fate of non-trauma Patients Returning to the Emergency Theatre

Abstract Background Offering a planned or unplanned second operation in emergency general surgery is not uncommon. However, there is a scarcity of data in this context. This study aims to evaluate the outcomes of patients who were offered two emergency operations to those who required one operation, focusing on complications, increased level of care at discharge and mortality rates. Method We identified those patients who underwent planned and unplanned revisits to the emergency theatre between July 2020 and July 2023. Inclusion criteria were consistent with the established UK National Emergency Laparotomy Audit (NELA at our centre over three years.. We examined demographics, ASA (American Society of Anesthesiologists) classification, indications and outcomes in terms of complications, increased post-operative care levels and mortality rates. Results 390 patients (89.3%) required one operation (1OP) and 47 (10.7%)patients underwent two operations (2OP) . The median age was 70 years for 1OP and 71 years for 2OP, with a male-to-female ratio of 192:198 in 1OPG and 22:25 in 2OP. The median ASA score (2 vs. 3), median frailty score (3 vs. 4) and the median Clavien-Dindo classification (2 vs. 4), and length of stay in days (12 vs. 21) were significantly higher for the 2OP. The increase in the level of care at discharge (30.6% vs. 59%) and the mortality (7.4% vs. 32%) were higher in the 2OP. Conclusion Our study shows that non-trauma patients requiring a second emergency operation face significantly worse outcomes compared to those undergoing only one surgery. Specifically, the group needing two operations experienced higher rates of complications, increased levels of post-operative care, and significantly higher mortality rates. These findings underscore the critical need for close monitoring and a multidisciplinary approach perioperatively. Moreover, these insights can help provide patients and their families with informed decision-making regarding the potential risks and benefits of additional surgical interventions. A prospective multicentre study would be valuable in providing further insights into this subgroup of patients.

Higher BMI Is Associated With Wound Breakdown Following Resection of Haglund Deformity.

Haglund deformity is characterized by an enlarged posterosuperior calcaneus, often with inflammation of the retrocalcaneal bursa and Achilles tendon. This study aims to determine if obesity is associated with an increased rate of complications after Haglund resection. A retrospective review was conducted on patients who underwent surgical resection for Haglund deformity from January 2015 to December 2023 at a single academic center. The patient cohort was initially stratified by body mass index (BMI) into normal (BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30). For those classified as obese, further subclassification was performed using the standard system: obesity class I (mild obesity) = BMI 30.0-34.9; obesity class II (moderate obesity) = BMI 35.0-39.9; and obesity class III (severe obesity) = BMI ≥40.0. Data on demographics, surgical techniques, and weightbearing were collected and analyzed. Postoperative complications were compared between groups. Of the 370 patients included in this study, 20 (5.4%) were classified as normal, 77 (20.8%) were overweight, and 273 (73.8%) were obese. Within the cohort of patients with obesity, 96 (35.2%) were classified as obesity class I, 96 (35.2%) as obesity class II, and 81 (29.7%) as obesity class III.The obese group had a higher proportion of females (70.0%) and Black/African American race (24.5%), and a higher prevalence of diabetes mellitus (22.0%) and American Society of Anesthesiologists scores compared with other groups. Additionally, analysis within the obesity subclassifications revealed significant differences in smoking status, with a higher proportion of nonsmokers as obesity class increased (58.3% in class I, 76.0% in class II, and 79.0% in class III; P = .01). Follow-up duration averaged 10.5 months, with wound breakdown rates significantly higher in the obese group vs the overweight or normal groups (11.0% vs 2.6% vs 0.0%, P = .02). No significant differences in wound complications or outcomes were observed between patients based on different obesity subclassifications. Our findings demonstrate that after Haglund resection, obese patients have a higher risk of complications, particularly wound breakdown. This underscores the necessity of careful patient selection and perioperative optimization.

The clinical value of integrated pulmonary index monitoring during an endobronchial ultrasound-guided transbronchial needle aspiration procedure under sedoanalgesia: A prospective study.

To evaluate the clinical relevance of Integrated Pulmonary Index (IPI) monitoring during transbronchial needle aspiration (EBUS-TBNA) under sedation and determine whether it reduces hypoxic events compared to standard monitoring. This prospective observational research was carried out at Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey, between July 2022 and July 2023. A total of 50 patients, aged 18-80 years with American Society of Anesthesiologists scores of I-III, undergoing EBUS-TBNA with deep sedation for diagnostic purposes were included. The IPI values were measured at 6 time points: baseline, induction, 3, 5, 10 minutes, and at the end of the procedure. Patients were categorized based on whether their IPI scores were above 7 (group 1) or below 7 (group 2). A total of 43 patients completed the study. Group 1 had higher end-tidal carbon dioxide and respiratory rate at multiple time points, including induction and at 3, 5, and 10 minutes post-induction (p<0.05). Group 2 experienced a higher rate of apnea at these times (p<0.05). Those with lower IPI scores (namely, IPI=3 and IPI=4) showed significantly higher apnea rates, while those with higher scores (namely, IPI=7 and IPI=8) were less likely to have apneic episodes. The IPI monitoring during EBUS-TBNA under sedation demonstrated improved detection of apnea episodes and enhanced respiratory safety compared to standard monitoring techniques. Additional research involving more varied populations is necessary to confirm these results.

The Importance of Patient Systemic Health Status in High-Grade Chondrosarcoma Prognosis: A National Multicenter Study

Background: Due to the relatively advanced age and high mortality rate of patients with high-grade chondrosarcoma (CS), it is important to holistically assess patient- and tumor characteristics in multidisciplinary team and shared decision-making with regard to treatment options. While current prognostic models include multiple tumor and treatment characteristics, the only patient characteristics that are commonly included are age and gender. Based on clinical experience, we believe that factors related to patient preoperative systemic health status such as the American Society of Anesthesiologists (ASA) score may be equally important prognostic factors for overall survival (OS). Methods: A retrospective nationwide cohort study was identified from four specialized bone sarcoma centers in The Netherlands. Patients with a primary CS grade II, III, and dedifferentiated CS were eligible. Prognostic factors including age at presentation, gender, ASA score, CVD, tobacco use, BMI, histological tumor grade, tumor size, pathological fracture, presentation after unplanned excision, type of surgery and surgical margin were evaluated. The outcome measure was OS at the time of surgery. The Kaplan–Meier methodology was employed to estimate OS; a log-rank test was used to assess the difference in survival. To study the impact of prognostic factors on OS, a multivariate Cox proportional hazard regression model was estimated. Results: In total, 249 patients were eligible for this study, and 89 were deceased at the end of follow-up. In multivariate analysis, histological grade (HR 2.247, 95% CI 1.334–3.783), ASA score III (HR 2.615, 95% CI 1.145–5.976, vs. ASA I), and age per year (HR: 1.025, 95% CI 1.004–1.045) were negatively associated with OS. No association was found between tobacco use, BMI, gender or cardiovascular disease and OS in this cohort. Pathological fracture and tumor size were only associated with OS in univariate analysis. Conclusions: This multicenter study is the first on sarcomas to include ASA in a prognostic model. Results show that ASA score as a proxy for patients’ systemic health status should be included when providing a prognosis for patients with a high-grade primary CS, besides the conventional risk factors such as tumor grade and age. Specifically, severe systemic disease (ASA score III) is a strong negative predictor. Conversely, we found no difference in OS between ASA scores I and II. These findings aid multidisciplinary team and shared decision-making with regard to these complex sarcoma patients that often require life-changing surgeries. Level of Evidence: Prognostic level III. See the instructions for authors for the complete description of levels of evidence.

Development and Validation of a 30-Day Point-Scoring Risk Calculator for Open Groin Vascular Surgery: The George Washington Groin Score

BackgroundOpen groin vascular surgeries are important in managing peripheral arterial diseases. Given its inherent risks and the diverse patient profiles, there is a need for risk assessment tools. This study aimed to develop a 30-d point-scoring risk calculator for patients undergoing open groin vascular surgeries. MethodsPatients underwent open groin vascular surgery, including aortobifemoral, axillofemoral, femorofemoral, iliofemoral, femoral-popliteal, and femoral-tibial bypass as well as thromboendarterectomy, were identified in American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2021. Patients were randomly sampled into experimental (2/3) and validation (1/3) groups. The George Washington (GW) groin score, a weighted point-scoring system, was developed for 30-d mortality from multivariable regression on preoperative risk variables by Sullivan's method. GW groin score was subjected to internal and external validation. Furthermore, the effectiveness of GW groin score was evaluated in 30-d major surgical complications. ResultsA total of 129,424 patients were analyzed, with 86,715 allocated to experimental group and 42,709 to validation group. GW groin score is derived as follows: aortobifemoral bypass (2 points), axillofemoral bypass (1 point), age (>75 y, 2 points; 65-75 y, 1 point), disseminated cancer (2 points), emergent presentation (1 point), American Society of Anesthesiology score 4 or 5 (1 point), dialysis (1 point), and preoperative sepsis (1 point).GW groin score exhibited robust discrimination (c-statistic = 0.794, 95% CI = 0.786-0.803) and calibration (Brier score = 0.029). The transition from individual preoperative variables (c-statistic = 0.809, 95% CI = 0.801-0.818) to the point-scoring system was successful and external validation of the score was confirmed (c-statistic = 0.789, 95% CI = 0.777-0.801, Brier score = 0.030). Furthermore, GW groin score can effectively discriminate major surgical complications. ConclusionsThis study developed GW groin score, a concise and comprehensive 10-point risk calculator. This well-validated score demonstrates robust discriminative and predictive abilities for 30-d mortality and major surgical complications following open groin vascular surgeries. GW groin score can anticipate potential perioperative complications and guide treatment decisions.

Influences on the duration and success of out-of-hospital resuscitation of geriatric patients over 80 years of age - a retrospective evaluation

BackgroundSociety is experiencing an increasing shift in the age distribution and accordingly, increased resuscitation rates of patients over 80 years and older. In 2022, more than 34% of people resuscitated in Germany were older than 80 years, although older age is considered a poor predictor for the outcome of cardiopulmonary resuscitation (CPR). Professional societies provide ethical recommendations on when resuscitation may be considered futile and should be terminated. However, the extent to which these recommendations are implemented is unclear.MethodsRetrospective evaluation of pre-hospital documentation of out-of-hospital resuscitations in patients ≥ 80 years of age in the period 01/01/2014–12/31/2022 in one German county combined with data of the German Resuscitation Registry. For statistical testing, the significance level was set at p < 0.05.ResultsIn total 578 cases were analyzed. Return of spontaneous circulation (ROSC): 26% (n = 148). Survival to discharge: 6.1% (n = 35). Median CPR duration: 17 min (10–28 min). The older the patients were, the worse the survival rate (p = 0.05) and the shorter the time to termination (p < 0.0001). No patient over 90 years of age was discharged alive. Resuscitation was also significantly shorter until termination with poorer ASA (American Society of Anesthesiologists) score (p < 0.001). Residents resuscitated significantly longer than specialists (p = 0.02). In surviving patients, there was a significant correlation between short CPR duration and good cerebral performance category (CPC) value: Median CPC1/2 = 5 min [3–10 min] vs. CPC 3/4 = 18 min [10–21 min]; p = 0.01.InterpretationOld age and poor health status is associated with shorter CPR duration until termination and older age is associated with poorer prognosis in out-of-hospital cardiac arrest (OHCA) concerning the possibility of return of spontaneous circulation (ROSC) and survival. A short resuscitation time is associated with a better CPC value. Therefore, when resuscitating patients over 80 years of age, even greater care should be taken to ensure that reversible causes are quickly corrected in order to achieve a ROSC and a good neurological outcome. Alternatively, resuscitation should be terminated promptly, as good survival can no longer be guaranteed. Resuscitation lasting more than 20 min should be avoided in any case, in line with the termination of resuscitation (ToR) criteria.

From evidence to practice: real-world insights into outpatient management of acute uncomplicated diverticulitis.

Diverticulitis is experiencing a significant increase in prevalence and its widespread in-hospital management results in a high burden on healthcare systems worldwide. This study compared inpatient and outpatient approach of acute non-complicated diverticulitis using a non-selected population in a real-world setting. This observational retrospective study included all consecutive patients from two Portuguese institutions diagnosed between January 2017 and December 2021 with non-complicated diverticulitis according to the modified Hinchey Classification. The primary endpoints were to identify criteria for inpatient treatment and compare the outcomes on the basis of the treatment regimen. The secondary endpoints were to determine the predictive factors for clinical outcomes, focusing on treatment failure, pain recurrence, and the need for elective surgery following the initial episode. A total of 688 patients were included in this study, 437 treated as outpatients and 251 hospitalized. Inpatient management was significantly associated with higher preadmission American society of anesthesiologists (ASA) score (p = 0.004), fever (p = 0.030), leukocytosis (p < 0.001), and elevated C-reactive protein (CRP) (p < 0.001). No significant association was found between failure of conservative treatment and patient's age, ASA score, baseline CRP, presence of systemic inflammatory response syndrome (SIRS), and inpatient or outpatient treatment regimen. Pain recurrence was significantly associated with higher CRP levels (p = 0.049), inpatient treatment regime (p = 0.009) and post index episode mesalazine prescription (p = 0.006). Moreover, the need for elective surgery was significantly associated with the presence of previous episodes (p = 0.004) and pain recurrence (p < 0.001). The majority of patients with uncomplicated diverticulitis of the left colon experience successful conservative approach and can be safely managed in an ambulatory setting. Neither treatment failure, recurrence of pain, or need for posterior elective surgery are associated with outpatient treatment regimen.

The impact of economic crisis, COVID-19, and the Beirut Blast on colorectal cancer patients in Lebanon: A trend to operate more late-stage complex cases.

The convergence of the economic crisis, COVID-19 pandemic, and Beirut Blast has precipitated unprecedented challenges for the healthcare system in Lebanon, particularly for cancer patients. Amidst these crises, our study evaluates its contribution to a concerning trend of operating on more late-stage and complex colorectal cancer (CRC) cases. We included 155 patients operated for CRC between 2017 and 2023. Patients age; sex; operation type (emergency or elective); tumor size, grade, and location; tumour, node, metastasis stage; lymphatic, vascular and perineural invasions; American Society of Anesthesiologists (ASA) score, presentation and previous history, and complications were examined. Surgical outcomes remained relatively consistent before and after the crisis. However, there was a notable increase, with patients being 3.59 times more likely to undergo resection of adjacent organs in metastatic disease post-crisis. Patient characteristics also exhibited notable shifts, with a 9.60-fold increase in the likelihood of having an ASA score of at least 2 after the crisis. Additionally, there was a 5.36-fold decrease in the odds of patients undergoing a colonoscopy before their diagnostic one post-crisis. Preoperative carcinoembryonic antigen levels were significantly elevated post-crisis compared to pre-crisis levels. Pathological findings revealed increased odds of perineural, vascular, and lymphatic invasion post-crisis. Additionally, there was a notable increase in the likelihood of hepatic synchronous metastases post-crisis. Furthermore, a trend to operate on complicated diseases was noted with an increased number of colostomies. The economic crisis in Lebanon has profoundly affected early intervention and comprehensive treatment for CRC patients, resulting in a concerning rise in late-stage cases requiring surgical intervention.

Renal cell carcinoma with inferior vena cava thrombus: Survival and prognostic factors in surgically treated patients

Introduction: Renal cell carcinoma (RCC) often develops a tumor thrombus extending into the inferior vena cava (IVC). Radical nephrectomy with IVC thrombectomy is the standard treatment, although prognostic factors are yet to be properly established. Objectives: The objectives of this study were to review the clinicopathological features of surgically treated patients with RCC and IVC thrombus and to investigate potential prognostic factors. Materials and Methods: This retrospective analysis covered patients with RCC and IVC thrombus who underwent surgical treatment at a tertiary center over 12 years. Results: Of the 32 patients included, 56% and 41% had nodal (N1) and metastatic (M1) diseases, respectively. Thrombus level was 1 in 25% and 4 in 21.9% of cases, according to the Mayo classification. The median follow-up was 17.0 months. The median overall survival (OS) was 20.0 months, with a median OS of 36.0 months in M0 patients and 10.0 months in M1 patients (log-rank P = 0.029). Stage IV disease (T4 and/or M1 status) (hazard ratio [HR]: 2.85, P = 0.021), fat invasion (HR: 2.52, P = 0.044), positive margins (HR: 2.54, P = 0.037), American Society of Anesthesiologists score (HR: 2.59, P = 0.033), tumor size &gt;100 mm (HR: 2.538, P = 0.033), and higher neutrophil-to-lymphocyte ratio (r 2 = 0.304, P = 0.001) were significantly associated with worse OS in univariate analysis. Thrombus level did not impact prognosis. Conclusions: Certain clinicopathological factors, but not thrombus level, appear to influence prognosis. Prospective multicentric randomized studies are needed to better stratify patient risk, improve prognostic prediction, and evaluate systemic therapy responses.

Intraoperative dexmedetomidine administration and acute kidney injury in patients undergoing unilateral partial nephrectomy: a retrospective study

Partial nephrectomies are associated with an increased risk of acute kidney injury (AKI), but dexmedetomidine administration may improve renal outcomes. We hypothesized that intraoperative dexmedetomidine administration would be associated with a decrease in AKI development in patients undergoing unilateral partial nephrectomy. In this retrospective study, adult patients who underwent unilateral partial nephrectomy from April 2016 to October 2023 were included. Exclusion criteria were a history of end-stage renal disease, ineligible procedures (i.e., aborted procedure, conversion to radical nephrectomy, surgery on a horseshoe kidney), and reoperation within three days of the initial nephrectomy. Patients were categorized according to whether they received intraoperative dexmedetomidine. The primary outcome was AKI incidence within three days of surgery; AKI was defined according to the Kidney Disease Improving Global Outcomes definition. Propensity score matching (PSM) was conducted to account for potential confounders (age, body mass index, sex, American Society of Anesthesiologists score, final surgical approach, clamping-related ischemia for >15 min). We included 1,632 patients; 214 received dexmedetomidine and 1,418 did not. Before PSM, the AKI rate was 31.2% in patients who received dexmedetomidine and 25.7% in patients who did not (p = 0.081). After PSM, the AKI rate was 31.3% in patients who received dexmedetomidine and 27.6% in those who did not (p = 0.396). The post-PSM odds ratio for AKI following dexmedetomidine administration during unilateral partial nephrectomy was 0.910 (95% CI: 0.585–1.142; p = 0.677). Intraoperative dexmedetomidine was not associated with a reduction in postoperative AKI incidence or severity after unilateral partial nephrectomy.

Comparative performance of Boey, peptic ulcer perforation, and American Society of Anesthesiologists scores in predicting outcomes in patients with perforated peptic ulcer.

Comparative performance of Boey, peptic ulcer perforation, and American Society of Anesthesiologists scores in predicting outcomes in patients with perforated peptic ulcer.

A Retrospective Evaluation of Patients Who Had Den¬tal Treatments Under General Anesthesia

Aim: This retrospective study aimed to evaluate the demographic and operational data of uncooperative healthy individuals and individuals with special needs who underwent dental treatments under sedation and general anesthesia. Methods: Data of 458 patients with special needs and 77 healthy noncooperative patients who were examined at XXX University Faculty of Dentistry between January 2022 and May 2023 and underwent dental treatments under general anesthesia were examined retrospectively. Demographic data of the patients, American Society of Anesthesiologists (ASA) scores, mallampati (MP) scores, disability status, if they have systemic diseases, type of anesthesia (sedation/general anesthesia), anesthetic agents and analgesia used, operation duration and dental treatments, were evaluated. Results: The average age of 535 patients who received dental treatment was 13.5±9.9 years and 58.1% (n=311) of the patients were male and 41.9% (n=224) were female. According to ASA scores, the distribution was 15.7% ASA I, 77.6% ASA II, and 6.7% ASA III. While 14.4% of the patients were systemically healthy, 16.7% had epilepsy, 12.9% had cerebral palsy, 12.1% had mental retardation, and 7.1% had Down syndrome. Of 7.1% had various comorbidities such as cardiological problems. Sedation was applied to 7.3% (n=39) of the patients, and general anesthesia was applied to 92.7% (n=496). The average anesthesia duration was 74.5±34.6 minutes. While the average restorative treatment applied to the patients was calculated as 6.45±3.9, tooth extraction 5.25±4.3, fissure sealant 2.44±2.5, pulp treatment 1.62±0.9; Trauma splint was applied to 3 patients. Conclusions: While pre-anesthesia evaluation is very important in determining the risks in dental general anesthesia and sedation applications, the operating conditions and the general and oral health of the patients are effective in the dental treatment decision.

POST-MASTECTOMY SURGICAL SITE INFECTION RATES IN FEMALES WITH BREAST CARCINOMA IN PREMENOPAUSAL AGE: A SINGLE CENTER STUDY

Breast surgery, like mastectomy, is generally considered a low-risk procedure for surgical site infections (SSIs), but when SSIs do occur, they can lead to significant complications. Identifying risk factors to improve patient outcomes and minimize complications is essential. Objective: This study aimed to determine the frequency of post-mastectomy surgical site infections (SSI) in premenopausal females with breast carcinoma and to identify the associated risk factors. Methods: This descriptive case study included 100 premenopausal females diagnosed with breast carcinoma who underwent mastectomy at a tertiary care hospital, Shaikh Zayed Hospital Lahore, from April 2024 to August 2024. The age range of participants was 25-45 years, with a mean age of 39 ± 5.3 years. Demographic data, including age, gender, body mass index (BMI), comorbidities, and American Society of Anesthesiologists (ASA) score, were collected. Intraoperative variables such as blood loss (mean: 350 ± 50 ml) and surgery duration (mean: 120 ± 15 minutes) were also recorded. All patients received standard postoperative antibiotic prophylaxis, including cefazolin or clindamycin, for those allergic to penicillin. The surgical site was assessed 30 days postoperatively for signs of infection, including erythema, pus discharge, or fever exceeding 38°C. SSIs were categorized based on the Centers for Disease Control and Prevention (CDC) guidelines into superficial, deep, and organ/space infections. Results: The overall infection rate was 7.5% (n=7). Of these, 4 cases were superficial infections, while 3 involved deeper tissue layers, requiring drainage and further antibiotics. Factors significantly associated with an increased risk of disease in the multivariate logistic regression model included a high wound class (contaminated or dirty; OR: 3.2, p=0.01), elevated ASA score (ASA III-IV; OR: 2.8, p=0.03), high BMI &gt;30 (OR: 3.5, p=0.002), diabetes (OR: 4.1, p=0.001), use of surgical drains (OR: 2.9, p=0.02), and reoperation (OR: 4.3, p=0.005). The mean hospital stay was extended by 4.5 days (from 5.2 ± 1.5 days in non-infected patients to 9.7 ± 3.1 days in infected cases). Conclusion: The study found a post-mastectomy surgical site infection rate of 7.5% in premenopausal females, with significant risk factors including high BMI, diabetes, use of surgical drains, and the need for reoperation. A high wound class and elevated ASA score also predicted increased infection risk. Addressing these modifiable risk factors through optimized perioperative care, such as better glycemic control, judicious use of surgical drains, and minimizing reoperations, may help reduce SSI rates and improve outcomes for breast cancer patients.

Pain outcomes of outside-the-cage robotic thoracic surgery: a prospective matched-cohort study

Management of acute and chronic pain after thoracic surgery for pulmonary resection or thymectomy remains a challenge for both thoracic surgeons and anesthesiologists. Advances in minimally invasive robotic procedures have made subcostal outside-the-cage (OTC) resections possible, but the procedure’s pain benefits have not been previously measured. A single-center cohort was consented to undergo robotic-assisted thoracoscopic surgery (RATS) with an OTC or transthoracic (TT) approach. On every post-operative day (POD), patients were asked to complete the visual analog scale (VAS) of pain, assigning a score of 0–10 with higher scores equaling higher pain intensity. Additionally, patients’ opioid consumption was recorded and classified using morphine equivalent dose (MED). Descriptive statistics of demographics, Mann–Whitney, and Chi-squared tests were performed in a matched analysis. Altogether, 50 OTC patients and 50 TT patients were included. For each group, 1 pneumonectomy, 19 lobectomies, 10 segmentectomies, and 20 thymectomies were performed. Between groups, most were male (n = 54; p = 0.42) and there were no differences in American Society of Anesthesiologists scores (p = 0.51), or tobacco consumption (p = 0.45). Patients who received an OTC approach experienced significantly lower pain scores on POD-0 (p = 0.001), POD-1 (p < 0.001), and POD-2 (p < 0.001). POD-3 OTC VAS scores were not different from those of the TT group (p = 0.09). Similarly, MED was lower for the OTC group on POD-0 (p < 0.001), POD-1 (p = 0.03), and POD-3 (p = 0.03). The RATS-OTC approach results in a more rapid decrease in self-reported pain by the patient as well as significantly lower levels of MED.

Learning curve for a five-step procedure, transthoracic single-port assisted laparoscopic transabdominal diaphragmatic approach, for Siewert type II adenocarcinoma of the esophagogastric junction

Objective: To investigate the learning curve for a five-step procedure, namely, a transthoracic single-port assisted laparoscopic transabdominal diaphragmatic approach, for Siewert type II adenocarcinoma of the esophagogastric junction. Methods: In this retrospective cohort study, we analyzed relevant clinical data of 66 patients with Siewert type II adenocarcinoma of the esophagogastric junction who had undergone the five-step procedure performed by the same surgeon in the Gastrointestinal Surgery Department of Guangdong Provincial Hospital of Chinese Medicine from May 2017 to April 2023. The learning curve were plotted using cumulative summation analysis and selected indicators, including intraoperative blood loss, duration of surgery, time to first flatus, time to first tolerance of liquid food, length of hospital stay, and incidence of perioperative complications at different stages were compared. The data were analyzed using SPSS 24.0 statistical software. Numerical data are presented as cases (%) and data were analyzed using the χ2 test or Fisher's exact test. Normally distributed measurement data are presented as x±s, and independent sample t-testing was performed for inter group comparison. Non-normally distributed measurement data are presented as M(Q1, Q3) and the Mann-Whitney U test was used for inter group comparison. Results: The five-step procedure had been successfully completed without switching to open surgery in all 66 study patients. There were no perioperative deaths, blood loss was 100 (50, 200) mL and duration of surgery 329.4±87.3 minutes. The equation of optimal fit for the duration of surgery was y=0.031x3-4.4757x2+164.97x-264.4 (P<0.001, R2=0.9797). The cumulative summation learning curve reached a vertex when 25 surgical procedures had accumulated. Using 25 cases as the cut-off, we divided the learning curves into learning and proficiency periods and patients into learning (25) and proficiency period groups (41). There were no statistically significant differences between the two groups of patients in sex, age, body mass index, American Society of Anesthesiologists score, history of abdominal surgery, comorbidities, preoperative neoadjuvant therapy, maximum tumor diameter, surgical procedure, or T and N stage of tumor (P>0.05). The following factors differed significantly (all P<0.05) between the learning and proficiency stages: in the latter there was less intraoperative blood loss (100 [50, 100] ml vs. 200 [100, 200] ml, U=-3.940, P<0.001), shorter duration of surgery ([289.8±50.7] minutes vs. [394.4±96.0] minutes, t=5.034, P<0.001), more mediastinal lymph nodes removed (5 [2, 8] vs. 2 [1, 5], U=-2.518, P=0.012), earlier time to first flatus (2 [2, 3] days vs. 4 [3, 6] days, U=-4.016, P<0.001), earlier time to first tolerance of liquid food (5 [4, 6] days vs. 7 [6, 8] days, U=-2.922, P=0.003), shorter duration of hospital stay (8 [8, 10] vs. 10 [9, 12] days, U=-2.028, P=0.043). The incidence of surgical complications did not differ significantly between the two groups (P=0.238). Conclusion: Satisfactory results can be achieved with the five-step procedure for patients with Siewert type II adenocarcinoma of the esophagogastric junction once 25 procedures have been performed.

ASA-score is associated with 90-day mortality after complicated mild traumatic brain injury – a retrospective cohort study

PurposeThis study explores the association of the American Society of Anesthesiologists (ASA) score with 90-day mortality in complicated mild traumatic brain injury (mTBI) patients, and in trauma patients without a TBI.MethodsThis retrospective study was conducted using a cohort of trauma patients treated at a level III trauma center in Stockholm, Sweden from January to December 2019. The primary endpoint was 90-day mortality. The population was identified using the Swedish Trauma registry. The Trauma and Injury Severity Score (TRISS) was used to estimate the likelihood of survival. Trauma patients without TBI (NTBI) were used for comparison. Data analysis was conducted using R software, and statistical analysis included univariate and multivariate logistic regression.ResultsA total of 244 TBI patients and 579 NTBI patients were included, with a 90-day mortality of 8.2% (n = 20) and 5.4% (n = 21), respectively. Deceased patients in both cohorts were generally older, with greater comorbidities and higher injury severity. Complicated mTBI constituted 97.5% of the TBI group. Age and an ASA score of 3 or higher were independently associated with increased mortality risk in the TBI group, with odds ratios of 1.04 (95% 1.00–1.09) and 3.44 (95% CI 1.10–13.41), respectively. Among NTBI patients, only age remained a significant mortality predictor. TRISS demonstrated limited predictive utility across both cohorts, yet a significant discrepancy was observed between the outcome groups within the NTBI cohort.ConclusionThis retrospective cohort study highlights a significant association between ASA score and 90-day mortality in elderly patients with complicated mTBI, something that could not be observed in comparative NTBI cohort. These findings suggest the benefit of incorporating ASA score into prognostic models to enhance the accuracy of outcome prediction models in these populations, though further research is warranted.

Prognostic factors and clinical outcomes in Fournier’s Gangrene: a retrospective study of 35 patients

BackgroundFournier’s gangrene is a severe form of infectious necrotizing fasciitis affecting the perineum, perianal, and genital areas; it is associated with substantial morbidity and mortality. Hence, it is important to identify prognostic factors that can predict clinical outcomes and guide treatment strategies. Thus, our study aimed to analyze patient characteristics and determine prognostic factors affecting clinical outcomes in Fournier’s gangrene.MethodsThis retrospective study involved examining medical records spanning 18 years for patients with Fournier’s gangrene at our institution. Considering the exclusion criteria, data from 35 patients were included in this study.ResultsA total of 35 patients were included in the analysis. The mean age of the patients showed no statistically significant difference between the survivor and non-survivor groups. The Charlson Comorbidity Index, American Society of Anesthesiologists score, and Acute Physiology and Chronic Health Evaluation II score were not significantly different between the two groups. Notably, the initial Sequential Organ Failure Assessment score was significantly higher in the non-survivor group than that in the survivor group. The overall in-hospital mortality rate was 17.1%. Moreover, the prevalence of multidrug resistant bacterial infection was markedly higher in the non-survivor group than that in the survivor group. Coagulation dysfunction was significantly more prevalent in the non-survivor group than that in the survivor group, and had the most significant impact on in-hospital mortality. A multivariable logistic regression analysis identified multidrug resistant bacterial infection to be independently associated with high in-hospital mortality.ConclusionsCoagulation dysfunction and multidrug resistant bacterial infection were identified as independent negative prognostic factors, highlighting the need for prompt monitoring and proactive strategies against Fournier’s gangrene.

Adjuvant (chemo)radiotherapy for patients with head and neck cancer: can comorbidity risk scores predict outcome?

This study compares the objective American Society of Anesthesiologists (ASA) and Adult Comorbidity Evaluation-27 (ACE-27) scores with the subjective Eastern Cooperative Oncology Group performance status (ECOG PS) for patient outcome prediction. We retrospectively analyzed head and neck squamous cell carcinoma patients treated with adjuvant (chemo)radiotherapy at the LMU Munich from June 2008 to June 2015. The study focused on associations between patient outcomes; treatment failures; known risk factors (including human papillomavirus [HPV] status and tumor stage); and the comorbidity indices ECOG-PS, ASA score, and ACE-27. The Kaplan-Meier method and Cox proportional hazards model were used for survival analysis and identifying independent risk factors. A total of 302 patients were analyzed, 175 received concurrent chemotherapy. Median follow-up was 61.8 months, and median age at diagnosis was 61years. The 3‑ and 5‑year overall survival (OS) and disease-free survival (DFS) rates were 70.5%/60.2% and 64.7%/57.6%, respectively. Both ACE-27 and ASA showed significant correlations with OS in univariate and multivariate analyses, while ECOG-PS was significant only in univariate analysis. ASA and ACE-27 scores were also significantly correlated with local and locoregional recurrence, but only HPV status and tumor stage were significant in multivariate models. ACE-27 and ASA score effectively categorize patients' risks in adjuvant radiotherapy for head and neck cancer, proving more predictive of overall survival than ECOG-PS. These results underscore the importance of objective comorbidity assessment and suggest further prospective studies.

Poorer clinical outcomes after THA in patients with a spinal scoliotic deformity: a case-control study of 268 patients assessed with PROMS

IntroductionSpinal deformities can lead to specific complications after total hip arthroplasty (THA), such as functional leg length discrepancy due to a fixed pelvic obliquity, as well as an increased risk of prosthetic instability due to a lack of adaptive pelvic mobility, but these issues were not investigated in large comparative series. Therefore a retrospective case-control study was done aiming: 1) to analyze the impact of a preoperative scoliotic deformity on the functional outcomes of patients who underwent THA with a minimum 1-year follow-up, 2) to measure the prevalence of scoliosis in both the case and control groups 3) to screen other factors that may be correlated with poorer clinical outcomes in patients who underwent THA, including age, gender, Body Mass index (BMI), American Society of Anesthesiologists (ASA) score, primary THA etiology and postoperative complication occurrence. HypothesisThe presence of scoliosis would have a negative impact on THA outcomes as assessed by PROMs. Materials and methodsA case-control study was conducted using prospectively collected data including 268 patients who underwent THA between January 2009 and December 2021 through a direct anterior approach by the same senior surgeon. Cases were identified based on a 1-year follow-up modified Harris Hip score (mHHS) lower than 81 while controls were defined as patients with an excellent 1-year follow-up mHHS score (equal to or higher than 81). Three controls were randomly matched with each case based on the surgery period. To assess the impact of a concurrent scoliosis on clinical outcomes, a mathematical univariate and multivariate logistic model was used, including other confounding factors (age, gender, ASA score, BMI, Complication occurrence, etiology), to calculate the adjusted odds-ratio. ResultsIn the multivariate analysis, scoliosis was found to be a significant risk factor, with a three-fold higher adjusted odds-ratio of lower mHHS score (adjOR = 3.1; 95 CI:1.4–7, [p < 0.01]). The mean mHHS score was significantly lower in the scoliosis group compared to the non-scoliosis group (77 vs. 84 [p = 0.01]) as well as the mean Oxford Hip Score (36 vs. 43 [p < 0.001]). Among the other assessed risk factors, only the occurence of a postoperative complication was associated with an increased odds ratio of poorer mHHS scores (adjOR = 7.1; 95 CI: 2.78–18.24, [p < 0.001]). The prevalence of scoliosis in our practice was 19%. Discussion: Given the prevalence of 19% found in our study, we recommend screening for scoliosis in all patients scheduled for THA. Our results indicate that patients who had scoliosis experienced lower PROMs scores compared to those who had not. Surgeons should consider delivering this information to patients who have scoliosis undergoing THA to mitigate patient dissatisfaction. Level of evidenceIII; retrospective case-control study.

The Use of Tranexamic Acid for Primary Prophylaxis of Heterotopic Ossification Following Total Hip Arthroplasty

BackgroundHeterotopic ossification (HO) is a relatively common complication after total hip arthroplasty (THA) and can range from a radiographic observation only to severely disabling and requiring revision surgery. Prophylaxis is recommended for high-risk patients, though the ideal method and targeted population are open to debate. Tranexamic acid (TXA) is a medication increasingly being used to reduce blood loss associated with orthopaedic surgeries, including THA. MethodsA retrospective review of 357 patients undergoing THA from November 2020 through December 2023 was conducted. The patients were grouped based on whether they received intravenous TXA perioperatively or not, and their propensity score matched 2:1 TXA to no TXA on age, body mass index, sex, Charlson Comorbidity Index, and perioperative celecoxib use. Univariate and multivariate analyses were performed. ResultsAfter propensity score matching, the only significant differences between groups were American Society of Anesthesiologists (ASA) scores and preoperative celecoxib use between groups, as the TXA group had fewer patients who had an ASA of 3 or more (38.9 versus 58.5%, P < 0.001) and more patients who had taken celecoxib preoperatively (16.3 versus 5.9%, P = 0.010). Perioperatively, patients were more likely to undergo THA using the anterior approach (74.5 versus 57.6%, P = 0.002) and were more likely to receive postoperative celecoxib prescriptions (44.8 versus 31.4%, P = 0.021), but there was no difference in other nonsteroidal anti-inflammatory drug (NSAID) usage postoperatively. Postoperatively, patients who received TXA had a lower rate of HO on the last postoperative x-ray (20.1 versus 33.9%, P = 0.007). Multivariable logistic regression, to assess predictors of HO, found that patients who had TXA were 42% less likely to have visible HO (OR [odds ratio] = 0.58, P = 0.047), while holding surgical approach, American Society of Anesthesiologists score, preoperative and postoperative celecoxib use, and postoperative other nonsteroidal anti-inflammatory drug use constant. ConclusionsThe use of TXA in patients undergoing primary THA results in a decreased likelihood ofHO formation on postoperative x-rays.