Average Postoperative Day Research Articles

Advantages of robot-assisted resection of large mediastinal tumors: a single-center preliminary study.

Current study aims to assess the safety and efficacy of robot-assisted thoracoscopic surgery (RATS) for sizable mediastinal masses with a minimum diameter ≥6cm, compared with video-assisted thoracoscopic surgery (VATS) and open surgery. This study enrolled 130 patients with mediastinal tumors with no less than 6 cm diameter in Zhongnan Hospital, Wuhan University, including 33 patients who underwent RATS, 52 patients who underwent VATS and 45 patients who underwent open surgery. After classifying based on mass size and whether it has invaded or not, we compared their clinical characteristics and perioperative outcomes. There was no significant difference in age, gender, mass size, myasthenia gravis, mass location, pathological types (p>0.05) in three groups. Patients undergoing open surgery typically presenting at a more advanced stage (p<0.05). No obvious difference was discovered in the average postoperative length of stay, operation duration, chest tube duration and average postoperative day 1 drainage output between RATS group and VATS group (p>0.05), while intraoperative blood loss in RATS group was significantly lower than VATS group (p=0.046). Moreover, the postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss in RATS group were significantly lower than open surgery group (p<0.001). RATS is a secure and efficient approach for removing large mediastinal masses at early postoperative period. In comparison with VATS, RATS is associated with lower intraoperative blood loss. Compared with open surgery, RATS is also associated with shorter postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss.

Evolution of postoperative care: marked reduction of opioid consumption when ERAC pathway added to wound soaker therapy for cesarean delivery

Objective Achieving functional recovery after cesarean delivery is critical to a parturient’s ability to care for herself and her newborn. Adequate pain control is vital, and without it, many other aspects of the recovery process may be delayed. Reducing opioid consumption without compromising analgesia is of paramount importance, and enhanced recovery pathways have generated considerable interest given their ability to facilitate this. Our group’s process for reducing opioid consumption for cesarean delivery patients evolved over time. We first demonstrated that providing additional incisional pain control with continuous bupivacaine infusions through wound catheters, with the concurrent use of neuraxial morphine, reduced postoperative opioid use. Iterations of an enhanced recovery after cesarean (ERAC) delivery pathway were then implemented after the Society for Obstetric Anesthesia and Perinatology’s consensus statement for ERAC was issued to eliminate variability in both hospital course and in the treatment of postoperative pain. In this retrospective cohort analysis, we sought to identify whether adding ERAC protocols to our existing combination of neuraxial morphine and wound soaker catheters further reduced opioid consumption after cesarean delivery. Methods A retrospective cohort analysis of cesarean deliveries from 2015 through 2020 was performed. Deliveries were divided by analgesic pathway into four time-periods – time-point 1 [January 2015-April 2016, previous standard of care (control, N = 61)]: neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 2 [May 2016–May 2019, introduction of wound soaker (wound-soaker, N = 40)]: continuous wound catheter infusions of local anesthetic, neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 3 [May 2019–December 2019, wound soaker + early ERAC pathway (early ERAC, N = 78)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine, in addition to scheduled non-opioid analgesics (acetaminophen and ibuprofen) every 6 h, alternating in relation to one another so that one is given every 3 h; time-point 4 [January 2020–July 2020, wound soaker + late ERAC pathway (late ERAC, N = 57)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine in addition to non-opioid analgesics scheduled together every 6 h (to facilitate periods of uninterrupted rest). Cumulative and average daily opioid use for postoperative days (POD) 1–4 were analyzed using ANOVA and a mixed effect model, respectively. Results Average daily opioid consumption and total cumulative opioid consumption POD 1–4 (morphine milligram equivalents) for both early and late ERAC groups (23.9 ± 31.1 and 29.4 ± 35.1) were significantly reduced compared to control and wound soaker groups (185.1 ± 93.7 and 134.8 ± 77.1) (p < .001). Conclusion The addition of ERAC protocols to our standardized multimodal analgesic regimen (local anesthetic wound infusion catheters and neuraxial morphine) for cesarean delivery significantly reduced postoperative opioid consumption.

Evaluation of a Novel Multimodal Opioid-Free Postoperative Pain Management Pathway Following Robotic-Assisted Radical Prostatectomy: A Pilot Series in the Veteran Population.

Veterans have disproportionate risk of opioid misuse and abuse compared to the civilian population. Managing acute postoperative pain without opioids is of the utmost importance for the Veteran patient population. This pilot study evaluates a novel multimodal opioid-free pain control regimen by assessing postoperative pain in Veterans undergoing robotic-assisted radical prostatectomy (RARP). Prospective data was collected from patients undergoing RARP at a Department of Veterans Affairs Medical Center. Patients in the opioid-cohort received tramadol, hydrocodone-acetaminophen, or oxycodone-acetaminophen postoperatively. The opioid-free novel multimodal approach consisted of 100 mg gabapentin TID, 15 mg ketorolac Q6 hours, and 1 mg scheduled IV acetaminophen Q6 hours. Pain scores were collected using a visual analogue pain scale on postoperative days 0 and 1. Data was collected from 57 patients, 33 treated with opioids and 24 with the opioid-free pathway. There were no significant differences in demographics (P > .05) between cohorts. No significant differences were observed for preoperative and intraoperative variables (P > .05). Average postoperative day 0 pain scores for opioid-free (2.2 ± 3.1) and opioid treatments (3.1 ± 3.1) were not statistically different (P=.1321). Postoperative day 1 differences of average pain scores for opioid-free (0.9 ± 1.9) and opioid (1.6 ± 3.1) treatments were not statistically significant (P=.1647). The novel multimodal opioid-free treatment in this study may be effectively utilized for postoperative pain during hospital recovery of Veterans undergoing RARP. Future directions include a randomized control clinical trial in the general population.

Integra Dermal Regeneration Template in reconstructive surgery for cutaneous tumours: a two-year retrospective review.

Integra Dermal Regeneration Template (IDRT) (Integra LifeSciences, US) is a bioengineered dermal matrix that has been widely used in burn reconstruction since its first description. However, little is reported on its use in oncologic dermatological defects. Our objective was to evaluate reconstruction using IDRT on cutaneous tumour defects. We conducted a two-year retrospective review of patients with skin tumours who had an excision surgery, followed by reconstruction with IDRT, as a mid-step towards a final autograft procedure: a split-thickness skin graft. The records of all patients at a single academic institution were queried from the electronic medical record using data obtained from the operating surgeon. We identified 13 patients with different tumour types and locations. The mean defect size was 105.92cm². The matrix take rate was 92.3% and average postoperative day for definite autograft was 20 days. Patients were followed for a period of up to 12 months. Of the patients, one had exposed bone without periosteum; another patient showed recurrence six months after matrix placement, requiring a new second two-stage IDRT-autograft procedure before radiation therapy. Patients reported complete satisfaction with the cosmetic, functional and oncological results. No cases of infection were encountered. IDRT is a valid option for the reconstruction of oncologic surgical defects of the skin and can be used in different anatomical locations. Specifically, it is an alternative to the reconstructive ladder when grafts and local flaps are not possible in those patients, and an option for patients who will eventually need adjuvant radiotherapy.

Clinical study to estimate correlation between graft thickness as measured by anterior segment Optical Coherence Tomography and visual recovery after manual Descemet stripping endothelial keratoplasty.

Purpose: To estimate the correlation between graft thickness as measured by anterior segment Optical Coherence Tomography and visual recovery after manual Descemet stripping endothelial keratoplasty.Design: Prospective observational study.Materials and methods: This prospective observational study included 25 patients with pseudophakic bullous keratopathy, who underwent DSEK. Visual acuity in LogMAR units and estimation of graft thickness measured by Anterior Segment Optical Coherence Tomography (AS-OCT) was carried out on postoperative day 1, 3rd month and 6th month. Correlation analysis was performed between graft thickness and postoperative visual acuity on postoperative day 1, 3rd month and 6th month. Results: The mean LogMAR visual acuity improved in all patients post DSEK - 1.47 (±0.48) to 0.75 (±0.38) LogMAR units. The average postoperative day 1 central corneal thickness was 724.96 µm (±77.59 µm), which decreased to mean central corneal thickness of 655.56 (±61.08 µm) on 3rd month and 633.48 (58.72) by the 6th month. Mean donor graft thickness on postoperative day 1, 3rd month and 6th month in this study was found to be 169.3 µm (±36.6 µm), 135.9 µm (±29.8 µm) and 127.5 µm (±31 µm) corresponding to a BCVA of 1.94, 0.86 and 0.75 LogMAR units respectively. On correlation analysis, thinner grafts were found to be associated with better postoperative BCVA especially on the 3rd and 6th month follow-up period. Conclusion: This study found that a higher proportion of thinner grafts achieved better postoperative visual rehabilitation and earlier stabilization of visual acuity.

Prospective intraoperative and histologic evaluation of cavernous sinus medial wall invasion by pituitary adenomas and its implications for acromegaly remission outcomes

Recurrence and biochemical remission rates vary widely among different histological subtypes of pituitary adenoma. In this prospective study, we evaluated 107 consecutive primary pituitary adenomas operated on by a single neurosurgeon including 28 corticotroph, 27 gonadotroph, 24 somatotroph, 17 lactotroph, 5 null-cell and 6 plurihormonal. In each case, we performed direct endoscopic intraoperative inspection of the medial wall of the cavernous sinus, which was surgically removed when invasion was visualized. This was performed irrespective of tumor functional status. Medial wall resection was performed in 47% of pituitary adenomas, and 39/50 walls confirmed pathologic evidence of invasion, rendering a positive predictive value of intraoperative evaluation of medial wall invasion of 78%. We show for the first-time dramatic disparities in the frequency of medial wall invasion among pathological subtypes. Somatotroph tumors invaded the medial wall much more often than other adenoma subtypes, 81% intraoperatively and 69% histologically, followed by plurihormonal tumors (40%) and gonadotroph cell tumors (33%), both with intraoperative positive predictive value of 100%. The least likely to invade were corticotroph adenomas, at a rate of 32% intraoperatively and 21% histologically, and null-cell adenomas at 0%. Removal of the cavernous sinus medial wall was not associated with permanent cranial nerve morbidity nor carotid artery injury, although 4 patients (all Knosp 3-4) experienced transient diplopia. Medial wall resection in acromegaly resulted in the highest potential for biochemical remission ever reported, with an average postoperative day 1 GH levels of 0.96 ug/L and surgical remission rates of 92% based on normalization of IGF-1 levels after surgery (mean = 15.56 months; range 3–30 months). Our findings suggest that tumor invasion of the medial wall of the cavernous sinus may explain the relatively low biochemical remission rates currently seen for acromegaly and illustrate the relevance of advanced intradural surgical approaches for successful and durable outcomes in endonasal pituitary surgery for functional adenomas.

A randomized trial of standard vs restricted opioid prescribing following midurethral sling

Postoperative opioid prescribing has historically lacked information crucial to balancing the pain control needs of the individual patient with our professional responsibility to judiciously prescribe these high-risk medications. This study aimed to evaluate pain control, satisfaction with pain control, and opioid use among patients undergoing isolated midurethral sling randomized to 1 of 2 different opioid-prescribing regimens. Patients who underwent isolated midurethral sling placement from June 1, 2020, to November 22, 2021, were offered enrollment into this prospective, randomized, open-label, noninferiority clinical trial. Participants were randomized to receive either a standard prescription of ten 5-mg oxycodone tablets provided preoperatively (standard) or an opioid prescription provided only during patient request postoperatively (restricted). Preoperatively, all participants completed baseline demographic and pain surveys, including the 9-Question Central Sensitization Index, Pain Catastrophizing Scale, and Likert pain score (scale 0-10). The participants completed daily surveys for 1 week after surgery to determine the average daily pain score, number of opioids used, other forms of pain management, satisfaction with pain control, perception of the number of opioids prescribed, and need to return to care for pain management. The online Prescription Drug Monitoring Program was used to determine opioid filling in the postoperative period. The primary outcome was average postoperative day 1 pain score, and an a priori determined margin of noninferiority was set at 2 points. Overall, 82 patients underwent isolated midurethral sling placement and met the inclusion criteria: 40 were randomized to the standard arm, and 42 were randomized to the restricted group. Concerning the primary outcome of average postoperative day 1 pain score, the restricted arm (mean pain score, 3.9±2.4) was noninferior to the standard arm (mean pain score, 3.7±2.7; difference in means, 0.23; 95% confidence interval,-∞ to 1.34). Of note, 23 participants (57.5%) in the standard arm vs 8 participants (19.0%) in the restricted arm filled an opioid prescription (P<.001). Moreover, 18 of 82 participants (22.0%) used opioids during the 7-day postoperative period, with 10 (25.0%) in the standard arm and 8 (19.0%) in the restricted arm using opioids (P=.52). Of participants using opioids, the average number of tablets used was 3.4±2.3, and only 3 participants used ≥5 tablets. On a scale of 1="prescribed far more opioids than needed" to 5="prescribed far less opioids than needed," the means were 1.9±1.0 in the standard arm and 2.7±1.0 in the restricted arm (P<.001). Restricted opioid prescription was noninferior to standard opioid prescription in the setting of pain control and satisfaction with pain control after isolated midurethral placement. Participants in the restricted arm filled fewer opioid prescriptions than participants in the standard arm. On average, only 3.4 tablets were used by those that filled prescriptions in both groups. Restrictive opioid-prescribing practices may reduce unused opioids in the community while achieving similar pain control.

Effects of Age on Delayed Facial Palsy After Otologic Surgery: A Systematic Review and Meta-Analysis.

To report 4 cases of delayed facial palsy (DFP) after pediatric middle ear (ME) surgery and systematically review and analyze the associated literature to evaluate the effects of age on DFP etiology, management, and prognosis. Systematic review of PubMed, Cochrane Library, and Embase for articles related to DFP after cochlear implantation (CI) was performed. These articles were assessed for level of evidence, methodological limitations, and number of cases. Meta-analysis was performed to assess the effects of age on DFP incidence. Furthermore, a comprehensive list of all pediatric DFP cases after otologic surgery was assembled through a multi-institutional retrospective review and systematic review of the literature. Twenty-nine articles fit the criteria for inclusion in the meta-analysis. The incidence of DFP after CI was 0.23% and 1.01% for pediatric and adult cases, respectively. This difference was statistically significant (P < .001, odds ratio 4.36). Twenty-three cases, adding to the 4 presented herein, were suitable for a comprehensive list. The mean age was 6.9 years. Average postoperative day of paresis onset was 5.4, with an average maximum House-Brackmann grade of 3.5. All patients obtained full facial recovery after an average of 23.5 days. The systematic review demonstrates that DFP after pediatric CI is rare and occurs at a significantly lower rate than in adults, further supporting the viral reactivation hypothesis of DFP. The prognosis for pediatric DFP after otologic surgery is excellent, with a high rate of full recovery in a short time frame. However, steroid administration can be considered. IIa.

Detecting coagulopathy in pediatric patients with post-tonsillectomy hemorrhage

IntroductionPost-tonsillectomy hemorrhage (PTH) is a serious complication after a tonsillectomy. Utility of lab work at presentation for PTH was low. This study aims to determine the frequency and type of labs drawn at emergency department (ED) presentation and assess the incidence of uncovering a previously unidentified coagulopathy. MethodsA retrospective chart review was performed on pediatric patients who were seen in the ED after tonsillectomy at a tertiary care children's hospital from 2017 to 2019. Exclusion criteria were the following: no tonsillar bleed, history of known coagulopathy, treated by outside provider, ≥18 years old. Lab work included complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT), and von Willebrand factor (VWF). Results364/723 (50.3%) patients met inclusion criteria. 179/364 (49.2%) patients were male and 309/364 (84.9%) patients were Caucasian. Average age at surgery was 8.12 years (SD = 4.0) and average post-operative day at presentation was 6 days (SD = 2.1). Operative control of bleed was performed in 68/364 (18.7%) patients. 334/364 (91.8%) patients had labs drawn in the ED. 64/334 (19.1%) patients were anemic (hemoglobin (Hgb) < 11), 46/334 (13.8%) patients had thrombocytosis (platelets>450,000), 10/334 (3.0%) had elevated PTT and 8/334 (2.4%) had elevated PT. Hematology was consulted in 14/364 (3.8%) patients of whom 6/14 were diagnosed with von Willebrand disease and 1/14 with factor VII deficiency. Aminocaproic acid was used in 8/364 (2.2%) patients due to elevated PTT in 3/8 and multiple episodes of bleeding in 5/8.3/364 (0.8%) patients needed a blood transfusion. No difference was found in incidence of abnormal lab work in patients who did and did not need operative control of bleed (p = .125). Of the 334 patients who had ED labs drawn, 7 (2.1%) had an uncovered coagulopathy. ConclusionUncovering incidental coagulopathies is rare in patients who present with PTH. Though anemia was the most common abnormality noted, only a small percentage required transfusion, with all having abnormal vital signs. Thrombocytosis was the next common abnormality, and this can be seen in an inflammatory state. Developing algorithms is necessary to better guide appropriate lab work in patients who present with PTH and to provide optimal value of care to patients.

Somatotroph Adenomas have a Predilection to Invade the Cavernous Sinus and Resection of the Medial Wall of the Cavernous Sinus Offers the Highest Potential for Biochemical Remission in Acromegaly

Recurrence and remission rates vary widely among different histological subtypes of pituitary adenoma. Invasion of the medial wall of the cavernous sinus is a known mechanism that may account for such failed clinical outcomes as its removal has long been considered unattainable. The use of modern endoscopic techniques allows for direct intraoperative evaluation of invasion and resection of the medial wall of the cavernous sinus with low morbidity when performed by highly experienced surgeons. In this retrospective study we evaluated 105 consecutive primary pituitary adenomas operated by a single surgeon including 28 corticotroph, 27 gonadotroph, 24 somatotroph, 15 lactotroph, 5 null-cell, 5 plurihormonal, and 1 dual adenoma; 53 caused hypersecretory syndromes, specifically acromegaly (30), hyperprolactinemia (15) and Cushing’s disease (8). In each case, we performed meticulous intraoperative inspection of the medial wall with its surgical removal when invasion was suspected, regardless of functional status. Medial wall resection was performed in 46% of pituitary adenomas, and 38/48 walls confirmed pathologic evidence of invasion rendering a positive predictive value of intraoperative evaluation of medial wall invasion of 79%. Furthermore, we show for the first time that the rate of medial wall invasion among pathological subtypes is dramatically different. Somatotroph tumors invaded the medial wall much more often than other adenoma subtypes, 83% intraoperatively and 71% histologically, followed by plurihormonal tumors (40%) and gonadotrophs (33%), both with intraoperative positive predictive value of 100%. The least likely to invade were corticotroph, at a rate of 32% intraoperatively and 21% histologically, and null-cell adenomas at 0%. Removal of the medial wall caused no permanent morbidity with no carotid artery injuries and 2 patients with transient diplopia. We report that resecting the medial wall of the cavernous sinus in acromegaly offers the highest potential for biochemical remission with average postoperative day 1 GH levels at 0.96 ug/l and early surgical remission rates at 90% (100% with adjuvant therapy) based on normalization of IGF-1 levels 3 to 6 months after surgery; these results are significantly better than previously reported but longer follow-up is required for definitive conclusions. Our findings may explain the failed biochemical remission rates seen in acromegaly and illustrate the relevance of advanced surgical techniques for successful outcomes in pituitary surgery.

Inciting Events in the High Risk Post-Operative Pediatric Cardiac Patients – A Novel Three Hit Model for Bacteremia Prediction

Background: Blood stream infections (BSI) are well described in pediatric cardiac intensive care units (PCICU). We noted that postoperative high-risk patients may develop BSI after an inciting event. The aim of this study was to investigate whether high risk patients who developed bacteremia experienced more inciting events than a similar group of high-risk patients. Methods: In this retrospective case-control study, we enrolled patients who developed bacteremia from March 2010 to November 2019, after undergoing open-heart surgery at a referral pediatric center. The control group was comprised of case-matched patients with the immediate consecutive same surgery. The following were recorded: operative data, common risk factors, postoperative severity of illness parameters, mortality, and inciting events 72-24 hours before bacteremia emerged. Findings: A total of 200 patients were included (100 with bacteremia, and 100 controls). Main demographic and operative parameters were matched. Bacteremia emerged on average postoperative day (POD) 12·8. Gram-negative bacteria were cultured in 84%, and skin associated gram-positive bacteria in 10% of the patients. Average central-venous lines (CVL) duration was 9·5±8·4 days. Postoperatively (72 hours), severity of illness parameters were significantly worse in patients with bacteremia, with a higher rate of postoperative complications during PCICU length-of-stay (LOS). In the bacteremia group, 72-24 hours prior to development of bacteremia, 92(92%) inciting events were recorded, compared to 21 (21%) in controls during their entire LOS. (OR 43·3,CI 18·2-103·1, p<0·0001). Interpretation: We propose a three hit model demonstrating that high-risk patients undergoing open heart surgery have significant higher risk for bacteremia after an inciting event. Funding Statement: No funding was procured for this work. Declaration of Interests: Mrs· Shochat disclosed work for hire at Rabin Medical Center as a statistical consultant. The remaining authors have disclosed that they do not have any potential conflicts of interest. Ethics Approval Statement: The Institutional Review Board reviewed and approved the study, and waived the need for parental consent.

Prospective Study Assessing the Effect of Local Infiltration of Tranexamic Acid on Facelift Bleeding

Rebound bleeding during facelift surgery is a major cause of facelift hematomas. Subcutaneous infiltration of tranexamic acid (TXA) combined with lidocaine and epinephrine was recently retrospectively shown to decrease rebound bleeding. No study has prospectively examined the effect of subcutaneous TXA on intraoperative and postoperative bleeding during facelift surgery. The aim of this study was to prospectively demonstrate that TXA combined with local anesthesia safely reduces the effects of rebound bleeding, reduces operative time, and decreases postoperative drainage. This was a prospective, single-surgeon, case-control study performed between July 2019 and March 2020. Thirty-nine patients (35 female and 4 male; mean age, 64.9 years; age range, 49-80 years) underwent facelift surgery alone or in combination with facial rejuvenation procedures. All patients were injected subcutaneously with 1 or 2 mg/mL TXA + 0.5% lidocaine/1:200,000 epinephrine. Patient demographics, TXA dose, time to hemostasis, drain output, and minor and major complications were recorded. The mean time to hemostasis was 6.4 minutes for the left and right sides each. Average postoperative day (POD) 0 drain outputs were 13.9 mL (left) and 10.1 mL (right). Average POD 1 drain outputs were 15.1 mL (left) and 15.6 mL (right). Drains were removed from all patients on POD 1 or 2. There were 2 minor complications (flap necrosis plus infection, marginal mandibular neuropraxia) and no major complications. TXA safely and effectively decreased bleeding, operating room time, and drain output compared with traditional local anesthetic techniques. Our future goal is to determine if epinephrine can be completely removed from the local anesthetic and replaced with TXA for facelift surgery.

Experience on primary closure of fibular flap donor sites and development of an algorithm for closure based on different flap designs.

Most skin paddles of the fibula flap are harvested from the distal third of the lower leg, skin grafting for the donor-site is necessary. A retrospective review was done on patients with large bony defects using free fibula osteocutaneous flaps (FOSCFF) for head and neck reconstruction. We focus on the techniques for closure of donor sites were skin grafting, primary closure with tear drop design and propeller flap technique on the donor site closure using skin graft, primary closure and local propeller flap based on the different location of perforators of FOSCFF. Postoperative follow up include incidence of wound complications, postoperative days to ambulation and cosmetic outcome. A total of 48 patients were included. Twenty five patients had skin graft (Group A), and 23 patients had primary closure (Group B); in 16 patients tear-drop design was used, 6 had propeller flap, and the remaining 1 patient received a chimeric flap. Group A had more wound complication rates compared to Group B; 20% versus 4.3%, respectively (p = .19). The average postoperative days to ambulation for Group A were 15.1 days versus 7.3 days for Group B (p < .001). The cosmetic score in the B group (2.71) versus A group (4.89) was also statistically significant (p = .007). All the patients ambulated well at follow up. Primary closure using the tear drop technique and propeller flap is superior to skin grafting in terms of better cosmetic appearance, earlier postoperative ambulation, and no need for another donor site for skin graft.

Early results of displaced femoral neck fragility fractures treated with supercapsular percutaneous-assisted total hip arthroplasty

BackgroundTotal hip arthroplasty (THA) is the preferred treatment for displaced femoral neck fractures in select patients, although dislocation remains a concern. In some studies, the supercapsular percutaneously assisted (SuperPATH) approach has demonstrated early mobilization, short hospital stay, and low dislocation rates in primary THA, but there are little data on its use for fractures. This study describes the perioperative outcomes and early dislocation rate of SuperPATH THA for displaced femoral neck fragility fractures.MethodsA retrospective review was performed of previous ambulatory patients with a displaced femoral neck fragility fracture treated with THA using the SuperPATH approach. Demographic data, time to ambulation, length of stay, and in-hospital complications during the hospital stay and follow-up period were recorded. Phone interviews were conducted to check for dislocations 1 year after surgery.ResultsThirty-seven consecutive patients were included with an average age of 75.0 years. Hospital stay averaged 5.5 days, and patients were discharged on average postoperative day 3.6. About 83.8% of patients were ambulatory by postoperative day 1, and 94.6% ambulatory before discharge. Twenty-seven percent of patients were discharged home, 46% to inpatient rehabilitation, 24% to skilled nursing facility, and 1 patient to hospice. At follow-up, there was no symptomatic heterotopic ossification and no infections. Thirty-two patients were available for telephone interviews at 1 year, with no dislocations reported.ConclusionsIn this small cohort, the SuperPATH approach for THA appears to be safe and effective for use in femoral neck fragility fractures, resulting in early ambulation and a low dislocation rate.

WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet

BackgroundThe wide-awake local anesthesia no tourniquet (WALANT) technique is applied during various hand surgeries. We investigated the perioperative variables and clinical outcomes of open reduction and internal fixation (ORIF) for distal radius fractures under WALANT.MethodsFrom January 2015 to January 2017, 60 patients with distal radius fractures were treated, and 24 patients (40% of all) were treated with either a volar or a dorsal plate via WALANT procedure. Of these 24 patients, 21 radius fractures were fixed with a volar plate, and the other 3 were fixed with a dorsal plate. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated.ResultsOne of the 24 patients could not tolerate the WALANT procedure and was reported as a failed attempt at WALANT. In the cohort, 23 patients successfully received distal radius ORIF under WALANT procedure. The average age is 60.9 (range, 20–88) years. The average operation time was 64.3 (range, 45–85) minutes, the average blood loss was 18.9 (range, 5–30) ml, and the average of duration of hospitalization is 1.8 (range, 1–6) days. The average postoperative day one VAS was 1.6 (range, 1–3). The average time of union was 20.7 (range, 15–32) weeks. The mean follow-up period was 15.1 (range, 12–24) months. Functional 1-year postoperative outcomes revealed an average Quick DASH score of 7.60 (range, 4.5–13.6) and an average wrist flexion and extension of 69.6° (range, 55–80°) and 57.4° (range, 45–70°). There was no wound infection, neurovascular injury, or other major complication noted.ConclusionsWALANT for distal radius fracture ORIF is a method to control blood loss by the effects of local anesthesia mixed with hemostatic agents. Without a tourniquet, the procedure prevents discomfort caused by tourniquet pain. Without sedation, patients could perform the active range of motion of the injured wrist to check if there is impingement of implants. It eliminates the need of numerous preoperative examinations, postoperative anesthesia recovery room care, and side effects of the sedation. However, patients who are not amenable to the awake procedure are contraindications.

EFFECT OF POSTOPERATIVE EPIDURAL ANALGESIA AFTER MAJOR ORTHOPEDIC SURGERIES, A RETROSPECTIVE STUDY

INTRODUCTION: Epidural analgesia has been used in many major surgeries like upper abdominal surgery, cardio-thoracic surgery, orthopedic surgery etc. Epidural analgesia is one of the commonly used methods of postoperative pain control despite its associated complications. So, this study was conducted to find out its effectiveness in major orthopedic surgeries done in Universal College of Medical Sciences. MATERIAL AND METHODS: A retrospective study was done at Universal College of Medical Sciences &amp; Teaching Hospital, Bhairahawa, Nepal from July 2012 to June 2014. Data of 57 patients, aged between 17 to 91 years having American Society of Anesthesiologists (ASA) physical status 1 and 2 who had undergone major orthopedic surgeries under spinal anesthesia and lumber epidural catheterization were collected and important information regarding anesthesia and surgery, epidural catheter and postoperative epidural analgesia, any complications if occurred throughout the study period were recorded. Departmental Protocol for epidural analgesia was followed in these patients. Patients who received intraoperative epidural anesthesia or analgesia and any other anesthetic or analgesic agents were excluded in this study. RESULTS: This study found epidural analgesia, a very effective way to relieve pain in patients undergoing major orthopedic surgeries, when given according to the Departmental Protocol. There were no any complications related to epidural analgesia till 4th postoperative day. Out of 57, only 2 patients received injection Ketorolac intravenously as a rescue analgesic at the same day of operation before epidural top up. Average time to demand for analgesic after the last dose of epidural top up was 21.933 hours. All patients were mobilized around their beds on 2nd postoperative day. The average postoperative days of hospital stay was only 6.5 days. CONCLUSION: Epidural mixture of Bupivacaine-morphine in lower dose and concentration given as an intermittent bolus dosing via lumber epidural catheter is safe and very effective in relieving postoperative pain after major orthopedic surgeries without any significant complications.Journal of Universal College of Medical Sciences (2015) Vol.03 No.02 Issue 10

Nissen fundoplication in severely ill infants: A STROBE compliant study

Aim: Anti-reflux surgery is offered to those who fail medical management for gastroesophageal reflux disease (GERD) in the pediatric population. A handful of studies show that those with neurologic impairment have benefited from these procedures; however, there are a few studies that document the indications and outcomes for infants < 6 months of age. Methods: A retrospective analysis of children < 6 months of age who underwent a Nissen fundoplication (NF) at St. Joseph's Regional Medical Center from December 2006 to June 2013 was performed. The following factors, such as surgical indications, comorbidities, hospital course data, weight gain, length of stay, and complications, were analyzed. Results: A total of 23 patients with the average age of 95.8 days were studied in this analysis. Presurgery, the average weight of these patients was 9.88 percentile (interquartile range: 5.85). A total of 65.2% patients were considered having failure to thrive (FTT) as they were under the 10th percentile and 78% patients had anatomic or genetic abnormalities. Nearly 47.8% patients underwent upper gastrointestinal studies that were positive for reflux. All patients had a concomitant gastrostomy tube (G-tube) placed during the NF. Diet was advanced on the average postoperative day of 2, and the patients tolerated the highest diet by the postoperative day of 6. Most patients saw a decrease in medications after the procedure. Moreover, 7 patients had complications related to the G-tube, with the main complication reported as leakage around the tube. There were two mortalities, both unrelated to the operation. Conclusion: Infants undergoing NF under the age of 6 months typically present with multiple comorbidities. NF in this population will not only lead to weight gain but also decrease in overall need for GERD-related medications. Early recognition of the failure of nasojejunal feeds will facilitate NF before significant FTT is present.

Diagnosis and Treatment of Abdominal Arterial Bleeding After Radical Gastrectomy: a Retrospective Analysis of 1875 Consecutive Resections for Gastric Cancer

BackgroundMassive abdominal arterial bleeding is an uncommon yet life-threatening complication of radical gastrectomy. The exact incidence and standardized management of this lethal morbidity are not known. MethodsBetween January 2003 and December 2013, data from 1875 patients undergoing radical gastrectomy with D2 or D2 plus lymphadenectomy were recorded in a prospectively designed database from a single institute. The clinical data and management of both early (within 24 h) and late (beyond 24 h) postoperative abdominal arterial hemorrhages were explored. For late bleeding patients, transcatheter arterial embolization (TAE) and re-laparotomy were compared to determine the better initial treatment option. ResultsThe overall prevalence of postoperative abdominal arterial bleeding was 1.92 % (n = 36), and related mortality was 33.3 % (n = 12). Early and late postoperative bleedings were found in 6 and 30 patients, respectively. The onset of massive arterial bleeding occurred on average postoperative day 19. The common hepatic artery and its branches were the most common bleeding source (13/36; 36.1 %). All the early bleeding patients were treated with immediate re-laparotomy. For late bleeding, patients from the TAE group had a significantly lower mortality rate than that of the patients from the surgery group (7.69 vs. 56.25 %, respectively, P = 0.008) as well as a shorter procedure time for bleeding control (2.3±1.1 vs. 4.8±1.7 h, respectively, P < 0.001). Four rescue reoperations were performed for TAE failures; the salvage rate was 50 % (2/4). Ten patients developed massive re-bleeding after initial successful hemostasis by either TAE (5/13) or open surgery (5/16). Three out of the 10 re-bleeding patients died of disseminated intravascular coagulation (DIC), while the other 7 recovered eventually by repeated TAE and/or surgery. ConclusionAbdominal arterial bleeding following radical gastrectomy tends to occur during the later phase after surgery, with further complications such as abdominal infection and fistula(s). For late bleeding, TAE can be considered as the first-line treatment when possible.

Laparoscopic sigmoid colectomy: Are all laparoscopic techniques created equal?

Laparoscopic colectomy has been associated with improved postoperative pain control, earlier return to work, and shorter hospital stays compared to open colectomy. However, there are varied technical approaches to laparoscopic resections. We therefore sought to determine whether the straight laparoscopic approach was associated with shorter length of stay compared to hand-assisted and laparoscopic-assisted techniques for sigmoid colectomies. A retrospective review of laparoscopic sigmoid colectomies performed by five colorectal surgeons from 2010 to 2014 was performed. Approaches were defined as: (1) straight laparoscopic if colon mobilization, inferior mesenteric artery transection and intra-corporeal anastomosis were performed laparoscopically, (2) hand assisted if a hand port was utilized to assist with mobilization and vessel transection, and (3) laparoscopic assisted if only the colon mobilization was performed intra-corporeally. Poisson regression was performed to determine the impact of surgical technique on LOS while controlling for differences in patient factors. A total of 191 patients were identified with 71 straight laparoscopic, 57 hand-assisted, and 63 laparoscopic-assisted cases. Substantial variability in choice of surgical technique was seen across surgeons. Patient populations were similar, with the exception of hand-assisted procedures being more often used in obese patients. Unadjusted average postoperative days to discharge were 3.6days for straight laparoscopic and 4.1 and 4.0days for hand-assisted and laparoscopic-assisted approaches, respectively. While controlling for factors associated with longer hospital stay, the straight laparoscopic approach was associated with a 14% shorter stay compared to laparoscopic-assisted colectomy and a 15% shorter stay compared to hand-assisted colectomy. The straight laparoscopic approach was also associated with earlier return of bowel function compared to other approaches. The straight laparoscopic approach to sigmoid colectomy is associated with substantially shorter postoperative stay and earlier return of bowel function when compared to hand-assisted and laparoscopic-assisted techniques. When technically feasible, the straight laparoscopic approach is preferred.

Laparoscopic management of complicated foreign body ingestion: a case series.

This study aims to demonstrate the safety and feasibility of laparoscopic management of complicated foreign body (FB) ingestion in a series of 5 patients. We present the merits of a minimally-invasive approach in this clinical setting from our series as well as published case reports. FB ingestion is occasionally complicated by abscess formation or perforation, requiring surgical intervention. Anecdotal reports of such cases managed by laparoscopic surgery have alluded to its merits over the conventional approach of open surgery. Over an 18-month period, 5 of 256 patients with FB ingestion at our unit were managed by laparoscopic surgery. Clinical and operative data were collected for this study. In all 5 cases, patients could not recall their FB ingestion and had normal plain radiographs. The diagnosis was made on a computed tomography (CT) scan. Laparoscopy was successfully employed to retrieve all FBs (fish bones), deroof abscesses, and primarily repair gastrointestinal perforations. The mean operative time was 69 minutes (55-85), utilizing 2 to 4 noncamera ports. There was no operative mortality and patients were discharged on average postoperative day (POD) 5 (2-8). Laparoscopic surgery is safe and feasible in small-diameter, complicated FB ingestion requiring surgical intervention and should be considered in similar patients.