Elective General Surgery Research Articles

WTP5.2 Length of stay and it’s predictors after elective general surgical procedures at a district hospital in NHS

Abstract Aims To study the length of stay of patients following elective general surgical procedures at a district hospital in NHS and the predictors for long stay. To be able to better predict the pattern of hospital stay and discharge. To understand the patients which stay longer in the hospital. Methods Retrospective analysis of elective general surgeries conducted at a busy district hospital in NHS from December 2021 to May 2022. Emergency cases were excluded. Data was collected form the theatreman app, which was hospital number, age, sex, ASA category, surgical time, anaesthesia time, list number of the patient in the theatre list. Statistical calculations were done on the StatsDirect 3 software. Results A total of 181 patients were studied of which 90 male and 91 female patients. Total admission days utilised were 318 and a median of 1 day per elective surgical patient. 94 patients (52 %) got discharged on the 0 post operative day (POD), 67 (37 %) were discharged on POD 1, 12 (6.6 %) on POD 2, 1 (0.55 %) on POD 3, 2 (1.1 %) on POD 4, 1 (0.55 %) on POD 5, 3 (1.65 %) on POD 6, 1 (0.55 %) on POD 12. Multiple linear regression analysis resulted in a p <0.0001 for surgical time and ASA grade and 0.0231 for age. Conclusion Surgical time, ASA grade and age have a statistically significant correlation on the length of stay after elective surgeries. Patients aged > 60 years, ASA >2 and Surgical time > 100 minutes will stay for 2 days or more in the hospital and such patients must be booked as inpatient.

452 Impact of COVID-19 on the closure of temporary ileostomies following colorectal surgery

Abstract Aims Temporary defunctioning ileostomies are created in emergency general surgery and elective colorectal surgery with the aim of reversal in the near future. Ileostomies come with associated morbidity. There is a nationwide delay to closure of ileostomies in the UK for a variety of reasons and Covid-19 has had a further significant impact on surgical waiting lists. We aim to assess the length of delay to reversal of ileostomy and whether there is greater morbidity associated with delayed reversal. Methods All reversal of ileostomy patients referred to the National Waiting Times Centre over a one year period between November 2021 and November 2022 we included. Demographics and details of index surgery were collected, as well as reversal peri-operative details, complications and length of stay. Results Twenty-three patients underwent reversal of ileostomy. Mean age 60.4 years. Mean number of days from index procedure to reversal was 648 days (range 99 – 2136). Reasons for delay were; adjuvant chemotherapy (n=6), waiting list/Covid-19 delays (n=13), patient preference/no reason documented (n=4). There were 7 end ileostomies who underwent laparotomy and 16 loop ileostomies reversed. Mean length of stay was 7.04 days (range 2-19 days). 7 patients had ileus following reversal, 3 had an anastomotic leak requiring return to theatre, 1 returned to theatre for bleeding and 1 developed Clostridium difficile. Conclusion Half of this cohort of patients who were referred as ‘long-waiters’ to the National Waiting Times Hospital developed a complication following reversal of ileostomy. This cohort of patients waited on average 377 days longer than pre-Covid-19 waits (Close-IT).

Defining major surgical complications using administrative data in Ontario: a validation study.

Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data. This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system. The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications. Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

A comparative study between covering ileal loop-without ostomy or delayed ostomy and diversion ileostomy for patients undergoing large bowel anastomosis

Background: In elective and emergency general surgery, bowel anastomoses are common procedures. Although several stoma-related issues may arise following stoma creation, establishing a stoma is incredibly morbid. Aims and Objectives: The study compares patients with diversion ileostomies (stomas) to those who had to cover ileal loops without ostomies or delayed ostomies for large bowel anastomosis to compare the risks and advantages of each procedure. Materials and Methods: This prospective and comparative study was conducted on 50 patients undergoing large bowel anastomosis. Patients were divided into two groups: Group A: Those with covering ileal loop without or delayed ostomy, and Group B: Those undergoing diversion ileostomy. Results: Demographic data of the study indicated that most of the participants in both groups were male (72% in covering ileal loop and 64% in diversion ostomy). In both groups, most participants belonged to the >45 age group. We have seen a significant difference in the setting of surgery, Vitamin B 12 levels, early complications, late complications, and time of takedown comparing covering ileal loop to the diversion ostomy group. Conclusion: This study showed reduced postoperative morbidity and complications of stomas following covering ileal loop compared to diversion ileostomy. Hence, the technique should be considered.

Prevalence of preoperative asymptomatic deep vein thrombosis in patients undergoing elective general surgery for benign disease.

The systemic inflammatory response following surgery as well as that of malignant disease itself is associated with a hypercoagulable state, and thromboprophylaxis is thus recommended during postoperative management of cancer patients. However, limited information is available on the prevalence of preoperative deep vein thrombosis (DVT) and its risk factors in surgical candidates, especially those receiving operations for benign diseases. This is a retrospective observational study with data of all patients scheduled for elective general surgery between January 2011 and September 2020, undergoing lower extremity venous ultrasonography as preoperative screening for DVT. The prevalence of preoperative asymptomatic DVT was estimated and its associations with clinical variables were evaluated. Among 1512 patients included in the study, 161 (10.6%) had asymptomatic DVT before surgery. DVT prevalence was 13.7% in patients with malignant disease, while it was 8.6% in those with benign disease. The site of the thrombus was distal type in 141 (87.6%) patients, most commonly in the soleal vein. Advanced age (>70 years), female sex, and decreased hemoglobin level were significantly associated with preoperative asymptomatic DVT by multivariate analysis. The odds ratio for advanced age was the highest and rose as age increased. Malignant disease was not an independent risk factor for preoperative DVT. This study showed the prevalence of asymptomatic DVT to be equal in patients with and without malignant disease undergoing elective general surgery. Preoperative DVT assessment is necessary regardless of the disease indicated for surgery, especially in patients with the risk factors identified in this study.

Massaging as a pain-relieving intervention before performing intravenous access

PurposePain is “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of damage”. Stimulating the skin by rubbing, stroking, massaging, or applying pressure near the injection site is pain-relieving. Needle-related procedures induce anxiety, distress, and fear in children and adults. The present study aimed to test the effectiveness of massaging the access site in reducing pain associated with intravenous access. DesignAfter obtaining institutional ethics committee approval, this prospective randomized single-blinded study was performed on 250 ASA I-II patients 18 to 65 years old, scheduled for elective minor general surgery under general anaesthesia. MethodsPatients were randomized into the Massaging Group (MG) and the Control Group (CG). A Situational Trait Anxiety Inventory (STAI) was conducted to evaluate the anxiety levels of the patients. In addition, the skin adjacent to the intravenous access site was massaged for 15 s in circular motions with moderate intensity by the investigator's right thumb before performing the intravenous access in the MG. The CG did not receive any massage adjacent to the access site. The primary endpoint, the intensity of perceived pain, was rated on a non-graduated 10-cm Visual Analogue Score (VAS). FindingsThe groups' demographic data and STAI I-II scores were similar. There was a significant difference between the VAS scores of the two groups (p < 0.05). ConclusionsOur results support massaging as an effective pain-relieving technique before intravenous intervention. As massaging is a universal and non-invasive intervention that requires no advanced preparation, we recommend massaging before each intravenous cannulation to reduce pain caused by intravenous access.

Long-term outcomes after lower extremity bypass in the actively smoking claudicant

ObjectiveSmoking is known to increase complications, including poor wound healing, coagulation abnormalities, and cardiac and pulmonary ramifications. Across specialties, elective surgical procedures are commonly denied to active smokers. Given the base population of active smokers with vascular disease, smoking cessation is encouraged but is not required the way it is for elective general surgery procedures. We aim to study the outcomes of elective lower extremity bypass (LEB) in actively smoking claudicants. MethodsWe queried the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network LEB database from 2003 to 2019. In this database we found 609 (10.0%) never smokers (NS), 3388 (55.3%) former smokers (FS), and 2123 (34.7%) current smokers (CS) who underwent LEB for claudication. We performed two separate propensity score matches without replacement on 36 clinical variables (age, gender, race, ethnicity, obesity, insurance, hypertension, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, previous coronary artery bypass graft, carotid endarterectomy, major amputation, inflow treatment, preoperative medications and treatment type), one of FS to NS and a second analysis of CS to FS. Primary outcomes included 5-year overall survival (OS), limb salvage (LS), freedom from reintervention (FR), and amputation-free survival (AFS). ResultsPropensity score matches resulted in 497 well-matched pairs of NS and FS. In this analysis we found no difference in terms of OS (HR, 0.93; 95% CI, 0.70-1.24; P = .61), LS (HR, 1.07; 95% CI, 0.63-1.82; P = .80), FR (HR, 0.9; 95% CI,0.71-1.21; P = .59), or AFS (HR, 0.93; 95% CI,0.71-1.22; P = .62). In the second analysis, we had 1451 well-matched pairs of CS and FS. There was no difference in LS (HR, 1.36; 95% CI,0.94-1.97; P = .11) or FR (HR, 1.02; 95% CI,0.88-1.19; P = .76). However, we did find a significant increase in OS (HR, 1.37; 95% CI,1.15-1.64, P <.001) and AFS (HR, 1.38; 95% CI,1.18-1.62; P < .001) in FS compared with CS. ConclusionsClaudicants represent a unique nonemergent vascular patient population that may require LEB. Our study found that FS have better OS and AFS when compared with CS. Additionally, FS mimic nonsmokers at 5-year outcomes for OS, LS, FR, and AFS. Therefore, structured smoking cessation should be a more prominent part of vascular office visits before elective LEB procedures in claudicants.

Comparison of Diathermy versus Surgical Scalpel for Skin Incisions in Elective General Surgical Procedures

Objective: To compare diathermy versus surgical scalpel in skin incisions in elective general surgical procedures regarding incision time, post-operative pain and surgical site infection.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Study Duration: Department of Surgery, Combined Military Hospital, Peshawar Pakistan, from Feb to Jul 2020.&#x0D; Methodology: A total of 106 patients undergoing general elective procedures aged 20-60 years belonging to either gender were included in the study. They were divided into two equal groups of 53 patients each. Patients with ischemic heart disease, diabetes mellitus, hypertension, and dirty and contaminated procedures were excluded. Group-A patients underwent skin incisions with diathermy, while Group-B patients underwent skin incisions with a surgical blade on a scalpel. The incision time was noted for both groups. All patients were followed for post-operative pain per visual analogue score and development of surgical site infection. &#x0D; Results: Mean incision time in Group-A (Diathermy-Group) was 46.58±8.03 seconds, while in Group-B (Scalpel-Group), it was 54.75±7.91 seconds (p&lt;0.001). The mean post-operative pain score in Group-A (Diathermy Group) was 2.25±0.76, while in Group-B (Scalpel Group), it was 3.58±0.91 (p&lt;0.001). Wound infection was found in 3.77% of patients in Group-A, while in Group- B, it was found in 15.09% (p=0.046).&#x0D; Conclusion: Incision with Diathermy is better than scalpel skin incisions regarding incision time, post-operative pain and postoperative surgical site infection.

Evaluation of fluid responsiveness with dynamic superior vena cava collapsibility index in mechanically ventilated patients

BackgroundThis study aimed to evaluate the predictive accuracy of the superior vena cava collapsibility index measured by transesophageal echocardiography and compare the index with stroke volume variation measured by FloTrac™/Vigileo™ in mechanically ventilated patients.MethodsIn the prospective study, a total of 60 patients were enrolled for elective general surgery under mechanical ventilation, where all patients received 10 ml/kg of Ringer’s lactate. Five kinds of related data were recorded before and after the fluid challenge, including the superior vena cava collapsibility index (SVC-CI), the ratio of E/e’, cardiac index (CI), stroke volume variation (SVV), and central venous pressure (CVP). Based on the collected data after the fluid challenge, we classified the patients as responders (FR group) if their CI increased by at least 15% and the rest were non-responders (NR).ResultsTwenty-five of 52 (48%) of the patients were responders, and 27 were non-responders (52%). The SVC-CI was higher in the responders (41.90 ± 11.48 vs 28.92 ± 9.05%, P < 0.01). SVC-CI was significantly correlated with △CI FloTrac (r = 0.568, P < 0.01). The area under the ROC curve (AUROC) of SVC-CI was 0.838 (95% CI 0.728 ~ 0.947, P < 0.01) with the optimal cutoff value of 39.4% (sensitivity 64%, specificity 92.6%). And there was no significant difference in E/e’ between the two groups (P > 0.05). The best cutoff value for SVV was 12.5% (sensitivity 40%, specificity 89%) with the AUROC of 0.68 (95% CI 0.53 ~ 0.826, P < 0.05).ConclusionsThe SVC-CI and SVV can predict fluid responsiveness effectively in mechanically ventilated patients. And SVC-CI is superior in predicting fluid responsiveness compared with SVV. The E/e’ ratio and CVP cannot predict FR effectively.Trial registrationChinese clinical trial registry (ChiCTR2000034940).

Accuracy of Self-Estimated BMI in the Context of Telephone Assessment Before Elective General Surgery.

Background This study aimed to determine if self-estimated body mass index (BMI) from telephone consultation was accurate and useful for surgical planning prior to elective general surgery. Methods A prospective cohort study was performed under a single surgeon at a district general hospital in the United Kingdom. Estimated BMI was collected from consecutive patients attending a pre-operative telephone consultation. Actual BMI was measured on the day of surgery and compared. Patient age and gender were also collected. Results Data were collected from 124 participants (median age 59 years, 49.2% male). A total of 33 participants under-estimated, 53over-estimated, and 38 accurately estimated their BMIs. The median change in BMI was 0.0 (IQR -0.1, 0.3, p = 0.003). The median change in males was 0.0 (-0.1, 0.2, p = 0.479) compared to 0.1 (0.0, 0.7, p = 0.002) in females. Those with an actual BMI > 29.9 had a significantly higher median change (0.2 {0.0, 1.1}) compared to those with BMI≤ 29.9 (0.0 {-0.2, 0.1}; p <0.001). Only two patients could have required a change in surgeon on the day of the procedure and this was not statistically significant (p = 0.500). Conclusions Self-estimated BMI, collected via telephone consultation, is a suitable method for assessing patients for surgical planning ahead of elective general surgery procedures, particularly for males. However, it is important to be aware that those with higher BMIs, particularly females, may underestimate their BMIs.

Literature Review for Office-Based Anesthesia

Literature Review for Office-Based Anesthesia

Risk-adjusted perioperative bridging anticoagulation reduces bleeding complications without increasing thromboembolic events in general and visceral surgery

BackgroundPerioperative bridging of oral anticoagulation increases the risk of bleeding complications after elective general and visceral surgery. The aim of this study was to explore, whether an individual risk-adjusted bridging regimen can reduce bleeding events, while still protecting against thromboembolic events.MethodsWe performed a quality improvement study comparing bridging parameters and postoperative outcomes before (period 1) and after implementation (period 2) of a new risk-adjusted bridging regimen. The primary endpoint of the study was overall incidence of postoperative bleeding complications during 30 days postoperatively. Secondary endpoints were major postoperative bleeding, minor bleeding, thromboembolic events, postoperative red blood cell transfusion, perioperative length-of-stay (LOS) and in-hospital mortality.ResultsA total of 263 patients during period 1 and 271 patients during period 2 were compared. The included elective operations covered the entire field of general and visceral surgery. The overall incidence of bleeding complications declined from 22.1% during period 1 to 10.3% in period 2 (p < 0.001). This reduction affected both major as well as minor bleeding events (8.4% vs. 4.1%; p = 0.039; 13.7% vs. 6.3%; p = 0.004). The incidence of thromboembolic events remained low (0.8% vs. 1.1%). No changes in mortality or length-of-stay were observed.ConclusionIt is important to balance the individual thromboembolic and bleeding risks in perioperative bridging management. The risk adjusted bridging regimen reduces bleeding events in general and visceral surgery while the risk of thromboembolism remains comparably low.

Comparison of effect of prophylactic administration of ondansetron and placebo on prevention of post induction hypotension in elderly patients undergoing surgery in general anesthesia

Background: Post-induction hypotension is a frequently encountered complication seen particularly in elderly population. Hypotension, by impairing vital organ perfusion, increases the morbidity and mortality of the patients. prophylactic use of ondansetron in preventing hypotension after induction of general anaesthesia in elderly patients , hence getting the benefit of preventing both hypotension and postoperative nausea and vomiting by the use of a single drug.&#x0D; Subjects and method: This randomized controlled clinical trial was carried out in the operation theaters of general surgery, Mayo Hospital, Lahore, from 09-09-2017 to 09-09-2018. A total of 80 patients who were to undergo general anaesthesia for elective general surgical procedures were recruited for this study. After taking informed consent, the patients were randomly divided into two groups. Patients in group A received ondansetron and those in group B received placebo prior to the induction of anaesthesia. Efficacy was labeled in terms of absence of hypotension i.e. a drop in mean arterial pressure of no more than 25% of baseline at 1, 3, 5, 9 and 11 minutes after induction of anaesthesia. The data was recorded on a predesigned proforma. Statistical analysis was done using SPSS version 21.&#x0D; Results: Both groups were comparable in terms of age, gender, ASA status, BMI and weight. Efficacy was seen in 19 (47.50%) cases managed by ondansetron vs. 10 (25%) in placebo group (p = 0.03). There was significant difference of efficacy in patients with age between 60 to 70 years where 63.63% patients in the Group A effectively maintained their blood pressure (p=0.02). Patients having age 70 years or above did not show statistically significant difference. History of hypertension made no impact on the efficacy of ondansetron for maintaining blood pressure after induction (p=0.53)&#x0D; Keywords: &#x0D; Ondansetron, Efficacy, Hypotension

Malnutrition via GLIM Criteria in General Surgery Patients

Purpose: The purposes are to determine malnutrition in elective general surgery patients via GLIM criteria, compare GLIM criteria with NRS2002 and to determine the effect of malnutrition on Length of Stay (LoS). &#x0D; Materials and Methods: Malnutrition was detected with NRS2002 and GLIM. GLIM was evaluated in two different ways as 1-NRS2002 (first four questions) was used as a preliminary malnutrition screening tool for GLIM and 2-All patients were evaluated with GLIM without a preliminary assessment. Reduced muscle mass in GLIM, was assessed using different anthropometric measurements and cut-off points. In total, 10 different GLIM models were constituted. Data were collected within 48 hours of admission. Agreement between malnutrition tools was determined via Kappa. Logistic regression models were established to present the effect of malnutrition on long LoS. p

Postoperative outcomes in patients undergoing elective general surgery after recovery from Covid-19 at a tertiary care centre: A one-year case series.

Background Planned elective surgery had to be postponed for a large number of patients who tested positive for Covid-19 in the preoperative period. We aimed to assess the postoperative outcomes of patients who were operated on for elective indications, following recovery from Covid-19 infection. Methods We did a retrospective study of patients who underwent elective general surgery between 1 April 2020 and 31 March 2021, following recovery from Covid-19. The 30-day postoperative morbidity and mortality were analysed. The data relevant for the study were retrieved from the hospital's electronic medical records. Results Of the 109 patients included, 54.1% were women and the median (range) age was 49 (16-76) years; 53.2% of operations were performed for benign indications and the rest were for malignancies. Eighty-five (78%) patients underwent surgery following recovery from an asymptomatic Covid-19 infection and 23 (21.1%) patients following recovery from mild Covid-19 infection; 73.3% of the operations were performed following a planned delay of 2- 5 weeks from the diagnosis of Covid-19. The 30-day major postoperative morbidity (Clavien-Dindo grade ≥3) was 6.4%, the postoperative pulmonary morbidity was 0.9%, and there was no 30-day mortality. Conclusions Elective general surgical procedures can be done safely in patients who have recovered from asymptomatic and mild Covid-19 infection, following a minimum wait period of 2 weeks.

The novel derived preoperative-POSSUM score as a predictor of surgical patients’ allocation to an elective postoperative ICU ordered by anesthesiologists at Cairo University Hospital

Backgroun d Anesthesiologists depend on multiple factors to request a postoperative ICU bed after elective surgeries. This decision may be based on the risk of surgery and comorbidities. Some surgeries may be postponed, or some patients may be exposed to unnecessary ICU admission. So, this aroused the need for certain scores upon which anesthesiologist could build their request for ICU admission. Aim To evaluate the accuracy of the pre-Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) score as a predictor for the need for postoperative ICU. Patients and methods This study calculated the POSSUM score preoperatively (pre-POSSUM) for 308 patients who underwent elective general surgeries at Kasr Alainy Hospital, a leading tertiary care hospital in Cairo, Egypt. Results Our study showed the possibility of having a cutoff value of pre-POSSUM score that could predict patients who would benefit most from a postoperative ICU stay. The best cutoff value for the estimated morbidity percent was 19.545, with 100% sensitivity and 64.3% specificity. Moreover, the estimated mortality percent at a cutoff value of 3.375 showed 100% sensitivity and 62% specificity. Conclusion The pre-POSSUM could be used as a reliable tool for the allocation of patients after elective general surgeries, identify those who require intensive postoperative care, and use the cutoff values shown in a study to help to triage patients after elective surgeries.

Comparison of the outcome of diathermy versus scalpel skin incision in surgical cases

Aim and Objectives: The present study compared the outcome of diathermy versus scalpel skin incision in surgical cases. Materials and Method: The present Prospective interventional study was done at Santosh Medical College &amp; Hospital for a period of 1.5 years. Group A included 100 patients treated with Scalpel and Group B included 100 patients treated with Diathermy. Results: The mean Incision time (s), Incision time (s/cm2) and Pain VRS score at day 1 and 2 was significantly more among Scalpel group compared to Diathermy group. The mean Blood loss in incision (ml) was significantly more among Diathermy group compared to Scalpel group. Conclusion: Due to shorter incision times, less blood loss, and less early postoperative discomfort, diathermy incisions have substantial benefits over scalpels in both elective and emergency general surgery.

Gynaecological Complications in General Surgery Unit: A Single-Center Study

Introduction: This study aims to investigate the frequency of gynecological complications reported during emergency and elective general surgeries. Methodology: This is a cross-sectional study, data were collected retrospectively, approximately 500 patients went through surgical management in the general surgery department while only 125 reported associated issues requiring surgical management and required gynecological interventions. Data was entered &amp; analyzed using SPSS version 22. Frequency and percentage were calculated for quantitative variables such as presenting complaints, reported gynecological issues, required intervention, and reported associated problems. Results: A total of 125 patients were enrolled in the study with the most commonly reported presenting complaint being pain with the vaginal discharge with vomiting documented in 72(57.5%) of patients. Puss discharge from wounds, peritonitis, and abdominal swelling were other frequently reported issues in 14(11.2%), 11 (8.7%), and 11 (8.7%) patients respectively. 98(78%) were discharged after successful management of gynecological as well as general surgical problems, 25(20%) were referred to tertiary care health care setup for more appropriate care and 1(1%) had a burst abdomen. Only 1 (1%) out of 125 patients expired during the study period. Conclusion: Gynecological complications have been markedly reported in the general surgery unit, necessitating general surgeons to intercede and deliver significant benefits in terms of lowering morbidity, mortality, postoperative complications, and length of hospital stay from a diagnostic and therapeutic point of view.

Electroencephalography can provide advance warning of technical errors during laparoscopic surgery.

Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery. In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40s prior and 10s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses. Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p = .008) and motor uncertainty (p = .034) was detected 17s prior to errors, but not prior to good surgical performance. These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions-before errors occur and cause patient harm.

Frailty in emergency general surgery: Low-risk procedures pose similar risk as high-risk procedures for frail patients

BackgroundThe association of frailty on postoperative outcomes after elective and emergency general surgery procedures has been widely studied. However, this association has not been examined in the geriatric population stratified by emergency general surgery procedural risk. MethodsA retrospective cohort study was performed using the 2012 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database. We identified geriatric patients (age ≥65 years) undergoing an emergency general surgery procedure within 48 hours of admission stratified by the procedural risk. Frailty was accessed using Modified 5-item Frailty Index, and the patients were divided into 4 groups Modified 5-item Frailty Index = 0, 1, 2, and ≥3. Multivariable logistic regression was used to assess the impact of increasing Modified 5-item Frailty Index score on postoperative complications, failure-to-rescue, and readmissions. ResultsIn the study, 16,911 low risk procedure emergency general surgery patients were grouped as (33.3%) Modified 5-item Frailty Index = 0, (45.1%) Modified 5-item Frailty Index = 1, (18.7%) Modified 5-item Frailty Index = 2, and (2.9%) Modified 5-item Frailty Index ≥3 respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 2.1 [1.3-3.5], Modified 5-item Frailty Index ≥ 3: 2.2 [1.2-4.2]), failure-to-rescue (Modified 5-item Frailty Index = 2: 2.3 [1.3-4.0], Modified 5-item Frailty Index ≥ 3: 2.3 [1.2-4.6]), readmission (Modified 5-item Frailty Index = 2: 1.4 [1.2-1.7], Modified 5-item Frailty Index ≥ 3: 1.5 [1.1-2.1]). In addition, 30,305 high-risk patients undergoing procedure emergency general surgery were grouped as (24.1%) Modified 5-item Frailty Index = 0, (44.9%) Modified 5-item Frailty Index = 1, (24.0%) Modified 5-item Frailty Index = 2, and (7.0%) Modified 5-item Frailty Index ≥3, respectively. After multivariable analyses, increasing Modified 5-item Frailty Index score (versus Modified 5-item Frailty Index = 0) was associated with complications (odds ratio [95% confidence interval]; Modified 5-item Frailty Index = 2: 1.2 [1.2–1.3], Modified 5-item Frailty Index ≥3: 1.7 [1.5–2.0]), failure-to-rescue (Modified 5-item Frailty Index = 2: 1.3 [1.2–1.5], Modified 5-item Frailty Index ≥3: 1.5 [1.3–1.7]), readmission (Modified 5-item Frailty Index = 2: 1.3 [1.2–1.4], Modified 5-item Frailty Index ≥3: 1.6 [1.4–1.9]). ConclusionIncreasing levels of frailty in geriatric emergency general surgery patients are associated with higher levels of postoperative complications, failure-to-rescue, and readmission. Clinicians should consider frailty in assessing the risk of even low-risk surgeries in this population.