Longer Operative Time Research Articles

High-frequency ultrasound-assisted Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans

BackgroundDermatofibrosarcoma protuberans (DFSP) is a superficial sarcoma characterized by infiltrative growth with tentacle-like borders. Mohs micrographic surgery (MMS) is the preferred treatment option for DFSP. However, the imprecise boundary localization in MMS leads to an increased number of Mohs layers required and a longer surgery time. High-frequency ultrasound has excellent tissue recognition capability for DFSP, allowing for precise boundary marking. Materials and MethodsIn this study, we retrospectively analyzed 14 cases of DFSP treated with MMS using preoperative ultrasound localization and three-dimensional reconstruction at Xiangya Hospital over the past 5 years. We also reviewed previous studies on MMS for DFSP treatment. ResultsIt was found that the average number of Mohs layers for patients after preoperative ultrasound localization was 1.57, ranging from 1 to 3, which was less than the previously reported 1.86 layers, ranging from 1 to 12. This effectively reduced the number of Mohs layers required. ConclusionsBy utilizing preoperative high-frequency ultrasound to determine the boundaries and depth of DFSP, the number of Mohs layers can be effectively reduced, leading to less workload for pathological examination, shorter operation time, and reduced surgical risks for patients. Ultrasound imaging data can be used for three-dimensional reconstruction, enabling less experienced Mohs surgeons to have a visual understanding of the morphology and extent of infiltration of the lesions. This aids in developing optimal surgical plans, smoothing the learning curve, and promoting the wider adoption of MMS.

Prophylactic muscle flaps in high-risk-for-poor-healing patients with prosthetic bypasses increases deep wound complications.

Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis. We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared. Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p=0.03), especially deep incisional infection (4.9% vs. 2.4%; p=0.04). Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.

Safety and efficacy of minimally invasive gastrectomy for older patients with gastric cancer after neoadjuvant chemotherapy and immunotherapy: a propensity score-matched analysis

BackgroundThe effect of neoadjuvant immunotherapy on minimally invasive gastrectomy (MIG) in older patients with gastric cancer remains controversial. This study aimed to evaluate the safety, and efficacy of MIG for older patients who underwent neoadjuvant chemotherapy and immunotherapy (NICT).MethodsThe clinical data of 726 older patients aged over 65 years who underwent upfront MIG or MIG after NICT in the Department of General Surgery, Chinese PLA General Hospital First Medical Center between Jan 2020 and Nov 2023 were retrospectively analyzed. Propensity score-matched (PSM) analysis at a ratio of 1:2 was performed to reduce bias from confounding patient-related variables, short- and long-term outcomes were compared between the two groups.ResultsThe baseline characteristics were comparable between 61 patients in the NICT-MIG group and 114 patients in the MIG group after PSM (P > 0.05). The major pathological response (MPR) rate and pathological complete response (pCR) rate were 44.2% and 21.3%, respectively, in the NICT-MIG group. Patients in the NICT-MIG group had longer operation times (P = 0.005) and postoperative days (P = 0.030) than those in the MIG group. No significant differences were found in intraoperative bleeding, number of retrieved lymph nodes, first flatus day, R0 resection rate, overall postoperative complication (POC) morbidity, severe POC morbidity, 2-year overall, and recurrence-free survival between the MIG and NICT-MIG groups (P > 0.05). Multivariate logistic analysis revealed that an estimated blood loss > 200 mL (P = 0.010) and a lymphocyte-to-monocyte ratio (LMR) ≤ 3.25 (P = 0.006) were independent risk factors for POCs after MIG in older patients.ConclusionThe safety, and efficacy of NICT-MIG were comparable to those of upfront MIG in older patients with GC. Patients with an estimated blood loss > 200 mL or an LMR ≤ 3.25 should be carefully evaluated for an increased risk of POCs in older patients who undergo MIG.Trial registrationChinese Clinical Trial Registry (Registration Number: ChiCTR2400086827).

What Is the Risk of Irrigation and Debridement Following Foot and Ankle Surgery? Development of a Risk Severity Scoring System.

Surgical site infection (SSI) after foot and ankle surgery has serious negative effects on patient health and quality of life. While previous studies have looked at predisposing factors for SSI, to our knowledge, no study has proposed a risk severity score. Can a risk severity score, based on patient demographic characteristics and surgical variables, be developed for preoperative use in patients undergoing foot and ankle surgery that will calculate the risk of an irrigation and debridement (I&D) procedure within 90 days of surgery utilizing data from previous surgeries? A retrospective chart study was performed on patients undergoing foot and ankle surgery. Data on demographic characteristics including age, sex, and BMI were recorded. Data on patient factors including diabetes and smoking history were also recorded. Surgical details including length of surgery, procedure type, surgeon, antibiotic delivery time, antibiotic type, and antibiotic dose were analyzed. Of 2979 procedures, 1% (36) of I&Ds were performed within 90 days. The mean age at surgery was 49 ± 17 years, and 57% (1702) of patients were female. The mean BMI was 28 ± 6 kg/m2. The primary outcome was I&D within 90 days postoperatively. Descriptive statistics of differences in patient characteristics between those who underwent I&D and those who did not were examined using chi-square tests and t-tests (p < 0.05 was taken as significant). Significant variables from a simple regression analysis were included in a multiple logistic regression model with a forward stepwise procedure for variable selection. We required all data in the model to be categorical; thus, continuous variables such as time were dichotomized. We factored odds ratios determined by multiple regression for significant variables into the final risk severity score, and an easy-to-use tool based on this risk severity score was created in Excel (Microsoft). Current tobacco use, diabetes, and longer operative times were the only factors associated with I&D within 90 days postoperatively. A risk severity score was developed using current tobacco use, diabetes, and length of surgery greater than 60 minutes as factors. A patient with a severity score of 0 (no risk factors) had a 0.6% chance of I&D within 90 days, while a severity score of 1 indicated a 1.1% chance, a score of 2 indicated a 2.1% chance, a score of 3 indicated a 4.0% chance, and a score of 4 (all risk factors) indicated a 7.5% chance of I&D within 90 days. A spreadsheet that can be used at the point of care was created based on these findings. Our risk severity score may help inform preoperative patient guidance and operative planning. Calculating the score in the office setting during preoperative visits can also improve communication between physician and patient. Future research should focus on validation of this risk severity score at multiple institutions. Level III, prognostic study.

Analysis of risk factors of postoperative complication for non-small cell lung cancer

BackgroundThe relationship between risk factors of common postoperative complications after pulmonary resection, such as air leakage, atelectasis, and arrhythmia, and patient characteristics, including nutritional status or perioperative factors, has not been sufficiently elucidated.MethodsOne thousand one hundred thirty-nine non-small cell lung cancer patients who underwent pulmonary resection were retrospectively analyzed for risk factors of common postoperative complications.ResultsIn a multivariate analysis, male sex (P = 0.01), age ≥ 65 years (P < 0.01), coexistence of chronic obstructive pulmonary disease (COPD) (P < 0.01), upper lobe (P < 0.01), surgery time ≥ 155 min (P < 0.01), and presence of lymphatic invasion (P = 0.01) were significant factors for postoperative complication. Male sex (P < 0.01), age ≥ 65 years (P = 0.02), body mass index (BMI) < 21.68 (P < 0.01), coexistence of COPD (P = 0.02), and surgery time ≥ 155 min (P = 0.01) were significant factors for severe postoperative complication. Male sex (P = 0.01), BMI < 21.68 (P < 0.01), thoracoscopic surgery (P < 0.01), and surgery time ≥ 155 min (P < 0.01) were significant risk factors for postoperative air leakage. Coexistence of COPD (P = 0.01) and coexistence of asthma (P < 0.01) were significant risk factors for postoperative atelectasis. Prognostic nutrition index (PNI) < 45.52 (P < 0.01), lobectomy or extended resection more than lobectomy (P = 0.01), and surgery time ≥ 155 min (P < 0.01) were significant risk factors for postoperative arrhythmia.ConclusionLow BMI, thoracoscopic surgery, and longer surgery time were significant risk factors for postoperative air leakage. Coexistence of COPD and coexistence of asthma were significant risk factors for postoperative atelectasis. PNI, surgery time, and surgical procedure were revealed as risk factors of postoperative arrhythmia. Patients with these factors should be monitored for postoperative complication.Trial registrationThe Institutional Review Board of Kanazawa Medical University approved the protocol of this retrospective study (approval number: I392), and written informed consent was obtained from all patients.

Comparison of the efficacy of gasless robotic surgery through transaxillary apporach and open surgery for papillary thyroid carcinoma

Objective: To compare the efficacy of gasless robotic surgery through transaxillary approach and open surgery for papillary thyroid carcinoma (PTC). Methods: The data of patient undergoing robotic surgery through transaxillary approach and traditional open surgery for PTC at the Sun Yat-sen Memorial Hospital, Sun Yat-sen University, from November 2016 to June 2023 were retrospectively analyzed. A 1∶1 propensity score matching (PSM) was performed to balance age, sex, extent of surgery, tumor size, capsule invasion, and multifocality. Surgical data, postoperative pathological data, complications, postoperative 2-month visual analog scale (VAS) scores for aesthetics, and follow-up data were compared between the two groups. Results: A total of 728 PTC patients were included. There were 339 patients in the robotic group, among which 262 were female (77.3%) and 77 were male (22.7%), with the age of [M (Q1, Q3)] 39 (32, 46) years and a body mass index (BMI) of 22.8 (20.7, 25.0) kg/m². Meanwhile, 389 patients were in the open group, among which 290 were female (74.6%) and 99 were male (25.4%), with the age of 47 (38, 55) years and a BMI of 23.2 (21.3, 25.5) kg/m2. Further analysis after PSM (there were 264 cases in both groups) showed that in the subtotal thyroidectomy and central neck dissection (LT+CCND) subgroup, the robotic group had longer operative time, higher blood loss, and greater drainage volume compared with the open group [100 (80, 130) min vs 60 (50, 80) min; 10 (10, 20) ml vs 10 (10, 20) ml; 103 (69, 145) ml vs 75 (57, 98) ml; all P<0.001], and the central lymph node metastasis rate was higher in the robotic group [45.6% (57/125) vs 31.8% (47/148), P=0.019]. In the total thyroidectomy and central neck dissection (TT+CCND) subgroup, the robotic group also had longer operative time, higher blood loss, and greater drainage volume compared with the open group [150 (110, 180) min vs 85 (75, 100) min; 20 (10, 20) ml vs 10 (10, 20) ml; 155 (107, 206) ml vs 90 (70, 120) ml; all P<0.001]. The incidence of chest skin numbness at 3 months postoperatively was higher in the robotic group compared with the open group (12.9% vs 0, P<0.001), while there were no statistically significant differences in other postoperative complications (all P>0.05). The VAS score at 2 months postoperatively was higher in the robotic group compared with the open group [9 (9, 9) vs 8 (7, 9), P<0.001]. Three cases of contralateral lobe recurrence occurred in the open group, while there were no case of recurrence in the robotic group. The 5-year overall survival rate was 100.0% in both the robotic and open groups, and there was no statistically significant difference in the 5-year disease-free survival rate between the robotic and open groups (100.0% vs 98.6%, P=0.068). Conclusion: Gasless robotic surgery through transaxillary approach for total thyroidectomy or lobectomy in the treatment of PTC is safe, feasible, and effective, with good cosmetic outcomes and comparable efficacy to traditional surgery.

Early marginal ulceration prevalence following primary RYGB: a rare events model of the MBSAQIP 2015-2021

PurposeMarginal ulceration (MU) following Roux-en-Y gastric bypass (RYGB) is an established complication, with early MU (within 30-days of operation) being less understood compared to its late counterpart. This study aims to identify risk factors for early MU in patients undergoing primary RYGB. MethodsUtilizing data from the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP 2015-2021), 1,346,468 records were evaluated. After exclusions for revisions, conversions, pediatric cases, nonbinary gender, missing body mass index (BMI) data, and missing operative time; 291,625 cases of primary RYGB were included for full analysis and rare events modeling of early MU. ResultsThe prevalence of early MU was .29% (n = 850). Higher rates of early MU were associated with BMI, race, history of diabetes mellitus (DM), prior thrombotic complications (deep vein thrombosis (DVT) and pulmonary embolism (PE)), prior percutaneous cardiac intervention (PTC), immunosuppressive therapy, and anticoagulation status. Additionally, procedural aspects like the nonspecialization of the surgeon and longer operative times also correlated with higher early MU rates. Rare-events regression modeling noted significant associations of early MU with younger age, diabetes requiring insulin, history of PTC, DVT, immunosuppressive therapy, and anticoagulation status. ConclusionEarly MU remains a relatively rare complication. The lower than previously reported occurrence suggests possible improvements in both patient preparation and surgical technique. The identification of relevant risk factors enables better perioperative and intraoperative management of patients at risk of developing early MU.

Current and Future of Robotic Surgery in Thyroid Cancer Treatment.

Thyroid cancer is among the most common endocrine malignancies, necessitating effective surgical interventions. Traditional open cervicotomy has long been the standard approach for thyroidectomy. However, the advent of robotic surgery has introduced new possibilities for minimally invasive procedures with benefits in terms of cosmetic outcomes, enhanced precision, comparable complication rates, and reduced recovery time. This study mainly reviewed the most widely used and well-known robotic thyroidectomy approaches: the transaxillary approach, the bilateral axillo-breast approach, and the transoral approach. This review examines the current status and future potential of robotic surgery in thyroid cancer treatment, comparing its efficacy, safety, and outcomes with those of conventional open cervicotomy. Challenges such as a longer operative time and higher costs exist. Future directions include technological advancements, tele-surgery, single-port surgery, and the integration of artificial intelligence. Robotic surgery holds promise in optimizing patient outcomes in thyroid cancer treatment.

Gastrointestinal Stromal Tumors of the Stomach: Is There Any Advantage of Robotic Resections? A Systematic Review and Meta-Analysis.

Background: The role of robotic surgery for gastrointestinal stromal tumor (GIST) resection remains unclear. This systematic review and meta-analysis aimed to investigate the outcomes of robotic versus laparoscopic surgery in patients requiring surgery for gastric GISTs. Methods: MEDLINE, EMBASE, and the Cochrane databases were searched from inception to September 4, 2023. Two independent reviewers conducted a systematic review of the literature to select all types of analytic studies comparing robotic versus laparoscopic surgery for GISTs and reporting intraoperative, postoperative, and/or pathological outcomes. Results: Overall, 4 retrospective studies were selected, including a total of 264 patients, specifically 111 (42%) in the robotic and 153 (58%) in the laparoscopic group. Robotic surgery was associated with longer operating time (+42.46 min; 95% confidence interval [CI]: 9.34, 75.58; P=0.01; I2: 85%) and reduced use of mechanical staplers (odds ratio [OR]: 0.05; 95%CI: 0.02, 0.11; P<0.00001; I2: 92%;) compared with laparoscopy. Although nonsignificant, conversion to open surgery was less frequently reported for robotic surgery (2.7%) than laparoscopy (5.2%) (OR: 0.59; 95%CI: 0.17, 2.03; P=0.4; I2: 0%). No difference was found for postoperative and oncological outcomes. Conclusions: Robotic surgery for gastric GISTs provides similar intraoperative, postoperative, and pathological outcomes to laparoscopy, despite longer operative time.

P-743 Laparoscopic radical excision of deep endometriosis: A positive impact of fertility outcome

Abstract Study question Does laparoscopic radical excision of deep endometriosis (DE) and endometrioma enucleation impact fertility outcomes and recurrence rates when compared to partial excision group? Summary answer In stage IV endometriosis, laparoscopic radical surgery significantly reduced the recurrence rates.The laparoscopic radical excision group tended to have a higher rate of natural conception. What is known already Endometriosis-related symptoms can be significantly improved through surgery, leading to better pregnancy rates. However, the optimal surgical approach can vary due to the complexity of DE. As a result, the recurrence of postoperative symptoms and pregnancy rates can differ due to the lack of randomized trials comparing primary surgery with first-line IVF studies. Thus, the ESHRE stated that there was no evidence supporting surgical management of DE prior to ART to improve pregnancy rates. However, the higher probability of postoperative spontaneous conception in patients undergoing radical resection versus conservative treatment of DE has been reported. Study design, size, duration study design: Retrospective cohort study in a tertiary referral center. size: 77 patients diagnosed with moderate or severe endometriosis and DE. duration: between 2018 and 2020 Participants/materials, setting, methods 77 patients underwent laparoscopic surgery for dysmenorrhea or infertility. Group 1 (n = 22) underwent conservative treatment through partial excision of endometriosis, indicating incomplete resection. Group 2 (n = 55) underwent radical excision of endometriosis and restoration of pelvic anatomy, indicating complete resection. We compared the baseline characteristics, peri-operative data, and follow-up outcomes, aiming to investigate whether radical excision yields superior results in terms of recurrence rate, re-intervention, and pregnancy rate. Main results and the role of chance Main results: Group 2 showed significantly higher surgical complexity with higher revised American Fertility Society classification scores, a greater proportion of severe endometriosis, multiple sites with endometriotic lesions, and longer operation times. Both groups had comparable pregnancy, recurrence, and re-intervention outcomes during the follow-up period of 28.2±16.4 months. While Group 2 tended to have a higher pregnancy rate (84% versus 67%, p = 0.56) and higher live birth rates (80% versus 67%, p = 0.59) when compared with group 1. In the population with stage IV endometriosis, group 2 significantly reduced the recurrence rates (9% versus 50%, p = 0.04) when compared to group 1. Conclusions: The group that underwent laparoscopic endometrioma enucleation with radical excision of extra-ovarian endometriosis exhibited significantly higher surgical complexity. In the population with stage IV endometriosis, radical surgery significantly reduced the recurrence rates. Surgical excision of ovarian endometriosis and extra-ovarian disease is advisable to limit disease progression and ensure complete symptom resolution. Additionally, the laparoscopic radical excision group tended to have a higher rate of natural conception, indicating potential benefits for fertility in patients who have moderate and severe endometriosis with DE. Limitations, reasons for caution The main limitations were the small sample size and recall bias. But, additionally, the limited cases in the research group might have influenced the results and restricted the extrapolation of related conclusions. Further studies with larger sample sizes are needed in the future. Wider implications of the findings We believe that a standardized surgical technique outlining a step-by-step method to delineate all important structures and address altered planes as in endometriosis, with the aim of restoring normal pelvic anatomy, ensures the avoidance of high complication rates, leads to lower recurrence rates and positive impact on fertility outcomes. Trial registration number not applicable

Does Marijuana Smoking Increase the Odds of Surgical Site Infection After Orthopaedic Surgery? A Retrospective Cohort Study

OBJECTIVES: Does marijuana smoking increase the risk of surgical site infection (SSI) after open reduction and internal fixation of fractures? METHODS: Design: Retrospective. Setting: Single academic level 1 trauma center in Southern California. Patient Selection Criteria: Adult patients who underwent open treatment for closed fractures between January 2009 and December 2021, had hardware placed, and had at least 6 months of postoperative follow-up. Outcome Measures and Comparisons: Risk factors associated with the development of SSI were compared between current inhalational marijuana users and nonmarijuana users. RESULTS: Complete data were available on 4802 patients after exclusion of 82 who did not have a complete variable set. At the time of surgery, 24% (1133 patients) were current users of marijuana. At the final follow-up (minimum 6 months), there was a 1.6% infection rate (75 patients). The average age of the infection-free group was 46.1 ± 23.1 years, and the average age of the SSI group was 47.0 ± 20.3 (P = 0.73) years. In total, 2703 patients (57%) in the infection-free group were male compared with 48 (64%) in the SSI group (P = 0.49). On multivariate analysis, longer operative times (OR 1.002 [95% CI, 1.001–1.004]), diabetic status (OR 2.084 [95% CI, 1.225–3.547]), and current tobacco use (OR 2.493 [95% CI, 1.514–4.106]) (P &lt; 0.01 for all) were associated with an increased risk of SSI; however, current marijuana use was not (OR 0.678 [95% CI, 0.228–2.013], P = 0.48). CONCLUSIONS: Tobacco use, diabetes, and longer operative times were associated with the development of SSI after open reduction and internal fixation of fractures; however, marijuana smoking was not shown to be associated with the development of SSI. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A comparative cohort study of surgical approaches for adult spinal deformity at a minimum 2-year follow-up.

This study was a retrospective multi-center comparative cohort study. A retrospective institutional database of operative adult spinal deformity patients was utilized. All fusions > 5 vertebral levels and including the sacrum/pelvis were eligible for inclusion. Revisions, 3 column osteotomies, and patients with < 2-year clinical follow-up were excluded. Patients were separated into 3 groups based on surgical approach: 1) posterior spinal fusion without interbody (PSF), 2) PSF with interbody (PSF-IB), and 3) anteroposterior (AP) fusion (anterior lumbar interbody fusion or lateral lumbar interbody fusion with posterior screw fixation). Intraoperative, radiographic, and clinical outcomes, as well as complications, were compared between groups with ANOVA and χ2 tests. One-hundred and thirty-eight patients were included for study (PSF, n = 37; PSF-IB, n = 44; AP, n = 57). Intraoperatively, estimated blood loss was similar between groups (p = 0.171). However, the AP group had longer operative times (547.5min) compared to PSF (385.1) and PSF-IB (370.7) (p < 0.001). Additionally, fusion length was shorter in PSF-IB (11.4) compared to AP (13.6) and PSF (12.9) (p = 0.004). There were no differences between the groups in terms of change in alignment from preoperative to 2years postoperative. There were no differences in clinical outcomes. While postoperative complications were largely similar between groups, operative complications were higher in the AP group (31.6%) compared to the PSF (5.4%) and PSF-IB (9.1) groups (p < 0.001). While there were differences in intraoperative outcomes (operative time and fusion length), there were no differences in postoperative clinical or radiographic outcomes. AP fusion was associated with a higher rate of operative complications.

Additional Procedures at the Time of Total Ankle Replacement Do Not Increase Risk of Short-term Complications: A Matched Cohort Analysis.

This retrospective cohort study compared short-term complication rates following total ankle arthroplasty (TAA), alone or with concomitant procedures. Secondary independent risk factors were also examined as they related to postoperative outcomes. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology (CPT) codes to identify patients who underwent TAA (27702) between 2010 to 2021. Patients were divided into cohorts based on the presence or absence of ancillary procedures. Propensity score matching was employed to account for demographic differences, and statistical analyses were performed to compare short-term complication rates between matched cohorts. A total of 2225 patients were identified, with 1432 (64.4%) receiving TAA alone and 793 (35.6%) with ancillary procedure(s). After matching, 793 patients were included in each cohort. The ancillary cohort had longer operative times (P < .001) and length of hospital stay (LOS) (P < 0.001). Rates for extended LOS were significantly higher in the ancillary cohort than in the simple cohort (P = .01). No other complications varied significantly between cohorts, including the incidence of any adverse event (AAE). American Society of Anesthesiologists classification of 4 was found to be an independent risk factor for development of AAE (odds ratio [OR] = 1.091, P = .04). Matched subgroup analysis excluding tendon lengthening as a concomitant procedure found that the ancillary cohort still had longer operative time (P < .001) and LOS (P < .05) than patients undergoing simple TAA. Without significant difference in rates of AAE other than extended LOS, the relative safety of ancillary TAA appears similar to that of TAA alone. Such knowledge can help inform surgical decision-making and assuage safety concerns for patients requiring additional corrective procedures at the time of TAA. Level III, retrospective comparative study.

Comparison between mini-percutaneous nephrolithotomy and retrograde intra renal surgery for the management of lower calyceal calculi of size less than 1.5 cm : Our institutional experience

Background: The treatment of lower calyceal calculi with a size &lt;1.5 cm remains a subject of debate. Mini-percutaneous nephrolithotomy (Mini PCNL) and retrograde intrarenal surgery (RIRS) are both effective options, but there is a need for comparative analysis to determine the optimal approach. Mini-perc has the advantage of direct visualization and efficient fragmentation and clearance, while RIRS is a minimally invasive technique with excellent visualization and minimal morbidity. Aims and Objectives: This study aims to evaluate and compare the efficacy, safety, and outcomes of mini-perc PCNL and RIRS in the management of lower calyceal calculi. Materials and Methods: This retrospective comparative cohort study included a total of 72 patients with lower calyceal calculi &lt;1.5 cm. Thirty-six patients underwent mini-perc, and 36 patients underwent RIRS. Results: No significant differences were observed in patient demographic characteristics, stone size, or stone location between the mini-perc and RIRS groups. The mini-perc group had a significantly higher stone-free rate (SFR) (94.4%) compared to the RIRS group (86.1%) (P&lt;0.05). The mini-perc technique had a higher success rate in first-session stone clearance (88.9%) compared to RIRS (77.8%) (P&lt;0.05). The mini-perc group had a longer operative time, higher estimated blood loss, and a longer post-operative hospital stay compared to the RIRS group (P&lt;0.05). Conclusion: Both mini-perc and RIRS techniques are effective for managing lower calyceal calculi &lt;1.5 cm. Mini-perc offers a SFR and a better success rate in first-session stone clearance compared to RIRS. However, mini-perc procedures are associated with longer operative time, higher estimated blood loss, and a longer post-operative hospital stay.

Splenic flexure mobilization in left-sided colonic and rectal resections: A meta-analysis and meta-regression of factors associated with anastomotic leak and complications.

Splenic flexure mobilization (SFM) is commonly performed during left-sided colon and rectal resections. The aim of the present systematic review was to assess the outcomes of SFM in left-sided colon and rectal resections and the risk factors for complications and anastomotic leak (AL). This study was a PRISMA-compliant systematic review. PubMed, Scopus and Web of Science were searched for studies that assessed the outcomes of sigmoid and rectal resections with or without SFM. The primary outcomes were AL and total complications, and the secondary outcomes were individual complications, operating time, conversion to open surgery, length ofhospital stay (LOS) and pathological and oncological outcomes. Nineteen studies including data on 81 116 patients (49.1% male) were reviewed. SFM was undertaken in 40.7% of patients. SFM was associated with a longer operating time (weighted mean difference 24.50, 95% CI 14.47-34.52, p < 0.0001) and higher odds of AL (OR 1.19, 95% CI 1.06-1.33, p = 0.002). Both groups had similar odds of total complications, splenic injury, anastomotic stricture, conversion to open surgery, (LOS), local recurrence, and overall survival. A secondary analysis of rectal cancer cases only showed similar outcomes for SFM and the control group. SFM was associated with a longer operating time and higher odds of AL, yet a similar likelihood of total complications, splenic injury, anastomotic stricture, conversion to open surgery, LOS, local recurrence, and overall survival. These conclusions must be cautiously interpreted considering the numerous study limitations. SFM may have only been selectively undertaken in cases in which anastomotic tension was suspected. Therefore, the suboptimal anastomoses may have been the reason for SFM rather than the SFM being causative of the anastomotic insufficiencies.

Clinical Analysis of Different Anesthesia and Analgesia Methods for Patients Undergoing Uniportal Video-assisted Lung Surgery

PurposeA comparison of three intra-op modalities to determine a best and convenient pain control for uniportal lung surgery. This study compared general anesthesia with serratus plane block, general anesthesia with epidural and general anesthesia alone to look at post-operative pain scores in patients. Methods80 patients were enrolled and statistically analyzed. There were three interventions studied: Group S: General Anesthesia with Serratus Plane Block, Group E: General Anesthesia with thoracic epidural, Group G: General Anesthesia only. Outcome measures compared among 3 groups included demographic characters; surgical types; anesthesia and operative time; postoperative pain scores; vitals sign; morphine consumption at 0, 2, 6 hours, day1 and day2 postoperative; incidence of opioid-related adverse events and chronic pain; LOS hospital and overall expenses.The numerical rating scale was used to assess the degree of pain on the first and second postoperative days. Postoperative morphine consumption, incidence of opioid-related side effects, LOS(length of stay) hospital and overall hospital expenses were documented, as well as incidence of chronic postoperative pain. FindingsThere was no difference in incidence of opioid-related adverse events and chronic pain, LOS hospital and overall expenses among 3 groups. After investigating factors that may influence LOS hospital and overall expenses, the multivariable analysis indicated only longer operative time was associated with longer hospital stay and more hospital expenses. ImplicationsThis prospective study demonstrates that general anesthesia alone offers an easy and efficient approach resulting in similar postoperative pain scores and morphine consumption compared with nerve block and epidural. Longer operative time was associated with longer hospital stay and more hospital expenses.

Predictive value of leukocyte derived markers for postoperative delirium after cardiac valve surgery

To explore the predictive value of leukocyte derived markers for postoperative delirium (POD) in patients undergoing cardiac valve surgery. A prospective cohort study was conducted. The patients who underwent cardiac valve surgery admitted to Beijing Anzhen Hospital of Capital Medical University from October 2021 to March 2023 were enrolled. The demographic, baseline and perioperative data were collected, and the neutrophil to lymphocyte ratio (NLR) and platelet to white blood cell ratio (PWR) were calculated before operation and within 24 hours after operation. Delirium assessment was conducted twice a day for patients within 1-5 days after surgery or discharged within 5 days. According to the evaluation results, the patients were divided into delirium group and non-delirium group. The clinical indexes between the two groups were compared. Multivariate Logistic regression analysis was used to screen the independent risk factors of POD, and the POD predictive model was constructed. The predictive value of POD predictive model was evaluated by receiver operator characteristic curve (ROC curve). A total of 235 patients were enrolled in the analysis, of which 83 patients had POD (35.32%) and 152 patients did not have POD (64.68%). Compared with the non-delirious group, the patients in the delirious group had higher Charlson comorbidity index (CCI) score and lower mini-mental state examination (MMSE) score. In terms of perioperative data, compared with the non-delirium group, the patients in the delirium group had longer operative time, duration of cardiopulmonary bypass, length of intensive care unit (ICU) stay, duration of mechanical ventilation, and postoperative hospital stay, higher incidence of perioperative atrial fibrillation, and lower discharge life score. In terms of leukocyte derived markers, NLR within 24 hours after surgery in both groups were significantly higher than those before surgery, and PWR were significantly lower than those before surgery. The NLR within 24 hours after surgery, PWR difference and NLR difference in the delirium group were significantly higher than those in the non-delirium group. Multivariate Logistic regression analysis showed that CCI score [odds ratio (OR) = 1.394, 95% confidence interval (95%CI) was 1.038-1.872, P = 0.027], perioperative atrial fibrillation (OR = 3.697, 95%CI was 1.711-7.990, P < 0.001), duration of cardiopulmonary bypass (OR = 1.008, 95%CI was 1.002-1.015, P = 0.016), length of ICU stay (OR = 1.006, 95%CI was 1.002-1.010, P = 0.002), NLR difference (OR = 1.029, 95%CI was 1.009-1.050, P = 0.005) and PWR difference (OR = 1.044, 95%CI was 1.009-1.080, P = 0.013) were independently correlated with POD. POD predictive model was constructed by multivariate Logistic regression analysis result: POD predictive model index = -4.970+0.336×CCI score+1.317×perioperative atrial fibrillation+0.009×duration of cardiopulmonary bypass+0.006×length of ICU stay+0.030×NLR difference+0.044×PWR difference. ROC curve analysis showed that the area under the ROC curve (AUC) of NLR difference for predicting POD was 0.659 (95%CI was 0.583-0.735), the optimal critical value was 16.62, the sensitivity was 60.2%, and the specificity was 70.4% (P < 0.05). The AUC of PWR difference for predicting POD was 0.608 (95%CI was 0.528-0.688), the optimal critical value was 25.68, the sensitivity was 51.8%, and the specificity was 75.7% (P < 0.05). The AUC of POD predictive model for predicting POD was 0.805 (95%CI was 0.745-0.865), the optimal critical value was 0.39, the sensitivity was 74.7%, and the specificity was 79.6% (P < 0.05). The differences of NLR and PWR are independently related to POD, which has potential value in predicting POD after cardiac valve surgery.

Evaluating Access and Outcomes in Gender-affirming Breast Augmentation: A Comparative Study of a County Hospital and an Academic Center.

Research on the diverse patient population undergoing gender-affirming breast augmentation remains scarce. We compared patients undergoing this procedure at San Francisco General Hospital (ZSFG), a county hospital, and the University of California, San Francisco (UCSF), an academic medical center. This was a retrospective cohort study of patients who underwent primary gender-affirming breast augmentation at ZSFG (August 2019 to June 2023) and UCSF (March 2015 to June 2023). Differences in sociodemographic characteristics, surgical access, and outcomes between sites were assessed. Of 195 patients, 122 patients had surgery at UCSF and 73 patients at ZSFG. ZSFG patients were more likely to be unstably housed (P < 0.001), Spanish-speaking (P = 0.001), and to have obesity (P = 0.011) and HIV (P = 0.004). Patients at ZSFG took hormones for longer before surgical consultation (P < 0.001) but had shorter referral-to-surgery intervals (P = 0.024). Patients at ZSFG more frequently underwent a subglandular approach (P = 0.003) with longer operative times (P < 0.001). Major surgical complications were uncommon (2.1%) with no differences between sites. Aesthetically, implant malposition/rotation occurred more often in patients at UCSF (P = 0.031), but revision rates were similar at both sites. Patients at UCSF had longer follow-up periods (P = 0.008). County hospital patients seeking gender-affirming breast augmentation have distinct sociodemographic profiles and more comorbidities than academic medical center patients. County patients might experience greater barriers that delay surgical eligibility, such as stable housing. Nevertheless, this procedure can be safely and effectively performed in both patient populations.

Rotator Cuff Repair: Racial Disparities in Operative Time and Utilization of Arthroscopic Techniques.

Background Racial disparities are prevalentwithin the field of orthopedics and include the utilization of varying resources as well as outcomes following surgery. This study investigates racial differences between Black and White patients in the surgical treatment of rotator cuff repair (RCR) and 30-day postoperative complications following RCR. Materials and methods Data were drawn from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to create a study population consisting of Black and White patients who underwent RCR between 2015 and 2019. A bivariate analysis was conducted to compare patient demographics and comorbidities. Multivariate logistic regression, controlling for all significantly linked patient demographics and comorbidities, was performed to examine the relationships between Black race and complications. Results Our analysis included 32,073 patients, of whom 3,318 (10.3%) were Black and 28,755 (89.7%) were White. The female gender, younger age groups, greater BMI groups, ASA classification ≥3, cigarette use, and comorbid congestive heart failure (CHF), diabetes, and hypertension were all significantly associated with patients who identified as Black. We found no significant differences in 30-day postoperative complications between Black and White patients. Furthermore, Black patients were found to be independently associated with a greater likelihood of undergoing arthroscopic RCR versus open RCR, as well as experiencing a longer total operation time of ≥80 minutes. Conclusions We report no differences in 30-day postoperative complications between Black and White patients undergoing RCR between 2015 and 2019. However, Black race was independently associated with higher rates of arthroscopic RCR and longer operative times.

Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure

BackgroundThe Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution. MethodsThis retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications. ResultsWe identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores. ConclusionsOver six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience. Level of EvidenceLevel III – Retrospective comparative study.