Low-risk Surgery Research Articles

Optimal Timing for Postanesthesia Care Unit Discharge Using Physiological-Based Criteria in In-Patients Undergoing Low-Risk Surgery with General Anesthesia: A Prospective Observational Study

Objective: All postanesthesia patients must be monitored in the postanesthesia care unit (PACU) until they meet PACU discharge protocols. These included both physiological-based discharge (PBD) criteria and time-based discharge (TBD) criteria. The efficacy of using only PBD criteria to determine PACU discharge remains unclear. Therefore, this study aimed to determine the optimal timing for PACU discharge using PBD criteria alone for in-hospital patients undergoing low-risk surgeries. Material and Methods: This was a prospective observational study, involving 532 patients who had undergone elective low-risk surgery under general anesthesia (GA). At the PACU, the following data points were recorded: patient demographics, anesthesia and surgical data, the time required to meet PBD criteria, the actual PACU discharge time, complications during PACU admission, and causes of delayed PACU discharge. This study analyzed the comparison between the average time to meet PBD criteria and the ‘actual’ PACU discharge time. Results: A total of 532 patients admitted to the PACU were enrolled in this study. The mean PBD time was 12.6± 8.4 minutes, and the mean actual PACU time was 65.1±15.5 minutes: a difference that was statically significant [mean difference 52.5 (51.1, 54.0) minutes, p-value<0.001]. No severe complications were observed. Severe pain was the most recorded complication during PACU admission. The highest cause of delayed PACU discharge was the unavailability of hospital patient transporters. Conclusion: The PACU discharge time for in-hospital patients undergoing low-risk surgery under GA, based on PBD criteria, was significantly shorter than that based on TBD criteria; additionally, no severe complications were reported.

Effects of intracuff and intravenous lignocaine on recovery from anaesthesia after thyroid surgery. A single-centre randomised double-blind placebo-controlled trial (The IOLANT study)

Background and Aims: Despite evidence that local intracuff alkalinised lignocaine may reduce the incidence of exaggerated laryngeal reflexes after thyroid surgery, its effects on the quality of recovery (QoR) from anaesthesia remain unknown. This study aimed to test if local intracuff alkalinised lignocaine improves the QoR from anaesthesia after thyroid surgery compared to placebo. Methods: Patients over 45 years old scheduled for thyroid surgery with electromyographic monitoring under general anaesthesia were enroled in a randomised, single-centre, double-blind, placebo-controlled trial. They were randomised into three groups (1:1:1 ratio): intravenous lignocaine (IVL), topical and intracuff lignocaine (TL), and placebo. The sample size was initially set at 231, but the study was terminated early after an interim analysis of 110 patients showed no significant difference between groups. The primary outcome was the QoR-40 score 24 hours post-surgery. Secondary outcomes included rates of arterial hypotension, coughing during emergence, bispectral index (BIS) values, and electromyographic monitoring characteristics. Results: An interim analysis after 110 patients showed mean QoR-40 scores of 185 (standard deviation(SD): 11.4) (placebo), 186.1 (SD: 13.6) (IVL), and 185.1 (SD: 14.3) (TL) (P = 0.662). Mean differences were 1.1 (IVL vs placebo, 95%CI: −5.03, 7.15, z = 0.347) and 0.1 (TL vs placebo, 95%CI: −6.02, 6.23, z = 0.035). The study was stopped due to lack of effectiveness as the superiority of IVL and TL was not demonstrated. No differences were found in secondary outcomes. Conclusion: Neither IVL nor TL improved the QoR from anaesthesia and did not affect electromyographic monitoring in low-risk thyroid surgery.

Gastric Pouch Resizing for Recurrent Weight Gain After Roux-en-Y Gastric Bypass-Does It Have Its Rational?

The most effective treatment for obesity and associated comorbidities is metabolic-bariatric surgery (MBS). Nevertheless, recurrent weight gain is reported in up to 40% of patients after Roux-en-Y gastric bypass (RYGB), eventually with a recurrence of obesity-associated comorbidities. Gastric pouch resizing (GPR) is performed as a low-risk secondary surgery to cease weight regain. We herewith analyzed the effect of GPR after primary RYGB on long-term weight loss, course of comorbidities, safety, and patient satisfaction. Forty-eight patients undergoing GPR between 2016 and 2020 at the University Hospital of Zurich were included. Data were collected from a prospective database. GPR was performed laparoscopically and included a resection of the enlarged gastric pouch and a redo of the gastrojejunostomy. Additionally, 37 patients participated in a survey to evaluate PROMs (patient-reported outcome measures). GPR followed RYGB after a mean time of 106.2 ± 45.5months at a mean BMI of 39 ± 5.4kg/m2. Mean follow-up was 55.9 ± 18.5months with a mean BMI 1- and 5-years postoperative of 37 ± 5.5kg/m2 and 35 ± 7.5kg/m2, respectively. Obesity-associated comorbidities were resolved in 53% of patients at follow-up (p < 0.05). Minor postoperative complications occurred in 12.5% while major complications occurred in 10.4% of patients. The PROMs showed high levels of satisfaction after GPR. GPR for recurrent weight gain after primary RYGB is a safe procedure resulting in weight stabilization and resolution of obesity-associated comorbidities. It is thus a valuable surgical option in well-selected patients.

Perioperative outcomes in congenital heart disease: a review of clinical factors associated with prolonged ventilation and length of stay in four common CHD operations

ObjectivesPerioperative management strategies and outcomes for low-risk congenital heart disease (CHD) surgery vary between institutions. To date, no consensus exists on standardized management for pediatric patients undergoing cardiac surgery. This study seeks to benchmark the perioperative management of four common CHD lesions and explore clinical factors affecting postoperative outcomes. DesignA retrospective review of CHD procedures performed 2015-2020. SettingThe study was conducted at a single academic tertiary pediatric hospital. ParticipantsAll patients presenting for repair of ventricular septal defects (VSD), complete atrioventricular canal defects (CAVC), tetralogy of Fallot (TOF) and transposition of the great arteries (TGA) were reviewed. InterventionsDemographic and clinical data were collected; clinical outcomes were defined as postoperative length of ventilation (LOV) and hospital length of stay (LOS), divided into reference and prolonged course groups analyzed for variables associated with differences in outcomes. Measurements and Main Results931 patients were selected for review. Prolonged LOV and LOS in all cohorts were associated with longer operative, cardiopulmonary bypass and cross-clamp times; higher intraoperative requirements for inotropic support; more blood transfusions and higher opioid administration; lower pH pre-operatively and higher lactic acid post-operatively. Worse outcomes were associated with younger age in VSD, older age in TGA and lower weight in TOF and TGA. Worse outcomes were also associated with higher preoperative hematocrit in VSD and TOF and elevated preoperative blood glucose in VSD and TGA. ConclusionsA better understanding of clinical factors affecting outcomes may facilitate streamlining perioperative management strategies for pediatric patients undergoing low-risk cardiac surgery.

Incidence, characteristics, and outcome of noncardiac surgery following transcatheter aortic valve implantation.

Planning noncardiac surgery after transcatheter aortic valve implantation (TAVI) is challenging. We evaluated the incidence, characteristics, and outcome of noncardiac surgeries in patients who underwent TAVI. We retrieved data from the Prospective Segeberg TAVI registry of all patients who received TAVI between 2007 and 2020. Type, timing, urgency, and risk of noncardiac surgery were assessed. We evaluated the patients' clinical outcomes within 30days following noncardiac surgery that included death, myocardial infarction, bleeding, stroke, and acute heart failure. A composite outcome of all adverse events was proposed to independently predict 30day adverse events. Among 1602 patients, 104 patients (mean age, 79.9 ± 7.14 years; 61 (58.7%) females) underwent 148 noncardiac surgeries after TAVI. More than half of the noncardiac surgeries were considered elective (n = 84, 56.7%). Procedures were categorized into low-risk (n = 27, 18.2%), intermediate-risk (n = 102, 68.9%), and high-risk (n = 19, 12.8%) surgery. The composite outcome of adverse events occurred after 57 noncardiac surgeries (38.5% of all procedures) and after more than half of the surgeries in the high-risk group (n = 11, 57.9%). Major or life-threatening bleeding occurred in 24 noncardiac surgeries (19.1%) and was more frequent in high-risk surgeries than in low- and intermediate-risk surgeries (36.8%, p < 0.047). High-risk category of surgery was independently associated with increased risk of the composite outcome (adjusted OR, 3.99; 95% CI 1.12-14.23; p = 0.033). Noncardiac surgery after TAVI was performed in 6.5% patient of our study cohort. High-risk noncardiac surgeries were associated with increased risk of adverse events.

Independent factors for the development of vasoplegic syndrome in patients undergoing coronary artery bypass surgery.

Vasoplegic syndrome remains a common complication of cardiac surgery. It has serious implications for the healthcare system and individual patients, as it leads to rising healthcare costs and higher mortality. A better understanding of factors triggering vasoplegic syndrome is essential for the development of effective prevention strategies. We aimed to identify clinical characteristics and intraoperative parameters associated with the development of vasoplegic syndrome in coronary artery bypass graft surgery and the influence of vasoplegia on outcome. We retrospectively analyzed the data of all patients who underwent isolated coronary artery bypass graft surgery or coronary artery bypass graft surgery combined with atrial appendage occlusion, using the heart-lung machine at our institution from 04/2019 to 12/2020. Vasoplegic syndrome was defined as MAP ≤60 mmHg and norepinephrine equivalence dosage of ≥0.2 μg/kg/min with a central venous saturation ≥60% within 2 days from surgery. Of 647 patients included in this study, 72 (11.1%) developed vasoplegic syndrome. Patients experiencing vasoplegia had longer stay in ICU, more frequently underwent tracheostomy and suffered more often from pneumonia. The duration of extracorporeal circulation, intraoperative application of platelet concentrates and usage of cold crystalloid cardioplegia (Bretschneider) independently predicted development of vasoplegic syndrome. Even in relatively low-risk cardiac surgery, vasoplegic syndrome is a common complication and was associated with serious adverse effects. The use of warm blood cardioplegia (Calafiore) seems to be safer than cold crystalloid cardioplegia (Bretschneider) and might be preferable in patients that are vulnerable to the consequences of vasoplegic syndrome.

Pre-operative triAge proCedure to streaMline elective surgicAl patieNts (PACMAN) improves efficiency by selecting patients eligible for phone consultation: A retrospective cohort study.

Pre-operative screening is a high volume task consuming time and resource. Streamlining patient flow by gathering information in advance reduces costs, optimises resources and diminishes patient burden whilst maintaining safety of care. To evaluate whether 'Pre-operative triAge proCedure to streaMline elective surgicAl patieNts' (PACMAN) is able to improve pre-operative screening by selecting patients eligible for evaluation by telephone. A single-centre, retrospective, observational cohort analysis. A tertiary medical teaching hospital in 's-Hertogenbosch, The Netherlands. Adults scheduled for clinical interventions under procedural sedation and all types of elective medium or low risk surgery with anaesthetic guidance were eligible. Patients answered a questionnaire to calculate the PACMAN score. This score combined with risk factors related to surgery determines suitability for phone consultation (PhC) or the need for an in-person consultation (in-PC). Evaluation of standard care. Primary outcome was the reduction in number of in-PCs. Secondary outcomes included reliability of PACMAN, peri-operative patient outcomes and cost-effectiveness. Of 965 patients triaged by PACMAN, 705 (73.1%) were identified as suitable for a PhC. Of those, 688 (97.6%) were classified American Society of Anesthesiologists Physical Status (ASA-PS) I to II or III with stable comorbidities. Of the 260 in-PC patients, 47.4% were classified ASA-PS III with unstable comorbidities or ASA-PS IV. The overall incidence of unanticipated adverse peri-operative events was 1.3%. Finally, implementation of PACMAN led to a 20% increase in pre-operative department efficiency due to better deployment of personnel and resources. Implementation of PACMAN resulted in a 73.1% reduction in pre-operative in-PCs at our hospital. Given the increasing pressure on healthcare systems globally, we suggest developing further optimisation and integration of smart triage solutions into the pre-operative process. ClinicalTrials.gov Identifier: NCT06148701.

Nurse Practitioner and Physician Assistant-led Cardiovascular Surgery Postoperative Intensive Care Unit Staffing Model.

To determine whether a nurse practitioner and physician assistant (NP/PA)-led rapid staffing. Model in the cardiac surgical intensive care unit (ICU) can optimize resource utilization without compromising safety or increasing hospital length of stay (LoS). Retrospective observational cohort study comparing before-and-after implementation of an NP/PA-led rapid recovery pathway. A large tertiary referral academic cardiac surgery ICU. There were 116 patients in the prerapid recovery cohort and 153 in the postimplementation rapid recovery phase. Low-risk cardiac surgery patients were selected for postoperative care by an NP/PA-led ICU staffing model. Mean hospital LoS in the prerapid recovery cohort was 5.7 days compared to 5.2 days in the rapid recovery pathway cohort (P = .02). Thirty-day hospital readmission in the prerapid recovery pathway cohort was 7.8% compared with 2.0% in the rapid recovery cohort (P = .04). The ICU readmission rate for prerapid recovery cohort was 4.3%, while the rapid recovery percentage was 2.0% (P = .30). Overall, implementation of an NP/PA-led postcardiac surgical ICU team (rapid recovery pathway) was associated with similar ICU LoS, hospital LoS, ICU readmission rates, 30-day readmission rates, and no significant signal of increased adverse events or safety concerns.

Opportunities to improve the diagnosis and treatment of primary hyperparathyroidism: retrospective cohort study.

Although primary hyperparathyroidism (PHPT) is readily diagnosed biochemically and can be cured with low-risk surgery, it is often underrecognized and undertreated. Our objectives were to characterize, within our health system, how often patients with hypercalcemia were evaluated for PHPT and how often patients with PHPT underwent definitive treatment with parathyroidectomy. Ambulatory patients aged 18 years or older seen at our health system between January 2018 and June 2023 with chronic hypercalcemia were identified from the medical record. After excluding causes of secondary hyperparathyroidism, the proportion of patients with parathyroid hormone (PTH) tests was calculated. Among patients with biochemical evidence of PHPT, the proportion of patients who underwent parathyroidectomy was calculated. Multivariable logistic regression was used to identify factors associated with an evaluation for PHPT and, separately, with parathyroidectomy. Of 7,675 patients with chronic hypercalcemia, 3,323 (43.3%) had a PTH test obtained within 6 months. An age between 40-49 vs. <30 years [(odds ratio (OR) =3.2; 95% confidence interval (CI): 1.8-5.6; P<0.001], a serum calcium level between 11.6-12.0 vs. <11.0 mg/dL (OR =3.9; 95% CI: 3.2-4.7; P<0.001), and osteoporosis (OR =3.1; 95% CI: 2.7-3.5; P<0.001) were associated with an evaluation for PHPT. Among those with PTH levels, 1,327 (39.9%) had PHPT but only 916 (69.0%) were recognized. Three hundred and forty-five (26.0%) patients with PHPT underwent parathyroidectomy. An increasing number of surgical indications was associated with parathyroidectomy (P<0.001), though overall rates remained less than 40%. Among indications for surgery, including age and serum total calcium level, only osteoporosis was associated with parathyroidectomy (OR =2.0; 95% CI: 1.4-2.8; P<0.001). In this study, more than half of patients with chronic hypercalcemia were not evaluated for PHPT. Among patients with biochemical evidence of PHPT, one-third were unrecognized and only one-in-four received curative treatment. Opportunities to improve the management of PHPT exist within our large integrated health system.

The use of minimally invasive surgical techniques ın pediatric patients with partial anomalous pulmonary venous return

Aim The use of minimally invasive procedures in low-risk congenital heart surgeries has been increasing recently. Compared to traditional median sternotomy, minimally invasive techniques offer better cosmetic results and provide more satisfaction to both the patient and their parents. Partial anomalous pulmonary venous return (PAPVR) can be safely repaired using these techniques. Material and Metods The perioperative data of right- sided PAPVR patients who were operated on using minimally invasive approaches in our clinic between March 2019 and January 2023 were reviewed retrospectively. The perioperative data of the patients' including , type of surgery , cardiopulmonary bypass time, cross-clamp time, postoperative cardiac rhythm, total operation time, total drainage, total intensive care unit time, and total hospital stay time were obtained. The results were compared with the data in the current literature. Results During the study period, 14 patients underwent surgical repair. Five (36%) of them were female and nine (64%) were male. Patients undergoing right infraaxillary vertical thoracotomy (RIAVT) and right anterolateral thoracotomy (RALT) had mean ages of 48±26.6 and 42±18.2 month, respectively. High venosum type atrial septal defect (ASD) was detected in 12 (85.7%) of the patients. The most frequently used surgical treatment was the double patch technique which was used in 12 patients (85.7%). This was followed by single patch repair with one patient (7.1 %). The Warden procedure was used in one patient (7.1%) who was operated on with the RIAVT technique. Patients’ cross-clamp, cardiopulmonary bypass (CPB), and total operation times were comparable to those reported in the medical literature. Conclusion RIAVT and RALT are two of the oftenly used minimally invasive surgical techniques in congenital heart surgery. After gaining sufficient experience, both of these methods can be safely applied to PAPVR repair.

Anaesthesiologists’ guideline adherence in pre-operative evaluation: a retrospective observational study

BackgroundSurveys suggest a low level of implementation of clinical guidelines, although they are intended to improve the quality of treatment and patient safety. Which guideline recommendations are not followed and why has yet to be analysed. In this study, we investigate the proportion of European and national guidelines followed in the area of pre-operative anaesthetic evaluation prior to non-cardiac surgery.MethodsWe conducted this monocentric retrospective observational study at a German university hospital with the help of software that logically links guidelines in such a way that individualised recommendations can be derived from a patient's data. We included routine logs of 2003 patients who visited our pre-anaesthesia outpatient clinic between June 2018 and June 2020 and compared the actual conducted pre-operative examinations with the recommendations issued by the software. We descriptively analysed the data for examinations not performed that would have been recommended by the guidelines and examinations that were performed even though they were not covered by a guideline recommendation. The guidelines examined in this study are the 2018 ESAIC guidelines for pre-operative evaluation of adults undergoing elective non-cardiac surgery, the 2014 ESC/ESA guidelines on non-cardiac surgery and the German recommendations on pre-operative evaluation on non-cardiothoracic surgery from the year 2017.ResultsPerformed ECG (78.1%) and cardiac stress imaging tests (86.1%) indicated the highest guideline adherence. Greater adherence rates were associated with a higher ASA score (ASA I: 23.7%, ASA II: 41.1%, ASA III: 51.8%, ASA IV: 65.8%, P < 0.001), lower BMI and age > 65 years. Adherence rates in high-risk surgery (60.5%) were greater than in intermediate (46.5%) or low-risk (44.6%) surgery (P < 0.001). 67.2% of technical and laboratory tests performed preoperatively were not covered by a guideline recommendation.ConclusionsGuideline adherence in pre-operative evaluation leaves room for improvement. Many performed pre-operative examinations, especially laboratory tests, are not recommended by the guidelines and may cause unnecessary costs. The reasons for guidelines not being followed may be the complexity of guidelines and organisational issues. A software-based decision support tool may be helpful.Trial registrationClinicalTrials.gov ID NCT04843202.

Clinical features and outcomes of young patients with low-grade non-rhabdomyosarcoma soft tissue sarcomas treated with a risk-based strategy: A report from Children's Oncology Group study ARST0332.

In retrospective analyses, the Pediatric Oncology Group [POG) and the Federation National des Centres de Lutte Contre le Cancer (FNCLCC) histologic grade predict outcome in pediatric non-rhabdomyosarcoma soft tissue sarcoma (NRSTS), but prospective data on grading, clinical features, and outcomes of low-grade NRSTS are limited. We analyzed patients less than 30years of age enrolled on Children's Oncology Group (COG) study ARST0332 (NCT00346164) with POG grade 1 or 2 NRSTS. Low-risk patients were treated with surgery alone. Intermediate-/high-risk patients received ifosfamide/doxorubicin and radiotherapy, with definitive resection either before or after 12weeks of chemoradiotherapy. Estimated 5-year event-free and overall survival were 90% and 100% low risk (n=80), 55% and 78% intermediate risk (n=15), and 25% and 25% high risk (n=4). In low-risk patients, only local recurrence was seen in 10%; none with margins greater than 1mm recurred locally. Sixteen of 17 intermediate-/high-risk patients who completed neoadjuvant chemoradiotherapy underwent gross total tumor resection, 80% with negative margins. Intermediate-/high-risk group events included one local and seven metastatic recurrences. Had the FNCLCC grading system been used to direct treatment, 29% of low-risk (surgery alone) patients would have received radiotherapy ± chemotherapy. Most low-risk patients with completely resected POG low-grade NRSTS are successfully treated with surgery alone, and surgical margins greater than 1mm may be sufficient to prevent local recurrence. Patients with intermediate- and high-risk low-grade NRSTS have outcomes similar to patients with high-grade histology, and require more effective therapies. Use of the current FNCLCC grading system may result in overtreatment of low-risk NRSTS curable with surgery alone.

Antibiotic impregnated catheters and intrathecal antibiotics for CSF shunt infection prevention in children undergoing low-risk CSF shunt surgery

BackgroundCerebrospinal fluid (CSF) shunts allow children with hydrocephalus to survive and avoid brain injury (J Neurosurg 107:345-57, 2007; Childs Nerv Syst 12:192-9, 1996). The Hydrocephalus Clinical Research Network implemented non-randomized quality improvement protocols that were shown to decrease infection rates compared to pre-operative prophylactic intravenous antibiotics alone (standard care): initially with intrathecal (IT) antibiotics between 2007–2009 (J Neurosurg Pediatr 8:22-9, 2011), followed by antibiotic impregnated catheters (AIC) in 2012–2013 (J Neurosurg Pediatr 17:391-6, 2016). No large scale studies have compared infection prevention between the techniques in children. Our objectives were to compare the risk of infection following the use of IT antibiotics, AIC, and standard care during low-risk CSF shunt surgery (i.e., initial CSF shunt placement and revisions) in children.MethodsA retrospective observational cohort study at 6 tertiary care children’s hospitals was conducted using Pediatric Health Information System + (PHIS +) data augmented with manual chart review. The study population included children ≤ 18 years who underwent initial shunt placement between 01/2007 and 12/2012. Infection and subsequent CSF shunt surgery data were collected through 12/2015. Propensity score adjustment for regression analysis was developed based on site, procedure type, and year; surgeon was treated as a random effect.ResultsA total of 1723 children underwent initial shunt placement between 2007–2012, with 1371 subsequent shunt revisions and 138 shunt infections. Propensity adjusted regression demonstrated no statistically significant difference in odds of shunt infection between IT antibiotics (OR 1.22, 95% CI 0.82–1.81, p = 0.3) and AICs (OR 0.91, 95% CI 0.56–1.49, p = 0.7) compared to standard care.ConclusionIn a large, observational multicenter cohort, IT antibiotics and AICs do not confer a statistically significant risk reduction compared to standard care for pediatric patients undergoing low-risk (i.e., initial or revision) shunt surgeries.

Near-infrared fluorescence-assisted superficial inguinal lymph-node excision for low-risk penile cancer.

Identification of superficial inguinal lymph nodes during low-risk penile cancer surgery using near-infrared (NIR) fluorescence to improve the accuracy of lymph-node dissection and reduce the incidence of missed micrometastases and complications. Thirty-two cases were selected, which were under the criteria of < T1, and no lymph-node metastasis was found with magnetic resonance imaging (MRI) detection. Two groups were randomly divided based on the fluorescence technique, the indocyanine green (ICG) group and the non-ICG group. In the ICG group, the ICG preparation was subcutaneously injected into the edge of the penile tumor 10min before surgery, and the near-infrared fluorescence imager was used for observation. After the lymph nodes were visualized, the superficial inguinal lymph nodes were removed first, and then, the penis surgery was performed. The non-ICG group underwent superficial inguinal lymph-node dissection and penile surgery. Among the 16 patients in the ICG group, we obtained 11 lymph-node specimens using grayscale values of images (4.13 ± 0.72 vs. 3.00 ± 0.82 P = 0.003) along with shorter postoperative healing time (7.31 ± 1.08 vs. 8.88 ± 2.43 P = 0.025), and less lymphatic leakage (0 vs. 5 P = 0.04) than the 16 patients in the non-ICG group. Out of 11, 3 lymph nodes that are excised were further grouped into fluorescent and non-fluorescent regions (G1/G2) and found to be metastasized. Near-infrared fluorescence-assisted superficial inguinal lymph-node dissection in penile carcinoma is accurate and effective, and could reduce surgical complications.

Perioperative outcome, long-term mortality and time trends in elderly patients undergoing low-, intermediate- or major non-cardiac surgery

BackgroundDecision-making whether older patients benefit from surgery can be a difficult task. This report investigates characteristics and outcomes of a large cohort of inpatients, aged 80 years and over, undergoing non-cardiac surgery.MethodsThis observational study was performed at a tertiary university medical centre in the Netherlands. Patients of 80 years or older undergoing elective or urgent surgery from January 2004 to June 2017 were included. Outcomes were length of stay, discharge destination, 30-day and long-term mortality. Patients were divided into low-, intermediate and high-risk surgery subgroups. Univariable and multivariable logistic regression were used to evaluate the association of risk factors and outcomes. Secondary outcomes were time trends, assessed with Mantel–Haenszel chi-square test.ResultsData of 8251 patients, undergoing 19,027 surgical interventions were collected from the patients’ medical record. 7032 primary procedures were suitable for analyses. Median LOS was 3 days in the low-risk group, compared to six in the intermediate- and ten in the high-risk group. Median LOS of the total cohort decreased from 5.8 days (IQR 1.9–14.5) in 2004–2007 to 4.6 days (IQR 1.9–9.0) in 2016–2017. Three quarters of patients were discharged to their home. Postoperative 30-day mortality in the low-risk group was 2.3%. In the overall population 30-day mortality was high and constant during the study period (6.7%, ranging from 4.2 to 8.4%).ConclusionPatients should not be withheld surgery solely based on their age. However, even for low-risk surgery, the mortality rate of more than 2% is substantial. Deciding whether older patients benefit from surgery should be based on the understanding of individual risks, patients’ wishes and a patient-centred plan.

A mixed-method study evaluating an innovative care model for rural patients undergoing outpatient breast surgery.

The Delta Oasis program was launched in New Brunswick in 2006 to offer patients from rural areas who were undergoing breast cancer surgery and their families 1 night of free accommodations and a postoperative consultation with an extramural nurse. We sought to investigate patient experiences with this program. This mixed-method retrospective study took place from 2020 to 2022 and compared the preoperative anxiety and quality of recovery of program participants and control patients who were discharged home over 100 km from hospital. We conducted 2 × 2 analysis of variance to evaluate the effects of intervention group and surgery type. We conducted semistructured interviews with intervention participants, which we then thematically analyzed. Two patient partners were engaged during data synthesis to support the interpretation of results. We included 34 patients who participated in the program and 18 control patients. No statistically significant differences were found between treatment groups in preoperative anxiety and quality of recovery, regardless of surgery type. Thematic analysis of interviews with 17 intervention participants revealed that they were highly satisfied with the program and that the experience helped reduce stress and discomfort related to their surgery. The Delta Oasis program is a cost-effective alternative to inpatient care after breast cancer surgery and is highly regarded by rural patients; expansion to other regions with the inclusion of additional low-risk surgeries could help address hospital capacity issues. This study contributes to our understanding of the patient experience with the Delta Oasis program and informs the development of similar programs elsewhere.

Fluids and body composition during anesthesia in children and adolescents: A pilot study

The purpose of this study is to evaluate the intracellular and extracellular volume before and after anesthesia in order to ascertain their variations and determine the potential utility of this information in optimizing intraoperative fluid administration practices. A bioimpedance spectroscopy device (body composition monitor, BCM) was used to measure total body fluid volume, extracellular volume, and intracellular volume. BCM measurements were performed before and after general anesthesia in unselected healthy children and adolescents visiting the Pediatric Institute of Southern Switzerland for low-risk surgical procedures hydrated with an isotonic solution. In 100 children and adolescents aged 7.0 (4.8–11) years (median and interquartile range), the average total body water increased perioperatively with a delta value of 182 (0–383) mL/m2 from pre- to postoperatively, as well as the extracellular water content, which had a similar increase with a delta value of 169 (19–307) mL/m2. The changes in total body water and extracellular water content significantly correlated with the amount of fluids administered. The intracellular water content did not significantly change. Conclusion: Intraoperative administration of isotonic solutions results in a significant fluid accumulation in low-risk schoolchildren during general anesthesia. The results suggest that children without major health problems undergoing short procedures do not need any perioperative intravenous fluid therapy, because they are allowed to take clear fluids up to 1 h prior anesthesia. In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy.What is Known:• Most children who undergo common surgical interventions or investigations requiring anesthesia are nowadays hydrated at a rate of 1700 mL/m2/day with an isotonic solution.• The use bioimpedance spectroscopy for the assessment of fluid status in healthy children has already been successfully validated.• The bioimpedance spectroscopy is already currently widely used in various nephrological settings to calculate fluid overload and determine patient’s optimal fluid status.What is New:• Routine intraoperative fluid administration results in a significant fluid accumulation during general anesthesia in low-risk surgical procedures.• This observation might be relevant for children and adolescents with conditions predisposing to fluid retention.• In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy.

Prevalence and Cost of Routine Preoperative Care for Low-Risk Cataract Surgery a Decade after Choosing Wisely

ObjectiveExamine the frequency and cost of procedural clearance tests and exams in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the US. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts post-surgical adverse events. DesignRetrospective health care claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania, USA. ParticipantsMembers aged ≥65 years who were continuously enrolled 6 months before and after having cataract surgery from 2018 through 2021 and had approved surgery claim(s). MethodsPreoperative exams or tests occurring in the 30 days prior to surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., CPT codes for blood panels and preprocedural ICD-10 CM codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling. Main Outcome MeasuresTotal costs, prevalence, and strength of association as indicated by odds ratios. ResultsUp to 42% of members having cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed either in isolation or along with clearance visit(s). The combined costs for the preoperative visits and tests were $4.3M (approximately $107-114 per impacted member). There was little difference in member characteristics between those receiving and not receiving either preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member’s care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two. ConclusionsRates of routine preoperative testing before cataract surgery have not declined despite intervening guidance from the Choosing Wisely campaign to reduce this utilization. Additionally, preoperative evaluations, many likely unnecessary, were very common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level.

Telehealth for general surgery postoperative care

BackgroundTelehealth utilization rapidly increased following the pandemic. However, it is not widely used in the Veteran surgical population. We sought to evaluate postoperative telehealth in patients undergoing general surgery. MethodsRetrospective review of Veterans undergoing general surgery at a level 1A VA Medical Center from June 2019 to September 2021. Exclusions were concomitant procedure(s), discharge with drains or non-absorbable sutures/staples, complication prior to discharge or pathology positive for malignancy. Results1075 patients underwent qualifying procedures, 124 (12 ​%) were excluded and 162 (17 ​%) did not have follow-up. 443 (56 ​%) patients followed-up in-person (56 ​%) vs 346 (44 ​%) via telehealth. Telehealth patients had a lower rate of complications, 6 ​% vs 12 ​%, p ​= ​0.013. There were no significant differences in ED visits, 30-day readmission, postoperative procedures or missed adverse events. ConclusionTelehealth follow-up after general surgical procedures is safe and effective. Postoperative telehealth care should be considered after low-risk general surgery procedures.

Long-term follow-up of patients with complex coronary artery disease treated with minimally invasive direct coronary artery bypass.

Patients with complex coronary artery disease (CAD) may benefit from surgical myocardial revascularization but weighing the risk of peri-operative complications against the expected merit is difficult. Minimally invasive direct artery bypass (MIDCAB) procedures are less invasive, provide the prognostic advantage of operative revascularization of the left anterior descending artery and may be integrated in hybrid strategies. Herein, the outcomes between patients with coronary 1-vessel disease (1-VD) and patients with 2-VD and 3-VD after MIDCAB procedures were compared in this single-center study. Between 1998 and 2018, 1363 patients underwent MIDCAB at the documented institution. 628 (46.1%) patients had 1-VD, 434 (31.9%) patients 2-VD and 300 (22.0%) patients suffered from 3-VD. Data of patients with 2-VD, and 3-VD were pooled as multi-VD (MVD). Patients with MVD were older (66.2 ± 10.9 vs. 62.9 ± 11.2 years; p < 0.001) and presented with a higher EuroScore II (2.10 [0.4; 34.2] vs. 1.2 [0.4; 12.1]; p < 0.001). Procedure time was longer in MVD patients (131.1 ± 50.3 min vs. 122.2 ± 34.5 min; p < 0.001). Post-operatively, MVD patients had a higher stroke rate (17 [2.3%] vs. 4 [0.6%]; p = 0.014). No difference in 30-day mortality was observed (12 [1.6%] vs. 4 [0.6%]; p = 0.128). Survival after 15 years was significantly lower in MVD patients (p < 0.01). Hybrid procedures were planned in 295 (40.2%) patients with MVD and realized in 183 (61.2%) cases. MVD patients with incomplete hybrid procedures had a significantly decreased long-term survival compared to cases with complete revascularization (p < 0.01). Minimally invasive direct coronary artery bypass procedures are low-risk surgical procedures. If hybrid procedures have been planned, completion of revascularization should be a major goal.