Postoperative Care Management Research Articles

Case report: Hybrid reconstruction of quadriceps function after sarcoma resection using a reinnervated free flap and tendon transfer

We describe a case of a leiomyosarcoma of the thigh, the resection of all the anterior muscular compartment, and the reanimation of knee extension, using a latissimus dorsi (LD) free flap and tendon transfer.Surgical technique and post-operative care management are described. Functional results, neuropathic pain, and range of motion (ROM) were assessed at 3 months and 12 months after discharge.A complete excision (R0) was carried out and rapid wound healing was obtained despite developing a seroma infection. The patient was able to walk without technical support nor limping at 3 months post-surgery. The patient was still in remission at 12 months follow-up, with Medical Research Council (MRC) scale assessed at 4/5 and ROM rated at 5-105°.In case of total quadriceps resection, knee extension reconstruction can be obtained with tendon transfers and reinnervated free muscular flaps. Combining these techniques could be a good strategy for rapid recovery, with optimal scarring and tissue coverage.

Use of a Postoperative Care Management Pathway Reduces the Incidence of Chylothorax Post-Fontan Palliation

Use of a Postoperative Care Management Pathway Reduces the Incidence of Chylothorax Post-Fontan Palliation

The efficacy of nursing interventions in preventing surgical site infections in patients undergoing surgery for congenital heart disease.

Surgical site infections (SSIs) pose significant risks to patients undergoing surgery for congenital heart disease (CHD), impacting recovery and increasing healthcare burdens. This study assesses the efficacy of targeted nursing interventions in reducing SSIs and enhancing wound healing in this vulnerable patient group. A prospective cohort study was conducted from January 2022 to August 2023 at a single institution, involving 120 paediatric patients divided into control (standard postoperative care) and observation (specialized nursing interventions) groups. Nursing interventions included preoperative disinfection, strategic use of antibiotics, rigorous aseptic techniques and comprehensive postoperative care. Inclusion criteria encompassed a broad spectrum of CHD patients, while exclusion criteria aimed to minimize confounders. The Institutional Ethics Committee approved the study protocols. Baseline characteristics were comparable across groups, ensuring homogeneity. The observation group exhibited significantly lower SSI rates (1.7%) compared to the control group (11.6%), with a notable increase in optimal wound healing (Grade A) outcomes (73.3% vs. 30%). The differences in healing efficacy and infection rates between the two groups were statistically significant, emphasizing the effectiveness of the targeted nursing interventions in enhancing postoperative recovery for paediatric patients undergoing CHD surgery. The study demonstrates that targeted nursing interventions can significantly reduce SSI rates and improve wound healing in paediatric CHD surgery patients. These results underscore the importance of specialized nursing care in postoperative management. Future research, including larger-scale clinical trials, is necessary to validate these findings and develop comprehensive nursing care guidelines for this population.

Postoperative Management of Osteochondral Lesions of the Ankle: A Survey Among German-Speaking Foot and Ankle Surgeons.

To assess the current treatment of osteochondral lesions of the ankle (OCLA) by German-speaking foot and ankle surgeons, focusing on the management of postoperative care and rehabilitation. A questionnaire was created by a panel of 4 experienced foot and ankle surgeons on behalf of the "Clinical Tissue Regeneration" (CTR) working group of the German Society of Orthopaedics and Trauma Surgery (DGOU), and distributed electronically to members of the CTR, participants of the German Cartilage Registry (Knorpelregister DGOU©), and members of 6 German-speaking orthopedics or sports medicine societies. Results were classified depending on the consensus within the answers (agreement ≥75% "strong tendency," 50%-74% "tendency," 25%-49% "weak tendency," <25% "no tendency"). A total of 60 participants returned the questionnaire. The main results are as follows: regarding the frequency of surgical procedures for OCLA, refixation of the fragment, retrograde drilling, and bone marrow stimulation with or without using a matrix were performed by at least 75% of the surgeons and was considered a strong tendency. There was a strong tendency to stabilize the ankle (76.7%) and perform corrective osteotomies (51.7%). In total, 75.5% and 75% of the surgeons performed bone marrow stimulation with and without using a matrix, respectively. Corrective osteotomy and ankle stabilization were performed in 64.5% and 65.2% cases, respectively. Most participants included published recommendations on postoperative rehabilitation and the return to sports activities in their postoperative management. The main surgical procedures were considered the most critical factor in influencing the postoperative management by 81% of the participants (strong tendency). Adjunct surgical procedures such as corrective osteotomy and stabilization of the ankle were considered important by 67.8% of the respondents (tendency). The management of OCLA varies among German-speaking foot and ankle surgeons. Therefore, guidelines remain essential to standardize the management of OCLA, to achieve improved and stable results. This survey will assist clinicians and patients with rehabilitation to return to sports after treating the ankle's cartilage injury.

Clinical Efficacy of Katutrikadya Churna in the Management of PostOperative Care in Bhagandara w.s.r to Fistula in Ano: A Comparative Study

In Ayurveda, there are eight branches. Ayurveda has eight branches. Because of its rapid action, use of surgical instruments (Yantra &amp; shastra), Kshar &amp; Agni, and inclusion of characteristics common to other branches, Shalyatantra is regarded as a notable branch. anushastra treats a wide range of illnesses (Para-surgical measures). The treatment of Bhagandara serves as the most significant, practical illustration of how anushastra, or ksharsutra, is used (Fistula-in-ano). Ayurveda classifies several disorders as “Mahagada” based on their severity and problematic behaviors. One of these is called Bhagandara (Fistula-inano). Many surgeons employ ksharsutra, with some somewhat successful outcomes. A lot of discomfort is experienced by the patient both during and after ksharsutra treatment. They are therefore afraid to change the kshar sutra later. In this study, katutrikadya churna with anupana of kulattha kwath, medications in compound formulation (30 patients), and Control group (30 Patients) were chosen. This group was given tab. diclofenac sodium as treatment. After meals, each group receives their particular medication twice daily. When the applied kshar-sutra has been changed with new kshar-sutra, follow-up is done every seventh day (weekly) for twenty days in a row. Aim: To Study the clinical efficacy of katutrikadya churna in the management of postoperative care W.S.R to bhagandara. Objectives • To assess the effect of compound formulation of katutrikadya churna after kshara-sutra application w.s.r to bhagandara. • To assess the agnidipan, vatanulomana property of katutrikadya churna. • Comparison in between the effect of katutrikadya churna and diclofenac sodium after kshar-sutra application w.s.r to bhagandara. • This clinical investigation was comparative, open, randomized, and study. The study's findings demonstrated that katutrikadya churna is a potent vedanasthapan aushadhi (analgesic) in the pain experienced over the anal region during the administration of kshar-sutra for the treatment of bhagandara. Not only does katutrikadya churna heal the symptoms of ailments, but it also addresses their root causes.

Developing a mobile health application for wound telemonitoring: a pilot study on abdominal surgeries post-discharge care

BackgroundMany early signs of Surgical Site Infection (SSI) developed during the first thirty days after discharge remain inadequately recognized by patients. Hence, it is important to use interactive technologies for patient support in these times. It helps to diminish unnecessary exposure and in-person outpatient visits. Therefore, this study aims to develop a follow-up system for remote monitoring of SSIs in abdominal surgeries.Material and methodsThis pilot study was carried out in two phases including development and pilot test of the system. First, the main requirements of the system were extracted through a literature review and exploration of the specific needs of abdominal surgery patients in the post-discharge period. Next extracted data was validated according to the agreement level of 30 clinical experts by the Delphi method. After confirming the conceptual model and the primary prototype, the system was designed. In the pilot test phase, the usability of the system was qualitatively and quantitatively evaluated by the participation of patients and clinicians.ResultsThe general architecture of the system consists of a mobile application as a patient portal and a web-based platform for patient remote monitoring and 30-day follow-up by the healthcare provider. Application has a wide range of functionalities including collecting surgery-related documents, and regular assessment of self-reported symptoms via systematic tele-visits based on predetermined indexes and wound images. The risk-based models embedded in the database included a minimum set with 13 rules derived from the incidence, frequency, and severity of SSI-related symptoms. Accordingly, alerts were generated and displayed via notifications and flagged items on clinicians’ dashboards. In the pilot test phase, out of five scheduled tele-visits, 11 (of 13) patients (85%), completed at least two visits. The nurse-centered support was very helpful in the recovery stage. Finally, the result of a pilot usability evaluation showed users’ satisfaction and willingness to use the system.ConclusionImplementing a telemonitoring system is potentially feasible and acceptable. Applying this system as part of routine postoperative care management can provide positive effects and outcomes, especially in the era of coronavirus disease when more willingness to telecare service is considered.

SERRATUS ANTERIOR PLANE BLOCK FOR TOTALLY ENDOSCOPIC AORTIC VALVE REPLACEMENT SURGERY: A RANDOMIZED CONTROLLED TRIAL

<h3>Objective</h3> Totally endoscopic aortic valve replacement (AVR) has several benefits compared to the classic approach via sternotomy. However, pain after this thoracoscopic intervention is still a problem. The current pain treatment after AVR consists of opioids. Unfortunately, opioids have various side effects, such as nausea, constipation and respiratory depression. These side effects prevent a fast recovery after surgery. Therefore, it is essential to keep postoperative opioid consumption to a minimum. This study aims to investigate the efficacy of the serratus anterior plane (SAP) block in reducing acute postoperative pain after totally endoscopic AVR surgery. During a SAP block, local anaesthetics are injected in the plane beneath the anterior serratus muscle and in the plane between latissimus dorsi and serratus anterior in an ultrasound guided manner. This induces analgesia in dermatomes T2 to T9, which includes the place where surgical incision is realized. In this study, postoperative pain was compared between a treatment with the postoperative SAP block and a treatment without the SAP block. <h3>Design and method</h3> This double-blinded, mono-center, prospective, randomized controlled superiority trial took place in the Jessa Hospital in Hasselt, Belgium. Patients undergoing totally endoscopic AVR were included and randomly allocated to the experimental group, receiving the standard of care plus SAP block, or the control group, receiving normal standard of care. The primary outcome was total opioid (piritramide) consumption during the first 24h after surgery. Secondary outcome measures were physical and mental health measured by the SF-36 questionnaire on postoperative day 2 and length of stay in the ICU and hospital. <h3>Results</h3> Between December 3, 2020 and May 11, 2022, 67 patients were included, of which 62 were analysed. The need for opioid consumption was lower in the experimental group compared to the control group (12 mg [8-26] vs. 19 mg [13.5-30.5], p=0.06). Physical (p=0.70) and mental health (p=0.93) on postoperative day 2 and length of stay in the ICU (p=0.79) and hospital (p=0.84) were similar in both groups. <h3>Conclusions</h3> These preliminary data show a tendency towards reduced opioid consumption when postoperative single-shot serratus anterior plane block is added to routine postoperative care management after thoracoscopic AVR.

Evolving liver transplantation in Pakistan: Future challenges.

Liver transplantation is a life-saving procedure that started in the early 60s. Initially, it struggled with multiple failed attempts but later it progressed and emerged as a gold standard procedure for liver failure secondary to various etiologies. In the first two decades, it faced various challenges like peri and post-operative care management, the quality of graft, optimal immunosuppressant use, and recipient selection criteria. Because of these challenges, the 1-year survival remained below 30% initially. Liver transplantation flourished tremendously over time due to advancements in organ preservation techniques, immunosuppressive therapies, and a better understanding of immunology. The invention of calcineurin inhibitors changed the dynamics of immunosuppressive therapies altogether. The donor organ shortage remains the leading challenge, Deceased donor transplantation activities have not yet started here due to various socio-cultural, and religious resistance. The majority population of the country is underprivileged and faces financial issues to afford the costly liver transplant procedure. The other challenges include the emerging NASH and obesity epidemics. The prevalence of viral hepatitis has not decreased in the country despite advancements in antiviral therapies and vaccine availability against hepatitis B. The local transplant community needs to overcome the limitation of organ supply through various donor expansion approaches. Although it may seem difficult to address all these challenges, still, the transplant community and health authorities need to find an effective way to sort out all these challenges.

Expert Consensus on the Use of the PRESERFLO™ MicroShunt Device in the Treatment of Glaucoma: A Modified Delphi Panel.

IntroductionThe implantation of the PRESERFLO™ MicroShunt (PMS) device has been shown to significantly lower increased intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG). However, guidelines on best practice for patient selection and pre-/peri-/postoperative care management are lacking. The aim of this modified Delphi panel was to achieve expert consensus on the role of the PMS to treat patients with glaucoma in Europe.MethodsTwelve European glaucoma surgeons experienced with the PMS procedure participated in a three-round modified Delphi panel. A targeted literature review and expert steering committee guided round 1 questionnaire development. Consensus was set at a pre-defined threshold of at least 70% of panellists selecting ‘Strongly disagree’/‘Disagree’ or ‘Strongly agree’/‘Agree’ for six–point Likert scale questions, or at least 70% selecting the same option for multiple-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions.ResultsConsensus was achieved for 60.3% (n = 38/63), 60.0% (n = 18/30), and 100.0% (n = 11/11) of Likert/multiple-choice questions in rounds 1, 2, and 3, respectively. There was agreement that the PMS procedure is effective at reducing IOP in patients with high-tension POAG (greater than 21 mmHg). Although surgical techniques may vary slightly, consensus was reached on several points, including the importance of posterior application of mitomycin C (MMC). Panellists agreed that the PMS postoperative follow-up appointment schedule is reasonably predictable and mostly characterised by fewer visits than with trabeculectomy, particularly in the early phase. Although panellists agreed that combined cataract/PMS surgery and the use of non-MMC wound-healing modulators/antifibrotics during the procedure are possible, further data are needed to determine efficacy.ConclusionThe expert consensus reached in this panel will help inform best practice guidelines in the treatment of patients with glaucoma in Europe. Panellists also highlighted key areas for future research to improve understanding of the PMS in the treatment algorithm of glaucoma.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-022-00529-4.

A Decision Support System on Postoperative Care Management of Total Joint Replacement Patients Using Clinical Outcome Measurement

The postoperative care of total joint replacement patients is of interest to healthcare practitioners due to the high number of annual replacements and growing economic burden on the U.S. healthcare system. Minimizing postoperative care costs and maximizing patients’ functional outcomes are the key aspects of postoperative care management. In this paper, a novel analytical framework is introduced in which multiple measurements are concurrently utilized to dynamically assess the recovery progress of the patients, and furthermore, be used as a tool to devise personalized post-discharge intervention plans for the patients. A Markov decision process model is formulated to provide decision support on determining cost-effective intervention care plans that can be used as clinical guidelines in practice. The results clearly demonstrate the risk of using a single measurement method which may lead to inadequate level of intervention, and justifies the need of such modeling based approaches for devising the most appropriate care levels especially in the early recovery periods.

Self-reported allergies correlate with a worse patient-reported outcome after hip arthroscopy: a matched control study.

Patient-reported outcome measures (PROMs) in patients with and without at least one self-reported allergy undergoing hip arthroscopy were compared. Data on 1434 cases were retrospectively reviewed, and 267 patients were identified with at least one self-reported allergy and randomly matched to a control group on a 1:2 ratio. Four PROMs [Modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports (HOS-Sport) and 33-item International Hip Outcome Tool (iHOT-33)] were collected preoperatively, and at 5–11, 12–23 and 24–35 months postoperatively. Significant PROM differences were found 5–11 months postoperative on mHHS (P < 0.001), HOS-ADL (P = 0.002), HOS-Sport (P < 0.001) and iHOT-33 (P < 0.001). At 12–23 months postoperative, the allergy cohort had significantly worse scores on mHHS (P = 0.002), HOS-ADL (P = 0.001), HOS-Sport (P < 0.001) and iHOT-33 (P < 0.001). They also had significantly worse measures 24–35 months postoperative on mHHS (P = 0.019), HOS-Sport (P = 0.006) and iHOT-33 (P < 0.001). Multivariable logistic regression showed that each additional allergy reported significantly increased the risk of failing to meet the minimal clinically important difference 5–11 months after surgery on mHHS by 1.15 [OR (95% CI): 1.15 (1.03, 1.30), P = 0.014], on HOS-ADL by 1.16 [OR (95% CI): 1.16 (1.02, 1.31), P = 0.021] and on iHOT-33 by 1.20 [OR (95% CI): 1.20 (1.07, 1.36), P = 0.002]. Results suggest self-reported allergies increase the likelihood of a patient-perceived worse outcome after hip arthroscopy. An understanding of this association by the physician is essential during presurgical planning and in the management of postoperative care.

Association of Geriatric Comanagement and 90-Day Postoperative Mortality Among Patients Aged 75 Years and Older With Cancer

Collaboration between geriatricians and surgeons in the perioperative treatment of older patients has been associated with improved outcomes in several nononcologic specialties. Similar associations may be possible among older patients with cancer. To investigate the associations of geriatric comanagement of care for older patients undergoing cancer-related surgical treatment with 90-day postoperative mortality, rate of adverse surgical events, and postoperative use of inpatient supportive care services. This retrospective cohort study assessed outcomes of patients who received geriatric comanaged care vs those who did not using multivariable logistic regression analysis, with 90-day mortality as the outcome and geriatric comanagement of care as the main variable, with adjustment for age, sex, American Society of Anesthesiology score, Memorial Sloan Kettering Frailty Index score, preoperative albumin level, operative time, and estimated blood loss. A similar model was used to assess the association of geriatric comanagement with adverse surgical events, defined as any major complication, readmission, or emergency department visit within 30 days. Patients aged 75 years and older who underwent an elective surgical procedure with a hospital stay of at least 1 day at a single tertiary-care cancer center between February 2015 and February 2018 were included. Data were analyzed from January to July 2019. Postoperative care comanaged by the geriatrics service and surgical service (geriatric comanagement group) vs by the surgical service only (surgical service group). 90-day mortality, adverse surgical events, and use of supportive care services. Of 1892 patients included, 1020 (53.9%) received geriatric comanagement of care; these patients, compared with those who received care managed by the surgery service only, were older (mean [SD] age, 81 [4] years vs 80 [4] years; P < .001), had longer operative time (mean [SD], 203 [146] minutes vs 138 [112] minutes; P < .001), and longer length of stay (median [interquartile range], 5 [3-8] days vs 4 [2-7] days; P < .001). There were no differences in the proportions of men (488 [47.8%] men vs 450 [51.6%] men; P = .11). Adverse surgical events were not significantly different between groups (odds ratio, 0.93 [95% CI, 0.73-1.18]; P = .54). However, the adjusted probability of death within 90 days after surgical treatment was 4.3% for the geriatric comanagement group vs 8.9% for the surgical service group (difference, 4.6% [95% CI, 2.3%-6.9%]; P < .001). Additionally, compared with patients who received postoperative care management from the surgery service only, a higher proportion of patients in the geriatric comanagement group received inpatient supportive care services, including physical therapy (555 patients [63.6%] vs 820 patients [80.4%]; P < .001), occupational therapy (220 patients [25.2%] vs 385 patients [37.7%]; P < .001), speech and swallow rehabilitation (42 patients [4.8%] vs 86 patients [8.4%]; P = .002), and nutrition services (637 patients [73.1%] vs 803 patients [78.7%]; P = .004). This cohort study found that geriatric comanagement was associated with significantly lower 90-day postoperative mortality among older patients with cancer. These findings suggest that such patients may benefit from geriatric comanagement, which could improve their ability to survive adverse postoperative events.

Hemşirelik Öğrencilerine Verilen Standart Hasta Eğitiminin, Ameliyat Sonrası Bakım Yönetimine Etkisi

Hemşirelik Öğrencilerine Verilen Standart Hasta Eğitiminin, Ameliyat Sonrası Bakım Yönetimine Etkisi

Postoperative pulmonary complications - Still room for improvement.

Postoperative pulmonary complications - Still room for improvement.

Goal-Directed Perfusion Methodology for Determining Oxygenator Performance during Clinical Cardiopulmonary Bypass

New generation oxygenators incorporate arterial line filtration either sequential to, or directly in, the gas exchange module. This unique design may affect gas exchange performance by altering the operational characteristics of the device. The present study was designed to evaluate three oxygenators in a clinical setting using a goal-directed perfusion algorithm during cardiopulmonary bypass (CPB). After institutional review board approval, 60 adult patients undergoing cardiac surgery for acquired heart disease were matched for disease state and body size into three groups based on oxygenator type: Terumo SX18™(n= 20), Terumo FX15™(n= 20), and LivaNova Inspire6F™6 Dual (n= 20). An external arterial line filter was used with the FX15, whereas the SX18 and Inspire6F had integrated arterial filters. All perfusion, anesthetic and postoperative care management was standardized using institutional goal-directed patient management processes. Data were collected and stored according to quality improvement guidelines. There were no differences in demographics or type of surgical procedure performed among groups. The Inspire6F patients required lower fraction of inspired oxygen values as compared to the SX18 (67.9% ± 6.2% vs. 75.4% ± 6.5%,p&lt; .005) and FX15 (79.1% ± 8.4%,p&lt; .0001) groups. Arterial oxygen content and oxygen delivery were slightly higher in the FX15 group as compared to SX18 (13.1 ± 1.4 mL O2/dL vs. 12.4 ± 1.1 mL O2/dL, 611.1 ± 150.4 mL O2vs. 528.2 ± 102.3 mL O2,p&lt; .05). The FX15 patients had significantly higher CPB hematocrits compared to SX18 patients (30.3% ± 3.9% vs. 27.7% ± 2.6%,p&lt; .05), but were not different when compared to the Inspire6F group (28.8% ± 3.5%,p&lt; .50). There were no differences in intraoperative transfusion rates, but a higher percent of patients received postoperative transfusions in the SX18 group as compared to either FX15 or Inspire6F groups (p&lt; .039). There were no differences in postoperative morbidity or complications in any group. In conclusion, the use of the SX18 was comparable to newer generation oxygenators in regard to gas exchange performance and the degree of hemodilution.

Use of video-based education and tele-health home monitoring after liver transplantation: Results of a novel pilot study

In this observational study, we analyzed the feasibility and early results of a perioperative, video-based educational program and tele-health home monitoring model on postoperative care management and readmissions for patients undergoing liver transplantation. Twenty consecutive liver transplantation recipients were provided with tele-health home monitoring and an educational video program during the perioperative period. Vital statistics were tracked and monitored daily with emphasis placed on readings outside of the normal range (threshold violations). Additionally, responses to effectiveness questionnaires were collected retrospectively for analysis. In the study, 19 of the 20 patients responded to the effectiveness questionnaire, with 95% reporting having watched all 10 videos, 68% watching some more than once, and 100% finding them effective in improving their preparedness for understanding their postoperative care. Among these 20 patients, there was an observed 19% threshold violation rate for systolic blood pressure, 6% threshold violation rate for mean blood glucose concentrations, and 8% threshold violation rate for mean weights. This subset of patients had a 90-day readmission rate of 30%. This observational study demonstrates that tele-health home monitoring and video-based educational programs are feasible in liver transplantation recipients and seem to be effective in enhancing the monitoring of vital statistics postoperatively. These data suggest that smart technology is effective in creating a greater awareness and understanding of how to manage postoperative care after liver transplantation.

Clinical Pathway Implementation Improves Efficiency of Care in a Maxillofacial Head and Neck Surgery Unit

Clinical pathways have become an important and simple method of improving patient outcomes and decreasing health care resource usage. The purpose of this study was to evaluate early outcomes associated with the implementation of a clinical pathway in a maxillofacial head and neck surgery unit. This investigation is a retrospective cohort study of patients who underwent microvascular reconstruction of the head and neck from January 1, 2014 through December 31, 2014. Continuous variables were compared among 4 groups using analysis of variance or Kruskal-Wallis test, and categorical variables were compared using χ2 test or Fisher exact test where appropriate. The primary predictor variable was use of the clinical pathway. Groups included patients treated by surgeon A during periods before and after implementation of a postoperative clinical pathway. Two groups treated by surgeon B also were evaluated during the same periods and served as external controls. Each period covered a span of 6months. Outcome variables across groups were evaluated, including length-of-stay metrics, infection rates, transfers to the intensive care unit, and unplanned return to the operating room. Sixty-six patients who underwent microvascular head and neck reconstruction were included. There was a significant decrease in the average length of stay (P= .0364) and an increase in the rate of discharge within 7days (P= .0416) in the group treated with the clinical pathway. Other outcomes, including infection rate, transfer to the intensive care unit, and unanticipated return to the operating room, showed no relevant difference among groups. The results of this study suggest that implementation of a clinical pathway can be beneficial for efficient management of postoperative care in the setting of microvascular head and neck reconstruction. More predictable and shorter lengths of stay are achievable and the clinical pathway serves as a valuable means of improving communication of the clinical care team.

Risk factors of hospital mortality after initial hepatic resection among patients with primary hepatocellular carcinoma.

352 Background: Hepatectomy is widely used to treat patients with hepatocellular carcinoma (HCC), even those with intermediate and advanced disease. Despite its well-demonstrated clinical efficacy in many patients, postoperative mortality is an inevitable problem. This study aims to investigate the risk factors of mortality after hepatectomy. Methods: A consecutive sample of 1518 patients with HCC who underwent initial hepatectomy from January 1, 2004 to October 31, 2013 were retrospective analyzed. Multivariate analysis to identify independent risk factors of postoperative mortality was carried out using the Cox proportional hazards model. Parameters for multivariate analyses included age, gender, tumor size, tumor number, preoperative serum albumin, alanine aminotransferase, total bilirubin, α-fetoprotein, prothrombin time, tumor capsule, macrovascular invasion, portal hypertension, diabetes mellitus, ascites, major hepatectomy, surgical time, blood loss, blood transfusion, and clamping portal hepatis time. Results: A total of 18 (1.19%) and 45 (2.96%) patients died within 30 and 90 days after hepatectomy, respectively. Multivariate analysis revealed that tumor number ( ≥ 4), macrovascular invasion, and major hepatectomy were independent risk factors of 30 and 90 days mortality, while portal hypertension was also an independent risk factor of 90 days mortality. Conclusions: Among HCC patients with tumor number equal or more than four, macrovascular invasion, portal hypertension, or underwent major hepatectomy, intensive postoperative care management are in particular.

The Clinical Use of Intravenous Acetaminophen Postoperatively on Patients Who Have Undergone Bowel Surgery

The purpose of this quality improvement project was to determine the effect of using IV acetaminophen postoperatively for 48 hours or until a return to a general diet in adult patients who have undergone bowel surgery at a Midwestern hospital. The sample included 50 adults who underwent bowel surgery and a comparison group of 50 adult patients of the same surgeons who received usual care before the intervention period. Outcome measures included the number of narcotic requests after surgery and the number of hours from the end surgical time to (1) first bowel movement, (2) return to a general diet, (3) first hallway ambulation, and (4) discharge. The data analysis revealed a significant improvement in the time to ambulation (acetaminophen group, 14.46 hours versus 30.51 hours; P = .036). The results of this project inform current postoperative care management at the Midwestern hospital in which the project was conducted.

Optimisation de l’augmentation mammaire primaire par implants : approche basée sur le niveau de preuve

The primary aesthetic breast augmentation has been the most performed cosmetic surgery procedure in the world for over 40 years. The current literature focuses on the new concept of "process of breast augmentation" and the importance of non-surgical part (patient selection, preoperative planning and personalized management of postoperative care) in potentiating the cosmetic results and reducing the rate of complications and reoperations. This review of literature discusses, through an analysis of scientific evidence levels, every step of the whole process of breast augmentation in order to determine the current best practices tailored to each patient to optimize satisfactory and durable cosmetic outcomes.