Multiple Surgical Disciplines Research Articles

The Modified Frailty Index Predicts Major Complications in Oncoplastic Reduction Mammoplasty

Background An important component of preoperative counseling and patient selection involves surgical risk stratification. There are many tools developed to predict surgical complications. The Modified Frailty Index (mFI) calculates risk based on the following five elements: hypertension, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and functional status. Recent literature demonstrates the efficacy of the mFI across multiple surgical disciplines. We elected to investigate its utility in oncoplastic reductions (OCR). Methods A retrospective review of all patients with breast cancer who underwent OCR from 1998 to 2020 was queried from a prospectively maintained database. Patient demographics, comorbidities, and surgical details were reviewed. The mFI was computed for each patient. The primary clinical outcome was the development of complications. Results 547 patients were included in the study cohort. The average age was 55 and the average body mass index was 33.5. The overall complication rate was 19% (n = 105) and the major complication rate was 9% (n = 49). Higher frailty scores were significantly associated with the development of major complications (P < 0.05). mFI scores of 0 had a major complication rate of 5.7%; scores of 1, 13%; and scores of 2, 15.1%. The relative risk of a major complication in patients with elevated mFI (>0) was 2.2. Age, body mass index, and resection weights were not associated with complications (P = 0.15, P = 0.87, and P = 0.30 respectively) on continuous analysis. Conclusions Elevated mFI scores are associated with an increased major complication profile in patients who are undergoing OCR. Hypertension and diabetes are the most common comorbidities in our population, and this tool may assist with preoperative counseling and risk stratification. Benefits of this risk assessment tool include its ease of calculation and brevity. Our study is the first to demonstrate its utility in OCR; however, further study in high-risk patients would strengthen the applicability of this frailty index.

The association of thromboembolic complications and the use of tranexamic acid during resection of intracranial meningiomas: systematic review and meta-analysis of randomized controlled trials.

Antifibrinolytics, such as tranexamic acid (TXA), have been shown to decrease intraoperative blood loss across multiple surgical disciplines. However, they carry the theoretical risk of thromboembolic events secondary to induced hypercoagulability. Therefore, the aim of this study was to systematically review the available literature and perform a meta-analysis on the use of TXA in meningioma resection to assess thromboembolic risks. The PubMed, Web of Science, and Google Scholar databases were reviewed for all randomized controlled trials presenting primary data on TXA use during resection of intracranial meningiomas. Data were gathered on operative duration, venous thromboembolic complications, deep venous thrombosis, use of allogeneic blood transfusion, estimated blood loss (EBL), and postoperative hemoglobin. Patients who received TXA were compared with controls who did not receive TXA intraoperatively using random-effects models. A total of 508 unique articles were identified, of which 493 underwent full-text review. Ultimately, 6 studies with 381 total patients (190 receiving TXA) were included in the final analysis. All 6 trials were randomized, blinded, and placebo controlled with a TXA administration rate of a 20-mg/kg load followed by a 1-mg/kg/hr infusion. All studies were performed in lower-middle-income countries. There were no reported instances of venous thromboembolism (VTE) in the TXA and non-TXA cohorts. Patients receiving TXA exhibited fewer allogeneic transfusions (21.5% vs 41.6% [OR 0.26, 95% CI 0.09-0.77], p = 0.02) and lower EBL (MD -282.48 mL [95% CI -367.77 to -197.20 mL], p < 0.001) compared with patients who did not receive TXA, and they also had lower rates of perioperative complications (10.7% vs 19.9% [OR 0.47, 95% CI 0.2-0.95], p = 0.04). Current literature suggests that TXA is not associated with increased risk for VTE when administered during resection of intracranial meningioma. TXA appears to decrease intraoperative blood loss and allogeneic transfusion requirements during meningioma resection and thus may improve the safety of surgical management of this pathology.

Impact of ERAS compliance on the short-term outcomes for distal radius surgery: a single-center retrospective study

BackgroundDistal radius fractures (DRF) account for one in five bony injuries in both primary and secondary trauma care. Enhanced recovery after surgery (ERAS) has been adopted successfully to improve clinical outcomes in multiple surgical disciplines; however, no study has investigated the effect of different degrees of compliance with ERAS protocol on short-term outcomes following distal radius surgery. We aimed to analyze whether different degrees of compliance with the ERAS pathway are associated with clinical improvement following surgery for DRF.MethodsWe retrospectively analyzed all consecutive patients with ERAS who underwent surgery for DRF at our department between May 2019 and October 2022. Their pre-, peri-, and post-operative compliance with the 22 elements of the ERAS program were assessed. We compared parameters between low- (< 68.1%) and high-compliance (> 68.1%) groups, including patient complications, total length of hospitalization, discharge time after surgery, hospital costs, time taken to return to preinjury level performance level, number of visual analogue scale (VAS) pain scores > 3 points during hospitalization, disabilities of the arm, shoulder and hand (DASH) scores. We performed multiple linear regression analyses to assess the impact of ERAS compliance on the postoperative function level (DASH scores).ResultsNo significant differences were detected between the high- and low-compliance groups with respect to demographics, including sex, age, body mass index (BMI), and comorbidities (P > 0.05). We observed significant differences between the high- and low-compliance groups in terms of the DASH score (32.25 ± 9.97 vs. 40.50 ± 15.65, p < 0.05) at 6 months postoperatively, the discharge time after surgery (2.45 ± 1.46 vs. 3.14 ± 1.50, p < 0.05), and number of times when the VAS pain score was > 3 points during hospitalization (0.88, [0.44, 1.31], p < 0.05). Our study demonstrated a significant negative association between ERAS compliance and the function level of patients postoperatively (DASH scores) when adjusted for age, comorbidity, sex, and BMI.ConclusionsThis study provided a realistic evaluation and comparison of the ERAS protocol among patients with DRF and can guide clinical decision making. The ERAS protocol may improve outcomes after surgery, with high postoperative function levels and reduced pain and discharge time after surgery, without increased complication rates or hospital costs.

Robotic Surgery and Hospital Reimbursement.

The field of plastic surgery remains at the forefront of technological and surgical innovation. However, the promising applications of robotics in plastic surgery must be thoughtfully balanced with hospital finances and reimbursements. Robotic systems have been studied extensively across multiple surgical disciplines and across diverse health care systems. The results show that there may be equal or better patient outcomes than alternatives. In an era where fiscal responsibility in health care is a top priority, thoughtful budgeting and spending must be considered and revisited frequently to attain sustainable organizational models that ensure appropriate use of robotic technology.

Surgical Site Infections During the Pandemic: The Impact of the "COVID Bundle".

A reduction in surgical site infections (SSIs) has been reported in several discrete patient populations during the COVID-19 pandemic. Herein, this study evaluates the impact of the COVID-19 pandemic on SSI in a large patient cohort incorporating multiple surgical disciplines. We hypothesize that enhanced infection control and heightened awareness of such measures is analogous to an SSI care bundle, the hypothetical "COVID bundle", and may impact SSI rates. Data collected for the American College of Surgeons National Surgical Quality Improvement Program between January 1, 2015, and April 1, 2021, were retrospectively analyzed. SSI rates were compared among time-dependent patient cohorts: Cohort A (pre-pandemic, N = 24,060, 87%) and Cohort B (pandemic, N = 3698, 13%). Time series and multivariable analyses predicted pre-pandemic and pandemic SSI trends and tested for association with timing of surgery. The overall SSI incidence was reduced in Cohort B versus Cohort A (2.8% vs. 4.5%, p < 0.001). Multivariable analysis indicated a downward SSI trend before pandemic onset (IRR 0.997, 95% CI 0.994, 1). At pandemic onset, the trend reduced by a relative factor of 39% (IRR 0.601, 95% CI 0.338, 1.069). SSI then trended upward during the pandemic (IRR 1.035, 95% CI 0.965, 1.111). SSI rates significantly trended downward in general surgical patients at pandemic onset (IRR 0.572, 95% CI 0.353, 0.928). Although overall SSI incidence was reduced during the pandemic, a statistically significant decrease in the predicted SSI rate only occurred in general surgical patients at pandemic onset. This trend may suggest a positive impact of the "COVID bundle" on SSI rates in these patients.

Global observational survey verifying surgeon utilization of the Validated Intraoperative Bleeding (VIBe) scale for use in clinical practice

Based on US-FDA guidelines to create tools for development and evaluation of medical devices in non-clinical and clinical studies, the Validated Intraoperative Bleeding (VIBe) Scale was developed. The current investigation expands upon the earlier validation study with multi-specialty surgeons to further corroborate these findings and establish feasibility to implement VIBe SCALE into clinical practice and surveys degree of anticipated bleeding across common procedures in multiple surgical disciplines. Following online didactic VIBe SCALE training, participating surgeons graded bleeding in ten porcine model videos corresponding to the original validation study. Surgeon and practice information were collected along with percentage of hemostatic product utilization in surgical procedures, the top three surgical procedures performed in their specialty, together with self-reported percentage of bleeding per VIBe SCALE bleeding grade typically encountered in those procedures. Using a web-based interface, survey data were collected from 585 participating surgeons; 339 (58%) participants were from academic or university setting, 170 (29%) had >20 years of surgical experience, 217 (37%) performed 11-20 surgeries per month. Overall, 125 (21%) surgeons reported conducting up to 10% minimally invasive surgeries in their practice. Total, 334 (57%) participants considered patient's coagulation status while selecting intraoperative adjunctive hemostatic product, if required; majority (n=552 [94%]) considered bleeding intensity important when selecting a hemostatic product intraoperatively. Interobserver concordance for VIBe SCALE of 0.89 (perfect concordance=1.0) as a measure of reproducibility, was achieved. This survey strengthens the findings of the earlier validation study and provides human factors verification of the VIBe SCALE as a relevant tool to evaluate and assess bleeding severity across multiple surgical specialties, while demonstrating the useability in contemporary clinical practice and may facilitate hemostatic product choice.

The Surgical Apgar Score: A Systematic Review of Its Discriminatory Performance.

The SAS is a simple metric calculated at the end of surgery that provides clinicians with information about a patient's postoperative risk of morbidity and mortality. The SAS differs from other prognostic models in that it is calculated from intraoperative rather than preoperative parameters. The SAS was originally derived and validated in a general and vascular surgery population. Since its inception, it has been evaluated in many other surgical disciplines, large heterogeneous surgical populations, and various countries. A database and gray literature search was performed on March 3, 2020. Identified articles were reviewed for applicability and study quality with prespecified inclusion criteria, exclusion criteria, and quality requirements. Thirty-six observational studies are included for review. Data were systematically extracted and tabulated independently and in duplicate by two investigators with differences resolved by consensus. All 36 included studies reported metrics of discrimination. When using the SAS to correctly identify postoperative morbidity, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.59 in a general orthopedic surgery population to 0.872 in an orthopedic spine surgery population. When using the SAS to identify mortality, the area under the receiver operating characteristic curve or concordance-statistic ranged from 0.63 in a combined surgical population to 0.92 in a general and vascular surgery population. The SAS provides a moderate and consistent degree of discrimination for postoperative morbidity and mortality across multiple surgical disciplines.

The Role of Augmented Reality in the Next Phase of Surgical Education.

Concomitant with such a shift toward competency-based curricula, there has been increasing adoption of surgical simulation coupled with virtual, mixed, and augmented reality. These technologies have become more commonplace across multiple surgical disciplines, in domains such as preoperative planning, surgical education, and intraoperative navigation. However, there is a relative paucity of literature pertaining to the application of this technology to plastic surgery education. This review outlines the advantages of mixed and augmented reality in the pursuit of an ideal simulation environment, their benefits for the education of plastic surgery trainees, and their role in standardized assessments. In addition, we offer practical solutions to commonly encountered problems with this technology. Augmented reality has tremendous untapped potential in the next phase of plastic surgery education, and we outline steps toward broader implementation to enhance the learning environment for our trainees and to improve patient outcomes.

Importance of Cadaveric Dissections and Surgical Simulation in Plastic Surgery Residency.

As plastic and reconstructive surgeons, our intimate knowledge of anatomy enables us to operate with confidence across the human body and allows us to engage with colleagues across multiple surgical disciplines to solve complex problems. This also poses a significant challenge to operating surgeons, as they must be adept with the surgical anatomy of the entire human body to deliver optimal surgical outcomes. Precise knowledge of anatomy is an absolute prerequisite for surgical success. Historically, surgical training was supplemented with embalmed cadaveric dissections, as this foundation proved to be an important adjunct to intraoperative education.1 This was thought to be essential because it provided early exposure to human anatomy in an environment where residents could explore without time constraints and could also ask questions to faculty without worry of morbidity to patient care. Recently, ACGME residency guidelines have been amended through work hour restrictions and strict faculty supervision that limit resident independence in the operating room. This has far-reaching implications, as limited operative independence may lead to decreased resident confidence and a diminished surgical skill set.2 The erosion of resident autonomy has forced our surgical educators to search for practical solutions to augment resident education and, in turn, operative skill set. As we know, the fear of surgery is the fear of anatomy, and this proverb underscores the importance of utilizing surgical simulation and cadaver dissections to achieve these goals. Multiple institutions have implemented a cadaver-based curriculum showing promising results. Srinivasan et al3 and Askari et al4 developed curriculums at their respective institutions with the goal of standardizing exposure to fundamental skills to improve resident autonomy.3,4 They found that their cadaveric curriculum increased resident autonomy, as both residents and faculty had improved confidence in the trainee’s operative skills. In addition, faculty observed an increase in knowledge of anatomy and in technical skill ability amongst all resident cohorts. Faculty members surveyed at the conclusion of the course also believed that the residency program should continue cadaver-based studies and simulations.3,4 Additional benefits of surgical simulation or cadaver dissections include the potential to identify poor technical knowledge and poor surgical techniques early in training, which allows for individualized educational plans for struggling residents.3 Conversely, skilled junior residents will obtain the opportunity to refine more complex surgical skills. In conclusion, although cadaveric dissections and surgical simulation models will never be a complete substitute for operative experience, history has shown us the importance of using these resources as an adjunct in residency training (Fig. 1). In today’s landscape for surgical education, utilization of these resources could translate to more faculty entrustment, increased resident confidence, and increased autonomy in the operating room. Although this model may be cost-prohibitive, there have been multiple strategies employed to mitigate this issue, such as outreach to program alumni, business and industry sponsorship, or creating collaborative relationships amongst departments.1 Furthermore, we recognize the differences in access to cadaveric models in international training programs and hope to reconcile these disparities to achieve widespread access to cadaveric dissections. While surgical simulation and cadaver studies in the current literature have focused on technical skill acquisition, we need to begin to validate patient outcomes and safety benefits, trainee confidence levels, and degree of achieved autonomy to supplement the literature.Fig. 1.: Landmark anatomical study by Siebert et al5 describing the blood supply to the LeFort 1 maxillary segment. From Siebert JW, Angrigiani C, McCarthy JG, et al. Blood supply of the Le Fort I maxillary segment: an anatomic study. Plast Reconstr Surg. 1997;10(Supp. 1):843–851. © 1997, Wolters Kluwer Health. Used with permission.The Creative Commons license does not apply to this content. Use of the material in any format is prohibited without written permission from the publisher, Wolters Kluwer Health, Inc. Please contact [email protected] for further information.DISCLOSURE The authors have no financial interest to declare in relation to the contents of this article. No funding was received for this work.

How is surgical antibiotic prophylaxis prescribed for open reduction internal fixation procedures by Australian orthopaedic surgeons?

How is surgical antibiotic prophylaxis prescribed for open reduction internal fixation procedures by Australian orthopaedic surgeons?

Hemopatch® is effective and safe to use: real-world data from a prospective European registry study

Surgical procedures are often impeded by bleeding and/or leakage of body fluids. These complications cannot always be resolved by conventional surgical techniques. Hemopatch® is a hemostatic patch that also functions as a sealant. Here we document the effectiveness and safety of Hemopatch® for routine procedures of multiple surgical disciplines. To this end, we performed a prospective, multicenter, single-arm, observational registry study. Patients were eligible if they had received Hemopatch® during an open or minimally invasive procedure in one of these specialties: hepatobiliary, cardiovascular, urological, neurological/spinal, general, or lung surgery. Patients were excluded if they had a known hypersensitivity to bovine proteins or brilliant blue, intraoperative pulsatile or severe bleeding and/or infection at the target application site (TAS). The primary endpoint for intraoperative effectiveness was hemostasis assessed as the percentage of patients achieving hemostasis within 2 min and the percentage of patients achieving hemostasis without re-bleeding at the time of surgical closure. The registry enrolled 621 patients at 23 study sites in six European countries. Six hundred twenty patients had completed follow-up information. Hemostasis within 2 min was achieved at 463 (74.5%) of all 621 TASs. Hemostasis without re-bleeding was observed at 620 (99.8%) TASs. Adverse events were reported in 64 patients (10.3%). This Hemopatch® registry shows that Hemopatch® efficiently establishes hemostasis and sealing in a variety of surgical specialties, including minimally invasive procedures. Furthermore, we provide evidence for the safety of Hemopatch® across all the specialties included in the registry. This study is registered at clinicaltrials.gov: NCT03392662.

European Reference Network for Rare Vascular Diseases (VASCERN): When and how to use intravenous bevacizumab in Hereditary Haemorrhagic Telangiectasia (HHT)?

Hereditary haemorrhagic telangiectasia (HHT) is a rare vascular multisystemic disease that leads to epistaxis, anaemia due to blood loss, and arteriovenous malformations (AVMs) in organs such as the lungs, liver and brain. HHT prevalence is estimated at 1/6000, i.e. around 85,000 European citizens, and is served by the European Reference Network for Rare Multisystemic Vascular Diseases (VASCERN). HHT treatments depend on clinical manifestations, and span multiple different medical, surgical and interventional disciplines. Separate to local treatments in the nose, in severe settings, intravenous bevacizumab has been proposed as treatment option, and the purpose of the current article is to assess the use of intravenous bevacizumab in patients with HHT in 2022 according to available data.

Lost in translation: A qualitative analysis of facilitators and barriers to collecting patient reported outcome measures for surgical patients with limited English proficiency

BackgroundPatient-reported outcome measures (PROMs) are increasingly being used throughout surgical disciplines, but their use is limited in multilingual patient populations. We aimed to investigate facilitators and barriers to PROMs collection for patients with limited English proficiency (LEP). MethodsSemi-structured interviews were performed with providers from multiple surgical disciplines across six academic medical centers until thematic saturation was achieved. ResultsAmong 24 interviews, respondents noted either systematic exclusion of patients with LEP or significant barriers to implementation. Barriers included lack of valid and translated PROMs, lack of multi-lingual electronic medical record integration, and insufficient time and resources to accommodate patients with LEP. Facilitators to collection included institutional leadership and funding support for validating translations. ConclusionThese barriers may result in inadvertent but systematic exclusion of patients with LEP from outcomes datasets as well as clinical decision making. Future implementation projects should consider these themes when developing initiatives for more equitable PROMs collection and utilization.

A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education

We conducted a comprehensive review of surgical simulation models used in robotic surgery education. We present an assessment of the validity and cost-effectiveness of virtual and augmented reality simulation, animal, cadaver and synthetic organ models. Face, content, construct, concurrent and predictive validity criteria were applied to each simulation model. There are six major commercial simulation machines available for robot-assisted surgery. The validity of virtual reality (VR) simulation curricula for psychomotor assessment and skill acquisition for the early phase of robotic surgery training has been demonstrated. The widespread adoption of VR simulation has been limited by the high cost of these machines. Live animal and cadavers have been the accepted standard for robotic surgical simulation since it began in the early 2000s. Our review found that there is a lack of evidence in the literature to support the use of animal and cadaver for robotic surgery training. The effectiveness of these models as a training tool is limited by logistical, ethical, financial and infection control issues. The latest evolution in synthetic organ model training for robotic surgery has been driven by new 3D-printing technology. Validated and cost-effective high-fidelity procedural models exist for robotic surgery training in urology. The development of synthetic models for the other specialties is not as mature. Expansion into multiple surgical disciplines and the widespread adoption of synthetic organ models for robotic simulation training will require the ability to engineer scalability for mass production. This would enable a transition in robotic surgical education where digital and synthetic organ models could be used in place of live animals and cadaver training to achieve robotic surgery competency.

V05-01 USING 3D SCANNING TO CREATE A CNC MACHINED POLYURETHANE BED FOR PATIENT POSITIONING DURING PERCUTANEOUS NEPHROLITHOTOMY

You have accessJournal of UrologyUrolithiasis & Endourology (V05)1 Sep 2021V05-01 USING 3D SCANNING TO CREATE A CNC MACHINED POLYURETHANE BED FOR PATIENT POSITIONING DURING PERCUTANEOUS NEPHROLITHOTOMY Donald Fedrigon, and Sri Sivalingam Donald FedrigonDonald Fedrigon More articles by this author , and Sri SivalingamSri Sivalingam More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002012.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephrolithiasis is a cause of significant morbidity in patient populations with musculoskeletal abnormalities, spinal cord injury, and multiple sclerosis often requiring surgical intervention such as percutaneous nephrolithotomy (PCNL). Safely positioning patients with limb contractures or other musculoskeletal abnormalities in the prone position for PCNL can be a challenge intraoperatively and is an area that has not been previously explored in the literature. Therefore, we present a case report on the production and implementation of a custom foam bed designed from a 3D-scan of a percutaneous nephrolithotomy patient with upper extremity contractures. METHODS: A female patient with a history of congenital hydrocephalus, seizures, developmental disabilities, and a left upper extremity permanently contracted across her chest was identified preoperatively as a candidate for a custom bed. Informed consent was obtained from the family in accordance with our institutional review board policies. Prior to surgery, a Microsoft Kinect V2 was used to 3D scan a patient with Meshmixer and Fusion 360 (Autodesk) being used to develop the 3D custom bed model. The model was then machined out of Airtex 5'' 160 oz High-Density Foam using a ShopBot PRSAlpha 96x48 CNC machine with an Amana HSS1614 router bit. RESULTS: The custom foam bed was successfully utilized in place of traditional positioning padding in the operating room during the patient’s surgery. The foam bed was used to cushion the patient’s upper body during the prone split leg procedure while appropriately relieving pressure on the patients arm that needed to be positioned across her chest. CONCLUSIONS: We report a novel use for custom contoured polyurethane beds in the operating room and we demonstrated a reproduceable workflow for a 3D-scanning and CNC milling production process. The custom bed performed as expected within the operating room, providing both easy prone positioning and adequate cushioning for the patient’s contracted upper limb. This technique is reproducible with equipment accessible to most academic care centers and has applications across multiple surgical disciplines that commonly utilize prone positioning such as endourology and spinal surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e386-e386 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Donald Fedrigon More articles by this author Sri Sivalingam More articles by this author Expand All Advertisement Loading ...

Increasing accesibility to surgical knowledge-sharing across Southern Africa: the “horizontal” conference model (conference report)

Recognizing that advancements in global surgery are urgently needed in South Africa, where health inequity is rampant and surgical knowledge gaps remain, the Southern African Student Surgical Society partnered with the University of Cape Town Division of Global Surgery to organize a symposium entitled “Reimagining Perioperative Care in Africa.” The aim of the symposium was to address these needs through informative Global Surgery presentations, a virtual research competition, and an online Theory of Change Workshop, thereby advocating for improved surgical care in Africa through knowledge-sharing and education. By breaking down hierarchical structures through the formation of a collaborative, multidisciplinary Organizing Committee comprised of students and clinicians, a virtual “horizontal” conference model was created. This successfully allowed for the development of a cost-effective, far-reaching, collaboratively organized conference, that catered to both students’ and clinicians’ needs. Endorsed by the Director General of the World Health Organisation, Dr Tedros Ghebreyesus, this virtual “horizontal” model enabled the Organizing Committees to assemble experts from multiple surgical disciplines across Southern Africa, to achieve their mutual goal of finding African solutions to strengthen surgical systems.

Evaluating the Quality of Cost-Effectiveness Literature in Breast Surgery: What Do We Do Well and How Can We Do Better? A Systematic Review

Surgical options for breast cancer are numerous and span multiple surgical disciplines. Decision analyses aid surgeons in making the most cost-effective choice, thus reducing health care expenditure while maximizing patient outcome. In this study, we aimed to evaluate existing breast surgery cost-effectiveness literature against the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) validated scoring system. A PRISMA search was performed for cost-effectiveness within breast surgery. Articles were scored with CHEERS criteria on a 0-24 scale and qualitative data were collected. Subgroup analysis was performed comparing pre-CHEERS (published in 2013 or earlier) and post-CHEERS (published in 2014 or later) cohorts. Chi-squared analysis was performed to compare where studies lost points between cohorts. Of 2279 articles screened, 46 articles were included. The average CHEERS score was 18.18. Points were most often lost for characterizing heterogeneity, followed by discount rate, incremental costs and outcomes, and abstract. Quality-adjusted life year was the most commonly used health outcome, with visual model or analog scales as the most commonly used measure of effectiveness obtained primarily from surgeons or physicians. Most articles characterized uncertainty by deterministic sensitivity analysis, followed by both deterministic and probabilistic, then probabilistic. Average CHEERS scores were similar between pre- and post-CHEERS cohorts (17.67 vs. 18.40, P > .05) There were several significant differences in where articles lost points between pre- and post-CHEERS cohorts. In order to standardize the reporting of results, cost-effectiveness studies in breast surgery should adhere to the current CHEERS criteria and aim to better characterize heterogeneity in their analyses.

Elevation of High-sensitive Troponin T Predicts Mortality After Open Pancreaticoduodenectomy.

Open pancreaticoduodenectomy has a high complication and measurable mortality rate. Recent reports (based across multiple surgical disciplines) demonstrate that elevated postoperative high sensitivity troponin T (hsTnT) predicts adverse outcomes in non-cardiac surgery. The aim of this study was to evaluate postoperative hsTnT as a prognostic marker of mortality, major adverse cardiovascular events (MACE), post-operative non-cardiac complications and length of stay (including intensive care stay) in open pancreaticoduodenectomy. A retrospective review of open pancreaticoduodenectomy patients was undertaken from 01/10/2017-31/03/2019. Receiver operating characteristic (ROC) curves were calculated to identify ideal cut-off values for hsTnT. Univariate and multivariate analyses were performed to scrutinize the relationship between mean hsTnT and 30-day, 90-day mortality, MACE, post-operative non-cardiac complications and length of stay. One hundred and nine patients were identified. ROC curves demonstrated a strong correlation between elevated mean hsTnT and 30-day, 90-day mortality and MACE (AUC = 0.937, AUC = 0.852, AUC = 0.779, respectively). Multivariate analysis showed mean hsTnT > 21ng/l was significantly associated with 90-day mortality (OR 43.928, p = 0.004) and MACE (OR 8.177, p = 0.048). HsTnT is predictive of mortality and MACE in the context of open pancreaticoduodenectomy. Association between hsTnT and prolonged critical care stay was less significant. Non-cardiac complications and length of stay show no significant association with hsTnT.

Frailty Is Associated with In-Hospital Morbidity and Nonroutine Disposition in Brain Tumor Patients Undergoing Craniotomy

Frailty is associated with postoperative morbidity in multiple surgical disciplines. We evaluated the association between frailty and early postoperative outcomes for brain tumor patients using a national database. We reviewed the Nationwide Readmissions Database from 2010 to 2014. International Classification of Diseases, ninth revision, codes were used to identify benign and malignant brain tumors treated with surgical resection. Pituitary tumors were excluded. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression was used to conduct analyses assessing the association between frailty and the outcome variables. Statistical significance was defined as P < 0.001. The criteria for frailty were met for 7209 of 87,835 patients (8.2%). After adjustment for patient and hospital factors, frailty was independently associated with in-hospital surgical complications (odds ratio [OR], 1.48; 95% confidence interval [CI] 1.37-1.59; P < 0.0001), mental status changes (OR, 1.9; 95% CI, 1.72-2.09; P < 0.0001), and pulmonary insufficiency (OR, 1.75; 95% CI, 1.55-1.96; P < 0.0001). Frailty was associated with an increased length of stay (incident rate ratio, 1.92; 95% CI, 1.87-1.98; P < 0.0001) and nonroutine disposition (OR, 1.84; 95% CI, 1.72-1.97; P < 0.0001). In-hospital mortality was greater for frail patients (2.2% vs. 1.4%; P < 0.0001), but the difference did not achieve significance on multivariate analysis. Frail patients were not more likely to be readmitted. Frailty is associated with in-hospital complications and nonroutine disposition after craniotomy for benign and malignant brain tumors. Additional work is needed to identify prehabilitation or in-hospital strategies to improve the care and outcomes of these at-risk patients.

Frailty predicts worse outcomes after intracranial meningioma surgery irrespective of existing prognostic factors.

Frailty has been recognized as a predictor of adverse surgical outcomes across multiple surgical disciplines, but until now the relationship between frailty and intracranial meningioma surgery has not been studied. The goal of the present study was to determine the relationship between increasing frailty (determined using the modified Frailty Index [mFI]) and intracranial meningioma resection outcomes (including hospital length of stay [LOS], discharge location, and reoperation and readmission rates). This is a single-center retrospective cohort study of patients who underwent intracranial meningioma resection between August 2012 and May 2018. Seventy-six patients met the inclusion criteria. Frailty was associated with increased hospital LOS (p = 0.0218), increased reoperation rate (p = 0.029), and discharge to a higher level of care: an inpatient rehabilitation facility or a skilled nursing facility (p = 0.0002). After multivariable analysis, frailty was determined to be an independent risk factor for increased LOS, worse discharge disposition, and subsequent readmission. Frailty is an independent risk factor for worse outcomes following intracranial meningioma resection, including increased LOS, reoperations, and worse discharge disposition. Frailty may help stratify preoperative surgical risk, and thus may provide important clinical information to help neurosurgeons and elderly patients weigh the risks and benefits of resection.