Operative Volume Research Articles

Bariatric surgery and relevant comorbidities: a systematic review and meta-analysis.

Obesity is a growing epidemic in the United States, and with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD). Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and non-randomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects. Routine use of IOC was associated with a significantly decreased rate of common bile duct injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rates of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of the IOC group, but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications. Low-quality data limited the conclusions that were drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Future research proposals are suggested to further answer the questions posed.

Impact of COVID-19 pandemic on surgical training in the United States.

The impact of the coronavirus disease COVID-19 pandemic on surgical training in the United States remains a controversial topic. In this study, we examined resident and fellow operative volumes in the pre-COVID-19 and COVID-19 periods across ten different surgical specialties. Accreditation Council for Graduate Medical Education (ACGME) national data reports were collected for ten surgical specialties, including general surgery, neurological surgery, ophthalmology, orthopedic surgery, pediatric surgery, plastic surgery (independent), thoracic surgery, urology, vascular surgery (integrated), and vascular surgery (traditional). Operative volumes were compared between graduates from the pre-COVID-19 (2013-2019) and COVID-19 (2020-2022) periods. Linear regression analysis was used to calculate trends in operative volume. Surgical residents and fellows graduating during the COVID-19 pandemic have greater or similar case volumes, when compared with graduates from the pre-pandemic period. These data suggest that surgical training in the United States has not been compromised by COVID-19 with regard to operative experience.

Abstract TP128: Association Between Hospital Volume and Outcomes of Surgical Procedures for Carotid Stenosis in Japan

Background: Postoperative complication rates of carotid endarterectomy (CEA) and carotid artery stenting (CAS) for carotid artery stenosis are recommended to be maintained below a certain threshold. While the association between hospital volume and the complications has been reported, the situation is uncertain in Japan, one of the countries with the highest density of neuro-specialists. This study aimed to investigate the association between hospital volume and outcomes in patients who underwent CEA or CAS in Japan. Methods: We retrospectively analyzed data from the Japanese nationwide inpatient database on CEA and CAS procedures performed between 2018 and 2021. Hospitals were categorized into four quartiles based on surgical volume, ranging from highest (Q1) to lowest (Q4), with approximately equal numbers of procedures in each quartile. The association between hospital volume and moderate to severe disability (modified Rankin scale > 2 at discharge), in-hospital mortality, perioperative stroke, perioperative pneumonia, and length of hospital stay (LHS) was investigated using multivariate logistic regression and other appropriate analyses. Results: The analysis included 26,675 CEA or CAS procedures performed in 681 hospitals. The overall rates of disability, mortality, perioperative stroke, and pneumonia were 7.4%, 0.5%, 6.6%, and 5.0%, respectively. The rates of disability in Q1, Q2, Q3, and Q4 quartiles were 6.0%, 7.5%, 8.5%, and 7.4%, respectively (Table 1). After adjusting for covariates, Q3 and Q4 were associated with a higher risk of disability (Q3: odds ratio [OR] 1.41, 95% confidence interval [CI] 1.22 – 1.64, Q4: OR 1.41, 95% CI 1.00 - 1.37). Furthermore, Q2, Q3, and Q4 quartiles were associated with a higher risk of perioperative stroke (Q2: OR 1.46, 95% CI 1.26 - 1.70, Q3: OR 1.45, 95% CI 1.25 - 1.69, Q4: OR 2.04, 95% CI 1.77 – 2.36) and pneumonia (Q2: OR 2.01, 95% CI 1.68 – 2.39, Q3: OR 1.89, 95% CI 1.59 – 2.26, Q4: OR 1.79, 95% CI 1.50 – 2.14). The mortality rate was comparable among the four quartiles (Table 2). Additionally, Q2, Q3, and Q4 quartiles were associated with longer LHS. Similar results were observed in patients aged 80 and above. Conclusions: Our findings suggest an association between lower hospital volume and poorer patient outcomes following CEA or CAS. This study indicates the importance of considering surgical volume as a factor to improve outcomes of CEA and CAS in Japan.

Determination of Excavation Volume Using UAV-Based PPK Method in Open Mining Sites Tatlıdere Forests in Düzce

Remote sensing technologies have the potential to provide cost-effective, fast, and easy solutions for the determination of surface changes (material volume) after quarrying (open-pit mine) activities. In areas where the topography is rugged and difficult to access, the use of ground measurement techniques causes difficulties. In such cases, the use of remote sensing techniques is indispensable. The Post Processing Kinematic (PPK) measurement technique provides an alternative solution to other photogrammetry methods in areas whose topography is not suitable for satellite-based positioning. This study investigates the applicability of the UAV based PPK method for the calculation of cut volume in quarry operations. The study area was selected as a quarry located within the boundaries of Tatlıdere Forestry Operation Chief in Düzce province and operated by a legal entity. Using a DJI Phantom 4 RTK unmanned aerial vehicle (UAV) with a PPK application module, a total of two flights in PPK flight mode were performed at the quarry on 30 September 2021 and 19 May 2022 (covering a period of approximately 7 months). The material volume, which is important for quarry operation, was calculated and the excavation volume in the two flight time intervals was found to be 104.170 m³ and the cut area was found to be 44.348 m2. According to the results obtained, UAV systems should be used in quarry management in terms of time and work safety in obtaining data.

NIFTy: near-infrared fluorescence (NIRF) imaging to prevent postsurgical hypoparathyroidism (PoSH) after thyroid surgery—a phase II/III pragmatic, multicentre randomised controlled trial protocol in patients undergoing a total or completion thyroidectomy

IntroductionPostsurgical hypoparathyroidism (PoSH) is an iatrogenic condition that occurs as a complication of several different procedures with thyroid surgery being the most common. PoSH has significant short- and long-term morbidities....

Experience of surgical treatment of combat pancreatic trauma

Background. Pancreatic injuries is a complex challenge for trauma surgeons, especially if combat, due to the presence of combined injuries and complications. The aim: to provide a structure, peculiarities of diagnosis and treatment of combat pancreatic trauma. Materials and methods. A retrospective analysis was done of medical records of 58 inpatients who sustained combat pancreatic trauma during the war in Ukraine. Their average age was 37.4 ± 3.6 years (range 21–60 years). The mechanism of combat injury included gunshot wounds (87.9 %), explosive (10.3 %) and closed injuries (1.7 %). All the wounded underwent laboratory and instrumental investigations. Results. According to the nature of the combat injury, pancreatic injuries were categorised into gunshot shrapnel wounds — 50 (86.2 %), gunshot bullet wounds — 1 (1.7 %), explosive trauma — 6 (10.3 %), and closed combat trauma — 1 (1.7 %) case. Distribution by location of pancreatic injury: tail — 38 (65.5 %), head — 11 (19 %), body — 5 (8.6 %), body and tail — 2 (3.4 %), head and tail — 2 (3.4 %) cases. The following methods of surgical intervention were used: damage control surgery (DCS) — 51 (87.9 %) cases, one-stage surgery — 7 (12.1 %) cases. Distribution by the type of surgical intervention for pancreatic injury: drainage of the parapancreatic space — 45 (77.6 %), pancreatorrhaphy — 4 (6.9 %), distal pancreatosplenectomy — 3 (5.2 %), removal of foreign bodies (metal fragments) — 3 (5.2 %), distal resection of the pancreas with spleen preservation — 1 (1.7 %), pancreatoduodenectomy — 1 (1.7 %), subtotal resection of the body and tail of the pancreas with splenectomy — 1 (1.7 %) case. Common complications (n = 42): peritonitis — 9 (21.4 %), acute surgical sepsis — 8 (19 %), acute renal failure — 7 (16.7 %), multiple organ failure syndrome — 7 (16.7 %), pneumonia — 6 (14.3 %), bleeding — 4 (9.5 %), pulmonary embolism — 1 (2.4 %). Organ-specific complications (n = 28) were as follows: acute pancreatitis — 21 (75 %), pancreatic fistula — 4 (14.3 %), pseudocysts — 2 (7.1 %), abscess — 1 (3.6 %) case. Treatment outcomes: 33 patients (56.9 %) were transferred to the next stage of treatment, 19 (32.8 %) died, and 6 (10.3 %) were discharged with a definite outcome. Mortality rate: 5 (26.3 %) died in the first 3 days, 14 (73.7 %) cases died in the period from 4 to 15 days. Conclusions. The incidence of combat pancreatic trauma among abdominal wounds is 8.7 %. Surgical treatment for combat pancreatic trauma using the DCS is performed in 87.9 % of cases, and in the volume of a single-stage operation, in 12.1 %. The DCS leads to a reduction in the incidence of complications. The overall complication rate for combat pancreatic trauma is 72.4 %, and the incidence of organ-specific complications is 48.3 %. Mortality from pancreatic injuries is 32.8 %. Combat trauma to the head of the pancreas was mainly treated with closed drainage. Distal injuries were treated by resection or drainage.

Colorectal Cancer Surgery at a Regional Cold Site Centre During the SARS-CoV-2 Pandemic: A Comparison With Prepandemic Practices.

Stockholm, Sweden had among the highest excess mortality rates during the first wave of the SARS-CoV-2 pandemic. In March 2020, an entire hospital implemented an infection-free cold site infrastructure and scaled up imperative mainly colorectal cancer surgery, for the Stockholm health care region. The study evaluated the efficacy of the concept. Strict preadmission screening and prophylactic interventions were implemented. The outcomes of the cold site cohort (30th March-21st June 2020) were compared to a prepandemic control. Population-based data on colorectal cancer patients were collected from the Swedish Colorectal Cancer Registry. There were 107 patients in the cold site cohort and 109 in the control cohort. None developed COVID-19 within 30 days postoperatively. The proportions of pelvic and laparoscopic surgery were similar. The cold site cohort had more potentially avoidable stomas (32/94 (34%) vs 19/91 (21%), p = 0.0442). In the region, the proportion of colorectal cancer resections at the cold site increased from prepandemic 12.9% (58 of 448) to 43.3% (94 of 217) (p < 0.001). A SARS-CoV-2-cold site can be kept infection-free by screening, allowing increased volumes of colorectal cancer surgery with outcomes comparable to prepandemic practice. The cold site model should be more widely adopted in future similar scenarios. This study reports on the implementation of an entire cold site hospital for imperative colorectal surgery, in particular colorectal cancer, during the SARS-CoV-2 pandemic. By comparing outcomes to prepandemic practices, we demonstrated that the cold site hospital was effective in preventing infection and safely increasing surgical volume many-fold.

Utility of Diaphragm Dome Height as a Marker of Operational Lung Volume Changes, Disease Burden and Exacerbations in Patients with Mild-to-Moderate COPD: An Observational Study Within the CanCOLD Cohort

BackgroundDynamic hyperinflation is central to dyspnoea, exercise limitation, and exacerbations in chronic obstructive pulmonary disease (COPD). While studied previously in moderate-severe COPD, the relevance of diaphragm dome height on clinically important outcomes has been under-investigated in mild-to-moderate COPD.MethodsCanadian Cohort Obstructive Lung Disease participants with spirometry-confirmed COPD, symptom-limited incremental cardiopulmonary exercise testing, and computed tomography image data were included. Base-to-apex left and right diaphragm dome height (DDH) was automatically segmented, with increased height implying less flattening and thus less hyperinflation. Dynamic hyperinflation was defined as ≥150 mL reduction in inspiratory capacity (IC) from rest to peak-exercise. Cross-sectional linear regression models were fitted between left and right DDH (predictor variables) with peak IC (ICpeak), peak workload (Wpeak), FEV1, and CAT score (outcome variables), and in longitudinal (Anderson-Gill) models with “symptom-based” and “event-based” exacerbations. Results are reported as parameter estimates or hazard ratios with 95%CIs per interquartile range dome height increment.ResultsAmong 304 participants (mean age 64.7±10.3, 41.8% female, 44.4% with mild COPD), each left and right DDH increment, respectively, was associated with ICpeak(0.21[0.13,0.29]L, 0.13[0.07,0.19]L), Wpeak(9.54[5.03,14.04]W, 6.04[2.45,9.62]W), FEV1(0.17[0.10,0.25]L, 0.08[0.02,0.14]L), and CAT score (−1.36[−2.39,−0.33], −0.82[−1.63,0.00]). Left DDH alone was associated with both symptom-based (HR: 0.82[0.74,0.91]) and event-based (0.83[0.73,0.95]) exacerbations. Of 167/304 participants with confirmed dynamic hyperinflation (ΔIC=−0.47±0.25 L), left DDH alone was associated with all outcomes (ICpeak, Wpeak, FEV1, CAT, and symptom-based/event-based exacerbations).ConclusionsLeft DDH appears to be a clinically important marker for operational lung volume changes, lung function, exercise performance, disease burden, and exacerbations in mild-to-moderate COPD.

Does orthognathic surgery affect tooth root length and volume: a retrospective cohort study.

To examine tooth root length and root volume in cone beam computed tomography (CBCT) images in patients with skeletal Class II and III anomalies who have undergone single-jaw (SJ) and double-jaw (DJ) orthognathic surgery, and to compare the changes between jaws with and without osteotomy. This study was conducted on the archive records of a total of 60 adults: 36 women and 24 men with an average age of 21.1 ± 3.1 years, whose CBCT images were recorded just before orthognathic surgery and within 6-12 months after surgery. The sample was divided into four groups with 15 individuals in each: Class II SJ (mandibular advancement only), Class II DJ (maxillary advancement and impaction with mandibular advancement), Class III SJ (maxillary advancement and impaction), and Class III DJ (maxillary advancement and impaction with mandibular setback). Within groups, statistically significant decreases in root length and root volume were found in the period between preorthognatic and postorthognathic surgery (P < .05). No statistically significant differences were found in comparisons between groups (P > .05). Regardless of the type of skeletal anomaly in the sagittal direction and the orthognathic surgery performed, a statistically significant but clinically insignificant decrease was found in tooth root length and root volume during the postorthognathic surgery period, both in jaws with and without osteotomy.

The application of full-thickness advancement flap of upper abdominal wall in breast-conserving surgery for lower quadrant breast cancer

Objective: To explore the application of full-thickness advancement flap of upper abdominal wall in breast-conserving surgery for lower quadrant breast cancer. Methods: This is a retrospective case series study. The clinic data of 25 lower quadrant breast cancer patients who underwent a breast-conserving surgery with advancement flap of full-thickness of upper abdominal wall at the Breast Center, Beijing Tongren Hospital, Capital Medical University, from June 2022 to September 2023 were analyzed retrospectively. All patients were female, aged (47.6±5.8) years (range: 38 to 57 years). Tumor staging included stageⅠ in 8 cases, stageⅡA in 13 cases, stageⅡB in 4 cases. The subcutaneous fat thickness of the upper abdominal walls and the volume of wide local excision of the tumor were measured and recorded. The operation time of repairing the breast, the duration of retention of postoperative drainage tubes, postoperative complications, and cosmetic results were recorded. Results: The subcutaneous fat thickness in the upper abdominal walls was (1.7±0.2) cm (range: 1.3 to 2.2 cm), the excision volume of breast-conserving surgery was (70.8±13.6) mm3 (range: 49 to 97 mm3), the operation time of repairing the breast was (55.4±5.1) minutes (range: 45 to 65 minutes) and the retention time of the drainage tube was (7.4±0.8) days (range: 6 to 9 days). Cosmetic results: excellent in 12 cases (48.0%), good in 9 cases (36.0%) and fair in 4 cases (16.0%). There was 1 case of postoperative seroma in the donor area, which healed after repositioning the negative pressure drain. Conclusion: In breast-conserving surgery for lower quadrant breast cancer, using a full-thickness abdominal wall advancement flap to repair breast defects is a simple and effective tumor reconstructive technique, yielding good results in achieving postoperative symmetry of the lower quadrant of the breast.

Favorable 30-day outcomes of initial open inguinal hernia repair with local anesthesia among frail patients.

Open inguinal hernia repair (OIHR) can be conducted under either general anesthesia (GA) or local anesthesia (LA). Despite a lack of evidence supporting improved perioperative outcomes, GA is the predominant anesthesia type used in OIHR. Frailty is defined as a clinically recognizable state of age-related increased vulnerability. This study aimed to compare the 30-day perioperative outcomes of frail patients undergoing OIHR with either GA or LA. Patients who underwent initial OIHR were identified in the ACS-NSQIP database from 2005-2021. Patients with a Modified Frailty Index (mFI)≥2 were included. Patients were divided based on GA or LA administered. Multivariable logistic regression was used to compare 30-day perioperative outcomes between frail patients undergoing OIHR under GA or LA. Among 20,129 frail patients who underwent initial OIHR, 13,473 had GA, and 3686 had LA. The 30-day mortality rates for LA and GA were low. However, frail patients who underwent LA had a lower risk of bleeding (aOR 0.282, P=0.04), superficial surgical site infection (aOR 0.450, P=0.03), and discharge not to home (aOR 0.792, P<0.01). In addition, frail patients who underwent LA had shorter operation time (58.42±25.26 vs 67.60±37.17 mins, P<0.01) and a shorter length of stay (0.45±2.30 vs 0.57±2.96 days, P<0.01). Although GA is the dominant anesthesia use (4:1) in OIHR among frail patients, LA emerges as a safe alternative to GA for these patients, offering potential benefits such as reduced complications and increased day-case surgery volume, which may be associated with decreased healthcare costs.

Chronic total occlusion- Percutaneous coronary intervention (CTO-PCI) experience in a single, multi-operator Tunisian center : A Five-Year Report.

In recent years, advancements in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have been notable, improving procedural techniques, imaging, and management of complications. We sought to assess the performance and the practice of a high-volume Tunisian PCI center in treating patients with a CTO. We retrospectively evaluated data from consecutive CTO patients who underwent percutaneous revascularization from October 2019 to January 2024 at the cardiology department of Habib Thameur Teaching Hospital, Tunisia. Operators' experience and CTO-PCI volume were also documented. The cohort consisted of 58 patients, predominantly male (86.2%), with an average age of 59.8±9.6 years. The right coronary artery was the most common CTO site (56.9%). The antegrade approach was adopted in 96.5% of the cases, with the antegrade wiring (AW) being the preferred technique (81%). Key procedural characteristics included the use of multiple access sites and dual coronary injection in 44.8% of the cases, multiple guidewires in 50%, additional support modality in 68.9% and drug-eluting stents in all instances. The procedural success rate was 75.9%, with an in-hospital adverse outcome rate of 13.8% and a major adverse cardiac event (MACE) rate of 3.4%. A significant impact of operator experience and volume on success rates (85.3% vs 62.5%, p=0.04) and adverse outcomes (25% vs 5.8%, p=0.03) was observed, with trained operators and higher-volume practitioners achieving better results. In a single-center setting with a conservative CTO cohort, acceptable PCI success rates were achieved. We highlighted the positive impact of CTO training programs and PCI procedures volume on the overall outcomes.

Treatment modalities and trends for hospitalized patients with neovascular glaucoma: A retrospective study of 10 years.

To analyze the treatment modalities and trends for neovascular glaucoma (NVG) over the past 10 years, we conducted a retrospective analysis at Zhongshan Ophthalmic Center on 1331 NVG inpatients who received 1459 treatments for 1383 eyes between January 1, 2012, and December 31, 2021. Over time, we observed a progressive annual increase in both the number of patients and the volume of surgeries for NVG, with an annual percentage change (APC) of 10.23% (95% confidence interval [CI]: 5.5-15.2%, P = 0.001) and 11.59% (95% CI: 6.6-16.9%, P = 0.001), respectively. Drainage valve implantation (46.88%), cyclodestructive procedures (22.55%) and trabeculectomy (6.24%) were the three most commonly selected treatment options. The frequency of drainage valve implantation (APC = 6.59%, 95% CI = 0.9-12.6%, P = 0.028), cyclodestructive procedures (APC = 17.26%, 95% CI = 9.3-25.8%, P = 0.001) and trabeculectomy (APC = 21.93%, 95% CI = 1.6-46.3%, P = 0.036) increased. The proportion of drainage valve implantation gradually decreased (APC = -4.48%, 95% CI = -8.6 to -0.2%, P = 0.042), while that of cyclodestructive procedures increased (APC = 5.08%, 95% CI = 0.6-9.8%, P = 0.042), with no significant alteration observed in the proportion of trabeculectomy (APC = 9.26%, 95% CI = -8.8 to 30.9%, P = 0.290). Over the course of the study, both the cases of NVG and the volume of related surgeries escalated year by year. Among the three most frequently employed procedures-drainage valve implantation, cyclodestructive procedures and trabeculectomy-annual frequency trends revealed an increase in drainage valve implantation alongside a decreasing proportion, while cyclodestructive procedures exhibited a rising trend in both frequency and proportion; simultaneously, trabeculectomy showed an increasing frequency without a significant change in its proportion.

Outpatient surgical institutions in the rural United States: Trends from 2010 to 2020.

The volume and proportion of surgeries occurring in outpatient settings has increased. However, the growth and distribution of outpatient surgical institutions, namely ambulatory surgery centers (ASCs) and hospital-based outpatient surgical departments (HOPDs), remains understudied in rural areas. We used descriptive statistics and a multivariate logistic regression to assess the growth and distribution of ASCs and HOPDs in rural areas from 2010 to 2020, leveraging the Area Health Resources Files and American Community Survey. From 2010 to 2020, the number of ASCs in rural counties decreased by 4.9​% (410 vs. 390), and rural HOPDs decreased by 14.3​% (1400 vs. 1200). Completely rural counties were over five times likelier to lack both ASCs and HOPDs (AOR​=​5.32; 95​% CI​=​[4.82-5.89]); p​<​0.001). Outpatient surgical institution access in rural America declined. Policymakers should protect rural HOPDs, promote the creation of ASCs in rural communities, and incentivize surgeons to enter rural practice.

Feasibility Study on Helicopter Operation Volume Modeling under VFR for Monitoring Specific Ground Location

Feasibility Study on Helicopter Operation Volume Modeling under VFR for Monitoring Specific Ground Location

National Trends and Outcomes of Pedal Bypass Surgery

ObjectiveThe technical demands associated with pedal bypass (PB) surgery place it at risk of underutilization and may be limiting its widespread adoption as a valuable revascularization modality. This study aims to evaluate trends in PB performance, assess its outcomes, and compare its results between high- and low-volume centers. MethodsAll patients receiving a PB between 2003 and 2023 were identified in the Vascular Quality Initiative (VQI) infrainguinal bypass (IIB) module. The ratio of PB to total IIB performed was calculated for each year and trended over the study period. Centers performing PB were categorized according to their annual PB volume into tertiles of low-volume centers (LVC, <2 PB/year), medium-volume centers (MVC, 2-4 PB/year), and high-volume centers (HVC, >4 PB/year) for comparison. Patient characteristics and outcomes were compared using the χ2 or Fisher exact test as appropriate for categorical variables and the analysis of variance test or Kruskal-Wallis test as appropriate for continuous variables. Cox regression analysis was used to study the association between center volume and the primary outcomes of primary patency, primary-assisted patency, secondary patency, reintervention, amputation, and major adverse limb events (MALE), defined as the composite outcome of amputation and/or reintervention. ResultsA total of 3466 patients received a PB during the study period. The ratio of PB to IIB dropped from 14% to 4% between 2003 and 2023. Primary, primary-assisted, and secondary patency rates were 65%, 76%, and 80%, respectively, and limb salvage rate was 83% at 1 year. Nineteen percent of centers performing IIBs in the VQI did not perform any PBs during the study period. Of the 246 centers performing PBs, 78% were LVC, 15% were MVC, and only 7% were HVC. On Cox regression analysis, HVCs were associated with a lower risk of primary patency loss (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66-0.95; P = .010), reintervention (HR, 0.75; 95% CI, 0.60-0.95; P = .016), amputation (HR, 0.77; 95% CI, 0.61-0.98; P = .034), and MALE (HR, 0.78; 95% CI, 0.66-0.93; P = .005) compared with LVCs. No difference in secondary patency between high- and low-volume centers was observed (P = .680). ConclusionsThe utilization of PB operations experienced a four-fold decrease over the past 20 years, despite favorable patency and limb salvage outcomes. Centers with a higher operative volume in PB achieve better outcomes than LVCs, and accordingly, patients with extensive tibioperoneal disease may benefit from evaluation at centers with documented expertise in PB before resorting to an alternative revascularization modality or a major limb amputation.

Spontaneous pneumothorax: intubated or non-intubated surgery?

The aim of our clinical study was to justify and implement non-intubated video assisted thoracic surgery as a part of enhanced recovery after surgery pathway in treatment of spontaneous pneumothorax. Data of 150 patients who underwent surgical treatment were retrospectively analyzed. Among them group 1 of 75 patients underwent video-assisted thoracoscopic surgery (VATS) and group 2 of 75 patients underwent non-intubated VATS surgical treatment. All patients underwent atypical resection of the lung and pleural abrasion, diaphragm augmentation with mesh if diaphragm endometriosis was suspected. The perioperative data, short-term outcomes and recurrence rates of these two groups were compared. The two groups had comparable demographic, perioperative investigations, fluid infusions during surgery, the volume of surgery intraoperatively, blood loss, time for chest drain removal, length of stay in the hospital and the rate of complications. There were no conversions to thoracotomy or intubated general anaesthesia, no mortality. The peak end-tidal carbon dioxide was significantly higher in the non-intubated group than in the intubated group (mean: 48±8.6 vs 34±6.2 mmHg, p&lt;0.001). The mean follow-up was 20.2±3.9 months in the non-intubated group and 24.7±4.2 months in the intubated group (p&gt;0.05). Chest tube duration was 4.11 days in group 1 and 3.76 days in group 2. The recurrence rate of pneumothorax after surgery was 4% in both groups. Nnon-intubated video-assisted thoracic surgery for spontaneous pneumothorax could be considered a feasible, safe and effective method of treatment, even with mesh diaphragm augmentation, in cases of catamenial pneumothorax and can be a part of Enhanced Recovery After Surgery pathway. Continious follow-up and additional clinical investigations are supposed to validate the profits of the suggested approach.

Comparison of volumetric analysis between conventional and rotary files in the preparation of root canals in primary molars-an in vitro study.

To compare and evaluate the efficacy of canal preparation and volumetric filling of primary molars instrumented by conventional hand K-file, ProAF baby rotary file and Kedo-S square file using cone beam computed tomography. Thirty freshly extracted human primary second molars were randomly divided into 3 groups of 10 teeth each. After access opening and working length determination, preoperative volume analysis was done using cone beam computed tomography (CBCT). The canals were then instrumented by either hand K-files, Pro AF Baby rotary files and Kedo-S square rotary files. Post operative volume analysis was performed using CBCT. All the canals were obturated using Metapex and scanned again using CBCT. Mean values of the pre- and post-operative canal volumes were analyzed using one-way ANOVA. Inter- and intra- group volumetric changes were analyzed statistically by post hoc test. The mean difference in volume after canal preparation and obturation was the highest in the hand K-file group, followed by Pro AF Baby Gold group and the least in the Kedo-S square group. Inter and intra group comparison showed statistically significant differences for all the file groups used. Kedo- S square showed the least difference in preparation volume and better obturating volume compared to Pro AF baby gold file systems.

Analisis Retention Time Terhadap Pemisahan Fasa Pada Three Phase Separator di Unit Lube Oil Complex (LOC) III

This research analyzes the retention time of the three phase separator in separating oil, water, and gas phases at PT Pertamina refinery unit IV Cilacap. With an initial retention time ranging from 31 - 34 minutes, there are phases that are still not separated in the separator. This study aims to provide recommendations for retention time based on unseparated phases and how to apply them to the separator at the refinery. This study involves three types of lube oil analyzed, namely DAO, MMO, and LMO. The results show that there is still a difference between the phases at the inlet and outlet which indicates that the phase separation at the initial retention time is still not optimal so that new retention time recommendations need to be made. In the type of DAO lube oil with a retention time of 33 minutes with the largest difference at the inlet and outlet of 0.040. In the type of MMO lube oil with a retention time of 31.2 minutes with the largest difference of 0.037. In the type of LMO lube oil with a retention time of 34.2 minutes with the largest difference of 0.036. After making retention time recommendations based on the results of the difference between inlet and outlet, the retention time recommendations for DAO are 54.6 minutes, MMO is 51.6 minutes, and LMO is 55.8 minutes. The application of retention time recommendations for the separator can be done by optimizing the flow rate at 432,439 m3/day or adding new separator facilities that can accommodate operational volumes of up to 60.4 m3.

Demographics of Ophthalmology and Optometry Practices and Changes in Utilization Patterns of Procedures and Services Following Private Equity Acquisition.

To characterize private equity (PE) acquisition of ophthalmology and optometry practices and compare procedural utilization before and after acquisition. Ophthalmologists and optometrists in practices acquired from 2012 to 2016 were identified and characterized using an internet archive with an additional search in 2017 to characterize doctor turnover. United States Census Bureau and Internal Revenue Service Data were used to determine population health insurance and adjusted gross income (AGI). Healthcare Common Procedure Coding System codes were drawn from the Medicare database. Six platform companies acquired 36 practices between 2012 and 2016, including 518 optometrists and 136 ophthalmologists with a net doctor decrease of 3% and 7%, respectively (years 2016 to 2017). PE firm-owned practices were primarily located in metropolitan core areas with above-average AGI and insurance coverage. Diagnostic procedures, total encounters, cataract surgery, and yttrium aluminum garnet (YAG) capsulotomy volume increased per physician 1-year post-acquisition. In adjusted difference-in-difference comparisons, cataract surgery (13.3% relative increase, P<0.001) and YAG capsulotomy (35.6% relative increase, P<0.001) remained significant. PE practices demonstrated an increase in cataract surgery procedures (28,813/platform pre-acquisition to 33,930/platform post-acquisition, P=0.015). PE acquisitions of ophthalmology and optometry practices were centered in metropolitan core areas with above-average AGI and insurance coverage. PE acquisition led to less optometrists and ophthalmologists employed at the practice. Overall, they exhibited doctor turnover with a net doctor decrease. When compared to non-PE doctors, PE-acquired doctors demonstrated an increase in cataract surgery and YAG capsulotomy volume. Overall, cataract surgery volume increased among PE practices after acquisition.