Part Of Preoperative Assessment Research Articles

Current practice of pre-operative assessment at a public sector hospital in Pakistan - a clinical audit.

To assess the practice of ordering unnecessary laboratory investigations by primary surgical teams. The clinical audit was conducted from December 17, 2022, to January 15, 2023, at the Civil Hospital, Karachi, and comprised primary surgeons working in different surgical units who ordered laboratory investigations for patients as a part of preoperative assessment. Data was collected using a self-administered questionnaire. Data was analysed using SPSS 20. Of the 280 surgeons approached, 249(89%) responded. The units covered were General surgery 96(38.5%), Gynaecology 74(29.7%), Neurosurgery 5(2.0%), Ear, Nose and Throat 19(7.6%), Plastic surgery 15(6.02%), Paediatric surgery 13(5.2%), Vascular surgery 8(3.21%), Oromaxilofacial 9(3.61%), Opthalmology 6(2.4%), and Orthopaedics 4(1.60%).As part of baseline investigations, 244(98%) surgeons ordered complete blood count, 173(69.5%) ordered urea and creatinine, 229(92%) ordered viral markers, 197(78.7%) ordered fasting and random blood glucose, and 178(71.5%) focussed on cardiac fitness. A need was found to establish standard protocols for pre-surgery evaluation so that unnecessary investigations may be avoided.

Sarcopenia as a Preoperative Risk Stratification Tool among Older Adults with Inflammatory Bowel Disease.

Sarcopenia, defined as a loss of muscle mass and function, is a physiologic factor that has been implicated as a predictor of adverse postoperative outcomes in many older adult populations. However, data related to sarcopenia in older adults with inflammatory bowel disease (IBD) remain limited. Older adults with IBD are particularly vulnerable to adverse postoperative outcomes, in part, due to muscle depletion from systemic inflammation, malnutrition, and reduced physical activity. However, few patients undergo routine muscle evaluation as a part of preoperative assessment. Moreover, cut-off values for measures of sarcopenia in the literature are modeled after non-IBD populations. The lack of standardized measures and values for sarcopenia in the IBD patient population has led to heterogenous findings and a paucity of preoperative risk stratification tools. Therefore, we aim to explore the scope of sarcopenia as a preoperative risk stratification tool among older adults with IBD.

Determination of Cutoff Diameter of Great Saphenous Vein as Indicative of SaphenoFemoral Junction Incompetence in Cases of Varicose Veins

Abstract Introduction: Saphenofemoral junction (SFJ) incompetence is the most commonly attributed etiological factor in varicose veins of lower limbs with a consequent increase in the caliber of the great saphenous vein (GSV). This study aimed to assess GSV diameter to determine its cutoff diameter value for predicting reflux at the SFJ, in cases of varicose veins. Methods: This hospital-based prospective study was conducted on 156 patients (245 diseased limbs) over a period of 2 years, involving patients referred from the outpatient department for evaluation of varicose veins or those being evaluated as a part of preoperative assessment. Results: The cutoff value of GSV diameter to detect SFJ incompetence was determined at 5.4 mm with best sensitivity of 74.3%, specificity of 78.5%, and accuracy of 75.1%. Conclusion: GSV diameter assessment is of immense clinical importance as it can help the treating physician to filter out the false-negative cases solely being diagnosed based on reflux at SFJ, especially those with an absence of obvious clinical signs.

Angle κ Measurement and Its Correlation with Other Ocular Parameters in Normal Population by a New Imaging Modality.

This study obtained normative database for angle κ using Orbscan 3. The average angle κ values were 2.3 ± 1.34° in the whole sample, 2.23 ± 1.36° in myopic eyes, and 3.3 ±1.5° in hyperopic eyes. This is very important to optimize refractive surgery outcomes. The aim of this cross-sectional study was to obtain the value of mean angle κ in normal eyes of patients seeking laser vision correction, by the Orbscan 3. The study was conducted on healthy eyes of people seeking laser refractive surgery. A total of 1815 eyes of 908 candidates were included. These were examined as a part of pre-operative assessment. Orbscan 3 was used to measure angle κ and its XY intercepts, keratometry readings, central corneal thickness, thinnest location, white-to-white diameter, and corneal asphericity of front surface (Qf) and back surface (Qb). The mean ± standard deviation angle κ in all eyes was 2.3 ± 1.34°. The values were 2.23 ± 1.36° in myopic eyes, 3.3 ±1.5° in hyperopic eyes, and 2.9 ±1.6° in emmetropic eyes. Positive correlation was found between angle κ and age, spherical equivalent, subjective sphere, and white-to-white diameter. On the other hand, axial length, average keratometry, central corneal thickness, pupil diameter, and asphericity Q front were negatively correlated with angle κ. The mean ± standard deviation angle κ value measured by the Orbscan 3 was 2.3 ± 1.34°. This could be attributed to different software used, in addition to the relatively high axial length in the studied eyes.

Current and Future Directions of Breast MRI.

Magnetic resonance imaging (MRI) is the most sensitive exam for detecting breast cancer. The American College of Radiology recommends women with 20% or greater lifetime risk of developing breast cancer be screened annually with MRI. However, other high-risk populations would also benefit. Hartmann et al. reported women with atypical hyperplasia have nearly a 30% incidence of breast cancer at 25-year follow-up. Women with dense breast tissue have up to a 4-fold increased risk of breast cancer when compared to average-risk women; their cancers are more likely to be mammographically occult. Because multiple cohorts of women are at high risk for developing breast cancer, there has been a movement to develop an abbreviated MRI (abMRI) protocol to expand the availability of MRI screening. Studies on abMRI effectiveness have been promising, with Weinstein et al. demonstrating a cancer detection rate of 27.4/1000 in women with dense breasts after a negative digital breast tomosynthesis. Breast MRI is also used to evaluate the extent of disease as part of preoperative assessment in women with newly diagnosed breast cancer, and to assess a patient’s response to neoadjuvant chemotherapy. This paper aims to explore the current uses of MRI and propose future indications and directions.

696 Are Group and Save Samples Necessary for Common Urological Procedures?

Abstract Aim Blood tests are routinely performed as a part of pre-operative assessment (pre-op). We looked at the number of group and save (G+S) samples taken at pre-op and compared that to the number of patients needing blood transfusion having undergone common Urological procedures at our hospital. Our objective was to assess the utility of this invasive procedure in this clinical setting. Method Data was retrospectively collected from electronic patient records on 413 patients undergoing elective urological procedures 1st June 2020 to 30th September 2020 at Colchester General Hospital. Major procedures like radical prostatectomies, nephrectomies were excluded. Patients who had G+S samples done prior to surgery were checked. This was compared to the patients who required transfusions. Results Amongst 413 patients who underwent an elective urological procedure, 169(41%) were day-case endoscopic, 151(37%) were inpatient, and 93(22%) were penoscrotal procedures. 104(25%) patients had G+S taken, with only 5 patients (1.2%) requiring transfusion. 24(14.2%) patients undergoing day case procedures,79(52.3%) patients undergoing inpatient procedures and 1(1.1%) patient undergoing penoscrotal procedures had G+S tests done. Only 7(1.7%) patients had a baseline haemoglobin of less than 100. Conclusions Our data showed that many G+S samples were unnecessary. TURBTs (transurethral resection of bladder tumours) were most likely to need transfusion. Education was fed-back to those running pre-operative assessment clinics that G+S should be considered for TURBTs and those with Hb < 100. We recommend running this audit again to further quantify the G+S tests which could be avoided.

Pulmonary hypertension: A simplified pulmonologists' perspective

Pulmonary hypertension (PH) is a progressive disorder of the pulmonary vasculature caused due to vasoconstriction, vasodestruction, or vaso-obliteration. PH results from heterogeneous pathophysiologic mechanisms culminating in elevation of mean pulmonary arterial pressure. Patients may either present with symptoms or with chest radiographic, electrocardiographic, or echocardiographic findings done as a part of diagnostic evaluation for the primary disease or as a part of preoperative assessment. And hence, the clinician resorted to could be a family physician, pulmonologist, cardiologist, surgeon, or anesthesiologist. Hence, there is a necessity of a basic awareness about its clinical presentations, diagnostic modalities, and the available treatment options. The diagnosis can be perplexing and warrants a stepwise evaluation. Echocardiography (ECHO) is the preliminary diagnostic modality and provides a fairly accurate judgment of the pulmonary artery pressure; however, some patients may require an invasive evaluation by right heart catheterization. The definitive management of PH depends on the underlying etiology. Pulmonary arterial hypertension has a specific set of targeted pharmacotherapy, while for other categories of PH, treatment majorly focuses on counseling, management of the underlying disorder, and cardiopulmonary rehabilitation. The 6th World Symposium on PH has catered to all these issues and has incorporated manifold pertinent modifications in all these areas. Hence, we conducted an online survey to gauge the awareness about the entity and its facets among pulmonologists and penned down this review based the current concepts about PH to bridge the gaps in the existing knowledge.

Motor Cortical Network Plasticity in Patients With Recurrent Brain Tumors.

Objective: The adult brain’s potential for plastic reorganization is an important mechanism for the preservation and restoration of function in patients with primary glial neoplasm. Patients with recurrent brain tumors requiring multiple interventions over time present an opportunity to examine brain reorganization. Magnetoencephalography (MEG) is a noninvasive imaging modality that can be used for motor cortical network mapping which, when performed at regular intervals, offers insight into this process of reorganization. Utilizing MEG-based motor mapping, we sought to characterize the reorganization of motor cortical networks over time in a cohort of 78 patients with recurrent glioma.Methods: MEG-based motor cortical maps were obtained by measuring event-related desynchronization (ERD) in ß-band frequency during unilateral index finger flexion. Each patient presented at our Department at least on two occasions for tumor resection due to tumor recurrence, and MEG-based motor mapping was performed as part of preoperative assessment before each surgical resection. Whole-brain activation patterns from first to second MEG scan (obtained before first and second surgery) were compared. Additionally, we calculated distances of activation peaks, which represent the location of the primary motor cortex (MC), to determine the magnitude of movement in motor eloquent areas between the first and second MEG scan. We also explored which demographic, anatomic, and pathological factors influence these shifts.Results: The whole-brain activation motor maps showed a subtle movement of the primary MC from first to second timepoint, as was confirmed by the determination of motor activation peaks. The shift of ipsilesional MC was directly correlated with a frontal-parietal tumor location (p < 0.001), presence of motor deficits (p = 0.021), and with a longer period between MEG scans (p = 0.048). Also, a disengagement of wide areas in the contralesional (ipsilateral to finger movement) hemisphere at the second time point was observed.Conclusions: MEG imaging is a sensitive method for depicting the plasticity of the motor cortical network. Although the location of the primary MC undergoes only subtle changes, appreciable shifts can occur in the setting of a stronger and longer impairment of the tumor on the MC. The ipsilateral hemisphere may serve as a reservoir for functional recovery.

Association Between Preoperative Magnetic Resonance Imaging–based Urethral Parameters and Continence Recovery Following Robot-assisted Radical Prostatectomy

BackgroundStudies demonstrated the significance of membranous urethral length (MUL) as a predictor of continence following robot-assisted radical prostatectomy (RARP). There are other magnetic resonance imaging (MRI) parameters that might be linked to continence outcome. ObjectiveTo evaluate the association between preoperative urethral parameters on MRI and continence outcome, to estimate the risk of incontinence using different cut-off values, and to assess interobserver variability in measuring urethral parameters. Design, setting, and participantsPatients with localised prostate cancer who underwent RARP were retrospectively reviewed. Baseline patient characteristics, perioperative, and pathological outcomes were assessed. Continence was defined as no pad or a safety pad with <2g/24h pad weight. Outcome measurements and statistical analysisSeveral MRI variables were measured by a uroradiologist, a uro-oncology fellow, and a urologist. Binary logistic regression analyses were performed to identify predictors of incontinence. Interclass correlation was used to evaluate interobserver variability. Results and limitationsA total of 190 patients met the study inclusion criteria. The mean MUL was 14.6mm. Age and MUL were significantly associated with incontinence outcome. The area under the receiver operating characteristic curve for continence based on MUL was 0.78 at 12 mo. The risk of incontinence in patients with MUL of <10mm was 27.8% (13.8% and 39.1% for patients aged <65 and >65 yr respectively). Conversely, the risk of incontinence with MUL >15mm was 2.7% (1.5% and 4.5% for patients aged <65 and >65 yr, respectively). The concordance rate between different observers was 89% for coronal MUL, but 77%, 74%, and 62% for sagittal MUL, membranous urethral thickness, and intraprostatic urethral length, respectively. ConclusionsThis study confirmed the significance of MUL for the continence outcome following RARP. There was also excellent consistency in measuring MUL values between different observers. Patient summaryAlthough further studies would be required to verify our findings, we support the significance of membranous urethral length in predicting the risk of incontinence and the need to incorporate it as part of preoperative assessment and counselling. This can reliably be measured by urologists and can further facilitate a patient-tailored approach to radical treatment of prostate cancer.

Impact of Functional Magnetic Resonance Imaging on Clinical Outcomes in a Propensity-Matched Low Grade Glioma Cohort

This study aims to evaluate the impact of preoperative functional magnetic resonance imaging (fMRI) on clinical outcomes in patients with low grade glioma (LGG). In a retrospective propensity-matched cohort study, we compared patients with LGG based on whether they underwent fMRI as part of preoperative assessment. Twelve patients with LGG who underwent preoperative fMRI were selected, and a contemporaneous group of 12 control patients with LGG who did not undergo fMRI were matched to the fMRI group based on age, sex, and 1p/19q status. fMRI group subjects tended to have more aggressive surgeries (67% resection, 33% biopsy) than the control group (33% resection, 67% biopsy). There were no significant differences in outcomes between the 2 groups. Time between clinical assessment and surgery tended to be longer in the fMRI group (6.3 ± 4.2 weeks) than in the control group (2.7 ± 2.2 weeks). Extent of resection was similar between the 2 cohorts. fMRI group subjects had lower preoperative functional status and tended to have a greater postoperative functional status improvement than control group subjects. Mean survival was not significantly different (fMRI group 5-year survival: 88.9%, control group 5-year survival: 61.1%). We evaluated the impact of preoperative fMRI in patients with LGG in this propensity-matched cohort study. This study has not demonstrated any significant difference in outcomes between the fMRI and control groups; however, there were nonsignificant trends for patients who underwent fMRI to undergo more aggressive surgical interventions and have a greater postoperative functional status improvement.

MP05-13 ASSOCIATION BETWEEN MRI BASED URETHRAL PARAMETERS AND CONTINENCE FOLLOWING ROBOT ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy I1 Apr 2018MP05-13 ASSOCIATION BETWEEN MRI BASED URETHRAL PARAMETERS AND CONTINENCE FOLLOWING ROBOT ASSISTED RADICAL PROSTATECTOMY Lawrence H C Kim, Amit Patel, Netty Kinsella, Mansour Taghavi Azar Sharabiani, Derfel Ap Dafydd, and Declan Cahill Lawrence H C KimLawrence H C Kim More articles by this author , Amit PatelAmit Patel More articles by this author , Netty KinsellaNetty Kinsella More articles by this author , Mansour Taghavi Azar SharabianiMansour Taghavi Azar Sharabiani More articles by this author , Derfel Ap DafyddDerfel Ap Dafydd More articles by this author , and Declan CahillDeclan Cahill More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.184AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Studies demonstrated various predictors of incontinence following radical prostatectomy. Although there is no consensus on the exact anatomy of the structures believed to be integral to continence, membranous urethral length (MUL) has been demonstrated to be a predictor in several studies. It is also postulated that other urethral parameters such as intraprostatic urethral length (IUL) and membranous urethral thickness (MUT) might play a part. The objectives of our study were: (1) To evaluate the association between preoperative urethral parameters on MRI and continence; (2) To estimate the risk of incontinence using different cut off values; (3) To assess interobserver variability in measuring urethral parameters. METHODS We conducted a retrospective review of patients who underwent robot-assisted robotic Prostatectomy (RARP) by a high volume single surgeon. Patients who received previous treatment, adjuvant therapy (ie. Radiotherapy or hormonal therapy) or were lost to follow up were excluded from the study. Baseline patient characteristics were obtained: age, BMI, ASA, prostate volume, IPSS, PSA, estimated blood loss, Gleason score, pelvic lymph node dissection, staging, nerve sparing, surgical margin status, and complications. Continence was defined as no pad or a safety pad. MRI variables such as MUL, IUL, and MUT were measured by consultant uro-radiologist, uro-oncology fellow, and consultant urologist. Multivariate logistic regression analyses were performed to identify predictors of incontinence. Interclass correlation was used to evaluate interobserver variability. RESULTS 190 patients met the study inclusion criteria. The mean age was 62 years. The mean MUL was 14.6cm (6-24). Age and MUL were significantly associated with incontinence outcome at immediate, 3, 6 and 12 months postoperatively. After age adjustment, MUL remained to be a significant predictor. The area under the ROC curve for continence based on MUL was 0.79 at 12 months. The risk of incontinence in patients with MUL of <10mm was 32.4% (19.5%, and 44.7% for patients <65 years of age, and =65, respectively). Conversely, the risk of incontinence with MUL > 15mm was 1.3% (0.8%, and 2.2% for patients <65 years, and =65, respectively). The concordance rate between different observers was 89% for coronal MUL but 77%, 74% and 62% for sagittal MUL, MUT and for IUL, respectively. CONCLUSIONS Our study confirmed the significance of MUL on the continence outcome following RARP. There was also excellent consistency in measuring MUL between different observers. This could mean that urologists can reliably measure and predict urinary incontinence. Although a larger, prospective study would be required to verify our findings, we support the significance of MUL in predicting the risk of incontinence and need to incorporate it as part of preoperative assessment and counselling. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e47-e48 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Lawrence H C Kim More articles by this author Amit Patel More articles by this author Netty Kinsella More articles by this author Mansour Taghavi Azar Sharabiani More articles by this author Derfel Ap Dafydd More articles by this author Declan Cahill More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pre-operative group and save for elective total knee Arthroplasty: Is it indicated?

Background: Total knee arthroplasty (TKA) is a commonly performed surgical procedure in UK. Routine use of tourniquets and tranexamic acid raises the question of whether pre-operative group and save (G&S) is necessary. Methods: Retrospective review of 100 patients who underwent TKA. We reviewed if G&S was performed as part of pre-operative assessment and cost of doing so, whether a tourniquet and tranexamic acid were administered, change in haemoglobin (Hb) concentration, and whether blood transfusion was required. We also investigated the time taken to provide type specific and fully cross-matched blood in an emergency, for patients with and without pre-operative G&S sample. Results: Tranexamic acid and tourniquets were used in all cases. Mean drop in Hb was 15.1 g/l. In 48-hour post-operative period, none of patients received any intraoperative blood transfusions. Conclusion: Pre-operative G&S results in only a minimal reduction in time to availability of blood products. In emergency situation, O negative blood can be administered immediately with or without a pre-operative sample. None of the cases required blood transfusion suggesting that pre-operative G&S represents a financial burden. There is minimal benefit to be gained from pre-operative G&S for elective TKA. Although further assessment is necessary, we advocate that G&S could be safely omitted.

Impact of preoperative magnetic resonance imaging in breast cancer patients candidates for an intraoperative partial breast irradiation

Objective: Partial breast irradiation (PBI) could be a reasonable option in patients with early breast cancer (BC) provided that an adequate patient selection, based on robustly established criteria is performed. A preoperative magnetic resonance imaging (MRI) in patient selection for PBI is not consensual. The aim of this retrospective study was to assess the impact of preoperative MRI on patient eligibility for PBI. Methods: Since March 2012, patients with early BC, meeting the Inca’s criteria for PBI were offered the possibility of shortened treatment through intra-operative radiation therapy, either in a prospective trial or off protocol. Eligibility criteria based on physical examination, mammography and ultrasound, and a pathological exam of biopsy, were as follows: menopaused woman 55 years or older with a T1, N0, hormonal-receptor-positive and HER2-negative, invasive, non-lobular epithelioma, without extensive intraductal component (defined as more than 25% of ductal component on biopsy), non-fast-growing tumor, without lymphovascular invasion (LVI), without criteria for adjuvant chemotherapy. A contrast-enhanced MRI was not routinely performed, but at the discretion of the physician as was the rule in TARGIT-A trial. We assessed the rate of additional cancer revealed by the preoperative MRI, remote in the same breast not detected by mammography and/or ultrasound. Results: Between March 2012 and February 2014, 179 early BC patients meeting the required criteria were planned for an intraoperative radiotherapy (IORT)-PBI. Seventy nine percent of them (141/179) underwent a breast MRI as part of preoperative assessment. ACR3-ACR4 abnormalities not detected by mammograms or ultrasound were found in 44 patients (31%), which prompted a focused mammary ultra-sound, and a biopsy was realized in 29/141 patients (21%). A second breast carcinoma was found in 10 patients (7% of patients with a preoperative MRI, 4 ipsilateral lesions, 5 contralateral lesions, and one both ipsi- and contralateral lesion, precluding IORT-PBI in 5/141 patients (4%). Conclusions: The use of preoperative MRI in patient staging leads to diagnosis of an ipsilateral second BC in 4% of cases, which appears substantial in a highly selected population. We therefore support the routine use of this exam for the staging of patient candidate for a PBI.

39. Prediction of cognitive changes in patients with parkinson’s disease after DBS STN with the use of p300 cognitive event related potential

Objective Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective long-term treatment for motor symptoms in advanced Parkinson’s disease (PD). However, it is evident that at least in some patients the change in cognitive functions after STN-DBS may have a clinical importance. Thorough neuropsychological examination is an established part of preoperative assessment of candidates for DBS surgery. We studied whether scalp P300 wave can be used as an additional tool that could improve the selection process and predict the cognitive decline after the procedure. Patients and methods 30 patients with Parkinson’s disease who had been implanted with DBS STN were included in the pilot study. They were examined by a neuropsychologist before the DBS and a year after the DBS. The latencies and amplitudes of P300 wave were measured before the operation and again one year after the DBS STN. Results We found indirect correlation between latencies of preoperative P300 and neuropsychological status 1 year after the operation. We observed that patients with longer latencies of preoperative P300 tended to have more psychiatric side effects and worse neuropsychological performance one year after the DBS. Conclusion Scalp P300 can be proposed as a tool for selection of suitable candidates for the DBS STN surgery in PD. Keywords Parkinson’s disease; DBS; Subthalamic nucleus; P300; Event-related potentials

The challenges and excitement of liver transplantation.

The challenges and excitement of liver transplantation.

Testicular Arteries Originating from Accessory Renal Arteries

A healthy 20-year-old man underwent catheter angiography as part of preoperative assessment as a potential living-related kidney donor. The right and left testicular arteries (arrows in Figs 1, 2) originated from the middle of the right and left accessory renal arteries (arrowheads in Figs 1, 2), respectively, which originated from the ventral aorta and supplied the lower pole of the corresponding kidney. The testicular arteries traveled caudally to supply each testicle (arrows in Figs 3, 4).

Anaerobic threshold, is it a magic number to determine fitness for surgery?

The use of cardiopulmonary exercise testing (CPET) to evaluate cardiac and respiratory function was pioneered as part of preoperative assessment in the mid 1990s. Surgical procedures have changed since then. The patient population may have aged; however, the physiology has remained the same. The use of an accurate physiological evaluation remains as germane today as it was then. Certainly no ‘magic’ is involved. The author recognizes that not everyone accepts the classical theories of the anaerobic threshold (AT) and that there is some discussion around lactate and exercise. The article looks at aerobic capacity as an important predictor of perioperative mortality and also looks at some aspects of CPET relative to surgical risk evaluation.

Gas insufflation of stomach and laparoscope intubation of distal esophagus for measurement of gap in esophageal atresia without distal fistula

Evaluation of gap length is an important part of preoperative assessment of esophageal atresia (EA) without distal tracheoesophageal fistula. A technique of measuring the esophageal gap in isolated EA using carbon dioxide gas insufflation of the stomach through a port and a laparoscope is described.

Routine Peri-Operative Transoesophageal Echocardiography in Paediatric Cardiac Surgical Procedures

Introduction: Perioperative transoesophageal echocardiography (TOE) is recognised as a valuable diagnostic investigation for paediatric cardiac surgery, but is not performed on all cases in most centres. This study investigates the value of performing perioperative TOE for all procedures. Methods: All patients undergoing cardiac surgery between September 2011 and February 2012 had pre- and post-operative TOE studies. Demographic data, preoperative investigations, diagnosis and surgical procedure were documented prospectively. The influence of new diagnostic information determined by the pre-operative TOE on surgical procedure and the impact of post-operative TOE on subsequent surgical management was assessed. Results: Eighty-eight patients with median age 1.0 year (range; 4 days to 17.6 years) and weight 9.3 kg (range; 2.7–80 kg) were studied, with no TOE related complications. Twenty-five (28.4%) patients had cardiac catheters and four (4.5%) patients had cardiac magnetic resonance imaging as part of preoperative assessment. TOE was not possible in two (2.2%) cases. The preoperative TOE defined new information in six (7.0%) patients – new lesions identified in two; more detailed anatomic information which influenced surgical strategy in four. Post-operative TOE defined anatomical issues in five (5.8%) cases which resulted in further surgical intervention in four and a decision not to perform further surgery in one. The postoperative TOE findings did not differ from discharge assessments. Conclusions: This study demonstrates that perioperative TOE is an important adjunct for guiding surgical management. Performing TOE for every procedure is labour intensive, but the incidence of important findings which influenced management in this study, may support this strategy.

Postoperative disposition and health services use in elderly patients undergoing colorectal cancer surgery: A population-based study

Little is known about the postoperative status and support needs of patients undergoing colorectal cancer operations. The objective of this study was to describe the disposition and resource use of Ontario's elderly population undergoing colorectal cancer operations as well as to identify predictors of outcomes using population-based data. A total of 33,238 patients aged 50 years and older with a diagnosis of colorectal cancer were identified using International Classification of Diseases 9 and 10 codes in the Ontario Cancer Registry linked to procedure codes in the Canadian Institute for Health Information Discharge Abstract Database representing colorectal operations within 6 months of diagnosis from 1997 to 2004. Data on an individual's home-care use were collected from the Ontario Home Care Administrative System. The cohort was divided into the following age groups: 50-64 years, 65-74 years, 75-79 years, and 80 years and older. The primary outcomes assessed were postoperative mortality, length of stay, discharge disposition, need for home care, and readmission within 30 days. Based on univariate and multivariate analyses, patients aged 75-79 years and 80 years and older were more likely to die in hospital (odds ratio 2.84; 95% confidence interval 2.32-3.47 and odds ratio 5.72; 95% confidence interval 4.76-6.88), stay longer in hospital (2.78 [standard error 0.22] and 5.16 [standard error 0.19] days, respectively), not return home (odds ratio 5.62; confidence interval 3.99-7.98 and odds ratio 11.59; confidence interval 8.32-16.13), receive home care (odds ratio 1.44; 95% confidence interval 1.34-1.55 and odds ratio 1.71; 95% confidence interval 1.59-1.83), and be readmitted (odds ratio 1.31; 95% confidence interval 1.19-1.45 and odds ratio 1.59; 95% confidence interval 1.44-1.75) compared with younger individuals. The rate of discharge home for patients aged 80 years and older was more than 78%. Factors predisposing patients older than 75 years to poorer outcomes were higher Charlson comorbidity score, urgent admission, construction of a stoma, and reoperation. Although discharge-related outcomes worsen with age, most elderly patients do well and can return home after a colorectal cancer operation. Elderly patients require more support; therefore, discharge planning should be part of preoperative assessment and discussions.