Perioperative Pathway Research Articles

Impact of an Acute Care Surgery Clinical Pathway on Patient Outcomes in Acute Appendicitis.

Objectives: Acute care surgery (ACS) encompasses surgical critical care, emergency general surgery, and the surgical management of trauma. Following ACS implementation at our institution, we developed a perioperative clinical pathway for acute appendicitis (AA) to improve efficiency and standardize post-operative care. The purpose of our study is to assess patient outcomes utilizing our ACS clinical pathway for patients with AA. Methods: This is a retrospective cohort study involving patients admitted to our tertiary care facility with AA who underwent appendectomy. Patients were classified by pre-implementation (January 1, 2016-July 31, 2018) and post-implementation (August 1, 2018-December 31, 2020) of our ACS clinical pathway. The primary outcome was hospital length of stay (LOS). Statistical analysis was performed using SAS with a p-value <0.05 determined as significant. Results: Of the 492 patients included, 225 were in the pre- and 267 were in the post-implementation cohorts. Hospital LOS was substantially decreased in the post-implementation cohort (31.2 vs. 50.4 h, p < 0.001). The post-implementation group had a substantial decrease in computed tomography (CT) to operating room (OR) start time (6.81 vs. 11.4 h, p < 0.001), CT to antibiotic agents' administration (2.20 vs. 3.37 h, p < 0.001), inpatient opioid utilization (125 morphine equivalents [ME] vs. 172 ME, p < 0.001), and discharge antibiotic agents' prescription rates (23.6% vs. 30.7%, p = 0.077). Recovery unit discharges (20 vs. 9%, p < 0.001) were increased in the post-implementation cohort. Conclusion: Our ACS clinical pathway for AA resulted in earlier surgical intervention, enhanced opioid and antimicrobial stewardship, and gains in surgical care efficiencies.

Utilizing a Defined Multiphase, Multispecialty Perioperative Pathway to Achieve Functional Recovery after Surgery

This article emphasizes the need for a personalized approach in managing older cancer patients, highlighting the importance of a multidisciplinary team that tailors treatment to the patient's specific health conditions and goals. The objective is to balance positive oncological outcomes with the restoration of independence, reduction of disabilities and enhancement of quality of life. Functional recovery is central to treatment decisions as disability can impact cancer patients more than the prognosis itself. The paper stresses the value of frailty screening tools, nutritional assessment and physical evaluation which help predict postoperative outcomes and guide clinical management. It advocates for comprehensive preoperative evaluations, including geriatric assessments, to prevent both undertreatment and overtreatment. Multimodal prehabilitation can improve postoperative outcomes, reduce healthcare costs, and help older patients remain engaged in society. The article concludes by recommending a patient-centered, individualized approach to optimize functional recovery and alleviate the economic burden on healthcare systems.

Complications associated with the use of mesh to treat female urinary incontinence and pelvic organ prolapse

Complications can result from the use of mesh to treat female stress urinary incontinence or pelvic organ prolapse. While some of these complications are also common to non-mesh-based procedures, the risk of vaginal exposure of mesh, or mesh extrusion into other pelvic organs are unique complications that must be considered when using mesh. Chronic pain after mesh-based procedures can be a difficult complication to manage and may occur. Patients with stress incontinence or prolapse that are considering surgical treatment should be counseled on the potential complications and their likelihood of them occurring. Although there has been focus on the development, introduction and regulation of mesh, the diagnostic clinical decision-making process has not been put under scrutiny, and likely significantly impacts patient outcomes. There is a need to develop patient reported outcome measures for mesh procedures, and further work is needed to create a standardized way to measure and communicate different types of mesh-related complications. Future research will need to focus on the diagnostic clinical decision making process is recommended, including education on the ‘whole journey’ of the patient during the perioperative pathway.

Consensus-Building Processes for Implementing Perioperative Care Pathways in Common Elective Surgeries: A Systematic Review.

To identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries. Systematic review. Five databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023. Two reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions. The initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full-text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions. Local consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented. Advancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals. These findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives. This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. No patient or public contribution. CRD42023413817.

Preoperative Care Intensity and Cost for Renal Colic: Implications for Surgical Value-Based Reforms.

The aim of this study was to identify preoperative patient/facility factors associated with postoperative and total episode-related costs using renal colic as a model surgical condition to improve value-based payment models. Using state Healthcare Cost and Utilization Project data, we performed a retrospective cohort study examining perioperative costs for individuals presenting to an emergency department for renal colic and who ultimately underwent definitive surgical management. We estimated multivariable ordered and binary logistic regressions to examine the association between preoperative and operative cost quartiles on the probability of specific postoperative cost quartiles after accounting for hospital and individual factors. We also performed logistic regressions to identify patients who deviated from predicted perioperative cost pathways. Among 2736 individuals included in our analysis, episode-related costs ranged from $4536 (bottom quartile) to $26,662 (top quartile). Individuals in the highest preoperative cost quartile experienced an 11.7% higher probability of remaining in the highest postoperative cost quartile relative to those in the lowest preoperative cost quartile (95% CI, 0.0709-0.163; P < .001). Delays in surgery (95% CI, 0.0869-0.163; P < .001) and Medicaid vs private insurance (95% CI, 0.01-0.0728; P < .01) were associated with a 12.5% and 4.1% higher probability of being in the top quartile of preoperative costs, respectively. Treating facility experience with value-based payment models did not influence perioperative costs. Using renal colic as a model surgical condition, our novel findings suggest that preoperative costs are associated with both postoperative and total episode-related costs and should be accounted for when designing future value-based payment models.

Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society.

Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients. We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals. We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain. We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.

Airway Management and General Anesthesia in Pediatric Patients with Special Needs Undergoing Dental Surgery: A Retrospective Study

Background: The definition of patients with special needs (SNs) is used in the literature to refer to individuals with mental and physical disorders for whom the usual perioperative pathways are not applicable due to lack of cooperation, regardless of age. Studies in the literature recognize the appropriateness of general anesthesia for performing day surgery dental care in this type of patient. Objectives: The main objective was to assess the possible incidence of difficult airway management, understood as difficulty ventilating and/or intubating the patient. A secondary objective was to highlight the influence of general anesthesia on patient outcomes by testing the incidence of perioperative complications. Methods: The present retrospective, single-center, observational study involved 41 uncooperative patients aged between 3 and 17 undergoing dental surgery under general anesthesia. Data relating to airway management and general anesthesia present in the medical records were analyzed. Results: Tracheal intubation was successfully completed in all of the patients considered, and in no case did the patient have to be woken up because of difficulty in airway management. No perioperative complications attributable to anesthesia were found in any patients. Conclusions: From the present experience, it can be concluded that general anesthesia is a suitable option for performing dental care in pediatric subjects with special needs, and that although the peculiar perioperative management of these patients might increase the risk of possible anesthesia-related side effects, no complications have been encountered in any case.

ThP7.16 - Multidisciplinary management of elderly patients undergoing emergency laparotomy: an audit at a small district general hospital

Abstract Aims The National Emergency Laparotomy Audit (NELA) suggests early involvement of the multidisciplinary geriatrician team for preoperative care of elderly patients aged over 80, or 65 and frail. Methods we audited our unit against the NELA guidelines for elderly patients. We looked at all emergency laparotomies carried out at our hospital over a 6 month period against the audit standards as set out by NELA. Results A total of 55 laparotomies were carried out in 6 months. 17 patients fit the criteria of patients needing early geriatrician involvement. Of the 34 patients aged 65 and above, 22 patients had their frailty score recorded in the notes (64%). Less than 10% of patients had early geriatrician input. Overall, six patients (11%) died within 30 days of their initial operation, and all were aged over 65. Conclusions we must take the perioperative care of elderly patients seriously and work with the Geriatric Medicine teams for early perioperative review, including accurate clinical frailty score assessments. We will initiate a project with the Geriatric Medicine department to implement an Elderly Laparotomy Perioperative Pathway for these patients.

ThP1.4 - Evidence-Based Perioperative Improvements in Microvascular Breast Free Flap Reconstruction: An Audit-Centric Evaluation &amp; Retrospective Cohort Study

Abstract Aim This audit aimed to evaluate and improve the results of microvascular breast free flap reconstruction by implementing an enhanced perioperative care approach. Method All microvascular breast free flap reconstructions between June to August 2023 were included. Additionally, a three year retrospective review was conducted in adherence to ABS and the BAPRAS guidelines. Our team plans to introduce an evidenced-based modified Enhanced Recovery After Surgery (ERAS) protocol via MDT collaboration with a focus on pre-operative and post-operative care to improve postoperative outcomes. Results During June – August 2023, 22 flaps were performed with an average length of stay (LOS) of 5.47 days (target &amp;lt;3d). There were no unplanned readmissions, an 18% return to theatre (RTT) rate and a total complication rate of 18%. Over the past three years, out of 323 flaps, there was a 13% RTT rate with no unplanned readmissions. Suggested modifications to reduce length of stay include pre-surgical counselling and nutritional loading. Post-operatively, using a multi-modal opioid sparing analgesia (MOSA) regime, along with laxatives, early mobilisation and feeding has proven to enhance recovery. Pre-admission patient optimisation, VTE and perioperative antibiotic prophylaxis have been shown to reduce rates of flap failures and post-operative complications. Effective wound care, post-discharge support and physiotherapy are also crucial in accelerating recovery and preventing readmissions. Conclusion Implementing these ERAS modification to our current protocol is predicted to significantly improve post-operative recovery, thus improving surgical outcomes. This underscores the potential for continual improvement in patient care through an efficient evidence-based perioperative pathway.

561. COMMONALITY AND VARIATION IN PERIOPERATIVE ESOPHAGEAL CANCER MANAGEMENT IN HIGH VOLUME EUROPEAN CENTERS

Abstract Background Esophageal cancer is a leading cause of cancer related death worldwide. For patients with locally advanced, non-metastatic, esophageal cancer (EC), surgical resection remains an essential pillar. The multitude of surgical options have driven innovation, however, lack standardization and at times high-quality data-driven practices. A surgeon-level in-depth interview and questionnaire was created to understand the perioperative care pathways and intraoperative techniques used by high-volume European EC centres to gain insight into commonality and variation of current practice. Methods Eight (8) expert upper gastrointestinal surgeons were invited to participate in an in-depth interview and questionnaire. The focus included preoperative care pathways for esophageal adenocarcinoma of the distal esophagus/GE junction, technical aspects of esophageal resection (Ivor-Lewis) and postoperative pathways. The involvement of allied health, dedicated research programs, multidisciplinary cancer conference (MCC), follow up protocols and management of T4b EC was also assessed. Results The response rate was 100% (8/8). Majority of respondents indicated a country-level regionalization of EC care. The number of centres performing esophageal resection varied from 4 – &amp;gt;100. Average number of esophagectomies/year ranged from 60-150. All centres presented EC patients at MCC, had dedicated research programs, and participated in National and International EC databases. Chemoradiotherapy was the predominate neoadjuvant treatment for GEJ cancers. Pretreatment clinical staging varied, with all centres having different, but pre-defined, preoperative and postoperative pathways. Intraoperative techniques including conduit preparation, feeding tube use, pyloric intervention, thoracic duct ligation and anastomotic technique varied substantially. There was no consensus regarding follow up or management of T4b EC. Conclusion The perioperative pathways and technical aspects of esophageal resection shared some commonalities however also differed substantially across high-volume EC centres in Europe. Multicenter, pragmatic randomized controlled trials (RCTs) are needed to better delineate which techniques should be included as standard of care, and which should be abandoned.

Mechanisms and causes of death after abdominal surgery in low-income and middle-income countries: a secondary analysis of the FALCON trial

Death after surgery is devasting for patients, families, and communities, but remains common in low-income and middle-income countries (LMICs). We aimed to use high-quality data from an existing global randomised trial to describe the causes and mechanisms of postoperative mortality in LMICs. To do so, we developed a novel framework, learning from both existing classification systems and emerging insights during data analysis. This study was a preplanned secondary analysis of the FALCON trial in 54 hospitals across seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa). FALCON was a pragmatic, 2 × 2 factorial, randomised controlled trial that compared the effectiveness of two types of interventions for skin preparation (10% aqueous povidone-iodine vs 2% alcoholic chlorhexidine) and sutures (triclosan-coated vs uncoated). Patients who did not have surgery or were lost to follow-up were excluded (n=231). The primary outcomes of the present analysis were the mechanism and cause of death within 30-days of surgery, determined using a modified verbal autopsy strategy from serious adverse event reports. Factors associated with mortality were explored in a mixed-effects Cox proportional hazards model. The FALCON trial is registered with ClinicalTrials.gov, NCT03700749. This preplanned secondary analysis of the FALCON trial included 5558 patients who underwent abdominal surgery, of whom 4248 (76·4%) patients underwent surgery in tertiary, referral centres and 1310 (23·6%) underwent surgery in primary referral (ie, district or rural) hospitals. 3704 (66·7%) of 5558 surgeries were emergent. 306 (5·5%) of 5558 patients died within 30 days of surgery. 226 (74%) of 306 deaths were due to circulatory system failure, which included 173 (57%) deaths from sepsis and 29 (9%) deaths from hypovolaemic shock including bleeding. 47 (15%) deaths were due to respiratory failure. 60 (20%) of 306 patients died without a clear cause of death: 45 (15%) patients died with sepsis of unknown origin and 15 (5%) patients died of an unknown cause. 46 (15%) of 306 patients died within 24 h, 111 (36%) between 24 h and 72 h, 57 (19%) between >72 h and 168 h, and 92 (30%) more than 1 week after surgery. 248 (81%) of 306 patients died in hospital and 58 (19%) patients died out of hospital. The adjusted Cox regression model identified age (hazard ratio 1·01, 95% CI 1·01-1·02; p<0·0001), ASA grade III-V (4·93, 3·45-7·03; p<0·0001), presence of diabetes (1·47, 1·04-2·41; p=0·033), being an ex-smoker (1·59, 1·10-2·30; p=0·013), emergency surgery (2·08, 1·45-2·98; p<0·0001), cancer (1·98, 1·42-2·76; p<0·0001), and major surgery (3·94, 2·30-6·75; p<0·0001) as risk factors for postoperative mortality INTERPRETATION: Circulatory failure leads to most deaths after abdominal surgery, with sepsis accounting for almost two-thirds. Variability in timing of death highlights opportunities to intervene throughout the perioperative pathway, including after hospital discharge. A high proportion of patients without a clear cause of death reflects the need to improve capacity to rescue and cure by strengthening perioperative systems. National Institute for Health and Care Research Global Health Research Unit.

2354 Clinical assessment and documentation of delirium in older patients undergoing vascular surgery: a quality improvement project

Abstract Introduction The Centre for Perioperative Care recommends the assessment and documentation of delirium using a validated tool such as the 4-AT in older people undergoing surgery. Aim This quality improvement project (QIP) aimed to improve the assessment and documentation of delirium in patients aged 65 and above following vascular surgery in a tertiary centre. Methods Patients aged ≥65 years who had undergone vascular surgery were identified and data was collected with access to the electronic patient record system. Analysis was carried out using Microsoft Excel and SPSS. Following baseline measurements taken in August 2023, 1 plan-do-study-act (PDSA) cycle was completed between September 2023–January 2024. Baseline measures Baseline data collected between August 1-31st 2023 identified 51 patients, of which delirium was screened using the 4-AT tool in 39.2% (n = 20), on average 90 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review (100%, n = 51). There were clinical concerns of post-operative delirium documented in 7 patients, with the 4-AT documented in 5 of those cases. Intervention Interventions included stakeholder discussions to identify key barriers in the assessment and documentation of delirium, multidisciplinary team education and poster reminders across the ward. These were introduced between November–December 2023. Results Post-intervention results reviewed between 10th-31st January 2024 showed that the 4-AT was used to screen for delirium in 61.9% of patients (n = 13), on average 45 hours post-operatively. The 4-AT was never documented in a consultant-led surgical post-operative review. In addition, 2 patients developed delirium post-operatively with the 4-AT reported in both cases. Conclusions This QIP has demonstrated a marked improvement in compliance with national guidelines on the assessment of delirium, highlighting the impact of multidisciplinary education in improving the perioperative clinical pathway for older people undergoing surgery. Future PDSA cycles will focus on improving the documentation of 4AT in the post-operative surgical review.

Perioperative pathways for children with neurodevelopmental conditions and behaviours that challenge: An evaluation of parent experiences for service improvement.

To elicit experiences of parents of children with neurodevelopmental conditions using a new perioperative pathway. Parents of children accessing an adapted perioperative clinical pathway in a tertiary children's hospital between July 2019 and December 2020 were invited to participate. A mixed method study was conducted comprising a short survey questionnaire followed by telephonic interviews. From 67 postal surveys sent out, 20 were completed. Six out of 20 parents participated in phone interviews and one parent submitted written prose. Parents were positive about their experiences. Six themes emerged: Negative past experiences (highlighting the need for adapted perioperative pathways); Reasonable adjustments (improving child and parent's hospital journey); Facilitating communication, convenience and collaboration; Parent's satisfaction and relief; Barriers to overcome and Areas in need of improvement were discussed. Parents of children with neurodevelopmental conditions report great satisfaction and relief from their experiences of a more efficient, streamlined and stress-free way for their child to have tests or procedures done. Parents report improved communication, convenience and collaboration with staff resulted in timely, safe and high-quality care.

If the peri-operative patient pathway was right, what would it look like?

Patients undergoing surgery deserve the best possible peri-operative outcomes. Each stage of the peri-operative patient journey offers opportunities to improve care delivery, with shorter lengths of stay, less complications, reduced costs and better value. These opportunities were identified through narrative review of the literature, with consultation and consensus at the hidden pandemic (of postoperative complications) summit 2, July 2023 in Adelaide, Australia RESULTS: Before surgery: Some patients who receive timely alternative treatments may not need surgery at all. The period of waiting after listing should be a time of preparation. Risk assessment at the time of surgical listing facilitates recognition of need for comorbidity optimisation and identifies those who will most benefit from prehabilitation, particularly frail and deconditioned patients. During the surgical admission, ERAS programs result in less postoperative complications, shorter length of stay and better patient experience but require agreement between clinicians, and coordinated monitoring of delivery of the elements in the ERAS bundle of care. At-risk patients need to have the appropriate levels of monitoring for cardiovascular instability, renal impairment or respiratory dysfunction, to facilitate timely, proactive management if they develop. Access to allied health in the early postoperative period is also critical for promoting mobility, and earlier discharge, particularly after joint surgery. Where appropriate, provision of rehabilitation services at home improves patient experience and adds value. The peri-operative patient journey begins and ends with primary care so there is a need for clear communication, documentation, around sharing of responsibility between practitioners at each stage. Identifying and mitigating risk to reduce complications and length of stay in hospital will improve outcomes for patients and deliver the best value for the health system.

The carbon footprint of the perioperative transurethral resection of bladder tumour pathway.

To evaluate the carbon footprint of the perioperative transurethral resection of bladder tumour (TURBT) pathway from decision to treat to postoperative discharge, and model potential greenhouse gas (GHG) emissions reduction strategies. This process-based attributional cradle-to-grave life-cycle assessment (LCA) of GHG emissions modelled the perioperative TURBT pathway at a hospital in Southwest England. We included travel, energy and water use, all reusable and consumable items, and laundry and equipment sterilisation. Resource use for 30 patients undergoing surgery was recorded to understand average GHG emissions and the inter-case variability. Sensitivity analysis was performed for manufacturing location, pharmaceutical manufacturing carbon-intensity, and theatre list utilisation. The median (interquartile range) perioperative TURBT carbon footprint was 131.8 (119.8-153.6) kg of carbon dioxide equivalent. Major pathway categories contributing to GHG emissions were surgical equipment (22.2%), travel (18.6%), gas and electricity (13.3%), and anaesthesia/drugs and associated adjuncts (27.0%), primarily due to consumable items and processes. Readily modifiable GHG emissions hotspots included patient travel for preoperative assessment, glove use, catheter use, irrigation delivery and extraction, and mitomycin C disposal. GHG emissions were higher for those admitted as inpatients after surgery. This cradle-to-grave LCA found multiple modifiable GHG emissions hotspots. Key mitigation themes include minimising avoidable patient travel, rationalising equipment use, optimally filling operating theatre lists, and safely avoiding postoperative catheterisation and hospital admission where possible. A crucial next step is to design and deliver an implementation strategy for the environmentally sustainable changes demonstrated herein.

Effects of a perioperative educational pathway on ostomy self-care, level of independence and need for visiting nurse services: a comparative observational cohort study.

Most new ostomy patients are not able to manage ostomy self-care when they are discharged and rely on visiting nurse services for ostomy care. The aim of this study was to determine if a perioperative ostomy educational pathway increases the level of independence and decreases the need for visiting nurse services in new ostomy patients. A prospective longitudinal study was conducted between July 2018 and February 2020. Patients who received a colostomy or ileostomy and were treated on the surgery ward were included. Patients who followed a perioperative ostomy educational pathway were compared to a historical control group. The primary outcome measure was the level of independence in ostomy care and the need for visiting nurse services. After discharge, 67.6% of patients in the intervention group (n = 244) were able to independently perform ostomy care and were therefore not relying on visiting nurse services, compared to 15.2% of the patients in the control group (n = 33). The need for visiting nurse services was higher in patients aged ≥70 years (OR 3.20, P < 0.001), those who did not attend the preoperative practice session (OR 3.02, P = 0.002), those with a history of transient ischaemic attack (OR 10.22, P = 0.045) and those with mild cognitive impairment (OR 28.98, P = 0.002). A perioperative ostomy educational pathway effectively increased the level of independence and decreased the need for visiting nurse services in new ostomy patients.

Validation of Perioperative Troponin Levels for Predicting Postoperative Mortality and Long-Term Survival in Patients Undergoing Surgery for Hepatobiliary and Pancreatic Cancer.

Background: Hepatopancreato and biliary (HPB) tumors represent some of the leading cancer-related causes of death worldwide, with the majority of patients undergoing surgery in the context of a multimodal treatment strategy. Consequently, the implementation of an accurate risk stratification tool is crucial to facilitate informed consent, along with clinical decision making, and to compare surgical outcomes among different healthcare providers for either service evaluation or clinical audit. Perioperative troponin levels have been proposed as a feasible and easy-to-use tool in order to evaluate the risk of postoperative myocardial injury and 30-day mortality. The purpose of the present study is to validate the perioperative troponin levels as a prognostic factor regarding postoperative myocardial injury and 30-day mortality in Greek adult patients undergoing HPB surgery. Method: In total, 195 patients undergoing surgery performed by a single surgical team in a single tertiary hospital (2020-2022) were included. Perioperative levels of troponin before surgery and at 24 and 48 h postoperatively were assessed. Model accuracy was assessed by observed-to-expected (O:E) ratios, and area under the receiver operating characteristic curve (AUC). Survival at one year postoperatively was compared between patients with high and normal TnT levels at 24 h postoperatively. Results: Thirteen patients (6.6%) died within 30 days of surgery. TnT levels at 24 h postoperatively were associated with excellent discrimination and provided the best-performing calibration. Patients with normal TnT levels at 24 h postoperatively were associated with higher long-term survival compared to those with high TnT levels. Conclusions: TnT at 24 h postoperatively is an efficient risk assessment tool that should be implemented in the perioperative pathway of patients undergoing surgery for HPB cancer.

A multicentre survey investigating the knowledge, behaviour, and attitudes of surgical healthcare professionals to frailty assessment in emergency surgery: DEFINE(surgery)

Key summary pointsAimsThis study aimed to assess the knowledge, behaviour, and attitudes of healthcare professionals to frailty assessment in emergency surgical admissions.FindingsFrailty assessment is well supported by healthcare professionals working in surgery. However, in clinical practice, standardised tools are not routinely being used and only half of respondents were able to accurately identify frailty from clinical vignettes.MessageBetter education around frailty assessment is needed for healthcare professionals working in surgery to improve perioperative pathway for people living with frailty.

Evaluation of an Opioid-free Pathway for Perineal Reconstructive Surgery: A 1-year Pilot Study

ObjectiveTo evaluate the impact of a standardized perioperative pain management pathway on postoperative opioid prescribing practices following male perineal reconstructive surgery at our institution. MethodsPatients undergoing perineal reconstructive surgery (urethroplasty, artificial urinary sphincter, urethral sling) by a single surgeon from July 2022 to June 2023 were prospectively followed. A standardized nonopioid pathway was implemented in the perioperative period. Intraoperative local anesthetic included liposomal bupivacaine mixed with 0.25% bupivacaine. Opioids are administered in the recovery room at the discretion of anesthesiology providers. As of July 2022, our standard practice does not include a postoperative opioid prescription unless pain is poorly controlled in the recovery area. Postoperative communication encounters and opioid prescriptions were tracked through the electronic health record in order to assess the efficacy of an opioid-free pathway. Results67 patients met criteria during the study period, 64/67 performed in an outpatient setting. 6/67 (9%) patients were prescribed an opioid postoperatively; 4 related to post-surgical pain, and 2 related to chronic pain. No refills were prescribed. Of the 26 patients who received an opioid in the recovery area, 2 (7.6%) were prescribed an opioid at discharge. 15/67 (22%) patients had a communication encounter related to pain within 30 days, most commonly related to bladder spasm management. Only 2 of these encounters resulted in an electronic opioid prescription. ConclusionAn opioid-free pathway is appropriate for opioid naïve men undergoing perineal reconstructive surgery. When necessary, electronic opioid prescribing should be employed following discharge for breakthrough pain.

Early chest tube removal on the 1st postoperative day protocol of an enhanced recovery after cardiac surgery programme is safe.

The aim of this study was to assess the safety of early chest tube removal (CTR) protocol on the 1st postoperative day (POD1) of our Enhanced Recovery After Surgery (ERAS) programme by comparing the risk of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. All consecutive patients undergoing elective coronary revascularization and/or valve surgery between 2015 and 2021 were assessed in terms of their perioperative management pathways: conventional standard of care (control group) versus standardized systematic perioperative ERAS programme including an early CTR on POD1 (ERAS group). A propensity score matching was applied. The primary end-point was a composite of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. A total of 3153 patients were included. Propensity score analysis resulted in 2 groups well-matched pairs of 1026 patients. CTR on POD1 was significantly increased from 29.5% in the control group to 70.3% in the ERAS group (P < 0.001). The incidence of the primary end-point was 6.4% in the control group and 6.9% in the ERAS group (P = 0.658). Patients in the ERAS group, as compared with control group, had significant lower incidence of bronchopneumonia (9.0% vs 13.5%; P = 0.001) and higher incidence of mechanical ventilation ≤6 h (84.6% vs 65.2%; P < 0.001), length of intensive care unit ≤1 day (61.2% vs 50.8%; P < 0.001) and hospital ≤6 days (67.3% vs.43.2%; P < 0.001). CTR on POD1 protocol can be safely incorporated into a standardized systematic ERAS programme, enabling early mobilization, and contributing to the improvement of postoperative outcomes. Ethics committee of the French Society of Thoracic and Cardio-Vascular Surgery (CERC-SFCTCV-2022-09-13_23140).