Perioperative Interventions Research Articles

Anaesthetic Techniques and Strategies: Do They Influence Oncological Outcomes?

Background: With the global disease burden of cancer increasing, and with at least 60% of cancer patients requiring surgery and, hence, anaesthesia over their disease course, the question of whether anaesthetic and analgesia techniques during primary cancer resection surgery might influence long term oncological outcomes assumes high priority. Methods: We searched the available literature linking anaesthetic-analgesic techniques and strategies during tumour resection surgery to oncological outcomes and synthesised this narrative review, predominantly using studies published since 2019. Current evidence is presented around opioids, regional anaesthesia, propofol total intravenous anaesthesia (TIVA) and volatile anaesthesia, dexamethasone, dexmedetomidine, non-steroidal anti-inflammatory medications and beta-blockers. Conclusions: The research base in onco-anaesthesia is expanding. There continue to be few sufficiently powered RCTs, which are necessary to confirm a causal link between any perioperative intervention and long-term oncologic outcome. In the absence of any convincing Level 1 recommending a change in practice, long-term oncologic benefit should not be part of the decision on choice of anaesthetic technique for tumour resection surgery.

P06 Prediction of surgical-site infection (SSI) in adult patients undergoing gastrointestinal surgery: a systematic review of prognostic risk models

Abstract Introduction Surgical site infections (SSI) are among the most common postoperative complications following gastrointestinal surgery. This review aimed to identify and evaluate prognostic tools for prediction of SSI in gastrointestinal surgery. Methods Studies describing the development or validation of prognostic models for 30-day SSI after gastrointestinal surgery were identified (PROSPERO: CRD42022311019). An English language restricted search of MEDLINE, EMBASE, and EBSCO was undertaken from 1st January 2000 to 31st December 2021. Studies were excluded if prognostic models included postoperative parameters, or were procedure-specific. Quality assessment was undertaken using TRIPOD and PROBAST guidelines, with narrative synthesis comparing discrimination (area under the curve [AUROC]) and prognostic accuracy between models. Results Of 2953 records reviewed, 23 eligible prognostic models were identified. Thirteen (56.5%) reported no internal validation, and only 4 (17.4%) had undergone external validation. Most identified operative contamination (54.5%, n=12) and duration (54.5%, n=12) as important predictors, however, there remained substantial heterogeneity in other predictors identified (range: 2-28). All models demonstrate a high risk of bias due to analytic approaches, with overall low applicability to an undifferentiated gastrointestinal surgical population. Model discrimination was reported in most studies (86.4%, n=19); however, calibration (22.7%, n=5) and prognostic accuracy (18.2%, n=4) was infrequently assessed. Of externally validated scores (n=4), none displayed “good” discrimination (AUROC ≥0·70). Conclusion The risk of SSI following gastrointestinal surgery is insufficiently described by existing risk prediction tools, which are not suitable for routine use. Novel risk stratification tools are required to target perioperative interventions and mitigate modifiable risk factors.

Prevalence of preoperative opioid usage and its impact on postoperative outcomes: a retrospective cohort study.

Preoperative opioid treatment increases postoperative adverse events. This study was aimed to analyze preoperative opioid prevalence in countries with low opioid consumption. Additionally, the effect of low opioid usage on postoperative outcomes was also investigated. We conducted this single center retrospective cohort analysis in a Japanese university-affiliated hospital to investigate opioid usage and its impact on the duration of postoperative hospitalization and in-hospital mortality. Adult patients who underwent general anesthesia between 2015 and 2020 were included. We extracted the patients' characteristics, surgical information and postoperative outcomes. Subgroup analysis to address opioid dose effect was performed in high and low dose opioid subgroups. Among 20,306 inpatients, 535 (2.63%) patients used opioids preoperatively. Tramadol was the most frequently used opioid. The median morphine equivalent (MME) dose was 15mg/day. Median duration of hospitalization was 18 and 9days in the opioid and non-opioid groups, and in-hospital mortality was 2.06% and 0.42%. Multivariable regression analysis demonstrated that preoperative opioid use was associated with a longer duration of hospitalization and in-hospital mortality. Subgroup analysis demonstrated longer durations of hospitalization in both high (> 30mg/day MME) and low (≤ 30mg/day MME) dose opioid groups, while higher in-hospital mortality was seen only in the high dose opioid group. Preoperative opioid usage was one-tenth of the United States average. Despite its low prevalence and small dosage, preoperative opioid usage was associated with poor postoperative outcomes. Dedicated perioperative interventions to prevent opioid-associated adverse events should be developed even in countries with low opioid consumption.

Can perioperative psychological interventions reduce chronic pain after surgery?

Chronic post-surgical pain is a relatively common adverse effect following surgery. Several prognostic factors for chronic post-surgical pain have been identified, including psychological states and traits. Psychological factors are modifiable, and perioperative psychological interventions may reduce the incidence of chronic post-surgical pain. A meta-analysis showed preliminary evidence for the benefits of such interventions for the prevention of chronic post-surgical pain. Further research must be conducted to better understand the specific type, intensity, duration and timing of interventions that are most effective. The number of studies in this area has recently increased, with additional randomised controlled trials currently being carried out, which may allow for the development of more robust conclusions in the coming years. In order to implement perioperative psychological care alongside routine surgical interventions, efficient and accessible interventions should be available. In addition, demonstration of cost-effectiveness may be a prerequisite for wider adoption of perioperative psychological interventions in regular healthcare. Offering psychological interventions selectively to patients at risk of chronic post-surgical pain could be a means to increase cost-effectiveness. Stepped-care approaches should also be considered, where the intensity of psychological support is adapted to the needs of the patient.

Analysis of Characteristics Associated With Pregnancy Duration After Cervical Cerclage Placement in Singleton Gestations [ID: 1378088

INTRODUCTION: Cervical cerclage technique and perioperative interventions vary widely among providers because of lack of evidence to inform management. Our aim was to identify factors independently associated with pregnancy duration in singleton gestations after cerclage placement. METHODS: This was a retrospective cohort analysis from 2008 to 2020 at an academic tertiary care center. Because of the inclusion of one or more pregnancies for ∼37% of the cohort, a linear mixed-effects model was utilized to evaluate the association between various factors and pregnancy duration. Variables with P<.2 on unadjusted analysis were considered for incorporation into a multivariable model. Model fit was assessed using Akaike’s information criterion (AIC). RESULTS: Out of 762 pregnancies, 42% underwent history-indicated, 22% ultrasound-indicated, and 36% physical exam-indicated cerclage placement. Mean gestational age (GA) at delivery was 35.0±5.8 weeks. 22% occurred less than 32 weeks and 7% resulted in previable delivery. Mean duration of pregnancy after cerclage placement was 17.1±7.0 weeks. An 8-covariate multivariable analysis revealed adjusted differences (β) in weeks of GA at delivery (95% CI): nulliparity +1.61 (0.57, 2.64), multiparity with most recent delivery 34 weeks or greater +1.31 (0.53, 2.10), married +0.94 (0.18, 1.70), concomitant progesterone use +1.06 (0.35, 1.76), preoperative cervical dilation 0.5 cm or higher −1.26 (−2.10, −0.41), utilization of Foley balloon for membrane elevation −2.27 (−3.53, −1.01), postoperative cervical length less than 20 mm −6.34, (−7.37, −5.32), and requiring cerclage revision −3.79 (−5.40, −2.18). CONCLUSION: Apart from use of a Foley balloon for membrane elevation and concomitant progesterone, we did not find any modifiable factors associated with pregnancy duration after cervical cerclage placement. However, this information may inform counseling as well as management for those with a postoperative cervical length less than 20 mm.

The Impact of Preoperative Pain on Outcomes After Vaginal Reconstructive Surgery and Perioperative Pelvic Floor Muscle Training.

The impact of preoperative pain on outcomes can guide counseling. The objective of this study was to compare outcomes after vaginal reconstructive surgery and pelvic muscle training between women with and without preoperative pain. This is a secondary analysis of the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial, which randomized patients to a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (pelvic floor muscle training vs usual care). Preoperative pain was defined as a response of "5" or greater on the pain scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question "Do you usually experience pain in the lower abdomen or genital area?" The OPTIMAL trial included 109 women with preoperative pain and 259 without pain. Although women with pain had worse pain scores and pelvic floor symptoms at baseline and postoperatively, they had greater improvement on pain scores (-2.3 ± 2.4 vs -0.2 ± 1.4, P < 0.001), as well as Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores. Among women with pain who underwent a sacrospinous ligament fixation, those who received pelvic floor muscle training had a greater reduction in pain compared with those in the usual care group (-3.0 ± 2.3 vs -1.3 ± 2.1, P = 0.008). Persistent or worsening pain was present at 24 months in 5 (16%) women with preoperative pain. Women with preoperative pain experience significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery. Pelvic floor muscle training perioperatively may be beneficial for select patients.

Are All Patients Going Home after Total Knee Arthroplasty? A Temporal Analysis of Discharge Trends and Predictors of Nonhome Discharge (2011-2020).

Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.

Safety of laparoscopic cholecystectomy in patients with a cerebrospinal fluid shunt in the peritoneal cavity.

The management of patients with a cerebrospinal fluid (CSF) shunt located in the peritoneal cavity undergoing laparoscopic surgery is an issue that has not yet been settled. These patients are at risk of increased intracranial pressure caused by peritoneal insufflation, shunt dysfunction, and shunt infection/retrograde meningitis. This study aimed to determine the need for perioperative shunt intervention in CSF shunt patients undergoing laparoscopic cholecystectomy. We reviewed and analyzed five shunt patients who underwent laparoscopic cholecystectomy in our institution between 2012 and 2022, as well as 17 patients described in previous reports. Among the 22 patients, shunt type was ventriculoperitoneal in 14 and lumboperitoneal in eight. The most common indication for CSF shunt was hydrocephalus caused by cerebral vascular accident (50.0%). Laparoscopic cholecystectomy was performed for cholecystolithiasis in 13 patients (59.1%), acute cholecystitis in eight (36.4%), and gallbladder polyp in one (4.5%). Shunt clamping or externalization was performed in six patients. Two patients in the group that did not undergo shunt clamping or externalization experienced complications (intra abdominal abscess and subcutaneous emphysema). However, the incidence of short-term complications (both overall and shunt-related) and median length of hospital stay did not significantly differ between the two groups. Routine shunt clamping, externalization, or removal might not be necessarily required in patients with a ventriculoperitoneal or lumboperitoneal shunt undergoing laparoscopic cholecystectomy.

In the thicket of fears, doubts, and murky facts: some reflections on treatment modalities for endometriosis-associated pain.

Endometriosis-associated pain can be managed by either surgery or hormonal therapy. The final decision as to which treatment modality to take is based on efficacy and possible complications of different treatment modalities, risk of recurrence, and the patient's wishes and preferences. But in the thicket of fears, doubts, and murky facts, the choice may ultimately be the trade-off between irrational fears and ignorance versus scientific evidence. We elaborate some pros and cons of the two treatment modalities and highlight some notable downsides of hormonal therapy, in particular the possible yet unquantified risk of long-term hormonal therapy for malignant transformation, perhaps with the only exception of combined oral contraceptives. Thus, when discussing with patients, we advocate the approach of discussing the advantages and disadvantages of all treatment options in detail, accounting for the known pros and cons with a full understanding of the predictive irrationality of human beings. For endometriosis-associated pain, surgery is definitely not a failure of medicine but, rather, a viable option, especially given the recently surfaced undercurrent of wariness and dissatisfaction with the current hormonal drugs among patients with endometriosis. Above all, there is a pressing need to fill the knowledge gap of perioperative interventions intended to reduce the risk of recurrence and to fulfill the demand for the development of safe and efficacious non-hormonal therapeutics.

Let's Get Physical! A Comprehensive Review of Pre- and Post-Surgical Interventions Targeting Physical Activity to Improve Pain and Functional Outcomes in Spine Surgery Patients.

The goal of this comprehensive review was to synthesize the recent literature on the efficacy of perioperative interventions targeting physical activity to improve pain and functional outcomes in spine surgery patients. Overall, research in this area does not yet permit definitive conclusions. Some evidence suggests that post-surgical interventions may yield more robust long-term outcomes than preoperative interventions, including large effect sizes for disability reduction, although there are no studies directly comparing these surgical approaches. Integrated treatment approaches that include psychosocial intervention components may supplement exercise programs by addressing fear avoidance behaviors that interfere with engagement in activity, thereby maximizing the short- and long-term benefits of exercise. Efforts should be made to test brief, efficient programs that maximize accessibility for surgical patients. Future work in this area should include both subjective and objective indices of physical activity as well as investigating both acute postoperative outcomes and long-term outcomes.

Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists

Background Among the different types of perioperative organ injury, acute kidney injury (AKI) occurs frequently and is consistently associated with increased rates of mortality and mortality. Despite development of many clinical trials to assess perioperative interventions, reliable means to prevent or reverse AKI are still lacking. Objectives This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and potential directions for future research. Methods A Pubmed search with the relevant keywords was done for articles published in the last 10 years. Results New insights into preoperative identification and optimisation, intraoperative strategies, including the choice of anaesthetic, haemodynamic and fluid management, have been made, with the aim of preventing perioperative AKI. Conclusion A patient-centric multidisciplinary approach is essential to protect kidney function of patients going for surgery. Much can be done by anaesthesiologists perioperatively, to reduce the risk of development of AKI, especially in susceptible patients. There is a need for further multicentred trials to enhance the currently generic perioperative recommendations.

Prediction of major postoperative events after non-cardiac surgery for people with kidney failure: derivation and internal validation of risk models

BackgroundPeople with kidney failure often require surgery and experience worse postoperative outcomes compared to the general population, but existing risk prediction tools have excluded those with kidney failure during development or exhibit poor performance. Our objective was to derive, internally validate, and estimate the clinical utility of risk prediction models for people with kidney failure undergoing non-cardiac surgery.Design, setting, participants, and measuresThis study involved derivation and internal validation of prognostic risk prediction models using a retrospective, population-based cohort. We identified adults from Alberta, Canada with pre-existing kidney failure (estimated glomerular filtration rate [eGFR] < 15 mL/min/1.73m2 or receipt of maintenance dialysis) undergoing non-cardiac surgery between 2005–2019. Three nested prognostic risk prediction models were assembled using clinical and logistical rationale. Model 1 included age, sex, dialysis modality, surgery type and setting. Model 2 added comorbidities, and Model 3 added preoperative hemoglobin and albumin. Death or major cardiac events (acute myocardial infarction or nonfatal ventricular arrhythmia) within 30 days after surgery were modelled using logistic regression models.ResultsThe development cohort included 38,541 surgeries, with 1,204 outcomes (after 3.1% of surgeries); 61% were performed in males, the median age was 64 years (interquartile range [IQR]: 53, 73), and 61% were receiving hemodialysis at the time of surgery. All three internally validated models performed well, with c-statistics ranging from 0.783 (95% Confidence Interval [CI]: 0.770, 0.797) for Model 1 to 0.818 (95%CI: 0.803, 0.826) for Model 3. Calibration slopes and intercepts were excellent for all models, though Models 2 and 3 demonstrated improvement in net reclassification. Decision curve analysis estimated that use of any model to guide perioperative interventions such as cardiac monitoring would result in potential net benefit over default strategies.ConclusionsWe developed and internally validated three novel models to predict major clinical events for people with kidney failure having surgery. Models including comorbidities and laboratory variables showed improved accuracy of risk stratification and provided the greatest potential net benefit for guiding perioperative decisions. Once externally validated, these models may inform perioperative shared decision making and risk-guided strategies for this population.

Quality contract ‘prevention of postoperative delirium in the care of elderly patients’ study protocol: a non-randomised, pre–post, monocentric, prospective trial

IntroductionPostoperative delirium (POD) is seen in approximately 15% of elderly patients and is related to poorer outcomes. In 2017, the Federal Joint Committee (Gemeinsamer Bundesausschuss) introduced a ‘quality contract’ (QC)...

Influence of opioid analgesia type on circulating tumor cells in open colorectal cancer surgery (POACC-1): study protocol for a prospective randomized multicenter controlled trial

BackgroundOpioids and epidural analgesia are a mainstay of perioperative analgesia but their influence on cancer recurrence remains unclear. Based on retrospective data, we found that cancer recurrence following colorectal cancer surgery correlates with the number of circulating tumor cells (CTCs) in the early postoperative period. Also, morphine- but not piritramide-based postoperative analgesia increases the presence of CTCs and shortens cancer-specific survival. The influence of epidural analgesia on CTCs has not been studied yet.MethodsWe intend to enroll 120 patients in four centers in this prospective randomized controlled trial. The study protocol has been approved by Ethics Committees in all participating centers. Patients undergoing radical open colorectal cancer surgery are randomized into epidural, morphine, and piritramide groups for perioperative analgesia. The primary outcome is the difference in the number of CTCs in the peripheral blood before surgery, on the second postoperative day, and 2–4 weeks after surgery. The number of CTCs is measured using molecular biology methods. Perioperative care is standardized, and relevant data is recorded. A secondary outcome, if feasible, would be the expression and activity of various receptor subtypes in cancer tissue. We intend to perform a 5-year follow-up with regard to metastasis development.DiscussionThe mode of perioperative analgesia favorably affecting cancer recurrence would decrease morbidity/mortality. To identify such techniques, trials with long-term follow-up periods seem suboptimal. Given complex oncological therapeutic strategies, such trials likely disable the separation of perioperative analgesia effects from other factors. We believe that early postoperative CTCs presence/dynamics may serve as a sensitive marker of various perioperative interventions´ influences on cancer recurrence. Importantly, it is unbiased to the influence of long-term factors and minimally invasive. Analysis of opioid/cannabinoid receptor subtypes in cancer tissue would improve understanding of underlying mechanisms and promote personalization of treatment. We are not aware of any similar ongoing studies.Trial registration numberNCT03700411, registration date: October 3, 2018. Study status: recruiting.

Perioperative nutrition for gastrointestinal surgery: On the cutting edge.

Evidence on perioperative nutrition interventions in gastrointestinal surgery is rapidly evolving. We conducted a narrative review of various aspects of nutrition support, including formula choice and route of administration, as well as duration and timing of nutrition support therapy. Studies have demonstrated that nutrition support is associated with improved clinical outcomes in malnourished patients and those at nutrition risk, emphasizing the importance of nutrition assessment, for which several validated nutrition risk assessment tools exist. The assessment of serum albumin levels has fallen out of favor, as it is an unreliable marker of nutrition status, whereas imaging evidence of sarcopenia has prognostic value and may emerge as a standard component of nutrition assessment. Preoperatively, evidence supports limiting fasting to reduce insulin resistance and improve oral tolerance. Benefits to preoperative carbohydrate loading remain unclear, whereas literature suggests preoperative parenteral nutrition (PN) may reduce postoperative complications in high-risk patients with malnutrition or sarcopenia. Postoperatively, early oral feeding is safe with benefits in time to return of bowel function and reduced hospital stay. There is a signal for potential benefit to early postoperative PN in critically ill patients, though evidence is sparse. There has also been a recent emergence in randomized studies evaluating the use of ω-3 fatty acids, amino acids, and immunonutrition. Meta-analyses have reported favorable outcomes for these supplements, though individual studies are small and with significant methodological limitations and risk of bias, emphasizing the need for high-quality randomized studies to guide clinical practice.

Impact of malnutrition on early outcomes after cancer surgery: an international, multicentre, prospective cohort study

Malnutrition represents a key priority for global health policy, yet the impact of nutritional state on cancer surgery worldwide remains poorly described. We aimed to analyse the effect of malnutrition on early postoperative outcomes following elective surgery for colorectal or gastric cancer. We did an international, multicentre, prospective cohort study of patients undergoing elective surgery for colorectal or gastric cancer between April 1, 2018, and Jan 31, 2019. Patients were excluded if the primary pathology was benign, they presented with cancer recurrence, or if they underwent emergency surgery (within 72 h of hospital admission). Malnutrition was defined with the Global Leadership Initiative on Malnutrition criteria. The primary outcome was death or a major complication within 30 days of surgery. Multilevel logistic regression and a three-way mediation analysis were done to establish the relationship between country income group, nutritional status, and 30-day postoperative outcomes. This study included 5709 patients (4593 with colorectal cancer and 1116 with gastric cancer) from 381 hospitals in 75 countries. The mean age was 64·8 years (SD 13·5) and 2432 (42·6%) patients were female . Severe malnutrition was present in 1899 (33·3%) of 5709 patients, with a disproportionate burden in upper-middle-income countries (504 [44·4%] of 1135) and low-income and lower-middle-income countries (601 [62·5%] of 962). After adjustment for patient and hospital risk factors, severe malnutrition was associated with an increased risk of 30-day mortality across all country income groups (high income: adjusted odds ratio [aOR] 1·96 [95% CI 1·14-3·37], p=0·015; upper-middle income: 3·05 [1·45-6·42], p=0·003; low income and lower-middle income: 11·57 [5·87-22·80], p<0·0001). Severe malnutrition mediated an estimated 32% of early deaths in low-income and lower-middle-income countries (aOR 1·41 [95% CI 1·22-1·64]) and an estimated 40% of early deaths in upper-middle-income countries (1·18 [1·08-1·30]). Severe malnutrition is common in patients undergoing surgery for gastrointestinal cancers and is a risk factor for 30-day mortality following elective surgery for colorectal or gastric cancer. There is an urgent need to examine whether perioperative nutritional interventions can improve early outcomes following gastrointestinal cancer surgery worldwide. National Institute for Health Research Global Health Research Unit.

Perioperative Interventions to Prevent Gastroesophageal Reflux Disease and Marginal Ulcers After Bariatric Surgery - an International Experts' Survey.

This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate perioperative interventions to prevent gastroesophageal reflux disease (GERD) and marginal ulcers (MU) after MBS. Very important long-term complications after MBS include GERD, Barrett's esophagus, and MU. Prevention might be fundamental to reduce the incidence, severe complications, and the increasing number of revisional bariatric surgeries. An international scientific team designed an online confidential questionnaire with 45 multiple-choice questions. The survey was sent to 110 invited experts and 96 of them (from 41 different countries) participated from 21 July 2022 to 4 September 2022. Most experts (≥ 90%) prescribe postoperative acid suppression agents after MBS. Life-long proton pump inhibitors prophylaxis in smokers with avoidance of non-steroidal anti-inflammatory drugs are recommended by most of the experts (66%, 73%) after any type of gastric bypass. Two-thirds of experts (69%) perform Helicobacter pylori eradication prior to MBS. Two-thirds of experts (68%) routinely perform EGD and biopsy before MBS. Follow-up esophagogastroduodenoscopy (EGD) and timing threshold for revisional and conversional MBS were variable among experts. This expert survey underlines important perioperative interventions that reached a two-thirds consensus among MBS international experts. Variability in follow-up EGD, approach to complication management, and thresholds for revisional and conversional MBS emphasize the need for further researches and consensus guidelines.

Enhanced recovery after surgery (ERAS) protocol in geriatric patients underwent unicompartmental knee arthroplasty: A retrospective cohort study.

The enhanced recovery after surgery (ERAS) pathway was formulated with the aim to reduce surgical stress response, alleviate pain and guarantee the best-fit experience of patients' perioperative period. However, the application of ERAS in geriatric patients who underwent unicompartmental knee arthroplasty (UKA) was relatively lacking. We hypothesize that UKA patients can benefit from the ERAS protocol. A total of 238 patients were recruited in this retrospective study from August 2018 to December 2021, and Oxford phase III UKA was applied to all patients. ERAS pathway included nutrition support, anesthesia mode, interoperative temperature, and blood pressure control, application of tranexamic acid, early initiation of oral intake and mobilization, and pain management. Demographic data, operation-relative variables, and postoperative complications were analyzed. Forgotten Joint Scores, Oxford Knee Score, Lysholm score, numerical rating scale, and knee range of motion were introduced to estimate the activity function and pain of surgical knee, and these variables were compared between the 2 groups. There were 117 patients in the ERAS group and 121 patients in the traditional group, respectively. The ERAS group had a shorter length of surgical incision and less intraoperative blood loss. Postoperative hemoglobin and albumin of patients in the ERAS group were better than those in the traditional group (P < .05), after 17.0 ± 10.8 months follow-up, the numerical rating scale, Lysholm, Oxford Knee Score, Forgotten Joint Scores, and knee range of motion of patients in the ERAS group were significantly better than the traditional group. The length of hospital stay for patients who underwent ERAS was 11.7 ± 3.8 days and the postoperative complication rate was lower for the ERAS group patients (P = .000 and 0.031). ERAS can reduce the length of hospital stay, and patients can achieve excellent postoperative knee function. The formulation and implementation of the ERAS protocol require good collaboration across multiple disciplines, as well as a deep understanding of the existing clinical evidence and the concept of the ERAS program.

Surgeon-Specific Treatment Selection Bias and Heterogeneous Perioperative Practices in an Observational Spine Surgery Study. A Statistical Tutorial with Implications for Analysis of Observational Studies of Perioperative Interventions

It is essential that treatment effects reported from retrospective observational studies are as reliable as possible. In a retrospective analysis of spine surgery patients, we obtained a spurious result: tranexamic acid (TXA) had no effect on intraoperative blood loss. This statistical tutorial explains how this result occurred and why statistical analyses of observational studies must consider the effects of individual surgeons. We used an observational database of 580 elective adult spine surgery patients, supplemented with a review of perioperative medication records. We tested whether common statistical methods (multivariable regression or propensity score-based methods) could adjust for surgeons' selection bias in TXA administration. Because TXA administration (frequency, timing, and dose) and surgeon were linked (collinear), estimating and testing the independent effect of TXA on outcome using multivariable regression without including surgeon as a variable would provide biased (spurious) results. Likewise, because of surgeon/TXA linkage, assumptions of propensity score-based analysis were violated, statistical methods to improve comparability between groups failed, and spurious blood loss results were worsened. Others numerous differences among surgeons existed in intraoperative and postoperative practices and outcomes. In observational studies in which individual surgeons determine whether their patients receive the treatment of interest, consideration must be given to inclusion of surgeon as an independent variable in all analyses. Failure to include the surgeon in an analysis of observational data carries a substantial risk of obtaining spurious results, either creating a spurious treatment effect or failing to detect a true treatment effect.

Effectiveness of perioperative family-centered educational interventions in the anxiety, pain and behaviors of children/adolescents and their parents: Systematic Review Protocol

Introduction: Every year, millions of children and adolescents undergo surgery, 50%-75% of them experience fear and anxiety. Children are particularly susceptible to stress and anxiety surrounding surgery as a result of their cognitive development, previous experiences, and knowledge about healthcare; this leads to additional interventions to prevent and reduce these symptoms. Objective: To evaluate the effectiveness of family-centered educational interventions in the children’s and adolescents’ anxiety, pain, and behaviors and their parents’ anxiety during the perioperative period. Methods: This review will follow the Joanna Briggs Institute guidelines for systematic reviews of effectiveness and will consider those studies (experimental and quasi-experimental) in which perioperative educational interventions have been applied to children and adolescents and their parents; these studies measured children and adolescents’ pain, anxiety, and behaviors, as well as their parent’s anxiety. An initial search of MEDLINE and CINAHL will be followed by a second search for published and unpublished studies from January 2007 on, available in English, Spanish and Portuguese. After all full texts are retrieved, the methodological quality assessment and data extraction will be independently and critically evaluated by two reviewers, and the data will then be presented in a tabular format. An explanatory synthesis will accompany the results. Whenever possible, a meta-analysis will be performed, and a Grading of Recommendations, Assessment, Development, and Evaluation Summary of Findings will be presented. Expected Results: This review will provide guidance on how family-centred educational interventions can be used as a resource to manage anxiety, pain, and behavior in children, adolescents and their relatives during the perioperative processes.