Perioperative Management Strategies Research Articles

Same Day Discharge After Robotic Radical Prostatectomy.

This review evaluates the current landscape of same-day discharge (SDD) following robotic-assisted laparoscopic prostatectomy (RARP), highlighting perioperative management strategies and proposing future research directions. RARP has been shown to improve perioperative outcomes including reduced blood loss, postoperative pain, and hospital length of stay (LOS) when compared to open radical prostatectomy. Recently, the question of the feasibility of SDD for RARP has been proposed, aiming to reduce postoperative complications, hospital-acquired infections, and healthcare costs. The advent of single-port robotic systems aims to further minimize postoperative morbidity. Recent literature has reported SDD for RARP is safe and feasible in appropriately selected patients, with postoperative outcomes, including complication and readmission rates, similar to inpatient RARP. Our findings show SDD can be safely implemented without compromising patient outcomes, as evidenced by similar complication, readmission, and emergency department visit rates compared to inpatient cohorts. Future research should be aimed to refining patient selection criteria, enhancing opioid-free anesthesia pathways, and exploring new surgical technologies to improve SDD outcomes.

Development and validation of a nomogram for predicting perioperative transfusion in children undergoing cardiac surgery with CPB

BackgroundTimely recognition of perioperative red blood cell transfusion (PRT) risk is crucial for developing personalized blood management strategies in pediatric patients. In this study, we sought to construct a prediction model for PRT risk in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).MethodsFrom September 2014 to December 2021, 23,884 pediatric patients under the age of 14 were randomly divided into training and testing cohorts at a 7:3 ratio. Variable selection was performed using univariate logistic regression and least absolute shrinkage and selection operator (LASSO) regression. Multivariate logistic regression was then used to identify predictors, and a nomogram was developed to predict PRT risk. The model’s performance was evaluated based on discrimination, calibration, and clinical utility in both cohorts.ResultsAfter multiple rounds of variable selection, eight predictors of PRT risk were identified: age, weight, preoperative hemoglobin levels, presence of cyanotic congenital heart disease, CPB duration, minimum rectal temperature during CPB, CPB priming volume, and the use of a small incision. The predictive model incorporating these variables demonstrated strong performance, with an area under the curve (AUC) of 0.886 (95% CI: 0.880–0.891) in the training cohort and 0.883 (95% CI: 0.875–0.892) in the testing cohort. The calibration plot closely aligned with the ideal diagonal line, and decision curve analysis indicated that the model provided a net clinical benefit.ConclusionsOur predictive model exhibits good performance in assessing PRT risk in pediatric patients undergoing cardiac surgery with CPB, providing clinicians a practical tool to optimize individualized perioperative blood management strategies for this vulnerable population.

Peritoneal dialysis and kidney transplantation: Your questions answered.

Peritoneal dialysis (PD) and kidney transplantation are important therapeutic options in patients with advanced kidney disease. This article delineates the relationship between PD and kidney transplantation in several key domains, including: (1) Comparative merits and limitations of PD versus center-based hemodialysis prior to kidney transplantation, (2) Patient outcomes after kidney transplantation in individuals receiving PD prior to kidney transplantation, (3) Perioperative management strategies of patients receiving PD at the time of kidney transplantation, and (4) The relative advantages and clinical outcomes of PD use following kidney allograft failure compared to other modalities. This article aims to provide comprehensive guidance for optimizing care across the PD-kidney transplant transitions continuum.

Biomechanical Advances in Total Hip Arthroplasty: From Surgical Approach to Functional Recovery

This technical article discusses biomechanical advancements in total hip arthroplasty (THA), from surgical techniques to functional recovery. Focusing on the evolution of surgical approaches, it highlights the use of robotics and artificial intelligence to enhance implant positioning precision and minimize misalignments. Advanced materials, such as high-density polyethylene, and innovative prosthesis designs were also discussed, emphasizing their contribution to prosthesis durability and functionality. Additionally, perioperative management strategies, including modern analgesic blocks and nutritional support, have improved postoperative recovery, while structured rehabilitation protocols are essential for restoring gait and joint biomechanics. Finally, long-term considerations regarding prosthesis survival and patients' quality of life were explored, reinforcing the importance of a multidisciplinary approach and cutting-edge technologies.

Innovative Strategies in the Management of Hypoplastic Left Heart Syndrome: A Multidisciplinary and Translational Approach

Background: Hypoplastic Left Heart Syndrome (HLHS) represents one of the most severe congenital cardiac malformations, characterized by underdevelopment of left-sided heart structures, necessitating a complex surgical and medical management strategy. Despite advancements in staged palliation and neonatal care, outcomes remain suboptimal for a significant subset of patients. Recent progress in molecular biology, regenerative medicine, and surgical innovations offers novel approaches that may transform the clinical trajectory of these patients. Objectives: This article explores emerging strategies for HLHS management, including stem cell therapy, tissue engineering, genomic medicine, hybrid procedures, and long-term monitoring protocols facilitated by artificial intelligence (AI). Methods: A comprehensive review of contemporary literature was conducted, focusing on the translational application of novel therapies and their integration into current staged palliation frameworks. Results: Early-stage studies demonstrate promise for stem cell therapies and myocardial regeneration in improving ventricular function. Advances in 3D printing and bioengineering have facilitated patient-specific surgical planning and the development of biocompatible grafts. Furthermore, AI-driven algorithms provide personalized risk assessment and optimized perioperative management strategies. Conclusions: The integration of multidisciplinary and translational approaches offers an opportunity to redefine HLHS management, potentially improving survival and quality of life for affected individuals. However, further clinical trials and international collaboration are essential to establish these novel therapies as standard of care.

A single-center prospective cohort study assessing preoperative gait speed assessment as a prognostic tool for morbidity and mortality in frail elderly patients undergoing abdominal surgery.

Frailty is a significant risk factor for adverse outcomes in elderly surgical patients. Gait speed assessment is a new tool recently used to stratify risk for these pre-operative adverse outcomes. In this prospective study of 392 frail elderly patients undergoing abdominal surgery, we investigated the predictive value of preoperative gait speed for postoperative outcomes. Patients were divided into two groups based on their 6-meter gait speed: normal (≥0.8 m/s, n=184) and slow (<0.8 m/s, n=208). The slow group was older, had more comorbidities, and higher American Society of Anesthesiologists (ASA) grades (P<0.05). They also had significantly higher rates of 30-day overall complications (38.9 vs 18.5%, P<0.01), severe complications (12.0 vs 4.3%, P<0.01), and 1-year mortality (15.4 vs 6.5%, P=0.008) compared to the normal group. Pulmonary infection, wound infection, and delirium were the most common complications. Multivariate logistic regression confirmed slow gait speed as an independent risk factor for 30-day complications (OR=2.38, 95%CI: 1.41-4.01) and 1-year mortality (OR=2.19, 95%CI: 1.07-4.48). Our findings demonstrated that preoperative 6-meter gait speed effectively predicted short-term complications and mid-term mortality in frail elderly patients undergoing abdominal surgery. This suggests the need for individualized perioperative management strategies for high-risk patients with slow gait speed to potentially improve their prognosis.

Evidence-based Algorithms for Free Deep Inferior Epigastric Perforator Flap Salvage in Autologous Breast Reconstruction.

Breast reconstruction with the deep inferior epigastric perforator (DIEP) free flap has become the gold standard for autologous breast reconstruction. Flap take-back to the operating room (OR) is an uncommon but difficult situation, requiring prompt and accessible resources. We conducted a literature review and independent expert review to inform evidence-based perioperative algorithms in the event of DIEP flap compromise. A review of the literature was conducted, including MEDLINE, Embase, Google Scholar, and Cochrane Controlled Register of Trials. Publications examining free flap re-exploration in breast reconstruction were used to inform evidence-based clinical algorithms. The algorithms then underwent expert review and revisions from 6 international experts in microsurgery. Three evidence-based management algorithms were created. The first algorithm outlines perioperative management strategies to optimize patient care and prompt return to the OR. Nonconstricting flap inset after take-back, salvage medical strategies and postoperative management following flap failure were additionally included. Algorithms 2 (venous congestion) and 3 (vascular thrombosis) provide specific intraoperative strategies surrounding mechanical decompression, pedicle exposure, assessment and extraction of thrombosis, identification and use of alternative recipient vessels, and the usage of intraoperative thrombolytics. A coherent and stepwise approach to DIEP flap compromise in breast reconstruction was developed. These expert-reviewed algorithms provide an approachable and evidence-based structure to support return to the OR and serve as readily available resources.

The impact of body mass index on intraoperative and postoperative blood transfusion amounts in coronary artery bypass surgery

Aims: The relationship between obesity, bleeding volume, and transfusion requirements during and after coronary artery bypass surgery remains unclear. This study aimed to investigate the impact of body mass index (BMI) on the amount of intraoperative and postoperative blood transfusions in patients undergoing coronary artery bypass grafting (CABG). Methods: This retrospective study included 288 patients who underwent isolated cardiopulmonary bypass for CABG between 2011 and 2017. Patients were stratified into five BMI categories: underweight (&lt;18.5 kg/m²), normal weight (18.5–24.9 kg/m²), overweight (25.0–29.9 kg/m²), and obese (30.0 kg /m2 &lt;= BMI &lt; 35.0 kg/m2), and morbid obese (BMI &gt;= 35.0 kg/m2). Demographic data, pump times, cross-clamp times, and the amounts of intraoperative and postoperative blood transfusions were retrospectively collected. Results: Among the patients, obese and morbidly obese individuals comprised 38.2% of the cohort, while underweight patients accounted for only 1.0%. The number of bypassed vessels and mean cross-clamp times did not significantly differ between the BMI groups. The mean amount of blood transfused during surgery ranged from 1.66 to 3.43 units, with the highest amounts observed in the morbidly obese group. However, no significant differences were found in the amount of blood transfused postoperatively between the BMI groups. Conclusion: Patients at the extremes of the BMI spectrum, specifically morbidly obese individuals, required higher amounts of blood transfusions intraoperatively compared to other groups. In contrast, postoperative transfusion amounts were comparable across all BMI categories. These findings underscore the importance of tailoring perioperative management strategies based on BMI levels to optimize patient outcomes.

Redefining Clinically Significant Blood Loss in Complex Adult Spine Deformity Surgery.

Retrospective analysis of prospectively-collected data. This study aims to define clinically relevant blood loss in adult spinal deformity (ASD) surgery. Current definitions of excessive blood loss following spine surgery are highly variable and may be suboptimal in predicting adverse events (AE). Adults undergoing complex ASD surgery were included. Estimated blood loss (EBL) was extracted for investigation, and estimated blood volume loss (EBVL) was calculated by dividing EBL by the preoperative blood volume utilizing Nadler's formula. LASSO regression was performed to identify five variables from demographic and peri-operative parameters. Logistic regression was subsequently performed to generate a receiver operating characteristics (ROC) curve and estimate an optimal threshold for EBL and EBVL. Finally, the proportion of patients with AE plotted against EBL and EBVL to confirm the identified thresholds. In total 552 patients were included with a mean age of 60.7±15.1 years, 68% females, mean CCI was 1.0±1.6, and 22% experienced AEs. LASSO regression identified ASA score, baseline hypertension, preoperative albumin, and use of intra-operative crystalloids as the top predictors of an AE, in addition to EBL/EBVL. Logistic regression resulted in ROC curve which was used to identify a cut-off of 2.3 liters of EBL and 42% for EBVL. Patients exceeding these thresholds had AE rates of 36% (odds-ratio: 2.1, 95% CI [1.2-3.6]) and 31% (odds-ratio: 1.7, 95% CI [1.1-2.8]), compared to 21% for those below the thresholds of EBL and EBVL, respectively. In complex ASD surgery, intraoperative EBL of 2.3 liters and an EBVL of 42% are associated with clinically-significant AEs. These thresholds may be useful in guiding preoperative-patient-counseling, healthcare system quality initiatives, and clinical perioperative bloodloss management strategies in patients undergoing complex spine surgery. Additionally, similar methodology could be performed in other specialties to establish procedure-specific clinically-relevant bloodloss thresholds.

Incidence and Predictors of Cardiac Complications Following Elective Versus Urgent Non-cardiac Surgeries.

Cardiac complications following non-cardiac surgeries are a significant cause of perioperative morbidity and mortality. This meta-analysis aimed to assess the incidence and predictors of cardiac complications in patients undergoing elective and urgent non-cardiac surgeries. A comprehensive literature search was conducted in PubMed, Embase, and Cochrane Library databases for studies published between 2010 and 2024. Eligible studies evaluated cardiac outcomes such as myocardial infarction, arrhythmias, congestive heart failure, and cardiac arrest, reporting odds ratios (ORs) and confidence intervals (CIs) for associated risk factors. A total of seven studies were included, encompassing data from diverse populations and surgical settings. The pooled analysis revealed an overall incidence of cardiac complications of 2.8% (95% CI = 2.1%-3.5%) in elective surgeries and 5.4% (95% CI = 4.0%-6.8%) in urgent surgeries. Urgent procedures were associated with a significantly higher risk of cardiac events compared to elective surgeries (OR = 1.42, 95% CI = 1.15-1.76). Independent predictors of cardiac complications included advanced age, preoperative comorbidities such as hypertension and diabetes, reduced left ventricular ejection fraction, and elevated preoperative cardiac biomarkers, such as troponin levels. Significant heterogeneity was observed across studies, largely attributed to variations in surgical populations and definitions of cardiac outcomes. Subgroup analyses demonstrated that age >75 years (OR = 1.50, 95% CI = 1.20-1.90) and emergency procedures in patients with pre-existing cardiovascular disease (OR = 1.75, 95% CI = 1.30-2.10) were critical determinants of adverse outcomes. Additionally, intraoperative hypotension and prolonged surgical duration were associated with increased risk. The findings underscore the need for comprehensive preoperative risk assessment and tailored perioperative management strategies to mitigate cardiac risk, particularly in high-risk patients undergoing urgent surgeries. Enhanced utilization of preoperative biomarkers and risk scoring systems, coupled with vigilant intraoperative monitoring, may help reduce the burden of cardiac complications. While improvements in perioperative care have mitigated some risks, disparities remain, especially in resource-limited settings, warranting further research.

Association between preoperative antifungal therapy and postoperative complications in patients with pulmonary aspergilloma: A national database study in Japan.

Postoperative complications of pulmonary resection in patients with pulmonary aspergilloma are common. Preoperative antifungal therapy is a perioperative management strategy to reduce postoperative complications; however, the benefit of the treatment remains controversial. A retrospective cohort study was conducted using data from the Diagnosis Procedure Combination database (July 2010-March 2021), a national inpatient database in Japan. Patients with pulmonary aspergilloma with or without chronic necrotizing pulmonary aspergillosis who underwent pulmonary resection were identified and divided into two groups based on whether they received preoperative antifungal therapy. Propensity-score overlap weighting was performed to compare the occurrence of composite postoperative complications and postoperative length of hospital stay between the two groups. We identified 98 patients with pulmonary aspergilloma who received preoperative antifungal therapy and 399 patients who did not. After propensity-score overlap weighting, the preoperative antifungal therapy group had a significantly lower proportion of composite postoperative complications than the non-preoperative antifungal therapy group (6.8% vs. 14.2%, P=.038). There was no significant difference in postoperative length of stay between the groups with and without preoperative antifungal therapy (median 14.6 vs. 15.8 days, P=.41). Preoperative antifungal therapy was associated with a reduction in postoperative complications in patients with pulmonary aspergilloma. Preoperative treatment with antifungals may be beneficial in reducing the risk of postoperative complications in patients with pulmonary aspergilloma undergoing pulmonary resection.

GLP-1 receptor agonists and delayed gastric emptying: implications for invasive cardiac interventions and surgery.

Glucagon-like peptide-1 (GLP-1) is a hormone involved in glucose homeostasis and satiety regulation. The review highlights the importance of understanding the interplay between GLP-1 and gastric motility. This paper explores the intricate connection between GLP-1 and delayed gastric emptying, specifically gastroparesis, and its implications in the context of pulmonary aspiration during anesthesia along with the potential effects of GLP-1 medications on absorption of other medications. The findings noted in this paper serve as a catalyst for continued exploration into the intricate dynamics of GLP-1 and its implications in the context of perioperative care, aiming to enhance patient safety and optimize anesthesia practices. The inquiry suggests that an in-depth examination of this relationship is crucial for refining perioperative management strategies. It underscores the need for further research to elucidate the mechanisms involved and to establish guidelines that address the potential risks associated with GLP-1 modulation, particularly in patients undergoing anesthesia for various cardiac surgeries and procedures. Specifically in the context of cardiac interventions understanding the potential for delayed absorption of critical cardiac medications due to the influence of GLP-1 on gastric emptying is particularly important as drug absorption can play a crucial role for ensuring successful outcomes.

Thrombotic events in patients underwent simultaneous bilateral total knee arthroplasty with modern perioperative blood management strategy.

Thrombotic events, the leading cause of death after total knee arthroplasty (TKA), occurred more frequently in simultaneous bilateral TKA than unilateral TKA under conventional perioperative management. The aim of the study was to determine whether the simultaneous bilateral TKA using contemporary blood management strategies would be associated with higher risk of thrombotic events than unilateral TKA. This propensity score-matched cohort study included 1,069 patients, with 324 undergoing simultaneous bilateral TKA and 745 undergoing unilateral TKA. All TKAs were performed without use of a tourniquet and with use of intravenous tranexamic acid administration. For patients receiving chronic antithrombotic therapy, the antithrombotic medications were continued during the perioperative period, including on the day of the operation. The primary outcome was the thrombotic events up to 1 year after TKA. The propensity score-matched cohort consisted of 324 matched pairs of patients. There was no significant difference between simultaneous bilateral and unilateral TKA groups in the occurrence of the thrombotic events (25 of 324 [7.7%] versus 19 of 324 [5.9%] patients, p = 0.44). Additionally, no significant differences were found in the occurrence of the bleeding events (1 of 324 [0.3%] versus 1 of 324 [0.3%] patients, p > 0.99) and death within the postoperative 1 year (1 of 324 [0.3%] versus 3 of 324 [0.9%] patients, p = 0.62). The rate of thrombotic events after simultaneous bilateral TKA with contemporary perioperative blood management strategies did not significantly differ from that after unilateral TKA.

When and how to adapt care in frail older adults

Adults ≥65 years of age comprise nearly 20 % of the U.S. population and over half of surgical patients. Older adults, particularly when frail, are at increased risk of adverse physical, cognitive, and functional changes after undergoing surgery. This manuscript highlights the importance of tailored care for frail older adults considering or undergoing colorectal surgery to optimize perioperative outcomes and recovery and better inform decision-making and promote goal-concordant care. We examine the challenges these patients face and outline evidence-based strategies for comprehensive preoperative assessment, perioperative management, and postoperative care to mitigate the risks associated with surgery and improve patient outcomes.

Perioperative outcomes in congenital heart disease: a review of clinical factors associated with prolonged ventilation and length of stay in four common CHD operations

ObjectivesPerioperative management strategies and outcomes for low-risk congenital heart disease (CHD) surgery vary between institutions. To date, no consensus exists on standardized management for pediatric patients undergoing cardiac surgery. This study seeks to benchmark the perioperative management of four common CHD lesions and explore clinical factors affecting postoperative outcomes. DesignA retrospective review of CHD procedures performed 2015-2020. SettingThe study was conducted at a single academic tertiary pediatric hospital. ParticipantsAll patients presenting for repair of ventricular septal defects (VSD), complete atrioventricular canal defects (CAVC), tetralogy of Fallot (TOF) and transposition of the great arteries (TGA) were reviewed. InterventionsDemographic and clinical data were collected; clinical outcomes were defined as postoperative length of ventilation (LOV) and hospital length of stay (LOS), divided into reference and prolonged course groups analyzed for variables associated with differences in outcomes. Measurements and Main Results931 patients were selected for review. Prolonged LOV and LOS in all cohorts were associated with longer operative, cardiopulmonary bypass and cross-clamp times; higher intraoperative requirements for inotropic support; more blood transfusions and higher opioid administration; lower pH pre-operatively and higher lactic acid post-operatively. Worse outcomes were associated with younger age in VSD, older age in TGA and lower weight in TOF and TGA. Worse outcomes were also associated with higher preoperative hematocrit in VSD and TOF and elevated preoperative blood glucose in VSD and TGA. ConclusionsA better understanding of clinical factors affecting outcomes may facilitate streamlining perioperative management strategies for pediatric patients undergoing low-risk cardiac surgery.

The association of the perioperative neutrophil-to-lymphocyte ratio with wound healing in patients with Wagner grade 3 and 4 diabetic foot ulcers after tibial cortex transverse transport surgery: a prospective observational cohort study.

Diabetic foot ulcers (DFUs) are severe complications of diabetes, involving multiple etiological factors including neuropathy, vascular insufficiency, and impaired wound healing. The global burden of DFUs is substantial, with significant morbidity and high management costs. Recent advancements have introduced the tibial cortex transverse transport (TTT) technique, which has shown promising results in the management of severe DFUs by promoting angiogenesis and immunomodulation. This prospective cohort study enrolled patients with Wagner grade 3 and 4 DFUs, treated using the TTT technique from May 2022 to September 2023 at MianYang Central Hospital. The study assessed the influence of TTT on the perioperative neutrophil-to-lymphocyte ratio (NLR), an established biomarker of systemic inflammation, and its correlation with wound healing outcomes. A total of 82 patients were enrolled, with 66 completing the study. The survival analysis revealed that patients with a lower preoperative NLR experienced significantly faster wound healing compared with a high NLR (log rank test P< 0.05; hazard ratio (HR) = 0.46; 95% CI: 0.26-0.83). The optimal NLR cutoff values (4.25) were established to predict wound healing times for DFUs. The median NLR was significantly different before TTT surgery, 3 days after TTT surgery, and 1 month after TTT surgery (P<0.05). The TTT technique significantly influences the perioperative NLR and is associated with improved wound healing in DFU patients. The perioperative NLR serves as an effective predictive biomarker for wound healing outcomes, highlighting the significance of interventions targeting NLR values in perioperative management strategies and postoperative monitoring protocols for the treatment of diabetic foot ulcers (DFUs) in clinical practice.

International Alliance of Urolithiasis (IAU) consensus on miniaturized percutaneous nephrolithotomy

Over the past three decades, there has been increasing interest in miniaturized percutaneous nephrolithotomy (mPCNL) techniques featuring smaller tracts as they offer potential solutions to mitigate complications associated with standard PCNL (sPCNL). However, despite this growing acceptance and recognition of its benefits, unresolved controversies and acknowledged limitations continue to impede widespread adoption due to a lack of consensus on optimal perioperative management strategies and procedural tips and tricks. In response to these challenges, an international panel comprising experts from the International Alliance of Urolithiasis (IAU) took on the task of compiling an expert consensus document on mPCNL procedures aimed at providing urologists with a comprehensive clinical framework for practice. This endeavor involved conducting a systematic literature review to identify research gaps (RGs), which formed the foundation for developing a structured questionnaire survey. Subsequently, a two-round modified Delphi survey was implemented, culminating in a group meeting to generate final evidence-based comments. All 64 experts completed the second-round survey, resulting in a response rate of 100.0%. Fifty-eight key questions were raised focusing on mPCNLs within 4 main domains, including general information (13 questions), preoperative work-up (13 questions), procedural tips and tricks (19 questions), and postoperative evaluation and follow-up (13 questions). Additionally, 9 questions evaluated the experts’ experience with PCNLs. Consensus was reached on 30 questions after the second-round survey, while professional statements for the remaining 28 key questions were provided after discussion in an online panel meeting. mPCNL, characterized by a tract smaller than 18 Fr and an innovative lithotripsy technique, has firmly established itself as a viable and effective approach for managing upper urinary tract stones in both adults and pediatrics. It offers several advantages over sPCNL including reduced bleeding, fewer requirements for nephrostomy tubes, decreased pain, and shorter hospital stays. The series of detailed techniques presented here serve as a comprehensive guide for urologists, aiming to improve their procedural understanding and optimize patient outcomes.

Obesity, kidney and metabolic bariatric surgery: a surgeon’s narrative review

Excess body weight impacts kidney function in individuals with severe obesity, primarily through metabolic alterations in adipocytes, especially in visceral adipose tissue. The relationship between persistent sterile inflammation associated with obesity and the progression of obesity-related kidney disease to chronic kidney disease (CKD) is an area of growing interest. The beneficial effects of weight loss on the prevention of kidney disease and the improvement of kidney function in individuals with obesity have been well documented. Currently, the most effective weight loss strategy is metabolic bariatric surgery (MBS), which has been proven to not only prevent the progression of CKD but also reverse it. However, awareness and understanding of the impact of obesity on the kidney should also extend to the severely obese population with clinically normal renal function. The purpose of this review is to outline the current knowledge on the pathophysiology of obesity-induced kidney damage, the effects of MBS on renal function in severely obese individuals with or without CKD, and provide the current evidence on perioperative management strategies for CKD patients, including diet and nutrition.

Implementing enhanced recovery after surgery protocol in elderly patients following multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases.

Enhanced recovery after surgery (ERAS) is an evidence-based multimodal perioperative management strategy. The aim of the present study was to analyze the clinical efficacy of ERAS in elderly patients (> 70 years old) undergoing multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases. Patients older than 70 years undergoing multi-level lumbar or thoracolumbar instrumented fusion for degenerative disk diseases or spinal stenosis from January 2017 to December 2018 (non-ERAS group) and from January 2020 to December 2021 (ERAS group) were enrolled in present study. Patient-specific and procedure-specific clinical characteristics were collected. Univariate and multivariate regression were performed to determine the risk factors related to length of stay (LOS) and complications. A total of 233 patients were enrolled in this study, 70 in non-ERAS group and 163 in ERAS group. There were comparable baseline characteristics between groups. Further there were no significant differences in 90-day readmission rates and complication rates. However, we observed a significant reduction in LOS (14.89 ± 7.78 days in non-ERAS group versus 11.67 ± 7.26 days in ERAS group, p = 0.002) and overall number of complications (38 in non-ERAS group versus 58 in ERAS group, p = 0.008). Univariate linear regression denoted that operation time (p < 0.001), intraoperative blood loss (p < 0.001), intraoperative blood transfusion (p < 0.001), fusion number ≥ 5 (p < 0.001), spinal surgery including the thoracic spine (p < 0.001), CCI > 2 (p = 0.018), ERAS (p = 0.003) and spinal surgery including lumbar (p = 0.030) were associated with LOS. Furthermore, multivariate linear regression showed that ERAS (p = 0.001), CCI > 2 (p = 0.014), and Fusion number ≥ 5 (p = 0.002) were independent risk factors for LOS. Analogously, univariate logistic regression revealed that longer operation time (p = 0.005), more intraoperative blood loss (p < 0.001), more intraoperative blood transfusion (p = 0.001), fusion number ≥ 5 (p = 0.001), ERAS (p = 0.004) and spinal surgery including thoracic spine (p = 0.002) were related to complications, while implementing ERAS was associated with less complications. Multivariate logistic regression denoted that implementation of ERAS (p = 0.003), Intraoperative blood loss (p = 0.003) and Fusion number ≥ 5 (p = 0.008) were independent risk factors for postoperative complications. In conclusion, the present study reported the first ERAS principles performed in multi-level lumbar or thoracolumbar instrumented fusion for degenerative conditions. Our outcomes shown that the implementation of ERAS in these populations is favorable for reducing LOS and decreasing overall number of complications though the comparable complication rates between two groups. Totally, our ERAS protocols were safe and feasible in these populations.

Data-driven Machine Learning Models for Risk Stratification and Prediction of Emergence Delirium in Pediatric Patients Underwent Tonsillectomy/Adenotonsillectomy.

In the pediatric surgical population, Emergence Delirium (ED) poses a significant challenge. This study aims to develop and validate machine learning (ML) models to identify key features associated with ED and predict its occurrence in children undergoing tonsillectomy or adenotonsillectomy. The analysis involved data cleaning, exploratory data analysis (EDA), supervised predictive modeling, and unsupervised learning on a medical dataset (n = 423). After preliminary data cleaning, EDA encompassed plotting histograms, boxplots, pairplots, and correlation heatmaps to understand variable distributions and relationships. Four predictive models were trained including logistic regression (LR), random forest (RF), Support Vector Machine (SVM), and Gradient Boosting (XGBoost). The models were evaluated and compared using Receiver Operating Characteristic (ROC) Area Under the Curve (AUC), precision, recall, and feature importance. The RF model showed better performance and was used for the test (AUC-ROC 0.96, precision 1.00, and recall 0.92 on the validation set). K-means clustering was applied to find groups within the data. Elbow method and silhouette scores were used to determine the optimal number of clusters. The formed clusters were analyzed by aggregating features to understand the characteristics of each cluster. EDA revealed significant positive correlations between age, weight, American Society of Anesthesiologists (ASA) health score, and surgery duration with the risk of developing ED. Among the ML models, RF achieved the highest performance. Key predictive variables, based on the model's feature importance, included delirium screening scales, extubation time, and time to regain consciousness. Unsupervised K-means clustering identified 2-3 optimal clusters, which represented distinct patient subgroups: younger, healthier, low-risk individuals (cluster 0), and older patients with increasing chronic disease burden, higher delirium screening scores, and consequently higher post-operative delirium risk (clusters 1 and 2). ML techniques are valuable tools for extracting insights and making accurate predictions from healthcare data. High-performing algorithm-based models can be implemented for clinical decision support systems, facilitating early identification and intervention for ED in pediatric patients. By investigating various variables, it is possible to assess risk and implement preventive measures effectively. Furthermore, unsupervised clustering reveals distinct patient subgroups, enabling personalized perioperative management strategies and enhancing overall patient care.