Postoperative Instructions Research Articles

Do Different Modes of Delivering Postoperative Instructions to Patients Help Reduce the Side Effects of Tooth Extraction? A Randomized Clinical Trial

Postoperative instructions that are properly delivered can decrease postextraction side effects, such as stress, anxiety, and pain, in patients undergoing dental extraction. This study examined the role of the mode of delivering postoperative instructions in decreasing the side effects of dental extraction and increasing patient satisfaction after the procedure. This randomized clinical trial was conducted on a population of 120 patients presenting to the oral and maxillofacial outpatient clinic affiliated with the Shiraz University of Medical Sciences (Shiraz, Iran) in 2015. The patients were randomly assigned to 3 groups of 40 per group. The first group received only verbal instructions after their surgical procedure. The second group received only written instructions. The third group received verbal and written instructions. Details on the patient's age, gender, and formal education were recorded before the operation using a questionnaire. The second part of the questionnaire was completed by patients 1week after their tooth extraction and recorded their postoperative pain, bleeding, swelling, and satisfaction. Data were analyzed using the Mann-Whitney test, Kruskal-Wallis test, χ2 test, and analysis of covariance at a significance level of 95%. Of the 120 participants, 77 were women and 43 were men; the participants' mean age was 36.45±10.69years. The results showed that the mode of delivering instructions had a marked relation with pain and patient satisfaction. Pain intensity was significantly higher in the verbal instructions group compared with the written instructions (P=.002) and verbal plus written instructions (P=.000) groups. The mode of delivering postoperative instructions meaningfully affected pain intensity and general patient satisfaction. Patients who received verbal instructions reported the most intense pain and the least satisfaction, and patients who received verbal and written instructions were the most satisfied.

Nutritional care of bariatric/metabolic surgery for the treatment of type 2 diabetes mellitus

Bariatric/metabolic surgery (BMS) is highly effective in treating obese associated type 2 diabetes mellitus (T2DM) and a commonly performed surgical procedure worldwide now. However, vitamin D, calcium and iron deficiencies are commonly presented in obese patients before operation because of reduced bioavailability and poor dietary intake. These un-recognized or under-treated nutritional deficiencies might lead to devastating complications of bone, immune function, neurologic and muscular systems. Therefore, the benefit of BMS may be tempered by the associated post-operative nutritional deficiencies. Pre-operative nutritional screening and treatment thus are essential for BMS patients. The pre-operative existing nutritional deficiencies might be exacerbated after BMS due to reduced absorption, poor dietary intake and compliance with postoperative supplement instructions. Protein deficiency is the most commonly met macronutrient deficiencies after BMS. Iron, calcium and vitamin D deficiencies are commonly met micronutrient deficiencies after BMS and may bring significant clinical problems to the patients. Some micro-nutrient deficiencies, such as copper, selenium and zinc, are difficult to diagnose because difficult in assessment and frequently confounded by deficiencies in other nutrients. Therefore, post-operative nutritional supplements following established recommendations are essential for patients received BMS. In addition, all the patients should receive regular follow-up by a multidisciplinary team for the prevention and treatment of nutritional deficiencies in order to optimize the outcomes of BMS.

Improving the documentation of flexible cystoscopy notes: Case for introduction of electronic patient records?

Introduction/Objective: Good surgical practice dictates that comprehensive and legible records are maintained by surgeons of all their interactions with patients. Flexible cystoscopy (FC) notes should be no exception to this standard. Currently at our institution, for every cystoscopy, FC operators document the same information in two different locations: handwritten in patient notes and electronic discharge letter. Methods: A closed-loop audit of FC notes at our institution was undertaken and data were collected prospectively using patients’ notes. Notes were scrutinised against the Royal College of Surgeons (RCS)/British Association of Urological Surgeons (BAUS) standards. The first period was 13–17 October 2015, and the second period was 20–31 May 2016. A total of 73 patients were included (43+30). Results: The first cycle highlighted several areas requiring improvement. Eight of 15 parameters fell short of the 100% target compliance: time (5.9%), responsible consultant (32.4%), operator (50%), postoperative instructions (82.4%), indication for FC (85.3%), date (88.2%), procedure name (91.2%) and signature (97%). Subsequently, a new electronic FC proforma was designed using the RCS/BAUS criteria for data to be documented. A successive re-audit using identical criteria established 100% compliance in all fields. Conclusion: Adopting the new proforma significantly improved the quality of FC documentation. Subsequently, new online software incorporating our proforma was introduced as part of electronic patient records, allowing for data to be easily accessed and read. We discuss the relevance of this in the context of existing literature. Level of evidence: Not applicable for this multicentre audit.

Perioperative care for lumbar microdiscectomy: a survey of Australasian neurosurgeons.

Lumbar microdiscectomy is the most commonly performed spine surgery procedure. Over time it has evolved to a minimally invasive procedure. Traditionally patients were advised to restrict activity following lumbar spine surgery. However, post-operative instructions are heterogeneous. The purpose of this report is to assess, by survey, the perioperative care practices of Australasian neurosurgeons in the minimally invasive era. A survey was conducted by email invitation sent to all full members of the Neurosurgical Society of Australasia (NSA). This consisted of 11 multi-choice questions relating to operative indications, technique, and post-operative instructions for lumbar microdiscectomy answered by an electronically distributed anonymized online survey. The survey was sent to all Australasian Neurosurgeons. In total, 68 complete responses were received (28.9%). Most surgeons reported they would consider a period of either 4 to 8 weeks (42.7%) or 8 to 12 weeks (32.4%) as the minimum duration of radicular pain adequate to offer surgery. Unilateral muscle dissection with unilateral discectomy was practiced by 76.5%. Operative microscopy was the most commonly employed method of magnification (76.5%). The majority (55.9%) always refer patients to undergo inpatient physiotherapy. Sitting restrictions were advised by 38.3%. Lifting restrictions were advised by 83.8%. Australasian neurosurgical lumbar microdiscectomy perioperative care practices are generally consistent with international practices and demonstrate a similar degree of heterogeneity. Recommendation of post-operative activity restrictions by Australasian neurosurgeons is still common. This suggests a role for the investigation of the necessity of such restrictions in the era of minimally invasive spine surgery.

Utility of preoperative voice therapy on the voice recovery of vocal cord polyps patients undergoing the microsurgery

To evaluate the therapeutic effect on the voice recovery of patients with vocal cord polyps undergoing the microsurgery of preoperative voice therapy. Twenty-six patients diagnosed with unilateral vocal cord polyp under stroboscope, who needed to undergo vocal cord loss resection under supportive laryngoscope, were randomly divided into control group (non-voice training) and treatment group (voice training), with each group of 13 patients. Patients in control group were just treated with surgical operation. Apart from surgical treatment, patients in treatment group received 6 hours intensive vocal therapy one week before the surgery. The therapy courses consist of the propaganda and education of voice care, postoperative vocal instruction and the patients' self-training under the guidance of voice therapists. The acoustic parameters (irregularity, breathiness, grade, jitter and shimmer) of the same patient were collected 24 to 48 hours before the surgery and 14 days after the surgery with Ling WAVES. The results were analyzed with SPSS 19.0. The differences of all the five preoperative voice parameters between control group and treatment group are not significant; but postoperative breathiness and jitter in treatment group were significantly lower than that in control group, while the differences of irregularity, overall severity and shimmer were not significant between control group and treatment group. In control group, breathiness and jitter were significantly improved after surgery, while the differences of irregularity, breathiness and shimmer were not significant between preoperation and postoperation. In treatment group, all the five voice parameters were significantly improved after surgery. According to the laryngostroboscopic examination, the vocal fold polyps were excised completely in both groups. Preoperative voice therapy contributes to the recovery of voice quality of the patients with vocal cord polyps. Combined intervention of surgery and voice therapy is an effective method to treat the patients with vocal cord polyps.

Control of Postoperative Nausea and Vomiting in Oral and Maxillofacial Surgery Patients with Isopropyl Alcohol: A Prospective Randomized Clinical Trial.

The present study was undertaken to evaluate the effectiveness of inhaled 70% isopropyl alcohol (IPA) in controlling postoperative nausea and vomiting (PONV) in oral and maxillofacial surgery patients undergoing surgery under general anesthesia (GA). This was a prospective, randomized, case-controlled study done on 208 maxillofacial surgery patients operated under GA. Patient's demographic data, APFEL score for risk of PONV, duration of surgery and duration of anesthesia were recorded preoperatively. The test arm of the study received inhalation of 70% IPA every half an hour in the postoperative period for 8h along with ondansetron 4mg i.v. every 6h. The control arm received only ondansetron 4mg i.v. every 6h. Both the groups followed the same preoperative and postoperative instruction and drug protocol except the test drug. PONV was recorded using the simplified PONV intensity score and VAS. The scores were analyzed with Mann-Whitney test with <0.05 considered significant. The groups were similar with regard to age (p=0.083), BMI (p=0.1.00), sex (p=0.379), type of surgery (p=0.504), duration of anesthesia (p=0.621), duration of surgery (p=0.515) and APFEL score (p=0.687). IPA inhalation group achieved significantly better simplified PONV scores and VAS scores at 4h (p=0.000), 6h (p=0.000) and 8h (p=0.000). PONV control at 2h was similar to the control group. Inhalation of 70% IPA every half an hour was associated with significant PONV control in maxillofacial surgery patients undergoing surgery under GA.

Treatment of chronic tibial osteomyelitis of Cierny-Mader type IV with Ilizarov technique and lesion osteotomy

Objective To evaluate surgical treatment of chronic tibial osteomyelitis of Cierny-Mader type Ⅳ with Ilizarov technique and lesion osteotomy. Methods From January 2010 to May 2016, 39 patients with chronic tibial osteomyelitis of Cierny-Mader type Ⅳ were treated at our center. They were 33 males and 6 females, 8 to 54 years of age (average, 33.8 years) . After debridement and lesion osteotomy, the tibia was fixated with Ilizarov external fixator. Bone was transported to the bone defect after corticotomy was performed on the proximal and/or distal tibial metaphyses simultaneously. Bifocal corticotomy was performed in 11 cases, proximal corticotomy in 21 cases, and distal corticotomy in 7 cases. The transport began 3 to 5 days after operation at a speed of 0.5 to 1.0 mm/d initially. The speed was lowered according to the bone healing and pain. Radiographic examination was done every 2 weeks to observe transporting deviation and osteogenesis in the transporting area. The transporting was adjusted whenever any abnormality was observed. The bone transporting lasted for 50 to 130 days (average, 62.4 days) . Results The patients were followed up for 11 to 49 months (average, 21 months) . All the soft tissue wounds healed uneventfully and there was no relapse of osteomyelitis. The bone defects in the 32 cases were reconstructed primarily. Nonunion of fracture ends happened in 5 cases and nonunion of the bone lengthening zone in 2 cases. The 7 cases of nonunion were healed after secondary bone grafting. Malalignment happened in 5 cases, 4 of which responded to timely adjustment of the external fixation and one of which had to receive secondary bone grafting after failure in adjustment of the external fixation. Ankle joint dysfunction occurred in 7 cases, 5 of which responded to functional exercise and 2 of which accepted joint dysfunction because they refused surgery after unsatisfactory functional exercise. Pin tract infection of different severities occurred in 9 cases, one of which was treated by replacement of the K-wires under local anesthesia and the other 8 of which responded to reinforced dressing change. Conclusions Chronic tibial osteomyelitis of Cierny-Mader type Ⅳ can be treated by Ilizarov technique and lesion osteotomy. However, the Ilizarov technique should be improved because of the risks of multiple complications which can be reduced significantly by strengthening postoperative instruction, nursing, and regular follow-up. Key words: Tibia; Osteomyelitis; External Fixators; Ilizarov technique; Bone lengthening

Field evaluation of the safety, acceptability, and feasibility of early infant male circumcision using the AccuCirc device.

BackgroundAs countries scale up adult voluntary medical male circumcision (VMMC) for HIV prevention, they are looking ahead to long term sustainable strategies, including introduction of early infant male circumcision (EIMC). Although a number of devices for EIMC are prequalified by the World Health Organization, evaluation of additional devices can provide policy-makers and clinicians the information required to make informed decisions. We undertook a field evaluation of the safety and acceptability of the AccuCirc device in Kisumu County, Kenya.MethodsProcedures were performed by four trained clinicians in two public facilities. Participants were recruited from surrounding public health facilities through informational talks at antenatal clinics, maternity wards, and maternal neonatal child health clinics. Healthy infants ages 0–60 days, with no penile abnormality, without a family history of bleeding disorder, with current weight-for-age within –2 Z-scores of WHO growth standards, and whose mother was at least 16 years of age were eligible for EIMC. The procedure was performed after administration of a penile dorsal nerve block using 2% lidocaine and administration of Vitamin K. The mother was given post-operative instructions on wound care and asked to remain in the clinic with the baby for an observational period of one hour, during which a face-to-face questionnaire was administered.ResultsOf 1259 babies screened, 704 were enrolled and circumcised. Median age of the infants was 16 days (IQR: 7–32.5) and of the mothers was 26 years (IQR: 22–30). Median time for the procedure was 19 minutes (IQR: 15–23). There were no serious adverse events (AE), and 20 (2.8%) moderate AEs, all of which were due to bleeding that required application of one to three sutures. There were 22 (3.8%) procedures in which the device did not fully incise the entire circumference of the foreskin and had to be completed using sterile scissors. 89.9% of mothers had knowledge of EIMC, but few (8.1%) had any knowledge of devices used for EIMC. Protection against HIV/AIDS was the most cited reason to circumcise a baby (65.3%), while the baby being ill (38.1%) and pain (34.4%) were the most cited barriers to uptake. 99% of mothers were “very satisfied” or “completely satisfied” with the procedure.ConclusionsThis evaluation of the AccuCirc device is the largest to date and indicates that the device is safe and acceptable, achieving high levels of parental satisfaction. The AccuCirc device should be considered for WHO prequalification to increase options for safe and sustainable provision of EIMC.

Patient satisfaction on post operative instructions given by hospital staff on discharge

No abstract available

Utilization of a postoperative adenotonsillectomy teaching video: A pilot study

BackgroundPediatric tonsillectomies are increasingly being performed as an outpatient procedure thereby increasing the parental role in post-operative pain management. However, it is unclear if parents receive adequate teaching regarding pain management. We introduced a video teaching tool and compared its efficacy alone and in combination with the standard verbal instruction. MethodsA prospective study which randomized parents or caregivers of children undergoing tonsillectomy ± adenoidectomy into three groups: 1) standard verbal post-operative instructions; 2) watching the video teaching tool along with standard verbal instructions or 3) video teaching tool only. Parents completed pre and post-instruction assessments of their knowledge of post-operative pain management with responses scored from 0 to 8. Telephone assessments were conducted within 48 post-operative hours with a subjective rating of the helpfulness of the video teaching tool. ResultsThe study cohort included 99 patients and their families. The median pre-instruction score was 5 of 8 points (Interquartile range [IQR]: 4, 6) and this remained at 5 following instruction. (IQR:4, 6; p = 0.702 difference from baseline). Baseline scores did not vary across the groups (p = 0.156) and there was no increase in the knowledge score from pre to post-test across the three groups. Groups B and C rated the helpfulness of the video teaching tool with a median score of 4 of 5. (IQR: 4, 5). ConclusionsA baseline deficit exists in parental understanding of post-operative pain management that did not statistically improve regardless of the form post-operative instruction used (verbal vs. video-based instruction). However, the high helpfulness scores in both video groups support the use of video instruction as an alternative to or to complement to verbal instruction. However, further identification of knowledge deficits is required for optimization of post-operative educational materials.

Abstract: The Use of Antibiotic Beads to Salvage the Infected Breast Implant

INTRODUCTION: Implant-based breast reconstruction is a well-established method for breast reconstruction. Although generally a safe procedure, when an infection arises in the implant-pocket, it is often necessary for the patient to return to the operating room where the choices are to remove the implant and place the patient on antibiotics, or salvage the implant and give intravenous antibiotics. Recently, there has been a rise in the use of antibiotic-impregnated beads for the treatment of surgical site infections. These beads, made of biodegradable materials and loaded with antibiotics, are placed inside a surgical site prior to closure. As the beads break down, they release antibiotics locally over an extended period of time, thus allowing for implant salvage and eliminating the morbidity of systemic IV antibiotics. The goal of this study is to present a case series illustrating how the use of antibiotic beads prevents the need for IV antibiotics administered via a PICC line and, more importantly, increases the likelihood of implant salvage and infection recurrence. METHODS: A single-center, retrospective analysis of all patients who underwent implant-based breast reconstruction at Mount Sinai Hospital was performed. All patients who developed an implant infection and then underwent capsulectomy with implant exchange and STIMULAN beads impregnated with antibiotics were included. Patient demographics, medical history, operative complications, and surgical outcomes were reviewed. RESULTS: Twelve patients were identified at Mount Sinai Hospital who fit the criteria. Ten patients had prior diagnoses of cancer in the affected breast. Comorbidities included hypertension, smoking, and immunocompromised status. Infections were noted anywhere from 5 days to 3 months post initial implant surgery. The surgical team was able to successfully salvage nine out of the twelve infected implants through the use of antibiotic bead therapy without the continued use of IV antibiotics. CONCLUSION: The use of antibiotic beads is promising for salvaging infected breast implants and reducing the need for IV antibiotics. The study team was able to salvage 75% of the implants. Of the three patients who had unsalvageable implants, one was infected with antibiotic resistant rhodococcus that was refractory to bead therapy and one was noncompliant with post-operative instructions. Overall, antibiotic beads allowed the surgical team to salvage the majority of implants without the need for PICC lines and associated morbidity.

Implementation of a perioperative surgical home protocol for pediatric patients presenting for adenoidectomy

IntroductionThe perioperative surgical home (PSH) is a patient-centered model designed to improve health, streamline the delivery of health care, and reduce the cost of care. Following the national introduction of PSH in 2014 by the ASA, adult hospitals have reported success with this model, with studies validating the benefits of PSH including reducing length of stay, lowering costs, and improving patient satisfaction. MethodsEligible patients, ranging in age from 16-35 months of age, were identified by the pre-admission testing (PAT) registered nurses (RNs) and faculty anesthesiologists upon review of the patient history. Participation in Pediatric PSH (PPSH) was introduced to the families by the pediatric otolaryngologists. Either the patient's family or physician team could elect to decline participation in the PPSH model. On the day of surgery, the PPSH protocol included a paper checklist to ensure that all patients met eligibility standards. A standardized order-set was implemented in the electronic medical record (EMR) for pre-operative and post-operative nursing instructions and eligible medications. Patients received at least 3 hours of postoperative monitoring prior to discharge home to address postoperative issues. Prior to discharge, caregivers watched a standard teaching video, available on YouTube, which was developed in conjunction with the hospital educational and technical support staff. An attending anesthesiologist made a postoperative followup phone call on the evening of surgery to ensure no untoward events were experienced by the patient as well as elicit caregiver feedback concerning the discharge process. The protocol was discontinued if at any time family members, physicians, or nurses were uncomfortable with completing the protocol or felt that the patient did not meet discharge criteria. ResultsOne hundred sixty-six patients were evaluated for PPSH inclusion. Forty patients were excluded (23 did not meet inclusion criteria, 5 had viral upper respiratory infections, and 10 for other non specified reasons such as tonsillectomy added, sibling with surgery, and incorrect documentation). Therefore, a total of 126 were eligible for PPSH (male/female = 69/57; age 22 ± 4 months). The comparison group included 1,029 children (male/female = 645/384; age 22 ± 7 months of age) undergoing adenoidectomy who were not evaluated for PPSH inclusion. Of the 126 PPSH participants included in the analysis, 27 were excluded at some point during the pathway. Nine cases experienced oxygen desaturation, laryngospasm, or required supplemental oxygen. Noncompliance with the protocol was noted in 5 cases, parental concerns were noted in 17 cases, and there were concerns from the pediatric anesthesiologist or otolaryngologist in 5 cases. In the comparison group, hospital length of stay was significantly longer than in the PSH group (p<0.001), with 524 (51%) patients discharged on the day of service compared to 99 (79%) in the PSH group. No major morbidity or mortality occurred. There was no difference between the two groups in return to the emergency department (ED) visits within 30 days (PSH: 7/126, 6%; control: 59/1,029, 6%; p=0.935). Within 14 days of the procedure, 4 PPSH patients visited urgent care or a primary care physician; 4 visited the ED; and 1 was readmitted to the hospital. Twenty families contacted the otorhinolaryngology triage phone line primarily related to pain and fever. ConclusionWe present our experience and success in developing a PPSH for patients, ranging in age from 16 to 35 months of age, undergoing adenoidectomy either alone or with tympanostomy tube insertion by protocolizing care, collaborating among care providers, and educating families. With this process in place, a significant percentage of these patients who were previously admitted were discharged home the same day of surgery.

Surgical patient selection and counseling

The objectives of patient selection and counseling are ultimately to enhance successful outcomes. However, the definition for success is often narrowly defined in published literature (ability to complete surgery, complications, satisfaction) and fails to account for patient desires and expectations, temporal changes, natural history of underlying diseases, or independent validation. Factors associated with satisfaction and dissatisfaction are often surgery-specific, although correlation with pre-operative expectations, revisions, and complications are common with most procedures. The process of appropriate patient selection is determined by the integration of patient and surgeon factors, including psychological capacity to handle unsatisfactory results, baseline expectations, complexity of case, and surgeon volume and experience. Using this model, a high-risk scenario includes one in which a low-volume surgeon performs a complex case in a patient with limited psychological capacity and high expectations. In contrast, a high-volume surgeon performing a routine case in a male with low expectations and abundant psychiatric reserve is more likely to achieve a successful outcome. To further help identify patients who are at high risk for dissatisfaction, a previously published mnemonic is recommended: CURSED Patient (compulsive/obsessive, unrealistic, revision, surgeon shopping, entitled, denial, and psychiatric). Appropriate patient counseling includes setting appropriate expectations, reviewing the potential and anticipated risks of surgery, post-operative instruction to limit complications, and long-term follow-up. As thorough counseling is often a time-consuming endeavor, busy practices may elect to utilize various resources including educational materials, advanced practice providers, or group visits, among others. The consequences for poor patient selection and counseling may range from poor surgical outcomes and patient dissatisfaction to lawsuits, loss of credibility, or even significant patient or personal harm.

Chronic Boutonniere Deformities, Supple, or Stiff: A New Surgical Technique With Early Mobilization in 11 Cases.

Injuries to the central slip of the extensor mechanism can lead to a Boutonniere deformity with important functional consequences. We report a series of 11 patients treated by lengthening-dorsalizing the lateral bands and tightening the central slip with early mobilization. The average age of the patients was 42 years (14;52). The extension defect of the proximal interphalangeal (PIP) joint was 64 degrees (80;55) and the hyperextension of the distal interphalangeal joint was 10 degrees (15;5). The surgery was performed with peripheral nerve block (sensitive), allowing dynamic adjustment of the tendinous sutures. With a dorsal incision, a tenolysis of the extensor was performed. The central slip was tightened and the lateral bands dorsalized by cross-stitches over the PIP joint. The active flexion/extension was tested, and then lengthening of the lateral bands by "mesh graft" tenotomy was performed over the second phalange. There was no immobilization. The deformity was improved in 10 patients with a total flexion of the finger. The mean lack of extension in the PIP was 8 degrees (0;20) and the active flexion of the distal interphalangeal joint was 80 degrees (70;85). There was 1 failure. The majority of techniques necessitate an immobilization of 3 to 6 weeks. Our procedure uses the elastic properties of the elongation and allows immediate mobilization. The result can be compromised in case of insufficient tendinous surface or if postoperative instructions are not followed.

Use of antibiotic beads to salvage infected breast implants

When an implant becomes infected, implant salvage is often performed where the implant is removed, capsulectomy is performed, and a new implant is inserted. The patient is discharged with a PICC line and 6-8 weeks of intravenous (IV) antibiotics. This method has variable success and subjects the patient to long-term systemic antibiotics. In the 1960s, the use of antibiotic-impregnated beads for the treatment of chronic osteomyelitis was described. These beads deliver antibiotic directly to the site of the infection, thereby eliminating the complications of systemic IV antibiotics. This study aimed to present a case series illustrating the use of STIMULAN calcium sulfate beads loaded with vancomycin and tobramycin to increase the rate of salvage of the infected implant and forgo IV antibiotics. A retrospective analysis was performed of patients who were treated at Mount Sinai Hospital for implant infection with salvage and antibiotic beads. Twelve patients were identified, 10 of whom had breast cancer. Comorbidities included hypertension, smoking, and immunocompromised status. Infections were noted anywhere from 5 days to 8 years postoperatively. Salvage was successful in 9 out of the 12 infected implants using antibiotic bead therapy without home IV antibiotics. The use of antibiotic beads is promising for salvaging infected breast implants without IV antibiotics. Seventy-five percent of the implants were successfully salvaged. Of the three patients who had unsalvageable implants, one was infected with antibiotic-resistant Rhodococcus that was refractory to bead therapy and one was noncompliant with postoperative instructions.

PD25-06 PRE-VAGINOPLASTY BILATERAL ORCHIECTOMY FOR TRANSGENDER WOMEN: AN EFFICIENT SURGICAL TECHNIQUE THAT PRESERVES COLLATERAL TISSUES AND SENSATION

You have accessJournal of UrologySexual Function/Dysfunction: Surgical Therapy III1 Apr 2017PD25-06 PRE-VAGINOPLASTY BILATERAL ORCHIECTOMY FOR TRANSGENDER WOMEN: AN EFFICIENT SURGICAL TECHNIQUE THAT PRESERVES COLLATERAL TISSUES AND SENSATION Maurice Garcia Maurice GarciaMaurice Garcia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1201AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For M to F transgender women, bilateral orchiectomy provides significant medical benefit: if allows many patients to use a lower dose of estrogen (used for feminization). Estrogen at the high doses that transgender women require has significant cardiovascular risks. Bilateral orchiectomy also allows immediate and complete discontinuation of Spironolactone, a potent diuretic also commonly used for feminization. In general, patients not ready for vaginoplasty benefit from early bilateral orchiectomy. A technique specific for transgender patients which anticipates future vaginoplasty surgery by preserving collateral tissues to be used later with vaginoplasty, and which can be done via a minimally invasive approach, has not been described. METHODS We describe a trans-scrotal technique for bilateral orchiectomy via a single midline scrotal incision that excises the cord at the level of the external inguinal ring. In our experience, is fast/efficient, and is associated with very low post-operative pain and morbidity. Furthermore, this technique spares a little described adipose tissue pedicle that is superficial to the spermatic cord, and which we use to support the neo-labia majora at time of subsequent MtoF vaginoplasty surgery. Outcomes for a consecutive series (single surgeon) of 40 MtoF transgender women are described, including specific post-operative wound care instructions and complications. RESULTS All patients were discharged home on same day of surgery. Mean operative time was 27 minutes. No significant complications occurred in this series. A total of 3 small (<2 cm) hematomas occurred. No wound infections or wound dehiscence occurred. Post op pain was minimal, and over half of the patients in this series managed post-op pain with NSAIDS only within the first 5 days, and thereafter required no analgesics. CONCLUSIONS Bilateral orchiectomy for transgender women has significant medical benefit and can be done with minimal morbidity, on an outpatient basis. Given the latter, bilateral orchiectomy should be offered to transgender patients that meet WPATH Standards of Care Guidelines criteria. The technique we describe anticipates future vaginoplasty surgery, spared adipose tissue needed for vaginoplasty, and minimizes risk to scrotal skin that will be later used for vaginoplasty. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e503-e504 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Maurice Garcia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP96-19 RETURN TO EMERGENCY DEPARTMENT AFTER PEDIATRIC UROLOGY PROCEDURES

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety III1 Apr 2017MP96-19 RETURN TO EMERGENCY DEPARTMENT AFTER PEDIATRIC UROLOGY PROCEDURES Naimet K Naoum Alsaigh, Michael Chua, Jessica Ming, Joana Dos Santos, Megan Saunders, Roberto I Lopes, Martin Koyle, and Walid Farhat Naimet K Naoum AlsaighNaimet K Naoum Alsaigh More articles by this author , Michael ChuaMichael Chua More articles by this author , Jessica MingJessica Ming More articles by this author , Joana Dos SantosJoana Dos Santos More articles by this author , Megan SaundersMegan Saunders More articles by this author , Roberto I LopesRoberto I Lopes More articles by this author , Martin KoyleMartin Koyle More articles by this author , and Walid FarhatWalid Farhat More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3042AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Unplanned postoperative return to emergency department (ED) and readmission represent a quality bench outcome and pose a considerable cost burden for health care systems. Here we evaluate a free-standing tertiary care children′s hospital to identify potential causes and explore areas for improvement. METHODS A Quality Improvement Board approved retrospective study was performed in our institution identifying all surgical cases done under the service of Urology from October 2012 to September 2015. Baseline demographics, surgeon, operation type and duration, ASA class, and type of admission were evaluated. Patients who returned to ED within 30 days from surgery date were identified. The ED records were reviewed for time of ED return, reason for visit, and treatment received. Univariate and multivariate statistical analysis were done to identify variables that are associated with ED return. Odds ratio (OR) and 95% confidence Intervals (95%CI) were generated to determine the magnitude of relationships. RESULTS A total of 4125 surgical cases were performed. Overall mean age was 59.9 months (SEM 0.94); with 85.1% of the patients were males. Three hundred forty-nine (8.5%) had unplanned return to the ED within 30 days from the surgery. 15.2% (53) of these returned patients required readmission and 4.3% (15) of them needed further surgical interventions, which were mainly urinary drainage procedures. Penile surgeries accounted for 34.9% of the returns. The most common reason for the ED visit was urinary tract infection in 17.2%, followed by issues related to urethral catheters and wounds (14.3% each). Univariate analysis and multivariate analysis revealed that, the directly associated variables to ED returns were patients younger than 3 yr old (OR 1.48 95%CI 1.18 to 1.87), those lived in the same city with our institution (OR 2.16 95%CI 1.69 -2.76) , procedure time > 150mins (OR 1.5 95%CI 1.12 to 2.00) and in-patient procedures (OR 1.4 95%CI 1.06 to 1.84). The Inguino-scrotal surgery types have significantly lesser ED returns (OR 0.30 95%CI 0.22 to 0.43). CONCLUSIONS This study shows that the majority of ED returns can be managed conservatively, and probably are preventable. This offers an opportunity for quality improvement by highlighting the importance of optimizing peri-operative family / patient education, reinforcing post-operative instructions and assures an understanding of family expectations. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1302 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Naimet K Naoum Alsaigh More articles by this author Michael Chua More articles by this author Jessica Ming More articles by this author Joana Dos Santos More articles by this author Megan Saunders More articles by this author Roberto I Lopes More articles by this author Martin Koyle More articles by this author Walid Farhat More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Improving the Standard of Orthopaedic Operation Documentation Using Typed Proforma Operation Notes: A Completed Audit Loop.

IntroductionThe Royal College of Surgeons (RCS) published Good Surgical Practice guidelines in 2008 and revised them in 2014. They outline the basic standard that all surgical operation notes should meet.ObjectivesTo retrospectively audit 57 typed orthopaedic operation notes from St. James’s Hospital in Dublin (from August to November 2015) against the RCS Good Surgical Practice guidelines published in 2014. They were then compared with the department’s previous audit of handwritten notes to complete the audit loop.Materials and methodsA total of 57 orthopaedic operation notes were audited by a single reviewer. They were prospectively collected between August and November 2015. All notes were typed on the standard St. James’s Hospital operation note proforma.ResultsOf the surgeries, 89.5% were emergencies with 77.2% of them being performed by trainees. All of the operation notes were typed and signed by trainees. The procedure name, incision and closure details, tourniquet time (when relevant), and postoperative instructions were documented in 100% of the notes. In total, 80.7% had an operative diagnosis included while only 26.9% of the documentation had prosthesis serial numbers. All of the typed notes were deemed to be legible.ConclusionThe use of printed operation notes allows for improved legibility when compared to typed notes. Documentation standards remained very high in the same areas as the handwritten notes and a marked improvement was seen in areas that had been poorly documented.

215 Bilateral Orchiectomy For Transgender Patients: An Efficient Surgical Technique That Anticipates Future Vaginoplasty and is Associated with Minimal Morbidity

For M to F transgender women, bilateral orchiectomy provides significant medical benefit: if allows many patients to use a lower dose of estrogen (used for feminization). Estrogen at the high doses that transgender women require has significant cardiovascular risks. Bilateral orchiectomy also allows immediate and complete discontinuation of Spironolactone, a potent diuretic also commonly used for feminization. In general, patients not ready for vaginoplasty benefit from early bilateral orchiectomy. A technique specific for transgender patients which anticipates future vaginoplasty surgery by preserving collateral tissues to be used later with vaginoplasty, and which can be done via a minimally invasive approach, has not been described. We describe a trans-scrotal technique for bilateral orchiectomy via a single midline scrotal incision that excises the cord at the level of the external inguinal ring. In our experience, is fast/efficient, and is associated with very low post-operative pain and morbidity. Furthermore, this technique spares a little-described adipose tissue pedicle that is superficial to the spermatic cord, and which we use to support the neo-labia majora at time of subsequent MtoF vaginoplasty surgery. Outcomes for a consecutive series (single surgeon) of 40 MtoF transgender women are described, including specific post-operative wound care instructions and complications.

Effectiveness of postoperative home-exercise compared with usual care on kinesiophobia and physical activity in spondylolisthesis: A randomized controlled trial.

To study the effectiveness of a 12-month exercise therapy on kinesiophobia and physical activity in patients with spondylolisthesis after lumbar spine fusion. Randomized controlled trial. Patients (n = 98) with spondylolisthesis who had undergone lumbar spine fusion. All patients (mean age 59 years) had received lumbar spine fusion surgery and identical postoperative instructions. Three months postoperatively, they were randomized into an exercise group (n = 48) or usual care group (n = 50). The exercise group received 12-month progressive home-based training with regular booster sessions, and the usual care group a single session of physiotherapy instruction. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK) and physical activity by the International Physical Activity Questionnaire (IPAQ) preoperatively, 3 months after lumbar spine fusion, and at the end of the 12-month intervention. Before the intervention, the median (first quartile; third quartile) of TSK was 32.5 (29.0; 37.0) in the exercise group and 30.0 (25.8; 36.0) in the usual care group, changing to 30.0 (25; 36) in the exercise group and to 30.5 (24; 36.3) in the usual care group (between-group p = 0.17). IPAQ metabolic equivalent minutes per week increased from 1,863 (1,040; 3,042) to 3,190 (1,634; 6,485) in the exercise group and from 2,569 (1,501; 4,075) to 3,590 (1,634; 6,484) in the usual care group (between-group p = 0.92). Progressive 12-month home-exercise starting 3 months postoperatively was not superior to usual care in decreasing kinesiophobia or increasing physical activity in spondylolisthesis.