Postoperative Outpatient Visits Research Articles

Intercostal nerve cryoablation versus thoracic epidural analgesia for minimal invasive Nuss repair of pectus excavatum: a protocol for a randomised clinical trial (ICE trial)

IntroductionEpidural analgesia is currently considered the gold standard in postoperative pain management for the minimally invasive Nuss procedure for pectus excavatum. Alternative analgesic strategies (eg, patient-controlled analgesia and paravertebral nerve...

Pancreatectomy Induces Cancer-Promoting Neutrophil Extracellular Traps.

Neutrophil extracellular traps (NETs) occur when neutrophil chromatin is decondensed and extruded into the extracellular space in a web-like structure. Originally described as an anti-microbial function, this process has been implicated in the pathogenesis of pancreatic disease. In addition, NETs are upregulated during physiologic wound-healing and coagulation. This study evaluated how the inflammatory response to pancreatic surgery influences NET formation. For this study, 126 patients undergoing pancreatectomy gave consent before participation. Plasma was collected at several time points (preoperatively and through the postoperative outpatient visit). Plasma levels of NET markers, including cell-free DNA (cfDNA), citrullinated histone H3 (CitH3), interleukin (IL)-8, IL-6, and granulocyte colony-stimulating factor (G-CSF) were measured using enzyme-linked immunosorbent assay (ELISA). Patient clinical data were retrospectively collected from a prospectively maintained database. After pancreatic resection, NET markers (cfDNA and CitH3) were elevated, peaking on postoperative days 3 and 4. This increase in NETs was due to an inherent change in neutrophil biology. Postoperatively, NET-inducing cytokines (IL-8, IL-6, and G-CSF) were increased, peaking early in the postoperative course. The patients undergoing the robotic approach had a reduction in NETs during the postoperative period compared with those who underwent the open approach. The patients who experienced a pancreatic leak had an increase in NET markers during the postoperative period. Pancreatectomy induces cancer-promoting NET formation. The minimally invasive robotic approach may induce fewer NETs, although the current analysis was limited by selection bias. Pancreatic leak resulted in increased NETs. Further study into the potential for NET inhibition during the perioperative period is warranted.

Do postoperative hemodynamic parameters add prognostic value for the prediction of mortality after surgical aortic valve replacement?

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): The PERIGON Pivotal Trial was funded by Medtronic. Background While different parameters to assess prosthetic valve performance are available, prosthesis-patient mismatch (PPM) is exclusively based on indexed effective orifice area (EOAi). Purpose We investigated the prognostic value of multiple postoperative hemodynamic parameters, independent of the STS predicted risk of mortality (STS PROM), for prediction of 5-year mortality after surgical aortic valve replacement (SAVR). Methods The study population consisted of patients enrolled in a prospective multicenter study. All patients underwent SAVR with the same stented bioprosthesis. Patients who underwent previous open-heart surgery, or died or withdrew consent before echocardiographic assessment at their first follow-up visit (3–6 months), were excluded. Cox regression models were fitted to estimate the relation between STS PROM, postoperative hemodynamic parameters (as continuous variables except for PPM), and all-cause mortality. Follow-up started at the first postoperative outpatient clinic visit and continued until death or withdrawal from the study, whichever came first. In addition to the STS PROM, candidate predictors included peak aortic jet velocity (Vmax), mean pressure gradient (MPG), EOA, predicted and measured EOAi, Doppler velocity index (DVI), internal prosthesis orifice area indexed (POAi) by stroke volume, and Valve Academic Research Consortium (VARC) 3 categories for PPM (1). All echocardiograms were evaluated by a core laboratory. Although the STS PROM was initially developed to predict 30-day mortality (2), it has also been proven to predict late mortality (3). Model performance was investigated using the c-statistic, likelihood ratio test, and net reclassification improvement (NRI), among others. Results Among 1118 patients enrolled, 1022 patients were included in the study. Patients were on average 70 years, 75% was male, and 88% had a left ventricle ejection fraction of ≥50%. At 5-year follow-up, 89 patients had died, and the median follow-up time was 1697 days. In univariate analysis, STS PROM was the only significant predictor of 5-year mortality (hazard ratio 1.40, 95%-confidence interval [CI] 1.26, 1.55). Moreover, STS PROM performed best in terms of the c-statistic (0.66, 95%-CI 0.60, 0.72). When extending the STS PROM with single hemodynamic parameters (Table 1), neither the c-statistics nor the NRI demonstrated added prognostic value compared to a model with STS PROM alone. Similar findings were observed when multiple hemodynamic parameters were added to STS PROM (c-statistic 0.68, 95%-CI 0.62, 0.74, and NRI 0.04, 95%-CI −0.08, 0.16). Conclusions The STS PROM was found to be the main predictor of patients’ prognosis. In this analysis, the added prognostic value of postoperative hemodynamic parameters for 5-year mortality after SAVR was limited (Figure 1). These results warrant further research on the value of PPM, residual postoperative hemodynamic obstruction and their relation with adverse outcomes.

One-year costs of incisional glaucoma surgery and laser therapy.

This study aimed to calculate one-year total costs of incisional glaucoma surgery and laser therapy in a real-world clinical setting. We conducted a retrospective cohort study from July 2010 to March 2021 using the Diagnosis Procedure Combination database. We included patients hospitalized for incisional glaucoma surgery (trabeculectomy, trabeculotomy, tube shunt surgery, Ex-PRESS surgery, or iStent implantation) or laser therapy (laser peripheral iridotomy, surgical iridectomy, laser trabeculoplasty, cyclocryotherapy, or cyclophotocoagulation). The outcomes were total costs, including costs of hospitalization, re-admissions, antiglaucoma drugs, ophthalmic examinations, and outpatient visits for incisional glaucoma surgery and laser therapy within one year. We identified 49,202 eligible hospitalizations. The one-year median total cost was 707,497 yen [interquartile range: 546,887-944,664 yen]. The median total cost was the highest in patients undergoing tube shunt surgery, followed by Ex-PRESS surgery, iStent implantation, and trabeculectomy. The number and cost of postoperative outpatient visits and length of hospital stay were higher in patients who underwent trabeculectomy and Ex-PRESS surgery than in those after tube shunt surgery. The total costs of laser therapies were lower than those of incisional glaucoma surgeries. The total cost was the highest in the 0-19 age group (856,398 [649,419-1,258,844] yen). Tube shunt surgery was the costliest in terms of total one-year costs. Trabeculectomy and Ex-PRESS surgery were associated with long hospital stays and incurred high postoperative costs. The costs of laser therapies were relatively low. However, cost-effectiveness of laser therapies compared with incisional surgeries needs to be analyzed in future research.

Evaluation of the COVID-19 Infection Rate in the Perioperative Period of Elective Surgeries of the Hand and Microsurgery.

After the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic (coronavirus disease 2019 [COVID-19]), the world started reducing the number of elective surgeries to reduce the transmission of the coronavirus. Some priority elective surgeries were performed, and there was no increase in contagion rates due to safety protocols and protection measures. The study aims to present the coronavirus infection rate of elective hand surgeries and microsurgery performed during pandemics. A retrospective study evaluating 188 patients submitted to elective surgical procedures. The exclusion criteria were patients infected by COVID-19 before the surgery and patients who submitted to trauma surgery. Only 108 patients were eligible for this study. The mean age was 47.8 years (range: 15 days-81 years). There were 63 females and 45 males. They were divided into 2 groups: outpatient (n = 49) and inpatient (n = 59) procedures. The overall COVID infection rate was 6.48%. The outpatient infection rate was 2.08%, whereas the inpatient infection rate was 10.17% (Student t test: P = .089). The main factor correlated with infection in the postoperative period was the number of postoperative outpatient visits (Student t test: P = .089). No statistical differences were observed between the variables studied, but there was a tendency for patients who submitted to inpatient surgery to get infected by COVID-19 (P = .089). The statistical power was 0.8 (Cohen's d test), showing that large samples are needed to analyze the correlation better. We concluded that the safety of performing elective hand surgery during the pandemic remains unclear, and more studies with larger samples are needed.

The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform.

On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery. This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery. A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform. Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Minimal Lateral Internal Sphincterotomy (LIS): Is It Enough to Cut Less Than the Conventional Tailored LIS?

PurposeAnal fissure is a common anorectal condition, yet its pathogenesis remains unclear. Lateral internal sphincterotomy (LIS) is the gold standard treatment for chronic anal fissures that do not respond to conservative treatment; however, it has a risk of anal incontinence. We believe that fibrosis of the internal anal sphincter is an important factor in the pathogenesis of chronic anal fissure. In this study, we describe the minimal LIS method, a minimally invasive method where only the fibrotic portion of the internal anal sphincter is cut. We also describe the outcomes of this method.MethodsWe performed a retrospective review of 468 patients (270 male and 198 female) who underwent minimal LIS for chronic anal fissure in 2017 at Seoul Song Do Hospital. We analyzed the patients’ clinical characteristics, manometry data, complications, and outcomes of minimal LIS. The outcomes of the surgery were assessed via questionnaires during the postoperative outpatient visits, beginning 2 weeks postoperatively.ResultsThe overall complication rate was 4.0% (19 patients). Delayed healing occurred in 14 patients (3.0%), perianal abscess was present in 3 patients (0.6%), and gas incontinence occurred in 2 patients (0.4%). All complications were improved with conservative treatment. Recurrence, defined as the recurrence of anal fissure more than 4 weeks after healing, was present in 6 patients (1.3%).ConclusionMinimal LIS is a safe and effective treatment option for patients with chronic anal fissure. Postoperative complications, especially incontinence and recurrence, are rare.

Comparison of FreeHand® robot-assisted with human-assisted laparoscopic fundoplication

Objective To compare the safety, operative time and feasibilty of FreeHand® robot (FreeHand Ltd, Guildford, United Kingdom) with manual camera control approach for Laparoscopic Fundoplication. Material and methods A case control study was performed for patients undergoing laparoscopic fundoplication. Primary outcome was operative time; secondary outcomes included length of stay, post-operative morbidity, symptoms at first follow-up and total post-operative out-patient visits. Results Forty-four patients underwent laparoscopic fundoplication between January 2014 and June 2016. Twenty-six (59%) underwent conventional human-assisted fundoplication while 18 (41%) had FreeHand® robot assisted procedures. Mean operative time for conventional laparoscopic fundoplication was 165 min compared with 129 min in the robot-assisted group, saving 36 min (p < .001). The median length of stay was 1.5 days in the robot-assisted as compared to two days in the conventional group. Sixteen percent of robot-assisted as opposed to 30% of conventional group patients experienced complications. There was no 30-day mortality. Two patients required more than one post-operative clinic visit in robot-assisted against six in conventional group. Conclusion Robot-assisted fundoplication is safe, feasible and reduces operative time. Furthermore, this negates need of assistant. Mean operative time for robot-assisted fundoplication was 36 min less than for conventional fundoplication. Advantages also include fewer adverse events, shorter length of stay and less post-operative clinic visits.

Assessment of postoperative nausea and vomiting after bariatric surgery using a validated questionnaire.

Postoperative nausea and vomiting (PONV) is known to occur after bariatric surgery, with over two thirds of patients affected. However, variability exists in how to objectively measure PONV. The goals of the present study were to use a validated, patient-centered scoring tool, the Rhodes Index of Nausea, Vomiting, and Retching to measure the severity of PONV after bariatric surgery, to directly compare PONV between patients who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), and to identify risk factors for the development of PONV after bariatric surgery. Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, Missouri, United States of America. The Washington University Weight Loss Surgery team prospectively surveyed patients from January 1, 2017 to December 1, 2018 at the following 6 different timepoints: postoperative day (POD) 0, POD 1, POD 2, POD 3 to 4, the first postoperative outpatient visit (POV 1: POD 5-25), and the second postoperative visit (POV 2: POD 25-50). At each timepoint, a cumulative Rhodes score was calculated from the sum of 8 questions. The American Society for Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to collect patient demographic characteristics and perioperative clinical data. A total of 274 patients met study criteria and completed 605 Rhodes questionnaires. Two hundred fifty Rhodes questionnaires were completed by patients after SG and 355 were completed by patients after LRYGB. Total Rhodes scores are statistically higher in LSG patients compared with patients who underwent LRYGB (LSG = 5.45 ± 6.27; LRYGB = 3.08 ± 4.19, P = .0002). Additionally, at the earlier timepoints, scores were higher among patients who underwent LSG than those who had undergone LRYGB as follows: POD 0 (LSG = 6.96 ± 6.50; LRYGB = 2.89 ± 2.90, P = .0115), POD 1 (LSG = 8.20 ± 6.76; LRYGB = 2.88 ± 3.44, P < .0001), and POD 2 (LSG = 4.05 ± 4.88; LRYGB = 2.06 ± 3.43, P = .05). On subset analysis, examining patients who either underwent an LSG or LRYGB, both procedures had a statistically significant PONV peak emerge on POV 2. Last, overall Rhodes scores were statistically higher in female patients compared with male patients (female: 4.43 ± 5.46; male: 2.35 ± 3.90, P = .021). Although the magnitude of the difference varied somewhat across POD time intervals, the difference was most pronounced at POV2. This is the largest study using a validated nausea and vomiting questionnaire to objectively measure PONV after bariatric surgery. The factors found to be most associated with increased PONV were LSG and female sex. Ultimately, these data can help bariatric surgery programs, including Washington University Weight Loss Surgery, identify patients who may require more intensivetreatment of PONV, particularly POD 0 to 2, and help to identify patients that continue to struggle with PONV in the later surgical recovery phase.

Effect of Vitamin D Supplementation on Relapse-Free Survival Among Patients With Digestive Tract Cancers

Randomized clinical trials of vitamin D supplementation for secondary prevention in patients with cancer are needed, given positive results of observational studies. To determine whether postoperative vitamin D3 supplementation can improve survival of patients with digestive tract cancers overall and in subgroups stratified by 25-hydroxyvitamin D (25[OH]D) levels. The AMATERASU trial, a randomized, double-blind, placebo-controlled trial conducted at a single university hospital in Japan. Enrollment began in January 2010 and follow-up was completed in February 2018. Patients aged 30 to 90 years with cancers of the digestive tract from the esophagus to the rectum, stages I to III, were recruited. Of 439 eligible patients, 15 declined and 7 were excluded after operation. Patients were randomized to receive oral supplemental capsules of vitamin D (2000 IU/d; n = 251) or placebo (n = 166) from the first postoperative outpatient visit to until the end of the trial. The primary outcome was relapse-free survival time to relapse or death. The secondary outcome was overall survival time to death due to any cause. Subgroups analyzed had baseline serum 25(OH)D levels of 0 to less than 20 ng/mL, 20 to 40 ng/mL, and greater than 40 ng/mL; because of small sample size for the highest-baseline-level group, interactions were tested only between the low- and middle-baseline-level groups. All 417 randomized patients (mean age, 66 years; male, 66%; esophageal cancer, 10%; gastric cancer, 42%; colorectal cancer, 48%) were included in the analyses. There was 99.8% follow-up over a median 3.5 (interquartile range, 2.3-5.3) years, with maximal follow-up of 7.6 years. Relapse or death occurred in 50 patients (20%) randomized to vitamin D and 43 patients (26%) randomized to placebo. Death occurred in 37 (15%) in the vitamin D group and 25 (15%) in the placebo group. The 5-year relapse-free survival was 77% with vitamin D vs 69% with placebo (hazard ratio [HR] for relapse or death, 0.76; 95% CI, 0.50-1.14; P = .18). The 5-year overall survival in the vitamin D vs placebo groups was 82% vs 81% (HR for death, 0.95; 95% CI, 0.57-1.57; P = .83). In the subgroup of patients with baseline serum 25(OH)D levels between 20 and 40 ng/mL, the 5-year relapse-free survival was 85% with vitamin D vs 71% with placebo (HR for relapse or death, 0.46; 95% CI, 0.24-0.86; P = .02; P = .04 for interaction). Fractures occurred in 3 patients (1.3%) in the vitamin D group and 5 (3.4%) in the placebo group. Urinary stones occurred in 2 patients (0.9%) in the vitamin D group and 0 in the placebo group. Among patients with digestive tract cancer, vitamin D supplementation, compared with placebo, did not result in significant improvement in relapse-free survival at 5 years. UMIN Identifier: UMIN000001977.

Single vertical incision thoracoabdominal flap for chest wall reconstruction following mastectomy of locally advanced breast cancer.

PurposeSkin grafts have been widely used in managing extensive chest wall defects after mastectomy for advanced breast cancer. However, their durability and tolerability to radiotherapy is still controversial. A thoracoabdominal (TA) flap with a few technical refinements can safely transfer a larger flap while minimizing complications.MethodsFrom January 2007 to February 2018, a retrospective review was performed to compare 2 groups after wide breast excision: skin graft group (group 1) and lateral-based, single vertical incision rotation-advancement TA flap (group 2). Patients' demographics, operative details, complications, hospital stay, postoperative outpatient visits, cost, and start of adjuvant therapy were analyzed between the 2 groups.ResultsDuring the study period, 34 patients received skin graft and 41 patients received TA flap. group 2 had a shorter hospital stay (6.41 ± 2.64 days vs. 12.62 ± 4.60 days, P < 0.001) and shorter time to complete wound healing (29.27 ± 18.68 days vs. 39.24 ± 27.70 days, P = 0.03) than group 1. There was also a difference in the period from surgery to initiation of adjuvant therapy (group 1, 45.04 days ± 17.79 days; group 2, 37.07 ± 15.38 days, P = 0.073). Although limitation in shoulder motion was more frequent in group 2, limitation of motion for >1 year was observed in 4 patients in only group 1 (43.90% vs. 38.24%, P = 0.613).ConclusionTA flap has a simple design that minimizes concerns involving the donor site. Moreover, it does not require complicated procedures and allows for re-elevation whenever necessary. Finally, it guarantees faster wound recovery than skin graft with fewer complications.

Peripheral lymphadenopathy: role of excisional biopsy in differential diagnosis based on a five-year experience.

Peripheral lymphadenopathy can be caused by benign disease, or it could be a manifestation of underlying hematological disease or metastasis of a yet undiagnosed malignant condition. Fine-needle aspiration cytology (FNAC) and image-guided core biopsy usually make up the first line of investigation. There are several disadvantages to these techniques: FNAC is an acellular aspirate that may provide non-diagnostic specimens, while core biopsy may fail in the presence of composite lymphoma, nodal necrosis, and insufficiency or fragmentation of the specimens. Our aim was to evaluate the safety and effectiveness of excisional biopsy (EB) in a large case series. The study included 220 consecutive patients who underwent lymph node EB under local anesthesia. All patients underwent complete and systematic physical examination. Any palpable lymph node was evaluated for its location, size, consistency, fixation, and tenderness. All specimens were sent to the pathologist as fresh tissue. The EB materials demonstrated 89 (40.5%) benign lesions, 130 (59%) malignant diagnoses, and one (0.5%) unclear diagnosis. Mean operative time was 42.9 minutes (range 10-120 minutes). Harvested lymph nodes had a mean diameter of 3.3 x 2.3 cm. All patients were discharged within 8 hours. No major complications were reported, with a mean of 1.16 postoperative outpatient visits. Temporary seroma and/or minor lymph leak at the site of the incision occurred in 14 cases (6.4%), hematoma in 7 (3.2%), and dehiscence of the surgical incision in 4 (1.8%), and in 3 cases (1.4%) pain was reported up to 7 days postoperatively. Excisional biopsy is a diagnostic method that can be applied safely with minimal morbidity and mortality.

Risk stratification with longitudinal neutrophil to lymphocyte ratio assessment after left ventricular assist device implantation.

Inflammatory processes are well-characterized risk factors in cardiovascular disease including advanced heart failure. Previous studies have utilized individual white cell subtypes in risk analysis, and a recent study has focused on the efficacy of the neutrophil-to-lymphocyte ratio in evaluating negative outcomes following left ventricular assist device implantation. To investigate the interaction between the left ventricular assist device and white cell counts, we assessed longitudinal changes in neutrophil-to-lymphocyte ratio following left ventricular assist device implantation. This retrospective study included 100 patients who underwent left ventricular assist device implantation between 2012 and 2013. The neutrophil-to-lymphocyte ratio was calculated prior to left ventricular assist device implantation, daily for the first 30 postoperative days, and at the first two postoperative outpatient visits. Preoperative demographic and clinical data were collected for all patients. The mean neutrophil-to-lymphocyte ratio immediately before left ventricular assist device implantation was 5.2 ± 4.9. After surgery, the neutrophil-to-lymphocyte ratio decreased asymptotically, from a peak of 29.2 on postoperative day 1 to 4.1 at the second outpatient visit ( p < 0.001). Lack of improvement in the neutrophil-to-lymphocyte ratio at postoperative day 10 was associated with increased length of stay, right heart failure, and a trend toward worsened survival. Our results indicate a significant inflammatory response to implantation of the left ventricular assist device, a known effect. The magnitude of this response may be effectively and easily monitored over time using the neutrophil-to-lymphocyte ratio. In general, approximately 30 days is required for the neutrophil-to-lymphocyte ratio to return to preoperative levels. After several months, the neutrophil-to-lymphocyte ratio improves to below preoperative levels. It is possible that this reduction reflects the reversal of various heart failure-mediated inflammatory processes following left ventricular assist device implantation.

A novel method for treatment of chronic anal fissure: adipose-derived regenerative cells - a pilot study.

The purpose of this study was to investigate the safety and feasibility of autologous adipose-derived regenerative cells (ADRC) in the treatment of chronic anal fissure. A prospective pilot study was conducted in six patients with chronic anal fissures at the First Surgical Clinic, Clinical Center of Serbia and at the BelPrime Clinic, Belgrade, Serbia. All patients were candidates for surgical treatment. The average duration of symptoms was 24months. Pain assessment was quantified using a visual analogue scale and bowel continence was assessed using the Wexner incontinence score. Both were assessed before treatment and during each postoperative outpatient visit. Liposuction was performed under local or general anaesthesia. Extraction of ADRC was achieved with a closed automated medical device. The fat and ADRC were injected subcutaneously into the edge of the fissure. The rest of the pellet was infiltrated into the internal anal sphincter. The study has been registered at ClinicalTrials.gov (NCT02628522). Complete healing of the anal fissure and the disappearance of symptoms was achieved in all patients. The average time to complete pain cessation was 33.7±15.0days. All fissures healed after 3months and remained healed 12months after the procedure. There were no complications related to the procedure. The application of ADRC may be an alternative to lateral sphincterotomy and a reliable procedure which avoids faecal incontinence.

Decreased length of stay and earlier oral feeding associated with standardized postoperative clinical care for total gastrectomies at a cancer center

Standardization of postoperative care has been shown to decrease postoperative length of stay. In June 2009, we standardized postoperative care for all gastrectomies at our institution. Four years' worth of total gastrectomies (2years prior to standardization and 2years after standardization) were reviewed to determine the effect of standardization on postoperative care, length of stay, complications, and readmissions. Between June 2007 and July 2011, 99 patients underwent curative intent open total gastrectomy: 51 patients prior to standardization, and 48 patients poststandardization. Patients were predominantly male (70%); median age was 63; and median body mass index was 26. Standardization of postoperative care was associated with a decrease in median time to beginning both clear liquids and a postgastrectomy diet, earlier removal of epidural catheters, earlier use of oral pain medication, less time receiving intravenous fluids, and decreased length of stay (all P<.01). Groups showed no differences in complication rates, complication severity, diet intolerance, return to our Urgent Care Center, or readmission. Institution of standardized postoperative orders for total gastrectomy was associated with a significantly decreased length of stay and earlier oral feeding without increasing postoperative complications, early postoperative outpatient visits, or readmissions.

Type and frequency of healthcare encounters can predict poor surgical outcomes in anterior cruciate ligament reconstruction patients

BackgroundSeveral challenges are associated with collecting clinically meaningful post-operative outcomes. The widespread implementation of electronic medical records (EMR) offers a new opportunity to evaluate surgical outcomes using routinely collected data in these systems. This study evaluated whether surgical outcomes can be ascertained from EMR’s hospital and outpatient encounters. Specifically, we evaluated anterior cruciate ligament reconstructions (ACLR) outcomes. MethodsA retrospective cohort study of 6985 ACLRs performed between 2/2005-9/2012 was conducted. Patient encounters during days 1–90 and days 91–180 after ACLR surgery were the exposures of interest. Nine hospital and eight outpatient encounter types were evaluated. The main endpoint of the study was revision surgery six months after ACLR. ResultsThe cohort was 66.7% male, the mean age was 28 (standard deviation=11) years-old, and the incidence of revision was 1.5% (n=105). After adjustments, in days 1–90 post-ACLR, compared to patients with 0–4 orthopedic office visits, patients with 5–9 (hazard ratio (HR)=9.9, 95% confidence interval(CI), 4.3–23.2) and those with 10 or more (HR=13.8, 95%CI, 5.6–33.8) visits had a higher risk of revision. In days 91–180, patients with any outpatient hospital encounters (HR=2.5, 95%CI 1.4–4.5) had a higher risk of revision than patients without visits. Additionally, patients with 4–5 regular office visits (HR=3.8 times, 95%CI, 2.0–7.0) had a higher risk of revision surgery than those with 0–1 visits. DiscussionThe number of post-operative outpatient visits was associated with ACLR revision surgery. Using EMR encounters to assess surgical outcomes is a viable option for monitoring ACLR patients. The simple assessment of visit types and number of encounters alone can provide valuable information regarding the normal course of rehabilitation of a surgical patient and possible deviation from this normal course. In large cohorts of patients, this type of patient surveillance can assist surgeons with monitoring their patients.

Rural hospital outcomes versus non-rural hospital outcomes following emergency laparotomy: A Scottish retrospective cohort study

Rural hospital outcomes versus non-rural hospital outcomes following emergency laparotomy: A Scottish retrospective cohort study

Posttransplantation Outcomes in Veterans With Serious Mental Illness.

Anticipating poor recovery due to impaired self-management and appointment-keeping, clinicians may consider serious mental illness (SMI) a significant concern in organ transplantation. However, little empirical evidence exists regarding posttransplantation outcomes for patients with SMI. This study analyzed health services data to evaluate posttransplantation 3-year survival by SMI status in a nationwide cohort of patients in the Veterans Health Administration (VHA). A total of 960 recipients of solid organ or bone marrow transplants were identified from Veterans Health Administration administrative data extracts for fiscal years 2006 to 2009. Of these, 164 (17%) had an SMI diagnosis before transplantation (schizophrenia, posttraumatic stress, major depressive, and bipolar disorders); 301 (31%) had some other mental illness diagnosis (such as anxiety, adjustment reactions, or substance abuse); and 495 (52%) had no mental health diagnosis. Twenty-two patients (2%) required retransplantation and 208 patients (22%) died during follow-up. Data on whether these were primary or repeat transplantations were unavailable. Rates of attendance at postoperative outpatient visits and number of months for which immunosuppressive drugs fills were recorded were similar among mental illness groups, as were rates of diagnosed immunological rejection. Three-year mortality was equivalent among mental health groups: no mental health (19%) versus other mental illness (23%) versus SMI (27%; χ(2) = 5.11; df = 2; P = .08). In adjusted survival models, no effect of mental health status was observed. Serious mental illness diagnosis does not appear to be associated with adverse transplantation outcomes over the first 3 years; however, a potentially diverging survival curve may portend higher mortality at 5 years.

Impact of post-operative complications on quality of life after pancreatectomy.

Pancreatectomies for malignant and benign diseases are increasingly being performed worldwide. Recent studies, that have evaluated quality of life in pancreatectomy, have reported conflicting outcomes. This study was undertaken to analyze the quality of life changes reported by patients with pancreatic cancer undergoing pancreatectomy. Post-hoc analysis was performed of a clinical trial examining the safety of intraoperative autotransfusion during oncologic resections. Perioperative (90-day) complications were graded prospectively using a validated 5-point scale. Quality of life parameters were recorded prospectively by a single trained interviewer preoperatively, at the first post-operative outpatient visit, and at 6 weeks, 3 months, and 6 months follow-up using the EORTC QLQ-C30 and FACT-An instruments. Pancreatectomy for adenocarcinoma was performed in 34 patients with a median follow-up of 2 years (range: 1-1.5 years). Major (grade≥3) complications occurred in 12 (35.3%) of patients. Early (<6 month) recurrence was noted in 2 patients (5.9%). Increased severity of fatigue, pain, dyspnea, and loss of appetite over baseline were noted at initial follow-up (P<0.05); however, symptom scores normalized at 6-week follow-up, and remained stable at 6 months. No significant difference was noted in quality of life metrics between patients with or without major complications (P>0.11). A significant (P=0.023) decline in cognitive function vs. baseline was noted at 6-month follow-up after pancreatectomy. Using a repeated-measures generalized linear model, neither age, nor complication occurrence, nor adjuvant therapy, nor early recurrence accounted for this cognitive decline (P>0.10). Quality of life metrics tend to normalize to preoperative levels after pancreatectomy at 6 weeks post-operatively. The occurrence of major complications does not predict a decreased quality of life. The decrease in self-reported cognitive function at six months in this cohort merits further study.

QL-15 * A RETROSPECTIVE ANALYSIS OF INTRACRANIAL HEMORRHAGE IN PATIENTS RECEIVING ANTICOAGULATION FOR VENOUS THROMBOEMBOLISM IN THE SETTING OF GLIOBLASTOMA

BACKGROUND: Venous thromboembolism (VTE) is a complication of glioblastoma. Anticoagulating patients with glioblastoma carries a theoretical risk of intracranial hemorrhage (ICH). METHODS: We performed a retrospective review of consecutive glioblastoma patients (2007-2013) diagnosed with VTE, with documentation of historical, clinical, and radiologic findings. RESULTS: 173 (33%) of 523 glioblastoma patients had VTE events. Seventeen (9.8%) had ICH: 6 (35%) subdural hematomas and 11 (65%) intratumoral hemorrhage. Enhancement in the area of subsequent intratumoral hemorrhage was noted in 9 of 10 with available pre-ICH scans. Multivariable regression did not show associations between ICH and tumor enhancement diameter or VEGF-inhibitor use. Fifteen (16%) patients receiving anticoagulation had ICH compared to 2 (2.6%) not receiving anticoagulation (p = 0.005). The type of anticoagulant used was not associated with development of ICH. Median survival from VTE diagnosis to death was 7.2 months in ICH group, compared to 6.2 months in non-ICH individuals (p = 0.4). Median survival from VTE diagnosis to death were 7.9 and 4.7 months (p = 0.07) in patients receiving anticoagulation and those not on anticoagulation, respectively; percentage of patients with KPS scores ≥ 70 was not statistically significant between the groups (p = 0.14). Of fifty-one patients with perioperative VTEs, 38 (74%) were not treated with anticoagulation, while 13 (26%) did receive anticoagulation post-VTE diagnosis (p < 0.0001). CONCLUSION: Patients with glioblastoma and VTE on anticoagulation have increased incidence of ICH. However, ICH was not associated with lower median survival from time of VTE. Additionally, patients receiving anticoagulation trended towards longer survival from time of VTE. Intratumoral hemorrhage typically occurs within the enhancing portion of tumor; however, no relationship was identified between the development of ICH and (i)the diameter of enhancement or (ii)type of anticoagulant used. It is appropriate to initiate anticoagulation in glioblastoma patients with VTEs and, in the case of peri-operative VTEs, start anticoagulation during post-operative outpatient visits.