Preoperative Patient Optimization Research Articles

Effective Pediatric Blood Management in Craniosynostosis Surgery: A Long-Term Update.

Blood transfusion is common in cranial vault surgery, and protocolized efforts to minimize transfusion have been reported in recent years. This study assesses the long term, prospective outcomes of a pediatric blood management protocol for the cranial vault reconstruction (CVR) population. Data from a retrospective control cohort and a prospective cohort employing a protocol for preoperative hematologic optimization of patients undergoing CVR from January 2015 to October 2023 was reviewed. Preoperative hemoglobin (Hgb) determined the preoperative protocol. Intraoperative tranexamic acid (TXA) and/or aminocaproic acid, cell-saver technology, and postoperative iron or erythropoietin alfa supplementation were also used in the protocol. For statistical analysis, P<0.05 was deemed significant. The cohort consisted of 194 successive patients (20 control and 174 treatment). Age, sex, and weight were not significantly different between groups. Mean postoperative Hgb was significantly higher in the control group (P<0.01). No difference was observed in Hgb at discharge between control and treatment groups. Mean estimated blood loss, volume of intraoperative packed red blood cells, rate of packed red blood cell transfusion, and mean total transfusion volume during hospitalization were significantly higher in the control group compared with the treatment group (P<0.01). Mean length of stay did not differ between groups. Efforts to optimize blood management in the CVR population are critical. This prospective study represents a robust and reproducible protocol for pediatric blood management with significant reductions in transfusion requirements.

Machine learning model outperforms the ACS Risk Calculator in predicting non-home discharge following primary total knee arthroplasty.

Despite the increase in outpatient total knee arthroplasty (TKA) procedures, many patients are still discharged to non-home locations following index surgery. The ability to accurately predict non-home discharge (NHD) following TKAs has the potential to promote a reduction in associated adverse events and excess healthcare costs. This study aimed to evaluate whether a machine learning (ML) model could outperform the American College of Surgeons (ACS) Risk Calculator in predicting NHD following TKA, using the same set of clinical variables. We hypothesised that the ML model would outperform the ACS Risk Calculator. Data from 365,240 patients who underwent a primary TKA between 2013 and 2020 were extracted from the ACS-National Surgical Quality Improvement Program database and used to develop an artificial neural network (ANN) to predict discharge disposition following primary TKA. The ANN and ACS calculator were assessed and compared using discrimination, calibration and decision curve analysis. Age (>68 years), BMI (>35.5 kg/m2) and ASA Class (≥2) were found to be the most important variables in predicting NHD following TKA. When compared to the ACS calculator, the ANN model demonstrated a significantly superior ability to distinguish the area under the receiver operating characteristic curve (AUC) among NHD patients and provided probability predictions well aligned with the true outcomes (AUCANN = 0.69, AUCACS = 0.50, p = 0.002, slopeANN = 0.85, slopeACS = 4.46, interceptANN = 0.04, and interceptACS = 0.06). Our findings support the hypothesis that machine learning models outperform the ACS Risk Calculator in predicting non-home discharge after TKA, even when constrained to the same clinical variables. Our findings underscore the potential benefits of integrating machine learning models into clinical practice for improving preoperative patient risk identification, optimisation, counselling and clinical decision-making. III.

The Effect of Varying Preoperative Hemoglobin Levels on the Risk of Major Complications and Surgical Site Infections After Single Level Lumbar Fusion.

Blood transfusions are associated with an increased risk of complications after lumbar fusion, and current anemia hemoglobin thresholds are not surgery specific. We aimed to calculate single-level lumbar fusion-specific preoperative hemoglobin strata that observe the likelihood of 90-day transfusion and evaluate whether these strata are associated with increased risk of 90-day complications and 2-year infections. A national database identified patients undergoing primary single-level lumbar fusion with preoperative hemoglobin values (g/dL). Stratum-specific likelihood ratio analysis calculated sex-based hemoglobin strata associated with the risk of 90-day transfusion. Incidence and risk of 90-day major complications and 2-year infections were observed between strata. Three female (hemoglobin strata, likelihood ratio [<10.9, 2.41; 11.0 to 12.4, 1.35; 12.5 to 17.0, 0.78]) and male (<11.9, 2.95; 12.0 to 13.4, 1.46; 13.5 to 13.9, 0.71) strata were associated with varying likelihood of 90-day blood transfusion. Increased 90-day complication risk was associated with two female strata (hemoglobin strata, relative risk [11.0 to 12.4, 1.52; <10.9, 3.40]) and one male stratum (<11.9, 2.02). Increased 2-year infection risk was associated with one female (<10.9, 3.67) and male stratum (<11.9, 2.11). Stratum-specific likelihood ratio analysis established sex-based single-level lumbar fusion-specific hemoglobin strata that observe the likelihood of 90-day transfusion and the risk of 90-day major complications and 2-year infections. These thresholds are a unique addition to the literature and can assist in counseling patients on their postoperative risk profile and in preoperative patient optimization. Level III.

The impact of geriatric-specific variables on long-term outcomes in patients with hepatopancreatobiliary and colorectal cancer selected for resection

BackgroundPreoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined. Study designThis observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65–74, 75–84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility. Results577 patients were included: 62.6 % were 65–74 years old, 31.7 % 75–84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility. ConclusionGeriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.

Incremental Societal Costs of Perioperative Complications Following Adult Elective Inpatient Major Therapeutic Surgery in the State of Florida: A Seven-Year Retrospective Epidemiological Analysis.

Introduction There is an expanding role for anesthesiologists in the preoperative optimization and postoperative management of patients, often in the context of a so-called perioperative surgical home. Such efforts typically include enhanced recovery after surgery (ERAS) protocols and often an anesthesiologist-led team for perioperative management. Studies of the cost-effectiveness of such approaches have generally been conducted at single institutions, with most patients cared for by small numbers of surgeons. This limitation creates generalizability issues as to whether improvement was related mostly to organizational culture or the studied surgeons' practices (non-generalizable) versusthe procedures (generalizable). We studied whether other organizations can rely on achieving similar benefits following the adoption of a studied process improvement strategy at a single institution. Methods All patients undergoing elective major therapeutic inpatient surgery discharged between October 2015 and June 2022 at non-federal hospitals in the state of Florida were included. For each discharge, the United States Medicare Severity Diagnosis-Related Group (MS-DRG) weighting factor (i.e., the multiplier for the hospital's base rate for admissions that determines reimbursement) and the Clinical Classification Software Refined (CCSR) code for the principal procedure were determined at admission and discharge from the state's inpatient healthcare database based on the diagnoses present at those time points. An increase in the weighting factor from admission to discharge represents societal costs from perioperative complications. Statewide, by hospital, and by surgeon, we calculated the total increase for each CCSR's weighting factor. Our primary hypothesis was that surgeon variability would be statistically greater than CCSR variability but that the incremental effect would be <5%. If CCSR and surgeon variability were comparable, this would be supportive of generalizability. In contrast, if there were a predominant effectrelated to the surgeon, results from one institution might not be applicable to others. Results Among the 1,482,344 discharges studied, the pooled (N=7 years) contributions to MS-DRG weighting factor increases from the upper 20% of surgeons were 2.8% more than from the upper 20% of CCSRs (95% CI 1.9%-3.9%, p=0.0006). Those CCSRs accounted for 85.5% (95% CI 79.4%-91.7%, p<0.0001) of the total increase in the MS-DRG weighting factor. The average contribution of the top two surgeons at each hospital to that hospital's increase in the weighting factor ranged among CCSRs from 68% to 97%.The median and 75th percentile of surgeons performing at least 10% of the total number of cases at each hospital was similar to those values for the contributions to the increases in the MS-DRG weighting factor, median 2.0 to 3.0, and 75th percentile 1.75 to 4.0. Conclusions Because variability among surgeons in their contributions to increases in the MS-DRG weighting factor only slightly exceeded the variability among CCSR surgical categories, perioperative surgical home and ERAS study research results involving single institutions and a small number of surgeons would likely be generalizable to other hospitals and healthcare systems. Funding agencies should not be hesitant to fund single-center perioperative surgical home studiesand ERAS interventions based on concerns related to lack of generalizability.

Complications Rate and Related Factors After Laparoscopic Sphincter-Preserving Total Mesorectal Excision for Low Rectal Cancer: A Single-Center Study in Vietnam.

Colorectal cancer is a significant health concern. Surgery remains a critical component of the multimodal treatment strategy. The laparoscopic sphincter-preserving total mesorectal excision (TME) is increasingly utilized and effective, offering enhanced quality of life for patients compared to previous traditional methods. This study aims to determine the rate of complications and the related factors associated with complications following laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer. This retrospective study was conducted at the University Medical Center of Ho Chi Minh City from March 2022 to March 2023. It included patients aged 18 years and older diagnosed with low rectal cancer who underwent laparoscopic sphincter-preserving total mesorectal excision. Data on patient demographics, surgical details, and postoperative complications were retrospectively collected and analyzed. Follow-ups were conducted up to six months after surgery. Of the 83 patients included, the postoperative complications rate was 14.5%. The complications observed included surgical wound infections (five cases), anastomotic leaks (five cases, including three recto-vaginal fistulas and two pelvic abscesses), urinary retention (one case), and pneumonia (one case). A significant finding was the higher rate of distant metastases in patients with complications compared to those without (p=0.033). Laparoscopic sphincter-preserving total mesorectal excision for low rectal cancer is safe and effective, with a high success rate and low complication rate during or after surgery. Anastomotic leakage remains the most significant complication. Despite advancements in surgery, modern suturing tools, and preoperative patient optimization, complications are avoidable. Therefore, understanding the related factors and implementing preventive interventions is crucial.

Time to Start a New Enhanced Recovery After Surgery (ERAS): A Retrospective Cohort Study.

The enhanced recovery after surgery (ERAS®) is a multimodal perioperative care pathway designed to reduce surgical stress and ultimately improve patient recovery and outcome. It can require significant resources but with proven benefits. The main goal of this study was to perform a diagnostic assessment of perioperative practice in a local colorectal surgical center. 93 patients who underwent elective colorectal surgery from January to December 2022 were analyzed. Preadmission, preoperative, and postoperative data of all patients were collected in a database developed by the researchers, according to ERAS® guidelines. Descriptive statistics were employed to summarize demographic and clinical characteristics. Chi-square and T-test were performed to identify possible associations between categorical variables and postoperative complications. Overall analysis showed deficient preoperative patient optimization, especially regarding nutritional counseling and supplementation, smoking and alcohol cessation, anemia treatment (9%), and pre-anesthetic medication (42%). Removal of invasive devices was significantly delayed (removal of urinary catheter average on the fourthday and surgical drain average on the fifthday) in the postoperatively period and oral intake (average onset on the sixthday). Both contribute to hospital length of stay (mean of 13 days) and a significant number of complications. The results lead us to an individual and multidisciplinary reflection on current practices and outcomes. ERAS® program, already adopted by many centers, could have a positive impact on the immediate postoperative recovery of colorectal patients in Funchal Central Hospital andimplementation seems necessary.

30-Day complications, operative time, and overnight admission following elective elbow arthroscopy

Background Although arthroscopic procedures are generally considered safer than open procedures, they are not without complications. This study's purpose is to characterize patient demographics, medical complications, overnight admissions, and prolonged operative times for patients undergoing elective elbow arthroscopy using a national database. Methods This retrospective study used the ACS NSQIP database with data from 2015 to 2020. Patients undergoing elbow arthroscopy were identified, and those undergoing emergent surgery were excluded. Patient demographics, clinical characteristics, medical comorbidities, 30-day complications, overnight admission rates, and operative times were recorded and analyzed. Results Overall, 815 patients undergoing elective elbow arthroscopy were included. The mean age was 46.8 years. Mean BMI was 29.7 kg/m2, and 75.2% (n = 613) were male sex. The most common comorbidity was smoking (14.8%, n = 121). The cumulative complication rate was 2.5% (n = 20). The most common complication was surgical site infection (n = 7, 0.9%). 10.7% of patients required at least one overnight hospital stay. 20.2% of patients had a prolonged operative time ≥ 120 min. Conclusion Elbow arthroscopy is not without complications and morbidity despite being a minimally invasive procedure and advances made in surgical technique. Surgeons should use this information to facilitate shared-surgical decision making, preoperative patient counselling, and preoperative patient optimization.

Preoperative Optimization of Crohn's Patients before Abdominopelvic Surgery

AbstractIn this article, we review and identify modifiable risk factors associated with postoperative complications of Crohn's disease. We highlight the importance of factors such as nutrition, corticosteroids, immunomodulators, abscesses, ideal timing of surgery, and biologic and small-molecule therapy on surgical outcomes. Herein, we discuss the strategies for attenuating these risk factors. Special consideration is given to venous thromboembolism prophylaxis in this patient population.

Patient-related risk factors for early unplanned reoperation following revision total shoulder arthroplasty

Purpose There has been an increase in the number of total shoulder arthroplasty (TSA) revisions performed as the number of primary surgeries increases rapidly. Revision procedures have a higher failure rate and there is a lack of understanding of patient risk factors for needing another repeat surgery following revision TSA. Methods Revision patients were separated into two cohorts: those needing an unplanned reoperation and those that did not within 30 days following revision TSA. Multivariate logistic regression was performed to identify independent risk factors for an unplanned reoperation. Results 1909 revision TSA patients were included in the final analysis. Sixty-nine of these patients underwent an unplanned reoperation within 30 days and 1840 did not. Multivariate logistic regression analyses found an ASA class of III or IV, male sex, congestive heart failure, and inpatient setting to be independent risk factors. Conclusion 3.6% of revision TSA patients require an unplanned reoperation within 30 days postoperatively. An ASA class of III or IV, male sex, congestive heart failure, and inpatient setting were found to be independent risk factors for early reoperation. Surgeons should be aware of these risks to improve preoperative patient optimization and guide shared decision making with patients considering revision.

Preoperative Optimization of Patients Using Tobacco

Preoperative Optimization of Patients Using Tobacco

Predictive Factors of Pain and Functional Outcome 5 Years Following Total Hip Arthroplasty: A Prospective Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement Cohort Study

BackgroundPrevious reports have identified a number of potential predictors of pain and function after total hip arthroplasty (THA). However, the results of these studies were conflicting, and most had a short follow-up after THA. The purpose of this study was to identify factors predictive of pain and function 5 years after THA. MethodsA multicenter cohort of 7,934 primary unilateral THA patients was prospectively enrolled in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement consortium. Demographic data, comorbidities, and patient-reported outcome measures were collected preoperatively and postoperatively at 5 years, including the Hip Disability and OSteoarthritis Outcome Score (HOOS) pain and activities of daily living (ADL) scores. Multivariate logistic regression models with 95% confidence interval were used to identify independent predictors of pain and function at 5 years. ResultsThe patient dissatisfaction percentage was 8.2% at 5 years after THA. The multivariate regression identified the following predictive factors for the HOOS pain score at 5 years: age, educational level, insurance, smoking, race, Charlson Comorbidity Index, back pain severity, number of other lower extremity painful joints, the Knee Injury and Osteoarthritis Outcome Score pain severity of the ipsilateral knee, preoperative Short-Form Health Survey 36-item (SF-36) mental component summary score, and HOOS pain scores. The multivariate regression identified the following predictor factors for HOOS ADL score at 5 years: body mass index, insurance, smoking, race, back pain severity, number of other lower extremity painful joints, Knee Injury and Osteoarthritis Outcome Score pain severity of ipsilateral knee, preop HOOS ADL, and preoperative SF-36 mental component summary score and SF-36 physical component summary score. ConclusionsOverall, 8.2% of patients were dissatisfied 5 years after primary THA. We have identified a number of factors that predict less improvement in pain and function 5 years after THA. These potentially modifiable factors can be targeted with preoperative patient optimization programs to improve patient outcomes and satisfaction after primary THA. Knowledge of these factors that predict less improvement in pain and function can assist the surgeon and patient during shared decision-making, and in setting appropriate patient expectations preoperatively.

Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database

Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques. Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified. A total of 7473 patients were included (72.1% male, mean age 66.2±13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean:0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE:0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009). Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.

Preoperative optimization of patients in hepatobiliopancreatic surgery

Preoperative optimization of patients in hepatobiliopancreatic surgery

The Pre-Operative Evaluation Clinic: An Underutilized Service in Optimizing Analgesic Outcomes in Patients on Buprenorphine, Methadone, and Naltrexone for Substance Use Disorder or Chronic Pain.

Patients receiving methadone, buprenorphine, and naltrexone for either chronic pain or substance use disorder (SUD) pose perioperative challenges. Due to their complex pharmacology, perioperative recommendations continue to evolve. Deviations from these recommendations may result in worse perioperative outcomes. A formal preoperative evaluation (POE) and optimization of patients on these medications are recommended to address these concerns. A single-center retrospective electronic health record review was performed with adult patients on methadone, buprenorphine, and naltrexone undergoing elective surgery between January 1, 2010 and December 31, 2020. The primary outcome of interest was the percentage of patients referred to the POE clinic for evaluation prior to the scheduled elective surgery. In addition, we assessed differences in variables (perioperative opioid, hospital length of stay, perioperative multimodal analgesics, perioperative complications, inpatient pain service consult, readmission within 30 days, cancellation of surgery, addiction medicine consult) based on POE clinic evaluation. This analysis was performed separately for patients prescribed these medications for SUD versus chronic pain. Continuous outcomes were analyzed using linear regression with generalized estimating equations (GEE) and robust variance estimates. A total of 714 patients were included in the final analysis, of which 572 (80%) took buprenorphine, methadone, or naltrexone for chronic pain and 142 (20%) took these medications for SUD. Within the chronic pain and SUD subpopulations, 193 (34%) and 35 (25%) patients had formal POE clinic assessments, respectively. Among those taking these medications for chronic pain, POE clinic evaluation was associated with a higher likelihood for receiving non-opioid multimodal analgesics perioperatively (p = 0.016). Formal preoperative evaluations are currently underutilized in patients who take buprenorphine, methadone, or naltrexone for chronic pain or SUD. These patients may benefit from POE clinic assessment to optimize perioperative outcomes.

An overview of unresolved issues in the perioperative management of liver transplant patients.

Over the past decade, the field of solid organ transplantation has undergone significant changes, with some of the most notable advancements occurring in liver transplantation. Recent years have seen substantial progress in preoperative patient optimization protocols, anesthesia monitoring, coagulation management, and fluid management, among other areas. These improvements have led to excellent perioperative outcomes for all surgical patients, including those undergoing liver transplantation. In the last few decades, there have been numerous publications in the field of liver transplantation, but controversies related to perioperative management of liver transplant recipients persist. In this review article, we address the unresolved issues surrounding the anesthetic management of patients scheduled for liver transplantation.

Preoperative optimization of the radical cystectomy patient: Current state and future directions.

Radical cystectomy (RC) is associated with high rates of morbidity and mortality despite adoption of robotics and implementation of enhanced recovery after surgery protocols. There have been increased efforts to investigate preoperative optimization through comprehensive nutritional evaluation, preoperative supplementation, and prehabilitation outside of previously described enhanced recovery after surgery protocols to reduce mortality and morbidity from RC. In this review, we summarize and evaluate the current literature on preoperative assessment and optimization in RC.

Primary Closure Versus Delayed Primary Closure of Class III and IV Surgical Wounds Following Emergency Laparotomy: A Prospective Comparative Study.

Introduction Emergency surgery has a high risk of complications due to the detrimental effect of perioperative sepsis and the relative lack of preoperative optimization of patients. Despite advances in critical care for the management of sepsis, its prevention is dependent on various patient and surgeon factors. Surgical site infection continues to be a major determinant of morbidity and mortality following emergency abdominal surgery, especially in contaminated or dirty wounds. This study aims to compare two techniques of abdominal wall closure, primary closure with subcutaneous suction drains and delayed primary closure following negative pressure wound therapy, in terms of incidence of surgical site infection and morbidity. Materials and methods The study was a prospective comparative study including 50 patients with an acute surgical abdomen requiring laparotomy. The patients were randomized into two groups, Group A (n=25) who underwent primary closure, and Group B (n=25) who underwent delayed primary closure. In Group B patients, a vacuum-assisted closure device was applied in the subcutaneous space for five days prior to the closure of the skin. Outcomes were compared in terms of the incidence of superficial and deep surgical site infection, its association with diabetes mellitus, and the total duration of hospital stay. A chi-square test and an unpaired t-test were used for the test of significance. Results A total of 50 patients, comparable in age, were included in the study. The overall incidence of surgical site infection was significantly higher in patients of Group A as compared to Group B (p=0.0046). There was a positive correlation between diabetes mellitus and the occurrence of wound infection in both groups with the odds ratio being 2.67 and 2.38 respectively. The incidence of superficial wound infection was significantly higher in Group A when compared to Group B (52% versus 24%; p=0.04). Deep surgical site infection was higher in patients of Group A (20% versus 8%) but was not statistically significant (p=0.22). The average duration of hospital stay was 41.56 ± 6.96 and 37.86 ± 6.68 days for patients who developed complications fromGroups A and B respectively, while it was nearly two and a half times lower in uncomplicated cases of Groups A and B (11.71± 1.70 days and 16.58± 1.06 days respectively). The one-tailed unpaired t-test showed a significant difference in means of hospital stay between patients with and without complications (T: 17.06, critical value: 1.677). Conclusion Delayed primary closure is an effective method of managing contaminated and dirty wounds following emergency laparotomy. Negative pressure wound therapy is one technique for preventing wound bed infection and accelerating wound healing in such cases. By combining the above in emergency surgeries, the incidence of surgical site infection and duration of hospital stay can be significantly reduced.

Acute postoperative infections after dual head arthroplasty in geriatric patients

Acute periprosthetic joint infections (PJI) after dual head arthroplasty represent amajor challenge with a1-year mortality rate up to 50% in the mostly multimorbid geriatric patient collective. Due to the limited possibilities of preoperative patient optimization, infection rates of up to 9% have been reported, which is significantly higher than in elective arthroplasty. Atherapeutic gold standard has not yet been established due to the heterogeneous study situation and the lack of prospective randomized studies. The most promising therapeutic option currently appears to be asingle-stage stem replacement in combination with implantation of acup component (conversion to total hip arthroplasty, infection eradication in up to 100%). An approach of débridement, antibiotics, implant retention (DAIR) alone shows significantly poorer success rates (16-82%). Surgical treatment should always be followed by antibiotic treatment with atotal duration of 12weeks. In addition to the established perioperative antibiotic prophylaxis, the use of antibiotic-loaded bone cement seems to be superior to cementless stem fixation in preventing PJI in dual head arthroplasty.

Enhanced recovery protocols for ambulatory surgery.

In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery.