Preoperative Optimization Research Articles

Preoperative assessment and optimisation prior to planned aortic aneurysm repair: a UK survey examining current practice and attitudes of vascular surgeons and vascular anaesthetists

BackgroundThe majority of those diagnosed with aortic aneurysm in the UK are older, multi-morbid patients. Decision-making as to who may benefit from intervention (open or endovascular aneurysm repair) is highly variable across the NHS (as is the mode of intervention), in part because there are no detailed guidelines or consensus on preoperative assessment. Thus, there is likely to be significant variation in the pre-operative assessment and optimisation of these patients.MethodsA survey was designed to understand current practice and attitudes of vascular surgeons and vascular anaesthetists in the UK regarding preoperative assessment and optimisation of patients undergoing elective aortic aneurysm repair. The survey was reviewed and validated by an expert panel, then distributed electronically to all vascular surgical and vascular anaesthetic leads in the UK.ResultsOverall, the response rate was 68%. The responses were varied between surgeons and anaesthetists, with differences reported in the preoperative assessment and optimisation of patients, the approach to shared decision-making, and the perioperative pathway.ConclusionsDespite initiatives such as Getting It Right First Time (GIRFT) and National Institute for Health and Care Excellence (NICE) guidelines, variation still exists between centres with some differences in opinion observed between surgeons and anaesthetists. These differences may be leading to duplication of work in the perioperative pathway, inconsistencies in how risk is assessed and communicated with consequent variation in patient care. Addressing these issues requires awareness and implementation of existing guidelines, transdisciplinary working, efficient data-driven pathways, and structured aortic aneurysm multi-disciplinary team to promote meaningful shared decision-making.

Managing Recurrent Clavicle Nonunion and Construct Failure: A Case Report

Case A 36-year-old male who suffered a left midshaft clavicle fracture, following a fall from a mountain bike, was treated unsuccessfully with two ORIF surgeries. Smoking cessation and management of hypovitaminosis was addressed preoperatively before final revision with a dual plate construct and tibial autologous bone graft. Follow-up radiographs taken at 12 months from the initial surgery showed intact hardware and full bone healing. Conclusion Successful management of clavicle nonunions can be optimized through optimal plate selection, plate positioning, number of plates, construct biomechanics, biologic augmentation, and preoperative risk optimization. Efforts to minimize controllable risk factors for nonunion, such as smoking cessation or vitamin D supplementation, should be utilized both preoperatively and postoperatively.

Placenta Accreta Spectrum Disorders: A National Survey

ObjectivesDescribe the current practice of Canadian obstetricians-gynaecologists in managing placenta accreta spectrum (PAS) disorders from suspicion of diagnosis to delivery planning and explore the impact of the latest national practice guidelines on this topic. MethodsWe distributed a cross-sectional bilingual electronic survey to Canadian obstetricians-gynaecologists in March–April 2021. Demographic data and information on screening, diagnosis, and management were collected using a 39-item questionnaire. The survey was validated and pretested among a sample population. Descriptive statistics were used to present the results. ResultsWe received 142 responses. Almost 60% of respondents said they had read the latest Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on PAS disorders, published in July 2019. Nearly 1 in 3 respondents changed their practice following this guideline. Respondents highlighted the importance of 4 key points: (1) limiting travel to thereby remain close to a regional care centre, (2) preoperative anemia optimization, (3) performance of cesarean-hysterectomy leaving the placenta in situ (83%), (4) access via midline laparotomy (65%). Most respondents recognized the importance of perioperative blood loss reduction strategies such as tranexamic acid and perioperative thromboprophylaxis via sequential compression devices and low-molecular-weight heparin until full mobilization. ConclusionsThis study demonstrates the impact of the Society of Obstetricians and Gynaecologists of Canada's PAS clinical practice guideline on management choices made by Canadian clinicians. Our study highlights the value of a multidisciplinary approach to reducing maternal morbidity in individuals facing surgery for a PAS disorder and the importance of regionalized care that is resourced to provide maternal-fetal medicine and surgical expertise, transfusion medicine, and critical care support.

Smokeless Tobacco Use is Associated With Worse Medical and Surgical Outcomes Following Total Hip Arthroplasty

Studies have demonstrated increased complication risk after total hip arthroplasty (THA) in patients who smoke cigarettes. However, it is unclear if smokeless tobacco use confers a similar impact. The purpose of this study was to (1) evaluate rates of postoperative complications after THA in smokeless tobacco users and people who smoke as compared to matched controls, and (2) compare rates of postoperative complications in smokeless tobacco users versus people who smoke. A retrospective cohort study was conducted using a large national database. For patients who underwent primary THA, smokeless tobacco users (n = 950) and people who smoke (n = 21,585) were matched 1:4 with controls (n = 3,800 and 86,340, respectively), and smokeless tobacco users (n = 922) were matched 1:4 with people who smoke (n = 3,688). Rates of joint complications within 2 years and medical complications within 90 days postoperatively were compared using multivariable logistic regressions. Within 90 days of primary THA, smokeless tobacco users demonstrated significantly higher rates of wound disruption, pneumonia, deep vein thrombosis, acute kidney injury (AKI), cardiac arrest, transfusion, readmission and longer length of stay compared to tobacco naïve controls. Within 2 years, smokeless tobacco users demonstrated significantly higher rates of prosthetic joint dislocations and overall joint-related complications compared to tobacco naïve controls. Smokeless tobacco use is associated with higher rates of medical- and joint-related complications following primary THA. Smokeless tobacco use may be under-diagnosed in patients undergoing elective total hip arthroplasty. Surgeons may consider delineating between smoking and smokeless tobacco use during preoperative medical optimization.

Anaesthetic Management of a Case of Down Syndrome with Chronic Kidney Disease Undergoing Major Orthopaedic Surgery

Background: Down syndrome is one of the common congenital chromosomal disorders. Renal complications in Down syndrome patients are rare but is increasing in number due to increased survival. Anaesthesia in such patients is challenging due to intellectual disability, anatomical complications and multiple comorbidities. Case: This case report describes the pre-operative evaluation and anaesthetic management of a 19 -year-old male patient with Down syndrome with hypothyroidism with Chronic Kidney Disease stage 4 who underwent open reduction internal fixation with plating for bilateral subtrochanteric fracture under general anaesthesia. It was a complicated surgery for both surgeon and anaesthetist because the patient was anaemic with significant anticipated blood loss along with fluid restriction during the perioperative period. We had major challenges like patient positioning, significant blood loss, hypotension, and early fluid overload. But an extensive preoperative evaluation, optimization prior and proper coordination we overcame the challenges. Conclusion: Major orthopaedic surgeries in patients like Down syndrome with chronic kidney disease create a major anaesthetic challenge due to expected significant blood loss, chances of fluid overload, multiple comorbidities and intellectual disability. Thorough preoperative evaluation, intraoperative monitoring as well as postoperative period is important as several complications are envisaged. So a closed group management with orthopaedic surgeon, nephrologist, anaesthesiologist, endocrinologist, nursing team is required to handle such complicated cases.

Serious complications of pancreatoduodenectomy correlate with lower rates of adjuvant chemotherapy: Results from the recurrence after Whipple's (RAW) study

IntroductionAdjuvant chemotherapy (AC) can prolong overall survival (OS) after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). However, fitness for AC may be influenced by postoperative recovery. We aimed to investigate if serious (Clavien-Dindo grade ≥ IIIa) postoperative complications affected AC rates, disease recurrence and OS. Materials and methodsData were extracted from the Recurrence After Whipple's (RAW) study (n = 1484), a retrospective study of PD outcomes (29 centres from eight countries). Patients who died within 90-days of PD were excluded. The Kaplan-Meier method was used to compare OS in those receiving or not receiving AC, and those with and without serious postoperative complications. The groups were then compared using univariable and multivariable tests. ResultsPatients who commenced AC (vs no AC) had improved OS (median difference: (MD): 201 days), as did those who completed their planned course of AC (MD: 291 days, p < 0.0001). Those who commenced AC were younger (mean difference: 2.7 years, p = 0.0002), more often (preoperative) American Society of Anesthesiologists (ASA) grade I-II (74% vs 63%, p = 0.004) and had less often experienced a serious postoperative complication (10% vs 18%, p = 0.002). Patients who developed a serious postoperative complication were less often ASA grade I-II (52% vs 73%, p = 0.0004) and less often commenced AC (58% vs 74%, p = 0.002). ConclusionIn our multicentre study of PD outcomes, PDAC patients who received AC had improved OS, and those who experienced a serious postoperative complication commenced AC less frequently. Selected high-risk patients may benefit from targeted preoperative optimisation and/or neoadjuvant chemotherapy.

P240 PREOPERATIVE OPTIMISATION FOR A PATIENT WITH HEART FAILURE UNDERGOING MAJOR NON–CARDIAC SURGERY: AN EXAMPLE OF COLLABORATION BETWEEN THE MULTIMODAL PREHABILITATION CENTRE AND THE HEART FAILURE CLINIC AT CAREGGI UNIVERSITY HOSPITAL

Abstract Introduction Heart failure (HF) is a risk factor for postoperative mortality in major non–cardiac surgery. Collaboration between the Multimodal Preoperative Prehabilitation unit (MPP) and Heart Failure Clinic (HFC) could allow optimization of heart failure therapy and negative prognostic factors such as reduced functional capacity (FC), malnutrition, and sarcopenia to improve the prognosis of these patients. Case report: Mrs. C.M. is a 58–year–old patient who presents to the MPP unit in anticipation of total colectomy for drug–refractory ulcerative colitis. Mrs. C.M. has a past medical history significant for heart failure with reduced ejection fraction (EF 25%) of presumably valvular–arrhythmic etiology. She underwent tricuspid annuloplasty and mitral replacement surgery some years ago and is affected by atrial fibrillation. At the MPP unit, Mrs. C.M. had a reduced FC and was malnourished and sarcopenic. Blood tests showed iron deficiency anemia. Heart failure therapy (NYHA II) was not optimized according to guidelines. Therefore, the patient started multimodal prehabilitation consisting of aerobic and resistance exercise, nutritional intervention, intravenous iron infusion, and optimization of HF therapy. After the patient was evaluated at the HFC, she started empagliflozin, sacubitril/valsartan, and ranolazine; intermittent levosimendan therapy was also performed. She also underwent cardiac NMR, which showed non–ischemic fibrosis, and coronary angiography, which was negative. Finally, she underwent PM–ICD implantation. After six months of multimodal prehabilitation, there was an increase in EF (38% vs. 25%), a reduction in NT–proBNP (700 vs 4988 pg/mL), and mitigation of HF symptoms. There was also a marked improvement in FC (383 vs 269 meters at 6–minute walking test), nutritional status (stage B vs stage C at PG–SGA test), and muscle strength (handgrip strength test 14.6 vs 8.5 kg). Considering the excellent preoperative optimization response, it was decided to proceed with surgery after a collegial discussion (anesthetist, heart failure cardiologist, surgeon, and patient). Conclusions Multimodal preoperative prehabilitation, based on the collaboration between the Multimodal Preoperative Prehabilitation Unit and Heart Failure Clinic, can effectively improve the preoperative functional capacity of HF patients.

Symptomatic Neuroma Development following En Bloc Resection of Skeletal and Soft-Tissue Tumors: A Retrospective Analysis of 331 Cases.

Although symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aimed to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. The authors retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014 to 2019. The authors included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics, and multivariable regression modeling was performed. The authors included 231 patients undergoing 331 en bloc resections (female, 46%; mean age, 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on examination and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18 to 39 [adjusted OR (aOR), 3.6; 95% CI, 1.5 to 8.4; P < 0.01] and 40 to 64 (aOR, 2.2; 95% CI, 1.1 to 4.6; P = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7 to 5.9; P < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI, 1.2 to 6.0; P = 0.01), and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3 to 1.0; P = 0.045). The authors' results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden. Risk, III.

Artificial Intelligence and Machine Learning Applications in Spine Surgery.

The complexity of patients with spine pathology and high rates of complications has driven extensive research directed toward optimizing outcomes and reducing complications. Traditional statistical analysis has been limited both in validity and in the number of predictor variables considered. Over the past decade, artificial intelligence and machine learning have taken center stage as the possible solution to creating more accurate and applicable patient-centered predictive models in spine surgery. This review discusses the current published machine learning applications on preoperative optimization, risk stratification, and predictive modeling for the cervical, lumbar, and adult spinal deformity populations.

Risk factors for acute postoperative hypertension in non-cardiac major surgery: a case control study

PurposeAcute postoperative hypertension (APH) is a common complication during the anesthesia recovery period that can lead to adverse outcomes, including cardiovascular and cerebrovascular accidents. Identification of risk factors for APH will allow for preoperative optimization and appropriate perioperative management. This study aimed to identify risk factors for APH.Patients and methodsIn this retrospective single-center study, 1,178 cases were included. Data was entered by two investigators, and consistency analysis was performed by another. Patients were divided into APH and non-APH groups. A predictive model was built by multivariate stepwise logistic regression. The predictive ability of the logistic regression model was tested by drawing the receiver operating characteristic (ROC) curve and calculating the area under the curve (AUC). Hosmer and Lemeshow goodness-of-fit (GOF) test was performed to reflect the goodness of fit of the model. Calibration curve was created to represent the relationship between predicted risk and observed frequency. Sensitivity analysis was performed to evaluate the robustness of the results.ResultsMultivariate logistic regression analysis showed that age over 65 years (OR = 3.07, 95% CI: 2.14 ~ 4.42, P < 0.001), female patients (OR = 1.37, 95% CI: 1.02 ~ 1.84, P = 0.034), presence of intraoperative hypertension (OR = 2.15, 95% CI: 1.57 ~ 2.95, P < 0.001), and use of propofol in PACU (OR = 2.14, 95% CI: 1.49 ~ 3.06, P < 0.001) were risk factors for APH. Intraoperative use of dexmedetomidine (OR = 0.66, 95% CI: 0.49 ~ 0.89, P = 0.007) was a protective factor. Higher baseline SBP (OR = 0.90, 95% CI: 0.89 ~ 0.92, P < 0.001) also showed some correlation with APH.ConclusionsThe risk of acute postoperative hypertension increased with age over 65 years, female patients, intraoperative hypertension and restlessness during anesthesia recovery. Intraoperative use of dexmedetomidine was a protective factor for APH.

The Risk Assessment and Prediction Tool (RAPT) Score Predicts Discharge Destination, Length of Stay, and Postoperative Mobility After Total Joint Arthroplasty

BackgroundPredicting an arthroplasty patient’s discharge disposition, length of stay (LOS), and physical function is helpful because it allows for preoperative patient optimization, expectation management, and discharge planning. The goal of this study was to evaluate the ability of the Risk Assessment and Prediction Tool (RAPT) score to predict discharge destination, LOS, and postoperative mobility in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). MethodsPrimary unilateral TKAs (n = 9,064) and THAs (n = 8,649) performed for primary osteoarthritis at our institution from 2018 to 2021 (excluding March to June 2020) were identified using a prospectively maintained institutional registry. We evaluated the associations between preoperative RAPT score and (1) discharge destination, (2) LOS, and postoperative mobility as measured by (3) successful ambulation on the day of surgery and (4) Activity Measure for Post-Acute Care (AM-PAC) “6-Clicks” score. ResultsOn multivariable analyses adjusting for multiple covariates, every one-point increase in RAPT score among TKA patients was associated with a 1.82-fold increased odds of home discharge (P < .001), 0.22 days shorter LOS (P < .001), 1.13-fold increased odds of ambulating on postoperative day 0 (P < .001), and 0.25-point higher Activity Measure for Post-Acute Care score (P < .001). Similar findings were seen among THAs. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict home discharge. ConclusionAmong nearly 18,000 TKA and THA patients, RAPT score was predictive of discharge disposition, LOS, and postoperative mobility. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict discharge to home. In contrast to prior studies of the RAPT score which have grouped TKAs and THAs together, this study ran separate analyses for TKAs and THAs and found that THA patients seemed to perform better than TKA patients with equal RAPT scores, suggesting that RAPT may behave differently between TKAs and THAs, particularly in the intermediate risk RAPT range.

V-002 Robotic suprapubic eTEP retrorectus repair for incisional hernia

Abstract Aim A retrorectus mesh position is often considered the most suitable for the repair of a midline incisional hernia. The minimal invasive extraperitoneal approach is gaining popularity. Material &amp; Methods A 56-year-old female patient, who had a laparoscopic deroofing of a bile cyst in her history, presented with an incisional midline hernia (EHS M2-M3, width 6.6 cm). Preoperative optimization via dietary instructions reduced her BMI from 40 kg/m2 to a BMI of 35 kg/m2. Results A robotic extraperitoneal approach via suprapubic docking was performed. The patient is positioned supine and flexed for 15° at the level of the spina iliaca. An intraperitoneal trocar is placed to explore the abdomen for adhesions. Three trocars are placed in the suprapubic position in the extraperitoneal plane whereafter the robot is docked. A dissection in the cranial direction is performed in the retrorectus plane by incising both posterior rectus fascia in a symmetric way. A preperitoneal plane behind the linea alba is created. At the level of the hernia defect the hernia sac is opened, and adhesions are freed. Once the retrorectus space is dissected up to the xyphoid, the linea alba is reconstructed with a barbed suture size 0. A self-fixating mesh is placed in the retrorectus position. The posterior layer of the peritoneum is closed. The postoperative course was uneventful. Conclusions We present an extraperitoneal minimal invasive approach to the retrorectus plane allowing for an adequate retrorectus dissection and mesh placement like in a classical Rives-Stoppa repair.

Determining the impact of individual ventral hernia repair complications on patient-reported quality of life

Ventral hernia repair (VHR) postoperative complications vary in presentation, management, and severity. The aim of this study is to determine the impact of individual postoperative complications on long-term quality of life (QoL) after VHR. Data from the Abdominal Core Health Quality Collaborative were analyzed retrospectively. Propensity score matching compared 1-year postoperative Hernia-Related Quality of Life Survey (HerQLes) summary scores between non-wound events (NWE), surgical site infection (SSI), and surgical site occurrence requiring procedural intervention (SSOPI) versus No-Complications. 2796 patients who underwent VHR between 2013 and 2022 met the study criteria. Patients with SSI and SSOPI had lower QoL vs No-Complications (median (Interquartile range): 71 (40-92) vs 83 (52-94), P = 0.02; 68 (40-90) vs 78 (55-95), P = 0.008). NWE vs no-complications HerQLes score differences were similar (83 (53-92) vs 83 (60-93), P = 0.19). Wound events seem to have larger impact on patients' long-term QoL compared to NWE. Continued and aggressive efforts including preoperative optimization, technical points, and appropriate use of minimally invasive techniques can continue to reduce impactful wound events.

Enabling personalized perioperative risk prediction by using a machine-learning model based on preoperative data

Preoperative risk assessment is essential for shared decision-making and adequate perioperative care. Common scores provide limited predictive quality and lack personalized information. The aim of this study was to create an interpretable machine-learning-based model to assess the patient’s individual risk of postoperative mortality based on preoperative data to allow analysis of personal risk factors. After ethical approval, a model for prediction of postoperative in-hospital mortality based on preoperative data of 66,846 patients undergoing elective non-cardiac surgery between June 2014 and March 2020 was created with extreme gradient boosting. Model performance and the most relevant parameters were shown using receiver operating characteristic (ROC−) and precision-recall (PR-) curves and importance plots. Individual risks of index patients were presented in waterfall diagrams. The model included 201 features and showed good predictive abilities with an area under receiver operating characteristic (AUROC) curve of 0.95 and an area under precision-recall curve (AUPRC) of 0.109. The feature with the highest information gain was the preoperative order for red packed cell concentrates followed by age and c-reactive protein. Individual risk factors could be identified on patient level. We created a highly accurate and interpretable machine learning model to preoperatively predict the risk of postoperative in-hospital mortality. The algorithm can be used to identify factors susceptible to preoperative optimization measures and to identify risk factors influencing individual patient risk.

Preoperative Patient Optimization: Outcomes from Elective Total Joint Arthroplasty in a Large US Healthcare System.

Patient factors are known to affect outcomes in arthroplasty surgery. A preoperative program to address modifiable factors may aid in more appropriate patient selection. We sought to assess patient selection and 90-day postoperative outcomes for total joint arthroplasty (TJA) candidates before and after implementation of a preoperative optimization protocol. A retrospective time-trend study using data from an integrated healthcare system's total joint replacement registry was done. The study sample consisted of patients aged 18 years or older who underwent primary elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis between 2009 and 2019. Patients were divided into two cohorts: procedures performed from 2009 to 2013 ("preoptimization protocol") and those from 2015 to 2019 ("postoptimization protocol"); 2014 was excluded because an evidence-based preoperative patient optimization protocol was progressively implemented throughout the year. Patient characteristics, optimization factors, and 90-day outcomes (including emergency department [ED] visits, readmission, all-cause revision, deep infection, venous thromboembolism, and mortality) were compared between the two cohorts using the Pearson chi-square test or Wilcoxon test. The study sample included 25,925 THA and 60,484 TKA. In the THA cohort, 10,364 (40.0%) and 15,561 (60.0%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization THA cohort saw lower rates of ED visits (12.1% vs. 9.4%, P < 0.001) and readmissions (5.6% vs. 3.8%, P < 0.001). In the TKA cohort, 24,054 (39.8%) and 36,430 (60.2%) were from the preoptimization and postoptimization cohorts, respectively. The postoptimization TKA cohort saw lower rates of ED visits (13.1% vs. 11.9%, P < 0.001), readmissions (5.6% vs. 3.0%, P < 0.001), all-cause revisions (0.5% vs. 0.3%, P = 0.003), venous thromboembolism (1.3% vs. 0.9%, P < 0.001), and mortality (0.3% vs. 0.2%, P = 0.011). An evidence-based protocol to improve patient selection based on modifiable patient factors was adopted by orthopaedic surgeons in the system and utilization of the protocol before TJA was associated with fewer postoperative complications over time. Level IV.

Preoperative and postoperative optimisation of patients undergoing thyroid surgery: a multicentre quality improvement project at Barts Health NHS Trust

Hypocalcaemia following thyroid surgery can occur in up to 38% of patients. With over 7100 thyroid surgeries performed in 2018 in the UK, this is a common postoperative complication. Undertreated...

Metrics for Monitoring Preoperative Optimization Programs for Total Joint Arthroplasty: A Survey of Orthopaedic Nurses.

Preoperative optimization programs are becoming more common for patients seeking total joint arthroplasty; yet, limited research has been conducted to monitor the long-term effects of these programs on patient outcomes. Our aim was to develop a set of metrics that programs can use to monitor the success of preoperative optimization programs. As part of a larger survey of orthopaedic nurses, we collected data regarding current monitoring techniques for preoperative optimization programs and the feasibility of collecting specific variables. Surgical factors such as length of stay and 30-day readmissions were most often used to monitor the success of preoperative optimization programs. Surgical factors were the most likely to be accessible using the electronic medical record. Surgical factors and patient characteristics are the most feasible components for programs to monitor in order to track the outcomes of patients participating in preoperative optimization programs.

Otolaryngology Considerations of Pituitary Surgery: What an Endocrinologist Should Know.

Endoscopic endonasal skull base surgery is the preferred surgical approach for the management of pituitary adenomas. Perioperative management of pituitary lesions requires multidisciplinary care and typically includes a dual surgeon team consisting of a neurosurgeon and an otolaryngologist. The involvement of the otolaryngologist allows for a safe surgical approach with excellent intraoperative visualization of the tumor to enable an effective resection of the tumor by the neurosurgeon. Detection and treatment of sinonasal pathology is essential prior to surgery. Patients may experience sinonasal complaints following endoscopic transsphenoidal surgery, although this is typically temporary. Sinonasal care in the postoperative period can expedite recovery to baseline. Here we discuss the perioperative factors of endoscopic pituitary surgery that endocrinologists should be aware of, ranging from preoperative patient selection and optimization to postoperative care, with a particular emphasis on anatomic and surgical factors.

Multi-Site Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative.

The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the United States. The aims of this study were to 1) determine implementation feasibility for 30 selected standards, 2) identify barriers and best practices in their implementation, and 3) further refine these geriatric standards and verification process. The CQGS requested participation from hospitals involved in the ACS National Surgical Quality Improvement Project (NSQIP) Geriatric Surgery Pilot Project, prior CQGS feasibility analyses, and hospitals affiliated with a core development team member. 30 standards were selected for implementation. Following implementation, site visits were conducted, and post-visit surveys were distributed. Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "Fully Compliant" standards. Goals and decision making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of "Fully Compliant" standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. Over 80% of the institutions reported that participation changed the surgical care provided for older adults. This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.

44. Symptomatic Neuroma Formation following Skeletal and Soft Tissue Tumor Resection

PURPOSE: While symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aims to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. METHODS: We retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014-2019. We included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics and multivariable regression modeling was performed. RESULTS: We included 231 patients undergoing 331 en bloc resections (46% female; mean age 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on exam and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18-39 (aOR, 3.6; 95% CI, 1.5-8.4; p < 0.01) and 40-64 (aOR, 2.2; 95% CI, 1.1-4.6; p = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7-5.9; p < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI 1.2-6.0; p = 0.01) and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3-1.0; p = 0.045). CONCLUSION: Our results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden.