Preoperative Management Research Articles

Advances in artificial intelligence for predicting complication risks post-laparoscopic radical gastrectomy for gastric cancer: A significant leap forward

In a recent paper, Hong et al developed an artificial intelligence (AI)-driven predictive scoring system for potential complications following laparoscopic radical gastrectomy for gastric cancer patients. They demonstrated that integrating AI with random forest models significantly improved the preoperative prediction and patient outcome management accuracy. By incorporating data from multiple centers, their model ensures standardization, reliability, and broad applicability, distinguishing it from the prior models. The present study highlights AI's potential in clinical decision support, aiding in the preoperative and postoperative management of gastric cancer patients. Our findings may pave the way for future prospective studies to further enhance AI-supported diagnoses in clinical practice.

Influence of preoperative glaucoma medication on long-term outcomes of trabeculectomy.

This retrospective study evaluated the association between preoperative topical glaucoma medication containing preservatives and long-term trabeculectomy outcomes in 309 eyes from 201 patients with primary open-angle glaucoma, followed for over 10 years. The Glaucoma Medication Intensity Index (GMII) was calculated to quantify the cumulative preoperative exposure to these medications. Kaplan-Meier analysis revealed cumulative success rates of 89.3%, 59.2%, and 46% at 1, 10, and 20 years postoperatively. At 20 years, the success group had a significantly lower GMII (3.28 vs. 8.74, p = 0.004). A GMII threshold of ≥ 4.35 was associated with poorer long-term intraocular pressure (IOP) control and shorter surgical success duration. Cox regression analysis identified advanced age at surgery, higher GMII, and subsequent cataract surgery as significant risk factors for trabeculectomy failure. These findings underscore the adverse impact of prolonged preoperative use of glaucoma medications on long-term surgical outcomes, highlighting GMII as a valuable predictor for guiding preoperative management strategies.

A bird-eye view of diaphragmatic endometriosis: current practices and future perspectives

Diaphragmatic endometriosis is one of the most common localization of extra-pelvic endometriosis and may cause debilitating symptoms such as cyclic shoulder pain, right upper abdominal pain, and right-sided chest pain. Diaphragmatic endometriosis may also be asymptomatic. The exact mechanisms by which diaphragmatic endometriosis originates are unknown. The high correlation between severe pelvic endometriosis and diaphragmatic endometriosis suggests that the latter originates from endometriotic cells that reach the upper abdomen by circulating with the peritoneal fluid current. Robust evidence regarding the preoperative diagnosis and optimal management of diaphragmatic endometriosis is lacking. Most reports rely on Magnetic Resonance Imaging (MRI) for the radiologic diagnosis of diaphragmatic endometriosis. Although its sensitivity ranged between 78% and 83%, MRI was found to underestimate the extent of diaphragmatic endometriosis in comparison with the surgical findings. Accumulating evidence indicates that asymptomatic diaphragmatic endometriosis is very unlikely to progress, and therefore, could be left in situ when incidentally found. The efficiency of ablative and excisional approaches for symptomatic endometriosis has not been assessed thoroughly to date. In addition, it is unclear whether combining the laparoscopic approach with video-assisted thoracoscopy (VATS) may result in an optimized result. This gap exists due to the lack of data about the association between diaphragmatic and thoracic endometriosis. In this review, we aimed to provide a state of the art description of the current knowledge and gaps about the pathogenesis, diagnostics, and treatment modalities of diaphragmatic endometriosis.

GIANT LUMBO-SACRAL TUMORS

Objectives Despite comprising just 8% of all spinal tumors, sacral tumors present a long list of issues that should be taken in consideration when neurosurgical approach is tempted. Their unique anatomic location, close relation with neural structures and pelvic organs and high-vascularity are just a few nuances of these type of conditions. This paper outline the importance of a good preoperative and intraoperative management in order to facilitate the maximum recovery of the patients. Material and Methods This paper analyses retrospectively a series of 2 cases of giant sacral tumors (>100 cm3) that were operated in our clinic in 2024 by a multidisciplinary team (neurosurgeons and general surgeons). Follow-up data were obtained from the charts and medical records. All the lesions were localised under L4 vertebra with invasion of sacrum. Results Our first case was a 47-years old man who accused diffuse mild lumbar pain for more than 2 years, but acutely aggravated in the last months with lumbosacral radicular pain, palsy of the inferior lumbar nerves, urinary incontinence and paraesthesia. MRI showed a giant L5-S2 mass and biopsy diagnostic was myxopapillary ependymoma. Second case was of a young woman with lumbosacral radicular pain debuted a few months ago, whose clinical state worsened rapidly becoming paralytic of lower limbs. MRI showed a giant sacral mass with invasion of the pelvic musculature and surrounding the iliac vessels (intraoperative aspect: sarcoma). Both patients ameliorated postoperatively, and are currently enrolled in a recovery program. Sub-total resection and near-total resection were obtained. Conclusions Sacral tumors exhibit a challenge in the field of spine surgery being clinical silence over a period of months and years, and then followed by gross deficit. We diagnosed sacral tumors based on clinical, radiographic and laboratory aspects. Prognostic factors were preoperative clinical status and gross-total resection.

HPB SO24 - Recurrence Pattern of Pancreatic Ductal Adenocarcinoma based on Time-to-Recurrence: A 5-year Single-Centre Retrospective Study

Abstract Background A vast majority of patients with pancreatic ductal adenocarcinoma (PDAC) develop early disease recurrence, even after curative-intent surgical resection. Understanding the pattern of disease recurrence will enable identification of areas for improvement within the preoperative diagnostic and management algorithms for these patients. The aim of the retrospective cohort study was to compare the recurrence pattern of PDAC in patients with early (<12 vs >12 months) and very early (<6 vs >6 months) recurrence following surgical resection. Method A retrospective review of histologically confirmed pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy (N=151) between 2015-2020 at a tertiary HPB centre was undertaken. All patients underwent CT and PET-CT for initial staging before resection. Initial recurrence after resection was identified through postoperative imaging and/or HPB MDT outcomes. Early recurrence (ER) was defined as recurrence within the first 12 months after surgery (n=78). Additionally, very early recurrence (VEM) was defined as recurrence within the first six months after surgery (n=46). Statistical analysis was performed using GraphPad Prism 8.0. Results In total, 117 (77.5%) of patients experienced recurrence, with a median recurrence-free survival of 11.3 (5.1-19.6) months. Patients with ER had significantly higher pathological T staging (p=0.01), greater margin positivity rate (p=0.01) and higher lymph node ratio (p=0.046), while those in VER had significantly larger maximum tumour diameter and number of involved lymph nodes (p=0.04) compared to their counterparts. Patients with ER (47.4 vs 31.5%, p=0.046) and VER (60.9 vs 30.5%, p<0.001) had significantly greater rates of liver metastasis compared to their counterparts. There were no differences in loco-regional recurrence, peritoneal or pulmonary metastasis between the groups. Conclusion Approximately 20% of patients undergoing surgical resection for PDAC developed liver metastasis within six months of surgery. This raises concerns for the presence of micro-metastatic disease within the liver unidentified on preoperative imaging. Therefore, there is a need to enhance preoperative imaging and treatment algorithms to improve survival of patients with PDAC.

Preoperative management and anticoagulant efficacy in atrial myxoma-associated acute ischemic stroke: a case report and literature review

Acute ischemic stroke (AIS) is a common complication of atrial myxoma (AM), and most emboli originate from a thrombus attached to the surface of the myxoma, with occasional shedding of tumor fragments leading to stroke. Clinical manifestations of AM include mitral valve obstruction, systemic embolism, and weakness. However, neurological deficits and other nonspecific manifestations may mask the presence of AM. The surgical resection is the most effective treatment for these conditions. However, the main problem is the lack of consensus regarding the prevention and treatment of stroke complicated by myxoma during the perioperative period. This study aims to improve the diagnosis and treatment of AM and the associated AIS. Here, we report the case of a 27-year-old patient with AM who presented with chest pain, palpitations, and sudden dizziness and had a stroke under anticoagulant treatment during the admission period. We also reviewed and summarized the clinical presentations and characteristics of similar previously reported cases. Our review emphasized the importance of early diagnosis and appropriate perioperative management of AM and its associated AIS.

Refining a Multidisciplinary “Vasculo-plastic” Approach to Limb Salvage: An Institutional Review Examining 300 Lower Extremity Free Flaps

Background: The use of free tissue transfer (FTT) is effective for chronic, non-healing lower extremity (LE) wounds, requiring collaboration across plastic, vascular, podiatric, orthopedic, and infectious disease disciplines for comprehensive treatment plants to optimize limb salvage. This study aims to describe our vasculo-pathic approach with 300 LE FTTs, comparing outcomes between the first 200 LE FTT and the most recent 100 procedures performed. Methods: A single-institution, retrospective review of 300 LE FTTs from July 2011 to January 2023 was performed. Patients were compared between the first 200 (Group 1, July 2011 – February 2020) and last 100 flaps (Group 2, February 2020 – January 2023) performed. Patient characteristics, preoperative management, intraoperative details, and outcomes were collected. Results: Group 2 patients had significantly higher rates of diabetes (67.0% vs. 48.5%, p=0.002), peripheral vascular disease (56.0% vs. 24.5%, p<0.001), history of venous thromboembolisms (13.0% vs. 6.0%, p=0.039), venous reflux (81.9% vs. 67.8%; p=0.028), and preoperative venous thromboses on venous testing (25.5% vs. 10.5%; p=0.003) compared to Group 1. Group 2 underwent more pre-FTT endovascular interventions (23.0% vs. 16.5%, p=0.039) and vascular bypasses (4.0% vs. 0.0%, p =0.012). While immediate flap success and amputation rates were similar between the groups, Group 2 had higher rates of partial flap necrosis (7% vs. 3%; p=0.012). Conclusions: The adoption of a vasculo-plastic approach allows LE FTT to remain successful and achieve long-term limb salvage despite a highly comorbid population.

Establishment of a Predictive Model for Seroma Formation After TAPP Repair for Unilateral Indirect Inguinal Hernia in Males.

Inguinal hernia repair, particularly using TAPP, is common in males, and acclaimed for minimal invasiveness but often complicated by seromas, significantly affecting recovery and health care costs. This retrospective study analyzed data from 266 male patients with unilateral indirect inguinal hernia who underwent transabdominal preperitoneal (TAPP) repair. We divided the patients into a training set (n = 188) and a validation set (n = 78). We employed logistic regression to identify independent risk factors for post-TAPP seroma and developed a nomogram to predict the occurrence of seromas. The model's accuracy was evaluated using receiver operating characteristic (ROC) curves, Hosmer-Lemeshow goodness-of-fit test, calibration curves, and decision curve analysis (DCA). Postoperatively, 20.3% of patients developed a seroma. Multivariate logistic regression analysis highlighted several independent risk factors for seroma formation: the use of anticoagulants, an internal ring defect ≥5cm, scrotal hernia, incarcerated hernia, and transected hernia sac (P < 0.05). The ROC curves for the training and validation sets demonstrated areas under the curve of 0.893 (95% CI: 0.845-0.942) and 0.864 (95% CI: 0.765-0.963), respectively, indicating good model fits (P > 0.05). DCA confirmed significant clinical applicability of the model. The findings suggest that the use of anticoagulants, an internal ring defect ≥5cm, scrotal hernia, incarcerated hernia, and transected hernia sac are significant independent risk factors for seroma formation after TAPP repair. Clinical consideration of these factors and proactive preventive measures are essential. Although many of these factors are non-modifiable, understanding them is crucial for preoperative risk assessment and patient management.

Rigid intramedullary nailing of lower limb segments in children and adolescents with metabolic bone disease.

Children and adolescents with metabolic bone disease present to the orthopedic surgeon with pain, fractures (which may be impending), and deformity. Different modalities of orthopedic management are available. Scant literature exists on the use of rigid intramedullary nailing in this population. This study sought to evaluate the utilization of this treatment modality in the pediatric cohort, focusing on indications, techniques, and outcomes of the procedures. A retrospective review was performed over an 11-year period at a single tertiary pediatric institution in the UK. Medical records and radiographs were reviewed. Preoperative surgical and medical management, time to bony union, and complications were specifically ascertained. Twenty-seven patients (63 lower limb segments) had rigid intramedullary nailing over the specified period. The majority of patients had an underlying diagnosis of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright Syndrome). Surgical indications included acute fractures, prophylactic stabilization, previous nonunion and malunions, deformity correction, and limb lengthening. All fractures healed and deformity correction was successful. In one patient, delayed union occurred after deformity correction and was successfully treated with dynamization. Fractures healed faster than corrective osteotomies. Complications included implant prominence, cortical penetrance, and screw loosening. Nonunion occurred with limb lengthening in one patient. Rigid intramedullary nailing is a safe and effective method of treatment for lower limb fractures and deformities in children and adolescents. This technique is, therefore, recommended for patients with metabolic bone disease. However, care must be taken in preoperative surgical planning and a multidisciplinary approach should be utilized.

Return on Investment of Preoperative Anemia Management Programs in Cardiac Surgery: An Advisory From the Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Committee With Endorsement by the Society for the Advancement of Patient Blood Management

Despite multiple recent guidelines recommending the diagnosis and treatment of anemia before elective cardiac surgery, few institutions have formal programs or methods in place to accomplish this. A major limitation is the perceived financial shortfall and the leadership buy-in required to undertake such an initiative. The purpose of this advisory from the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee with endorsement by the Society for the Advancement of Patient Blood Management (SABM) is to provide an overview of preoperative anemia management programs with an emphasis on the associated financial implications. This advisory reviews the evidence for preoperative anemia management programs in both cardiac and noncardiac surgery, discusses options for managing preoperative anemia, provides novel financial modeling regarding the implementation of preoperative anemia management programs, and describes implementation challenges, potential solutions, and opportunities for improvement.

Students’ performance in clinical class II composite restorations: a case study using analytic rubrics

BackgroundThe analytical rubric serves as a permanent reference for guidelines on clinical performance for undergraduate dental students. This study aims to assess the rubric system used to evaluate clinical class II composite restorations performed by undergraduate dental students and to explore the impact of gender on overall student performance across two academic years. Additionally, we investigated the relationship between cumulative grade point averages (CGPAs) and students’ clinical performance.MethodsAn analytical rubric for the assessment of clinical class II composite restoration in the academic years of 2022/2023 and 2023/2024 was used by two evaluators. These two evaluators were trained to use the rubric before doing the evaluations. The scores were based on a 4-point scale for the evaluation of five major parameters for pre-operative procedures (10 points), cavity preparation (20 points), restoration procedures (20 points), and time management (4 points). At the same time, chairside oral exam parameter was 15 points based on a 5-point scale. Descriptive statistics were calculated for the different analytical rubric parameters, and the independent t-test was used to compare the scores between the student groups and the evaluators. Other tests, such as the Kappa test and Pearson’s correlation coefficient, were used to measure the association among CGPA, evaluators, and gender participants.ResultsThe overall score out of 69 slightly increased for females/males (61.28/59.42) and (61.18/59.49) in the 2022/2023 and 2023/2024 academic years, respectively, but the differences were not statistically significant. In the 2022/2023 academic year, female students scored significantly higher than male students in pre-operative procedures, as evaluated by both evaluators (p = 0.001), and in time management, as assessed by both evaluators (p = 0.031). The Kappa test demonstrated a moderate to substantial level of agreement between the two evaluators in both academic years. Strong and significant correlations were noted between students’ CGPA and some tested parameters (p = 0.000).ConclusionThe overall performance was very good and high among both genders, but it was marginally higher among females than among males. This study found some differences in performance between male and female students and variability in the evaluations by the two raters ranging from moderate to substantial agreement and similar performances for students with different CGPA.

Effect of preoperative inspiratory muscle training combined with preoperative education on postoperative pulmonary complications in high-risk patients with lung cancer: protocol for a randomised controlled trial.

Preoperative inspiratory muscle training (IMT) is recognised as an important component of the preoperative management of lung cancer, although there is limited evidence for the delivery of a home-based IMT programme combined with preoperative education. We developed a programme combining short-term home-based IMT and preoperative physiotherapy education ('the programme'). This study aims to evaluate the effectiveness of this programme in reducing postoperative pulmonary complications (PPCs) after lung cancer resection compared with standard care. In this randomised controlled trial, 114 participants scheduled for lung cancer surgery at the First Affiliated Hospital of Fujian Medical University will be randomly assigned (1:1) to either receive usual care (information booklet) or usual care combined with the programme, which consist of short-term home-based IMT and preoperative physiotherapy education. The primary outcome measure will be PPCs using the Melbourne Group Score. Secondary outcomes will include health-related quality of life, maximal inspiratory pressure, 6 min walk distance, length of hospital stay, anxiety and depression levels, and hospital costs. The study has received ethics approval from the ethics committee of the first affiliated hospital of Fujian Medical University (approval no: MRCTA, ECFAH of MFU [2021]569). Participants will be required to provide written informed consent. The results of the study will be submitted for publication in peer-reviewed journals. ChiCTR2300067464.

Schwannomas of the upper limb: Clinical presentation, preoperative management and outcomes of surgical treatment.

Schwannomas are the most common tumors of the peripheral nervous system. Surgical eradication with excision or enucleation is the treatment for symptomatic and large schwannomas.

Comprehensive strategies for preoperative pulmonary risk evaluation and management.

Postoperative pulmonary complications (PPCs) significantly increase morbidity and mortality in surgical patients, particularly those with pulmonary conditions. The incidence of PPCs varies widely, influenced by surgery type, patient age, smoking status, and comorbidities like chronic obstructive pulmonary disease (COPD) and congestive heart failure. Preoperative pulmonary function tests and chest radiographs, while critical for lung resection surgery, should be selectively used based on individual risk factors. Effective risk stratification models, including ASA classification, Arozullah Respiratory Failure Index, Gupta Calculators, and ARISCAT model, aid in predicting PPCs. Key strategies to reduce PPCs involve preoperative optimization of pulmonary conditions, smoking cessation, and respiratory rehabilitation. In COPD and asthma patients, maintaining optimal disease control through inhaled therapies, systemic corticosteroids, and preoperative respiratory exercises is crucial. Anemia and hypoalbuminemia are notable predictors of PPCs, warranting careful management. The type and duration of anesthesia significantly impact PPC risk, with regional anesthesia preferred over general anesthesia when feasible. Comprehensive preoperative evaluation and tailored interventions are essential to improve surgical outcomes and reduce PPC incidence. Further study involving domestic patients is needed to refine national guidelines for managing patients at risk of PPCs.

The effect of prebiotic fibre on the gut microbiome and surgical outcomes in patients with prosthetic joint infection (PENGUIN) - study protocol for a randomised, double-blind, placebo-controlled trial (ACTRN12623001273673)

BackgroundProsthetic Joint Infection (PJI) is the most devastating complication of arthroplasty surgery and affects 1–5% of patients. Despite strict adherence to aseptic protocols and preventive measures, infection is the most common reason for revision arthroplasty, and the incidence is increasing. Treatment of PJI is challenging and often requires repeated major surgeries with sequentially poor results. The continued occurrence of PJI, and persistence after treatment, brings into question the current treatment paradigm. Preclinical evidence suggests a link between altered gut health and the risk of PJI in arthroplasty patients. Resistant starches helps to restore gut physiology by enhancing the beneficial microbiome and producing short-chain fatty acids, which have several health-conferring properties. The primary aim of this study is to investigate the effect of a commercially available prebiotic fibre formulation on the gut microbiome in PJI patients planned for a two-stage revision surgery.MethodsA double-blind placebo-controlled trial will assess the effect of 8-week supplementation of a commercially available prebiotic supplement in patients presenting with first-time PJI undergoing two-stage revision surgery. The supplementation phase will start after the first stage revision, and 80 patients will be randomised to receive either a test product (34 g of resistant starch) or a placebo (custard powder) daily for eight weeks. Stool and blood specimens will be collected at baseline, four weeks and eight weeks after the first-stage surgery and once at second-stage surgery. Gut microbiome profile, inflammatory cytokines and gut permeability biomarkers will be measured. Tissue specimens will be collected intra-operatively during first and second-stage surgeries. Baseline dietary patterns and gut symptoms will be recorded using validated questionnaires. Treatment outcomes will be reported for both cohorts using the Delphi criterion at one and two years after second-stage surgery.DiscussionThis will be the first study to investigate the relationship between gut health optimisation and preventing PJI recurrence in arthroplasty patients. If supplementation with resistant starch improves gut health and reduces systemic inflammation, optimising the gut microbiome will be a recommended preoperative management strategy for arthroplasty patients.Trial registration noACTRN12623001273673.

Holistic Patient Care: A Narrative Review on the Synergy of Internal Medicine, Anesthesiology, and Surgical Practices

Introduction: holistic patient care, which integrates the efforts of Internal Medicine, Anesthesiology, and Surgical Practices, has been shown to improve patient outcomes across the continuum of care. This review aimed to explore the synergy between these specialties and highlight how their collaboration contributes to comprehensive, patient-centered care.Method: a narrative review was conducted using peer-reviewed literature from databases such as PubMed, Scopus, and Google Scholar. The search focused on articles published in the last 15 years, using terms related to interdisciplinary collaboration in healthcare. Data from relevant studies were synthesized and grouped into preoperative, intraoperative, and postoperative phases, with emphasis on how each specialty contributes to holistic care.Results: the review demonstrated that collaboration between these specialties is essential for optimizing preoperative risk management, ensuring intraoperative stability, and enhancing postoperative recovery. Internal Medicine played a key role in managing chronic conditions preoperatively, while Anesthesiology tailored anesthesia plans and managed perioperative pain. Surgical Practices, guided by insights from the other specialties, executed patient-centered surgeries. Despite the benefits, challenges such as communication barriers and resource limitations were identified.Conclusion: this review highlighted the critical role of interdisciplinary collaboration in holistic patient care. While the synergy between Internal Medicine, Anesthesiology, and Surgical Practices improved patient outcomes, addressing communication challenges and resource constraints is essential for further enhancing care quality.

Patient Blood Management in 2023: a Nationwide Survey of Anesthesiologists in Romania following the 2018 Guidelines.

In 2018, Romania established national guidelines for patient blood management (PBM), endorsed by the Romanian Society of Anesthesia and Intensive Care (SRATI) and approved by the Ministry of Health. These guidelines emphasize managing anemia, coagulation issues, and the cautious use of allogeneic transfusions to improve patient outcomes. A national survey was conducted among Romanian anesthesiologists to assess PBM guideline adoption. It included 38 questions addressing PBM strategies, resources, transfusion practices, and barriers to implementation. The survey was distributed via email to the SRATI database. Out of 512 professionals who opened the survey, 74% had adopted some PBM measures, and 97% recognized PBM's efficacy in improving outcomes. However, only 33% of anesthesiologists worked in hospitals with formal PBM groups, and 39% had attended PBM-related educational events. Preoperative anemia management was inconsistent, with only 33.5% routinely treating anemia. Access to diagnostic and therapeutic tools was limited; transferrin saturation testing was available in 27% of cases, and erythropoietin was used in 24%. Despite these limitations, 72% of respondents treated anemia with intravenous iron. The main challenges to implementation included insufficient time for pre-surgical assessments, lack of standardized procedures, and difficulties in surgeon-anesthetist collaboration. The survey highlights the need for systemic improvements in PBM adoption. Recommendations include enhancing organizational structures, standardizing protocols, and improving interdisciplinary collaboration to boost PBM implementation in Romania. While progress has been made, a national program with dedicated funding and auditing could facilitate widespread PBM integration into clinical practice.

Factors contributing to persistent shoulder pain after arthroscopic rotator cuff repair: Protocol for a scoping review

Introduction Rotator cuff (RC) tears are the most common and disabling musculoskeletal ailments among patients with shoulder pain. Although most individuals show improvement in function and pain following arthroscopic rotator cuff repair (ARCR), a subgroup of patients continue to suffer from persistent shoulder pain following the surgical procedure. Identifying these factors is important in planning preoperative management to improve patient outcomes. Objective This scoping review aims to identify biological factors, psychological factors, and social determinants of health contributing to the development of persistent pain in individuals after the ARCR procedure. Inclusion criteria All prospective and retrospective longitudinal studies reporting the risk factors contributing to persistent pain three months or longer after the ARCR surgery will be considered for this scoping review. Methods Our review will adhere to the Joanna Briggs Institute (JBI) scoping review methodology. Four electronic databases PubMed, CINAHL, Embase, and Scopus will be searched for studies in the English language. Additional studies can be found by conducting a citation analysis of the included studies. Title and abstract screening will be performed by two independent reviewers following the inclusion criteria, a third reviewer will be consulted about any differences. Next, full-text screening will be conducted, and the remaining search results will be reviewed to extract data, as well as to synthesize findings from all research. An overview of findings will be depicted in tabular format accompanied with a narrative summary of various factors contributing to persistent pain.

Strategies for Preventing Tunnel Convergence in Multiligament Knee Injury Reconstructions.

Multiligament knee injuries (MLKIs) are complex and heterogeneous, often associated with concomitant injuries, and necessitates precise treatment strategies. Effective preoperative management in MLKIs requires comprehensive evaluation, starting with a detailed patient history to identify the mechanisms of injury and prior treatments. Physical examination assesses for knee stability, while imaging techniques including magnetic resonance imaging (MRI) and radiographs detail ligament, cartilage, and meniscal injuries to identify all injured structures. Vascular evaluations are critical given the high risk of concomitant neurovascular injuries especially in dislocated knees, bicruciate injuries, and lateral-sided injuries. Anatomic reconstruction of the torn ligaments has been biomechanically and clinically validated to improve knee stability and function. When performing multiple anatomic reconstructions, the risk of tunnel convergence is high. Therefore, surgical intervention aimed at optimizing outcomes necessitates careful planning to avoid tunnel convergence. This involves strategic tunnel placement, orientation, and techniques, such as adjusting tunnel angulation and using intraoperative imaging. These measures are vital for restoring knee functionality and minimizing future complications. Managing tunnel convergence is vital in treating MLKIs. Avoiding convergence on the medial side of the femur and tibia is more challenging due to the number of tunnels. In an MLKI involving all ligaments, 4 femoral tunnels and 4 tibial tunnels are required on the medial side, compared to 3 on the femur and 1 on the tibia for the lateral side, respectively. The successof a multiligament knee reconstruction depends on a precise diagnosis, thorough preoperative management, and strategic tunnel placement. A multidisciplinary approach not only enhances surgical outcomes, but also ensures long-term improvement in knee function, effectively addressing the complexities and risks associated with these injuries.

Impact of enhanced recovery after surgery (ERAS) on surgical site infection and postoperative recovery outcomes: a retrospective study of 1276 cases

This retrospective observational study aimed to evaluate the incidence of surgical site infection (SSI) in the era of enhanced recovery after surgery (ERAS) and the effect of ERAS on postoperative outcomes. Totally 1,276 patients (565 in ERAS group and 711 in non-ERAS group) who underwent operations at the department of general surgery during 2017–2021 were included. Risk factors were identified via logistic regression analysis and meta-analysis of all relevant published studies was performed. Subsequently, propensity score matching was used to match different risk factors. Overall, 40 patients were diagnosed with SSI, and the pooled incidence of SSI was 3.13%. In total, 14 (2.48%) and 26 (3.66%) patients in the ERAS and non-ERAS groups, respectively, were diagnosed with SSI (P = 0.230). Among patients for whom the ERAS protocol was adopted, 7 independent risk factors of SSI were identified. After propensity score matching, in patients without SSI, the number of hospital days was significantly lower in the ERAS group than in the non-ERAS group (2 [2, 5] vs. 3 [2, 7], P = 0.005), whereas in patients with SSI, the number of hospital days was similar between the ERAS and non-ERAS groups. ERAS had no effect on the incidence of SSI but could significantly accelerate the discharge of uninfected patients. In the era of ERAS, SSI incidence was affected by the type of surgery; number of postoperative hospital days; type of incision; serum hemoglobin, total protein, and albumin levels; and antibiotic prophylaxis. Furthermore, these results will significantly affect the implementation of the ERAS protocol and optimal preoperative management.