Preoperative Protocol Research Articles

Third molar surgical difficulty scales: systematic review and preoperative assessment form

Background The main objective of this systematic review was to collect the pre-existing scales for assessing the difficulty of third molar extraction. The secondary objective was to design a proposal for a preoperative evaluation protocol for the difficulty of third molar extraction.Material and Methods Two independent researchers conducted an electronic search in Pubmed (MEDLINE), Cochrane, and Scopus databases during March 2021. Included studies evaluated the prediction of the difficulty of surgical removal of impacted upper or lower third molars using new indices/scales or pre-existing scales with or without modifications. Articles referring to coronectomies or assessing pre-surgical difficulty using other tools were excluded. Neither language nor publication date restrictions were applied.Results Out of 242 articles, 13 prospective cohort studies were finally selected. Seven developed new indices/scales, and 6 assessed the predictive ability of some pre-existing scales. Most of the indices/scales contained radiological variables and few added any patient-related variables. We proposed a preoperative assessment protocol of the difficulty of third molar extraction to facilitate treatment planning and/or considerate referral in cases of high difficulty. This proposal used patient-related, radiological and surgical variables.Conclusions Using a preoperative protocol to evaluate the surgical difficulty, including different patient-specific, radiological and surgical variables, could facilitate treatment planning, help clinicians prevent complications and assess the possibility of referral. Key words:Wisdom teeth, patient characteristics, radiological variables, surgeon experience, assessment form.

Are preoperative chlorhexidine gluconate showers associated with a reduction in surgical site infection following craniotomy? A retrospective cohort analysis of 3126 surgical procedures.

Surgical site infection (SSI) is a complication linked to increased costs and length of hospital stay. Prevention of SSI is important to reduce its burden on individual patients and the healthcare system. The authors aimed to assess the efficacy of preoperative chlorhexidine gluconate (CHG) showers on SSI rates following cranial surgery. In November 2013, a preoperative CHG shower protocol was implemented at the authors' institution. A total of 3126 surgical procedures were analyzed, encompassing a time frame from April 2012 to April 2016. Cohorts before and after implementation of the CHG shower protocol were evaluated for differences in SSI rates. The overall SSI rate was 0.6%. No significant differences (p = 0.11) were observed between the rate of SSI of the 892 patients in the preimplementation cohort (0.2%) and that of the 2234 patients in the postimplementation cohort (0.8%). Following multivariable analysis, implementation of preoperative CHG showers was not associated with decreased SSI (adjusted OR 2.96, 95% CI 0.67-13.1; p = 0.15). This is the largest study, according to sample size, to examine the association between CHG showers and SSI following craniotomy. CHG showers did not significantly alter the risk of SSI after a cranial procedure.

The preoperative evaluation of post-COVID-19 patients scheduled for elective surgery - What is important not to miss!

Continuous rise in the number of COVID-19 cases, since it was first diagnosed in 2019, forced the entire medical fraternity to delay elective surgeries. The preoperative evaluation guidelines that were used in the pre-COVID-19 era underwent significant changes, adding modifications to meet the post-COVID patients' specific criteria and requirements. Currently, all patients before or at the time of hospital admission were tested using a nasopharyngeal swab, by RT-PCR for SARS-CoV-2. Apart from this, for a patient undergoing elective surgery in their post-COVID-19 period, it is mandatory to obtain a detailed history of COVID-19 disease/SARS-CoV-2 infection, to identify residual symptoms or any organ dysfunction the infection might have caused. As well as the functional optimization of the patient to achieve the best clinical and biological status before the surgery. After all the systems have been thoroughly investigated, the risk-benefit ratio needs to be calculated, keeping in mind the cytokine storm and inflammatory responses encountered postoperatively. A mere negative RT-PCR test cannot be considered as the only decisive factor to operate, as the post-COVID-19 phase can influence postoperative outcome of the patient. Hence, the pre-operative evaluation protocols of post-COVID patients should be set and followed thoroughly, in order to avoid post-surgical complications. For better surgical and post-surgical management of post-COVID-19 patients, conducting clinical tests, assessing previously administered medications, evaluating the need for deep venous thrombosis prophylaxes, and identifying subclinical inflammatory state are the measures that should be taken.

Long-term Use of Ultrasound for Locating Optimal LVA Sites: A Descriptive Data Analysis.

Preoperative mapping of lymphatic vessels for lymphovenous anastomosis (LVA) surgery is frequently performed by indocyanine green (ICG) lymphography solely; however, other imaging modalities, such as ultrasound (US), might be more efficient, particularly for Caucasian patients. We present our preoperative assessment protocol, experience, and approach of using US for locating optimal LVA sites. Fifty-six (16 males) lymphedema patients who underwent LVA surgery were included in this study, 5 of whom received two LVA operations. In total, 61 LVA procedures with 233 dissected lymphatic vessels were evaluated. Preoperative US was performed by the author S.M. 2 days before intraoperative ICG lymphography. Fluid-predominant lymphedema regions were scanned more profoundly. Skin incisions followed preoperative US and ICG lymphography markings. Detection of lymphatic vessels was compared between ICG lymphography and the US by using the intraoperative verification under the microscope with 20 to 50x magnification as the reference standard. Among the dissected lymphatic vessels, 83.3% could be localized by US, and 70% were detectable exclusively by it. In all, 7.2% of US-detected lymphatic vessels could not be found and verified intraoperatively. Among the lymphatic vessels found by US, only 16% were apparent with ICG before skin incision. In total, 23.2% of the dissected lymphatic vessels could be visualized with ICG lymphography preoperatively. Only 9.9% of the lymphatic vessels could be found by ICG alone. High-frequency US mapping accurately finds functional lymphatic vessels and matching veins. It locates fluid-predominant regions for targeted LVA surgeries. It reveals 3.6 times as many lymphatic vessels as ICG lymphography. In our practice, it has an integral role in planning LVA procedures.

Influence of tomographic and biomechanical corneal indexes on myopic refractive surgery indications: A multicenter study.

To evaluate the influence of corneal tomographic and biomechanical indexes on the refractive technique indication. A total of 251 eyes from 251 patients interested in refractive surgery were enrolled in this cross-sectional and multicenter study. Previous to the surgeon decision, a preoperative protocol was performed by refractive optometrists, containing four sections: refraction, biometry, corneal tomography and biomechanics. The refractive surgeons made a first decision based only on refraction, biometric and tomographic information. Biomechanical indexes were revealed, and refractive surgeons made a second indication. Additionally, for Laser-Assisted in-situ Keratomileusis cases, the percent tissue altered were calculated. Possible indications were no refractive surgery, photorefractive keratectomy, Laser-Assisted in-situ Keratomileusis or intraocular Collamer lens. After the first surgery indication, the distribution was photorefractive keratectomy (47.4%), Laser-Assisted in-situ Keratomileusis (48.2%) while intraocular Collamer lens achieved 2.8%. This proportion changed significantly after the second indication regarding corneal biomechanics and photorefractive keratectomy and Laser-Assisted in-situ Keratomileusis decreased by 24% while intraocular Collamer lens increased 19%. A total of 69 eyes changed the indication (27.5%) and 182 eyes (72.5%) remained unchanged. All indications changes were from photorefractive keratectomy or Laser-Assisted in-situ Keratomileusis to intraocular Collamer lens or no surgery. Indication changes to intraocular Collamer lens were observed in 49 eyes (71%). Tomographic, biomechanical indexes, ablation depth and percent tissue altered achieved statistically significant differences between eyes without and with indication changes (all, P < .01). New corneal biomechanical indexes could change the indication decision regarding biometric and tomographic data alone. Intraocular Collamer len was the preferred indication for eyes at risk of ectasia or with subclinical keratoconus due to corneal biomechanical parameters.

Recommendations for outpatient activity in COVID-19 pandemic.

The spread of the COVID-19 disease substantially influenced the International Healthcare system, and the national governments worldwide had before long to decide how to manage the available resources, giving priority to the treatment of the COVID-infected patients. Then, in many countries, it was decided to limit the elective procedures to surgical oncology and emergency procedures. In fact, most of the routine, middle-low complexity surgical interventions were reduced, and the day surgery (DS) activities were almost totally interrupted. As a result of this approach, the waiting list of these patients has significantly increased. In the current phase, with a significant decrease in the incidence of COVID-19 cases, the surgical daily activity can be safely and effectively restarted. Adjustments are mandatory to resume the DS activity. The whole separation of pathways with respect to the long-stay and emergency surgery, an accurate preoperative protocol of patient management, with a proper selection and screening of all-day cases, careful scheduling of surgical organization in the operating room, and planning of the postoperative pathway are the goals for a feasible, safe, and effective resumption of DS activity.

Adhesive Taping Shows Better Cosmetic Outcomes Than Tissue Adhesives for Sutured Upper Extremity Incisions: A Single-Blind Prospective Randomized Controlled Trial.

Adhesive taping is commonly used to reinforce wound closure and approximate minor lacerations. Recently, tissue adhesives such as 2-octylcyanoacrylate have gained popularity because of their high tensile strength, bacteriostatic properties, and spontaneous peeling. We sought to evaluate the cosmetic result of upper extremity incisions closed primarily by subcuticular suture, randomizing the application of tissue adhesive vs adhesive taping to different halves of the same surgical incision. Subjects were recruited from patients undergoing common procedures at the senior surgeon's hand surgery clinic. After primary closure, we applied either quarter-inch adhesive tape or tissue adhesive to the proximal and distal aspects of the wounds, based on a preoperative randomization protocol. We assessed the scars at approximately 3 months (range, 2-5 months). Subjects completed a validated scar assessment questionnaire, and a blinded photograph was obtained to allow 2 independent surgeons to assess the scar. Mean age was 63 years (SD, 11.8 years; range, 21-88 years); 56% of patients were women, and 44% were men. Most of the incisions were open carpal tunnel release and thumb carpometacarpal arthroplasty (14 each). Adhesive taping showed a better overall mean score based on evaluation by the hand surgeons, a finding that was statistically significant. The greatest differences were observed between color and size, but no subcategories were significantly different. Patients reported nonstatistical, but slightly better overall cosmetic outcomes with adhesive taping rather than tissue adhesive. Adhesive strips provide a modest but significant improvement in cosmetic outcomes vs more expensive tissue adhesive. Future evaluation of closure methods that evaluate cost, speed of application, suture technique, and dressing will optimize scar appearance. [Orthopedics. 2022;45(1):e42-e46.].

Implementation of the pre-operative rehabilitation recovery protocol and its effect on the quality of recovery after colorectal surgeries.

Background:Patients’ recovery after surgery is the major concern for all perioperative clinicians. This study aims to minimize the side effects of peri-operative surgical stress and accelerate patients’ recovery of gastrointestinal (GI) function and quality of life after colorectal surgeries, an enhanced recovery protocol based on pre-operative rehabilitation was implemented and its effect was explored.Methods:A prospective randomized controlled clinical trial was conducted, patients were recruited from January 2018 to September 2019 in this study. Patients scheduled for elective colorectal surgeries were randomly allocated to receive either standardized enhanced recovery after surgery (S-ERAS) group or enhanced recovery after surgery based on pre-operative rehabilitation (group PR-ERAS). In the group PR-ERAS, on top of recommended peri-operative strategies for enhanced recovery, formatted rehabilitation exercises pre-operatively were carried out. The primary outcome was the quality of GI recovery measured with I-FEED scoring. Secondary outcomes were quality of life scores and strength of handgrip; the incidence of adverse events till 30 days post-operatively was also analyzed.Results:A total of 240 patients were scrutinized and 213 eligible patients were enrolled, who were randomly allocated to the group S-ERAS (n = 104) and group PR-ERAS (n = 109). The percentage of normal recovery graded by I-FEED scoring was higher in group PR-ERAS (79.0% vs. 64.3%, P < 0.050). The subscores of life ability and physical well-being at post-operative 72 h were significantly improved in the group PR-ERAS using quality of recovery score (QOR-40) questionnaire (P < 0.050). The strength of hand grip post-operatively was also improved in the group PR-ERAS (P < 0.050). The incidence of bowel-related and other adverse events was similar in both groups till 30 days post-operatively (P > 0.050).Conclusions:Peri-operative rehabilitation exercise might be another benevolent factor for early recovery of GI function and life of quality after colorectal surgery. Newer, more surgery-specific rehabilitation recovery protocol merits further exploration for these patients.Trial Registration:ChiCTR.org.cn, ChiCTR-ONRC-14005096

Preoperative weight loss is linked to improved mortality and leaks following elective bariatric surgery: an analysis of 548,597 patients from 2015-2018.

The effects of preoperative weight loss on bariatric surgery outcomes are still unclear, despite the practice being adopted by bariatric centers worldwide. Ongoing studies are needed for routine adoption of this practice given the multiple issues patients face with following difficult preoperative weight loss protocols. The aim of this study was to characterize the prevalence of preoperative weight loss and evaluate its impact on outcomes following elective bariatric surgery. This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015-2018. All primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) procedures were included, whereas prior revisional surgeries and emergency surgeries were excluded. Cases were then divided into preoperative weight loss (PWL) and control cohorts. PWL was defined categorically if the highest 30-day preoperative weight was greater than the closest recorded weight before surgery. Primary outcomes included identifying the impact of PWL on postoperative complications. Multivariable logistic regression modelling was used to examine the influence of PWL on serious complications and mortality after adjusting for patient co-morbidities and procedure type. A total of 548,597 patients were identified with the majority experiencing preoperative weight loss (n= 459,500; 83.8%). The PWL cohort was older (44.8 ± 12.0 versus 43.2 ± 11.9 yr), had a reduced body mass index (BMI) (45.0 ± 7.4 versus 46.1 ± 7.6 kg/m2), and was more likely to be male (20.3% versus 18.7%). Patients with preoperative weight loss also were more likely to have metabolic co-morbidities including medication and insulin-dependent diabetes (27.0% versus 23.2%), hypertension (HTN) (48.9% versus 44.7%), dyslipidemia (DLP ) (24.6% versus 21.0%), and sleep apnea (39.6% versus 32.3%). No clinically significant differences were observed for operative length between cohorts (85.3 ± 46.9 min PWL versus 83.9 ± 46.2 min control). The protective benefit was found to be most significant for patients experiencing greatest weight loss with those experiencing a >10% PWL showing 30% decreased odds of leak (OR .68%; 95% CI [confidence interval] .56-.84; P < .0001) and a 40% decrease in odds of mortality versus those with no PWL (OR .60; 95% CI .39-.92; P = .02). Preoperative weight loss before bariatric surgery is common, occurring in >80% of elective cases. Our findings suggest that preoperative weight loss is associated with improved odds of 30-day mortality and leaks but no differences in bleeds or overall serious complications. Additional prospective trials are needed to further evaluate the role of routine PWL in addition to ongoing development of tolerable preoperative weight-loss protocols.

Preoperative Elemental Diet before Laparoscopic Anterior Resection in Patients with Advanced Stenotic Rectal Cancer.

Objectives: To evaluate the feasibility of our new preoperative enteral nutrition protocol using ElentalⓇ without mechanical bowel preparation (MBP) before laparoscopic anterior resection (LAR) in patients with advanced stenotic rectal cancer. Methods: Among 74 patients with advanced rectal cancer (clinical stages T3 and T4) scheduled to undergo LAR, 42 patients with stenotic rectal cancer were administered ElentalⓇ (900 kcal/day) without MBP before LAR (group S). Thirty-two patients without stenosis (group NS) did not receive preoperative nutritional support but underwent MBP. Results: Group S patients were maintained in a fasting state and received an elemental diet approximately 10 days preoperatively without severe adverse effects. The incidence of postoperative complications (Clavien-Dindo classification ≥ grade 2) was significantly lower in group S than that in group NS (adjusted odds ratio [OR]: 6.046, P = 0.008). Logistic regression analysis revealed that group NS exhibited higher risks of developing postoperative complications than those exhibited by group S (OR: 4.32, 95% confidence interval [CI]: 1.28-17.28, P = 0.018). Among preoperative characteristics, the clinical tumor stage indicated a significant intergroup difference. Thus, the clinical stage was selected as a covariate and adjusted in the logistic regression model to calculate a covariate-adjusted OR. Group NS exhibited a higher incidence of postoperative complications than group S (adjusted OR: 6.05, 95% CI: 1.58-28.35, P = 0.008). Conclusions: Administration of an elemental diet using ElentalⓇ without MBP before LAR is a feasible strategy in patients with advanced stenotic rectal cancer. Application of this research may encourage use of ElentalⓇ in the clinical setting.

Preoperative multimodal protocol reduced postoperative nausea and vomiting in patients undergoing mastectomy with reconstruction

Mastectomy with immediate reconstruction is a high-risk cohort for postoperative nausea and vomiting (PONV). Known risk factors for PONV include female gender, prior PONV history, nonsmoker, age < 50, and postoperative opioid exposure. The objective of this observational, cohort analysis was to determine whether a standardized preoperative protocol with nonopioid and anti-nausea multimodal medications would reduce the odds of PONV.After IRB approval, retrospective data were collected for patients undergoing mastectomy with or without a nodal resection, and immediate subpectoral tissue expander or implant reconstruction. Patients were grouped based on treatment: those receiving the protocol - oral acetaminophen, pregabalin, celecoxib, and transdermal scopolamine (APCS); those receiving none (NONE), and those receiving partial protocol (OTHER). Logistic regression models were used to compare PONV among treatment groups, adjusting for patient and procedural variables.Among 305 cases, the mean age was 47 years (21-74), with 64% undergoing a bilateral procedure and 85% having had a concomitant nodal procedure. A total of 44.6% received APCS, 30.8% received OTHER, and 24.6% received NONE. The APCS group had the lowest rate of PONV (40%), followed by OTHER (47%), and NONE (59%). Adjusting for known preoperative variables, the odds of PONV were significantly lower in the APCS group versus the NONE group (OR=0.42, 95% CI: 0.20, 0.88 p = 0.016).Premedication with a relatively inexpensive combination of oral non-opioids and an anti-nausea medication was associated with a significant reduction in PONV in a high-risk cohort. Use of a standardized protocol can lead to improved care while optimizing the patient experience.

Targeting Coping to Improve Surgical Outcomes in Pediatric Patients With Median Arcuate Ligament Syndrome: Feasibility Study.

Background: Median arcuate ligament syndrome (MALS) is a vascular compression syndrome leading to postprandial epigastric pain, nausea, and weight loss; it can be treated surgically. While most patients report improved quality of life following surgical intervention, 30% continue to experience chronic abdominal pain. Pre-surgical diagnoses of depression and/or anxiety have been found to significantly predict post-surgical: quality of life, highest experience of pain, anxiety, and parent- and self-reported coping strategies. As such, increasing the coping strategies of pediatric patients with MALS may impact their post-surgical outcomes. The purpose of the current study was to: (1) implement a pre-operative cognitive behavioral therapy protocol with a focus on psychoeducation and coping strategies; and (2) determine feasibility of a pre-surgical intervention for this population.Method: Children (<18 years of age) with a diagnosis of MALS who were eligible for surgical intervention were invited to participate in a 7-week in-person or video-based pre-surgical cognitive behavioral therapy intervention. Psychiatric comorbidities were assessed at baseline and post-surgery; patient-reported distress, pain interference and intensity, health-related quality of life, and health status were assessed at four time points (baseline, week 4, week 7, and post-surgery). Descriptive analyses were used to characterize the sample, assess feasibility outcomes (i.e., attrition rates), and explore symptom-based outcomes across time.Results: Twelve pediatric patients (M age = 15.2 ± 1.7; 91.7% female) and their parents (91.7% mothers) participated. Feasibility metrics based on protocol completion were exceeded for engagement at the stages of consent (68.4% vs. goal of ≥50%), treatment initiation (92.3% vs. 85%), and treatment completion (84.6% vs. 75%). Out of the 12 participants, nine (75%) met criteria for at least one comorbid psychiatric diagnosis at baseline and nine (75%) elected to undergo MALS surgery after completing the intervention.Conclusion: The intervention implementation was feasible, despite chronic pain symptoms experienced by the sample, a high prevalence of psychiatric diagnoses, and an international pandemic, suggesting that it would be beneficial to further evaluate the efficacy of the intervention. Future research should include stakeholder input in the design, deployment, and evaluation of a pilot efficacy trial of pre-surgical cognitive behavioral therapy for pediatric patients with MALS.

Preoperative SARS-CoV-2 Screening Fails to Detect Viral Particles Prior to Airway Surgery.

Objectives/HypothesisChildren have higher rates of asymptomatic SARS‐CoV‐2 infections or milder courses of infection, and their carrier status may potentially impact viral transmission to those providing them care. The aim of this study is to compare the existing COVID‐19 preoperative screening protocols to the detection of SARS‐CoV‐2 viral particles in surgical samples.Study DesignCross‐sectional study.MethodsWe conducted a prospective study with consecutive convenience sampling of children undergoing adenoidectomy between January and April 2021. Total nucleic acid was extracted from adenoid tissue and real‐time reverse transcription‐polymerase chain reaction was conducted to test for the presence of SARS‐CoV‐2 viral particles. Univariate logistic regression was used to summarize the effect size of variables of interest on the odds of having SARS‐CoV‐2 positive adenoid tissue.ResultsForty adenoid samples were collected and 11 (27.5%) had a positive SARS‐CoV‐2 reverse transcriptase‐polymerase chain reaction. Patients with positive adenoids were older (11.8 vs. 7.9 years, odds ratio: 1.3, P = .01) and more likely to have had a positive nasopharyngeal swab in the previous 90 days (4/11 or 36% vs. 0).ConclusionThese data are the first report on the presence of SARS‐CoV‐2 particles in pediatric adenoidectomy specimens, with a high percentage of patients showing evidence of viral particles within the adenoid. This finding calls in to question the utility of preoperative COVID screening protocols which have yet to be rigorously validated in asymptomatic patients and have the potential to delay patients' surgical care.Level of Evidence3 Laryngoscope, 2021

Small incision lenticule extraction (SMILE) refractive surgery: Our initial experience

BackgroundSmall incision lenticule extraction (SMILE) is femtosecond laser based, minimally invasive, flap-free refractive surgery gaining worldwide acceptance as a safe alternative to flap based refractive surgeries. MethodsA retrospective data review study was done where preoperative and postoperative data were collected for 202 eyes of 101 patients who underwent SMILE surgery at a tertiary care Armed Forces hospital from Jan 2019 to Dec 2019. All participants included in the study were followed up for 3 months postoperative period. ResultsMean age of the participants was 24.139 ± 0.515 years (males 22.1 years, females 25.3 years). Male participants were 36 (72 eyes) while female participants were 65 (130 eyes). Of the participants, 75.2% underwent the procedure for cosmetic indication, while 24.8% underwent clearing some medical examination later. Preoperative UCVA was 1.049 ± 0.028 logMAR units, which improved on first postoperative day to 0.038 ± 0.01 logMAR units, at 1 wk 0.015 ± 0.01 logMAR units, at 1 month 0.006 ± 0.005 logMAR units and at 3 months postoperative period to 0.03 ± 0.003 logMAR units. There were two adverse events of difficult lenticule extraction with small (<1 mm) cap tear. ConclusionSMILE surgery is a flap-free refractive surgical technique. It reduces postoperative complications like dry eyes and flap-related complications. Hence, it may be recommended for all serving personnel after a thorough preoperative screening protocol.

922 Pre-Operative Chest X-Ray Prior To Aneurysm Surgery Is Unnecessary

Abstract Aim Over 4100 elective abdominal aortic aneurysm (AAA) cases are performed each year in the UK. In our tertiary centre the anaesthetic pre-operative protocol for these patients includes a chest x-ray (CXR), because some risk factors for aneurysmal disease (smoking, older age) cross over with those for lung cancer. This study was performed to see if the CXR changed management in AAA patients. Method A retrospective radiology review of 191 consecutive patients who had an elective AAA repair at one unit in 2017-2018 was carried out. Computed tomography angiogram (CTA) and CXR findings were compared. Where an abnormality was reported, patient records were reviewed and the impact of the abnormal result on the patient journey assessed. Results Of 191 patients, 148 had pre-op CXRs. Of the CXRs, 60 reported abnormalities, most of which were minor (cardiomegaly, atelectasis, reticular shadowing). Of the 60, 28 had no lung abnormalities on CTA, 18 had not had a reported CTA, 8 corresponded with the CTA and 6 had a different chest abnormality reported on the CTA. 2 patients had CTs of the chest following CXR findings and no patients had an operation cancelled or delayed due to findings on CXR. Conclusions Each CXR costs around £20 including reporting and administration time. In addition, there is inconvenience to the patient and additional radiation dose. None of the pre-operative CXRs resulted in a change to patient operative management therefore the requirement for pre-operative CXR was removed from the units’ protocol.

Effect of Pre-operative Nutritional Protocol Implementation on Postoperative Outcomes Following Gastrointestinal Surgeries: A Randomized Clinical Trial.

Introduction: A significant proportion of patients undergoing major gastrointestinal operations suffer from malnutrition. Although the benefit of postoperative nutritional support is well established, the effects of energy intake during pre-operative period is less reported. The present study was designed to test the effect of structured pre-operative nutritional therapy on the postoperative recovery of patients undergoing major gastrointestinal operations. Methods: A randomized clinical trial was conducted among 80 patients of the surgical gastroenterology department of a tertiary care center in south India. A simple random sampling method was used. The nutritional status of all participants was assessed by subjective global assessment (SGA). While control group received standard energy intake nutrition, the experimental group received calculated nutrition with an extra 50 g of soy protein for seven days pre operatively. Data were analysed using SPSS version 20. Results: The median day of removal of abdominal drainage tube was 3 (0-5) compared to 5 (2.5-7.5) in the control group. In the intervention group, the median time for the appearance of bowel sounds and starting of enteral feeding was 1.1 (0.5) days and 2 (1-2) days, while in the control group, it was 1.6 (0.9) days, 3 (1-4) days, respectively which was significant at P < 0.05. Similarly, the mean (SD) postoperative serum albumin on third day was 3.6 (0.4) g/dL vs 3.4 (0.4) g/dL experimental and in the control group. Conclusion: Preoperative nutrition protocol improved the patients’ clinical outcomes in terms of post-operative serum albumin, the timing of bowel sounds, and early initiation of enteral feeds.

Desensitization Regimen Consisting of High-Dose Intravenous Immunoglobulin, Plasmapheresis, and Rituximab (an Anti-CD20 Antibody), Without Eculizumab and/or Bortezomib, in 41 Highly Sensitized Kidney Transplant Recipients.

Antibody-mediated rejection in patients with positive crossmatches can be severe and result in sudden onset of oliguria, leading to graft loss. In an attempt to prevent posttransplant oliguria, we adopted a preoperative desensitization protocol involving the use of high-dose intravenous immunoglobulin/plasmapheresis and the anti-CD20 antibody, rituximab, in 41 transplant recipients with positive crossmatch test results. We retrospectively examined the clinical courses of the 41 kidney transplant recipients, paying special attention to renal graft function, urine volume, and changes in the titers of donor-specific antibodies. Four grafts were lost during an average of 4.5-year follow-up. Average graft function was excellent, with a serum creatinine level of 1.3 ± 0.4 mg/dL. Sufficient urine output, with no oliguria or anuria, was achieved postoperatively in 40 of the 41 patients. However, among the 34 patients who underwent graft biopsies, the biopsies revealed acute antibody-mediated rejection in 21 patients (62%), and chronic antibodymediated rejection in 10 patients (30%). The high-dose intravenous immunoglobulin treatment included in our desensitization protocol was shown to be safe and effective for achieving successful transplant outcomes and allowed the avoidance of more aggressive B-cell-targeted treatments, such as C5 inhibitors and/or proteosome inhibitors, for preventing posttransplant oliguria and anuria.

PD40-05 NEOADJUVANT IMMUNOTHERAPY IN PATIENTS WITH RENAL CELL CARCINOMA UNDERGOING NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Advanced (including Drug Therapy) II (PD40)1 Sep 2021PD40-05 NEOADJUVANT IMMUNOTHERAPY IN PATIENTS WITH RENAL CELL CARCINOMA UNDERGOING NEPHRECTOMY Kyrollis Attalla, Maria Carlo, Sounak Gupta, Sujata Patil, Devon Coskey, Samuel Murray, Ritesh Kotecha, Jonathan Coleman, Robert Motzer, Yingbei Chen, Jeremy Durack, Paul Russo, A Ari Hakimi, and Martin Voss Kyrollis AttallaKyrollis Attalla More articles by this author , Maria CarloMaria Carlo More articles by this author , Sounak GuptaSounak Gupta More articles by this author , Sujata PatilSujata Patil More articles by this author , Devon CoskeyDevon Coskey More articles by this author , Samuel MurraySamuel Murray More articles by this author , Ritesh KotechaRitesh Kotecha More articles by this author , Jonathan ColemanJonathan Coleman More articles by this author , Robert MotzerRobert Motzer More articles by this author , Yingbei ChenYingbei Chen More articles by this author , Jeremy DurackJeremy Durack More articles by this author , Paul RussoPaul Russo More articles by this author , A Ari HakimiA Ari Hakimi More articles by this author , and Martin VossMartin Voss More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002050.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Immune checkpoint inhibitor (ICI) therapy improves survival in patients with advanced renal cell carcinoma (RCC), but has not been studied preoperatively in patients with localized RCC who may be at high risk of recurrence, or in patients with metastatic disease who are candidates for cytoreductive nephrectomy. We evaluate the safety and feasibility of neoadjuvant immunotherapy in patients with localized, high-risk RCC. METHODS: Single institution pilot study of neoadjuvant nivolumab in patients with localized, high-risk RCC undergoing nephrectomy. Patients were eligible if their risk of metastatic recurrence within the first 12 years was >20% by nomogram. Nivolumab was administered every 2 weeks for 4 treatments, with a follow-up renal MRI prior to nephrectomy. In addition, we retrospectively assessed a separate cohort of 21 patients with metastatic disease who received preoperative ICI off protocol. RESULTS: In the prospective study cohort, 18 patients (11 men; median age 60) with clear cell RCC were enrolled. All received at least 1 dose of nivolumab; 16/18 patients completed all doses. Two patients had nivolumab discontinued for immune-related adverse events, including grade 3 transaminitis (1) and grade 2 arthralgias (1). All patients had stable disease as the best response prior to surgery. 17/18 (94%) patients completed at least 3 doses and had nephrectomy without delay. 4 patients had surgical complications per Clavien-Dindo classification, including 2 patients with Grade IIIa chylous ascites after lymphadenectomy. The metastatic cohort included 20 patients with ccRCC and one with epithelioid AML. 15 patients received ipilimumab+nivolumab, 6 received single-agent PD-1 or PD-L1 inhibitors. 3 (14%) patients achieved a near or complete pathologic response, including a patient with epithelioid AML. No patient experienced a major intraoperative complication or 30- or 90-day mortality, and one patient was readmitted for pneumonia, metastatic bronchial occlusions requiring bronchoscopy and eventual intubation (Clavien 4a). 5 patients experienced grade 3 or 4 irAEs. CONCLUSIONS: In a pilot study of nivolumab prior to nephrectomy in patients with localized RCC, the approach appeared safe and feasible with no surgical delays and expected rate of immune related adverse events. A retrospective review of patients with metastatic disease who underwent cytoreductive nephrectomy after ICI showed favorable surgical outcomes, with an association of combination CTLA-4 and PD-1 inhibitor with higher grade irAE and pathologic complete responses. Source of Funding: This work was funded in part through the National Institute of Health (NIH)’s Cancer Therapy Evaluation Program (CTEP), and the NIH/NCI Cancer Center Support Grant P30 CA008748 © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e675-e676 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyrollis Attalla More articles by this author Maria Carlo More articles by this author Sounak Gupta More articles by this author Sujata Patil More articles by this author Devon Coskey More articles by this author Samuel Murray More articles by this author Ritesh Kotecha More articles by this author Jonathan Coleman More articles by this author Robert Motzer More articles by this author Yingbei Chen More articles by this author Jeremy Durack More articles by this author Paul Russo More articles by this author A Ari Hakimi More articles by this author Martin Voss More articles by this author Expand All Advertisement Loading ...

Risk factors for major complications after liver resection: A large liver resection study from Morocco and audit of a non-Eastern/non-Western experience

Background and Study AimsIn developing countries, endemic indications, blood shortages, and the scarcity of liver surgeons and intensive care providers can affect liver resection (LR) outcomes, but these have been rarely addressed in the literature. Therefore, in this study we determined risk factors for major complications after LR in a North African general surgery and teaching department. Patients and MethodsFrom January 2010 to December 2015, 213 consecutive LRs were performed on 203 patients. All patients underwent a postoperative follow-up of >90 days. Postoperative complications were assessed according to the Clavien–Dindo (CD) classification of surgical complications. A score of CD ≥III is considered as major postoperative complications. In this study, we analyzed the variables assumed to affect these complications. ResultsThe overall 90-day complication rate was 35.7% (n = 76), including a CD ≥III of 14% (n = 30) and a mortality rate of 6.1% (n = 14). According to the multivariate analysis, a preoperative performance status (PS) of ≥2 (P = 0.011; odds ratios [OR], 6.8; 95% confidence intervals [CI], 1.55–29.8), an estimated intraoperative blood loss of >500 ml (P = 0.002; OR, 3.71; 95% CI, 1.23–11.20), and bilioenteric anastomosis (P < 0.004; OR, 7.76; 95% CI, 1.5–3.89) were independent risk factors for major complications after LR. ConclusionWe recommend that, in the setting of a non-Eastern/non-Western general surgery and teaching department, patients with a PS of ≥2 should undergo a specific selection and preoperative optimization protocol; intermittent clamping indications should be extended; and special attention should paid to patients undergoing LR associated with biliary reconstruction, such as for perihilar cholangiocarcinoma.

Predicting the histological invasiveness of pulmonary adenocarcinoma manifesting as persistent pure ground-glass nodules by ultra-high-resolution CT target scanning in the lateral or oblique body position.

Ultra-high-resolution computed tomography (U-HRCT) has improved image quality for displaying the detailed characteristics of disease states and lung anatomy. The purpose of this study was to retrospectively examine whether U-HRCT target scanning in the lateral or oblique body position (protocol G scan) could predict histological invasiveness of pulmonary adenocarcinoma manifesting as pure ground-glass nodules (pGGNs). From January 2015 to December 2016, 260 patients with 306 pathologically confirmed pGGNs who underwent preoperative protocol G scans were retrospectively reviewed and analyzed. The U-HRCT findings of preinvasive lesions [atypical adenomatous hyperplasias (AAH) and adenocarcinomas in situ (AIS)] and invasive pulmonary adenocarcinomas [minimally invasive adenocarcinomas (MIA) and invasive adenocarcinomas (IAC)] were manually compared and analyzed using orthogonal multiplanar reformation (MPR) images. The logistic regression model was established to determine variables that could predict the invasiveness of pGGNs. Receiver operating characteristic (ROC) curve analysis was performed to evaluate their diagnostic performance. There were 213 preinvasive lesions (59 AAHs and 154 AISs) and 93 invasive pulmonary adenocarcinomas (53 MIAs and 40 IACs). Compared with the preinvasive lesions, invasive adenocarcinomas exhibited a larger diameter (13.5 vs. 9.3 mm, P=0.000), higher mean attenuation (-571 vs. -613 HU, P=0.002), higher representative attenuation (-475 vs. -547 HU, P=0.000), lower relative attenuation (-339 vs. -292 HU, P=0.000) and greater frequencies of heterogeneity (P=0.001), air bronchogram (P=0.000), bubble lucency (P=0.000), and pleural indentation (P=0.000). Multiple logistic analysis revealed that larger diameter [odds ratio (OR), 1.328; 95% CI: 1.208-1.461; P=0.000] and higher representative attenuation (OR, 1.005; 95% CI: 1.003-1.007; P=0.000) were significant predictive factors of invasive pulmonary adenocarcinomas from preinvasive lesions. The optimal cut-off value of the maximum diameter for invasive pulmonary adenocarcinomas was larger than 10 mm (sensitivity, 66.7%; specificity, 72.8%). The imaging features based on protocol G scanning can effectively help predict the histological invasiveness of pGGNs. The maximum diameter and representative attenuation are important parameters for predicting invasiveness.