Preoperative Protocol Research Articles

Preventive treatment of unruptured intracranial aneurysms in adult patients with sickle cell anemia: A cohort study

Background and PurposeIntracranial aneurysms are frequent in patients with sickle cell anemia, while subarachnoid hemorrhage is a major cause of death and disability in young adult patients. Several characteristics, such as younger age and smaller size at rupture, may incline therapeutic decision towards exclusion treatments. Clinical guidelines on treatment of unruptured intracranial aneurysms in this population are still missing. We aimed to assess the safety and efficacy of the treatment of unruptured intracranial aneurysm in patients with sickle cell anemia, using an adapted hematological preparation regimen. Patients and MethodsAdult patients with sickle cell anemia and treated unruptured aneurysms by endovascular therapy or neurosurgery were included in this retrospective cohort study. Treatment decision was reached after multi-disciplinary assessment. A pre-operative blood transfusion protocol was undertaken targeting a HbS below 30%. Demographic data, hematological preparation parameters and clinical and radiological outcomes were documented. Results and ConclusionsTwenty-five procedures were performed in 18 patients encompassing 19 aneurysms treated by embolization and 6 by surgery. Median age at treatment was 34 years-old and median aneurysm dome size was 4.4 mm. Immediate aneurysm exclusion rate was 85.7% after endovascular therapy and 100% after neurosurgery. Median follow-up was 6 months, with all patients being asymptomatic at last follow-up. Two transitory ischemic neurological deficits, as well as four cases of iodine-induced encephalopathy were identified after embolization. No complication occurred after surgery.Endovascular therapy by coiling and neurosurgical treatment of unruptured intracranial aneurysms appears to be safe in patients with sickle cell anemia and should be considered given the specific hemorrhagic risk observed in this population. A rigorous hematological preparation, associated with a dedicated peri‑operative protocol and an adequate therapeutic strategy are essential prerequisites.

High-resolution MR imaging with gadoxetate disodium for the comprehensive evaluation of potential living liver donors.

Several major transplantation centers have used composite multimodality evaluation for the preoperative evaluation of potential living liver donors. This approach can be time-consuming and, although rare, can cause complications. We aimed to demonstrate the clinical feasibility of our comprehensive preoperative MR protocol for the preoperative assessment of living liver donor candidates instead of composite multimodality evaluation. Thirty-five consecutive living liver donor candidates underwent multiphasic liver CT and comprehensive donor protocol MR examinations for preoperative evaluation in a single large-volume liver transplantation (LT) center. Three blinded abdominal radiologists reviewed the CT and MR images for vascular and biliary variations. The strength of agreement between CT and MR angiography was assessed using the kappa index. The detection rate of biliary anatomical variations was calculated. The sensitivity and specificity for detecting significant steatosis (>5%) were calculated. The estimated total volume and right lobe volumes measured by MR volumetry were compared with the corresponding CT volumetry measurements using the intraclass correlation coefficient (ICC). Among the 35 patients, 26 underwent LT. The measurement of agreement showed a moderate to substantial agreement between CT and MR angiography interpretations (kappa values, 0.47-0.79; p < 0.001). Combining T2-weighted and T1-weighted MR cholangiography techniques detected all biliary anatomical variations in 9 of the 26 patients. MR-proton density fat fraction showed a sensitivity of 100% (3/3) and a specificity of 91.3% (21/23) for detecting pathologically determined steatosis (>5%). MR volumetry reached an excellent agreement with CT volumetry (reviewers 1 and 2: ICC, 0.92; 95% CI, 0.84-0.96). Our one-stop comprehensive liver donor MR imaging protocol can provide complete information regarding hepatic vascular and biliary anatomies, hepatic parenchymal quality, and liver volume for living liver donor candidates and can replace composite multimodality evaluation.

Validation of a Suggested Pre-Operative Protocol for the Prevention of Traumatic Dental Injuries during Oroendotracheal Intubation: A Pilot Study

The aim of this study was to develop a protocol for oral pre-operative registration and dental risk assessment by the anaesthesiologist, determining its reliability through the inter-observer agreement between a senior dental student and an internal physician specializing in anaesthesiology. A convenience sample consisting of 35 patients was selected. These were observed during the anaesthesiology consultation, at Hospital de São João, Porto, Portugal. The protocol included a self-administered questionnaire and a brief clinical examination by the two observers. A descriptive analysis (qualitative and quantitative variables) was performed. The Fleiss Kappa index was used to measure the degree of agreement between the two observers. In most of the parameters defined, the agreement presented Kappa index values between 0.6 and 1, corresponding to good and excellent correlation, respectively. The general oral status was considered “poor”, with a great number of missing teeth, namely the upper central and lateral incisors. The proposed pre-anaesthetic protocol can be a reliable tool for the anaesthesiologists, which suggests the relevancy of incorporating interdisciplinary training between future health professionals. Further research is needed to assess its implementation, providing information about the pre-operative oral status, preventing intraoperative damage and potential medicolegal litigation.

DETERMINATION OF PREOPERATIVE RISK FACTORS FOR ILIOPSOAS TENDONITIS

Iliopsoas impingement occurs in between 5-30% of patients after hip arthroplasty and has been thought to only be caused by an oversized cup, cup malpositioning, or the depth of the psoas valley. However, no study has associated the relationship between preoperative measurements with the risk of impingement. This study sought to assess impingement between the iliopsoas and acetabular cup using a novel validated model to determine the risk factors for iliopsoas impingement.413 patients received lower limb CT scans and lateral x-rays that were segmented, landmarked, and measured using a validated preoperative planning protocol. Implants were positioned according to the preference of ten experienced surgeons. The segmented bones were transformed to the standing reference frame and simulated with a novel computational model that detects impingement between the iliopsoas and acetabular cup. Definitions of patients at-risk and not at-risk of impingement were defined from a previous validation study of the simulation. At-risk patients were propensity score matched to not at-risk patients.21% of patients were assessed as being at-risk of iliopsoas impingement. Significant differences between at-risk patients and not at-risk patients were observed in standing pelvic tilt (p &lt;&lt; 0.01), standing femoral internal rotation (p &lt;&lt; 0.01), medio-lateral centre-of-rotation (COR) change (p &lt;&lt; 0.01), supine cup anteversion (p &lt;&lt; 0.01), pre- to postoperative cup offset change (p &lt;&lt; 0.001), postoperative gross offset (p = 0.009), and supero-inferior COR change (p = 0.02).Impingement between the iliopsoas and acetabular cup is under-studied and may be more common than is published in the literature. Previously it has been thought to only be related to cup size or positioning. However, we have observed significant differences between at-risk and not at-risk patients in additional measurements. This indicates that its occurrence is more complex than simply being related to cup position.

Deliberate Compensated Vasoplegia-A Novel Pharmaceutical Approach for Controlling Blood Pressure During Surgery for Pheochromocytoma.

The most dreaded adverse event of pheochromocytoma surgery is operative severe blood pressure fluctuations. Preoperative protocols with alpha-blockade have achieved controversial results. No study to date evaluated the use of operative protocols in pheochromocytoma patients. Deliberated compensated vasoplegia (DCV) is a novel pharmaceutical regimen developed at our institution to decrease severe hypertensive events. The aim of this study is to compare outcomes of pheochromocytoma resection with and without DCV protocol. A retrospective analysis of all pheochromocytoma resections between the years 2012 and 2021 was performed. Resections performed with and without DCV protocol were compared. The primary outcome measured was the incidence of severe hypertension (MAP > 150mmHg) during surgery. Secondary outcomes included other abnormal blood pressure measurements as well as perioperative data and complications. A total of 41 resections were included, 21 performed under DCV protocol, and 20 without the protocol. Analysis demonstrated no significant difference in preoperative parameters including tumor size, catecholamine levels, and preoperative alpha-blockade protocol. The use of DCV protocol resulted in significant decrease in severe hypertension incidence from 1.95 ± 3.6 to 0.03 ± 0.13 events/h, p = 0.008. Application of the DCV protocol was not associated with any other adverse events. This study suggests that DCV anesthesia protocol significantly decreases the incidence of severe hypertensive episodes during pheochromocytoma resection. This is the first study that describes a highly effective protocol for controlling hypertension in pheochromocytoma patients.

Determining a preoperative international normalised ratio threshold safe for hip fracture surgery.

The purpose of this study was first, to assess the relationship between preoperative INR (international normalised ratio) and postoperative complication rates in patients with a hip fracture, and second, to establish a threshold for INR below which the risk of complications is comparable to those in patients with a normal INR. We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and found 35,910 cases who had undergone surgery for a hip fracture between 2012 and 2018. Cases were stratified into 4 groups based on their preoperative INR levels: <1.4; ⩾1.4 and <1.6; ⩾1.6 and <1.8 and ⩾1.8. These cohorts were assessed for differences in preoperative factors, intraoperative factors, and postoperative course. Multivariate logistic regression was used to assess the risk of transfusion, 30-day mortality, cardiac complications, and wound complications adjusting for all preoperative and intraoperative factors. Of the 35,910 cases, 33,484 (93.2%) had a preoperative INR < 1.4; 867 (2.4%) an INR ⩾1.4 and <1.6; 865 (2.4%) an INR ⩾ 1.6 and <1.8 and 692 (1.9%) an INR ⩾ 1.8. A preoperative INR ⩾ 1.8 was independently associated with an increased risk of bleeding requiring transfusion. A preoperative INR ⩾ 1.6 was associated with an increased risk of mortality. We found that an INR of <1.6 is a safe value for patients who are to undergo surgery for a hip fracture. Below this value, patients avoid an increased risk of both transfusion and 30-day mortality seen with higher INR values. These findings may allow adjustment of preoperative protocols and improve the outcome of hip fracture surgery in this group of patients.

Deferring gonadectomy in patients with turner syndrome with a genetic Y component is not a safe practice

Patients with Turner syndrome who harbor Y chromosome material are known to be at increased risk of developing germ cell neoplasms. The optimal timing to perform gonadectomy to reduce the risk of cancer development in these patients is not well defined. We present outcomes of Turner with a Y component (TSY) patients who underwent gonadectomy at our institution. We hypothesized that tumors could occur in a significant portion of TSY patients at any age and gonadectomy can be safely performed at diagnosis rather than deferred. We performed an IRB-approved retrospective single center study in which we queried our institutions electronic health record to identify all patients with TSY who underwent gonadectomy at our institution from 2012 to 2021. In our series of 18 consecutive TSY patients, a tumor was identified in 6 patients (33.3%): 4 (22.2%) with dysgerminoma (DG) [Fig.1] and 2 (11.1%) with gonadoblastoma (GB). Our cohort of 18 consecutive TSY who underwent gonadectomy over a 9-year period is the largest published single site cohort to date. Additionally, our patient who was found to have GB at 40 days is to our knowledge the youngest TSY patient to be diagnosed with GB in the literature. This patient's remarkably early incidence of tumor occurrence illustrates the urgency of protective gonadectomy. Given the high incidence of tumor formation in this population and the minimal morbidity associated with gonadectomy, we do not recommend delaying gonadectomy in this population for any reason. Our study is vulnerable to selection bias and confounding innate to any retrospective study. There was variation with respect to the frequency and timing of pre-operative imaging as a strict preoperative imaging protocol with sequential studies was not in place at our institution. Additionally, we do not have a comparison cohort of patients who are being followed without operative intervention as all TSY patients at our institution have undergone gonadectomy. TSY patients cannot be safely observed for tumor formation based on clinical factors such as imaging or age. Gonadectomy is safe with a low complication rate and without tumor recurrence during three-year follow-up. We continue to recommend bilateral gonadectomy in this patient population at the time of diagnosis.

Bone-Anchored Hearing Devices for Single-Sided Deafness: A New Preoperative Evaluation Protocol and Widening of Indications Proposal

Introduction: Bone-anchored hearing devices (BAHD) are well-known good solution for single-sided deafness (SSD). Despite power extension of recently introduced BAHD with implanted active transducer, with indications up to 65 dB Hl of bone conduction (BC) threshold on the implanted side, their indications for SSD still remain better than 25 dB on the good ear, with regards to bone conduction thresholds. The aim of this study was to assess the possibility to enlarge BAHD indications for SSD by means of a newly proposed candidacy evaluation protocol, which includes a new software-aided method. Methods: 20 SSD patients (mean age 56 years, 9 females, and 11 males) were divided into two groups: group A (10 patients, BC <25 dB Hl on the hearing side) and group B (10 patients, BC between 25 and 35 dB Hl). Recipients were submitted to bisyllabic words speech audiometry in silence and to authors’ newly proposed IFastSRT50 test by means of software which shift noise intensity of a single word list on the basis of correct recipient recognition responses. A sound speaker for signal (bisyllabic words) and noise (babble) was disposed at 1 m from the deaf side of the patient. An earphone covering only the good ear of the recipient was used in order to perform its air conduction masking with white noise. A BAHD test device was disposed on the mastoid of the deaf side. Both signal and masking intensities were set to 55 dB SPL in order to mask airway conduction on the good ear without masking its bone way interaural conduction from the BAHD tester. Results: With BAHD tester turned off, no recognition was detected. Speech audiometry with BAHD tester turned on revealed mean values of 92% for group A and 89% for group B, with a difference of 3.0% (χ² = 0.285 and p = 0.5935). As for IFastSRT50 with BAHD tester turned on, mean signal-to-noise ratio value to obtain 50% of recognition was −6.89 for group A and −6, with a difference of 0.89 (t = 1,201 and p = 0.2453). Conclusion: BAHD are confirmed to be a good solution for SSD cases. The absence of statistically significant differences in our two tested groups suggests that newer implanted active transducer device indications should be extended up to 35 dB Hl on the hearing ear. The IFastSRT50 is a reliable and quick method to enhance preoperative candidacy evaluation.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

Steep ramp test protocol for preoperative risk assessment and short-term high-intensity interval training to evaluate, improve, and monitor cardiorespiratory fitness in surgical oncology.

Promotion of a venous thromboembolism prevention protocol at a perioperative management center

Perioperative venous thromboembolism (VTE) is a potentially fatal complication, making preoperative VTE diagnosis and secondary thromboprophylaxis important. This study was performed to investigate the impact of promotion of a preoperative VTE protocol at a perioperative management center (PMC) on detecting the preoperative VTE rate and subsequent treatment. This retrospective study involved patients aged ≥20 years who underwent elective anesthesia. The patients were divided into two groups: the pre-PMC group (January to October 2014, before the opening of the PMC) and the post-PMC group (January to December 2019, after the opening of the PMC). The rates of preoperative lower-limb compression ultrasonography (CUS), VTE detection, anticoagulation therapy, and new postoperative pulmonary embolism (PE) were compared between the two groups. The pre-PMC and post-PMC groups comprised 3737 and 5388 patients, respectively. The preoperative CUS and VTE detection rates were significantly higher in the post-PMC than pre-PMC group (7.2% and 1.43% vs. 25.6% and 3.93%, respectively; P<0.001). There was no significant difference in the rate of anticoagulation therapy in patients with preoperative VTE (88.9% vs. 84.7%, P=0.43). Heparin and direct oral anticoagulants were primarily used in the pre-PMC and post-PMC groups, respectively. The efficacy and safety were comparable between the two groups. No new postoperative PE was detected in either group. Promotion of the preoperative VTE protocol led by the PMC increased the rates of preoperative CUS and preoperative VTE detection. This may aid in secondary thromboprophylaxis in the preoperative period and prevention of postoperative PE.

Effects of Preoperative Oral Carbohydrate Loading on Neutrophil/Lymphocyte Ratio and Postoperative Complications following Colorectal Cancer Surgery: A Randomized Controlled Study

Introduction: Preoperative carbohydrate oral (CHO) drinks attenuate the surgical stress response; however, the effects of CHO supplementation on the neutrophil-to-lymphocyte ratio (NLR) as an inflammatory and immunology-based predictor remain unclear. This study evaluated the effects of preoperative CHO loading on NLR values and complications following open colorectal surgery compared with a conventional fasting protocol. Methods: Sixty eligible participants having planned for routine and open colorectal cancer surgery from May 2020 to January 2022 were prospectively and randomly allocated to either the control (fasting) group, whose members discontinued oral intake beginning the midnight before surgery, or the intervention (CHO) group, whose members consumed a CHO solution the night before surgery and 2 h prior to anaesthesia. NLR was assessed at 06:00 h before surgery (baseline) and at 06:00 h on postoperative days 1, 3, and 5. The incidence and severity of postoperative complications were assessed by Clavien-Dindo Classification up to postoperative day 30. All data were analysed using descriptive statistics. Results: Postoperative NLR and delta NLR values were significantly higher in controls (p < 0.001; p < 0.001). Control group participants also demonstrated grade IV (n = 5; 16.7%, p < 0.01) and grade V (n = 1; 3.3%, p < 0.313) postoperative complications. There were no major postoperative complications in the CHO group. Conclusion: Preoperative CHO consumption reduced postoperative NLR values and the incidence and severity of postoperative complications following open colorectal surgery, compared with a preoperative fasting protocol. Preoperative carbohydrate loading may improve recovery following colorectal cancer surgery.

Multiple Renal Veins in Donor Nephrectomy-Preoperative Assessment of Feasibility for Safe and Selective Ligation

The aim of the study is to provide an objective preoperative assessment protocol by computerized tomography angiography by measuring the vein volume (pr2h) instead of the vein diameter for accurate size and blood flow assessment in case of multiple renal veins during donor nephrectomy. To reduce rewarm ischemia time, smaller renal veins were safely ligated without compromising drainage due to their robust intrarenal anastomotic communications. The selection of vein for safe ligation is crucial to avoid congestion and high intrarenal pressures in the allograft venous system and was made by calculating the vein volume. Application of this formula in 343 donors with multiple veins (2003–2021) has led to uneventful intra- and postoperative course. This method prevails over the existing subjective assessment techniques, thereby ensuring the best possible perfusion and drainage of the allograft.

Multi-parametric MRI without artificial erection for preoperative assessment of primary penile carcinoma: A pilot study on the correlation between imaging and histopathological findings

PurposeWe aimed to evaluate the diagnostic potential of non-erectile multi-parametric magnetic resonance imaging (mpMRI) for preoperative assessment of primary penile squamous cell carcinoma (SCC). MethodTwenty-five patients who underwent surgery for penile SCC were included. Preoperative mpMRI without artificial erection was performed in all patients. The preoperative MRI protocol consisted of high-resolution morphological and functional sequences (diffusion-weighted imaging and dynamic contrast-enhanced MRI perfusion) covering the penis and lower pelvis. T and N staging, according to the 8th edition of the Union for International Cancer Control TNM classification, as well as the largest diameter and thickness/infiltration depth of the primary lesions were determined in all patients. Imaging data were retrospectively collected and compared with the final histopathology reports. ResultsVery good agreement was observed between MRI and histopathology for the involvement of corpus spongiosum (p = 0.002) and good agreement was observed for the involvement of penile urethra and tunica albuginea/corpus cavernosum (p < 0.001 and p = 0.007, respectively). Good agreement was observed between MRI and histopathology for overall T staging and weaker, but still good agreement was observed for N staging (p < 0.001 and p = 0.002, respectively). A strong and significant correlation was observed between MRI and histopathology for the largest diameter and thickness/infiltration depth of the primary lesions (p < 0.001). ConclusionsGood concordance was observed between MRI and histopathological findings. Our initial findings indicate that non-erectile mpMRI is useful in preoperative assessment of primary penile SCC.

Coronavirus Disease 2019, a Popup Differential to the Postoperative Inflammatory State and its Impact on Outcomes after Cardiac Surgery – A Single-Center Experience

Introduction: Coronavirus disease 2019 (COVID-19) affected care among surgical patients. Considering the underlying comorbidities, physical status, and intricate perioperative course, the cardiac surgery patient represents a vulnerable cohort. This study describes baseline characteristics, laboratory findings, diagnosis, postoperative course, and their correlation with immediate outcomes in patients undergoing cardiac surgery. Methodology: Patients who underwent cardiac surgery at our institute for 1 year were screened for COVID-19 with the reverse transcription-polymerase chain reaction swab test and then were posted for surgery only after corroborating negative reports, except for emergency cases. Dedicated preoperative areas and COVID-appropriate measures were taken. Data from the electronic patient records of those diagnosed with COVID-19 in the immediate postoperative period were reviewed retrospectively. Continuous normal distributed variables are presented as mean ± standard deviation, alternatively as median ± interquartile range, and categorical variables as percentages. Results: A total of 22 patients were infected in the immediate postoperative period in spite of appropriate screening and had a high mortality of 36.36% (vs. non-COVID 6.27%,P&lt; 0.001). Days from index surgery to diagnosis were 6 (±3.75). The median stay in the intensive care unit and hospital stay was 6 (±2.75) and 10 (±3.2) days, respectively. The moderate and high-risk categories of the European System for Cardiac Operative Risk Evaluation II showed mortality of 33.3% (vs. 2.69% in non-COVID, odds ratio of 18.42) and 71.4% (vs. 11.2% in non-COVID, odds ratio of 19.65). Patients with C-reactive protein &gt;100 mg/lit, D dimer &gt;1000 ng/ml, and neutrophil/lymphocyte ratio &gt;3.5 showed very high mortality. Noninvasive and invasive ventilation in 27.27% and 31.8%, respectively. Two patients acquired acute kidney injury that required hemodialysis. Conclusions: Despite requisite measures, COVID infection still remains a momentous differential to postoperative complications affecting early outcomes. Therefore, more robust preoperative protocols, better strategies for the COVID-free environment, and early clinical suspicion and workup are required to mitigate its effect on this cohort.

Benign tumors of the superficial lobe of the parotid gland.

The study retrospectively reviewed all parotidectomies for benign parotid tumors of the superficial lobe performed in the Department of ENT, Municipal Emergency Clinical Hospital, Timişoara, Romania, between January 2014 and December 2018. The following patient data were collected: age; sex; follow-up duration; extension of the resection; use of FN monitoring and lesion features, including position, pathology, and size. Preoperative investigation protocol included a computed tomography (CT) scan to assess the size and location of the tumor helping the treatment planning. The same surgical team performed both standard SP and ECD for the treatment of these tumors. All cases were confirmed as benign parotid tumors. Recurrences of any kind and tumors involving the deep lobe of the gland were excluded from the study. All patients underwent a macroscopically complete resection of the tumor. The main outcome was the postoperative complications in the two groups. Data regarding these complications were recorded on follow-up visits at one, six, 12 and 24 months. Ninety-five patients with benign parotid tumors were operated by the same surgical team at the Department of ENT, Municipal Emergency Clinical Hospital, Timişoara, between January 2014 and December 2018 but only 89 (38 men and 51 women) met the follow-up criteria and were included in the study. Sixteen (18%) patients underwent ECD, and 73 (82%) patients underwent SP as a primary intervention. The mean lesion size for ECD group was 2.0±0.9 cm and 4.2±1.7 cm in the SP group, and it was statistically significant (p<0.05). As expected, the most common type of tumor was PA but the distribution between the groups was different: in the SP group, PA represents 83% (61∕73) of cases but only 44% (7∕16) of cases in the ECD group. Median follow-up time was comparable in the two groups - 33±8 months for the ECD group and 39±11 months for the SP group. There were also differences between the two groups regarding the postoperative complication rate. There were significantly more transient and permanent FN paralysis, transient and permanent great auricular nerve (GAN) dysfunctions and Frey's syndrome (FS) in the SP group. A comparison between ECD and SP as surgical procedures for the treatment of benign tumors of the parotid seems inappropriate as their indications do not overlap. ECD showed similar effectiveness and fewer side effects than SP and can be considered the treatment of choice for small, superficial and/or marginal tumors located in the lateral lobe of the parotid gland.

OGC P40 The RM Partners Cancer Hub approach to Upper Gastrointestinal Surgery during the COVID-19 pandemic

Abstract Background The COVID-19 pandemic led to significant cancellations of major surgery to maximise critical care capacity. Our unit instituted the ‘RM Partners Cancer Hub’ based at the Royal Marsden Hospital in London, which allowed cancer surgery from multiple NHS Trusts to continue in a ‘COVID-lite’ setting. We present the outcomes for Upper GastroIntestinal (UGI) surgery managed via this approach over the course of the pandemic. Methods From April 2020 to April 2021, the Royal Marsden Hospital formed the ‘RM Partners Cancer Hub’. This was designed to co-ordinate resources and deliver as much oncological treatment and cancer surgery as feasible for patients across the RM Partners West London Cancer Alliance. An UGI clinical case prioritisation strategy, along with strict infection control pathways and pre-operative screening protocols were adopted. Results Overall, 231 patients underwent surgery for confirmed UGI cancer via the RM Partners Cancer Hub, with 213 completed resections and combined 90-day mortality rate of 3.5%. Good short-term survival outcomes were demonstrated with 2-year Disease Free Survival (DFS) and Overall Survival (OS) for oesophageal (DFS 70.8%; OS 72.9%), gastric (DFS 66.7%; OS 83.3%) and pancreatic cancer resections (DFS 68.0%, OS 88.0%). One patient developed peri-operative COVID-19 during the RM Partners Cancer Hub operation; they made a full recovery with no lasting clinical sequelae. Conclusions The ‘RM Partners Cancer Hub’ approach provided a workable model for delivering multidisciplinary UGI cancer care and surgery with favourable 2-year DFS and OS when compared to nationally published pre- and post-pandemic data. It also established a template for cancer service during periods of marked disruption to healthcare service delivery and should be a useful guide in the future planning of safe operating pathways.

Reduced Narcotic Utilization in Total Joint Arthroplasty Patients in an Urban Tertiary Care Center.

Opioid use after total joint arthroplasty must be balanced against the risks of opioid dependence and diversion. This study sought to define the baseline patient characteristics and discharge opioid use after the initiation of a preoperative and postoperative institutional opioid prescription protocol in a population with a high prevalence of opioid dependence and substance use. Data on 1004 patients undergoing total joint arthroplasties from July 1, 2017, to June 30, 2019, were retrospectively reviewed. Demographics were collected, and data were grouped into high- and low-discharge opioid groups based on 1 standard deviation above or below the mean. Patient characteristics of the high and low groups were compared using one-way analysis of variance and Pearson chi-square test. The prevalence of preoperative opioid dependence was 21.8%. The mean discharge opioid prescription was 264 morphine milligram equivalents (MMEs). The cutoffs of high- and low-use groups were above 424 MMEs and below 104.5 MMEs. The high-discharge opioid group was more likely to be male, younger, to have a history of preoperative opioid use, to undergo general anesthesia, and to be uninsured. The lower-discharge opioid group was more likely to be older, female, to have Medicare, and to stay approximately 1day longer in the hospital. Body mass index, intraoperative opioid requirement, American Society of Anesthesiologists Classification score, race, total knee vs total hip arthroplasty, or surgical approach for total hip arthroplasty did not affect discharge opioid prescriptions. Reduction of opioid prescriptions at discharge in total joint arthroplasty patients may be possible with the use of preoperative and postoperative protocols, optimizing patient risk factors for opioid use and utilizing a patient-specific opioid taper regimen.

How Early Can We Predict the Need for VPI Surgery?

This retrospective study reviewed documentation of children with moderate-to-severe VPI at age 3 years who did not undergo VPI surgery until age 5 years. Based on the national cleft register, 959 patients with syndromic and nonsyndromic CP were treated by the craniofacial team at Helsinki University Hospital, Finland between 2000 and 2014. Eighty-six patients fulfilled the study inclusion criteria. The speech pathologist evaluated velopharyngeal function at age 3, 5, and 8 years. Of the 86 children presenting with moderate-to-severe VPI at age 3 years, 94% still had moderate-to-severe VPI at age 5 years, even though speech therapy was offered to 77%. Of those whose velopharyngeal function improved by age 5 years, function regressed to incompetent over time. Overall, 93% underwent VPI surgery and 82% underwent VPI surgery between ages 5 and 8 years. Only 23% at age 8 years still had moderate-to-severe VPI. Speech therapy alone did not improve VPI speech characteristics. Moderate-to-severe VPI did not improve from 3 to 5 years or improved but subsequently relapsed. This suggests that the decision for VPI surgery can be made for children aged 3 years with moderate-to-severe VPI.

Implementation of the use of SPECT-portable for evaluation of surgical margins in breast cancer with indication of ROLL: First results

ObjectivesMain objective: To compare the effectiveness for checking surgical margins between SPECT-portable and mammography of the piece (RxM). Secondary objectiveTo standardize a pre-operative protocol using SPECT-portable and to evaluate the time required in the use of this technique. Material and methodsProspective longitudinal study with 36 patients (39 lesions) diagnosed with breast cancer (CM) with criteria for SNOLL/ROLL.A pre-surgical study of the tumor lesion was performed, after the eco-guided administration of 99mTc-nanocolloids of albumin/99mTc-macroaggregates of albumin, in the tumor lesion. Hybrid images (optical + SPECT) and 3D navigation images with gamma probe are obtained using freehandSPECT.In the operating room, 4–5 images are obtained with freehandSPECT, (I) on skin for tumor location, (II) after exposure of surgical bed for resection guide, (III) of the surgical bed after exeresis, (IV and V) the anterior–posterior and lateral surface of the surgical specimen. The three criteria to decide to extend the margins are: (a) residual activity (cps) at the edges of the surgical bed resection; (b) visual analysis of the uptake in the specimen; (c) a minimum distance of 10 mm from the edges of the specimen to the center of greatest uptake, plus the radius of the lesion.We study the concordance of: the depth measurement between ultrasound and freehandSPECT; the surgical margins between freehandSPECT vs. mammography of the specimen (RxM), considering anatomical pathology (AP) as the gold standard technique as reference; surgical time used with freehandSPECT and RxM. ResultsIntraoperative localization was performed in all cases.False negative (FN: no detection margin affected) with freehandSPECT: 9 margins; with RxM: 8. True positive (TP: detection margin affected) with freehandSPECT: 5 margins, with RxM: 6. True negative (TN: consider free margin when healthy) with freehandSPECT: 213 margins; with RxM: 196. Negative predictive value (NPV: probability of negative margin on unaffected part) with freehandSPECT: 95.9%, with RxM: 96.07%. Specificity with freehandSPECT: 96.8%, with RxM: 97%.The concordance of surgical bed margins between freehandSPECT and RxM: 94.5%. Between freehandSPECT and AP: 93.1%. Between RxM and PA: 93.5%, being all statistically significant (p-value <0.000), so we can affirm that both techniques are related or dependent on the reference technique, the PA. Degree of correlation between SPECT-portable and low PA (Kappa index: 0.34, 95% CI [0.22–0.47], and between RxM and moderate PA (Kappa index: 0.42, 95% CI [0.29–0.56], p-value <0.001. Comparison of the successes and failures of both techniques (SPECT-portable and RxM) and PA: Distribution χ2: 0.023 with degree of freedom 1, with value <0.05, so we can affirm that both techniques are similar, since there are no significant statistical differences.Median total OR time: 60.25 min (30–145). Mean freehandSPECT OR time: 5 scans = 10 min. ConclusionsThere are no statistically significant differences in the probability to rule out affective margins that require a second surgery between both techniques (SPECT-portable and RxM) so, the technique performed with SPECT-Portable is a useful and effective procedure, which requires specific training with an optimized and multidisciplinary protocol. The time spent with SPECT-portable is feasible for daily practice.

CT of hemorrhagic adrenal adenomas: radiologic-pathologic correlation.

To describe the appearance of chronically hemorrhagic adenomas on adrenal protocol CT and correlate imaging with pathologic findings. Retrospective case series of adult patients with resected adrenal adenomas showing internal hemorrhage at histology. Seven of nine patients underwent pre-operative adrenal protocol CT and 2/7 underwent unenhanced CT with portal venous phase CT. Two abdominal radiologists in consensus assessed the CT images for the presence of calcifications, macroscopic fat, cystic/necrotic appearance, and the presence, pattern, and percent nodule volume of areas < 10 HU on unenhanced CT. Absolute washout was calculated using a large ROI, and ROIs on the highest and lowest attenuating regions on the portal venous phase. Mean adenoma length was 4.9cm. All adenomas had areas measuring < 10 HU on unenhanced CT, ranging from < 20 to > 80% nodule volume. Calcifications were present in 4/9 adenomas and gross fat in 4/9 on CT. Of the seven cases with adrenal protocol CT, the absolute washout was < 60% in 5/7 using the large ROI, 5/7 using the low attenuation ROI, and 7/7 using the high attenuation ROI. At histology, all nine cases had microscopic evidence of hemorrhage, lipid rich adenoma cells, and fibrosclerosis. Myelolipomatous changes were identified in 4/9 cases, with the remaining five cases showing lipomatous metaplasia without a myeloid component. Chronically hemorrhagic adrenal adenomas demonstrated variable areas < 10 HU on unenhanced CT corresponding to lipid rich adenoma cells. Absolute washout was most often < 60%, hypothesized to be due to fibrosclerosis within the adenomas.