Preoperative Protocol Research Articles

How preoperative upper gastrointestinal investigations affect the management of bariatric patients: results of a cohort study of 897 patients.

Preoperative diagnostic protocols vary worldwide, some prioritizing safety while others question routine procedures. Building on prior research, this study explores the impact of diverse preoperative findings on bariatric management and procedure selection. In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022 undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) were analyzed. Preoperative assessment included upper endoscopy, upper GI series, and esophageal manometry. Sonography data were excluded. The primary endpoint examined the influence of preoperative exams on procedure selection, the secondary endpoint evaluated their therapeutic impact. 897 patients (741 RYGB, 156 SG) were included. All underwent upper endoscopy, revealing common findings such as type C gastritis and reflux esophagitis. Upper endoscopy prompted a therapeutic consequence in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1. Upper GI series and manometry were more frequently performed before LSG. Upper GI series detected hiatal hernias and motility disorders but did not result in any change of procedures. Esophageal manometry found pathologies in 37 (25.3%) patients rising to 41.5% if symptoms were present. Overall, 16 (1.8%) patients experienced a change in the planned procedure, with 14 changes prompted by preoperative findings and two by technical difficulties. We advise routine upper endoscopies for all patients undergoing LRYGB or LSG, while reserving upper GI series only for selected cases. Manometry should be exclusively performed on symptomatic patients undergoing LSG, ensuring a balanced and individualized preoperative assessment.

The Use of a Novel Surgical Irrigant May Be Associated with Decreased Incidence of Surgical Site Infections

Background Periprosthetic joint infection (PJI) represents a formidable challenge to patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This investigation evaluated a novel antimicrobial surgical irrigation solution, XPerience (XP) (Next Science LLC, Jacksonville, FL), with proven high & persistent in-vivo efficacy against planktonic bacteria and biofilm. The primary objective of this investigation was to compare the incidence of PJI following TKA performed with use of XP versus a standard control rinse (povidone-iodine). The secondary outcome was an all-cause return to operating room (OR) rate. Methods A retrospective cohort study was conducted from 824 consecutive patients undergoing primary THA/TKA from 12/1/2019 - 11/30/2021 treated using povidone-iodine solution and 471 consecutive patients undergoing primary THA/TKA from 12/1/2021 - 12/30/2022 treated with XP at a single institution by the senior author. All surgeries in both groups followed largely identical preoperative, perioperative, and postoperative protocols. A total of 1,295 cases were analyzed. The groups shared largely analogous background characteristics pertaining to age, sex, BMI, and American Society of Anesthesiologists (ASA) class. Results The overall SSI rate was 0% (0/471) in the XP group and 0.49% (4/824) in the control group (P = 0.3). The overall return to OR rate was 0.21% (1/471) in the XP group and 0.85% (7/824) in the control group (P = 0.3). Control group cases returned to the OR for hematoma debridements, periprosthetic fracture fixation, and PJI revisions. Conclusion This investigation is the first to remark on the clinical efficacy of a novel surgical irrigant. There was no statistically significant difference in rates of PJI or return to OR with the irrigant versus without, though a trend towards lower rates was observed in the context of a low baseline infection rate. Limitations pertaining to a single-center experience and sample size may be addressed by further studies incorporating broader enrollments.

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

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

Do prospective randomized controlled trials comply with filed protocols? Spin study of 206 trials from 2010 to 2023

IntroductionProspective randomized controlled trials (RCT) have a robust methodology, but some distortions may occur during the course of study. Some protocols may not be available at the time an article is reading. Some authors may change the methodology between the time the protocol was submitted and when the trial results are actually published. Others may distort results to favor more attractive findings and draw conclusions that support prior hypotheses. This has rarely been investigated and none explored the RCTs published in the Journal of Bone and Joint Surgery (JBJS). Therefore, we did a retrospective investigation aiming to determine: (1) the proportion of trials with a protocol deposited and accessible to the reader, (2) whether the trials scrupulously followed the filed protocols. HypothesisProtocols were available in over 80% of cases, and these protocols were followed in over 80% of trials for the primary endpoint. Patients and methodsThis was a retrospective study of articles published in the JBJS between January 2010 and November 2023. Differences in primary and secondary endpoints between protocols and articles were sought. ResultsOf the 206 RCT articles studied, 113 (54.9%) described clear and identifiable endpoints, and 93 (45.1%) were not identifiable and were inferred in the results; 184 (89.3%) articles identified a trial protocol. For the 184 articles (89.3%) declaring a trial protocol in the text, 23 (11.1%) protocols were not accessible. In all, 45 articles (21.8%) thus had no protocol available on the Internet (i.e., not available to the reader either because it was not cited in the text or because it was not accessible) so we analyzed 161 articles. The primary endpoint remained unchanged in 97 articles (60.2%) out of the 161 studied, was changed in 64 articles (39.8%), and was lacking (protocol not accessible) in 45 articles (21.8% of all articles). The secondary endpoints of the articles were unchanged in 61 articles (37.9%) out of the 161 studied. DiscussionLike other leading journals, JBJS publishes RCT articles containing a significant proportion of inconsistencies between preoperative trial protocols and the methods actually used in the research. Level of evidenceIII; retrospective comparative study non randomized

Treatment of distal femur aseptic nonunion after lateral locking plate fixation: results of medial custom made plating and free fibula flap transfer using CAD-CAM technology

BackgroundAim of the present paper is to report the preliminary results of CAD-CAM (Computer-Aided Design - Computer-Aided Manufacturing) technology application to distal femur nonunion treatment with free fibula flap, custom made medial plating and maintenance of a stable lateral locking plate. MethodsTwo cases of distal femur nonunion that occurred after lateral locking plating were treated and prospectively followed-up. Surgical planning followed the same preoperative protocol adopted for mandibular CAD-CAM reconstruction. Wide cutting sections were planned to obtain radical debridement. The tailored custom-made plate, a 3D rendering of bone defect and the cutting guides were produced and sterilized. Surgical intervention was conducted by steps (medial approach, bone resection, recipient vessels isolation, fibula harvesting and cutting, plate-fibula construct assembly, microvascular anastomosis, final fixation). ResultsThe mean follow-up was 13 (12-15) months. Bone union was achieved in both cases at mean 3.1 months. Full weight bearing without referred pain or discomfort was reached in both cases at mean 8,5 months (range 7 – 10). No complications occurred. ConclusionsCAD-CAM technology proved to be useful and reliable in custom made medial plating combined with free fibula transfer for the treatment of distal femur nonunion after lateral locking plating. Trial registrationnone.

Are prophylactic antibiotics effective in preventing osteoradionecrosis after high-risk dental extractions?

A systematic review and meta-analysis. To assess and compare the effectiveness of different adjunctive treatments during tooth extraction in post-radiotherapy head and neck patients for preventing osteoradionecrosis (ORN). Two independent reviewers conducted an electronic search through PubMed, Embase, Cochrane Libraries, Scopus and Web of Science databases using relevant search terms. Additionally, references of relevant articles were manually searched for eligible studies. Included were full-length articles (randomized controlled trials (RCTs), clinical trials, or observational studies) published in English, reporting on ORN occurrence after dental extraction, with or without adjunctive interventions, in patients who had previous radiotherapy. Data extraction was similarly performed by two independent researchers. For quality assessment, bias in observational studies was evaluated using the ROBINS-I tool, while the RoB 2 tool was used for RCTs. One-arm meta-analyses estimated pooled ORN prevalence rates for different adjunctive treatments based on patient-level outcomes. For studies with direct comparisons between two modalities, pooled odds ratios for ORN were calculated using pairwise meta-analyses. This systematic review followed PRISMA guidelines and was registered in the PROSPERO database. A total of 29 studies with 1520 patients were included, comprising 4 RCTs, 4 prospective studies, and 21 retrospective observational studies. Five adjunctive treatment modalities around the time of dental extractions were identified: hyperbaric oxygen (HBO), pentoxifylline-tocopherol (PENTO), antibiotics (ABX), platelet-rich fibrin and photobiomodulation. Of the 25 observational studies included, 11 had a serious risk of bias, while all RCTs but 1 had low risk of bias. Egger's test showed no publication bias for the HBO and ABX groups (p > 0.05). Antibiotics were used in 17 studies, with significant variations in preoperative and postoperative protocols. Most studies utilized penicillin or clindamycin. The pooled prevalence of ORN was significantly lower in the HBO (4.6%), PENTO (3.4%), and ABX (3.8%) groups compared to the Control (17.6%), as indicated by the non-overlapping 95% CIs between the Control and any of the intervention groups. In studies with direct comparisons, HBO exhibited lower odds of developing ORN than the Control (odds ratio [OR] = 0.27) and ABX (OR = 0.57), although these differences were not statistically significant. HBO, PENTO, and ABX show similar reduction in ORN rates compared to no intervention. Given its cost-effectiveness and accessibility, ABX may be the most practical prophylactic modality at present.

Surgical abortion service reorganization in response to the COVID-19 pandemic: a unique experience of attending second trimester D&E procedures under spinal anesthesia as emergency procedures.

The COVID-19 pandemic created a massive shift in how health care systems interact with COVID testing for patients. To avoid delay in accessing second trimester surgical abortion at our hospital (St. Paul's Hospital Millennium Medical College) during this pandemic, dilation and evacuation (D&E) procedures were attended as emergency cases, instead of as elective surgical procedures, which then required adherence to the universal preoperative COVID-19 testing protocol. This study aimed at documenting the experience of this unique abortion service adjustment in response to the COVID-19 pandemic. This was a retrospective descriptive study conducted at St. Paul's Hospital Millennium Medical College (SPHMMC) in Addis Ababa, Ethiopia, from April 1, 2021 to July 31, 2021. We reviewed second trimester surgical abortion cases managed with D& E procedures, performed under spinal anesthesia using the emergency COVID-19 pre-operative testing protocol. Data were analyzed using SPSS version 23 and simple descriptive statistics were applied. Percentages and proportions were used to present the results. Nineteen cases of second trimester D&E cases were reviewed. The median gestational age of the abortion clients was 21.57 weeks. Eight of 19 cases had cervical preparation with overnight intra-cervical Foley catheter placement while the rest 11 (57.9%) cases had their cervical preparation with Laminaria. The median time interval from initial evaluation of the abortion client to time of doing D& E procedure was 21.83 h. Surgical abortion service reorganization enabled abortion clients to access dilation and evacuation procedures within 24 h of their initial presentation. This prevented significant delays in accessing abortion care that could otherwise have occurred as a result of adhering to the preoperative COVID-19 testing protocols applied to elective surgeries.

Postoperative outcomes among patients evaluated via telemedicine-based preoperative consultations for inguinal hernia care.

In an era where telehealth is gaining traction within healthcare systems, its integration into preoperative assessment protocols presents both challenges and opportunities. Preoperative assessments have an important role in determining the best plan of action for each patient. Recent studies have reported adequate operative outcomes after telemedicine preoperative consultations. This study examines telehealth's efficacy relative to traditional in-person evaluations in the context of preoperative consultations for inguinal hernia repairs and provides a deeper insight into how telemedicine might be utilized for pre-surgical assessments. We analyzed a prospectively maintained single-center database at a tertiary referral hospital with a dedicated hernia and abdominal wall reconstruction center for pre, intra and postoperative variables comparing patients that received telemedicine (phone or video) preoperative consultations versus in-person clinic visits only. Secondary analysis with propensity score matching was employed to adjust for possible confounders. 265 patients that underwent inguinal hernia repair were included, with 60 encounters being telemedicine only and the rest in-person. This analysis found no difference in rates of postoperative complications between the telemedicine and in-person groups. The telemedicine group required less preoperative encounters with their surgeon (P < 0.001). In the preoperative in-person group, 41% switched to virtual follow-ups, while in the virtual group, only 18% chose in-person follow-ups (P = 0.003). Based on our analysis, the use of telemedicine for preoperative assessments in inguinal hernia repairs as a feasible and safe choice for patients opting for this approach, potentially reshaping the preoperative paradigm in surgical practices.

WP1.17 - Double Trouble - A Case of Duplex Appendix

Abstract Introduction Duplex appendix, a rare anatomical anomaly is often encountered incidentally during appendicectomy procedures. It is characterised by the presence of two appendiceal lumens and can be classified using the Cave-Wallbridge classification system. Case An 18-year-old male presents to the Emergency Department with a two-day history of migratory right iliac fossa pain. He was consented and booked for a laparoscopic appendicectomy based on clinical suspicion of acute appendicitis. Intra-operatively, an unexpected finding surfaces—a second pendunculated mass adjacent to the inflamed appendix. Employing laparoscopic linear staples, both the appendix and the adjacent mass were divided. One day post-discharge, the patient presents with severe abdominal pain and computed tomography imaging suggests an intra-abdominal leak. The patient underwent an emergency laparotomy and ileo-caecal resection overnight. Histology revealed the second pedunculated mass was indeed a second appendix, a phenomenon with a reported incidence of 0.004 to 0.009%. Discussion Addressing the nuances of using imaging modalities in the diagnosis and operative planning of acute appendicitis, our discussion raises pertinent questions regarding the necessity of definitive pre-operative imaging in suspected cases. Considering potential pitfalls of incorrect clinical diagnoses; the presence of anatomical anomalies; and other factors influencing surgical decision-making; we scrutinise the proposition of pre-operative imaging protocols in suspected acute appendicitis. Conclusively our case encapsulates the diagnostic and therapeutic conundrums posed by duplex appendix instances, prompting a deeper exploration into the use of imaging techniques in a traditionally clinically diagnosed presentation and the implications thereof in surgical management.

Ultrasound assessment of gastric content in elective surgery

Objective: To determine the prevalence of patients with ultrasound signs of a full stomach during surgery at the Sominé Dolo Hospital in Mopti. Methodology: Observational study investigated prospective, single-center over a period of one month include patients in surgery program aged 18 to 85 years. Our data was collected on individual survey sheets and analysed with the Epi info7 software. Result: Out of a total of 140 patients, 41 patients were included in our study, i.e. a frequency of 29.28%. The mean age of patients was 38 years +/-17. The average body mass index was 23+/- 4.65. Females predominated: 60.98% (n=25) compared to 39.02% (n=16) for males, with a sex ratio of 0.6/1. The ASA classification was rated at II in 51.22% of patients (n=21). The gastric antrum was visualized in 40 patients, i.e. an ultrasound sensitivity of 97.56%, of which seven (07) were difficult to see and not visualized in one patient. We found a relationship between high BMI and difficulty in visualizing gastric contents (P-value = 0.00001), but no relationship was found between BMI and Perlas score (P-Value = 0.75411). The Perlas score was rated at 0 in 85% (n=34), fluid content was found in 12.5% (n=5) of patients while one patient had solid content. Patients observed an estimated preoperative fasting duration of an average of 11 hours +/- 2.86. Conclusion: Despite the implementation of a preoperative fasting protocol, cases of full stomachs are still to be feared and the ultrasound at the bedside of patients is a simple, quick examination to best adjust the anesthesia protocol. Keywords: full stomach, gastric antrum, ultrasound, Perlas score, Mopti.

Evolving role of staging CT scans during CT-angiography for DIEP flap reconstruction planning

BackgroundPre-operative planning with CTA in DIEP flap reconstruction is an essential preoperative tool. The aim of this study was to describe the management of the incidental findings following introduction and further modification of a combined CTA and CT-staging pre-operative protocol which include chest, abdomen, pelvis and musculoskeletal system. Material, methodA retrospective case series of 292 patients (Group1) with breast cancer who underwent DIEP flap between 2015 and 2019. This was followed by a re-assessment between 2019 and 2021 for 101 patients (Group 2) following modification of the staging-CT protocol for only those patients who received chemotherapy. Group 1 includes both of immediate and delayed reconstruction and, but the Group 2 includes only the high-risk cases of delayed reconstruction. Both groups had CT staging. Result30% of Group 1, most likely who had the delayed reconstruction, had findings which were recommended for further follow-up. This led to a change in staging of high-risk patients only at the end of 2019 to those who underwent chemotherapy who had delayed reconstruction.56.4% of Group 2 demonstrated incidental findings, 42.1% of them necessitated repeat scanning, 7% were referred to other specialties and 47.4% did not require further action There were no cases of occult metastatic breast cancer in either series; however, 1% were diagnosed with de novo primary cancers at non breast sites in the first series only. ConclusionThe screening of asymptomatic breast cancer patients as part of CTA scanning prior to autologous reconstruction is not universally practiced and not supported by NICE guidelines. This unit has changed practice to stop pre-operative staging for low-risk patients at the end of 2019, reserving it for the high-risk patient groups to reduce cost.

A Survey of United States Transplant Center Donation After Circulatory Death Kidney Transplant Practices in the Modern Era

IntroductionThe mismatch between the number of patients awaiting kidney transplantation and the supply of donor organs has in part resulted in a rise in kidney transplantation from donors after circulatory death (DCD). Persistently long waiting times have led the transplant community to continue to explore the use of expanded criteria DCD kidneys. In parallel, advances in organ preservation strategies have contributed to an overall increase in DCD organ transplantation and are altering the transplant landscape. Some of these techniques may improve kidney allograft outcomes and affect how DCD kidneys are utilized. We aimed to better understand practices in accepting DCD kidney offers in the modern era. MethodsDirectors of 196 U.S. kidney transplant centers were emailed a link to an online survey over a 5-week period. Results48 (13%) out of the 364 directors responded with all UNOS regions represented. Definitions of warm ischemia time (WIT) used in DCD kidney evaluation varied widely amongst respondents. The maximum total WIT limit varied with 19 (39.6%) less than 60 minutes responses, followed by 16 (33%) less than 90 minutes responses, and 10 (20.8%) less than 120 minutes responses. ConclusionDespite increasing DCD kidney transplantation volumes in the U.S. there are no standardized procurement biopsy practices, OPO pre-operative protocols, or consensus definition or limits of WIT. Agreement upon terminology may facilitate rapid clinical communication, efficiency of organ allocation and utilization, recording of data, research, and improvements in policy.

Reducing Length of Stay in Reconstructive Head and Neck Surgery Patients: A Quality Improvement Initiative.

To investigate whether a new preoperative education and discharge planning protocol reduced unexpected discharge delays for patients undergoing reconstructive surgery for head and neck cancer. A quality improvement (QI) intervention was implemented in January 2021 with several components to address historically prolonged observed lengths of stay (LOS) with head and neck cancer patients. The intervention added a preoperative educational visit with a head and neck cancer advanced practice provider, a standardized preoperative speech and swallow assessment, a personalized patient care plan document, discussion of inpatient hospital stay expectations, and early discharge planning. The intervention group included patients who underwent the preoperative education protocol from February to December 2021. For comparison, an age and sex-matched control group was constructed from inpatients who had been admitted for similar procedures in the 2 years prior to the QIintervention (2019-2020) and received standard of care counseling. Our study demonstrated a significant reduction in observed to expected LOSratio after implementation of the intervention (1.24 ± 0.74 control, 0.95 ± 0.52 intervention; P = .012). We discuss a preoperative education QI intervention at our institution. Our findings demonstrate that our intervention was associated with decreased LOS for patients undergoing head and neck reconstructive surgeries. This QI study shows the benefit of a new standardized preoperative education and discharge planning protocol for patients undergoing head and neck reconstructive surgeries.

Omitting the Escalating Dosage of Alpha-adrenergic Blockade before Pheochromocytoma Resection: Implementation of a Treatment Strategy in Discordance with Current Guidelines.

This study describes the effects of introducing a protocol omitting preoperative α-blockade dose-escalation (de-escalation) in a prospective patient group. The decline of mortality and morbidity associated with pheochromocytoma resection is frequently attributed to the introduction of preoperative α-blockade. Current protocols require preoperative α-blockade dose-escalation and multiple-day hospital admissions. However, correlating evidence is lacking. Moreover, recent data suggest equal perioperative safety regardless of preoperative α-blockade escalation. Single-institution evaluation of protocol implementation, including patients who underwent adrenalectomy for pheochromocytoma between 2015 and 2023. Intraoperative hemodynamic control was regulated by active adjustment of blood pressure using vasoactive agents. The primary outcome was intraoperative hypertension, defined as time-weighted average of systolic blood pressure (TWA-SBP) above 200mm Hg. Secondary outcomes included perioperative hypotension, postoperative blood pressure support requirement, hospital stay duration and complications. Of 102 pheochromocytoma patients, 82 were included; 44 in the de-escalated preoperative α-adrenergic protocol and 38 following the previous dose-escalation protocol. Median [IQR] TWA-SBP above 200mm Hg was 0.01 [0.0-0.4] mm Hg in the de-escalated group versus 0.0 [0.0-0.1] mm Hg in the dose-escalated group (P=0.073). Median duration of postoperative continuous norepinephrine administration was 0.3 hrs [0.0-5.5] versus 5.1 hrs [0.0-14.3], respectively (P=0.003). Postoperative symptomatic hypotension occurred in 34.2% versus 9.1% of patients (P=0.005). Median hospital stay was 2.5 days [1.9-3.6] versus 7.1 days [6.0-11.9] (P<0.001). No significant differences in complication rates were observed. Our data suggest that adrenalectomy for pheochromocytoma employing a de-escalated preoperative α-blockade protocol is safe and results in a shorter hospital stay.

Anesthetic key points in a patient with a terminal ileum neuroendocrine tumor and a rare carcinoid left heart disease presented for non-cardiac surgery: case report

BackgroundCarcinoid tumors are rare neuroendocrine malignancies presenting in an increasing number in our center. The incidence of carcinoid tumors is approximatively between 2.5 and 5 cases per 100,000 people of whom about 50% develop carcinoid syndrome. Once the carcinoid syndrome has developed, a carcinoid cardiomyopathy can occur. Carcinoid heart disease (CaHD) remains a serious and rare complication associated with a significant increase in morbidity and mortality. Although carcinoid tumors have been known and studied for several years, there are still scarce data on the anesthetic management and the peri operative period.Case presentationWe describe a case of a Caucasian 44-year-old woman with an unusual presentation of left CaHD with an ileal neuroendocrine tumor and liver metastases. Our preoperative somatostatin administration protocol, limit the cardiac damage. The maintenance of stable hemodynamics, the use of balanced anesthetic technique, all along with a good understanding of the pathology, played a major role in the successful management of anesthesia. This case report allows us to introduce our decision algorithm for the management of this type of pathology in our tertiary hospital, Cliniques Universitaires Saint-Luc.ConclusionDespite the paucity of data, anesthetic management of patients with carcinoid tumor can be safely performed with effective hemodynamic monitoring and a good understanding of the pathophysiology. Knowledge and application of a clear institutional algorithm for octreotide administration and multidisciplinary consultation at a referral center are essential for the management of these patients.

Improving Compliance With Evidence-Based Laboratory Testing Recommendations and Monitoring Associated Patient Outcomes.

A team comprising nursing, medical staff, and administrative leaders at an urban academic orthopedic hospital in the northeastern United States sought to revise a preoperative laboratory testing protocol based on evidence and practice guidelines. The goal was to decrease unnecessary tests by 20% without negatively affecting patient outcomes. After adding the revised protocol to the electronic health record, audits revealed that the target goal was not met and additional strategies were implemented, including educational webinars for surgeon office personnel who ordered tests, additional webinars for advanced practice professionals, and the creation of scorecards to track surgeons' progress. Overall, a downward trend in the ordering of unnecessary laboratory tests for patients without identified risks was observed, but a 20% reduction was not achieved. Surgical complications during the project were not associated with laboratory tests. Clinicians continue to use the revised preoperative laboratory testing protocol at the facility.

The impact of extended preoperative examination on the treatment tactics choice before the second stage of revision hip arthroplasty

Background. Reinfection and recurrence of periprosthetic infection rates during the second stage of revision hip arthroplasty (RHA) remain quite high. Performing preoperative diagnostic aspiration in patients with the installed hip spacer is a controversial issue. Aims of the study: 1) to compare the diagnostic accuracy, specificity and sensitivity of the used infection markers as a part of preoperative diagnostic protocols in order to exclude reinfection in patients with installed hip spacer before the second stage of RHA; 2) to analyze and compare the microbiological spectrum obtained at the stages of RHA. Methods. Diagnostic accuracy parameters of the used infection markers were assessed in order to exclude reinfection/recurrence in 107 patients with installed hip spacer. All patients were divided into two groups. In Group 1 (prospective), blood tests as well as diagnostic aspiration of synovial fluid were performed within the extended diagnostic protocol. In Group 2 (retrospective), the examination was performed according to the screening preoperative diagnostic protocol including blood tests. The used reference range of inflammatory biomarkers was based on the “small criteria” of ICM 2018. According to the results of the intraoperative microbiological examination of peri-implant tissue samples at the first and second stages of RHA, the analysis of detected microflora was conducted in order to assess probable reinfection/recurrence. Results. According to the results of the intraoperative microbiologic examination during the second stage of RHA, reinfection was detected in 40% of cases: in Group 1 — 9 cases, in Group 2 — 31 case. Synovial fluid was obtained from 85% of cases when preoperative diagnostic aspiration was performed. Synovial fluid could not be obtained in 15% cases (dry joint). Conclusion. Performing preoperative diagnostic aspiration before the second stage of RHA in patients with the installed spacer allowed choosing correct treatment tactics in 9% of cases. The parameters of diagnostic accuracy accounted for 82,6%. In the structure of detected pathogens in case of recurrence and reinfection, the representatives of Gram-positive coagulase-negative flora were the most frequent.

Enhanced Recovery after Surgery Protocol (ERAS) versus Standard Protocol for Undergoing Radical Cystectomy in an Egyptian Population

Abstract Background bladder cancer has been one of the commonest cancer. The gold standard for treatment of muscle invasive bladder cancer is radical cystectomy with pelvic lymphadenectomy and associated with considerable morbidity and mortality and healthcare cost. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures. Aim and Objectives The aim of this study was to compare between the standard preoperative bowel preparation (SP) and ERAS protocol in terms of postoperative length of stay (LOS) and postoperative morbidity. Subjects and Methods This was a prospective randomized study was conducted in Ain shams university hospital – Alexandria university hospital involving fifty (50) patients were randomly divided into two equal groups twenty-Five (25) patient in group A follow ERAS protocol and twenty-Five (25) patients in group B following standard protocol. The duration of the study ranged from 6-12 months. Results There was statistically significant difference found between group A and group B regarding the studied parameters ( Readmission in 30 days, Ileus, Vomiting, and UTI) while there was no statistically significant difference between them regarding (early mobilization, urine leakage, dehesince and DVT), there was no statistically significant difference found between group A and group B regarding (Length of stay). Conclusion In patients undergoing radical cystectomy, enhanced recovery protocol is considered as a safe procedure and not associated with any increase in intraoperative and postoperative complications compared to standard protocol. The length of hospital stay was shorter in ERAS group.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Payer Status and Medication Management-Part Six of the Movement Is Life Special ONJ Series.

This article is the sixth in the Movement is Life series and focuses on insurance coverage and medication management in the perioperative period, 2 tangentially related variables that affect patient outcomes. Our aim is to use current practices and literature to develop recommendations for nurse navigators' execution of preoperative optimization protocols related to payer status and medication management. Discussions with nurse navigators and a literature search were used to gather information and develop recommendations specific to optimizing payer status and medication management. Nurse navigators connected patients to resources and provided education regarding financial concerns and medications, and findings from the literature discussed insurance status among TJA patients. Nurse navigators can contribute to payer status and medication management optimization by providing patient education and resource referrals. In addition, we recommend conducting repeated medication reconciliation and developing awareness of financial resources and perioperative medication management guidelines.

Assessment of Arterial Involvement in Pancreatic Cancer: Utility of Reconstructed CT Images Perpendicular to Artery.

The purpose of this study was to investigate the utility of reconstructed CT images perpendicular to the artery for assessing arterial involvement from pancreatic cancer and compare the interobserver variability between it and the current diagnostic imaging method. This retrospective study included patients with pancreatic cancer in the pancreatic body or tail who underwent preoperative pancreatic protocol CT and distal pancreatectomy. Five radiologists used axial and coronal CT images (current method) and perpendicular reconstructed CT images (proposed method) to determine if the degree of solid soft-tissue contact with the splenic artery was ≤180° or >180°. The generalized estimating equations were used to compare the diagnostic performance of solid soft-tissue contact >180° between the current and proposed methods. Fleiss' ĸ statistics were used to assess interobserver variability. The sensitivity and negative predictive value for diagnosing solid soft-tissue contact >180° were higher (p < 0.001 for each) and the specificity (p = 0.003) and positive predictive value (p = 0.003) were lower in the proposed method than the current method. Interobserver variability was improved in the proposed method compared with the current method (ĸ = 0.87 vs. 0.67). Reconstructed CT images perpendicular to the artery showed higher sensitivity and negative predictive value for diagnosing solid soft-tissue contact >180° than the current method and demonstrated improved interobserver variability.