Preoperative Testing Research Articles

Poor preoperative performance at Clock Drawing Test is associated with postoperative decline in olfaction in older patients: an observational pilot study

BackgroundDecline in olfaction may occur after general anesthesia, but the exact incidence and underlying physiopathology remain scarcely investigated. Olfactory dysfunction arises with aging and is known to be linked to cognitive impairment. In this pilot study, we evaluated the incidence of immediate postoperative decline in olfaction and its association with a preoperative cognitive test, performance at Clock Drawing Test (CDT), in a group of older patients.MethodsThis pilot study is a sub-analysis of a prospective observational study. Patients ≥ 65 years old and scheduled for elective non-cardiac surgery under sevoflurane-based anesthesia were enrolled. CDT was part of the preoperative evaluation. We assessed olfaction on the day before and the day after surgery (between 16 and 26 h postoperatively) using the Sniffin’ Sticks 12-item identification test, which consists of pen-like devices displaying 12 different odors. Postoperative decline in olfaction was defined as a decrease of at least 1 standard deviation in the olfactory score.ResultsWe included a total of 93 patients, among whom 19 (20.4%) presented a postoperative decline in olfaction. The incidence of postoperative decline in olfaction was higher in the “CDT low-score” (score ≤ 5/8) group (11/34, 32.4%) than in the “CDT high-score” (score ≥ 6/8) group (8/58, 13.6%) (P = 0.030). Despite adjusting for confounding variables, CDT score remained independently associated with immediate postoperative decline in olfactory identification function (OR 0.67, 95% CI 0.48 to 0.94, P = 0.022).ConclusionsPostoperative decline in olfaction occurred in 20.4% of older patients and was associated with poor preoperative performance at CDT.Trial registrationThis study was retrospectively registered on https://clinicaltrials.gov/ under the NCT04700891 number (principal investigator: Victoria Van Regemorter), in December 2020.

483. INTRAOPERATIVE EVALUATION OF HIATAL HERNIA SIZE AND CANDIDACY IN TIF ELIGIBLE PATIENTS

Abstract Background Transoral incisionless fundoplication (TIF) is gaining prominence in treatment of gastroesophageal reflux disease (GERD) for patients with absent or small hiatal hernia. As TIF gains popularity, appropriate patient evaluation and selection is paramount in establishing anatomical candidacy hence successful outcome. We evaluated patients who were intended to be treated with TIF and underwent a standard evaluation but instead underwent robotic hiatal hernia repair. We compared their preoperative evaluation of hernia size with intraoperative findings. Methods A cohort of seventy-six patients from a single-center database from January 2020 to March 2023 were retrospectively analyzed. All were deemed candidates for TIF based on our inclusion criteria (pH confirmation of GERD, hiatal hernia <2 cm) and underwent preoperative testing with endoscopy, esophagram, pH and manometry. Twenty-seven of these patients either were denied TIF by their insurance company or had personal preference for surgery (daVHH) over endoscopic intervention and underwent robotic assisted paraesophageal hernia repair. We examined intraoperative measurements of hiatal hernia size and EG junction anatomy and compared them to standard preoperative evaluation. Results On pre-operative endoscopy 23 patients were found to have no hiatal hernia, 20 were found to have a small hernia, 3 a medium hernia, and 1 a large hernia. Esophagram evaluation demonstrated no hiatal hernia in 17 patients and a small hernia in 23 patients. The average hiatal hernia size seen during manometry was 0.54 cm (0–2 cm) while the average hernia seen intra-operatively was 3.26 cm (1.5–4.8 cm). There was a significant difference between preoperative hernia size evaluated by manometry and intraoperative hernia size (p-value 0.04). Conclusion Standard preoperative evaluation of patients intended to be treated with TIF appears to have a tendency to underestimate the size of hiatal hernia and omits evaluation of paraesophageal anatomy. This can lead to poor patient selection of failure of this treatment modality. Addition of cross-sectional imaging to the evaluation of patients with small hiatal hernias can facilitate a more meaningful therapeutic decision making for endoscopic, surgical, and combination treatment options.

Efficacy of Eustachian Tube Function Tests in Predicting Myringoplasty Success Rate

Abstract Background Tympanoplasty is a commonly performed surgical procedure to close perforations of the tympanic membrane. The results of tympanic membrane based on multiple factors as the eustachian tube dysfunction. Aim of the Work to assess the efficacy of the eustachian tube function test in predicting myringoplasty success rate and compare the efficacy of different tests in prediction of myringoplasty outcome. Material and Methods An electronic search via PubMed, Cochrane library, google scholar and web of science (WOS) until janurary2021.We included articles published in English language and conducts adult cases only. We excluded studies based on expert opinion and laboratory studies. Outcomes of interest were success rate of tympanoplasty according to eustachian tube function test and the efficacy of the different tests of eustachian tube function. Analysis was conducted using Comprehensive Meta Analysis© version 3 (Biostat© Englewood, NJ) and the jamovi project (2021); jamovi (Version 1.6.23.0) [Computer Software] for the efficacy of the eustachian tube function tests in predicting tympanoplasty success rate and using Review Manager (RevMan) [Computer program]. Version 5.4. The Cochrane Collaboration, 2020, and MetaDTA: Diagnostic Test Accuracy Meta-Analysis v2.01, 2021 for detecting and comparing the accuracy of different eustachian tube function tests. Results Regarding tympanoplasty success rate meta-analysis of the revelent 14 studies shows that preoperative normal Eustachian tube function is associated with significantly higher probability of successful graft taking (Log odds ratio = 1.78, 95% CI = 1.10 to 2.46).Regarding to the different accuracy of eustachian tube function test meta-analysis of the revelent 14 studies shows that accuracy of the tests are ranked as follows: methylene blue (most accurate), saccharine, impedance audiometry, tubomanometry and sonotubometry (least accurate). Further studies are needed to validate our findings. Conclusions Our pooled estimate suggest a good benefits of preoperative eustachian tube function test and tympanoplasty success rate. According to efficacy of different test of tympanoplasty our pooled estimate that methylene blue test is the most accurate test while the sonotubometry test is the least accurate test.However, our evidence have several limitations and there is controversy among these studies. We suggest further studies are needed to validate our findings to detect the most accurate test of eustachian tube function.

P32. Preoperative penicillin allergy testing is economically justifiable prior to posterior lumbar fusion surgery

P32. Preoperative penicillin allergy testing is economically justifiable prior to posterior lumbar fusion surgery

SP8.9 Pre-operative blood tests in abscess patients: Audit and cost analysis

Abstract Introduction Abscess is one of the most common presentations in the emergency surgical setting. It is common practice in our unit to perform blood tests as part of the initial triage process by our nurses. However, NICE guidance (NG45) recommends that bloods should not be taken routinely for patients undergoing minor surgery (including abscess) who are ASA 1 or 2. Aims To determine the department’s compliance with NICE guidance, identify ways to improve compliance if required, Identify methods to improve patient experience e.g. waiting times and perform a cost analysis of unnecessary blood tests. Methods Retrospective analysis of 100 consecutive patients from June to September 2022, who had incision and drainage of abscess. The patients were selected from Surgical Emergency Unit admission book. Patient data including demographics, immunological compromise status, Morbidities such as diabetes, abscess site, anaesthetic type, blood tests performed and results, and admission and discharge times. Results 56 females, 44 males. Majority fall in age group 25-59. 7 patients were ASA 3 or higher. 10 patients were diabetic. 93 patients had blood tests performed preoperatively. 16 patients had CRP >50, and 9 patients had WCC >15. Only 6 patients spent more than 1 day inpatient. Cost of unnecessary blood tests in this group is 4,092£, cost over a year period is 24,552£. Conclusion There was poor compliance with NICE guidance costing the trust 24,552£ yearly. Blood tests did not change management plans or patients’ course. Better compliance can improve patient experience and save significant cost.

Can inflammatory indices predict sentinel lymph node status in patients with early-stage breast cancer?

Breast cancer research has focused on the early detection and treatment of breast cancer. Axillary lymph node status is essential for primary breast cancer staging, recurrence, and survival. The current quest for precision medicine is to identify predictive markers that offer the advantage of individualized treatment options. This study aimed to investigate the value of inflammatory indices in predicting positive sentinel nodes in breast cancer. We studied 602 patients with early-stage breast cancer who underwent sentinel lymph node biopsies (SLNB) at the Bülent Ecevit University General Surgery Clinic. We obtained data, including the clinical and demographic characteristics of the patients, such as age, histological type, and sentinel lymph nodes. Neutrophil, lymphocyte, platelet, and monocyte counts were obtained from preoperative complete blood count test data from the patient registry. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), systemic inflammatory index (SII), and sentinel lymph node biopsy were analyzed. Sentinel LAP was negative in 391 (65%) patients and positive in 211 (35%). In the receiver operating characteristic curve analysis, no significant difference was found between SLNB positivity and negativity in terms of NLR, PLR, LMR, or SII. In contrast to previous research, NLR, PLR, LMR, or SII did not affect SLNB positivity prediction in our study.

A systematic review of predictive accuracy via c-statistic of preoperative frailty tests for extended length of stay, post-operative complications, and mortality.

Frailty, as an age-related syndrome of reduced physiological reserve, contributes significantly to post-operative outcomes. With the aging population, frailty poses a significant threat to patients and health systems. Since 2012, preoperative frailty assessment has been recommended, yet its implementation has been inhibited by the vast number of frailty tests and lack of consensus. Since the anesthesiologist is the best placed for perioperative care, an anesthesia-tailored preoperative frailty test must be simple, quick, universally applicable to all surgeries, accurate, and ideally available in an app or online form. This systematic review attempted to rank frailty tests by predictive accuracy using the c-statistic in the outcomes of extended length of stay, 3-month post-operative complications, and 3-month mortality, as well as feasibility outcomes including time to completion, equipment and training requirements, cost, and database compatibility. Presenting findings of all frailty tests as a future reference for anesthesiologists, Clinical Frailty Scale was found to have the best combination of accuracy and feasibility for mortality with speed of completion and phone app availability; Edmonton Frailty Scale had the best accuracy for post-operative complications with opportunity for self-reporting. Finally, extended length of stay had too little data for recommendation of a frailty test. This review also demonstrated the need for changing research emphasis from odds ratios to metrics that measure the accuracy of a test itself, such as the c-statistic.

Can machine learning models predict prolonged length of hospital stay following primary total knee arthroplasty based on a national patient cohort data?

The total length of stay (LOS) is one of the biggest determinators of overall care costs associated with total knee arthroplasty (TKA). An accurate prediction of LOS could aid in optimizing discharge strategy for patients in need and diminishing healthcare expenditure. The aim of this study was to predict LOS following TKA using machine learning models developed on a national-scale patient cohort. The ACS-NSQIP database was queried to acquire 267,966 TKA cases from 2013 to 2020. Four machine learning models-artificial neural network (ANN), random forest, histogram-based gradient boosting, and k-nearest neighbor were trained and tested on the dataset for the prediction of prolonged LOS (LOS exceeded the 75th of all values in the cohort). The model performance was assessed by discrimination (area under the receiver operating characteristic curve [AUC]), calibration, and clinical utility. ANN delivered the best performance among the four models. ANN distinguished prolonged LOS in the study cohort with an AUC of 0.71 and accurately predicted the probability of prolonged LOS for individual patients (calibration slope: 0.82; calibration intercept: 0.03; Brier score: 0.089). All models demonstrated clinical utility by generating positive net benefits in decision curve analyses. Operation time, pre-operative transfusion, pre-operative laboratory tests (hematocrit, platelet count, and white blood cell count), and BMI were the strongest predictors of prolonged LOS. ANN demonstrated modest discrimination capacity and excellent performance in calibration and clinical utility for the prediction of prolonged LOS following TKA. Clinical application of the machine learning models has the potential to improve care coordination and discharge planning for patients at high risk of extended hospitalization after surgery. Incorporating more relevant patient factors may further increase the models' prediction strength.

Effect of Phacoemulsification Cataract Surgery on the Clinical Outcomes of Advanced Glaucoma Patients

Purpose: To identify the clinical outcomes of cataract surgery in patients with advanced glaucoma.Methods: A retrospective chart review of open-angle glaucoma patients who underwent cataract surgery and were followed-up for 1 year was conducted. Advanced glaucoma was defined as a mean deviation (MD) < -12 dB on the preoperative visual field test. A group with mild-to-moderate glaucoma (MD ≥ -12 dB) served as the control group. Changes in intraocular pressure (IOP) at 1, 3, 6, and 12 months, and in the postoperative visual acuity (VA) as well as in the visual field indices (MD and the pattern standard deviation), and the number of antiglaucoma medications were compared.Results: Eighty-seven eyes (87 patients) of the advanced group and 109 eyes (109 patients) of the mild-to-moderate group were finally included. From 1 week to 24 months postoperatively, both groups evidenced IOP decreases compared to the preoperative values (both <i>p</i> < 0.05). The IOP spike prevalence was similar in the two groups (11% vs. 13%, <i>p</i> = 0.199). The mean IOP difference between the two groups was not significant at months 1, 3, 6, 12, or 24 postoperatively (all <i>p</i> > 0.05). Both groups evidenced VA improvements at 1 year postoperatively and the visual field (VF) indices did not differ from those before surgery. The numbers of antiglaucoma medications used decreased after surgery, but the decrease was significant only in the advanced glaucoma group (<i>p</i> = 0.030).Conclusions: The advanced and mild-to-moderate glaucoma groups evidenced similar IOP and VF changes after cataract surgery. The VA improved and the number of antiglaucoma medications decreased. Our findings suggest that cataract surgery for patients with advanced glaucoma may afford similar clinical outcomes compared to other less severe glaucoma groups.

Therapeutic Effects and Limitations of Lacrimal Endoscopy without Silicone Tube Intubation

Purpose: To evaluate the effects and limitations of lacrimal endoscopy without silicone tube intubation in patients with epiphora.Methods: We conducted a retrospective chart review of 64 eyes in 49 patients who underwent lacrimal endoscopy between May 2021 and May 2022. The clinical characteristics, irrigation test results, lacrimal endoscopic findings, and type of surgery were analyzed.Results: The mean duration of symptoms was 31.2 months, and was significantly longer in the failure group than in the success group (<i>p</i> = 0.043). Irrigation tests showed passage, partial obstruction, and complete obstruction in 20 (31.3%), 16 (25.0%), and 28 (43.7%) eyes, respectively. Lacrimal endoscopy showed narrowing, mucus, fibrosis, granulation, and stones in 41 (64.0%), 12 (18.8%), 6 (9.3%), 3 (4.7%), and 2 (3.1%) eyes, respectively. Following lacrimal endoscopy, 32 (50.0%) eyes each were included in the success and failure groups. Preoperative irrigation test results did not affect the success rate (<i>p</i> = 0.203). Silicone tube intubation and dacryocystorhinostomy were performed in 5 (7.8%) and 8 (12.5%) eyes, respectively, because the symptoms did not improve after lacrimal endoscopy.Conclusions: Lacrimal endoscopy, performed without silicone tube intubation, was effective in improving symptoms and may guide the choice of surgical technique, if required.

Two novel prehabilitation apps to help patients stop smoking and risky drinking prior to hip and knee arthroplasty

PurposeDaily smoking or risky drinking increases the risk of complications after surgery by ~50%. Intensive prehabilitation aimed at complete cessation reduces the complication rate but is time-consuming. The purpose of this study was to carry out preoperative pilot tests (randomized design) of the feasibility (1A) and validation (1B) of two novel prehabilitation apps, habeat® (Ha-app) or rehaviour® (Re-app).MethodsPatients scheduled for hip or knee arthroplasty with daily smoking, risky drinking, or both were randomised to one of the two apps. In part 1A, eight patients and their staff measured feasibility on a visual analog scale (VAS) and were interviewed about what worked well and the challenges requiring improvement. In part 1B, seven patients and their staff tested the improved apps for up to two weeks before validating the understanding, usability, coverage, and empowerment on a VAS and being interviewed.ResultsIn 1A, all patients and staff returned scores of ≥5 for understanding the apps and mostly suggested technical improvements. In 1B, the scores varied widely for both apps, with no consensus achieved. Two of four patients (Ha-app) and one-third of the patients (Re-app) found the apps helpful for reducing smoking, but without successful quitting. The staff experienced low app competencies among patients and high time consumption. Specifically, patients most often needed help for the Ha-app, and the staff most often for Re-app; however, the staff reported the Re-app dashboard was more user-friendly. Support and follow-up from an addiction specialist staff member were suggested to complement the apps, thereby increasing the time consumption for staff.ConclusionsThis pilot study to test prototype apps generated helpful feedback for the app developers. Based on the patient and staff comments, multiple improvements in functionality seem required before scaling up the evaluation for effect on prehabilitation and postoperative complications.

The effects of a multidisciplinary pathway for perioperative management of patients with hip fracture

ABSTRACT Objectives To determine if a multidisciplinary pathway focused on non-opioid pain management, delirium assessment, and resource utilization improved outcomes in geriatric hip fracture patients. The goal was to reduce opioid usage, consultation not congruent with guidelines, and increase use of regional anesthesia to reduce delirium and improve outcomes. Methods An observational study was performed on hip fracture patients before and after the intervention. Hospitalists were educated on indications for preoperative cardiac consultation and specialized preoperative cardiac testing according to evidence-based guidelines with the inpatient cardiology service. Additional education on multimodal analgesia, limiting opioids, and peripheral nerve blocks was provided by the acute pain service. Pre-intervention outcomes from 1 July 20171 July 2017 to 31 May 201831 May 2018 (N = 92) were compared to post-intervention outcomes from 1 July 20181 July 2018 to 31 May 201931 May 2019 (N = 98) and included delirium, length of stay, 30-day readmission rate, time from arrival to procedure start time, time to first physical therapy session, and completion of cardiology consult time. We examined adherence, use of nerve blocks, and pre- and post-operative pain scores and opioid use. Results Delirium was reduced from 50.0% (N = 46/92) to 28.6% (N = 28/98); p = 0.002. Postoperative opioid use (IV morphine milligram equivalents) decreased from an average of 57.2 mg (±67.7) to 42.6 mg (±58.2),P < .0001. There was a significant decrease in mean pre-operative (5.4 ± 4.14 to 5.05 ± 2.8, P < .0001) and post-operative pain scores (4.3 ± 5.2 to 3.2 ± 2.2, P < .0001). There was a significant reduction in time to cardiology consultation from 18 h] to 12 h ; p < .001). Conclusions A multidisciplinary collaboration between hospitalists, anesthesiologists, and cardiologists for hip fracture patients was associated with a reduction in pain and delirium and time to cardiologist evaluation. Prospective studies focusing on additional patient-centered outcomes are warranted.

Intra-operative electroencephalogram frontal alpha-band spectral analysis and postoperative delirium in cardiac surgery: A prospective cohort study.

Postoperative delirium (POD) remains a frequent complication after cardiac surgery, with pre-operative cognitive status being one of the main predisposing factors. However, performing complete pre-operative neuropsychological testing is challenging. The magnitude of frontal electroencephalographic (EEG) α oscillations during general anaesthesia has been related to pre-operative cognition and could constitute a functional marker for brain vulnerability. We hypothesised that features of intra-operative α-band activity could predict the occurrence of POD. Single-centre prospective observational study. University hospital, from 15 May 2019 to 15 December 2021. Adult patients undergoing elective cardiac surgery. Pre-operative cognitive status was assessed by neuropsychological tests and scored as a global z score. A 5-min EEG recording was obtained 30 min after induction of anaesthesia. Anaesthesia was maintained with sevoflurane. Power and peak frequency in the α-band were extracted from the frequency spectra. POD was assessed using the Confusion Assessment Method for Intensive Care Unit, the Confusion Assessment Method and a chart review. Sixty-five (29.5%) of 220 patients developed POD. Delirious patients were significantly older with median [IQR] ages of 74 [64 to 79] years vs. 67 [59 to 74] years; P < 0.001) and had lower pre-operative cognitive z scores (-0.52 ± 1.14 vs. 0.21 ± 0.84; P < 0.001). Mean α power (-14.03 ± 4.61 dB vs. -11.59 ± 3.37 dB; P < 0.001) and maximum α power (-11.36 ± 5.28 dB vs. -8.85 ± 3.90 dB; P < 0.001) were significantly lower in delirious patients. Intra-operative mean α power was significantly associated with the probability of developing POD (adjusted odds ratio, 0.88; 95% confidence interval (CI), 0.81 to 0.96; P = 0.007), independently of age and only whenever cognitive status was not considered. A lower intra-operative frontal α-band power is associated with a higher incidence of POD after cardiac surgery. Intra-operative measures of α power could constitute a means of identifying patients at risk of this complication. NCT03706989.

PROSPECTIVE RANDOMIZED STUDY USING PHARMACOGENETICS TO OPTIMIZE PERIOPERATIVE PAIN MANAGEMENT AFTER TOTAL KNEE ARTHROPLASTY

AbstractIntroductionAdverse reactions to pain medication and pain can delay discharge after outpatient knee arthroplasty (TKA). Pharmacogenomics is an emerging tool that might help reduce adverse events by tailoring medication use based on known genetic variations in the CYP genes determining drug metabolism. This study was undertaken to evaluate whether pre-operative pharmacogenomic testing could optimize peri-operative pain management in patients undergoing total knee arthroplasty (TKA).MethodsThis prospective, randomized study was performed in adults undergoing primary TKA. Patients in the experimental group underwent pre-operative pharmacogenomic evaluation and medication adjustments. Medications were not optimized for control patients. The Overall Benefit of Analgesic Score (OBAS) at 24 hours post-op was the primary outcome. Postoperative pain scores (VAS scale), total opioid use, time in recovery, and time to discharge were also compared.Results76 patients enrolled. 93% of patients had a poor-intermediate phenotype for at least one of four CYP genes. OBAS did not differ significantly between the two groups (4.2 control vs. 4.7 experimental; 95% CI −1.1 to 2.1) and was below the minimum clinically important difference of 2.0 points. Furthermore, there were no differences in any OBAS subscale including pain, satisfaction, or nausea. There were no differences in time in the recovery area or to discharge from hospital, or narcotic use.ConclusionsDespite many patients having a poor-intermediate phenotype for a CYP gene, pharmacogenomic testing prior to TKA and medication adjustment did not improve anesthesia or pain management outcomes, time to discharge or mean total opioid use after surgery.

Blood Products Utilization Status in Off-Pump Cardiac Surgery Patients.

Background: Transfusion support has an essential role in coronary artery bypass graft (CABG). The time-honored gold standard for CABG is the on-pump procedure (ONCAB); however, off-pump coronary artery bypass (OPCAB) is also a safe, cost-benefit procedure with fewer blood transfusion requirements. This study was performed to evaluate transfusion patterns in OPCAB due to the diversity of transfusion practices. Materials and Methods: This retrospective study was performed to determine the transfusion rate and triggers in OPCAB patients. Medical files of all patients undergoing OPCAB surgery at Sanandaj Tohid Hospital in 2014 were reviewed. Patients' demographics data, preoperative laboratory tests (PT, aPTT, Hb, Hct, Platelet count), underlying medical conditions, and their possible relation to further transfusions and the ward department in which the transfusion had taken place were extracted. SPSS 16 Chicago software, T-student Test, One Way Anova, and χ2 exam were applied for data analysis. P values ≤0.05was considered significant. Results: Among 91 elective OPCAB patients: 28(30.8%) women and 63(69.2%) men with mean age of 64.80±9.02 years, 63(69.23%) received a blood product. Mean utilization of PRBC, FFP, Platelet, and Cryoprecipitate were 2.17±2.044, 2.46±2.86, 2.86±3.80 and 0.40±2.10 units, respectively. ICU revealed the highest consumption rate for all products. Female sex (p<0.001), Hypertension (P=0.002), and low hemoglobin(P=0.004) were noted as predictive factors for transfusion. Conclusion: This study concluded that the transfusion rate in OPCAB is still very high in Iran (regarding a study in a countryside hospital) and that the highest utilization rate is seen in the ICU.

Preventing quality improvement drift: evaluation of efforts to sustain the cost savings from implementing best practice guidelines to reduce unnecessary electrocardiograms (ECGs) during the preadmisison testing evaluation.

Medical professionals commonly fail to follow best practice guidelines. Drift, or a return to previous tendencies, is abundant in healthcare even when guidelines are followed initially. This "drift" was found internally at Temple University Hospital with preoperative electrocardiograms (ECGs). Best-practice guidelines were instituted and followed as a first step, but sustaining performance improvement was the ultimate goal. The objectives are to improve and maintain adherence to published guidelines for preoperative ECG testing at Temple University Hospital in a physician-led, nurse practitioner (NP)-staffed preadmission testing (PAT) clinic. To start this quality improvement (QI) project, a retrospective chart review was completed to determine the number of ECGs performed in PAT at Temple University Hospital in 2017. New guidelines for ordering preoperative ECGs were then implemented, and Plan-Do-Study-Act (PDSA) cycles were performed over 3 years. A repeat retrospective chart review was completed and looked at ECGs ordered from 2018 through 2020. The number of ECGs completed in PAT before and after implementation of the new guidelines was then compared. In addition, the complexity of our surgical patients was estimated by looking at the yearly average American Society of Anesthesiology Physical Health Status (American Society of Anesthesiology [ASA] status) values assigned. Finally, the cost of performing each ECG was calculated, and the cost savings to the hospital over 4 years was determined. The baseline ECG rate for PAT in 2017, 2018, 2019, and 2020 at Temple University Hospital was 54.0 , 20.7, 22.3, and 21.9 %, respectively, which was a statistically significant decrease in ECG performance rate in the years after implementation of the PDSA project. The ASA status average remained constant, demonstrating that while patients' medical diagnoses remained on average the same, reinforced training had been effective in preventing a return to previous liberal ordering tendencies. Over the course of 4 years, the reduction in unnecessary ECGs led to an estimated direct cost savings of $213,000. Self-adoption of best-practice guidelines among clinicians is often poor; however, the barriers to adoption can be overcome with education and individual feedback. Sustaining performance improvement gains is challenging, but possible, as shown by example in one urban, academic teaching hospital's physician-led, NP-staffed outpatient clinic.

Pancreatic duct filling during cholecystectomy intraoperative cholangiogram and incidence of postoperative pancreatitis

AbstractBackground and AimLaparoscopic cholecystectomy (LC) with intraoperative cholangiography (IOC) is a commonly performed surgical procedure in most hospitals. Anecdotal evidence suggests that when the pancreatic duct (PD) inadvertently fills during IOC, there may be an increased risk of postoperative pancreatitis (POP). However, there is a paucity of information in the literature about both the incidence of pancreatitis post LC and the incidence of PD filling on IOC and any potential relationship between the two.MethodsA retrospective review was performed of all LC performed in our institution over a 10‐year period. IOC images were reviewed and clinical data collated.ResultsOf the 1243 procedures identified, 952 had IOC images available for review and were included in the study. The incidence of POP was 0.7%. The incidence of PD filling was 13.4%. Patient's age, sex, urgency of surgery, preoperative liver function tests (LFTs), history of pancreatitis, contrast leakage, and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were not statistically related to the incidence of POP. Of those with PD filling, 2% had POP versus 0.5% who had no PD filling. This trended toward significance on univariate analysis (P = 0.05). However, on logistic regression, POP was the only significant independent risk factor (P = 0.02).ConclusionThe incidence of pancreatitis post LC and IOC is low. PD filling is associated with increased incidence of pancreatitis in this scenario and it is crucial for clinicians to be aware of this potential risk. This retrospective study was based on the review of saved images, and therefore PD filling might have been underestimated. Prospective studies would be useful to ascertain any definitive clinical association.

The role of planned two-stage surgery in the management of congenital cholesteatoma.

The purpose of this study is to verify the role of "planned two-stage surgery" in the management of advanced congenital cholesteatoma regarding disease recurrence rates, complications and the need for salvage surgery. Retrospective review of all congenital cholesteatoma under the age of 18 years underwent surgery from October 2007 to December 2021 in a single tertiary referral center. Patients with Potsic stage I/II who had closed-type congenital cholesteatoma received one-stage surgery. Advanced cases or those with open-type infiltrative congenital cholesteatomas underwent planned two-stage surgery. The second stage of surgery was performed 6-10 months after the first stage of surgery. Ossiculoplasty would be performed in the second operation if a significant air-bone gap was detected in the preoperative pure-tone audiometry test. Twenty-four patients were included in the series. Six patients received one-stage surgery and no recurrence was noted in this group. The remaining 18 underwent planned two-stage surgery. Residual lesions found in the second operative phase were observed in 39% of patients who received planned two-stage surgery. Except for one patient whose ossicular replacement prosthesis protruded and two patients who had perforated tympanic membranes, none of the 24 patients required salvage surgery during follow-up (mean, 77 months after surgery), and no major complications occurred. Planned two-stage surgery for advanced-stage or open infiltrative congenital cholesteatoma could timely detect residual lesions to avoid extensive surgery and reduce complications.

The use of serum alkaline phosphatase as a choledocholithiasis marker to mitigate the cost of magnetic resonance cholangiography.

To assess the predictive value of preoperative serum laboratory test results for identifying choledocholithiasis and reduce the use of cholangioresonance and its inherent costs. Patients aged 21-69 years who underwent preoperative cholangioresonance examination at our institute were included. Patients with a history of fluctuating jaundice or biliary pancreatitis, bile duct dilatation on ultrasonography, and elevated levels of canalicular enzymes (alkaline phosphatase >100U/L and gamma-glutamyl transferase >50U/L) underwent cholangioresonance-guided surgery. Cases of choledocholithiasis confirmed by cholangioresonance were compared with those without choledocholithiasis. Serum laboratory data were evaluated and the diagnostic capabilities of these examinations were analyzed. A total of 104 patients were included. For detecting choledocholithiasis using alkaline phosphatase, the cut-off point was 78U/L, sensitivity was 97.6% (95%CI: 87.4-99.9), and specificity was 72.6% (95%CI: 59.8-83.1). In the binary logistic regression analysis, age (OR= 0.92; 95%CI: 0.86-0.98) and alkaline phosphatase level (OR= 1.02; 95%CI: 1.01-1.05) were selected for the final model. Serum alkaline phosphatase levels may aid preoperative diagnosis of asymptomatic choledocholithiasis. After a global clinical assessment of the patient, serum laboratory findings may contribute to a reduction in cholangioresonance-related heathcare costs.

Evaluation of the Preoperative Slide Test in the Prediction of Intra-Abdominal Adhesions: A Single-Center, Double-Blinded, Prospective Observational Study.

To evaluate the efficacy of the preoperative ultrasonographic sliding sign in predicting intra-abdominal adhesions. This was a single-center, double-blinded, prospective observational study undertaken from March and September 2021 on 110 patients with a history of previous abdominal surgery. All patients who were scheduled for laparoscopy underwent slide test in 5 zones of abdomen: right lower quadrant, left lower quadrant, previous operation site, vesicouterine pouch, and rectovaginal pouch. Adhesions were assessed by the same gynecologic surgeon using ultrasonography before the surgery and by gynecological surgeons during surgery, and by a third gynecologic surgeon to compare the preoperative slide test findings and laparoscopic findings after the surgery. Seventy-three (66.4%) patients underwent laparoscopic surgery, and 37 (33.6%) patients underwent laparotomy. The mean age of patients was 46.9 ± 1.0years. Sensitivity, specificity, and positive and negative predictive values of preoperative ultrasonography in predicting adhesions were 89.5%, 91.7%, 97.5%, and 71.0%, respectively. The accuracy of the slide test was calculated as 90.0%. It was found that as the total number of cesarean sections increased the estimates of vesicouterine adhesions and actual adhesions increased (P = .008). Also, the prediction of intra-abdominal adhesions and actual adhesions significantly increased as the total number of surgical operations increased (P = .002). Intra-abdominal adhesions can be detected with the slide test, which is a non-invasive and well-tolerated procedure. Slide test can guide the physician before the elective operation in patients with previous abdominal surgery and may assist in counseling patients.