Preoperative Workup Research Articles

Integrating the 5-SENSE Score for Patient Selection in Vagus Nerve Stimulation for Drug-Resistant Epilepsy.

Addressing the challenge of drug-resistant epilepsy, our study offers a novel perspective by retrospectively applying the 5-SENSE score, initially created for stereoelectroencephalography (SEEG) planning, to evaluate its predictive value in patients undergoing vagus nerve stimulation (VNS) therapy. We conducted a comprehensive preoperative diagnostic work-up, including computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography-CT (PET-CT), video-electroencephalogram (video-EEG), and clinical semiology. We then stratified 76 patients into three groups - low, moderate, and high focality - based on the focality of the seizure-onset zone. Such stratification was made to check the scoring ability in predictingVNStherapy seizure reduction. Our findings demonstrate an association between the extent of focality at the seizure-onset zone and the effectiveness of VNS, which may help to define the role of the 5-SENSE score in patient selection for VNS. This high dispersion of responses in the group with high focality reinforces the idea that outcome estimation is difficult and argues for an individualized strategy in the treatment of drug-resistant epilepsy. A study at the level of the 5-SENSE score indicates the importance of detailed preoperative assessments that may better optimize selection for VNS therapy and further improve clinical outcomes.

Prevalence, risk factors, microbiological results and clinical outcome in unexpected positive intraoperative cultures in unclear and presumed aseptic hip and knee revision arthroplasties – A ten-year retrospective analysis with a minimum follow up of 2 years

BackgroundThe aim of this study was to assess the prevalence, microbiological spectrum, risk factors, and clinical outcomes of unexpected-positive-intraoperative-cultures (UPIC) in presumed aseptic and unclear revision-total-hip-/knee-arthroplasties (rTHA and rTKA) compared to culture-negative (CN) revisions. MethodsThis study reviewed all International-consensus-meeting-2018 (ICM 2018) negative or inconclusive rTHA (n = 751) and rTKA (n = 679) performed at our institution from 2011 to 2020 with a minimum follow-up of two years. A Kaplan-Meier-analysis was performed to determine the septic and aseptic-free implant survival in cases with UPIC's and matched culture-negative cases. Patient demographics, risk factors, microbiological spectrum and clinical outcomes were evaluated. ResultsThere were significantly more UPIC cases in rTHA 196/751 (26.1 %) compared to rTKA 113/679 (16.6 %); (p < 0.001). UPICs in rTKA and rTHA have a lower septic and aseptic implant-free-survival compared to CN revisions. Patients with a history of nickel allergy have a higher risk of an UPIC in rTHA and rTKA (p < 0.001). Septic re-revisions after UPIC had a significantly (H: p = 0.004; K: p = 0.030) shorter time period to the primary/previous surgery (H: 84 (IQR:41–797); K: 115 (IQR:55–446)) compared to patients with aseptic re-revisions after UPIC (H:1248 (IQR:178-3534); K: 827 (IQR:361-1183)). ConclusionUPICs have a higher rate of septic and aseptic failure than CN outcomes. UPICs are twice as common in rTHA compared to rTKA. Preoperative PJI workup reduces the UPIC rate. Nickel allergy is a risk factor for UPIC. Early revisions with UPICs after primary THA or TKA have a higher risk of septic failure. The translational potential of this articleThis article provides new information on revision rates for UPIC and potential risk factors for UPIC and its treatment failure.

Anaesthesia considerations in heart transplantation: A comprehensive review

In over 56 years since the first heart transplant, the science of heart transplantation has evolved from an experimental procedure to an established standard of care for end-stage heart failure. The process involves appropriate patient selection, the listing of recipients, pre-operative optimization, intraoperative management, post-operative care, and follow-up. A robust transplant team, strong government backing, and positive support from the population are essential criteria for the success of any transplant program. Management of heart transplant recipients from the Anaesthesia perspective is challenging due to a myriad of patient risk factors; and the urgent nature of surgery due to the unpredictable nature of donor heart availability. The intraoperative aim is safe induction of anaesthesia, strict asepsis, immunosuppressive therapy, anticipation of major vascular injury, managing pulmonary vascular resistance, ventricular support, optimal ventilatory strategy, and good haemostasis. The postoperative goal is preventing infection, haemodynamic management, gradual weaning of supports, adequate analgesia, monitoring for complications, physiotherapy, and early discharge of the patient from the intensive care unit. There is an increased complexity of heart transplant recipients, due to the increasing use of pre-transplantation mechanical circulatory support devices. The cardiac anaesthesiologist needs to have knowledge of the modern changes in the field of Heart Transplant. The goal of this paper is to provide an overview of the heart transplant origins in India, donor pre-operative workup, intra-operative anaesthesia care, and early post-operative management of heart transplant patients.

Low bone mineral density: a primer for the spine surgeon.

Within spinal surgery, low bone mineral density is associated with several postoperative complications, such as proximal junctional kyphosis, pseudoarthrosis, and screw loosening. Although modalities such as CT and MRI can be utilized to assess bone quality, DEXA scans, the "Gold Standard" for diagnosing osteoporosis, is not routinely included in preoperative workup. With an increasing prevalence of osteoporosis in an aging population, it is critical for spine surgeons to understand the importance of evaluating bone mineral density preoperatively to optimize postoperative outcomes. The purpose of this state-of-the-art review is to provide surgeons a summary of the evaluation, treatment, and implications of low bone mineral density in patients who are candidates for spine surgery.

Severe Dysphagia in a Patient with Wallenberg Syndrome and Killian Jamieson Diverticulum: A Case Report

Lateral medullary syndrome (Wallenberg syndrome) and Killian Jamieson diverticulum are both conditions known to cause dysphagia. Here, we present the first reported case of severe dysphagia due to Wallenberg syndrome and a Killian Jamieson diverticulum discovered incidentally during videofluoroscopic swallowing study. A 66-year-old male previously diagnosed with Wallenberg syndrome was referred to our hospital due to severe dysphagia. Pre-operative work-up revealed decreased left-sided pharyngeal contraction, left vocal fold paralysis, impaired laryngeal elevation, and poor upper esophageal sphincter relaxation during swallowing. Furthermore, on videofluoroscopic swallowing study, an incidental finding of a contrast-filled outpouching of the esophagus on the left, below the level of the cricopharyngeus, indicated the presence of a pharyngoesophageal diverticulum. The patient underwent bilateral cricopharyngeal myotomy with diverticulectomy, laryngeal suspension surgery, and tracheostoma revision. The diagnosis of a Killian Jamieson diverticulum was confirmed based on intra-operative findings, as the diverticular pouch was indeed seen to be located below the cricopharyngeal muscle. For patients with severe dysphagia that does not improve with swallowing rehabilitation, swallowing improvement surgery is an option. It aims to improve pre-operatively identified dysfunctional sites in the swallowing mechanism. It is important to always consider pharyngoesophageal diverticula as a possible cause of dysphagia so as not to miss the diagnosis. In this patient’s case, diverticulectomy was necessary to ensure the best possible outcomes in terms of improving his dysphagia.

Insight Into the Clinical Practices of US-Based Surgical Nongovernmental Organizations

IntroductionA growing sector of humanitarian surgical nongovernmental organizations (NGOs) is providing care in low- and middle-income countries. Minimal data exists regarding this extremely heterogeneous community. This study aims to describe the demographics and clinical practices of surgical NGOs. We hypothesize there are identifiable attributes of such organizations which correlate with success. MethodsA survey was sent to 83 US-based surgical NGOs directly providing general or subspecialty surgical care in low- and middle-income countries. Further information was obtained from organizations’ websites. Descriptive statistics were performed to analyze organizational attributes and define protocol-driven practices. ResultsThirty NGOs (36%) responded, averaging 20 ± 11 y of operation. Annually, US humanitarian surgical organizations performed a wide range of operations (10-15,000) with 52% performing fewer than 200 operations per year. Sixty-seven percent of responders were classified as strongly protocol-driven. Only twenty percent reported deviation from standard US practice occurs often or very often, most commonly in pain management (18%), preoperative workup (16%), and operative technique (16%). ConclusionsTo our knowledge, this is the first effort to describe the characteristics and clinical practices of the humanitarian surgical sector. There exists a wide scope of clinical practice among responding surgical NGOs, however mostly consistent with US standards, with a prevalance of protocol-driven clinical approach. Developing consensus-based protocols may help standardize and improve quality of care for surgical NGOs.

New Perspectives on Risk Assessment and Anticoagulation in Elective Spine Surgery Patients: The Impact of Ultra-Minimally Invasive Endoscopic Surgery Techniques on Patients with Cardiac Disease.

The advent of ultra-minimally invasive endoscopic spine surgery, characterized by significantly reduced surgery times, minimal blood loss, and minimal tissue trauma, has precipitated a paradigm shift in the preoperative management of patients with cardiac disease undergoing elective spine procedures. This perspective article explores how these advancements have influenced the requirements for preoperative cardiac workups and the protocols surrounding the cessation of anticoagulation and antiplatelet therapies. Traditionally, extensive cardiac evaluations and the need to stop anticoagulation and antiplatelet agents have posed challenges, increasing the risk of cardiac events and delaying surgical interventions. However, the reduced invasiveness of endoscopic spine surgery presents a safer profile for patients with cardiac comorbidities, potentially minimizing the necessity for rigorous cardiac clearance and allowing for more flexible anticoagulation management. This perspective article synthesizes current research and clinical practices to provide a comprehensive overview of these evolving protocols. It also discusses the implications of these changes for patient safety, surgical outcomes, and overall healthcare efficiency. Finally, the article suggests directions for future research, emphasizing the need for updated guidelines that reflect the reduced perioperative risk associated with these innovative surgical techniques. This discussion is pivotal for primary care physicians, surgeons, cardiologists, and the broader medical community in optimizing care for this high-risk patient population.

Surgical Nonresponders in Zenker Diverticulum and Lower Esophageal Pathology (POUCH Collaborative).

To identify characteristics of patients who have poor improvement in symptoms following surgical management of Zenker Diverticulum (ZD). Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgical repair of ZD between August 2017 and January 2024. Patient demographics, esophagrams, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were obtained from a REDCap database. t-tests, Wilcoxon rank sum tests, Chi-square or Fisher's exact tests were used to compare the characteristics. Patients with <50% improvement in their EAT-10 scores were deemed surgical nonresponders (SNRs). Those with ≥50% improvement in their EAT-10 scores were deemed surgical responders (SRs). A total of 184 patients were prospectively followed after undergoing either open or endoscopic surgical management. Twenty-two patients (12%) were deemed SNRs. Preoperative presence of a hiatal hernia was statistically significant characteristic between the SNRs (63.6%) and SRs (32.1%) (p = 0.004). Size of the ZD and history of previous ZD surgery was not a significant characteristic. The length of stay and complication rate were not statistically different between the groups. Coexistent esophageal pathology may lead to poor symptomatic improvement following ZD surgery. Preoperative workup of other esophageal disorders is recommended to detect likely SNRs. For SNRs, further esophageal workup may be necessary to evaluate for other esophageal causes related to poor symptomatic improvement following ZD surgery. Level 3 Laryngoscope, 2024.

Uterus transplantation: A scoping review focused on obstetric outcomes.

Congenital uterine anomalies include a wide diversity of uterine malformations that can compromise reproductive potential. Uterus transplantation (UTx) proposes an innovative treatment for absolute uterine factor infertility; however, there is a lack of standardized protocols to guide clinical management among this population. To describe recipient and donor characteristics and obstetric outcomes in patients undergoing UTx. We performed a literature search using the PubMed database to retrieve available scientific articles. We analyzed the references of included articles to assess additional articles that could be eligible to be included in the review. Likewise, we identified further studies using other methods, including Google Scholar. Titles and abstracts were screened in duplicate to select original reports with information available for the outcomes of interest. This review assessed the advantages and disadvantages of the techniques used, patient characteristics, obstetric and non-obstetric complications, functional duration of the organ, and neonatal outcomes. Among the 36 reports included in this review we found 55 pregnancies and 38 live births following UTx and a higher success rate for invivo uterine donations. The most common obstetric complications reported included miscarriage, pre-eclampsia, and gestational hypertension. The most common non-obstetric complications reported include episodes of rejection, acute kidney injury, anemia, and cholestasis. Living donors required a comprehensive preoperative workup, decreasing organ rejection, infection, and vascular complications. More studies are needed to standardize the UTx procedure and improve obstetric, fetal, and neonatal outcomes. Further understanding of which recipient and donor characteristics minimize complications will significantly decrease the risk of adverse outcomes.

Incidence of Recurrence Post Hemi Thyroidectomy in Thyroid Papillary Carcinoma: A Meta-Analysis

Abstract Background Papillary thyroid carcinoma (PTC) is the most common subtype of thyroid carcinoma. It has an excellent prognosis, with a 10-year survival rate of more than 95 per cent, although outcome is poorer for aggressive subtypes. Aim of the Work Our work in this study shows that the incidence of recurrence post hemi thyroidectomy is significantly higher compared to post total thyroidectomy and in case of multifocal and insular carcinoma with hemi thyroidectomy it increases the incidence of recurrence and drastically affecting the 10-year survival rate and the quality of life. Material and Methods We followed the PRISMA statement guideline during this systematic review and meta-analysis preparation and performed all steps according to the Cochrane handbook of systematic reviews of intervention. We searched PubMed, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, Embase, and Science Direct till November 2021 relevant keywords. We used the following search strategy for searching different databases: (“Papillary Thyroid Cancer” OR “Papillary Thyroid Cancers” OR “Papillary Thyroid Carcinomas” OR “Papillary Carcinoma Of Thyroid” OR “Papillary Thyroid Carcinoma” OR “Familial Non medullary Thyroid Cancer” OR “Non medullary Thyroid Carcinoma” OR “Non medullary Thyroid Carcinomas” OR “Thyroid Carcinoma, Non medullary” OR “Thyroid Carcinomas, Non medullary”) AND (Hemithyroidectomy OR Thyroidectomy OR Thyroidectomies OR thyroid removal). All the references of the included studies were searched for relevant studies. Results Multifocality and insular carcinoma and bilaterality increase the incidence of recurrence drastically so it is recommended for total thyroidectomy. Gender plays a role in the aggressiveness of the tumor but not in the incidence of recurrence as this is determined by the selection criteria of the candidate and the surgical technique. We studied 7 risk factors through this meta-analysis and it is recommended for application of LNR as a post op prognostic tool for recurrence and to apply hemi thyroidectomy for tumor size &amp;lt;2 cm instead of &amp;lt; 4 also meticulous pre-operative workup, accurate risk assessment, stratification and staging this is to customize a road map for every patient through a multi-disciplinary team. Conclusion In this meta-analysis we found that in low grade differentiated papillary thyroid carcinoma the recurrence is higher with hemithyroidectomy than in total thyroidectomy after applying the ATA guidelines for 10 years retrospectively but in case of 10 year survival it showed no significant difference.

Issues and considerations in perioperative management of robotic coronary bypass grafting.

Minimally invasive approaches to address coronary artery disease, such as robotic coronary bypass grafting, are emerging in surgery and have been shown to be beneficial with a reduction in morbidity. The perioperative management of this subset of patients is crucial to the success of the operation as there are several preoperative and postoperative issues and considerations that need to be addressed. A meticulous preoperative workup with an extensive history, physical exam, and appropriate imaging are instrumental to ensure a successful operation. Protocolized postoperative care is also essential to garnish the most benefit from this minimally invasive approach. All of these factors, in conjunction with a heart team approach and surgeon experience, are imperative for the successful outcome of robotic coronary artery revascularization.

Radiologic and Blood Markers Predicting Long-Term Neurologic Outcome Following Decompressive Craniectomy for Malignant Ischemic Stroke: A Preliminary Single-Center Study.

Malignant ischemic stroke (MIS) is defined by progressive cerebral edema leading to increased intracranial pressure (ICP), compression of neural structures, and, eventually, death. Decompressive craniectomy (DC) has been advocated as a lifesaving procedure in the management of patients with MIS. This study aims to identify pre- and postoperative predictive variables of neurologic outcomes in patients undergoing DC for MIS. We conducted a retrospective study of patients undergoing DC in a single center from April 2016 to April 2020. Preoperative workup included baseline clinical status, laboratory data, and brain computed tomography (CT). The primary outcome was the 6-month modified Rankin score (mRS). The secondary outcome was the 30-day mortality. During data capture, a total of 58 patients fulfilled the criteria for MIS, of which 22 underwent DC for medically refractory increased ICP and were included in the present analysis. The overall median age was 58.5 years. An immediate (24 hour) postoperative extended Glasgow Outcome Scale (GOSE) score ≥5 was associated with a good 6-month mRS (1-3; p = 0.004). Similarly, low postoperative neutrophils (p = 0.002), low lymphocytes (p = 0.004), decreased neutrophil-to-lymphocyte ratio (NLR; p = 0.02), and decreased platelet-to-lymphocytes ratio (PLR; p = 0.03) were associated with good neurologic outcomes. Preoperative variables independently associated with worsened 6-month mRS were the following: increased age (odds ratio [OR]: 1.10; 95% confidence interval [CI]: 1.01-1.20; p = 0.02), increased National Institutes of Health Stroke Scale (NIHSS) score (OR: 7.8; 95% CI: 2.5-12.5; p = 0.035), Glasgow Coma Scale (GCS) score less than 8 at the time of neurosurgical referral (OR: 21.63; 95% CI: 1.42-328; p = 0.02), and increased partial thromboplastin time (PTT) before surgery (OR: 2.11; 95% CI: 1.11-4; p = 0.02). Decreased postoperative lymphocytes confirmed a protective role against worsened functional outcomes (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). Decreased postoperative lymphocyte count was associated with a protective role against increased mRS (OR: 0.01; 95% CI: 0.01-0.4; p = 0.02). The occurrence of hydrocephalus at the postoperative CT scan was associated with 30-day mortality (p = 0.005), while the persistence of postoperative compression of the ambient and crural cistern showed a trend towards higher mortality (p = 0.07). This study reports that patients undergoing DC for MIS showing decreased postoperative blood inflammatory markers achieved better 6-month neurologic outcomes than patients with increased inflammatory markers. Similarly, poor NIHSS score, poor GCS score, increased age, and larger PTT values at the time of surgery were independent predictors of poor outcomes. Moreover, the persistence of postoperative compression of basal cisterns and the occurrence of hydrocephalus are associated with 30-day mortality.

Three-dimensional reconstruction technology in the preoperative workup of complex hepatic resections. Our experience on 11 consecutive cases.

Three-dimensional liver modeling can be a useful tool when planning the preoperative strategy in liver surgery. The present study aims to review our case series of patients requiring complex hepatic resections for primary and secondary liver tumors, and for whom 3D models were built, to add further evidence in this direction. All consecutive patients undergoing complex liver resection were enrolled. Cross-sectional triphasic CT images were obtained for each patient. DICOM images were processed, and full virtual 3D models were generated. The additional details provided by 3D models were employed to better understand the anatomy, to define the most adequate surgical pathway, and, in case, to switch to a different surgical procedure. From January 2020 to September 2022, 11 complex hepatic resections requiring 3D reconstruction technology were performed. Eight 3D models scored ≥ 15 points in the quality control system. A detailed analysis of each case was reported. In three cases (27%) 3DVT helped to understand the anatomy and/or to detect vascular abnormalities. In six cases (54.5%) 3DVT led to a variation of the surgical planning. 3DVT may be helpful in planning preoperatively the most appropriate surgical procedure. Further large-scale, well-designed studies are needed to prove its true effectiveness in HPB surgical oncology.

Gerbode defect resulting from Group B Streptococcus infective endocarditis: a case report

BackgroundGerbode defect is an unusual abnormal communication between the left ventricle and the right atrium and is a serious complication of aortic infective endocarditis. Group B Streptococcus is an uncommon cause of infective endocarditis and has a markedly destructive effect on valvular tissue. Acute fistulation between the left ventricle and the right atrium associated with this form of infective endocarditis is a life-threatening, aggressive complication that often requires urgent surgical intervention. However, the identification of actual communication is often extremely difficult. Herein, we describe an unusual case of Gerbode defect resulting from Group B Streptococcus infective endocarditis and discuss the issues surrounding such a rare cardiac defect and such an infection.Case presentationA 60-year-old man with underlying uncontrolled diabetes mellitus underwent endoscopic retrograde biliary drainage for acute cholangitis. On the 10th postoperative day, the patient developed multiple acute cerebral embolisms. Transthoracic echocardiography demonstrated severe aortic regurgitation and a large mobile vegetation near the tricuspid annulus. No obvious fistula between the left ventricle and the right atrium could be demonstrated. The blood culture examination was positive for Group B Streptococcus. The patient was diagnosed with Group B Streptococcus infective endocarditis, and antibiotic therapy was initiated. Transesophageal echocardiogram performed after referral to our hospital confirmed detachment of the right coronary cusp of the aortic valve from the annulus and an abnormal cavity immediately below the right coronary cusp. Color Doppler imaging finally revealed systolic blood flows from the left ventricle into the right atrium through the cavity. Therefore, we diagnosed the patient with Gerbode defect resulting from Group B Streptococcus infective endocarditis. In addition to aortic valve replacement, defect closure and left ventricular outflow tract repair were successfully performed urgently for severely complicated and uncommon infective endocarditis. The patient was uneventfully discharged without any complications.ConclusionsWe reported successful surgical treatment of unusual active IE and Gerbode defect caused by GBS. Careful preoperative echocardiographic work-up is imperative for accurate early diagnosis and successful repair.

Von Willebrand Factor Antigen Improves Risk Stratification for Patients with a Diagnosis of Resectable Hepatocellular Carcinoma.

Posthepatectomy liver failure (PHLF), complications of portal hypertension, and disease recurrence determine the outcome for hepatocellular carcinoma (HCC) patients undergoing liver resection. This study aimed to evaluate the von Willebrand factor antigen (vWF-Ag) as a non-invasive test for clinically significant portal hypertension (CSPH) and a predictive biomarker for time to recurrence (TTR) and overall survival (OS). The study recruited 72 HCC patients with detailed preoperative workup from a prospective trial (NCT02118545) and followed for complications, TTR, and OS. Additionally, 163 compensated patients with resectable HCC were recruited to evaluate vWF-Ag cutoffs for ruling out or ruling in CSPH. Finally, vWF-Ag cutoffs were prospectively evaluated in an external validation cohort of 34 HCC patients undergoing liver resection. In receiver operating characteristic (ROC) analyses, vWF-Ag (area under the curve [AUC], 0.828) was similarly predictive of PHLF as indocyanine green clearance (disappearance rate: AUC, 0.880; retention rate: AUC, 0.894), whereas computation of future liver remnant was inferior (AUC, 0.756). Cox-regression showed an association of vWF-Ag with TTR (per 10%: hazard ratio [HR], 1.056; 95% confidence interval [CI] 1.017-1.097) and OS (per 10%: HR, 1.067; 95% CI 1.022-1.113). In the analyses, VWF-Ag yielded an AUC of 0.824 for diagnosing CSPH, with a vWF-Ag of 182% or lower ruling out and higher than 291% ruling in CSPH. Therefore, a highest-risk group (> 291%, 9.7% of patients) with a 57.1% incidence of PHLF was identified, whereas no patient with a vWF-Ag of 182% or lower (52.7%) experienced PHLF. The predictive value of vWF-Ag for PHLF and OS was externally validated. For patients with resectable HCC, VWF-Ag allows for simplified preoperative risk stratification. Patients with vWF-Ag levels higher than 291% might be considered for alternative treatments, whereas vWF-Ag levels of 182% or lower identify patients best suited for surgery.

Dedicated anticoagulation management protocols in fragility femoral fracture care – a source of significant variance and limited effectiveness in improving time to surgery: The hip and femoral fracture anticoagulation surgical timing evaluation (HASTE) study

IntroductionApproximately 20 % of femoral fragility fracture patients take anticoagulants, typically warfarin or Direct Oral AntiCoagulant (DOAC). These can impact timing of surgery affecting patient survival. Due to several possible approaches and numerous factors to consider in the preoperative workup of anticoagulated patients, potential for variations in clinical practice exist. Some hospitals employ dedicated anticoagulation management protocols to address this issue, and to improve time to surgery. This study aimed to determine the proportion of hospitals with such protocols, compare protocol guidance between hospitals, and evaluate the effectiveness of protocols in facilitating prompt surgery. MethodsData was prospectively collected through a collaborative, multicentre approach involving hospitals across the UK. Femoral fragility fracture patients aged ≥60 years and admitted to hospital between 1st May to 31st July 2023 were included. Information from dedicated anticoagulation management protocols were collated on several domains relating to perioperative care including administration of reversal agents and instructions on timing of surgery as well as others. Logistic regression was used to evaluate effects of dedicated protocols on time to surgery. ResultsDedicated protocols for management of patients taking warfarin and DOACs were present at 41 (52.6 %) and 43 (55.1 %) hospitals respectively. For patients taking warfarin, 39/41 (95.1 %) protocols specified the dose of vitamin k and the most common was 5 milligrams intravenously (n=21). INR threshold values for proceeding to surgery varied between protocols; 1.5 (n=28), 1.8 (n=6), and 2 (n=6). For patients taking DOACs, 35/43 (81.4 %) and 8/43 (18.6 %) protocols advised timing of surgery based on renal function and absolute time from last dose respectively. Analysis of 10,197 patients from 78 hospitals showed fewer patients taking DOACs received surgery within 36 h of admission at hospitals with a dedicated protocol compared to those without (adjusted OR 0.73, 95% CI 0.54–0.99, p=0.040), while there were no differences among patients taking warfarin (adjusted OR 1.64, 95% CI 0.75–3.57, p=0.219). ConclusionsAround half of hospitals employed a dedicated anticoagulation management protocol for femoral fragility fracture patients, and substantial variation was observed in guidance between protocols. Dedicated protocols currently being used at hospitals were ineffective at improving the defined targets for time to surgery.

A non-inferiority study of MRI versus CT for staging and image-defined risk factor assessment in the preoperative work-up of abdominopelvic neuroblastoma

BackgroundNeuroblastoma accounts for 15 % of cancer deaths in children. Complete surgical resection is associated with a higher overall survival rate but also a higher morbidity rate. An international group of experts has defined a nomenclature of image-defined risk factors (IDRFs) for the determination of operability and the anticipation of reasonably foreseeable complications of surgery. However, there is no consensus on the optimal imaging modality (CT or MRI) for the assessment of IDRFs. The objective of the present study was to determine the non-inferiority of MRI vs. CT in the preoperative assessment of abdominopelvic neuroblastoma. The secondary objective was to assess the contribution of gadolinium contrast enhancement. MethodsAll children diagnosed with abdominopelvic neuroblastoma and whose preoperative work-up included a contrast-enhanced CT or MRI scan of the abdomen and pelvis between January 2014 and January 2023 were included. To evaluate the IDRFs, all the images were reviewed in three steps: (i) non-contrast MRI scans, (ii) both non-contrast and contrast-enhanced MRI scans, and (iii) contrast-enhanced CT scans. ResultsTwenty-five patients were found to be eligible, and fifteen were included. The mean time interval between MRI and preoperative CT was 23 days. In all patients, the identified IDRFs were similar for all three imaging modalities. Fourteen patients underwent full resection of the tumour. The surgical reports were fully consistent with the IDRFs described on CT and/or MRI. ConclusionA high-resolution three-dimensional T2 MRI sequence agreed fully with contrast-enhanced CT for the detection of IDRFs. Contrast-enhanced MRI did not add value. However, surgeons will need time to adapt to this MRI-based approach and learn how to interpret the results with confidence.

Unsuspected Positive Intraoperative Cultures in Aseptic Revision Knee Arthroplasty: Prevalence, Management, and Infection-Free Survivorship

BackgroundThe purpose of this study was to evaluate the management and outcomes of aseptic revision total knee arthroplasty (arTKA) with unsuspected positive cultures (UPCs) compared to those with sterile cultures. MethodsThe institutional database at a single tertiary center was retrospectively reviewed for arTKA from January 2013 to October 2023. Patients who met Musculoskeletal Infection Society criteria for periprosthetic joint infection (PJI) based on available preoperative infectious workup, received antibiotic spacers, or did not have at least 1 year of follow-up were excluded. Patients were stratified based on intraoperative cultures into 4 cohorts: sterile cultures, 1 UPC, ≥ 2 UPCs with different organisms, and ≥ 2 UPCs with the same organism. Univariable analyses were used to compare these groups. Kaplan-Meier survivorship analysis assessed infection-free survival at 5 years, and Cox proportional hazards regressions were used to evaluate factors that influence infection-free survival. A total of 691 arTKAs at a mean follow-up of 4.2 years were included in the study. Of these, 49 (7.1%) had 1 UPC with a new organism, 10 (1.4%) had ≥2 UPCs of the same organism, and 2 (0.2%) had ≥2 UPCs with different organisms. ResultsPostoperative antibiotics were prescribed to 114 (16.5%) patients—13 (26.5%) with 1 UPC, 6 (60.0%) with ≥2 UPCs of the same organism, and 0 (0.0%) of patients who had ≥2 UPCs of different organisms. There were no differences in infection-free survival at 5 years between patients who had sterile cultures and 1 UPC (96 versus 89%; P = .39) nor between sterile cultures and ≥2 UPCs of different organisms (96 versus 100%; P < .72). However, patients who had ≥2 UPCs of the same organism had significantly worse infection-free survival at 5 years compared to patients who had sterile cultures (58 versus 96%; P < .001). Cox proportional hazards regression suggested that when adjusting for covariates, an American Society of Anesthesiologists classification of ≥3 (hazard ratio [HR] = 3.1; P = .007), ≥2 UPCs of the same organism (HR = 11.0; P < .001), 1 UPC (HR = 4.2; P = .018), and arTKA with hinge constructs (HR = 4.1; P = .008) were associated with increased risk of rerevision for PJI. ConclusionsPatients who had 1 UPC or ≥2 UPCs with different organisms had similar infection-free survival at 5 years as patients who had sterile cultures. However, patients who had ≥2 UPCs of the same organism had significantly worse infection-free survival at 5 years. Overall, 1 UPC or ≥2 UPCs of the same organism at the time of arTKA may suggest the patient is at higher risk of rerevision for PJI. More studies are needed to determine what interventions can be implemented to mitigate this risk.

Potential Survival Benefit of Upfront Surgery for Lung Tumors Unconfirmed but Highly Suspicious for Stage I Lung Cancer.

Patients with early-stage lung tumors that are highly suspicious for malignancy typically undergo a preoperative diagnostic workup, primarily through bronchoscopy or transthoracic biopsy. Those without a preoperative diagnosis may alternatively be treated with upfront surgery, contingent upon the potential for intraoperative diagnosis. Previous studies have yielded conflicting results regarding the impact of upfront surgery on the survival of these patients. Our study aimed to elucidate the effect of upfront surgery on the survival outcomes of patients undergoing surgery for early-stage lung cancer without a preoperative diagnosis. We analyzed the survival rate of 158 consecutive patients who underwent pulmonary resection for stage I lung cancer, either with or without a preoperative diagnosis. A total of 86 patients (54%) underwent upfront surgery. This approach positively impacted both disease-free survival (p=0.031) and overall survival (p=0.017). However, no significant differences were observed across subgroups based on sex, smoking status, forced expiratory volume in 1 second, histologic tumor size, or histologic subtype. Univariate analysis identified upfront surgery (p=0.020), age (p=0.002), maximum standardized uptake value (SUVmax) exceeding 7 (p=0.001), and histological tumor size greater than 20 mm (p=0.009) as independent predictors. However, multivariate analysis indicated that only SUVmax greater than 7 (p=0.011) was a significant predictor of unfavorable survival. Upfront surgery does not appear to confer a survival advantage in patients with stage I lung cancer undergoing surgical intervention.

Super-elderly, spinal surgery, evaluating the risks and benefits: a retrospective single-centre cohort study.

An increasingly ageing population presents emerging healthcare challenges. Adequate clinical evaluation and understanding of outcome-predicting factors are integral to delivering safe spinal surgery to super-elderly patients. To evaluate spine surgery outcomes in patients aged 80 or above. We retrospectively evaluated patients 80 years and above who underwent elective or emergency spinal surgery between 2017 and 2022. The Eurospine Surgery Classification (ESC) was used to classify operations into Large, Medium, and Small. We calculated and compared Clinical Frailty Scores (CFS) pre- and post-operatively. Two hundred forty-five patients met the inclusion criteria. Most were male (n = 145). The age range was 80 to 99 (mean 83.3). Most operations were elective (n = 151, 62%). In our cohort, 211, 22, 10,2 and 1patients had degenerative, trauma, tumour, infective and vascular pathologies, respectively. According to the Eurospine classification, 201 (82.0%) had Minor spine surgery (63 emergently and 138 electively), 38 had Medium surgery (15.5% - 30 emergently and 8 electively), and 6 had Large surgery (2.4% - 1 emergently and 5 electively). 163 (66.5%) were discharged or under follow-up. There were 11 in-patient mortalities (4.5%). Outpatient mortality was 51 (20.8%), with the median time from surgery to death being 504.5 days, all the outpatient mortalities were neither non-spinal pathology nor spinal surgical related. CFS improved across the cohort, from 5 pre-operatively to 4 post-operatively (p < 0.001). Spine surgery in those over the 80s can be performed safely and improve their quality of life, as demonstrated by improvements in the CFS. Good patient selection and adequate pre-operative workup is essential, although it may not be possible in emergencies.