Procedure-specific Risks Research Articles

Do Interns Learn On-The-Job How to Obtain Proper Informed Consent for Surgical Procedures?

Obtaining surgical informed consent (SIC) is a critical skill most residents are expected to learn "on-the-job." This study sought to quantify the effect of 1 year of clinical experience on performance obtaining SIC in the absence of formal informed consent education. In this case-control cohort study, PGY1 and PGY2 surgical residents in an academic program were surveyed regarding their experiences and confidence in obtaining SIC; then assessed obtaining informed consent for a right hemicolectomy from a standardized patient. Single academic general surgery residency program in Buffalo, NY. Ten PGY1 and eight PGY2 general surgery residents were included in the study, after excluding residents with additional years of training. PGY2 residents had significantly more experience obtaining SIC compared to PGY1 residents (median response: ">50" vs "between 6 and 15," p = 0.001), however there was no difference in self-reported confidence in ability obtaining SIC (mean 3.2/5 in PGY1 vs 3.4/5 in PGY2, p = 0.61), self-reported knowledge of SIC (mean 3.1/5 in PGY1 vs 3.6/5 in PGY2, p = 0.15), performance on a test regarding SIC (mean score 9.0/20, SD 3.9 for PGY1 vs mean score 9.6/20, SD 3.5, t = 0.387, p = 0.739) or performance during a standardized patient interview (mean 11.2/20, SD 2.78 for PGY1 vs mean 11.4/20, SD 1.51 for PGY2, p = 0.87). In the interviews all residents addressed general risks (bleeding/infection), however both groups performed worse in addressing procedure-specific risks including anastomotic leak as risk for hemicolectomy. A year of clinical training between PGY1 to PGY2 did not improve performance in obtaining surgical informed consent when lacking formal education, despite self-confidence in their ability. A curriculum covering the content, delivery and assessment of informed consent should be initiated for residents upon arrival to surgical training.

Periprocedural management of patients on a direct oral anticoagulant undergoing elective gastrointestinal endoscopy.

This narrative review summarizes the current body of literature regarding periprocedural management of direct oral anticoagulant (DOAC)-treated patients undergoing digestive endoscopy since the publication of the 2022 American College of Gastroenterology - Canadian Association of Gastroenterology guidelines. We provide a detailed analysis of the thromboembolic risk, endoscopic procedure-specific bleeding risks, contemporary intraprocedural techniques to reduce the bleeding risk, and a summary of periprocedural DOAC guidelines developed by major gastrointestinal societies, including recommendations on procedure risk stratification. Despite data heterogeneity, the overall trend of the current literature supports the contemporary practice of a minimal DOAC interruption without the need for heparin bridging.

Decrease Venous Thromboembolism Without Anticoagulation in Plastic Surgery: The Paradigm of Risk Identification, Risk Modification, and Risk Reduction

Venous thromboembolism (VTE) is an important patient safety issue and potentially a life or limb threatening complication that can occur following plastic surgery. Patients are at different levels of VTE risk, based on patient-centric and procedure-specific risks. The following review discusses the paradigms of risk identification, risk modification and risk reduction for VTE risk in plastic surgery, with an ultimate goal of reducing VTE risk and improving patient safety.

1051 Procedure-Specific Consent Forms in Clinical Practice: A Systematic Review

Abstract Aim Consent forms play an active role in the consent process. Generic, hand-written consent forms are used as the standard across the NHS. However, increasingly procedure-specific consent forms (PSCF) are being used as an alternative. Their proponents suggest PSCF improve the consent process however concerns remain about whether they meet the standard for consent. We therefore conducted the first review evaluating the use of PSCF in clinical practice and give suggestions regarding their future use. Method A literature review was conducted via PubMed using the key terms ‘pre-printed consent form’ and ‘procedure-specific consent form'. Results Few studies investigating PSCF in clinical practice were identified including no systematic reviews. Most studies identified were quality improvement projects. However, no studies assessed the role of PSCF in litigation after procedural complications. PSCF were associated with improved legibility, documentation and patient understanding versus generic consent forms. PSCF generally improved documentation of procedure-specific complications and risks versus generic consent forms. PSCF are not routinely used in clinical practice and are not endorsed by the Department of Health and Royal College of Surgeons. There is no definitive legal guidance attesting to their use in the consent process, despite concerns their use will lead to procedures and associated complications not being fully explained to patients. Conclusions Evidence supporting the use of PSCF is available however it is heterogeneous and substantial legal concerns remain. Additional, high-quality studies evaluating their use is warranted, including their impact on medico-legal claims. Finally, a collaborative approach between clinicians and those within the legal profession is necessary.

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery.

To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery. The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain. We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty. After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer. VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.

Procedure-specific risks of robotic simultaneous resection of colorectal cancer and synchronous liver metastases.

An estimated 25% of patients with colorectal cancer (CRC) present with distant metastases at the time of diagnosis, the most common site being the liver. Although prior studies have reported that a simultaneous approach to resections in these patients can lead to increased rates of complications, emerging literature shows that minimally invasive surgical (MIS) approaches can mitigate this additional morbidity. This is the first study utilizing a large national database to investigate colorectal and hepatic procedure-specific risks in robotic simultaneous resections for CRC and colorectal liver metastases (CRLM). Utilizing the ACS-NSQIP targeted colectomy, proctectomy, and hepatectomy files, 1,721 patients were identified who underwent simultaneous resections of CRC and CRLM from 2016 to 2021. Of these patients, 345 (20%) underwent resections by an MIS approach, defined as either laparoscopic (n = 266, 78%) or robotic (n = 79, 23%). Patients who underwent robotic resections had lower rates of ileus compared to those who had open surgeries. The robotic group had similar rates of 30-day anastomotic leak, bile leak, hepatic failure, and post-operative invasive hepatic procedures compared to both the open and laparoscopic groups. The rate of conversion to open (8% vs. 22%, p = 0.004) and median LOS (5 vs. 6days, p = 0.022) was significantly lower for robotic compared to laparoscopic group. This study, which is the largest national cohort of simultaneous CRC and CRLM resections, supports the safety and potential benefits of a robotic approach in these patients.

Interview: Kari Tikkinen

Interview: Kari Tikkinen

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in Hepatopancreatobiliary Surgery

Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in Hepatopancreatobiliary Surgery

Risk of SARS-CoV-2 contagion in otolaryngology specialists.

SUMMARYCOVID-19 has rapidly spread in the past two years with a profound impact on otolaryngological activities, which has undergone radical transformation to guarantee diagnostic and therapeutic procedures mainly in oncology and urgent patients, while ensuring protection for healthcare personnel and patients. During the initial phases of the pandemic, scheduled visits and elective surgeries were postponed leading to a delay in the diagnosis and treatment of several diseases, including head and neck cancer, with a shift toward more advanced cancer stages and more aggressive treatments. Aerosol and droplets are the main routes of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), thus leading to a high risk of contagion during otolaryngology visits and surgery. Therefore, the correct use of personal protective equipment (PPE) and attention to procedure-specific risks and measures to avoid contagion are of utmost importance for healthcare professionals, and especially for those dealing with otolaryngology diseases. This narrative review highlights that otolaryngological activity implies a high risk of contagion during outpatient visit, surgery, or urgent conditions. The correct use of PPE, evaluation of procedure-specific risks and reduction of non-urgent procedures are considered the main strategies to limit contagion.

Procedure-Specific Complications Associated with Ultrasound-Guided Erector Spinae Plane Block for Lumbar Spine Surgery: A Retrospective Analysis of 342 Consecutive Cases.

PurposePresumed benefits of erector spinae plane blocks (ESPB) include an enhanced safety profile and few complications. There are few large series, which report the incidence of complications associated with ESPB on a procedure-specific basis. The objective of this retrospective cohort study was to estimate the incidence of complications of ESPB in a large series of patients undergoing lumbar spine surgery.Patients and MethodsWe included 342 consecutive patients who underwent any primary lumbar spine surgery via posterior approach (November 2018–July 2020). All patients received bilateral ultrasound-guided ESPB. The primary study outcome was the incidence of any perioperative complication, defined a priori as sensory, motor, hematologic, hemodynamic or respiratory complication consistent with plausible contribution from the ESPB. Secondary outcomes included the incidence of numeric rating scale (NRS) pain scores ≥7 in the post anesthesia care unit (PACU) and risk factors associated with NRS ≥7 (age, sex, ASA class, BMI, opioid tolerance, surgical type, and duration).ResultsWe did not identify any pre-specified complications associated with ESPB. There was one unilateral pneumothorax, in one patient, deemed unlikely to have been related to ESPB. NRS ≥7 was found in 17/342 patients (5%) and was independent of any background differences or risk factors assessed.ConclusionUltrasound guided ESPB for lumbar spine surgery was associated with zero complications, no interference with intraoperative neuromonitoring or the early postoperative neurological examination, and low incidence of poorly controlled pain in the PACU. These results help to establish procedure-specific risks and benefits of ESPB for spine surgery.

324 Improving Consenting Practices in a Breast Surgery Unit

Abstract Introduction Gaining consent, defined as “the process of providing the information that enables the patient to make a decision to undergo a specific treatment,” is a key part of a patient’s journey when having an operation. Consent forms serve as a significant medico-legal document; it is therefore imperative that they are completed accurately. The aim of this audit was to assess the current consent practice in a breast surgery unit, to monitor compliance with RCS and GMC guidelines and local policy on consent. Method Consent forms for all patients undergoing an operation over a three-week period within the breast surgery unit were reviewed. Data collected included use of abbreviations, patient and surgeon details and adequacy of procedure-specific complications. Interventions were then made in an attempt to improve compliance with guidelines. A repeat audit over another three-week period was performed to assess for improvement. Results The first cycle identified issues including incomplete documentation and inadequate complications listed. Targeted teaching and procedure-specific complication stickers were introduced to improve consent accuracy. Data was collected three-months post-intervention to evaluate for sustained improvement in consenting practices. Correct documentation of essential items (patient and surgeon name) increased from 83% to 100% (p&amp;lt;0.05). Results revealed a statistically significant improvement in consent form accuracy. Use of abbreviations reduced from 14% to 3% and record of procedure-specific risks improved. Conclusions The interventions employed significantly improved consenting practice within our unit. The insight gained from this audit can be applied across other trusts to improve compliance with the consent process.

Evaluating post-operative venous thromboembolism risk in urology patients using a validated risk assessment model

BackgroundVenous thromboembolism (VTE) is an important cause of post-surgical morbidity and mortality. This study aimed to apply a validated risk assessment model to evaluate the risk of post-operative VTE in urology patients.MethodsThis prospective descriptive observational study used the Caprini risk assessment model to evaluate VTE risk in patients planned for elective urology surgery at a tertiary Johannesburg hospital from January to June 2020.ResultsTwo hundred and twenty-six patients with a mean age of 52 years were evaluated for post-operative VTE risk. The population was generally overweight, with a mean BMI of 26.3 kg/m2. The mean Caprini score was 4.42, reflecting a population at high risk for post-operative VTE. There was no statistically significant difference between males and females in this regard. On average, participants had three risk factors for post-operative VTE. Fifteen per cent of all patients were at low risk for VTE, while 40.3% of participants were categorised as moderate risk. The category with the highest percentage of participants (44.7%) was the high-risk category (Caprini score ≥ 5). High-risk patients undergoing oncology surgery comprised 16.8% of the population, and these patients may require extended duration pharmacological thromboprophylaxis to prevent VTE. The most clinically significant risk factors for post-operative VTE included age, obesity, malignancy and HIV infection.ConclusionVenous thromboembolism may be difficult to diagnose, and clinicians may underestimate the risk for it to develop. Risk assessment models, such as the Caprini score, are objective and a practical tool to guide the application of thromboprophylaxis. The application of the Caprini RAM in the elective urological surgery population at Chris Hani Baragwanath Academic Hospital yields similar results to studies performed elsewhere on similar surgical populations. Further research is required to evaluate whether the actual incidence of VTE correlates with the risk assessment in this population. Clinician compliance with the use of RAMs as well as the corresponding recommendations for prophylaxis may need to be evaluated. A validated risk assessment model which accounts for procedure-specific risks in urology may be useful.

Digital approach to informed consent in bariatric surgery: a randomized controlled trial.

Informed consent is of paramount importance in surgery. Digital media can be used to enhance patient's comprehension of the proposed operation. The objective of this study was to examine the effects of adding a digital educational platform (DEP) to a standard verbal consent (SVC) for a laparoscopic Roux-en-Y gastric bypass (LRYGB) on patient's knowledge of the procedure, satisfaction with the clinical encounter and duration of the consent appointment. This prospective non-blinded randomized controlled trial allocated 51 patients, who were candidates for a LRYGB, into DEP+SVC (intervention, n = 26) or SVC (control, n = 25) groups. Data were collected at one Bariatric Centre of Excellence (Ontario, Canada) between December 2018 and December 2019. DEP consisted of a 29-slide video-supplemented module detailing the risks, benefits, expectations and outcomes for the LRYGB. Primary outcome was knowledge about the LRYGB operation following the consent discussion. Secondary outcomes were knowledge retention, patient satisfaction, and duration of time required to obtain an informed consent. Baseline demographic data were equivalent between groups except for a greater proportion of male patients in the DEP+SVC group (7/19 vs 0/25; p < 0.01). Baseline procedure-specific knowledge was equivalent between the groups (72.3 ± 11.3% vs 74.7 ± 9.6%; p = 0.41). Post-consent knowledge was significantly higher in the DEP + SVC vs SVC group (85.0 ± 8.8% vs 78.7 ± 8.7%; p = 0.01; ES = 0.72). The duration of time to obtain informed consent was significantly shorter for the DEP + SVC vs SVC group (358 ± 198sec vs 751 ± 212sec; p < 0.01; ES = 1.92). There was no difference in knowledge retention at 4-6weeks (84.4 ± 10.2% vs 82.9 ± 6.8%; p = 0.55) and in patient satisfaction (31.5 ± 1.1 vs 31 ± 2.7; p = 0.10). The addition of a DEP online module to a standard verbal consent for LRYGB resulted in improved patient's understanding of the procedure-specific risks and benefits, high patient satisfaction, and over 50% time savings for the bariatric surgeon conducting the consent discussion.

Development and content validation of the percutaneous nephrolithotomy assessment score.

To develop and content validate a percutaneous nephrolithotomy assessment score, taking into consideration the procedure-specific risks. This prospective international study utilized the Healthcare Failure Mode and Effect Analysis to systematically outline percutaneous nephrolithotomy and failure modes for each step. A total of 25h was spent observing percutaneous nephrolithotomy carried out by six expert surgeons. Hazard analysis scoring was carried out by 11 experts. It was determined if the steps were single point weaknesses. Single point weaknesses and those assigned a hazard score ≥4 were included in the percutaneous nephrolithotomy assessment score. The tool was then content validated by 16 experts from 10 countries. Application of the Healthcare Failure Mode and Effect Analysis identified 64 failure modes; 37 failure modes had a hazard score ≥4. After adaptations based on expert feedback the final percutaneous nephrolithotomy assessment score was developed containing 10 phases, 21 processes and 47 subprocesses. All participants agreed that the tool contained pertinent procedural steps. This study has developed and shown the international content validity of a novel percutaneous nephrolithotomy assessment score. The tool can be utilized in modular operating room training to quantify operator progress, and can be used in conjunction with other modules as part of a complete percutaneous nephrolithotomy curriculum for trainees.

Thirty-Day Outcomes After Bilateral Total Hip Arthroplasty in a Nationwide Cohort.

BackgroundApproximately 42% of patients with end-stage osteoarthritis have bilateral disease. Although bilateral total hip arthroplasty (THA) is physiologically demanding, certain patients may benefit from simultaneous rather than staged bilateral procedures. This study examines the intraoperative differences and 30-day outcomes in patients receiving bilateral THA compared with those who underwent unilateral THA.MethodsPatients undergoing THA were selected from the National Surgical Quality Improvement Program database from 2008 to 2015. Patients were selected according to those with primary and concurrent coding for Current Procedural Terminology 27130. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether concurrent THA was a risk factor for poor outcomes.ResultsA total of 97,804 patients and 587 patients who underwent unilateral and bilateral THA, respectively, were identified. Patients who underwent bilateral procedures were younger (57.3 vs 64.6 years, P < .001), were of lower body mass index (29.2 vs 30.2, P < .001), and had fewer comorbidities than patients who underwent unilateral procedures. Length of stay was not increased for bilateral recipients (3.13 vs 2.93 days, P = .308), although fewer were discharged to home (62.8% vs 77.6%, P < .001). The bilateral recipients required postoperative transfusions at a higher rate (29.8% vs 10.9%, P < .001) and had an increased incidence of deep wound infections on univariate analysis (1.2% vs 0.3%, P = .002). There was no increased risk of superficial infection, medical complications, or thromboembolic events for the bilateral cohort.ConclusionsAlthough bilateral THA recipients are younger with fewer preoperative comorbidities, bilateral THA is associated with an increased rate of transfusion in a nationwide setting. With this knowledge, specific interventions should be instituted to target these procedure-specific risks.

Improving the surgical consenting process for patients with acute hip fractures: a pilot quality improvement project

BackgroundConsenting patients for trauma procedures following hip fracture is a key stage in the treatment pathway from admission to the operating theatre. Errors in this process can result in delayed procedures which may negatively impact patient recovery. The aim of this project was to identify and reduce errors in our consenting process for patients with capacity.MethodsConsent forms for all adult patients with capacity admitted for surgical repair of traumatic hip fracture were reviewed over a 4-week period. The baseline measurement (n = 24), identified errors in three key process measures: clarity of documentation, failure to record procedure-specific risks and not offering a copy of the consent form to the patient. Pre-printed stickers and targeted teaching were then introduced as quality improvement measures. Their impact was evaluated over subsequent 4-week review of the same patient demographic, with further refinement of these interventions being carried out and re-evaluated for a final cycle.ResultsCycle 1 (n = 26) following targeted teaching demonstrated a reduction in abbreviations from 38 to 20%, while doubling the documentation of discussion of procedure-specific risks from 31 to 72%. More patients were offered a copy of their consent form, rising from 12 to 48%. Cycle 2 (n = 24) saw the introduction of pre-printed “risk of procedure” stickers. Although clarity measures continued to improve, quality of pre-procedure risk documentation remained static while the number of forms being offered to patients fell to 8%.ConclusionsOur project would suggest that while pre-printed stickers can be useful memory aids, specific teaching on consenting produces the greatest benefit. The usage of such tools should therefore be limited, as adjuncts only to specific training.

EDITORIAL COMMENT

The authors have conducted informative and important health services research on the “trends in extended-duration pharmacological prophylaxis (EDPP) to prevent venous thromboembolism (VTE) following radical cystectomy (RC)” using the national administrative claims database for the period 2012-2017. 1 URL-D-19-01447R1. 2019. Google Scholar Allowing for limitations of methodology using such databases, it was notable that a low proportion (19%) of cases received EDPP overall in the study period. Encouragingly, there was an improving time-trend from 9% utilization in 2012 to 26% in 2017. However, given that VTE following radical abdominal and/or pelvic surgery for cancer is a major cause of morbidity, mortality and cost, the findings of the current study portray an unfavorable picture for the current state of clinical practice with respect to EDPP utilization. Indeed, provided there are no contraindications, most international and/or national guidelines recommend the use of EDPP in this setting for high-risk cases. 2 Tikkinen KAO Craigie S Agarwal A et al. Procedure-specific risks of thrombosis and bleeding in urological cancer surgery: systematic review and meta-analysis. Eur Urol. 2018; 73: 242-251 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar ,3 Key NS Bohlke K Falanga A Venous thromboembolism Prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update summary. J Oncol Practice. 2019; (Jop1900368) Crossref PubMed Scopus (19) Google Scholar The AUA Best Practice Statement from 2008 highlights the importance of thromboprophylaxis following RC, amongst other urological procedures, but falls short of touching upon the subject of EDPP in that context. 4 Forrest JB Clemens JQ Finamore P et al. AUA best practice statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery. J Urol. 2009; 181: 1170-1177 Crossref PubMed Scopus (90) Google Scholar However, the evidence is accumulating to issue clear guidelines in support of EDPP, particularly as over 50% of symptomatic VTEs occur after discharge from hospital. 5 Sagalovich D Say R Kaouk J Mehrazin R The role of extended venous thromboembolism prophylaxis following urologic pelvic surgery. Urol Oncol. 2018; 36: 83-87 Crossref PubMed Scopus (5) Google Scholar , 6 VanDlac AA Cowan NG Chen Y et al. Timing, incidence and risk factors for venous thromboembolism in patients undergoing radical cystectomy for malignancy: a case for extended duration pharmacological prophylaxis. J Urol. 2014; 191: 943-947 Crossref PubMed Scopus (76) Google Scholar , 7 Kukreja JE Levey HR Scosyrev E et al. Effectiveness and safety of extended-duration prophylaxis for venous thromboembolism in major urologic oncology surgery. Urol Oncol. 2015; 33 (387.e387-316) Crossref PubMed Scopus (35) Google Scholar Lower compliance to EDPP use may in part be due to underappreciation of the risks in the absence of clear guidelines. 8 Sterious S Simhan J Uzzo RG et al. Familiarity and self-reported compliance with american urological association best practice recommendations for use of thromboembolic prophylaxis among american urological association Members. J Urol. 2013; 190: 992-998 Crossref PubMed Scopus (40) Google Scholar By highlighting the current trends in EDPP utilization after RC, the current study provides opportunities to look more closely into this issue and update the guidelines in relation to EDPP use following major urological oncological surgery, including RC.

Causative Factors for Complications in Transpalatal Advancement.

Transpalatal advancement (TPA) is a procedure that is used when modern variants of uvulopharyn-gopalatoplasty are unable to provide enough anterior traction. Although successful in reduction of obstructive sleep apnea (OSA) parameters, it also comes with procedure-specific risks. Formation of an oro-nasal fistula (ONF) is a complication that results in significant morbidity and a protracted treatment course. After approval from the University of Wollongong Health Research Ethics Committee, a retrospective chart review of all cases undergoing TPA performed by a single surgeon over a 10-year period from 2008 to 2018 was performed. Patients underwent pre- and postoperative level 1 or 2 polysomnography. Factors potentially contributing to palatal complications, as well as pre- and postoperative polysomnographic parameters, subjective sleep questionnaires, and body mass index (BMI) were statistically analyzed where a P value <.05 was considered a significant result. A total of 59 patients were included. Overall palatal complication rate was 25.4% (15/59), with the most common being transient velo-palatal insufficiency (VPI) (8/59, 13.6%). ONF developed in 4/59 (6.8%) of patients. None of the analyzed contributing factors for palatal complications were statistically significant, except the presence of a high-arched palate and development of ONF. All analyzed sleep parameters, as well as BMI, were significantly different when comparing pre- to postoperative results. This study suggests that TPA has a role in current sleep surgery paradigms and can significantly improve both objective and subjective outcome measures of OSA. Surgeons contemplating TPA on patients with high-arched hard palates should do so with caution.

Completion thyroidectomy: A risky undertaking?

BackgroundCompletion thyroidectomy (cT) is sometimes necessary after thyroid lobectomy (TL), and it remains controversial whether 2-stage thyroidectomy adds operative risk. This study compares complication rates for TL, total thyroidectomy (TT), and cT. MethodsUsing a cohort design, we reviewed 100 consecutive cases each of TL, TT, and cT. Complications examined included reoperation for hematoma, temporary/permanent recurrent laryngeal nerve (RLN) dysfunction, and hypoparathyroidism. ResultsTwo patients had reoperation for hematoma, both in the TT cohort (p = 0.33). No patients in any cohort had permanent hypoparathyroidism or RLN injury, but transient RLN paresis occurred in three (3%) TL, two (2%) TT, and no (0%) cT patients (p = 0.38). Transient hypoparathyroidism occurred in 3% following TT versus 0% after cT (p = 0.12). Overall complication rate was higher after TT (7%) compared to TL (3%) and cT (0%, p = 0.02). ConclusionsAt a high-volume center, the observed complication rates were equivalently low for TL, TT, and cT. SummaryCompletion thyroidectomy is occasionally needed after lobectomy, but its procedure-specific risks are not well characterized. In a cohort study at a high-volume center, operative outcomes for patients undergoing thyroid lobectomy, total thyroidectomy, and completion thyroidectomy were compared and equivalently low complication rates were observed for all 3 procedures.

Consent in paediatric neurosurgery: adequacy of documentation and parental perspectives.

Consenting paediatric patients for surgical procedures remains inherently unique in that it is underpinned by principles such as parental responsibility, assessment of the child's capacity to consent, and adherence to national/legal guidelines. Quality record keeping is an important objective evidence to demonstrate the highest standards of medical care provided to our patients. The consent form is a crucial medical record encapsulating the attainment of informed consent from a parent/guardian for performing a procedure on their child. We aimed to prospectively evaluate the consenting process in our department to assess adequacy of documentation and parental perspectives. A prospective study using qualitative descriptive design was conducted with parents of 50 children requiring neurosurgical procedures over a 3-month period. All patients understood the primary diagnosis and type of surgery. Procedure-specific risks were understood by 98% and 84% could remember the mentioning of general risks of surgery. Only a minority of parents (24%) could recollect that alternative options of management including no treatment were discussed. In cases where relevant, laterality was only documented in 56% of consent forms. All patients felt that an informed decision regarding consent to surgery was made. However, 12% suggested areas where further improvement could be made in the timing of consent and the way information could be better provided. Consent is more than a signature on a form. It provides objective evidence of a shared decision-making process between the surgeon, patient, and their parent/guardian. Our initial study highlights multiple areas for improvement.