Routine Preoperative Evaluation Research Articles

An Incidental Finding of Severe Hypoxia in an Asymptomatic Patient Caused by Pulmonary Arteriovenous Malformations

SESSION TITLE: Pulmonary Vascular Disease Cases I SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 26, 2015 at 11:00 AM - 12:00 PM INTRODUCTION: Pulmonary arteriovenous malformations (AVMs) are a rare clinical entity, especially when found in isolation with no underlying etiology. Literature review suggest that pulmonary AVMs are symptomatic in 91% of cases, with dyspnea in 82% and cyanosis in 79% of patients. Furthermore, 70% are also associated with Osler Weber Rendu Syndrome. We report a case of severe asymptomatic hypoxia, discovered incidentally on routine pre-operative evaluation, found to have isolated multiple large pulmonary AVMs. Workup failed to show any underlying etiology. CASE PRESENTATION: The patient is a 54 year old female, with a history of COPD and severe aortic valve insufficiency, diagnosed via an echocardiogram at another facility, referred to cardiovascular surgery at our hospital. During pre-surgical evaluation, she was found to be hypoxic, with oxygen saturation in the 80%s on 2L of oxygen by nasal cannula and was admitted. Upon admission, her oxygen saturation was at 85% on a non re-breather mask. She denied any symptoms. Physical examination was unremarkable. Laboratory values showed hemoglobin of 17.3g/L and hematocrit of 48.9%. Chest X-Ray revealed a mass like density in the right lower lobe (RLL). CT scan of the thorax with contrast was negative for pulmonary embolus but 4 AVMs in RLL and 2 in right upper lobe were identified. Further questioning and workup was negative for Osler-Weber-Rendu syndrome or other underlying etiology. Resting echo showed an EF of 70% and a Bubble Echocardiogram revealed extensive right to left shunting. Bubbles entered from the pulmonary venous drainage into the left atrium consistent with AVMs. She had a pulmonary angiogram and AVMs of the RLL were embolizedx2 and an amplatzer vascular occlusion plug was deployedx2. After embolization, the patient's oxygen saturation was at 95% on 6L of oxygen. A Transesophageal Echo showed moderate aortic insufficiency and she decided to forego cardiac surgery. DISCUSSION: Studies show most cases of pulmonary AVMs have an underlying etiology and are symptomatic in 91% of patients. Our case represents a patient with large asymptomatic pulmonary AVMs with no underlying etiology. CONCLUSIONS: It shows that in patients presenting with hypoxia with no clear underlying cause, pulmonary AVMs can be considered as a cause and that pulmonary angiogram and embolization of AVMS is the cornerstone of treatment of pulmonary AVMs. Reference #1: Faughnan ME, LUI YW, Wirth JA, et al. Diffuse Pulmonary arteriovenous malformations: characteristics and prognosis. Chest 2000; 117:31 DISCLOSURE: The following authors have nothing to disclose: Asad Omar No Product/Research Disclosure Information

Higher Diagnostic Yield for Preoperative EGD in Asymptomatic Patients Undergoing Sleeve Gastrectomy

Introduction: Sleeve Gastrectomy (SG) has become an increasingly popular option for bariatric surgery. Current ASGE guidelines recommend that only symptomatic patients undergo preoperative EGD prior to bariatric surgery. The aim of this study was to compare the diagnostic yield for preoperative EGD in asymptomatic and symptomatic patients. Methods: Our institution evaluated a consecutive series of SG patients, all of whom underwent routine preoperative EGD with antral biopsy between February 2011 - February 2015. Symptomatic indications included reflux, dysphagia or dyspepsia. Endoscopic findings were extracted directly from the patient's original endoscopy report. Results: A total of 227 patients (172 Female, 55 Male) underwent a successful EGD prior to sleeve gastrectomy. Patient demographics included a mean age of 45.3 with an mean BMI of 44.2. Abnormalities were seen in 177 patients (77.6 %) of the preoperative EGD reports. EGD findings included gastritis in 148 cases (64.9%), hiatal hernia in 13 cases (6.1%), H.pylori in 12 cases (5.2%), PUD in 5 cases (2.2%) and Barrett's esophagus in 4 cases (1.6%). Of these,164 patients were asymptomatic and 63 patients were symptomatic. Gastritis was seen in 32 cases (51%) of symptomatic patients and 116 cases (70.7%) of asymptomatic patients. Additionally 10 cases of H.pylori, 3 cases PUD, and 3 cases of Barrett's esophagitis were seen in asymptomatic patients. Conclusion: There is a paucity of data in regards to preoperative management prior to bariatric surgery. Routine preoperative EGD had a high overall diagnostic yield for abnormalities although the majority included gastritis which would not change surgical management. Overall, 12.7% of patients had clinically significant pathology including hiatal hernia, H.pylori, PUD and Barrett's esophagus. Selectively screening in symptomatic patients seems to have limited value as there was a higher diagnostic yield of overall and clinically significant endoscopic abnormalities in the asymptomatic patient group. This may suggest routine preoperative endoscopic evaluation to determine clinically significant lesions.Table 1: Preoperative EGD Findings in Asymptomatic and Symptomatic Sleeve Gastrectomy Patients

Is routine pre-operative cardiac evaluation necessary in obese children undergoing adenotonsillectomy for OSA?

BackgroundAdenotonsillectomy (T&A) is a common surgery performed for obstructive sleep apnea (OSA) in children. Obese children are at increased risk for OSA, but are also at increased risk for cardiovascular changes that might heighten their risk of undergoing a general anesthetic. There is currently no standard of care recommendation for cardiac workup prior to T&A. PurposeTo ascertain whether a preoperative cardiac workup is predictive of postoperative complications in obese children undergoing T&A for OSA. DesignRetrospective cohort review. Material and Methods241 children with BMI ≥ 25 kg/m2 underwent T&A for OSA. This cohort was divided into three groups — those who had no preoperative cardiac evaluation, those who had a preoperative cardiac evaluation but no significant findings and those who had a preoperative cardiac evaluation with at least one significant finding. Postoperative cardiac-related complications were compared between the three groups. ResultsThere were significantly more postoperative complications in Group 3, the group with findings on preoperative cardiac evaluation. However, these were heavily weighted toward “hospital stay > 24 hours” without clear cardiac sequelae. Notably there were no incidents of pulmonary edema, re-intubation postoperatively or death. ConclusionIn obese children undergoing T&A at a tertiary care center, a preoperative cardiac workup was not shown to be beneficial in predicting postoperative complications.

PTU-123 Lessons learnt from a hundred consecutive laparoscopic nissen’s fundoplications

Introduction Laparoscopic Nissen’s fundoplication (LNF) is the procedure of choice in the surgical management of refractory gastroesophageal reflux disease (GORD). Few studies have reported subjective symptomatic outcome and objective investigative outcome postoperatively. The correlation between these two outcome measurements is unclear. The objective of this study is to evaluate a hundred consecutive LNFs in relation to patient’s anatomic and physiologic status after the procedure, patient’s functional outcome, and the rate and pattern of procedure failures. Method Patients who underwent LNFs from 2007 to 2014 under a single surgeon were identified retrospectively. Patient demographics, morbidities, follow-up investigations and any redo operation were recorded. Surgical outcome was reported using the Viscik symptom evaluation tool. Patient telephone survey was performed using the validated GERD-HRQL (Health Related Quality of Life) questionnaire to assess patients’ functional outcome. Results A total of 100 consecutive patients were identified in the 8 year period. Redo operations had been performed or planned for 11 of these patients. 30 patients underwent postoperative oesophagogastroduodenoscopy (OGD) and 29 patient were investigated with barium studies to evaluate the recurrence of symptoms. 37 patients have been contactable for telephone follow-up survey; 13 of the interviewed patients reported symptoms of gas bloat syndrome; 15 patients experienced a recurrence of their reflux symptoms, while 9 patients experienced a degree of regurgitation. 24 patients were satisfied with the operation, while 8 patients remained neutral. Conclusion Postoperative symptomatic evaluation revealed a suboptimal subjective outcome that is inexplicable by the endoscopic/ radiological findings, suggesting the need for a standardised procedure-specific postoperative objective evaluation tool. The high incidence of post operative gas bloat syndrome suggests the need for routine pre-operative evaluation of gastric motility and tailoring the fundoplication accordingly. The higher than expected rate of anatomical failures highlighted the inadequacy of primary hiatorraphy, and the need for selective crural reinforcement. Disclosure of interest None Declared.

Clinical relevance of echocardiogram in patients with cerebral palsy undergoing posterior spinal fusion.

Spinal deformity is one of the secondary musculoskeletal problems that occur with cerebral palsy (CP). Of the co morbidities associated with CP and spinal deformity, cardiac function is of theoretical concern. The goal of our study was to determine the clinical relevance of routine preoperative cardiology evaluation via echocardiogram for patients with CP presenting for posterior spine fusion (PSF) surgery. A retrospective chart review was performed of CP patients presenting for scoliosis surgery. The data collected for each patient included: age, sex, height, weight, Cobb angle, and medical history. All patients had a preoperative cardiac evaluation. Seventy-two patients were included. The mean age was 13.6±3.4years. Left ventricular systolic function was normal in all patients; the mean shortening fraction was 39.3±6.2%. No patient had more than mild insufficiency of either the semilunar or atrioventricular valve. One patient was diagnosed with aortic root dilation as well as aortic valve insufficiency. All patients had PSF surgery without changes in anesthetic or surgical plans, and no patient experienced complications attributable to a cardiac origin. The results suggest that routine preoperative cardiology evaluation via echocardiogram for children with CP in the absence of clinical history or physical examination findings suggestive of cardiac disease is not necessary.

The epiploic flow‐through flap: preoperative evaluation of right gatroepiploic artery on multidetector computed tomography.

The gastroepiploic artery (GEA) and the greater omentum are nowadays commonly used in many reconstructive surgeries including cardiac, vascular and plastic surgery. There are cases in which the GEA is found to be unsuitable only after partial harvesting following an upper laparotomy, and an improved method of preoperative evaluation is required to eliminate the need for intraoperative small laparotomyMethodsMultidetector computed tomography was performed for 30 consecutive patients admitted for lower limb ischemia in a routine preoperative evaluation of lower limb atherosclerotic arteritis. The origin of the GEA was checked on coronal and sagital slices, its pathway was identified on the three‐dimensional rendering. We assessed length and mean diameter of the distal and proximal right GEA, and the mean distances between the origins of GEA and the omental branches.Results30 patients were included in our study. Routine pre operative MCDT during lower limb artherosclerotic arteritis workup enabled identification of GEA in all casesThe mean internal diameter of the GEA at its origin was 3.28mm (±3.3). The mean internal diameter of the distal GEA was 1.26mm (±0.29). The mean length of GEA was 23,22cm (± 5,28). At least one omental descending branch was detected and in 63% (19 patients) at least two branches were visualised.ConclusionRoutine preoperative MDCT imaging is an effective tool to assess precisely the different anatomical properties of the GEA. This exam could be useful for both diagnosis of lower limb arteritis and evaluation of the GEA suitability for flow‐through flap lower limb revascularisation.

The yield of routine pre-operative cardiovascular evaluation in stable patients scheduled for elective non-cardiac surgery

Preoperative cardiovascular evaluation is commonly performed in patients scheduled for non-cardiac surgery. The recent ACC/AHA guidelines provide an algorithm for such an evaluation but whether all patients scheduled for surgery would benefit from it is not known. We determined the yield of preoperative cardiovascular evaluation in 522 stable patients, with no prior history of heart disease, who were scheduled for elective non-cardiac surgery. There were 14 patients (2.7%) in which the cardiac consultant requested further testing pre-operatively, and in 5 of them (1%), the findings on cardiac consultation and further testing would be considered to have impacted the decision on performing the surgery or the long term outcome of the patients. Using multivariable logistic regression analysis, the only clinical variable predictive of further testing was age > 65 years (OR=4.47, p=0.001). The yield of preoperative cardiovascular evaluation in stable patients scheduled for non-cardiac surgery is relatively low. Further studies are needed to identify what subgroup of patients might benefit most from it and those in whom it might not be warranted.

Hidden unilateral aplasia of the frontal sinus: a radioanatomic study.

Hidden unilateral frontal sinus aplasia is the absence of 1 frontal sinus with increased pneumatization of contralateral sinus toward the aplastic side. It may give the false impression of the presence of 2 separate frontal sinuses, creating potential for complications during the surgery. The aim of this study was to evaluate the prevalence and morphology of this anatomical variation using multiplanar reconstruction of computed tomography (CT) results. A total of 305 CT examinations were analyzed. Hidden unilateral frontal sinus aplasia was defined as lack of pneumatization of 1 frontal sinus beyond the level of the orbital roof, with increased pneumatization of the contralateral sinus, extending to the sagittal plane, crossing the lamina papyracea on the side of the aplastic sinus. Eleven patients (3.6%) with hidden unilateral frontal sinus aplasia were identified, 5 on the left and 6 on the right side, in 5 female and 6 male patients. Twenty-four (7.8%) patients with "regular" frontal sinus aplasia (without hyperplastic contralateral frontal sinus) were found, 4 with bilateral aplasia and 20 with unilateral aplasia. Hidden unilateral aplasia of the frontal sinus is a relatively uncommon anatomical variation. Its presence should be considered during routine preoperative CT evaluation because it poses the risk of intraoperative complications.

Thyroid malignancy markers on sonography are common in patients with benign thyroid disease and previous iodine deficiency.

The purpose of this study was to evaluate the characteristics of benign thyroid nodules on sonography and ultrasound elastography in a population exposed to iodine deficiency. We conducted a prospective systematic evaluation of preoperative thyroid sonography and elastography in patients assigned for surgical excision of benign thyroid nodules. Two experienced sonographers performed all sonographic and elastographic examinations. Thyroid nodules were evaluated by 7 generally accepted sonographic malignancy risk markers and assigned an elasticity score on elastography. The final diagnosis of a benign thyroid nodule was based on histopathologic analysis of resected thyroid gland tissue. We evaluated 232 thyroid nodules in 105 patients (86 women and 19 men). In total, 57% of the examined nodules had 1 or 2 malignancy risk markers present, and 24% did not have any markers present. A solid nodule larger than 15 mm was the most common malignancy risk marker observed (63%), followed by low elasticity (33%), microcalcifications (26%), and hypoechogenicity (15%). In an analysis stratified according to the number of nodules (solitary versus multiple), low elasticity was described more frequently in solitary nodules (61.9% versus 30.4%; P= .004). A large nodular volume was a predictor (P < .05) of microcalcifications and intranodular vascularization, whereas an absent halo sign and a solid nodule were found less frequently in nodules with larger volumes. Our results show that routine preoperative malignancy risk evaluation of presumably benign thyroid nodules is of little value when performed on patients exposed to iodine deficiency.

心臓カテーテル検査によって得られた結果をどう解釈するか

心エコー，CT，MRIなどの非侵襲的検査法の進歩に従い，心臓カテーテル造影検査はカテーテル治療の目的で施行されることが多くなり，多くの先天性心疾患（以下CHD）の術前のルーチンの検査として施行していた時代と比較してその適応は大きく変わった．現在の診断カテーテルの適応は，1）大動脈弁，僧房弁狭窄の重症度やFontan型手術適応など，より正確な血行動態評価が必要な時，2）心奇形の形態異常が非侵襲的検査法では充分に描出されず評価できない時，3）カテーテル治療を計画し，その前に施行する場合，4）肺動脈閉塞性病変の有無を決定するなど，血行動態評価が治療方針の決めてとなる時，5）電気生理学的検査，または生検が必要な時，などである．このように以前と診断カテーテルの適応は変わったが，未だCHDの，特に複雑心奇形の形態，血行動態を評価する“Gold Standard”な検査として施行されている．このReviewでは酸素飽和度，圧などから計算される血行動態の指標や造影所見などをいかに得て，どう解釈するかについて概説した．

Silent, but not Unseen: Multimicrocystic Aspect on T2-Weighted MRI in Silent Corticotroph Adenomas

Introduction: Silent corticotroph adenomas (SCAs) present as nonfunctional pituitary tumors in routine preoperative evaluation. The objective of this study was to evaluate the diagnostic accuracy of MRI T2-weighted sequences for detecting the corticotroph subtype preoperatively. The preoperative T2-weighted MRI sequences were retrospectively evaluated in patients with SCA and two control groups: clinically manifest corticotroph macroadenomas (CSMs) and case-matched, nonfunctional gonadotroph macroadenomas (NFGMs). All were selected from a registry of 1,096 patients in whom transsphenoidal surgery was performed in the same tertiary reference center. T2-weighted MRI sequences were independently classified by one senior endocrinologist and one senior radiologist who were blinded to the clinical and histological features. Patients: Overall 17 patients with SCA, 14 with CSM, and 60 with NFGM were included in the study. Measurements: Pituitary MRI including T2-weighted sequences. Two aspects were retained: multiple microcysts (MMs) and the absence of microcysts. Hormonal data included plasma prolactin, IGF-1, testosterone or estradiol, LH, FT4, TSH, morning plasma cortisol, and an ACTH-stimulation test, when available. Results: MMs were present in 76% (13/17) of SCAs, 21% (3/14) of CSMs, and 5% (3/60) of NFGMs. The presence of MMs in clinically nonfunctioning macroadenomas had a sensitivity of 76% and a specificity of 95% for predicting SCA. Conclusion: The presence of MMs in T2-weighted MRI is a good diagnostic tool.

Perceptions about blood transfusion: a survey of surgical patients and their anesthesiologists and surgeons.

Although blood transfusion is a common therapeutic intervention and a mainstay of treating surgical blood loss, it may be perceived by patients and their physicians as having associated risk of adverse events. Practicing patient-centered care necessitates that clinicians have an understanding of an individual patient's perceptions of transfusion practice and incorporate this into shared medical decision-making. A paper survey was completed by patients during routine outpatient preoperative evaluation. An online survey was completed by attending anesthesiologists and surgeons at the same institution. Both surveys evaluated perceptions of the overall risk of transfusions, level of concern regarding 5 specific adverse events with transfusion, and perceptions of the frequency of those adverse events. Group differences were evaluated with conventional inferential biostatistics. A total of 294 patients and 73 physicians completed the surveys. Among the surveyed patients, 20% (95% confidence interval, 15%-25%) perceived blood transfusions as "very often risky" or "always risky." Greater perceived overall blood transfusion risk was associated with African American race (P = 0.028) and having a high school or less level of education (P = 0.022). Greater perceived risk of allergic reaction (P = 0.001), fever (P < 0.001), and dyspnea (P = 0.001) were associated with African American race. Greater perceived risk of allergic reaction (P = 0.009), fever (P = 0.039), dyspnea (P = 0.004), human immunodeficiency virus/acquired immune deficiency syndrome and hepatitis (P = 0.003), and medical error (P = 0.039) were associated with having a high school or less level of education. Patients and physicians also differed significantly in their survey responses, with physicians reporting greater overall perceived risk with a blood transfusion (P = 0.001). Despite improvements in blood transfusion safety in the United States and other developed countries, the results of this study indicate that a sizeable percentage of patients still perceive transfusion as having significant associated risk. Furthermore, patients and their anesthesiologists/surgeons differ in their perceptions about transfusion-related risks and complications. Understanding patients' perceptions of blood transfusion and identifying groups with the greater specific concerns will better enable health care professionals to address risk during the informed consent process and recommend blood management in accordance with the individual patient's values, beliefs, and fears or concerns.

Silent, but not unseen: multimicrocystic aspect on T2‐weighted MRI in silent corticotroph adenomas

Silent corticotroph adenomas (SCAs) present as nonfunctional pituitary tumours in routine pre-operative evaluation. The objective of this study was to evaluate the diagnostic accuracy of MRI T2-weighted sequences for detecting the corticotroph subtype pre-operatively. The pre-operative T2-weighted MRI sequences were retrospectively evaluated in patients with SCA and two control groups: clinically manifest corticotroph macroadenomas (CSMs) and nonfunctional gonadotroph macroadenomas (NFGMs). All were selected from a registry of 1096 patients in whom transsphenoidal surgery was performed in the same tertiary reference centre. T2-weighted MRI sequences were independently classified by one senior endocrinologist and one senior radiologist who were blinded to the clinical and histological features. Seventeen patients with SCA, 14 with CSM and 60 with NFGM were included in this study. Pituitary MRI with T2-weighted sequences. Two aspects were retained: multiple microcysts (MMs) and the absence of microcysts. Hormonal data included plasma prolactin, IGF-1, testosterone or oestradiol, LH, FT4, TSH, morning plasma cortisol and an ACTH-stimulation test, when available. Multiple microcysts were present in 76% (13/17) of SCAs, 21% (3/14) of CSMs and 5% (3/60) of NFGMs. The presence of MMs in clinically nonfunctioning macroadenomas had a sensitivity of 76% and a specificity of 95% for predicting SCA. The presence of MMs in T2-weighted MRI is a good diagnostic tool to suggest the corticotroph subtype in an apparently nonfunctional pituitary tumour.

Preoperative Consultation Before Cataract Surgery

Amajor focus in fixing the health care crisis has been a shift fromvolume-based tovalue-based care.1One approach to improving the value equation is the elimination of unnecessary or wasteful tests and procedures. This forms part of the basis of theChoosingWisely campaign from theAmericanBoardof Internal Medicine Foundation.2 A major theme within the Choosing Wisely campaign has been the elimination of routine preoperative evaluation in low-risk patients. Given that 30million Americans undergo surgery annually and approximately 60% of them undergo a procedure on an ambulatory basis, the eliminationof extensivepreoperative tests and consultations represents an area of potentially large health care savings. In this issue of JAMA Internal Medicine, Thilen and colleagues3demonstratenotonly that this is not occurringbut that the incidenceof preoperative consultations is actually increasing in the Medicare population for patients undergoing cataract surgery. Cataract surgery is unique among the surgical procedures in having a very large randomized clinical trial with sufficient power todemonstrate that routinepreoperative laboratory testing is not associatedwith improvement in outcome compared with those who did not receive routine testing.4 In fact, perioperativemorbidity andmortality after cataract surgery is extremely low, and even a history of myocardial infarction doesnot adversely affect outcome. The American College of Cardiology Foundation/American Heart Association guidelines propose proceeding to the operating room without further cardiovascular testing unless unstable symptoms are present in this low-risk cohort of patients.5 The list of 5 things proposed by theAmerican Society of Anesthesiologists for the ChoosingWisely campaign includes a statement to avoiddiagnostic testing in thiscohortofpatients.6Giventheevidenceand clearguidelines,whydoestherecontinuetobeasubstantialand increasing incidence of preoperative consultations in patients undergoing cataract surgery? Toanswer thisquestion, it is important tounderstandwhat theauthorsdidandthe limitationsof theirapproach.Theyused a 5% national random sample of Medicare part B files for the years 1995 to 2006.They identified consultation codes that occurred within 42 days of surgery and reported that the frequency of consultation increased from 11.0% in 1995 to 18.4% in2006.When internalmedicinephysiciansarecombinedwith family practitioners, this group provided 85% of all consultations,whereasspecialists suchascardiologistsandpulmonologists together representedonly 11%of the consultations. Such ahigh incidence of consultations byprimary caregivers could represent routine follow-up by the patient's primary physicianasopposed toanadditional evaluationobtained solely for thepurposes of the surgical procedure. If the formerwas true, then the incremental costswouldbenegligible comparedwith those of routine care unless the consultation led to additional laboratory tests beingobtained solely for thepurposeof clearing the patient for the surgical procedure. If no tests were obtained, then clearly the consultation could be consideredpart of routine care. However, if the consultation was performed solely for the purpose of an evaluation for the surgical procedure, then such additional medical services could be consideredunnecessaryandof lowvalue.Thekeyquestion iswhether thepatienthasbeen in stable condition since theprevious routine examination. It is hoped that the surgeon or anesthesiologist can assess the patient and, if the patient’s condition is stable, obtaina simplehistoryandmedication list fromtheprimary care provider. Given this framework, the authors attempt to address the question of appropriateness of the preoperative consultations by assessing geographic variations. They report increased utilization in the Northeast sector of the country and whenanesthesiologists are involved. They also observed substantial variation in frequency of consultation across hospital referral regions, again suggesting that this practice may reflect local utilizationpatterns rather thanunderlyingmedical necessity. Aswith all analyses of administrative claims, the goals are clearly togenerateahypothesis rather than toanswer thequestion ofwhether these consultations are truly indicated. However, the results of this study suggest that a great deal of lowvalue care is occurring among patients who undergo cataract surgery. Because much of this care occurs more frequently when patients undergo the procedure with an anesthesiologist present, better communication between the anesthesiologist, surgeon, and internists or other primary care providers is required inorder todefine thepopulationwhoneedssuch evaluation testing, which could lead to reduced testing. The resultsofThilenet al3 alsoparallel thoseof another recentpublication concerningpotentially low-value care,whichdemonstrated increased use of stress testing in noncardiac surgical patients without risk factors.7 This is the motivation behind thePerioperativeSurgicalHomeconcept recentlyproposedby the American Society of Anesthesiologists.8 So how do we ensure that provision of low-value or novalue care is reducedor eliminated? Payment reform inwhich either the entire surgical episode is bundled or the patient is enrolled in anaccountable care organizationmay itself lead to moreappropriateuseof consultationand testing. Itwill be important forphysicians, armedwith this informationabout current practice patterns, to take the lead in choosingwiselywith respect to which patients require a consultation and test before external forces do it for us. Related article page 380 Medicare Patients Undergoing Cataract Surgery Original Investigation Research

An umbilical/paraumbilical hernia as a sign of an intraabdominal malignancy in the elderly.

The umbilical area can present with a variety of signs associated with an intra abdominal malignancy. An umbilical/paraumbilical hernia might itself be a sign of an internal malignancy. The correlation between the presence of an umbilical/paraumbilical hernia and an intra abdominal malignancy has been previously based only on case reports. The aim of the study was to evaluate the significance of an umbilical/paraumbilical hernia as a symptom of an intraabdominal malignancy. A retrospective analysis was performed; review of the medical records of 145 patients (113 female and 32 male; mean age 66.4±11.9) with an umbilical/paraumbilical hernia treated during the period of 2005-2013. Twenty-three patients (15.9%) were diagnosed with an intra abdominal malignancy; 34% were in the age group over 75 years of age. The most common malignancies were: colorectal cancer, followed by pancreatic cancer, and cancers of the adnexa and kidneys. The patients with a concomitant malignancy identified were significantly older than those without a malignancy. In 65% of patients, the diagnosis was made postoperatively. Logistic regression analysis demonstrated that age, the presence of preoperative symptoms, anemia, and weight loss were independent risk factors for concomitant abdominal cancer. The findings of this study support intensive preoperative diagnostic evaluation of elderly patients that are qualified for surgery for an umbilical/paraumbilical hernia. This is particularly important because most of these patients had a small/medium hernia orifice, which did not allow for accurate manual abdominal exploration. Currently, the routine preoperative diagnostic evaluation is often insufficient for an accurate diagnosis.

Comparison of Mallampati test with lower jaw protrusion maneuver in predicting difficult laryngoscopy and intubation.

Background:Failure to maintain a patent airway is one of the commonest causes of anesthesia-related morbidity and mortality. Many protocols, algorithms, and different combinations of tested methods for airway assessment have been developed to predict difficult laryngoscopy and intubation. The reported incidence of a difficult intubation varies from 1.5% to 13%. The objective of this study was to compare Mallampati test (MT) with lower jaw protrusion (LJP) maneuver in predicting difficult laryngoscopy and intubation.Materials and Methods:Seven hundred and sixty patients were included in the study. All the patients underwent MT and LJP maneuver for their airway assessment. After a standardized technique of induction of anesthesia, primary anesthetist performed laryngoscopy and graded it according to the grades described by Cormack and Lehane. Sensitivity, specificity, accuracy, and positive predictive value (PPV) and negative predictive value (NPV) were calculated for both these tests with 95% confidence interval (CI) using conventional laryngoscopy as gold standard. Area under curve was also calculated for both, MT and LJP maneuver. A P < 0.05 was taken as significant.Results:LJP maneuver had higher sensitivity (95.9% vs. 27.1%), NPV (98.7% vs. 82.0%), and accuracy (90.1% vs. 80.3%) when compared to MT in predicting difficult laryngoscopy and intubation. Both tests, however, had similar specificity and PPV. There was marked difference in the positive and negative likelihood ratio between LJP and MT. Similarly, the area under the curve favored LJP maneuver over MT.Conclusion:The results of this study show that LJP maneuver is a better test to predict difficult laryngoscopy and tracheal intubation. We recommend the addition of this maneuver to the routine preoperative evaluation of airway.

Retrorectal tumours: optimization of surgical approach and outcome

The aim was to identify the radiological features of retrorectal tumours that influence management and to highlight technical points that facilitate safe surgical excision. A consecutive series of patients was identified from a prospective database. All cases were discussed within a multidisciplinary team. Medical records, radiology and pathology reports were also checked retrospectively. Fifty-six patients [37 women; median age 51 (20-88) years] underwent excision of retrorectal tumours between 2002 and 2010 under the care of one surgeon. Seventeen (37.5%) had a malignant tumour. The commonest symptom was pain or discomfort. Features identified after MRI that suggested malignancy included heterogenous signal intensity (15/17 malignant lesions vs 5/39 benign lesions), an irregular infiltrative margin (14/17 malignant lesions vs 4/39 benign lesions) and enhancement (14/17 malignant lesions vs 2/39 benign lesions) (all P < 0.05). An abdominal approach was used in 27 (48%) patients, a perineal/trans-sacral approach in 20 (36%) and a composite abdomino-sacral approach in nine (16%). The perineal approach was used if the tumours were below the middle of S3 without sacral, pelvic side-wall or visceral involvement. The three most common types of tumour were schwannoma (n = 11), tail gut cyst (n = 13) and chordoma (n = 9). Over a median follow-up period of 46 (6-90) months there were two local recurrences among the malignant tumours (both resected) and two deaths (both sarcomas). MR imaging, avoidance of routine preoperative biopsy and careful clinical evaluation result in a good outcome after surgical excision of retrorectal tumours.

The Role of the Preoperative Screening of Sleep Apnoea by Berlin Questionnaire and Epworth Sleepiness Scale for Postoperative Atrial Fibrillation

Undiagnosed obstructive sleep apnoea (OSA) is a risk factor for postoperative atrial fibrillation (POAF) as well as for heart disease in general. This necessitates screening during preoperative assessment to facilitate the implementation of strategies to minimise the postoperative risk. Overnight polysomnography is the "gold standard" for the diagnosis of OSA but may be impractical during preoperative assessment, and so questionnaires may be useful for screening OSA. The Berlin Questionnaire (BQ) and Epworth Sleepiness Scale (ESS) are two of the widely prescreening tools for persons who may suffer from sleep disorders. Thus, screening for and treating OSA as part of the routine preoperative evaluation of cardiac surgical patients may be a useful strategy for preventing POAF. We investigated whether there is an association between POAF and sleep disorders evaluated by the BQ and ESS in this settings. In 73 consecutive patients undergoing CABG with cardiopulmonary bypass, preoperative clinical characteristics and operational data were examined. During the clinical evaluation, all patients answered the ESS and BQ voluntarily upon admission. Patients were continuously monitored for the occurrence of sustained postoperative AF while hospitalised. There were 33 patients with POAF and 40 patients without POAF as age- and gender-matched controls. The prevalence of high score in ESS was higher in POAF group compared to control group (52% vs 27%; p: 0.030). There was a higher prevalence of high risk for OSA in BQ in the POAF group (58% vs 34%; p: 0.044). Preoperative questionnaire-based diagnosis of OSA by the simple BQ and ESS may be useful in predicting POAF, and can be easily incorporated into routine screening of surgical patients undergoing CABG operation.

Clinical Value of Preoperative Coronary Risk Assessment by Computed Tomographic Arteriography Prior to Adult Living Donor Liver Transplantation

PurposePatients with advanced liver diseases are at increased risk of cardiovascular events, resulting in a higher incidence of cardiac complications following liver transplantation (OLT). We assessed the clinical value of computed tomographic coronary arteriography (CTCAG) as a routine preoperative cardiac evaluation test in adult patients scheduled for living donor OLT (LDLT). MethodsThis single-center, prospective, observational study evaluated 247 adult patients being assessed for LDLT from April 2010 to March 2011. CTCAG was performed in patients with all-negative findings on routine cardiac workup, including thallium single photon emission computed tomography (SPECT). ResultsOf the 247 patients evaluated, 27 (10.9%) showed abnormal findings on CTCAG, with 18 (7.3%) showing mild to moderate involvement of one vessel; 7 (2.8%), two-vessel; and 2 (0.8%), three-vessel involvement. Coronary artery calcification was identified in patients with significant coronary artery stenosis. No adverse events occurred after CTCAG. Noticeable hypotensive episodes during LDLT surgery occurred in 5% of patients, mostly related to massive bleeding or postperfusion syndrome. During the first 3 months after LDLT, 3% of patients showed stress cardiomyopathy, but all recovered with supportive care. ConclusionsThe poor general medical condition of LDLT candidates and the diagnostic accuracy of CTCAG suggest that this test should be included in the routine pretransplant cardiac workup, along with thallium SPECT, for these patients.

Preoperative Prediction of Non-Home Discharge: A Strategy to Reduce Resource Use after Cardiac Surgery

Patients requiring discharge to a continuing care facility after cardiac surgery (non-home discharge) frequently have prolonged hospital stays while arrangements are made for posthospital care. We hypothesized that preoperatively identifying patients likely to require non-home discharge would allow earlier discharge planning, shorten length of stay, and thereby reduce resource use. This study sought to develop a validated tool for preoperative planning of non-home discharge. From October 2008 to December 2009, 4,243 patients were discharged alive after cardiac surgery at Cleveland Clinic. Of these, 4,031 resided in the 48 contiguous states or Alaska and formed the study cohort. Logistic regression analysis of non-home discharge was performed using preoperative data generally readily available at admission. A subsequent group of 2,005 patients discharged alive from December 2009 to July 2010 was used to validate this model. Eighteen percent of patients had non-home discharge, which was predictable from data readily available at admission for cardiac surgery (C-statistic 0.88 for model development, 0.87 for model validation). The strongest predictors included intra-aortic balloon pumping (odds ratio [OR] 7.5; 95% confidence interval [CI] 1.7 to 32), emergency status (OR 3.7; CI 2.1 to 6.5), older age (p < 0.001), longer preoperative stays (p < 0.001), poor nutritional state (p < 0.001), a number of comorbidities, and descending thoracic aorta procedures (OR 4.3; 95% CI 2.5 to 7.4). Non-home discharge can be easily predicted using data obtained during routine preoperative evaluation of cardiac surgical patients. We expect that early identification of patients at high risk for non-home discharge will allow for more intensive, personalized discharge planning, and will reduce wasted days and resource use.