Standard Preoperative Preparation Research Articles

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

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

OPTIMIS PRO – A Novel Algorithm to Improve Perioperative Antibiotic Administration

Objectives The selection and dosing of surgical antimicrobial prophylaxis (SAP) to prevent surgical site infections (SSIs) is often improvisational and inappropriate in clinical settings resulting in increased risk of SSI. We therefore developed and implemented a novel computer decision support tool, OPTIMIS PRO (OPTIMIzing PROphylaxis), to improve appropriate SAP selection specific to each patient’s procedure and clinical context. Methods: This quality improvement study was conducted at a tertiary hospital network over 2 years, divided into pre-intervention (June 2021-June 2022) and post-intervention (June 2022-June 2023) periods. The intervention was a computer decision support tool programmed within the hospital’s health information system to provide patient-specific SAP recommendations based on four variables: procedure name, patient’s beta-lactam allergy status, MRSA status, and weight. Approximately 3046 unique surgical procedures were identified and a specific best practice SAP recommendation for each surgery was identified based on international practice guidelines, up-to-date literature, and panel expertise input from 14 surgical divisions at our institution. Safety of cefazolin prophylaxis among patients with self-reported beta-lactam allergy was established in the pre-operative clinic using a validated simple two-item questionnaire (Figure 1). During each standard preoperative preparation, a best practice SAP recommendation alert was then provided to the responsible anesthesiologist based on the inputs from the four aforementioned variables (Figure 2). To assess the impact of the OPTIMIS PRO tool on antibiotic prescribing, we retrospectively audited SAP selection before and after implementation, also assessing appropriateness for each of the specific inputs using evidence-based criteria. Results: Over 30 000 OPTIMIS PRO recommendation alerts were logged in the 12-month post-intervention period. A random sample audit of 408 surgical encounters were selected from the pre- and post-intervention period for analysis. Overall, appropriate antibiotic administration rose from 77% (161/208) to 92.5% (185/200) (x2=18.0, p < 0 .001) post-intervention. Usage of cefazolin among patients reporting a beta lactam allergy rose from 48% (16/33) to 100% (12/12). None of these 12 patients experienced adverse reactions as a result of beta lactam exposure. Appropriate antibiotic selection based on MRSA status was high pre- and post-implementation (98.4% vs 99.4%); but significant improvements were made for procedure-specific antibiotic selection (80.5 vs 94.5%; x2=19.3, p < 0 .001) and weight-based dosing (92.5% vs 98.4%; x2=7.45, p=0.006). Conclusion: In this first-ever intervention designed to direct SAP prescribing based on patient specific variables, we significantly improved appropriate SAP selection across a comprehensive list of surgical procedures. Future analysis should include assessing potential reductions in SSIs as result of using the support

Giant retroperitoneal liposarcoma with spread to the upper third of the left thigh

Background. Large tumors, such as giant liposarcoma, are a challenge for modern medicine because of difficulty of treatment and possible impact on functions of the adjacent tissues and organs. The review of this clinical case may help develop new strategies and approaches to treatment of similar pathologies. Purpose. Review of the clinical case has a goal to educate medical specialists and students by helping to expand their understanding of rare oncologic diseases and to prove high effectiveness of surgery in locally advanced types of retroperitoneal liposarcomas using the clinical case as an example. Materials and methods. Female patient C., 56 years old, sought for medical help in the clinical unit of State Organization «Grigoriev Institute for Medical Radiology and Oncology of the National Academy of Medical Sciences of Ukraine» in June 2021. The following diagnosis was established: retroperitoneal liposarcoma with spread to the left thigh, St. II–ІІІ сТ3N0M0. An en-bloc surgery (removal of the retroperitoneal tumor with mobilization of the left ureter, intraabdominal removal of the thigh part of the tumor of the left thigh from beneath the inguinal ligament) was performed after the standard preoperative preparation. The surgery went without complications. The wound healed primarily. The follow-up period of the patient was 16 months. Clinical laboratory examination did not show any local recurrences and distant metastases. Results. For retroperitoneal sarcoma, the goal of surgery is to achieve the complete resection of the tumor (R0). Partial removal (R2) tumor should be strongly avoided, as this has been demonstrated to have higher recurrence risk and a detrimental effect on oncologic outcomes. The tumor involvement of organs and structures does necessitate concomitant resection. Resection of one or more adjacent organs is carried out in 58–87% of all cases of primary RPS. Most commonly, ipsilateral nephrectomy and partial colectomy are also performed. In cases of hypothetical necessity of removing all adjacent organs, an extended or compartmental approach to resection is recommended. The main idea is to resect not only evidently affected organs but also surfaces to obtain circumferential «soft tissue margins». This approach is controversial but data from some sarcoma care centers in Italy and France indicate its effectiveness. Conclusions. Treating RPS in specialized centers of oncosurgery with surgical planning based on CT and MRI data is of vital importance, especially using assessment by related surgical specialists. In large RPS, achieving a classic R0 resection level is a challenge, even in a compartmental approach, therefore division of resections into R2 and R0/R1 is reasonable. The choice of approach determines success of the surgery due to the narrowness of the surgical field.

Microbiocenosis of adenocarcinoma tissue in colon cancer patients with different preoperative preparation

Purpose of the study. To assess the effect of inclusion of lactoglobulin in complex preoperative preparation of colon cancer patients on their tumor and resection line tissue microbiota.Materials and methods. 40 patients with colon cancer stages II–III, in whom the operation was the first stage of treatment, during standard preoperative preparation, were injected with a preparation of antibodies against opportunistic intestinal microorganisms obtained from colostrum of immunized cows, 2 g twice a day orally before surgery for 3 days (total dose of 12 g) (main group); 40 patients received standard antibiotic prophylaxis (control group). The quantitative composition of the microbiota was determined in the samples of the removed tumor and tissue of the resection line.Results. The total microbial contamination of the tumor was 9.2 times lower in the main group relative to the control group; the frequency of E.coli and Clostridiae excretion was also statistically significantly lower (p = 0.004 and 0.03, respectively). In the tumors of patients of the main group out of twelve studied representatives of microorganisms, the number of six was statistically significantly lower than in control group, and three of those found in the control group were not detected. Since they were potentially pathogenic (Pseudomonas aeruginosa, Staphylococcus aureus, fungi of the Candida spp.), the microbial composition of the tumor of patients in the main group can be considered more favorable than the control group. Similar differences were noted in non-t umor intestinal tissue, in which the content of Enterobacter spp, Streptococcus, Clostridiae, Peptostreptococci was statistically significantly lower than in the control group.Conclusion. Thus oral administration of colostrum antibodies caused positive changes in tumor and colon tissue microbiota. We suggest the application of lactoglobulin to be useful for surgical treatment of such patients taking into account the possible impact of microbiota in patients’ response to chemo- and immunotherapy.

Effect of making skin incision with electrocautery on positive Cutibacterium acnes culture rates in shoulder arthroplasty: a prospective randomized clinical trial

Cutibacterium acnes remains the most commonly detected organism in shoulder arthroplasty. C. acnes infection is thought to occur during shoulder arthroplasty through contamination of the surgical field with C. acnes from the incised dermis. The purpose of this study was to examine whether using electrocautery for making skin incisions would decrease C. acnes culture rates at the incised dermis compared to using scalpels during shoulder arthroplasty. Patients undergoing primary shoulder arthroplasty were randomized into 2 groups, Electrocautery vs. Scalpel incision group. All patients received a standard preoperative antiseptic preparation including chlorhexidine gluconate showers, intravenous antibiotic administration, and topical application of hydrogen peroxide, povidone iodine, isopropyl alcohol, and DuraPrep. Cultures were obtained from the incised dermal edge immediately after skin incision and later from surgeon's gloves and forceps immediately prior to humeral component implantation. The primary outcome was positive C. acnes culture rates compared between the groups. A total of 64 patients (32 in each group) were enrolled. There were 24 males in each group. Regarding dermis cultures, 10 patients (31%) in the Scalpel group were positive with 8 of them positive for C. acnes, whereas no patients in the Electrocautery group were positive (p < 0.001). Regarding glove cultures, the Electrocautery group had 8 patients positive C. acnes, while the Scalpel group had 8 (p = 0.777). Regarding forceps cultures, the Electrocautery group had 4 patients positive for C. acnes, and the Scalpel group had 6 (p = 0.491). All positive cultures were exclusively from male patients. There were no wound complications or infection in the Electrocautery group while the Scalpel group had one acute postoperative infection. Making skin incisions using electrocautery resulted in zero C. acnes culture at the incised dermis, suggesting its potential effect against C. acnes. However, despite this initial antibacterial effect, C. acnes still appeared on surgeon's gloves and forceps during surgery of male patients. All positive cultures were from male patients, suggesting that the source of C. acnes was specifically related to the male body. While the study hypothesis was supported by the results, the present study also raises new questions and calls for further research.

Role of Interleukin-6 in Prediction of Early Complications After Minimally Invasive Oesophagectomy-a Pilot Study.

Infectious complications following oesophagectomy are associated with significant morbidity. Early prediction of these complications may mitigate significant morbidity and mortality. Patients undergoing minimally invasive oesophagectomy for carcinoma oesophagus between January 2019 and June 2020 were included in the study. All patients underwent standard preoperative investigations and preparation. Post-operative complications including infectious complications were recorded. Association of post-operative serum interleukin-6 (IL-6) levels with post-operative complications were analysed. A total of twenty-two participants were included in the study (median age; 51 years, 13 (%) male). The tumour site was middle 1/3rd of oesophagus in 13 (59.1%), lower 1/3rd of oesophagus in 9 (40.9%). The tumour histology was squamous cell carcinoma in all patients. Eight (36.4 %) patients developed major complications and five of them developed anastomotic leak. IL-6 levels were significantly higher on POD 3 in patients who developed major complications (p = 0.009) and anastomotic leak (p = 0.031). At receiver operating characteristic curve (ROC curve) analysis, an IL-6 cut-off level of 36.4 pg/ml on POD 3 yielded a sensitivity of 87% and a specificity of 79% for the prediction of major complication and cut-off level of 44.3 pg/ml on POD 3 yielded a sensitivity of 80% and a specificity of 82% for the prediction of anastomotic leak. A high post-operative IL-6 level helps in the prediction of major complications and cervical oesophagogastric anastomotic leak.

Association of Intra-Operative Bile Culture with Post-Operative Complications after Pancreaticoduodenectomy.

Background: Infectious complications after pancreaticoduodenectomy (PD) are a major cause of morbidity. The association of bactibilia with the occurrence of surgical site infection (SSI) is debatable. Patients and Methods: Consecutive patients who underwent PD between July 2019 and December 2020 were included. All patients underwent standard pre-operative preparation and imaging. Pre-operative biliary drainage (PBD) was done as clinically indicated. A bile sample was collected just before the transection of common bile duct (CBD). Post-operative outcomes including SSI were analyzed. Results: Fifty-four patients were assessed for enrollment; 50 were found to be resectable during surgery and were included. The incidence of bactibilia was 46%. Nineteen (38%) patients developed SSIs and the occurrence was higher in patients who had positive bile culture (14 [60.8%] vs. 5 [18.5%]; p = 0.002). A similar organism between bile culture and SSI was seen in nine (64.2%) of 14 patients. Patients who had positive bile culture had more frequent change of antibiotic (16 [69%] vs. 8 [29.6%]; p = 0.005) and required prolonged duration of postoperative antibiotic agents (12 days [IQR, 8-14] vs. 8 days [IQR, 6-10]; p = 0.003). There was no association between bile culture growth and development of post-operative pancreatic fistula, delayed gastric emptying, and post-operative pancreatic hemorrhage. Patients with bactibilia had prolonged post-operative stay (17 days [IQR, 11-20] vs. 11 days [IQR, 8-14]; p = 0.010) and severe post-operative complications (8 [34.7%] vs. 2 [7.4%]; p = 0.008). Conclusions: Bactibilia is associated with the development of SSI and may provide a guide in selection of antibiotics.

Effectiveness of preoperative bath using chloroxylenol antiseptic soap on the incidence of post emergency cesarean section surgical site infection at Mbarara Regional Referral hospital, Uganda: a randomized controlled trial.

IntroductionSurgical Site Infections (SSIs) constitute 15%-45% of hospital acquired infections in sub-Saharan Africa. Cesarean section (CS) increases the risk of developing sepsis by 5-20 times and is highest when the operation is emergency. Therefore, the purpose of this study was to measure the effect of chloroxylenol in reducing the incidence of post cesarean SSIs at Mbarara Regional Referral Hospital (MRRH).Methodsa randomized controlled trial was conducted at MRRH maternity ward and mothers were randomized into either control or intervention arms. The intervention was a complete body bath with chloroxylenol antiseptic soap before the operation, while the control arm participants received a standard ward pre-operative preparation procedures. All participants were followed up for 30 days and assessed using an SSI screening tool.Resultsninety-six women were randomized, and 48 were assigned to each arm. The overall incidence of SSI was 30.21%. The incidence of SSI was significantly lower in the intervention compared to the control arm (6.25% in the intervention arm versus 54.17% in the control arm) (p-value <0.001). Chloroxylenol bath was protective of SSI with a 90% risk reduction for SSI (95% confidence interval of 67%–97%).Conclusiona preoperative bath with chloroxylenol for pregnant mothers is associated with a significantly lower risk of post cesarean section surgical site infections. Health facilities with a high burden of post SSI should consider adding this simple and effective intervention to the existing infection prevention measures. Clinical Trials.gov registration (NCT03544710).

COMPREHENSIVE PREOPERATIVE APPROACH AND ENDOVENOUS ELECTRIC WELDING IN THE TREATMENT OF CHRONIC VENOUS INSUFFICIENCY C6 CLINICAL CLASS

The evaluation was done in the sphere of preoperative preparation trophic ulcer in patients with CVI using the proposed tactics of mechanochemical debridement and elimination of vertical venous reflux EVEZ method, in comparison with standard preoperative management tactics and EVLT of saphenous veins. It is established that the proposed tactics of preoperative preparation are more effective than classical approaches.&#x0D; Purpose. The use of the EVEZ method in combination with the proposed preoperative preparation of trophic ulcers in the treatment of CVI was determined to be effective.&#x0D; Materials and methods. An analysis of the treatment of 68 patients with CVI C6 clinical class was performed. The patient of the main group received the EVEZ treatment tributaries and perforating veins with preoperative trophic preparation ulcers, which includes: active mechanochemical debridement and control moisture balance in the wound, installation of negative pressure wound therapy system, platelet rich plasma therapy, application drugs based on diosmin and hesperidin. The proposed scheme of preoperative preparation has the following algorithm:&#x0D; &#x0D; Taking a smear from the sore to determine the bacterial spectrum and subsequent rational antibacterial therapy following the results of the antibioticogram;&#x0D; Active mechanochemical debridement with solutions of 0.1% polyaminopropyl biguanide + 0.1% surfactant, povidone-iodine + ethanol + glycerin + laureate 9 and control of moisture balance in the wound with modern hydrogel sore dressings;&#x0D; Installation of VAC system with a constant negative pressure of 120 mm Hg for 3 days for the first 3 performances of the system. Subsequently, VAC therapy was performed in a constant mode with a pressure of 80-120 mm Hg. in patients with insufficient wound cleanliness;&#x0D; After active cleaning, PRP therapy was performed, which involves the introduction of platelet-enriched plasma along the edge of the wound to a depth of 3 to 5 mm. The amount of PRP used depended on the size of the defect and ranged from 1 to 2 ml.&#x0D; All patients of the main group underwent correction of concomitant pathology with systemic use of capillary stabilizing drugs based on diosmin / hesperidin.&#x0D; &#x0D; Patients in the comparison group received standard preoperative preparation and EVLT. Patients of both groups were outpatient for 6 months. 39 of them (57.35%) were women and 29 (42.65%) were men aged 36 to 78 years. The duration of ulcers ranged from 3 months to 7 years. The following localization of venous trophic ulcers was observed: in the area of the medial bone - in 49 (72%) patients, 10 (14.7%) - on the anterior surface, 9 (13.3%) - on the lateral, posterior, anterior medial or anterolateral surface of the tibia.&#x0D; Results. Tactics of preoperative preparation that is offered allowed to achieve: reduction of redness and swelling in the main group on 7.3 ± 0.8 days (comparison group 10.2 ± 0.7 days); complete cleaning of the wound from fibrin and necrotic tissues at 9.1 ± 0.5 days (15.0 ± 1.1); the appearance of granulation tissues at day 12.6 ± 0.9 (18 ± 0.7); the appearance of marginal epithelialization at 15.3 ±0.7 days (20 ± 1.1).&#x0D; Conclusions. The proposed tactics can reduce the term by 1.7 times the preparation of the ulcer for surgery and 1.6 times the healing time of ulcers. The EVEZ method allows performing ablation efficiently and safely trunk great saphenous vein. The use of phlebotonic drugs, which is called Normoven, allows you to accelerate the healing of ulcers and prevent their recurrence.

Effects of the use neuromuscular electrical stimulation of the lower extremities in the prehabilitation of patients in a before cardiac surgery

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Research Institute for Complex Issues of Cardiovascular Diseases Aim To evaluate the effects of neuromuscular electrostimulation in the prehabilitation and prevention of muscle weakness in patients awaiting cardiac surgery. Materials and methods 122 patients waiting for elective cardiac surgery were included. Exclusion criteria: age less than 25 and more than 80 years; emergency and urgent surgical interventions; arthropathies; low pain threshold; rhabdomyolysis and other myopathies; cognitive dysfunction. Routine laboratory and instrumental examinations were performed in all patients upon admission to the hospital, as part of a standard examination. 62 patients were randomly selected for the preoperative NMES group, in addition to the standard preoperative preparation and treatment program. The standard program included 60 control patients. Patients of the NMES group underwent quadriceps stimulation for at least 5 sessions, lasting 90 minutes, daily before surgery. Results. The groups were comparable and did not have significant differences in gender and age characteristics, according to the main clinical and anamnestic data and types of operations. Initially, there were no differences in the state of the muscles of the lower extremities, the distance of the six-minute walking test (6MWT), and the strength of the hand grip. After NMES, there was an increase in muscle strength relative to the control group, both stimulated muscle groups and unstimulated antagonist muscles, as well as a greater 6MWT distance and hand compression force. All the differences were significant. Conclusions The course of pre-rehabilitation of NMES before surgery, allowed to maintain, and in some cases improve the condition of the muscle frame of the lower extremities. A positive effect was observed not only in stimulated muscle groups, but also in antagonist muscles Indicators of muscle status NMES (n = 62) Control group (n = 60) Baseline Discharge Baseline Discharge P-level Right knee extensors strength (kg) 24,4 [18,3; 31,4] 30,4 [23,8; 36,2]* 24,7 [20,1; 33,2] 22,25 [18,9; 30,4] &amp;lt;0,001 Left knee extensors strength (kg) 23,8 [19,3; 31,3] 29,2 [23,6; 35,4]* 25,75 [19,2; 31,3] 22,9 [18,9; 27,8] &amp;lt;0,001 Right knee flexors strength (kg) 18,9 [13,3; 24,0] 21,7 [16,6; 25,1] 19,55 [13,1; 26,0] 16,7 [12,1; 23,3] 0,006 Left knee flexors strength (kg) 19,3 [14,3; 24,5] 21,9 [17,3; 26,7] 19,5 [13,0; 24,3] 18,2 [13,4; 22,2] 0,005 6-MWT (m) 300,0 [261,0; 371,0] 331,0 [280,0; 375,0] 304,5 [253,0; 380,0] 285,5 [246,0; 342,0] 0,006 Right handgrip strength (kg) 28,5 [20,5; 34,0] 31,5 [22,0; 34,0] 29,0 [19,0; 34,0] 27,0 [19,0; 33,0] 0,054 Left handgrip strength (kg) 25,0 [18,0; 31,0] 25,0 [18,0; 32,0] 24,0 [15,0; 31,0] 22,0 [14,0; 28,0] 0,062 * - p-level from baseline data &amp;lt; 0,05 Abstract Figure. dynamics of stimulated muscles

Distal clavicle fractures with “superior intact cortical bone”: minimally invasive surgery

Distal clavicle fractures represent 12%-26% of all clavicle fractures. For unstable cases, surgical fixation is the preferred method of treatment. To date, there is still controversy regarding the best fixation method with a high reoperation and complication rate reported. The purpose of this article is to describe a minimally invasive method for reduction and stabilization of displaced distal clavicle fractures, using cortical buttons. After standard preoperative preparation, a 3-cm incision is made at the coracoclavicular area. Using both coracoid and clavicle tunnels, fracture reduction and fixation is obtained using a cortical fixation button. Standard postoperative care is given. A total of 21 patients (19 men) with a mean age of 34.7 years were treated using this technique. The follow-up was between 6 and 41 months, with an average of 23.4 months. The mean simple shoulder test score was 79.4 (range 66-91.7), and the QuickDASH score was 11 (range 6.8-15.9). Consolidation of the fracture was confirmed at the 12-week follow-up radiography, with no cases of nonunion or malunion identified. No patients presented infection or complications at the surgical site. Implant removal was not needed in this series. All the patients returned to work. Minimally invasive button fixation of unstable distal clavicle fractures is a safe and reliable alternative treatment. The initial outcome report is promising with excellent clinical and radiological results and no complications or implant removals.

Effect of bile duct clamping versus no clamping on surgical site infections in patients undergoing pancreaticoduodenectomy: a randomized controlled study.

Infectious complications cause significant morbidity after pancreatoduodenectomy (PD). The impact of uncontrolled spillage of bile during PD has not been systematically studied. Patients undergoing PD for malignant lesions between March 2017 and May 2019 were considered for inclusion. All patients underwent standard pre-operative preparation and antibiotic prophylaxis. After confirmation of resectability, the patients were randomized into one of the two groups: common hepatic duct clamping using atraumatic bulldog clamp after biliary division (Group I) or no clamping (Group II). Post-operative outcomes including surgical site infection (SSI) were compared. Fifty-two patients were assessed for eligibility and eventually 40 were randomized (median age: 53.5 years, 28 (70%) males). Twenty patients were randomized into each group and 14 in each group had undergone pre-operative biliary drainage. Incidence of co-morbidities, operative time and blood loss were comparable between the two groups. SSI was significantly lower in Group I (4 (20%) versus 11 (55%), P = 0.02). Number needed to treat to prevent one SSI was 3. Incidence of intra-abdominal collections was higher in Group II, though, not statistically significant (2 (10%) versus 6 (30%), P = 0.23). The duration of post-operative antibiotics was significantly higher in Group II (7 IQR 4 versus 11 IQR 7 days, P = 0.04). Among the risk factor evaluated in the entire population, higher incidence of SSI was seen in patients with positive bile culture (13 (65%) versus 2 (10%), P = 0.04). Bile duct clamping during PD reduces risk of superficial SSI.

Analysis of the 3D prototyping in the surgical correction of congenital kyphoscoliosis

Objective . To analyze the advantages of additive technologies and 3D modeling in surgery for severe congenital spinal deformities caused by mixed and non-classified developmental anomalies, including assessing the quality of transpedicular screws. Material and Methods . A total of 20 patients with complex spinal anatomy caused by congenital vertebral anomalies were treated. Nine patients had complex unclassifiable anomalies of the spine, 11 had mixed anomalies, 3 of them had aplasia of the structures of the spinal column. In order to assess the results, patients were divided into two groups of 10 people. In Group I, standard preoperative preparation was performed according to X-ray, CT and MRI data. In Group II, preoperative preparation was accompanied by the use of a prefabricated 3D model of the patient’s spine. CT data were used to create STL-models which were printed using 3D printer. To analyze the effectiveness of 3D prototyping in preoperative planning, a survey among surgeons specializing in pathology of the spine was conducted. Results . Survey results demonstrated that there were cases of changes in surgical treatment tactics after the 2nd stage of the survey, based on the results of applying standard methods of radiation diagnostics and 3D model of the entire spine with prototyping of the thoracic, lumbar, and sacral spine. In 25.3 % of cases, tactics were changed. Significant improvement in surgical treatment results were observed in Group II with preoperative 3D modeling (94.9 % without screw malposition), compared to Group I in which surgical correction was performed using standard methods of imaging (78.1 % without screw malposition). Conclusion . 3D modeling allows increasing the accuracy of the placement of transpedicular screws and reducing the risk of malposition, which favorably affects the biomechanical properties of the instrumentation and reduces the risk of damage to neural structures. The use of 3D modeling can statistically significantly reduce the time taken to install one screw, and the number of x-rays required. Reducing the number of images allows you to reduce radiation exposure not only to the patient, but also to the staff of the department.

Cutibacterium acnes in primary reverse shoulder arthroplasty: from skin to deep layers

The aim of this study was to determine the presence of Cutibacterium acnes (formerly Propionibacterium acnes) on the skin and in deep tissue in a real clinical scenario of primary reverse shoulder arthroplasty. This prospective study included 90 primary reverse shoulder arthroplasties, and 12 cultures were obtained from each patient. Each sample was homogenized and used to inoculate PolyVitex (bioMérieux, Marcy-l'Etoile, France) agar and Schaedler (bioMérieux) agar plates. The same procedure was also followed with a thioglycolate broth. Culture was considered positive for C acnes when 2 or more colonies were observed. Total DNA from C acnes isolates was extracted using the InstaGene Matrix (Bio-Rad Laboratories, Hercules, CA, USA) method. The phylotype was determined, and single-locus sequence typing was done on all isolates. We obtained 1080 tissue cultures from the 90 patients included, and 62 of those tissue cultures (5.7%) were positive for C acnes. There were 22 C acnes-positive tissue cultures before prosthesis implantation and 40 after implantation. C acnes was isolated in 17 patients (18.8%). We sent 38 positive samples for blinded phylotyping, single-locus sequence typing, and multi-locus sequence typing type determination. Many of the clusters isolated belonged to phylotype IB and clonal complex (CC) 36 or phylotype II and CC53. In the real scenario of patients undergoing primary reverse shoulder arthroplasty using antibiotic prophylaxis and standard preoperative skin preparation with chlorhexidine, C acnes was isolated in the deep layers of 18.8% of the patients. The C acnes K1 and K2 subtypes (belonging to phylotype II and CC53), reported to be commonly involved in prosthetic joint infection, were usually isolated.

ПРЕДОПЕРАЦИОННАЯ КОРРЕКЦИЯ СИМПТОМОВ ЭНДОГЕННОЙ ИНТОКСИКАЦИИ И НАРУШЕНИЙ КИСЛОРОДНОГО СТАТУСА У БОЛЬНЫХ КОЛОРЕКТАЛЬНЫМ РАКОМ

The purpose of the study is to propose a method of preoperative correction of the symptoms of endogenous intoxication syndrome and associated respiratory disorders in patients with colorectal cancer. The study involved 68 patients having a surgery for colorectal cancer of different localization, with an increased leukocyte index of intoxication by V.K.Ostrovsky in preoperative period. The first group patients (37 subjects) in the preoperative preparation program took Cytoflavin® according to the developed scheme. The second group patients (31 subjects) had a standard preoperative preparation. As result of the research, there was revealed a positive effect of the proposed method of preoperative preparation on hematological parameters of endogenous intoxication (decrease in values of the parameters of Calf-Caliph, Ostrovsky and integral index of intoxication) and parameters of oxygen status, which changes indicated a decrease in tissue hypoxia (decrease in tissue oxygen consumption). The positive effect of the proposed method of preoperative preparation was observed in the postoperative period (reduced severity of respiratory disorders and hematological symptoms of endogenous intoxication).

Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty.

Propionibacterium acnes (P. acnes) is the most common bacteria associated with infection after shoulder arthroplasty. These bacteria can be grown on culture of skin after standard preoperative skin preparation and antibiotics. The purpose of this study was to determine whether adding preoperative intravenous doxycycline reduces the prevalence of positive P. acnes cultures of skin and deep tissues at the time of prosthetic joint implantation during shoulder arthroplasty. This was a randomized controlled trial. An a priori power analysis determined that a sample size of 56 patients was necessary. Patients scheduled to undergo shoulder arthroplasty were randomized to receive either standard perioperative cefazolin or a combination of doxycycline and cefazolin. Tissue specimens for culture were then taken from the skin edge, and swabs of the superficial dermal tissue and glenohumeral joint were obtained. All cultures were maintained for 14 days to allow for P. acnes detection. Groups were compared to determine if the addition of doxycycline reduced the rate of culture positivity. Fifty-six patients were enrolled and randomized. Twenty-one (38%) had ≥1 positive cultures for P. acnes, with no significant difference between the group treated with cefazolin alone (10 [37%] of 27 patients) and the combined doxycycline and cefazolin group (11 [38%] of 29 patients) (p = 0.99). The greatest numbers of culture-positive samples were obtained from the skin (30%), followed by dermal tissue (20%) and the glenohumeral joint (5%). Patients who had ≥1 positive cultures were younger than those who did not (mean age [and standard deviation], 64.9 ± 7.7 versus 69.4 ± 7.7 years; p = 0.041), had a greater tendency to be male (16 [76%] of 21 versus 17 [49%] of 35; p = 0.053), and had a lower Charlson Comorbidity Index (3.35 ± 1.3 versus 4.09 ± 1.4; p = 0.051). There were no significant differences between the culture-positive and culture-negative groups in terms of body mass index (BMI) (p = 0.446) or arthroplasty type, with positive cultures found for 8 of the 29 anatomic shoulder arthroplasty procedures compared with 13 of the 27 reverse shoulder arthroplasty procedures (p = 0.280). There were no doxycycline-related adverse events. In this randomized controlled trial, doxycycline did not significantly decrease P. acnes culture positivity of the skin, dermis, or glenohumeral joint of patients undergoing shoulder arthroplasty. The addition of prophylactic intravenous antibiotics to cover P. acnes may not be an effective method to reduce postoperative and periprosthetic shoulder joint infections. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Bacterial Contamination of a Marking Pen in Anterior Cruciate Ligament Reconstruction.

Background:A sterile surgical marking pen is commonly used during anterior cruciate ligament reconstruction (ACLR) to outline the proposed skin incision and then to mark the graft during preparation. Once in contact with the skin, the pen is a potential source of bacterial transmission and subsequent infections after ACLR.Purpose/Hypothesis:The purpose of this study was to assess whether the skin marking pen is a fomite for contamination during arthroscopic ACLR. We hypothesized that there would be a difference in the rate of culture-positive pens between control pens and the study pens used to delineate the proposed skin incision.Study Design:Controlled laboratory study.Methods:Twenty surgical marking pens were collected prospectively from patients undergoing ACLR over a 12-month period. All patients underwent standard preoperative sterile preparation and draping procedures. Proposed incisions were marked with a new sterile pen, and the pen tip was immediately sent for a 5-day inoculation in broth and agar. Negative controls (unopened new pen) and positive controls (used to mark the skin incisions preoperatively) were also cultured. Additionally, blank culture dishes were observed during the growth process. All pens were removed from the surgical field before incision, and new marking pens were used when needed during the procedure.Results:Three of the 20 study pens (15%) demonstrated positive growth. All 3 pens grew species of Staphylococcus. None of the negative controls demonstrated growth, 6 of the 12 positive controls showed growth, and none of the blank dishes exhibited growth.Conclusion:This study found a 15% rate of surgical marking pen contamination by Staphylococcus during ACLR. It is recommended that the skin marking pen not be used for any further steps of the surgical case and be discarded once used.Clinical Relevance:Infections after ACLR are rare but may result in significant morbidity, and all measures to reduce them should be pursued. Surgeons performing ACLR should dispose of the surgical marking pen after skin marking and before intraoperative use such as graft markup.

The Effectiveness of Preoperative Preparation for Improving Perioperative Outcomes in Children and Caregivers.

Most children experience significant anxiety during the preoperative period. Greater preoperative anxiety may be related to a higher incidence of negative behaviors. This study aimed to develop a family-centered preoperative preparation program and to evaluate the effects of this program on children's preoperative emotional behaviors, postoperative behavior, and posthospital behavior, and on caregiver anxiety. A prospective, randomized controlled study was conducted. The population consisted of children who underwent minor surgery and their caregivers. The control group received standard care, and the experimental group received standard care plus preoperative preparation, which included a tour, a cartoon video depicting a boy's surgical journey, and familiarization with medical equipment. Children's emotional behaviors and caregiver anxiety were measured at the preoperative visit, in the preoperative holding area, and at induction of anesthesia. Postoperative behavior was measured when children were in the recovery room, and the researcher also contacted caregivers 2 weeks after the surgery to assess the children's behavior at home. A linear mixed-effects model results showed that as the surgery approached, the experimental group had fewer and more stable preoperative emotional behaviors (least squares means of preoperative emotional behaviors from preoperative visit to induction of anesthesia = 10.01-10.95). However, the control group exhibited significantly increased preoperative emotional behaviors as the surgery approached (least squares means of preoperative emotional behaviors from the preoperative visit to induction of anesthesia = 7.87-12.23). Family-centered preoperative preparation can effectively improve children's negative emotional behaviors from their time in the preoperative holding area to the induction of anesthesia.

Post-appendectomy Infected Wounds and Ideal Management A Retrospective Study

Background :Abdominal operations are traditionally classified into elective and emergency procedures both of which may be complicated by postoperative wound infections. Although postoperative wound infection is usually infrequent following elective procedures, it is an anticipated and acceptable complication of emergency surgeries as these operations are usually of a contaminated nature with no standard preoperative preparation associated with an urge to operate.Objectives :This study tries to compare the results of a two adopted regimes to manage post-appendectomy wound infections in regard to the significance of using parenteral antibiotics.&#x0D; Methods : This study had evaluated (108) patients with clinical postoperatively wound infections over a period of (3) years in Al-Hilla General Teaching Hospital. All cases with normal appendices and those on preoperative antibiotics therapy for any reason had been excluded from the study. Two treatment regimes had been evaluated : Regime (A) consisting of changing antiseptic wound dressings only while Regime (B) consisted of changing antiseptic wound dressings combined with parenteral administration of intravenous metronidazole (500) mg thrice daily with intravenous cefotaxime (1000) mg twice daily. The study group had been allocated to a randomized single-blind trial to assess the outcomes. Patients were followed– up to an average of (50) days.Results :There is a beneficial effects of adopting Regime (B) in the management of infected wounds following perforated appendectomies in terms of reducing the number of dressings change and the period of inpatients hospitalization . This was not the case with infected wounds following nonperforatedappendectomies.Conclusion : According to the literature reviewed, in order to prevent or reduce the rate of post-appendectomy infected wounds it is recommended to use preoperative prophylactic antibiotics which is not a routine in our practice.Wound irrigation with antiseptics may be beneficial in prevention of wound infection following complicated appendectomy. Regime (B) of treatment should be reserved for infected wounds following complicated appendectomy.&#x0D;

What Do Scottish Patients Expect of Their Total Knee Arthroplasty?

BackgroundThe aim of this study was to carry out an in-depth assessment of patient expectations before surgery in a representative sample of the Scottish population undergoing primary total knee arthroplasty and also assess the influence of demographic factors and preoperative functions on expectations. MethodsThis was a prospective cohort study of 200 patients treated in our institution from November 2011 to July 2013. Patients received standard preoperative preparation including consultation with a surgeon, an information booklet and a DVD. Patients completed the Hospital for Special Surgery Knee Replacement Expectation Survey along with the EuroQol EQ-5D-3L health questionnaire on the day of admission. ResultsFifty-nine percent of the cohort were women, mean age 67.7 years (45-84 years), mean body mass index 32.5 (21-50), mean preoperative Oxford Knee Score 17 (1-44). Relief of pain and improved ability to walk were the most important expectations, followed by the ability to use public transport and/or drive, ability to change position, ability to walk down stairs, and the ability to carry out routine daily activities and/or chores. Some expectations were unrealistic. No relationships between expectations and demographics, including preoperative function, were found. ConclusionThis study suggests that patients have very high and sometimes unrealistic expectations regarding their improvements after total knee arthroplasty even after detailed preoperative consultation and education. In addition, these expectations cover a wide range of dimensions. We suggest that to effectively manage patients' expectations, it is important to assess each patient individually and reinforce what expectations can realistically be achieved.