Surgeon Factors Research Articles

Failed Acellular Nerve Allografts: A Critical Review.

Acellular nerve allograft (ANA) occupies an increasingly prominent role in the treatment of peripheral nerve reconstruction. There is demonstrable efficacy; however, some grafts fail to support axonal regrowth and the reasons for this are unclear. This study examines the ANA experience in a specialized peripheral nerve surgery department to discuss the clinical and histological findings in failed cases. Failed ANA grafts were identified from a prospective database using Medical Research Council Classification (MRCC) S3 and M3 as thresholds for success. Cases in which ANA grafting was indicated for nerve related pain and dysesthesia but where no subjective improvement in symptoms occurred were also included. Patients requiring revision surgery after ANA grafting were also considered failures. Cases were then examined in conjunction with a literature review to identify possible mechanisms of failure, including detailed histological analysis in 2 cases. Eight failed procedures were identified from a database of 99 separate allograft records on 74 patients. This included procedures for 2 tibial nerves, 2 superficial radial nerves, 2 median nerves, 1 digital nerve and a lateral cord brachial plexus injury (male/female, 5:3; age range, 24-54 years). Allograft length range 25 to 120 mm. One postoperative infection was identified. Histological findings in 2 cases included adequate vascularization of allograft material without subsequent axonal regeneration, a reduction of large myelinated fibers proximal to a tibial nerve allograft in the setting of a chronic injury, and a preference for small rather than large fiber regeneration. This article reports instances of ANA graft failure in a variety of contexts, for which the primary reasons for failure remain unclear. The etiology is likely to be multifactorial with both patient, graft and surgeon factors contributing to failure. Further clinical and histological analysis of ANA failures will improve our understanding of the mechanisms of graft failure.

Utilization of Techniques for Upper Extremity Amputation Neuroma Treatment and Prevention

This study aimed to understand the current utilization of surgical approaches for nerve ending management in upper extremity amputation to prevent and treat nerve-related pain. We administered a survey to 190 of 1270 surgeons contacted by email (15% response rate) and analyzed their demographics, practice patterns, and perceptions regarding techniques for nerve ending management in upper extremity amputees. Although many surgical techniques were employed, most surgeons (54%) performed traction neurectomy during amputation and, alternatively, bury nerve into muscle if a neuroma subsequently develops (52%). Surgeons in practice less than 10 years were more likely to perform targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI) than surgeons in practice greater than 10 years (p<0.001). TMR and RPNI were performed more frequently for proximal amputations than distal amputations, but there is no consensus regarding the optimal timing to utilize these techniques. Surgeons commonly cited improved prosthetic control, pain, and phantom limb symptoms as reasons for performing TMR and RPNI. Increased physician compensation as a consideration was more commonly cited among TMR non-adopter than adopters (31% vs 14%, p=0.008). There is no consensus regarding techniques for the prevention or treatment of nerve ending pain in upper extremity amputees. TMR and RPNI are being utilized with increasing frequency and both patient and surgeon factors affect implementation in clinical practice.

Predictors of same-day discharge after minimally invasive hysterectomy for benign indications.

To identify predictors of same-day discharge after benign minimally invasive hysterectomy. In this retrospective cohort study, we identified women (n=1084) undergoing benign minimally invasive hysterectomy from 2009 to 2016. Multivariate logistic regression was used to examine demographic, operative, and surgeon factors associated with discharge on postoperative day 0. In our study population, 238 women (22%) were discharged on the same day. Robotic hysterectomy (risk ratio [RR] 2.24; 95% confidence interval [CI] 1.13-4.44), shorter operative time (lowest quartile; RR 5.28; 95% CI 2.66-10.46), and minimal blood loss (lowest quartile; RR 3.01; 95% CI 1.68-6.23) were associated with higher same-day discharge likelihood whereas later procedure start time (2-5pm; RR 0.38; 95% CI 0.17-0.85) and postoperative complications (RR 0.19; 95% CI 0.06-0.55) significantly decreased its likelihood. The strongest predictor was surgeon's number of years in practice, with recently graduated surgeons more likely to discharge their patients on the same day (RR 3.15; 95% CI 2.09-4.77). Same-day discharge after minimally invasive hysterectomy is determined by several patient, operative, and surgeon factors that can be incorporated into an implementation plan to promote earlier discharge. Most especially, scheduling patients based on perceived case complexity and targeted surgeon education can qualify a larger cohort for same-day discharge.

Effect of Surgeon and Hospital Factors on Length of Stay after Colorectal Surgery

Effect of Surgeon and Hospital Factors on Length of Stay after Colorectal Surgery

Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua.

Higher rates of postoperative complication following cleft lip or palate repair have been documented in low resource settings, but their causes remain unclear. This study sought to delineate patient, surgeon, and care environment factors in cleft complications in a low-income country. Prospective outcomes study. Comprehensive Cleft Care Center. Candidate patients presenting for cleft lip or palate repair or revision. Patient anthropometric, nutritional, environmental and peri- and post-operative care factors were collected. Post-operative evaluation occurred at standard 1-week and 2-month postoperative intervals. Complication was defined as fistula, dehiscence and/or infection. Among 408 patients enrolled, 380 (93%) underwent surgery, of which 208 (55%) underwent lip repair (124) or revision (84), and 178 (47%) underwent palate repair (96) or revision (82). 322 (85%) were evaluated 1 week and 166 (44%) 2 months postoperatively. 50(16%) complications were identified, including: 25(8%) fistulas, 24(7%) dehiscences, 17(5%) infections. Mid-upper arm circumference (MUAC) ≤12.5 cm was associated with dehiscence after primary lip repair (OR = 28, p = 0.02). Leukocytosis ≥11,500 on pre-operative evaluation was associated with dehiscence (OR = 2.51, p = 0.04) or palate revision fistula (OR = 64, p < 0.001). Surgeons who performed fewer previous-year palate repairs had higher likelihood of palate complications, (OR = 3.03, p = 0.01) although there was no difference in complication rate with years of surgeon experience or duration of surgery. Multiple patient, surgeon, and perioperative factors are associated with higher rates of complication in a low-resource setting, and are potentially modifiable to reduce complications following cleft surgery.

Barriers to salpingectomy for permanent contraception: A qualitative study with obstetricians and gynaecologists.

Consideration of risk-reducing bilateral salpingectomy has been recommended instead of tubal occlusive procedures for female sterilisation due to the role of the Fallopian tubes in the aetiology of serous ovarian malignancies. This study identified barriers to performing salpingectomy for permanent contraception. Twenty-two semi-structured interviews were conducted with Australian gynaecologists, and transcripts analysed qualitatively. Barriers to performing bilateral salpingectomy included: (a) patient factors (younger age and risk of regret); (b) operative complexity and complications (particularly risk of bleeding); (c) surgeon factors (lack of awareness of guidelines supporting salpingectomy; less comfort with laparoscopic surgery); and (d) practical system challenges (including cost and equipment availability).

Adjusting for Variation in Patient-Reported Outcome Measures Is Needed to Improve Care After Total Knee Arthroplasty

Limited quantitative information exists about the patient and surgeon factors driving variation in patient-reported outcome measure (PROM) scores, limiting the use of these data in understanding and improving quality. The overall goal of this study was to learn how to adjust PROM scores to enable both individual and group quality improvement. Observational study in which preoperative Oxford Knee Score (OKS) and Patient Reported Outcomes Measurement System (PROMIS)-10 measures were prospectively obtained through patient survey from 1,173 of 1,435 possible patients before total knee arthroplasty and from 810 of the 1,173 patients at 12 months postoperatively (response rates = 81.7% and 69.0%). Regression analyses identified the relative contribution of patient and surgeon risk factors to OKS change from baseline to 12 months. Variation in patient scores and surgeon performance was described and quantified. Adjusted outcomes were used to calculate an observed and expected score for each surgeon. (1) Moderate variation was observed in pre-/post-OKS change among the surgeons (n = 16, mean change = 15.5 ± 2.2, range = 12.1-21.1). Forty-five percent of the variance in OKS change was explained by the factors included in our model. (2) Patient preoperative OKS and PROMIS physical score, race, and BMI were markedly associated with change in OKS, but other patient factors, surgeon volume, and years of experience were not. (3) Eight surgeons had observed scores greater than expected after adjustment, providing an opportunity to learn what strategies were associated with better outcomes. Traditional age/sex adjustment of patient mix would have had no effect on mean PROM scores by surgeon. An adjustment model that includes the factors found to be markedly associated with outcomes will allow care systems to identify individual surgeon care management strategies potentially important for improving patient outcomes.

Management of postoperative complications during laparoscopic anterior rectal resection.

Laparoscopic anterior resection (LAR) is currently a routine practice in specialized high-volume centers, with equivalent oncological outcomes in historical, open surgery. Appropriate pelvic dissection can be measured by the adequacy of circumferential margin (CRM) and distal margin, both are risk factors of local recurrence. Among the various operative procedures for colorectal cancer, low anterior resection (LAR) for rectal cancer is one of the most demanding procedures because it requires resection of cancer with surrounding mesorectal tissue and reconstruction with anastomosis in the narrow pelvis while preserving the autonomic nerves of the urogenital organs particularly in the male pelvis. Low anterior resection is associated with a relatively high incidence of postoperative morbidities, including anastomotic leakage and other operative site infections, and asymptomatic patients infected with COVID-19 submitted to elective could be at higher risk which sometimes result in postoperative mortality. Therefore, recognition of the incidence and risk factors of postoperative complications following low anterior resection is essential to prevent it. The importance of some risk factors such as age, nutrition status of the patient, experience of the surgeon and many other factors that influence outcome of colorectal surgery which could be modified preoperatively to prevent postoperative complications. In the other hand long term postoperative complications may promote tumor recurrence and decrease survival. The aims of this review are to provide an overview of the current literature on postoperative complications of rectal surgery and to describe risk factors and strategies to prevent, treat or reduce complications.

MP16-16 EVALUATION OF PEER-RATED SURGICAL SKILL AND MUSCLE SAMPLING IN TRANSURETHRAL RESECTION OF BLADDER TUMOR

You have accessJournal of UrologyBladder Cancer: Non-invasive II (MP16)1 Sep 2021MP16-16 EVALUATION OF PEER-RATED SURGICAL SKILL AND MUSCLE SAMPLING IN TRANSURETHRAL RESECTION OF BLADDER TUMOR Minh Pham, Oliver Ko, Reiping Huang, Amanda Vo, Kyle Tsai, Jeremy Lai, Matthew Hudnall, Joshua Halpern, Joshua Meeks, Jonas Benson, Ricardo Soares, Ronald Kim, Jonah Stulberg, and Gregory Auffenberg Minh PhamMinh Pham More articles by this author , Oliver KoOliver Ko More articles by this author , Reiping HuangReiping Huang More articles by this author , Amanda VoAmanda Vo More articles by this author , Kyle TsaiKyle Tsai More articles by this author , Jeremy LaiJeremy Lai More articles by this author , Matthew HudnallMatthew Hudnall More articles by this author , Joshua HalpernJoshua Halpern More articles by this author , Joshua MeeksJoshua Meeks More articles by this author , Jonas BensonJonas Benson More articles by this author , Ricardo SoaresRicardo Soares More articles by this author , Ronald KimRonald Kim More articles by this author , Jonah StulbergJonah Stulberg More articles by this author , and Gregory AuffenbergGregory Auffenberg More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002001.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prior work has shown that detrusor muscle sampling (MS) from transurethral resection of bladder tumor (TURBT) is related to oncologic outcomes. It is unknown if surgeon skill can be assessed with operative videos or if skill is associated with MS. We aim to assess the reliability of peer review of TURBT videos to quantify skill and whether skill is associated with MS. METHODS: Urologists from our health system were recruited to submit a TURBT video. Each was rated by blinded peer surgeons using a structured scoring instrument. Interrater reliability (IRR) was determined for each domain on the instrument (Table 1). Items with IRR ≥0.4 were used to generate a normalized composite skill score. Using retrospective data, we measured surgeon MS rates for TURBTs performed from 9/2018 to 9/2019. A random-intercept logistic regression model was fit, adjusting for surgeon and non-surgeon factors to assess the relationship between surgical skill and MS. RESULTS: 13 surgeons submitted a TURBT video, each reviewed by 10 raters. Of 10 domains assessed, 6 had IRR ≥0.4 and were used for a composite skill score (Table 1). Normalized composite skill score varied significantly among surgeons (Figure 1). With data from 228 TURBTs by 8 surgeons with >5 cases, the overall MS rate was 72%, varying from 50% to 90% across surgeons. Regression modeling showed an association between sending a separate deep sample to pathology and MS (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02 – 3.81; p=0.045) but not between peer-rated skill and MS (OR: 0.81; 95% CI: 0.57 – 1.17; p=0.191; Table 2). CONCLUSIONS: Video-based peer review is a mechanism to assess TURBT performance, with modest IRR and significant variation in skill across surgeons. Surgeon skill was not associated with MS in TURBT. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e303-e304 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Minh Pham More articles by this author Oliver Ko More articles by this author Reiping Huang More articles by this author Amanda Vo More articles by this author Kyle Tsai More articles by this author Jeremy Lai More articles by this author Matthew Hudnall More articles by this author Joshua Halpern More articles by this author Joshua Meeks More articles by this author Jonas Benson More articles by this author Ricardo Soares More articles by this author Ronald Kim More articles by this author Jonah Stulberg More articles by this author Gregory Auffenberg More articles by this author Expand All Advertisement Loading ...

Contemporary Pure Laparoscopic vs Robot-Assisted Laparoscopic Radical Nephrectomy: Is the Transition Worth It?

Introduction: The proportion of robotic procedures continues to rise. The literature reinforces that robotic procedures take longer and are often more costly. We compared cost and perioperative outcomes of laparoscopic radical nephrectomy (LRN) and robot-assisted radical nephrectomy (RARN) at our high-volume center. Materials and Methods: We retrospectively reviewed our 2012-2015 data repository for patients undergoing RARN and LRN for a renal mass. Perioperative and oncologic outcomes were compared. We performed a multivariate analysis of operative time, estimated blood loss, length of stay (LOS), and overall and major 90-day complication rates while controlling for demographic data, Charlson comorbidity index (CCI), tumor size, and surgeon factors. We compared fixed, variable, and distinct procedural costs. Results: We identified 99 LRN and 95 RARN cases. There was no difference in demographic data, tumor size, preoperative renal function, and malignant histology. LRN patients had more comorbidities (49.5% vs 27.3% CCI 2+, p = 0.018). The mean preoperative glomerular filtration rate was higher in the robotic cohort (84.8 vs 75.1, p = 0.48). Mean operative time was 32.7 minutes longer (p = 0.002) and estimated blood loss 145 mL higher (p = 0.007) for the RARN cohort. There was no difference in mean LOS. Major and all 90-day complication rates were no different. The mean procedural cost for RARN was higher by $464 when controlling for operative time (p < 0.001). Fixed costs were not statistically different. Variable costs for RARN were estimated to be $2,310 higher (p = 0.045). Conclusions: Even with cost-conscious, experienced renal surgeons, RARN is associated with a longer procedure, higher supply costs, and higher hospitalization costs. There was no difference in positive surgical margin and complications. There were fewer 30-day readmissions for the RARN cohort, which may represent under-recognized cost savings. With fewer LRN cases in the United States each year, discussion to address cost is warranted. Without better outcomes for robotic surgery, a change in reimbursement to cover costs is unlikely to happen.

Analysis of retrieved STRYDE nails.

AimsThe aim of this study was to present the first retrieval analysis findings of PRECICE STRYDE intermedullary nails removed from patients, providing useful information in the post-market surveillance of these recently introduced devices.MethodsWe collected ten nails removed from six patients, together with patient clinical data and plain radiograph imaging. We performed macro- and microscopic analysis of all surfaces and graded the presence of corrosion using validated semiquantitative scoring methods. We determined the elemental composition of surface debris using energy dispersive x-ray spectroscopy (EDS) and used metrology analysis to characterize the surface adjacent to the extendable junctions.ResultsAll nails were removed at the end of treatment, having achieved their intended lengthening (20 mm to 65 mm) and after regenerate consolidation. All nails had evidence of corrosion localized to the screw holes and the extendable junctions; corrosion was graded as moderate at the junction of one nail and severe at the junctions of five nails. EDS analysis showed surface deposits to be chromium rich. Plain radiographs showed cortical thickening and osteolysis around the junction of six nails, corresponding to the same nails with moderate – severe junction corrosion.ConclusionWe found, in fully united bones, evidence of cortical thickening and osteolysis that appeared to be associated with corrosion at the extendable junction; when corrosion was present, cortical thickening was adjacent to this junction. Further work, with greater numbers of retrievals, is required to fully understand this association between corrosion and bony changes, and the influencing surgeon, implant, and patient factors involved.Cite this article: Bone Jt Open 2021;2(8):599–610.

How to salvage the delivery of a wrong-sided meniscal allograft: A rare case series

IntroductionAlthough rare, tissue processing errors have occurred during meniscal transplantation. The anatomic differences between the lateral and medial menisci makes this problematic for surgeons who find themselves with an incorrectly labeled graft. ObjectiveTo describe the management of a wrong-sided meniscal allograft transplant (MAT) and technical pearls when converting a lateral to a medial MAT. MethodsRetrospective case series of two patients with a wrong-sided MAT. ResultsBoth patients were found to have a properly sized left lateral MAT for a planned right medial MAT and the decision was made to proceed with surgery. Converting the bone tunnel to bone plugs and suturing the body to bone are key technical steps to replicate the biomechanics of the medial meniscus in these circumstances. Acceptable long-term outcomes were seen in the patient with available follow-up data. ConclusionThe decision to proceed with surgery in these circumstances should be made on an individual basis considering graft, patient, and surgeon factors. Knowledge of the technique for converting a wrong-sided meniscal transplant may reduce waste of grafts and prevent patients from being exposed to additional anesthesia.

Factors associated with surgeon recommendation for additional cast immobilization of a CT-verified nondisplaced scaphoid waist fracture

IntroductionData from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8–12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This study aimed to investigate (1) the degree to which surgeons use fracture tenderness and radiographic appearance of union, among other factors, to decide whether or not to recommend additional cast immobilization after 8 or 12 weeks of immobilization; (2) identify surgeon factors associated with the decision to continue cast immobilization after 8 or 12 weeks.Materials and methodsIn a survey-based study, 218 surgeons reviewed 16 patient scenarios of CT-confirmed nondisplaced waist fractures treated with cast immobilization for 8 or 12 weeks and recommended for or against additional cast immobilization. Clinical variables included patient sex, age, a description of radiographic fracture consolidation, fracture tenderness and duration of cast immobilization completed (8 versus 12 weeks). To assess the impact of clinical factors on recommendation to continue immobilization we calculated posterior probabilities and determined variable importance using a random forest algorithm. Multilevel logistic mixed regression analysis was used to identify surgeon characteristics associated with recommendation for additional cast immobilization.ResultsUnclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons’ decision to recommend continued cast immobilization. Women surgeons (OR 2.96; 95% CI 1.28–6.81, p = 0.011), surgeons not specialized in orthopedic trauma, hand and wrist or shoulder and elbow surgery (categorized as ‘other’) (OR 2.64; 95% CI 1.31–5.33, p = 0.007) and surgeons practicing in the United States (OR 6.53, 95% CI 2.18–19.52, p = 0.01 versus Europe) were more likely to recommend continued immobilization.ConclusionAdoption of shorter immobilization times for CT-confirmed nondisplaced scaphoid waist fractures may be hindered by surgeon attention to fracture tenderness and radiographic appearance.

Optimal reconstructive strategies in the setting of post-mastectomy radiotherapy - A systematic review and network meta-analysis

BackgroundA third of breast cancer patients require mastectomy. In some high-risk cases postmastectomy radiotherapy (PMRT) is indicated, threatening reconstructive complications. Several PMRT and reconstruction combinations are used. Autologous flap (AF) reconstruction may be immediate (AF→PMRT), delayed-immediate with tissue expander (TE [TE→PMRT→AF]) or delayed (PMRT→AF). Implant-based breast reconstruction (IBBR) includes immediate TE followed by PMRT and conversion to permanent implant (PI [TE→PMRT→PI]), delayed TE insertion (PMRT→TE→PI), and prosthetic implant conversion prior to PMRT (TE→PI→PMRT). AimPerform a network metanalysis (NMA) assessing optimal sequencing of PMRT and reconstructive type. MethodsA systematic review and NMA was performed according to PRISMA-NMA guidelines. NMA was conducted using R packages netmeta and Shiny. Results16 studies from 4182 identified, involving 2322 reconstructions over three decades, met predefined inclusion criteria. Studies demonstrated moderate heterogeneity. Multiple comparisons combining direct and indirect evidence established AF-PMRT as the optimal approach to avoid reconstructive failure, compared with IBBR strategies (versus PMRT→TE→PI; OR [odds ratio] 0.10, CrI [95% credible interval] 0.02 to 0.55; versus TE→PMRT→PI; OR 0.13, CrI 0.02 to 0.75; versus TE→PI→PMRT OR 0.24, CrI 0.05 to 1.05). PMRT→AF best avoided infection, demonstrating significant improvement versus PMRT→TE→PI alone (OR 0.12, CrI 0.02 to 0.88). Subgroup analysis of IBBR found TE→PI→PMRT reduced failure rates (OR 0.35, CrI 0.15–0.81) compared to other IBBR strategies but increased capsular contracture. ConclusionImmediate AF reconstruction is associated with reduced failure in the setting of PMRT. However, optimal reconstructive strategy depends on patient, surgeon and institutional factors. If IBBR is chosen, complication rates decrease if performed prior to PMRT. Prospero registrationCRD 42020157077.

Osseointegration of retrieved 3D-printed, off-the-shelf acetabular implants.

AimsThe main advantage of 3D-printed, off-the-shelf acetabular implants is the potential to promote enhanced bony fixation due to their controllable porous structure. In this study we investigated the extent of osseointegration in retrieved 3D-printed acetabular implants.MethodsWe compared two groups, one made via 3D-printing (n = 7) and the other using conventional techniques (n = 7). We collected implant details, type of surgery and removal technique, patient demographics, and clinical history. Bone integration was assessed by macroscopic visual analysis, followed by sectioning to allow undecalcified histology on eight sections (~200 µm) for each implant. The outcome measures considered were area of bone attachment (%), extent of bone ingrowth (%), bone-implant contact (%), and depth of ingrowth (%), and these were quantified using a line-intercept method.ResultsThe two groups were matched for patient sex, age (61 and 63 years), time to revision (30 and 41 months), implant size (54 mm and 52 mm), and porosity (72% and 60%) (p > 0.152). There was no difference in visual bony attachment (p = 0.209). Histological analysis showed greater bone ingrowth in 3D-printed implants (p < 0.001), with mean bone attachment of 63% (SD 28%) and 37% (SD 20%), respectively. This was observed for all the outcome measures.ConclusionThis was the first study to investigate osseointegration in retrieved 3D-printed acetabular implants. Greater bone ingrowth was found in 3D-printed implants, suggesting that better osseointegration can be achieved. However, the influence of specific surgeon, implant, and patient factors needs to be considered.Cite this article: Bone Joint Res 2021;10(7):388–400.

Renal oncocytoma: landscape of diagnosis and management.

Renal oncocytoma represents between 6-12% of T1 renal tumours in surgical series (1-2). Contemporary imaging cannot differentiate oncocytoma from malignant renal cell carcinoma (RCC). Uptake of renal tumour biopsy in clinical practice has been variable (3) and surgery with partial or radical nephrectomy is the first-line in the management of RCC (4,5). Therefore, many patients with renal masses undergo empirical surgery for presumed RCC with post-operative histologic diagnosis of benign oncocytoma.

Comparative Study between Preoperative Ultrasonographic Based Scoring System and Intraoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has become the treatment of choice for cholelithiasis. Still some patients required conversion to open cholecystectomy (OC). The condition of the patient, the level of experience of the surgeon and technical factors all play a role in the decision for conversion. Inability to define the anatomy and difficult dissection are the leading reasons for conversion. Aims and objectives: To compare between and to validate: preoperative ultrasonographic based scoring system and intraoperative scoring system (SURGUE ET AL, IRELAND) as predictors for difficult laparoscopic cholecystectomy. Materials and Methods: This prospective randomized study was conducted at Kempegowda Institute of Medical Sciences Hospital, Bangalore after obtaining the Hospital Ethical Committee clearance for a period of 6 months from AUGUST 2018-JANUARY 2019. Pre-operative Ultrasonographic based scoring system was compared with Intra-operative scoring system to predict laparoscopic cholecystectomy. Results: In the study among those with Easy Pre-operative score, 90.9% had easy, 9.1% had moderate Intra-operative score. Among those with difficult pre-operative score, 33.3% had easy, 11.1% had moderate, 22.2% had difficult and 33.3% had extreme Intra-operative score. There was significant association between Pre-operative score and Intra-operative score. Conclusion: With the help of accurate prediction, high risk patient may be informed beforehand regarding the probability of conversion and hence they may have a chance to make arrangements accordingly. Surgeons can also be aware about the possible complications that may arise in high risk patients. Our study also concludes that radiological parameters are good predictors of difficulty.

Preoperative Advance Care Planning for Older Adults Undergoing Major Abdominal Surgery.

Advance care planning (ACP) is recommended for older patients undergoing surgery. ACP consists of creating advance directives (ADs), identifying surrogate decision makers (SDMs), and documenting goals of care. We identified factors associated with documentation of preoperative ACP to identify opportunities to optimize ACP for older surgical patients. This was a retrospective study of surgical patients ≥70 years old who underwent elective, high-risk abdominal procedures between 01/2015-08/2019. Clinical data were obtained from our institution's National Surgical Quality Improvement Project database. ACP metrics were extracted from the electronic medical record. We analyzed the data to identify patient factors associated with ACP metrics. We also analyzed whether ACP was more frequent for patients who experienced postoperative complications or death. 267/1,651 patients were included. 97 patients (36%) had an AD available on the day of surgery, 57 (21%) had an SDM identified, and 31 (12%) had a documented goals of care conversation. On multivariable analysis, older age and white race were associated with an increased likelihood of having an AD available on the day of surgery. Women were 1.7 times more likely to have an SDM (p = 0.02). No patient or surgeon factors were significantly associated with goals of care documentation. ACP was not performed more frequently in patients who experienced postoperative complications or death. In this series, ACP was not routinely documented for older patients undergoing major surgery. ACP was not more frequent in patients who experienced complications or death, demonstrating the importance of universal preoperative ACP in older patients.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction.

An Analysis of Formal Patient Complaints and Malpractice Events Involving Hand and Upper Extremity Surgeons.

Our purpose was to define and categorize patient complaints within a hand surgery practice over a 10-year period. In addition, we aimed to define surgeon and patient factors associated with formal complaints. All patients who filed a complaint with our institution's patient advocacy service against six hand surgeons in an academic practice over a 10-year period were recorded and categorized using the Patient Complaint Analysis System. A control group consisting of all patients seen by the surgeons during the study period was created. Demographic differences between the complaint and control groups were analyzed, as were complaint rates between surgeons. We obtained the number of malpractice events involving each of the surgeons. During the 10-year study period, 73 of 36,010 unique patients seen (0.20%) filed a complaint. Care and treatment category comprised the highest percentage of complaint designations (30%), followed by access and availability (23%). Forty-three patients (59%) who filed complaints were treated surgically. Patients with a complaint had a significantly higher percentage of mental, behavioral, or neurodevelopmental disorders compared with controls (55% versus 42%, P = 0.03). The complaint rate (total complaints/total new patients seen) ranged between 0.09% and 0.29% for the six surgeons, and these results were not statistically significant. Within an academic hand and upper extremity surgery practice, the rate of patient complaints is 0.20% or approximately one complaint for every 500 new patients seen. Most patient complaints are categorized within the care and treatment domain. Underlying mental health conditions are associated with more frequent complaints. Communication issues appear to represent a modifiable area that hand surgeons can improve to help mitigate potential complaints. Understanding both the frequency and types of patient complaints may allow hand surgeons to recognize areas for improvement and avoid potential exposure to malpractice litigation. Prognostic level III (case-control).