Surgical Classification Research Articles

Expert consensus on classification evaluation methods of burn surgery in China (2019 version)

At the beginning of 2009, the 38th principle of the Administrative Measures for Clinical Application of Medical Technology, issued by the former Ministry of Health, clearly pointed out that medical institutions should establish a hierarchical management system for surgery. Then the Trial of Administrative Measures for Surgical Classification of Medical Institutions was published and implemented in 2012, but the official introduction of surgical classification catalogue in the national level has not been seen. Therefore, the writing group of this expert consensus has organized numerous well-known experts and scholars in China, taking the three elements of the 38th principle of the Administrative Measures for Clinical Application of Medical Technology issued by the Ministry of Health--risk coefficient, complexity, and technical difficulty as the basic norm to grade scientifically through the four indicators of burn index, surgical area, surgical repair method, and anesthesia risk (each indicator with 4 grades and scores). The total score is then accumulated to divide four grades of operations. The Expert Consensus on Classification Evaluation Methods of Burn Surgery in China (2019 Version) is strategized together expecting to provide academic reference for the government departments to issue or further improve and perfect surgical classification catalogue in the national level as soon as possible, and lay a foundation for the stable development of burn discipline with the significance of national strategic reserve.

Real-Time Extraction of Important Surgical Phases in Cataract Surgery Videos

The present study aimed to conduct a real-time automatic analysis of two important surgical phases, which are continuous curvilinear capsulorrhexis (CCC), nuclear extraction, and three other surgical phases of cataract surgery using artificial intelligence technology. A total of 303 cases of cataract surgery registered in the clinical database of the Ophthalmology Department of Tsukazaki Hospital were used as a dataset. Surgical videos were downsampled to a resolution of 299 × 168 at 1 FPS to image each frame. Next, based on the start and end times of each surgical phase recorded by an ophthalmologist, the obtained images were labeled correctly. Using the data, a neural network model, known as InceptionV3, was developed to identify the given surgical phase for each image. Then, the obtained images were processed in chronological order using the neural network model, where the moving average of the output result of five consecutive images was derived. The class with the maximum output value was defined as the surgical phase. For each surgical phase, the time at which a phase was first identified was defined as the start time, and the time at which a phase was last identified was defined as the end time. The performance was evaluated by finding the mean absolute error between the start and end times of each important phase recorded by the ophthalmologist as well as the start and end times determined by the model. The correct response rate of the cataract surgical phase classification was 90.7% for CCC, 94.5% for nuclear extraction, and 97.9% for other phases, with a mean correct response rate of 96.5%. The errors between each phase’s start and end times recorded by the ophthalmologist and those determined by the neural network model were as follows: CCC’s start and end times, 3.34 seconds and 4.43 seconds, respectively and nuclear extraction’s start and end times, 7.21 seconds and 6.04 seconds, respectively, with a mean of 5.25 seconds. The neural network model used in this study was able to perform the classification of the surgical phase by only referring to the last 5 seconds of video images. Therefore, our method has performed like a real-time classification.

Evaluation of concordance among surgeons and pathologists regarding the diagnosis and classification of acute appendicitis in children

Acute appendicitis is the most frequent urgent abdominal surgical pathology in children. Therapeutic decisions in patients who have undergone an appendectomy are made based on the macroscopic findings at the moment of surgery. There is high variability between surgical and histopathological findings. MethodConcordance among surgeons and pathologists regarding the diagnosis and classification of acute appendicitis was assessed in children who have undergone an appendectomy. Surgical site infection (SSI) incidence was measured for both the surgical and pathological classification. ResultsThe statistical analysis included 1092 children. The pathologists confirmed the presence of appendicitis in 90.4% of the patients. Concordance in the diagnosis of appendicitis among surgeons and pathologists was weak (kappa 0.57), while concordance in the classification of perforated or non-perforated appendicitis was moderate (kappa 0.7). There were no significant differences in these findings determined by the surgeons’ experience or the open or laparoscopic approach. In the discordant group of 70 patients in which the surgeon classified the appendicitis as non-perforated but the pathologist classified as perforated, just one patient developed an intra-abdominal abscess. ConclusionsThe classification of appendicitis as perforated or non-perforated shows moderate concordance between the surgical and histopathological diagnosis. This concordance is not determined by the surgeons’ experience or the surgical approach. Type of StudyDiagnostic Test Level of EvidenceLevel II

Surgical resection margin classifications for high-grade pleomorphic soft tissue sarcomas of the extremity or trunk: definitions of adequate resection margins and recommendations for sampling margins from primary resection specimens

Adequacy of surgical resection margins for soft tissue sarcomas are poorly defined because of the various classifications and definitions used in prior studies of heterogeneous patient cohorts and inconsistent margin sampling protocols. Surgical resection margins of 166 primary, high-grade, pleomorphic sarcomas of the extremity or trunk were classified according to American Joint Committee on Cancer R and Musculoskeletal Tumor Society categories, as well as by metric distance and tissue composition. None of the cases were treated with neoadjuvant therapy. Multivariable competing risk regression models were evaluated and optimal surgical resection margins for each classification system were defined. Minimum safe tumor clearance was 5 mm without use of adjuvant radiotherapy and 1 mm with adjuvant radiotherapy. Predictive accuracy of margin classification systems was compared by area under receiver-operating characteristic curves generated from logistic regression of 2½-year local recurrence-free survival and other standard tests of diagnostic accuracy. The Musculoskeletal Tumor Society and margin distance classifications performed similarly, both of which showed higher sensitivity and negative predictive value compared to the American Joint Committee on Cancer R classification. The prognostic power of close or positive margins in prediction models significantly increased when six or more slides were submitted for assessment of surgical resection margins. Surgical resection margins for soft tissue sarcoma should be reported using the Musculoskeletal Tumor Society classification or metric distance to the closest resection margin. Musculoskeletal Tumor Society wide/radical margins or tumor clearances of 5 mm (without adjuvant radiotherapy) or 1 mm (with adjuvant radiotherapy) appear to define the minimum safe surgical resection margins necessary to decrease the likelihood of local recurrence of high-grade pleomorphic sarcomas of the extremity or trunk.

P4671A well-defined subgroup of chronic thromboembolic pulmonary hypertension patients are positive for antiphospholipid antibodies

Abstract Introduction Recurrent thromboembolism is a major risk factor for chronic thromboembolic pulmonary hypertension (CTEPH). Antiphospholipid antibodies (aPL) are a recognized risk factor for recurrent thromboembolism, however, their contribution to the development of CTEPH is currently unknown. Purpose The aim of this study was to evaluate the prevalence of antiphospholipid autoantibodies in a large cohort of consecutive patients with CTEPH. Methods Starting May 2013 to December 2018, 297 CTEPHpatients were consecutively enrolled. Diagnosis was confirmed with standardized right heart catheterization, 2D or/and 3D pulmonary angiography in all patients.All patients were also screened for thrombophilia including lupus anticoagulant IgG/IgM anticardiolipin antibodies and IgG/IgM aβ2GPI antibodies. Clinical and demographic characteristics, laboratory profile and hemodynamic data were compared between patients with aPL positive and aPL negative laboratory profiles. Results Overall, 297 consecutive patients with CTEPH were assessed for aPLs. Of these, 23 patients (7.7%) resulted positive for laboratory tests exploring aPL. Among patients with positive aPL, profile 17 (74%) were positive for all three test exploring aPL (LA+, aCL+, aB2GPI+). When compared to CTEPH patients without aPL test positivity, those positive for aPL were significantly younger (30.0 vs 55.6 years, p<0.0001), had a positive history of pulmonary embolism (95.6% vs 65.7%, p=0.003), deep venous thrombosis (78.3% vs 41.9%, p=0.0008) and were more frequently affected by other autoimmune diseases (43.5% vs 2.9%, p<0.0001). Moreover, positive aPL patients showed better hemodynamics on right heart catheterization, had more proximal lesions, and had more frequently level I and II surgical classification (82.6% vs 40.5%, p=0.0002) on pulmonary angiography. Conclusions These findings suggest that young patients with pulmonary embolism should be assessed for aPLs to guide anticoagulation therapy and prevent recurrences. Additionally, younger age, more proximal lesions and less severe hemodynamic profiles make majority patients with APS good candidates for PEA surgery.

Comprehensive analysis of unplanned abdominal - pelvic reoperations in Peking University Cancer Hospital and Institute from 2008 to 2018

Objective: To summarize the characteristics of abdominal-pelvic unplanned reoperation (URO) in a cancer hospital. Methods: Retrospectively descriptive cohort research was adopted. The classification of diseases was based on ICD-10, and surgical classification was based on ICD-9-CM-3. Medical record summary database from 2008 to 2018 in Beijing Cancer Hospital was collected, and all URO information of abdominal-pelvic surgery was retrieve. The time of URO, disease type, surgery type and cause were statistically analyzed. Distribution of main disease incidence and constituent ratio, and the application of major surgery and surgery type composition ratio were analyzed as well. Results: From 2008 to 2018, a total of 46854 cases underwent abdominal-pelvic surgery (including gastrointestinal, hepatic-biliary-pancreatic, gynecological, urological, or esophageal cancer surgery) and 713 patients received URO (1.52%), including 486 males and 227 females (2.14:1.00) with a mean age of (58.1±12.2) years. A total of 246 patients (34.50%) had comorbidity, and with comorbidity: without comorbidity was 1.13:1.00. The hospital stay was (44.5±43.0) days, and the total cost was (178000±112000) yuan. There were 22 deaths (3.09%). The median interval between URO and the first operation was 8 (0 to 131) days. The highest rate of URO was 2.45% (89/3629) in 2012, while the lowest was 0.95% (53/5596) in 2015. The top 3 major cancer types of URO included colorectal cancer (222 cases, 31.14%), gastric cancer (166 cases, 23.28%) and esophageal cancer (45 cases, 6.31%). The cancer types with the highest URO rate included pancreatic cancer (3.97%, 30/756), gastric cancer (1.81%, 166/9171) and colorectal cancer (1.80%, 222/12333). The top 3 surgical procedures resulting in URO were rectal resection (109 cases, 15.29%), total gastrectomy (79 cases, 11.08%), and total pancreatectomy (64 cases, 8.98%). Focusing on 497 URO cases from 2012 to 2018, 465 cases (93.56%) followed relatively difficult grade III and IV surgery, while only 32 cases (6.44%) followed grade I and II surgery. The top 5 main causes of URO were bleeding (225 cases, 31.56%), anastomotic leak (225 cases, 31.56%), infection (89 cases, 12.48%), intestinal obstruction (53 cases, 7.43%), and wound dehiscence (35 cases, 4.91%), adding up to a total of 87.94% of all URO. Conclusion: This study summarizes the epidemiology of abdominal - pelvic URO in our cancer institution, providing the solid baseline for future investigation of URO and the subsequent formulation of corresponding prevention and intervention measures.

Impact of safety protocol in an ambulatory surgical setting vs a hospital setting for laparoscopic-assisted myomectomy (LAM)

Ambulatory surgery center (ASC) for major gynecological surgery improves efficiency and decreases cost compared to a hospital setting. Protocols to ensure safety when performing major gynecologic surgeries are critical in the ASC setting. The objective of this study is to assess whether protocols do ensure safety when performing major gynecological surgeries such as laparoscopic-assisted myomectomy (LAM) in a high-volume ASC and compare it with protocols and outcomes in a hospital setting. This is a descriptive / retrospective study. This paper descriptively outlines the similarities and differences of a surgical safety protocol in an ambulatory surgical center compared to a hospital setting. Furthermore there is retrospective analysis of LAM outcomes that are commonly considered as safety standards in both settings including intraoperative and postoperative complications. The protocols were similar with regards to preoperative patient selection and checklist, surgical precautions including prevention of retained surgical items, DVT prophylaxis, infection control, surgical wound classification, vaginal and genital antisepsis for the surgical patient, postoperative care in PACU and discharge criteria for surgical management. The major preoperative differences from hospital protocol were transfusion criteria preoperatively. In the ASC, a cut-off of 9.0 g/dl was used, and a cut-off of < 7.5 g/dl was used in the hospital setting. LAM cases are only scheduled as morning cases. 23 hour observation is available at ASC. Additionally myomectomy patients at the ASC have ISTAT (blood analysis system to check Hemoglobin/Hematocrit) prior to procedure and at 1 and 2 hours after the procedure in the PACU to detect any signs of bleeding. Any patients that did require blood transfusion postoperatively were transferred to the local hospital from the ASC. There were 588 patients that underwent LAM at the ASC compared to 228 patients at the hospital. There was no significant difference in case complexity factors between settings including BMI, number of previous abdominal and pelvic surgeries or other comorbidities. Intraoperative complication rate was 3.4% (95% CI 1.8-5.0) at the ASC compared to 4.9% (95% CI 1.7-8.1) , p = 0.4430. There were no significant differences in postoperative complications between the ASC and the hospital setting including infections and thromboembolic events. Blood transfusion was required in 1.7% of the cases at ASC compared to 8.8% at the hospital setting. The estimated blood loss and average fibroid weight were not statistically different between the two groups. The LAM safety protocol at a free-standing ASC allows for patient complication outcomes that are comparable to an in-hospital setting without apparent limitations in patient complexity.

Surface EMG-based Surgical Instrument Classification for Dynamic Activity Recognition in Surgical Workflows

Abstract We introduce a wearable-based recognition system for the classification of natural hand gestures during dynamic activities with surgical instruments. An armbandbased circular setup of eight EMG-sensors was used to superficially measure the muscle activation signals over the broadest cross-section of the lower arm. Instrument-specific surface EMG (sEMG) data acquisition was performed for 5 distinct instruments. In a first proof-of-concept study, EMG data were analyzed for unique signal courses and features, and in a subsequent classification, both decision tree (DTR) and shallow artificial neural network (ANN) classifiers were trained. For DTR, an ensemble bagging approach reached precision and recall rates of 0.847 and 0.854, respectively. The ANN network architecture was configured to mimic the ensemble-like structure of the DTR and achieved 0.952 and 0.953 precision and recall rates, respectively. In a subsequent multi-user study, classification achieved 70 % precision. Main errors potentially arise for instruments with similar gripping style and performed actions, interindividual variations in the acquisition procedure as well as muscle tone and activation magnitude. Compared to hand-mounted sensor systems, the lower arm setup does not alter the haptic experience or the instrument gripping, which is critical, especially in an intraoperative environment. Currently, drawbacks of the fixed consumer product setup are the limited data sampling rate and the denial of frequency features into the processing pipeline.

A Treatise on The Surgical Management and A Suggested Amendment of Surgical Classification of Left Ventricular Rupture Following Mitral Valve Replacement

The present perspective is a synthesis of 108 published investigations in the setting of different types of left ventricular rupture following mitral valve replacement (MVR). We identified 109 investigations and reviewed the clinical presentation, diagnostic modalities, surgical techniques and outcomes. Clinical presentation, roentgenography, cross-sectional transthoracic/transesophageal echocardiography and computerized tomography provided the diagnostic information and defined the causative mechanism. Magnetic resonance imaging had been used for further clarification of the native ventricular anatomy in high-risk subset of patients, undergoing non-traditional transapical off-pump mitral valve repair with neochordal implantation. In this article, we have attempted to address several concerning issues and controversies with reference to the possible causative mechanisms, preventive measures, the issue of chordal preservation during MVR, the degree of decalcification required in cases of heavily calcified mitral annulus, selection of appropriate sized prosthetic valves, the surgical importance of a small left ventricle, various techniques of repair, role of cardiopulmonary bypass and cardioplegic arrest during the repair of left ventricular rupture, the role of biodegradable epicardial tissue sealants, to repair or not to repair the atrio-ventricular groove hematoma during mitral valve surgery, and the role of intra-aortic balloon counterpulsation in the perioperative period. Additionally, we have highlighted a new type of left ventricular rupture described in the literature located between the base of the papillary muscle and the apex, which can be categorized as a complication of new technologies of mitral valve repair such as NeoChord device artificial chordal implantation. We have classified this category as type IV ventricular rupture. Overall, this review attempts to address the guidelines for different surgical approaches and techniques of repair of different types of left ventricular rupture for a successful outcome. We submit that an increased appreciation of the causative mechanisms of different types of left ventricular rupture and its prevention may well contribute to improved surgical management.

Osteoarthritis classifications : Modification proposal for the criteria of Kellgren and Vallotton

In imaging diagnostics, classification schemes are very common. As far as osteoarthritis is concerned, the Kellgren classification is the most popular. However, the Kellgren classification, which has been used for more than 50years, is based on nonspecific criteria; thus, high interobserver variability has been reported. In addition, the Kellgren classifications have not been coordinated with magnetic resonance imaging (MRI)-based classification schemes, e.g., Vallotton. In this paper, we present some modifications concerning the criteria for both the Kellgren classification and its comparison with the MRI-based Vallotton classification. The current surgical and imaging classifications and the precision of the nomenclature are analyzed. X‑ray and MRI findings are compared. Suggestions for both amodification of the Kellgren classification as far as the criteria are concerned and ahierarchy (ranking) of X‑ray and MRI findings to make clinical decisions more valuable are proposed. These proposed modifications (Kellgren and ranking) would be helpful for routine reporting and allow for better interobserver reliability, in particular for special reports (e.g. consultations, expert opinions, advanced diagnostics).

Accurate and interpretable evaluation of surgical skills from kinematic data using fully convolutional neural networks.

Manual feedback from senior surgeons observing less experienced trainees is a laborious task that is very expensive, time-consuming and prone to subjectivity. With the number of surgical procedures increasing annually, there is an unprecedented need to provide an accurate, objective and automatic evaluation of trainees' surgical skills in order to improve surgical practice. In this paper, we designed a convolutional neural network (CNN) to classify surgical skills by extracting latent patterns in the trainees' motions performed during robotic surgery. The method is validated on the JIGSAWS dataset for two surgical skills evaluation tasks: classification and regression. Our results show that deep neural networks constitute robust machine learning models that are able to reach new competitive state-of-the-art performance on the JIGSAWS dataset. While we leveraged from CNNs' efficiency, we were able to minimize its black-box effect using the class activation map technique. This characteristic allowed our method to automatically pinpoint which parts of the surgery influenced the skill evaluation the most, thus allowing us to explain a surgical skill classification and provide surgeons with a novel personalized feedback technique. We believe this type of interpretable machine learning model could integrate within "Operation Room 2.0" and support novice surgeons in improving their skills to eventually become experts.

Low intra-operative diagnostic accuracy does not affect postoperative treatment of acute appendicitis

Background The intra-operative classification of appendicitis defines postoperative treatment. The correct designation can influence patient recovery, complications and hospital costs. Recent research has shown that intra-operative classification criteria varies among surgeons, and is not always the same as the pathologist’s report. Classification accuracy can lower costs by preventing unnecessary treatment or sub-optimal interventions. Methods During a period of 4 months, N = 133 appendix specimens were received and evaluated by the pathology department of a single teaching hospital. Five surgeons extracted the specimens and one experienced pathologist drew the histopathology reports. A comparison between the surgeons’ classifications and the pathologist’s was made. Classification accuracy was determined and statistical analyses was performed using chi-square, and p values were obtained. A p < 0.05 was considered significant. Results A total of N = 133 specimens were obtained, 127 belonged to patients following emergency surgery due to acute abdominal pain; the other six were from elective hemi-colectomies for right colonic adenocarcinomas, and were not included. Of the 127 specimens analyzed, 14 (11%) were negative, 21 (16.5%) were edematous, 81 (63.7%) were phlegmonous and 11 (8.6%) were gangrenous. A total of 18 (14%) perforated appendices were also reported. Surgical accuracy was 60.6% (N = 67) with a statistically significant p < 0.001. Only five patients with incorrect intraoperative classifications received unnecessary or lacked treatment. Conclusions An overall accuracy of 60.6% is seen when the surgical classification is compared to the pathological classification. Although the surgeons’ accuracy is low when comparing intra-operative versus histopathological classification, this variation in designation does not affect postoperative treatment significantly.

Savaş sırasında sivil ateşli silah yaralanmalarını takiben ortaya çıkan mortalite: Retrospektif bir kohort araştırması

Background: This study aims to identify factors affecting mortality following surgery for civilian firearms injuries using surgical classification as a surrogate marker of injury severity. Methods: This was a retrospective study of patients who underwent surgery at a tertiary university hospital in Turkey between 2011 and 2014. All patients had sustained firearms injury and had an American Society of Anesthesiologists score of I-II. A grading system defined by the Communiqué on Health Practices in Turkey was used based on the surgery type and anesthetic procedure to determine the severity of injury and its relation with patient outcome (survival or death). Results: The median duration of hospital stay of patients who were discharged post healing was significantly longer than those who died [12 (0–559).vs 7.5 (0–468) days, respectively]. Overall mortality was 11.3%; however, the mortality of patients was 8.1%, 40.3%, and 40.3% in groups A2, C, and D, respectively. Healing in groups A2, C, and D was 2.4%, 54.1% and 25.8%, respectively. Independent variables affecting the coefficient of patient discharge status for sex, age, and surgical groups A2, C, and D were found to be significant. Conclusion: There was an association between the surgical groups and the firearms injuries sustained by civilians. Moreover, the coefficients associated with surgical group in our model may help predict the mortality risk in similar populations.

Pediatric thyroglossal duct cysts: Post-operative complications

IntroductionThyroglossal duct cysts (TGDCs) result from incomplete involution of the thyroglossal duct and are resected with a Sistrunk-procedure. We studied and graded severity of postoperative complications in children who underwent this procedure, with corresponding risk factors. MethodsIn our electronic health record system we reviewed the medical records of all patients aged <18 years, with surgically treated TGDC between 01-01–2005 and 31-12-2015 in two university hospitals. Risk factors (age, gender, recurrence at presentation, treatment hospital, cyst inflammation, cyst rupture, drain placement, antibiotics or postoperative infection) were studied by univariate analysis. The Clavien-Dindo surgical complication classification was used as postoperative surgical grading system. ResultsOf the ninety-one patients, with a mean age of 4.4 years, seven were referred from other hospitals with a recurrent TGDC. 24 patients (26.4%) had a complication. Hemorrhage and resection of thyroid cartilage were the most severe complications. Recurrence and wound infection (both n = 7, 7.7%) were most common. We could not identify risk factors for these complications. ConclusionsThe treatment of children with thyroglossal duct cysts shows a considerable amount of complications. Pre-selected risk factors did not show any significant correlation with these complications.

Clinical Outcomes in Early Cervical Cancer Patients Treated with Nerve Plane–sparing Laparoscopic Radical Hysterectomy

To explore the feasibility of nerve plane-sparing laparoscopic radical hysterectomy (NPS-LRH) as a simplified C1-type surgery for cervical cancer patients and to compare this technique with laparoscopic radical hysterectomy (LRH). A retrospective comparative study. An academic tertiary hospital affiliated with the Chinese National Cancer Center. Six hundred fifteen patients with Fédération Internationale de Gynécologie et d'Obstétrique stage Ib and IIa cervical cancer who underwent laparoscopic radical hysterectomy between January 2010 and December 2017 were enrolled. Among them, 263 patients underwent the NPS-LRH surgery, and 352 patients underwent the LRH surgery. Intraoperative data and postoperative outcomes were compared between the 2 groups. NPS-LRH is a simplified type C1 procedure that preserves the ureteral mesentery and its nerve plane, whereas LRH is a type C2 procedure in the Querleu-Morrow surgical classification system. There were no statistically significant differences in age, body mass index, Fédération Internationale de Gynécologie et d'Obstétrique stage, tumor differentiation, pathological type, depth of invasion, lymphovascular space invasion, parametrial tissue invasion, lymphatic metastasis, neoadjuvant chemotherapy, or postoperative adjuvant radiotherapy and chemotherapy between the 2 groups. Compared with the LRH group, the NPS-LRH group had a shorter length of operation (238.7 ± 53.9 minutes vs 259.8 ± 56.6 minutes, p < .01), less intraoperative bleeding (p < .01), more resected lymph nodes (p = .028), shorter duration of urinary catheterization (p < .01), lower incidences of postoperative hydronephrosis (p = .044), less long-term frequent urination (p < .01), less acute urinary incontinence (p < .01), poor bladder sensation (p = .028), and constipation (p = .029). There were no statistically significant differences in the disease-free survival and overall survival between the 2 groups (p = .769 and .973, respectively). NPS-LRH is a simplified, safe, and feasible type C1 operation that had a shorter length of operation, less intraoperative bleeding, more resected lymph nodes, and better postoperative bladder function compared with the LRH group. Further studies are required to assess its benefits on rectal function and long-term prognosis.

Recent advances in the management of penile cancer.

Penile cancer is a rare condition and can be very complex to manage. Advances in surgical techniques, imaging, pathological classification and patient pathways have led to improved patient care. The diagnosis of pre-malignant change, penile cancer and metastatic disease along with advances in their treatment are detailed in this review which aims to update clinicians from multiple specialties and countries on penile cancer.

Tolerability and Effects of the Use of Energy-Enriched Infant Formula After Congenital Heart Surgery: A Randomized Controlled Trial.

Undernutrition is a common problem among children with congenital heart disease (CHD) and may lead to poorer surgical outcomes. A higher intake of energy during the postoperative period of CHD surgery seems to be associated with better outcomes. This study aimed to investigate the effect of the use of energy-enriched formula (EE-formula) compared with normocaloric formula during 30 days after CHD surgery. A randomized controlled trial with patients undergoing heart surgery in a tertiary hospital in southern Brazil from March 2017 to December 2017 was performed. The intervention group received EE-formula (1 kcal/mL), and the control group received normocaloric formula (0.67kcal/mL). The researcher in charge of anthropometric evaluation was blinded to the randomization. Fifty-nine patients were included; 30 in control group and 29 in intervention group. There were no statistically significant differences between groups regarding age, gender, anthropometry, and surgical risk classification after randomization. A statistically significant difference in z-score of weight for age and in weight gain variation rate between groups after intervention was observed. Antibiotic use was less frequent in the intervention group, and hospital length of stay was shorter. General gastrointestinal side effects were similar between groups, whereas diarrhea was more frequent in the intervention group. However, this side effect was limited and had spontaneous resolution in 4 out of 6 cases. This study demonstrates that EE-formula use after heart surgery of patients with CHD is well tolerated and may improve short-term nutrition outcome, decrease hospital stay, and reduce antibiotic use.

Endométriose : évaluation du score Ultrasound-Based Endometriosis Staging System (UBESS) dans la prédiction de la difficulté chirurgicale

ObjectivesSurgical management of endometriosis may require different levels of surgical skill which influences the orientation of the patient. The Ultrasound-Based Endometriosis Staging System (UBESS) is a score developed in 2016 to predict the difficulty of surgery. To study the correlation between UBESS score and two main surgical classifications in the literature. MethodsStudy performed at the center of Poissy, France, between July 2016 and December 2017. Patients who underwent prospective UBESS staging then operated of their endometriosis were included. The patients were classified according to the levels of surgical difficulty of the Royal College of Obstetricians and Gynecologists (RCOG) and the classification created by Chi et al. The criterion of judgment was the correlation between the UBESS stages and RCOG and CHI levels. In a second analysis, we determined the predictive value of the operative plan for items included in the systematic sonographic evaluation described by Menakaya et al. ResultsThirty-three patients were included in the study. Correlation was found to be low between UBESS and RCOG (θ=0.22) and between UBESS and CHI (θ=0.30). The prediction of the operative plan was good for endometrioma, sites specific tenderness, sliding sign, vaginal and digestive tract involvement; but modest for the anterior compartment and uterosacrals ligaments. ConclusionIn our study on a small number of patients, the UBESS score does not adequately predict the surgical difficulty. Taken separately, the items of systematic sonographic evaluation based on 5 domains successfully predict the operative plan.

The Urgent Surgery Elderly Mortality risk score: a simple mortality score.

an increasing number of elderly patients undergo urgent abdominal surgery and this population has a higher risk of mortality. The main objective of the study was to identify mortality-associated factors in elderly patients undergoing abdominal surgery and to design a mortality scoring tool, the Urgent Surgery Elderly Mortality risk score (the USEM score). this was a retrospective study using a prospective database. Patients > 65 years old that underwent urgent abdominal surgery were included. Risk factors for 30-day mortality were identified using multivariate regression analysis and weights assigned using the odds ratios (OR). A mortality score was derived from the aggregate of weighted scores. Model calibration and discrimination were judged using the receiver operating characteristics curves and the Hosmer-Lemeshow test. in the present study, 4,255 patients were included with an 8.5% mortality rate. The risk factors significantly associated with mortality were American Society of Anesthesiologists (ASA) score, age, preoperative diagnosis (OR: 37.82 for intestinal ischemia, OR: 5.01 for colorectal perforation, OR: 6.73 for intestinal obstruction), surgical wound classification and open or laparoscopic surgery. A risk score was devised from these data for the estimation of the probability of survival in each patient. The area under the ROC curve (AUROC) for this score was 0.84 (95% CI: 0.82-0.86) and the AUROC correct was 0.83 (0.81-0.85). a simple score that uses five clinical variables predicts 30-day mortality. This model can assist surgeons in the initial evaluation of an elderly patient undergoing urgent abdominal surgery.

Retrospective Study of Infection Rate in Small Animal Surgery – of UBASMV Timișoara (2007-2017)

Surgical site infections (SSIs) remain an important concern in veterinary practice. The purpose of this work was to determine the SSIs rate in the Surgery Clinic of the Faculty of Veterinary Medicine, Timișoara and to correlate SSIs incidence with surgical wound classification by degree of contamination and with the use of antimicrobial prophylaxis and / or applied therapy. Records of all animals operated on between 2007 and 2017 were closely checked for development of postoperative wound infection and were reviewed. The rate of surgical site infection was 0.77%, and by categories was 0.70% in clean surgeries, 0.15% in clean-contaminated surgeries, 1.76% in contaminated surgeries, and 1.08% in infected surgeries. Baseline information for SSIs surveillance in our surgical clinic and for comparison with other studies was defined. SSIs frequency in companion animals in our service is comparable with the frequency observed in another studies.