Surgical Decision-making Process Research Articles

The Use of near Infra-Red Radiation Imaging after Injection of Indocyanine Green (NIR-ICG) during Laparoscopic Treatment of Benign Gynecologic Conditions: Towards Minimalized Surgery. A Systematic Review of Literature.

Background and Objectives: To assess the use of near infrared radiation imaging after injection of indocyanine green (NIR–ICG) during laparoscopic treatment of benign gynecologic conditions. Materials and Methods: A systematic review of the literature was performed searching 7 electronic databases from their inception to March 2022 for all studies which assessed the use of NIR–ICG during laparoscopic treatment of benign gynecological conditions. Results: 16 studies (1 randomized within subject clinical trial and 15 observational studies) with 416 women were included. Thirteen studies assessed patients with endometriosis, and 3 studies assessed non-endometriosis patients. In endometriosis patients, NIR–ICG use appeared to be a safe tool for improving the visualization of endometriotic lesions and ureters, the surgical decision-making process with the assessment of ureteral perfusion after conservative surgery and the intraoperative assessment of bowel perfusion during recto-sigmoid endometriosis nodule surgery. In non-endometriosis patients, NIR–ICG use appeared to be a safe tool for evaluating vascular perfusion of the vaginal cuff during total laparoscopic hysterectomy (TLH) and robotic-assisted total laparoscopic hysterectomy (RATLH), and intraoperative assessment of ovarian perfusion in adnexal torsion. Conclusions: NIR–ICG appeared to be a useful tool for enhancing laparoscopic treatment of some benign gynecologic conditions and for moving from minimally invasive surgery to minimalized surgery. In particular, it might improve treatment of endometriosis (with particular regard to deep infiltrating endometriosis), benign diseases requiring TLH and RATLH and adnexal torsion. However, although preliminary findings appear promising, further investigation with well-designed larger studies is needed.

Can CA 19-9 predict inferior surgical and pathological outcomes for resectable pancreatic cancer?

e16228 Background: Previous data have established that patients with pancreatic surgical specimens showing lymphovascular invasion (LVI) and positive surgical resection margins are associated with poor survival outcomes. However, there are no biomarkers to identify these high-risk patients preoperatively. In this study, we hypothesized that increased carbohydrate antigen 19-9 (CA 19-9) levels could be used to predict high-risk resectable pancreatic cancer features, including LVI and positive residual margins, thereby guiding the surgical decision-making process. Methods: We sampled the National Cancer Database for patients undergoing pancreatic cancer resection between 2004-2018. Logistic regression analysis was performed to analyze sociodemographic and disease characteristics associated with elevated CA 19-9 levels (> 98 U/ml) versus low CA 19-9 levels (< 98 U/ml). Additionally, Cox regression analyses were used to compare hazard ratios for demographic and disease characteristics. A p < 0.05 was considered statistically significant. Results: 12208 patients (50.76% males) with pancreatic cancer were sampled. Pathological findings of LVI (n = 5963), microscopic residual tumor margins (R1) (n = 1547), and residual margins (R), not otherwise specified (NOS) (n = 885) had a stronger association with high preoperative CA 19-9 levels when compared to those with low CA 19-9 levels (LVI: OR 1.212, 95% CI 1.125–1.305, p < 0.001, R1: OR 1.260, 95% CI 1.129–1.408, p = 0.001 and R NOS: OR 1.212, 95% CI 1.052–1.395, p = 0.008). Macroscopic residual margins (R2) (n = 85) were also associated with high CA 19-9 but statistically not significant (OR 1.242, 95% CI 0.802–1.924, p = 0.332) probably due to the low sample size for this subpopulation. Furthermore, all the factors listed below were independently associated with poor prognosis: (A) Elevated CA 19-9 levels: HR 1.411, 95% CI 1.350–1.475, p < 0.001, (B) LVI: HR 1.333, 95% CI 1.275–1.394, p < 0.001, (C) R NOS: HR = 1.517, 95% CI = 1.401–1.643, p < 0.001, (D) R1: HR 1.594, 95% CI 1.499–1.695, p < 0.001, (E) R2: HR 2.015, 95% CI 1.597–2.543, p < 0.001. Conclusions: Elevated CA 19-9 can be used as a biomarker to identify a subset of pancreatic cancer patients with high-risk surgical pathological features such as LVI or residual tumor margins. In these patients, perhaps neoadjuvant chemotherapy can facilitate downstaging and provide superior surgical and oncological outcomes.

Timely cancer genetic counseling and testing for young women with breast cancer: impact on surgical decision-making for contralateral risk-reducing mastectomy.

Genetic testing (GT) can identify individuals with pathogenic/likely pathogenic variants (PV/LPVs) in breast cancer (BC) predisposition genes, who may consider contralateral risk-reducing mastectomy (CRRM). We report on CRRM rates in young women newly diagnosed with BC who received GT through a multidisciplinary clinic. Clinical data were reviewed for patients seen between November 2014 and June 2019. Patients with non-metastatic, unilateral BC diagnosed at age ≤ 45 and completed GT prior to surgery were included. Associations between surgical intervention and age, BC stage, family history, and GT results were evaluated. Of the 194 patients, 30 (15.5%) had a PV/LPV in a BC predisposition gene (ATM, BRCA1, BRCA2, CHEK2, NBN, NF1), with 66.7% in BRCA1 or BRCA2. Of 164 (84.5%) uninformative results, 132 (68%) were negative and 32 (16.5%) were variants of uncertain significance (VUS). Overall, 67 (34.5%) had CRRM, including 25/30 (83.3%) PV/LPV carriers and 42/164 (25.6%) non-carriers. A positive test result (p < 0.01) and significant family history were associated with CRRM (p = 0.02). For the 164 with uninformative results, multivariate analysis showed that CRRM was not associated with age (p = 0.23), a VUS, (p = 0.08), family history (p = 0.10), or BC stage (p = 0.11). In this cohort of young women with BC, the identification of a PV/LPV in a BC predisposition gene and a significant family history were associated with the decision to pursue CRRM. Thus, incorporation of genetic services in the initial evaluation of young patients with a new BC could contribute to the surgical decision-making process.

A Novel Method for Stratification of Major Complication Risk Using Body Mass Index Thresholds for Patients Undergoing Total Hip Arthroplasty: A National Cohort of 224,413 Patients

IntroductionElevated body mass index (BMI) is associated with complications following Total Hip Arthroplasty (THA). Since obese individuals are almost 10 times more likely to require THA compared to non-obese individuals, we need to understand the risk-benefit continuum while considering THA in obese patients. We aimed to determine data-driven thresholds for BMI at which the risk of major complications following THA increases significantly. MethodsPatients were identified in a national database who underwent primary THA from 2010 to 2020. BMI thresholds were identified using the stratum-specific likelihood ratio (SSLR) methodology, which is an adaptive technique that allows for identification of BMI cut-offs, at which the risk of major complications is increased significantly . BMI cutoffs identified using SSLR were used to create a logistic regression model. ResultsA total of 224,413 patients were identified with a mean age of 66 ± 10, BMI 32 ± 6.7, and 7,186 (3%) sustained a major complication. BMI thresholds were defined as 19-31, 32-37, 38-49 and 50+. Overall, the absolute risk of major complications increased from 2.9% in the lowest BMI strata to 7.5% in the highest BMI strata. Compared to patients with a BMI between 19-31, the odds of sustaining a major complication sequentially increased by 1.2, 1.6, and 2.5-times for patients in each higher BMI strata (all, P < .05). ConclusionsWe have identified BMI cutoffs using SSLR that categorizes patients into four categories of risk for major complications in a nationally representative patient sample. These thresholds can be used in the surgical decision-making process between patients and surgeons.

Artificial Intelligence and Surgery: Ethical Dilemmas and Open Issues.

Artificial intelligence (AI) applications aiming to support surgical decision-making processes are generating novel threats to ethical surgical care. To understand and address these threats, we summarize the main ethical issues that may arise from applying AI to surgery, starting from the Ethics Guidelines for Trustworthy Artificial Intelligence framework recently promoted by the European Commission. A modified Delphi process has been employed to achieve expert consensus. The main ethical issues that arise from applying AI to surgery, described in detail here, relate to human agency, accountability for errors, technical robustness, privacy and data governance, transparency, diversity, non-discrimination, and fairness. It may be possible to address many of these ethical issues by expanding the breadth of surgical AI research to focus on implementation science. The potential for AI to disrupt surgical practice suggests that formal digital health education is becoming increasingly important for surgeons and surgical trainees. A multidisciplinary focus on implementation science and digital health education is desirable to balance opportunities offered by emerging AI technologies and respect for the ethical principles of a patient-centric philosophy.

MR Imaging Provides Practical Information for Preoperative Assessment of Radial Polydactyly with Bifurcation at the Metacarpophalangeal Joint Level.

PurposeWe aimed to evaluate the use of magnetic resonance imaging (MRI) to visualize unossified bone sites that are often not visible with radiography in pediatric radial polydactyly patients with bifurcation at the metacarpophalangeal (MP) joint level. The MRI validation could help in planning for surgical procedures.Patients and MethodsA total of 141 thumbs in 139 pediatric patients with bifurcation at the MP joint on radiography were included in this study. All the patients had undergone MRI with proton density-weighted fat-suppressed fast spin-echo (FS PDWI) sequence and fast fat-suppressed 3D spoiled gradient-recalled echo (FS 3D SPGR) sequence. The MR images of the cartilaginous structure and joint characteristics at the MP joint were evaluated and categorized by two experienced radiologists.ResultsOur analysis demonstrated that MR imaging, especially the FS 3D SPGR sequence, yields better visibility of the cartilaginous structure and shows clearer joint characteristics that could not be detected by radiography. The abnormalities included a cartilaginous connection on the base of duplicated proximal phalanx, cartilaginous joint connection and the shape of articular cartilage on the head of metacarpal and soft tissue band. Radiologically encountered duplications at the MP joint level were successfully classified into six types based on the MRI-detected structural changes. The distribution of the six types was 17.7% (25/141) in type 1, 53.9% (76/141) in type 2, 2.8% (4/141) in type 3, 9.9% (14/141) in type 4, and 13.5% (19/141) in type 5.ConclusionThis data showed that MR imaging provides practical information on the anatomic characteristics in radial polydactyly with bifurcation at the MP joint level that could aid surgical decision-making processes. Thus, the FS 3D SPGR sequence could be used as a MR imaging technique in radial polydactyly.

Increased Risk of 90-Day Surgical-Site Infection and Hospital Readmission but Not Reoperation After Open Arthrotomy When Compared With Arthroscopy for Septic Ankle Arthritis

To compare the rates of reoperation and 90-day perioperative complications between open arthrotomy and arthroscopy for the treatment of septic ankle arthritis using a national all-payer claims database. Patients with a diagnosis of septic ankle arthritis who underwent irrigation and debridement through arthroscopy or arthrotomy were identified in a national data set from 2015-2020 through an all-payer claims database. Demographic and comorbidity characteristics including age, sex, infectious etiologies, and Elixhauser comorbidities were obtained. The rate of reoperation, defined as a proxy for failure of initial intervention, was the primary outcome. Secondary outcomes including readmissions, surgical-site infections, amputations, wound complications, and 90-day medical complications were compared between the 2 cohorts. In total, 168 patients undergoing arthroscopy and 794 patients undergoing arthrotomy for septic ankle arthritis were identified. There were no significant differences in reoperation rates between patients who underwent open arthrotomy and those who underwent arthroscopy (P= .997). However, the rates of surgical-site infection (P= .014) and hospital readmission (P < .001) were significantly higher in the open arthrotomy cohort compared with the arthroscopy cohort. Although there was no significant difference in reoperation rates between arthroscopic and open irrigation and debridement for the treatment of septic ankle arthritis, this study showed significantly higher odds of surgical-site infection and hospital readmission in patients who underwent open arthrotomy when compared with arthroscopy. Case-specific patient and technical considerations should guide the surgical decision-making process to limit secondary complications because this study exemplifies similar reoperation rates between the 2 surgical modalities. Level III, nonrandomized cohort analysis.

The relationship between perceptions of shared decision-making and patient-reported outcomes in a cross-sectional cohort of haemorrhoidectomy patients.

Shared decision-making between patients and clinicians is important to surgical practice and patients' perceptions of their healthcare experience. This study aims to measure associations between patients' perceptions of their shared decision-making (SDM) process and health-related quality of life among a cohort of patients choosing surgical management of an elective surgical procedure, haemorrhoidectomy. This study is a single-site study based in Vancouver, Canada. Consecutive patients of five colorectal surgeons registered for elective haemorrhoidectomy between September 2016 and June 2020 were eligible to participate. Participants completed the CollaboRATE instrument which measures patients' perceptions of their SDM after the surgical consultation, along with a number of other patient-reported outcomes. The participation rate was 45.3%, with 157 patients scheduled for haemorrhoidectomy providing complete information. Unadjusted results found that participants having the most comorbidities reported better communication with their surgeon. The adjusted results show that socioeconomic status and depression were associated with lower CollaboRATE scores. There was no effect of sex, pain interference, anxiety or perceived health status on participants' CollaboRATE scores. This study found evidence that participants with lower economic status or those reporting depressive symptoms had worse perceptions of their SDM process with their surgeon. These findings suggest that special attention should be paid to the surgical decision-making process for these patient populations.

Efficacy of geriatric multidisciplinary oncology clinic in the surgical treatment decision-making process for frail elderly patients with colorectal cancer.

PurposeMultidisciplinary care has become a cornerstone of colorectal cancer management. To evaluate the clinical efficacy of a geriatric multidisciplinary oncology clinic (GMOC), we analyzed the surgical treatment decision-making process and outcomes.MethodsThis retrospective single-center study reviewed the data of patients aged ≥65 years who participated in the GMOC at a tertiary referral hospital between 2015 and 2021. The clinical adherence rate, comprehensive geriatric assessment, and a multidimensional frailty score (MFS) were obtained. The groups that were recommended and not recommended for surgery were compared, analyzing the factors impacting the decision and 1-year survival outcomes. Furthermore, the postoperative complications of patients who underwent surgery were evaluated.ResultsA total of 165 patients visited the GMOC, and 74 had colorectal cancer (mean age, 85.5 years [range, 81.2–89.0 years]). Among patients with systemic disease (n = 31), 7 were recommended for surgery, and 5 underwent surgery. Among patients with locoregional disease (n = 43), 18 were recommended for surgery, and 12 underwent surgery. Patients recommended and not recommended for surgery had significantly different activities of daily living (ADL) (P = 0.024), instrumental ADL (P = 0.001), Mini-Mental State Examination (P = 0.014), delirium risk (P = 0.039), and MFS (P = 0.001). There was no difference in the 1-year overall survival between the 2 groups (P = 0.980). Of the 17 patients who underwent surgery, the median (interquartile range) of operation time was 165.0 minutes (120.0–270.0 minutes); hospital stay, 7.0 days (6.0–8.0 days); and 3 patients had wound complications.ConclusionProper counseling of patients through the GMOC could lead to appropriate management and favorable outcomes.

Evaluation of Biventricular Volume and Systolic Function in Children with Ventricular Septal Defect and Moderate to Severe Pulmonary Hypertension Using Real-Time Three-Dimensional Echocardiography

Background: Real-time three-dimensional echocardiography (RT-3DE) could obtain ventricular volume and ejection fraction rapidly and non-invasively without relying on ventricular morphology. This study aims to use RT-3DE to evaluate the changes in biventricular volume and systolic function in children with ventricular septal defect (VSD) and moderate to severe pulmonary hypertension (PH) before surgery. Methods: In this study 18 children with VSD and moderate to severe PH (VSD + PH Group) and 18 healthy children of the same age (Control Group) were recruited. Biventricular volume and systolic function were evaluated by RT-3DE. The measurements included: left and right ventricular volume indexed to body surface area (BSA), stroke volume (SV) indexed to BSA, and ejection fraction (EF). Results: The results showed left and right ventricular volume indexed to BSA and SV indexed to BSA were significantly increased in VSD + PH Group (VSD + PH Group vs. Control Group), LVEDV/BSA (ml/m2 ): 48.67 ± 21.46 vs. 25.59 ± 6.96, RVEDV/BSA (ml/m2 ): 55.98 ± 15.35 vs. 27.69 ± 4.37, LVSV/BSA (ml/m2 ): 24.08 ± 9.30 vs. 15.14 ± 4.29, RVSV/BSA (ml/m2 ): 26.02 ± 8.87 vs. 14.11 ± 2.89, (P < 0.05). While for EF in VSD + PH Group decreased (VSD + PH Group vs. Control Group), LVEF: 50.93 ± 7.50% vs. 59.38 ± 7.24%, RVEF: 45.84 ± 7.71% vs. 51.05 ± 6.90% (P < 0.05). Conclusion: In children with VSD and moderate to severe PH, increased biventricular volume and decreased systolic function were observed with RT-3DE, but biventricular systolic function remained within acceptable limits. The children in this study recovered well after surgery without serious perioperative complications, suggesting that biventricular systolic function may help facilitate the surgical decision-making process in children with VSD and moderate-tosevere PH.

Clinical utility of stimulated cholescintigraphy using a standardized Ensure-Plus fatty meal protocol in patients with suspected functional gallbladder disorder: a retrospective study of seven-years clinical experience.

The clinical utility of fatty meal stimulated cholescintigraphy particularly using a standardized formulation in patients with suspected functional gallbladder disorder has not been extensively studied. We present our seven-year clinical experience using an Ensure plus protocol. A retrospective study was performed on patients undergoing stimulated cholescintigraphy using Ensure Plus for evaluation of suspected functional gallbladder disorder. A gallbladder ejection fraction (GBEF) of <33% was considered abnormal. Of the 173 patients evaluated, 57 (33%) had an abnormal GBEF, 112 (65%) had a normal GBEF and 4 (2%) had no gallbladder visualization. Of the 57 patients with an abnormal GBEF, symptom improvement occurred in 30/31 (97%) who underwent cholecystectomy and in 17/26 (65%) who were managed conservatively (p= 0.003). Of the 112 patients with a normal GBEF, symptom improvement occurred in 8/10 (80%) who underwent cholecystectomy and 74/102 (73%) who were managed conservatively (p= 1.000). In the subgroup of 102 patients with a normal GBEF managed conservatively, those without symptomatic improvement had lower GBEFs compared to those with symptomatic improvement (median GBEF 46% versus 57%, p= 0.019). Our retrospective results support a clinical role for stimulated cholescintigraphy using Ensure Plus in the evaluation of patients with suspected functional gallbladder disorder. While an abnormal GBEF predicts good surgical outcome, our results suggest that using an absolute GBEF cut off value of <33% may not apply to all patients and hence GBEF results should only be used as an adjunct in the surgical decision-making process.

Risk assessment and management of primary patellar dislocation is complex and multifactorial: a survey of Australian knee surgeons

ObjectivesRecurrent patellar instability following first-time lateral patellar dislocation is associated with a variety of bony, soft tissue and patient-related risk factors. The specific management of recurrent dislocation may vary depending on the presence and combination of these factors as well as the treating physician’s interpretation of these. Therefore, this study aimed to determine which factors Australian knee surgeons regard as increasing the risk of recurrence following first-time patellar dislocation and to characterise the surgical decision-making process of these surgeons in the management of lateral patellar instability.MethodsAn online survey was sent to all active members of the Australian Knee Society (AKS). The survey addressed (i) risk factors for recurrence following first-time patellar dislocation and (ii) the surgical decision-making process in treating patellar instability.ResultsSeventy-seven per cent (53 of 69) Australian Knee Society members responded. Factors identified by respondents as significantly increasing the risk of recurrence were a history of contralateral recurrent patellar dislocation (74% respondents), an atraumatic injury mechanism (57%), trochlear dysplasia (49%) younger age (45%), patella alta (43%) and generalised ligamentous laxity (42%). Forty-four per cent replied that there may be an indication for surgical intervention following first-time patellar dislocation with no apparent loose body present. All respondents would recommend operative management of recurrent patellar dislocation after a third episode, with 45% of surgeons recommending surgery after a second episode. The most common surgical procedures performed by respondents were medial patellofemoral ligament (MPFL) reconstruction (94%), tibial tuberosity medialisation (91%) and tibial tuberosity distalisation (85%). Only 23% of respondents consider trochleoplasty for primary surgical intervention.ConclusionSurgeons identified a large number of factors that they use to assess risk of recurrence following first-time patellar dislocation, many of which are not supported by the literature. The two highest ranked factors (history of contralateral recurrent patellar dislocation and an atraumatic injury mechanism) are without a significant evidence base. There was considerable variation in the criteria used to make the decision to perform a patellar stabilisation procedure. MPFL reconstruction was the most commonly used procedure, either in isolation or combined with another procedure.Level of evidenceCross-sectional study; expert opinion (Level V).

Treatment trends in distal humerus fractures between ABOS part II candidates

PurposeThe purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF). MethodsThe American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications. ResultsThere were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%). ConclusionOur data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF. Level of EvidenceIII.

IS THE SWAN-GANZ CATHETER EXCLUSIVELY A TOOL FOR PRESSURE MEASUREMENTS INSIDE THE PULMONARY CIRCULATION? THE MECHANICAL CONTRIBUTION OF THE PULMONARY ARTERY CATHETER TO A CRITICAL DECISION MAKING INTRAOPERATIVELY

Introduction The Pulmonary Artery Catheter (PAC) Swan-Ganz, despite the widespread rumours regarding the possible complications that correlate with its insertion, such as the pulmonary artery rupture, is still - in the experienced hands - an essential tool of hemodynamic monitoring in cardiac surgery. In combination with Transoesophageal Echocardiography (TOE) though, they offer to the Anaesthesiologist an integrated profile of pressure, volume, flow velocity and anatomical information. However, there can still be occasions where the above mentioned hemodynamic and non-hemodynamic data are not enough to guide the surgical decision-making process intraoperatively. In this case report, we present the contribution of the difficulty in advancing the PAC into the Right Atrium (RA), as an indication of Superior Vena Cava (SVC) stenosis, and the need to return to CardioPulmonary Bypass (CPB) to repair it, during a surgery of totally endoscopic Atrial Septal Defect (ASD) closure. Methods A 40yr old female patient is undergoing totally endoscopic cardiac surgery with CPB for the closure of a Superior Sinus Venosus ASD with simultaneous anomalous drainage of the Right Upper Pulmonary Vein (RUPV) into the SVC. The anaesthetic monitoring includes arterial line, PAC and TOE, which confirms the preoperative findings (Figure 1,2,3), while for the needs of the operation the Anaesthesiologist inserts also a CPB cannula in the Right Internal Jugular Vein. Later on, during the phase that the surgeon is advancing the second venous CPB cannula through the femoral vein and the Inferior Vena Cava (IVC) into the RA, the PAC is being withdrawn from its wedge position and is left high inside the SVC, showing the Central Venous Pressure (CVP). Results After the closure of the ASD and the flow diversion of the RUPV into the Left Atrium with a bovine pericardial patch, deairing is taking place, the restoration of the ASD is being confirmed with the TOE and successful CPB weaning occurs. A subsequent TOE scan shows turbulence inside the SVC with the colour Doppler (Figure 4), indicative of stenosis, while the CVP is 15mmHg, and the dilemma that is coming up is if the stenosis is clinically significant or not. However, at the same time it is impossible to readvance the PAC into the RA, an indication of severe SVC stenosis, and the team decides to return to CPB to repair it. After the placement of a second pericardial patch that widens the RA-SVC junction on a beating heart, laminar flow is being depicted inside the SVC (Figure 5), the PAC is being seamlessly floated into the RA (Figure 6) until its wedge position, and the CVP is 8mmHg. The short and the long-term postoperative periods were uncomplicated. Discussion The intraoperative use of the PAC in the current case report, and the difficulty in readvancing it more specifically, proved to be crucial in making an undoubtedly critical decision towards repairing a stenosis that could have been overlooked, if we had simply relied on the CVP, and become even fatal in case of delayed diagnosis. The mechanical contribution of the PAC has been underlined.

Breast cancer patient participation in surgical treatment decision making: A cross-sectional study

BackgroundTo investigate the current situation of participation of Chinese breast cancer patients in surgical treatment decision-making, in particular the preferred and actual roles of the participants, and the degree of consistency between the two. The objective of the study is to provide a reference basis for helping patients make appropriate surgical decisions in the future. MethodsA total of 279 breast cancer inpatients from the Tianjin Medical University's Cancer Hospital in China, from October to December 2020. Data on demographic and clinical characteristics was collected via a questionnaire and Control Preference Scale (CPS). Descriptive statistics, an independent samples T-test or one-way ANOVA, and multiple regression analyses were then applied to the results. ResultsThe analysis of 279 valid questionnaires received showed that, during the surgical treatment decision-making process, the congruence rate of patients who preferred family participation and the families’ actual participation was 87%; the congruence rate of patients’ selected participation style and patients’ authentic participation style was 40.8%; age, marital status, living environment, education level, and medical burden significantly affected patients’ decision-making participation style (P < 0.05). ConclusionsFamily members are essential to the preoperative decision-making process of breast cancer patients. Patients’ willingness to participate in decision-making should be respected, and the consistency between actual and expected patient participation should be improved.

TN‐USMA Net: Triple normalization‐based gastrointestinal stromal tumors classification on multicenter EUS images with ultrasound‐specific pretraining and meta attention

Accurate quantification of gastrointestinal stromal tumors' (GISTs) risk stratification on multicenter endoscopic ultrasound (EUS) images plays a pivotal role in aiding the surgical decision-making process. This study focuses on automatically classifying higher-risk and lower-risk GISTs in the presence of a multicenter setting and limited data. In this study, we retrospectively enrolled 914 patients with GISTs (1824 EUS images in total) from 18 hospitals in China. We propose a triple normalization-based deep learning framework with ultrasound-specific pretraining and meta attention, namely, TN-USMA model. The triple normalization module consists of the intensity normalization, size normalization, and spatial resolution normalization. First, the image intensity is standardized and same-size regions of interest (ROIs) and same-resolution tumor masks are generated in parallel. Then, the transfer learning strategy is utilized to mitigate the data scarcity problem. The same-size ROIs are fed into a deep architecture with ultrasound-specific pretrained weights, which are obtained from self-supervised learning using a large volume of unlabeled ultrasound images. Meanwhile, tumors' size features are calculated from the same-resolution masks individually. Afterward, the size features together with two demographic features are integrated to the model before the final classification layer using a meta attention mechanism to further enhance feature representations. The diagnostic performance of the proposed method was compared with one radiomics-based method and two state-of-the-art deep learning methods. Four evaluation metrics, namely, the accuracy, the area under the receiver operator curve, the sensitivity, and the specificity were used to evaluate the model performance. The proposed TN-USMA model achieves an overall accuracy of 0.834 (95% confidence interval [CI]: 0.772, 0.885), an area under the receiver operator curve of 0.881 (95% CI: 0.825, 0.924), a sensitivity of 0.844 (95% CI: 0.672, 0.947), and a specificity of 0.832 (95% CI: 0.762, 0.888). The AUC significantly outperforms other two deep learning approaches (p<0.05, DeLong et al). Moreover, the performance is stable under different variations of multicenter dataset partitions. The proposed TN-USMA model can successfully differentiate higher-risk GISTs from lower-risk ones. It is accurate, robust, generalizable, and efficient for potential clinical applications.

Patient-reported outcomes following total thyroidectomy and lobectomy in thyroid cancer survivors: an analysis of the PROFILES Registry data

Patient-reported outcomes are important in the surgical decision-making process for low-risk, differentiated thyroid cancer. Current study aimed to assess patient-reported outcomes in thyroid cancer survivors comparing total thyroidectomy (TT) and lobectomy (LT) using the Patient Reported Outcomes Following Initial treatment and Long term Evaluation of Survivorship (PROFILES) registry. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scales, illness perception questions, Beliefs about Medicines Questionnaire (BMQ) scales and questions about thyroid surgery-related medication use were compared between thyroid cancer patients who underwent TT versus LT using descriptive analyses. In total, 58 thyroid cancer patients who underwent TT or LT were included in this study. None of the EORTC QLQ-C30 scales or questions regarding illness perception were significantly different between the surgical groups. Patients in the TT group had significantly higher belief in the necessity of their medication (21.0 vs 15.4; p = 0.003) and greater concerns about taking their medicines (14.7 vs 11.1; p = 0.008) versus patients in the LT group. Concerns about post-surgical medication use specifically in the TT group may indicate that clinicians should consider LT in patients with low-risk, differentiated thyroid cancer when LT and TT are viable surgical options. Clinicians should be aware of the impact of post-surgical medication use in particular following TT and use this knowledge to align goals of treatment with the extent of surgery, allowing for a better-informed decision-making process.

Activities of daily living associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery: An observational cohort study.

Elderly patients who undergo major abdominal surgery are being in increasing numbers. Intensive care unit (ICU) survival is critical for surgical decision-making process. Activities of daily living (ADL) are associated with clinical outcomes in the elderly. We aimed to investigate the relationship between ADL and postoperative ICU survival in elderly patients following elective major abdominal surgery.We conducted a retrospective cohort study involving patients aged ≥65 years admitted to the surgical intensive care unit (SICU) following elective major abdominal surgery. Data from all patients were extracted from the electronic medical records. The Barthel Index (BI) was used to assess the level of dependency in ADL at the time of hospital admission.ICU survivors group had higher Barthel Index (BI) scores than non-survivors group (P < .001). With the increase of BI score, postoperative ICU survival rate gradually increased. The ICU survivals in patients with BI 0–20, BI 21–40, BI 41–60, BI 61–80 and BI 81–100 were 55.7%, 67.6%, 72.4%, 83.3% and 84.2%, respectively. In logistic regression, The Barthel Index (BI) was significantly correlated with the postoperative ICU survival in elderly patients following elective major abdominal surgery (OR = 1.33, 95% CI: 1.20–1.47, P = .02). The area under the receiver operating characteristic (ROC) curve of Barthel Index in predicting postoperative ICU survival was 0.704 (95% CI, 0.638–0.771). Kaplan–Meier survival curve in BI≥30 patients and BI < 30 patients showed significantly different.Activity of daily living upon admission was associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery. The Barthel Index(BI) ≥30 was associated with increased postoperative ICU survival. For the elderly with better functional status, they could be given more surgery opportunities. For those elderly patients BI < 30, these results provide useful information for clinicians, patients and their families to make palliative care decisions.

Delayed variations in the diagnostic accuracy of intraoperative neuromonitoring in the resection of intramedullary spinal cord tumors.

The use of intraoperative neuromonitoring (IONM) has become an imperative adjunct to the resection of intramedullary spinal cord tumors (IMSCTs). While the diagnostic utility of IONM during the immediate postoperative period has been previously studied, its long-term diagnostic accuracy has seldom been thoroughly assessed. The aim of this study was to evaluate long-term variations in the diagnostic accuracy of transcranial motor evoked potentials (tcMEPs), somatosensory evoked potentials (SSEPs), and D-wave recordings during IMSCT excision. The authors performed a retrospective evaluation of imaging studies, patient charts, operative reports, and IONM recordings of patients who were operated on for gross-total or subtotal resection of IMSCTs at a single institution between 2012 and 2018. Variations in the specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) for postoperative functional outcome (McCormick Scale) were analyzed at postoperative day 1 (POD1), 6 weeks postoperatively (PO-6 weeks), and at the latest follow-up. Overall, 28 patients were included. The mean length of follow-up was 19 ± 23.4 months. Persistent motor attenuations occurred in 71.4% of the cohort. MEP was the most sensitive modality (78.6%, 87.5%, and 85.7% sensitivity at POD1, PO-6 weeks, and last follow-up, respectively). The specificity of the D-wave was the most consistent over time (100%, 83.35%, and 90% specificity at the aforementioned time points). The PPV of motor recordings decreased over time (58% vs 33% and 100% vs 0 for tcMEP and D-wave at POD1 and last follow-up, respectively), while their NPV consistently increased (67% vs 89% and 70% vs 100% for tcMEP and D-wave at POD1 and last follow-up, respectively). The diagnostic accuracy of IONM in the resection of IMSCTs varies during the postoperative period. The decrease in the PPV of motor recordings over time suggests that this method is more predictive of short-term rather than long-term neurological deficits. The increasing NPV of motor recordings indicates a higher diagnostic accuracy in the identification of patients who preserve neurological function, albeit with an increased proportion of false-negative alarms for the immediate postoperative period. These variations should be considered in the surgical decision-making process when weighing the risk of resection-associated neurological injury against the implications of incomplete tumor resection.

A qualitative study with orthopaedic surgeons on pain catastrophizing and surgical outcomes: shifting from a medical towards a biopsychosocial model of surgery.

Pain catastrophizing (PC) moderates surgical outcomes and behavioural interventions are recommended to optimise post-operative results. Less is known about surgeons' experiences of providing care and their attitudes towards the use of interventions in practice. It is therefore invaluable to understand surgeons' views on how best to support patients who may be at risk of suboptimal recovery. Eleven surgeons and three registrar orthopaedic practitioners took part in semi-structured interviews within a hospital setting. The surgical decision-making process, views of PC and the use of behavioural interventions in surgical practice were explored. Thematic analysis identified five themes: pain expressions and pain behaviours affect the surgeons' decision-making process, when pathologies and symptoms do not match, psychological factors pertaining to unsatisfactory outcomes, a service gap in surgical care and the acceptability of using a screening tool in surgical practice to identify patients at risk of suboptimal recovery. Orthopaedic surgeons face challenges in identifying who is likely to reach optimal versus suboptimal outcome. Surgeons are becoming increasingly aware of patient psychological distress being detrimental to outcomes, and they support the use of behavioural interventions to optimise post-operative outcomes or stop unnecessary treatments. The surgeons accept the use of a screening tool in surgical practice with better access to support services with input from allied health professionals. A screening tool may provide great utility for identifying at risk patients, to allow for modification of surgical patients care plans.