Surgical Guidelines Research Articles

Improving Cefazolin Administration for Surgical Prophylaxis in Reported Penicillin Allergy: A Retrospective Study of a Health System Intervention

Cefazolin is the most common first-line antibiotic to prevent surgical-site infections. Patients with penicillin allergy labels often receive alternative antibiotics, which is associated with increased rates of surgical-site infections, multi-drug-resistant infections, and cost. We sought to determine whether a hospital-wide guideline recommending first-line surgical prophylaxis in patients with penicillin allergy labels can increase the use of cefazolin without compromising safety. We conducted a retrospective cohort study of adult surgical patients with penicillin allergy labels. The main intervention was updated hospital-wide surgical guidelines recommending first-line prophylaxis in most patients with penicillin allergy labels. We compared the preintervention and postintervention groups. The primary outcome was cefazolin use. Secondary perioperative outcomes included alternative antibiotic use and severe allergic episodes (anaphylaxis). The total sample comprised 7187 patients with penicillin allergy labels who underwent 8945 surgical encounters (median age [interquartile range], 61 [46-71] years); 4891 [68%] female). Cefazolin was used in 2256 (73%) patients in the preintervention group and 3390 (83%) patients in the postintervention group (P< .001), with an adjusted odds ratio of 1.87 (95% CI, 1.67-2.10). There was a decrease in the use of clindamycin from 14% to 8% (P< .001) and gentamicin from 16% to 8% (P< .001). There were no episodes of severe allergic reactions among patients who received guideline-directed therapy. A hospital-wide guideline can improve use of cefazolin in surgical patients with penicillin allergy labels without increasing the risk for severe allergic reactions. National and international guidance should be considered to enhance administration of cefazolin in surgical patients with penicillin allergy labels.

Evidence-Based Surgical Guidelines for Treating Children With Rhabdomyosarcoma.

Surgery remains the cornerstone of treatment for rhabdomyosarcoma (RMS) in children. However, there is considerable variation in surgical management practices worldwide, highlighting the need for standardized Clinical Practice Guidelines (CPG). The CPG development involved assembling a multidisciplinary group, prioritizing 10 key topic areas, conducting evidence searches, and synthesizing findings. Recommendations were voted on using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology. The panel recommended regional lymph node evaluation for patients with paratesticular RMS who are more than 10years old and extremity RMS. Other suggestions included pretreatment re-excision for incompletely resected RMS, preoperative radiation therapy for unresectable tumors, maintaining a 0.5cm resection margin, and tumor bed marking with surgical clips. The panel also suggests resection of residual metastatic disease following chemotherapy, resection of relapsed disease, and the least invasive approach for managing patients presenting with obstruction. This CPG provides evidence-based surgical management recommendations for RMS that can be adapted to diverse resource settings.

Society of American Gastrointestinal and Endoscopic Surgeons guidelines development: patient engagement update to standard operating procedure.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee develops evidence-based surgical guidelines. Involvement of patient partners is important to ensure patient concerns and values are adequately addressed and incorporated. This standard operating procedure (SOP) for the process of patient partner involvement within the guidelines is described here. This document outlines the SAGES Patient Partners SOP to involve patient partners in a consistent and reproducible manner. SAGES has now developed a SOP to include patient partners so that patient views are represented in current guidelines. Guidelines must be patient centric and in order to do so must include patient partners. The SAGES Guidelines Patient Engagement Update to Standard operating Procedure aims to provide an outline for systematically doing so.

Transferability of the Surgical Attire Guideline Adherence Decision-Making Theory Beyond New England.

The AORN surgical attire guideline promotes cleanliness in the perioperative environment to minimize patients' risks of developing surgical site infections. In 2020, the surgical attire guideline adherence decision-making model was published based on findings from a study involving New England intraoperative team members. To explore the model's transferability across the United States, we replicated the 2020 study with intraoperative personnel who did not live or work in New England. The study results included the same core category as the 2020 study (ie, critical thinking), and we confirmed that intraoperative team members across the United States weigh the influence of various factors when deciding to what extent they would adhere to the surgical attire guideline. The results showed transferability of the theoretical model to perioperative settings across the United States. This model can be used to enhance intraoperative team members' surgical attire guideline adherence decisions.

Impact of antimicrobial stewardship interventions on post-elective caesarean antibiotic prophylaxis and surgical site infections

Background Antimicrobial stewardship programs (ASP) aim to improve appropriate antimicrobial use but few studies have described its impact on unique population such as obstetrics. Post-operative antibiotics are unnecessary especially in those without surgical site infections (SSI) risk factors (e.g., obesity). Objectives To evaluate the impact of ASP interventions on post-elective caesarean (eLSCS) oral antibiotic prophylaxis rates and patient outcomes. Methods This pre-post quasi-experimental study was conducted over 18 months (2 months pre- and 16 months post-intervention) in all women admitted for eLSCS in our institution. Interventions included eLSCS surgical prophylaxis guideline dissemination and post-eLSCS oral antibiotics was actively discouraged in those without SSI risk factors. This was followed by ASP intervention notes (phase 1) for 3 months, contacting the ward team for the next 7 months (phase 2) and subsequently the primary obstetrics attending in Phase 3 (next 6 months). The primary outcome was post-operative oral antibiotics prescription rates, and secondary outcomes included 30-day post-operative SSI rates. Results A total of 1751 women was reviewed. Appropriateness of pre-operative antibiotic prophylaxis was 99%. There were 244 (13.9%) women pre-intervention and 1507 (86.1%) post-intervention. Post-eLSCS antibiotic prescribing rates reduced significantly post-intervention (200, 82% vs 705, 46.8%, p &lt; 0.001). There was no significant difference in SSI rates pre-post intervention (2, 0.8% vs 28, 1.9%, p = 0.420). There was also no significant difference in SSI rates among those who received post-operative oral antibiotics compared to those without (1.9%, 17 of 905 vs 1.5%, 13 of 846, p = 0.582). Conclusions ASP interventions can reduce unnecessary post-eLSCS antibiotic prophylaxis use without adversely impacting patient safety.

Evaluation of Surgical Antibiotic Prophylaxis Guideline Adherence: A Cross-Sectional Study of Two Iranian Teaching Hospitals

Evaluation of Surgical Antibiotic Prophylaxis Guideline Adherence: A Cross-Sectional Study of Two Iranian Teaching Hospitals

Variation in the surgical management of complicated diverticulitis: a cross-sectional study of European surgeons.

There are many options for the surgical management of complicated diverticulitis, and standards vary widely despite international practice recommendations. We conducted a survey to capture the variation in practice across Europe. An online questionnaire was distributed to fellow and surgeon members of the European Association of Endoscopic Surgery (EAES) via email using the Opinio survey platform. Participants shared their demographic details. We asked members to rank the most likely intervention for patients with both stable and unstable Hinchey Class III, as well as Hinchey Class IV diverticulitis based on practice standards in their country. We used descriptive statistics, including counts and percentages, to characterize survey results. We created a heatmap to visualize the percentage of votes received for each intervention. We received 233 responses from surgeons and fellows across Europe from various countries, including Italy (35.6%), Greece (11.2%), and the United Kingdom (9.9%). Most members (79.4%) self-reported having expertise in colorectal surgery. For patients with stable Hinchey III diverticulitis, surgeons offered Hartmann's resection (HR) (41.6%), primary resection and anastomosis (PRA) (18.5%), laparoscopic peritonea lavage (LPL) prior to HR (16.9%), or LPL prior to PRA (15.5%), or LPL only (8.6%). In total, 31.4% of respondents offered LPL prior to sigmoid resection (HR + PRA). For patients with unstable Hinchey III diverticulitis, respondents offered HR (73.9%), PRA (3.85%), LPL only (6.84%), or LPL followed by sigmoid resection (15.4%). For patients with stable Hinchey IV diverticulitis, surgeons offered HR (71.7%), PRA (4.7%), LPL only (1.3%), or LPL then sigmoid resection (22.3%). Finally, for patients with unstable Hinchey IV diverticulitis, surgeons offered HR (83.1%), PRA (1.3%), LPL only (3.5%), or LPL followed by sigmoid resection (12.1%). Significant variation exists in the surgical management of complicated diverticulitis across Europe. Efforts must be made to increase the awareness and uptake of surgical guideline recommendations in clinical practice.

Association Between Thromboelastography and Coagulation for Disease Severity Evaluation in Patients With Lower Extremity Arteriosclerosis Obliterans.

Thromboelastography (TEG) and coagulation tests can be used to detect hypercoagulability to assess thrombus formation. This study explored the association between TEG and coagulation in evaluating disease severity in elderly patients with lower extremity arteriosclerotic occlusive disease (LEASO), aimed to provide surgical treatment guideline. We retrospectively analyzed the clinical characteristics, laboratory biomarkers, TEG and coagulation parameters of 233 elderly LEASO patients treated between 2020 and 2023. Among them, 86 underwent surgical amputation, 51 received vascular intervention, and the remaining were treated conservatively. Differences in TEG and coagulation among the three groups were assessed using Spearman's correlation. Multivariate logistic regression and receiver operating characteristic curves analyzed the relationships among TEG, fibrinogen (FIB), and D-dimer (D-D) levels for surgical evaluation. Inflammatory factors, platelet counts, and Fontaine stages III-IV differed significantly between the surgery and conservative groups (p < 0.05). The surgery group had higher α-angle, maximum amplitude (MA), coagulation comprehensive index (CI), FIB, and D-D, whereas lower clotting time (K) compared to the conservative group (p < 0.05), correlated with a lower ankle brachial index (ABI), indicating more severe clinical presentation. Spearman's analysis identified positive associations between α-angle, MA with FIB and D-D levels in surgical patients. Area under curve analysis indicated that combining MA, α-angle, FIB, and D-D could enhance accuracy in evaluating surgical necessity in LEASO. In elderly LEASO patients, TEG and coagulation analysis revealed a positive association between thrombus intensity and disease severity. Increased MA, α-angle, FIB, and D-D levels serve as predictors for surgical treatment necessity in LEASO.

Appraisal of current surgical guidelines for inflammatory bowel disease using the AGREE-S instrument: A scoping review.

Guidelines play a crucial role in improving patient care by providing clinicians with up to date evidence-based recommendations. A vast number of guidelines exist on the surgical management of inflammatory bowel disease (IBD). The aim of this scoping review was to identify current surgical IBD guidelines, assess their quality and identify areas of variation between the existing guidelines. A systematic search of the literature from January 2008 to September 2023 was conducted. After identifying eligible guidelines, they were assessed for quality using the Appraisal of Guidelines for Research and Evaluation for Surgical Interventions (AGREE-S) instrument. Data were extracted on descriptive guideline characteristics and recommendations. Fifteen guidelines were identified globally. Most guidelines were published between 2011 and 2023, with six focusing solely on Crohn's disease, five on ulcerative colitis and four on both. Six guidelines focused exclusively on surgical management, while nine contained both medical and surgical recommendations. The overall mean AGREE-S score was 59%, with more recent guidelines scoring higher. The quality of IBD surgical guidelines varies considerably. High-quality, collaborative, international guidelines are needed to reduce duplication and ensure consistent, evidence-based surgical care for IBD patients worldwide. Future guideline development should adhere to the AGREE-S criteria to enhance methodological rigour and transparency.

Clinical and Radiological Criteria for Surgery in Posttraumatic Extradural Hematoma: An Update from Central India

Abstract Background The surgical management guidelines for any intracranial hemorrhage were objectively defined by the Brain Trauma Foundation (BTF) in 2006 for patients who should be treated surgically or conservatively. Since then, not much work has been done toward the identification of patients who are at high risk and may have progression of the hematoma who may ultimately require surgery. This study aimed to apply the said criteria to all patients coming to the hospital with extradural hematoma (EDH) and analyze the outcome of the patient whether treated conservatively or surgically on the basis of the Glasgow Outcome Scale (GOS) and to observe the factors and variables that are associated with EDH that will help in furthering the demographic design of the entity in central India. Materials and Methods A prospective and retrospective, ambivalent cohort study was performed at a hospital in central India involving all cases of computed tomography (CT) diagnosed EDH that were reported to the center from October 2016 to March 2018. A total of 78 patients were included in the study. Patients were selected and managed conservatively or surgically as per the criteria and were followed up until the outcome. In retrospective analysis, we evaluated the current criteria for surgery in all patients of posttraumatic EDH in the past 5 years and whose records were available. Condition on discharge or the outcome along with GOS was taken as the endpoint for retrospective analysis. Results Temporoparietal and frontal regions were the most common sites of EDH and also presented higher mortality rates as compared with other sites. The majority of patients had EDH of length of greater than 5 cm and the mortality rate for the same group also increased with lesser survival chances with length of greater than 10 cm. Patients who presented with an EDH of greater than 1-cm width were higher in numbers, with survival rates decreasing with an increase in width, especially with an EDH greater than 2 cm. Conclusion We conclude that the criteria laid out by the BTF, namely, CT findings of an EDH volume greater than 30 mL, width greater than 15 mm, and mildline shift of greater than 5 mm, hold good in cases of EDH. This study reviewed the previous criteria in the Indian setting and found them to hold good so far.

A review of the ethmoidal foramina and their clinical application.

The ethmoidal foramina (EF), located on the medial orbital wall along the frontoethmoidal sutures, are critical anatomical landmarks for surgeries involving the medial orbital wall. This review aimed to review the surgical anatomy of the EF, including their embryology and radiology. Although the frontoethmoidal sutures mostly have two foramina passing through them, there are reports of single foramen or multiple, up to six foramina. These foramina provide a passage for the ethmoidal arteries and nerves, branches of ophthalmic arteries and nerves. The surgical guideline "24-12-6" is based on the approximate distance between the anterior lacrimal crest, the anterior and posterior ethmoidal arteries, and the optic canal, commonly used to navigate this area. However, some studies from various populations defined different ratios. Embryologically, the EF were formed by the union of intramembranous ossified frontal bones and endochondral ossified ethmoid bones. EF and neurovascular structures can be identified in computed tomography even in the 3 mm sectional intervals. A comprehensive anatomical understanding of EF will help clinicians improve surgical guidelines and ultimately reduce the risk of complications.

Psychological distress does not predict decisional regret in patients undergoing spinal reconstruction for adult spinal deformity

PurposeThe study aimed to assess the link between preoperative psychological distress and postoperative decisional regret in adult spinal deformity (ASD) surgery patients. We hypothesized that greater pre-surgery distress would correlate with higher post-surgery regret. This evaluation was based on a retrospective case series from an institution with standardized surgical guidelines for ASD.MethodsThis IRB-approved retrospective study analyzed our institution’s ASD database from 2014 to 2020. Eligible patients had a minimum two-year post-op follow-up and preoperative psychological distress assessment. Patients were grouped based on psychological distress levels: green, yellow, and yellow minus. Regret post-surgery was assessed using the Decision Regret Scale and SRS-22 Question 22. Logistic regression evaluated the impact of distress levels on regret, controlling for age and sex.ResultsOut of 167 eligible patients, 112 responded and were analyzed. No significant demographic differences were observed between responders and non-responders. Using the Decision Regret Scale, 41% expressed no regret, while 63% expressed no regret with the SRS-22 questionnaire’s Single-Item scale. Only the yellow minus group showed significant regret difference based on osteotomy, with non-recipients more likely to express regret.ConclusionThis study found no significant link between psychological distress and post-operative regret in adult spinal deformity surgery after a minimum 2-year follow-up. Although nearly 60% exhibited some post-surgery regret, predicting regret based on psychological burden or demographics remains challenging. Further research is essential to identify factors contributing to post-operative regret in spinal deformity surgery patients.

The Effect of Reverse Shoulder Arthroplasty Design and Surgical Indications on Deltoid and Rotator Cuff Muscle Length

BackgroundAdvancements in surgical planning, technique, and prosthesis design have improved adaptation to patient anatomy in reverse total shoulder arthroplasty (rTSA). Postoperative changes in deltoid and rotator cuff muscle length are important and may vary based on preoperative indications and prosthesis selection. The purpose of this study is to demonstrate the changes in deltoid and rotator cuff muscle length for planned rTSA using the spectrum of prosthesis configurations in both GHOA and RCA. MethodsTen shoulder arthroplasty surgeons used preoperative planning software to plan rTSA cases for 20 subjects (10 GHOA, 10 RCA) following surgical guidelines. Each surgeon planned each case using three prosthesis configurations: (1) 8-mm lateralized glenosphere and 135° neck-shaft angle (135+8), (2) 4-mm lateralized glenosphere and 145° neck-shaft angle (145+4), and (3) 0-mm lateralized glenosphere and 155° neck-shaft angle (155+0). Pre- and postoperative deltoid and rotator cuff muscle lengths and percentage-change were calculated and compared between prosthesis configurations within each indication. Different muscle lines of action were included representing the deltoid, subscapularis, infraspinatus, and teres minor. ResultsPreoperatively, the RCA cohort had significantly shorter muscle lines of action in the posterior, lateral, and anterior deltoid (P<0.001), a longer inferior subscapularis (P=0.022), and a longer teres minor (P=0.001) than the GHOA cohort. ANOVA and post-hoc analysis showed that post-planning lengths of each deltoid action line were greater in the 155+0 configuration compared to the 135+8 configuration in the RCA cohort (P<0.001, P=0.003, P=0.032, respectively), and post-planning lengths of the anterior and middle deltoid action lines were also greater for the same comparison in the GHOA cohort (P=0.004 and P=0.017, respectively). There were no significant differences in post-planning deltoid lengths between the 135+8 and 145+4 configurations in either diagnosis cohort (P>0.05). All post-planning rotator cuff muscle lengths (subscapularis, infraspinatus, and teres minor) differed significantly (P<0.001) between all prosthesis configurations in both diagnosis cohorts, with the 135+8 configuration resulting in the longest lengths and the 155+0 configuration resulting in the shortest lengths. ConclusionAutomated preoperative planning software calculates the lengths of muscle action lines, which vary between GHOA and RCA diagnoses. Varying rTSA implant geometries result in predictable differences in deltoid lengthening and rotator cuff shortening. Shoulder prostheses with a more lateralized center of rotation show greater rotator cuff muscle length and similar deltoid muscle length when compared to medialized designs with similar deltoid lengthening. Surgeons can use this software to understand the impact of implant geometry on muscle length.

NET guidelines for white patients may not fit Asian patients

IntroductionPancreatic neuroendocrine tumors (pNETs) are slow growing, malignant tumors that show different survival outcomes by race. Current size-based guidelines were largely developed in White patients. Our aim was to investigate tumor size and incidence of lymph node metastasis (LNM) between White and Asian pNET patients to evaluate generalizability of established guidelines. MethodsUsing the National Cancer Database (NCDB), we conducted a multi-institutional analysis of patients with low grade, resected, nonfunctional, sporadic, non-metastatic pNETs. Chi-squared tests were implemented to determine correlation between PTS and LMN incidence as well as race and LMN incidence. A logistic regression model was utilized to determine correlation between LMN, tumor size, and race. Overall survival was assessed using the Kaplan-Meier method. ResultsA total of 4977 pNET patients (205 Asian and 4772 White) were included in our analysis. Asian patients presented with smaller tumors (3.0 ​cm vs 3.9 ​cm, p ​= ​0.029) but when grouped by size, there was no difference in the distribution (p ​= ​0.77). White patients demonstrated a higher incidence of lymph node metastasis at presentation compared to Asian patients (27 ​% vs 19 ​%, p ​= ​0.013), a higher likelihood of an R0 resection (95.3 ​% vs. 89.3 ​%, p ​< ​0.0001).Within both populations, tumor size (<2 ​cm, 2–3 ​cm, and ≥3 ​cm) positively correlated with incidence of LNM (11.5 ​%, 24.6 ​%, and 39.1 ​%). No difference of LNM was seen between racial cohorts at PTS <3 ​cm, however, Asian patients were less likely to exhibit LNM at PTS ≥3 ​cm (28.2 ​% and 39.5 ​%, p ​= ​0.04). Overall survival was not significantly different between racial groups (p ​= ​0.92). ConclusionSize based surgical resection guidelines for pancreatic neuroendocrine tumors based on a predominantly White patient population may not be generalizable to the Asian population. Within this population, we found the risk of lymph node metastasis did not increase at similar rates with increasing primary tumor size.

Clinicians' and Patients' Experiences and Perceptions on the Prevention and Management of Surgical Site Infections: A Mixed-Methods Systematic Review.

To explore clinicians' and patients' perceptions of implementing evidence-based practice to improve clinical practice for preventing and managing surgical site infections within hospital acute care settings. A convergent integrated mixed-methods systematic review using the Joanna Briggs Institute approach. Included studies reported (i) acute care hospital clinicians' and patients' experiences and preferences for preventing and managing surgical site infections and (ii) barriers and facilitators to implementing surgical site infection prevention and management guidelines. The Mixed Methods Appraisal Tool and the Quality Improvement Minimum Quality Criteria Set were used for critical appraisal. Quantitative data was transformed into qualitised data, then thematically synthesised with qualitative data and coded all findings into themes. Clinicians' and patients' views were also compared. English language peer-reviewed studies published from 2009 to March 2023 were identified from Medline, EMBASE, CINAHL, PsycINFO and Cochrane Central Library. Thirty-seven studies (16 quantitative, 17 qualitative, 3 mixed-methods and 1 quality improvement) met the inclusion criteria. Five main themes represent key factors believed to influence the implementation of evidence-based surgical site infection prevention and management guidelines: (1) Intentional non-adherence to insufficiently detailed and outdated guidelines, (2) Knowledge deficits on evidence-based SSI care bring about inconsistent clinical practice, (3) Collaborative interdisciplinary and patient-provider relationship to enhance guideline uptake, (4) Infection surveillance to improve patient safety and quality of life and (5) Negative physical and psychological impacts on patients. The five themes reflect a need for updated hospital guidelines as a medium to improve surgical site infection knowledge and ensure consistent and evidence-based clinical practice. This review also highlights the significance of interdisciplinary and patient-provider collaboration and infection surveillance to facilitate guideline uptake. The effectiveness of intervention bundles designed to improve these aspects of care will need to be evaluated in future research. A future intervention bundle that includes (1) ensuring up-to-date hospital guidelines/policies; (2) fostering collaborative interdisciplinary teamwork culture between physicians, nurses, podiatrists, pharmacists and allied health professionals; (3) encouraging patient or carer involvement in shared decision-making and (4) implementing audit and feedback mechanism on infection surveillance is proposed to improve SSI prevention and management in acute care settings. This paper followed the PRISMA 2020 checklist guideline for reporting systematic reviews. This mixed-methods systematic review collates evidence of clinicians' and patients' experiences and preferences for preventing and managing surgical site infections. The inclusion of hospital patients' perspectives supports the development of patient-centred interventions. The review protocol is registered on the International Prospective Register of Systematic Reviews (PROSPERO 2021 CRD42021250885). Available at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021250885.

A Survey on Surgical Site Infections Prevention Guidelines Knowledge and Implementation Level of Trauma Centre Healthcare Professionals.

Aims/Background Surgical site infections (SSIs) significantly influence patient safety and healthcare quality, particularly in low- and middle-income countries where the burden is most evident. This manuscript aims to evaluate the awareness and adherence to SSI prevention guidelines among healthcare providers at a tertiary trauma centre situated in Tirana, Albania. Methods This cross-sectional survey was conducted among practising surgeons, residents and nurses of Trauma University Hospital, Tirana. The questionnaire explores awareness, attitudes and practices towards SSI prevention in preoperative, perioperative and postoperative phases. Results The participants demonstrated a high level of patient education about SSI risks (91.9%), but lower adherence to individual prevention practices. Conclusion Despite adequate knowledge, there remains a significant gap in the implementation of SSI prevention guidelines. Strengthening continuous medical education is crucial to addressing systemic barriers, improving compliance with guidelines, and decreasing SSI rates.

EGS SO16 - Retrospective review of adherence of emergency theatres operation notes to Royal College of Surgeons in England Guidelines

Abstract Background Adherence to standardized operation note guidelines is crucial for ensuring patient safety and maintaining high standards of surgical practice. This study aims to evaluate the compliance of emergency theatre operation notes with the Royal College of Surgeons in England guidelines, identifying areas for improvement to enhance documentation practices. Method A retrospective review of 50 patients was conducted on operation notes from emergency theatres. The notes were assessed for adherence to the Royal College of Surgeons in England guidelines. Parameters evaluated included completeness of patient information, surgical procedure details, intraoperative findings, and postoperative instructions. Results There was good compliance in sections such as the name of the operative and assistance, operative findings, and closure. However, improvements are needed in sections such as problems encountered, anticipated blood loss, and the name of antibiotics used. Compliance can be improved by making the notes clearer and more comprehensive. Conclusion Our analysis suggests room for improvement in adherence to postoperative surgical note guidelines. We recommend adding further details such as the name of the scrub nurse, indication, to the operative notes. A postoperative checklist template has been devised to ensure adherence to guidelines and improve documentation practices.

Outcomes of Pediatric Hepatocellular Carcinoma: A Single-Center Experience With Resection Versus Transplantation.

Pediatric hepatocellular carcinoma (HCC) presents significant challenges due to its aggressive nature, with survival depending on complete resection. We aimed to assess outcomes between liver resection (LR) and liver transplantation (LT). A total of 25 patients were retrieved, four of whom were classified as palliative at diagnosis. A subanalysis comparing cirrhotic liver (n = 14) versus de novo (n = 11) HCC was performed to identify confounding variables. Further evaluation focused on the 21 children with histologically confirmed HCC who underwent LR (n = 7) versus LT (n = 14). Kaplan-Meier survival curves were constructed. The mean age was 7.8 ± 6.1 years for patients with cirrhotic liver and 12.1 ± 3.5 years for de novo HCC. Our group observed overall total survival rates of 100%, 85%, and 77% at 12, 36, and 60 months, respectively. De novo tumors had a higher recurrence rate and a poorer prognosis (p = 0.039 and p = 0.045). The disease-free survival at 60 months in our cohort was significantly lower among the LR group compared to the LT group (14% vs. 82%; p = 0.0081). Recurrence after initial management (n = 8) showed location differences between LR and LT. Preoperative alpha-fetoprotein (AFP) was elevated in 71% of children, but did not correlate with recurrence or compromised survival. Elevated AFP 3 months post-operation affected the course negatively (p = 0.044). Tumor number and diameter exhibited a trend towards poorer outcomes. These findings emphasize the need for comprehensive pediatric surgical guidelines for HCC. We recommend LT over LR in pediatric cases. Extrahepatic disease post-neoadjuvant chemotherapy remains the only absolute contraindication.

Annals of Surgical Oncology Practice Guidelines Series: Adjuvant and Neoadjuvant Therapy for Melanoma.

Surgery has always been the mainstay of melanoma treatment, but the risk of recurrence after curative-intent surgery remains high for some stages of the disease. In this Annals of Surgical Oncology Guidelines Review, we provide an overview of practice changing studies, review international guidelines, and highlight current recommendations and areas of controversy when treating melanoma patients in the adjuvant and neoadjuvant setting. Recent clinical trials have established important roles for adjuvant and neoadjuvant therapy in conjunction with surgery for selected patients with stage II, stage III, and even resectable stage IV melanoma. Patients with melanoma should be evaluated for multimodality therapy, including a combination of surgery, systemic therapy (i.e., BRAF-targeted therapy or checkpoint blockade immunotherapy), and at times radiotherapy. With the rapid pace of advances in the field, it is crucial for surgical oncologists to remain updated on the latest guidelines and recommendations for adjuvant and neoadjuvant therapy and to continue to be leaders in this paradigm shift. Given the complex and evolving nature of treatment, this report reviews the latest practice guidelines in the context of modern multidisciplinary management of melanoma.

Time delay and evidence profiles forming clinical recommendations of US surgical society guidelines

Surgical society guidelines facilitate implementation of up-to-date, evidence-based care, but concerns regarding the contemporality and quality of evidence can hinder adherence. We aimed to evaluate the time gap between evidence publication and their inclusion within clinical guidelines-the publication-to-guideline delay-and characterize the quality of evidence within contemporary surgical society guidelines. This cross-sectional study analyzed guidelines published by U.S. surgical societies between 2015 and 2020 and references informing clinical recommendations. The primary outcomes were the publication-to-guideline delay and the quality of evidence supporting clinical recommendations. Differences between societies were analyzed using the Kruskal Wallis and Fisher exact tests. All data were extracted by three reviewers, and inter-rater reliability was assessed using the Kappa coefficient. Fifty-seven guidelines met inclusion criteria; among 6200 cited references, 3892 informed specific clinical recommendations. The median [IQR] publication-to-guideline delay was 9 [5-14] years and ranged across societies between 7 and 11 years. A majority (54%) of evidence informing recommendations comprised retrospective observational studies (54%). Despite only 14% of evidence graded as high-quality, 59% of clinical recommendations were strong. Societies showed statistically significant variations in their proportion of study designs, quality of evidence, and strength of recommendations. U.S. surgical societies have a unique potential to disseminate evidence through guidelines. We found that concerns regarding the contemporality and quality of evidence constituting surgical guidelines may be valid. Societies should critically evaluate procedures for reviewing the timeliness and quality of evidence to ensure guidelines remain up-to-date and reliable.