Surgical Management Of Patients Research Articles

Dual Mobility Trapeziometacarpal Joint Arthroplasty: A Survey on Variations in Surgical Techniques and Patient Management.

Background: Dual mobility total joint arthroplasty is gaining popularity for trapeziometacarpal joint (TMCJ) arthritis, with evolving indications, surgical technique and rehabilitation. The aim of this study was to obtain detailed insight into the variations in indications, surgical technique and rehabilitation for TMCJ arthroplasty with dual mobility implants, across a large international cohort of surgeons. The secondary aim was to analyse if there were differences in TMCJ arthroplasty between highly and less experienced surgeons. Methods: An anonymised online survey was developed and distributed to the international hand surgery community of surgeons performing TMCJ arthroplasty. Responses were summarised, and a sub-analysis comparing indications, contra-indications, surgical technique, implant placement, rehabilitation and complications between highly and less experienced surgeons was performed. Results: Of the 203 included respondents, 59 were considered highly experienced. Most respondents perform TMCJ arthroplasty under regional anaesthesia (84%), via a dorsolateral approach (78%) and with image-guidance for cup placement (84%). However, there is considerable variation in handling of scaphotrapeziotrapezoidal (STT) arthritis, cup positioning landmarks, postoperative immobilisation, first extensor compartment release and revision techniques. Highly experienced surgeons performed TMCJ arthroplasty for a larger proportion of their patients undergoing surgery for TMCJ arthritis, and a trapezium smaller than 8 mm or STT-OA was less frequently considered a contra-indication. Highly experienced surgeons preferred freehand osteotomy of the metacarpal and allowed office workers to return to work earlier. Conclusions: This survey shows that there is considerable variation in (contra)indications, surgical technique and rehabilitation amongst surgeons performing TMCJ arthroplasty, but only a few differences between highly and less experienced surgeons were identified. This data provides a reference for surgeons who want to familiarise themselves with increasingly popular procedure and may help surgeons already performing TMCJ arthroplasty to identify potential topics for future research to optimise its outcome. Level of Evidence: Level V (Therapeutic).

Enhancing interventions of metastatic epidural spinal cord compression (MESCC) in elderly patients: prompt for further reflection.

This addresses the study by Lenga P. et al. on the surgical management of elderly patients with metastatic spinal cord compression (MSCC), acknowledging its valuable insights but suggesting areas for improvement. The absence of Patient-Reported Outcomes Measurement Information System (PROMIS) tools, arguing that patient-reported outcomes are crucial for evaluating the impact of interventions, the need for standardization in surgical approaches, the integration of a multidisciplinary team to optimize patient outcomes, non-surgical management strategies and stressing the importance of long-term follow-up is elaborated.

Protocol for a phase 3, randomised, active-control study of four-factor prothrombin complex concentrate versus frozen plasma in bleeding adult cardiac surgery patients requiring coagulation factor replacement: the LEX-211 (FARES-II) trial

IntroductionReduced thrombin generation is an important component of post cardiopulmonary bypass (CPB) coagulopathy. To replenish coagulation factors and enhance thrombin generation in bleeding surgical patients, frozen plasma (FP) and four-factor...

A Monocentric Analysis of Implantable Ports in Cancer Treatment: Five-Year Efficacy and Safety Evaluation.

Daily clinical practice requires repeated and prolonged venous access for delivering chemotherapy, antibiotics, antivirals, parenteral nutrition, or blood transfusions. This study aimed to investigate the performance and the safety of totally implantable vascular access devices (TIVADs) over a 5-year follow-up period through a standardized well-trained surgical technique and patient management under local anesthesia. In a retrospective, observational, and monocentric study, 70 patients receiving POLYSITE® TIVADs for chemotherapy were included. The safety endpoints focused on the rate of perioperative, short-term, and long-term complications. The performance endpoints included vein identification for device insertion and procedural success rate. The study demonstrated no perioperative or short-term complications related to the TIVADs. One (1.4%) complication related to device manipulation was identified as catheter flipping, which led to catheter adjustment 56 days post-placement. Moreover, one (1.4%) infection due to usage conditions was observed, leading to TIVAD removal 3 years and 4 months post-surgery. Catheter placement occurred in cephalic veins (71.4%), subclavian veins (20%), and internal jugular veins (8.6%). The procedural success rate was 100%. Overall, the implantable ports typically remained in place for an average of 22.4 months. This study confirmed the TIVADs' performance and safety, underscored by low complication rates compared to published data, thereby emphasizing its potential and compelling significance for enhancing routine clinical practice using a standardized well-trained surgical technique and patient management.

ASO Visual Abstract: Contemporary Axillary Surgical Management in Patients with Pathologically Node-Positive Disease After Neoadjuvant Chemotherapy: A Survey of Members of the American Society of Breast Surgeons.

ASO Visual Abstract: Contemporary Axillary Surgical Management in Patients with Pathologically Node-Positive Disease After Neoadjuvant Chemotherapy: A Survey of Members of the American Society of Breast Surgeons.

Genetic and Modifiable Risk Factors for Postoperative Complications of Total Joint Arthroplasty: A Genome-Wide Association and Mendelian Randomization Study.

Background: Total joint arthroplasty (TJA) is an orthopedic procedure commonly used to treat damaged joints. Despite the efficacy of TJA, postoperative complications, including aseptic prosthesis loosening and infections, are common. Moreover, the effects of individual genetic susceptibility and modifiable risk factors on these complications are unclear. This study analyzed these effects to enhance patient prognosis and postoperative management. Methods: We conducted an extensive genome-wide association study (GWAS) and Mendelian randomization (MR) study using UK Biobank data. The cohort included 2964 patients with mechanical complications post-TJA, 957 with periprosthetic joint infection (PJI), and a control group of 398,708 individuals. Genetic loci associated with postoperative complications were identified by a GWAS analysis, and the causal relationships of 11 modifiable risk factors with complications were assessed using MR. Results: The GWAS analysis identified nine loci associated with post-TJA complications. Two loci near the PPP1R3B and RBM26 genes were significantly linked to mechanical complications and PJI, respectively. The MR analysis demonstrated that body mass index was positively associated with the risk of mechanical complications (odds ratio [OR]: 1.42; p < 0.001). Higher educational attainment was associated with a decreased risk of mechanical complications (OR: 0.55; p < 0.001) and PJI (OR: 0.43; p = 0.001). Type 2 diabetes was suggestively associated with mechanical complications (OR, 1.18, p = 0.02), and hypertension was suggestively associated with PJI (OR, 1.41, p = 0.008). Other lifestyle factors, including smoking and alcohol consumption, were not causally related to postoperative complications. Conclusions: The genetic loci near PPP1R3B and RBM26 influenced the risk of post-TJA mechanical complications and infections, respectively. The effects of genetic and modifiable risk factors, including body mass index and educational attainment, underscore the need to perform personalized preoperative assessments and the postoperative management of surgical patients. These results indicate that integrating genetic screening and lifestyle interventions into patient care can improve the outcomes of TJA and patient quality of life.

Surgical management of pancreatic cancer in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: a 5 years retrospective descriptive study

IntroductionThe incidence of Pancreatic cancer is different in different parts of the world. It is a cancer with the worst prognosis of all malignancies. Pancreatic cancer is predominantly a disease of an older population. There are different environmental (modifiable) and non-modifiable risk factors associated with the development of pancreatic cancer. At present, surgical resection is the only potential cure for pancreatic cancer. However, as only 10–20% of the patients have resectable disease at the time of diagnosis. The morbidities associated with surgeries for pancreatic cancers remain high though the post-operative mortality has shown significant reduction in the past few decades. So far, no study has been conducted to investigate pancreatic cancer in Ethiopia.ObjectivesTo assess the clinico-pathologic profile, associated factors, surgical management and short-term outcome of patients with pancreatic cancer in Tikur Anbessa Specialized hospital.MethodsA 5 years retrospective hospital-based cross-sectional study was conducted on 52 patients operated with the diagnosis of pancreatic cancer with either curative or palliative intents. The study period was from April 2016 to July 2021. The data collected includes demographic profile, associated risk factors and comorbidities, clinical presentations, biochemical parameters, pathologic features of the tumors as well as type of treatment offered and short term treatment outcome. The data was analyzed using SPSS version 25.ResultThe mean and median age of patients was 54.1 and 54.5% respectively. Males constitute about 52% the patients. 21% of the patients have potential risk factors; whereas only 10 (19.2%) of the patients had medical comorbidities. Median duration of symptoms at diagnosis was 12 weeks. Abdominal pain (88.5%) was the most common presenting symptom followed by anorexia (80.8%) and significant weight loss (78.8%), while 71.2% of the patients have jaundice. On clinical evaluation, 69.2% were jaundiced, while 34.6% had a palpable gallbladder. More than two third of patients presented with advanced disease. 76.9% of the tumors are located in the head of pancreas. More than three quarters (77%) of the surgeries performed were palliative. Postoperative morbidity and mortality were 19.2% and 3.8% respectively.ConclusionAge at first diagnosis of pancreatic cancer is relatively earlier in our setup. Most patients present with advanced condition, only amenable for palliative measures. The post-operative morbidity and mortality are more or less comparable with similar studies. The need for adjuvant therapy in pancreatic cancer should be emphasized.

Surgical management of iSGS in pregnant patients: Survey among North American expertise centers

ObjectiveTo identify, group and document the surgical management of idiopathic subglottic stenosis (iSGS) in pregnant women among North American centers with expertise in the treatment of airway stenosis. BackgroundIdiopathic subglottic stenosis is a rare airway disease that primarily affects women in their third to fifth decade of life. Symptoms of iSGS often worsen during pregnancy and can present as a threat to optimal maternal and fetal health; however there is a lack of evidence addressing the management of iSGS in pregnancy. Study designCross-Sectional Survey Study. MethodsA twenty-four question survey was designed to query the surgical management, ventilation, and perioperative considerations for pregnant patients with iSGS. Twenty-nine North American academic tertiary care centers with airway surgery expertise were identified. A designated surrogate for each center was contacted by email to distribute and obtain results of the survey. Results17 centers responded. Most centers include differences in perioperative assessment such as frequency of consultation with a maternal/fetal medicine specialist. There is occasional use of a tocometer and rarely a non-stress test. Ventilation with intermittent jet ventilation or high-flow nasal cannula is favored. The surgical protocols include positional modifications, with pregnant patients in the left lateral decubitus position. The preferred timing for intervention is in the second or third trimester. ConclusionThis is the first national survey describing surgical and perioperative considerations for the pregnant patient with iSGS among centers with airway expertise in the United States and Canada.

ORTHOGNATHIC SURGERY AS SECONDARY TREATMENT IN PATIENTS WITH CLEFT LIP AND PALATE: An Integrative Review

Cleft lip and cleft palate (CLP) is the most common craniofacial anomaly worldwide and can influence maxillary growth, leading to midface hypoplasia. Various therapies are proposed for managing this condition, including orthodontic interventions, conventional orthognathic surgery (CO), and/or distraction osteogenesis (DO) to achieve functional and aesthetic outcomes and improve the quality of life for affected individuals. This is an integrative literature review on orthognathic surgery as a surgical approach to address secondary clinical features in patients with cleft lip and palate. The research was conducted using databases such as Cochrane Library, Embase, PubMed (MEDLINE), Lilacs, and SciElo, with indexed descriptors from DeCS/MeSH, considering studies published between 2019 and 2024 in Portuguese, English, and Spanish. Based on preliminary analysis, 26 articles were selected for full reading, including primary studies and reference books on the topic. Ultimately, 13 studies were included due to their relevance to the research focus. It is concluded that the use of CO and DO techniques is effective for the surgical management of cleft patients, necessitating surgical planning and evaluation of the effects of different surgeries on CLP patients.

DEXMEDETOMIDINE: A VERSATILE, MULTITASKING ANESTHETIC AGENT FOR PERIOPERATIVE MANAGEMENT, A NARRATIVE REVIEW

Dexmedetomidine stands out as a versatile anesthetic agent with a unique combination of sedative, analgesic, and sympatholytic properties, making it highly suitable for various perioperative applications. Its ability to provide arousable sedation, reduce opioid requirements, and maintain hemodynamic stability offers significant advantages in the perioperative management of surgical patients, particularly those with cardiovascular risks or a history of opioid use. The neuroprotective potential of dexmedetomidine further broadens its clinical applicability, especially in neurosurgical and trauma settings. While generally well-tolerated, its use necessitates careful monitoring to mitigate side effects such as bradycardia and hypotension, particularly in patients with hepatic impairment. The availability of atipamezole as an antidote enhances the safety profile of dexmedetomidine, allowing for rapid and effective reversal of its sedative and cardiovascular effects. Given the comprehensive benefits and the evolving evidence supporting its use, dexmedetomidine represents a valuable addition to the anesthesiologists toolkit, warranting its continued exploration and integration into perioperative care protocols.

Preoperative imaging of colorectal liver metastases: what the radiologist and the multidisciplinary team need to know.

The management of patients with colorectal liver metastases (CRLM) has transformed over the past 2 decades. Advances in surgical techniques, systemic therapies, and local treatments have resulted in a paradigm shift. Disease that would once have been considered terminal is now frequently treated aggressively with both a disease-free and overall survival benefit. In line with the expanding range of treatment options, there has been an increase in the volume and complexity of imaging required in the management of these patients to ensure optimal patient selection and outcome. The radiologist plays a pivotal role in interpreting these studies, conveying the relevant information and informing the discussion at multidisciplinary team meetings. The purpose of this review is to provide an update for radiologists on the current surgical management of patients with CRLM highlighting specific imaging information that is required by the multidisciplinary team when assessing resectability and/or the need for additional liver-directed therapies.

Surgical Management for Patients with Toxic Megacolon due to Ulcerative Colitis.

The present study reviewed cases of Toxic megacolon (TM) treated in our department, summarized the timing and technique of surgery, and considered key points for surgical management. This single-center retrospective study included the medical records of patients clinically diagnosed with TM who underwent surgery between 1985 and 2020. The diagnostic criteria and screening scores for sepsis, such as the systemic inflammatory response syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA) score, and Modified Early Warning Score (MEWS), were validated. The preoperative clinical features and perioperative findings were also investigated. There were eight male and six female patients. Nine patients (64.3%) satisfied the criteria for toxemia proposed by Narabayashi, and 10 patients (71.4%) fulfilled the SIRS criteria. A positive qSOFA score was confirmed in 1 patient (7.1%). The MEWS was high in 2 patients (14.3%). Intestinal perforation occurred in 2 patients (14.3%), and 1 of them died from disseminated intravascular coagulation. The mortality rate of TM with perforation was 50%. Eleven patients (78.6%) underwent total colectomy with end ileostomy. TM does not have well-defined diagnostic criteria, in addition to developing sometimes as borderline or fulminant cases, and must be recognized at an early stage, taking various findings into consideration. The criteria proposed by Narabayashi and the SIRS criteria, which met in a high percentage of our cases, are recommended as indicators for determining the toxicity of TM. It is also important to consider surgery in the early stages of TM, even if clinical findings do not meet all the criteria.

Indexing left ventricular end-systolic dimension to body size: Association with mortality in patients with degenerative mitral regurgitation.

In patients with degenerative mitral regurgitation (DMR), left ventricular (LV) dysfunction is associated with increased risk of heart failure and excess mortality. LV end-systolic diameter (LVESD) is an established trigger for intervention, yet recommended LVESD thresholds apply poorly to patients with small body size. Whether LV normalization to body surface area (BSA) may be used as a trigger for DMR correction is unknown. We examined the link between LVESD index (LVESDi) and outcome in DMR to identify appropriate thresholds for excess mortality. This study focuses on 2753 consecutive patients with DMR due to flail leaflets diagnosed in tertiary centres from Europe and the United States, with prospective echocardiographic measurement of LVESD and BSA and long-term follow-up. The primary endpoint was mortality after diagnosis under conservative management. Secondary endpoints were mortality under conservative and surgical management and postoperative mortality of patients who underwent surgery. The optimal LVESDi cut-off for mortality prediction was 20 mm/m2. Irrespective of management type, 10-year survival was lower with LVESDi ≥20 mm/m2 than with LVESDi <20 mm/m2 (both p < 0.001). After covariate adjustment, LVESDi ≥20 mm/m2 was independently predictive of mortality under conservative management (adjusted hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.15-1.75), and with conservative and surgical management (adjusted HR 1.34, 95% CI 1.17-1.54). LVESDi remained associated with poorer postoperative outcome in patients who underwent intervention. LVESDi showed higher incremental predictive value over the baseline model compared to LVESD. The association between LVESDi ≥20 mm/m2 and outcome was consistent in subgroups of patients with DMR. In severe DMR due to flail leaflets, LVESDi is a marker of risk additive and incremental to LVESD. Its use in clinical practice should lead to earlier referral to mitral valve surgery and improved long-term outcome.

Comparative Outcomes of Immediate and Delayed Wound Closure Techniques in Appendectomies for Gangrenous Appendicitis

Background: Post-operative medical complications are very common in patients with gangrenous nonperforated appendicitis, especially surgical site infections (SSIs). Currently no conclusive answers on the relative benefits of immediate vs delayed wound clear therefore a comparison is essential. Objectives: In order to compare the results of immediate versus delayed wound closure in patients with gangrenous appendicitis who underwent appendectomy, SSIs, wound healing, and general postoperative recovery will be assessed. Methodology: The present study is a retrospective cohort study, using data from 185 patients, operated for gangrenous appendicitis during the period between from January 2023 to February, 2024. Total patients were categorized into two groups based on the wound closure technique employed, immediate wound closure (IWC, n=105) and delayed wound closure (DWC, n=80). Specific dependent variables were the overall SSI rate, days to wound healing and days of hospitalization. Secondary endpoints included a return of symptoms and overall postoperative morbidity. Results: The study also revealed that the incidence of SSIs was relatively low in the DWC group at 8. 0% compared to the (22.0± 0.01) % in the IWC group, which was statistically significant (p&lt;0. 001). The overall IWC time was significantly shorter in the IWC group (11 days) as compared to the DWC group (15 days) (P value = 0. 02). In our study, the DWC group was found to have a lower median LOS of 6 days as compared to IWC group that had a LOS of 8 days. When compared the two groups regarding readmission rates, the difference was not statistically significant (p-value = 0. 05). Conclusion: These delayed wound closure strategies in appendectomy for gangrenous appendicitis are a safe means of decreasing SSIs and hospital stay without a predisposing effect on wound healing and readmission. Based on these findings, it is recommended that DWC is the better approach in the management of such high-risk surgical patients.

Trends and epidemiology in robotic-assisted total knee arthroplasty: Reduced complications and shorter hospital stays.

This study provides an in-depth analysis of the immediate postoperative outcomes and implications or robotic-assisted total knee arthroplasty (RA-TKA) compared with conventional TKA (C-TKA), particularly with regard to mortality, complications, hospital stay and costs, drawing from a comprehensive nationwide data set. The Nationwide Inpatient Sample (NIS) database, the largest all-payer inpatient healthcare database in the United States, was used to identify all patients who underwent RA-TKA or C-TKA from 2016 to 2019. A total of 527,376 cases, representing 2,638,679 patients who underwent elective TKA were identified, of which 88,415 had RA-TKA. To mitigate potential variations and selection bias in baseline characteristics between the two groups, a propensity score-matched analysis was employed to further balance and refine our data set, resulting in 176,830 patients evenly distributed between the groups. Analysis was performed according to demographics, immediate post-operative complications, and economic data, including payor class, length of stay and total charges. There was a marked shift towards RA-TKA, from an initial 0.70% in 2016 to a notable 7.30% by 2019. Patients who underwent RA-TKA were slightly younger (66.2 ± SD years), compared to the C-TKA group (66.7 ± SD years). Hospital stay was 1.89 days and 2.29 days for RA-TKA and C-TKA, respectively. Charges metrics revealed slightly higher charges for RA-TKA. Less postoperative complications were found in the RA-TKA group, such as blood loss, anaemia, acute kidney injury, venous thromboembolism, pulmonary embolism, pneumonia and surgical wound complication. Even following the propensity score matching, these findings remained consistent and statistically significant. RA-TKA use in the United States has grown substantially in the last few years and has been associated with significantly reduced immediate post-operative complications and length of hospital stay compared to C-TKA, offering safer surgical management for TKA patients. Further studies on the short- and long-term outcomes of RA-TKA would improve the understanding of the full potential of this technology. Level III.

Évolution du parcours patient en chirurgie : de l’ambulatoire à la réhabilitation améliorée en chirurgie

Until the early 2000s, the management of patients undergoing surgery followed highly standardized procedures. Medical and surgical considerations primarily focused on technical aspects. Various stakeholders worked independently without a global coordination, resulting in complex and time-consuming procedures.Two models of patients’ management have changed these practices: outpatient surgery and enhanced recovery after surgery (ERAS). Outpatient surgery, initially developed in the United States, has become the standard of care in France despite shy beginnings. It emphasizes patient-centered organization to optimize hospital stay duration. ERAS, initiated in Denmark in the 1990s, aims to accelerate postoperative recovery by optimizing medical practices before, during, and after surgery.These two approaches converge towards optimizing patient’ pathways and perioperative medicine. Anesthesiologists play a critical role in this coordination, thanks to their expertise in managing recovery of vital functions. Pathway optimization has a positive economic impact by reducing length of stay and hospital costs while improving clinical outcomes.In conclusion, management of surgical patients are evolving towards a patient-centered approach, based on the coordination of all the healthcare providers. Beyond ERAS and ambulatory surgery, this transition is essential to guarantee the best possible care for patients.

Modern challenges of surgical management of patients with moderate and borderline ischemic mitral regurgitation

Modern challenges of surgical management of patients with moderate and borderline ischemic mitral regurgitation

Contemporary Axillary Surgical Management in Patients with Pathologically Node Positive Disease After Neoadjuvant Chemotherapy: A Survey of Members of the American Society of Breast Surgeons.

Axillary lymph node dissection (ALND) is increasingly omitted for breast cancer patients with pathologic nodal disease after neoadjuvant chemotherapy (NAC). This study aimed to understand when and why surgeons consider omitting ALND after NAC. The American Society of Breast Surgeons membership was surveyed, and responses were tabulated. To identify patterns, multiple correspondence analyses followed by cluster analysis on coordinates provided by the former were performed. Chi-squared analyses determined whether cluster characteristics were significantly (P < 0.05) associated with omission of ALND. Of members, 328/2172 (15.1%) completed the survey. Most (60.7%) always offer sentinel lymph node surgery to cN1 patients who respond to NAC, and many (43.9%) sometimes omit ALND in the setting of residual nodal disease. Respondents less often consider omitting ALND with increasing volume of pathologic nodal disease after NAC and are less likely to omit ALND among patients with cN1 disease at presentation than cN0 (P < 0.05 across all volumes). Respondents cited radiation administration (74.1%) and belief that ALND would not improve locoregional (48.2%), distant recurrence or survival (47.6%) outcomes when axillary radiation is administered as reasons to omit ALND. The respondent group comprising male private practice surgeons, practicing ≥ 21 years, consider omitting ALND significantly more frequently. Surgeons sometimes consider ALND omission for patients with pathologic nodal disease after NAC but are more likely to do so in cN0 patients and patients with smaller volumes of nodal disease. These decisions are largely based on perceived lack of oncologic benefit despite absence of prospective data supporting this deescalation.

Outcomes following endorectal pull-through for Hirschsprung disease: a retrospective study

PurposeTo share our experience in the surgical management of patients with Hirschsprung disease (HD) using the trans-anal endorectal pull-through “Soave” technique.MethodsThe study included cases diagnosed as HD who were operated during the period 2008 through 2018. Cases of total colonic aganglionosis were excluded to be discussed in a separate report.ResultsThe study included 67 consecutive cases of HD. All included cases underwent trans-anal endorectal pull-through which was purely trans-anal in 31 (46%), while abdominal-assisted trans-anal endorectal pull-through was applied in the remaining (54%). Early postoperative complications included 2 cases of partial dehiscence at the colo-anal anastomosis; 1 of them deteriorated after re-exploration and unfortunately died. Twenty-six cases were available to assess functional outcomes after corrective surgery. Their age at follow-up ranged between 44 months and 17 years (mean = 78.8 months; median = 72 months). All cases achieved voluntary defecation. However, fecal soiling was a common finding after surgery for HD (69%). Constipation was another common postoperative finding (73%). Lastly, a history of attacks of postoperative enterocolitis was prevalent in 19 cases (73%), which ranged between 1 and 7 attacks usually in the first 2 years after the operation.ConclusionThe trans-anal endorectal pull-through provides an effective surgical treatment for Hirschsprung disease. The high prevalence of fecal soiling after surgery highlights the importance of long-term follow-up to provide the required support for these patients during adolescence and transition into adulthood.

Optimizing anticoagulation therapy for in-hospital patients on direct oral anticoagulants: a single-centre modified Delphi study.

The management of patients treated with direct oral anticoagulants (DOACs) during hospitalization is a common challenge in clinical practice. Although bridging is generally not recommended, too often DOACs are switched to parenteral therapy with low molecular weight heparins. Our objectives were to update a local guideline for perioperative DOAC management and to develop a guideline for the anticoagulation management in non-surgical patients regarding temporary DOAC discontinuation. We executed a two-step modified Delphi study in a 1000-bed university hospital in Belgium. The Delphi questionnaires were developed based on a literature review and a telephone survey of prescribers. Two expert panels were established: one dedicated to perioperative DOAC management and the other to DOAC management in non-surgical patients. Both panels completed two rounds, commencing with an individual and online round, followed by a face-to-face group session. After the two-round Delphi process, the updated perioperative guideline on DOAC management included reasons for delaying the resumption of DOACs following surgery, such as oral intake not possible, the probability of re-intervention within 3 days, and insufficient haemostasis (e.g. active clinically significant haematoma, haemorrhagic drains or wounds). Furthermore, a guideline for non-surgical hospitalized patients was developed, outlining possible reasons for interrupting DOAC therapy. Both guidelines offer clear anticoagulation therapy strategies corresponding to the identified scenarios. We have updated and developed guidelines for DOAC management in surgical and non-surgical patients during hospitalization, which aim to support prescribers and to enhance targeted prescription review by hospital pharmacists.