Surgical Management Research Articles

Spontaneous Transvaginal Small Bowel Evisceration After Laparoscopic Hysterectomy

Vaginal cuff dehiscence can be a rare complication of total hysterectomy, with an estimated prevalence of 0.032% to 1.25% and a high mortality rate of 6 to 10%. Dehiscence is also reported in cases following total laparoscopic hysterectomy, with a prevalence of 0.87%. This case report details the emergency management of a 59-year-old female who complained of abdominal and pelvic pain and the feeling of a foreign body in her vagina. The patient reported a history of laparoscopic total hysterectomy 6 months prior to presenting at the Emergency Department. A clinical examination revealed small bowel loops protruding through the vagina. The patient underwent exploratory laparotomy through a Pfannenstiel incision, and the terminal ileum was found prolapsing through the vaginal cuff. The bowel loops were identified as viable and the vagina was sutured. The patient had an unremarked post operative course. This case report showcases that in patients with transvaginal evisceration, immediate surgical management is crucial in order to avoid serious life threatening complications, and both surgeons and gynecologists should remain vigilant regarding this pathology.

Rigid intramedullary nailing of lower limb segments in children and adolescents with metabolic bone disease.

Children and adolescents with metabolic bone disease present to the orthopedic surgeon with pain, fractures (which may be impending), and deformity. Different modalities of orthopedic management are available. Scant literature exists on the use of rigid intramedullary nailing in this population. This study sought to evaluate the utilization of this treatment modality in the pediatric cohort, focusing on indications, techniques, and outcomes of the procedures. A retrospective review was performed over an 11-year period at a single tertiary pediatric institution in the UK. Medical records and radiographs were reviewed. Preoperative surgical and medical management, time to bony union, and complications were specifically ascertained. Twenty-seven patients (63 lower limb segments) had rigid intramedullary nailing over the specified period. The majority of patients had an underlying diagnosis of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright Syndrome). Surgical indications included acute fractures, prophylactic stabilization, previous nonunion and malunions, deformity correction, and limb lengthening. All fractures healed and deformity correction was successful. In one patient, delayed union occurred after deformity correction and was successfully treated with dynamization. Fractures healed faster than corrective osteotomies. Complications included implant prominence, cortical penetrance, and screw loosening. Nonunion occurred with limb lengthening in one patient. Rigid intramedullary nailing is a safe and effective method of treatment for lower limb fractures and deformities in children and adolescents. This technique is, therefore, recommended for patients with metabolic bone disease. However, care must be taken in preoperative surgical planning and a multidisciplinary approach should be utilized.

Mirror Aneurysms of the Pericallosal Artery Clipped During a Single Surgical Procedure: Case Report and Literature Review

Pericallosal artery aneurysms are rare, accounting for 2–9% of all intracranial aneurysms, and mirror aneurysms in this location are exceptionally uncommon, presenting unique surgical challenges due to their deep location and proximity to critical neurovascular structures. The aim of this case report is to describe the surgical management and successful outcome of a patient with mirror pericallosal artery aneurysms and to contribute insights into the clinical and surgical considerations for this rare condition. We report the case of a 71-year-old female with multiple cardiovascular and metabolic conditions, including hypertension and smoking—well-established risk factors for intracranial aneurysm formation and rupture. She presented with a Hunt and Hess grade II subarachnoid hemorrhage resulting in communicating internal hydrocephalus. Preoperative angiography revealed mirror aneurysms of the pericallosal artery. The patient underwent a left basal paramedian frontal craniotomy, during which a ruptured aneurysm on the right A2 segment and an unruptured aneurysm on the left A2 segment were identified. Both aneurysms were successfully clipped using curved Yasargil clips. Postoperative recovery was favorable, with no neurological deficits and stable imaging findings at a three-month follow-up. This case underscores the necessity for precise microsurgical intervention and a thorough understanding of pericallosal artery anatomy to manage such rare and challenging conditions effectively. The role of hyperlipidemia and statin use in intracranial aneurysm development remains debated and warrants further investigation. Our successful management of mirror pericallosal artery aneurysms contributes to the limited literature on this rare condition and highlights the importance of meticulous surgical techniques for favorable outcomes.

Cataract surgery combined with glaucoma surgery.

This review evaluates the surgical management of glaucoma in patients undergoing cataract surgery. Combining both procedures present challenges in balancing intraocular pressure (IOP) control, minimizing postoperative complications, and achieving optimal refractive outcomes. Recent studies highlight the effectiveness of combined glaucoma and cataract surgeries, with traditional filtering surgeries and MIGS showing significant IOP reduction. The abundance of long-term studies shows that MIGS can offer an effective and safer alternative when carefully tailored to meet the specific needs of each patient. Combining glaucoma and cataract surgery is a promising approach for patients with coexisting conditions. While traditional surgeries offer robust IOP reduction, MIGS procedures offer better safety profiles with fewer complications and more predictable refractive results. Surgeons must carefully consider the timing and choice of procedures, with further research required to develop standardized treatment algorithms.

Acute diverticulitis requiring hospitalization according to regional discrepancies in France between 2013 and 2022: a nationwide study

PurposeThe prevention of colon diverticulitis tends to be tailored according to the patients. In order to improve the public health policy to prevent diverticulitis, the influence of regional parameters at a department scale has to be assessed.ObjectiveThis analysis aimed to assess the occurrence of acute diverticulitis in France in general and according to environmental factors suspected to affect such diseases.MethodsAll patients above 18 years old admitted to a general hospital with a diverticulitis diagnosis between 2013 and 2022 in France were included. Data were extracted from the French national hospital discharge database. The primary outcome was the occurrence of diverticulitis according to French territories and known risk factors.ResultsIn this nationwide cohort study, the 10-years cumulative occurrence of diverticulitis in France was 3.45% (n = 2 0.248.099 patients). Diverticulitis was influenced by older age and male gender but was not significantly associated with ecological parameters (obesity, alcohol consumption, smoking or economic discrepancies) at a departmental scale. Of all patients diagnosed with diverticulitis, 5% had at least one surgical intervention. The surgical management of diverticulitis was associated with an increased number of surgeons in the department, even after adjustment for age and sex.ConclusionsExcept for smoking, the frequency of diverticulitis requiring an hospitalization was independent of regional parameters (nor alcohol intake, nor obesity nor the economic discrepancies).

Surgical Management of Symptomatic Recurrent/Progressive Craniopharyngioma: Is There a Gold-Standard Approach?

The standard treatment for craniopharyngiomas (CPs) involves either initial gross total resection or subtotal resection with adjuvant radiotherapy. However, there is no consensus regarding the management of recurrent cases. We reviewed a series of patients with CP to evaluate the characteristics of patients with recurrent/progressing CP. We retrospectively reviewed 31 patients with biopsy-proven recurrent/progressed CP who were initially operated on at our clinic from 2015 to 2023. Demographic and clinical data, including age, sex, tumor localization, lesion size and features, radiological findings, and endocrine, neurologic, and ophthalmological issues, were compared between those with and without recurrence. Fifteen out of 31 patients (48.4%) underwent transnasal/transsphenoidal endoscopic surgery; the remaining 16 underwent microscopic transcranial or neuroendoscopic surgery. After treatment, recurrence and events (any medical condition related to the patient's current condition other than recurrence) were observed in 48.4% and 32.3% of the cases, respectively. There were no statistically significant disparities between patients with and without recurrence in terms of age, tumor dimensions, tumor localization, gender distribution, surgical modality, or the presence of calcifications or hydrocephalus (p > 0.05). The highest and lowest overall survival was 25 years and 6 months, respectively. The management of recurrent CP is too complicated to fit into a standard treatment algorithm. Therefore, surgical treatment for these patients should be individualized and planned according to patient symptoms and radiological findings, which is presumably a more versatile, efficient, and safe approach for recurrent CPs.

Postpartum Pubic Diastasis with Significant Widening: A Rare Case Series.

Postpartum pubic symphysis diastasis is a relatively rare entity. It is usually associated with cephalopelvic disproportion, macrosomia, multiparity, precipitate labor, difficult labor, difficult forceps delivery, any other pelvic bone pathologies, and underlying connective tissue disorders. Management is typically conservative in most cases, but surgical intervention is sometimes required in cases where pubic symphysis is >4 cm and not responding to conservative management. Case with more than 4 cm of pubic diastasis is usually associated with disruption of the symphyseal ligament, sacroiliac joint capsule, and ligaments. Surgical management promotes early ambulation with good functional recovery and decreases the chances of symphyseal sclerosis, functional disability, and chronic pain. Four female patients with postpartum pubic diastasis of more than 7 cm with an age ranging from 20 to 30 years underwent open reduction and internal fixation using plates and screws.In all four cases, the patient got early ambulation and full functional recovery without any pain, discomfort, and disability at 3 months of follow up. Although conservative management has been advocated for postpartum pubic diastasis typically, surgical intervention should be sought for significant pubic diastasis (more than 4 cm) to promote early full functional recovery and avoid chronic pain, functional disability, and symphyseal sclerosis.

Pediatric open-globe injury: Current perspectives, surgical principles, and literature review

Abstract Open-globe injury (OGI), referring to the full-thickness violation of the eye wall, is a severe consequence of ocular trauma which can lead to permanent vision loss. Here, we review the current literature on pediatric OGI including a focused review of studies published in the past 10 years. Scoring systems for final visual prognosis, important aspects of clinical examination, and imaging at the point of care are discussed. We furthermore provide an overview of primary and secondary surgical management of the initial OGI and sequelae. Amblyopia management differentiates pediatric from adult visual rehabilitation following OGI, and we discuss the current state-of-the-art approaches for the prevention of vision loss.

Case Report: Surgical management of traumatic giant coronary artery pseudoaneurysm with pericardial patch repair and ostium isolation

Case Report: Surgical management of traumatic giant coronary artery pseudoaneurysm with pericardial patch repair and ostium isolation

A prospective cohort study: promising results with minimally invasive plate osteosynthesis of anterior bridge plating in adult humeral shaft fractures.

Adult humeral shaft fractures have traditionally been managed conservatively, but surgical intervention is considered for displaced fractures or when conservative treatment is unlikely to be successful. The optimal surgical approach remains controversial, with open reduction and internal fixation (ORIF) using plates and screws considered the gold standard. However, concerns about soft tissue damage have led to the development of less invasive techniques, such as anterior bridge plating using minimally invasive plate osteosynthesis (MIPO). This study aimed to evaluate the outcomes of MIPO for humeral shaft fractures. A prospective cohort study included 43 patients who underwent anterior bridge plating with MIPO for closed, displaced humeral shaft fractures. Forty patients had full follow-up (functional and radiological) and three patients were lost to follow-up. Fractures were classified using the AO classification system. Surgical technique involved incision, reduction, and fixation with locking compression plates. Follow-up assessments were conducted at various intervals, and functional outcomes were evaluated. Fracture union was achieved in 38 of 40 patients (95%). Two patients required secondary bone grafts for non-union. The mean time to union was between 12 and 16 weeks. Excellent shoulder function was observed in 82.5% of patients, and excellent elbow function in 77.5%. The range of motion on the operated side differed statistically significantly from the non-operated side but was not clinically significant. MIPO with anterior bridge plating is a viable option for the surgical management of humeral shaft fractures. It offers good fracture healing rates and satisfactory functional outcomes and avoids extensive soft tissue dissection associated with ORIF. Level of evidence: II.

Features of acute coronary syndrome after a COVID-19 in the aspect of pulmonary hypertension

BACKGROUND: After recovery from COVID-19 patients may develop new risk factors that lead to changes in cardiopulmonary interactions, i.e. an increase in the afterload on the right ventricle due to increased pressure in the pulmonary artery and change in pulmonary vascular resistance. It can be assumed that the presence of such a spectrum of problems can influence the severity of dyspnea and the development of pathogenetic events (pulmonary hypertension, right ventricular failure, subendocardial ischemia), which in turn can determine the outcome. AIM: To identify the characteristics of acute coronary syndrome after a COVID-19, taking into account angiographic data on coronary artery lesions and hemodynamic manifestations. MATERIALS AND METHODS: A comparative analysis of the clinical and hemodynamic consequences of the COVID-19 and the development of acute coronary syndrome in 157 patients was carried out. The group 1 included 69 patients who had had COVID-19 (vaccinated — 24.6%) during the 6 months preceding acute coronary syndrome; group 2 — 88 patients without a history of COVID-19 (vaccinated — 42%). The 12-lead electrocardiogram has been used in the diagnosis of subendocardial ischemia in acute coronary syndrome. The ST segment displacement in lead aVR was analyzed. RESULTS: After COVID-19, dispnoe occurred in 52% of the patients and in 14.8% without previous infection. Echocardiographic signs of right ventricular overload were present in 42% of the patients in group 1 and 10.2% in group 2. The mean pressure in the pulmonary artery was increased after COVID-19 in 58% of the patients in group 1 and in 10.2% of group 2 in the range from 20 to 24 mm Hg and in the range from 25 to 36 mm Hg in 29% of the patients in group 1 and 2.3% of the patients in group 2. The average value of left ventricular ejection fraction in the patients who had had COVID-19 was 55.9 ± 14%, which was less than in the patients in the control group (63.2 ± 5.5%; p 0.001). ST segment elevation in lead aVr indicated high incidence of subendocardial ischemia. 40.6% in group 1, and 11.4% in group 2 (χ2 = 17.9; p 0.001); in group 1 vaccinated — 17.6%, and not vaccinated — 48.1% (χ2 = 4.9; p = 0.027), in group 2 vaccinated — 8.1%, and not vaccinated — 13.7% (χ2 = 0.7; p = 0.41). All the patients had drug-eluting stents implanted in the infarct-related artery. After stenting, no recurrence of pain or further increase in chest pain was observed. CONCLUSIONS: After coronavirus infection COVID-19, 58% of patients have increased mean pressure in the pulmonary artery in the range from 20 to 24 mm Hg and in the range from 25 to 36 mm Hg in 29%. Atherothrombosis is the main mechanism of acute coronary syndrome after COVID-19 coronavirus infection. The main feature of acute coronary syndrome after a coronavirus infection COVID-19 is increased pressure in the pulmonary artery after a lung injury, which must be taken into account when planning surgical treatment tactics and management tactics in the postoperative period.

Current Endoscopic and Surgical Management of Pancreatic Cystic Lesions: A Comprehensive Review

Current Endoscopic and Surgical Management of Pancreatic Cystic Lesions: A Comprehensive Review

Comparison of surgical management and outcomes of acute right colic and sigmoid diverticulitis: a French national retrospective cohort study.

Acute right colic diverticulitis (ARD) is less frequent in Western countries than acute sigmoid diverticulitis (ASD). We aimed to compare the management of ARD and ASD operated on in emergency. All consecutive patients who had emergency surgery for ASD and ARD (2010-2021) were included in a retrospective, multicenter, cohort study. Patients were identified from databases in French centers that were members of the French Surgical Association. Emergency surgery was performed during the same hospitalization for peritonitis or after failure of conservative treatment. Early and late postoperative outcomes were studied. A total of 2297 patients were included with 2256 (98.2%) ASD and 41 (1.8%) ARD patients. Baseline characteristics were similar. Overall, patients were rated Hinchey 3-4 (63.9%, n = 1468, p = 0.287). ARD was more often treated with resection and anastomosis, protected or not (53.7%, n = 22), whereas ASD was mainly treated with resection and terminal ostomy (62.5% (n = 1409), p < 0.001). Median operative time was shorter for ARD (120 vs 146min, p = 0.04). The group of ARD patients showed a higher prevalence of Clavien III/IV complications compared to the group of ASD patients, although no statistically significant difference was observed (41.5%, n = 17 vs. 27.6%, n = 620, p = 0.054). However 90-day mortality only happened in ASD patients (9.8%, n = 223 vs 0, p = 0.03). ARD patients had more diverticulitis recurrence (46.3%, n = 19 vs 13.4%, n = 303, p < 0.001). Multivariate analysis identified female sex as a protective factor for recurrence [odds ratio (OR) 0.55, p < 0.001] and ARD as a risk factor (OR 8.85, p < 0.001). Operated on in emergency, ARDs have more resection anastomosis, with a similar rate of complications, less mortality, and more recurrence of diverticulitis than ASD.

The role of intervention timing and treatment modality in visual recovery following pituitary apoplexy: a systematic review and meta-analysis.

Pituitary apoplexy has historically been considered an emergent condition that necessitates surgical intervention when there is acute symptomatic onset. This potentially serious condition often occurs in the setting of an underlying adenoma, cystic lesion, or other sellar mass. When these mass lesions hemorrhage within the confined space of the sella turcica, the pituitary gland is subjected to hemorrhagic ischemia. Furthermore, critical neurovasculature in close proximity to the sella can sustain collateral damage. In the present study, we investigate whether early versus delayed surgical intervention (in terms of three timelines: before versus after 48h, 72h, and 7days, respectively) results in differences in visual outcomes for patients experiencing pituitary apoplexy with acute onset neurological and/or neuro-opthalmic symptoms. Furthermore, we compare the efficacy of surgical decompression versus expectant management of this condition. Accordingly, we queried the PubMed, Scopus, and Embase databases in adherence to PRISMA guidelines. Quantitative meta-analysis was performed according to the Mantel-Haenszel method and forest plots were generated using Review Manager v5.4. P-values < 0.05 were defined as the threshold for statistical significance. Twenty-nine studies remained eligible for review following initial search and screen, including 16 studies describing the role of intervention timing and 15 studies comparing intervention modality. Most patients presented with a visual deficit, and all patients underwent surgery - most commonly via the endoscopic endonasal (EEA) approach. Two hundred and twenty patients were included in the sub-analysis for the 7-day cutoff point. Furthermore, 81 patients underwent surgical decompression of the sella prior to 48h, and 32 patients underwent surgical decompression between 48-72h following presentation. Almost all patients exhibited improved vision post-decompression, including 19/19 patients (100%) in the post-72-h cohort. On meta-analysis using the Mantel-Haenszel method, there was a significant difference in vision outcomes in favor of patients who underwent surgical decompression before 7days as compared to after seven days (OR 5.88, 95% CI [1.77, 19.60], I2 = 0%, p < 0.01). In a separate sub-analysis, there was a total of 288 patients across 15 studies comparing surgical versus conservative management of pituitary apoplexy. These management options proved equivocal on meta-analysis (p > 0.05). In the present study, timing of surgical intervention for pituitary apoplexy was predictive of visual function recovery only at the 7-day timepoint, as has been reported by previous studies. Ultimately, this suggests that pituitary apoplexy involving severe visual deficits or altered mental status is best addressed within the first seven days post-presentation, and that both surgery and conservative management can offer similar outcomes. When apoplexy is suspected, IV corticosteroids should be administered independent of acuity or severity to prevent secondary adrenal crisis. Subsequently, for patients presenting without severe visual or other neurological deficits, expectant management is recommended. Management should be patient-specific and dependent upon the severity of symptoms present at onset.

Current Trends in the Surgical Management of Yolk Sac Tumors

Mediastinal yolk sac tumors (YST) constitute a highly malignant subtype of primary non-seminomatous germ cell tumors, which are often locally advanced and unresectable at diagnosis. Due to their rarity and aggressiveness, there is not yet a standard optimal treatment approach. A widely employed multimodal strategy involves neoadjuvant cisplatin-based combination chemotherapy followed by consolidation surgery. Tumor infiltration into the lungs and adjacent cardiovascular structures is common, such that surgical intervention typically requires extensive resections, performed either by sternotomy or thoracotomy. For this review, we extensively searched the PubMed and Embase medical databases, identifying articles describing surgical treatment of mediastinal yolk sac tumors. The current literature provides limited details regarding the utilized surgical procedures, leaving clinicians without comprehensive guidance about the demanding nature of these resections. Here, we present a narrative description of the range of current surgical procedures. By highlighting these techniques, we provide a comprehensive overview of the current surgical landscape, thereby helping clinicians understand the potential complexities and considerations involved in managing these rare and aggressive tumors.

Impact of an Acute Care Surgery Clinical Pathway on Patient Outcomes in Acute Appendicitis.

Objectives: Acute care surgery (ACS) encompasses surgical critical care, emergency general surgery, and the surgical management of trauma. Following ACS implementation at our institution, we developed a perioperative clinical pathway for acute appendicitis (AA) to improve efficiency and standardize post-operative care. The purpose of our study is to assess patient outcomes utilizing our ACS clinical pathway for patients with AA. Methods: This is a retrospective cohort study involving patients admitted to our tertiary care facility with AA who underwent appendectomy. Patients were classified by pre-implementation (January 1, 2016-July 31, 2018) and post-implementation (August 1, 2018-December 31, 2020) of our ACS clinical pathway. The primary outcome was hospital length of stay (LOS). Statistical analysis was performed using SAS with a p-value <0.05 determined as significant. Results: Of the 492 patients included, 225 were in the pre- and 267 were in the post-implementation cohorts. Hospital LOS was substantially decreased in the post-implementation cohort (31.2 vs. 50.4 h, p < 0.001). The post-implementation group had a substantial decrease in computed tomography (CT) to operating room (OR) start time (6.81 vs. 11.4 h, p < 0.001), CT to antibiotic agents' administration (2.20 vs. 3.37 h, p < 0.001), inpatient opioid utilization (125 morphine equivalents [ME] vs. 172 ME, p < 0.001), and discharge antibiotic agents' prescription rates (23.6% vs. 30.7%, p = 0.077). Recovery unit discharges (20 vs. 9%, p < 0.001) were increased in the post-implementation cohort. Conclusion: Our ACS clinical pathway for AA resulted in earlier surgical intervention, enhanced opioid and antimicrobial stewardship, and gains in surgical care efficiencies.

Ballooning and Bursting of Barrels and Pipes: A Rare Case of Suspected Vascular Ehlers–Danlos Disease

Vascular Ehler–Danlos disease (vEDS), a rare subtype of a rare disease, is a life-threatening disease, with an increased risk for spontaneous vascular or visceral rupture. These patients have fatal complications ranging from vascular aneurysms, dissection, and rupture of systemic vessels to frequent thromboembolic events, the common causes of death in these individuals with a shortened life span. In the present case, a 28-year-old male with history of shoulder dislocations and spontaneous colon perforation presented to the primary care clinic with right lower extremity swelling and pain. His history includes presentation to the emergency department with left lower leg swelling with compartment syndrome one year prior. A CT angiogram of lower extremities and abdomen revealed acute arterial extravasation of the left posterior tibial artery, indicating a ruptured aneurysm along with aneurysms of the splenic artery and left common iliac artery. He was treated with a saphenous vein graft, but was associated with post-operative complications that necessitated below-knee amputation. CT angiogram of his right leg revealed occlusion of the anterior tibial and peroneal arteries with aneurysms, and, ultimately, he was referred to a tertiary care center for aneurysm embolization. This case report emphasizes the frequent vascular complications encountered in vascular EDS patients, and thus advocates for close and regular monitoring for early referral and surgical management of their vascular anomalies. Finally, genetic counseling and screening of asymptomatic family members should be routinely implemented in these patients.

Management of radicular cyst – A case report

Radicular cysts are common jaw lesions, typically asymptomatic, and often found near the tooth apices. Radiographically, they appear as oval or pear-shaped unilocular radiolucencies in the periapical region. This case report highlights the successful surgical management of a large infected radicular cyst through enucleation and apicoectomy. These procedures were crucial in removing the cyst and promoting healing, with no post-surgical complications. Surgical intervention is vital in managing extensive radicular cysts to prevent further infection and damage to adjacent structures.

Utilization of Computer-Assisted Navigation Technology Within Craniomaxillofacial Fracture Surgery: A Systematic Review.

Use of intraoperative computer-assisted navigation (iCAN) has been well-established in otolaryngology and neurosurgery; however, its use in surgical management of facial fractures is yet to be reported on a large scale. This study aimed to review the existing literature to determine the outcomes, limitations, risks, and benefits of iCAN use in facial fracture management. A systematic review of iCAN use in craniomaxillofacial fracture surgery was performed by 2 authors in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted on 3 databases, PubMed, Cochrane Library, and Embase, using the search terms "navigation," "intraoperative," and "brain lab" in combination with "facial fractures" or "facial reconstruction." Study type, demographics, fracture characteristics, surgery characteristics, iCAN devices, intraoperative fracture fixation accuracy, postoperative outcomes, complications, navigation limitations, and risks and benefits were analyzed. There were 909 studies identified in the initial search, of which 42 were chosen for final use. iCAN use was most commonly reported in unilateral (57.1%) and complex (50%) facial fracture cases. Surgical accuracy ranged from 0.7 to 4 mm and postoperative discrepancy ranged from 0.05 to 8 mm. Benefits included improved intraoperative surgical accuracy (95.2%), improved postoperative surgical discrepancy (52.4%), and decreased total surgical time (35.7%). Limitations reported with iCAN device use included operative technical difficulties (23.8%) and persistent systematic errors during device registration (21.4%). None of the studies discussed cost analysis or risks compared to conventional fixation methods. Advancements in and increasing familiarity with iCAN technology have preliminarily shown favorable surgical outcomes in facial fracture fixation, which include improved operative accuracy and discrepancy and decreased surgical time.

Quality Improvement Initiatives for Pleural Infection Managed with Intrapleural Therapy.

Rationale Pleural infection is associated with significant mortality and its management is complex. Little attention has been given to care process metrics such as management delays, pleural drainage practices, and adequacy of intrapleural therapy administration despite their potential impact on outcomes. Audits revealed gaps in those care processes in our institution. Objectives To assess the impact of quality improvement initiatives on pleural effusion management in adults. Methods We performed a retrospective comparison of patients treated with intrapleural therapy for pleural infection at the McGill University Health Centre before (April 2013-April 2016, N=109) and after interventions (June 2020-June 2021, N=44). Interventions included a pleural drainage policy and order set, an intrapleural therapy protocol and pre-printed order, implementation of intrapleural therapy administration by nurses, local pleural infection guideline development, and an online learning module for physicians. Major outcomes (length of stay, mortality, surgical treatment) and care process metrics (management delays, pleural drainage practices, intrapleural therapy administration) were compared between the two periods. Results After implementation of the interventions, in-hospital mortality and length of stay were unchanged, but surgical management went from 14% to 0% (p=0,01). Delays in drain insertion and intrapleural therapy initiation were not significantly different. Insertion of drains smaller than 12Fr decreased from 51% to 7% (p<0,001). Drain blockage decreased from 20% to 2% (p=0,004). Additional drain insertions went from 62% to 48% (p=0,12). After interventions, 70% of intrapleural therapy doses were given by nurses, the intrapleural therapy protocol was more often adequately followed, less doses were missed, and less extended therapy was prescribed. Complications related to drain insertion and intrapleural therapy were similar between the two periods. Conclusions Following the implementation of multifaceted quality improvement interventions for pleural infection including involvement of nurses in pleural drain flushing and intrapleural therapy, improvements were observed in intrapleural therapy administration, chest drainage practices, and need for surgery. However, length of stay, mortality, and management delays were unchanged.