Surgical Pathway Research Articles

OGC O02 - Measurement of functional, psychosocial, and quality of life impacts of Robotic versus Hybrid Oesophago-gastrectomy

Abstract Background Since the introduction of Robotic-Assisted Minimally-Invasive Oesophago-gastrectomy (RAMIO), comparisons to other surgical approaches have focussed primarily on peri-operative and oncological outcomes. Few studies have focused on quality-of-life measures once the patient has been discharged home. We sought to compare physical, psychosocial, sleep, pain and employment related measures at six weeks following discharge in patients undergoing RAMIO versus Hybrid Oesophago-gastrectomy. Method We performed a prospective cohort study comparing RAMIO and Hybrid Oesophago-gastrectomy. Twenty-five consecutive patients on a curative surgical pathway were recruited to each group. Participants were contacted via telephone pre-operatively and six weeks post-operatively. Parameters studied were: physical activity, social activity, sleep, pain control, and employment. Psychological wellbeing was measured using the Hospital Anxiety and Depression Scale, and quality of life with the European Organisation for Research and Treatment of Cancer questionnaires C30 (all cancer patients) and OG25 (patients undergoing oesophago-gastric cancer treatment). Results were analysed using Chi Square and Mann-Whitney-U statistical tests. Results There were no differences in age, ASA, or anaerobic threshold between study groups. At six weeks the RAMIO group was more likely than Hybrid to have returned to pre-operative physical and social activity (physical 7/25 vs. 1/25, p=0.04, social 13/25 vs. 5/25, p=0.03). The RAMIO group stopped regular analgesia earlier, and required fewer opiates. Patients were more likely to return to work in the RAMIO group (7/15 vs. 1/12,p=0.04). The RAMIO group had fewer cases of depression (2 vs. 9, p=0.03), lower QLQ C30 and OG25 scores, and reported higher overall health and quality of life scores (p=0.001). Conclusion We have demonstrated an improvement in physical and social activity, a faster return to work, a reduction in analgesia requirements, lower rates of depression and improved health and quality of life, six weeks post-operatively when comparing RAMIO to hybrid oesophago-gastrectomy. This study has highlighted additional considerations for the selection of surgical modality in oesophago-gastrectomy beyond peri-operative outcomes. Further investigation across a larger sample size and longer time frame to quantify the full spectrum of potential benefits of robotic oesophago-gastric surgery is warranted.

Surgical Training Pathways in the United Kingdom and the United States: Lessons for Resource-Limited Settings From High-Income Countries.

Background Surgical training is a critical component of healthcare, especially in high-income countries such as the United Kingdom (UK) and the United States (US), which have established distinct, well-organised training frameworks. Comparing these systems provides valuable insights that may enhance global surgical education, particularly in low- and middle-income countries, where training and retaining proficient surgeons are considerable challenges. Methodology This comparative study examines the surgical training systems in the UK and the US, focusing on key aspects, including training structure, competency-based assessments, and work-hour regulations. Data were sourced from regulatory organisations such as the General Medical Council, the Royal College of Surgeons, the Accreditation Council for Graduate Medical Education, and the American Board of Surgery. The analysis explores how elements of these models might be adapted to support sustainable surgical education frameworks in resource-limited environments. Ethical approval was not required due to the use of publicly accessible data and no patient involvement. Results The UK and US surgical training systems differ substantially in their structure, training duration, and specialisation timing. The UK employs a tiered approach, offering generalist experience before specialisation, while the US favours early specialisation directly after medical school. Both systems implement competency-based evaluations, though the US system places a greater emphasis on case volume and procedural exposure. Work-hour regulations also vary, with the UK capping weekly hours at 48 under the European Working Time Directive, compared to an 80-hour maximum in the US, which results in differing levels of trainee satisfaction and burnout rates. Conclusions The competency-based assessments in both the UK and the US offer adaptable frameworks for resource-limited settings. The phased training approach in the UK is well-suited for environments requiring versatile surgeons capable of handling a wide range of cases. By implementing these adaptable elements, along with cost-effective training innovations such as simulation tools, e-learning platforms, and international partnerships, resource-constrained regions can foster a sustainable, skilled surgical workforce. These insights offer pathways to improve healthcare outcomes and equity globally by enhancing surgical capacity in regions with limited resources.

Variation in surgery postponement rates in the NHS in England.

Postponement of surgery at preoperative assessment in the days or weeks before the patient is admitted for surgery, as distinct from cancellation on the planned day of surgery, can be devastating for patients and an inefficient use of finite resources. However, postponements are often poorly recorded. The primary aim of this pilot study was to investigate elective surgical postponement rates during or after preoperative assessment across England, and the reasons for postponement for patients on an elective surgical pathway. A retrospective analysis of clinical audit data from 16 National Health Service (NHS) trusts in England was undertaken. Data were collected during a two-week period in March 2024 on all postponements within a service. The primary outcome of interest was the postponement rate. Some 8000 case notes were reviewed. There were 583 (7.3%) postponements. Postponement rates across trusts varied from 31.9% to 1.0%. Significantly shorter time from referral to preoperative assessment was observed for day-case patients, urgent patients, patients without early screening and patients without a 'to come in' date in place. Of the 342 routine patients, 293 (85.7%) had postponements for medical rather than pathways or process reasons. Half of all routine patients waited over 94 days and a quarter of patients waited 198 days from being added to a patient tracking list to preoperative assessment. Minimizing postponements and improving preoperative assessment efficiency should be part of wider initiatives to streamline perioperative pathways.

A nurse-led multidisciplinary service for Nipple-Areola complex tattooing after breast cancer: reporting on a complex intervention with TIDieR analysis

BackgroundThe Nipple-Areola Complex (NAC) tattooing can restore physical and mental integrity after breast cancer, but it is not always easily accessible for women. This paper aims to report on the development of a multidisciplinary nurse-led service for NAC tattooing for women who underwent breast cancer surgery with NAC removal to allow its thorough review and replication.MethodsThe Medical Research Council’s framework for developing complex healthcare interventions was followed. According to the results of a literature review, and the context analysis, an initial intervention was planned. The Template for Intervention Description and Replication checklist was chosen to ensure the quality and completeness of the intervention description.ResultsThe Breast Unit and the Research departments were engaged; three nurse-tattooists were selected; the informative material was created and shared with patients, families and local associations, involving them actively. Finally, the setting and the materials were defined. A monthly schedule of activities was set: patients with the indication for NAC tattooing were contacted by the nurse case manager. Each treatment involves 3–4 sessions, 30–40 days apart, in an ambulatory setting. It consists of NAC shaping and tattooing with a dermographer and sterile needles.ConclusionImplementing freely and equally multidisciplinary nurse-led clinics might provide this treatment ensuring the patient’s quality of life and nurse competence. The NAC tattooing is a complex intervention that represents the final part of the breast cancer surgical care pathway.

Chinese Expert Consensus on the Whole-Course Management of Hepatocellular Carcinoma (2023 Edition)

Background: Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. Most HCC patients have the complication of chronic liver disease and need overall consideration and whole-course management, including diagnosis, treatment and follow-up. To develop a reasonable, long-term, and complete management plan, multiple factors need to be considered, including the patient's general condition, basic liver diseases, tumor stage, tumor biological characteristics, treatment requirements and economic cost. Summary: To better guide the whole-course management of HCC patients, the Chinese Association of Liver Cancer and the Chinese Medical Doctor Association has gathered multidisciplinary experts and scholars in relevant fields to formulate the “Chinese Expert Consensus on The Whole-Course Management of Hepatocellular Carcinoma (2023).” Key Messages: This expert consensus, based on the current clinical evidence and experience, proposes surgical and nonsurgical HCC management pathways and involves 18 recommendations, including perioperative treatment, systematic treatment combined with local treatment, conversion treatment, special population management, symptomatic support treatment, and follow-up management.

DEXAMETHASONE WEAN POST CRANIOTOMY FOR MENINGIOMA- A CASE STUDY

Abstract AIMS Case review/analysis of dexamethasone wean post craniotomy for meningioma. To identify any quality of life issues experienced during the wean, how and why steroid wean was adjusted and any impact steroid use had on serum cortisol level causing adrenal insufficiency. METHOD Review of documentation to identify steroid related side effects, how and when this impacted on the patient’s quality of life. Collection of data; steroid doses, length of time on steroids (pre-surgery and post-surgery), serum cortisol result. Clinical choices regarding dose/timings of dexamethasone reviewed and compared to literature. RESULTS Delays/changes with theatre dates, capacity, neurological symptoms on presentation led this individual to a four month pre-surgical dose of dexamethasone which led to weight gain, pre-diabetes and insomnia. Quality of life pre and post-surgically affected by steroid use namely mental health, employment and social belonging. This case study confirms adrenal insufficiency was precipitated by the prolonged pre-surgical use of dexamethasone. Clinical nurse specialists are integral in adjusting steroid dose to manage neurological recovery and safely wean steroids to zero as well as identifying adrenal insufficiency. CONCLUSION Data collection from a large sample size is required to confirm how many patients coming through the neurooncology surgical pathway have confirmed adrenal insufficiency post neurosurgery secondary to Dexamethasone. Once data is collected guidance on how to manage a safe post surgical steroid wean and minimise impact of quality of life can be formalised.

Recent advances in peritoneal dialysis catheter placement: the association between method of insertion, operator, and prior abdominal surgery and outcomes.

Peritoneal dialysis (PD) is associated with comparable outcomes to hemodialysis and is much less expensive to provide in most parts of the world. A well functioning PD catheter is required, but complications are frequent, and while there are guidelines for the placement and care of a PD access, they are based on low-quality evidence. Data reporting the outcomes of percutaneous, as compared to surgical pathways for placement of catheters and the role of operator type in determining outcomes are examined. The impact of prior abdominal procedures on patient selection and the prognostic importance of the presence of adhesions at the time of catheter insertion are reviewed. There are conflicting data about the relative merits of percutaneous as compared to surgical placement of catheters that may relate to differences in patient selection, operator experience, or operator volume. Prior abdominal procedures are not associated with worse PD catheter outcomes and likely should not influence patient selection, except in exceptional circumstances. Finally, the presence of adhesions is associated with a higher risk of complications. However, even in the presence of adhesions, the termination of PD therapy and need for re-intervention occurs in <20% of patients.

The Use of Diffusion Tensor Imaging in the Differentiation and Surgical Planning of Suprasellar Hypothalamic-Opticochiasmatic Glioma and Craniopharyngioma in Children

Background and ObjectivesSuprasellar hypothalamic-opticochiasmatic glioma (HOCG) and craniopharyngioma (CP) have similar appearances on conventional MRI and are difficult to distinguish. Moreover, these tumors are situated near vital structures like the optic chiasm and hypothalamus, rendering conventional surgery susceptible to significant complications. We mainly discussed the surgical application value and diagnostic value of diffusion tensor imaging (DTI) in HOCG and CP. MethodsThe retrospective analysis of 13 cases of HOCG and 16 cases of CP was conducted. All patients underwent conventional MRI and DTI prior to surgery, and were pathologically diagnosed postoperatively. ResultsBoth CP and HOCG appeared as heterogeneous mixed signal masses on conventional MRI. For HOCGs, fiber tractography revealed two different growth patterns of the tumor: infiltrative type and inflated type. The surgical approach and risk levels differ between these growth patterns. Additionally, fiber tractography demonstrates significant differences compared to CPs. The surgical approach and extent of resection for all cases of these two tumors were guided by DTI. ConclusionDTI enhances the accuracy of HOCG and CP differentiation. Furthermore, patterns of tractography described in this study assist neurosurgeons in delineating the surgical pathway and tumor resection range without damaging important fiber bundles, thereby avoiding permanent neurological deficits and improving survival quality for patients.

Estimated Carbon Savings from Changing Surgical Trends in Primary Elective Total Hip Arthroplasty in England: A Retrospective Observational Study.

The National Health Service (NHS) in England has set a target to be net zero for carbon emissions by 2045. The aim of this study was to investigate how changes in key aspects of clinical practice over the last 8 years have contributed towards reducing the per-patient carbon footprint of elective total hip arthroplasty (THA). This was a retrospective analysis of administrative data. Data were extracted from the Hospital Episode Statistics database for all adult (≥ 17 years), primary, elective THA procedures conducted in England from 1 April, 2014 to 31 March, 2022. The estimated carbon footprint for key elements of the surgical pathway were calculated based on data from Greener NHS and the Sustainable Healthcare Coalition. Data were available for 537,441 THA procedures conducted during the study period. The per-patient carbon footprint associated with the primary THA (index) procedure fell by around 25% from 2014/15 to 2021/22. Length of stay was by far the largest contributor to this decline, falling from 169.1 kgCO2e to 117.6 kgCO2e per patient from 2014/15 to 2021/22. Absolute declines in the carbon footprint associated with emergency readmissions, revisions and outpatient attendances were more modest. If all patients in all years had the 2021/22 average carbon footprint, then carbon equivalent to powering 19,976 UK homes for 1year would have been saved. Improving per-patient efficiency of surgery is likely to contribute towards meeting the NHS's net-zero target whilst also helping to improve patient outcomes, reduce costs and cut waiting lists.

SP4.14 - Mild acute biliary pancreatitis: still a surgical disease. A post-hoc analysis of the MANCTRA-1 international study

Abstract Aims The current standard of care for mild acute biliary pancreatitis (MABP) involves early laparoscopic cholecystectomy (ELC) reducing the risk of early recurrence. The MANCTRA-1 project disclosed a discrepancy in translating this evidence into clinical practice, estimating a 35 to 70% probability of narrowing this gap within 2025. This study assesses the safety of suboptimal ELC implementation in MABP, looking for risk factors for recurrent acute biliary pancreatitis (ABP) in patients awaiting interval cholecystectomy after an uneventful episode of MABP. Methods We conducted a post hoc analysis of the MANCTRA-1 registry. Clinicaltrials.gov ID NCT04747990. We included MABP patients who did not undergo ELC during the index hospitalization, excluding those who experienced disease-related complications. The primary outcome was the 30-day hospital readmission rate due to ABP recurrence. We performed univariable and multivariable logistic regression to identify risk factors for 30-day ABP recurrence. Results Between January 2019 and December 2020, a total of 2,253 MABP patients from 150 centres were included. The 30-day readmission rate due to ABP recurrence was 6%. The multivariable logistic regression showed that admission to a medical ward (internal medicine or gastroenterology) odds ratio (OR) 1.62 (95%[CI] 1.1;2.37), p=0.01 was an independent risk factor for 30-day ABP recurrence. Conclusion Our real-world analysis provides valuable insights to manage MABP, particularly in centres where ELC strategies cannot be fully implemented due to organizational and clinical constraints. Despite the admitting ward, it underscores the importance of timely access to surgical care in reducing the risk of early recurrence, disclosing the need to implement surgical consultation pathways in ABP care bundles.

WP7.7 - TRUST: Transvaginal Ultrasound for Surgery Evaluation and Treatment. The use of invasive tests in the right iliac fossa surgical pathway

Abstract Transvaginal ultrasound (TVUS) is an invasive intimate test with strict guidance on its utilisation. This tool is commonly used in General surgery (GS) as a decision aid for operative or non-operative management. Aims Ensure patient selection for TVUS was equivalent in Gynae and GS pathways. Determine the influence of TVUS on the decision to operate. Ensure patients were consented adequately comparatively between general surgery and gynaecology. Methods This was a mixed methods study with retrospectively collected data from 1400 woman undergoing TVUS for RIF pain presenting to Gynae or GS in a DGH. Interviews were conducted with 50 GS and 50 Gynae patients. Ultrasound, blood, and histology results were reviewed. A positive GS TVUS was defined as free fluid or appendicitis, Gynae pathology was excluded. Interviews consisted of 8 likert scale questions on the process. Ethical approval was given by the hospital ethics committee. Results A total of 1445 patients were included (825 admitted under GS and 620 under gynae). Median age for the GS cohort was 28 and gynae 31 with no statistical difference in baseline characteristics. TVUS was positive in 14.8% of GS patients. Positive patients were more likely to proceed to laparoscopy (OR 2.43, 95% CI 1.46-4.03, p &amp;lt;.05). 50% of these had histologically confirmed appendicitis. Similarly, patients with raised WCC or CRP were more likely to proceed to laparoscopy (OR 1.87, 95% CI 1.26-2.76, p &amp;lt;.05); 56% had histologically confirmed appendicitis. There were no significant differences interviews. Conclusion TVUS remains an invasive tool, with similar diagnostic profile to blood tests. Careful consideration should be given to its use.

437. MEASUREMENT OF FUNCTIONAL, PSYCHOSOCIAL, AND QUALITY OF LIFE IMPACTS OF ROBOTIC VERSUS HYBRID OESOPHAGO-GASTRECTOMY

Abstract Background Since the introduction of Robotic-Assisted Minimally-Invasive Oesophago-gastrectomy (RAMIO), comparisons to other surgical approaches have focussed primarily on peri-operative and oncological outcomes. Few studies have focused on quality-of-life measures once the patient has been discharged home. We sought to compare physical, psychosocial, sleep, pain and employment related measures at six weeks following discharge in patients undergoing RAMIO versus Hybrid Oesophago-gastrectomy. Methods We performed a prospective cohort study comparing RAMIO and Hybrid Oesophago-gastrectomy. Twenty-five consecutive patients on a curative surgical pathway were recruited to each group. Participants were contacted via telephone pre-operatively and six weeks post-operatively. Parameters studied were: physical activity, social activity, sleep, pain control, and employment. Psychological wellbeing was measured using the Hospital Anxiety and Depression Scale, and quality of life with the European Organisation for Research and Treatment of Cancer questionnaires C30 (all cancer patients) and OG25 (patients undergoing oesophago-gastric cancer treatment). Results were analysed using Chi Square and Mann-Whitney-U statistical tests. Results There were no differences in age, ASA, or anaerobic threshold between study groups. At six weeks the RAMIO group was more likely than Hybrid to have returned to pre-operative physical and social activity (physical 7/25 vs. 1/25, p=0.04, social 13/25 vs. 5/25, p=0.03). The RAMIO group stopped regular analgesia earlier, and required fewer opiates. Patients were more likely to return to work in the RAMIO group (7/15 vs. 1/12,p=0.04). The RAMIO group had fewer cases of depression (2 vs. 9, p=0.03), lower QLQ C30 and OG25 scores, and reported higher overall health and quality of life scores (p=0.001). Conclusion We have demonstrated an improvement in physical and social activity, a faster return to work, a reduction in analgesia requirements, lower rates of depression and improved health and quality of life, six weeks post-operatively when comparing RAMIO to Hybrid Oesophago-Gastrectomy. This study has highlighted additional considerations for the selection of surgical modality in oesophago-gastrectomy beyond peri-operative outcomes. Further investigation across a larger sample size and longer time frame to quantify the full spectrum of potential benefits of robotic oesophago-gastric surgery is warranted.

The Transtemporal Isthmus Approach for Insular Glioma Surgery.

Maximal and safe removal of insular gliomas by a transinsular cortex approach is challenging. In this article, a new transtemporal isthmus approach to resect insular gliomas is presented. We retrospectively examined 53 patients with insular glioma who underwent resection through the temporal isthmus approach using magnetic resonance imaging and functional neuronavigation guidance and intraoperative electrophysiological monitoring. Extent of resection was determined using intraoperative magnetic resonance imaging. Fifty-three patients were included for analysis, 30 men and 23 women. The median (range) age was 45 (26-70) years. Tumor laterality was left in 22 patients and right in 31. All tumors involved at least zone III or IV (Berger-Sanai classification system), including zones I-IV were involved in 29 (54.7%) and zones III and IV in 17 (32.0%). Among the 37 low-grade gliomas, preoperative median (IQR) volume was 45.7 (31.8, 60.3) cm 3 , and gross total resection was achieved in 24 (64.9%). Among the 16 high-grade gliomas, preoperative median (IQR) volume was 45.3 (40.1, 54.0) cm 3 , and gross total resection was achieved in 14 (87.5%). The median (IQR) extent of resection of the whole group was 100% (89%-100%). The median (IQR) postoperative Karnofsky performance score 3 months after surgery was 90 (80-90). Mean temporal isthmus width was significantly higher in the affected side (involving tumor) than the contralateral one (21.6 vs 11.3 mm; 95% CI: 9.3 to 11.3, P < .01). Muscle strength was grade 4 or higher, and speech was nearly normal in all patients 3 months after surgery. Insular glioma surgery using the transtemporal isthmus approach can achieve safe and maximum resection. A widened temporal isthmus provides a surgical pathway for transisthmic resection of insular tumor.

2317 Geriatrician-led perioperative services: an example of value-based care

Abstract Background Perioperative services must adapt to the needs of an increasingly older surgical population. Perioperative medicine for Older People undergoing Surgery (POPS) services integrate geriatric medicine teams into surgical pathways to provide quality and cost-effective medical care. This project aims to examine value-based outcomes (clinical and financial impact) of embedding a POPS service at a district general hospital. Methods Following a period of implementation on an acute Trauma and Orthopaedic (T&amp;O) ward, a two-week pilot was undertaken. All emergency fragility fracture admissions aged over 65 years with Clinical Frailty Scores (CFS) of ≥5 were included. Patients with hip fractures were excluded. The POPS service provided medical consultation, medicine rationalisation, proactive treatment escalation planning and shared decision making, as well as leading multidisciplinary team meetings. Outcome metrics: geriatric medicine consults, medical emergency team (MET)/cardiac arrest calls, staff/patient satisfaction and clinical coding. The REDUCE trial cost calculator was used to estimate savings. Results 35 patients were included, mean age 84 years, mean CFS score 7. Ward MET calls and cardiac arrest calls were reduced from a weekly average of 2.5 to 0, and weekly referrals to geriatric medicine reduced from 3 to 0. Experience-based design surveys identified thematic improvements relating to leadership, communication, dignity and respect. Improved quality of documentation resulted in the comorbidity score tariff increasing from £3325 to £6096 per patient. For services introduced by POPS including Comprehensive Geriatric Assessment and delirium assessments, the REDUCE trial cost calculator estimated an additional saving of £2926 per patient totalling hospital savings of £2 million per year (for an estimated 700 patients per year). Conclusion Implementation of a POPS service at a district general hospital can lead to cost savings, improved patient and staff experience, and improved clinical outcomes within a sustainable workforce model.

Bibliometric Patent Review of Minimally Invasive Spine Surgery.

This study analyzes patents associated with minimally invasive spine surgery (MISS) found on the Lens open online platform. The goal of this research was to provide an overview of the most referenced patents in the field of MISS and to uncover patterns in the evolution and categorization of these patents. MISS has rapidly progressed, with a core focus on minimizing surgical damage, preserving the natural anatomy, and enabling swift recovery, all while achieving outcomes that rival traditional open surgery. While prior studies have primarily concentrated on MISS outcomes, the analysis of MISS patents has been limited. To conduct this study, we used the Lens platform to search for patents that included the terms "minimally invasive" and "spine" in their titles, abstracts, or claims. We then categorized these patents and identified the top 100 with the most forward citations. We further classified these patents into 4 categories: Spinal Stabilization Systems, Joint Implants or Procedures, Screw Delivery System or Method, and Access and Surgical Pathway Formation. Five hundred two MISS patents were identified initially, and 276 were retained following a screening process. Among the top 100 patents, the majority had active legal status. The largest category within the top 100 patents was Access and Surgical Pathway Formation, closely followed by Spinal Stabilization Systems and Joint Implants or Procedures. The smallest category was Screw Delivery System or Method. Notably, the majority of the top 100 patents had priority years falling between 2000 and 2009, indicating a moderate positive correlation between patent rank and priority year. Thus far, patents related to Access and Surgical Pathway Formation have laid the foundation for subsequent innovations in Spinal Stabilization Systems and Screw Technology. This study serves as a valuable resource for guiding future innovations in this rapidly evolving field.

Anatomical Features and Morphometric Characteristics of the Sphenoidal Sinus in MRI Studies.

Differential access to pathological sellar processes and adjacent regions is determined by the anatomic structures identified through diagnostic imaging. Both direct endonasal access (microscopic or endoscopic) and sublabial access utilize the sphenoid sinus (SS) as the primary surgical pathway. Critical factors include the pneumatization of the sinus, its intermediate septa, and the presence of a double wall, consisting of a connective tissue membrane along the dorsal wall of the SS. The present study aims to demonstrate the significance of the size and type of the SS based on MRI measurements. The type of SS, its pneumatization, and the proximity of adjacent brain structures are crucial for different surgical approaches to the SS and pituitary fossa. In neurosurgical practice, six main types of sinuses are recognized: sphenoid body type, lateral type, clival type, lesser wing type, anterior type, and combined type. Failure to consider these variations can lead to damage to the cavernous sinus, Meckel's cave, nerve structures in the middle cranial fossa, planum sphenoidale, suprasellar region, and vital brainstem structures located on the clivus. Randomly included MRI measurements were conducted on 112 patients from Pulmed University Hospital, Plovdiv, Bulgaria, categorized into two cohorts based on gender, with mean ages of 51 years for men and 47.8 years for women. The measurements, recorded in centimeters, were obtained using two imaging software programs, RadiAnt DICOM Viewer (Medixant, Poznan, Poland) and Weasis DICOM Viewer (Nicolas Roduit, https://github.com/nroduit/Weasis). No statistically significant differences were observed between the measurements produced by the two programs. Measurements of the SS were taken in two equal groups, using three different projections: axial, sagittal, and coronal. The results for height, width, and depth showed average sizes of 2.73-3.04 cm in axial projections, 1.70-2.64 cm in sagittal projections, and 2.86-3.03 cm in coronal projections. The minor differences between axial and coronal measurements of the same parameters (height and width) are statistically acceptable and attributed to the varying angles of the MRI scans. These measurements are crucial for planning surgical access to the sellar and parasellar regions, determining the necessary bony resection of the posterior wall of the SS, and preventing complications from excessive bony trepanation.

Surgical Strategies in Total Colonic Aganglionosis: Primary Pullthrough-Pathway of Care.

Background: Total colonic aganglionosis, as a rare variant of Hirschsprung Disease, still poses challenges to surgeons in terms of diagnosis and management. The optimal preparation for pullthrough is crucial for reconstructive surgery. This study aims to explore our surgical pathway for children with total colonic aganglionosis (TCA) and to describe the prehabilitation necessary to prepare for successful reconstructive pullthrough surgery. Methods: A prospective review of children with TCA receiving an abdominal surgical intervention between 1/22 and 4/24. The cohort included children receiving mapping +/- primary ileoanal pullthrough. An analysis of preoperative, perioperative, and postoperative data, and a short-term follow-up were performed. Results: A total of 18 children with TCA and no prior pullthrough received an abdominal intervention during the 29-month study period, and 5/18 (27.8%) were female. The children had a median of 4 (range 2-7) prior external surgeries; all had a stoma; 6 (33%) children received parental nutrition; 12 children underwent a mapping of the ganglia distribution and bowel length at a median age of 11 months (range 3-54), and in 10 of them, we relocated the stoma. There was a mean involvement of 15 (5-93) cm small bowel aganglionosis, with the remaining mean ganglionic small bowel having a length of 178 cm (110-254). A total of 11 children underwent straight primary ileoanal pullthrough of the stoma site at a median age of 16.7 months (10-133). Conclusions: The timely diagnosis of TCA still challenges the care team, and most children have a rough journey involving several surgeries until their diagnosis is established. The ensure bowel function with an adequate working stoma is the key to enabling enteral nutrition and growth, which are the baseline requirements to undertake a successful pullthrough procedure and restore continuity. Careful perioperative bowel management and parents' active involvement supports children with Hirschsprung Disease achieving the best possible quality of life.

Appendicectomy pathway: Insights from electronic medical records of a local health district in Australia

BackgroundThis study aims to identify the common pathways of appendicectomy, the most common emergency surgery in Australia’s public hospitals and any variations within a regional public health district in New South Wales, Australia. MethodsWe analyzed the electronic medical records of 3,943 patients who underwent appendicectomy between January 2014 and July 2020 at 2 hospitals in the Illawarra Shoalhaven Local Health District, New South Wales, Australia, using the PM2 approach for surgical pathway identification and subsequent statistical analyses. ResultsAmong 3,943 patients, 3,606 (91.5%) followed an 11-step main pathway: (1) emergency department admission, (2) surgery booking, (3) anesthesia start, (4) operating room entry, (5) surgery start, (6) surgery end, (7) anesthesia end, (8) operating room discharge, (9) postanesthesia care unit admission, (10) postanesthesia care unit discharge, and (11) hospital discharge. The median length of stay was 48.13 hours (interquartile range 32.74). The main pathway differed from either variation 1 (n = 246, 6.2%) or variation 2 (n = 30, 0.8%) only in the timing and location of anesthesia administration or conclusion. Variation 3 (n = 26, 0.7%) included patients who underwent appendicectomy twice, whereas variation 4 (n = 25, 0.6%) included patients booked for surgery before emergency department admission through community doctor referrals. Thirteen exceptional cases experienced combinations of the aforementioned pathways. The length of stay and phase durations varied between the main pathway and these variations. ConclusionThe appendicectomy pathway was largely standardized across the studied hospitals, with the location of anesthesia administration or conclusion affecting specific stages but not the overall length of stay. Only a complex 2-surgery pathway increased length of stay.

Power Relations in Optimisation of Therapies and Equity in Access to Antibiotics (PROTEA) Study: investigating the intersection of socio-economic and cultural drivers on antimicrobial resistance (AMR) and its influence on healthcare access and health-providing behaviours in India and South Africa.

Across social structures within society, including healthcare, power relations manifest according to gender, socioeconomic status, race, ethnicity, and class influencing infection related healthcare access and health providing-behaviours. Therefore, accounting for sociocultural drivers, including gender, race, and class, and their influence on economic status can improve healthcare access and health-providing behaviours in infection prevention and control (IPC) as well as antibiotic use, which in turn helps mitigate the spread of antimicrobial resistance (AMR). This Wellcome funded research will investigate how and why the social determinants of health and economic status influence how people seek, experience, and provide healthcare for suspected or proven (bacterial) infections and how these factors influence antibiotic prescribing and use in South Africa (upper middle-income country) and India (lower middle-income country). The aim of this body of work is to, (1) define and estimate the sociocultural and economic drivers for AMR in different resource settings, (2) design, implement and evaluate context-sensitive IPC and antimicrobial stewardship (AMS) interventions, and (3) inform policy and strategy for AMR mitigation. The population will be healthcare workers (HCWs), patients, and their carers across acute medical and surgical pathways where IPC and antibiotic-related healthcare access and health-providing behaviours will be studied. Qualitative methods will include ethnographic research, semi-structured in-depth interviews, and focus groups with healthcare providers, patients and carers. Quantitative analysis of bedside observational data from hospitals and population level data on antibiotic use will study the various predictors of AMR using bivariable and multivariable regression analyses. The research will provide high-quality evidence on how social determinants intersect with health, social well-being, and vulnerability in IPC practices and antibiotic use. Using this knowledge we will: 1) design, implement, and measure effects of interventions accounting for these factors; 2) provide a toolkit for advocacy for actors in AMR, and healthcare to assist them to promote dialogue, including policy dialogue on this issue. This work directly benefits the target population and informs healthcare services and practice across the participating countries with potential for wider translation. The setting will be hospitals in South Africa (middle-income country) and India (lower middle-income country). The population will be healthcare workers (HCWs), patients, and their carers across acute medical and surgical pathways where IPC and antibiotic-related health-seeking and health-providing behaviours will be studied. These populations represent communities most affected by infections and AMR because existing interventions do not address a) differences in how surgical versus medical teams manage infections; b) the role of the wider social network of individuals on their decision-making, c) intersection of the social determinants of health including race, gender, socioeconomic deprivation with AMR.

Surgical pathway for HIV‑infected patients based on the ERAS strategy (Review).

Enhanced recovery after surgery (ERAS), which is based on evidence-based medicine, focuses on patients and aims to reduce the psychological and physiological trauma stress reactions and complications of patients, thus shortening the duration of hospitalization, promoting rapid recovery and reducing medical expenses, readmission rate and mortality rates. Acquired immunodeficiency syndrome (AIDS) is caused by human immunodeficiency virus (HIV) infection. Patients with HIV/AIDS, as with other patient populations, can suffer from several surgical-related diseases. Therefore, the need for surgery in this group of patients exists and the surgical services required by patients with AIDS has gradually become an urgent matter of concern. According to relevant literature and the authors' clinical experience, the present review summarizes the current surgical approaches for patients infected with HIV based on ERAS. In the present review, the related issues observed at different stages of surgery, including pre-operative, intra-operative, post-operative and follow-up stages, are discussed.