Surgical Pathway Research Articles

Preoperative evaluation of the elderly patient.

Nowadays, the pre-operative evaluation of older patients is a critical step in the decision-making process. Clinical assessment and care planning should be considered a whole process rather than separate issues. Clinicians should use validated tools for pre-operative risk assessment of older patients to minimize surgery-related morbidity and mortality and enhance care quality. Traditional pre-operative consultation often fails to capture the pathophysiological and functional profiles of older patients. The elderly's pre-operative evaluation should be focused on determining the patient's functional reserve and reducing any possible peri-operative risk. Therefore, older adults may benefit from the Comprehensive Geriatric Assessment (CGA) that allows clinicians to evaluate several aspects of elderly life, such as depression and cognitive disorders, social status, multi-morbidity, frailty, geriatric syndromes, nutritional status, and polypharmacy. Despite the recognized challenges in applying the CGA, it may provide a realistic risk assessment for post-operative complications and suggest a tailored peri-operative treatment plan for older adults, including pre-operative optimization strategies. The older adults' pre-operative examination should not be considered a mere stand-alone, that is, an independent stage of the surgical pathway, but rather a vital step toward a personalized therapeutic approach that may involve professionals from different clinical fields. The aim of this review is to revise the evidence from the literature and highlight the most important items to be implemented in the pre-operative evaluation process in order to identify better all elderly patients' needs.

A Quality Improvement Initiative to Improve the Pediatric Surgical Pathway at an Academic Medical Center

A Quality Improvement Initiative to Improve the Pediatric Surgical Pathway at an Academic Medical Center

Median to Radial Nerve Transfer: An 8-Year Experience From a Lower-Middle Income Country

IntroductionWith an incidence of 2-16%, radial nerve palsy is one of the common forms of nerve injuries globally. Radial nerve palsy causes debilitating effects including loss of elbow extension, wrist drop and loss of finger extension. Reparative surgical pathways range from primary repair and neurolysis, to nerve grafting, nerve transfers, and tendon transfers. Due to ease of performance and acceptability and reproducibility of outcomes, tendon transfers are considered the gold standard of radial nerve palsy repair. However, independent finger function cannot be achieved and as such may not give truly desirable results. In lower-middle income countries, the question of nerve transfer versus tendon transfer for patients who are keen to get back to work is key. While tendon transfer recovery is faster, the functional loss is often considered devastating for fine hand function due to loss of grip secondary to lack of wrist and finger extension. In this study, we present our experience of performing median nerve transfers for radial nerve palsy in Pakistan. MethodsWe performed a retrospective case-series of patients undergoing median to radial nerve transfer for radial nerve palsy over a period of 6 y, from 2012 to 2019. Patients with radial nerve palsy were diagnosed via electromyography and nerve conduction studies. The procedure involved coapting the branches of the flexor carpi radialis and flexor digitorum superficialis (long and ring finger) nerves to the posterior interosseous nerve and extensor carpi radialis brevis, respectively. Patients were assessed using the Medical Research Council scale for muscle strength of wrist, finger and thumb extension separately at 1 y time. Our results were then compared to results from similar nerve transfer studies. ResultsWe operated on 10 right-hand dominant patients, eight males and two females with a median age of 33 y (6-63 y). four sustained injury to the right hand and six to the left. Causes of the injuries included road traffic accident (n = 3), firearm injury (n = 4), shrapnel (n = 1), iatrogenic injury (injection in deltoid region (n = 1) and fall (n = 1). Types of fracture included mid humerus fracture, fracture of the surgical neck of the humerus, and supracondylar fracture of the humerus. Median time to surgery since injury was 4 mo (1-8 mo). Independent wrist extension was M4+ in all patients and independent finger extension was M4+ in seven and M4-in two patients. However, a patient who presented late at 8 mo had poorer finger outcomes with extension at M2-. All patients had independent movement of fingers. ConclusionsNerve transfer is a reliable method of post traumatic nerve repair and reinnervation, particularly in lower-middle income countries, even in cases where the nerve damage is severe and extensive and up to 6 mo may have elapsed between injury and presentation. Timely median to radial nerve transfer is a highly recommended option for radial nerve palsy, with regular follow-ups and physical therapy added to ensure positive outcomes.

Impact of the SARS-CoV-2 Pandemic on Treatment Pathways and Outcomes of Esophagogastric Cancer: A Pre- Versus Post-Pandemic Comparison of International Prospective Cohort Data

Introduction: This study aimed to characterize the outcomes of esophagogastric (OG) cancer patients and compare perioperative outcomes with pre-pandemic data. Methods: Three international prospective cohort studies were included in this analysis. First, COVIDSurg-Cancer (n = 1999) included patients with an OG cancer planned for surgery from the start of the pandemic up to 14th April 2020 with follow-up until 31st August 2020. Treatment pathways and outcomes were compared against patients undergoing treatment for OG cancers before the pandemic, Oesophagogastric Anastomosis Audit (OGAA, n = 2246) and GlobalSurg 3 (n = 1256) study. The surgical composite outcome was defined as in patients achieving margin negative resection, resectability and no postoperative mortality. Results: This study included 1999 patients during the COVID-19 pandemic, of which 32.4% had a change from standard pre-pandemic management. Patients with delay to surgery had significantly higher rates of no surgery (24.7%vs 7.5%, P < .001) and less likely to have achieve a composite outcome (57.8%vs 73.4%, P < .001) than those without any delay in surgery. There was no significant difference in 30-day mortality (3.5% vs 3.4%; OR: 0.98, CI95%: 0.69-1.37) or anastomotic leak rate (10.9% vs 10.2%%; OR: 1.11, CI95%: 0.90-1.37) but higher reoperation rates (13.6% vs 10.4%; OR: 1.59, CI95%: 1.30-1.92) in patients between pre-pandemic and pandemic cohorts. Conclusion: The pandemic appears to have led to widespread changes in management pathways affecting one-third of patients. Developing elective surgical pathways resilient to periods of system “stress” are key to minimizing future harm from treatment delay for OG cancer patients.

Investigating Factors Associated with Postmastectomy Emergency Department Visits: A Population-Based Analysis.

In 2016, a multi-pronged pathway was implemented across 13 hospitals to improve the mastectomy perioperative care experience with one objective being to safely allow same day surgery mastectomy. While the pathway successfully increased same day mastectomy rates from 1.7 to 73.0%, the rate of postoperative emergency department (ED) visits remained high at >20%, despite focused interventions to enhance perioperative support. To investigate potential factors associated with high postoperative ED visits following mastectomies in Alberta, Canada. Data was collected using the Discharge Abstract Database and the National Ambulatory Care Reporting System database. Eligible patients included all women over 18 years old who underwent a mastectomy province-wide between 2004 and 2020. Patient demographics were collected. Primary outcome of interest was ED visit within 30 days of mastectomy. Univariate and multivariable analyses were performed to identify independent predictors for post-operative ED visits. A total of 19,974 patients had mastectomy during the study period, of which 4590 (23%) had an ED visit within 30 days of surgery. Independent factors associated with ED visits were increasing age, overnight stay mastectomy, reconstruction, certain comorbidities, and living rurally. Post-operative ED visits remain high despite initiating a province-wide surgical pathway in 2016 which emphasizes patient education and improved perioperative care and supports. Currently, the majority of ED visits are manageable in non-emergent settings. Patient populations at higher risk for ED visits groups may benefit from additional targeted support and resources to reduce unplanned ED visits.

Postoperative urinary retention in colorectal surgery patients on an enhanced surgical recovery pathway

Abstract Introduction: Postoperative urinary retention (POUR) is a complication of surgery defined as the inability to empty a full bladder. POUR can prolong hospital length of stay and increase rates of urinary tract infection in the postoperative period. Risk factors for the development of POUR include male sex, older age, select medications, and certain comorbid conditions. Surgical factors may also increase the risk of POUR. POUR occurs in up to 50% of patients undergoing colorectal surgery. Materials and Methods: This retrospective, single-center cohort study evaluated the incidence of POUR in patients admitted for colorectal surgery and were enrolled in a Colorectal Enhanced Surgical Recovery (CERAS) protocol. Our primary objective was to determine the incidence of POUR in patients treated under the CERAS protocol. Secondary objectives included evaluating the incidence of POUR in patients receiving intrathecal anesthesia. Results: Two hundred and twenty-eight patients were included. Sixty-six patients (28.9%) developed POUR during their hospitalization. Patients who developed POUR were more likely to be male (61.6% vs. 44.4%, P = 0.029) and tended to be older (mean ± standard deviation age, 61.4 ± 17.7 years vs. 56.8 ± 16.4 years; P = 0.069) compared to the non-POUR group. Regional anesthesia did not affect the incidence of POUR. Conclusions: We identified a rate of POUR in our CERAS patients consistent with previous studies. The risk of POUR increased with increasing age, male sex, and history of benign prostatic hyperplasia and diabetes mellitus. We found no difference in POUR incidence with the type of regional anesthesia utilized. The following core competencies are addressed in this article: Practice-Based Learning and Improvement and Medical Knowledge.

Is preoperative physical function testing predictive of length of stay in patients with colorectal cancer? A retrospective study

Surgery is the primary treatment for colorectal cancer. A prolonged Length of Stay (pLOS) can increase risk of complications and physical inactivity, leading to a decline in physical function. While promising results were seen from preoperative exercise training and post-operative functional recovery, the predictive potential of preoperative physical function has not yet been investigated. The objective of this study is to determine if preoperative physical function can predict pLOS in patients with colorectal cancer.A total of 459 patients from 7 cohorts were analyzed. Logistic regression was used to determine risk of pLOS (>3 days), and ROC curve was plotted to establish sensitivity/specificity. Selected variables included age, sex, BMI, comorbidity, ASA status, tumor site, surgical approach, handgrip strength, Timed-Up and Go, 30-s Sit-to-Stand, 30-s Arm Curl Test, 6-Minute-Walking Test (6MWT), CHAMPS Physical Activity Questionnaire for Older Adult and the 36-Item Short Form Survey.The results showed that patients with rectal tumor are 2.7x more at risk to be in the pLOS group compared to those with colon tumor (O.R. 2.7; C.I. 1.3–5.7, p=0.01). For every increment of 20 m in 6MWT, there is a decreased risk of 9% of being in pLOS group (C.I. 1.03–1.17, p=0.00). A cut-off of 431 m can predict 70% of patients in pLOS group (AUC 0.71 C.I 0.63–0.78, p=0.00). Tumor site (rectal) and 6MWT were significant predictors of pLOS. Using the 6MWT as a screening tool for pLOS with cut-off of 431 m should be implemented in the preoperative surgical pathway.

Two surgical pathways for isolated hip fractures: A comparative study.

Hip fractures (HF) are common among the aging population, and surgery within 48 h is recommended. Patients can be hospitalized for surgery through different pathways, either trauma or medicine admitting services. To compare management and outcomes among patients admitted through the trauma pathway (TP) vs medical pathway (MP). This Institutional Review Board-approved retrospective study included 2094 patients with proximal femur fractures (AO/Orthopedic Trauma Association Type 31) who underwent surgery at a level 1 trauma center between 2016-2021. There were 69 patients admitted through the TP and 2025 admitted through the MP. To ensure comparability between groups, 66 of the 2025 MP patients were propensity matched to 66 TP patients by age, sex, HF type, HF surgery, and American Society of Anesthesiology score. The statistical analyses included multivariable analysis, group characteristics, and bivariate correlation comparisons with the χ² test and t-test. After propensity matching, the mean age in both groups was 75-years-old, 62% of both groups were females, the main HF type was intertrochanteric (TP 52% vs MP 62%), open reduction internal fixation was the most common surgery (TP 68% vs MP 71%), and the mean American Society of Anesthesiology score was 2.8 for TP and 2.7 for MP. The majority of patients in TP and MP (71% vs 74%) were geriatric (≥ 65-years-old). Falls were the main mechanism of injury in both groups (77% vs 97%, P = 0.001). There were no significant differences in pre-surgery anticoagulation use (49% vs 41%), admission day of the week, or insurance status. The incidence of comorbidities was equal (94% for both) with cardiac comorbidities being dominant in both groups (71% vs 73%). The number of preoperative consultations was similar for TP and MP, with the most common consultation being cardiology in both (44% and 36%). HF displacement occurred more among TP patients (76% vs 39%, P = 0.000). Time to surgery was not statistically different (23 h in both), but length of surgery was significantly longer for TP (59 min vs 41 min, P = 0.000). Intensive care unit and hospital length of stay were not statistically different (5 d vs 8 d and 6 d for both). There were no statistical differences in discharge disposition and mortality (3% vs 0%). There were no differences in outcomes of surgeries between admission through TP vs MP. The focus should be on the patient's health condition and on prompt surgical intervention.

The Utilization of Lean Six Sigma Methodologies in Enhancing Surgical Pathways and Surgical Rehabilitation

The authors offer their perspective on the application of Lean Six Sigma methodology to surgical pathways, from referral to post-operative rehabilitation, and how it has resulted in sustainable improvements in patient outcomes, and patient and staff satisfaction. The origin of Lean Six Sigma is described before considering its application to improving scheduled surgical care. The concept of ‘flow’, and its relevance to pre-, intra-, and post-operative care, is discussed as well as the role of Lean Six Sigma in supporting innovation and in promoting an organizational culture that promotes openness to new ideas. The elements of the methodology that render it especially suitable for the redesign of surgical pathways include eliciting the customer voice, co-design, enabling system awareness and inculcating a continuous improvement mindset. The necessary conditions for the successful implementation of Lean Six Sigma initiatives include managerial support, high-quality education and training, and alignment with organizational strategy. Future directions for practice and research are discussed before presenting a key finding from the literature and from the authors’ collective experience: Lean Six Sigma initiatives will not lead to sustainable improvements where the key elements of the methodology are not recognized and enacted, and where the necessary conditions are absent.

Digital innovation in the surgical pathway: building a digital pre-operative triage and risk assessment tool using a population health platform

Background: We present the use of a Digital Population Health Platform to automate risk stratification and triage of patients awaiting preoperative assessment (POA). Our at-a-glance ‘surgical dashboard’ integrates the surgical waiting list (Patient Treatment List, PTL) operational data with the patient-level primary care data on their Integrated Care Record (ICR). The aim was to develop the dashboard to allow groups of patients to be identified and triaged according to their comorbidities. For surgical patients on the admitted pathways this enables high- and low-risk patients waiting for surgery, to be instantly identified. We present the results of pre-implementation dashboard testing to assess functionality and safety. Methods: Comorbidities were allocated to colour coded triage categories. These categories are used by POA nurses to streamline patients into appropriate POA clinics. The coding rules were then applied digitally to all 38 000 patients on the PTL, including the >5000 patients awaiting surgery. During development, iterative testing of the dashboard coding was ongoing. Testing involved comparison between the dashboard-allocated triage category and a manually defined triage after review of electronic medical records and the completed POA assessment. Our final patient cohort of low-risk ‘Gold Colour’ patients was tested, and each patient was declared either true low risk (ASA 1 equivalent) or a triage ‘failure’. Results: Of the final 100 patients sampled, the triage tool correctly identified 85% as ASA 1 equivalent. These patients are treated as ‘low risk’ and eligible for healthcare assistant (HCA) clinic only.Tabled 1Table 1 Incorrect triage ‘failures’—reasons for triage failure and Summary Care Record data available for each patientTriage failure (>ASA 1) reasonInformation from GP data/Summary Care Record interrogationBMI<18 (BMI=16.3)Incomplete height/weight data since 2021BMI>35 (BMI=36.1)No height, weight, or BMI visible on SCRBMI>35 (BMI=38.6)Last height/weight data entered 2016 when BMI=32.1BMI>35 (BMI=44.0)Last height/weight data entered 2020 when BMI=39.4BMI>35 (BMI=46.3)Last height/weight data entered 2017 when BMI=32.7BMI>35 (BMI=37.0) and OSA on CPAPNo data available on SCROSA on CPAPRecorded as ‘sleep apnoea’—possibly missed on comorbidity codingAsthma and type 2 diabetes mellitusAsthma last recorded 1969. Diabetes recorded as ‘non-diabetic hyperglycaemia’AsthmaDiagnosis not recorded on SCRAlcohol consumption 63 units/weekNot recorded on SCRIron deficiency anaemiaDiagnosis not recorded on SCRHypothyroidismNo SCR available for patientThyroiditis under investigationDiagnosis not recorded on SCR (new clinical issues since triage)Ulcerative colitisRecorded as ‘proctitis’ on SCRHIVDiagnosis not recorded on SCRHIV, human immunodeficiency virus; SCR, Summary Care Record Open table in a new tab HIV, human immunodeficiency virus; SCR, Summary Care Record Conclusion: Our surgical dashboard is accurate at triaging surgical patients according to their comorbidities and surgical risk determinants including smoking status and BMI. Triaging errors (Table 1) were either as a result of incomplete and inaccurate patient data held on the ICR or in the event of changes in a patient’s circumstances (e.g. BMI, new diagnoses) between the recording of data in primary care and POA. Using the dashboard, further collaborative work is ongoing with Primary Care and Public Health in Buckinghamshire, to identify patients awaiting surgery with medical conditions amenable to optimisation. We believe our PTL Surgical Dashboard Tool will be transformative in how elective surgical patients are managed at both a clinical and administrative level in Buckinghamshire Healthcare NHS Trust.

Implementation of a Multispecialty Geriatric Surgery Pathway Reduces Inpatient Cost for Frail Patients.

The objective of this study was to evaluate the effect of geriatric surgical pathway (GSP) implementation on inpatient cost of care. Achieving high-value care for older patients is the goal of the American College of Surgeons Geriatric Verification Program (ACS-GSV). We have previously shown that implementation of our geriatric surgery pathway, which aligns with the ACS-GSV standards, resulted in a reduction in loss of independence and complications. Patients ≥65 years who underwent an inpatient elective surgical procedure included in the American College of Surgeons National Quality Improvement Program (ACS NSQIP) registry from July 2016 through December 2017 were compared with those patients from February 2018 to December 2019 who were cared for on our GSP. An amalgamation of Clinformatics DataMart, the electronic health record, and the ACS NSQIP registry produced the analytical dataset. We compared mean total and direct costs of care for the entire cohort as well as through propensity matching of frail surgical patients to account for differences in clinical characteristics. The total mean cost of health care services during hospitalization was significantly lower in the cohort on our GSP ($23,361±$1110) as compared with the precohort ($25,452±$1723), P <0.001. On propensity-matched analysis, cost savings was more evident in our frail geriatric surgery patients. This study shows that high-value care can be achieved with the implementation of a GSP that aligns with the ACS-GSV program.

Potential Carbon Savings with Day-case Compared to Inpatient Transurethral Resection of Bladder Tumour Surgery in England: A Retrospective Observational Study Using Administrative Data

BackgroundThe National Health Service (NHS) in England has set a net-zero target for carbon emissions by 2040. Increasing use of day-case surgery pathways may help in meeting this target. ObjectiveTo investigate the estimated difference in carbon footprint between day-case and inpatient transurethral resection of bladder tumour (TURBT) surgery in England. Design, setting, and participantsThis was a retrospective analysis of administrative data extracted from the Hospital Episode Statistics database for all TURBT procedures conducted in England from April 1, 2013 to March 31, 2022. Outcome measurements and statistical analysisDay-case and inpatient TURBT procedures were identified and the carbon footprint for key elements of the surgical pathway was estimated using data from Greener NHS and the Sustainable Healthcare Coalition. Results and limitationsOf 209 269 TURBT procedures identified, 41 583 (20%) were classified as day-case surgery. The day-case rate increased from 13% in 2013–2014 to 31% in 2021–2022. The move from inpatient stays to day-case surgery between 2013–2014 and 2021–2022 demonstrates a trend toward a lower-carbon pathway, with an estimated saving of 2.9 million kg CO2 equivalents (equivalent to powering 2716 homes for 1 yr) in comparison to no change in practice. We calculated that potential carbon savings for the financial year 2021–2022 would be 217 599 kg CO2 equivalents (equivalent to powering 198 homes for 1 yr) if all hospitals in England not already in the upper quartile were able to achieve the current upper-quartile day-case rate. Our study is limited in that estimates are based on carbon factors for generic surgical pathways. ConclusionsOur study highlights potential NHS carbon savings that could be achieved by moving from inpatient stays to day-case surgery. Reducing variation in care across the NHS and encouraging all hospitals to adopt day-case surgeries, where clinically appropriate, would lead to further carbon savings. Patient summaryIn this study we estimated the potential for carbon savings if patient undergoing bladder tumour surgery were admitted and discharged on the same day. We estimate that increasing use of day-case surgery between 2013–2014 and 2021–2022 has saved 2.9 million kg CO2 equivalents. If all hospitals were to achieve day case-rates comparable to those in the highest quarter of hospitals in England in 2021–2022, then the carbon equivalent to powering 198 homes for 1 year could have been saved.

A Medicoeconomic Evaluation of a Telehealth Platform for Elective Outpatient Surgeries: Protocol for a Randomized Controlled Trial

The number of elective outpatient surgeries in Canada has increased markedly in the last 10 years. However, unanticipated cancellations on the day of surgery and adverse postoperative events are frequent. Modern technologies have been shown to be of great help in the medical field in improving patient care. Thus, it is likely that dedicated technologies could also significantly improve surgical outpatients' pathways. Therefore, the department of anesthesiology at the University of Montreal Medical Center, in collaboration with LeoMed, a telemedicine platform, has developed a telehealth solution to offer more efficient perioperative support and follow-up for patients undergoing ambulatory surgery. The objective is to evaluate the medicoeconomic benefit of a dedicated perioperative telehealth platform for patients undergoing day surgery. Our hypothesis is that this dedicated telecare solution will allow more efficient patient care, which will reduce all types of medical costs related to day surgery pathways. This study is a single-center, single-blinded, 2-group randomized controlled trial. One thousand patients aged over 18 years with internet access who are scheduled to undergo ambulatory surgery will be enrolled and randomized either to follow a perioperative path that includes a patient-tailored perioperative digital app via the LeoMed telecare platform for 1 month or to follow the standard of care, which does not offer personalized digital support. The primary outcome will be to evaluate the cost-effectiveness of the telecare platform, assessing direct costs from factors such as unanticipated cancellations on the day of surgery due to preoperative instructions not being followed, calls to the local health information line, calls to the provincial health information line, emergency department consultations, unplanned readmissions, or medical visits for problems related to the surgical procedure within the first 30 days after the intervention. The secondary outcome will be to evaluate cost utility using a questionnaire assessing quality-adjusted life years. A blinded independent research team will analyze outcomes. All data will be analyzed according to the intention-to-treat principle. A sample size of 500 subjects in each group was calculated to detect a 21% reduction in postoperative complications with a power of 90%. This study has been approved by the ethics board of Centre hospitalier de l'Université de Montréal (University of Montreal Health Centre). No employee of LeoMed was involved in the study conception, and none will be involved in either data collection or analysis. Results of this trial will be useful to determine the economic benefit of a telecare platform specifically developed for surgical outpatient pathways. We believe that the deployment of a dedicated perioperative telehealth app will lead to better patient care and fewer postoperative complications, which will lower all types of costs related to surgical outpatient care. ClinicalTrials.gov NCT04948632; https://ClinicalTrials.gov/ct2/show/NCT04948632. DERR1-10.2196/44006.

Clinical Efficacy Analysis of Different Surgical Methods for Giant Adrenal Tumors (≥10 cm): A Single-Center Study of 44 Cases.

Objective: The objective of this study was to compare the efficacy and safety of open adrenalectomy (OA) and laparoscopic adrenalectomy (LA) by summarizing the clinical features and treatment experience of giant adrenal tumors. Methods: The clinical data of 44 patients with adrenal tumors ≥10 cm admitted to the Second Hospital of Lanzhou University from January 2006 to August 2022 were retrospectively analyzed. The mean tumor diameter was 11.6 ± 1.8 cm. Regular follow-up was performed to observe the outcome of symptoms and the recurrence after operation. Results: All the 44 patients successfully completed the operation and were divided into the OA group (21 cases) and the LA group (11 cases of transabdominal laparoscopic adrenalectomy [TLA] and 12 cases of retroperitoneal laparoscopic adrenalectomy [RLA]) according to different operation methods. The analysis results showed that the proportion of estimated blood loss (EBL) >100 mL and the postoperative length of stay (PLOS) in the LA group were superior to those in the OA group, and there were no significant differences in other surgical indicators (P > .05); subgroup analysis was conducted for patients in the LA group according to different surgical pathways, and the results showed that there were no significant differences in each surgical indicator between TLA and RLA (P > .05). Among the 44 patients, 15 (34.1%) had intraoperative complications, 19 (43.2%) had postoperative complications, and 5 (21.7%) were converted from LA to OA. The median follow-up time was 68 (5-162) months. Conclusions: For adrenal tumors with diameter ≥10 cm, both LA and OA have relatively large damage to the patients, and the incidence of conversion to open surgery is also high. However, LA is superior to OA in EBL and PLOS. Given the fact that giant adrenal tumors are mainly pheochromocytoma and paraganglioma and have an increased possibility of malignancy, we suggest that the relationship between tumors and peripheral important blood vessels and organs should be carefully evaluated before operation, and the operative methods should be selected according to the experience of the surgeon.

A Multidisciplinary Approach to the Nonambulatory Bariatric Patient With Bilateral Knee Osteoarthritis

Obesity and lower-extremity arthritis are challenging problems to address as they are often mutually exacerbating. Due to the known perioperative risk of morbid obesity, the modality and timing of weight loss prior to arthroplasty is debated. We present a case of a 55-year-old nonambulatory female patient with an initial body mass index of 80.3 kg/m2. This individual underwent a staged bariatric and joint replacement surgical pathway employing personnel of differing treatment disciplines. Our patient successfully lost a substantial amount of weight and has been able to ambulate, exercise, and engage in new, strenuous physical activities. In the care of the nonambulatory bariatric patient, employing a multidisciplinary treatment plan can produce successful results.

The use of dexamethasone therapy for conservative management of chronic subdural hematomas: a question about efficacy and safety

BackgroundChronic subdural hematoma (CSDH) is a commonly encountered neurosurgical entity, particularly among the elderly population. Surgical intervention by trepanation or burr hole craniostomy remains the gold standard approach for symptomatic cases. However, despite the excellent outcome, the surgical pathway remains also associated with possible complications, some of which might be fatal, in addition to a recurrence rate of up to 25%. Dexamethasone (DXM) therapy was used as an alternative non-surgical approach, yet its clinical effectiveness remains controversial. Therefore, the objective of this study is to evaluate the outcome of DXM use for the management of chronic subdural hematomas with regard to the clinical results, safety, efficacy and potential incidence of complications.ResultsThis is a retrospective study of 30 patients, with symptomatic CSDH managed by the authors by DXM therapy protocol. Subjects were assessed upon admission then closely monitored to evaluate their response to conservative management, then followed up and their data were recorded at 2 weeks, 1 month, 3 months, and 6 months after protocol initiation. Clinical scoring systems included the Glasgow Coma Scale (GCS) and the Markwalder Grading Scale (MGS), whereas radiological evaluation consisted of serial Computerized tomography (CT)scans to assess CSDH changes between time of protocol initiation and over the same time intervals. There was a statistically highly significant improvement regarding the GCS and the MGS of the studied cases on comparing the starting values to those throughout the follow-up intervals at 2 weeks, 1 month, 3 months, or six months (p = 0.001). Patients presented with a neurological deficit also showed a statistically highly significant improvement on comparing the values at the beginning of our study to those recorded at the third month or those at the sixth month (p = 0.001).ConclusionsOur study concluded that dexamethasone use is a safe and effective choice for the management of chronic subdural hematoma with an acceptable success rate and a low incidence rate of serious complications. We do not advocate for the replacement of surgery by DXM treatment but to consider its possible role in selected cases. Larger series and further studies would be yet considered with longer follow-up periods.

The tricuspid valve in hypoplastic left heart syndrome: Echocardiography provides insight into anatomy and function.

Tricuspid regurgitation (TR) is commonly seen in surgically palliated patients with hypoplastic left heart syndrome, and when significant, is associated with an increase in both morbidity and mortality. Tricuspid valve dysfunction appears to be the result of a combination of inherent structural malformations and the unique physiological circumstances resulting from right ventricular pressure and volume overload. Valve dysfunction evolves rapidly, and manifests early on in the surgical pathway. Whilst traditional echocardiographic imaging can identify anatomical defects and dysfunction resulting in varying degrees of regurgitation even at early stages, more sophisticated investigations such as 3D echocardiography, strain imaging and transesophageal 3DE might prove useful to better demonstrate the complex interactions between abnormal anatomy of the valve complex, ventricular function, mechanical synchrony, and TR. Recognition of specific mechanisms of TR can enhance patient-specific care by directing precise surgical interventions and by informing the best timing for intervention on the valve.

Virtual reality and surgical oncology.

More than 80% of people diagnosed with cancer will require surgery. However, less than 5% have access to safe, affordable and timely surgery in low- and middle-income countries (LMICs) settings mostly due to the lack of trained workforce. Since its creation, virtual reality (VR) has been heralded as a viable adjunct to surgical training, but its adoption in surgical oncology to date is poorly understood. We undertook a systematic review to determine the application of VR across different surgical specialties, modalities and cancer pathway globally between January 2011 and 2021. We reviewed their characteristics and respective methods of validation of 24 articles. The results revealed gaps in application and accessibility of VR with a proclivity for high-income countries and high-risk, complex oncological surgeries. There is a lack of standardisation of clinical evaluation of VR, both in terms of clinical trials and implementation science. While all VR illustrated face and content validity, only around two-third exhibited construct validity and predictive validity was lacking overall. In conclusion, the asynchrony between VR development and actual global cancer surgery demand means the technology is not effectively, efficiently and equitably utilised to realise its surgical capacity-building potential. Future research should prioritise cost-effective VR technologies with predictive validity for high demand, open cancer surgeries required in LMICs.

A Call to Action to Train Underrepresented Minorities in Surgical Subspecialties and Fellowships.

With each succession along the surgical career pathway, from medical school to faculty, the percentage of those who identify as underrepresented in medicine (URiM) decreases. We sought to evaluate the demographic trend of surgical fellowship applicants, matriculants, and graduates over time. The Electronic Residency Application Service and the Graduate Medical Education Survey for general surgery fellowships in colorectal surgery, surgical oncology, pediatric surgery, thoracic surgery, and vascular surgery were retrospectively analyzed (2005 to 2020). The data were stratified by race and gender, descriptive statistics were performed, and time series were evaluated. Race/ethnicity groups included White, Asian, other, and URiM, which is defined as Black/African American, Hispanic/Latino(a), Alaskan or Hawaiian Native, and Native American. From 2005 to 2020, there were 5,357 Electronic Residency Application Service applicants, 4,559 matriculants, and 4,178 graduates to surgery fellowships. Whites, followed by Asians, represented the highest percentage of applicants (62.7% and 22.3%, respectively), matriculants (65.4% and 23.8% respectively), and graduates (65.4% and 24.0%, respectively). For URiMs, the applicants (13.4%), matriculants (9.1%), and graduates (9.1%) remained significantly low (p < 0.001). When stratified by both race and gender, only 4.6% of the applicants, 2.7% of matriculants, and 2.4% of graduates identified as both URiM and female compared to White female applicants (20.0%), matriculants (17.9%), and graduates (16.5%, p < 0.001). Significant disparities exist for URiMs in general surgery subspecialty fellowships. These results serve as a call to action to re-examine and improve the existing processes to increase the number of URiMs in the surgery subspecialty fellowship training pathway.

Residency Surgical BPH Training Paradigms from MIST to HOLEP.

Benign prostatic hyperplasia (BPH) is a common medical condition of older men that often requires medical or surgical therapy. Surgical options for BPH have grown exponentially over the last two decades. The numerous options and/or lack of access to them can make it challenging for new trainees to gain proficiency. We examine the literature for available BPH surgical simulators, learning curves, and training pathways. Each BPH surgical therapy has a learning curve which must be overcome. There is an abundance of TURP simulators which have shown face, content, and construct validity in the literature. Similarly, laser therapies have validated simulators. Newer technologies do have available simulators, but they have not been validated. There are strategies to improve learning and outcomes, such as having a structured training program. Simulators are available for BPH surgical procedures and some have been implemented in urology residencies. It is likely that such simulation may make urologists more facile on their learning curves for newer technologies. Further studies are needed. Future directions may include integration of simulator technology into training pathways that include surgical observation and proctorship.