Categories Of Surgical Procedures Research Articles

The impact of spinal versus general anesthesia on the variability of surgical times: a systematic review and meta-analysis.

With spinal anesthesia, when cases are taking longer than usual, there may be behavioural tendencies for surgical teams to work more quickly. We conducted a systematic review with meta-analysis to examine standard deviations of surgical times for single-dose spinal anesthetics versus general anesthesia. We compared ratios of mean surgical times as a secondary endpoint. We included randomized trials of humans where general or spinal anesthesia was used for one category of surgical procedure (e.g., hip arthroplasty) and the article reported the means and standard deviations of operative durations. We used statistical methods suitable for surgical times following log-normal distributions. We used generalized confidence intervals to calculate point estimates of ratios and standard errors for each study, followed by pooling among studies using DerSimonian and Laird random-effects meta-analysis with Knapp-Hartung adjustment. Among the 77 included studies, 96% were of high quality for our endpoint (i.e., had a low risk of bias), as no (0%) study focused on comparing variability of surgical times and none had surgical time as the primary endpoint. Spinal anesthesia was associated with 6.6% smaller standard deviations than general anesthesia (95% confidence interval, 15.8% smaller to 1.9% larger, P = 0.13). By meta-regression, there was no significant association of the ratios of standard deviations with study quality (P = 0.39), year of publication (P = 0.76), or categories of procedures (all five P ≥ 0.28). Spinal anesthesia was associated with 1.1% smaller means than general anesthesia (95% confidence interval, 3.7% smaller to 1.5% larger, P = 0.42). There were no significant associations between the ratios of means and study quality (P = 0.47), year of publication (P = 0.95), or categories of procedures (all five, P ≥ 0.63). The results of this systematic review and meta-analysis show with high confidence that the effect of choosing spinal anesthesia on variability in surgical time, if present, is sufficiently small to have no substantive direct economic effect. The same conclusion applies to mean surgical time. Therefore, although anesthetic choice has a clinical (biological) impact and affects anesthesia times, the direct effects on surgical times and workflow are minimal at most. Anesthetic choice does not influence operating theatre productivity via changes to surgical times. The impact of spinal anesthetic effects is limited to nonoperative times (e.g., reducing anesthesia-controlled times by using a block room before the patient enters the operating room). PROSPERO ( CRD42023461952 ); first submitted 8 September 2023.

When Antimicrobial Treatment and Surgical Prophylaxis Collide: A Stewardship Opportunity.

Background: In 2002, the Centers for Medicare and Medicaid Services (CMS) in collaboration with the Centers for Disease Control and Prevention (CDC) established the Surgical Infection Prevention (SIP) project for the purposes of developing and standardizing quality improvement measures known to reduce the rates of post-operative surgical site infections (SSIs). Four years later the Surgical Care Improvement Project (SCIP), an expansion of SIP, was published in governmental Specifications Manual for National Inpatient Quality Measures and provided several additional initiatives applicable to the perioperative period. Central to both projects are the assurance of the timeliness, selection, and duration of peri-operative surgical prophylactic antibiotics. In support of this objective, various medical associations, such as the American Society of Health-System Pharmacists (ASHP) and the Infectious Diseases Society of America (IDSA), have developed the Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. To ensure compliance with quality measures, hospitals are required to report data to the Physicians Quality Reporting System, which is then reviewed by CMS for reimbursement purposes and to measure hospital performance. To maintain optimal standards of care and satisfy all core measures, it is expected that patients undergoing most categories of surgical procedures receive prophylactic antibiotics. We recognized that patients already being administered antimicrobial therapy as treatment for the condition requiring the surgery not uncommonly also were prescribed unwarranted and redundant pre-operative antibiotics. Our study was meant to quantify such antibiotic redundancy, which only risks the development of antimicrobial resistance and adverse events, to bolster our and other hospitals antimicrobial stewardship programs. Methods: A retrospective analysis of computerized hospital records over a one-month period of time (November 2022) was conducted focusing on hospital admissions that involved surgical operative procedures. Only those patients who had received a pre-operative surgical prophylactic antibiotic were included in the analysis. Results: Of the 92 surgeries that fulfilled the inclusion criteria, 38 (41.3%) were performed on patients who were already receiving therapeutic antibiotics for more than 24 hours targeted to treat the infection for which they were undergoing surgery. These included laparoscopic cholecystectomy (24), appendectomy (12), wound debridement (12), and soft tissue incision and drainage procedures (9), comprising nearly 50% of each type of these operations performed during the study time period. Conclusion: These findings demonstrate a clear opportunity to strengthen both our, and presumably other, hospitals antimicrobial stewardship programs. Together with physician education, granting the pharmacy the ability to cancel unnecessary and redundant surgical prophylactic antibiotics would conceivably be of great benefit.

Recurrence Rates With Longer-Term Follow-up After Hallux Valgus Surgical Treatment With Distal Metatarsal Osteotomies: A Systematic Review and Meta-analysis.

Recurrence of hallux valgus (HV) following corrective surgery is a frequent concern. A recent systematic review estimated recurrence of HV in only 4.9%, which may be an underestimation, as most included studies had short- to mid-term follow-up. The purpose of this systematic review and meta-analysis was to assess long-term outcomes of distal osteotomies of the first metatarsal (M1) to treat HV without inflammatory disease or degenerative arthritis, and to assess HV recurrence rates reported in studies that had a minimum follow-up of 5 years. This systematic review conforms to the PRISMA guidelines. The authors conducted a search using PubMed, Embase, and Cochrane Central Register of Controlled Trials databases. Studies that report outcomes of distal osteotomies of the M1 for noninflammatory and nondegenerative HV at a minimum follow-up of 5 years. We found 17 eligible studies comprising 18 data sets, reporting outcomes of 4 categories of osteotomies: Chevron, Mitchell, Bösch, and "others." The HV recurrence rate was 64% considering the threshold of >15 degrees hallux valgus angle (HVA), 10% having >20 degrees, and 5% having >25 degrees. At a minimum of 5 years following distal osteotomies of the M1, the mean weighted postoperative HVA was significantly higher for Mitchell osteotomies compared with the 3 other osteotomies reviewed. There were otherwise no significant differences in recurrence rates using the 3 HVA thresholds, or intermetatarsal angle among any of the surgical techniques reported in 2 or more studies. The pooled HV recurrence rates considering the various thresholds of HVA were as follows: 64% having >15 degrees, 10% having >20 degrees, and 5% having >25 degrees. The recurrence rates in the long term for all categories of surgical procedures suggest that better understanding of pathogenesis and prognosis of HV is required before modifying or introducing new surgical techniques. Level IV, meta-analysis.

Perioperative Outcomes of Patients with Bleeding Disorders Undergoing Major Surgery at an Academic Hemophilia Treatment Center.

Persons with bleeding disorders (PwBD) are at high risk for bleeding with invasive procedures. However, the risk of bleeding in PwBD undergoing major surgery and outcomes of patients managed perioperatively at a hemophilia treatment center (HTC) are not well described. We performed a retrospective review of surgical outcomes among PwBD undergoing major surgery between January 1st, 2017 and December 31st, 2019 at the Cardeza Foundation Hemophilia and Thrombosis Center in Philadelphia, PA. The primary outcome was postoperative bleeding, assessed according to the ISTH-SSC's 2010 definition. Secondary outcomes included use of unplanned postoperative hemostatic therapy, LOS, and 30-day readmission rate. Results were compared to non-PwBD population from a surgical database, matched for surgery, age, and sex. During the study period, 50 PwBD underwent 63 major surgeries. The most common diagnoses were VWD (64%) and hemophilia A (20.0%). The most common surgical procedure category was orthopedic (33.3%), predominantly arthroplasties. Postoperatively,4.8% of procedures were complicated by major bleeding and 1.6% by non-major bleeding. The mean LOS was 1.65 days, and 30-day readmission rate was 1.6%. In comparison to matched, non-PwBD patients in a national surgical database undergoing the same procedures, study patients had a similar rate of bleeding complications per procedure (5.0% vs 1.04% P = .071, Fisher's exact test). PwBD undergoing major surgeries have low rates of major bleeding when receiving comprehensive care at an HTC. Bleeding and hospital readmission rates were similar to non-PwBD baseline in a large database.

Evaluation of the International Classification of Health Interventions (ICHI) in the coding of common surgical procedures.

To evaluate the International Classification of Health Interventions (ICHI) in the clinical and statistical use cases. We identified 300 most-performed surgical procedures as represented by their display names in an electronic health record. For comparison with existing coding systems, we coded the procedures in ICHI, SNOMED CT, International Classification of Diseases (ICD)-10-PCS, and CCI (Canadian Classification of Health Interventions), using postcoordination (modification of existing codes by adding other codes), when applicable. Failure analysis was done for cases where full representation was not achieved. The ICHI encoding was further evaluated for adequacy to support statistical reporting by the Organisation for Economic Co-operation and Development (OECD) and European Union (EU) categories of surgical procedures. After deduplication, 229 distinct procedures remained. Without postcoordination, ICHI achieved full representation in 52.8%. A further 19.2% could be fully represented with postcoordination. SNOMED CT was the best performing overall, with 94.3% full representation without postcoordination, and 99.6% with postcoordination. Failure analysis showed that "method" and "target" constituted most of the missing information for ICHI encoding. For all OECD/EU surgical categories, ICHI coding was adequate to support statistical reporting. One OECD/EU category ("Hip replacement, secondary") required postcoordination for correct assignment. In the clinical use case of capturing information in the electronic health record, ICHI was outperformed by the clinically oriented procedure coding systems (SNOMED CT and CCI), but was comparable to ICD-10-PCS. Postcoordination could be an effective and efficient means of improving coverage. ICHI is generally adequate for the collection of international statistics.

Short-term Effects of Canceled Elective Procedures Due to COVID-19: Evidence From the Veterans Affairs Healthcare System.

To determine whether delayed or canceled elective procedures due to COVID-19 resulted in higher rates of ED utilization and/or increased mortality. On March 15, 2020, the VA issued a nationwide order to temporarily pause elective cases due to COVID-19. The effects of this disruption on patient outcomes are not yet known. This retrospective cohort study used data from the VA Corporate Data Warehouse. Surgical procedures canceled due to COVID-19 in 2020 (n = 3326) were matched to similar completed procedures in 2018 (n = 151,863) and 2019 (n = 146,582). Outcome measures included 30- and 90-day VA ED use and mortality in the period following the completed or canceled procedure. We used exact matching on surgical procedure category and nearest neighbor matching on patient characteristics, procedure year, and facility. Patients with elective surgical procedures canceled due to COVID-19 were no more likely to have an ED visit in the 30- [Difference: -4.3% pts; 95% confidence interval (CI): -0.078, -0.007] and 90 days (-0.9% pts; 95% CI: -0.068, 0.05) following the expected case date. Patients with cancellations had no difference in 30- (Difference: 0.1% pts; 95% CI: -0.008, 0.01) and 90-day (Difference: -0.4% pts; 95% CI: -0.016, 0.009) mortality rates when compared to similar patients with similar procedures that were completed in previous years. The pause in elective surgical cases was not associated with short-term adverse outcomes in VA hospitals, suggesting appropriate surgical case triage and management. Further study will be essential to determine if the delayed cases were associated with longer-term effects.

Low Complication Rates in Patients with Bleeding Disorders Undergoing Major Surgery at an Academic Hemophilia Treatment Center

BACKGROUND: Hemophilia and von Willebrand disease (VWD) are the most common inherited bleeding disorders, and hemostatic management surrounding surgical procedures is complex. Hemophilia Treatment Centers (HTCs) devote significant time and resources to formulating perioperative hemostatic plans to allow these patients to safely undergo necessary procedures. Yet, scant data exists in the literature in the era of routine recombinant and plasma-derived factor concentrate use on outcomes of persons with bleeding disorders undergoing major surgeries. METHODS: We performed a retrospective chart review of surgical outcomes in patients with bleeding disorders at the Cardeza Hemophilia and Thrombosis Center, an HTC at a large academic medical center in Philadelphia, PA. The study included 50 patients, among whom a total of 63 surgeries occurred between 2017-2019. Patients carried a diagnosis of Hemophilia A or B, VWD, or other congenital coagulation factor deficiency. We included planned surgeries requiring general anesthesia for >30 minutes, as well as orthopedic and neurologic surgeries; only procedures occurring at our hospital were included. The primary outcome was postoperative bleeding, assessed according to the ISTH-SSC's 2010 definition. Secondary outcomes included use of unplanned postoperative hemostatic therapy, length of stay, and 30-day readmission rate. To compare outcomes in our population to that of a non-bleeding disorder population, the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database was queried for 2018 (N=251,682). Only patients with a primary surgical CPT code shared with our study population were included, and those with a surgery occurring beyond Day 0 of admission or with a known bleeding disorder were excluded. Not all procedures undergone by our patients are captured by NSQIP, so our comparison study population included 40 procedures among 35 patients. RESULTS: Characteristics of the study population are summarized in Table 1. Among 50 eligible patients in our registry, 21 (42%) were female and mean age at the time of surgery was 50.9 years. The most common diagnosis was VWD (64%), with Type 1 (42%) the most frequent subtype. Most patients (44%) had a mild bleeding disorder. Three (6%) had a severe phenotype, including 1 patient with an inhibitor, and 2 (4%) used chronic outpatient prophylaxis. Outcomes in the 63 surgeries are summarized in Table 2. The most common surgical procedure category was orthopedic (21, 33.3%), including 12 arthroplasties. 62 patients (98.4%) had a preoperative hemostatic plan documented in the chart. 58 (92.1%) patients received preoperative hemostatic therapy, and 34 (54.0%) had planned postoperative therapy. Postoperatively, 59 patients (93.7%) had no documented bleeding complications. One (1.6%) had clinical bleeding not meeting ISTH major bleeding criteria and 3 (4.8%) had major bleeding, including 2 patients with unexpected surgical site bleeding and Hgb drop ≥2 g/dL and 1 who had a Hgb drop and required 5 units of pRBCs. Seven (11.1%) patients required unplanned postoperative hemostatic therapy. The mean length of stay was 1.65 days, and only 4 patients (6.3%) re-presented to the hospital within 30 days related to surgery - 2 for bleeding complications - including 3 ED visits and 1 inpatient admission. To understand how this rate of complications compares to the general population at academic centers, we compared study patients to non-bleeding disorder patients in the 2018 NSQIP database. Characteristics of each group are shown in Table 3. NSQIP defines bleeding only as postoperative transfusion, however all bleeding events in the study patients in this comparison included transfusion. Postoperative bleeding rates were low in both groups (3.0% in study patients vs 1.2% in NSQIP controls, P=.082). There was no difference in unplanned 30-day readmission rates related to surgery. Mean length of stay was longer in study patients (2.25 vs 1.90 days, P=.003). DISCUSSION: This study at a single HTC suggests that, with comprehensive care and preoperative planning, patients with bleeding disorders can safely undergo major surgical procedures with risks of bleeding complications similar to the general population. We observed few bleeding events or readmissions, and length of stay remained relatively short despite most patients being planned for postoperative hemostatic therapy. Disclosures Drelich: Octapharma: Honoraria; Bayer: Honoraria; CSL Behring: Honoraria.

Forecasting the Probability That Each Surgical Case Will Either Be Ambulatory or the Patient Will Remain in the Hospital Overnight Versus Having a Length of Stay of Two or More Days.

When the hospital census is high, perioperative medical directors or operating room (OR) managers sometimes need to review with surgical departments as to which surgical cases scheduled to be performed within the next three days may need to be postponed. Although distributions of hospital length of stay (LOS) are highly skewed, a surprisingly effective summary measure is the percentage of patients previously undergoing the same category of procedure as that scheduled whose LOS was zero or one day. We evaluated how to forecast each hospital's percentage of cases with LOS of <2 days, segmented by category of surgical procedure. The large teaching hospital studied included several inpatient adult surgical suites, an ambulatory surgery center, and a pediatric surgical suite.We included 98,540 cases in a training dataset to predict 24,338 cases in a test dataset. For each category of procedure, we calculated the cumulative count of cases among quarters, from the most recent quarter, second most recent quarter, and so forth up to the quarter resulting in at least 800 cases. If every quarter combined had fewer than 800 cases for a given category of procedure, we included all cases for that category. For each combination of category and quarter, we used the cumulative counts of cases and cases with LOS of <2 days, excluding the current quarter. Then, for each category of procedure, and for each of the preceding quarters included for the category, we used the cumulative counts to calculate the asymptotic standard error (SE) for the proportion of cases with LOS of <2 days. If all preceding quarters combined provided a sample size such that the estimated SE for the proportion exceeded 1.25%, we included all preceding quarters. The observed absolute percentage error was 0.76% (SE: 0.12%). This error was nearly 100-fold smaller than the percentage of cases to which it would be used (i.e., 0.76% versus 73.1% with LOS of <2 days). The principal weakness of the forecasting methodology was a small bias caused by a progressive reduction in the overall LOS over time. However, this bias is unlikely to be important for predicting cases’ LOS when the hospital census is high. When performing these time series calculations quarterly, a reasonable approach is to perform calculations of both case counts and SEs for each category of procedure. We recommend using the fewest historical quarters, starting with the most recent quarter, either with at least 800 cases or an estimated asymptotic SE for the estimated percentage no greater than 1.25%. Applying our methodology with local LOS data will allow OR managers to estimate the number of patients on the elective OR schedule each day who will be hospitalized for longer than overnight, facilitating communication and decision-making with surgical departments when census considerations constrain the ability to run a full surgical schedule.

The Dentoalveolar Surgical Patient

Dentoalveolar surgery comprises more than 50% of the practice of oral and maxillofacial surgeons worldwide and is the most commonly performed category of surgical procedure. Optimal strategies for management of many medical problems, however, remain unclear. Remaining current on medical and surgical perioperative strategies is a standard for best practice. This article provides contemporary approaches for the perioperative management of patients presenting for dentoalveolar surgery. Attention will be directed to the perioperative management of cardiovascular disease, diabetes, and obesity. These diseases are chosen owing to controversies with respect to good scientific evidence that supports a standard of perioperative care.

Impact of reduced elective ophthalmic surgical volume on U.S. hospitals during the early coronavirus disease 2019 pandemic.

To estimate the financial impact of coronavirus disease 2019 (COVID-19)-related shutdowns on ophthalmic surgery performed at hospital outpatient departments (HOPDs) in the United States. Nationally representative sample of U.S. hospital payment and cost data. Retrospective review and economic impact analysis. The Nationwide Ambulatory Surgery Sample (NASS) was used to identify ophthalmic surgical procedures and associated charges, which were performed at HOPDs. The highest volume elective ophthalmic procedures were identified. The total hospital cost and payment amount was calculated for each procedure using the Hospital Outpatient Prospective Payment System (OPPS) maintained by the Centers for Medicare & Medicaid Services. Net facility income (estimated payments less OPPS rates) was determined for each elective surgical procedure category and stratified by hospital teaching status. In 2017, elective cataract, strabismus, and keratoplasty surgeries were performed 1 230 992 times at HOPDs. The total cost of these elective surgeries was 2350 million U.S. dollars (USD), with a total hospital payment of 3624 to 3786 million USD. This led to an estimated net income of 1278 to 1440 million USD overall to U.S. hospitals in the NASS dataset from elective ophthalmic surgery (approximately 107 to 120 million USD per month), with a larger proportion performed in teaching hospitals. The cessation of elective ophthalmic surgeries at HOPDs during COVID-19 resulted in a significant loss of income for hospitals in the United States and teaching experiences for trainees at academic medical centers.

Decrease in primary but not in secondary abdominal surgery for Crohn's disease: nationwide cohort study, 1990-2014.

Treatment of patients with Crohn's disease has evolved in recent decades, with increasing use of immunomodulatory medication since 1990 and biologicals since 1998. In parallel, there has been increased use of active disease monitoring. To what extent these changes have influenced the incidence of primary and repeat surgical resection remains debated. In this nationwide cohort study, incident patients of all ages with Crohn's disease, identified in Swedish National Patient Registry between 1990 and 2014, were divided into five calendar periods of diagnosis: 1990-1995 and 1996-2000 with use of inpatient registries, 2001, and 2002-2008 and 2009-2014 with use of inpatient and outpatient registries. The cumulative incidence of first and repeat abdominal surgery (except closure of stomas), by category of surgical procedure, was estimated using the Kaplan-Meier method. Among 21 273 patients with Crohn's disease, the cumulative incidence of first abdominal surgery within 5 years of Crohn's disease diagnosis decreased continuously from 54·8 per cent in 1990-1995 to 40·4 per cent in 1996-2000 (P < 0·001), and again from 19·8 per cent in 2002-2008 to 17·3 per cent in 2009-2014 (P < 0·001). Repeat 5-year surgery rates decreased from 18·9 per cent in 1990-1995 to 16·0 per cent in 1996-2000 (P = 0·009). After 2000, no further significant decreases were observed. The 5-year rate of surgical intervention for Crohn's disease has decreased significantly, but the rate of repeat surgery has remained stable despite the introduction of biological therapy.

Pediatric spinal anesthesia at D. G. Khan (Pakistan); Our experience of 20 years

Spinal anesthesia in adults, once very popular, passed through a phase of disrepute and decline, but then resurged and became widely acceptable as the first choice anesthesia in some categories of surgical procedures. It is a useful alternative to general anesthesia (GA) in adults. But this useful technique has been under-utilized in pediatric population in Pakistan. It has come to my knowledge vide personal communication that the anesthesiologists working in south Punjab even in tertiary care hospitals, public or private sector, spinal anesthesia is being administered by only a few anesthesiologists. At D. G. Khan, it has been administered to children (minimum age 16 days) for the last 20 years. No significant complication has been observed up till now.

In‐Hospital mortality varies by procedure type among cirrhosis surgery admissions

Patients with cirrhosis have increased peri-operative mortality risk relative to non-cirrhotic patients, however, the impact of surgical procedure category on this risk is poorly understood. We performed a retrospective cohort study of cirrhosis surgery admissions using the National Inpatient Sample between 2012 and 2014 to estimate the adjusted odds of in-hospital mortality by surgical procedure category. In-hospital mortality differed by surgical procedure category. Relative to major orthopedic surgeries, major abdominal surgeries had the highest odds of in-hospital mortality (odds ratio [OR] 8.27, 95% confidence interval [CI] 5.96-11.49), followed by major cardiovascular surgeries (OR 3.45, 95% CI 2.33-5.09). There was also a significant interaction term, whereby elective/non-elective admission status impacted in-hospital mortality risk differently for each surgical procedure category (P<0.001). In-hospital mortality varies substantially by surgical procedure type. Accounting for procedure type in models may improve risk prediction for peri-operative mortality in patients with cirrhosis.

2121. Shifting Surgical Site Infection Denominators and Implication on NHSN Reporting

BackgroundPer National Healthcare Safety Network (NHSN) rules, when multiple procedures are performed during a single operation, the operation is counted in the surgical site infection (SSI) denominator of each NHSN surgical procedure category. SSIs, however, are counted only in the highest-ranking procedure category. These rules result in procedures that are ineligible to have an associated SSI being counted in SSI denominators.MethodsWe analyzed 3 years (January 1, 2015–December 31, 2017) of laminectomy and rectal surgery SSI data from hospitals in the Duke Infection Control Outreach Network (DICON) that used ICD procedure codes to assign denominators per NHSN definitions. We compared SSI rates using two different denominators: NHSN denominators vs. reduced denominators that counted only primary laminectomy and rectal surgery procedures. We calculated rate ratios (RR) to compare the NHSN and adjusted SSI rates for each procedure for all hospitals that reported at least 1 SSI.ResultsEleven hospitals reported 87 infections following 17,247 laminectomy procedures. The overall SSI rate increased by 44% when only primary procedures were counted in the denominator (RR 1.44); but individual hospital RR ranged from 1.10 to 2.20 (Table 1). 5 hospitals reported seven SSIs following 740 rectal procedures. The overall SSI rate increased by 143% when only primary procedures were counted in the denominator (RR 2.43), but individual hospital RR ranged from 2.00 to 5.00 (Table 1).ConclusionNHSN’s method for calculating SSI denominators underestimates true SSI rate. The current method particularly impacts procedures that are frequently performed in conjunction with higher-ranking NHSN procedures. Counting only primary procedures in procedure category denominators would provide higher, more accurate SSI rates.Table 1.Comparison of SSI Rates Calculated Using Adjusted Denominators vs. NHSN DenominatorsLaminectomy ProceduresHospitalAdjusted RateNHSN RateRR10.550.501.1020.610.531.1530.630.551.1640.260.221.2251.180.901.3061.431.061.3470.240.181.3480.990.701.4190.820.461.77100.840.412.05111.090.502.20Overall0.720.501.44 Rectal Surgeries Hospital Adjusted Rate NHSN Rate RR 19.524.772.0020.600.272.2732.531.072.3742.700.813.3555.001.005.00Overall2.300.952.43Disclosures All authors: No reported disclosures.

Latent class analysis stratifies mortality risk in patients developing acute kidney injury after high-risk intraabdominal general surgery: a historical cohort study.

Risk stratification for postoperative acute kidney injury (AKI) evaluates a patient's risk for developing this complication using preoperative characteristics. Nevertheless, it is unclear if these characteristics are also associated with mortality in patients who actually develop this complication, so we aimed to determine these associations. The 2011-15 American College of Surgeons National Surgical Quality Improvement Program was used to obtain a historical, observational cohort of high-risk intraabdominal general surgery patients with AKI, which was defined as an increase in serum creatinine > 177µmol·L-1 (2mg·dL-1) above the preoperative value and/or the need for dialysis. Latent class analysis, a model-based clustering technique, classified patients based on preoperative comorbidities and risk factors. The associations between the latent classes and the time course of AKI development and mortality after AKI were assessed with the Kruskall-Wallis test and Cox models. A seven-class model was fit on 3,939 observations (derivation cohort). Two patterns for the time course of AKI diagnosis emerged: an "early" group (median [interquartile range] day of diagnosis 3 [1-10]) and a "late" group (day 9 [3-16]). Three patterns of survival after AKI diagnosis were identified (groups A-C). Compared with the group with the lowest mortality risk (group A), the hazard ratios (95% confidence intervals) for 30-day mortality were 1.79 [1.55 to 2.08] for group B and 3.55 [3.06 to 4.13] for group C. These differences in relative hazard were similar after adjusting for the postoperative day of AKI diagnosis and surgical procedure category. Among patients with AKI after high-risk general surgery, the preoperative comorbid state is associated with the time course of and survival after AKI. This knowledge can stratify mortality risk in patients who develop postoperative AKI.

Use of Tranexamic Acid Is Associated with Reduced Blood Product Transfusion in Complex Skull Base Neurosurgical Procedures

Compared with other procedures, complex skull base neurosurgery has the potential for increased intraoperative blood loss yet coagulation near eloquent cranial structures should be minimized. The safety and efficacy of the antifibrinolytic, tranexamic acid in elective neurosurgical procedures is not known. Our primary objective was to determine the relationship between the use of tranexamic acid and transfusion at our institution. Our secondary objective was to determine the incidence of adverse events associated with the use of tranexamic acid. In this retrospective cohort study, we included all patients who underwent complex skull base neurosurgical procedures at our institution between 2001 and 2013. Tranexamic acid was introduced during these procedures in 2006. Patient and surgical variables, transfusion data, and adverse events in the perioperative period were abstracted from the medical record. The rates of transfusion and adverse events were compared between patients who did and did not receive tranexamic acid. Multivariate regression was used to identify independent predictors of perioperative transfusion. We compared 245 patients who received tranexamic acid with 274 patients who did not receive the drug during the study period. The 2 groups were similar, with the exception that patients who received tranexamic acid had larger tumors (mean, 3.5 vs 2.9 cm; P < 0.001) and longer procedures (mean, 7.2 vs 6.2 hours, P < 0.001). The rate of perioperative transfusion in patients who received tranexamic acid was lower (7% vs 13%, P = 0.04). After adjusting for preoperative hemoglobin, tumor diameter, and surgical procedure category, the use of tranexamic acid was independently predictive of perioperative transfusion (adjusted odds ratio, 0.32; 95% confidence interval, 0.15-0.65, P = 0.002). The rates of thromboembolic events and seizure were similar between the 2 groups. Our results demonstrate that tranexamic acid use is associated with reduced transfusion rates in our study population, with no apparent increase in seizure or thrombotic complications. Our data support the need for further randomized clinical trials to evaluate the efficacy and safety of tranexamic acid on perioperative blood loss during complex skull base neurosurgery.

Pregabalin for the treatment of postoperative pain: results from three controlled trials using different surgical models.

PurposeTo evaluate the efficacy and safety of pregabalin (150 or 300 mg/d) as an adjunctive therapy for the treatment of postoperative pain.Patients and methodsThis study reports findings from three separate, multicenter, randomized, double-blind, placebo-controlled trials of adjunctive pregabalin for the treatment of postoperative pain. Patients underwent one of three categories of surgical procedures (one procedure per study): elective inguinal hernia repair (post-IHR); elective total knee arthroplasty (post-TKA); or total abdominal hysterectomy (posthysterectomy). The primary endpoint in each trial, mean worst pain over the past 24 hours, was assessed 24 hours post-IHR and posthysterectomy, and 48 hours post-TKA. Patients rated their pain on a scale from 0 to 10, with higher scores indicating greater pain severity.ResultsIn total, 425 (post-IHR), 307 (post-TKA), and 501 (posthysterectomy) patients were randomized to treatment. There were no statistically significant differences between the pregabalin and placebo groups with respect to the primary endpoint in any of the three trials. The least squares mean difference in worst pain, between 300 mg/d pregabalin and placebo, was −0.7 (95% confidence interval [CI] =−1.4, −0.1; Hochberg adjusted P=0.067) post-IHR; −0.34 (95% CI =−1.07, 0.39; P=0.362) post-TKA; and −0.2 (95% CI =−0.66, 0.31; P=0.471) posthysterectomy.ConclusionThere were no significant differences between pregabalin and placebo with respect to the primary pain intensity measure in each of the three clinical trials. These studies encompass a large dataset (1,233 patients in total), and their results should be considered when assessing pregabalin’s effectiveness in postoperative pain. Further studies are required to determine the potential pain-reducing benefit of pregabalin in the postoperative setting.

Hospital stay following complex major head and neck resection: what factors play a role?

Identify factors which have an impact on the length of postoperative hospital stay in patients undergoing major surgical resection for head and neck cancer. Retrospective study using hospital case notes. Tertiary centre. One hundred and eighty-four patients who underwent 191 major head and neck resections between 2006 and 2010 were identified from the head and neck oncology database. An additional cohort of 52 patients from a second centre was used to externally validate the model. Data collected on 13 variables including age, preoperative haemoglobin level, body mass index, timing of surgery (primary or recurrent tumour), category of surgical procedure (clean, clean-contaminated, contaminated, dirty), tracheostomy (yes or no) and duration of the operation were analysed using a multiple linear regression. In the 13 parameter model, the four variables that were found to significantly (P<0.05) prolong length of stay (LOS) were surgical wound type (clean-contaminated, P=2.19×10(-6) versus clean), tracheostomy (P=0.0034), operation time (P=0.011) and American Society of Anaesthesiologists (ASA) grades 3 and 4 (P=0.0067) versus 1 and 2. The statistically significant variables were used to generate a preoperative submodel without the operative time and a postoperative submodel with all four variables. Overall, the best model based on adjusted R(2) was the postoperative model. When fitted on the external data set, there was no significant difference in the residuals, indicating that the models generalise across centres. Clean-contaminated wound was the most significant factor affecting the LOS, with others being ASA grades 3 and 4, longer duration of surgery and presence of a tracheostomy. Using these parameters, it is possible to predict the LOS in patients undergoing major surgical resection for head and neck cancer.

Typy oczekiwanego wsparcia w okresie okołooperacyjnym u kobiet leczonych ginekologicznie

Introduction: Women at the periand post-menopausal age who are qualified for surgical procedures for gynaecological reasons are exposed to specific emotional problems related with the necessity to perform the surgery. Therefore, they often expect various types of support. A characteristic feature of this support is an exchange of emotions, information, instruments for action and tangible property. Aim of the study: The objective of the study was to perform an analysis of the type of support expected during the peri-operative period by women treated for gynaecological reasons. Material and methods: The study covered 232 women at the preand peri-menopausal age who received surgical treatment for various gynaecological reasons. The study was carried out using an author-designed questionnaire form. The results of the study obtained were analysed statistically. The p values p < 0.05 were considered statistically significant. Results: It was found out that respondents who had university education significantly more frequently (p < 0.05) expected information and instrumental support, compared to those with elementary/elementary vocational or secondary education level. In turn, patients who were married significantly more often expected emotional and information support, compared to those who were single. The respondents who had undergone a surgical procedure with considerable tissue injury significantly more frequently (p < 0.05) expected material support than women who had undergone surgery with moderate tissue injury. Conclusions: The education level and marital status of patients determined the expectations of support during the peri-operative period, whereas patients’ age and category of surgical procedure did not have any effect on the expectations of support during this time.

Surgical procedures before and after starting chronic hemodialysis in a predominantly male population with high prevalence of diabetes

The purposes of this study were to analyze changes in the frequency of different categories of surgical procedures after initiation of chronic hemodialysis (HD) and to identify the types of procedures associated with in-hospital postoperative mortality. This was a retrospective analysis of surgical procedures performed in an incident HD population of 392 patients followed in the dialysis unit of one hospital over 15 years. Among these patients, 384 were men and 258 had diabetes mellitus. At the start of HD, age of the patients was 66.3 ± 11.2 years and Charlson index 5.35 ± 2.41. Rates of procedures per patient year (n/[pt-yr]), reported as mean (95% Confidence Interval [CI]), were compared by nonparametric methods. In the whole HD population, the overall rate of procedures increased in the HD period (pre-HD 0.125 [95% CI 0.101-0.149] n/[pt-yr]; HD 0.928 [95% CI 0.795-1.061] n/[pt-yr]; p<0.001). The increase, noted in patients with and without diabetes, reflected increases in the rates for both vascular access and non-vascular access procedures from the pre-HD to the HD period. Amputations and surgery for hip fractures accounted for the increase in the rates of procedures related to non-vascular access. Procedures associated with mortality in the HD period included amputations, hip repair and abdominal surgery for septic conditions. Rates of surgical procedures for vascular access, amputations, and hip fractures ?increased after the start of HD. Amputations and hip fractures, both potentially preventable, are associated with mortality in HD patients.