Team Of Surgeons Research Articles

HPB SO61 - Benefits of Dual-surgeon On-call team on Emergency Laparoscopic Cholecystectomy – a Single Centre Experience

Abstract Background Since 2015, UK national guidance from National Institute for Health and Care Excellence (NICE) has been to offer laparoscopic cholecystectomy for patients presenting with acute cholecystitis within 7 days of admission. The aim of this study was to measure the benefits of a second team of surgeons doing emergency operations (first team dealt with emergency admissions and referrals) in terms of length of stay, conversion to open, morbidity, mortality, bile duct injury and rate of early cholecystectomy in a UK based district general hospital. Method Retrospective analysis of a prospectively maintained database was collected from electronic health records, admission and operative notes. Results were extracted in terms of index laparoscopic cholecystectomy, rate of conversion, intra-operative cholangiography, associated morbidity, mortality, bile duct injury, conversion to open, readmission rate and length of stay. The numbers and rates of cholecystectomy over the last six years duration was collected and compared year-on-year period, since early 2019 after the implementation of dual-surgeon on-call cover. Results Altogether, there was 944 cholecystectomy performed within 14 days, out of which 74% of cases was operated within the first week of presentation <8 days since admission. Majority of cholecystectomy was performed laparoscopically, there were twenty-three (2.43%) conversion to open, forty-six sub-total cholecystectomies (4.87%),intraoperative cholangiography was performed in 28.4% of cases and Indocyanine green (ICG) cholangiography was used in 50.5% of all cases. Average length-of-stay (LOS) was 2.2 days, there were eight cases (0.84%) of post-op bile leak, one bile-duct injury, one case of post-operative bleed, one case of small bowel injury and two deaths. Conclusion With the adoption of dual-surgeon on call, early laparoscopic cholecystectomy benefits both patient and hospital. It reduces time to surgery for patients, decreases overall length of stay, and reduces readmission rates and cost, with similar morbidity and mortality.

The effects of laparoscopic sleeve gastrectomy on serum levels of growth hormone and insulin-like growth factor 1

Background. It is unclear exactly how bariatric surgery affects the body’s metabolic and physiological functions. The purpose of the study was to assess the activity of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) levels in obese individuals before and six months after laparoscopic sleeve gastrectomy. Materials and methods. This study included 52 patients with a body mass index (BMI) ranging from 35 to 56 kg/m2 who qualified for laparoscopic sleeve gastrectomy and had completed data at the 6-month postoperative follow-up. All patients were clinically examined by a team of surgeons and a physician before operation. The serum levels of GH and IGF-1 were assessed pre- and post-operatively. Results. The study included 52 patients with obesity who were undergoing laparoscopic gastric sleeve surgery. Their mean age was 32.04 ± 6.90 years. More than half of the patients, 27 (51.9 %), were aged 19 to 32 years, 32 (61.5 %) patients were females, and 38 (73.1 %) had a BMI of 35–49.9 kg/m2. There was a significant increase in the serum GH after the sleeve gastrectomy compared to the pre-operative level (0.95 ± 0.30 vs 0.62 ± 0.40 ng/ml, p = 0.0001). IGF-1 also significantly increased after the surgery: 117.13 ± 32.40 vs 102.63 ± 33.90 ng/ml (p = 0.0001). Concerning BMI, there was no significant difference in the GH mean for patients with a BMI of 35–49.9 and 50–56 kg/m2 pre- and post-operatively: 0.6 vs 0.8 (p = 0.07) and 0.9 vs 1 (p = 0.5), respectively. On the other hand, IGF-1 exhibited a significant difference before and after surgery: 107.7 vs 88.9 ng/ml (p = 0.02) and 123.2 vs 100.7 (p = 0.03). Conclusions. This study concludes that sleeve gastrectomy significantly increases the serum level of both GH and IGF-1 and, consequently, their effects on disturbed lipid and protein metabolism in morbidly obese patients.

Role of the Pectoralis Major Muscle Flap in the Multidisciplinary Treatment of Esophageal Cancer.

Management of esophageal cancer is complex. Esophagectomy is associated with risk of significant complications. In this case series, we share the experience of our multidisciplinary team of thoracic surgeons and otolaryngologists in managing complications arising in the surgical treatment of esophageal cancer with the assistance of regional tissue transfer in the form of the pectoralis major flap. We present a case series highlighting 3 patients who underwent esophagectomy who experienced significant anastomotic or conduit complications which were managed with a pectoralis muscle flap. Complications included tracheoesophageal fistula, refractory stenosis, and gastric conduit necrosis. Using a pectoralis major muscle flap with both myocutaneous and myofascial transfers was key to successful management. In the first patient, esophageal stent erosion after posterior tracheal wall dissection resulted in a tracheoesophageal fistula reconstructed through interposition of a myofascial flap. In the second patient, a tubed myocutaneous flap was interposed between the remnant gastric conduit and cervical esophagus to manage a posttreatment stenosis following resection of the stenosed segment. Finally, a myofascial flap was utilized to bolster a colonic interposition flap after initial necrosis of a gastric conduit that necessitated the creation of a temporary pharyngocutaneous fistula and subsequent colon interposition. Multidisciplinary care and collaboration are integral components for optimization of patient outcomes. In this case series, otolaryngology and thoracic surgery utilized multiple tools within their armamentarium to manage complications associated with the surgical management of esophageal cancer.

Drain versus no-drain at the donor sites of iliac crest bone graft: a retrospective study

BackgroundClosed suction drainage is typically used in orthopaedic surgery to reduce the occurrence of incision complications. However, whether drainage tubes should be routinely placed in iliac crest bone graft surgeries is still unclear. This study aimed to evaluate the effect of closed suction drainage at iliac crest bone donor site on clinical prognosis.Materials and methodsG.Power was used for a prior analysis to estimate the required sample size. 91 patients with tibial plateau fractures who underwent iliac crest harvesting and grafting between January 2019 and January 2022 were enrolled in the study. All surgeries were performed by the same experienced surgeon team. Patients were divided into close suction drainage (CSD) group and no-CSD group according to the use of drainage tube. The demographic and perioperative data of the patients were collected and analyzed.ResultsThere were no significant differences in demographic characteristics between the two groups except that the CSD group had more people with diabetes. The use of closed suction drainage in patients undergoing iliac crest harvest can significantly reduce the incidence of incision complications without increasing pain level and extending hospital stay. However, the closed suction drainage obviously caused the increase of blood loss. More drainage tubes would cause more drainage fluid to flow out. And drainage tube placement may impose a higher financial burden on patients.ConclusionThe closed suction drainage should not be recommended routinely for iliac crest bone graft patients. Only when the patient is at high risk for infection and without severe blood loss, placing a single drainage tube is recommended.Trial registrationThis study was registered at (NCT04807062) and approved by the Ethics Committee of the participating institution (Theoretical No. 2015-003-1).

Utility and Outcomes of a Keystone Perforator Island Flap for Reconstruction at Various Anatomical Locations: A Prospective Study.

Background In Yemen, traumatic wounds are prevalent, imposing a substantial burden on plastic surgery teams operating within limited-resource settings. Advanced microsurgical reconstruction options are scarce, and expertise in free flap techniques is limited. While local flaps are commonly used for soft tissue reconstruction, there is a need for simpler, effective alternatives with lower complication rates. This study aimed to evaluate the effectiveness and outcomes of the keystone island perforator flap (KIPF) as a viable alternative for soft tissue coverage in resource-challenged facilities. Methods From February 2021 to December 2023, a single surgeon's team in three plastic and reconstructive surgery departments in Sana'a, Yemen, conducted this prospective study, which included 35 patients who underwent KIPF for various soft tissue defects. We assessed patient demographics, intraoperative variables, and postoperative outcomes, including aesthetic outcomes evaluated using the Patient and Observer Scar Assessment Scale (POSAS) at six months postoperatively. We analyzed the factors influencing flap success and complication rates. Results The mean age of patients was 29 ± 11.75 years, with the majority being males, comprising 86% of the sample. Trauma was the leading cause of tissue defects (77.1%), primarily affecting the legs (57.14%) and feet (11.43%). The mean operative time was 73.57 minutes. Complications occurred in 26% of patients, with flap dehiscence being the most common (11.43%). Ninety-seven percent of patients experienced flap survival, and 91.4% experienced complete wound healing within a median of 16 days.Scar assessments at six months postoperatively indicated satisfactory aesthetic outcomes, with scars resembling normal skin. Conclusion The KIPF technique proves to be a reliable and practical option for soft tissue reconstruction in resource-limited settings. Its simplicity, minimal postoperative care needs, and high flap survival rates make it an advantageous alternative to more complex reconstructive techniques. This study supports the adoption of KIPF as a standard approach in similar environments with limited reconstructive surgery capabilities.

The radiological primary survey: A systematic approach and guide to reading torso computed tomography images in trauma for surgeons

Background Trauma is a disease where time is of the essence. In many lower middle-income countries, definitive management and planning for trauma patients are often delayed after working hours because of either a lack of technicians to perform computed tomography (CT) scans or a lack of radiologists to interpret them. These lacunae can be bridged if more and more surgeons become confident in interpreting trauma CT images. Method In this narrative review, written in a ‘how to do it’ manner, we describe a way of doing a structured and quick ‘radiological primary survey’ of the torso CT, which we believe will help quickly identify major injuries systematically, thereby avoiding delays in management and forming a care plan. The method has been developed by a team of trauma surgeons and radiologists and stems from the DRS ABCDE technique used in interpreting trauma chest X-rays. Result The DRS ABCDE extrapolated to the trauma torso CT includes the following steps- Details, WRAP (W-windowing, R-Region, A-Axis, P-Phase), S- the Scout film, Airway, Breathing, Circulation, Disability and Extras. Conclusion The review will enable resident trainees and trauma care professionals to interpret trauma CTs using a structured approach.

What is known about near miss events in the operating room? A systematic review of studies of mixed methods design.

A near miss event (NME) in healthcare is an event that did not happen but would have caused serious harm if it did. The operating room (OR) is prone to risk and incidents, with estimates that 50% of all hospital adverse events occur in the OR, yet reporting of NME is uncommon in the OR. To carry out a systematic review of studies with mixed methods to establish what is known about NME reporting in the OR. Inclusion criteria will be those studies of mixed methods design, which have been conducted in the OR, with teams of surgeons, anaesthetists or nurses alone or in any combination. Using a publication timeframe of 2001-2023, the following databases were searched: Medline (OVID), CINAHL, Pubmed and Google Scholar. Selected papers for the review were assessed using the Quality Assessment Tool for Studies of Diverse Designs. Fourteen papers were included in the review. NMEs are common occurrences that are underreported in the OR. When NMEs occur in multiples for the same patient, the risk of serious harm increases. Feedback and education about NME helps to improve reporting; ORs with high rates of NME reporting have less serious patient harm events. The implications of the findings for improving healthcare safety are discussed and in particular the adoption of the science of Human Factors Ergonomics into healthcare.

Getting a colonoscopy at The Valley Hospital.

71 Background: Colorectal cancer (CRC) is the 3rd most common cancer in the U.S., yet it is preventable with evidence-based strategies such as early screening. The Valley Hospital (TVH) located in Bergen County NJ, is recognized for its high insured payer mix and median household income. According to the 2016 TVH Community Health Needs Assessment, only 71.4% of patients in TVH service area have had a CRC screening. The American Cancer Society National Colorectal Cancer Roundtable (NCCRT) campaigned to reach CRC screening rates of 80% and higher in communities across the nation. The Fast Track Screening Colonoscopy Program (FTSCP) at TVH was created to streamline the process of obtaining a screening colonoscopy and reach the NCCRT’s goal. Through the FTSCP, patients can omit the initial consultation with a gastroenterologist or colorectal surgeon. Patients are instead screened via a telephone call by a Physician Assistant (PA) or Advanced Practice Nurse (APN). The FTSCP is cost effective for patients as it potentially eliminates the initial consultation copayment and/or coinsurance. Methods: The purpose of the FTSCP is to achieve the NCCRT’s 80% goal of CRC screenings in TVH service area. An interdisciplinary team of gastroenterologists, colorectal surgeons, oncologists, anesthesiologists, and administration collaborated to create the FTSCP. A screening questionnaire was developed using the Lincoln Hospital in NYC’s existing criteria for patients who are eligible for a direct endoscopy referral. The questionnaire criteria ensures patients are safe to eliminate the initial consultation. A PA or APN determines the patients’ eligibility for the FTSCP over a screening telephone call. To qualify, patients cannot have significant medical comorbidities or exhibit signs or symptoms of CRC. If deemed eligible, the PA or APN sends a bowel preparation prescription to the patient’s pharmacy, reviews the instructions with them, and meets with them on the day of the procedure at TVH to perform a pre-procedural physical exam. To promote awareness and education of the FTSCP, multiple ongoing outreach events are held in the community. Patients also learn about the FTSCP through primary and specialty care referrals. Results: Since the inception of FTSCP in 2018, over 1300 patients have been screened for CRC. Additionally, adenocarcinomas, carcinoid tumors and tubular adenomas with high grade dysplasia have been detected. 394 tubular adenomas (30%) were identified and removed. In 2018, 59 patients were screened. The number of patients increased by 500% to 296 in 2023. The 2022 TVH Community Health Needs Assessment showed an increase to 79.6% of patients in TVH service area who have undergone CRC screening. Conclusions: The FTSCP at TVH is maximizing patient’s access to the prevention and timely screening for CRC. Additionally, TVH’s relocation from Ridgewood, NJ to Paramus, NJ offers further opportunities to educate a new community on CRC prevention.

Cross-Professional Evaluation of 3D Visualization of Liver Malignancies in the Decade of AI and Automatic Segmentation: A Benefit for Multidisciplinary Teams and Tumor Board Decisions?

Purpose To investigate whether automatic 3D visualization of computed tomography (CT) data sets with singular liver tumor compared to 2D images could foster a broader understanding of tumor localization and resectability in the liver within a multidisciplinary team and might therefore be a useful tool in multidisciplinary decision-making. Material and methods The study was configured as a web-based questionnaire. Physicians of all levels of medical training from surgery, radiology, and gastroenterology departments were recruited. A total of seven cases with singular liver tumor CT images with adequate quality were selected. Automatic 3D segmentation was performed using Universal Atlas (Release 5.0) as part of the Brainlab of Elements software suite (Brainlab AG, Munich, Germany). All cases were randomly presented in a 2D and 3D manner. After every case-presentation, multiple choice (single answer) questions concerning tumor extent and resectability were asked. The questions as well as the answers defined to be correct, were evaluated by two senior consultants from the radiology and surgery department.The primary outcome parameters were the correctness of answers stratified for medical specialty and for the level of medical training. The secondary outcome was the time needed for the evaluation of seven liver cases using 2D versus 3D images. Sixadditional questions were tailored to evaluate the subjective value of the 3D visualization. Results A total of 92 participants participated in the study, 31.5% of them were abdominal surgeons, 34.8% gastroenterologists, and 33.7% radiologists. Based on the level of medical training, 66 were residents (71.7%) and 26 consultants (28.3%). Only radiologists answered more questions correctly using 2D imaging compared to the 3D method (p = 0.006). There was no statistically significant difference between correctly answered questions when using 2D vs. 3D visualization in the gastroenterologist and surgeon groups (p > 0.05). The resident subgroup showed no statistically significant difference when using the 2D vs. 3D images (p > 0.05), the consultant subgroup answered more questions correctly using 2D imaging (p = 0.009). Physicians with elementary experience of liver pathology also showed no difference in 2D vs. 3D (p = 0.332), physicians with proficient experience of liver pathology answered more questions correctly using 2D imaging (p = 0.010). The median time taken for the evaluation of the seven liver cases was only significantly faster for the gastroenterologist group (p = 0.006) using the 3D analysis (median: 9.1 minutes) than the 2D analysis (median: 10.7 minutes). Over 80% of the participants found the 3D presentation to be a helpful additional tool for the clinical routine according to the subjective questionnaire. Conclusion In this study 3D visualization of liver tumors was evaluated as helpful within a multidisciplinary team of radiologists, surgeons, and gastroenterologists. However, significantly superior results in the understanding of liver anatomy could not be demonstrated by means of 3D visualization. It may be that more immersive technologies such as augmented reality or virtual reality will lead to a superior understanding compared to conventional presentation of information in 2D cross-sectional images.

Lower Limb Comprehensive Reconstructive Surgery: Experiences from an Orthopedic Teaching Unit

Abstract Introduction: The burden of open extremity fractures is well recognized in placing a burgeoning demand on an already exhausted medical facility in low- and middle-income countries. This study aims to evaluate the functional outcome following “orthoplastic management” by orthopedic surgeons trained in limb reconstruction surgery. Methodology: Adult patients with open lower limb injuries treated from January 1, 2022, to December 30, 2022, who underwent single or staged fixation and reconstruction procedures were identified. Patients with Gustilo–Anderson type IIIB fractures requiring skeletal stabilization with soft-tissue cover were included. Polytrauma patients requiring multidisciplinary surgical attention were excluded. A team of orthopedic surgeons trained in limb reconstruction was involved in the management. Inpatient and outpatient department follow-up by the treating team was done to document complications (infections, reoperations, and graft failures) and functional outcomes using the Lower Extremity Function Score. The duration of mean follow-up was 1 year since index surgery. Results: A total of 24 adult patients with open lower limb injuries with preoperative Ganga Hospital Score (GHS) were included. Decision toward fixation with primary closure or further reconstruction was made collectively. The gray zone (GHS score of 15–16) of patients was more aggressively managed with emphasis on salvage. Additional reconstructive procedures were carried out based on the assessment at consequent follow-up. Three patients had a suboptimal joint function (less than functional range of motion for the involved joint) due to the resultant loss of compartment(s) and joint contracture. Five patients were retaken to the theater for further supplementary or corrective procedures following the index, definitive surgical procedure (bone grafting, partial flap loss, and fixator readjustment). Conclusion: Good-to-excellent functional outcome was demonstrated with the “orthoplastic approach” where skeletal stabilization as well as soft-tissue reconstruction was performed by trained orthopedic surgeons. This study demonstrated that orthoplastic surgery is a safe and effective method of limb salvage.

Thoracic surgery in children and adolescents: Experience from the thoracic surgery unit of a single referral center.

The study aimed to highlight and evaluate thoracic surgical procedures performed in children and adolescents and demonstrate the extent to which thoracic surgeons can benefit this population. This retrospective study included 200 pediatric patients (100 males, 100 females; mean age: 14.7±6.7 years; range, 1 month to 21 years) who underwent thoracic surgery between January 2018 and January 2023. Patients' indications for surgery, surgical approach, complications, length of hospital stay, need for intensive care admission, and mortality were evaluated. The most commonly performed surgery was sympathectomy (30.5%), followed by decortication (16%) and traumatic exploration (14%). Approximately 50% of surgeries were minimally invasive. The average length of hospital stay was 2.8 days, and the rate of intensive care admission was 20%. The intraoperative and postoperative complication rate was 10%. The concept of treating pediatric patients as small-size adults is irrational. Pediatric patients need special care and tailored guidelines due to their peculiar physical, psychological, and anatomical characteristics. We believe that having a dedicated team of thoracic surgeons trained and subspecialized for pediatric thoracic pathologies will improve outcomes. Furthermore, more research must be directed to this age group to establish evidence-based consensus and guidelines.

444. QUALITY OF LIFE OF CHILDREN AFTER ESOPHAGEAL REPLACEMENT

Abstract Introduction For reconstruction of the esophagus in children colon interposition and reconstruction of the esophagus by stomach should are most often used. This work aims to compare the quality of life of patients in these groups to determine the optimal method for esophageal reconstruction in children. Material and methods. For 6 years 167 esophageal replacement was performed at the Filatov Children's Hospital. Of these, 57 children were evaluated for quality of life through a questionnaire, which was carried out when the child was re-admitted for follow-up examinations. All operations were performed by the same team of surgeons. We compiled the questions in the questionnaires specifically for this group of patients, which are shown in the table 1. The questionnaire for children under 14 years of age was completed by parents. Older children 14-year-olds filled out the questionnaire independently. The respondents were divided into 2 groups. Group 1 – 26 children who underwent reconstruction of the esophagus by stomach. The 2nd group included 29 children after colonic interpositions. In terms of gender, age and indications for surgery were comparable in both groups. Patients were interviewed from 6 months to 5 years after surgery. Results Tab. 1 Comparative analysis of results interviewed patients in two groups Despite the fact that esophageal reconstruction by stomach is easier to perform and it is even possible to perform this operation laparoscopically, as can be seen from the table above, children have significantly more problems in many indicators affecting the quality of life. Conclusions Reconstruction of the esophagus by stomach should be used for: reoperations after failed colon interposition; malformations and other pathologies of the colon and the “loose” type of blood supply to the colon. The operation of choice, in our opinion, is colon interposition, which demonstrates the best indicators of quality of life.

Early Diagnosis of Gall Bladder Cancer: An Appeal

A team of gastroenterologists, oncologists, pathologists, radiologists, and surgeons from a university teaching hospital in western India make an appeal, through the Journal, to the statutory bodies and the scientific societies related to surgery, oncology, gastroenterology, radiology, and pathology for considering measures, which, if implemented, can help in early diagnosis of gallbladder cancer, the most common nongender organ cancer in women in some parts of India.

Risk and Protective Factors of Postoperative and Persistent Hypoparathyroidism after Total Thyroidectomy in a Series of 1965 Patients.

Postoperative hypoparathyroidism (HypoPTH) is the most common complication following total thyroidectomy. Several risk factors have been identified, but data on postoperative follow-up are scarce. The study focused on 1965 patients undergoing surgery for benign and malignant thyroid diseases at a tertiary-level academic center. Anamnestic, biochemical, surgical, pathological, and follow-up data were evaluated. HypoPTH was defined by a serum concentration of PTH < 10 pg/mL on the first or the second post-operative day. Persistent HypoPTH was defined by the need for calcium/active vitamin D treatment > 12 months after surgery. Postoperative HypoPTH occurred in 542 patients. Multivariate analysis identified the association of central lymph-nodal dissection, reduced preoperative PTH levels, a lower rate of parathyroid glands preserved in situ, and longer duration of surgery as independent risk factors. At a median follow-up of 47 months, HypoPTH regressed in 443 patients (more than 6 months after surgery in 7%) and persisted in 53 patients. Patients receiving a lower dose of calcium/active vitamin D treatment at discharge (HR 0.559; p < 0.001) or undergoing prolonged, tailored, and direct follow-up by the operating endocrine surgeon team had a significantly lower risk of persistent HypoPTH (2.4% compared to 32.8% for other specialists) (HR 2.563; p < 0.001). Various patient, disease, and surgeon-related risk factors may predict postoperative HypoPTH. Lower postoperative calcium/active vitamin D treatment and prolonged, tailored follow-up directly performed by operating endocrine surgeons may significantly reduce the rate of persistent HypoPTH.

Hemodynamic Effects of Bone Cement Implantation in Hip Arthroplasty: Insights from a Prospective Study in Eastern India.

Bone cementation has various effects on hemodynamics including potentially fatal bone cement implantation syndrome (BCIS). Most of the studies on BCIS are from developed countries. We have studied the effect of bone cement on hemodynamics in hip arthroplasty in the eastern Indian population and compared it with the available literature. This prospective study was done by a team of orthopedic surgeons and anesthesiologists in a tertiary center in eastern India between March 2020 and December 2022. Seventy-two patients (Male 38: and Female 34) of age between 25 and 100 years fulfilling the inclusion criteria were included. In 43 patients (43/72, 59.72%) systolic and diastolic blood pressure fell in the range of 10 mmHg, in 22 patients (22/72, 30.56%) fall in blood pressure was in the range of 10-20 mmHg, and more than 20 mmHg fall in blood pressure were seen in seven patients (7/72, 9.72%). SPO2 decreased from 97-100% to 94-96% in 28 patients and 90-93% in six patients, which began to rise after 5 min of cementing and returned to normal after 10 min. Arrhythmias were seen in 16 patients with multiple comorbidity. Two patients had a cardiac arrest and one patient died after 6 h in the intensive care unit. Pre-operative evaluation, perioperative monitoring of hemodynamic parameters during cementing especially in high-risk patients with multiple comorbidities, and taking essential precautions during cemented arthroplasty are the key to preventing complications like BCIS.

Predicting Outcome after Acute Severe Ulcerative Colitis: A Contemporary Review and Areas for Future Research.

Acute Severe Ulcerative Colitis (ASUC) is a severe form of ulcerative colitis relapse which requires hospitalization and intensive medical intervention to avoid colectomy. The timely recognition of patients at risk of corticosteroid failure and the early initiation of medical rescue therapy are paramount in the management of ASUC. The choice of medical rescue therapy is influenced by multiple factors, especially patient's prior treatment history. This decision should involve the patient and ideally a multidisciplinary team of healthcare professionals, including gastroenterologists, radiologists, surgeons and enterostomal therapists. Although several predictive models have been developed to predict corticosteroid failure in ASUC, there is no single validated tool that is universally utilized. At present, infliximab and cyclosporine are the only agents systematically evaluated and recommended for medical rescue therapy, with recent reports of off-label utilization of tofacitinib and upadacitinib in small case series. The available evidence regarding the efficacy and safety of these oral small molecules for ASUC is insufficient to provide definitive recommendations. Early decision-making to assess the response to medical rescue therapy is essential, and the decision to pursue surgery in the case of treatment failure should not be delayed.

VIRTUAL PLANNING IN ORTHOGNATHIC SURGERIES: A systematic review

Orthognathic surgeries have had their surgical planning carried out in an analogue manner for a long time. However, with the advancement and popularization of technologies, surgeries began to be planned virtually, using intra-oral scanning, computed tomography, and software that simulates the steps, and the final result, also providing surgical guides that help to increase precision throughout the execution of the procedure. 3D planning may present some obstacles to its implementation, such as its high cost and the need for greater training of the surgeon team. Therefore, the objective of this work is to carry out a systematic review to evaluate and synthesize studies on virtual planning in orthognathic surgeries.

Top Ten Tips Palliative Care Clinicians Should Know Before Their Patient Undergoes Surgery.

Many seriously ill patients undergo surgical interventions. Palliative care clinicians may not be familiar with the nuances involved in perioperative care, however they can play a valuable role in enabling the delivery of patient-centered and goal-concordant perioperative care. The interval of time surrounding a surgical intervention is fraught with medical, psychosocial, and relational risks, many of which palliative care clinicians may be well-positioned to navigate. A perioperative palliative care consult may involve exploring gaps between clinician and patient expectations, facilitating continuity of symptom management or helping patients to designate a surrogate decision-maker before undergoing anesthesia. Palliative care clinicians may also be called upon to direct discussions around perioperative management of modified code status orders and to engage around the goal-concordance of proposed interventions. This article, written by a team of surgeons and anesthesiologists, many with subspecialty training in palliative medicine and/or ethics, offers ten tips to support palliative care clinicians and facilitate comprehensive discussion as they engage with patients and clinicians considering surgical interventions.

Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System.

Surgeons performing federal insurance-financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE's definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals. The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects. For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed. In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.

Clinical Evaluation of 51 Patients with Cleft Lip and/or Palate in Social Work at Syariah Hospital.

The study aims to evaluate the surgical outcomes, including post-operative complications, in patients undergoing cleft lip and palate surgery in social work. The study was conducted on 51 patients in three social work settings, with inclusion criteria of age over 3 months, weight over 10 pounds, and normal chest x-ray results. Patients with syndromic or cardiac abnormalities were excluded from the study. The surgery was performed by a team of oral and maxillofacial surgeons with a minimum of 2 years of surgical experience. The study found that post-operative complications were relatively rare and could be managed well. This study has important implications for improving the quality of healthcare services for patients with cleft lip and palate, as well as increasing public awareness of the importance of proper medical care for this condition.