Time Of Surgery Research Articles

Global strategies to reduce elective surgery waiting times for sustainable health outcomes: a systematic review

ABSTRACT Objective Long waiting times for elective surgery reflect not just backlog issues but systemic inefficiencies that disrupt the smooth flow of patients through the surgical care pathway. This systematic review adopts a holistic approach to summarize global policies, strategies, and interventions aimed at reducing elective surgery wait times. Method A comprehensive electronic search was performed in PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library from December 2019 to January 2020 and updated in April 2022. Eligible studies, published after 2013, focused on waiting lists for major elective surgeries in adults, excluding cancer-related surgeries. Both randomized and non-randomized studies and systematic reviews were included. Study quality was assessed using ROBINS-I, AMSTAR 2, and CASP tools, as appropriate. The review was registered in PROSPERO (CRD42019158455) and reported using a PRISMA flow diagram. Results From 7543 records, 92 articles met the inclusion criteria. Evidence was categorized into seven strategic areas: referral management, patient prioritization, preventing scheduled surgery cancellations, perioperative time management, quality improvement methods for surgical care pathways, and waiting time targets for hospitals. Strategies such as referral management, patient prioritization, and preventing cancellations had the most significant impact on reducing waiting times, while perioperative time management and waiting time targets proved less effective. Conclusion The review highlights that targeted interventions at different stages of the surgical care pathway yield variable impacts on overall waiting times. While individual measures had limited effects, combining multiple short-term strategies may be more beneficial, particularly for health systems recovering from the COVID-19 pandemic.

A comparison of postoperative microbiological and histological test results with the indication for revision as listed at the time of surgery in the National Joint Registry: a single-centre cohort study of metal-on-metal total hip replacement and hip resurfacing revision procedures.

Surgeons allocate an indication(s) for revision surgery on NJR Minimum Data Set forms in the immediate perioperative period, when results from intraoperative histology and microbiology samples are not available. We evaluated to what extent the postoperative diagnostics obtained for patients undergoing metal-on-metal hip arthroplasty (MoMHA) revision surgery align with the indication for revision listed in the NJR. NJR data for MoMHA revision patients (2004-2015) at a single centre were linked to hospital records of microbiology and histology testing for prosthetic joint infection (PJI) and adverse reaction to metal debris (ARMD). The Musculoskeletal Infection Society and Mirra classifications were used as "gold standards' to classify PJI and ARMD respectively and to assess the diagnostic accuracy of the clinician selected revision indication recorded on MDS forms. Of 301 cases, 5.6% (n = 17) and 3.7% (n = 11) were revised for PJI and ARMD respectively. In a further 6.6% (n = 20, PJI) and 15.6% (n = 47, ARMD) the indication for revision selected at the time of surgery did not corroborate with the test results from intraoperative samples. Diagnostic accuracy analysis revealed sensitivity and specificity of indication for surgery at the time of revision for PJI of 35.5% (95% CI, 19.2-54.6) and 97.8% (CI, 54.6-95.2) respectively, and for ARMD of 7.41% (CI, 2.06-17.9) and 97.2% (CI, 94.3-98.9) respectively. We observed that the results of histology and microbiology analyses of intraoperative samples may provide evidence to support alternative diagnoses in 20% of cases. This indicates a need for a change in the work-up of these cases to allow a more accurate prediction of the indication for revision. Alternatively, if there was evidence of a difference in outcome for patients where the indication may be changed when such data becomes available, the feasibility of a facility to add additional information from samples taken intraoperatively when it becomes available should be explored.

Out-of-Hours Laparoscopic Appendectomy: A Risk Factor for Postoperative Complications in Acute Appendicitis?

Background: The surgical environment can influence the clinical outcomes of procedures and patient conditions. This retrospective study aimed to evaluate how surgical timing affects short-term outcomes in emergency laparoscopic appendectomy for acute appendicitis. Methods: A total of 647 patients with acute appendicitis who underwent emergency laparoscopic appendectomy at Chuncheon Sacred Heart Hospital between January 2018 and June 2021 were included in this study. The study cohort was divided into the following two groups based on the timing of surgery: work hours and out-of-hours (weekends, holidays, or weekday nights). Clinical outcomes were then compared between the groups. Results: Work-hour and out-of-hours appendectomies were performed in 282 and 365 patients, respectively. Baseline characteristics and types of appendicitis were similar between the groups (complicated appendicitis: 26.6% in the work-hours group versus 30.4% in the out-of-hours group, P = .288). Operation times were comparable (35.10 minutes versus 34.33 minutes, P = .620), with no cases requiring conversion to open appendectomy in either group. The overall rate of 30-day postoperative complications did not differ significantly between the groups (7.8% versus 10.4%, P = .849). The severity of postoperative complications, categorized by the modified Clavien-Dindo classification, did not show significant differences between the groups (P = .849). In addition, the time to functional recovery was similar in both groups. Conclusions: The clinical outcomes of out-of-hours laparoscopic appendectomy were similar to those of procedures performed during working hours. Therefore, scheduling emergency surgery can be determined based on the patient's condition and the hospital's capacity to manage acute appendicitis.

Obstacles and sustainability of enhanced recovery after surgery in pediatric laparoscopic pyeloplasty

ObjectivesPrevious studies on Enhanced Recovery After Surgery (ERAS) in pediatric Laparoscopic Pyeloplasty (LP) lacked clear control cases and discussed the obstacles in the implementation process. This article details the obstacles and lessons learned during the implementation of ERAS in patients with ureteropelvic junction obstruction (UPJO).MethodsAn ERAS protocol was implemented in the UPJO population undergoing LP, which included preoperative, intraoperative, and postoperative management. The clinical data of ERAS program Before Implementation (BI) and After Implementation (AI) were collected and analyzed retrospectively.ResultsA total of 107 patients (BI 46, AI 61) were enrolled. Compared with the BI group, the AI group had an earlier normal diet (19.83 h vs. 9.53 h, p < 0.001), ambulation (39.10 h vs. 12.70 h, p < 0.001), resumption of defecation (89.88 h vs. 27.90 h, p < 0.001), less need for additional analgesia (19.5% vs. 1.6%, p = 0.002) and shorter postoperative hospital stay (POS) (6.00 d vs. 1.91 d, p < 0.001) without increasing complications and readmission rates. Patients in the AI group had a median protocol score of 17 (IQR 16–18), and the compliance rate of the ERAS protocol was negatively correlated with the length of POS (R2 = 0.69, p < 0.001).ConclusionsThe application of ERAS in pediatric LP is feasible and sustainable, with the potential for even greater impact as compliance improves. Common barriers were uncertain start time of surgery, lack of knowledge of ERAS among pathway participants, and support from anesthesiologists. Pre-determining the start time of surgery, strengthening preoperative education and positive communication among team members can help to promote the full implementation of ERAS program.

Does Frequent Use of Advanced Energy Devices Improve Hysterectomy Outcomes?

Background and Objectives: The objective of this study was to assess the efficient use of advanced energy devices by examining the impact of their usage frequency on surgical outcomes of total laparoscopic hysterectomies. Materials and Methods: A retrospective study was conducted between 2020 and 2023 by a single surgeon. The patients’ medical records and surgical videos were reviewed. Cases were categorized into three groups based on the frequency of usage of advanced energy devices: Group 1 (≤10 uses), Group 2 (11–20 uses), and Group 3 (≥21 uses). The differences in blood loss, surgery time, and surgical outcomes among these groups were analyzed. This study was conducted as a single-center retrospective analysis. It included 126 patients who underwent total laparoscopic hysterectomy and provided informed consent for video recording. To evaluate the usage of advanced energy devices, anonymized surgical videos were reviewed, and outcomes were analyzed based on the frequency of usage of advanced energy devices. Results: The time required for surgery differed significantly among the three groups (p = 0.006). However, no significant differences were observed in the changes in hemoglobin levels or estimated blood loss (p = 0.255 and 0.053, respectively). Additionally, the application of hemostatic agents, the need for intraoperative or postoperative transfusions, and the use of intravenous hemostatic agents postoperatively showed no notable variation. Complication rates, including rates of hematoma, urinary tract injury, gastrointestinal injury, and infections necessitating reoperation, were also comparable. Conclusions: The findings suggest that the prudent and strategic use of advanced energy devices, rather than their frequent application, may improve surgical efficiency without increasing the risk of complications.

Comparison of the prophylactic effect of cefazolin injection versus oral levofloxacin as prophylactic antibiotic in TURP surgery: a randomized clinical trial

IntroductionUse of antibiotic prophylaxis before transurethral resection of the prostate (TURP) is highly recommended. However, there is no agreement on the use of a single antibiotic for this purpose. This study aimed to compare the prophylactic effect of cefazolin injection with oral levofloxacin on postoperative complications in TURP surgery.Trial designBody temperature and urine culture results were obtained two and five days after surgery. Drugs’ side effects as well as surgery and catheterization time were also recorded.MethodsIn an analytical-comparative trial, the participants were randomly divided into two groups to receive cefazolin or levofloxacin before the surgery.ResultsThe duration of surgery (min) and catheterization (days) were 41.5 ± 11.7 and 4.7 ± 1.8 for levofloxacin-treated group and 43.9 ± 11.9 and 4.7 ± 1.8 for cefazolin-treated group, respectively. The number of positive urine cultures, 2 and 5 days post-surgery were 12 and 14 for levofloxacin-treated group and 9 and 12 for cefazolin-treated group, respectively. Furthermore, both groups reported one fever two days after surgery and had no fever after 5 days. In total, no significant difference was observed between the two groups. Additionally, no correlation was observed between the demographic data (i.e. age, BMI and prostate volume) and the postoperative complications (i.e. fever and urinary culture tests), except between age and urinary culture 2 days after the surgery.ConclusionConsidering the lack of significant differences between the two groups, the use of oral levofloxacin is suggested as an easy to take and cost-effective alternative to injection of cefazolin before TURP surgery.Trial registrationIranian registry of clinical trials, IRCT registration number IRCT20160514027893N4, available through www.irct.ir, Registration date: 2024-03-13 (Retrospectively registered).

Post-biopsy to Surgery Interval Tends to Increase Axillary Nodal Metastasis, Especially in Early Breast Cancer Patients

Objective: Delays between diagnosis and breast cancer surgery may raise concerns about tumor progression. Tumors of the same size should exhibit same proportions of N staging. We aimed to evaluate the impact of time to surgery (TTS) on the proportion of metastatic axillary lymph nodes (N-Staging), controlled by tumor size. Materials and Methods: A cross-sectional study of primary breast cancer patients treated between October 2021 - December 2022 at the Division of Head Neck and Breast Surgery, Siriraj Hospital, Thailand examined the association between lymph node staging and TTS, stratified by primary tumor size. Patients with neoadjuvant therapy, DCIS, or underwent excisional biopsy were excluded. Results: Of 424 patients, mean age 60.95 years, had an average tumor size 17±13.38 mm, and 20.8% LNs metastasis. The mean TTS was 7 ± 3.11 weeks. The proportion of + LNs patients stratified by tumor size was 10.6% for T1, 34.56% for T2, and 43.75% for T3 lesions. There was no significant difference between TTS and the proportion ofN-staging for all T2 and T3 tumors. In contrast, a significant finding was observed among T1 tumors. Axillary nodal metastasis became more advanced as TTS increased (p-value = 0.022); and increased N2 and N3 nodal staging was noted in patients with delayed surgery. No significant additional differences were found concerning breast cancer subtype, pathological grading, or lympho-vascular/perineural invasion. Conclusion: Increasing TTS was significantly associated with more advanced N staging. This finding highlights the need for timely intervention in early breast cancer, particularly in T1 tumors.

A simple technique to improve docking time in robotic surgery

The docking process is a crucial step in robotic surgery, which determines the technical capability of moving the robotic arms during surgery and affects the performance of surgery. Robotic companies, therefore, provide setup guides recommending the trocar placement, arm carts, and operating table positioning for each procedure or body quadrant, to facilitate this process. This process takes time and although improves with experience, reported docking times range from 4 to 29 min. The final step of docking the robot is sometimes challenging and includes the insertion of the robotic instruments into the surgical field which involve patient safety. We implemented a simple new technique for safe insertion of robotic instruments and overcome the challenge of manipulating the camera arm for visualizing the trocars and advancing of the robotic instruments into the surgical field. This technique utilizes simple laparoscopic skills of laparoscopic instrument insertion. Docking times were recorded in ten consecutive patients undergoing robotic surgeries with the Hugo RAS™ and compared to our prospectively collected data registry prior to this technique. The new technique reduced the average docking time by 3.5 min and resulted in improvement of 45% in docking time. Integrating trivial laparoscopic skills into the docking process may simplify and reduce the docking time in robotic surgery.

Hemiarthroplasty for Hip Fracture in Down Syndrome: A Retrospective Series of Five Cases.

There is limited evidence regarding the outcomes of hip hemiarthroplasty (HA) following trauma in individuals living with Down syndrome (DS). This study aims to summarize the outcomes of hip HA in a series of individuals living with DS following femoral neck fractures. This retrospective study includes five cases of hip HA in four individuals with DS and displaced femoral neck fractures. Subjects (four males) had a mean age of 49.3 years (range, 26.1-59.7 years) at the time of surgery. All subjects presented with hip pain, loss of weight-bearing ability, and decreased activity level as reported by the subject caregivers. In all cases, the precise time of injury was not known. After a mean follow-up of 15.2 months, all subjects had returned to the pre-injury activity level without any recorded complications. One individual died 32 months after surgery for unrelated causes; the remaining subjects are alive and ambulating without pain at a mean of 24.2 months since the surgery. When treating femoral neck fractures in those living with DS, careful history taking should be performed as regards the timing of trauma and the individual's functional status. Hip HA seems a viable treatment option for those living with DS if a proper surgical procedure is utilized.

The Impact of Minimally Invasive Gynecologic Surgery Subspecialty Training on Outcomes of Myomectomy: A Retrospective Cohort Study

Study ObjectiveTo compare surgical outcomes among patients undergoing minimally invasive myomectomy (MIM) or abdominal myomectomy (AM) with MIGS subspecialists versus general obstetrician/gynecologists (OB/GYNs), and to characterize the complexity of myomectomies by surgeon type. DesignRetrospective cohort study. SettingQuaternary care institution. ParticipantsPatients who underwent MIM (laparoscopic or robotic) or AM with a fellowship-trained MIGS subspecialist or general OB/GYN from 3/15/2015-3/14/2020. InterventionsMyomectomy. ResultsOf 609 myomectomies, 460 (75.5%) were MIM, 404 (87.8%) of which were performed by MIGS subspecialists. The remaining 149 (24.5%) cases were AM, 36 (24.1%) of which were performed by MIGS subspecialists. Compared to general OB/GYNs, MIGS subspecialists excised a greater number of fibroids for both MIM (median 3.0 [range 1.0-30.0]) vs. 2.0 [1.0-9.0], p<.001) and AM (21.0 [10.0-60.0] vs. 6.0 [1.0-42.0], p<.001), and had a greater proportion of uteri >20 weeks size for AM (22.2% vs. 3.5%, p=.003). Composite perioperative complication rates were significantly higher for general OB/GYNs than for MIGS subspecialists (29.0% vs. 11.8%, adjusted odds ratio [aOR] 2.70, 95% confidence interval [CI] 1.48-4.92). In a subgroup analysis of MIM only, general OB/GYNs had higher rates of composite perioperative complications (28.6% vs. 9.9%, aOR 4.51, 95% CI 2.27-8.97), excessive blood loss and/or transfusion (10.7% vs. 3.0%, unadjusted odds ratio [OR] 3.92, 95% CI 1.41-10.91), surgery time ≥ 90%ile (25.0% vs. 8.9%, aOR 5.05, 95% CI 2.39-10.64), and conversions to laparotomy (10.7% vs. 0.2%, unadjusted OR 48.36, 95% CI 5.71-409.93). For AM only, there were no significant differences in perioperative complication rates between groups. ConclusionFellowship-trained MIGS subspecialists had improved surgical outcomes for MIM compared to general OB/GYNs, with fewer conversions to laparotomy, reduced surgery time, and less blood loss, while outcomes for AM were similar by surgeon type. MIGS subspecialists excised a greater number of fibroids regardless of surgical approach, highlighting a level of comfort in complex benign gynecology beyond endoscopic surgery at our institution.

Cumulative dissipated energy during phacoemulsification is Associated with bleb failure in eyes with prior trabeculectomy

IntroductionTrabeculectomy is the most effective method of lowering the intraocular pressure (IOP) in patients with open-angle glaucoma refractory to pharmacological treatment or laser trabeculoplasty. Many phakic glaucoma patients later require cataract surgery after trabeculectomy. The purpose of this study is to determine factors that predict bleb failure after phacoemulsification. MethodsThis retrospective, observational study included 33 eyes from 30 patients with open-angle glaucoma who had successful trabeculectomy with mitomycin (MMC) and subsequently underwent uncomplicated cataract surgery by means of clear corneal phacoemulsification performed by a single surgeon between 2006 and 2018. Bleb failure was defined as an eye that required the addition of two or more glaucoma medications or had an IOP > 21 mmHg at any follow-up visit more than one month after surgery. Kaplan-Meier analysis was conducted to visualize bleb survival over the two-year study period. ResultsTen eyes (30.3%) experienced bleb failure, at an average of 325 ± 254 days after phacoemulsification surgery. A further six eyes (18.2%) partially failed over this period. Blebs that remained fully functional (51.5%) two years after phacoemulsification surgery received lower total cumulative dissipated energy (CDE; 12.6 ± 7.2 versus 19.0 ± 7.7, P = 0.027). ConclusionHigher levels of ultrasound energy at the time of cataract surgery, as reflected by CDE, are associated with bleb failure. Removing cataracts at a stage when the lens is less dense so that it will require less total ultrasound energy and allow shorter duration for surgery may benefit eyes with functioning filtering blebs.

Cystine urolithiasis-free duration after first occurrence and treatment is longer for castrated dogs than for sexually intact male dogs.

To evaluate outcome in 60 dogs with cystine urolithiasis treated with surgical removal with and without castration and postoperative therapeutic diet to determine frequency of recurrence and urolith-free duration. Patient records were reviewed for dogs with documented cystine urolithiasis from September 2010 to December 2020. Medical records, client interviews, and referring veterinarians were contacted to document the absence of clinical signs associated with subsequent urolith formation and to evaluate risk factors for urolith reoccurrence. 80 patients were identified with cystine uroliths, with 60 qualifying for inclusion in the study. Seven dogs were neutered prior to surgery, and 25 dogs were neutered at the time of the first surgery. Recurrence occurred in 20 dogs; 17 of those patients were intact (85%) at the time of recurrent urinary signs. Of the 20 dogs with recurrence, 50% (10 of 20) were being treated with dietary modifications. The risk of recurrence among neutered pets was 23% versus 47% for intact pets, but this difference was not statistically significant; however, neutered pets had a longer urolithiasis-free duration. There was no statistically significant difference in risk of recurrence and urolith-free duration between pets with and without therapeutic diet management, (30% vs 32.5%) respectively. Multivariant analysis showed no significant interaction between surgical intervention with therapeutic diet, with nonsignificant hazard ratios (HRs) for neuter status (HR = 0.503), diet (HR = 1.056), and their interaction (HR = 4.32 to 9). Sexually intact (vs castrated) male dogs should be monitored more closely for recurrence of surgical cystine urolithiasis.

Immunological impact of intraperitoneal and intravenous chemotherapy in ovarian cancer, translational analyses of the Phase 3 iPocc trial

BackgroundThe iPocc trial, a randomized, global phase 3 study that compared intraperitoneal (IP) and intravenous (IV) carboplatin with dose-dense paclitaxel chemotherapy in epithelial ovarian cancer (EOC) patients, demonstrated improved progression-free survival in patients who received IP chemotherapy. The present study aimed to investigate the role of preexisting tumor immunity in the clinical outcomes of patients receiving IP chemotherapy. MethodsThis study involved analyzing patient data from the iPocc trial, selectively of those whose tumor specimens were preserved at the time of primary surgery. A total of 116 cases ((IP; n = 59), (IV; n = 57)) were subjected to microarray analysis. Single-sample gene set enrichment analyses were performed to evaluate the tumor immune microenvironment. ResultsPatients with enhanced tumor infiltration of T cells, natural killer (NK) cells, and cytotoxic lymphocytes in the IP group had a longer overall survival (OS) than those in the IV group, but not in the group with low infiltration. IP therapy improved the OS of patients with high expression of immune-related genes such as CD8A and FOXP3. In patients' subdivided into “immune Hot” and “immune Cold” groups based on hierarchical clustering analysis using four parameters representing “Innate immunity,” “T cells,” “IFNG response” and “Inhibitory molecules,” IP therapy significantly improved prognosis in the “immune Hot” group, but not in the “immune Cold” group compared to that of IV therapy. ConclusionsIP chemotherapy enhances the survival rates of patients with EOC with an immune-Hot phenotype in the tumor microenvironment prior to treatment.(Japan Registry of Clinical Trials number, jRCTs031180141.)

Surgical repair of post infarct ventricular septal rupture in Peshawar Institute of cardiology: Experience in a newly established tertiary care hospital.

Objective: To share our experience of post infarct closure of ventricular septal rupture in newly established cardiac center. Study Design: Retrospective study. Setting: Department of Cardiac Surgery, Peshawar Institute of Cardiology, Peshawar. Period: Jan 2021 to August 2024. Methods: All VSR repair cases done during this period were included which were 10. Results: A total of 10 cases of surgical repair of VSR were included in the study. 50 % were males. Mean age was 65 years (IQR 14.7). 40 % were diabetic while 80% were hypertensive. 20% patients had thrombolysis while 60% had PPCI. 50 % patients presented with NYHA IV symptoms. 10% patients were in pre operative AKI. 40% were in cardiogenic shock. 10 % had pre operative IABP passed while 50 % were stabilized with preoperative ionotropic support. 90% of VSR were anterior while 10% posterior. Median VSR size was 13.5 mm (IQR 12.2mm). 20 % VSR were multiple. Median time from onset of symptoms to VSR was 4 days (IQR 2.5). Median time from hospital presentation to VSR repair was 15 days (IQR 20.7). Concomitant CABG was performed in 90% cases. Post operative median ICU stay was 4 days (IQR 4.7) while hospital stay was 7 days (IQR 7.2). Residual VSR, pleural effusion, reopening, post Operative AKI, stroke and heart failure each were present in 10% cases. In hospital mortality was 10%. Conclusion: Optimal timing of surgery and preoperative status of patients are important determinant to decrease postoperative complications and mortality.

Surgical Timing and Stenting in Neonatal Choanal Atresia

Background and Objectives: Congenital choanal atresia is a rare condition that occurs in approximately 1 in 7,000 to 8,000 live births and involves the obstruction of the posterior nasal airway. It may present as either unilateral or bilateral, with bilateral cases being more severe due to the risk of immediate neonatal respiratory distress. Bilateral congenital choanal atresia (BCCA) necessitates prompt medical intervention to prevent cyanosis and significant breathing difficulties. This study focuses on the timing of surgery, the duration of stent use, and postoperative care in patients with bilateral congenital choanal atresia who underwent endoscopic transnasal surgery. Unlike previous studies, this research emphasizes the efficacy of an extended stenting period and introduces novel stenting techniques aimed at reducing restenosis.Methods: From 2018 to 2021, three patients with BCCA underwent transnasal surgery that included the placement of stents. We retrospectively analyzed their medical records, focusing on the surgical outcomes in relation to the duration of stent placement and postoperative care. A novel approach was adopted, involving the use of customized stent sizes tailored to the specific anatomical factors of each patient, which facilitated improved neochoana maintenance.Results: The average interval from diagnosis to surgery was 3.6 weeks. Surgery was successful in all cases, and the stent was removed after 6 months. In all patients, stable neochoanae were maintained without significant restenosis. Additionally, we observed that maintaining a stent for a period longer than previously recommended significantly reduced the risk of restenosis compared to the shorter durations used in earlier studies.Conclusion: Our study suggests that an extended stenting period of 6 months or more is crucial for maintaining long-term patency in patients with BCCA. This approach could lead to a more reliable stenting protocol and improved postoperative care, potentially establishing a new standard for managing BCCA.

Comparison of Ketamine/Diazepam and Tiletamine/Zolazepam Combinations for Anaesthesia Induction in Horses Undergoing Partial Intravenous Anaesthesia (PIVA): A Retrospective Clinical Study

The aim of this retrospective clinical study was to compare the combinations of ketamine/diazepam (KD group) and tiletamine/zolazepam (TZ group) for the induction of general anaesthesia in horses undergoing elective surgery. The data from the clinical and the anaesthetic records of 138 horses from 2021 to 2023 were evaluated, and the horses were divided in two groups: KD (n = 60) and TZ (n = 72). The horses were premedicated with romifidine and methadone IV; anaesthesia was induced with ketamine/diazepam for the KD group and tiletamine/zolazepam for the TZ group and was maintained with isoflurane and a constant rate infusion of romifidine. The data encompassed sex and neuter status, age, breed, weight, American Society of Anaesthesiologists physical status, type of surgical procedure performed under anaesthesia, induction time, induction score, surgery time, recovery time, and the recovery score using a descriptive scale. Baseline heart rate (HR), intraoperative HR, baseline respiratory rate (fR), intraoperative fR, mean arterial pressure (MAP), oxygen saturation (SpO2), and fraction of expired isoflurane (FE’Iso) were also recorded. The induction time was significantly longer (p = 0.004) in the TZ group (60 (40–120)) as compared to the KD group (50 (30–120)). Recovery time was also significantly longer (p ≤ 0.001) in the TZ group (46.5 (15–125)) as compared to the KD group (30 (5–105)). These findings suggested that, in adult horses undergoing elective surgery, TZ could be considered a valid alternative to KD for the induction of general anaesthesia. Additional experimental studies comparing the two induction regimens and their pharmacokinetic and pharmacodynamic characteristics are needed.

The Impact of a Resident, Fellow, or Physician Assistant on Operative Time and Complication Rate in Closed Reduction and Percutaneous Pin Fixation of Pediatric Distal Humerus Supracondylar Fractures

We sought to compare operative times and complications for attending surgeons operating alone or with an assistant including an orthopedic resident, fellow, or physician assistant (PA) for closed reduction and percutaneous pinning (CRPP) of pediatric supracondylar humerus fractures (SCH), an archetypal procedure integral to the education of orthopedic trainees. Using a retrospective database collected following institutional review board approval, a 1-way ANOVA (non-parametric) was used to assess the effect of assistant absence or presence by type of assistant on mean operative time. We analyzed the association between the attending surgeon assistant categories and the complication rate using Fisher's Exact Test. The study was performed at Gillette Children's Specialty Healthcare, St. Paul, Minnesota, and Children's Minnesota in St. Paul and Minneapolis. These three affiliated metropolitan hospitals, the last of which is a level 1 trauma facility, all share the same group of orthopedic surgeons, trainees, and physician assistants. All patients under 14 years of age treated with CRPP for Gartland type 2, 3, 4 and flexion type closed supracondylar fractures between April 2006 and September 2016 were analyzed. Of 1053 patients identified by Current Procedure Terminology code 24358, data was available for 888 patients. Out of the 888 patients, 44.1% were operated on by a surgeon alone, 48.4% with a resident, 4.8% with a fellow and 2.6% with a physician assistant. The ANOVA revealed a statistically significant increase (p < 0.001) in operative times when a resident participated compared to the other categories. The shortest mean surgery time (34.7 minutes) occurred when an attending surgeon and PA were present. The longest mean time (44.3 minutes) occurred with a surgeon and resident. This difference, at 9.6 minutes, constituted 28% more time. There were 40 patients with a complication, a rate of 4.5%. The rate for each of the assistant categories was surgeon alone 5.6%, with a resident 3.3%, with a fellow 4.7%, with a PA 8.7%. The Fisher's Exact Test results showed no statistically significant association between the type or absence of assistant and the complication rate. Differences in operative times were observed across assistant categories although the mean time difference was statistically insignificant between the surgeon unassisted versus assisted by the fellow or a PA. The finding of statistically increased operative times with resident participation in this study for this specific procedure is consistent with results for most other reported orthopedic surgeries. Complication rates did not vary based on the participating personnel.

The importance of timing: evaluating the optimal age for surgical intervention in asymptomatic dermal sinus tracts.

Dermal sinus tracts (DSTs) are rare congenital lesions resulting from errors of spinal cord disjunction, leading to a persistent connection between the cutaneous ectoderm and underlying neural elements. As patients are at increased risk of infection and irreversible neurological compromise due to tethering, resection and detethering are recommended as a prophylactic measure. The ideal timing of surgical intervention in an asymptomatic cohort, however, remains unclear. A retrospective chart review was performed at a single institution from 1998 to 2022 of all patients surgically treated for lumbar DST by 10 different surgeons. Demographic, presentation, operative, and postoperative details were obtained. Five patients who presented with infectious or neurological symptoms were excluded from primary analysis. The age at the time of surgery was then analyzed as a continuous variable against the operative details and postoperative outcomes utilizing Spearman's correlation coefficient and the Mann-Whitney U-test. Fifty-two patients underwent prophylactic surgical excision of their DST as well as detethering. Overall, 65% of patients were female and the median age at diagnosis was 3 months, while the median age at the time of surgery was 7 months. An additional cutaneous finding was identified in 71% of patients, with hemangioma being most frequent (40%). Additional spinal lesions were radiographically identified in 29% of patients, including lipoma (19%), dermoid and epidermoid inclusion cysts (8%), and an arachnoid cyst (2%). Postoperative complications occurred in 8% (n = 4) of patients, primarily related to wound healing (3/4), with significant risk attributed to younger age at time of surgery (mean 3 months, range 1-5 months) (p = 0.01). During 56 months of follow-up, long-term rates of retethering (6%, p = 0.02) and abnormal neurological examinations (8%, p = 0.001) were associated with concurrent lipomas, but not with age at operation. In a series of 52 pediatric patients undergoing prophylactic resection of a DST with detethering, the complication rate was 8% and was significantly associated with age < 6 months at the time of operation. Associated spinal lipomas significantly influenced long-term outcomes. When evaluating asymptomatic infants with DST, patient age is a significant factor in assessing the risks and benefits of surgical timing.

The impact of surgical time of day and surgical site infection.

Disruption to the circadian clock has impacts on health and wellbeing, including impaired immune function and wound healing. It is plausible that the timing of surgical procedures could impact the body's response to trauma and susceptibility to infections. Using the Health Quality & Safety Commission data on surgical site infections (SSI) we sought to investigate any possible time of day effects on the incidents of recorded infections. All recorded data from June 2017 to July 2021 were extracted for cardiac and orthopaedic operations in New Zealand. The incidence of SSI was calculated for each 4-hour bin of time across the day. There was a total of 87,034 cases in the analysis, of which 1,327 (1.5%) had an infection. Univariately, there was a significant time of day effect, with operations after 8 pm being 3.91 times more likely to have an infection (p<0.001), and operations between 4 pm and 8 pm being 0.71 times more likely (p=0.03) to have an infection compared to operations conducted between 12 pm and 4 pm. However, when age, acuity and American Society of Anesthesiologists score were included in the model, there were no differences in the rate of infection by time of day. This preliminary work suggests that surgical time of day does not significantly impact incidence of surgical infection when other variables are controlled for. However, this work has not considered other factors that may also be important. We plan to link the SSI data with the National Minimum Dataset to investigate these other factors and conduct a more comprehensive analysis.

Lymph node metastasis risk factors in T2 colorectal cancer.

This study evaluates risk factors for lymph node metastasis (LNM) in T2 colorectal cancer to refine patient selection for endoscopic resection. We reviewed records from consecutive patients who had undergone curative surgical resection of T2 colorectal cancerat our institution in Japan between April 2001 and December 2021. Data on conventional clinicopathologic variables were retrieved from the pathology reports at the time of surgery. The clinicopathological features included patient age, sex, tumor diameter, morphology, tumor location, lymphatic invasion, vascular invasion, tumor differentiation, carcinoembryonic antigen and carbohydrate antigen 19-9 levels, number of lymph node dissections, presence of adenoma component, and LNM. Among the patients (338 men, 320 women), 170 (25.8%) exhibited LNM. Multivariate logistic regression identified three independent risk factors for LNM: lymphatic invasion (odds ratio [OR], 32.6; 95% confidence interval [CI], 17.3-61.4; p < 0.0001), female sex (OR, 1.70; 95% CI, 1.10-2.62; p = 0.02), and elevated carcinoembryonic antigen levels (OR, 2.56; 95% CI, 1.10-5.96; p = 0.03). Lymphatic invasion, female sex, and high carcinoembryonic antigen levels significantly increase the risk of LNM in T2 colorectal cancer.