Variations In Surgical Procedures Research Articles

Transcutaneous electrical acupoint stimulation reduces postoperative patients' length of stay and hospitalization costs: a systematic review and meta-analysis.

To study the effects of transcutaneous electrical acupoint stimulation (TEAS) on length of stay (LOS) and hospitalization costs in postoperative inpatients. Two researchers collectively searched PubMed, Embase, Cochrane Library, China Network Knowledge Infrastructure, and Wanfang Database. The search time was set from the beginning to 25 April 2023, to identify randomized controlled trials articles that met the criteria. Statistical analyses were performed using the Stata software (version 16.0). The risk of bias was assessed using the Cochrane risk-of-bias tool, and publication bias was evaluated using a funnel plot and Egger's test. The quality of evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Thirty-four randomized controlled trials were included. The main results showed that TEAS reduced hospitalization costs [standardized mean difference (SMD)=-1.92; 95% CI: -3.40, -0.43), LOS (SMD=-1.00; 95% CI: -1.30, -0.70) and postoperative LOS (SMD=-0.70; 95% CI: -0.91, -0.49] in postoperative patients. Subgroup analyses further revealed that TEAS was effective in reducing both the overall and postoperative LOS in patients undergoing multiple surgical procedures. It is worth noting that the observed heterogeneity in the results may be attributed to variations in surgical procedures, stimulation frequencies, and stimulation points utilized in different trials. TEAS can help postoperative patients reduce their LOS and hospitalization cost. However, considering the bias identified and heterogeneity, the results of this review should be interpreted with caution.

Cross-sectional survey of surgical practices among gynecologic oncologists in the United States

ObjectiveWe sought to document current surgical practices among gynecologic oncologists in the United States. MethodsIn March/April 2020, we conducted a cross-sectional survey among members of the Society of Gynecologic Oncology to identify gynecologic oncology practice trends in the United States. The survey collected demographic data and queried participants on types of surgical procedures performed and chemotherapy use. Univariant and multivariant analyses were used to evaluate the association between surgeon practice type, region of practice, working with gynecologic oncology fellows, time in practice, and dominant surgical modality of practice on performance of specific procedures. ResultsAmong 1199 gynecologic oncology surgeons who were emailed the survey, 724 completed the survey (60.4% response rate). Of these respondents, 170 (23.5%) were within 6 years of fellowship graduation, 368 (50.8%) identified as female; and 479 (66.2%) worked in an academic setting. Surgeons who worked with gynecologic oncology fellows were more likely to perform bowel surgery, upper abdominal surgery, complex upper abdominal surgery, and prescribe chemotherapy. Surgeons who were ≥ 13 years out from fellowship graduation were more likely to perform bowel surgery and complex abdominal surgery and less likely to prescribe chemotherapy and perform sentinel lymph node dissections (P < 0.05). ConclusionsThese findings highlight the variation in surgical procedures performed by gynecologic oncologists in the United States. These data support that there are practice variations that would benefit from further investigation.

The risk of lymph node metastasis in patients with T2 colon cancer.

It is often safe to treat pT1 tumours with local resection due to the low risk of lymph node metastasis. The risk of lymph node metastasis in pT2 colon cancer is less well investigated. The recommendation for patients diagnosed with T2 colon cancer is a segmental resection including regional lymph nodes. The aim of this work was to determine the risk of lymph node metastasis in pT2 colon cancer and identify the possible associated clinical and pathological risk factors for lymph node metastasis. PubMed and Embase were systematically searched for studies describing patients with T2 colon cancer and lymph node status after histopathological assessment. Lymph node metastasis and the effect of histological and clinical factors were included. Overall, 5489 studies were screened, and 10 studies consisting of a total of 91 460 patients were included in the review. The overall risk of lymph node metastasis was 19.3% (95% confidence interval 19.0%-19.5%). A meta-analysis was not possible as very few studies described the clinical and pathological risk factors for lymph node metastasis. The risk of lymph node metastasis in patients with pT2 colon cancers is higher than for pT1. The studies included patients operated on from 1985 to 2015 with variations in surgical procedure, pathological handling, and definition of lymph node metastasis. Further studies reporting risk factors for lymph node metastasis in pT2 colon cancer are warranted as more data are needed to determine if local resection for a subgroup of patients could be an alternative treatment modality.

Laparoscopic D3 oncological resection in splenic flexure cancer: Technical details and its impact on long-term survival.

The applicability of laparoscopic D3 oncological resection for splenic flexure cancer (SFC) surgery has not been fully explored due to technical difficulties and variations in surgical procedure. The aim of this work is to describe the feasibility of performing laparoscopic D3 resection in SFC and its impact on long-term survival. A retrospective study on 47 out of 52 consecutive patients who underwent elective laparoscopic colectomy for SFC from December 2006 until December 2019 at Korea University Anam Hospital was performed. Data on patients' demographic and clinical features, surgical procedures, intraoperative and postoperative complications, pathological features and follow-up were collected. Categorical data are expressed as frequencies (n) and percentages (%). Continuous data are expressed as mean ± standard deviation and median (range). The Kaplan-Meier test was used to determine the overall survival (OS), progression-free survival (PFS) and disease-free survival (DFS). The median age of patients was 67.0 years (range 27-87 years) and 72.3% were men. Ten (21.3%) patients presented with an obstructing tumour and underwent an elective laparoscopic colectomy, while 68.1% of patients presented with Stage II and III disease. The conversion rate was 4.3% and the morbidity rate was 31.9%. There was one postoperative death secondary to splenic infarction and anastomotic leak leading to multi-organ failure. Four deaths occurred due to disease progression during a median follow-up of 63.8months. The rate of recurrence was 20%, the 5-year OS was 89.6% and the 5-year PFS was 72.9%. After R0 resection, the 5-year OS was 91.5% and the 5-year DFS was 74.5%. Laparoscopic D3 colectomy for SFC is feasible, with an acceptable morbidity and long-term oncological outcome when performed by highly skilled laparoscopic colorectal surgeons with knowledge of the complex anatomy around the splenic flexure. Further randomized trials should be performed to determine the advantage of laparoscopic D3 colectomy over conventional colectomy for SFC.

Diverticulitis Management, a Snapshot Collaborative Audit Study (DAMASCUS): Protocol for an international, multicentre, prospective observational study.

Diverticular disease is an increasingly common problem in Western society with a variety of treatment options for those presenting with acute diverticulitis, dependent on clinical presentation. Additionally, there is significant international variability in the index management, and few published data on real-world clinical practice. The aim of DAMASCUS is to identify areas of practice variability and their potential association with differences in short- and medium-term clinical outcomes. DAMASCUS is an international, collaborative, prospective observational study, recruiting patients from over 200 sites across six continents. The study opened in October 2020, with a rolling start. Identification of new sites ceased in February 2021 and data collection will cease in August 2021. All adult patients diagnosed with acute diverticulitis (radiologically or intra-operatively) at each participating centre will be included. The primary objective of DAMASCUS is to assess for national and international variability in the presentation and index management of acute diverticulitis (medical, interventional radiology and surgical). Secondary objectives include assessing 30-day and 6-month clinical outcome data (readmission, re-intervention, morbidity and mortality) and variations in surgical procedures for those undergoing surgery. All data will be recorded and managed using a secure REDCap electronic data capture tool and analysed using Stata (SE) version 16.1. The results will be reported in accordance with the STROBE statement. By analysing variations in the management of acute diverticulitis and the subsequent outcomes, DAMASCUS will be an important step towards identifying optimal care for patients with diverticulitis.

Variations in Surgical Procedures for Inducing Hind Limb Ischemia in Mice and the Impact of These Variations on Neovascularization Assessment.

Mouse hind limb ischemia is the most common used preclinical model for peripheral arterial disease and critical limb ischemia. This model is used to investigate the mechanisms of neovascularization and to develop new therapeutic agents. The literature shows many variations in the model, including the method of occlusion, the number of occlusions, and the position at which the occlusions are made to induce hind limb ischemia. Furthermore, predefined end points and the histopathological and radiological analysis vary. These differences hamper the correlation of results between different studies. In this review, variations in surgical methods of inducing hind limb ischemia in mice are described, and the consequences of these variations on perfusion restoration and vascular remodeling are discussed. This study aims at providing the reader with a comprehensive overview of the methods so far described, and proposing uniformity in research of hind limb ischemia in a mouse model.

Identification of essential surgical competencies to be imparted in urological residency: A survey-based study.

Introduction:There are variations in surgical procedures included in urology residency curricula across various programs. We conducted a survey of practicing urologists to determine which procedures are considered essential to a core urology residency curriculum.Materials and Methods:A web-based survey was conducted between October 2016 and February 2017 using SurveyMonkey. The questionnaire, comprising a set of 5-questions, was sent to the members of the Urological Society of India. Respondents were requested to grade 37 of the most common urological procedures (competencies) into three groups. Group A, were those that the respondent believed were vital for the trainee to learn (must know). Group B, were those that the respondent thought were essential to acquire (good to know). Group C procedures were labeled as desirable to know by respondents.Results:A total of 485 (15.75%) responses were received out of 3018 members contacted. 67% respondents were working in the private-sector. Out of the 37 listed procedures, 20 procedures received a median weightage of 1 indicating vital clinical competency for urology curriculum, 15 were identified as “essential to know” while two procedures were identified as “desirable to know.”Conclusions:Twenty surgical procedures were identified as‘must-know’ for a urology trainee. The choice of procedures was not affected by the region of the responder or his practice type, suggesting a wide consensus.

Morbidity and oncologic outcome after saphenous vein-sparing inguinal lymphadenectomy in melanoma patients

BackgroundInguinal lymph node dissection (LND) is a surgical procedure with a high morbidity rate. Variations in surgical procedure, such as sparing of the saphenous vein, have been proposed to reduce surgical morbidity. While sparing of the saphenous vein has shown promising results in earlier studies, data for this procedure in melanoma patients are rare. In this retrospective study, we report 10-year findings on the effects of saphenous vein-sparing LND on surgical morbidity and oncologic outcomes in melanoma patients.MethodsA retrospective analysis of melanoma patients receiving inguinal LND in our facility between 2003 and 2013 was performed. Patients were divided into two groups: the saphenous vein resection group and the vein sparing group. Surgical morbidity, including wound infection, lymphatic fistula, severe bleeding, neurological complications, and chronic lymphedema, as well as regional recurrence-free survival were investigated.ResultsA total of 106 patients were included in this study; of these, the saphenous vein was spared in 41 patients (38.7%). The rate of lymphatic fistula was 51.6 vs. 48.8%, wound infection occurred in 31.3 vs. 24.4%, and patients suffered from chronic lymphedema in 30.0 vs. 26.5% in V. saphena magna resection vs. sparing group. Differences observed, however, were not significant. No difference in regional recurrence-free survival between the two study groups was detected.ConclusionsThe results of our retrospective analysis could not confirm the promising results reported in earlier studies. Thus, sparing of the saphenous vein appears to be optional.

Practice variation in surgical procedures and IUD-insertions among general practitioners in Norway \u2013 a longitudinal study

BackgroundStudies of Primary Health Care (PHC) reveal considerable practice variations in terms of the range of services provided. In Norway, general practitioners (GPs) are traditionally expected to perform IUD-insertions and several surgical procedures as a part of comprehensive PHC. We aimed to investigate variation in the provision of surgical procedures and IUD-insertions across GPs and over time and explore determinants of such variation.MethodsRetrospective registry study of Norwegian GPs. From a comprehensive database of GPs’ reimbursement claims, we obtained procedure codes and GP characteristics such as age, gender, list size and municipality characteristics from 2006 through 2013. Multivariable logistic regression models were fitted to explore determinants of practice variation.ResultsWe extracted data from 4,828 GPs. In 2013, 91.0, 76.1 and 74.8% were reimbursed at least once for minor and major surgical procedures and IUD-insertion, respectively. Female GPs had lower odds for performing major surgical procedures (OR 0.38, 95% CI 0.32–0.45) and higher odds for performing IUD-insertions (OR 6.28, 95% CI 4.47–8.82) than male GPs. Older GPs and GPs with shorter patient lists were less likely to perform surgical procedures. GPs with longer patient lists had higher odds for performing IUD-insertions. The proportion of GPs performing surgical procedures increased over time, while the proportion decreased for IUD-insertions. The number of IUD-insertions in specialist care increased from 12,575 in 2011 to 15 216 (+21.0%) in 2014.ConclusionWe observed a large variation in the provision of surgical procedures and IUD-insertions amongst GPs in Norway. The GPs’ age, gender, list size and size of municipality were associated with performing the procedures. Our findings suggest a shift of IUD-insertions from primary to specialist care.

Changing surgical trends in young patients with early stage breast cancer, 2003 to 2010: a report from the National Cancer Data Base.

Young patients with breast cancer represent a unique cohort of patients who often have different treatment plans than older patients. We hypothesized that the rates of contralateral prophylactic mastectomy (CPM) were significantly higher and those of lumpectomy were significantly lower in young patients compared with older patients and that this trend persists when adjusting for patient, tumor, and facility factors. We used the National Cancer Data Base (NCDB) to study 553,593 patients from all ages with American Joint Committee on Cancer (AJCC) stage 0 to II breast tumors, who underwent lumpectomy, unilateral mastectomy, or CPM from 2003 to2010. Over the entire cohort, lumpectomy rates decreased from 67.7% in 2003 to 66.4% in 2010 in contrast to women 45 years old or less, in whom the lumpectomy rates went from 61.3% in 2003 to 49.4% in 2010. Unilateral mastectomy went from 28.2% to 23.9% and CPM from 4.1% to 9.7% compared with women 45 years old or less, in whom unilateral mastectomy rates went from 29.3% to 26.4% and CPM rates from 9.3% to 26.4%. Age was the most significant factor related to increasing CPM rates: 19.7% of women between 41 and 45 years old underwent CPM vs 5.1% of women between 66 and 70 years old. There was substantial regional variation in surgical procedures for young women: lumpectomy rates were lowest in the West and CPM rates were highest in the Midwest. Multivariate logistic regression showed that women 45 years old or younger compared with women more than 45 years who underwent CPM were more likely to be Caucasian, treated at an academic/research institution, have larger tumors, higher grade, higher stage, and lobular histology. The rate of CPM continues to increase, with one-quarter of younger women undergoing CPM. This trend persists across all patient, tumor, and facility characteristics.

Variations in Surgical Procedures for Hind Limb Ischaemia Mouse Models Result in differences in Collateral Formation

Objective To identify the optimal mouse model for hind limb ischaemia, which offers a therapeutic window that is large enough to detect improvements of blood flow recovery, for example, using cell therapies. Materials and Methods Different surgical approaches were performed: single coagulation of femoral and iliac artery, total excision of femoral artery and double coagulation of femoral and iliac artery. Blood flow restoration was analysed with Laser Doppler Perfusion Imaging (LDPI). Immuno-histochemical stainings, angiography and micro-computed tomography (CT) scans were performed for visualisation of collaterals in the mouse. Results Significant differences in flow restoration were observed depending on the surgical procedure. After single coagulation, blood flow already restored 100% in 7 days, in contrast to a significant delayed flow restoration after double coagulation (54% after 28 days, P < 0.001). After total excision, blood flow was 100% recovered within 28 days. Compared with total excision, double coagulation displayed more pronounced corkscrew phenotype of the vessels typical for collateral arteries on angiographs. Conclusion The extent of the arterial injury is associated with different patterns of perfusion restoration. The double coagulation mouse model is, in our hands, the best model for studying new therapeutic approaches as it offers a therapeutic window in which improvements can be monitored efficiently.

Cold and compression in the management of musculoskeletal injuries and orthopedic operative procedures: a narrative review

Cold and compression are routinely applied immediately after acute injury or following surgery to alleviate pain, reduce swelling and speed functional recovery. The objective of this literature review is to describe the published clinical findings regarding combined cold and compression therapy in the management of musculoskeletal injuries and after orthopedic operative procedures. Of 33 potential articles triaged, the findings of 21 randomized controlled trials were assessed and summarized. The findings reported by these 21 studies were largely subjective pain outcomes and, to a lesser degree, swelling and range of motion, and were inconsistent and divergent, making it difficult to recommend the most appropriate, effective clinical application of cold and compression. Further, 18 of the 21 reported studies evaluated cold and static compression, where the extent and duration of the compression was not uniform within or across studies. Operative procedures may offer a more controlled environment for rigorous investigations. However, such studies must be powered sufficiently to account for variations in surgical procedure that could affect outcomes. More uniform operative procedures, such as total knee arthroplasty, represent a well circumscribed intervention for studying the clinical utility of cold compression therapy because the operative technique is standardized, surgical tissue damage is extensive, intraoperative blood loss is high, and post-operative edema and pain are severe. Findings from randomized controlled trials of knee arthroplasty generally showed cold compression therapy provides better outcomes such as pain relief than alternative interventions. While the effects of cold and static compression are clearly better than no treatment, they do not appear to be directly additive.

Outlier detection for a hierarchical Bayes model in a study of hospital variation in surgical procedures

One of the most important aspects of profiling healthcare providers or services is constructing a model that is flexible enough to allow for random variation. At the same time, we wish to identify those institutions that clearly deviate from the usual standard of care. Here, we propose a hierarchical Bayes model to study the choice of surgical procedure for rectal cancer using data previously analysed by Simons et al.(1) Using hospitals as random effects, we construct a computationally simple graphical method for determining hospitals that are outliers; that is, they differ significantly from other hospitals of the same type in terms of surgical choice.

Twist and its effect on ACL graft forces

Graft tension is a controversial topic in anterior cruciate ligament (ACL) surgery. Evidence suggests a narrow range of graft tensions, which allow the graft to remodel to a stable and mature neoligament. In previous cadaver experiments, we showed that twisting the graft could modulate the graft forces. In this study we hypothesized that the same phenomena would be found in patients, and that twisting the graft intraoperatively can reduce peak forces in the graft. The effects of twist on graft forces in bone–patellar tendon–bone grafts were measured during anterior cruciate ligament surgery on 15 consecutive patients using a custom-made tension-measurement device. Variations in surgical procedure that could potentially affect the graft force patterns were quantified. Graft force as a function of knee-flexion angle was measured with the graft in the neutral, untwisted position and repeated with the tibial bone block rotated externally or internally by 180°. In eight of the 15 knees, external twisting of the graft reduced the maximal graft force to 50%. However, in five knees the forces in extension increased by twisting to a maximum of 300%. Of the surgical variables, only the femoral tunnel position appeared to have a consistent effect on the graft force pattern. Due to the unpredictable effect of graft twisting, a general recommendation on whether the graft should be twisted, and if so, in which direction, cannot be given. Intraoperatively, graft twisting may however be considered in every individual knee to modulate the graft force as a function of flexion angle.

Predictors of developmental outcomes in children with complete transposition.

Cognitive, functional, educational achievement and behavioural measures were employed to assess neurobehavioral status in 57 of 60 participants who were initially enrolled in the Baltimore-Washington Infant Study, and who survived surgical correction of complete transposition (concordant atrioventricular and discordant ventriculo-arterial connections). Charts were reviewed to investigate the relationship between birth variables, surgical strategy and developmental outcomes. Higher preoperative weight was associated with better outcomes on the Stanford-Binet Short-term Memory subtest, while lower preoperative oxygen tension was associated with better outcomes on the Abstract/Visual Reasoning subtest and a test of Visual-Motor Integration. Longer total bypass time was associated with poor outcomes on the Short-term Memory subtests. Higher average flow rates during cooling and rewarming were associated with higher scores in the test of short term memory but poorer outcomes on a test for visual motor integration. Longer cooling times were associated with higher scores on the test for Visual-Motor Integration. Patients suffering seizures scored lower on the Stanford-Binet Composite, as well as in their tests of achievement. The data indicate that non-verbal skills may be particularly sensitive to variations in surgical strategies employed to correct complete transposition. Overt neurological events, such as seizures, were related to global deficits in intellectual functioning. Prospective studies evaluating systemic variations in surgical procedures and attempts to prevent and manage perioperative neurological events are important for further investigation of neurodevelopmental outcomes in children surviving surgical correction.

Axial Length in Keratoconus

Axial length is a major determinant of ocular refractive power that has not been well established for keratoconus eyes. The purpose of this study was to establish the mean and range of axial length among both keratoconus eyes with no previous surgery and postkeratoplasty keratoconus eyes, and to determine if there is a significant reduction of axial length following variations in surgical techniques in penetrating keratoplasty. The axial length of 157 keratoconus eyes with no previous surgery was measured using applanation ultrasonography. The mean axial length measurement was 24.39 (+/- 1.13 mm), with a range of 21.82-28.69 mm. The axial length of 66 postkeratoplasty keratoconus eyes was similarly measured. The mean axial length measurement was 24.10 (+/- 1.22 mm), with a range of 21.83-26.87 mm. These values are not significantly different from the axial length mean and range found among emmetropic eyes. A significant shortening of the axial length (F = 5.2, p = 0.04) was obtained in the postoperative penetrating keratoplasty eye if the donor trephine was 0.3 mm smaller in diameter than the recipient trephine. The axial length of individual keratoconus eyes is a major factor in determining postoperative refractive error. It therefore becomes important when considering variations in surgical procedures to reduce postoperative myopia.

Axial Length in Keratoconus

Axial length is a major determinant of ocular refractive power that has not been well established for keratoconus eyes. The purpose of this study was to establish the mean and range of axial length among both keratoconus eyes with no previous surgery and postkeratoplasty keratoconus eyes, and to determine if there is a significant reduction of axial length following variations in surgical techniques in penetrating keratoplasty. The axial length of 157 keratoconus eyes with no previous surgery was measured using applanation ultrasonography. The mean axial length measurement was 24.39 (±1.13 mm), with a range of 21.82-28.69 mm. The axial length of 66 postkeratoplasty keratoconus eyes was similarly measured. The mean axial length measurement was 24.10 (±1.22 mm), with a range of 21.83-26.87 mm. These values are not significantly different from the axial length mean and range found among emmetropic eyes. A significant shortening of the axial length (F = 5.2, p = 0.04) was obtained in the postoperative penetrating keratoplasty eye if the donor trephine was 0.3 mm smaller in diameter than the recipient trephine. The axial length of individual keratoconus eyes is a major factor in determining postoperative refractive error. It therefore becomes important when considering variations in surgical procedures to reduce postoperative myopia.

The Effects of a Pacifying Stimulus on Behavioral and Adrenocortical Responses to Circumcision in the Newborn

Eighteen, healthy male newborns, 2–5 days old, were subjects in this study of the effects of a pacifier on the newborn's behavioral and adrenocortical responses to circumcision. Half of the subjects were randomly assigned to a condition in which they were encouraged to suck on a pacifier during circumcision, while half served in a no pacifier, control condition. Behavioral observations were made for 1/2 hour before, during, and after circumcision; while blood samples for serum cortisol determination were obtained immediately before circumcision and 30 min later. The results showed that stimulating the newborn with the pacifier reduced crying by about 40%. Reducing crying, however, had no significant effect on the adrenocortical response. Elevations of serum cortisol predicted average behavioral state following circumcision, whereas crying during circumcision did not. Furthermore, there was evidence that the neonatal adrenocortical system was sensitive to variations in surgical procedures. The results indicate the importance of obtaining data on both behavioral and hormonal systems in studies of stress and coping in human newborns.

NEW SURGICAL PROCEDURES IN CERTAIN CASES OF CONGENITAL PULMONARY STENOSIS

THE TECHNIC of subclavian-pulmonary or aortic-pulmonary anastomosis for the classic case of congenital pulmonary stenosis has been fairly well standardized. Unpredictable findings at operation necessitate use of improved variations in surgical procedures. The following 2 cases illustrate emergency deviations in surgical technic necessitated by anomalies of the pulmonary artery. Case 1. —T. K., a girl aged 7 years, weighing 43 pounds (19.5 Kg.), was admitted to the Children's Memorial Hospital, Oct. 12, 1948. She had been mildly cyanotic since birth, became dyspneic on slight exertion and after walking about one block would squat in characteristic fashion. Physical examination revealed a frail child with cyanosis visible only in the lips, fingers and toes. Suffusion of the conjunctiva was moderate; clubbing of the fingers and toes was minimal. A loud, harsh systolic murmur was heard at the left third interspace along the edge of the sternum. An accompanying thrill was palpable. Fluoroscopic