Day case hernia repair: weak evidence or practice gap?

PubMed

Scarfe, Anje; Duncan, Joanna; Ma, Ning; Cameron, Alun; Rankin, David; Karatassas, Alex; Fletcher, David; Watters, David; Maddern, Guy

2018-06-01

Analysis of a private insurer's administrative data set revealed significant variation in the length of hospital stay following hernia surgery. This review examined factors influencing the performance of day surgery for inguinal, femoral and umbilical hernia repair in adults. A systematic literature search was conducted in the PubMed, Embase and Cochrane Library databases to identify studies and clinical practice guidelines (CPGs) comparing same day hernia surgery to surgery followed by an overnight stay. Screening of studies by abstract and full text was completed by a single researcher and checked by a second. Studies were selected for inclusion based on a step-wise approach across three phases. Limited evidence from one systematic review, and three case series studies including 3213 patients found that same day hernia surgery was as safe and effective as an overnight stay. All identified CPGs recommended a same day procedure for most patients. Two case series studies reported that 3-8% of patients were ineligible for day procedures due to medical reasons; however, the characteristics of patients, in general, which are not suitable, have not been adequately investigated. Day surgery for groin hernia repair is safe and effective for most patients. However, evidence-based support is only one of many factors that may contribute to the uptake of day surgery in Australia. There is an opportunity for key stakeholders across the private healthcare system to deliver an equally effective but more sustainable and affordable hernia care by increasing the day surgery rates. © 2018 Royal Australasian College of Surgeons.

The management pattern carried out in a cataract surgery day ward.

PubMed

Lin, Jing; Fang, Xiaoqun; Wu, Suhong

2013-06-01

To evaluate the management practice and process of a cataract surgery day ward. From January to December in 2012, a portion of the cataract patients were evaluated for the pattern of day ward management. Methods were as follows: 1) Establish the cataract day ward. 2) Enroll the patients who met the following criteria: voluntary, local residents or outsiders who stayed in a hotel near the hospital, accompanied by family, and who had simple senile cataract without any systemic major diseases. 3) Establish the hospitalization process. 4) Analyze the nursing process. After cataract day surgery, the patients were followed for 2 hours and completed a questionnaire about their needs and sentiments. A total of 3971 cases were observed in this study; 49 cases were switched to a normal pattern of hospitalization because of operative complications, 1 case had a strong desire to switch to a normal pattern of hospitalization because of ocular discomfort, 8 cases went back to the hospital for treatment because of ocular pain, and 52 cases called on the phone to seek help. Overall, 3820 cases(96.2%) returned on time the next day to visit the doctor. No patients showed severe postoperative complications and 98% expressed great satisfaction with the day ward process. Only 200 cases expressed great concern about not knowing how to deal with postoperative pain, the changes in condition outside the hospital, the therapeutic effects, and the problem of expense reimburse-ment. Day ward cataract surgery is an efficient and safe mode, and has the potential to relieve the demand for inpatient beds and to ensure timely treatment of the patients. In addition, it helps the patients enjoy health care at public expense, reserving reimbursement for those who need to be hospitalized. Nurses should pay more attention to systemic evaluation of the patients, health education, and psychological guidance, and keep in close communication with doctors, which is the key to ensure the safety of day ward

Postoperative Calcium Management in Same-Day Discharge Thyroid and Parathyroid Surgery.

PubMed

Nelson, Kurt L; Hinson, Andrew M; Lawson, Bradley R; Middleton, Derek; Bodenner, Donald L; Stack, Brendan C

2016-05-01

To describe a safe and effective postoperative prophylactic calcium regimen for same-day discharge thyroid and parathyroid surgery. Case series with chart review. Tertiary referral academic institution. In total, 162 adult patients who underwent total thyroidectomy, completion thyroidectomy, unilateral parathyroidectomy, parathyroidectomy with bilateral neck exploration, or revision parathyroidectomy were identified preoperatively to be candidates for same-day discharge. All patients in this study were successfully discharged the same day on our standard prophylactic calcium regimen. Less than 1% (1/162) of patients re-presented to the hospital within 30 days of surgery, and that patient was successfully discharged from the emergency department after negative workup for hypocalcemia. There was no significant difference between preoperative and postoperative calcium levels in the total/completion thyroidectomy groups (9.3 vs 9.2 mg/dL, respectively; P = .14). The average postoperative calcium level in the parathyroid group was well within normal limits (9.5 mg/dL), and the difference in postoperative calcium levels between revision and primary parathyroidectomy cases was not significantly different (P = .34). The reported calcium regimen demonstrates a safe, effective, and objective means of postoperative calcium management in outpatient thyroid and parathyroid surgery in appropriately selected patients. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

Trends in 30-day mortality rate and case mix for paediatric cardiac surgery in the UK between 2000 and 2010.

PubMed

Brown, Katherine L; Crowe, Sonya; Franklin, Rodney; McLean, Andrew; Cunningham, David; Barron, David; Tsang, Victor; Pagel, Christina; Utley, Martin

2015-01-01

To explore changes over time in the 30-day mortality rate for paediatric cardiac surgery and to understand the role of attendant changes in the case mix. Included were: all mandatory submissions to the National Institute of Cardiovascular Outcomes Research (NICOR) relating to UK cardiac surgery in patients aged <16 years. The χ(2) test for trend was used to retrospectively analyse the proportion of surgical episodes ending in 30-day mortality and with various case mix indicators, in 10 consecutive time periods, from 2000 to 2010. Comparisons were made between two 5-year eras of: 30-day mortality, period prevalence and mean age for 30 groups of specific operations. 30-day mortality for an episode of surgical management. Our analysis includes 36 641 surgical episodes with an increase from 2283 episodes in 2000 to 3939 in 2009 (p<0.01). The raw national 30-day mortality rate fell over the period of review from 4.3% (95% CI 3.5% to 5.1%) in 2000 to 2.6% (95% CI 2.2% to 3.0%) in 2009/2010 (p<0.01). The case mix became more complex in terms of the percentage of patients <2.5 kg (p=0.05), with functionally univentricular hearts (p<0.01) and higher risk diagnoses (p<0.01). In the later time era, there was significant improvement in 30-day mortality for arterial switch with ventricular septal defect (VSD) repair, patent ductus arteriosus ligation, Fontan-type operation, tetralogy of Fallot and VSD repair, and the mean age of patients fell for a range of operations performed in infancy. The raw 30-day mortality rate for paediatric cardiac surgery fell over a decade despite a rise in the national case mix complexity, and compares well with international benchmarks. Definitive repair is now more likely at a younger age for selected infants with congenital heart defects.

Applying a managerial approach to day surgery.

PubMed

Onetti, Alberto

2008-01-01

The present article explores the day surgery topic assuming a managerial perspective. If we assume such a perspective, day surgery can be considered as a business model decision care and not just a surgical procedure alternative to the traditional ones requiring patient hospitalization. In this article we highlight the main steps required to develop a strategic approach [Cotta Ramusino E, Onetti A. Strategia d'Impresa. Milano; Il Sole 24 Ore; Second Edition, 2007] at hospital level (Onetti A, Greulich A. Strategic management in hospitals: the balanced scorecard approach. Milano: Giuffé; 2003) and to make day surgery part of it. It means understanding: - how and when day surgery can improve the health care providers' overall performance both in terms of clinical effectiveness and financial results, and, - how to organize and integrate it with the other hospital activities in order to make it work. Approaching day surgery as a business model decision requires to address in advance a list of potential issues and necessitates of continued audit to verify the results. If it does happen, day surgery can be both safe and cost effective and impact positively on surgical patient satisfaction. We propose a sort of "check-up list" useful to hospital managers and doctors that are evaluating the option of introducing day surgery or are trying to optimize it.

Laparoscopic liver surgery: towards a day-case management.

PubMed

Tranchart, Hadrien; Fuks, David; Lainas, Panagiotis; Gaillard, Martin; Dagher, Ibrahim; Gayet, Brice

2017-12-01

Ambulatory surgery (AS) is a contemporary subject of interest. The feasibility and safety of AS for solid abdominal organs are still dubious. In the present study, we aimed at defining potential surgical criteria for AS by analyzing a large database of patients who underwent laparoscopic liver surgery (LLS) in two French expert centers. This study was performed using prospectively filled databases including patients that underwent pure LLS between 1998 and 2015. Patients whose perioperative medical characteristics (ASA score <3, no associated extra-hepatic procedure, surgical duration ≤180 min, blood loss ≤300 mL, no intraoperative anesthesiological or surgical complication, no postoperative drainage) were potentially adapted for ambulatory LLS were included in the analysis. In order to determine the risk factors for postoperative complications, multivariate analysis was carried out. During the study period, pure LLS was performed in 994 patients. After preoperative and intraoperative characteristics screening, 174 (17.5%) patients were considered for the final analysis. Lesions (benign (46%) and liver metastases (43%)) were predominantly single with a mean size of 37 ± 32 mm in an underlying normal or steatotic liver parenchyma (94.8%). The vast majority of LLS performed were single procedures including wedge resections and liver cyst unroofing or left lateral sectionectomies (74%). The global morbidity rate was 14% and six patients presented a major complication (Dindo-Clavien ≥III). The mean length of stay was 5 ± 4 days. Multivariate analysis showed that major hepatectomy [OR 29.04 (2.26-37.19); P = 0.01] and resection of tumors localized in central segments [OR 41.24 (1.08-156.47); P = 0.04] were independent predictors of postoperative morbidity. In experienced teams, approximately 7% of highly selected patients requiring laparoscopic hepatic surgery (wedge resection, liver cyst unroofing, or left lateral sectionectomy) could benefit

[Orthopaedic day surgery in Emilia-Romagna].

PubMed

Rolli, M; Rodler, M; Petropulacos, K; Baldi, R

2001-09-01

It is well known that the organizational model of day surgery, concerning surgical problems defined by the literature as minor, has the aim of optimising the use of hospital resources and facilitating patients and their families, from a psychological and social point of view, by reducing hospitalisation time and the associated complications, and ensuring the same efficacy and more appropriateness of treatment. This study is firstly aimed at analysing the impact that the healthcare policy of the Emilia Romagna Region has had on the development of day surgery practice. Secondly, it compares the patients treated in orthopaedic day surgery in the hospitals of Bologna, Modena, Ferrara, Parma, Reggio Emilia, Maggiore hospital of Bologna and Rizzoli Orthopaedic Institute of Bologna (II.OO.R). In the period 1997-2000 there was a marked increase in the number of operations carried out in day surgery in all of the above-mentioned hospitals. Also in the unispecialistic orthopaedic hospital there was a surprising increase in the percentage of operations carried out in day surgery with respect to the total number of operations performed. The aim of the Rizzoli Orthopaedic Institute and the Emilia Romagna Region is to further implement this form of healthcare, contextually potentiating the appropriateness of hospital admission and avoiding, when not necessary, other forms of healthcare.

REMIFENTANIL VS FENTANYL DURING DAY CASE DENTAL SURGERY IN PEOPLE WITH SPECIAL NEEDS: A COMPARATIVE, PILOT STUDY OF THEIR EFFECT ON STRESS RESPONSE AND POSTOPERATIVE PAIN.

PubMed

Sklika, Eirini; Kalimeris, Konstantinos; Perrea, Despina; Stavropoulos, Nikolaos; Kostopanagiotou, Georgia; Matsota, Paraskevi

2016-06-01

People with special needs undergoing dental surgery frequently require general anesthesia. We investigated the effect of remifentanil vs fentanyl on stress response and postoperative pain in people with special needs undergoing day-case dental surgery. Forty-six adult patients with cognitive impairment undergoing day-case dental surgery under general anesthesia were allocated to receive intraoperatively either fentanyl 50 μg iv bolus (group F, n = 23) or continuous infusion of remifentanil 0.5-1 μg/kg/min (group R, n = 23). Iintraoperative hemodynamic parameters were recorded and serum inflammatory mediators [tumor necrosis factor-α, substance-P], stress hormons (melatonin, cortisol) and β-endorphin were measured. Postoperative pain was assessed during the first postoperative 12 hours with the Wong-Baker faces pain-rating scale. Demographics were similar in two groups. The two groups did not differ regarding their effects on inflammatory mediators, stress hormons and postoperative pain scores. However, the use of remifentanil prevented intraoperative increases of arterial blood pressure and heart rate. Remifentanil and fentanyl did not affect differently stress and inflammatory hormones during day-case dental surgery, although remifentanil may render intraoperative management of hemodynamic responses easier. Both opioids are equally efficient for postoperative pain management following dental surgery in people with special needs.

Lumbar microdiscectomy as a day-case procedure: Scope for improvement?

PubMed

Ahuja, Neeraj; Sharma, Himanshu

2018-06-01

There are no significant differences in outcomes between patients receiving inpatient and day-case lumbar microdiscectomy, but the latter is still underused in the NHS. Here we aimed to identify factors contributing to successful same-day discharge in day-case patients. This was a retrospective observational study of patients undergoing elective lumbar microdiscectomy between August 2012 and December 2014. Age, gender, day of surgery, distance to hospital, ASA grade, regular opiate use, smoking status, order on the operating list, and side and level of surgery were examined by logistic regression to assess their influence on same-day discharge. 28/95 (29.5%) patients were discharged on the day of surgery. Age (p = 0.041), ASA grade (p = 0.016), distance to hospital (p = 0.011), and position on the list (p = 0.004) were associated with day-case discharge by univariate analysis. ASA grade (p = 0.032; OR 0.176), distance to hospital (p = 0.003; OR 0.965), and position on the operating list (morning case; p = 0.011; OR 8.901) remained significant in multivariate analysis. Thirteen (13.7%) patients were identified who could have been managed as day cases had they been listed for morning operations. Day-case lumbar microdiscectomy is viable when patients are carefully selected. Younger, fit patients living close to the hospital and operated on in the morning are more likely to be discharged on the same day. Knowledge of these factors while planning elective lists can help optimise bed space and improve spinal services. Copyright © 2017 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Are “knife and fork” good enough for day case surgery of resistant tennis elbow?

PubMed Central

Govindaswamy, Raja; Elbouni, Tariq; Chambler, Andrew F. W.

2008-01-01

This observational retrospective study was performed on 22 consecutive patients treated surgically in a day surgery unit for resistant tennis elbow to ascertain the effectiveness of the “knife and fork” procedure. All patients had an unfavourable response to nonsurgical treatment lasting at least six months. A simple and inexpensive “knife and fork” technique yielded excellent results in 90.5% of patients and a high percentage (95.2%) of satisfied patients at an average follow-up of two years. There were no fair or poor results and no complications. We conclude that the “knife and fork” technique is a simple and dependable day case procedure. In the present National Health Service (NHS) era of tariff and “payment by results”, this approach is more cost effective than an arthroscopic alternative. PMID:19096844

The nurse's role in day surgery: a literature review.

PubMed

Gilmartin, J; Wright, K

2007-06-01

This paper reports a literature review to synthesize the evidence on day surgery, demonstrating its usefulness for innovative nurses. Day surgery growth has developed rapidly in recent years. Such a rapid growth has triggered a shift in nursing roles and interventions. Nursing roles are taking shape within modern day surgical units but have not been widely reviewed in developing countries. The RCN library, BNI, CINAHL and Medline databases were searched using the terms 'day surgery and technological advantages', 'financial/economic benefits', 'patient experiences/satisfaction', 'day surgery/international comparisons', 'day surgery and developing countries'. Only papers in the English language from 1990 to 2005 were reviewed, with a predominantly adult focus. The papers examined mainly used research techniques and some opinion papers, policy documents and textbooks were examined for additional information. The key strengths of day surgery are cost-effectiveness, increased patient satisfaction and low infection rates. Patients indicated that effective information provision and psychological preparation helped them cope with the experience. The use of music, story telling and distraction reduced pre-operative anxiety. Contrastingly, the deficits included poor information giving and psychological preparation resulting in high anxiety levels. Many patients encountered variable pain and nausea management and education strategies. This review highlights the importance of adequate preparation and continuous psychological support for patients undergoing day surgery. The challenges faced by practitioners involved with innovation are also emphasized.

Day care versus in-patient surgery for age-related cataract.

PubMed

Lawrence, David; Fedorowicz, Zbys; van Zuuren, Esther J

2015-11-02

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract living in lower income countries. With the increased number of people with cataract, it is important to review the evidence on the effectiveness of day care cataract surgery. To provide authoritative, reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of day case cataract extraction by comparing clinical outcomes, cost-effectiveness, patient satisfaction or a combination of these in cataract operations performed in day care versus in-patient units. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2015), EMBASE (January 1980 to August 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 August 2015. We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation. Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials. We included two trials. One study was conducted in the USA in 1981 (250 people randomised and completed trial) and one study conducted in Spain in 2001 (1034 randomised, 935 completed trial). Both trials

[Organizational recommendations for day surgery].

PubMed

Bontemps, Gilles

2014-03-01

In France, the delayed development of day surgery compared to other countries led the ANAP and the HAS in 2011 to enter into a joint work program to provide some reference guide for hospitals to change their practices to outpatient. In this context, organizational guidelines and operational tools were published in May 2013. The method of construction of the recommendations resulting from an original work that combined a three-fold approach: field vision by identifying the highlights of 15 hospitals selected for their representative performance and analyzing the risks of five voluntary hospitals, mobilization organizational theories from the social sciences, using 53 professional experts. The work concluded on 16 organizational recommendations under four forms (basic principles, strategic elements, operational elements and perspectives). These recommendations are accompanied by tools and guides diagnosis and implementation, as well as productions for further reflection. These organizational recommendations confirmed the specificity of day surgery, which is not related to the act, but to the organization, management and optimization of different flows of a hospital (patient flow, professional flows, logistical, informational…). The performance of a day surgery organization is linked to its ability to control its flow and anticipation. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Setting up pre-admission visits for children undergoing day surgery: a practice development initiative.

PubMed

O'Shea, Maria; Cummins, Ann; Kelleher, Ann

2010-06-01

The hospital experience can bring about a range of negative emotions for children. The literature clearly states that children who are prepared for surgery recover faster and have fewer negative effects. Pre-admission programmes seek to prepare children (and their parents) for surgery. This paper describes in detail how a pre-admission programme was established for children and their families who were scheduled for day case surgery.

Toward Shorter Hospitalization After Endoscopic Transsphenoidal Pituitary Surgery: Day-by-Day Analysis of Early Postoperative Complications and Interventions.

PubMed

Shimanskaya, Viktoria E; Wagenmakers, Margreet A E M; Bartels, Ronald H M A; Boogaarts, Hieronymus D; Grotenhuis, J André; Hermus, Ad R M M; van de Ven, Annenienke C; van Lindert, Erik J

2018-03-01

It is unclear which patients have the greatest risk of developing complications in the first days after endoscopic transsphenoidal pituitary surgery (ETS) and how long patients should stay hospitalized after surgery. The objective of this study is to identify which patients are at risk for early postoperative medical and surgical reinterventions to optimize the length of hospitalization. The medical records of 146 patients who underwent ETS for a pituitary adenoma between January 2013 and July 2016 were reviewed retrospectively. Data were collected on baseline patient-related characteristics, characteristics of the pituitary adenoma, perioperative complications and interventions, and postoperative outcomes. Patients who underwent additional interventions on days 2, 3, and 4 after ETS were identified as cases, and patients who did not have any interventions after day 1 postoperatively were identified as controls. Diabetes mellitus (odds ratio [OR], 4.279; 95% confidence interval [CI], 1.149-15.933; P = 0.03), incomplete adenoma resection (OR, 2.840; 95% CI, 1.228-6.568; P = 0.02) and increased morning sodium concentration on day 2 after surgery (OR, 5.211; 95% CI, 2.158-12.579; P <0.001) were associated with reinterventions. Patients without interventions on day 1 or 2 had only an 18.6% chance of a reintervention (OR, 0.201; 95% CI, 0.095-0.424). Patients with diabetes mellitus, incomplete adenoma resection, and increased morning sodium concentration on day 2 after surgery have an increased chance on reinterventions. In addition, patients without any interventions on day 1 and 2 are at low risk for later reinterventions. These patients could be suitable candidates for early hospital discharge. Copyright © 2018 Elsevier Inc. All rights reserved.

Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A hospital.

PubMed

Zhuang, Min; Cao, Juan; Cui, Minglan; Yuan, Songtao; Liu, Qinghuai; Fan, Wen

2018-06-05

High cataract incidence and low cataract surgical rate are serious public health problems in China, despite the fact that efficient day care cataract surgery has been implemented in some public Tertiary A hospitals in China. In this study, we compared not only clinical outcomes, hospitalization time and total costs but also payment manners between day care and inpatient procedures for cataract surgery in a Jiangsu public Tertiary A hospital to put forward several instructional suggestions for the improvement of government medical policies. In total, 4151 day care cases and 2509 inpatient cases underwent the same cataract surgery in the day care ward and ordinary ward respectively, and were defined as two groups. General information, complications, postoperative best corrected visual acuity (BCVA), hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient. The general data display no significant differences (P > 0.05), and no significant difference between complications and postoperative BCVA were observed between the two groups (P > 0.05). The period of stay in hospital was significantly different (P < 0.001). The total costs were lower for day care than for inpatients (P < 0.001). To avoid sampling error, we analyzed the data of payment manner for each patient among this period. Day care patients tended to pay for the procedure using the Urban Employees Basic Medical Insurance (UEBMI) method, while inpatients tended to use the Out-of-Pocket Medical Treatment (OMT) payment method (P < 0.001). Day surgery of cataract is more cost-effective and efficient than inpatient surgery with equivalent clinical outcomes. As an efficient therapeutic regimen, day care surgery should be further promoted and supported by the government policies.

Initial experience using a femtosecond laser cataract surgery system at a UK National Health Service cataract surgery day care centre

PubMed Central

Dhallu, Sandeep K; Maurino, Vincenzo; Wilkins, Mark R

2016-01-01

Objectives To describe the initial outcomes following installation of a cataract surgery laser system. Setting National Health Service cataract surgery day care unit in North London, UK. Participants 158 eyes of 150 patients undergoing laser-assisted cataract surgery. Interventions Laser cataract surgery using the AMO Catalys femtosecond laser platform. Primary and secondary outcome measures Primary outcome measure: intraoperative complications including anterior and posterior capsule tears. Secondary outcome measures: docking to the laser platform, successful treatment delivery, postoperative visual acuities. Results Mean case age was 67.7±10.8 years (range 29–88 years). Docking was successful in 94% (148/158 cases), and in 4% (6/148 cases) of these, the laser delivery was aborted part way during delivery due to patient movement. A total of 32 surgeons, of grades from junior trainee to consultant, performed the surgeries. Median case number per surgeon was 3 (range from 1–20). The anterior capsulotomy was complete in 99.3% of cases, there were no anterior capsule tears (0%). There were 3 cases with posterior capsule rupture requiring anterior vitrectomy, and 1 with zonular dialysis requiring anterior vitrectomy (4/148 eyes, 2.7%). These 4 cases were performed by trainee surgeons, and were either their first laser cataract surgery (2 surgeons) or their first and second laser cataract surgeries (1 surgeon). Conclusions Despite the learning curve, docking and laser delivery were successfully performed in almost all cases, and surgical complication rates and visual outcomes were similar to those expected based on national data. Complications were predominately confined to trainee surgeons, and with the exception of intraoperative pupil constriction appeared unrelated to the laser-performed steps. PMID:27466243

Patient and staff satisfaction with 'day of admission' elective surgery.

PubMed

Sofela, Agbolahan A; Laban, James T; Selway, Richard P

2013-04-01

To evaluate patient and staff satisfaction with day of admission surgery in a neurosurgical unit and its effect on theatre start times. Patients were admitted to a Neurosciences admission lounge (NAL) for neurosurgery on the morning of their operation if deemed appropriate by their neurosurgical consultant. All patients in the NAL were asked to complete patient satisfaction questionnaires. Staff members involved in the care of these patients also completed a satisfaction questionnaire. Theatre start times were compared with those whose patients had been admitted prior to the day of surgery. 378 patients admitted on the day of surgery, 16 doctors (5 anaesthetists, 7 neurosurgeons and 4 neuro high dependency unit, HDU doctors) and 5 nurses. Patients completed an anonymised emotional mapping patient satisfaction questionnaire, and short interviews were carried out with staff members. Theatre start times were obtained retrospectively from the theatre database for lists starting with patients admitted on the day of surgery, and lists starting with patients admitted prior to the day of surgery. 83% of patients felt positive on arrival in the NAL and 88% felt positive on being seen by the doctors and nurses prior to surgery. Overall 79% of patients gave positive responses throughout their patient pathway. 90% of staff were positive about day of admission surgery and all staff members were satisfied that there were no negative effects on surgical outcome. Theatre start time was on average 27 minutes earlier in patients admitted on the day of surgery. Neurosurgical patients, appropriately selected, can be admitted on the day of surgery with high staff and patient satisfaction and without delaying theatre start times.

Day care versus in-patient surgery for age-related cataract.

PubMed

Fedorowicz, Zbys; Lawrence, David; Gutierrez, Peter; van Zuuren, Esther J

2011-07-06

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract found in the developing world. With the increased number of people with cataract there is an urgent need for cataract surgery to be made available as a day care procedure. To provide reliable evidence for the safety, feasibility, effectiveness and cost-effectiveness of cataract extraction performed as day care versus in-patient procedure. We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 5), MEDLINE (January 1950 to May 2011), EMBASE (January 1980 to May 2011), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 23 May 2011. We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation. Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Adverse effects information was collected from the trials. We included two trials (conducted in Spain and USA), involving 1284 people. One trial reported statistically significant differences in early postoperative complication rates in the day care group, with an increased risk of increased intraocular pressure, which had no clinical relevance to visual outcomes four months postoperatively. The mean change in visual acuity (Snellen lines) of the operated eye four months postoperatively was 4.1 (standard deviation (SD) 2.3) for the day care group and 4.1 (SD 2.2) for the in-patient group and not statistically

Management of Uncomplicated Acute Appendicitis as Day Case Surgery: Feasibility and a Critical Analysis of Exclusion Criteria and Treatment Failure.

PubMed

Grelpois, Gérard; Sabbagh, Charles; Cosse, Cyril; Robert, Brice; Chapuis-Roux, Emilie; Ntouba, Alexandre; Lion, Thierry; Regimbeau, Jean-Marc

2016-11-01

Day case surgery (DCS) for uncomplicated acute appendicitis (NCAA) is evaluated. The objective of this prospective, single-center, descriptive, nonrandomized, intention-to-treat cohort study was to assess the feasibility of DCS for NCAA with a critical analysis of the reasons for exclusion and treatment failures and a focus on patients discharged to home and admitted for DCS on the following day. From April 2013 to December 2015, NCAA patients meeting the inclusion criteria were included in the study. The primary end point was the success rate for DCS (length of stay less than 12 hours) in the intention-to-treat population (all NCAA) and in the per-protocol population (no pre- or perioperative exclusion criteria). The secondary end points were morbidity, DCS quality criteria, predictive factors for successful DCS, patient satisfaction, quality of life, and reasons for pre- or perioperative exclusion. A subgroup of patients discharged to home the day before operation was also analyzed. A total of 240 patients were included. The success rate of DCS was 31.5% in the intention-to-treat population and 91.5% in the per-protocol population. The rates of unplanned consultations, hospitalization, and reoperation were 13%, 4%, and 1%, respectively. An analysis of the reasons for DCS exclusion showed that 73% could have been modified. For the 68 patients discharged to home on the day before operation, the DCS success rate was 91%. Day case surgery is feasible in NCAA. A critical analysis of the reasons for exclusion from DCS showed that it should be possible to dramatically increase the eligible population. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Association between Socioeconomic Status and 30-Day and One-Year All-Cause Mortality after Surgery in South Korea.

PubMed

Oh, Tak Kyu; Kim, Kooknam; Do, Sang-Hwan; Hwang, Jung-Won; Jeon, Young-Tae

2018-03-10

Preoperative socioeconomic status (SES) is associated with outcomes after surgery, although the effect on mortality may vary according to region. This retrospective study evaluated patients who underwent elective surgery at a tertiary hospital from 2011 to 2015 in South Korea. Preoperative SES factors (education, religion, marital status, and occupation) were evaluated for their association with 30-day and one-year all-cause mortality. The final analysis included 80,969 patients who were ≥30 years old, with 30-day mortality detected in 339 cases (0.4%) and one-year mortality detected in 2687 cases (3.3%). As compared to never-married patients, those who were married or cohabitating (odds ratio (OR): 0.678, 95% confidence interval (CI): 0.462-0.995) and those divorced or separated (OR: 0.573, 95% CI: 0.359-0.917) had a lower risk of 30-day mortality after surgery. Similarly, the risk of one-year mortality after surgery was lower among married or cohabitating patients (OR: 0.857, 95% CI: 0.746-0.983) than it was for those who had never married. Moreover, as compared to nonreligious patients, Protestant patients had a decreased risk of 30-day mortality after surgery (OR: 0.642, 95% CI: 0.476-0.866). The present study revealed that marital status and religious affiliation are associated with risk of 30-day and one-year all-cause mortality after surgery.

Day case stapled anopexy for the treatment of haemorrhoids and rectal mucosal prolapse.

PubMed

Hidalgo Grau, L A; Heredia Budó, A; Llorca Cardeñosa, S; Carbonell Roure, J; Estrada Ferrer, O; García Torralbo, E; Suñol Sala, X

2012-06-01

Stapled anopexy (SA) gives better early postoperative results than classical haemorrhoidectomy. The aim of this study is to demonstrate that SA is a safe and effective procedure for the treatment of haemorrhoids and rectal mucose prolapse in a day-case surgery programme. From January 2000 to December 2008, 297 SA procedures were performed; 230 (77.4%) were performed in the Day Surgery Unit (DSU). Third- and fourth-degree haemorrhoids, second-degree haemorrhoids with no response to conservative treatment and several cases of rectal prolapse were included. The mean age of the patients in the series was 48.1 years (range 21-85). Preoperative preparation included phosphate enemas and antibiotic prophylaxis. Patients were operated on mainly under spinal anaesthesia. Day-case rate, postoperative pain (measured by a visual analogic scale, 1-10), admissions, re-admissions, early postoperative situation and recurrence were evaluated in the study. The overall DSU rate was 78%, with a progressive increase from 46% to 99% in 2008. One hundred and eighty-five patients (80%) had pain scores under 2; no patient had a pain score over 7. Eighteen (8%) patients required admission on the day of surgery. Late admission was needed for 3 (3%) patients. Thirty-three patients reported their situation as excellent, 174 as good, 20 as acceptable and three as bad when they answered a phone questionnaire 24 h after surgery. Overall, 20 (9%) patients had recurrence of symptoms. SA is a safe and effective procedure for prolapsing haemorrhoids in the day case setting. The recurrence rate is higher than that observed in classical haemorrhoidectomy. Most patients can be managed as day-cases. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

Association between Socioeconomic Status and 30-Day and One-Year All-Cause Mortality after Surgery in South Korea

PubMed Central

Oh, Tak Kyu; Kim, Kooknam; Do, Sang-Hwan; Hwang, Jung-Won; Jeon, Young-Tae

2018-01-01

Preoperative socioeconomic status (SES) is associated with outcomes after surgery, although the effect on mortality may vary according to region. This retrospective study evaluated patients who underwent elective surgery at a tertiary hospital from 2011 to 2015 in South Korea. Preoperative SES factors (education, religion, marital status, and occupation) were evaluated for their association with 30-day and one-year all-cause mortality. The final analysis included 80,969 patients who were ≥30 years old, with 30-day mortality detected in 339 cases (0.4%) and one-year mortality detected in 2687 cases (3.3%). As compared to never-married patients, those who were married or cohabitating (odds ratio (OR): 0.678, 95% confidence interval (CI): 0.462–0.995) and those divorced or separated (OR: 0.573, 95% CI: 0.359–0.917) had a lower risk of 30-day mortality after surgery. Similarly, the risk of one-year mortality after surgery was lower among married or cohabitating patients (OR: 0.857, 95% CI: 0.746–0.983) than it was for those who had never married. Moreover, as compared to nonreligious patients, Protestant patients had a decreased risk of 30-day mortality after surgery (OR: 0.642, 95% CI: 0.476–0.866). The present study revealed that marital status and religious affiliation are associated with risk of 30-day and one-year all-cause mortality after surgery. PMID:29534463

[Phacoemulsification: advantages of a consultation the day after surgery?].

PubMed

Pajot, O; Mazit, C; Jallet, G; Ebran, J-M; Cochereau, I

2010-03-01

Cataract surgery is the most frequent surgery in France. The D1 consultation limits the extension of ambulatory care to patients who can return on their own the day after sugery. We assessed the usefulness of this systematic D1 consultation in terms of therapeutic modifications. MATERIAL AND MéTHODE: Retrospective study of patients who underwent cataract surgery in a teaching hospital from february to july 2006. The major parameter was the modification of postsurgical treatment after the D1 consultation. Of the 380 operated eyes studied, the patients included 145 men and 235 women, the mean age was 73.8 years (range, 43-92), 86% underwent conventional hospitalization, 70% had been operated by a senior surgeon, and 66% had no suture. At the D1 visit, 11 modifications (2.9%) were recorded: one case of athalamia, one Seidel-positive test, four cases of high IOP (>30mmHg), and five severe inflammations of the anterior segment. All the treatment changes were reported in the group of hospitalized patients, none were reported in the ambulatory patients. Of the 380 eyes studied, only one required sutures at D1, the other treatment changes were minor. The low output of the D1 visit raises the problem of its relevance in terms of public health. In most of the English-speaking and Scandinavian countries, patients have only one postoperative visit at 1 month. Patients could receive written and oral recommendations and a hotline number to contact the surgical team, which could allow the D1 visit to be discontinued for standard patients with uncomplicated surgery.

[Plastic surgery in day hospital conditions: comparison between two hospital models].

PubMed

Faga, A; Carminati, M; Falconi, D; Gatti, S; Rottino, A

2003-12-01

Personal experience of plastic surgery carried out in Day Hospital conditions is reported. The experience took place within the hospital structure through two different organisational models called here transversal and divisional organisation models: characteristic of the former is that it uses a dedicated interdivisional structure within the hospital involving the centralization of all day-surgery activities, whereas the latter organizes Day Surgery activities within the operating unit whose structures it shares. On the basis of a comparison between the two models we were able to note advantages and disadvantages. We can review our experience in brief by stating that our own preference went to the transversal model which presents the indubitable advantage of being a logistic structure which is hinged on daytime activity and is ready therefore to satisfy on the one hand the needs of this type of patient and, on the other, the needs of the structure itself in efficiency terms. We propose to correct the disadvantages of the transversal model which can be outlined in its lack of homogeneity in the pathology treated and in the subtraction of the criterion of clinical priority in waiting lists through the attainment of a critical dimensional threshold such as to permit programmable sessions with patients with homogeneous pathology (i.e. belonging to the same hospital unit) and through the maintenance of a certain number of Day Hospital beds (around 25%) reserved for new emergency clinical cases.

Is surgical case order associated with increased infection rate after spine surgery?

PubMed

Gruskay, Jordan; Kepler, Christopher; Smith, Jeremy; Radcliff, Kristen; Vaccaro, Alexander

2012-06-01

Retrospective database review. To determine whether surgical site infections are associated with case order in spinal surgery. Postoperative wound infection is the most common complication after spinal surgery, with incidence varying from 0.5% to 20%. The addition of instrumentation, use of preoperative prophylactic antibiotics, length of procedure, and intraoperative blood loss have all been found to influence infection rate. No previous study has attempted to correlate case order with infection risk after surgery. A total of 6666 spine surgery cases occurring between January 2005 and December 2009 were studied. Subjects were classified into 2 categories: fusion and decompression. Case order was determined, with each procedure labeled 1 to 5 depending on the number of previous cases in the room. Variables such as the American Society of Anesthesiologists score, number of operative levels, wound class, age, sex, and length of surgery were also tracked. A step-down binary regression was used to analyze each variable as a potential risk factor for infection. Decompression cases had a 2.4% incidence of infection. Longer surgical time and higher case order were found to be significant risk factors for lumbar decompressions. Fusion cases had a 3.5% incidence of infection. Posterior approach and revision cases were significant risk factors for infection in cervical cases. For lumbar fusion cases, longer surgical time, higher American Society of Anesthesiologists score, and older age were all significant risk factors for infection. Decompressive procedures performed later in the day carry a higher risk for postoperative infection. No similar trend was shown for fusion procedures. Our results identify potential modifiable risk factors contributing to infection rates in spinal procedures. Specific risk factors, although not defined in this study, might be related to contamination of the operating room, cross-contamination between health care providers during the course of

Same-day breast cancer surgery: a qualitative study of women's lived experiences.

PubMed

Greenslade, M Victoria; Elliott, Barbara; Mandville-Anstey, Sue Ann

2010-03-01

To understand the experiences of women having same-day breast cancer surgery and make recommendations to assist healthcare professionals effect change to enhance quality of care. Thematic analysis of audiotaped interviews. Outpatient departments of two city hospitals on the east coast of Canada. Purposive sample of 13 women who had undergone same-day breast cancer surgery. A constructivist approach with in-depth interviews and comparative analysis to develop and systemically organize data into four major interrelated themes and a connecting essential thread. Women's experiences with same-day breast cancer surgery. The themes of preparation, timing, supports, and community health nursing intervention were of paramount importance for effective coping and recovery. Women who had a positive experience with same-day breast cancer surgery also reported having adequate preparation, appropriate timing of preparation, strong support systems, and sufficient community health nursing intervention. Those reporting a negative experience encountered challenges in one or more of the identified theme areas. Same-day surgery is a sign of the times, and the approach to it is changing. Healthcare systems need to be responsive to such changes. Although same-day surgery for breast cancer is not suitable for every patient, women undergoing this type of surgery should be assessed individually to determine whether it is appropriate for them. Women undergoing breast cancer surgery should be screened for same-day surgery suitability. Those having same-day breast cancer surgery should be prepared adequately with timely education. Most importantly, such women should receive community health nursing follow-up for assessment, continuing education, and psychosocial support.

Reducing Cancelations on the Day of Scheduled Surgery at a Children's Hospital.

PubMed

Pratap, Jayant Nick; Varughese, Anna M; Mercurio, Patti; Lynch, Terri; Lonnemann, Teresa; Ellis, Andrea; Rugg, John; Stone, W Ray; Bedinghaus, Cindi

2015-05-01

Cancelation on the day of surgery (DoSC) represents a costly wastage of operating room (OR) time and causes inconvenience, emotional distress, and financial cost to families. A quality improvement project sought to reduce lost OR time due to cancelation. Key drivers of the process included effective 2-way communication with families, compliance with fasting rules, and decision-making on patient illness before the day of surgery. A multidisciplinary team conducted serial tests of change addressing the various key drivers. Interventions were simplified, colorful, personalized preoperative instruction sheets and text-message reminders to caregivers' cellphones, as well as a defined institutional decision-making pathway to permit rescheduling before the day of surgery in case of patient illness concerns. After initial smaller-scale testing, the interventions were implemented across all patients and sites. Data were collected from the hospital information technology system and analyzed by using control charts and statistical process control methods. Mean OR time lost due to DoSC was decreased from a baseline of 5.7 to 3.6 hours/day in testing with a subset of surgical services at the hospital's base campus, and then from 6.6 hours to 5.5 hours/day when implemented across all services at both surgical sites. By applying quality improvement methods, significant reductions were made in time lost due to DoSC. The impact can be significant by improving institutional resource utilization. Copyright © 2015 by the American Academy of Pediatrics.

Paediatric day-case neurosurgery in a resource challenged setting: Pattern and practice

PubMed Central

Owojuyigbe, Afolabi Muyiwa; Komolafe, Edward O.; Adenekan, Anthony T.; Dada, Muyiwa A.; Onyia, Chiazor U.; Ogunbameru, Ibironke O.; Owagbemi, Oluwafemi F.; Talabi, Ademola O.; Faponle, Fola A.

2016-01-01

Background: It has been generally observed that children achieve better convalescence in the home environment especially if discharged same day after surgery. This is probably due to the fact that children generally tend to feel more at ease in the home environment than in the hospital setting. Only few tertiary health institutions provide routine day-case surgery for paediatric neurosurgical patients in our sub-region. Objective: To review the pattern and practice of paediatric neurosurgical day-cases at our hospital. Patients and Methods: A prospective study of all paediatric day-case neurosurgeries carried out between June 2011 and June 2014. Results: A total of 53 patients (34 males and 19 females) with age ranging from 2 days to 14 years were seen. Majority of the patients (77.4%) presented with congenital lesions, and the most common procedure carried out was spina bifida repair (32%) followed by ventriculoperitoneal shunt insertion (26.4%) for hydrocephalus. Sixty-eight percentage belonged to the American Society of Anesthesiologists physical status class 2, whereas the rest (32%) belonged to class 1. General anaesthesia was employed in 83% of cases. Parenteral paracetamol was used for intra-operative analgesia for most of the patients. Two patients had post-operative nausea and vomiting and were successfully managed. There was no case of emergency re-operation, unplanned admission, cancellation or mortality. Conclusion: Paediatric day-case neurosurgery is feasible in our environment. With careful patient selection and adequate pre-operative preparation, good outcome can be achieved. PMID:27251657

Outpatient Follow-Up versus 30-day Readmission among General and Vascular Surgery Patients: A Case for Redesigning Transitional Care

PubMed Central

Saunders, Richard Scott; Fernandes-Taylor, Sara; Rathouz, Paul J.; Saha, Sandeep; Wiseman, Jason T.; Havlena, Jeffrey; Matsumura, Jon; Kent, K. Craig

2014-01-01

Background The association between early outpatient follow-up and 30-day readmission has not been evaluated in any surgical population. Our study characterizes the relationship between outpatient follow-up and early readmissions among surgical patients. Methods We queried the medical record at a large, tertiary care institution (July 2008-December 2012) to determine rates of 30-day outpatient follow-up and readmission for general or vascular surgical procedures. Results The majority of discharges for general (84% of 7552) and vascular (75% of 2362) surgery had a follow-up visit before readmission or within 30 days of discharge. General surgery patients who were not readmitted had high rates of follow-up (88%) and received follow-up at approximately 2-weeks post-discharge (median time 11 days after discharge). In contrast, readmitted general surgery patients received first follow-up at one week (a median time of 8 days); 49% had follow-up. Vascular surgery patients showed a similar trend. Over half of patients readmitted after follow-up were readmitted within 24 hours of their most recent outpatient visit. Conclusions Current routine follow-up does not occur early enough to detect adverse events and prevent readmission. Early outpatient care may prevent readmission in some patients, but often serves as a conduit for readmission among patients already experiencing complications. PMID:25239351

30-Day Readmission After Spine Surgery: An Analysis of 1400 Consecutive Spine Surgery Patients.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing L; Karikari, Isaac O; Cheng, Joseph; Bagley, Carlos A

2017-04-01

Retrospective cohort review. To identify the rates, causes, and risk factors for 30-day unplanned readmissions in after elective spine surgery at our institution. Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery. Nearly 60% of these readmissions are unplanned, which translates into billions of dollars in healthcare costs. A total of 1400 patients undergoing elective spine surgery at Duke University Hospital between 2008 and 2010 were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. A total of 132 (9.4%) unplanned early readmissions were identified. The mean ± SD age was 58.6 ± 15.1 years. Lumbar decompression and fusion was the most common procedure The most common causes for readmission were infection or a concern for infection (34.8%) and pain (19.7%), and 26.5% of readmissions required a return to the operating room. The majority of patients that were readmitted presented to the emergency department from home (58.0%) whereas 25.2% were readmitted from a skilled nursing facility. The mean ± SD number of days from discharge to readmission was 9.8 ± 7.9 days and the average length of hospital stay for the readmissions was 7.5 days. This study suggests that infection and refractory pain were the most common primary reasons for unplanned readmission. Efforts at reducing unplanned early readmission after elective spine surgery should be focused on more effective post discharge care.

Years Versus Days Between Successive Surgeries, After an Initial Outpatient Procedure, for the Median Patient Versus the Median Surgeon in the State of Iowa.

PubMed

Dexter, Franklin; Jarvie, Craig; Epstein, Richard H

2018-03-01

Previously, we studied the relative importance of different institutional interventions that the largest hospital in Iowa could take to grow the anesthesia department's outpatient surgical care. Most (>50%) patients having elective surgery had not previously had surgery at the hospital. Patient perioperative experience was unimportant for influencing total anesthesia workload and numbers of patients. More important was the availability of surgical clinic appointments within several days. These results would be generalizable if the median time from surgery to a patient's next surgical procedure was large (eg, >2 years), among all hospitals in Iowa with outpatient surgery, and without regard to the hospital where the next procedure was performed. There were 37,172 surgical cases at hospital outpatient departments of any of the 117 hospitals in Iowa from July 1, 2013, to September 30, 2013. Data extracted about each case included its intraoperative work relative value units. The 37,172 cases were matched to all inpatient and outpatient records for the next 2 years statewide using patient linkage identifiers; from these were determined whether the patient had surgery again within 2 years. Furthermore, the cases' 1820 surgeons were matched to the surgeon's next outpatient or inpatient case, both including and excluding other cases performed on the date of the original case. By patient, the median time to their next surgical case, either outpatient or inpatient, exceeded 2 years, tested with weighting by intraoperative relative value units and repeated when unweighted (both P < .0001). Specifically, with weighting, 65.9% (99% confidence interval [CI], 65.2%-66.5%) of the patients had no other surgery within 2 years, at any hospital in the state. The median time exceeded 2 years for multiple categories of patients and similar measures of time to next surgery (all P < .01). In comparison, by surgeon, the median time to the next outpatient surgical case was 1 calendar day

The value of comparative research in major day surgery.

PubMed

Llop-Gironés, Alba; Vergara-Duarte, Montse; Sánchez, Josep Anton; Tarafa, Gemma; Benach, Joan

2017-05-19

To measure time trends in major day surgery rates according to hospital ownership and other hospital characteristics among the providers of the public healthcare network of Catalonia, Spain. Data from the Statistics of Health Establishments providing Inpatient Care. A generalized linear mixed model with Gaussian response and random intercept and random slopes. The greatest growth in the rate of major day surgery was observed among private for-profit hospitals: 42.9 (SD: 22.5) in 2009 versus 2.7 (SD: 6.7) in 1996. These hospitals exhibited a significant increase in major day surgery compared to public hospitals (coefficient 2; p-value <0.01) CONCLUSIONS: The comparative evaluation of hospital performance is a decisive tool to ensure that public resources are used as rationally and efficiently as possible. Copyright © 2017 SESPAS. Publicado por Elsevier España, S.L.U. All rights reserved.

The use of standard operating procedures in day case anterior cruciate ligament reconstruction.

PubMed

Khan, T; Jackson, W F; Beard, D J; Marfin, A; Ahmad, M; Spacie, R; Jones, R; Howes, S; Barker, K; Price, A J

2012-08-01

The current rate of day-case anterior cruciate ligament reconstruction (ACLR) in the UK remains low. Although specialised care pathways with standard operating procedures (SOPs) have been effective in reducing length of stay following some surgical procedures, this has not been previously reported for ACLR. We evaluate the effectiveness of SOPs for establishing day-case ACLR in a specialist unit. Fifty patients undergoing ACLR between May and September 2010 were studied prospectively ("study group"). SOPs were designed for pre-operative assessment, anaesthesia, surgical procedure, mobilisation and discharge. We evaluated length of stay, readmission rates, patient satisfaction and compliance to SOPs. A retrospective analysis of 50 patients who underwent ACLR prior to implementation of the day-case pathway was performed ("standard practice group"). Eighty percent of patients in the study group were discharged on the day of surgery (mean length of stay=5.3h) compared to 16% in the standard practice group (mean length of stay=21.6h). This difference was statistically significant (p<0.05, Mann-Whitney U test). All patients were satisfied with the day case pathway. Ninety-two percent of the study group were discharged on the day of surgery when all SOPs were followed and 46% where they were not. High rates of day-case ACLR with excellent patient satisfaction can be achieved with the use of a specialised patient pathway with SOPs. Copyright © 2011 Elsevier B.V. All rights reserved.

Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery.

PubMed

Soop, Mattias; Nygren, Jonas; Thorell, Anders; Weidenhielm, Lars; Lundberg, Mari; Hammarqvist, Folke; Ljungqvist, Olle

2004-08-01

Postoperative metabolism is characterised by insulin resistance and a negative whole-body nitrogen balance. Preoperative carbohydrate treatment reduces insulin resistance in the first day after surgery. We hypothesised that preoperative oral carbohydrate treatment attenuates insulin resistance and improves whole-body nitrogen balance 3 days after surgery. Fourteen patients undergoing total hip replacement were double-blindly randomised to preoperative oral carbohydrate treatment (12.5%, 800 + 400 ml, n = 8) or placebo (n = 6). Glucose kinetics (6,6-D2-glucose), substrate utilisation (indirect calorimetry) and insulin sensitivity (hyperinsulinaemic-euglycaemic clamp) were measured preoperatively and on the third day after surgery. Nitrogen losses were monitored for 3 days after surgery. Values are mean (SEM). Analysis of variance (ANOVA) statistics were used. Endogenous glucose release during insulin infusion increased after surgery in the placebo group. Preoperative carbohydrate treatment, as compared to placebo, significantly attenuated postoperative endogenous glucose release (0.69 (0.07) vs. 1.21 (0.13)mg kg(-1) x min(-1), P < 0.01), while whole-body glucose disposal and nitrogen balance were similar between groups. While insulin resistance in the first day after surgery has previously been characterised by reduced glucose disposal, enhanced endogenous glucose release was the main component of postoperative insulin resistance on the third postoperative day. Preoperative carbohydrate treatment attenuated endogenous glucose release on the third postoperative day. Copyright 2004 Elsevier Ltd.

Same-Day Evaluation and Surgery for Otitis Media and Tympanostomy Tube Placement: A Feasibility Study.

PubMed

Billings, Kathleen R; Hajduk, John; Rose, Allison; De Oliveira, Gildasio S; Suresh, Suresh S; Thompson, Dana M

2016-10-01

To determine the feasibility of providing streamlined same-day evaluation and surgical management of children with recurrent otitis media or chronic serous otitis media who meet criteria for tympanostomy tube (TT) placement. Retrospective matched case series. Tertiary care children's hospital. A comparison group (age, sex, insurance product) was utilized to determine if the same-day process decreased facility time and surgical time for the care episode. A parent satisfaction survey was administered. Thirty children, with a median age of 16 months (range, 12-22 months), participated in the same-day surgery process for TT. Twenty-one patients (70.0%) were male, and these patients were matched to a comparison group (similar age, sex, and insurance product) having non-same-day (routine) TT placement. The same-day patients spent significantly less time in clinic for the preoperative physician visit (average, 15 minutes) when compared with the non-same-day patients (average, 51.5 minutes; P < .001). The operative experience for the same-day patients was similar to the non-same-day patients (average, 145 vs 137 minutes, respectively; P = .35), but the overall experience was significantly shorter for the same-day patients (average, 151 vs 196 minutes for comparisons; P < .001). All parents surveyed in the same-day group were satisfied with the efficiency of the experience. The same-day surgery process for management of children who meet the criteria for TT placement is a model of improved efficiency of care for children who suffer from otitis media. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: A retrospective analysis.

PubMed

McCracken, Graham C; Montgomery, Jane

2018-05-01

Guidance on pre-operative fluids fasting policy continues to evolve. Current European guidelines encourage the intake of oral fluids up to 2 h before the induction of general anaesthesia. From October 2014, Torbay Hospital Day Surgery Unit commenced an unrestricted fluid policy, encouraging patients to drink clear fluids up until the time of transfer to theatre. The aim of this study was to assess the incidence of postoperative nausea and vomiting before and after the change to the unrestricted pre-operative clear oral fluids. Retrospective, before and after study. Single district general hospital between November 2013 and February 2016. A total of 11 500 patients on the day case pathway who were receiving either sedation, general anaesthesia, regional anaesthesia or their combination. The data from these patients were collected routinely. This number of patients represents approximately 78% of all patients before the change in fluids policy and 74% after the change. Exclusions were patients undergoing a termination of pregnancy, or patients undergoing community dental procedures, from whom patient experience data are not collected. Introduction of a change to the day surgery pathway policy permitting unrestricted clear oral fluids preoperatively until transfer to theatre (from October 2014). Incidence of postoperative nausea and vomiting. The rates of nausea within 24 h postoperatively were 270/5192 (5.2%) when patients could not drink within 2 h of surgery, and 179/4724 (3.8%) when patients could drink up until surgery, a relative rate (95% confidence interval) of 0.73 (0.61 to 0.88), P = 0.00074. The corresponding rates of vomiting were 146/5186 (2.8%) and 104/4716 (2.2%), a relative rate (95% confidence interval) of 0.78 (0.61 to 1.00), P = 0.053. Our data suggest that the liberal consumption of clear fluids before the induction of scheduled day case anaesthesia reduced the rates of postoperative nausea and vomiting.

Serratia marcescens endophthalmitis after pterygium surgery: a case report.

PubMed

Yi, Myeong Yeon; Chung, Jin Kwon; Choi, Kyung Seek

2017-11-02

To report a case of Serratia marcescens endophthalmitis after pterygium surgery using the bare sclera technique with mitomycin C (MMC). A 69-year-old male patient underwent pterygium excision surgery using the bare sclera technique and 0.02% MMC. The patient presented with decreased visual acuity and pain from the day after the operation. Trans pars plana vitrectomy was performed and intravitreal antibiotics were administered. Cultures from the aqueous humor and intraocular lens were all positive for S. marcescens, which was sensitive to an empiric antibiotic regimen. The best corrected distant visual acuity, 1 month after treatment, was a finger count/50 cm, but the retinal layer structure and the vasculature were relatively well preserved. This is the first reported case of S. marcescens endophthalmitis after pterygium surgery. Endophthalmitis caused by S. marcescens has a devastating visual prognosis and may show a high clinical risk-benefit ratio for the application of MMC in pterygium surgery.

Pain management following discharge after ambulatory same-day surgery.

PubMed

Watt-Watson, Judy; Chung, Frances; Chan, Vincent W S; McGillion, Michael

2004-05-01

Same-day surgeries are becoming routine for many surgical procedures. However, the degree to which patients need help with pain management at home following laparoscopic cholecystectomy (LC), shoulder, or hand ambulatory day surgery has received minimal examination. This study examined pain and related interference, analgesic use and adverse events, complications and resources utilized, and adequacy of postdischarge information at four time periods. Data were collected from 180 patients by telephone interviews at 24, 48 and 72 hours, and 7 days after discharge. Patients (n = 78 hand, 48 shoulder, 54 LC surgery) were on average 41 years old. For all patients, worst 24-hour pain was reported as moderate to severe at all time periods. Using repeated measures anova demonstrated that shoulder patients had significantly more pain and overall pain-related interference, particularly in sleep and work, from 24 hours to day 7 than did hand or LC patients. The main analgesic taken was acetaminophen (paracetamol) with codeine 30 mg; 50% took no analgesia from 72 hours. About 20% experienced analgesic adverse events within 72 hours, mainly constipation and nausea. Only day-surgery patients after discharge.

Perceived quality in Day Surgery Units Proposal of an enquiry postoperative questionnaire.

PubMed

Palumbo, Piergaspare; Perotti, Bruno; Amatucci, Chiara; Pangrazi, Maria Pia; Leuzzi, Barbara; Vietri, Francesco; Illuminati, Giulio

2016-01-01

Assessing patient satisfaction could be particularly useful in Day Surgery Units, as it helps maintaining and increasing medical care demand. Moreover, it provides feedback that turns out useful for improving quality in departments, and for assessing competence and skill of the whole staff. Background and aim - The purpose of this study was to evaluate the quality perceived in a day surgery unit through a questionnaire, covering the 10 main aspects of the care pathway. The results of a questionnaire filled by patients undergoing Day Surgery between January 2007 and December 2012 were retrospectively reviewed. Patients undergoing surgery between 2007 and 2009 filled up the questionnaire at the time of the discharge, whereas those operated on between 2009 and 2012 filled up the same questionnaire 30 days after discharge. The results were good in terms of number of returned questionnaires, underlining its comprehensibility and suitability to be filled out. The questionnaires' scores were good in both groups, although quality perceived by the group that completed it in 30 days after surgery were lightly better than the other group's. The advantages of the questionnaire consisted of an overall improvement of the quality of care, whereas limitations consisted of the difficulty in setting up the questionnaire accurately, interpreting patients' answers correctly, and dispensing the questionnaire in a timely fashion, in order to evaluate the quality perceived by the patients without any bias related to delay, pain and anxiety. Day Surgery, Nursing, Questionnaire, Quality.

Use of perioperative dialogues with children undergoing day surgery.

PubMed

Wennström, Berith; Hallberg, Lillemor R-M; Bergh, Ingrid

2008-04-01

This paper is a report of a study to explore what it means for children to attend hospital for day surgery. Hospitalization is a major stressor for children. Fear of separation, unfamiliar routines, anaesthetic/operation expectations/experiences and pain and needles are sources of children's negative reactions. A grounded theory study was carried out during 2005-2006 with 15 boys and five girls (aged 6-9 years) scheduled for elective day surgery. Data were collected using tape-recorded interviews that included a perioperative dialogue, participant observations and pre- and postoperative drawings. A conceptual model was generated on the basis of the core category 'enduring inflicted hospital distress', showing that the main problem for children having day surgery is that they are forced into an unpredictable and distressful situation. Pre-operatively, the children do not know what to expect, as described in the category 'facing an unknown reality'. Additional categories show that they perceive a 'breaking away from daily routines' and that they are 'trying to gain control' over the situation. During the perioperative period, the categories 'losing control' and 'co-operating despite fear and pain' are present and intertwined. Post-operatively, the categories 'breathing a sigh of relief' and 'regaining normality in life' emerged. The perioperative dialogue used in our study, if translated into clinical practice, might therefore minimize distress and prepare children for the 'unknown' stressor that hospital care often presents. Further research is needed to compare anxiety and stress levels in children undergoing day surgery involving the perioperative dialogue and those having 'traditional' anaesthetic care.

[Results of a survey on urologic activity in 1-day surgery in Midi-Pyrénées].

PubMed

Sanson, S; Gamé, X

2013-12-01

One-day surgery is an exercise whose development has grown significantly over the last decade. This survey aims at reviewing the different aspects of this practice in urology, in the second largest region of France. A cross-sectional study was conducted among the 57 urologists working in the Midi-Pyrénées region. A computerized questionnaire was made available on Internet. The non-responder urologists received a reminder email every week. The questionnaire included 25 questions, divided into four subgroups. The response rate was 57.9% (33/57 urologists). Results showed that the 1-day surgery rate was 26.4%. It was higher in the private sector (33.07 ± 17.16 vs. 20.42 ± 13.54%, P=0.04). Surgeries were made mainly in non-dedicated operating theaters (75.0%) and in the conventional list (71.8%). There was a written output protocol in 90.6% of cases (29 urologists), which was never given to the patient in 7.0% of cases (2 urologists) and never sent to the family doctor in 75.8% of cases (22 urologists). This study has shown that outpatient surgery accounted for a quarter of urologic surgery in Midi-Pyrénées region, and that the organization follows the recommendations of the International Association for Ambulatory Surgery. The main problems were the lack of information of the family doctor, and the lack of organized follow. Organizational problems were considered as the limiting factors of this activity development. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Laparoscopic Heller myotomy for achalasia: changing trend toward "true" day-case procedure.

PubMed

Agrawal, Sanjay; Super, Paul

2008-12-01

Laparoscopic Heller myotomy is the most effective therapy for achalasia. All case series have reported a minimum length of stay of more than 1 day. "True" day-case laparoscopic Heller myotomy has not been reported, so far. The aim of this study was to review our results with laparoscopic Heller myotomy with respect to the length of stay following the procedure. All patients undergoing laparoscopic Heller myotomy between August 2000 and July 2007 under the care of one surgeon were included in the study. This was performed by incising 6 cm of distal esophageal musculature, extending to 2 cm below the gastroesophageal junction. The myotomy was covered by an anterior fundoplication. All patients were reviewed in the clinic at a median of 6 weeks after surgery and, thereafter, if necessary. Over the 7-year period, 24 consecutive patients with achalasia were treated in this manner. There were 13 women and 11 men, with an age range of 12-73 years. Intraoperative complications included mucosal perforation in 2 patients (sutured immediately) with no postoperative complications or conversion to open surgery. There were no deaths. The average length of stay was 1.9 days (range, 0-4). The last 2 patients were discharged on the same day, and the 5 previous to this were discharged within 23 hours of surgery. There were no adverse outcomes related to early discharge, and there were no readmissions. All patients reported good to excellent results with a relief of dysphagia on follow-up. Three patients (12%) developed recurrent dysphagia after an initial improvement, requiring dilatation only several months later. Based on our own experience, we believe that laparoscopic Heller myotomy with anterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia. It is well tolerated and can be considered a true day-case procedure.

Risk model of thoracic aortic surgery in 4707 cases from a nationwide single-race population through a web-based data entry system: the first report of 30-day and 30-day operative outcome risk models for thoracic aortic surgery.

PubMed

Motomura, Noboru; Miyata, Hiroaki; Tsukihara, Hiroyuki; Takamoto, Shinichi

2008-09-30

The objective of this study was to collect integrated data from nationwide hospitals using a web-based national database system to build up our own risk model for the outcome from thoracic aortic surgery. The Japan Adult Cardiovascular Surgery Database was used; this involved approximately 180 hospitals throughout Japan through a web-based data entry system. Variables and definitions are almost identical to the STS National Database. After data cleanup, 4707 records were analyzed from 97 hospitals (between January 1, 2000, and December 31, 2005). Mean age was 66.5 years. Preoperatively, the incidence of chronic lung disease was 11%, renal failure was 9%, and rupture or malperfusion was 10%. The incidence of the location along the aorta requiring replacement surgery (including overlapping areas) was: aortic root, 10%; ascending aorta, 47%; aortic arch, 44%; distal arch, 21%; descending aorta, 27%; and thoracoabdominal aorta, 8%. Raw 30-day and 30-day operative mortality rates were 6.7% and 8.6%, respectively. Postoperative incidence of permanent stroke was 6.1%, and renal failure requiring dialysis was 6.7%. OR for 30-day operative mortality was as follows: emergency or salvage, 3.7; creatinine >3.0 mg/dL, 3.0; and unexpected coronary artery bypass graft, 2.6. As a performance metric of the risk model, C-index of 30-day and 30-day operative mortality was 0.79 and 0.78, respectively. This is the first report of risk stratification on thoracic aortic surgery using a nationwide surgical database. Although condition of these patients undergoing thoracic aortic surgery was much more serious than other procedures, the result of this series was excellent.

Evaluation of cardiac surgery mortality rates: 30-day mortality or longer follow-up?

PubMed

Siregar, Sabrina; Groenwold, Rolf H H; de Mol, Bas A J M; Speekenbrink, Ron G H; Versteegh, Michel I M; Brandon Bravo Bruinsma, George J; Bots, Michiel L; van der Graaf, Yolanda; van Herwerden, Lex A

2013-11-01

The aim of our study was to investigate early mortality after cardiac surgery and to determine the most adequate follow-up period for the evaluation of mortality rates. Information on all adult cardiac surgery procedures in 10 of 16 cardiothoracic centres in Netherlands from 2007 until 2010 was extracted from the database of Netherlands Association for Cardio-Thoracic Surgery (n = 33 094). Survival up to 1 year after surgery was obtained from the national death registry. Survival analysis was performed using Kaplan-Meier and Cox regression analysis. Benchmarking was performed using logistic regression with mortality rates at different time points as dependent variables, the logistic EuroSCORE as covariate and a random intercept per centre. In-hospital mortality was 2.94% (n = 972), 30-day mortality 3.02% (n = 998), operative mortality 3.57% (n = 1181), 60-day mortality 3.84% (n = 1271), 6-month mortality 5.16% (n = 1707) and 1-year mortality 6.20% (n = 2052). The survival curves showed a steep initial decline followed by stabilization after ∼60-120 days, depending on the intervention performed, e.g. 60 days for isolated coronary artery bypass grafting (CABG) and 120 days for combined CABG and valve surgery. Benchmark results were affected by the choice of the follow-up period: four hospitals changed outlier status when the follow-up was increased from 30 days to 1 year. In the isolated CABG subgroup, benchmark results were unaffected: no outliers were found using either 30-day or 1-year follow-up. The course of early mortality after cardiac surgery differs across interventions and continues up to ∼120 days. Thirty-day mortality reflects only a part of early mortality after cardiac surgery and should only be used for benchmarking of isolated CABG procedures. The follow-up should be prolonged to capture early mortality of all types of interventions.

Which is the better timing between embolization and surgery for hypervascular spinal tumors, the same day or the next day?: A retrospective comparative study.

PubMed

Tang, Benqiang; Ji, Tao; Guo, Wei; Tang, Xiaodong; Jin, Long; Dong, Sen; Xie, Lu

2018-06-01

Previous series presented the timing between embolization and surgery in a wide range on the basis of their experience rather than supportive data. And comparative studies were limited to small samples. In addition, there is no study publishing the timing by considering both safety and efficacy of embolization. The aim of this study was to determine the better timing (the same day or the next day) between embolization and surgery for hypervascular spinal tumors by assessing the safety and efficacy of embolization.One hundred twenty-five embolizations with subsequent 120 operations for hypervascular spinal tumors between January 2010 and April 2013 were retrospectively reviewed. The time between embolization and surgery was mainly determined by interventional radiologist schedules and operating room available. Major complications of embolization were documented. The efficacy of embolization was compared between the same day and the next day group.Of the 125 embolizations, there were 4 major complications, all of which occurred on the same day of procedure. Of the 120 operations, 36 cases were operated on the same day of embolization, 74 on the next day, and 10 on the second day. When comparing the efficacy of embolization between the same day and the next day group, intraoperative blood loss (1483 ± 1475 vs 1548 ± 1099 mL, P = .80), intraoperative transfusion requirement (1011 ± 1200 vs 1112 ± 890 mL, P = .62), and postoperative blood loss (1146 ± 933 vs 1031 ± 777 mL, P = .50) were not significantly different.Embolization carries certain risks (4/125, 3.2%) for major complications, which may occur within the time window of 1 day. Two patient groups showed no difference on the efficacy of embolization. Operation should be scheduled on the next day of embolization if possible.

A perspective on the use of an enhanced recovery program in open, non-instrumented day surgery for degenerative lumbar and cervical spinal conditions.

PubMed

Venkata, Hari K; van Dellen, James R

2018-06-01

A means of significantly shortening patients' length of hospital stay, improving their outcome and thereby also reducing costs is to use an enhanced recovery program (ERP) which is increasingly being used in a number of surgical sub-specialties. This paper provides a perspective on its prospective use in a wide-ranging, unselected cohort of patients undergoing open spinal surgery for degenerative lumbar and cervical spinal conditions. Selected spinal cases undergoing day surgery have been increasingly reported. A prospective, unselected, consecutive cohort of 246 cases, over an 18-month period, undergoing open, non-instrumented decompression spinal surgery and using ERP (and the concept of "bundles of care") was analyzed. Nine cases could not be included as they did not fully meet the entry criteria. No routine follow-up was arranged for the study group. The ages ranged widely, from 23-90 years (mean 57). In 187 the surgery for degenerative conditions was lumbar and in 50 cervical. The ASA (American Association of Anesthesiologists) ratings were 108=1; 107=2 and 22=3. Using the United Kingdom (UK) National Health Service (NHS) definitions of length of stay 225 (95%) could be finally classified as "ambulatory" and 12 (5%) were "short stay". A sub-cohort of 126 (53.2%) were "day cases". The follow-up was >1 year for all. There were no wound infections reported; 5 postdischarge cases (2.1%) needed to be seen in the Accident and Emergency (A&E) Department (less than 4 days postsurgery), but none needed re-admission; and there were 7 re-admissions (2.5%), between 4 and 30 days, and of these 6 required a further surgical procedure. There were no long-term instability complications reported in this cohort. ERP can be used for spinal surgery. There were identifiable and correctable medical and social factors found on analysis which could significantly increase the "day cases" number to over 90%.

[Plastic surgery in the setting of a public hospital day care unit].

PubMed

Faga, A; Valdatta, L; Magnani, S; Thione, A

2000-09-01

The authors describe the advantages and disadvantages of plastic surgery performed in a day-care public hospital unit. A retrospective study was made of the day-surgery activities over 16 months (1998-1999) as part of a centralized system. Data were compared to day-surgery activities undertaken in 1997 using a non-centralized system. The study was based in the Macchi Foundation Hospital in Varese. A total of 179 patients were treated from all age group whose clinical, intellectual and social characteristics enabled them to be treated using a day-hospital regime. The pathologies treated can be classified into six groups: benign skin pathologies, malignant skin pathologies, scar pathologies, hand disorders, burns and others. All operations were performed as planned under general, local or regional anesthesia with the help of an anesthetist. The centralized system has a number of advantages of a social and technical kind; there are few disadvantages, mainly consisting in the impossibility of using this approach for emergency surgery and its overall rigidity. This form of surgery provides a service that stands out for its quality, organisational efficiency and low cost.

Day-of-Surgery Mobilization Reduces the Length of Stay After Elective Hip Arthroplasty.

PubMed

Okamoto, Taro; Ridley, Ryan J; Edmondston, Stephen J; Visser, Mariet; Headford, Julie; Yates, Piers J

2016-10-01

To determine the effect of mobilization on the day of surgery on the readiness for discharge and length of stay after elective total hip arthroplasty (THA). We devised a randomized control trial with concealed allocation and intention-to-treat analysis. Overall, 126 patients who underwent THA and met the criteria for mobilization on the day of surgery were randomly allocated into 2 groups; the intervention group was mobilized on the day of surgery, n = 58 and the control group was mobilized on the day after surgery, n = 68. Apart from timing of mobilization, both groups received the same postoperative management. The primary outcome measures were length of hospital stay and time to readiness for discharge. The early mobilization group was ready for discharge 63 hours (standard deviation [SD] = 15 hours) after surgery, compared to 70 hours (SD = 18 hours) for the control group (P = .03, 95% CI, 0.7-12.8). There was no significant difference in hospital stay in the early mobilization group (77 hours [SD = 30 hours]), compared to the control group (87 hours [SD = 35 hours]; P = .11, 95% CI, -2.1 to 21.6). Despite this at any point in time after the surgery, the intervention group was 1.8 times (P = .003, 95% CI, = 1.2-2.7) more likely to have been discharged. Mobilization on the day of THA surgery significantly increases the probability of discharge at any singular point in time compared with mobilization on the day after surgery and decreases the time to readiness for discharge. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

Iatrogenic Pseudoaneurysm of Superficial Temporal Artery After Surgery for Scaphocephaly: Case Report and Review of Literature.

PubMed

Anania, Pasquale; Pacetti, Mattia; Ravegnani, Marcello; Pavanello, Marco; Piatelli, Gianluca; Consales, Alessandro

2018-03-01

Iatrogenic pseudoaneurysm of the superficial temporal artery after surgery for craniosynostosis is a complication that has never been described in the pertinent literature. Although reported for other types of surgeries, no case has been described in the pediatric population. We report on a case of pseudoaneurysm of the superficial temporal artery that occurred 9 days after corrective surgery for scaphocephaly. We also describe the management of this complication. Pseudoaneurysm is an exceptional complication in surgery for craniosynostosis, but it should be considered in case of swelling in the temporal region. Copyright © 2017 Elsevier Inc. All rights reserved.

Day of surgery urine cultures identify urogynecologic patients at increased risk for postoperative urinary tract infection.

PubMed

Fok, Cynthia S; McKinley, Kathleen; Mueller, Elizabeth R; Kenton, Kimberly; Schreckenberger, Paul; Wolfe, Alan; Brubaker, Linda

2013-05-01

Despite preoperative screening and treatment for urinary tract infections, a postoperative urinary tract infection develops in approximately 1 in 5 urogynecologic patients. In this study we assess the proportion of urogynecologic patients with a positive day of surgery urine culture, the clinical consequences of a positive day of surgery culture and differences in postoperative urinary tract infection risks based on day of surgery culture. After institutional review board approval, patients undergoing urogynecologic surgery at Loyola University Medical Center were recruited for the study. Catheterized urine samples were collected in the operating room before intravenous antibiotic administration. Clinical cultures were considered positive if 1,000 colonies per ml or more bacteria were found on routine culture. For analysis we matched each woman with a positive culture with 2 women with negative culture by age within 10 years and within surgical groups (ie prolapse and/or incontinence). Data were analyzed using SPSS® version 19. Nearly a tenth (9.5%) of participants had positive day of surgery cultures. The clinical and demographic characteristics were similar in women with negative vs positive day of surgery cultures. However, women with positive day of surgery cultures were more likely to experience a postoperative urinary tract infection despite standard perioperative antibiotic administration (29.6% vs 5.6%, p = 0.005, odds ratio 7.2). Regardless of day of surgery culture status no participant experienced postoperative systemic urinary complications. Nearly a tenth of urogynecologic patients had positive day of surgery cultures. Patients with a positive day of surgery culture had an increased risk (29.6%) of postoperative urinary tract infection within 6 weeks of surgery. These findings highlight an opportunity to identify and treat patients with positive day of surgery cultures and reduce the incidence of postoperative urinary tract infections. Copyright �

[Sclerotherapy and hydrocelectomy for the management of hydrocele in outpatient and day-surgery setting].

PubMed

Erdas, Enrico; Pisano, Giuseppe; Pomata, Mariano; Pinna, Giovanni; Secci, Lucia; Licheri, Sergio; Daniele, Giovanni Maria

2006-01-01

The purpose of this report was to compare two different procedures in the treatment of idiopathic hydrocele, namely, hydrocelectomy and percutaneous sclerotherapy, both of which performed in the outpatient or day surgery setting. A detailed description of the technical local anaesthesia steps is reported together with the sclerotherapy method. The study was conducted in 71 patients with a total of 77 hydroceles treated from 1993 to 2004. Surgery was carried out in 53 cases and sclerotherapy in 24. The latter was more frequently opted for elderly subjects as well as in those patients who requested it. Local or locoregional anaesthesia was reserved to patients treated surgically. The two treatments were compared on the basis of the following parameters: age, operative time, length of hospital stay, success rate and complications. The efficacy of the two procedures was comparable (sclerotherapy 95.8% vs surgery 100%), but sclerotherapy proved more favourable in terms of simplicity, rapidity of execution, shortness of hospital stay and risk of complications. However, 41.7% of patients required more than one treatment to obtain a radical cure, whereas surgery was effective in all cases in just one step. Hospital stay and morbidity were almost the same when surgery was performed under local anaesthesia. Sclerotherapy is an efficient alternative to the classic hydrocelectomy. The choice between the two treatment modalities should be made, taking into account above all the patient's individual preference.

Failure Modes and Effects Analysis of bilateral same-day cataract surgery

PubMed Central

Shorstein, Neal H.; Lucido, Carol; Carolan, James; Liu, Liyan; Slean, Geraldine; Herrinton, Lisa J.

2017-01-01

PURPOSE To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN Retrospective cohort study. METHODS Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry. Potential failures in human factors and communication (modes) were identified. Rates of endophthalmitis, toxic anterior segment syndrome (TASS), and unintended intraocular lens (IOL) implantation were assessed in eyes having bilateral same-day surgery from 2010 through 2014. RESULTS The study comprised 4754 eyes. The analysis identified 15 significant potential failure modes. These included lapses in instrument processing and compounding error of intracameral antibiotic that could lead to endophthalmitis or TASS and ambiguous documentation of IOL selection by surgeons, which could lead to unintended IOL implantation. Of the study sample, 1 eye developed endophthalmitis, 1 eye had unintended IOL implantation (rates, 2 per 10 000; 95% confidence intervals [CI] 0.1–12.0 per 10 000), and no eyes developed TASS (upper 95% CI, 8 per 10 000). Recommendations included improving oversight of cleaning and sterilization practices, separating lots of compounded drugs for each eye, and enhancing IOL verification procedures. CONCLUSIONS Potential failure modes and recommended actions in bilateral same-day cataract surgery were determined using a FMEA. These findings might help improve the reliability and safety of bilateral same-day cataract surgery based on current evidence and standards. PMID:28410711

Follow-Up After Cardiac Surgery Should be Extended to at Least 120 Days When Benchmarking Cardiac Surgery Centers.

PubMed

Hansen, Laura S; Sloth, Erik; Hjortdal, Vibeke E; Jakobsen, Carl-Johan

2015-08-01

Short-term (30 days) mortality frequently is used as an outcome measure after cardiac surgery, although it has been proposed that the follow-up period should be extended to 120 days to allow for more accurate benchmarking. The authors aimed to evaluate whether mortality rates 120 days after surgery were comparable to general mortality and to compare causes of death between the cohort and the general population. A multicenter descriptive cohort study using prospectively entered registry data. University hospital. The cohort was obtained from the Western Denmark Heart Registry and matched to the Danish National Hospital Register as well as the Danish Register of Causes of Death. A weighted, age-matched general population consisting of all Danish patients who died within the study period was identified through the central authority on Danish statistics. A total of 11,988 patients (>15 years) who underwent cardiac-surgery at Aarhus, Aalborg and Odense University Hospitals from April 1, 2006 to December 31, 2012 were included. Coronary artery bypass grafting, valve surgery and combinations. Mortality after cardiac surgery matches with mortality in the general population after 140 days. Mortality curves run almost parallel from this point onwards, regardless of The European system for cardiac operative risk evaluation (EuroSCORE) and intervention. The causes of death in the cohort differed statistically significantly from the background population (p<0.0001; one-sample t-test) throughout the first postoperative year. The leading cause of death in the cohort was cardiac (38%); 53% of which was categorized as heart failure. A total of 54% of these patients were assessed preoperatively as having normal or mildly impaired heart function (EuroSCORE). This study supported an extended follow-up period after cardiac surgery when benchmarking cardiac surgery centers. Regardless of preoperative heart function, heart failure was the consistent leading cause of death. Copyright �

Tonsillectomy in children and in adults: changes in practice following the opening of a day-surgery unit with dedicated operating room.

PubMed

Bartier, S; Gharzouli, I; Kiblut, N; Bendimered, H; Cloutier, L; Salvan, D

2018-05-30

To study the impact of the opening of a day-surgery unit on the practice of tonsillectomy in adults and children in the light of the experience of our department, and to compare complications between day-surgery and conventional admission. A retrospective review was conducted of all tonsillectomies performed since the opening of a dedicated day-surgery room, using the ENT and emergency department data-bases. Between October 2013 and December 2014, 179 tonsillectomies were performed (51 in adults, 128 in children), including 108 day-surgeries. Between 2012 and 2014, the number of tonsillectomies increased by 12.7%, with an 18.27% increase in children and stable adult rate. Within 1 year, day-surgery became predominant for children (73.19%) and equaled conventional admission for adults (47.22%). For almost all patients without same-day discharge, the reasons were organizational or due to malorientation (comorbidity, or unsuitable home environment). Day-case tonsillectomy in children showed a 30-day complications rate comparable to those reported in the literature (8.3% postoperative hemorrhage), with a higher rate in adults (35.3%). Onset of complications was at a mean 6 days in adults and 9 days in children; only 2 patients developed complications between 6 and 24hours postoperatively. The present study showed that opening a day-surgery unit led to changes in practice, with most tonsillectomies now performed on an outpatient basis, without increased complications, and notably immediate complications. Outpatient tonsillectomy thus seems to be a solution of choice compared to conventional admission, in terms of cost saving and of patient comfort, without sacrificing safety. The dedicated operating room facilitates scheduling and thereby increasing turnover by reducing wait time. Copyright © 2018. Published by Elsevier Masson SAS.

Postoperative Pain, an Unmet Problem in Day or Overnight Italian Surgery Patients: A Prospective Study

PubMed Central

Antonielli D'Oulx, Maria Delfina; Paradiso, Rosetta; Perretta, Laura; Dimonte, Valerio

2016-01-01

Background. Because of economic reasons, day surgery rates have steadily increased in many countries and the trend is to perform around 70% of all surgical procedures as day surgery. Literature shows that postoperative pain treatment remains unfulfilled in several fields such as orthopedic and general surgery patients. In Italy, the day surgery program is not yet under governmental authority and is managed regionally by local practices. Aim. To investigate the trends in pain intensity and its relation to type of surgeries and pain therapy protocols, in postoperative patients, discharged from three different Ambulatory Surgeries located in North West Italy (Piedmont region). Method. The present study enrolled 276 patients who undergone different surgical procedures in ambulatory regimen. Patients recorded postoperative pain score twice a day, compliance with prescribed drugs, and pain related reasons for contacting the hospital. Monitoring lasted for 7 days. Results. At discharge, 72% of patients were under weak opioids, 12% interrupted the treatment due to side effects, 17% of patients required extra drugs, and 15% contacted the hospital reporting pain problems. About 50% of patients experienced moderate pain during the first day after surgery. Results from our study show that most of the patients experienced avoidable pain after discharge. PMID:28115878

Pharyngoesophageal perforation 3 years after anterior cervical spine surgery: a rare case report and literature review.

PubMed

Yin, Dan-Hui; Yang, Xin-Ming; Huang, Qi; Yang, Mi; Tang, Qin-Lai; Wang, Shu-Hui; Wang, Shuang; Liu, Jia-Jia; Yang, Tao; Li, Shi-Sheng

2015-08-01

Pharyngoesophageal perforation after anterior cervical spine surgery is rare and the delayed cases were more rarely reported but potentially life-threatening. We report a case of pharyngoesophageal perforation 3 years after anterior cervical spine surgery. The patient presented with dysphagia, fever, left cervical mass and developing dyspnea 3 years after cervical spine surgery for trauma. After careful examinations, he underwent an emergency tracheostomy, neck exploration, hardware removal, abscess drainage and infected tissue debridement. 14 days after surgery, CT of the neck with oral contrast demonstrated no contrast extravasation from the esophagus. Upon review of literature, only 14 cases of pharyngoesophageal perforation more than 1 year after anterior cervical spine surgery were found. We discussed possible etiology, diagnosis and management and concluded that in cases of dysphagia, dyspnea, cervical pain, swelling and edema of the cervical area even long time after anterior cervical spine surgery, potential pharyngoesophageal damage should be considered.

The impact of mental health disorders on 30-day readmission after bariatric surgery.

PubMed

Litz, Megan; Rigby, Andrea; Rogers, Ann M; Leslie, Douglas L; Hollenbeak, Christopher S

2018-03-01

Mental health disorders are common among bariatric surgery patients. Mental health disorders, particularly depression, have been associated with poorer surgical outcomes, indicating the bariatric surgery patient population warrants special clinical attention. Our study sought to examine the effect of diagnosed mental health disorders on 30-day readmission for those undergoing bariatric surgery in hospitals across Pennsylvania from 2011 to 2014. We used Pennsylvania Healthcare Cost Containment Council data to perform this analysis. Inclusion criteria encompassed patients aged>18 years who underwent bariatric surgery at any hospital or freestanding surgical facility in Pennsylvania between 2011 and 2014. Mental health disorders were identified using predetermined International Classification of Disease, Ninth Revision codes. Logistic regression was used to model the risk of 30-day readmission and estimate the effect of mental health disorders on 30-day readmission. Of the 19,259 patients who underwent bariatric surgery, 40.3% had a diagnosed mental health disorder; 6.51% of all patients were readmitted within 30 days. Patients with a diagnosed mental health disorder had 34% greater odds of readmission (odds ratio = 1.34, 95% confidence interval: 1.19-1.51) relative to patients with no diagnosed mental health disorder. Patients with major depressive disorder/bipolar disorder had 46% greater odds of being readmitted compared with patients with no major depressive disorder/bipolar disorder diagnosis. Study findings imply the need for risk assessment of patients before postoperative discharge. Given that patients with mental health diagnoses are at increased risk of 30-day readmission after bariatric surgery, they may benefit from additional discharge interventions designed to attenuate potential readmissions. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Same-Day Versus Next-Day Repair of Fovea-Threatening Primary Rhegmatogenous Retinal Detachments.

PubMed

Gorovoy, Ian R; Porco, Travis C; Bhisitkul, Robert B; de Juan, Eugene; Schwartz, Daniel M; Stewart, Jay M

2016-01-01

To evaluate the outcomes of same-day versus next-day repair of fovea-threatening rhegmatogenous retinal detachments (FT RRD). Retrospective, multi-surgeon observational case series. Operative reports and medical records were reviewed to evaluate a number of visual and anatomic outcomes, including presenting features, intraoperative complications, and postoperative results in the repair of primary FT RRD undergoing same-day versus next-day repair with scleral buckling, pars plana vitrectomy, or both procedures. A total of 96 consecutive patients (43 same-day, 45 next-day, and eight two days later) were compared. There was no statistically significant difference in visual outcomes between same-day and next-day repair at postoperative months 3 and 6 and at last follow-up (month 3 mean BCVA 20/30 same day; 20/32 next day; p = 0.82). Preoperative vision was strongly correlated with postoperative acuity. Effect of differences in length or type of visual symptoms, location of RRD, gender, or lens status on postoperative month 3 best-corrected visual acuity (BCVA) was not statistically significant. Overall, 85% of patients had a BCVA of 20/40 or better at postoperative month 3. Reoperation rate and intraoperative complications were not statistically different between the two groups. Re-attachment was achieved in all but one patient in both groups. Time in the operating room was longer for same-day surgery (2.98 ± 0.46 hours) compared to next-day surgery (2.54 ± 0.38 hours) (p < 0.001), which was statistically significant even when factoring in the type of surgery performed. However, one case did progress to a macula-off detachment in a superior RRD with breaks found in lattice degeneration. Next-day surgery provided equivalent visual outcomes. Emergent, same-day surgery has logistical and resource implications as it may be more expensive, may necessitate rescheduling of previously booked cases, and may limit preoperative examination by the surgeon and

Parental Satisfaction with Pediatric Day-Care Surgery and its Determinants in a Tertiary Care Hospital

PubMed Central

Sam, Cenita James; Arunachalam, Pavai A.; Manivasagan, Sivamani; Surya, T.

2017-01-01

Objective: The objective is to assess the level of parental satisfaction of pediatric day-care surgery and its different determinants. Materials and Methods: This is a descriptive study performed in a tertiary care hospital in India among parents of pediatric day-care surgery patients from June 2013 to March 2015. The core questionnaire for the assessment of patient satisfaction for general day care (COPS-D) was used. Variables related to surgery, overall satisfaction, one open-ended question, and socio-demographic data were also collected. Calculated sample size was 121. Results: The mean and standard deviation of parental satisfaction were estimated in eight domains of day care (COPS-D) using Likert scale 1–5. Preadmission visit had a mean of 4.63 (0.52), day of surgery 4.65 (0.58), operating room 4.76 (0.51), nursing care 4.46 (0.79), medical care 4.89 (0.48), information 4.51 (0.68), autonomy 4.64 (0.56), and discharge 4.50 (0.72). In elder children, there was less satisfaction on the information and discharge domains. Overall satisfaction was good in 88% of patients and was less than satisfactory when they had significant pain. Conclusion: Perception of quality of pediatric day-care surgery was assessed with a questionnaire and was found to be good. Variables related to surgery such as pain may be included in the questionnaire for assessing satisfaction in the day-care surgery. PMID:28974875

Seventh-day syndrome: a catastrophic event after liver transplantation: case report.

PubMed

Pereira, M; Ferreira, I; Gandara, J; Ferreira, S; Lopes, V; Coelho, A; Vizcaino, R; Marinho, A; Daniel, J; Miranda, H P

2015-05-01

Seventh-day syndrome (7DS) is an early serious complication of liver transplantation, characterized by sudden failure of a previously normally functioning liver graft ∼1 week after the surgery. Although it is an uncommon event, it has major associated mortality. As its etiology is yet to be recognized, the only currently available treatment is retransplantation. We present 3 cases of orthotopic liver transplantation recipients who had an initial uneventful recovery after surgery followed by a dramatic rise of serum liver enzyme levels ∼7 days later and hepatic failure with subsequent graft loss and death despite high-dose immunosuppressive therapy. Histologic findings showed massive centrolobular hemorrhage and hepatocellular necrosis with reduced inflammation. It is essential to review and accumulate more clinical and laboratory information to better understand this syndrome and to better prevent and treat it. Copyright © 2015 Elsevier Inc. All rights reserved.

Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery.

PubMed

Devereaux, P J; Chan, Matthew T V; Alonso-Coello, Pablo; Walsh, Michael; Berwanger, Otavio; Villar, Juan Carlos; Wang, C Y; Garutti, R Ignacio; Jacka, Michael J; Sigamani, Alben; Srinathan, Sadeesh; Biccard, Bruce M; Chow, Clara K; Abraham, Valsa; Tiboni, Maria; Pettit, Shirley; Szczeklik, Wojciech; Lurati Buse, Giovanna; Botto, Fernando; Guyatt, Gordon; Heels-Ansdell, Diane; Sessler, Daniel I; Thorlund, Kristian; Garg, Amit X; Mrkobrada, Marko; Thomas, Sabu; Rodseth, Reitze N; Pearse, Rupert M; Thabane, Lehana; McQueen, Matthew J; VanHelder, Tomas; Bhandari, Mohit; Bosch, Jackie; Kurz, Andrea; Polanczyk, Carisi; Malaga, German; Nagele, Peter; Le Manach, Yannick; Leuwer, Martin; Yusuf, Salim

2012-06-06

Of the 200 million adults worldwide who undergo noncardiac surgery each year, more than 1 million will die within 30 days. To determine the relationship between the peak fourth-generation troponin T (TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality. A prospective, international cohort study that enrolled patients from August 6, 2007, to January 11, 2011. Eligible patients were aged 45 years and older and required at least an overnight hospital admission after having noncardiac surgery. Patients' TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We undertook Cox regression analysis in which the dependent variable was mortality until 30 days after surgery, and the independent variables included 24 preoperative variables. We repeated this analysis, adding the peak TnT measurement during the first 3 postoperative days as an independent variable and used a minimum P value approach to determine if there were TnT thresholds that independently altered patients' risk of death. A total of 15,133 patients were included in this study. The 30-day mortality rate was 1.9% (95% CI, 1.7%-2.1%). Multivariable analysis demonstrated that peak TnT values of at least 0.02 ng/mL, occurring in 11.6% of patients, were associated with higher 30-day mortality compared with the reference group (peak TnT ≤ 0.01 ng/mL): peak TnT of 0.02 ng/mL (adjusted hazard ratio [aHR], 2.41; 95% CI, 1.33-3.77); 0.03 to 0.29 ng/mL (aHR, 5.00; 95% CI, 3.72-6.76); and 0.30 ng/mL or greater (aHR, 10.48; 95% CI, 6.25-16.62). Patients with a peak TnT value of 0.01 ng/mL or less, 0.02, 0.03-0.29, and 0.30 or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs without (C index = 0.85 vs 0.81; difference, 0.4; 95% CI, 0.2-0.5; P < .001 for difference between C

Accreditation Council for Graduate Medical Education Case Log: General Surgery Resident Thoracic Surgery Experience

PubMed Central

Kansier, Nicole; Varghese, Thomas K.; Verrier, Edward D.; Drake, F. Thurston; Gow, Kenneth W.

2014-01-01

Background General surgery resident training has changed dramatically over the past 2 decades, with likely impact on specialty exposure. We sought to assess trends in general surgery resident exposure to thoracic surgery using the Accreditation Council for Graduate Medical Education (ACGME) case logs over time. Methods The ACGME case logs for graduating general surgery residents were reviewed from academic year (AY) 1989–1990 to 2011–2012 for defined thoracic surgery cases. Data were divided into 5 eras of training for comparison: I, AY89 to 93; II, AY93 to 98; III, AY98 to 03; IV, AY03 to 08; V, AY08 to 12. We analyzed quantity and types of cases per time period. Student t tests compared averages among the time periods with significance at a p values less than 0.05. Results A total of 21,803,843 general surgery cases were reviewed over the 23-year period. Residents averaged 33.6 thoracic cases each in period I and 39.7 in period V. Thoracic cases accounted for nearly 4% of total cases performed annually (period I 3.7% [134,550 of 3,598,574]; period V 4.1% [167,957 of 4,077,939]). For the 3 most frequently performed procedures there was a statistically significant increase in thoracoscopic approach from period II to period V. Conclusions General surgery trainees today have the same volume of thoracic surgery exposure as their counterparts over the last 2 decades. This maintenance in caseload has occurred in spite of work-hour restrictions. However, general surgery graduates have a different thoracic surgery skill set at the end of their training, due to the predominance of minimally invasive techniques. Thoracic surgery educators should take into account these differences when training future cardiothoracic surgeons. PMID:24968766

Safety of lornoxicam in the treatment of postoperative pain: a post-marketing study of analgesic regimens containing lornoxicam compared with standard analgesic treatment in 3752 day-case surgery patients.

PubMed

Rawal, Narinder; Krøner, Karsten; Simin-Geertsen, Marija; Hejl, Charlotte; Likar, Rudolf

2010-01-01

Post-marketing surveillance studies can provide supplemental data on the safety of medications in the general population. This study aimed to evaluate the safety of analgesic regimens including the NSAID lornoxicam in the short-term treatment of postoperative pain in a clinically relevant population. Randomized, open-label, multicentre, multinational, observational cohort study of 4 days' duration. In-hospital postoperative setting, with discharge to home treatment within 24 hours of surgery. Adults aged > or =18 years expected to be in need of analgesic treatment after day-case surgery. Analgesic regimens containing lornoxicam were compared with a standard analgesic treatment, which was defined as the treatment that the patient would normally receive at the centre. Following day-case surgery, patients were provided with appropriate analgesic medication, and adverse events (AEs; defined as all recorded events with symptoms) were recorded by the investigator during the in-hospital stay and by the patient for the next 3 days using entries recorded morning and evening in a patient diary. Statistical analyses tested for between-treatment differences in AEs, adverse drug reactions (ADRs; defined as events probably, possibly or unlikely to be related to treatment) and gastrointestinal AEs (GI-AEs). A total of 4152 patients were randomized to treatment. Since 400 patients did not take any analgesic, the safety population consisted of 1838 patients for lornoxicam and 1914 patients for standard analgesic treatment. Demographic and disease characteristics were similar between the two treatment groups, as were the type of surgery and the anaesthesia used in surgery. In the safety population, 16.9% of patients received no analgesic in hospital, and when analgesics were provided they were often administered in combination. Similarly, approximately 17% of patients did not take any analgesics at home. AEs were reported in 27.1% and 29.4% of patients in the lornoxicam and standard

Day-case surgery for total hip and knee replacement: How safe and effective is it?

PubMed

Lazic, Stefan; Boughton, Oliver; Kellett, Catherine F; Kader, Deiary F; Villet, Loïc; Rivière, Charles

2018-04-01

Multimodal protocols for pain control, blood loss management and thromboprophylaxis have been shown to benefit patients by being more effective and as safe (fewer iatrogenic complications) as conventional protocols.Proper patient selection and education, multimodal protocols and a well-defined clinical pathway are all key for successful day-case arthroplasty.By potentially being more effective, cheaper than and as safe as inpatient arthroplasty, day-case arthroplasty might be beneficial for patients and healthcare systems. Cite this article: EFORT Open Rev 2018;3:130-135. DOI: 10.1302/2058-5241.3.170031.

Congenital craniopharyngioma treated by radical surgery: case report and review of the literature.

PubMed

Kageji, Teruyoshi; Miyamoto, Takeshi; Kotani, Yumiko; Kaji, Tsuyoshi; Bando, Yoshimi; Mizobuchi, Yoshifumi; Nakajima, Kohei; Nagahiro, Shinji

2017-02-01

Craniopharyngiomas are 5-10 % of all pediatric tumors, but are seldomly encountered in the perinatal period. Only seven instances of a truly antenatal diagnosis of a congenital craniopharyngioma that subsequently underwent radical surgery have been reported. We present the case of a patient who received the diagnosis of a suprasellar tumor during the prenatal period and received radical surgery. We report a case of a neonatal craniopharyngioma treated surgically. The pregnancy progressed uneventfully until a routine ultrasound at 37 weeks of gestation showed a 15 × 15 mm high echoic mass in the center of the fetal head. Neonatal Gd-enhanced T1-weighted MRI at 5 days of life showed a homogenously enhanced mass (16×22×15 mm) in the sellar and suprasellar lesion. As the tumor showed rapid growth at the 3rd month of life, the patient underwent a surgical treatment and the mass was totally removed. Three years later, the physical and mental development of the patient was normal, and Gd-MRI studies showed no tumor recurrence. The present case is the eighth case of a truly antenatal diagnosis of a craniopharyngioma that underwent successful radical surgery. Craniopharyngioma is a benign tumor and thought to be a slow growing tumor in childhood. The results of radical surgery were very poor, and the mortality and morbidity rates were high in the previous reports due to the huge size of tumor at operation. The present case demonstrated the rapid growth in short interval of Gd-MRI. This is the first report of tumor kinetics of congenital craniopharyngioma with previous reports. The calculated tumor doubling time in our case was 37 days.

Time of day is not associated with increased rates of mortality in emergency surgery: An analysis of 49,196 surgical procedures.

PubMed

Gabriel, Rodney A; A'Court, Alison M; Schmidt, Ulrich H; Dutton, Richard P; Urman, Richard D

2018-05-01

There is a lack of large, multi-institutional studies analyzing the association of timing of emergency surgery with death occurring either intraoperatively or in the recovery room setting. The primary objective of this study was to determine if time of day for emergency surgeries was associated with mortality. Retrospective analysis. U.S. healthcare facilities. Adult patients undergoing emergency surgery and general anesthesia. No intervention. Utilizing the National Anesthesia Clinical Outcomes Registry database, all emergency non-cardiac, non-obstetric surgeries undergoing general anesthesia occurring between 2010 and 2015 in the United States were identified. We performed mixed effects logistic regression to determine the effect of time of day with mortality occurring during the intraoperative and immediate postoperative period. There were 46,196 cases that were eligible for this analysis, in which 24,247 and 21,949 occurred during day and after-hours shifts, respectively. The overall morality rate was 0.28%. Mortality rates were 0.17% and 0.41% in the day and after-hour shifts, respectively. There was no statistically significant association of time of day with mortality (odds ratio 1.31, 95% CI 0.90-1.92, p = 0.16). American Society of Anesthesiologists physical status classification, age, and operative body part were all associated with mortality. Although, theoretically, health care providers working after-hour shifts may be impacted by sleep deprivation and/or limited resources, we found that time of day was not associated with increased risk of mortality during the intraoperative and immediate postoperative period in emergency surgery. Copyright © 2018 Elsevier Inc. All rights reserved.

Mortality after surgery in Europe: a 7 day cohort study.

PubMed

Pearse, Rupert M; Moreno, Rui P; Bauer, Peter; Pelosi, Paolo; Metnitz, Philipp; Spies, Claudia; Vallet, Benoit; Vincent, Jean-Louis; Hoeft, Andreas; Rhodes, Andrew

2012-09-22

Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe. We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ(2) and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries. We included 46,539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9-3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0-3·0] for Iceland to 21·5% [16·9-26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19-1·05; p=0·06] for Finland to 6·92 [2·37-20·27; p=0·0004] for Poland). The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care

Picture book support for preparing children ahead of and during day surgery.

PubMed

Nilsson, Elisabeth; Svensson, Gunnar; Frisman, Gunilla Hollman

2016-10-07

Aim To develop and evaluate the use of a specific picture book aiming to prepare children for anaesthesia and surgery. Methods An intervention comparing two different information methods before ear, nose and throat day surgery was performed. The intervention involved using a specific information sheet and a specific picture book. Parents (n=104) of children aged 2-12 years completed open-ended questions that were analysed with qualitative content analysis. They were divided into two groups: one group received routine information and one received routine information and the intervention. Findings The picture sheet and picture book were valuable aids to prepare small children for anaesthesia and surgery by explaining the procedures that would take place. The parents expressed that knowledge of the procedures made them and the child feel secure. Conclusion Peri-operative information through pictures supports children and their parents during day surgery and may be helpful in future healthcare visits.

Alfentanil and memory function. A comparison with fentanyl for day case termination of pregnancy.

PubMed

Kennedy, D J; Ogg, T W

1985-06-01

Two groups of 20 patients undergoing day case vaginal termination of pregnancy received either methohexitone and alfentanil 7.5 micrograms/kg or methohexitone and fentanyl 1.5 micrograms/kg. Their recovery times and memory function at 1 and 2 hours after surgery were compared. No difference in the recovery of the 2 groups was noted but at 2 hours after operation the alfentanil group showed impairment of memory for new facts compared with pre-operative memory function testing. This was not evident in the fentanyl group. Apart from this finding alfentanil was adjudged to be a suitable agent for day case anaesthesia.

"Like a trip to McDonalds": a grounded theory study of patient experiences of day surgery.

PubMed

Mottram, Anne

2011-02-01

The amount and complexity of (ambulatory) day surgery is rapidly expanding internationally. Nurses have a responsibility to provide quality care for day surgery patients. To do this they must understand all aspects of the patient experience. There is dearth of research into day surgery using a sociological frame of reference. The study investigated patients' experiences of day surgery using a sociological frame of reference. A qualitative study using the grounded theory approach was used. The study was based in two day surgery units in two urban public hospitals in the United Kingdom. 145 patients aged 18-70 years and 100 carers were purposely selected from the orthopaedic, ear nose and throat and general surgical lists. They were all English speaking and were of varied socio-economic background. The data was collected from 2004 to 2006. Semi-structured interviews were conducted on three occasions: before surgery, 48 h following surgery and one month following discharge. Permission was received from the Local Research Ethics Committee. Analysis of the data involved line-by-line analysis, compilation of key words and phrases (codes) and constant comparison of the codes until categories emerged. Patients liked day surgery and placed it within the wider societal context of efficiency and speed. Time was a major issue for them. They wished surgery, like all other aspects of their life to be a speedy process. They likened it to a McDonald's experience with its emphasis on speed, predictability and control. This study throws new light on patient experiences and offers an understanding of day surgery against a western culture which emphasises the importance of speed and efficiency. It is a popular choice for patients but at times it can be seen to be a mechanistic way of providing care. The implications for nurses to provide education and information to add to the quality of the patient experience are discussed. Copyright © 2010 Elsevier Ltd. All rights reserved.

Rates and causes of 30-day readmission and emergency room utilization following head and neck surgery.

PubMed

Wu, Vincent; Hall, Stephen F

2018-05-18

Unplanned returns to hospital are common, costly, and potentially avoidable. We aimed to investigate and characterize reasons for all-cause readmissions to hospital as in-patients (IPs) and visits to the Emergency Department (ED) within 30-days following patient discharge post head and neck surgery (HNS). Retrospective case series with chart review. All patients within the Department of Otolaryngology - Head and Neck Surgery who underwent HNS for benign and malignant disease from January 1, 2010 to May 31, 2015 were identified. The electronic medical records of readmitted patients were reviewed for reasons of readmission, demographic data, and comorbidities. Following 1281 surgical cases, there were 41 (3.20%) IP readmissions and 109 (8.43%) ED visits within 30-days after discharge for HNS. For IP readmissions, most common causes included infection (26.8%), respiratory symptoms (17.1%), and pain (17.1%). Most common reasons for ED visits were for pain (31.5%), bleeding (17.6%), and infection (14.8%). Readmitted IPs had significantly higher health burden at pre-operative baseline as compared to patients who visited the ED when assessed with the American Society of Anesthesiology scores (p = 0.002) and the Cumulative Illness Rating Scale (p = 0.004). Rate of 30-day IP readmission and ED utilization was 3.20 and 8.43%, respectively. Pain and infection were common causes for returns to hospital. Discharge planning may be improved to target common causes for post-surgical hospital visits in order to decrease readmission rates.

Prediction of 30-day morbidity after primary cytoreductive surgery for advanced stage ovarian cancer.

PubMed

Gerestein, C G; Nieuwenhuyzen-de Boer, G M; Eijkemans, M J; Kooi, G S; Burger, C W

2010-01-01

Treatment in advanced stage epithelial ovarian cancer (EOC) is based on primary cytoreductive surgery followed by platinum-based chemotherapy. Successful cytoreduction to minimal residual tumour burden is the most important determinant of prognosis. However, extensive surgical procedures to achieve maximal debulking are inevitably associated with postoperative morbidity and mortality. The objective of this study is to determine predictors of 30-day morbidity after primary cytoreductive surgery for advanced stage EOC. All patients in the South Western part of the Netherlands who underwent primary cytoreductive surgery for advanced stage EOC between January 2004 and December 2007 were identified from the Rotterdam Cancer Registry database. All peri- and postoperative complications within 30 days after surgery were registered and classified according to the definitions of the National Surgical Quality Improvement Programme (NSQIP). To investigate independent predictors of 30-day morbidity, a Cox proportional hazards model with backward stepwise elimination was utilised. The identified predictors were entered into a nomogram. Two hundred and ninety-three patients entered the study protocol. Optimal cytoreduction was achieved in 136 (46%) patients. 30-day morbidity was seen in 99 (34%) patients. Postoperative morbidity could be predicted by age (P=0.007; odds ratio [OR] 1.034), WHO performance status (P=0.046; OR 1.757), extent of surgery (P=0.1308; OR=2.101), and operative time (P=0.017; OR 1.007) with an optimism corrected c-statistic of 0.68. 30-day morbidity could be predicted by age, WHO performance status, operative time and extent of surgery. The generated nomogram could be valuable for predicting operative risk in the individual patient.

Malignant Hyperthermia: Report of Two Cases with a Neglected Complication in Cardiac Surgery.

PubMed

Neshati, Mahdi; Azadeh, Manizheh; Neshati, Parinaz; Burnett, Tyrone; Saenz, Ryan; Karbasi, Bahman; Shahmohammadi, Ghader; Nourizadeh, Eskandar; Rostamzadeh, Mohsen

2017-10-01

Malignant hyperthermia (MH) can develop after contact with volatile anesthetics (halothane, enflurane, isoflurane, sevoflurane, and desflurane) as well as succinylcholine and cause hypermetabolism during anesthesia, which is associated with high mortality when untreated. Early diagnosis and treatment could be life-saving. During cardiac surgery, hypothermia and cardiopulmonary bypass make the diagnosis of MH extremely challenging compared with other settings such as general surgery. We herein report 2 cases of MH, graded as "very likely" or "almost certain" based on the MH clinical grading scale. A 14-month-old infant and a 53-year-old male underwent surgery for severe pulmonary valve stenosis and mitral valve replacement, respectively. Both of them were extubated on the operation day, but they deteriorated with the development of high-grade fever, hypotension, renal failure, and acidosis. The first case had muscle spasms. Unfortunately, the delayed symptoms of MH in the early postoperative course were not diagnosed in these 2 cases, which caused permanent neurologic damage in the first case and death in the second one. However, the infant was discharged from the hospital after 2 months.

Guillain-Barré Syndrome after Coronary Artery Bypass Graft Surgery: a Case Report.

PubMed

Hekmat, Manouchehr; Ghaderi, Hamid; Foroughi, Mahnoosh; Mirjafari, S Adeleh

2016-01-01

Guillain-Barre syndrome is a neurologic disorder that may appear after infection or major surgery. Guillain-Barré syndrome following cardiac surgery is rare and only based on case reports, and we review all of the published cases. A 52-year-old man after 5 months suffering from chest pain was referred to our hospital and underwent coronary artery bypass graft for 3 vessel disease. The patient was discharged without complication on the 5th postoperative day. He presented Guillain-Barré syndrome after 12 months. He has not completely recovered weakness of upper extremities grade 4/5 with atrophy of both upper extremities remains after 18 months. This disorder is similar to classic GBS. It is important to be alert to de novo autoimmune neurological disorders after cardiac surgery. These disorders are similar to classic autoimmune disease and treated with standard therapies.

Development of a diagnosis- and procedure-based risk model for 30-day outcome after pediatric cardiac surgery.

PubMed

Crowe, Sonya; Brown, Kate L; Pagel, Christina; Muthialu, Nagarajan; Cunningham, David; Gibbs, John; Bull, Catherine; Franklin, Rodney; Utley, Martin; Tsang, Victor T

2013-05-01

The study objective was to develop a risk model incorporating diagnostic information to adjust for case-mix severity during routine monitoring of outcomes for pediatric cardiac surgery. Data from the Central Cardiac Audit Database for all pediatric cardiac surgery procedures performed in the United Kingdom between 2000 and 2010 were included: 70% for model development and 30% for validation. Units of analysis were 30-day episodes after the first surgical procedure. We used logistic regression for 30-day mortality. Risk factors considered included procedural information based on Central Cardiac Audit Database "specific procedures," diagnostic information defined by 24 "primary" cardiac diagnoses and "univentricular" status, and other patient characteristics. Of the 27,140 30-day episodes in the development set, 25,613 were survivals, 834 were deaths, and 693 were of unknown status (mortality, 3.2%). The risk model includes procedure, cardiac diagnosis, univentricular status, age band (neonate, infant, child), continuous age, continuous weight, presence of non-Down syndrome comorbidity, bypass, and year of operation 2007 or later (because of decreasing mortality). A risk score was calculated for 95% of cases in the validation set (weight missing in 5%). The model discriminated well; the C-index for validation set was 0.77 (0.81 for post-2007 data). Removal of all but procedural information gave a reduced C-index of 0.72. The model performed well across the spectrum of predicted risk, but there was evidence of underestimation of mortality risk in neonates undergoing operation from 2007. The risk model performs well. Diagnostic information added useful discriminatory power. A future application is risk adjustment during routine monitoring of outcomes in the United Kingdom to assist quality assurance. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Prevalence of Post-tonsillectomy Bleeding as Day-case Surgery with Combination Method; Cold Dissection Tonsillectomy and Bipolar Diathermy Hemostasis

PubMed Central

Faramarzi, Abolahassan; Heydari, Seyed Taghi

2010-01-01

Objective Post-tonsillectomy hemorrhage remains an important factor in determining the safety of performing tonsillectomy as a day case procedure. The aim of this study was to determine the safety of day case tonsillectomy by using combination method, cold dissection tonsillectomy and bipolar diathermy hemostasis. Methods A prospective randomized clinical study conducted on the patients who had undergone day case tonsillectomy (DCT). There were two groups (DCT and control group) each group consisting of 150 cases. Tonsillectomy was performed by using combination method; cold dissection and hemostasis was achieved by ligation of vessels with bipolar electerocautery. Findings We found 3 cases of post-tonsillectomy bleeding in DCT group and 4 cases in the control group. There was no statistically significant difference in the rate of post-operative hemorrhage between the two groups. Conclusion The findings suggest the safety of the combination of cold dissection tonsillectomy and bipolar diathermy hemostasis as day case tonsillectomy. PMID:23056702

Atenolol Is Associated with Lower Day of Surgery Heart Rate as compared to Long and Short-acting Metoprolol

PubMed Central

Schonberger, Robert B.; Brandt, Cynthia; Feinleib, Jessica; Dai, Feng; Burg, Matthew M.

2012-01-01

Objectives We analyzed the association between outpatient beta-blocker type and day-of-surgery heart rate in ambulatory surgical patients. We further investigated whether differences in day of surgery heart rate between atenolol and metoprolol could be explained by once-daily versus twice-daily dosing regimens. Design Retrospective observational study. Setting VA Hospital Participants Ambulatory surgical patients on chronic atenolol or metoprolol. Interventions None. Measurements and Main Results Using a propensity-score matched cohort, we compared day of surgery heart rates of patients prescribed atenolol versus metoprolol. We then differentiated between once-daily and twice-daily metoprolol formulations and compared day of surgery heart rates within a general linear model. Day of surgery heart rates in patients prescribed atenolol vs. any metoprolol formulation were slower by a mean of 5.1 beats/min (66.6 vs. 71.7; 95% CI of difference 1.9 to 8.3, p=0.002), a difference that was not observed in preoperative primary care visits. The general linear model demonstrated that patients prescribed atenolol (typically QD dosing) had a mean day of surgery heart rate 5.6 beats/min lower compared to patients prescribed once-daily metoprolol succinate (68.9 vs. 74.5; 95% CI of difference: −8.6 to −2.6, p<0.001) and 3.8 beats/minute lower compared to patients prescribed twice-daily metoprolol tartrate (68.9 vs. 72.7; 95% CI of difference: −6.1 to −1.6, p<0.001). Day of surgery heart rates were similar between different formulations of metoprolol (95% CI of difference: −1.0 to +4.6, p=0.22). Conclusions Atenolol is associated with lower day of surgery heart rate vs. metoprolol. The heart rate difference is specific to the day of surgery and is not explained by once-daily versus twice-daily dosing regimens. PMID:22889605

First year experience of robotic-assisted laparoscopic surgery with 153 cases in a general surgery department: indications, technique and results.

PubMed

Tomulescu, V; Stănciulea, O; Bălescu, I; Vasile, S; Tudor, St; Gheorghe, C; Vasilescu, C; Popescu, I

2009-01-01

Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Since 1997 when the first robotic procedure was performed various papers pointed the advantages of robotic-assisted laparoscopic surgery, this technique is now a reality and it will probably become the surgery of the future. The aim of this paper is to present our preliminary experience with the three-arms "da Vinci S surgical system", to assess the feasibility of this technique in various abdominal and thoracic procedures and to point out the advantages of the robotic approach for each type of procedure. Between 18 January 2008 and 18 January 2009 153 patients (66 men and 87 women; mean age 48,02 years, range 6 to 84 years) underwent robotic-assisted surgical procedures in our institution; we performed 129 abdominal and 24 thoracic procedures, as follows: one cholecystectomy, 14 myotomies with Dor fundoplication, one gastroenteroanastomosis for unresectable antral gastric cancer, one transthoracic esophagectomy, 14 gastrectomies, one polypectomy through gastrotomy, 22 splenectomies,7 partial spleen resections, 22 thymectomy, 6 Nissen fundoplications, one Toupet fundoplication, one choledocho-duodeno-anastomosis, one drainage for pancreatic abscess, one distal pancreatectomy, one hepatic cyst fenestration, 7 hepatic resections, 29 colonic and rectal resections, 5 adrenalectomies, 12 total radical hysterectomies and pelvic lymphadenectomy, 3 hysterectomies with bilateral adnexectomy for uterine fibroma, one unilateral adnexectomy, and 2 cases of cervico-mediastinal goitre resection. 147 procedures were robotics completed , whereas 6 procedures were converted to open surgery due to the extent of the lesion. Average operating room time was 171 minutes (range 60 to 600 minutes, Median length of stay was 8,6 days (range 2 to 48 days). One system malfunctions was registered. Post-operatory complications occurred in 14 cases. There were no deaths. Our preliminary experience

Drivers of 30-Day Readmission in Elderly Patients (>65 Years Old) After Spine Surgery: An Analysis of 500 Consecutive Spine Surgery Patients.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing; Karikari, Isaac O; Cheng, Joseph; Bagley, Carlos A

2017-01-01

Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery, and more than one-third within 90 days; however, there is a paucity of data about the cause of early readmissions in elderly patients after elective spine surgery. A total of 500 elderly patients (>65 years old) undergoing elective spine surgery at a major academic hospital were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. A total of 50 (10%) unplanned early readmissions were identified. The mean ± SD age was 72.54 ± 5.84 years. The mean ± SD number of days from discharge to readmission was 11.02 ± 7.25 days, and the average length of hospital stay for the readmissions was 7.7 days. The majority of patients that were readmitted presented to the emergency department from home (46%), whereas 38% were readmitted from a skilled nursing facility. The most common causes for readmission were infection or a concern for infection (42%) and pain (14%), with 32% of readmissions requiring a return to the operating room. Our study suggests that in elderly patients undergoing elective spine surgery, infection or a concern for infection, pain, and altered mental status were the most common primary reasons for unplanned readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

Quality of counselling for knee and shoulder arthroscopy patients during day surgery.

PubMed

Kaakinen, Pirjo; Ervasti, Helka; Kääriäinen, Maria

2017-02-01

Counselling for day surgery patients is one of the core components for a knee or shoulder arthroscopy patient to succeed in self-care. This cross-sectional study examined the quality of counselling given to patients (n = 86) during their day surgery, using the Counselling Quality Instrument (CQI). The data were analysed using basic and multivariate statistical methods. Most respondents were male and aged over 50 years. Almost all knee and shoulder arthroscopy patients were satisfied with the counselling given on follow-up and rehabilitation as well as the counselling given relating to wound and pain treatment. There was a lack of patient-centred and goal-oriented counselling, although interaction during counselling was good. Counselling was perceived as providing benefit in regard to a patient's self-care, emotions and knowledge. Respondents aged below 40 years were more dissatisfied with counselling for day surgery than those aged 40 years and over. This study identified a need to train healthcare staff in patient-centred and goal-oriented counselling. Counselling with people who are aged below 40 years should take account of patients' specific concerns. Copyright © 2016 Elsevier Ltd. All rights reserved.

Racial Disparities in 30-Day Readmission Rates After Elective Spine Surgery: A Single Institutional Experience.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Mehta, Ankit I; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2016-11-01

Retrospective cohort review. The aim of this study is to investigate whether patient race is an independent predictor of unplanned 30-day hospital readmission after elective spine surgery. Racial disparities are known to exist for many aspects of surgical care. However, it is unknown if disparities exist in 30-day readmissions after elective spine surgery, an area that is becoming a prime focus for clinical leaders and policymakers. Records of 600 patients undergoing elective spine surgery at a major academic medical center were reviewed. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient's records were reviewed to determine the cause of readmission and the length of hospital stay. The main outcome measure was risk-adjusted odds of all-cause 30-day readmission. We used multivariate logistic regression to determine if Black patients had an increased likelihood of 30-day readmission compared with White patients. Baseline characteristics were similar between both groups. Black patients had higher readmission rates than White patients (10.56% vs. 7.86%, P = 0.04). In a univariate analysis, race, body mass index, sex, patient age, smoking, diabetes, and fusion levels were associated with increased 30-day readmission rates. However, in a multivariate logistic regression model, race was an independent predictor of 30-day readmission after elective spine surgery. In addition, no significant differences in baseline, 1-year and 2-year patient reported outcomes measures were observed between both groups. This study suggests that Black patients are more likely to be readmitted within 30-days of discharge after elective spine surgery. Efforts at reducing disparities should focus not only on race-based measures but also effective post discharge care. 3.

Nontrauma emergency surgery: optimal case mix for general surgery and acute care surgery training.

PubMed

Cherry-Bukowiec, Jill R; Miller, Barbra S; Doherty, Gerard M; Brunsvold, Melissa E; Hemmila, Mark R; Park, Pauline K; Raghavendran, Krishnan; Sihler, Kristen C; Wahl, Wendy L; Wang, Stewart C; Napolitano, Lena M

2011-11-01

To examine the case mix and patient characteristics and outcomes of the nontrauma emergency (NTE) service in an academic Division of Acute Care Surgery. An NTE service (attending, chief resident, postgraduate year-3 and postgraduate year-2 residents, and two physician assistants) was created in July 2005 for all urgent and emergent inpatient and emergency department general surgery patient consults and admissions. An NTE database was created with prospective data collection of all NTE admissions initiated from November 1, 2007. Prospective data were collected by a dedicated trauma registrar and Acute Physiology and Chronic Health Evaluation-intensive care unit (ICU) coordinator daily. NTE case mix and ICU characteristics were reviewed for the 2-year time period January 1, 2008, through December 31, 2009. During the same time period, trauma operative cases and procedures were examined and compared with the NTE case mix. Thousand seven hundred eight patients were admitted to the NTE service during this time period (789 in 2008 and 910 in 2009). Surgical intervention was required in 70% of patients admitted to the NTE service. Exploratory laparotomy or laparoscopy was performed in 449 NTE patients, comprising 37% of all surgical procedures. In comparison, only 118 trauma patients (5.9% of admissions) required a major laparotomy or thoracotomy during the same time period. Acuity of illness of NTE patients was high, with a significant portion (13%) of NTE patients requiring ICU admission. NTE patients had higher admission Acute Physiology and Chronic Health Evaluation III scores [61.2 vs. 58.8 (2008); 58.2 vs. 55.8 (2009)], increased mortality [(9.71% vs. 4.89% (2008); 6.78% vs. 5.16% (2009)], and increased readmission rates (15.5% vs. 7.4%) compared with the total surgical ICU (SICU) admissions. In an era of declining operative caseload in trauma, the NTE service provides ample opportunity for complex general surgery decision making and operative procedures for

Malignant Hyperthermia: Report of Two Cases with a Neglected Complication in Cardiac Surgery

PubMed Central

Neshati, Mahdi; Azadeh, Manizheh; Neshati, Parinaz; Burnett, Tyrone; Saenz, Ryan; Karbasi, Bahman; Shahmohammadi, Ghader; Nourizadeh, Eskandar; Rostamzadeh, Mohsen

2017-01-01

Malignant hyperthermia (MH) can develop after contact with volatile anesthetics (halothane, enflurane, isoflurane, sevoflurane, and desflurane) as well as succinylcholine and cause hypermetabolism during anesthesia, which is associated with high mortality when untreated. Early diagnosis and treatment could be life-saving. During cardiac surgery, hypothermia and cardiopulmonary bypass make the diagnosis of MH extremely challenging compared with other settings such as general surgery. We herein report 2 cases of MH, graded as “very likely” or “almost certain” based on the MH clinical grading scale. A 14-month-old infant and a 53-year-old male underwent surgery for severe pulmonary valve stenosis and mitral valve replacement, respectively. Both of them were extubated on the operation day, but they deteriorated with the development of high-grade fever, hypotension, renal failure, and acidosis. The first case had muscle spasms. Unfortunately, the delayed symptoms of MH in the early postoperative course were not diagnosed in these 2 cases, which caused permanent neurologic damage in the first case and death in the second one. However, the infant was discharged from the hospital after 2 months. PMID:29576786

Nomogram for 30-day morbidity after primary cytoreductive surgery for advanced stage ovarian cancer.

PubMed

Nieuwenhuyzen-de Boer, G M; Gerestein, C G; Eijkemans, M J C; Burger, C W; Kooi, G S

2016-01-01

Extensive surgical procedures to achieve maximal cytoreduction in patients with advanced stage epithelial ovarian cancer (EOC) are inevitably associated with postoperative morbidity and mortality. This study aimed to identify preoperative predictors of 30-day morbidity after primary cytoreductive surgery for advanced stage EOC and to develop a nomogram for individual risk assessment. Patients in The Netherlands who underwent primary cytoreductive surgery for advanced stage EOC between January 2004 and December 2007. All peri- and postoperative complications within 30 days after surgery were registered and classified. To investigate predictors of 30-day morbidity, a Cox proportional hazard model with backward stepwise elimination was utilized. The identified predictors were entered into a nomogram. The main outcome was to identify parameters that predict operative risk. 293 patients entered the study protocol. Optimal cytoreduction was achieved in 136 (46%) patients. Thirty-day morbidity was seen in 99 (34%) patients. Morbidity could be predicted by age (p = 0.033; OR 1.024), preoperative hemoglobin (p = 0.194; OR 0.843), and WHO performance status (p = 0.015; OR 1.821) with a optimism-corrected c-statistic of 0.62. Determinants co-morbidity status, serum CA125 level, platelet count, and presence of ascites were comparable in both groups. Thirty-day morbidity after primary cytoreductive surgery for advanced stage EOC could be predicted by age, hemoglobin, and WHO performance status. The generated nomogram could be valuable for predicting operative risk in the individual patient.

A case of anaphylaxis apparently induced by sugammadex and rocuronium in successive surgeries.

PubMed

Yamada, Yuko; Yamamoto, Takuji; Tanabe, Kumiko; Fukuoka, Naokazu; Takenaka, Motoyasu; Iida, Hiroki

2016-08-01

Rocuronium is the agent most frequently involved in perioperative anaphylaxis, and sugammadex has also been known to induce anaphylactic reactions. We describe a case of successive anaphylactic episodes that seemed to be induced by clinical doses of rocuronium and sugammadex. The patient was a 19-year-old woman who had a medical history of asthma, but no history of surgery. She had been injured in a fall, and several surgeries were scheduled for multiple bone fractures. At the first surgery under general anesthesia, she developed anaphylaxis 5 min after sugammadex administration. A second general anesthesia for treatment of calcaneal fracture was induced uneventfully without neuromuscular blockade after 10 days. A third general anesthesia was scheduled to reinforce the spinal column 12 days after the first surgery. She developed anaphylaxis 8 min after rocuronium administration. The level of plasma histamine was elevated, but serum tryptase level remained normal. This surgery was canceled and rescheduled without use of a neuromuscular blockade. Skin tests were performed in a later investigation. The patient showed positive results on intradermal tests for sugammadex and rocuronium, supporting a diagnosis of allergic reactions to both drugs. Clinicians must be aware that anaphylactic reactions can be induced by both sugammadex and rocuronium. Copyright © 2016 Elsevier Inc. All rights reserved.

Effect of neurological monitoring in postoperative 5-15 days residual thyroidectomy after primary thyroid cancer surgery.

PubMed

Long, Miao-Yun; Diao, Fei-Yu; Peng, Li-Na; Tan, Lang-Ping; Zhu, Yue; Huang, Kai; Li, Hong-Hao

2018-05-16

To explore the application of intraoperative neurological monitoring in residual thyroidectomy 5-15 days after thyroid cancer operation and the influence on postoperative serum thyroglobulin (Tg), recurrent laryngeal nerve and function of parathyroid glands. Material of patients receiving thyroid surgery from January 2010 to December 2016 was retrospectively analyzed. Cases meeting with standards were enrolled for analysis and the patients were divided into neurological monitoring group and non-neurological monitoring group in line with the use of neurological monitoring during the operation. Recurrent laryngeal nerve-injured hoarseness, hypoparathyroidism and concentration of serum Tg before and after the surgery were collected and analyzed. Four-hundred and thirty-five patients met with standards, among which 227 from neurological monitoring group and 208 from non-neurological monitoring group. Temporary hoarseness rate of non-neurological monitoring group and neurological monitoring group was 8.67% and 2.2%. Permanent hoarseness rate of non-neurological monitoring group and neurological monitoring group was 1.92% and 0.44%. Temporary hypoparathyroidism rate of non-neurological monitoring group and neurological monitoring group was 18.75% and 7.48%. Permanent hypoparathyroidism rate of non-neurological monitoring group and neurological monitoring group was 1.92% and 0.88%. Average Tg concentration 1 month after the surgery in non-neurological monitoring group and neurological monitoring group was 2.82 and 1.37 ng/mL, respectively. Rate of average Tg concentration less than 1 ng/mL 1 month after the surgery in non-neurological monitoring group and neurological monitoring group was 45.06% and 67.4%. Intraoperative neurological monitoring can be adopted in residual thyroidectomy in postoperative 5-15 days after primary thyroid cancer surgery, as to reduce incidence rate of recurrent laryngeal nerve injury and hypoparathyroidism and to enhance thorough removal of

Lung Function before and Two Days after Open-Heart Surgery.

PubMed

Urell, Charlotte; Westerdahl, Elisabeth; Hedenström, Hans; Janson, Christer; Emtner, Margareta

2012-01-01

Reduced lung volumes and atelectasis are common after open-heart surgery, and pronounced restrictive lung volume impairment has been found. The aim of this study was to investigate factors influencing lung volumes on the second postoperative day. Open-heart surgery patients (n = 107, 68 yrs, 80% male) performed spirometry both before surgery and on the second postoperative day. The factors influencing postoperative lung volumes and decrease in lung volumes were investigated with univariate and multivariate analyses. Associations between pain (measured by numeric rating scale) and decrease in postoperative lung volumes were calculated with Spearman rank correlation test. Lung volumes decreased by 50% and were less than 40% of the predictive values postoperatively. Patients with BMI >25 had lower postoperative inspiratory capacity (IC) (33 ± 14% pred.) than normal-weight patients (39 ± 15% pred.), (P = 0.04). More pain during mobilisation was associated with higher decreases in postoperative lung volumes (VC: r = 0.33, P = 0.001; FEV(1): r = 0.35, P ≤ 0.0001; IC: r = 0.25, P = 0.01). Patients with high BMI are a risk group for decreased postoperative lung volumes and should therefore receive extra attention during postoperative care. As pain is related to a larger decrease in postoperative lung volumes, optimal pain relief for the patients should be identified.

Lung Function before and Two Days after Open-Heart Surgery

PubMed Central

Urell, Charlotte; Westerdahl, Elisabeth; Hedenström, Hans; Janson, Christer; Emtner, Margareta

2012-01-01

Reduced lung volumes and atelectasis are common after open-heart surgery, and pronounced restrictive lung volume impairment has been found. The aim of this study was to investigate factors influencing lung volumes on the second postoperative day. Open-heart surgery patients (n = 107, 68 yrs, 80% male) performed spirometry both before surgery and on the second postoperative day. The factors influencing postoperative lung volumes and decrease in lung volumes were investigated with univariate and multivariate analyses. Associations between pain (measured by numeric rating scale) and decrease in postoperative lung volumes were calculated with Spearman rank correlation test. Lung volumes decreased by 50% and were less than 40% of the predictive values postoperatively. Patients with BMI >25 had lower postoperative inspiratory capacity (IC) (33 ± 14% pred.) than normal-weight patients (39 ± 15% pred.), (P = 0.04). More pain during mobilisation was associated with higher decreases in postoperative lung volumes (VC: r = 0.33, P = 0.001; FEV1: r = 0.35, P ≤ 0.0001; IC: r = 0.25, P = 0.01). Patients with high BMI are a risk group for decreased postoperative lung volumes and should therefore receive extra attention during postoperative care. As pain is related to a larger decrease in postoperative lung volumes, optimal pain relief for the patients should be identified. PMID:22924127

Does Day of Surgery Affect Hospital Length of Stay and Charges Following Minimally Invasive Transforaminal Lumbar Interbody Fusion?

PubMed

Hijji, Fady Y; Narain, Ankur S; Haws, Brittany E; Khechen, Benjamin; Kudaravalli, Krishna T; Yom, Kelly H; Singh, Kern

2018-06-01

Retrospective Cohort. To determine if an association exists between surgery day and length of stay or hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Length of inpatient stay after orthopedic procedures has been identified as a primary cost driver, and previous research has focused on determining risk factors for prolonged length of stay. In the arthroplasty literature, surgery performed later in the week has been identified as a predictor of increased length of stay. However, no such investigation has been performed for MIS TLIF. A surgical registry of patients undergoing MIS TLIF between 2008 and 2016 was retrospectively reviewed. Patients were grouped based on day of surgery, with groups including early surgery and late surgery. Day of surgery group was tested for an association with demographics and perioperative variables using the student t test or χ analysis. Day of surgery group was then tested for an association with direct hospital costs using multivariate linear regression. In total, 438 patients were analyzed. In total, 51.8% were in the early surgery group, and 48.2% were in the late surgery group. There were no differences in demographics between groups. There were no differences between groups with regard to operative time, intraoperative blood loss, length of stay, or discharge day. Finally, there were no differences in total hospital charges between early and late surgery groups (P=0.247). The specific day on which a MIS TLIF procedure occurs is not associated with differences in length of inpatient stay or total hospital costs. This suggests that the postoperative course after MIS TLIF procedures is not affected by the differences in hospital staffing that occurs on the weekend compared with weekdays.

Child drawings and salivary cortisol in children undergoing preoperative procedures associated with day surgery.

PubMed

Wennström, Berith; Törnhage, Carl-Johan; Hedelin, Hans; Nasic, Salmir; Bergh, Ingrid

2013-12-01

Perioperative procedures in children can impair their emotional status negatively with stress and/or anxiety. Cortisol concentrations and drawings could be helpful in gaining information about a child's levels of stress and/or anxiety when attending the hospital for surgery. The purpose of this study was to determine the degree of anxiety and stress as well as to explore the association between objective measures of stress (cortisol concentration in saliva) and subjective assessment of hospital anxiety (children's drawings) as interpreted by the Swedish version of the Child Drawing: Hospital manual. A total of 93 children scheduled for day surgery were included. Salivary cortisol was sampled preoperatively on the day of surgery at which time the children were also requested to make a drawing of a person at the hospital. Results showed no association between salivary cortisol concentration and the CD:H score. The drawings and salivary cortisol concentration preoperatively on the day of surgery reflect different components of the conditions of fear, anxiety, or stress emerging in the situation. Copyright © 2013 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Reconstructive valve surgery within 10 days of stroke in endocarditis.

PubMed

Raman, Jai; Ballal, Apoorva; Hota, Bala; Mirza, Sara; Lai, David; Bleck, Thomas; Lateef, Omar

2016-07-01

The optimal timing of surgical treatment for infective endocarditis complicated by cerebrovascular events is controversial, largely due to the perceived risk of perioperative intracranial bleeding. Current guidelines suggest waiting 2 weeks between the diagnosis of stroke and surgery. The aim of this study was to investigate the clinical and neurological outcomes of early surgery following a stroke. This was a single-center retrospective analysis of 12 consecutive patients requiring surgery for infective endocarditis between 2011 and 2014 at Rush University Medical Center, with either ischemic (n = 6) and/or hemorrhagic (n = 6) cerebrovascular complications. All underwent computed tomographic angiography prior to early valve reconstructive surgery to identify potentially actionable neurological findings. Early valve surgery was performed for ongoing sepsis or persistent emboli. Neurologic risk and outcome were assessed pre- and postoperatively using the National Institutes of Health Stroke Scale and the Glasgow Outcome Scale, respectively. All 12 patients underwent surgical treatment within 10 days of the diagnosis of stroke. Mortality in the immediate postoperative period was 8%. Eleven of the 12 patients exhibited good neurological recovery in the immediate postoperative period, with a Glasgow Outcome Scale score ≥ 3. There was no correlation between duration of cardiopulmonary bypass and neurological outcomes. Early cardiac surgery in patients with infective endocarditis and stroke maybe lifesaving with a low neurological risk. Comprehensive neurovascular imaging may help in identifying patient-related risk factors. © The Author(s) 2016.

Minimising preoperative anxiety with music for day surgery patients - a randomised clinical trial.

PubMed

Ni, Cheng-Hua; Tsai, Wei-Her; Lee, Liang-Ming; Kao, Ching-Chiu; Chen, Yi-Chung

2012-03-01

The objective of this study was to evaluate the effects of musical intervention on preoperative anxiety and vital signs in patients undergoing day surgery. Studies and systematic meta-analyses have shown inconclusive results of the efficacy of music in reducing preoperative anxiety. We designed a study to provide additional evidence for its use in preoperative nursing care. Randomised, controlled study. Patients (n = 183) aged 18-65 admitted to our outpatient surgery department were randomly assigned to either the experimental group (music delivered by earphones) or control group (no music) for 20 minutes before surgery. Anxiety, measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol. A total of 172 patients (60 men and 112 women) with a mean age of 40·90 (SD 11·80) completed the study. The largest number (35·7%) was undergoing elective plastic surgery and 76·7% of the total reported previous experience with surgery. Even though there was only a low-moderate level of anxiety at the beginning of the study, both groups showed reduced anxiety and improved vital signs compared with baseline values; however, the intervention group reported significantly lower anxiety [mean change: -5·83 (SD 0·75) vs. -1·72 (SD 0·65), p < 0·001] on the State-Trait Anxiety Inventory compared with the control group. Patients undergoing day surgery may benefit significantly from musical intervention to reduce preoperative anxiety and improve physiological parameters. Finding multimodal approaches to ease discomfort and anxiety from unfamiliar unit surroundings and perceived risks of morbidity (e.g. disfigurement and long-term sequelae) is necessary to reduce preoperative anxiety and subsequent physiological complications. This is especially true in the day surgery setting, where surgical admission times are often subject to change and patients may have to accommodate on short notice or too long a wait that may provoke

[Suspension laryngoscopic surgery for laryngotracheal stenosis of 32 cases].

PubMed

Wang, Chunyan; Qin, Yong; Xiao, Shuifang

2014-08-01

To investigate the efficacy of suspension laryngoscopic surgery for benign laryngotracheal stenosis (LTS). Thirty-two patients (aged from 5 to 70 years with a median of 36 years) with benign LTS were studied retrospectively who were treated by suspension laryngoscopic surgery with or without assistance of CO₂ Laser for LTS. Stents were placed in 17 cases. Among 32 patients, 13 cases were with LST in Cotton I, 8 cases in Cotton II, and 11 cases in Cotton III; 23 were with single level narrow, and 9 cases with multi-level narrow; the average narrow length was 1.3 cm and the average diameter at maximum stenosis was 0.5 cm; and 19 cases underwent tracheostomy before surgery. Follow-up period ranged from 1 to 18 years with median time of 10 years. Twenty-six patients (81.2%) were successfully decannulated with good airway patency and effective phonation. Six cases failed and 1 case of them was changed to open surgery. Among 17 cases with stent placement, 4 cases were applied additionally with T tube (effective rate of 50.0%), 1 case with laryngeal keel, 12 cases with stents alone (effective rate of 66.7%). Stent-related complications occurred in 2 cases. Patients with cotton I-II had a successful rate of 100% (21/21), while patients with Cotton III showed poor effectiveness (5/11), with a statistical significant difference between two groups (χ² = 14.098, P = 0.001). The patients with single level LTS were successfully treated by suspension laryngoscopic surgery with 100% successful rate (23/23), while the patients with multi-level LTS showed poor effectiveness (3/9), with a statistical significant difference between two groups (χ² = 18.872, P = 0.000) . Suspension laryngoscopic microsurgery can treat single level LTS with good results and also can be used as a pre-surgery in treatment of multi-level LTS with the virtue of minimal trauma and short recovery time. Application of stents can be helpful for suspension laryngoscope surgery for LST.

[Preemptive local anesthetic infiltration in hallux valgus one-day surgery].

PubMed

Gądek, Artur; Liszka, Henryk

2015-01-01

The surgical treatment of hallux valgus deformity is connected with significant postoperative pain. Spinal and general anesthesia as well as peripheral blocks are successfully used in foot surgery. The purpose of this study was to evaluate the influence of local anesthetic infiltration before hallux valgus one-day surgery on postoperative pain and the need for analgesics. 134 patients underwent chevron or miniinvasive Mitchell-Kramer osteotomy of the first distal metatarsal. After general anesthesia each patient randomly received an infiltration of 7ml of local anesthetic (4 ml of 0.25% bupivacaine and 3 ml of 2% lidocaine) or the same amount of normal saline 15 minutes before the skin incision. Both the patient and the surgeon were blinded. The patient was discharged after approximately 2 hours of observation. 2, 4, 8, 12, 16, 24 and 72 hours after the release of the tourniquet the level of pain was assessed by the visual analogue scale (VAS). Rescue analgesia, side effects and the use of painkillers were noted. Preemptive local anesthetic infiltration significantly decreased pain during the first 24 hours after the surgery. None of the patients from the injected group and 38 from the placebo group received 100 mg of ketoprofen intravenously for rescue analgesia in the first 2 hours after the release of the tourniquet. During the first 24 hours we noted significantly decreased use of 1000 mg of paracetamol and 100 mg mg of ketoprofen orally in the injected group. No systemic adverse effects were noted. One patient from placebo group had allergic rush after use of 100 mg ketoprofen. Preemptive local anesthetic infiltration in one-day hallux valgus surgery significantly decreases postoperative pain. It is safe, efficient and allows fast discharge.

Postoperative Care Fragmentation and 30-Day Unplanned Readmissions After Head and Neck Cancer Surgery

PubMed Central

Graboyes, Evan M.; Kallogjeri, Dorina; Saeed, Mohammed J.; Olsen, Margaret A.; Nussenbaum, Brian

2017-01-01

Objectives Post-discharge care fragmentation, readmission to a hospital other than the one performing the surgery, hasn’t been described in head and neck cancer patients. We sought to determine the frequency, risk factors, and outcomes for head and neck cancer patients experiencing post-discharge care fragmentation. Design Retrospective cohort study Methods We analyzed patients in the 2008–2010 California State Inpatient Database with a 30-day unplanned readmission following head and neck cancer surgery. The frequency of post-discharge care fragmentation, patient- and hospital-level risk factors for care fragmentation, readmission diagnosis, and readmission outcomes were determined. Results Of 561 patients with a 30-day unplanned readmission, 210 (37.4%) were readmitted to a hospital other than the one performing the surgery. Surgical hospitalization length of stay ≥ 15 days (OR 1.87; 95% CI 1.13–3.10) and discharge to a care facility (OR 2.85; 95% CI 1.77–4.58) were associated with care fragmentation. Overall, 39.8% of unplanned 30-day readmissions (223/561) were treatment complications and 30.9% of treatment complication readmissions (69/223) occurred at a non-index hospital. Patients with post-discharge care fragmentation had a 2.1-fold increased risk of in-hospital mortality within 30 days of readmission compared to patients readmitted to the index hospital (95% CI 1.04–4.26). Conclusions Post-discharge care fragmentation following head and neck cancer surgery is common, as 37% of readmitted patients, and 31% of patients readmitted with a treatment complication, are readmitted to a hospital other than the surgical hospital. Head and neck cancer patients experiencing care fragmentation are at increased risk of in-hospital mortality within 30 days of readmission. PMID:27740687

Postoperative care fragmentation and thirty-day unplanned readmissions after head and neck cancer surgery.

PubMed

Graboyes, Evan M; Kallogjeri, Dorina; Saeed, Mohammed J; Olsen, Margaret A; Nussenbaum, Brian

2017-04-01

Postdischarge care fragmentation, readmission to a hospital other than the one performing the surgery, has not been described in head and neck cancer patients. We sought to determine the frequency, risk factors, and outcomes for head and neck cancer patients experiencing postdischarge care fragmentation. Retrospective cohort study. We analyzed patients in the 2008 to 2010 California State Inpatient Database with a 30-day unplanned readmission following head and neck cancer surgery. The frequency of postdischarge care fragmentation, patient- and hospital-level risk factors for care fragmentation, readmission diagnosis, and readmission outcomes were determined. Of 561 patients with a 30-day unplanned readmission, 210 (37.4%) were readmitted to a hospital other than the one performing the surgery. Surgical hospitalization length of stay ≥15 days (odds ratio [OR]: 1.87, 95% confidence interval [CI]: 1.13-3.10) and discharge to a care facility (OR: 2.85, 95% CI: 1.77-4.58) were associated with care fragmentation. Overall, 39.8% of unplanned 30-day readmissions (223/561) were treatment complications, and 30.9% of treatment complication readmissions (69/223) occurred at a nonindex hospital. Patients with postdischarge care fragmentation had a 2.1-fold increased risk of in-hospital mortality within 30 days of readmission compared to patients readmitted to the index hospital (95% CI: 1.04-4.26). Postdischarge care fragmentation following head an neck cancer surgery is common, as 37% of readmitted patients and 31% of patients readmitted with a treatment complication are readmitted to a hospital other than the surgical hospital. Head and neck cancer patients experiencing care fragmentation are at increased risk of in-hospital mortality within 30 days of readmission. 4. Laryngoscope, 127:868-874, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Continuous irrigation with suction started at early days after pancreatic surgery prevents severe complications.

PubMed

Sawada, Shigeaki; Yamagishi, Fuminori; Suzuki, Syuuichiro; Matsuoha, Jiro; Arai, Hideki; Tsukada, Kazuhiro

2008-01-01

The management of pancreatic leakage is important after pancreatic resection because such leakagge can be associated with additional complications. In this paper, we present a new therapy "irrigation with suction" after pancreatic surgery. The addition of suction permits the start of irrigation early after surgery and prevents severe post-operative complications. Between January 1995 and June 2003, 29 consecutive patients underwent surgical treatment of the pancreas for a variety of indications. Among them, 18 patients were treated with continuous irrigation with suction prophylactically. In these 29 patients, we did not encounter any additional complications such as intraabdominal hemorrhage or abscess formation. A representative case report demonstrates the application of this treatment. The irrigation with suction therapy was started on the first post-operative day after the pylorus-preserving pancreatoduodenectomy with left lobectomy of the liver. CT with irrigation of contrast reagent showed that the reagent did not spread to the uninvolved abdominal area, and the patient did not develop hemorrhage or abscess. It seems that continuous irrigation with suction therapy was effective in preventing additional serious complications after pancreatic resection.

First 101 Robotic General Surgery Cases in a Community Hospital

PubMed Central

Robertson, Jarrod C.; Alrajhi, Sharifah

2016-01-01

Background and Objectives: The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed. Methods: Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics. Results: Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes. Conclusion: A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy. PMID:27667913

First 101 Robotic General Surgery Cases in a Community Hospital.

PubMed

Oviedo, Rodolfo J; Robertson, Jarrod C; Alrajhi, Sharifah

2016-01-01

The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed. Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics. Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes. A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy.

Delayed-onset descemet membrane detachment after uneventful cataract surgery treated by corneal venting incision with air tamponade: a case report.

PubMed

Bhatia, Harsimran Kaur; Gupta, Rakesh

2016-04-04

Descemet membrane detachment (DMD) is a significant complication noted during or early after cataract surgery. Review of literature revealed a few cases of delayed-onset DMD with presentation ranging from weeks to months after cataract surgery but most of them were treated with pneumatic descemetopexy and a few ended in penetrating keratoplasty. We report this case, to highlight the usefulness of corneal venting incision with air tamponade in late-onset DMD cases not responding to pneumatic descemetopexy. A retrospective case review of a 66 year old male who presented with diminution of vision in right eye 17 days after uneventful cataract surgery was done. Visual acuity in this eye was 20/200 at presentation. DMD was noted 3 days later (approximately 3 weeks post-operatively) and Anterior Segment Optical Coherence Tomography & Scheimpflug imaging were done in view of diffuse corneal edema. Pneumatic descemetopexy was attempted thrice (twice with SF6, once with air) over a week's span with limited success at re-attaching the DM. Finally, corneal venting incision with air tamponade was done resulting in egress of supra-descemet's fluid and DM appeared apposed to stroma. Bandage contact lens (BCL) was applied at the end of the procedure. DM was seen attached the next day. Corneal edema cleared completely in 1 week. Best corrected visual acuity (BCVA) at 6 weeks follow-up was 20/30. Delayed-onset DMD should be considered as a differential diagnosis in cases with late-onset corneal edema post-cataract surgery. Anterior segment Optical Coherence Tomography (AS-OCT) and Scheimpflug Imaging are useful tools in cases with dense corneal edema. Corneal venting incision with air tamponade is an option in cases where methods like pneumatic descemetopexy fail.

Patient Body Mass Index is an Independent Predictor of 30-Day Hospital Readmission After Elective Spine Surgery.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Vuong, Victoria D; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2016-12-01

Hospital readmission within 30 days of index surgery is receiving increased scrutiny as an indicator of poor quality of care. Reducing readmissions achieves the dual benefit of improving quality and reducing costs. With the growing prevalence of obesity, understanding its impact on 30-day unplanned readmissions and patients' perception of health status is important for appropriate risk stratification of patients. The aim of this study was to determine if obesity is an independent risk factor for unplanned 30-day readmissions after elective spine surgery. The medical records of 500 patients (nonobese, n = 281; obese, n = 219) undergoing elective spine surgery at a major academic medical center were reviewed. Preoperative body mass index (BMI) was measured on all patients. BMI that was ≥30 kg/m 2 was classified as obese. Patient demographics, comorbidities, and postoperative complication rates were collected. The primary outcome investigated was unplanned all-cause 30-day hospital readmission. The association between preoperative obesity and 30-day readmission rate was assessed via multivariate logistic regression analysis. Baseline characteristics and operative variables and complication profiles were similar between both cohorts. Overall, 8.6% of patients were readmitted within 30 days of discharge; obese patients experienced a 2-fold increase in 30-day readmission rates (obese 12.33% vs. nonobese 5.69%, P = 0.01). In a multivariate logistic regression analysis, preoperative obesity (BMI ≥30 kg/m 2 ) was found to be an independent predictor of 30-day readmission after elective spine surgery (P = 0.001). Preoperative obesity is an independent risk factor for readmission within 30 days of discharge after elective spine surgery. In a cost-conscious health care climate, preoperative BMI can identify patients at risk for early unplanned hospital readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

Relative to open surgery, minimally-invasive renal and ureteral pediatric surgery offers no improvement in 30-day complications, yet requires longer operative time: Data from the National Surgical Quality Improvement Program Pediatrics.

PubMed

Colaco, Marc; Hester, Austin; Visser, William; Rasper, Alison; Terlecki, Ryan

2018-05-01

Performance of minimally-invasive surgery (MIS) is increasing relative to open surgery. We sought to compare the contemporary rates of short-term complications of open versus laparoscopic renal and ureteral surgery in pediatric patients. A retrospective cross-sectional analysis of the National Surgical Quality Improvement Program Pediatrics database was performed of all cases in 2014 identified using CPT procedure codes for nephrectomy, partial nephrectomy (PN), ureteroneocystostomy (UNC), and pyeloplasty, and reviewed for postoperative complications. Univariate analysis was performed to determine 30-day complications, with comparison between open and MIS approaches. Receiver operator curve (ROC) analysis was performed to determine differences in body surface area (BSA) and age for open versus MIS. Review identified 207 nephrectomies, 72 PN, 920 UNC, and 625 pyeloplasties. MIS was associated with older age and larger BSA except for cases of UNC. Apart from PN, operative durations were longer with MIS. However, only PN was associated with significantly longer length of hospital stay (LOS). There was no difference in incidence of all other 30-day complications. When evaluating BSA via ROC, the area under the curve (AUC) was found to be 0.730 and was significant. Children with a BSA greater than 0.408 m 2 were more likely to have MIS (sensitivity, 66.9%; specificity, 69.3%). Regarding age, the AUC was 0.732. Children older than 637.5 days were more likely to have MIS (sensitivity, 72.8%; specificity, 63.3%). Pediatric MIS is associated with longer operative time for nephrectomy, but shorter LOS following PN. Surgical approach was not associated with difference in short-term complications.

Synergistic Effects of Perioperative Complications on 30-Day Mortality Following Hepatopancreatic Surgery.

PubMed

Merath, Katiuscha; Chen, Qinyu; Bagante, Fabio; Akgul, Ozgur; Idrees, Jay J; Dillhoff, Mary; Cloyd, Jordan M; Pawlik, Timothy M

2018-06-18

Data on the interaction effect of multiple concurrent postoperative complications relative to the risk of short-term mortality following hepatopancreatic surgery have not been reported. The objective of the current study was to define the interaction effect of postoperative complications among patients undergoing HP surgery on 30-day mortality. Using the ACS-NSQIP Procedure Targeted Participant Use Data File, patients who underwent HP surgery between 2014 and 2016 were identified. Hazard ratios (HRs) for 30-day mortality were estimated using Cox proportional hazard models. Two-way interaction effects assessing combinations of complications relative to 30-day mortality were calculated using the relative excess risk due to interaction (RERI) in separate adjusted Cox models. Among 26,824 patients, 10,886 (40.5%) experienced at least one complication. Mortality was higher among patients who experienced at least one complication versus patients who did not experience a complication (3.0 vs 0.1%, p < 0.001). The most common complications were blood transfusion (16.9%, n = 4519), organ space infection (12.2%, n = 3273), and sepsis/septic shock (8.2%, n = 2205). Combinations associated with additive effect on mortality included transfusion + renal dysfunction (RERI 12.3, 95% CI 5.2-19.4), pulmonary dysfunction + renal dysfunction (RERI 60.9, 95% CI 38.6-83.3), pulmonary dysfunction + cardiovascular complication (RERI 144.1, 95% CI 89.3-199.0), and sepsis/septic shock + renal dysfunction (RERI 11.5, 95% CI 4.4-18.7). Both the number and specific type of complication impacted the incidence of postoperative mortality among patients undergoing HP surgery. Certain complications interacted in a synergistic manner, leading to a greater than expected increase in the risk of short-term mortality.

Parents' experiences of their child's first anaesthetic in day surgery.

PubMed

Andersson, Lisbet; Johansson, Ingrid; Almerud Österberg, Sofia

Parents play an important part in their child's anaesthesia. When a child has to receive anaesthesia, it is of great importance that parents are there by his/her side as children depend on them for support. Many parents worry and experience fear before their child's anaesthesia and studies show that there is a correlation between a worried parent and a worried child. The purpose of this study was to illustrate the meaning of being a parent at one's child's first anaesthesia in day surgery. Six parents were interviewed and data were analysed using a descriptive qualitative approach inspired by phenomenology. The phenomenon, 'a child's first anaesthesia in day surgery as experienced by parents' is based on the following components: ambivalence between worry and relief, a feeling of losing control, needing to be prepared, being able to be present and a need of emotional support. Specific individually-adapted information with a compulsory preoperative visit, presence and participation from, if possible, both parents at their child's anaesthesia but also designated staff from the anaesthetic team to focus solely on supporting the parents at their child's anaesthesia induction can improve the conditions for security.

Orthognathic Surgery in Patients With Congenital Myopathies and Congenital Muscular Dystrophies: Case Series and Review of the Literature.

PubMed

Bezak, Brett J; Arce, Kevin A; Jacob, Adam; Van Ess, James

2016-03-01

This case series examined preoperative findings and the surgical, anesthetic, and postoperative management of 6 patients with congenital myopathies (CMs) and congenital muscular dystrophies (CMDs) treated at a tertiary medical institution with orthognathic surgery over 15 years to describe pertinent considerations for performing orthognathic surgery in these complex patients. According to the institutional review board-approved protocol, chart records were reviewed for all orthognathic surgical patients with a clinical, genetic, or muscle biopsy-proved diagnosis of CM or CMD. Six patients (5 male, 1 female) qualified, and they were treated by 4 surgeons in the division of oral and maxillofacial surgery from 1992 through 2007. Average age was 19.5 years at the time of orthognathic surgery. Five patients had Class III malocclusions and 1 patient had Class II malocclusion. All 6 patients had apertognathia with lip incompetence. Nasoendotracheal intubation with a difficulty of 0/3 (0=easiest, 3=most difficult) was performed in all cases. Routine induction and maintenance anesthetics, including halogenated agents and nondepolarizing muscle relaxants, were administered without malignant hyperthermia. All 6 patients underwent Le Fort level osteotomies; 4 also had mandibular setback surgery with or without balancing mandibular inferior border osteotomies. Five patients required planned intensive care unit care postoperatively (average, 18.4 days; range, 4 to 65 days). Postoperative respiratory complications resulting in major blood oxygen desaturations occurred in 5 patients; 4 of these patients required reintubation during emergency code response. Five patients required extended postoperative intubation (average, 4.2 days; range, 3 to 6 days) and ventilatory support. Average hospital length of stay was 21.8 days (range, 6 to 75 days). Average postoperative follow-up interval was 29.8 weeks (range, 6 to 128 weeks). Patients with CMs or CMDs often have characteristic

Day surgery and recovery in women with a suspicious breast lesion: evaluation of a psychoeducational nursing intervention.

PubMed

Allard, Nicole

2006-01-01

The study assessed whether a nursing intervention based on self-regulation theory, the Attentional Focus and Symptom Management Intervention (AFSMI), could help women who underwent day surgery for breast cancer to achieve better pain management and decreased emotional distress. The sample consisted of 117 patients with breast cancer who were outpatients and undergoing surgery as part of the initial treatment for their cancer. All subjects were interviewed at three different occasions. The subjects were randomized into the experimental group (n = 61) or the usual care group (control, n = 56). The subjects in the experimental group received the intervention in two sessions, 3-4 days and 10-11 days after surgery. The outcomes were the subjects' pain and emotional distress. Results showed significant differences between the experimental and control group at post-test on home management, total mood disturbance, confusion and tension scores implying that the intervention was effective in achieving these outcomes. Clinical significance has illustrated that a nursing intervention applied during immediate recovery of breast cancer surgery is quite clinically relevant to reduce emotional distress. Self-regulation theory could effectively be used as a guide in developing nursing intervention programs in practice for patients with cancer undergoing day surgery as a primary treatment.

Case-Cohort Studies: Design and Applicability to Hand Surgery.

PubMed

Vojvodic, Miliana; Shafarenko, Mark; McCabe, Steven J

2018-04-24

Observational studies are common research strategies in hand surgery. The case-cohort design offers an efficient and resource-friendly method for risk assessment and outcomes analysis. Case-cohorts remain underrepresented in upper extremity research despite several practical and economic advantages over case-control studies. This report outlines the purpose, utility, and structure of the case-cohort design and offers a sample research question to demonstrate its value to risk estimation for adverse surgical outcomes. The application of well-designed case-cohort studies is advocated in an effort to improve the quality and quantity of observational research evidence in hand and upper extremity surgery. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Staged bilateral single-port thoracoscopic lung volume reduction surgery: A report of 11 cases

PubMed Central

Zhang, Miao; Wang, Heng; Pan, Xue-Feng; Wu, Wen-Bin; Zhang, Hui

2016-01-01

The aim of the present study was to investigate the feasibility and efficacy of staged bilateral single-port thoracoscopic lung volume reduction surgery (LVRS) for patients with chronic obstructive pulmonary emphysema (COPE). Eleven male patients with a mean age of 60.27±12.11 years with bilateral COPE and bullae were admitted to the Department of Thoracic Surgery, Xuzhou Central Hospital from January 2013 to June 2014. The patients underwent staged bilateral single-port thoracoscopic LVRS. The hyperinflated bullae were resected using endoscopic staplers (Endo-GIA), followed by continuous suture and biological glue for reinforcement of the margin. In addition, pulmonary function, blood gas assay, 6-min walk distance (6MWD) and life quality evaluated by a short form 36-item health survey questionnaire (SF-36) were recorded before and after LVRS, respectively. All the patients survived after surgery. The chest tube drainage time was 9.09±1.31 days and postoperative hospital stay was 15.73±2.75 days, with 5 cases of persistent air leakage and 7 cases of pulmonary infection which were finally cured. The patients were followed up for 3 to 12 months, and the pulmonary function, partial pressure of oxygen (pO2), 6MWD and life quality after unilateral or bilateral LVRS were improved compared to these parameters before surgery. However, there was no significant difference between unilateral and bilateral LVRS in terms of life quality. In conclusion, staged bilateral single-port thoracoscopic LVRS may improve the short-term life quality of patients with COPE. PMID:27882084

The Impact of Specialty on Cases Performed During Hand Surgery Fellowship Training.

PubMed

Silvestre, Jason; Upton, Joseph; Chang, Benjamin; Steinberg, David R

2018-03-07

Hand surgery fellowship programs in the United States are predominately sponsored by departments or divisions of orthopaedic surgery or plastic surgery. This study compares the operative experiences of hand surgery fellows graduating from orthopaedic or plastic surgery hand surgery fellowships. Operative case logs of 3 cohorts of hand surgery fellows graduating during the academic years of 2012-2013, 2013-2014, and 2014-2015 were analyzed. The median case volumes were compared by specialty via Mann-Whitney U tests. An arbitrary 1,000% change between the 90th and 10th percentiles of fellows was used as a threshold to highlight case categories with substantial variability. In this study, 413 orthopaedic hand surgery fellows (87%) and 62 plastic surgery hand surgery fellows (13%) were included. Plastic surgery fellows reported more cases in the following categories: wound closure with graft; wound reconstruction with flap; vascular repair, reconstruction, replantation, or microvascular; closed treatment of fracture or dislocation; nerve injury; and congenital (p < 0.05). Orthopaedic surgery fellows reported more cases in the following categories: wound irrigation and debridement fasciotomy or wound preparation; hand reconstruction or releases; wrist reconstruction, releases, or arthrodesis; forearm, elbow, or shoulder reconstruction or releases; hand fractures, dislocation, or ligament injury; wrist fractures or dislocations; forearm and proximal fractures or dislocations; miscellaneous insertion or removal of devices; shoulder arthroscopy, elbow arthroscopy, and wrist arthroscopy; decompression of tendon sheath, synovectomy, or ganglions; nerve decompression; Dupuytren; and tumor or osteomyelitis (p < 0.05). Plastic surgery fellows reported substantial variability for 12 case categories (range, 1,024% to 2,880%). Orthopaedic surgery fellows reported substantial variability for 9 case categories (range, 1,110% to 9,700%). Orthopaedic and plastic hand surgery

Association Between Baseline Affective Disorders and 30-Day Readmission Rates in Patients Undergoing Elective Spine Surgery.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2016-10-01

There is a growing understanding of the prevalence and impact of affective disorders on perception of health status in patients undergoing elective spine surgery. However, the role of these disorders in early readmission is unclear. The aim of this study is to investigate the influence of psychiatric comorbidities on 30-day all-cause readmissions after elective spine surgery. The medical records of 400 patients undergoing elective spine surgery at a major academic medical center were reviewed, of which 107 patients had comprehensive 1- and 2-year patient-reported outcomes data. We identified all unplanned readmissions within 30 days of discharge. The prevalence of affective disorders, such as depression and anxiety, were also assessed. All-cause readmissions within 30 days of discharge was the primary outcome variable. Baseline characteristics were similar between groups. Approximately 6% of patients in this study were readmitted within 30 days of discharge. The rate of readmission was 3-fold more for individuals with a psychiatric comorbidity compared with those without a psychiatric comorbidity (10.34% vs. 3.84%, P = 0.03). In a univariate analysis, race, body mass index, gender, patient age, smoking, diabetes, and fusion levels were associated with increased 30-day readmission rates. However, in a multivariate logistic regression model, depression was an independent predictor of readmission within 30 days of discharge. In addition, there was no significant difference in baseline, 1- and 2-year patient-reported outcomes measures between groups. Our study suggests that psychologic disorders, like depression and anxiety, are independently associated with higher all-cause 30-day readmission rates after elective spine surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Management of an ingested fish bone in the lung using video-assist thoracic surgery: a case report.

PubMed

Tan, Sichuang; Tan, Sipin; Peng, Muyun; Yu, Fenglei

2015-06-01

We report a case of lung abscess caused by an ingested fish bone that was successfully treated by minimally invasive surgery. Although cases of ingested foreign body abscess are well reported, lung abscess caused by ingested fish bone is extremely rare. To date, less than 10 similar cases have been reported in the literature. To the best of our knowledge, the case presented in this case report is the first report of this kind that was successfully treated by video-assist thoracic surgery (VATS). A 47-year-old man was admitted to department of thoracic surgery with the complaint of continues dry cough and fever. The patient accidentally swallowed a long sharp-blade-shaped fish bone 20 days before, which perforated the upper thoracic esophagus on the right and embedded in the right upper lobe.The diagnosis was verified by computed tomography scan and a video-assist thoracic surgery procedure was successfully performed to treat the patient. The patient survived the esophageal perforation fortunately without involvement of great vessel injury and probable mediastinitis. This report may provide additional experience on lung abscess caused by ingested fish bones. However, it is also important to educate the public of the risks of trying to force an ingested object down into the stomach.

Administrative data measured surgical site infection probability within 30 days of surgery in elderly patients.

PubMed

van Walraven, Carl; Jackson, Timothy D; Daneman, Nick

2016-09-01

Elderly patients are inordinately affected by surgical site infections (SSIs). This study derived and internally validated a model that used routinely collected health administrative data to measure the probability of SSI in elderly patients within 30 days of surgery. All people exceeding 65 years undergoing surgery from two hospitals with known SSI status were linked to population-based administrative data sets in Ontario, Canada. We used bootstrap methods to create a multivariate model that used health administrative data to predict the probability of SSI. Of 3,436 patients, 177 (5.1%) had an SSI. The Elderly SSI Risk Model included six covariates: number of distinct physician fee codes within 30 days of surgery; presence or absence of a postdischarge prescription for an antibiotic; presence or absence of three diagnostic codes; and a previously derived score that gauged SSI risk based on procedure codes. The model was highly explanatory (Nagelkerke's R 2 , 0.458), strongly discriminative (C statistic, 0.918), and well calibrated (calibration slope, 1). Health administrative data can effectively determine 30-day risk of SSI risk in elderly patients undergoing a broad assortment of surgeries. External validation is necessary before this can be routinely used to monitor SSIs in the elderly. Copyright © 2016 Elsevier Inc. All rights reserved.

Organization of Hospital Nursing and 30-Day Readmissions in Medicare Patients Undergoing Surgery.

PubMed

Ma, Chenjuan; McHugh, Matthew D; Aiken, Linda H

2015-01-01

Growing scrutiny of readmissions has placed hospitals at the center of readmission prevention. Little is known, however, about hospital nursing—a critical organizational component of hospital service system—in relation to readmissions. To determine the relationships between hospital nursing factors—nurse work environment, nurse staffing, and nurse education—and 30-day readmissions among Medicare patients undergoing general, orthopedic, and vascular surgery. We linked Medicare patient discharge data, multistate nurse survey data, and American Hospital Association Annual Survey data. Our sample included 220,914 Medicare surgical patients and 25,082 nurses from 528 hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania). Risk-adjusted robust logistic regressions were used for analyses. The average 30-day readmission rate was 10% in our sample (general surgery: 11%; orthopedic surgery: 8%; vascular surgery: 12%). Readmission rates varied widely across surgical procedures and could be as high as 26% (upper limb and toe amputation for circulatory system disorders). Each additional patient per nurse increased the odds of readmission by 3% (OR=1.03; 95% CI, 1.00-1.05). Patients cared in hospitals with better nurse work environments had lower odds of readmission (OR=0.97; 95% CI, 0.95-0.99). Administrative support to nursing practice (OR=0.96; 95% CI, 0.94-0.99) and nurse-physician relations (OR=0.97; 95% CI, 0.95-0.99) were 2 main attributes of the work environment that were associated with readmissions. Better nurse staffing and work environment were significantly associated with 30-day readmission, and can be considered as system-level interventions to reduce readmissions and associated financial penalties.

Safety and feasibility of endovascular aortic aneurysm repair as day surgery.

PubMed

Hanley, Stephen C; Steinmetz, Oren; Mathieu, Eva S; Obrand, Daniel; Mackenzie, Kent; Corriveau, Marc-Michel; Abraham, Cherrie Z; Gill, Heather L

2018-06-01

The adoption of endovascular aneurysm repair (EVAR) during the past two decades has led to significantly shorter length of stay as well as lower hospital resource use. Currently, most patients are admitted to the hospital after EVAR; however, there are no standard observation periods, and timing of discharge is based on clinical judgment. The aim of this study was to confirm the safety and feasibility of performing EVAR as outpatient surgery. We developed criteria to identify patients for potential same-day discharge (infrarenal aneurysm, low perioperative risk, to be accompanied for first 24 hours). We then implemented a prospective trial that observed patients planned for same-day discharge and compared them with a historical control group (patients who had undergone EVAR during the previous 2 years and met same-day discharge criteria). Basic demographic and operative data as well as length of stay, inpatient and perioperative complications, emergency department visits, readmissions, reinterventions, and deaths were collected. The primary outcome was the 30-day complication rate, and the study was powered to assess noninferiority. Prospectively, we assessed 266 patients and planned 110 (41%) for outpatient EVAR (62% of historical controls met outpatient criteria). Demographic characteristics were similar between planned outpatients and historical controls. In planned outpatients, hospital stay was significantly shorter (0.7 ± 2.6 days vs 2.5 ± 6.9 days; P < .01), and 79% were discharged the same day of surgery. The 30-day follow-up was available for all study patients and 94% of control patients; there were no differences in complication (11% vs 9%), readmission (2% vs 4%), reintervention (4% vs 4%), or mortality (1% vs 1%) rates, but study patients had significantly more emergency department visits (15% vs 6%; P < .05). Unsuccessful same-day discharge was associated with longer operative times, increased blood loss, and use of general anesthesia. In

A 1470-nm laser combined with foam sclerotherapy in day surgery: a better choice for lower limb varicose veins.

PubMed

Zhang, Xing; Wang, Xin; Gao, Cheng; Qin, Jinbao; Zhao, Haiguang; Li, Weimin; Lu, Xinwu

2018-04-23

Day surgery is being more and more adopted by clinicians. Higher wavelength lasers give patients better experience than lower wavelength lasers, which makes it more suitable for day surgery. This study compares the short- and mid-term efficacy, postoperative morbidity, and patient satisfaction of "1470-nm endovenous laser ablation (EVLA) combining foam sclerotherapy in day surgery" with "810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery" on great saphenous vein (GSV) insufficiency postoperatively. A single-institution historical cohort study of 194 patients was performed in Shanghai Ninth People's Hospital, China. Ninety-seven patients received 1470-nm EVLA combining foam sclerotherapy in day surgery ("1470-nm group"), and 97 patients received 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery recommended by guidelines ("810-nm group"). No significant difference was found between the 1470-nm group and the 810-nm group in terms of GSV occlusion rate (both 100%), complication rate, and recurrence rate (8.2 vs. 11.3%) during the period of 1-12 months after surgery. Serious complications in the 1470-nm group and 810-nm group were 0 and 1.0%. Minor complications in the 1470-nm group and 810-nm group were ecchymosis at 20.6 and 18.6%, edema at 69.1 and 63.9%, and paresthesia around ankle at 0 and 3.1%, respectively. Advantage of the 1470-nm group over the 810-nm group was statistically significant considering the patient perioperative comfort and economic cost. Treatment of 1470-nm EVLA combining foam sclerotherapy in day surgery has similar efficacy as the 810-nm EVLA with high ligation combining foam sclerotherapy in hospital surgery in GSV insufficiency and is more comfortable with less incision, hospitalization procedure, and medical costs. It may be a new option for patients who are afraid or unable to be hospitalized.

Single port access laparoscopic surgery for large adnexal tumors: Initial 51 cases of a single institute

PubMed Central

Cho, Bo Ra; Han, Jae Won; Kim, Tae Hyun; Han, Ae Ra; Hur, Sung Eun; Lee, Sung Ki

2017-01-01

Objective Investigation of initial 51 cases of single port access (SPA) laparoscopic surgery for large adnexal tumors and evaluation of safety and feasibility of the surgical technique. Methods We retrospectively reviewed the medical records of the first 51 patients who received SPA laparoscopic surgery for large adnexal tumors greater than 10 cm, from July 2010 to February 2015. Results SPA adnexal surgeries were successfully completed in 51 patients (100%). The mean age, body mass index of the patients were 43.1 years and 22.83 kg/m2, respectively. The median operative time, median blood loss were 73.5 (range, 20 to 185) minutes, 54 (range, 5 to 500) mL, and the median tumor diameter was 13.6 (range, 10 to 30) cm. The procedures included bilateral salpingo-oophorectomy (n=18, 36.0%), unilateral salpingo-oophorectomy (n=14, 27.45%), and paratubal cystectomy (n=1, 1.96%). There were no cases of malignancy and none were insertion of additional ports or conversion to laparotomy. The cases with intraoperative spillage were 3 (5.88%) and benign cystic tumors. No other intraoperative and postoperative complications were observed during hospital days and 6-weeks follow-up period after discharge. Conclusion Our results suggest that SPA laparoscopic surgery for large adnexal tumors may be a safe and feasible alternative to conventional laparoscopic surgery. PMID:28217669

Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study.

PubMed

Swart, M; Carlisle, J B; Goddard, J

2017-01-01

Preoperative identification of high-risk surgical patients might help to reduce postoperative morbidity and mortality. Using a patient's predicted 30 day mortality to plan postoperative high-dependency unit (HDU) care after elective colorectal surgery might be associated with reduced postoperative morbidity. The 30 day postoperative mortality was predicted for 504 elective colorectal surgical patients in a preoperative clinic. The prediction was used to determine postoperative surgical ward or HDU care. Those with a predicted 30 day mortality of 1-3% mortality, and thus deemed at intermediate risk, had either planned HDU care (n=68) or planned ward care (n=139). The main outcome measures were emergency laparotomy and unplanned critical care admission. There were more emergency laparotomies and unplanned critical care admissions in patients with a predicted 30 day mortality of 1-3% who went to an HDU after surgery compared with patients who went to a ward: 0 vs 14 (10%), P=0.0056 and 0 vs 22 (16%), P=0.0002, respectively. Planned postoperative critical care was associated with a lower rate of complications after elective colorectal surgery. © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Management of adult recurrent respiratory papillomatosis with oral acyclovir following micro laryngeal surgery: a case series.

PubMed

Chaturvedi, Jagdish; Sreenivas, V; Hemanth, V; Nandakumar, R

2014-01-01

To demonstrate the role of oral acyclovir in monthly regimes after microdebrider assisted excision in 3 patients with adult recurrent respiratory papillomatosis (ARRP). Three patients with ARRP who presented to a tertiary referral hospital in stridor were initially treated with a tracheostomy in order to secure airway. On further evaluation by videolaryngoscopy extensive bilateral laryngeal papillomatosis was noted with history of similar conditions in the past for which they were repeatedly operated. They were admitted and underwent Microlaryngeal surgery and laryngeal microdebrider assisted surgery under general anesthesia. Post operatively a course of oral acyclovir at 800 mg/5 times/day for 5 days was administered. On repeat assessment with videolaryngoscopy at monthly intervals a complete remission of the disease was noted with no residual disease at the end of 1 year in 2 cases. One case had a recurrence. Renal parameters were monitored periodically. It may be concluded that the action of anti viral drugs at regular intervals in addition to a short course of oral steroids lead to rapid recovery and prevented latent virus activation within the laryngo tracheal system hence maintaining long term improvement. This can avoid multiple laryngeal surgeries, repeated respiratory emergencies and risk for malignant transformation in the future thereby reducing morbidity and effect on quality of life.

Outcome of appendicectomy in children performed in paediatric surgery units compared with general surgery units.

PubMed

Tiboni, S; Bhangu, A; Hall, N J

2014-05-01

Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30-day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0.37, 95 per cent confidence interval 0.23 to 0.59; P < 0.001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0.34, 0.21 to 0.57; P < 0.001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30-day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1.90, 1.18 to 3.06; P = 0.011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30-day adverse event rate existed (OR 1.59, 0.93 to 2.73; P = 0.091). The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a

Same-Day Discharge after Laparoscopic Roux-en-Y Gastric Bypass: An Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database.

PubMed

Inaba, Colette S; Koh, Christina Y; Sujatha-Bhaskar, Sarath; Zhang, Lishi; Nguyen, Ninh T

2018-05-01

Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been performed with successful discharge on postoperative day 1 (POD1). There are limited studies on same-day discharge after LRYGB. The objective of this study was to examine the frequency and outcomes of same-day discharge after LRYGB. The 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was analyzed for adult patients who underwent elective LRYGB cases with same-day vs POD1 discharge. Open and revisional cases were excluded. Multivariate analysis was performed to compare risk-adjusted 30-day mortality, overall morbidity, readmission, and reoperation. There were 354 (0.9%) patients who were discharged on the same day as surgery after LRYGB. After exclusion criteria, 319 patients with same-day discharge and 9,402 patients with POD1 discharge were examined. For same-day vs POD1 discharge groups, mean ages were 45.0 and 44.5 years, respectively, and mean BMIs were 47.3 kg/m 2 and 45.9 kg/m 2 , respectively. The unadjusted mortality rate was significantly higher for same-day compared with POD1 discharge (0.94% vs. 0.05%, respectively; p = 0.0017). Compared with POD1 discharge, same-day discharge had higher overall morbidity (3.76% vs 1.54%; adjusted odds ratio [AOR] 2.41; p = 0.0216), but no statistically significant differences for readmissions (3.45% vs. 3.66%; AOR 0.85; p = 0.9999) or reoperations (1.88% vs. 0.89%; AOR 2.33; p = 0.2428). Same-day discharge after LRYGB is associated with increased morbidity and mortality compared with POD1 discharge. The practice of same-day discharge after LRYGB should be considered experimental until further studies confirm which patient characteristics will ensure safe same-day discharge. Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Risk of Ischemic Stroke and Transient Ischemic Attack Is Increased up to 90 Days after Non-Carotid and Non-Cardiac Surgery.

PubMed

Grau, Armin J; Eicke, Martin; Burmeister, Christoph; Hardt, Roland; Schmitt, Eberhard; Dienlin, Sieghard

2017-01-01

The risk of stroke after cardiac and carotid surgery is well established. In contrast, stroke risk in association with non-cardiac and non-carotid surgery and its time course are insufficiently known. We investigated the prevalence of recent and planned surgery among patients with stroke and transient ischemic attack (TIA), time dependency of stroke risk, stroke etiology, and interruption of antithrombotic medication in association with surgery. Data on type and date of surgery and similar interventions within the last year or planned for the next 2 weeks were anonymously collected together with demographic data, vascular risk factors, stroke severity, handicap before stroke and stroke etiology within a state-wide, mandatory, hospital-based acute stroke care quality monitoring project (Rhineland-Palatinate, Germany) for 1 year (2010). Non-carotid and non-cardiothoracic surgery was reported as performed within 1 year before the index event or as planned for the next 2 weeks thereafter in 532 out of 12,120 patients with ischemic stroke/TIA (4.4%). Compared to 91-365 days before stroke/TIA as reference period, risk of cerebral ischemia (per day analysis) was increased for surgery within 61-90 days before ischemia (rate ratio 2.0, 95% CI 1.5-2.8) and continuously increased along shorter intervals between stroke and surgery (31-60 days: rate ratio 3.6, 95% CI 2.9-4.5; 15-30 days: rate ratio 8.2, 95% CI 6.7-10.1; 8-14 days: rate ratio 13.2, 95% CI 10.3-16.8; 4-7 days: rate ratio 16.5, 95% CI 12.2-22.1) peaking at an interval of 1-3 days before ischemia (rate ratio 34.0, 95% CI 26.9-42.8). On the day of surgery, rate ratio was 14.8 (95% CI 7.8-27.9) and for planned surgery it was 2.7 (95% CI 1.8-4.0). Results were similar for first-ever and for recurrent ischemic stroke. Perioperative stroke/TIA was positively associated with atrial fibrillation and cardioembolic stroke etiology, higher mortality, more severe neurological deficits at discharge, and longer hospital stay

[Office surgery: organization, legislative, and medico-legal problems. Personal experience].

PubMed

Pepe, N; Actis Dato, G M; Vennarecci, G; Anselmo, A

1993-11-01

The authors approach the subject of office surgery by underlining the advantages of this procedure. In particular, they focus attention on the anesthesiological and legislative problems. Depending on the setting used for surgery and the duration of hospitalisation, ambulatorial surgery can be divided into: day-hospital, office surgery, one-day surgery, short-stay surgery, same-day surgery, The authors report their own experience relating to 103 cases with relative complications. A total of 103 operations of medium-to- major ambulatorial surgery were performed (100 females and 3 males, mean age 36.8). One week prior to surgery all patients attended a medical out-patient examination in order to fill in medical records and be prescribed routine hematochemical tests, chest X-ray and ECG. The preoperative anesthesiological evaluation was made at the time of surgery. All patients received antibiotic prophylactic treatment. Postoperative complications were reported above all following neuroleptoanalgesia and amounted to a total of 5 cases: nausea (4 cases) associated with vomit (1 case), and postural hypotension (1 case). No infective complications were observed. The authors emphasise the importance of a careful preoperative selection of patients; an out-patient structure equipped with the appropriate instrument and machinery for surgery and the constant presence of anesthetists to ensure correct anesthesia (local, neuroleptoanalgesic, peridural general), reanimation and postoperative care. The aims of ambulatorial surgery are, in broad terms, the safety of procedures, convenience for the patient and organisational and economic savings for health structures. Ambulatorial surgery has an extremely high acceptance rate by patients. Lastly, the authors also report the juridical and bureaucratic problems faced by ambulatorial surgery and look forward to its wider diffusion. In the future office surgery might represent an important contribution to surgical therapeutic

Structural, Nursing, and Physician Characteristics and 30-Day Mortality for Patients Undergoing Cardiac Surgery in Pennsylvania.

PubMed

Lane-Fall, Meghan B; Ramaswamy, Tara S; Brown, Sydney E S; He, Xu; Gutsche, Jacob T; Fleisher, Lee A; Neuman, Mark D

2017-09-01

Cardiac surgery ICU characteristics and clinician staffing patterns have not been well characterized. We sought to describe Pennsylvania cardiac ICUs and to determine whether ICU characteristics are associated with mortality in the 30 days after cardiac surgery. From 2012 to 2013, we conducted a survey of cardiac surgery ICUs in Pennsylvania to assess ICU structure, care practices, and clinician staffing patterns. ICU data were linked to an administrative database of cardiac surgery patient discharges. We used logistic regression to measure the association between ICU variables and death in 30 days. Cardiac surgery ICUs in Pennsylvania. Patients having coronary artery bypass grafting and/or cardiac valve repair or replacement from 2009 to 2011. None. Of the 57 cardiac surgical ICUs in Pennsylvania, 43 (75.4%) responded to the facility survey. Rounds included respiratory therapists in 26 of 43 (60.5%) and pharmacists in 23 of 43 (53.5%). Eleven of 41 (26.8%) reported that at least 2/3 of their nurses had a bachelor's degree in nursing. Advanced practice providers were present in most of the ICUs (37/43; 86.0%) but residents (8/42; 18.6%) and fellows (7/43; 16.3%) were not. Daytime intensivists were present in 21 of 43 (48.8%) responding ICUs; eight of 43 (18.6%) had nighttime intensivists. Among 29,449 patients, there was no relationship between mortality and nurse ICU experience, presence of any intensivist, or absence of residents after risk adjustment. To exclude patients who may have undergone transcatheter aortic valve replacement, we conducted a subgroup analysis of patients undergoing only coronary artery bypass grafting, and results were similar. Pennsylvania cardiac surgery ICUs have variable structures, care practices, and clinician staffing, although none of these are statistically significantly associated with mortality in the 30 days following surgery after adjustment.

Computer Simulation Shows the Effect of Communication on Day of Surgery Patient Flow.

PubMed

Taaffe, Kevin; Fredendall, Lawrence; Huynh, Nathan; Franklin, Jennifer

2015-07-01

To improve patient flow in a surgical environment, practitioners and academicians often use process mapping and simulation as tools to evaluate and recommend changes. We used simulations to help staff visualize the effect of communication and coordination delays that occur on the day of surgery. Perioperative services staff participated in tabletop exercises in which they chose the delays that were most important to eliminate. Using a day-of-surgery computer simulation model, the elimination of delays was tested and the results were shared with the group. This exercise, repeated for multiple groups of staff, provided an understanding of not only the dynamic events taking place, but also how small communication delays can contribute to a significant loss in efficiency and the ability to provide timely care. Survey results confirmed these understandings. Copyright © 2015 AORN, Inc. Published by Elsevier Inc. All rights reserved.

How to improve plastic surgery knowledge, skills and career interest in undergraduates in one day.

PubMed

Davis, C R; O'Donoghue, J M; McPhail, J; Green, A R

2010-10-01

Plastic surgery now occupies a negligible component of many undergraduate curricula. The British Association of Plastic, Reconstructive and Aesthetic Surgeons Undergraduate Course aimed to introduce and improve students' plastic surgery knowledge and skills, as well as develop personal career interests. This research aims to quantify whether this was achieved. Students attending the one-day course were invited to complete a questionnaire before and after the course. Questions were self-reflective and incorporated four key themes: (1) plastic surgery knowledge; (2) awareness of the work of a plastic surgeon; (3) ability to perform basic plastic surgical skills; (4) career interest in plastic surgery. Non-medical students were given an identical questionnaire to quantify public perception of the work of a plastic surgeon. 121 students attended from 17 universities across the UK, with 93 completing the questionnaire (77% response rate). Paired analyses compared mean or median scores of the students' answers before and after the course. After completing the course, medical students significantly improved in all four key themes (p<0.01). 93 non-medical students completed questionnaires. Medical students were significantly more accurate at identifying plastic surgery procedures than non-medical students (P < 0.01), which was further strengthened after completing the course (P < 0.001). This study demonstrates the positive educational impact of a one-day plastic surgery event for medical students and supports the need for plastic surgery education at an undergraduate level. Copyright 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Clinic-day surgery for children: a patient and staff perspective.

PubMed

Criss, Cory N; Brown, Johnathan; Gish, Joshua S; Gadepalli, Samir K; Hirschl, Ronald B

2018-07-01

For the past 3 years, our institution has implemented a same clinic-day surgery (CDS) program, where common surgical procedures are performed the same day as the initial clinic evaluation. We sought to evaluate the patient and faculty/staff satisfaction following the implementation of this program. After IRB approval, patients presenting for the CDS between 2014 and 2017 were retrospectively reviewed. Of these, patient families who received CDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback. In addition, feedback from faculty/staff members directly involved in the program was obtained to determine barriers and satisfaction with the program. Twenty-nine patients received CDS, with the most commonly performed procedures being inguinal hernia repair (34%) and umbilical hernia repair (24%). Twenty (69%) patients agreed to perform the telephone survey. Parents were overall satisfied with the CDS program, agreeing that the instructions were easy to understand. Overall, 79% of parents indicated that it decreased overall stress/anxiety, with 75% saying it allowed for less time away from work, and 95% agreeing to pursue CDS again if offered. The most common negative feedback was an unspecified operative start time (15%). While faculty/staff members agreed the program was patient-centered, there were concerns over low enrollment and surgeon continuity, because there were different evaluating and operating surgeons. This study successfully evaluated the satisfaction of patients and faculty/staff members after implementing a clinic-day surgery program. Our results demonstrated improved patient family satisfaction, with families reporting decreased anxiety and less time away from work. Despite this, faculty and staff members reported challenges with enrollment and surgeon continuity.

Regional Cerebral Oxygen Saturation Level Predicts 30-Day Mortality Rate After Left Ventricular Assist Device Surgery.

PubMed

Ghosal, Soutik; Trivedi, Jaimin; Chen, James; Rogers, Michael P; Cheng, Allen; Slaughter, Mark S; Kong, Maiying; Huang, Jiapeng

2018-06-01

Left ventricular assist device (LVAD) surgery is complex, high risk, and expensive. The authors' hypothesis is baseline regional cerebral oxygen saturation (rSO 2 ) might be a predictor of postoperative clinical outcomes. Retrospective review of 210 consecutive continuous flow LVAD patients between 2008 and 2014. The primary measure is 30-day mortality rate and secondary measures include modified major adverse cardiocerebral events (MACE), length of stay (LOS), and intensive care unit (ICU) stay. Multiple logistic regression models were applied to examine if a binary outcome variable, such as 30-day mortality and MACE, is associated with rSO 2 at baseline. Log-linear model was used to examine whether LOS or ICU stay hours is associated with rSO 2 at baseline. Single institution, academic hospital. Patients who received LVAD surgery ​at Jewish Hospital, Louisville, KY. All patients received LVAD surgery. Cerebral oximetry monitoring was used in both the preoperative and intraoperative periods. The authors found that higher rSO 2 at baseline is associated with lower 30-day mortality with an odds ratio of 0.94 and 95% confidence interval (0.888, 0.995) for every 1% increase of rSO 2 . For secondary outcomes, baseline rSO 2 was not significantly associated with MACE, requirement for postoperative renal failure/dialysis, reoperation for bleeding, and LOS or ICU hours. Regional cerebral oxygen saturation levels at baseline are significantly associated with 30-day mortality after LVAD surgeries. Copyright © 2017 Elsevier Inc. All rights reserved.

Day surgery for vocal fold lesions using a double-bent 60-mm Cathelin needle.

PubMed

Toyomura, Fumimasa; Tokashiki, Ryoji; Hiramatsu, Hiroyuki; Tsukahara, Kiyoaki; Motohashi, Ray; Sakurai, Eriko; Nomoto, Masaki; Suzuki, Mamoru

2014-11-01

Day surgery for vocal cord lesions overcomes the disadvantages of laryngomicrosurgery under general anesthesia. We present our experience with treatment of vocal fold lesions using a long double-bend Cathelin needle that can access all parts of the vocal cords. A 23G, 60-mm-long Cathelin needle was bent twice by 45(o) at a distance of 1 and 2 cm from the tip, and was attached to a syringe. Under topical anesthesia and nasal endoscopy of the laryngopharynx, the needle was inserted percutaneously perpendicular to the skin, the direction of insertion being altered when the bends in the needle reached the skin surface. This allows the tip of the needle to access all parts of the glottis, allowing the performance of procedures such as biopsies, excision of lesions, and injection into the vocal folds. Between January 2011 and December 2013, we used this technique to perform vocal fold procedures in 566 patients presenting for treatment of spasmodic dysphonia (412 cases, 73 %) and other vocal fold lesions. Only minor complications, such as hematoma (3 patients, 0.5 %) and slight bleeding from the puncture site in the epiglottic vallecula (all patients, 100 %), which ceased spontaneously within 10 min, were seen. Erroneous puncture occurred in three patients (0.5 %) and the puncture had to be repeated in 38 patients (6.7 %). The procedure was completed successfully in all cases (100 %). Surgery for vocal fold lesions under topical anesthesia using our double-bend Cathelin needle technique is simple, safe, and useful.

Prevalence of Surgical Site Infections Following Orthognathic Surgery: A Double-Blind, Randomized Controlled Trial on a 3-Day Versus 1-Day Postoperative Antibiotic Regimen.

PubMed

Davis, Clayton M; Gregoire, Curtis E; Davis, Ian; Steeves, Thomas W

2017-04-01

The purpose of this study was to determine the effect of a 3- versus 1-day antibiotic regimen on the rate of surgical site infection (SSI) in patients undergoing orthognathic surgery at a department of oral and maxillofacial surgery in Halifax, Nova Scotia, Canada. A prospective, randomized controlled trial was conducted. All patients received 1 day of intravenous antibiotics after surgery. Then, patients were randomly distributed into groups that received 2 days of additional antibiotics (group A) or placebo (group B). The primary outcome measured was the presence of SSI. The operating surgeon, concomitant extraction of teeth, surgical procedures performed, duration of intermaxillary fixation, and length of hospital stay were analyzed for an effect on SSI. Patients were followed for 1 year after surgery to identify SSIs that might have been diagnosed outside the hospital. The trial started with 288 patients, and 117 patients were lost to follow-up. Statistical analyses were ultimately performed on those 171 patients who were adherent to the study medication regimen. Group A (n = 86) and B (n = 85) SSI rates were 7.0 and 17.6% (number needed to treat = 10; P = .04), respectively. Mandibular bilateral sagittal split osteotomy (BSSO) was involved in 71% of SSIs. Intra- and postoperative surgical variables did not have a relevant effect on the SSI rate. Patients were followed for 1 year after surgery, and group A (n = 46) and group B (n = 44) had SSI rates of 4 and 25% (P < .05), respectively. Three days of postoperative cefazolin and cephalexin markedly decreases SSI rates compared with 1 day. However, the number needed to treat of 10 suggests that the benefits of the extended regimen might not outweigh the risks. The high prevalence of SSIs at the mandibular BSSO incisions might have been caused by contamination, with more saliva and reception of a lower blood supply, than maxillary Le Fort I incisions. Mandibular osteotomies could benefit from an

Older Age Confers a Higher Risk of 30-Day Morbidity and Mortality Following Laparoscopic Bariatric Surgery: an Analysis of the Metabolic and Bariatric Surgery Quality Improvement Program.

PubMed

Haskins, Ivy N; Ju, Tammy; Whitlock, Ashlyn E; Rivas, Lisbi; Amdur, Richard L; Lin, Paul P; Vaziri, Khashayar

2018-04-17

There is a paucity of literature describing the association of age with the risk of adverse events following bariatric surgery. The purpose of this study is to investigate the association of age with 30-day morbidity and mortality following laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All adult patients undergoing laparoscopic Roux-en-Y gastric bypass (RNGYB) or sleeve gastrectomy (SG) were identified within the MBSAQIP database. Patients were divided into five equal age quintiles. Binary outcomes of interest, including cardiac, pulmonary, wound, septic, clotting, and renal events, in addition to the incidence of related 30-day unplanned reintervention, related 30-day mortality, and a composite morbidity and mortality outcome were compared across the age quintiles and procedures. A total of 266,544 patients met inclusion criteria. Older age was associated with an increased risk of all morbidity outcomes except venous thromboembolism events, 30-day mortality, and the composite morbidity and mortality outcome. Patients who underwent Roux-en-Y gastric bypass had worse outcomes per quintile for almost every outcome of interest when compared to patients who underwent sleeve gastrectomy. Older patients and patients who undergo Roux-en-Y gastric bypass are at an increased risk of perioperative morbidity and mortality following laparoscopic bariatric surgery. Additional studies are needed to determine the association of age with long-term weight loss and cardiometabolic comorbidity resolution following bariatric surgery in order to determine if the increased perioperative risk is offset by improved long-term outcomes in older patients undergoing bariatric surgery.

The ACGME case log: General surgery resident experience in pediatric surgery

PubMed Central

Gow, Kenneth W.; Drake, F. Thurston; Aarabi, Shahram; Waldhausen, John H.

2014-01-01

Background General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time. Methods The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989–1990 to 2010–2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989–90 to AY1993–94), Period II (AY1994–95 to AY1998–99), Period III (AY1999–00 to AY2002–03), Period IV (AY2003–04 to AY2006–07), and Period V (AY2007–08 to AY2010–11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05. Results Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time. Conclusions GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended. PMID:23932601

Atlantoaxial rotatory fixation as a rare complication from head positioning in otologic surgery: Report of two cases in young children.

PubMed

Sakaida, Hiroshi; Akeda, Koji; Sudo, Akihiro; Takeuchi, Kazuhiko

2017-01-01

Atlantoaxial rotatory fixation is a condition in which the first and second vertebrae of the cervical spine become interlocked in a rotated position. This condition can result in serious consequences and thus have a significant impact on patients, especially when diagnosis and treatment are delayed. Some cases of atlantoaxial rotatory fixation have been described in association with otologic surgery or plastic surgery involving the ear. We present the cases of two pediatric patients who developed atlantoaxial rotatory fixation following otologic surgery and we review the relevant literature. One patient was a 7-year-old boy who underwent tympanoplasty for cholesteatoma. The other patient was a 5-year-old girl with profound sensorineural hearing loss who underwent cochlear implantation. Both patients developed atlantoaxial rotatory fixation on the day after surgery, and they were treated conservatively. Our literature search using relevant terms identified 12 similar published cases. Thus, a total of 14 patients, including our 2 patients, were evaluated. Most of the patients were children and typically they complained of painful torticollis and exhibited a characteristic posture called the "cock-robin" position on the day after surgery. Mostly, the direction of torticollis was opposite to the side of surgery. Most of the patients received conservative treatment alone, but three underwent surgical treatment. The correlation between the direction of torticollis and the side of surgery suggests that rotation of the head during surgery has an impact on development of postoperative atlantoaxial rotatory fixation. Thus, children undergoing otologic surgery are thought to be at a risk of postoperative atlantoaxial rotatory fixation. Although rare, the surgical team needs to be aware of this adverse event and pay close attention to this possibility throughout the perioperative period. Perioperative management should include informed consent, preoperative assessment of the

Association of Breast Conservation Surgery for Cancer With 90-Day Reoperation Rates in New York State.

PubMed

Isaacs, Abby J; Gemignani, Mary L; Pusic, Andrea; Sedrakyan, Art

2016-07-01

For early-stage breast cancer, breast conservation surgery (BCS) is a conservative option for women and involves removing the tumor with a margin of surrounding breast tissue. If margins are not tumor free, patients undergo additional surgery to avoid local recurrence. To investigate the use of BCS in New York State and to determine rates of reoperation, procedure choice, and the effect of surgeon experience on the odds of a reoperation 90 days after BCS. A population-based sample of 89 448 women undergoing primary BCS for cancer were selected and examined from January 1, 2003, to December 31, 2013, in New York State mandatory reporting databases. All hospitals and ambulatory surgery centers in New York State were included. Data were analyzed from December 15, 2014, to November 1, 2015. Rate of reoperations within 90 days of the initial BCS procedure. During the study period, 89 448 women 20 years or older (mean [SD] age, 61.7 [13.7] years) underwent primary BCS. In 2013, 1416 women in New York aged 20 to 49 years underwent BCS compared with 3068 women aged 50 to 64 years and 3644 women 65 years or older. These numbers represent a significant decrease from 1960 women younger than 50 years in 2003 who underwent BCS (P < .001 for trend) but little change from the 2899 women aged 50 to 64 years and 3270 women 65 years or older who underwent BCS in 2003. Mean overall rate of 90-day reoperation was 30.9% (27 010 of 87 499 patients) and decreased over time from 39.5% (6630 of 16 805 patients) in 2003 to 2004 to 23.1% (5148 of 22 286 patients) in 2011 to 2013. Rates of reoperation were highest in women aged 20 to 49 years (37.7% [6990 of 18 524]) and lowest in women 65 years or older (26.3% [9656 of 36 691]) (P < .001 for trend). Over time, more patients underwent BCS as a subsequent procedure, from 4237 of 6630 patients (63.9%) in 2003 to 2004 to 4258 of 5148 (82.7%) in 2011 to 2013 (P < .001 for trend). Among the 19 466 women who underwent BCS as a

Willingness to pay for one-stop anesthesia in pediatric day surgery

PubMed Central

2011-01-01

Background This study assesses the parents' Willingness To Pay (WTP) for One Stop Anesthesia (OSA). OSA is part of a free screening procedure that determines the timing of the anesthesiological assessment. In OSA-positive patients, the preoperative assessment is carried out on the same day as the surgery. The OSA allows patients who have to undergo surgery in a pediatric day surgery to avoid accessing the pre-admission clinic. Method This is a descriptive cohort study. A sample of 106 parents were interviewed directly by means of a questionnaire. The questionnaire builds a hypothetical scenario where the interviewee has a chance to buy the OSA health service with the WTP. The WTP values are distributed in classes and are contingent to the market built in the questionnaire. The Chi Square and Cramer's V tests evaluate the WTP dependence on the parents' place of origin and occupation. Results The approximate average of the WTP classes is €87.21 per family. The Chi Square test relative to the WTP classes and the places of origin is statistically significant (p < 0.05). The Cramer's V test is 0.347 and points to a positive association between the two demographics. The Cramer's V test of the WTP classes and the types of job is 0.339 and indicates a positive association. Conclusion Nearly 90% of pediatric patients who were screened for timing the preoperative assessment are true positives to OSA. This allows doing away with the pre-hospitalization, with definite advantages for the families. This screening is a health service that families would be hypothetically willing to pay. PMID:21586162

Twice-Daily Enoxaparin among Plastic Surgery Inpatients: An Examination of Pharmacodynamics, 90-Day Venous Thromboembolism, and 90-Day Bleeding.

PubMed

Pannucci, Christopher J; Fleming, Kory I; Momeni, Arash; Prazak, Ann Marie; Agarwal, Jayant; Rockwell, W Bradford

2018-06-01

Low anti-factor Xa level, indicative of inadequate enoxaparin dosing, has a significant association with 90-day venous thromboembolism events. The authors examined the pharmacodynamics of enoxaparin 40 mg twice daily and its correlation with anti-factor Xa level, postoperative venous thromboembolism, and bleeding. Adult patients were admitted after plastic and reconstructive surgery and received enoxaparin 40 mg twice daily. Peak anti-factor Xa levels, which quantify enoxaparin's antithrombotic effect, were drawn, with a goal level of 0.2 to 0.4 IU/ml. Ninety-day symptomatic venous thromboembolism and clinically relevant bleeding were identified. The authors enrolled 118 patients who received enoxaparin 40 mg twice daily. Of these patients, 9.6 percent had low peak anti-factor Xa levels (<0.2 IU/ml), 62.6 percent had in-range peak anti-factor Xa levels (0.2 to 0.4 IU/ml), and 27.8 percent had high anti-factor Xa levels (>0.4 IU/ml). With enoxaparin 40 mg twice daily, 90.4 percent of patients received at least adequate prophylaxis. Patient weight predicted the rapidity of enoxaparin metabolism. Zero acute 90-day venous thromboembolism occurred. Eight patients (6.8 percent) had clinically relevant 90-day bleeding: clinical consequences ranged from cessation of enoxaparin prophylaxis to transfusion to operative hematoma evacuation. When enoxaparin 40 mg twice daily is provided, 90 percent of patients receive at least adequate venous thromboembolism prophylaxis (anti-factor Xa level >0.2 IU/ml). However, 27 percent of the overall population is overtreated (anti-factor Xa level >0.4 IU/ml). These pharmacodynamics data likely explain the low rate of 90-day acute venous thromboembolism (0 percent) and the high rate of clinically relevant bleeding (6.8 percent) observed. Future studies are needed to better optimize the risks and benefits of enoxaparin prophylaxis in plastic and reconstructive surgery patients. Therapeutic, IV.

Opioid use among same-day surgery patients: Prevalence, management and outcomes

PubMed Central

Wilson, Jennifer LC; Poulin, Patricia A; Sikorski, Robert; Nathan, Howard J; Taljaard, Monica; Smyth, Catherine

2015-01-01

OBJECTIVES: To determine whether the prevalence of opioid use among patients requiring elective same-day admission (SDA) surgery is greater than the 2.5% prevalence found in the general population. Secondary objectives were to assess compliance with expert recommendations on acute pain management in opioid-tolerant patients and to examine clinical outcomes. METHODS: A retrospective review of 812 systematically sampled adult SDA surgical cases between April 1, 2008 and March 31, 2009 was conducted. RESULTS: Among 798 eligible patients, 148 (18.5% [95% CI 15.9% to 21.2%]) were prescribed opioids, with 4.4% prescribed long-acting opioids (95% CI 3.0% to 5.8%). Use of opioids was most prevalent among orthopedic and neurosurgery patients. Among the 35 patients on long-acting opioids who had a high likelihood of being tolerant, anesthesiologists correctly identified 33, but only 13 (37%) took their usual opioid preoperatively while 22 (63%) had opioids continued postoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered preoperatively in 18 (51%), 15 (43%) and 18 (51%) cases, respectively, while ketamine was used in 15 (43%) patients intraoperatively. Acetaminophen, nonsteroidal anti-inflammatory drugs and pregabalin were ordered postoperatively in 31 (89%), 15 (43%) and 17 (49%) of the cases, respectively. No differences in length of stay, readmissions and emergency room visits were found between opioid-tolerant and opioid-naïve patients. CONCLUSION: Opioid use is more common in SDA surgical patients than in the general population and is most prevalent within orthopedic and neurosurgery patients. Uptake of expert opinion on the management of acute pain in the opioid tolerant patient population is lacking. PMID:26357683

Surgery-first orthognathic approach case series: Salient features and guidelines

PubMed Central

Gandedkar, Narayan H; Chng, Chai Kiat; Tan, Winston

2016-01-01

Conventional orthognathic surgery treatment involves a prolonged period of orthodontic treatment (pre- and post-surgery), making the total treatment period of 3–4 years too exhaustive. Surgery-first orthognathic approach (SFOA) sees orthognathic surgery being carried out first, followed by orthodontic treatment to align the teeth and occlusion. Following orthognathic surgery, a period of rapid metabolic activity within tissues ensues is known as the regional acceleratory phenomenon (RAP). By performing surgery first, RAP can be harnessed to facilitate efficient orthodontic treatment. This phenomenon is believed to be a key factor in the notable reduction in treatment duration using SFOA. This article presents two cases treated with SFOA with emphasis on “case selection, treatment strategy, merits, and limitations” of SFOA. Further, salient features comparison of “conventional orthognathic surgery” and “SFOA” with an overview of author's SFOA treatment protocol is enumerated. PMID:26998476

Being Wheeled or Walking: A Qualitative Study of Patients' Spatial Experience in Two Distinct Day Surgery Centers.

PubMed

Annemans, Margo; Audenhove, Chantal Van; Vermolen, Hilde; Heylighen, Ann

2016-04-01

In this article, we explore what a different way of moving-being wheeled versus walking-means for the spatial experience of day surgery patients. Day surgery centers can be conceived in very different manners. Some are organized similar to traditional hospital admittance; others are located in a specifically designed part of the hospital and receive patients as guests who walk through the entire procedure. We conducted semistructured interviews with 37 patients at two distinct day surgery centers. Despite the different managerial concepts and corresponding spatial designs, in both centers, patients' spatial experience is shaped by the interrelation of material, social, and time-related aspects. However, the chosen concept results in a different experience throughout patients' journey. Based on an analysis of the different journeys, we conclude that patients' interpretation of a hospital's care vision is influenced not only by what the hospital communicates explicitly or how it educates its staff but also by what is implicitly told by the built environment. © The Author(s) 2016.

Is case triaging a useful tool for emergency surgeries? A review of 106 trauma surgery cases at a level 1 trauma center in South Africa.

PubMed

Chowdhury, Sharfuddin; Nicol, Andrew John; Moydien, Mahammed Riyaad; Navsaria, Pradeep Harkison; Montoya-Pelaez, Luis Felipe

2018-01-01

The optimal timing for emergency surgical interventions and implementation of protocols for trauma surgery is insufficient in the literature. The Groote Schuur emergency surgery triage (GSEST) system, based on Cape Triaging Score (CTS), is followed at Groote Schuur Hospital (GSH) for triaging emergency surgical cases including trauma cases. The study aimed to look at the effect of delay in surgery after scheduling based on the GSEST system has an impact on outcome in terms of postoperative complications and death. Prospective audit of patients presenting to GSH trauma center following penetrating or blunt chest, abdominal, neck and peripheral vascular trauma who underwent surgery over a 4-month period was performed. Post-operative complications were graded according to Clavien-Dindo classification of surgical complications. One-hundred six patients underwent surgery during the study period. One-hundred two (96.2%) cases were related to penetrating trauma. Stab wounds comprised 71 (67%) and gunshot wounds (GSW) 31 (29.2%) cases. Of the 106 cases, 6, 47, 40, and 13 patients were booked as red, orange, yellow, and green, respectively. The median delay for green, yellow, and orange cases was within the expected time. The red patients took unexpectedly longer (median delay 48 min, IQR 35-60 min). Thirty-one (29.3%) patients developed postoperative complications. Among the booked red, orange, yellow, and green cases, postoperative complications developed in 3, 18, 9, and 1 cases, respectively. Only two (1.9%) postoperative deaths were documented during the study period. There was no statistically significant association between operative triage and post-operative complications ( p  = 0.074). Surgical case categorization has been shown to be useful in prioritizing emergency trauma surgical cases in a resource constraint high-volume trauma center.

Third-molar extraction with ultrasound bone surgery: a case-control study.

PubMed

Mozzati, Marco; Gallesio, Giorgia; Russo, Andrea; Staiti, Giorgio; Mortellaro, Carmen

2014-05-01

The aim of this case-control study was to evaluate the postoperative period and healing between 2 surgical methods (traditional and ultrasound bone surgery) that are used for mandibular third-molar extraction. Fifteen patients with impaction of both of the lower third molars and indications for their extractions were used in this study. Bilateral-mandibular third-molar extractions were performed at the same surgical time: traditional surgery with burrs was used on 1 side (control site), and ultrasound surgery was used on the other side (test [T] site). After surgery, the patients were examined at 7 and 14 days and at 1 and 3 months to evaluate tissue healing. The following was assessed at every follow-up: pain, trismus, swelling, and alveolar bone level. The study included 15 patients, and 30 mandibular third-molar extractions were performed. We found only 1 postoperative complication: 1 patient had alveolitis in the control site. Complete recoveries without any complications were reported in all of the patients at the T sites. Complete recoveries without any complication were reported in all patients at the T sites. The only disadvantage of the piezoelectric technique was the length of operation time, which was increased by approximately 8 minutes; however, this effect was offset by reducing the morbidity. Our preliminary study showed that Piezosurgery is an excellent tool for reducing the risk of complications and improving the postoperative period.

Intraoperative Methadone in Same-Day Ambulatory Surgery: A Randomized, Double-Blinded, Dose-Finding Pilot Study.

PubMed

Komen, Helga; Brunt, L Michael; Deych, Elena; Blood, Jane; Kharasch, Evan D

2018-05-25

Approximately 50 million US patients undergo ambulatory surgery annually. Postoperative opioid overprescribing is problematic, yet many patients report inadequate pain relief. In major inpatient surgery, intraoperative single-dose methadone produces better analgesia and reduces opioid use compared with conventional repeated dosing of short-duration opioids. This investigation tested the hypothesis that in same-day ambulatory surgery, intraoperative methadone, compared with short-duration opioids, reduces opioid consumption and pain, and determined an effective intraoperative induction dose of methadone for same-day ambulatory surgery. A double-blind, dose-escalation protocol randomized 60 patients (2:1) to intraoperative single-dose intravenous methadone (initially 0.1 then 0.15 mg/kg ideal body weight) or conventional as-needed dosing of short-duration opioids (eg, fentanyl, hydromorphone; controls). Intraoperative and postoperative opioid consumption, pain, and opioid side effects were assessed before discharge. Patient home diaries recorded pain, opioid use, and opioid side effects daily for 30 days postoperatively. Primary outcome was in-hospital (intraoperative and postoperative) opioid use. Secondary outcomes were 30 days opioid consumption, pain intensity, and opioid side effects. Median (interquartile range) methadone doses were 6 (5-6) and 9 (8-9) mg in the 0.1 and 0.15 mg/kg methadone groups, respectively. Total opioid consumption (morphine equivalents) in the postanesthesia care unit was significantly less compared with controls (9.3 mg, 1.3-11.0) in subjects receiving 0.15 mg/kg methadone (0.1 mg, 0.1-3.3; P < .001) but not 0.1 mg/kg methadone (5.0 mg, 3.3-8.1; P = .60). Dose-escalation ended at 0.15 mg/kg methadone. Total in-hospital nonmethadone opioid use after short-duration opioid, 0.1 mg/kg methadone, and 0.15 mg/kg methadone was 35.3 (25.0-44.0), 7.1 (3.7-10.0), and 3.3 (0.1-5.8) mg morphine equivalents, respectively (P < .001 for both versus

Elective colorectal surgery without bowel preparation: a historical control and case-matched study.

PubMed

Pitot, D; Bouazza, E; Chamlou, R; Van de Stadt, J

2009-01-01

Although full bowel preparation, including mechanical washout and non-absorbable antibiotherapy, has been considered for decades as a prerequisite to any elective colorectal surgery, recent literature has suggested that this habit was perhaps unjustified. The aim of this study was to assess the safety of ileocolic, colocolic and colorectal anastomosis in the absence of pre-operative mechanical bowel preparation. During a 1-year period, 59 consecutive patients underwent elective colorectal surgery with ileocolic, colocolic or colorectal anastomosis without any pre-operative preparation. This "non-prepared group" (NPG) was compared to a "control group" (CG) composed of the previous 127 consecutive cases of classically managed patients. To improve the statistical power we also compared the NPG to a "match-controlled group" (MCG) of 59 patients within the CG. Primary end-points were anastomotic leakage and abdominal infections. Secondary end-points were oral diet resume time and hospital stay. There were no differences between the 3 groups for age, gender, BMI, immunodepression status, anastomosis site and suture technique. There were no differences between NPG and CG or MCG for anastomotic leakage (3.5%, 4.7% and 6.8% respectively, NPG/CG p = 0.68 and NPG/MCG p = 0.4) or for infectious abdominal complications. Mean diet resume time was 1.4 (1-5) days in the NPG versus 3.4 (1-19) days in the CG and 3.1 (1-6) days in the MCG (p < 0.00001). Median length of postoperative hospital stay was 5 (2-81) days in the NPG versus 8 (4-100) and 8 (4-100) in the CG and the MCG respectively. In accordance with the recent literature, the present experience does not show any benefit of mechanical bowel preparation in elective colorectal resection. This suggests that bowel preparation could be omitted before this type of surgery.

Systematic review of general thoracic surgery articles to identify predictors of operating room case durations.

PubMed

Dexter, Franklin; Dexter, Elisabeth U; Masursky, Danielle; Nussmeier, Nancy A

2008-04-01

Previous studies of operating room (OR) information systems data over the past two decades have shown how to predict case durations using the combination of scheduled procedure(s), individual surgeon and assistant(s), and type of anesthetic(s). We hypothesized that the accuracy of case duration prediction could be improved by the use of other electronic medical record data (e.g., patient weight or surgeon notes using standardized vocabularies). General thoracic surgery was used as a model specialty because much of its workload is elective (scheduled) and many of its cases are long. PubMed was searched for thoracic surgery papers reporting operative time, surgical time, etc. The systematic literature review identified 48 papers reporting statistically significant differences in perioperative times. There were multiple reports of differences in OR times based on the procedure(s), perioperative team including primary surgeon, and type of anesthetic, in that sequence of importance. All such detail may not be known when the case is originally scheduled and thus may require an updated duration the day before surgery. Although the use of these categorical data from OR systems can result in few historical data for estimating each case's duration, bias and imprecision of case duration estimates are unlikely to be affected. There was a report of a difference in case duration based on additional information. However, the incidence of the procedure for the diagnosis was so uncommon as to be unlikely to affect OR management. Matching findings of prior studies using OR information system data, multiple case series show that it is important to rely on the precise procedure(s), surgical team, and type of anesthetic when estimating case durations. OR information systems need to incorporate the statistical methods designed for small numbers of prior surgical cases. Future research should focus on the most effective methods to update the prediction of each case's duration as these

[Seven Cases of Surgery for Breast Cancer under Tumescent Local Anesthesia].

PubMed

Hosoya, Tokuko; Nakagawa, Tsuyoshi; Oda, Goshi; Uetake, Hiroyuki

2015-11-01

Surgical procedures for breast cancer are usually performed under general anesthesia. However, general anesthesia needs to be avoided in some cases due to patient-related factors such as the presence of comorbid diseases. In these cases, we perform surgery under tumescent local anesthesia(TLA)in our department. Seven patients who were diagnosed with breast cancer underwent surgery under TLA instead of general anesthesia due to their comorbidities. The planned surgical procedures were successfully completed under TLA. A shift to general anesthesia could be avoided in all cases. The operative procedures for the breasts included modified radical mastectomy (Bt) in 3 cases and wide excision (Bp) in 4 cases. In addition, axillary lymph node dissection was performed in 2 cases; sampling, in 1 case; sentinel lymph node biopsy, in 2 cases; and no procedure for the axilla, in 2 cases. In terms of anesthesia, 2 cases were managed under TLA alone and 5 cases were managed under TLA combined with epidural anesthesia. Lidocaine was used for local anesthesia and did not reach the maximal permissive dose in all cases. No postoperative complication was observed. No local recurrence or new metastasis was observed during the observation period, which ranged from 1 to 67 months after the surgery. These findings demonstrate that surgery for breast cancer under TLA is safe and offers high curability for patients at high risk for complications of general anesthesia.

[Decree of anaesthesia of 1994, day surgery and medical responsibility: necessary reflections on the inevitable conciliation between regulations and recommendations].

PubMed

Bontemps, G; Daver, C; Ecoffey, C

2014-12-01

Day surgery is often considered as a marker of the necessity of reorganizing the hospital to take care globally and so better meet the expectations of improvement of the management of patients. But the actual deployment of day surgery can also act as a real revelation of the stakes of conciliation between the regulations, which supervise professional practices and organization, and the functioning of hospitals. Between the regulations supervising hospitals and professional practices and the place of the recommendations, between the general legal framework of the medical activity and specific legal framework (decree of anesthesia of 1994) and the Evidence-Based Medicine, the pretext of the improvement of the patient flow in day surgery, recommended by several institutions (Sfar, ANAP, HAS), questions about the legal obligation of the passage of all the patients in the postanesthesia care unit (PACU). Seen under the angle of a legal action against a medical doctor, the study of the French jurisprudence reveals that every practitioner has to respect the recommendations and the Evidence-Based Medicine, and this in the standardized frame of the MD's activity and the respect for a very strict legal environment. The question of an obvious conciliation between all these measures arises today clearly. In the case of a potential conflict, the key of resolution, based only on legal standards (constitution, laws, decrees), is not enough for arbitrating. Applying that the only respect for the decree of anesthesia would be enough for exempting itself from any contentious risk does not satisfy more. There is a real difficulty defining the legal precise nature of the recommendations, so best practices as better organization, which are more and more frequently. Even if these recommendations originally had not their place in the hierarchy of the legal standards, they are brought in there today. There is a real brake in the deployment of the day surgery because the strict respect for

A single-institution experience: the integrated vascular surgery residency's effect on fellowship and general surgery resident case volume and diversity.

PubMed

Carroll, Megan I; Downes, Kathryne; Miladinovic, Branko; Illig, Karl A; Armstrong, Paul A; Back, Martin R; Johnson, Brad L; Shames, Murray L

2014-01-01

To determine whether the formation of an integrated vascular surgery residency (0 + 5) has negatively impacted the case volume and diversity of the vascular surgery fellows (5 + 2) and chief general surgeons at the same institution. Operative data from the vascular integrated (0 + 5), independent (5 + 2), and general surgery residencies at a single institution were retrospectively reviewed and analyzed to determine vascular surgery case volumes from 2006-2012. National operative data (Residency Review Committee) were used for comparison of diversity and volume. Standard statistical methods were applied. During this period, the 5 + 2 fellows at our institution performed on average 741 (range, 554-1002) primary cases and 1091 (range, 844-1479) combined primary and secondary cases for the 2-year fellowship. Our integrated residency began in July 2007. Our fellows' primary case volumes remained relatively stable between 2006 and 2011, with a 4% increase in the number of cases, although their total (primary and secondary) case volumes fell 15%; by comparison, the equivalent national 50th percentile rates rose 16% during this time frame. Our institution's general surgery residents performed an average of 116 (range, 56-221) vascular cases individually during their 5-year residency from 2005-2011. From 2006-2011, the total case volume fell only 5%, while the national 50th percentile rate fell 24%. Across all years, however, resident and fellow volumes both continue to be above Accreditation Council for Graduate Medical Education minimum requirements, and the major vascular case volume at our institution in all groups studied remained statistically greater than or equal to the national 50th percentile of cases. Our first integrated resident to graduate finished in June 2012 with 931 total vascular cases and 249 general surgery cases for a total operative experience of 1180 cases during the 5-year residency. Finally, after an 8-year period (2003-2010) in which none of

The Black Cloud Phenomenon in Hand Surgery.

PubMed

Zhao, Emily; Tiedeken, Nathan; Wang, William; Fowler, John

2018-04-01

The term black cloud for a surgeon is generally used to describe someone who is unusually busy compared with his or her counterparts, and it is a superstition that tends to pervade the medical world. The purpose of this study is to investigate whether black clouds exist in hand surgery. We examined one academic year's worth of hand surgery-specific call at a level I trauma center and tabulated the number of hand-related patient transfers and add-on cases per surgeon. Each surgeon was given a black cloud rating by the fellows who were in training that year. Correlations were made between the black cloud rating and the surgeons' call volume. There were 12 surgeons who shared 365 days of hand call, and 5 of them are hand surgery fellowship trained. Those 5 surgeons tended to be busier on their call days, with more cases added on overnight and the next day, and also had worse black cloud ratings than the 7 non-hand fellowship trained surgeons. In regard to hand surgery, while true emergencies occur and require emergent intervention, how busy hand surgeons may be during call may be influenced by a variety of factors not related to their patients' problems but rather their daily schedules, their hospitals' ability to facilitate add-on cases, and their rapport with their fellow surgeons to share case loads.

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries

PubMed Central

Shibuya, Naohiro; Patel, Himani; Graney, Colin; Jupiter, Daniel C.

2018-01-01

ABSTRACT The number of emergency department (ED) visits within 30 days after elective surgery has been utilized as a quality measure by many institutions. The significance of the measure as a postoperative complication in foot and ankle surgery, and risk factors for it, are unknown. We conducted a retrospective cohort study involving 386 patients to determine risk factors associated with ED visits after outpatient foot and ankle surgeries. After adjusting for clinically relevant covariates, we found that previous ED visits within 6 months of surgery, and nonelective surgeries were associated with the postoperative ED visit. Having private insurance was protective against postoperative ED visits. Though these risk factors may not be easily modifiable by surgeons, understanding them may improve patient education and transitional care to prevent overcrowding of the ED. PMID:29706806

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries.

PubMed

Shibuya, Naohiro; Patel, Himani; Graney, Colin; Jupiter, Daniel C

2018-04-01

The number of emergency department (ED) visits within 30 days after elective surgery has been utilized as a quality measure by many institutions. The significance of the measure as a postoperative complication in foot and ankle surgery, and risk factors for it, are unknown. We conducted a retrospective cohort study involving 386 patients to determine risk factors associated with ED visits after outpatient foot and ankle surgeries. After adjusting for clinically relevant covariates, we found that previous ED visits within 6 months of surgery, and nonelective surgeries were associated with the postoperative ED visit. Having private insurance was protective against postoperative ED visits. Though these risk factors may not be easily modifiable by surgeons, understanding them may improve patient education and transitional care to prevent overcrowding of the ED.

An Ultralow-Dose 1-Day Protocol With Activities Lower Than 20 MBq for the Detection of Sentinel Lymph Nodes in Breast Cancer-Experiences After 150 Cases.

PubMed

Kolberg, Hans-Christian; Afsah, Shabnam; Kuehn, Thorsten; Winzer, Ute; Akpolat-Basci, Leyla; Stephanou, Miltiades; Wetzig, Sarah; Hoffmann, Oliver; Liedtke, Cornelia

2017-01-01

Common protocols for the detection of sentinel lymph nodes in early breast cancer often include the injection of the tracer 1 day before surgery. In order to detect enough activity on the day of surgery, the applied activity in many protocols is as high as several hundred MBq. So far, very few protocols with an activity below 20 MBq have been reported. We developed an ultralow-dose 1-day protocol with a mean activity lower than 20 MBq in order to reduce radiation exposure for patients and staff. Here, we are presenting our experiences in 150 consecutive cases. A total of 150 patients with clinically and sonographically negative axilla and no multicentricity underwent a sentinel lymph node biopsy using an ultralow-dose protocol performed on the day of surgery. No patient received systemic therapy prior to sentinel node biopsy. After peritumoral injection of the tracer Technetium-99m, a lymphoscintigraphy was performed in all cases. Seven minutes before the first cut, we injected 5 mL of blue dye in the region of the areola. In 148 (98.7%) of 150 patients, at least 1 sentinel lymph node could be identified by lymphoscintigraphy; the detection rate during surgery with combined tracers Technetium-99m and blue dye was 100%. The mean applied activity was 17.8 MBq (9-20). A mean number of 1.3 (0-5) sentinel lymph nodes were identified by lymphoscintigraphy and a mean number of 1.8 (1-5) sentinel lymph nodes were removed during sentinel lymph node biopsy. Ultralow-dose 1-day protocols with an activity lower than 20 MBq are a safe alternative to 1-day or 2-day protocols with significantly higher radiation doses in primary surgery for early breast cancer. Using Technetium-99m and blue dye in a dual tracer approach, detection rates of 100% are possible in clinical routine in order to reduce radiation exposure for patients and staff.

Single-Site Laparoscopic Surgery for Inflammatory Bowel Disease

PubMed Central

Bedros, Nicole; Hakiman, Hekmat; Araghizadeh, Farshid Y.

2014-01-01

Background and Objectives: Single-site laparoscopic colorectal surgery has been firmly established; however, few reports addressing this technique in the inflammatory bowel disease population exist. Methods: We conducted a case-matched retrospective review of 20 patients who underwent single-site laparoscopic procedures for inflammatory bowel disease compared with 20 matched patients undergoing multiport laparoscopic procedures. Data regarding these patients were tabulated in the following categories: demographic characteristics, operative parameters, and perioperative outcomes. Results: A wide range of cases were completed: 9 ileocolic resections, 7 cases of proctocolectomy with end ileostomy or ileal pouch anal anastomosis, 2 cases of proctectomy with ileal pouch anal anastomosis, and 2 total abdominal colectomies with end ileostomy were all matched to equivalent multiport laparoscopic cases. No single-incision cases were converted to multiport laparoscopy, and 2 single-incision cases (10%) were converted to an open approach. For single-incision cases, the mean length of stay was 7.7 days, the mean time to oral intake was 3.3 days, and the mean period of intravenous analgesic use was 5.0 days. There were no statistically significant differences between single-site and multiport cases. Conclusions: Single-site laparoscopic surgery is technically feasible in inflammatory bowel disease. The length of stay and period of intravenous analgesic use (in days) appear to be higher than those in comparable series examining outcomes of single-site laparoscopic colorectal surgery, and the outcomes are comparable with those of multiport laparoscopy. This may be because of the nature of inflammatory bowel disease, limiting the benefits of a single-site approach in this population. PMID:24960490

Major thoracic surgery in Jehovah's witness: A multidisciplinary approach case report

PubMed Central

Rispoli, Marco; Bergaminelli, Carlo; Nespoli, Moana Rossella; Esposito, Mariana; Mattiacci, Dario Maria; Corcione, Antonio; Buono, Salvatore

2016-01-01

Introduction A bloodless surgery can be desirable also for non Jehovah’s witnesses patients, but requires a team approach from the very first assessment to ensure adequate planning. Presentation of the case Our patient, a Jehovah’s witnesses, was scheduled for right lower lobectomy due to pulmonary adenocarcinoma. Her firm denies to receive any kind of transfusions, forced clinicians to a bloodless management of the case. Discussion Before surgery a meticulous coagulopathy research and hemodynamic optimization are useful to prepare patient to operation. During surgery, controlled hypotension can help to obtain effective hemostasis. After surgery, clinicians monitored any possible active bleeding, using continuous noninvasive hemoglobin monitoring, limiting the blood loss due to serial in vitro testing. The optimization of cardiac index and delivery of oxygen were continued to grant a fast recovery. Conclusion Bloodless surgery is likely to gain popularity, and become standard practice for all patients. The need for transfusion should be targeted on individual case, avoiding strictly fixed limit often leading to unnecessary transfusion. PMID:27107502

Improved Surgery Planning Using 3-D Printing: a Case Study.

PubMed

Singhal, A J; Shetty, V; Bhagavan, K R; Ragothaman, Ananthan; Shetty, V; Koneru, Ganesh; Agarwala, M

2016-04-01

The role of 3-D printing is presented for improved patient-specific surgery planning. Key benefits are time saved and surgery outcome. Two hard-tissue surgery models were 3-D printed, for orthopedic, pelvic surgery, and craniofacial surgery. We discuss software data conversion in computed tomography (CT)/magnetic resonance (MR) medical image for 3-D printing. 3-D printed models save time in surgery planning and help visualize complex pre-operative anatomy. Time saved in surgery planning can be as much as two thirds. In addition to improved surgery accuracy, 3-D printing presents opportunity in materials research. Other hard-tissue and soft-tissue cases in maxillofacial, abdominal, thoracic, cardiac, orthodontics, and neurosurgery are considered. We recommend using 3-D printing as standard protocol for surgery planning and for teaching surgery practices. A quick turnaround time of a 3-D printed surgery model, in improved accuracy in surgery planning, is helpful for the surgery team. It is recommended that these costs be within 20 % of the total surgery budget.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty.

PubMed

Radwan, R W; Gardner, A; Jayamanne, H; Stephenson, B M

2018-03-15

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

Epidural analgesia does not increase the rate of inpatient falls after major upper abdominal and thoracic surgery: a retrospective case-control study.

PubMed

Elsharydah, Ahmad; Williams, Tiffany M; Rosero, Eric B; Joshi, Girish P

2016-05-01

Postoperative epidural analgesia for major upper abdominal and thoracic surgery can provide significant benefits, including superior analgesia and reduced pulmonary dysfunction. Nevertheless, epidural analgesia may also be associated with decreased muscle strength, sympathetic tone, and proprioception that could possibly contribute to falls. The purpose of this retrospective case-control study was to search a large national database in order to investigate the possible relationship between postoperative epidural analgesia and the rate of inpatient falls. Data from the nationwide inpatient sample for 2007-2011 were queried for adult patients who underwent elective major upper abdominal and thoracic surgery. Multiple International Classification of Diseases, Ninth Revision, Clinical Modification codes for inpatient falls and accidents were combined into one binary variable. Univariate analyses were used for initial statistical analysis. Logistic regression analyses and McNemar's tests were subsequently used to investigate the association of epidural analgesia with inpatient falls in a 1:1 case-control propensity-matched sample after adjustment of patients' demographics, comorbidities, and hospital characteristics. Forty-two thousand six hundred fifty-eight thoracic and 54,974 upper abdominal surgical procedures were identified. The overall incidence of inpatient falls in the thoracic surgery group was 6.54% with an increasing trend over the study period from 4.95% in 2007 to 8.11% in 2011 (P < 0.001). Similarly, the overall incidence of inpatient falls in the upper abdominal surgery group was 5.30% with an increasing trend from 4.55% in 2007 to 6.07% in 2011 (P < 0.001). Postoperative epidural analgesia was not associated with an increased risk for postoperative inpatient falls in the thoracic surgery group (relative risk [RR], 1.18; 95% confidence interval [CI], 0.95 to 1.47; P = 0.144) and in the upper abdominal surgery group (RR, 0.84; 95% CI 0.64 to 1.09; P = 0

Achieving target refraction after cataract surgery.

PubMed

Simon, Shira S; Chee, Yewlin E; Haddadin, Ramez I; Veldman, Peter B; Borboli-Gerogiannis, Sheila; Brauner, Stacey C; Chang, Kenneth K; Chen, Sherleen H; Gardiner, Matthew F; Greenstein, Scott H; Kloek, Carolyn E; Chen, Teresa C

2014-02-01

To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institution's Comprehensive Ophthalmology Service. Retrospective study. We examined 1275 eye surgeries for this study. All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days. The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent. We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery. This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks. Copyright © 2014 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Case report classics in otolaryngology - head and neck surgery: citation analysis.

PubMed

Edelmayer, L W; Fenton, J E; Yellin, S A; Shearer, D J; Coelho, D H

2018-06-12

To analyse publication and citations trends of case reports within otolaryngology - head and neck surgery literature, with specific attention to the most-cited reports.Study designDatabase query. Web of Science was searched for article type 'case reports' published in the leading otolaryngology - head and neck surgery journals since 1945. Variables including publication dates, citation dates and numbers, author, author number, and others were recorded and analysed for trends. The reports with the most citations (classics) were further studied. Of nearly 67 000 published articles in leading otolaryngology - head and neck surgery journals, the overall number of case reports as a percentage of the total has substantially decreased over time. A total of 110 case report classics were identified for which citations have increased. Although the case report may not be worthy of its tarnished record, declining trends in publication suggest a limited future for this valuable research and educational resource.

Active Ankle Movement May Prevent Deep Vein Thrombosis in Patients Undergoing Lower Limb Surgery.

PubMed

Wang, Zhe; Chen, Qian; Ye, Mao; Shi, Guang-Hui; Zhang, Bo

2016-04-01

Our aim is to investigate the effect of active ankle movement to prevent deep vein thrombosis (DVT) in patients who received lower limb surgery, and to provide a theory of evidence for rehabilitation nursing of patients after orthopedic surgery. Between January 2012 and December 2013, a total of 174 patients were randomized as case group (n = 96) and control group (n = 78). Case group received routine nursing and active ankle movement (30 times/min, 1-7 days after surgery), while control group only received routine nursing. The symptoms and signs of DVT were in real-time observation during the experiment. Thigh and crus circumference, maximum venous outflow (MVO), maximum venous capacity (MVC), and MVO ratio (MVO ratio = MVO/MVC) in the two groups were measured 1-7 days after surgery. Six-month follow-up study was also conducted to observe the occurrence of DVT. Our study revealed that thigh circumference in the case group decreased compared with the control group in 5-7 days (fifth day: 39.98 ± 3.25 vs. 41.01 ± 3.38, P = 0.043; sixth day: 38.21 ± 3.81 vs. 39.49 ± 3.79, P = 0.029; seventh day: 37.13 ± 3.15 vs. 38.76 ± 3.31, P = 0.001), and crus circumference in the case group also decreased compared with the control group in 5-7 days (fifth day: 26.35 ± 2.11 vs. 27.01 ± 2.19, P = 0.045; sixth day: 25.99 ± 2.31 vs. 26.88 ± 3.12, P = 0.032; seventh day: 25.56 ± 1.99 vs. 26.38 ± 2.89, P = 0.028). MVO and MVC in the case group increased compared with the control group 7 days after surgery (MVO: 15.01 ± 2.56 vs. 14.12 ± 2.56, P = 0.024; MVC: 10.18 ± 3.15 vs. 8.91 ± 2.78, P = 0.006). Significant difference in the incidence of thrombus and DVT were found between the case group and the control group 1-7 days after surgery (thrombus: 1.0% and 7.7%, P = 0.027; DVT: 7.6% and 18.4%, P = 0.032). Our result manifested that active ankle movement can relieve the swelling of patients after lower limb surgery, and improve the MVO and MVC of patients to prevent

Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.

PubMed

Botto, Fernando; Alonso-Coello, Pablo; Chan, Matthew T V; Villar, Juan Carlos; Xavier, Denis; Srinathan, Sadeesh; Guyatt, Gordon; Cruz, Patricia; Graham, Michelle; Wang, C Y; Berwanger, Otavio; Pearse, Rupert M; Biccard, Bruce M; Abraham, Valsa; Malaga, German; Hillis, Graham S; Rodseth, Reitze N; Cook, Deborah; Polanczyk, Carisi A; Szczeklik, Wojciech; Sessler, Daniel I; Sheth, Tej; Ackland, Gareth L; Leuwer, Martin; Garg, Amit X; Lemanach, Yannick; Pettit, Shirley; Heels-Ansdell, Diane; Luratibuse, Giovanna; Walsh, Michael; Sapsford, Robert; Schünemann, Holger J; Kurz, Andrea; Thomas, Sabu; Mrkobrada, Marko; Thabane, Lehana; Gerstein, Hertzel; Paniagua, Pilar; Nagele, Peter; Raina, Parminder; Yusuf, Salim; Devereaux, P J; Devereaux, P J; Sessler, Daniel I; Walsh, Michael; Guyatt, Gordon; McQueen, Matthew J; Bhandari, Mohit; Cook, Deborah; Bosch, Jackie; Buckley, Norman; Yusuf, Salim; Chow, Clara K; Hillis, Graham S; Halliwell, Richard; Li, Stephen; Lee, Vincent W; Mooney, John; Polanczyk, Carisi A; Furtado, Mariana V; Berwanger, Otavio; Suzumura, Erica; Santucci, Eliana; Leite, Katia; Santo, Jose Amalth do Espirirto; Jardim, Cesar A P; Cavalcanti, Alexandre Biasi; Guimaraes, Helio Penna; Jacka, Michael J; Graham, Michelle; McAlister, Finlay; McMurtry, Sean; Townsend, Derek; Pannu, Neesh; Bagshaw, Sean; Bessissow, Amal; Bhandari, Mohit; Duceppe, Emmanuelle; Eikelboom, John; Ganame, Javier; Hankinson, James; Hill, Stephen; Jolly, Sanjit; Lamy, Andre; Ling, Elizabeth; Magloire, Patrick; Pare, Guillaume; Reddy, Deven; Szalay, David; Tittley, Jacques; Weitz, Jeff; Whitlock, Richard; Darvish-Kazim, Saeed; Debeer, Justin; Kavsak, Peter; Kearon, Clive; Mizera, Richard; O'Donnell, Martin; McQueen, Matthew; Pinthus, Jehonathan; Ribas, Sebastian; Simunovic, Marko; Tandon, Vikas; Vanhelder, Tomas; Winemaker, Mitchell; Gerstein, Hertzel; McDonald, Sarah; O'Bryne, Paul; Patel, Ameen; Paul, James; Punthakee, Zubin; Raymer, Karen; Salehian, Omid; Spencer, Fred; Walter, Stephen; Worster, Andrew; Adili, Anthony; Clase, Catherine; Cook, Deborah; Crowther, Mark; Douketis, James; Gangji, Azim; Jackson, Paul; Lim, Wendy; Lovrics, Peter; Mazzadi, Sergio; Orovan, William; Rudkowski, Jill; Soth, Mark; Tiboni, Maria; Acedillo, Rey; Garg, Amit; Hildebrand, Ainslie; Lam, Ngan; Macneil, Danielle; Mrkobrada, Marko; Roshanov, Pavel S; Srinathan, Sadeesh K; Ramsey, Clare; John, Philip St; Thorlacius, Laurel; Siddiqui, Faisal S; Grocott, Hilary P; McKay, Andrew; Lee, Trevor W R; Amadeo, Ryan; Funk, Duane; McDonald, Heather; Zacharias, James; Villar, Juan Carlos; Cortés, Olga Lucía; Chaparro, Maria Stella; Vásquez, Skarlett; Castañeda, Alvaro; Ferreira, Silvia; Coriat, Pierre; Monneret, Denis; Goarin, Jean Pierre; Esteve, Cristina Ibanez; Royer, Catherine; Daas, Georges; Chan, Matthew T V; Choi, Gordon Y S; Gin, Tony; Lit, Lydia C W; Xavier, Denis; Sigamani, Alben; Faruqui, Atiya; Dhanpal, Radhika; Almeida, Smitha; Cherian, Joseph; Furruqh, Sultana; Abraham, Valsa; Afzal, Lalita; George, Preetha; Mala, Shaveta; Schünemann, Holger; Muti, Paola; Vizza, Enrico; Wang, C Y; Ong, G S Y; Mansor, Marzida; Tan, Alvin S B; Shariffuddin, Ina I; Vasanthan, V; Hashim, N H M; Undok, A Wahab; Ki, Ushananthini; Lai, Hou Yee; Ahmad, Wan Azman; Razack, Azad H A; Malaga, German; Valderrama-Victoria, Vanessa; Loza-Herrera, Javier D; De Los Angeles Lazo, Maria; Rotta-Rotta, Aida; Szczeklik, Wojciech; Sokolowska, Barbara; Musial, Jacek; Gorka, Jacek; Iwaszczuk, Pawel; Kozka, Mateusz; Chwala, Maciej; Raczek, Marcin; Mrowiecki, Tomasz; Kaczmarek, Bogusz; Biccard, Bruce; Cassimjee, Hussein; Gopalan, Dean; Kisten, Theroshnie; Mugabi, Aine; Naidoo, Prebashini; Naidoo, Rubeshan; Rodseth, Reitze; Skinner, David; Torborg, Alex; Paniagua, Pilar; Urrutia, Gerard; Maestre, Mari Luz; Santaló, Miquel; Gonzalez, Raúl; Font, Adrià; Martínez, Cecilia; Pelaez, Xavier; De Antonio, Marta; Villamor, Jose Marcial; García, Jesús Alvarez; Ferré, Maria José; Popova, Ekaterina; Alonso-Coello, Pablo; Garutti, Ignacio; Cruz, Patricia; Fernández, Carmen; Palencia, Maria; Díaz, Susana; Del Castillo, Teresa; Varela, Alberto; de Miguel, Angeles; Muñoz, Manuel; Piñeiro, Patricia; Cusati, Gabriel; Del Barrio, Maria; Membrillo, Maria José; Orozco, David; Reyes, Fidel; Sapsford, Robert J; Barth, Julian; Scott, Julian; Hall, Alistair; Howell, Simon; Lobley, Michaela; Woods, Janet; Howard, Susannah; Fletcher, Joanne; Dewhirst, Nikki; Williams, C; Rushton, A; Welters, I; Leuwer, M; Pearse, Rupert; Ackland, Gareth; Khan, Ahsun; Niebrzegowska, Edyta; Benton, Sally; Wragg, Andrew; Archbold, Andrew; Smith, Amanda; McAlees, Eleanor; Ramballi, Cheryl; Macdonald, Neil; Januszewska, Marta; Stephens, Robert; Reyes, Anna; Paredes, Laura Gallego; Sultan, Pervez; Cain, David; Whittle, John; Del Arroyo, Ana Gutierrez; Sessler, Daniel I; Kurz, Andrea; Sun, Zhuo; Finnegan, Patrick S; Egan, Cameron; Honar, Hooman; Shahinyan, Aram; Panjasawatwong, Krit; Fu, Alexander Y; Wang, Sihe; Reineks, Edmunds; Nagele, Peter; Blood, Jane; Kalin, Megan; Gibson, David; Wildes, Troy

2014-03-01

Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Effects of using WeChat-assisted perioperative care instructions for parents of pediatric patients undergoing day surgery for herniorrhaphy.

PubMed

Liu, Jun; Zheng, Xin; Chai, Shouxia; Lei, Meirong; Feng, Zehui; Zhang, Xuelin; Lopez, Violeta

2018-02-19

This study examined the effects of WeChat-assisted perioperative instructions for parents whose children were to undergo herniorrhaphy. A randomized controlled trial was conducted in a day surgery center in China. Participants were randomly assigned to the intervention (WeChat) group (n = 209) and the control (Leaflet) group (n = 209). The primary outcomes of this study were parents' knowledge regarding hernia and rate of cancellation of children's surgery. The secondary outcomes were the rate of lost-to-follow-up and the rate of complications and adverse events during the seventh postoperative follow-up day. There was a significant difference in the rate of cancelling the surgery and the mean knowledge score between the WeChat group and leaflet groups. The lost-to-follow-up rate was significantly lower in the WeChat group (0.54%) than in the leaflet group (3.66%). The incidence of postoperative complications were higher in the control group. WeChat-assisted perioperative care instructions enhanced parents' knowledge on perioperative instructions and promoted the preparation of their children for day surgery resulting in lower rate of cancelling the surgery. WeChat has the ability to expand health services outside the hospital confines and could be used as an important low-cost health educational medium in China. Copyright © 2018 Elsevier B.V. All rights reserved.

Effect of employment status on length of hospital stay, 30-day readmission and patient reported outcomes after spine surgery.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Fialkoff, Jared; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2017-03-01

Growing scrutiny has placed hospitals at the center of readmission prevention. The relationship between pre-operative employment status, length of hospital stays (LOS) and 30-day readmission rates after elective spine surgery remains unclear. The medical records of 360 patients (employed: n=174, unemployed: n=70, retired: n=40, disabled: n=76) undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and post-operative complication rates were recorded. All patients had comprehensive 1-year patient reported outcomes (PROs) measures. We hypothesized that employment status is associated with decreased LOS and decreased risk of 30-day readmission after elective spine surgery. All-cause readmissions within 30 days of discharge was the primary outcome variable. Baseline characteristics were similar in all cohorts. There was no difference in operative time, estimated blood loss (EBL), or number of fusion levels between all patient cohorts. There were no significant differences in peri-operative complication rates between patient cohorts. On average, the LOS was shorter for the employed compared to non-employed patients (4.89 vs. 5.26 days). The rate of 30-day readmission was 2-fold greater unemployed compared to employed patients (5.17% vs. 10%). At 1-year after surgery, employed patients were more likely to express functional improvement (change in ODI score) compared to unemployed patients (ODI: employed: 33.80 vs. unemployed: 41.93). Our study suggests that employment status may be associated with shorter duration of hospital stay, lower 30-day readmission rates and greater functional improvement. Future interventions to reduce unplanned hospital readmissions should consider pre-operative employment status.

Continuous interscalene brachial plexus blockade provides good analgesia at home after major shoulder surgery-report of four cases.

PubMed

Nielsen, Karen C; Greengrass, Roy A; Pietrobon, Ricardo; Klein, Stephen M; Steele, Susan M

2003-01-01

Continuous interscalene brachial plexus blockade (CIBPB) in a hospital setting can provide excellent surgical conditions and postoperative analgesia for major shoulder surgery. This is a case report of four patients on the efficacy and advantages of CIBPB for postoperative analgesia at home. Four patients scheduled for rotator cuff repair under CIBPB were discharged home the day of surgery with an interscalene catheter connected to an automated infusion pump administering 0.2% ropivacaine at 10 mL x hr(-1) for 72 hr. Prior to discharge, patients and their attendant were given verbal and written instructions concerning local anesthetic toxicity and explicit contact information for an anesthesiologist or nurse. Outcomes were measured pre- and postoperatively, including verbal analogue pain scores (pain VAS), verbal analogue nausea scores (nausea VAS), side effects, cognitive function (mini-mental state questionnaire), sleep (hours/night), and patient satisfaction (Likert scale). Postoperative VAS scores over three days were very low. Two patients reported only one episode of nausea. There were no complications associated with local anesthetic toxicity or catheter use. Cognitive function improved over three days. Sleep increased from a mean of five hours before surgery to seven hours over the next three nights. Patient satisfaction with care was high. Significant cost savings were documented. The use of CIBPB for 72 hr in patients undergoing major ambulatory shoulder surgery can result in good analgesia with minimal opioid requirement, cost savings and possibly improvement in outcome measures.

Optimal culture incubation time in orthopedic device-associated infections: a retrospective analysis of prolonged 14-day incubation.

PubMed

Schwotzer, Nora; Wahl, Peter; Fracheboud, Dominique; Gautier, Emanuel; Chuard, Christian

2014-01-01

Accurate diagnosis of orthopedic device-associated infections can be challenging. Culture of tissue biopsy specimens is often considered the gold standard; however, there is currently no consensus on the ideal incubation time for specimens. The aim of our study was to assess the yield of a 14-day incubation protocol for tissue biopsy specimens from revision surgery (joint replacements and internal fixation devices) in a general orthopedic and trauma surgery setting. Medical records were reviewed retrospectively in order to identify cases of infection according to predefined diagnostic criteria. From August 2009 to March 2012, 499 tissue biopsy specimens were sampled from 117 cases. In 70 cases (59.8%), at least one sample showed microbiological growth. Among them, 58 cases (82.9%) were considered infections and 12 cases (17.1%) were classified as contaminations. The median time to positivity in the cases of infection was 1 day (range, 1 to 10 days), compared to 6 days (range, 1 to 11 days) in the cases of contamination (P < 0.001). Fifty-six (96.6%) of the infection cases were diagnosed within 7 days of incubation. In conclusion, the results of our study show that the incubation of tissue biopsy specimens beyond 7 days is not productive in a general orthopedic and trauma surgery setting. Prolonged 14-day incubation might be of interest in particular situations, however, in which the prevalence of slow-growing microorganisms and anaerobes is higher.

Sepsis Within 30 Days of Geriatric Hip Fracture Surgery.

PubMed

Bohl, Daniel D; Iantorno, Stephanie E; Saltzman, Bryan M; Tetreault, Matthew W; Darrith, Brian; Della Valle, Craig J

2017-10-01

Sepsis after hip fracture typically develops from one of the 3 potential infectious sources: urinary tract infection (UTI), pneumonia, and surgical site infection (SSI). The purpose of this investigation is to determine (1) the proportion of cases of sepsis that arises from each of these potential infectious sources; (2) baseline risk factors for developing each of the potential infectious sources; and (3) baseline risk factors for developing sepsis. The National Surgical Quality Improvement Program database was searched for geriatric patients (aged >65 years) who underwent surgery for hip fracture during 2005-2013. Patients subsequently diagnosed with sepsis were categorized according to concomitant diagnosis with UTI, SSI, and/or pneumonia. Multivariate regression was used to test for associations while adjusting for baseline characteristics. Among the 466 patients who developed sepsis (2.4% of all patients), 157 (33.7%) also had a UTI, 135 (29.0%) also had pneumonia, and 36 (7.7%) also had SSI. The rate of sepsis was elevated in patients who developed UTI (13.0% vs 1.7%; P < .001), pneumonia (18.2% vs 1.8%; P < .001), or SSI (14.8% vs 2.3%; P < .001). The mortality rate was elevated among those who developed sepsis (21.0% vs 3.8%; P < .001). Sepsis occurs in about 1 in 40 patients after geriatric hip fracture surgery. Of these septic cases, 1 in 3 is associated with UTI, 1 in 3 with pneumonia, and 1 in 15 with SSI. The cause of sepsis is often unknown on clinical diagnosis, and this distribution of potential infectious sources allows clinicians for direct identification and treatment. Copyright © 2017 Elsevier Inc. All rights reserved.

Evaluating the traditional day and night shift in an acute care surgery fellowship: Is the swing shift a better choice?

PubMed

Chestovich, Paul J; McNicoll, Christopher F; Ingalls, Nichole K; Kuhls, Deborah A; Fraser, Douglas R; Morrissey, Shawna L; Fildes, John J

2018-01-01

Fellowship trainees in acute care surgery require experience in the management of complex and operative trauma cases. Trauma center staffing usually follows standard 12-hour or 24-hour shifts, with resident and fellow trainees following a similar schedule. Although trauma admissions can be generally unpredictable, we analyzed temporal trends of trauma patient arrival times to determine the best time frame to maximize trainee experience during each day. We reviewed 10 years (2007-2016) of trauma registry data for blunt and penetrating trauma activations. Hourly volumetric trends were observed, and three specific events were chosen for detailed analysis: (1) trauma activation with Injury Severity Score (ISS) greater than 15, (2) laparotomy for trauma, and (3) thoracotomy for trauma. A retrospective shift log was created, which included day (7:00 AM to 7:00 PM), night (7:00 PM to 7:00 AM), and swing (noon to midnight) shifts. A swing shift was chosen because it captures the peak volume for all three events. Means and 95% confidence intervals were calculated, and comparisons were made between shifts using the Wilcoxon matched-pairs signed rank test with Bonferroni correction, and p less than 0.05 considered significant. During the 10-year study period, 28,287 patients were treated at our trauma center. This included the evaluation and management of 7,874 patients with ISS greater than 15, performance of 1,766 laparotomies, and 392 thoracotomies for trauma. Swing shift was superior to both day and night shifts for ISS greater than 15 (p < 0.001). Both swing and night shifts were superior to day shift for laparotomies (p < 0.001). Swing shift was superior to both day shift (p < 0.001) and night shift (p = 0.031). Shifts with the highest yield of ISS greater than 15, laparotomies, and thoracotomies include night and swing shifts on Fridays and Saturdays. Projected experience of acute care surgery fellows in managing complex trauma patients increases with the integration

Overweight/obesity and gastric fluid characteristics in pediatric day surgery: implications for fasting guidelines and pulmonary aspiration risk.

PubMed

Cook-Sather, Scott D; Gallagher, Paul R; Kruge, Lydia E; Beus, Jonathan M; Ciampa, Brian P; Welch, Kevin Conor; Shah-Hosseini, Sina; Choi, Jieun S; Pachikara, Reshma; Minger, Kim; Litman, Ronald S; Schreiner, Mark S

2009-09-01

The safety of 2-h preoperative clear liquid fasts has not been established for overweight/obese pediatric day surgical patients. Healthy children and obese adults who fasted 2 h have small residual gastric fluid volumes (GFVs), which are thought to reflect low pulmonary aspiration risk. We sought to measure the prevalence of overweight/obesity in our day surgery population. We hypothesized that neither body mass index (BMI) percentile nor fasting duration would significantly affect GFV or gastric fluid pH. In children who were allowed clear liquids up until 2 h before surgery, we hypothesized that overweight/obese subjects would not have increased GFV over lean/normal subjects and that emesis/pulmonary aspiration events would be rare. Demographics, medical history, height, and weight were recorded for 1000 consecutive day surgery patients aged 2-12 yr. In addition, 1000 day surgery patients (age 2-12 yr) undergoing general endotracheal anesthesia were enrolled. After tracheal intubation, a 14-18F orogastric tube was inserted and gastric contents evacuated. Medications, fasting interval, GFV, pH, and emetic episodes were documented. Age- and gender-specific Center for Disease Control and Prevention growth charts (2000) were used to determine ideal body weight (IBW = 50th percentile) and to classify patients as lean/normal (BMI 25th-75th percentile), overweight (BMI > or = 85th to <95th percentile), or obese (BMI > or = 95th percentile). Of all day surgery patients, 14.0% were overweight and 13.3% were obese. Obese children had lower GFV per total body weight (P < 0.001). When corrected for IBW, however, volumes GFV(IBW) were identical across all BMI categories (mean 0.96 mL/kg, sd 0.71; median 0.86 mL/kg, IQR 0.96). Preoperative acetaminophen and midazolam contributed to increased GFV(IBW) (P = 0.025 and P = 0.001). Lower GFV(IBW) was associated with ASA physical status III (P = 0.024), male gender (P = 0.012), gastroesophageal reflux disease (P = 0.049), and proton

[Case of neuroleptic malignant syndrome following open heart surgery for thoracic aortic aneurysm with parkinson's disease].

PubMed

Shinoda, Maiko; Sakamoto, Mik; Shindo, Yuki; Ando, Yumi; Tateda, Takeshi

2013-12-01

An 80-year-old woman with Parkinson's disease was scheduled for open heart surgery to repair thoracic aortic aneurysm. Parkinson's symptoms were normally treated using oral levodopa (200 mg), selegiline-hydrochloride (5 mg), bromocriptine-mesilate (2 mg), and amantadine-hydrochloride (200 mg) daily. On the day before surgery, levodopa 50mg was infused intravenously. Another 25 mg of levodopa was infused immediately after surgery. Twenty hours later, the patient developed tremors, heyperventilation, but no obvious muscle rigidity. Two days after surgery, the patient exhibited high fever, hydropoiesis, elevated creatine kinase, and a rise in blood leukocytes. She was diagnosed with neuroleptic malignant syndrome. She was intubated, and received dantrolene sodium. Symptoms of neuroleptic malignant syndrome disappeared on the fourth postoperative day. The stress of open heart surgery, specifically extracorporeal circulation and concomitant dilution of levodopa, triggered neuroleptic malignant syndrome in this patient. Parkinson's patients require higher doses of levodopa prior to surgery to compensate and prevent neuroleptic malignant syndrome after surgery.

Identification of complications that have a significant effect on length of stay after spine surgery and predictive value of 90-day readmission rate.

PubMed

Yadla, Sanjay; Ghobrial, George M; Campbell, Peter G; Maltenfort, Mitchell G; Harrop, James S; Ratliff, John K; Sharan, Ashwini D

2015-12-01

Complications after spine surgery have an impact on overall outcome and health care expenditures. The increased cost of complications is due in part to associated prolonged hospital stays. The authors propose that certain complications have a greater impact on length of stay (LOS) than others and that those complications should be the focus of future targeted prevention efforts. They conducted a retrospective analysis of a prospectively maintained database to identify complications with the greatest impact on LOS as well as the predictive value of these complications with respect to 90-day readmission rates. Data on 249 patients undergoing spine surgery at Thomas Jefferson University from May to December 2008 were collected by a study auditor. Any complications occurring within 30 days of surgery were recorded as was overall LOS for each patient. Stepwise regression analysis was performed to determine whether specific complications had a statistically significant effect on LOS. For correlation, all readmissions within 90 days were recorded and organized by complication for comparison with those complications affecting LOS. The mean LOS for patients without postoperative complications was 6.9 days. Patients who developed pulmonary complications had an associated increase in LOS of 11.1 days (p < 0.005). The development of a urinary tract infection (UTI) was associated with an increase in LOS of 3.4 days (p = 0.002). A new neurological deficit was associated with an increase in LOS of 8.2 days (p = 0.004). Complications requiring return to the operating room (OR) showed a trend toward an increase in LOS of 4.7 days (p = 0.09), as did deep wound infections (3.3 days, p = 0.08). The most common reason for readmission was for wound drainage (n = 21; surgical drainage was required in 10 [4.01%] of these 21 cases). The most common diagnoses for readmission, in decreasing order of incidence, were categorized as hardware malpositioning (n = 4), fever (n = 4), pulmonary (n

[Medical negligence in surgery: 112 cases retrospective analysis].

PubMed

Xiang, Jian; Chang, Lin; Wang, Xu; Zhang, Feng-Qin

2013-06-01

To explore the general characteristics of medical negligence in surgery in order to provide the reference for forensic practices. One hundred and twelve cases of medical negligence in surgical department were retrospectively analyzed in Fada Institute of Forensic Medicine and Science from 2008 to 2010. The common types of medical negligence cases in the surgery were improper operation procedure (28.57%), failure of consent (26.79%), and inadequate monitoring (22.32%). The results of complications included disability or functional impairment (61.61%), death (31.25%) and transient impairment with no obvious adverse reactions (7.14%). The most common roles played by the medical negligence cases were minor role (26.79%), equal role (19.64%), and slight role (14.29%). Significant attention should be paid to the operation procedure, consent, and monitoring. It should be cautious to not make assessment on involvement degree of medical negligence.

Cataract Surgery Outcomes in Glaucomatous Eyes: Results From the Veterans Affairs Ophthalmic Surgery Outcomes Data Project.

PubMed

Turalba, Angela; Payal, Abhishek R; Gonzalez-Gonzalez, Luis A; Cakiner-Egilmez, Tulay; Chomsky, Amy S; Vollman, David E; Baze, Elizabeth F; Lawrence, Mary; Daly, Mary K

2015-10-01

To compare visual acuity outcomes, vision-related quality of life, and complications related to cataract surgery in eyes with and without glaucoma. Retrospective cohort study. Cataract surgery outcomes in cases with and without glaucoma from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project were compared. We identified 608 glaucoma cases and 4306 controls undergoing planned cataract surgery alone. After adjusting for age, pseudoexfoliation, small pupil, prior ocular surgery, and anterior chamber depth, we found that glaucoma cases were more likely to have posterior capsular tear with vitrectomy (odds ratio [OR] 1.8, P = .03) and sulcus intraocular lens placement (OR 1.65, P = .03) during cataract surgery. Glaucoma cases were more likely to have postoperative inflammation (OR 1.73, P < .0001), prolonged elevated intraocular pressure (OR 2.96, P = .0003), and additional surgery within 30 days (OR 1.92, P = .03). Mean best-corrected visual acuity (BCVA) and Visual Function Questionnaire (VFQ) scores significantly improved after cataract surgery in both groups (P < .0001), but there were larger improvements in BCVA (P = .01) and VFQ composite scores (P < .0001) in the nonglaucoma vs the glaucoma group. A total of 3621 nonglaucoma cases (94.1%) had postoperative BCVA 20/40 or better, compared to 466 glaucoma cases (89.6%) (P = .0003). Eyes with glaucoma are at increased risk for complications and have more modest visual outcomes after cataract surgery compared to eyes without glaucoma. Despite this, glaucoma patients still experience significant improvement in vision-related outcomes after cataract extraction. Further study is needed to explore potential factors that influence cataract surgery outcomes in glaucomatous eyes. Published by Elsevier Inc.

Ureteral injury during gynecological laparoscopic surgeries: report of twelve cases.

PubMed

Gao, Jin-Song; Leng, Jin-Hua; Liu, Zhu-Feng; Shen, Keng; Lang, Jing-He

2007-03-01

To investigate ureteral injury during gynecological laparoscopic surgeries. From January 1990 to December 2005, 12 868 gynecological laparoscopic surgeries were conducted in Peking Union Medical College Hospital with 12 ureteral injuries reported. The present study investigated several aspects, including surgical indications, uterine size, pelvic adhesion, operative procedures, symptoms, diagnostic time and methods, injury site and type, subsequent treatment, and prognosis. The incidence of ureteral injury was 0.093% (12/12 868) in all cases, 0.42% (11/2 586) in laparoscopic hysterectomy [laparoscopically assisted vaginal hysterectomy (LAVH) or total laparoscopic hysterectomy (TLH)], and 0.01% (1/10 282) in non-LAVH surgeries. Enlarged uterus, pelvic adhesion, and endometrosis were risk factors associated with ureteral injury. Only one injury was found intraoperatively while others were found postoperatively. The injury sites were at the pelvic brim (2 cases) or the lower part of ureter (10 cases). Patients were treated with ureteral stenting (effective in 2 cases) or laparotomy and open repair. Prognoses were favorable in most cases. Most laparoscopic ureteral injuries occur during laparoscopic hysterectomy. Further evaluation is required when ureteral injury is suspected, and surgical repair is the major treatment for ureteral injury.

Development and validation of a predictive model for 90-day readmission following elective spine surgery.

PubMed

Parker, Scott L; Sivaganesan, Ahilan; Chotai, Silky; McGirt, Matthew J; Asher, Anthony L; Devin, Clinton J

2018-06-15

OBJECTIVE Hospital readmissions lead to a significant increase in the total cost of care in patients undergoing elective spine surgery. Understanding factors associated with an increased risk of postoperative readmission could facilitate a reduction in such occurrences. The aims of this study were to develop and validate a predictive model for 90-day hospital readmission following elective spine surgery. METHODS All patients undergoing elective spine surgery for degenerative disease were enrolled in a prospective longitudinal registry. All 90-day readmissions were prospectively recorded. For predictive modeling, all covariates were selected by choosing those variables that were significantly associated with readmission and by incorporating other relevant variables based on clinical intuition and the Akaike information criterion. Eighty percent of the sample was randomly selected for model development and 20% for model validation. Multiple logistic regression analysis was performed with Bayesian model averaging (BMA) to model the odds of 90-day readmission. Goodness of fit was assessed via the C-statistic, that is, the area under the receiver operating characteristic curve (AUC), using the training data set. Discrimination (predictive performance) was assessed using the C-statistic, as applied to the 20% validation data set. RESULTS A total of 2803 consecutive patients were enrolled in the registry, and their data were analyzed for this study. Of this cohort, 227 (8.1%) patients were readmitted to the hospital (for any cause) within 90 days postoperatively. Variables significantly associated with an increased risk of readmission were as follows (OR [95% CI]): lumbar surgery 1.8 [1.1-2.8], government-issued insurance 2.0 [1.4-3.0], hypertension 2.1 [1.4-3.3], prior myocardial infarction 2.2 [1.2-3.8], diabetes 2.5 [1.7-3.7], and coagulation disorder 3.1 [1.6-5.8]. These variables, in addition to others determined a priori to be clinically relevant, comprised 32

Pain after pediatric otorhinolaryngologic surgery: a prospective multi-center trial.

PubMed

Guntinas-Lichius, Orlando; Volk, Gerd Fabian; Geissler, Katharina; Komann, Marcus; Meissner, Winfried

2014-07-01

The purpose of this study was to describe postoperative pain within the first day after pediatric otorhinolaryngologic surgery and to identify factors influencing postoperative pain. Using a prospective evaluation and a Web-based multi-center registry, children ≥4 years of age (n = 365) rated their pain using questionnaires of the project Quality Improvement in Postoperative Pain Treatment for Children including faces numeric rating scales (FNRS, 0-10) for the determination of patient's pain on ambulation and his/her maximal and minimal pain within 8 h after day case surgery or at the first postoperative day for inpatient cases. Additionally, functional interference and therapy-related side effects were assessed. Half of the children were 4 or 5 years of age. The predominant types of surgery were adenoidectomy and tonsillectomy ± ear ventilation tubes. Although analgesics were applied preoperatively, intraoperatively, in the recovery room and on ward, maximal pain within the first day after surgery reached 4.4 ± 3.3 (FNRS). Pain was highest after oral surgery, especially after tonsillectomy and nose surgery. 39% of the children reported pain interference with breathing (39%). The most frequent side effect was drowsiness (55%). Multivariate analysis revealed that maximal pain was independently associated with the non-standardized use of opioids in the recovery room, or use of non-opioid or opioids on ward. Analgesia and perioperative pain management in pediatric otorhinolaryngologic surgery seems to be highly variable. Tonsillectomy and nose surgery are very painful. After otorhinolaryngologic surgery many children seem to receive less analgesia than needed or ineffective analgesic drug regimes.

The Australian litigation landscape - oral and maxillofacial surgery and general dentistry (oral surgery procedures): an analysis of litigation cases.

PubMed

Badenoch-Jones, E K; White, B P; Lynham, A J

2016-09-01

There are persistent concerns about litigation in the dental and medical professions. These concerns arise in a setting where general dentists are more frequently undertaking a wider range of oral surgery procedures, potentially increasing legal risk. Judicial cases dealing with medical negligence in the fields of general dentistry (oral surgery procedure) and oral and maxillofacial surgery were located using the three main legal databases. Relevant cases were analysed to determine the procedures involved, the patients' claims of injury, findings of negligence and damages awarded. A thematic analysis of the cases was undertaken to determine trends. Fifteen cases over a 20-year period were located across almost all Australian jurisdictions (eight cases involved general dentists; seven cases involved oral and maxillofacial surgeons). Eleven of the 15 cases involved determinations of whether or not the practitioner had failed in their duty of care; negligence was found in six cases. Eleven of the 15 cases related to molar extractions (eight specifically to third molar). Dental and medical practitioners wanting to manage legal risk should have regard to circumstances arising in judicial cases. Adequate warning of risks is critical, as is offering referral in appropriate cases. Preoperative radiographs, good medical records and processes to ensure appropriate follow-up are also important. © 2015 Australian Dental Association.

Conservative cricoid surgery for chondrosarcoma: a case report.

PubMed

Gaio, Elena; Maggiore, Giandomenico; Canesso, Alessandra; Artico, Riccardo

2014-02-01

We present the case of a 39-year-old man who presented with hoarseness and progressively worsening dyspnea. Findings on laryngoscopy and computed tomography strongly suggested the presence of a chondrosarcoma. The patient underwent open surgery for removal of the lesion with wide margins. Reconstruction was carried out with two segments of costal cartilage. Laryngeal chondrosarcomas are rare, malignant, usually well-differentiated neoplasms that should be treated with conservative surgery. Recurrences should be treated more aggressively.

Use of day 1 early morning cortisol to predict the need for glucocorticoid replacement after pituitary surgery.

PubMed

Bondugulapati, L N Rao; Campbell, Christopher; Chowdhury, Sharmistha Roy; Goetz, Pablo; Davies, J Stephen; Rees, D Aled; Hayhurst, Caroline

2016-01-01

Assessment of adrenal reserve in patients who have undergone pituitary surgery is crucial. However, there is no clear consensus with regards to the type and timing of the test that should be used in the immediate post-operative period. Recently, there has been increased interest in measuring post-operative cortisol levels. We present our data utilising day 1 post-operative early morning cortisol as a tool to assess adrenal reserve in steroid-naive patients. A retrospective analysis of endoscopic pituitary surgery undertaken over a 2-year period. 82 patients underwent 84 surgeries in total. Patients who were already on glucocorticoids pre-operatively and patients with Cushing's disease, pituitary apoplexy and those without follow-up data were excluded, leaving a study group of 44 patients with 45 operations. A 9am day 1 post-operative cortisol value of > 400 nmol/L was taken as an indicator of adequate adrenal reserve. All the patients were reassessed at 6 weeks with a standard short synacthen test (SST) using 250 micrograms of intravenous synacthen. 22 out of 45 patients had a cortisol value of > 400 nmol/L on day 1 post-operatively and were discharged without glucocorticoid supplementation. Of these, only 2 patients subsequently failed the SST when reassessed at 6-8 weeks. The remaining 23 patients had a cortisol value of < 400 nmol/L on day 1 post-operatively and were discharged on hydrocortisone 10 mg twice daily. At 6-8 weeks, nine continued to show suboptimal stimulated cortisol levels whereas the remaining fourteen patients showed adequate adrenal reserve. The 9 am cortisol value had high specificity (81.8%) and positive predictive value (90.9%) for integrity of the HPA axis. Sensitivity was 58.8% and negative predictive value was 39.1%. A day 1 post-operative early morning cortisol is a useful tool to predict adrenal reserve post-pituitary surgery, enabling clinicians to avoid unnecessary blanket glucocorticoid replacement.

Day of Surgery Impacts Outcome: Rehabilitation Utilization on Hospital Length of Stay in Patients Undergoing Elective Meningioma Resection.

PubMed

Sarkiss, Christopher A; Papin, Joseph A; Yao, Amy; Lee, James; Sefcik, Roberta K; Oermann, Eric K; Gordon, Errol L; Post, Kalmon D; Bederson, Joshua B; Shrivastava, Raj K

2016-09-01

Meningiomas account for approximately one third of all brain tumors in the United States. In high-volume medical centers, the average length of stay (LOS) for a patient is 6.8 days compared with 8.8 days in low-volume centers with median total admission charges equaling approximately $55,000. To our knowledge, few studies have evaluated day of surgery and its effect on hospital LOS. Our primary goal was to analyze patient outcome as a direct result of surgical date, as well as to characterize the individual variables that may impact their hospital course, early access to rehabilitation, and long-term functional status. A retrospective database was generated for cranial meningioma patients who underwent elective surgical resection at our institution over a 3-year study period (2011-2014). Inclusion criteria included any patient who underwent elective meningioma resection and was discharged either home or to a rehabilitation facility with at least 6 months of follow-up. Exclusion criteria included any patient who was not discharged after resection (i.e., expired). Each patient's medical record was evaluated for a subset of demographics and clinical variables. Given that patients who undergo surgical resection of meningiomas have a national median LOS of 6 days, we subdivided the patients into 2 cohorts: early discharge (LOS < 3) and late discharge (LOS ≥ 3). Statistical analysis was performed using SPSS 21.0 to assess the significance of the results. We identified 139 (25 male, 114 female) meningioma patients who underwent surgical resection. Seventy of these patients had surgery during the early week (defined as Monday-Wednesday), and 69 had surgery in the later week (Thursday-Friday). The median age for both early and late groups was 58, and the median diameter of the tumor was 3.1 cm and 3.3 cm, respectively. Overall, 55% of the patients had public insurance and 43% had private insurance, with no significant variation between the early and late groups. The

Case scheduling preferences of one Surgeon's cataract surgery patients.

PubMed

Dexter, Franklin; Birchansky, Lee; Bernstein, James M; Wachtel, Ruth E

2009-02-01

The increase in the number of operating rooms nationwide in the United States may reflect preferences of patients for scheduling of outpatient surgery. Yet, little is known of the importance that patients place on scheduling convenience and flexibility. Fifty cataract surgery patients seen by a surgeon at his main office during a 6-mo period responded to a marketing survey. All the patients had Medicare insurance and supplemental insurance permitting surgery at any facility. A telephone questionnaire included four vignettes describing different choices in the scheduling of cataract surgery. Respondents were asked how far they would be willing to travel for one option instead of another. For example, "Your surgery will be on Thursday in three weeks at 2 pm. You can drink water until 9 am. You arrive at 10 am, because your surgery might start early. If you travel farther, you would arrive at 8 am for 9 am surgery." The median (50th percentile) additional travel time was 60 min (lower 95% confidence bound >or=52 min) for each of four options: to receive care on a day chosen by the patient instead of assigned by the physician, to receive care at a single site instead of both the surgeon's office and a surgery center at a different location, to combine the examination and the surgery into a single visit instead of two visits, and to have surgery in the morning instead of the afternoon. The patients of this ophthalmologist placed a high value on convenience and flexibility in scheduling their surgery. In general, this would be achievable only if many operating rooms were available each morning.

Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data.

PubMed

Daniels, Alan H; Ames, Christopher P; Smith, Justin S; Hart, Robert A

2014-12-03

Current spine surgeon training in the United States consists of either an orthopaedic or neurological surgery residency, followed by an optional spine surgery fellowship. Resident spine surgery procedure volume may vary between and within specialties. The Accreditation Council for Graduate Medical Education surgical case logs for graduating orthopaedic surgery and neurosurgery residents from 2009 to 2012 were examined and were compared for spine surgery resident experience. The average number of reported spine surgery procedures performed during residency was 160.2 spine surgery procedures performed by orthopaedic surgery residents and 375.0 procedures performed by neurosurgery residents; the mean difference of 214.8 procedures (95% confidence interval, 196.3 to 231.7 procedures) was significant (p = 0.002). From 2009 to 2012, the average total spinal surgery procedures logged by orthopaedic surgery residents increased 24.3% from 141.1 to 175.4 procedures, and those logged by neurosurgery residents increased 6.5% from 367.9 to 391.8 procedures. There was a significant difference (p < 0.002) in the average number of spinal deformity procedures between graduating orthopaedic surgery residents (9.5 procedures) and graduating neurosurgery residents (2.0 procedures). There was substantial variability in spine surgery exposure within both specialties; when comparing the top 10% and bottom 10% of 2012 graduates for spinal instrumentation or arthrodesis procedures, there was a 13.1-fold difference for orthopaedic surgery residents and an 8.3-fold difference for neurosurgery residents. Spine surgery procedure volumes in orthopaedic and neurosurgery residency training programs vary greatly both within and between specialties. Although orthopaedic surgery residents had an increase in the number of spine procedures that they performed from 2009 to 2012, they averaged less than half of the number of spine procedures performed by neurological surgery residents. However

Forensic evaluation of medical liability cases in general surgery.

PubMed

Moreira, H; Magalhães, T; Dinis-Oliveira, Rj; Taveira-Gomes, A

2014-10-01

Although medical liability (disciplinary, civil and criminal) is increasingly becoming an issue, few studies exist, particularly from the perspective of forensic science, which demonstrate the extent to which medical malpractice occurs, or when it does, the reasons for it. Our aims were to evaluate the current situation concerning medical liability in general surgery (GS) in Portugal, the reasons for claims, and the forensic evaluations and conclusions, as well as the association between these issues and the judicial outcomes. We analysed the Medico-Legal Council (CML) reports of the National Institute of Legal Medicine and Forensic Sciences of Portugal related to GS during 2001-2010. The judicial outcomes of each case were requested from the Public Prosecutor Office (PPO) and the court. Alleged cases of medical liability in GS represented 11.2% of the total cases analysed by the CML. We estimated that in Portugal, 4:100,000 surgeries are subject to litigation. The majority of complaints were due to the patient's death (75.4%), with laparoscopic cholecystectomy surgeries representing 55.2% of cases. In 76.1% of the cases, the CML believed that there was no violation of legesartis and in 55.2% of cases, no causal nexus was found between the medical practice and the alleged harm. The PPO prosecuted physicians in 6.4% of the cases and resulted in one conviction. Finally, the importance of the CML reports as a relevant technical-scientific tool for judicial decision was evident because these reports significantly (p < 0.05) influenced the prosecutor's decision, whether to prosecute or not. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Anti-nerve growth factor therapy increases spontaneous day/night activity in mice with orthopedic surgery-induced pain.

PubMed

Majuta, Lisa A; Guedon, Jean-Marc G; Mitchell, Stefanie A T; Ossipov, Michael H; Mantyh, Patrick W

2017-04-01

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are 2 of the most common and successful surgical interventions to relieve osteoarthritis pain. Control of postoperative pain is critical for patients to fully participate in the required physical therapy which is the most influential factor in effective postoperative knee rehabilitation. Currently, opiates are a mainstay for managing postoperative orthopedic surgery pain including TKA or THA pain. Recently, issues including efficacy, dependence, overdose, and death from opiates have made clinicians and researchers more critical of use of opioids for treating nonmalignant skeletal pain. In the present report, a nonopiate therapy using a monoclonal antibody raised against nerve growth factor (anti-NGF) was assessed for its ability to increase the spontaneous activity of the operated knee joint in a mouse model of orthopedic surgery pain-induced by drilling and coring the trochlear groove of the mouse femur. Horizontal activity and velocity and vertical rearing were continually assessed over a 20 hours day/night period using automated activity boxes in an effort to reduce observer bias and capture night activity when the mice are most active. At days 1 and 3, after orthopedic surgery, there was a marked reduction in spontaneous activity and vertical rearing; anti-NGF significantly attenuated this decline. The present data suggest that anti-NGF improves limb use in a rodent model of joint/orthopedic surgery and as such anti-NGF may be useful in controlling pain after orthopedic surgeries such as TKA or THA.

Analysis of lawsuit cases in the Department of Surgery in Korea

PubMed Central

Jung, Ji Yun; Kim, So Yoon; Kim, Dong Gyu; Kim, Choong Bai; Chi, Kyong-Choun; Kang, Won Kyung

2018-01-01

Purpose The aim of this study is to prepare medical staff in order to prevent medical malpractice litigation through analysis of litigation cases related to the department of surgery in Korea. Methods A total of 94 litigation cases related to the department of surgery, where a certain amount of payment was ordered to the defendant between 2005 through 2010, were analyzed. We examined time of occurrence, amount claimed and awarded in damages, plaintiff claims, and court opinion. Results An average of 3.2 years was spent from the date of the incident occurring to the end of the litigation procedures. The average amount awarded in judgments for damages was 59,708,983 ± 67,307,264 (range, 1,700,000–365,201,482) Korean won. Cases were found involving the following opinion of the court: violation of duty of care (49 cases), violation of informed consent (7 cases), violation of duty of care and informed consent (5 cases), and settlement, reconciliation, and others (32 cases). By analyzing defendants' negligence in court opinions, diagnosis (30.8%) was the most common, followed by post-operation management (27.7%). Conclusion Physicians have to conduct treatment and surgery based on exact diagnosis and be careful to observe patients' conditions and symptoms after surgery. It is essential to identify the current status and characteristics of medical litigation for reducing further litigation and improving patient safety. In order to create a safe medical environment, national efforts should be made not only by individuals but also at the national level. PMID:29520344

Preoperative Red Cell Distribution Width and 30-day mortality in older patients undergoing non-cardiac surgery: a retrospective cohort observational study.

PubMed

Abdullah, H R; Sim, Y E; Sim, Y T; Ang, A L; Chan, Y H; Richards, T; Ong, B C

2018-04-18

Increased red cell distribution width (RDW) is associated with poorer outcomes in various patient populations. We investigated the association between preoperative RDW and anaemia on 30-day postoperative mortality among elderly patients undergoing non-cardiac surgery. Medical records of 24,579 patients aged 65 and older who underwent surgery under anaesthesia between 1 January 2012 and 31 October 2016 were retrospectively analysed. Patients who died within 30 days had higher median RDW (15.0%) than those who were alive (13.4%). Based on multivariate logistic regression, in our cohort of elderly patients undergoing non-cardiac surgery, moderate/severe preoperative anaemia (aOR 1.61, p = 0.04) and high preoperative RDW levels in the 3rd quartile (>13.4% and ≤14.3%) and 4th quartile (>14.3%) were significantly associated with increased odds of 30-day mortality - (aOR 2.12, p = 0.02) and (aOR 2.85, p = 0.001) respectively, after adjusting for the effects of transfusion, surgical severity, priority of surgery, and comorbidities. Patients with high RDW, defined as >15.7% (90th centile), and preoperative anaemia have higher odds of 30-day mortality compared to patients with anaemia and normal RDW. Thus, preoperative RDW independently increases risk of 30-day postoperative mortality, and future risk stratification strategies should include RDW as a factor.

Advanced Hysteroscopic Surgery Training

PubMed Central

McLaren, Glenda R.; Erian, Anna-Marie

2014-01-01

Hysteroscopic surgery is pivotal in management of many gynecological pathologies. The skills required for performing advanced hysteroscopic surgery (AHS), eg, transcervical hysteroscopic endometrial resection (TCRE), hysteroscopic polypectomy and myomectomy in the management of menorrhagia, hysteroscopic septulysis in fertility-related gynecological problems and hysteroscopic removal of chronically retained products of conception and excision of intramural ectopic pregnancy ought to be practiced by contemporary gynecological surgeons in their day-to-day clinical practice. AHS is a minimally invasive procedure that preserves the uterus in most cases. Whilst the outcome is of paramount importance, proper training should be adopted and followed through so that doctors, nurses, and institutions may deliver the highest standard of patient care. PMID:25392678

Safety and Efficacy of Day-case Percutaneous Nephrolithotomy: A Systematic Review from European Society of Uro-technology.

PubMed

Jones, Patrick; Bennett, Grace; Dosis, Alexios; Pietropaolo, Amelia; Geraghty, Robert; Aboumarzouk, Omar; Skolarikos, Andreas; Somani, Bhaskar K

2018-04-12

Day case or ambulatory percutaneous nephrolithotomy (PCNL) has risen over the last few years with the aim of discharging patients within 24h. We perform a systematic review of literature to evaluate the outcomes of day-case PCNL surgery. A Cochrane style search was performed and the following bibliographic databases were accessed: PubMed, Science Direct, Scopus, and Web of Science. This was carried out in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. All studies in the English language reporting on PCNL patients discharged within 24h were included. Based on the literature search of 97 articles, nine (502 patients) met the inclusion criteria (mean age: 47 yr), with a mean stone size of 20.5mm. The mean operating time was 66min, and over a mean hospital stay of 17.5h, the stone-free rate was 95%. The overall complication rate was 13.5%; the vast majority of these complications were Clavien I-II complications, with a readmission rate of 3%. Day-case PCNL is a safe and feasible strategy in carefully selected cases. However, for its success, detailed planning and adherence to surgical protocol are paramount with strict criteria for inpatient admission and a thorough follow-up plan. Day-case percutaneous nephrolithotomy procedure seems to be a safe procedure with good outcomes, and low risk of complications and readmissions. Detailed preoperative protocol and planning are paramount, with indications for inpatient admission as well as a thorough follow-up plan. Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Thirty-day unplanned hospital readmission in ovarian cancer patients undergoing primary or interval cytoreductive surgery: systematic literature review.

PubMed

Clark, Rachel M; Rice, Laurel W; Del Carmen, Marcela G

2018-06-18

Thirty-day readmission rate has been proposed as metric of quality and remains an ongoing clinical concern in the primary treatment of patients with advanced-stage ovarian epithelial ovarian cancer. We conducted a review of the literature to identify rates, risk factors, and predictors for 30-day readmission in this population. A 10-year period MEDLINE (PubMed) search of English literature studies published between January 01, 2008-January 01, 2018 was performed to identify appropriate studies for review. Thirty -day readmission rates for ovarian cancer patients undergoing primary treatment ranged from 2.5-19.3%. Neoadjuvant chemotherapy and interval cytoreductive surgery (NACT-ICS) surgery was associated with lower readmission rates, when compared to primary debulking surgery (PDS). The most frequently reported adverse events resulting in readmission include inpatient management of ileus/small bowel obstruction, wound-related complications, and thromboembolic events. Readmission predictors included the presence of other medical comorbidities, re-operation, and major complications occurring after initial hospital discharge. Some studies reported lower rates of readmission and survival in patients treated by NACT-ICS. Policies and programs should be designed to measure short- and long-term outcomes in this patient population to avoid bias in assigning patients to NACT-ICS to maintain low 30-day readmission rates. Copyright © 2018 Elsevier Inc. All rights reserved.

Safety, efficacy and cost-effectiveness of consecutive bilateral cataract surgery on two successive days in tribes at base hospital through community outreach program: A prospective study of Aravali Mountain, North West India

PubMed Central

Mohan, Amit; Kaur, Navjot; Bhatanagar, Vishal C

2017-01-01

Purpose: The aim of the study was to evaluate the safety and efficacy of consecutive bilateral cataract surgery (CBCS) on two successive days in a single hospital visit. Methods: Prospective study was conducted on 565 patients of various tribes of hilly area of West Rajasthan who had come to our hospital through community outreach programmed (CORP) between January 2015 and March 2016. Patients with significant bilateral cataract without any other ocular morbidity were advised bilateral manual small incision cataract surgery on two consecutive days. Intraoperative and postoperative complications were evaluated, and follow-up was done at 1 week, 1 month, and 3 months. Results: Out of 565 patients, 519 underwent both eye surgeries. Second eye surgery was deferred for a later date in 46 cases. Because of intraoperative and postoperative complications in the first eye, 31 had delayed surgeries while 15 patients refused to undergo another eye surgery either because of postoperative day 1 poor vision in the operated eye due to retinal pathologies (n = 8) or unwillingness (n = 7). The second eye surgery was performed for 519 patients, out of whom six had intra or postoperative complications. At 1 month follow-up, four patients had unilateral cystoid macular edema and three had prolonged postoperative inflammation. At 3 months, all patients were satisfied and had no complications. None of the patients had sight-threatening complications such as endophthalmitis, corneal decompensation, or vitreoretinal complications. Conclusion: CBCS may be considered safe and cost-effective for patients living in remote locations, dependent on CORP. PMID:29208839

Assessing the Risk of Occult Cancer and 30-day Morbidity in Women Undergoing Risk-reducing Surgery: A Prospective Experience.

PubMed

Bogani, Giorgio; Tagliabue, Elena; Signorelli, Mauro; Chiappa, Valentina; Carcangiu, Maria Luisa; Paolini, Biagio; Casarin, Jvan; Scaffa, Cono; Gennaro, Massimiliano; Martinelli, Fabio; Borghi, Chiara; Ditto, Antonino; Lorusso, Domenica; Raspagliesi, Francesco

To investigate the incidence and predictive factors of 30-day surgery-related morbidity and occult precancerous and cancerous conditions for women undergoing risk-reducing surgery. A prospective study (Canadian Task Force classification II-1). A gynecologic oncology referral center. Breast-related cancer antigen (BRCA) mutation carriers and BRCAX patients (those with a significant family history of breast and ovarian cancer). Minimally invasive risk-reduction surgery. Overall, 85 women underwent risk-reducing surgery: 30 (35%) and 55 (65%) had hysterectomy plus bilateral salpingo-oophorectomy (BSO) and BSO alone, respectively. Overall, in 6 (7%) patients, the final pathology revealed unexpected cancer: 3 early-stage ovarian/fallopian tube cancers, 2 advanced-stage ovarian cancers (stage IIIA and IIIB), and 1 serous endometrial carcinoma. Additionally, 3 (3.6%) patients had incidental finding of serous tubal intraepithelial carcinoma. Four (4.7%) postoperative complications within 30 days from surgery were registered, including fever (n = 3) and postoperative ileus (n = 1); no severe (grade 3 or more) complications were observed. All complications were managed conservatively. The presence of occult cancer was the only factor predicting the development of postoperative complications (p = .02). Minimally invasive risk-reducing surgery is a safe and effective strategy to manage BRCA mutation carriers. Patients should benefit from an appropriate counseling about the high prevalence of undiagnosed cancers observed at the time of surgery. Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.

A novel risk classification system for 30-day mortality in children undergoing surgery

PubMed Central

Walter, Arianne I.; Jones, Tamekia L.; Huang, Eunice Y.; Davis, Robert L.

2018-01-01

A simple, objective and accurate way of grouping children undergoing surgery into clinically relevant risk groups is needed. The purpose of this study, is to develop and validate a preoperative risk classification system for postsurgical 30-day mortality for children undergoing a wide variety of operations. The National Surgical Quality Improvement Project-Pediatric participant use file data for calendar years 2012–2014 was analyzed to determine preoperative variables most associated with death within 30 days of operation (D30). Risk groups were created using classification tree analysis based on these preoperative variables. The resulting risk groups were validated using 2015 data, and applied to neonates and higher risk CPT codes to determine validity in high-risk subpopulations. A five-level risk classification was found to be most accurate. The preoperative need for ventilation, oxygen support, inotropic support, sepsis, the need for emergent surgery and a do not resuscitate order defined non-overlapping groups with observed rates of D30 that vary from 0.075% (Very Low Risk) to 38.6% (Very High Risk). When CPT codes where death was never observed are eliminated or when the system is applied to neonates, the groupings remained predictive of death in an ordinal manner. PMID:29351327

Both bias and lack of knowledge influence organizational focus on first case of the day starts.

PubMed

Dexter, Elisabeth U; Dexter, Franklin; Masursky, Danielle; Garver, Michael P; Nussmeier, Nancy A

2009-04-01

The economic costs of reducing first case delays are often high, because efforts need to be applied to multiple operating rooms (ORs) simultaneously. Nevertheless, delays in starting first cases of the day are a common topic in OR committee meetings. We added three scientific questions to a 24 question online, anonymous survey performed before the implementation of a new OR information system. The 57 respondents cared sufficiently about OR management at the United States teaching hospital to complete all questions. The survey revealed reasons why personnel may focus on the small reductions in nonoperative time achievable by reducing tardiness in first cases of the day. (A) Respondents lacked knowledge about principles in reducing over-utilized OR time to increase OR efficiency, based on their answering the relevant question correctly at a rate no different from guessing at random. Those results differed from prior findings of responses at a rate worse than random, resulting from a bias on the day of surgery of making decisions that increase clinical work per unit time. (B) Most respondents falsely believed that a 10 min delay at the start of the day causes subsequent cases to start at least 10 min late (P < 0.0001 versus random chance). (C) Most respondents did not know that cases often take less time than scheduled (P = 0.008 versus chance). No one who demonstrated knowledge (C) about cases sometimes taking less time than scheduled applied that information to their response to (B) regarding cases starting late (P = 0.0002). Knowledge of OR efficiency was low among the respondents working in ORs. Nevertheless, the apparent absence of bias shows that education may influence behavior. In contrast, presence of bias on matters of tardiness of start times shows that education may be of no benefit. As the latter results match findings of previous studies of scheduling decisions, interventions to reduce patient and surgeon waiting from start times may depend principally

Emergency surgery for Crohn's disease.

PubMed

Smida, Malek; Miloudi, Nizar; Hefaiedh, Rania; Zaibi, Rabaa

2016-03-01

Surgery has played an essential role in the treatment of Crohn's disease. Emergency can reveal previously unknown complications whose treatment affects prognosis. Indicate the incidence of indications in emergent surgery for Crohn's disease. Specify the types of procedures performed in these cases and assess the Results of emergency surgery for Crohn's disease postoperatively,  in short , medium and long term. Retrospective analysis of collected data of 38 patients, who underwent surgical resection for Crohn's disease during a period of 19 years from 1992 to 2011 at the department of surgery in MONGI SLIM Hospital, and among them 17 patients underwent emergency surgery for Crohn's disease. In addition to socio-demographic characteristics and clinical presentations of our study population, we evaluated the indications, the type of intervention, duration of evolution preoperative and postoperative complications and overall prognosis of the disease. Of the 38 patients with Crohn's disease requiring surgical intervention, 17/38 patients underwent emergency surgery. Crohn's disease was inaugurated by the complications requiring emergency surgery in 11 patients. The mean duration of symptoms prior to surgery was 1.5 year. The most common indication for emergency surgery was acute intestinal obstruction (n=6) followed by perforation and peritonitis (n=5). A misdiagnosis of appendicitis was found in 4 patients and a complicated severe acute colitis for undiagnosed Crohn's disease was found in 2 cases. The open conventional surgery was performed for 15 patients. Ileocolic resection was the most used intervention. There was one perioperative mortality and 5 postoperative morbidities. The mean of postoperative hospital stay was 14 days (range 4-60 days). Six patients required a second operation during the follow-up period. The incidence of emergency surgery for Crohn's disease in our experience was high (17/38 patients), and is not as rare as the published estimates

Mesenteric panniculitis patients requiring emergency surgery: report of three cases.

PubMed

Duman, Mustafa; Koçak, Osman; Fazli, Olgaç; Koçak, Cengiz; Atici, Ali Emre; Duman, Uğur

2012-04-01

Mesenteric panniculitis is a rare, benign disease characterized by a chronic non-specific inflammatory process of mesenteric fat tissue with unknown etiology. The small bowel mesentery is affected mostly. This process rarely involves the large intestine mesentery. Mesenteric panniculitis includes symptoms as abdominal pain, nausea and vomiting, diarrhea, constipation, and fever. In our cases, we had difficulty in the preoperative diagnosis as the clinical changes imitated an obstruction or ischemia of the small bowel. All the cases required emergency abdominal surgery and partial jejunal resection. The aim of this article was to present three cases of mesenteric panniculitis of the small bowel mesentery requiring emergency surgery together with a short review of the literature.

Fetal monitoring during nonobstetric surgery: revisiting guidelines: a case report.

PubMed

Rothschild, Tod J; Morel, Bruce; Pace, Benjamin; Fuks, Aleksandr M

2015-01-01

Nonobstetric surgery during pregnancy is not an infrequent occurrence. Guidelines for fetal monitoring during nonobstetric surgery are limited. We describe a case of appendectomy during third trimester, complicated by in utero fetal demise (IUFD). A 30-year-old, Caucasian woman underwent open appendectomy for suspected acute appendicitis. The procedure was complicated by IUFD. Fetal monitoring was done prior to but not during surgery. Guidelines for fetal monitoring were revised, recommending continuous electronic fetal monitoring when possible during third trimester nonobstetric surgery after appropriate patient counseling. A subsequent series of 5 uncomplicated appendectomies demonstrated no difficulty in implementing these guidelines. Continuous electronic fetal monitoring during third trimester nonobstetric surgery should be available and implemented after appropriate patient counseling. This approach reduces the risk of fetal mortality.

Morbidity after intracranial tumor surgery: sensitivity and specificity of retrospective review of medical records compared with patient-reported outcomes at 30 days.

PubMed

Drewes, Christina; Sagberg, Lisa Millgård; Jakola, Asgeir Store; Gulati, Sasha; Solheim, Ole

2015-10-01

Published outcome reports in neurosurgical literature frequently rely on data from retrospective review of hospital records at discharge, but the sensitivity and specificity of retrospective assessments of surgical morbidity is not known. The aim of this study was to elucidate the sensitivity and specificity of retrospective assessment of morbidity after intracranial tumor surgery by comparing it to patient-reported outcomes at 30 days. In 191 patients who underwent surgery for the treatment of intracranial tumors, we evaluated newly acquired neurological deficits within the motor, language, and cognitive domains. Traditional retrospective discharge data were collected by review of hospital records. Patient-reported data were obtained by structured phone interviews at 30 days after surgery. Data on perioperative medical and surgical complications were obtained from both hospital records and patient interviews conducted 30 days postoperatively. Sensitivity values for retrospective review of hospital records as compared with patient-reported outcomes were 0.52 for motor deficits, 0.4 for language deficits, and 0.07 for cognitive deficits. According to medical records, 158 patients were discharged with no new or worsened deficits, but only 117 (74%) of these patients confirmed this at 30 days after surgery. Specificity values were high (0.97-0.99), indicating that new deficits were unlikely to be found by retrospective review of hospital records at discharge when the patients did not report any at 30 days. Major perioperative complications were all identified through retrospective review of hospital records. Retrospective assessment of medical records at discharge from hospital may greatly underestimate the incidence of new neurological deficits after brain tumor surgery when compared with patient-reported outcomes after 30 days.

Surgical site infection in lumbar surgeries, pre and postoperative antibiotics and length of stay: a case study.

PubMed

Khan, Inayat Ullah; Janjua, Muhammad Burhanuddin; Hasan, Shumaila; Shah, Shahid

2009-01-01

Postoperative wound infection also called as surgical site infection (SSI), is a trouble some complication of lumbar spine surgeries and they can be associated with serious morbidities, mortalities and increase resource utilization. With the improvement in diagnostic modalities, proper surgical techniques, antibiotic therapy and postoperative care, infectious complications can result in various compromises afterwards. The objective was to study the relation of surgical site infection in clean lumbar surgeries with the doses of antibiotics. This Retrospective study was conducted at Shifa International Hospital, from January 2006 to March 2008. Hundred post operated cases of lumber disc prolapse, lumbar stenosis or both studied retrospectively by tracing their operated data from hospital record section for the development of surgical site infection (SSI). The patients were divided into three groups depending upon whether they received single, three or more than three doses of antibiotics respectively. Complete data analyses and cross tabulation done with SPSS version 16. Of 100 cases, only 6% had superficial surgical site infection; only 1 case with co morbidity of hypertension was detected. Twenty-one cases had single dose of antibiotic (Group-I), 59 cases had 3 doses (Group-II) and 20 cases received multiple doses (Group-III). There was no infection in Group-I. Only one patient in Group-II and 5 patients in Group-III developed superficial SSI. While 4 in Group-II, 3 in Group-III, and none of Group-I had > 6 days length of stay (LOS). The dose of antibiotic directly correlates with the surgical site infection in clean lumbar surgeries. When compared with multiple doses of antibiotics a single preoperative shot of antibiotic is equally effective for patients with SSI.

Fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery for a pituitary tumor: A case report.

PubMed

Li, Chiao-Zhu; Li, Chiao-Ching; Hsieh, Chih-Chuan; Lin, Meng-Chi; Hueng, Dueng-Yuan; Liu, Feng-Chen; Chen, Yuan-Hao

2017-01-01

The fatal type of antiphospholipid syndrome is a rare but life-threating condition. It may be triggered by surgery or infection. Endoscopic transnasal-transsphenoidal surgery is a common procedure for pituitary tumor. We report a catastrophic case of a young woman died of fatal antiphospholipid syndrome following endoscopic transnasal-transsphenoidal surgery. A 31-year-old woman of a history of stroke received endoscopic transnasal-transsphenoidal surgery for a pituitary tumor. The whole procedure was smooth. However, the patient suffered from acute delirium on postoperative day 4. Then, her consciousness became comatose state rapidly with dilatation of pupils. Urgent magnetic resonance imaging of brain demonstrated multiple acute lacunar infarcts. The positive antiphosphoipid antibody and severe thrombocytopenia were also noted. Fatal antiphospholipid syndrome was diagnosed. Plasma exchange, corticosteroids, anticoagulant agent were prescribed. The hemodynamic condition was gradually stable. However, the consciousness was still in deep coma. The patient died of organ donation 2 months later. If patients have a history of cerebral stroke in their early life, such as a young stroke, the APS and higher risk of developing fatal APS after major surgery should be considered. The optimal management of APS remains controversial. The best treatment strategies are only early diagnosis and aggressive therapies combing of anticoagulant, corticosteroid, and plasma exchange. The intravenous immunoglobulin is prescribed for patients with refractory APS.

Thirty-day outcomes of sleeve gastrectomy versus Roux-en-Y gastric bypass: first report based on Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

PubMed

Chaar, Maher El; Lundberg, Peter; Stoltzfus, Jill

2018-05-01

According to recent American Society for Metabolic and Bariatric Surgery estimates, sleeve gastrectomy (SG) is now the most commonly performed procedure in the United States (~53.8% of all bariatric procedures), followed by Roux-en-Y gastric bypass (RYGB; 23.1% of all procedures). The objective of this study was to evaluate outcomes and safety of these 2 procedures in the first 30 days postoperatively using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. University health network, United States. We reviewed all SG and RYGB cases entered between January 1 and December 31, 2015 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ 2 , or Fisher's exact tests as appropriate, with P<.05 denoting statistical significance and no adjustment for multiple testing. A total of 141,646 patients were analyzed; 98,292 underwent SG and 43,354 underwent RYGB. Average age was 44.5 and 45.4 years for SG and RYGB, respectively. Preoperative body mass index was 45.1 and 46.1 for SG and RYGB, respectively. The 30-day mortality was .1% for SG and .2% for RYGB (P<.05). The incidence of unplanned intensive care unit admission after RYGB was twice as high compared with SG (1.3% versus .6%, respectively, P<.05). The incidence of at least 1 intervention or reoperation after RYGB was significantly higher compared with SG (2.8% and 2.5% for GB versus 1.2% and 1% for SG, P<.05). After RYGB, .4% of patients had a drain left in place at 30 days postoperatively versus .3% for SG (P<.05). The incidence of readmission was 2.8% for RYGB and 1.2% for SG (P<.05). The incidence of postoperative complications in the first 30 days after surgery is low for both RYGB and SG. However, SG seems to have a better safety profile in the first 30 days postoperatively compared with RYGB. These findings should

Bacterial endophthalmitis after resident-performed cataract surgery.

PubMed

Hollander, David A; Vagefi, M Reza; Seiff, Stuart R; Stewart, Jay M

2006-05-01

To determine if there is an increased rate of postoperative bacterial endophthalmitis after resident-performed cataract extraction relative to the reported rates of experienced surgeons. Retrospective, observational case series. The operative reports of the resident-performed cataract surgeries at San Francisco General Hospital between 1983 and 2002 were reviewed. Cases of culture-positive bacterial endophthalmitis and vitreous loss were identified. Between 1983 and 2002, three cases (0.11%) of culture-positive bacterial endophthalmitis occurred after 2718 resident-performed cataract extractions. The overall vitreous loss rate was 6.7%. Two endophthalmitis cases were acute (Staphylococcus epidermidis, Streptococcus viridans), presenting within five days of surgeries complicated by vitreous loss, and one case was delayed-onset (Corynebacterium species) after Nd:YAG posterior capsulotomy after uncomplicated cataract extraction. Despite higher rates of vitreous loss, the rate of endophthalmitis following resident-performed cataract surgery remains comparable with the rates of more experienced surgeons.

A liberal preoperative fasting regimen improves patient comfort and satisfaction with anesthesia care in day-stay minor surgery.

PubMed

Bopp, C; Hofer, S; Klein, A; Weigand, M A; Martin, E; Gust, R

2011-07-01

The aim of this study was to evaluate whether a single preoperative limited oral intake of a carbohydrate drink could improve perioperative patient comfort and satisfaction with anesthesia care in elective day-stay ophthalmologic surgery. A single-center, prospective, randomized clinical trial was conducted in a university hospital. The study included ASA I-III patients undergoing ophthalmologic surgery. Patients undergoing both general anesthesia and local anesthesia were included in the study. The control group fasted in accordance to nil per os after midnight, while patients in the experimental group received 200 mL of a carbohydrate drink 2 h before the operation. Both groups were allowed to drink and eat until midnight ad libitum. Patient characteristics, subjective perceptions, taste of the drink, and satisfaction with anesthesia care were ascertained using a questionnaire administered three times: after the anesthesiologist's visit, before surgery and before discharge from the ward to assess patient comfort. An analysis of variance and the Mann-Whitney U-test were used for statistical analysis. A total of 123 patients were included and 109 patients were randomly assigned to one of two preoperative fasting regimens. Patients drinking 200 mL 2 h before surgery were not as hungry (P<0.05), not as thirsty preoperatively (P<0.001) and not as thirsty after surgery (P<0.05), resulting in increased postoperative satisfaction with anesthesia care (P<0.05). Standardized limited oral preoperative fluid intake increases patient comfort and satisfaction with anesthesia care and should be a part of modern day-stay ophthalmologic surgery.

A population-based analysis of time to surgery and travel distances for brachial plexus surgery

PubMed Central

Dy, Christopher J.; Baty, Jack; Saeed, Mohammed J; Olsen, Margaret A.; Osei, Daniel A.

2016-01-01

Purpose Despite the importance of timely evaluation for patients with brachial plexus injuries (BPI), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. Methods We used statewide administrative databases from Florida (2007–2013), New York (2008–2012) and North Carolina (2009–2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. The distances between the treating hospitals and between the patient’s home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. Results Within the 222 patients in our cohort, the median time from injury to surgery was 7.6 months and exceeded 365 days in 29% of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, the distance between the two treating hospitals, or changing hospitals between injury and surgery did not significantly influence time to surgery. Conclusions Nearly one-third of patients in FL, NY, and NC underwent BPI surgery more than one year after their injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. Clinical Relevance These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers. PMID:27570225

How do patient demographics, time-related variables, reasons for cancellation, and clinical procedures affect frequency of same-day operating room surgery cancelation? A maximum likelihood method.

PubMed

Da'ar, Omar B; Al-Mutairi, Talal

2018-06-15

Cancelation of same-day surgery is a common global problem, wasting valuable hospitals' operating room (OR) times and imposing significant economic costs. There is limited evidence to support the association between frequency of same-day surgery cancelation and patient demographics, time-related variables, healthcare provider reasons for cancelation, and clinical procedures in Saudi Arabia. The aim of this study was to explore this relationship, providing an understanding of the local context. A retrospective cross-sectional study that retrieved medical records to examine the association between the frequency of same-day surgery cancelation and covariates including patient demographics, time-related variables, healthcare provider reason for cancelation, and clinical procedures. The data covered from January 2014 to December 2014 at King Fahad National Guard Hospital in Riyadh. We considered 440 patients that met the inclusion criteria for final analysis. The cancelation was regarded less frequent if a patient canceled once in the12 months and more frequent if a patient canceled two times or more in the same period. We used descriptive statistics to summarize data and employed a probit regression to estimate the association of frequency of same-day surgery cancelation and covariates via maximum likelihood method. King Abdullah International Medical Research Center granted the institutional approval. Our study suggests that while reasons of unavailability of OR time were associated with less frequent same-day surgery cancelation, scheduling issues were linked to more frequent cancelations, compared with reasons for patients being unwell on the day of surgery. Waiting time of more than six hours and morning sessions were associated with less frequent cancelations compared to shorter waiting time and afternoon sessions. Compared to general procedures, specialized clinical procedures were associated with cancelations that are more frequent. Further, female patients were

Effect of Endovascular Interventions on General Surgery Trainee Operative Experience; a Comparison of Case Log Reports.

PubMed

Pedersen, Rose C; Li, Yiping; Chang, Jason S; Lew, Wesley K; Patel, Kaushal Kevin

2016-05-01

Vascular surgery fellowship training has evolved with the widespread adoption of endovascular interventions. The purpose of this study is to examine how general surgery trainee exposure to vascular surgery has changed over time. Review of the Accreditation Council for Graduate Medical Education national case log reports for graduating Vascular Surgery Fellows (VF), and general surgery residents (GSR) from 2001 to 2012 was performed. The number of GSR increased from 1021 to 1098, and the number of VF increased from 96 to 121 from 2001 to 2012. The total number of vascular cases done by VF increased by 1161 since 2001 (298-762), whereas the total number of vascular cases done by GSR has decreased by 40% during this time period (186-116). Vascular fellows increase was due primarily to an increase in endovascular experience; a finding not noted in general surgery residents. Vascular fellow case log changes are due primarily to an increase in endovascular experience that has not been mirrored by general surgery trainees. Open surgery experience has decreased overall for general surgery residents in all major categories, a change not seen in vascular surgery fellows. Copyright © 2016 Elsevier Inc. All rights reserved.

Incidence and etiological mechanism of stroke in cardiac surgery.

PubMed

Arribas, J M; Garcia, E; Jara, R; Gutierrez, F; Albert, L; Bixquert, D; García-Puente, J; Albacete, C; Canovas, S; Morales, A

2017-12-14

We studied patients who had experienced a stroke in the postoperative period of cardiac surgery, aiming to analyse their progression and determine the factors that may influence prognosis and treatment. We established a protocol for early detection of stroke after cardiac surgery and collected data on stroke onset and a number of clinical, surgical, and prognostic variables in order to perform a descriptive analysis. Over the 15-month study period we recorded 16 strokes, which represent 2.5% of the patients who underwent cardiac surgery. Mean age in our sample was 69 ± 8 years; 63% of patients were men. The incidence of stroke in patients aged 80 and older was 5.1%. Five patients (31%) underwent emergency surgery. By type of cardiac surgery, 7% of patients underwent mitral valve surgery, 6.5% combined surgery, 3% aortic valve surgery, and 2.24% coronary surgery. Most cases of stroke (44%) were due to embolism, followed by hypoperfusion (25%). Stroke occurred within 2 days of surgery in 69% of cases. The mean NIHSS score in our sample of stroke patients was 9; code stroke was activated in 10 cases (62%); one patient (14%) underwent thrombectomy. Most patients progressed favourably: 13 (80%) scored≤2 on the modified Rankin Scale at 3 months. None of the patients died during the postoperative hospital stay. In our setting, strokes occurring after cardiac surgery are usually small and have a good long-term prognosis. Most of them occur within 2 days, and they are mostly embolic in origin. The incidence of stroke in patients aged 80 and older and undergoing cardiac surgery is twice as high as that of the general population. Copyright © 2017 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.

Surgery of intracranial aneurysms at Yonsei University: 780 cases.

PubMed

Lee, K C

1991-03-01

Seven hundred and eighty patients with intracranial aneurysm, which were surgically treated by the author since 1976, were analyzed. Strategies important for intracranial aneurysm surgery were the timing of surgery, preoperative preparation and intraoperative management. The best management outcome could be achieved by early operation, removal of subarachnoid blood clot, maintenance of circulating blood volume, administration of nimodipine, and meticulous surgical tactics to avoid pitfalls. Indications for aneurysm surgery in the acute phase were determined by intracerebral hematoma, angiographic findings, clinical grade, general physical status and readiness of the surgical team. Important goals to be considered during the operation were obtaining a slack brain, preparation of proximal control, protection of the brain, awareness of microsurgical anatomy, and complete dissection of the sac. The morbidity and mortality were 2.7% and 4.0%, respectively. The mortality was attributed to intracranial causes in 20 cases (poor grade, delayed ischemic deficits, rebleeding, postoperative infarction, and postoperative epidural hematoma), extracranial causes in 7 cases (pulmonary embolism, heparin induced intracerebral hemorrhage, hepatic failure, myocardial infarction, and gastrointestinal bleeding), and unknown problems in 5 cases. The postoperative intracerebral hemorrhage occurred in 16 cases and seemed to be caused by one or more of the following events: cerebral infarction developed during the preoperative period, occlusion of the cerebral veins during the Sylvian dissection, cerebral retraction and/or sudden change of intracranial hemodynamics. Hydrocephalus, almost always a communicating type as confirmed by isotope cisternography, was managed by lumboperitoneal shunt.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of Spinal and Epidural Anaesthesia for Day Care Surgery in Lower Limb and Inguinoscrotal Region

PubMed Central

Gupta, Asha; Kaur, Sarabjit; Khetarpal, Ranjana; Kaur, Haramritpal

2011-01-01

Background: Day care surgery is still in its infancy in India. Both regional and general anaesthesia can be used for this. Central neuraxial blocks are simple cheap and easy to perform. This study was done to evaluate usefulness of spinal and epidural anaesthesia for day care surgery. Patients & Method: 100 patients were randomized to either spinal (n=50) or epidural (n=50) group anaesthetized with either 0.5% hyperbaric 2ml bupivacaine or 0.5% 20ml bupivacaine respectively. In spinal group 27 gauze quincke needle and in epidural group 18 gazue tuohy needle was used. Both the groups were compared for haemodynamic stability, side effects, complications, postanaesthesia discharge score (PADS), time taken to micturate, total duration of stay in hospital and patient satisfaction score for technique. Results: We observed that spinal anaesthesia had significantly early onset of anaesthesia and better muscle relaxation (p<0.05) as compared to epidural block otherwise both groups were comparable for haemodynamic stability, side effects or complications. Although more patients in spinal group (64% vs 48%) achieved PADS earlier (in 4-8 hours) but statistically it was insignificant. Time to micturition (6.02 0.55 v/s 6.03 0.47 hours) and total duration of stay (7.49 1.36 v/s 8.03 1.33 hours) were comparable in both the groups. Conclusion: Both spinal and epidural anaesthesia can be used for day care surgery. Spinal anaesthesia with 27 gauze quincke needle and 2ml 0.5% hyperbaric bupivacaine provides added advantage of early onset and complete relaxation. PMID:21804709

Perioperative risk assessment in robotic general surgery: lessons learned from 884 cases at a single institution.

PubMed

Buchs, Nicolas C; Addeo, Pietro; Bianco, Francesco M; Gorodner, Veronica; Ayloo, Subhashini M; Elli, Enrique F; Oberholzer, José; Benedetti, Enrico; Giulianotti, Pier C

2012-08-01

To assess factors associated with morbidity and mortality following the use of robotics in general surgery. Case series. University of Illinois at Chicago. Eight hundred eighty-four consecutive patients who underwent a robotic procedure in our institution between April 2007 and July 2010. Perioperative morbidity and mortality. During the study period, 884 patients underwent a robotic procedure. The conversion rate was 2%, the mortality rate was 0.5%, and the overall postoperative morbidity rate was 16.7%. The reoperation rate was 2.4%. Mean length of stay was 4.5 days (range, 0.2-113 days). In univariate analysis, several factors were associated with increased morbidity and included either patient-related (cardiovascular and renal comorbidities, American Society of Anesthesiologists score ≥ 3, body mass index [calculated as weight in kilograms divided by height in meters squared] <30, age ≥ 70 years, and malignant disease) or procedure-related (blood loss ≥ 500 mL, transfusion, multiquadrant operation, and advanced procedure) factors. In multivariate analysis, advanced procedure, multiquadrant surgery, malignant disease, body mass index of less than 30, hypertension, and transfusion were factors significantly associated with a higher risk for complications. American Society of Anesthesiologists score of 3 or greater, age 70 years or older, cardiovascular comorbidity, and blood loss of 500 mL or more were also associated with increased risk for mortality. Use of the robotic approach for general surgery can be achieved safely with low morbidity and mortality. Several risk factors have been identified as independent causes for higher morbidity and mortality. These can be used to identify patients at risk before and during the surgery and, in the future, to develop a scoring system for the use of robotic general surgery

A Population-Based Analysis of Time to Surgery and Travel Distances for Brachial Plexus Surgery.

PubMed

Dy, Christopher J; Baty, Jack; Saeed, Mohammed J; Olsen, Margaret A; Osei, Daniel A

2016-09-01

Despite the importance of timely evaluation for patients with brachial plexus injuries (BPIs), in clinical practice we have noted delays in referral. Because the published BPI experience is largely from individual centers, we used a population-based approach to evaluate the delivery of care for patients with BPI. We used statewide administrative databases from Florida (2007-2013), New York (2008-2012), and North Carolina (2009-2010) to create a cohort of patients who underwent surgery for BPI (exploration, repair, neurolysis, grafting, or nerve transfer). Emergency department and inpatient records were used to determine the time interval between the injury and surgical treatment. Distances between treating hospitals and between the patient's home ZIP code and the surgical hospital were recorded. A multivariable logistic regression model was used to determine predictors for time from injury to surgery exceeding 365 days. Within the 222 patients in our cohort, median time from injury to surgery was 7.6 months and exceeded 365 days in 29% (64 of 222 patients) of cases. Treatment at a smaller hospital for the initial injury was significantly associated with surgery beyond 365 days after injury. Patient insurance type, travel distance for surgery, distance between the 2 treating hospitals, and changing hospitals between injury and surgery did not significantly influence time to surgery. Nearly one third of patients in Florida, New York, and North Carolina underwent BPI surgery more than 1 year after the injury. Patients initially treated at smaller hospitals are at risk for undergoing delayed BPI surgery. These findings can inform administrative and policy efforts to expedite timely referral of patients with BPI to experienced centers. Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

[Surgery in aged patients: a study on 476 surgical cases].

PubMed

Guglielminetti, D; Angelini, L; Pasi, L; Carosi, V

1990-06-01

The Authors report their experience from 1984 to 1989 with surgery in the elderly. Patients aged 75 years were considered as geriatric and entered the study. Mortality and morbidity rates were analysed in 476 cases operated. Pre-existent diseases were related to postoperative complications. The Authors conclude underlining the feasibility of geriatric surgery as well as the acceptable risk rate.

Assessment of 30-day mortality and complication rates associated with extended deep vein thrombosis prophylaxis following hip fracture surgery.

PubMed

Durand, Wesley M; Goodman, Avi D; Johnson, Joey P; Daniels, Alan H

2018-06-01

DVT is a common complication following lower extremity surgery, occurring in up to 60% of patients undergoing hip fracture surgery without postoperative anticoagulation. The risk of fatal PE continues well-beyond two weeks postoperatively, thus extended DVT prophylaxis beyond 14 days may be warranted. This investigation sought to examine the association between prescription of extended DVT prophylaxis and 30-day postoperative complications following hip fracture surgery. This study utilized the ACS NSQIP Hip Fracture Procedure Targeted dataset, a newly available set of patient variables for 2016. The outcome measures were death, occurrence of any postoperative complication, complication subtype, readmission or reoperation within 30-days postoperatively, and length of stay. The primary independent variable was medical DVT prophylaxis continued 28-days postoperatively ("extended DVT prophylaxis"). The control group contains both patients receiving no prophylaxis and those receiving short-duration prophylaxis. Multivariate stepwise logistic regression was employed to control for potential demographic, comorbidity, and procedural/medical confounding factors. In total, 7533 surgically treated hip fracture patients treated in 2016 were analyzed. Overall, 57.8% of patients (n = 4354) were prescribed extended DVT prophylaxis. On bivariate analysis, prescription of extended DVT prophylaxis was associated with significantly lower incidence of death (7.7% without vs. 2.7% with, p < 0.0001) and stroke/CVA (1.4% vs. 0.6%, p = 0.0016). In multivariate analysis, prescription of extended DVT prophylaxis was significantly associated with lower odds of death (OR 0.33, p < 0.0001), stroke/CVA (OR 0.44, p = 0.0010), and acute kidney injury (AKI) (OR 0.31, p = 0.0010). This retrospective cohort study of the 2016 ACS NSQIP found that hip fracture surgery patients prescribed ≥28 days of postoperative DVT prophylaxis exhibited 67% lower odds of death and

[Prognostic factors for severe infection after flexible ureteroscopy: Clinical interest of urine culture the day before surgery?].

PubMed

Alezra, E; Lasselin, J; Forzini, T; François, T; Viart, L; Saint, F

2016-01-01

The objectives of this study have been to determine prognostic factors for acute pyelonephritis (AP) after flexible ureteroscopy (FU), to assess the frequency of readmission for AP and to study the usefulness of urinalysis the day before surgery. Between 2010 and 2013, 266 patients have had at least one ureteroscopy (n=325). All infectious complications and unplanned readmissions within the month after FU were retrospectively evaluated. Several data have been collected: age, sex, BMI, surgical indication (calculis or tumor), number of previous ureteroscopies, number of previous surgeries for calculis, stones number, size and location, bilateral interventions, operating time, preoperative ureteral stenting, postoperative stenting, hospitalization stay, urine culture the day before surgery (j-1) and prescription of antibiotic therapy the week before FU. Correlation between these variables and acute pyelonephritis (AP) the month following the USSR was tested (StatView 4.5, SAS Institute) (P<0.05 significant). We observed 24 postoperative APs (7.4%), 17 prior to hospital discharge and 7 requiring rehospitalization. In univariate analysis, the significant prognostic factors of postoperative AP have been: stone size (>14 mm) (P=0.03); operating time (70 minutes) (P<0.005); positive day - 1 urine culture (P<0.001); antibiotics treatment the week before FU (P<0.001). In multivariate analysis, antibiotics prescription during the week before USSR remained significant (P<0.002; RR 5.8 [1.9-15]). Acute pyelonephritis requiring unplanned admission after ureteroscopy is a rare complication (2.4%). Urinalysis one day before ureteroscopy could allow early antibiotic therapy and may reduce 63% of unplanned hospital admissions for acute pyelonephritis. 5. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Acute respiratory failure due to hemothorax after posterior correction surgery for adolescent idiopathic scoliosis: a case report

PubMed Central

2013-01-01

Background Although posterior correction and fusion surgery using pedicle screws carries the risk of vascular injury, a massive postoperative hemothorax in a patient with adolescent idiopathic scoliosis (AIS) is quite rare. We here report a case of a 12-year-old girl with AIS who developed a massive postoperative hemothorax. Case presentation The patient had a double thoracic curve with Cobb angles of 63° at T2-7 and 54° at T7-12. Posterior correction and fusion surgery was performed using a segmental pedicle screw construct placed between T2 and T12. Although the patient's respiration was stable during the surgery, 20 minutes after removing the trachea tube, the patient’s pulse oximetry oxygen saturation suddenly decreased to 80%. A contrast CT scan showed a massive left hemothorax, and a drainage tube was quickly inserted into the chest. The patient was re-intubated and a positive end-expiratory pressure of 5 cmH2O applied, which successfully stopped the bleeding. The patient was extubated 4 days after surgery without incident. Based on contrast CT scans, it was suspected that the hemothorax was caused by damage to the intercostal arteries or branches during pedicle probing on the concave side of the upper thoracic curve. Extensive post-surgical blood tests, echograms, and CT and MRI radiographs did not detect coagulopathy, pulmonary or vascular malformation, or any other possible causative factors. Conclusion This case underscores the potential risk of massive hemothorax related to thoracic pedicle screw placement, and illustrates that for this serious complication, respiratory management with positive airway pressure, along with a chest drainage tube, can be an effective treatment option. PMID:23577922

Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature

PubMed Central

Hershman, Stuart H.; Kunkle, William A.; Kelly, Michael P.; Buchowski, Jacob M.; Ray, Wilson Z.; Bumpass, David B.; Gum, Jeffrey L.; Peters, Colleen M.; Singhatanadgige, Weerasak; Kim, Jin Young; Smith, Zachary A.; Hsu, Wellington K.; Nassr, Ahmad; Currier, Bradford L.; Rahman, Ra’Kerry K.; Isaacs, Robert E.; Smith, Justin S.; Shaffrey, Christopher; Thompson, Sara E.; Wang, Jeffrey C.; Lord, Elizabeth L.; Buser, Zorica; Arnold, Paul M.; Fehlings, Michael G.; Mroz, Thomas E.

2017-01-01

Study Design: Multicenter retrospective case series and review of the literature. Objective: To determine the rate of esophageal perforations following anterior cervical spine surgery. Methods: As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients’ charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis. Results: The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired. Conclusions: Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality. PMID:28451488

Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature.

PubMed

Hershman, Stuart H; Kunkle, William A; Kelly, Michael P; Buchowski, Jacob M; Ray, Wilson Z; Bumpass, David B; Gum, Jeffrey L; Peters, Colleen M; Singhatanadgige, Weerasak; Kim, Jin Young; Smith, Zachary A; Hsu, Wellington K; Nassr, Ahmad; Currier, Bradford L; Rahman, Ra'Kerry K; Isaacs, Robert E; Smith, Justin S; Shaffrey, Christopher; Thompson, Sara E; Wang, Jeffrey C; Lord, Elizabeth L; Buser, Zorica; Arnold, Paul M; Fehlings, Michael G; Mroz, Thomas E; Riew, K Daniel

2017-04-01

Multicenter retrospective case series and review of the literature. To determine the rate of esophageal perforations following anterior cervical spine surgery. As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients' charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis. The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired. Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality.

Obesity weight management and bariatric surgery case management programs: a review of literature.

PubMed

Echols, Jennie

2010-01-01

The proportion of Americans with clinically severe obesity has vast implications for the nation's healthcare system since this population have twice as many chronic medical conditions as people with normal weight. Through the use of review of literature, this article (a) describes the types of weight loss programs; (b) reviews the results from studies on effectiveness of bariatric surgery; and (c) identifies recommendations for obesity and bariatric surgery case management programs. Disease management companies appear to be concentrating on general weight loss strategies associated with wellness and other condition-specific disease management products, whereas larger national healthcare companies with at-risk and insurance products offer specific bariatric surgery management products. Case management programs within healthcare systems, health management organizations, and insurance companies are frequently faced with the management of individuals with morbid obesity and, increasingly, those who are requesting or have undergone bariatric surgery. Research shows that morbid obesity is a disease that remains generally unresponsive to diet and drug therapy but appears to respond well to bariatric surgery. Research findings suggest that surgical treatment is more effective than pharmacological treatment of weight loss and the control of some comorbidities associated with obesity. The number of Americans having weight loss surgery increased by 804% between 1998 and 2004, which appears to be a driver for the recent development of obesity disease management and bariatric surgery case management programs. Although the immaturity and lack of studies citing outcomes of obesity disease and case management programs limit the identification of best practices based on outcomes, emerging practices can be identified and recommendations for case management can be formulated. In addition to primary prevention and treatment programs for obesity, this article describes program

Prognostic model for psychological outcomes in ambulatory surgery patients: A prospective study using a structural equation modeling framework.

PubMed

Mijderwijk, Hendrik-Jan; Stolker, Robert Jan; Duivenvoorden, Hugo J; Klimek, Markus; Steyerberg, Ewout W

2018-01-01

Surgical procedures are increasingly carried out in a day-case setting. Along with this increase, psychological outcomes have become prominent. The objective was to evaluate prospectively the prognostic effects of sociodemographic, medical, and psychological variables assessed before day-case surgery on psychological outcomes after surgery. The study was carried out between October 2010 and September 2011. We analyzed 398 mixed patients, from a randomized controlled trial, undergoing day-case surgery at a university medical center. Structural equation modeling was used to jointly study presurgical prognostic variables relating to sociodemographics (age, sex, nationality, marital status, having children, religion, educational level, employment), medical status (BMI, heart rate), and psychological status associated with anxiety (State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS-A)), fatigue (Multidimensional Fatigue Inventory (MFI)), aggression (State-Trait Anger Scale (STAS)), depressive moods (HADS-D), self-esteem, and self-efficacy. We studied psychological outcomes on day 7 after surgery, including anxiety, fatigue, depressive moods, and aggression regulation. The final prognostic model comprised the following variables: anxiety (STAI, HADS-A), fatigue (MFI), depression (HADS-D), aggression (STAS), self-efficacy, sex, and having children. The corresponding psychological variables as assessed at baseline were prominent (i.e. standardized regression coefficients ≥ 0.20), with STAI-Trait score being the strongest predictor overall. STAI-State (adjusted R2 = 0.44), STAI-Trait (0.66), HADS-A (0.45) and STAS-Trait (0.54) were best predicted. We provide a prognostic model that adequately predicts multiple postoperative outcomes in day-case surgery. Consequently, this enables timely identification of vulnerable patients who may require additional medical or psychological preventive treatment or-in a worst-case scenario-could be

[Risk of hypocalcemia after thyroid surgery].

PubMed

Shulutko, A M; Semikov, V I; Gryaznov, S E; Gorbacheva, A V; Patalova, A R; Mansurova, G T; Kazakova, V A

2015-01-01

To reveal calcium metabolism disorders that frequently occur after thyroid surgery. The study included 202 patients who underwent thyroid surgery for different diseases and had normal calcium level in peripheral blood at baseline. Based on laboratory data postoperative hypocalcemia was diagnosed in 57 (28.8%) patients. It was not always accompanied by clinical symptoms. Clinical picture depended on degree of hypocalcemia. Symptoms was diagnosed more frequently if calcium concentration was less than 2.1 mmol/l. Clinical manifestations were absent in 64.9% of cases on background of hypocalcemia. Incidence of hypocalcemia was higher after thyroidectomy compared to organ-preserving surgery. Symptoms of hypocalcemia occurred after thyroidectomy only. Casual parathyroidectomy does not always cause hypocalcemia. Only in 14% of patients with hypocalcemia excised parathyroid was identified in specimen. At the same time 7.6% of patients with postoperative normocalcaemia also had excised parathyroids in specimens. Symptoms of hypocalcemia does not always occur at 1 day after surgery. They can appear later, for example at 5 days postoperatively and depend on severity of hypocalcemia. Thyroidectomy has high risk of postoperative hypocalcemia with clinical symptoms (19.6%) that is transient in 15.5% of cases and permanent in 4.1% of patients.

Robotic surgery start-up with a fellow as the console surgeon.

PubMed

Reinhardt, Susanne; Ifaoui, Inge Boetker; Thorup, Jorgen

2017-08-01

Owing to the encouraging data on fellowship training in robotic pyeloplasty and the documented benefits of robotic pyeloplasty, the aim of this study was to test the feasibility of starting up pediatric urological robotic surgery in a center with a limited case volume. The operative parameters and clinical outcome of the first 25 robotic pyeloplasties performed were compared to data on open and laparoscopic procedures from the previous 5 year period. The fellow was the only console surgeon. An experienced non-robotic pediatric urologist was supervising at the patient site. The learning curve was in accordance with previously published data on fellows. The median operating time in robotic surgery was 182 min and was significantly shorter than in laparoscopic surgery (median 250 min) and the postoperative inpatient length of stay was significantly shorter after robotic surgery (median 1 day) than after both laparoscopic (median 2 days) and open surgery (median 3.5 days). For robotic cases, postoperative renography showed either stable or increased function of the hydronephrotic kidney. The only complication was in one case with ureteral orifice edema after JJ-stent removal, requiring nephrostomy for 6 weeks. The benefits of overall shorter postoperative hospital stay after robotic pyeloplasty and faster operating time compared to the laparoscopic procedure are clearly in accordance with data from the recent literature. The fast learning curve for robotic pyeloplasty will allow pediatric urology fellowship programs to be integrated in the start-up phase of a pediatric robotic program even though the case material is limited. Operative success rates were in accordance with the gold standard of open surgery.

Clopidogrel and bleeding after general surgery procedures.

PubMed

Ozao-Choy, Junko; Tammaro, Yolanda; Fradis, Martin; Weber, Kaare; Divino, Celia M

2008-08-01

Although many studies in the cardiothoracic literature exist about the relationship between clopidogrel and postoperative bleeding, there is scarce data in the general surgery literature. We assessed whether there are increased bleeding complications, morbidity, mortality, and resource utilization in patients who are on clopidogrel (Plavix) within 1 week before undergoing a general surgery procedure. Fifty consecutive patient charts were retrospectively reviewed after identifying patients who had pharmacy orders for clopidogrel and who underwent a general surgery procedure between 2003 and 2007. Patients who took clopidogrel within 6 days before surgery (group I, n = 28) were compared with patients who stopped clopidogrel for 7 days or more (group II, n = 22). A larger percentage of patients who took their last dose of clopidogrel within 1 week of surgery (21.4% vs 9.5%) had significant bleeding after surgery requiring blood transfusion. However, there were no significant differences between the groups in operative or postoperative blood transfusions (P = 0.12, 0.53), decreases in hematocrit (P = 0.21), hospital stay (P = 0.09), intensive care unit stay (P = 0.41), late complications (P = 0.45), or mortality (P = 0.42). Although our cohort is limited in size, these results suggest that in the case of a nonelective general surgery procedure where outcomes depend on timely surgery, clopidogrel taken within 6 days before surgery should not be a reason to delay surgery. However, careful attention must be paid to meticulous hemostasis, and platelets must be readily available for transfusion in the operating room.

Variable Operative Experience in Hand Surgery for Plastic Surgery Residents.

PubMed

Silvestre, Jason; Lin, Ines C; Levin, Lawrence Scott; Chang, Benjamin

Efforts to standardize hand surgery training during plastic surgery residency remain challenging. We analyze the variability of operative hand experience at U.S. plastic surgery residency programs. Operative case logs of chief residents in accredited U.S. plastic surgery residency programs were analyzed (2011-2015). Trends in fold differences of hand surgery case volume between the 10th and 90th percentiles of residents were assessed graphically. Percentile data were used to calculate the number of residents achieving case minimums in hand surgery for 2015. Case logs from 818 plastic surgery residents were analyzed of which a minority were from integrated (35.7%) versus independent/combined (64.3%) residents. Trend analysis of fold differences in case volume demonstrated decreasing variability among procedure categories over time. By 2015, fold differences for hand reconstruction, tendon cases, nerve cases, arthroplasty/arthrodesis, amputation, arterial repair, Dupuytren release, and neoplasm cases were below 10-fold. Congenital deformity cases among independent/combined residents was the sole category that exceeded 10-fold by 2015. Percentile data suggested that approximately 10% of independent/combined residents did not meet case minimums for arterial repair and congenital deformity in 2015. Variable operative experience during plastic surgery residency may limit adequate exposure to hand surgery for certain residents. Future studies should establish empiric case minimums for plastic surgery residents to ensure hand surgery competency upon graduation. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Serratia spondylodiscitis after elective lumbar spine surgery: a report of two cases.

PubMed

Hadjipavlou, Alexander G; Gaitanis, Ioannis N; Papadopoulos, Charalampos A; Katonis, Pavlos G; Kontakis, George M

2002-12-01

This report describes two cases of acute spondylodiscitis, caused by, complicating two different conditions: microdiscectomy for herniated nucleus pulposus and decompressing laminotomy for spinal stenosis. To describe a rare and life-threatening spinal infection and discuss its successful management. To our knowledge, no published reports in the English language have described this potentially devastating infection as a complication of elective noninstrumented discectomy or decompressive laminotomy. Two cases of a very early onset of acute spondylodiscitis, caused by, after minimally invasive lumbar spine surgeries are presented. The elapsed time between these two complications was 1 week. The clinical presentation was characteristically stormy in both cases. On postoperative day 2, the patients developed high fever with intense chills and concomitant acute low back pain rapidly increasing in severity. The overall clinical appearance was alarming. The patients were carefully investigated immediately and scrutinized for possible origin of the infection. Treatment consisted of prompt intravenous antibiotics and surgical debridement. The history and clinical manifestations of postoperative spondylodiscitis were corroborated with magnetic resonance imaging findings and bacteriologic and hematologic laboratory examination. Blood cultures revealed as the responsible pathogenic microorganism. The source of the pathogens was contaminated normal saline used for surgical lavage. Both patients were able to completely resume their previous occupations after aggressive surgical debridement/irrigation and 3 months of antibiotic treatment. may become a potential pathogen, causing severe spinal infection after elective surgery. For prompt diagnosis and effective treatment of this life-threatening infection, one should maintain high index of suspicion and should not procrastinate in initiating treatment, which should consist of appropriate intravenous antibiotics and surgical

Reduced 30-day mortality in men after elective coronary artery bypass surgery with minimized extracorporeal circulation-a propensity score analysis

PubMed Central

2012-01-01

Background Impact of minimized extracorporeal circulation (MECC) for coronary surgery on mortality remains controversial and gender significantly influence outcome. Methods We analyzed 3,139 male patients undergoing elective coronary surgery between 01/2004 and 05/2009. Using propensity score matching after binary logistic regression, 1,005 patients (from 1,119 patients) undergoing surgery with MECC could be matched with 1,005 patients (from 2,020 patients) undergoing surgery with conventional extracorporeal circulation (CECC). Primary outcome was 30-day mortality. Results Unadjusted 30-day mortality was 2.7% in patients with CECC and 0.8% in those with MECC (mean difference -1.9%; p < 0.001). The adjusted mean difference (average treatment effect of the treated) after matching was -1.5% (95% confidence interval (CI) -2.6 to -0.4; p = 0.006). Postoperative hospital stay was shorter in patients operated with minimized systems (adjusted mean difference -0.8 days; 95% CI -1.46 to -0.09; p = 0.03) and incidence of postoperative neurocognitive dysfunction was also lower (adjusted mean difference -1.3%; 95% CI -2.2 to -0.4; p = 0.001). Chest tube drainage (adjusted mean difference +22 mL; 95% CI -47 to 91; p = 0.5) and risk for acute kidney injury, kidney injury and failure according to RIFLE criteria (adjusted mean difference -1.0%; 95% CI -2.5 to 0.6; p = 0.24) proved to be insignificant between both groups. Apart from reduced 30-day mortality, however, average treatment effects for intensive care unit stay, postoperative hospital stay, chest tube drainage and kidney injury did not significantly differ. Conclusion Using propensity score analysis, we observed an association between MECC and reduced 30-day mortality in men, but our results call for further analysis. PMID:22424497

Coordinating clinic and surgery appointments to meet access service levels for elective surgery.

PubMed

Kazemian, Pooyan; Sir, Mustafa Y; Van Oyen, Mark P; Lovely, Jenna K; Larson, David W; Pasupathy, Kalyan S

2017-02-01

Providing timely access to surgery is crucial for patients with high acuity diseases like cancer. We present a methodological framework to make efficient use of scarce resources including surgeons, operating rooms, and clinic appointment slots with a goal of coordinating clinic and surgery appointments so that patients with different acuity levels can see a surgeon in the clinic and schedule their surgery within a maximum wait time target that is clinically safe for them. We propose six heuristic scheduling policies with two underlying ideas behind them: (1) proactively book a tentative surgery day along with the clinic appointment at the time an appointment request is received, and (2) intelligently space out clinic and surgery appointments such that if the patient does not need his/her surgery appointment there is sufficient time to offer it to another patient. A 2-stage stochastic discrete-event simulation approach is employed to evaluate the six scheduling policies. In the first stage of the simulation, the heuristic policies are compared in terms of the average operating room (OR) overtime per day. The second stage involves fine-tuning the most-effective policy. A case study of the division of colorectal surgery (CRS) at the Mayo Clinic confirms that all six policies outperform the current scheduling protocol by a large margin. Numerical results demonstrate that the final policy, which we refer to as Coordinated Appointment Scheduling Policy considering Indication and Resources (CASPIR), performs 52% better than the current scheduling policy in terms of the average OR overtime per day under the same access service level. In conclusion, surgical divisions desiring stratified patient urgency classes should consider using scheduling policies that take the surgical availability of surgeons, patients' demographics and indication of disease into consideration when scheduling a clinic consultation appointment. Copyright © 2016 Elsevier Inc. All rights reserved.

[Postoperative visual loss due to conversion disorder after spine surgery: a case report].

PubMed

Bezerra, Dailson Mamede; Bezerra, Eglantine Mamede; Silva Junior, Antonio Jorge; Amorim, Marco Aurélio Soares; Miranda, Denismar Borges de

Patients undergoing spinal surgeries may develop postoperative visual loss. We present a case of total bilateral visual loss in a patient who, despite having clinical and surgical risk factors for organic lesion, evolved with visual disturbance due to conversion disorder. A male patient, 39 years old, 71kg, 1.72 m, ASA I, admitted to undergo fusion and discectomy at L4-L5 and L5-S1. Venoclysis, cardioscopy, oximetry, NIBP; induction with remifentanil, propofol and rocuronium; intubation with ETT (8.0mm) followed by capnography and urinary catheterization for diuresis. Maintenance with full target-controlled intravenous anesthesia. During fixation and laminectomy, the patient developed severe bleeding and hypovolemic shock. After 30minutes, hemostasis and hemodynamic stability was achieved with infusion of norepinephrine, volume expansion, and blood products. In the ICU, the patient developed mental confusion, weakness in the limbs, and bilateral visual loss. It was not possible to identify clinical, laboratory or image findings of organic lesion. He evolved with episodes of anxiety, emotional lability, and language impairment; the hypothesis of conversion syndrome with visual component was raised after psychiatric evaluation. The patient had complete resolution of symptoms after visual education and introduction of low doses of antipsychotic, antidepressant, and benzodiazepine. Other symptoms also regressed, and the patient was discharged 12 days after surgery. After 60 days, the patient had no more symptoms. Conversion disorders may have different signs and symptoms of non-organic origin, including visual component. It is noteworthy that the occurrence of this type of visual dysfunction in the postoperative period of spinal surgery is a rare event and should be remembered as a differential diagnosis. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

[Staphylococcal toxic shock syndrome after breast surgery].

PubMed

Pelissier, A; Dumesnil, J; Levy, R; Charron, C; Rouzier, R

2014-09-01

The surgical site infection occurs within 30 days after surgery. It is the most common complication of surgery, with a rate of 1 to 5% without antibiotic prophylaxis and less than 1% with antibiotic prophylaxis. The toxic shock syndrome (TSS) is a dramatic complication. We report the case 39-year-old woman who presented a life-threatening TSS acquired after breast surgery. We describe the signs and symptoms of this condition as well as treatment principles. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

High-power diode laser in the circumvestibular incision for Le Fort I osteotomy in orthognathic surgery: a prospective case series study.

PubMed

Jaeger, Filipe; Chiavaioli, Gustavo Marques; de Toledo, Guilherme Lacerda; Freire-Maia, Belini; Amaral, Marcio Bruno Figueiredo; Mesquita, Ricardo Alves

2018-01-01

The incisions during orthognathic surgery are classically performed with conventional scalpel or electrocautery. Considering that the high-power diode laser surgery may provide advantages when compared to conventional incision techniques, the current study aimed to present a prospective case series of patients submitted to circumvestibular incision for Le Fort I osteotomy. Ten patients with dentofacial deformities who underwent to rapid assisted maxillary expansion or bimaxillary orthognathic surgery were enrolled in the study. All incisions were performed by a single surgeon using an 808-nm diode laser, with an optical fiber of 600 μm, at a power of 2.5 W, in a continuous-wave mode. The performance of the incision was evaluated by incision velocity, bleeding, edema, secondary infection, clinical healing, and pain. The velocity of the incision ranged from 0.10 to 0.20 mm/s (mean 0.13 ± 0.03 mm/s). Considering bleeding during the soft tissue incision, all surgeries were classified as absent bleeding. All patients presented a clinical healing of the surgical wound in a period that range from 3 to 5 weeks and experienced swelling during the follow-up period. On average, approximately 50% of the swelling had resolved after the third postoperative week, and 28.8% of swelling remained after 2 months after the surgery. The pain decreased after 2 and 3 days, and 90.0% of the patients reported no pain after 7 postoperative days. High-power diode laser is effective and safety during circumvestibular incisions for Le Fort I osteotomy in orthognathic surgery decreasing bleeding, surgery time, pain, and edema after orthognathic surgery.

[Laparoscopic-assisted vaginal hysterectomy after multiple abdominal surgeries--case study].

PubMed

Malinowski, Andrzej; Wiecka-Płusa, Monika; Mołas, Justyna

2009-11-01

At present the laparoscopic-assisted vaginal hysterectomy (LAVH) is the most widespread and most frequently executed variation of hysterectomy. It is an effective and safe operating alternative for the traditional way--abdominal hysterectomy. Good cosmetic effects, short post-operative stay at hospital and, first of all, a small risk of intra- and postoperative complications are the major driving factors justifying the choice of this method of surgery. In the following article we describe a case of a 43-year-old woman who underwent many interventions in the peritoneal cavity (abdominal surgery) and was shortlisted for the laparoscopic-assisted vaginal hysterectomy. The cause of the operation was recurrent bilateral ovary cystis that could not be treated neither conservatively nor surgically, as well as the uterus myoma leading to abnormal uterus bleeding and hypermenorrhoea. Surgery in patients who have previously undergone abdominal operations is always difficult and the risk of complications is high indeed. In this case, while selecting the method of the next surgical procedure, surgeons must not exclude the vaginal and laparoscopic methods, or use them simultaneously. Experiences of other surgeons, as well as the unique case of a treated patient, show that previous abdominal surgical procedures are not a contraindication for either vaginal or laparoscopic procedures, and in some cases they might be safer than yet another laparotomy.

Major surgery in an osteosarcoma patient refusing blood transfusion: case report.

PubMed

Dhanoa, Amreeta; Singh, Vivek A; Shanmugam, Rukmanikanthan; Rajendram, Raja

2010-11-08

We describe an unusual case of osteosarcoma in a Jehovah's Witness patient who underwent chemotherapy and major surgery without the need for blood transfusion. This 16-year-old girl presented with osteosarcoma of the right proximal tibia requiring proximal tibia resection, followed by endoprosthesis replacement. She was successfully treated with neoadjuvant chemotherapy and surgery with the support of haematinics, granulocyte colony-stimulating factor, recombinant erythropoietin and intraoperative normovolaemic haemodilution. This case illustrates the importance of maintaining effective, open communication and exploring acceptable therapeutic alternative in the management of these patients, whilst still respecting their beliefs.

A 31-day time to surgery compliant exercise training programme improves aerobic health in the elderly.

PubMed

Boereboom, C L; Phillips, B E; Williams, J P; Lund, J N

2016-06-01

Over 41,000 people were diagnosed with colorectal cancer (CRC) in the UK in 2011. The incidence of CRC increases with age. Many elderly patients undergo surgery for CRC, the only curative treatment. Such patients are exposed to risks, which increase with age and reduced physical fitness. Endurance-based exercise training programmes can improve physical fitness, but such programmes do not comply with the UK, National Cancer Action Team 31-day time-to-treatment target. High-intensity interval training (HIT) can improve physical performance within 2-4 weeks, but few studies have shown HIT to be effective in elderly individuals, and those who do employ programmes longer than 31 days. Therefore, we investigated whether HIT could improve cardiorespiratory fitness in elderly volunteers, age-matched to a CRC population, within 31 days. This observational cohort study recruited 21 healthy elderly participants (8 male and 13 female; age 67 years (range 62-73 years)) who undertook cardiopulmonary exercise testing before and after completing 12 sessions of HIT within a 31-day period. Peak oxygen consumption (VO2 peak) (23.9 ± 4.7 vs. 26.2 ± 5.4 ml/kg/min, p = 0.0014) and oxygen consumption at anaerobic threshold (17.86 ± 4.45 vs. 20.21 ± 4.11 ml/kg/min, p = 0.008) increased after HIT. It is possible to improve cardiorespiratory fitness in 31 days in individuals of comparable age to those presenting for CRC surgery.

Impact of Gender on 30-Day Complications After Adult Spinal Deformity Surgery.

PubMed

Kothari, Parth; Lee, Nathan J; Leven, Dante M; Lakomkin, Nikita; Shin, John I; Skovrlj, Branko; Steinberger, Jeremy; Guzman, Javier Z; Cho, Samuel K

2016-07-15

Retrospective study of prospectively collected data. To determine if postoperative morbidity for patients undergoing spinal deformity surgery varies by sex. Influence of sex has been investigated in other surgical procedures but has not yet been studied in adult spinal deformity surgery. The American College of Surgeons National Surgical Quality Improvement Program is a large multicenter clinical registry that prospectively collects preoperative risk factors, intraoperative variables, and 30-day postoperative morbidity and mortality outcomes from about 400 hospitals nationwide. Current Procedural Terminology codes were used to query the database for adults who underwent fusion for spinal deformity. Patients were separated into groups of male and female sex. Univariate analysis and multivariate logistic regression were used to analyze the effect of sex on the incidence of postoperative morbidity and mortality. Female sex was found to be a predictor of any complication[odds ratio (OR): 1.4, 95% confidence interval (CI) 1.2-1.7, P < 0.0001], intra- or postoperative RBC transfusion (OR: 1.6, 95% CI 1.4-1.9, P < .0001), urinary tract infection (OR: 2.0, 95% CI 1.2-3.3, P = 0.0046), and length of stay >5 days (OR: 1.3, 95% CI 1.1-1.5, P = 0.0015). Male sex was associated with higher rate of pulmonary (2.9% vs. 2.0%, P = 0.0344) and cardiac complications (0.9% vs. 0.5%, P = 0.0497). However, male sex as an independent risk factor for pulmonary (OR: 1.4, 95% CI 1.0-2.1, P = 0.0715) and cardiac complications (OR: 1.9, 95% CI 0.9-4.0, P = 0.1076) did not reach significance. Female sex was found to increase overall morbidity, particularly for urinary tract infection, transfusion, and length of stay >5 days. Male sex was associated with greater incidence of pulmonary and cardiac complications. Thus, sex and other patient characteristics highlighted must be considered as part of surgical risk planning and patient counseling. 3.

Outpatient-based scalp surgery without shaving and allowing use of shampoo.

PubMed

Hwang, Sun-Chul; Kim, Soon-Kwon; Park, Kwan-Woong; Im, Soo-Bin; Shin, Won-Han; Kim, Bum-Tae

2012-02-01

To assess the authors' experience of wound management following scalp mass surgery after introducing a policy of leaving hair unshaved and allowing patients to use shampoo. The authors retrospectively reviewed 93 patients who underwent outpatient-based excision of a scalp or skull mass. Surgical complications, mass depth, and maximal mass size were analyzed. All of the surgeries were performed without shaving around the lesion; the hair was simply parted along the proposed incision, and the parting was maintained using adhesive plasters. Routine antiseptic scalp preparations, skin closure with staples after mass excision, and topical ointment on the day following surgery were used, and use of shampoo was allowed. The staples were removed on postoperative days 7-10. The masses were located in the skin (23 cases), subcutaneously (64 cases), and subgaleally (6 cases). All patients except one had satisfactory wound healing. No infections occurred. Leaving hair unshaved and allowing patients to use shampoo can be applied in wound management after scalp mass surgery. Copyright © 2012 Elsevier Inc. All rights reserved.

Peripheral nerve blocks for paediatric day-stay surgery: one year's experience in a district general hospital.

PubMed Central

Keohane, M.; McAuley, D.; Ardill, A. C.

1995-01-01

Two hundred children underwent day-care surgery using peripheral nerve blockade as an adjunct to general anaesthesia during a twelve month period. Total post-operative analgesia was achieved in 86%, simple oral analgesia was needed in 9% and the remaining 5% of patients required systemic opiate administration for pain. PMID:7502400

The New York risk score for in-hospital and 30-day mortality for coronary artery bypass graft surgery.

PubMed

Hannan, Edward L; Farrell, Louise Szypulski; Wechsler, Andrew; Jordan, Desmond; Lahey, Stephen J; Culliford, Alfred T; Gold, Jeffrey P; Higgins, Robert S D; Smith, Craig R

2013-01-01

Simplified risk scores for coronary artery bypass graft surgery are frequently in lieu of more complicated statistical models and are valuable for informed consent and choice of intervention. Previous risk scores have been based on in-hospital mortality, but a substantial number of patients die within 30 days of the procedure. These deaths should also be accounted for, so we have developed a risk score based on in-hospital and 30-day mortality. New York's Cardiac Surgery Reporting System was used to develop an in-hospital and 30-day logistic regression model for patients undergoing coronary artery bypass graft surgery in 2009, and this model was converted into a simple linear risk score that provides estimated in-hospital and 30-day mortality rates for different values of the score. The accuracy of the risk score in predicting mortality was tested. This score was also validated by applying it to 2008 New York coronary artery bypass graft data. Subsequent analyses evaluated the ability of the risk score to predict complications and length of stay. The overall in-hospital and 30-day mortality rate for the 10,148 patients in the study was 1.79%. There are seven risk factors comprising the score, with risk factor scores ranging from 1 to 5, and the highest possible total score is 23. The score accurately predicted mortality in 2009 as well as in 2008, and was strongly correlated with complications and length of stay. The risk score is a simple way of estimating short-term mortality that accurately predicts mortality in the year the model was developed as well as in the previous year. Perioperative complications and length of stay are also well predicted by the risk score. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Ambulatory surgery and anaesthesia in HUKM, a teaching hospital in Malaysia: the first two years experience.

PubMed

Norsidah, A M; Yahya, N; Adeeb, N; Lim, A L

2001-03-01

Ambulatory or day care surgery is still in its infancy in this part of the world. Our newly built university affiliated hospital started its Day Surgery Centre in February 1998. It is the first multidisciplinary ambulatory surgery centre in a teaching hospital in the country. It caters for Orthopaedic surgery, Urology, Plastic surgery, Otorhinolaryngology, General surgery, Paediatric surgery and Ophthalmology. We have done 2,604 cases and our unanticipated admission rate is less than 2%. There has been no major morbidity or mortality. The problems of setting up a multidisciplinary ambulatory centre in a teaching hospital are discussed.

Variability of Arthroscopy Case Volume in Orthopaedic Surgery Residency.

PubMed

Gil, Joseph A; Waryasz, Gregory R; Owens, Brett D; Daniels, Alan H

2016-05-01

To examine orthopaedic surgery case logs for arthroscopy case volume during residency training and to evaluate trends in case volume and variability over time. Publicly available Accreditation Council for Graduate Medical Education surgical case logs from 2007 to 2013 for orthopaedic surgery residency were assessed for variability and case volume trends in shoulder, elbow, wrist, hip, knee, and ankle arthroscopy. The national average number of procedures performed in each arthroscopy category reported was directly compared from 2009 to 2013. The 10th and 90th percentile arthroscopy case volume was compared between 2007 and 2013 for shoulder and knee arthroscopy procedures. Subsequently, the difference between the 10th and 90th percentile arthroscopy case volume in each category in 2007 was compared with the difference between the 10th and 90th percentile arthroscopy case volume in each category in 2013. From 2007 to 2013, shoulder arthroscopy procedures performed per resident increased by 43.1% (P = .0001); elbow arthroscopy procedures increased by 28.0% (P = .00612); wrist arthroscopy procedures increased by 8.6% (P = .05); hip arthroscopy procedures, which were first reported in 2012, increased by 588.9%; knee arthroscopy procedures increased by 8.5% (P = .0435); ankle arthroscopy increased by 27.6% (P = .00149). The difference in knee and shoulder arthroscopy volume between residents in the 10th and 90th percentile in 2007 and residents in the 10th and 90th percentile in 2013 was not significant (P > .05). There was a 3.66-fold difference in knee arthroscopy volume between residents in the 10th and 90th percentile in 2007, whereas the difference was 3.36-fold in 2013 (P = .70). There was a 5.86-fold difference in shoulder arthroscopy case volume between residents in the 10th and 90th percentile in 2007, whereas the difference was 4.96-fold in 2013 (P = .29). The volume of arthroscopy cases performed by graduating orthopaedic surgery residents has

[Ambulatory surgery--definition, socioeconomic and legal aspects].

PubMed

Hempel, K; Siewert, J R; Lehr, L

1995-04-01

One of the most important intentions of GSG 1992 is the favourization of traditional ambulatory surgery by legislative measures. However in general surgery a much higher potential for a significant reduction in cases of classical hospitalization and thus concomitant substantial financial savings lies in short-stay eg. one-day/one-night procedures. At present methods of laparoscopic cholecystectomy, thyroid surgery and herniorrhaphy-together about 50% of common hospital patients-are developed enough to be practiced safely under this strategy. In the future further suitable techniques could evolve from minor access surgical concepts.

A Comparison of Inpatient Cost Per Day in General Surgery Patients with Type 2 Diabetes Treated with Basal-Bolus versus Sliding Scale Insulin Regimens.

PubMed

Phillips, Victoria L; Byrd, Anwar L; Adeel, Saira; Peng, Limin; Smiley, Dawn D; Umpierrez, Guillermo E

2017-01-01

The identification of cost-effective glycaemic management strategies is critical to hospitals. Treatment with a basal-bolus insulin (BBI) regimen has been shown to result in better glycaemic control and fewer complications than sliding scale regular insulin (SSI) in general surgery patients with type 2 diabetes mellitus (T2DM), but the effect on costs is unknown. We conducted a post hoc analysis of the RABBIT Surgery trial to examine whether total inpatient costs per day for general surgery patients with T2DM treated with BBI ( n  = 103) differed from those for patients with T2DM treated with SSI ( n  = 99) regimens. Data were collected from patient clinical and hospital billing records. Charges were adjusted to reflect hospital costs. General linearized models were used to estimate the risk-adjusted effects of BBI versus SSI treatment on average total inpatient costs per day. Risk-adjusted average total inpatient costs per day were $US5404. Treatment with BBI compared with SSI reduced average total inpatient costs per day by $US751 (14%; 95% confidence interval [CI] 20-4). Being treated in a university medical centre, being African American or having a bowel procedure or higher-volume pharmacy use significantly reduced costs per day. In general surgery patients with T2DM, a BBI regimen significantly reduced average total hospital costs per day compared with an SSI regimen. BBI has been shown to improve outcomes in a randomized controlled trial. Those results, combined with our findings regarding savings, suggest that hospitals should consider adopting BBI regimens in patients with T2DM undergoing surgery.

THE PATTERN OF LONGITUDINAL CHANGE IN SERUM CREATININE AND NINETY-DAY MORTALITY AFTER MAJOR SURGERY

PubMed Central

Hobson, Charles E; Pardalos, Panos

2016-01-01

Objective Calculate mortality risk that accounts for both severity and recovery of postoperative kidney dysfunction using the pattern of longitudinal change in creatinine. Summary Background Data Although the importance of renal recovery after acute kidney injury (AKI) is increasingly recognized, the complex association that accounts for longitudinal creatinine changes and mortality is not fully described. Methods We used routinely collected clinical information for 46,299 adult patients undergoing major surgery to develop a multivariable probabilistic model optimized for non-linearity of serum creatinine time series that calculates the risk function for ninety-day mortality. We performed a 70/30 cross validation analysis to assess the accuracy of the model. Results All creatinine time series exhibited nonlinear risk function in relation to ninety-day mortality and their addition to other clinical factors improved the model discrimination. For any given severity of AKI, patients with complete renal recovery, as manifested by the return of the discharge creatinine to the baseline value, experienced a significant decrease in the odds of dying within ninety days of admission compared to patients with partial recovery. Yet, for any severity of AKI even complete renal recovery did not entirely mitigate the increased odds of dying as patients with mild AKI and complete renal recovery still had significantly increased odds for dying compared to patients without AKI (odds ratio 1,48 (95% confidence interval 1.30-1.68). Conclusions We demonstrate the nonlinear relationship between both severity and recovery of renal dysfunction and ninety-day mortality after major surgery. We have developed an easily applicable computer algorithm that calculates this complex relationship. PMID:26181482

Increasing Severity of Malnutrition Is Associated With Poorer 30-Day Outcomes in Patients Undergoing Hip Fracture Surgery.

PubMed

Chung, Andrew S; Hustedt, Joshua W; Walker, Robert; Jones, Clifford; Lowe, Jason; Russell, George V

2018-04-01

Low serum albumin levels (hypoalbuminemia) have classically been used to identify malnutrition. The effect of increasing severity of malnutrition on postoperative outcomes in patients undergoing hip fracture surgery has not been well delineated on a large scale. Retrospective. Multicenter. A total of 12,373 patients undergoing hip fracture surgery from 2006 to 2013 National Surgery Quality Improvement Project data were identified. Patient demographic, comorbidity, and preoperative laboratory data and complication, reoperation, and readmission data were collected. Multivariate logistic regression was used to determine the effect of increasing severity of malnutrition on rates of 30-day postoperative complications, readmissions, and reoperations. A total of 12,373 hip fractures met inclusion criteria. A total of 6506 (52.6%) patients had normal albumin levels (albumin ≥3.5 g/dL), 3205 (25.9%) patients were mildly malnourished (albumin 3.1-3.49 g/dL), 2265 (18.3%) were moderately malnourished (albumin 2.4-3.1 g/dL), and 397 (3.2%) patients were severely malnourished (albumin <2.4 g/dL). Mean age was similar between the 4 cohorts (P < 0.001). Severe malnutrition was associated with a 2-fold increase in the odds of postoperative complications and mortality when compared with mild malnutrition (P < 0.001). Increasing severity of malnutrition was associated with significantly longer lengths of stay and higher odds of experiencing a related readmission (P < 0.001). Increasing severity of hypoalbuminemia is independently associated with poorer outcomes in the 30 days after hip fracture surgery. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Capturing Plastic Surgery on Film-Making Reconstruction Visible.

PubMed

Lunger, Alexander; Ismail, Tarek; Sarraf, Namita; Epple, Christian; Schaefer, Kristin Marit; Schaefer, Dirk J

2017-09-01

The Swiss Plastic Surgery Association (https://plasticsurgery.ch/en/) decided to produce a corporate video to illustrate the concept of "plastic surgery of confidence" to the public. We show the diversity of specializations and the vast range of tasks that surgeons passionately handle day in and day out. We wanted to convey 2 main messages: first, that plastic surgery is more than just cosmetic surgery, and second, that plastic surgery in Switzerland is synonymous with quality and confidence. We selected 17 topics that we felt had good filmic potential and would best explain to the public what plastic surgery is about. This included the selection of appropriate patients, experts, and locations from all over the country. We thought it crucial to show the initial preoperative situation, as only in this case would the achievement of reconstruction be evident and comprehensive to the layman audience. The actual production was filmed in 5 different locations and took 5 days of shooting. We recorded 17 surgeons, 9 patients, and about 30 voluntary background actors. From 23 hours of footage, we created a 7 minute, 22 second corporate video, recorded in 3 of the Swiss national languages. The video was presented to the public online in June 2016, on the same day as the National Open Day of Plastic Surgery in Switzerland. The video is available online. We evaluated the impact of the video using a questionnaire for lay people and observed that it could substantially improve the perception of our specialty, especially regarding the reconstructive aspect. We feel that a freely available corporate video is a very useful means to promote plastic surgery and help patients better understand what it is all about.

Capturing Plastic Surgery on Film—Making Reconstruction Visible

PubMed Central

Ismail, Tarek; Sarraf, Namita; Epple, Christian; Schaefer, Kristin Marit; Schaefer, Dirk J.

2017-01-01

Summary: The Swiss Plastic Surgery Association (https://plasticsurgery.ch/en/) decided to produce a corporate video to illustrate the concept of "plastic surgery of confidence" to the public. We show the diversity of specializations and the vast range of tasks that surgeons passionately handle day in and day out. We wanted to convey 2 main messages: first, that plastic surgery is more than just cosmetic surgery, and second, that plastic surgery in Switzerland is synonymous with quality and confidence. We selected 17 topics that we felt had good filmic potential and would best explain to the public what plastic surgery is about. This included the selection of appropriate patients, experts, and locations from all over the country. We thought it crucial to show the initial preoperative situation, as only in this case would the achievement of reconstruction be evident and comprehensive to the layman audience. The actual production was filmed in 5 different locations and took 5 days of shooting. We recorded 17 surgeons, 9 patients, and about 30 voluntary background actors. From 23 hours of footage, we created a 7 minute, 22 second corporate video, recorded in 3 of the Swiss national languages. The video was presented to the public online in June 2016, on the same day as the National Open Day of Plastic Surgery in Switzerland. The video is available online. We evaluated the impact of the video using a questionnaire for lay people and observed that it could substantially improve the perception of our specialty, especially regarding the reconstructive aspect. We feel that a freely available corporate video is a very useful means to promote plastic surgery and help patients better understand what it is all about. PMID:29062635

Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery.

PubMed

Nunley, Pierce D; Mundis, Gregory M; Fessler, Richard G; Park, Paul; Zavatsky, Joseph M; Uribe, Juan S; Eastlack, Robert K; Chou, Dean; Wang, Michael Y; Anand, Neel; Frank, Kelly A; Stone, Marcus B; Kanter, Adam S; Shaffrey, Christopher I; Mummaneni, Praveen V

2017-12-01

OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

Impact of high- versus low-dose neuromuscular blocking agent administration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery.

PubMed

Boon, Martijn; Martini, Chris; Yang, H Keri; Sen, Shuvayu S; Bevers, Rob; Warlé, Michiel; Aarts, Leon; Niesters, Marieke; Dahan, Albert

2018-01-01

Recent data shows that a neuromuscular block (NMB) induced by administration of high doses of rocuronium improves surgical conditions in certain procedures. However, there are limited data on the effect such practices on postoperative outcomes. We performed a retrospective analysis to compare unplanned 30-day readmissions in patients that received high-dose versus low-dose rocuronium administration during general anesthesia for laparoscopic retroperitoneal surgery. This retrospective cohort study was performed in the Netherlands in an academic hospital where routine high-dose rocuronium NMB has been practiced since July 2015. Charts of patients receiving anesthesia between January 2014 and December 2016 were searched for surgical cases receiving high-dose rocuronium and matched with respect to procedure, age, sex and ASA classification to patients receiving low-dose rocuronium. The primary post-operative outcome was unplanned 30-day readmission rate. There were 130 patients in each cohort. Patients in the high- and low-dose rocuronium cohorts received 217 ± 49 versus 37 ± 5 mg rocuronium, respectively. In the high-dose rocuronium group neuromuscular activity was consistently monitored; matched patients were unreliably monitored. All patients receiving high-dose rocuronium were reversed with sugammadex, while just 33% of matched patients were reversed with sugammadex and 20% with neostigmine; the remaining patients were not reversed. Unplanned 30-day readmission rate was significantly lower in the high-dose compared to the low-dose rocuronium cohort (3.8% vs. 12.7%; p = 0.03; odds ratio = 0.33, 95% C.I. 0.12-0.95). This small retrospective study demonstrates a lower incidence of unplanned readmissions within 30-days following laparoscopic retroperitoneal surgery with high-dose relaxant anesthesia and sugammadex reversal in comparison to low-dose relaxant anesthesia. Further prospective studies are needed in larger samples to corroborate our findings and

Cutting Edge Treatment: Pain and Surgery in the Ashley X Case

ERIC Educational Resources Information Center

Sobsey, Dick

2009-01-01

Pain and surgery are phenomena that have frequently been mentioned in the discussions of the Ashley X case. This article describes how pain and surgery have been used selectively to argue for or against the Ashley X procedures. Few if any of the many publications discussing the merits of the Ashley-X procedures can be said to strike a reasonable…

Hindfoot arthroscopic surgery for posterior ankle impingement: a systematic surgical approach and case series.

PubMed

Smyth, Niall A; Murawski, Christopher D; Levine, David S; Kennedy, John G

2013-08-01

Hindfoot arthroscopic surgery has been described as a minimally invasive surgical treatment for posterior ankle impingement syndrome. The current article describes a systematic approach for identifying relevant hindfoot structures as well as the clinical results of a case series. To present a structured systematic surgical approach for identifying relevant anatomic structures and abnormalities during hindfoot arthroscopic surgery. In addition, we report the clinical results of a case series. Case series; Level of evidence, 4. The systematic surgical approach divides the extra-articular structures of the hindfoot into quadrants as defined by the intermalleolar ligament. Twenty-two patients underwent hindfoot arthroscopic surgery for the treatment of posterior ankle impingement syndrome. The mean follow-up time was 25 months (range, 14-35 months). Standard patient-reported outcome questionnaires of the foot and ankle outcome score (FAOS) and Short Form-12 (SF-12) general health survey were administered at standard time points after surgery. Return to sporting activities was also calculated as the time period from the date of surgery until the patient was able to participate at their previous level of activity. The mean FAOS score improved from 59 (range, 22-94) preoperatively to 86 (range, 47-100) postoperatively (P < .01). The mean SF-12 score showed similar improvement with a mean of 66 (range, 42-96) preoperatively to 86 (range, 56-98) postoperatively (P < .01). Nineteen patients reported competing at some level of athletic sport before surgery. All patients returned to their previous level of competition after surgery. The mean time to return to sporting activities was 12 weeks (range, 6-16 weeks). Two complications were reported postoperatively: 1 wound infection and 1 case of dysesthesia of the deep peroneal nerve. Hindfoot arthroscopic surgery is a safe and effective treatment strategy for posterior ankle impingement syndrome. In addition, it allows the

Revision surgery after cervical laminoplasty: report of five cases and literature review.

PubMed

Shigematsu, Hideki; Koizumi, Munehisa; Matsumori, Hiroaki; Iwata, Eiichiro; Kura, Tomohiko; Okuda, Akinori; Ueda, Yurito; Tanaka, Yasuhito

2015-06-01

Revision surgery after laminoplasty is rarely performed, and there are few reports of this procedure in the English literature. To evaluate the reasons why patients underwent revision surgery after laminoplasty and to discuss methods of preventing the need for revision surgery. A literature review with a comparative analysis between previous reports and present cases was also performed. Case report and literature review. Five patients who underwent revision surgery after laminoplasty. Diagnosis was based on the preoperative computed tomography and magnetic resonance imaging findings. Neurologic findings were evaluated using the Japanese Orthopedic Association score. A total of 237 patients who underwent cervical laminoplasty for cervical spondylotic myelopathy from 1990 to 2010 were reviewed. Patients with ossification of the posterior longitudinal ligament, renal dialysis, infection, tumor, or rheumatoid arthritis were excluded. Five patients who underwent revision surgery for symptoms of recurrent myelopathy or radiculopathy were identified, and the clinical courses and radiological findings of these patients were retrospectively reviewed. The average interval from the initial surgery to revision surgery was 15.0 (range 9-19) years. The patients were four men and one woman with an average age at the time of the initial operation of 49.8 (range 34-65) years. Four patients developed symptoms of recurrent myelopathy after their initial surgery, for the following reasons: adjacent segment canal stenosis, restenosis after inadequate opening of the lamina with degenerative changes, and trauma after inadequate opening of the lamina. One patient developed new radiculopathy symptoms because of foraminal stenosis secondary to osteoarthritis at the Luschka and zygapophyseal joints. All patients experienced resolution of their symptoms after revision surgery. Revision surgery after laminoplasty is rare. Inadequate opening of the lamina is one of the important reasons for

[Cerebral stereotactic biopsy and surgery: Report of 100 cases].

PubMed

Khouja, N; Khaldi, M; Boubaker, A; Yedeas, M; Bahri, K; Ben Hammouda, K; Aouidj, L; Jemel, H

1999-12-01

To report the results of the use of the stereotactic techniques in the management of intra cranial lesions. Between july 1994 and march 1998, we carried out 117 stereotactic procedures of whom only 100 cases were analyzed. All the procedures were achieved after a CT scan. Patients were separated in two groups: (A) stereotactic biopsy (91 patients), (B) surgery with laser guidance (9 patients). The mean age in group A was 38 years (2-75 years) versus 27 years (11-66 years) in group B. The sex-ratio was 1.3. In the group A, the correct pathological diagnosis was obtained in 91.2% of cases. Glial tumors was the frequent histopathological variety of tumor (67.47%). Only one patient was operated after biopsy for a bilateral meningioma of the anterior 1/3 of the falx. There was only one death (1.09%) and 3.29% of transitory complications. In the group B, all patients were operated with laser guidance. Thirty seven per cent of patients underwent radiotherapy after the stereotactic biopsy or surgery. Stereotactic biopsy is a reliable method for the histopathological diagnosis of deep-seated brain lesions. Surgery with laser guidance is a useful alternative for the management of small deep-seated lesions or lesions located in functional areas.

Tapia's Syndrome after Corrective Jaw Surgery under General Anesthesia: A Case Report.

PubMed

Izadi, Farzad; Ahmadi, Aslan; Daneshvar, Ali; Safdarian, Mahdi

2017-03-01

Tapia's syndrome is a rare complication of recurrent laryngeal and hypoglossal nerve paralysis due to anesthetic airway mismanagement or malpositioning of the patient's head during surgery. Here we present a case of Tapia's syndrome in a 22-year-old male after corrective jaw surgery under general anesthesia, with a long period of recovery, related to airway management procedures and/or overstretching of the neck during positioning for surgery. Although it is a rare condition, every surgeon should be aware of Tapia's syndrome in order to consider the correct positioning of the head and endotracheal tube during surgery and avoid this complication.

The day of surgery for your child

MedlinePlus

... to do the surgery. Find out about any medicines your child takes. Tell them about any prescription, over the ... give your child pain medicine and any other medicine your child needs. The nurse will also encourage your child ...

Periosteal grafts as barriers in periradicular surgery: report of two cases.

PubMed

Tobón-Arroyave, S I; Domínguez-Mejía, J S; Flórez-Moreno, G A

2004-09-01

To describe the usefulness of periosteal grafts as barriers for bone regeneration in periradicular surgery when advanced periodontal breakdown occurs. The treatment of advanced periodontal breakdown as a result of an associated endodontic lesion constitutes a multifaceted challenge to the clinician. If the source of the irritation cannot be removed by orthograde endodontic treatment, nonsurgical and surgical endodontic/periodontal intervention may be required. Two cases with suppurative chronic apical periodontitis with apicomarginal communication are described. Clinical and radiological evaluations were completed immediately prior to surgery, a week later and every 2 months after surgery for 10 months. Both patients were treated using split-thickness flaps and lateral displacement of the periosteum prior to suturing, in order to close the communication between the oral and the periapical surroundings. A remission of the clinical signs and symptoms, and successful healing in the short-term were achieved in these cases. Periapical and periodontal lesions are closely related through pathways of communication. Disruption of the cortical plate and the presence of dentoalveolar sinus tracts can have a deleterious effect on the regeneration process after periradicular surgery. The adoption of supplementary periodontal surgical techniques may help to solve some of the difficulties in the healing process in periradicular surgery. Periosteal grafts have been shown to have the potential to stimulate bone formation when used as a graft material.

Do prices reflect the costs of cardiac surgery in the elderly?

PubMed

Coelho, Pedro; Rodrigues, Vanessa; Miranda, Luís; Fragata, José; Pita Barros, Pedro

2017-01-01

Payment for cardiac surgery in Portugal is based on a contract agreement between hospitals and the health ministry. Our aim was to compare the prices paid according to this contract agreement with calculated costs in a population of patients aged ≥65 years undergoing cardiac surgery in one hospital department. Data on 250 patients operated between September 2011 and September 2012 were prospectively collected. The procedures studied were coronary artery bypass graft surgery (CABG) (n=67), valve surgery (n=156) and combined CABG and valve surgery (n=27). Costs were calculated by two methods: micro-costing when feasible and mean length of stay otherwise. Price information was provided by the hospital administration and calculated using the hospital's mean case-mix. Thirty-day mortality was 3.2%. Mean EuroSCORE I was 5.97 (standard deviation [SD] 4.5%), significantly lower for CABG (p<0.01). Mean intensive care unit stay was 3.27 days (SD 4.7) and mean hospital stay was 9.92 days (SD 6.30), both significantly shorter for CABG. Calculated costs for CABG were €6539.17 (SD 3990.26), for valve surgery €8289.72 (SD 3319.93) and for combined CABG and valve surgery €11 498.24 (SD 10 470.57). The payment for each patient was €4732.38 in 2011 and €4678.66 in 2012 based on the case-mix index of the hospital group, which was 2.06 in 2011 and 2.21 in 2012; however, the case-mix in our sample was 6.48 in 2011 and 6.26 in 2012. The price paid for each patient was lower than the calculated costs. Prices would be higher than costs if the case-mix of the sample had been used. Costs were significantly lower for CABG. Copyright © 2016 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Parotitis after epidural anesthesia in plastic surgery: report of three cases.

PubMed

Rosique, Marina Junqueira Ferreira; Rosique, Rodrigo Gouvea; Costa, Ilson Rosique; Lara, Brunno Rosique; Figueiredo, Jozé Luiz Ferrari; Ribeiro, Davidson Gomes Barbosa

2013-08-01

Acute swelling of the parotid glands after general anesthesia has become known as anesthesia mumps. Its cause is unknown. Only one case of postsurgical parotitis without general anesthesia is reported. This report describes three cases in this setting after plastic surgery. A 37-year-old women underwent breast surgery and abdominoplasty with a dual thoracic/lumbar epidural block (bupivacaine 0.5 %). The operative time totaled almost 6 h. Subsequently, 4 h after surgery, the patient experienced painless bilateral parotid swelling without palpable crepitus. The edema resolved completely within 12 h under clinical observation and parenteral hydration. A 45-year-old patient received subglandular breast implants and body contouring with liposuction, all with the patient under a dual thoracic/lumbar epidural block with 0.5 % marcaine. The total surgical time was 5 h. Subsequently, 3 h after surgery, the patient experienced a similar clinical presentation. The problem resolved completely in 36 h with clinical observation and parenteral hydration. CASE 3: A 30-year-old patient received a subglandular breast implant and underwent liposuction of the outer thighs using a dual thoracic/lumbar epidural block with lidocaine 1 %. The duration of surgery was 1 h. Subsequently, 5 h postoperatively, the patient experienced a similar clinical presentation. Dexamethasone and parenteral hydration were administered. The problem resolved completely in 48 h without sequelae. The occurrence of parotitis in patients undergoing surgery under epidural anesthesia is a novel situation, which increases the range of possible etiologies for this little known condition. Dehydration leading to transient parotid secretion obstruction may play a significant role. Further reports of parotitis occurring in the regional anesthesia setting are expected to help elucidate its pathophysiology. This journal requires that authors assign a level of evidence to each article. For a full description of

The Michigan Spine Surgery Improvement Collaborative: a statewide Collaborative Quality Initiative.

PubMed

Chang, Victor; Schwalb, Jason M; Nerenz, David R; Pietrantoni, Lisa; Jones, Sharon; Jankowski, Michelle; Oja-Tebbe, Nancy; Bartol, Stephen; Abdulhak, Muwaffak

2015-12-01

OBJECT Given the scrutiny of spine surgery by policy makers, spine surgeons are motivated to demonstrate and improve outcomes, by determining which patients will and will not benefit from surgery, and to reduce costs, often by reducing complications. Insurers are similarly motivated. In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved-and continue to improve-the quality of patient care throughout the state of Michigan. METHODS MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals. RESULTS As of July 1, 2015, a total of 6397 cases

Delayed Complications After Transsphenoidal Surgery for Pituitary Adenomas.

PubMed

Alzhrani, Gmaan; Sivakumar, Walavan; Park, Min S; Taussky, Philipp; Couldwell, William T

2018-01-01

Perioperative complications after transsphenoidal surgery for pituitary adenomas have been well documented in the literature; however, some complications can occur in a delayed fashion postoperatively, and reports are sparse about their occurrence, management, and outcome. Here, we describe delayed complications after transsphenoidal surgery and discuss the incidence, temporality from the surgery, and management of these complications based on the findings of studies that reported delayed postoperative epistaxis, delayed postoperative cavernous carotid pseudoaneurysm formation and rupture, vasospasm, delayed symptomatic hyponatremia, hypopituitarism, hydrocephalus, and sinonasal complications. Our findings from this review revealed an incidence of 0.6%-3.3% for delayed postoperative epistaxis at 1-3 weeks postoperatively, 18 reported cases of delayed carotid artery pseudoaneurysm formation at 2 days to 10 years postoperatively, 30 reported cases of postoperative vasospasm occurring 8 days postoperatively, a 3.6%-19.8% rate of delayed symptomatic hyponatremia at 4-7 days postoperatively, a 3.1% rate of new-onset hypopituitarism at 2 months postoperatively, and a 0.4%-5.8% rate of hydrocephalus within 2.2 months postoperatively. Sinonasal complications are commonly reported after transsphenoidal surgery, but spontaneous resolutions within 3-12 months have been reported. Although the incidence of some of these complications is low, providing preoperative counseling to patients with pituitary tumors regarding these delayed complications and proper postoperative follow-up planning is an important part of treatment planning. Copyright © 2017 Elsevier Inc. All rights reserved.

A case study of infant physiologic response to skin-to-skin contact following surgery for complex congenital heart disease

PubMed Central

Harrison, Tondi M.; Ludington-Hoe, Susan

2014-01-01

Background Infants with complex congenital heart disease requiring surgical intervention within the first days or weeks of life may be the most seriously ill infants needing intensive nursing and medical care immediately after birth. Skin to skin contact (SSC) is well-accepted and practiced as a positive therapeutic intervention in premature infants, but is not routinely offered to infants in cardiac intensive care units. Physiologic effects of SSC in the congenital heart disease population must be examined before recommending incorporation of SSC into standard care routines. Objective The purpose of this case study was to describe the physiologic response to a single session of SSC in an 18-day-old infant with hypoplastic left heart syndrome. Methods Repeated measures of heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature were recorded 30 minutes prior to SSC, during SSC (including interruptions for bottle and breast feedings), and 10 minutes after SSC was completed. Results All physiologic parameters were clinically acceptable throughout the 135-minute observation. Conclusion This case study provides beginning evidence that SSC is safe in full-term infants following surgery for complex congenital heart disease. Further research with a larger sample is needed to examine effects of SSC on infant physiology before surgery and earlier in the postoperative time period as well as on additional outcomes such as length of stay, maternal-infant interaction, and neurodevelopment. PMID:25325374

A Case Study of Infant Physiologic Response to Skin-to-Skin Contact After Surgery for Complex Congenital Heart Disease.

PubMed

Harrison, Tondi M; Ludington-Hoe, Susan

2015-01-01

Infants with complex congenital heart disease requiring surgical intervention within the first days or weeks of life may be the most seriously ill infants needing intensive nursing and medical care. Skin-to-skin contact (SSC) is well accepted and practiced as a positive therapeutic intervention in premature infants but is not routinely offered to infants in cardiac intensive care units. The physiologic effects of SSC in the congenital heart disease population must be examined before recommending incorporation of SSC into standard care routines. The purpose of this case study was to describe the physiologic response to a single session of SSC in an 18-day-old infant with hypoplastic left heart syndrome. Repeated measures of heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature were recorded 30 minutes before SSC, during SSC (including interruptions for bottle and breast feedings), and 10 minutes after SSC was completed. All physiologic parameters were clinically acceptable throughout the 135-minute observation. This case study provides beginning evidence that SSC is safe in full-term infants after surgery for complex congenital heart disease. Further research with a larger sample is needed to examine the effects of SSC on infant physiology before surgery and earlier in the postoperative time period as well as on additional outcomes such as length of stay, maternal-infant interaction, and neurodevelopment.

Pain and behaviour changes in children following surgery.

PubMed

Power, Nina Mary; Howard, Richard F; Wade, Angie M; Franck, Linda S

2012-10-01

To quantify postoperative pain and problematic behaviour (PB) in children at home following day-case (same day admission and discharge) or inpatient (≥1 night in hospital) surgery, to identify factors associated with PB at 2 and 4 weeks after discharge and to determine whether pain is associated with PB after adjustment for other factors. Children scheduled for elective surgery were recruited to a descriptive study involving direct observation and self-report questionnaires. The principal outcomes were pain and PB on the 2nd post-discharge day and after the 1st, 2nd and 4th weeks. 131 parents and their children (aged 2-12years) participated in the study. 93% of children had pain and 73% exhibited PB on day 2 after discharge. The incidence of pain and PB decreased over time, but 25% of children still had pain and 32% PB at week 4. Factors associated with PB were child's previous pain experience, parent and child anxiety and parent's level of education. There was a high incidence of pain and PB persisting for several weeks after surgery in this cohort of children. Previous painful medical experiences and anxiety were important modifiable factors that require further attention from healthcare providers and researchers to potentially improve health and social outcomes for children after surgery.

Acute respiratory failure due to hemothorax after posterior correction surgery for adolescent idiopathic scoliosis: a case report.

PubMed

Ogura, Yoji; Watanabe, Kota; Hosogane, Naobumi; Toyama, Yoshiaki; Matsumoto, Morio

2013-04-11

Although posterior correction and fusion surgery using pedicle screws carries the risk of vascular injury, a massive postoperative hemothorax in a patient with adolescent idiopathic scoliosis (AIS) is quite rare. We here report a case of a 12-year-old girl with AIS who developed a massive postoperative hemothorax. The patient had a double thoracic curve with Cobb angles of 63° at T2-7 and 54° at T7-12. Posterior correction and fusion surgery was performed using a segmental pedicle screw construct placed between T2 and T12. Although the patient's respiration was stable during the surgery, 20 minutes after removing the trachea tube, the patient's pulse oximetry oxygen saturation suddenly decreased to 80%. A contrast CT scan showed a massive left hemothorax, and a drainage tube was quickly inserted into the chest. The patient was re-intubated and a positive end-expiratory pressure of 5 cmH(2)O applied, which successfully stopped the bleeding. The patient was extubated 4 days after surgery without incident. Based on contrast CT scans, it was suspected that the hemothorax was caused by damage to the intercostal arteries or branches during pedicle probing on the concave side of the upper thoracic curve. Extensive post-surgical blood tests, echograms, and CT and MRI radiographs did not detect coagulopathy, pulmonary or vascular malformation, or any other possible causative factors. This case underscores the potential risk of massive hemothorax related to thoracic pedicle screw placement, and illustrates that for this serious complication, respiratory management with positive airway pressure, along with a chest drainage tube, can be an effective treatment option.

Outcome in dogs with advanced (stage 3b) anal sac gland carcinoma treated with surgery or hypofractionated radiation therapy.

PubMed

Meier, V; Polton, G; Cancedda, S; Roos, M; Laganga, P; Emmerson, T; Rohrer Bley, C

2017-09-01

Stage 3b anal sac gland carcinoma (ASGC) can be life-threatening. A surgical approach is not always possible or may be declined. Dogs with stage 3b ASGC treated with surgery or conformal radiation therapy (RT) with 8 × 3.8 Gy (total dose 30.4 Gy, over 2.5 weeks) were retrospectively evaluated. Patient characteristics, median progression-free interval (PFI) and median survival time (MST) were compared. Twenty-eight dogs were included; 15 underwent surgery, 13 underwent RT. At the time of presentation, 21% showed life-threatening obstipation and 25% showed hypercalcaemia. PFI and MST for surgery cases were 159 days (95% CI: 135-184 days) and 182 days (95% CI: 146-218 days), both significantly lower than for RT cases with 347 days (95% CI: 240-454 days) and 447 days (95% CI: 222-672 days), (P = 0.01, P = 0.019). Surgery as well as RT led to a fast relief of symptoms. PFI and survival of surgical patients were significantly inferior to that of a comparable patient group treated with conformal hypofractionated RT. © 2016 John Wiley & Sons Ltd.

Virtual reality case-specific rehearsal in temporal bone surgery: a preliminary evaluation.

PubMed

Arora, Asit; Swords, Chloe; Khemani, Sam; Awad, Zaid; Darzi, Ara; Singh, Arvind; Tolley, Neil

2014-01-01

1. To investigate the feasibility of performing case-specific surgical rehearsal using a virtual reality temporal bone simulator. 2. To identify potential clinical applications in temporal bone surgery. Prospective assessment study. St Mary's Hospital, Imperial College NHS Trust, London UK. Sixteen participants consisting of a trainer and trainee group. Twenty-four cadaver temporal bones were CT-scanned and uploaded onto the Voxelman simulator. Sixteen participants performed a 90-min temporal bone dissection on the generic simulation model followed by 3 dissection tasks on the case simulation and cadaver models. Case rehearsal was assessed for feasibility. Clinical applications and usefulness were evaluated using a 5-point Likert-type scale. The upload process required a semi-automated system. Average time for upload was 20 min. Suboptimal reconstruction occurred in 21% of cases arising when the mastoid process and ossicular chain were not captured (n = 2) or when artefact was generated (n = 3). Case rehearsal rated highly (Likert score >4) for confidence (75%), facilitating planning (75%) and training (94%). Potential clinical applications for case rehearsal include ossicular chain surgery, cochlear implantation and congenital anomalies. Case rehearsal of cholesteatoma surgery is not possible on the current platform due to suboptimal soft tissue representation. The process of uploading CT data onto a virtual reality temporal bone simulator to perform surgical rehearsal is feasible using a semi-automated system. Further clinical evaluation is warranted to assess the benefit of performing patient-specific surgical rehearsal in selected procedures. Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Extensive bilateral corneal edema 6 weeks after cataract surgery: Keratopathy due to Asclepias physocarpa: a case report.

PubMed

Matsuura, Kazuki; Hatta, Shiro; Terasaka, Yuki; Inoue, Yoshitsugu

2017-01-18

Surgeons may be unaware of the ability of plant toxins to cause corneal damage. Therefore, corneal damage following intraocular surgery due to plant toxins may be misdiagnosed as postoperative infection. A 74-year-old man presented with hyperemia and reduced visual acuity in both eyes 6 weeks after uneventful cataract surgery. We observed extensive hyperemia and corneal stromal edema with Descemet's folds in both eyes. After obtaining a detailed patient history, we diagnosed plant toxin-induced corneal edema due to Asclepias physocarpa, which can induce corneal edema by inhibiting the Na + /K + ATPase activity of the corneal endothelium. Antimicrobial and steroid eye drops and an oral steroid were prescribed accordingly. Symptons began to improve on day 3 and had almost completely resolved by day 6. At 1 month, the patient had fully recovered without any sequelae. The correct diagnosis was possible in the present case as symptoms were bilateral and the patient was able to report his potential exposure to plant toxins. However, if the symptoms had been unilateral and the patient had been unaware of these toxins, he may have undergone unnecessary surgical interventions to treat non-existent postoperative endophthalmitis.

Elective gastropexy with a reusable single-incision laparoscopic surgery port in dogs: 14 cases (2012-2013).

PubMed

Stiles, Mandy; Case, J Brad; Coisman, James

2016-08-01

OBJECTIVE To describe the technique, clinical findings, and short-term outcome in dogs undergoing laparoscopic-assisted incisional gastropexy with a reusable single-incision surgery port. DESIGN Retrospective case series. ANIMALS 14 client-owned dogs. PROCEDURES Medical records of dogs referred for elective laparoscopic gastropexy between June 2012 and August 2013 were reviewed. History, signalment, results of physical examination and preoperative laboratory testing, surgical procedure, duration of surgery, postoperative complications, duration of hospital stay, and short-term outcome were recorded. All patients underwent general anesthesia and were positioned in dorsal recumbency. After an initial limited laparoscopic exploration, single-incision laparoscopic-assisted gastropexy was performed extracorporeally in all dogs via a conical port placed in a right paramedian location. Concurrent procedures included laparoscopic ovariectomy (n = 4), gastric biopsy (2), and castration (7). Short-term outcome was evaluated. RESULTS Median duration of surgery was 76 minutes (range, 40 to 90 minutes). Intraoperative complications were minor and consisted of loss of pneumoperitoneum in 2 of 14 dogs. A postoperative surgical site infection occurred in 1 dog and resolved with standard treatment. Median duration of follow-up was 371 days (range, 2 weeks to 1.5 years). No dogs developed gastric dilation-volvulus during the follow-up period, and all owners were satisfied with the outcome. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that single-incision laparoscopic-assisted gastropexy with a reusable conical port was feasible and effective in appropriately selected cases. Investigation of the potential benefits of this reusable port versus single-use devices for elective gastropexy in dogs is warranted.

[Laparoscopic surgery for malignancies of the colon, rectum, and anus in Lithuania in 2008].

PubMed

Samalavicius, Narimantas Evaldas; Rudinskaite, Giedre; Pavalkis, Dainius; Latkauskas, Tadas; Kaselis, Nerijus; Sidlauskas, Zilvinas; Sniuolis, Pranas; Poskus, Tomas; Kvedaras, Vytautas; Strupas, Kestutis; Poskus, Eligijus

2009-01-01

THE OBJECTIVE OF THIS STUDY: was to analyze data on laparoscopic surgery for malignant diseases of the colon, rectum, and anus in Lithuania during the period of January 1, 2005, to February 15, 2008. During the above-mentioned period in Lithuania, 130 laparoscopic surgeries for malignancies of colon, rectum, and anus were performed in seven different hospitals. There were 73 males and 57 females with a mean age of 68 years (range, 35-85 years). Laparoscopic procedures were attempted in 140 cases. Out of them, 130 were completed laparoscopically; 10 operations were converted to open, and conversion rate was 7.1%. Twenty-seven (20.8%) patients had stage I, 45 (34.6%) stage II, 45 (34.6%) stage III, and 13 (10%) stage IV disease. Ninety-two (70.8%) patients underwent straight laparoscopic surgery and 38 (29.2%) - hand-assisted laparoscopic surgery. Time in surgery was from 50 to 365 min, with a mean of 183 min. During 130 operations, in 11 (8.5%) cases, blood vessels were ligated through specimen retrieval site. Out of 104 operations, where anastomosis was performed (23 abdominoperineal resections and 3 Hartmann's procedures), in 68 (65.4%) cases it was done laparoscopically and in 36 (34.6%) cases using conventional extracorporal suturing. Hospital stay ranged from 7 to 59 days, with a mean of 12 days. One (0.8%) patient died. Postoperative complications occurred in 27 (20.8%) cases. Reoperation rate was 4.6% (6 cases). Complications were as follows: suture insufficiency (3 cases), eventration (3 cases), wound infection (7 cases), intraperitoneal abscess (1 case), abdominal wall phlegmon (1 case), intra-abdominal infiltrate (1 case), perineal hematoma (1 case), proctovaginal fistula (2 case), intraoperative bleeding from uterus (1 case), urinary retention (4 cases), cystitis (1 case), pneumonia (1 case), acute cardiovascular insufficiently (1 case). In histological specimens, 10 lymph nodes were found on the average (range, 2 to 27). Laparoscopic surgery for

Individualized strategy for clopidogrel suspension in patients undergoing off-pump coronary surgery for acute coronary syndrome: a case-control study.

PubMed

Mannacio, Vito; Meier, Pascal; Antignano, Anita; Di Tommaso, Luigi; De Amicis, Vincenzo; Vosa, Carlo

2014-10-01

An increasing number of patients presenting for urgent coronary surgery have been exposed to clopidogrel, which constitutes a risk of bleeding and related events. Based on the wide variability in clopidogrel response and platelet function recovery after cessation, we evaluated the role of point-of-care platelet function testing to define the optimal time for off-pump coronary artery bypass graft (CABG) surgery in a case-control study. Three equally matched groups (300 patients in total) undergoing isolated off-pump CABG for acute coronary syndrome were compared. Group A were treated with clopidogrel and prospectively underwent a strategy guided by platelet function testing. Outcomes were compared with 2 propensity score matched groups: group B underwent CABG after the currently recommended 5 days without clopidogrel; group C were never exposed to clopidogrel. Patients in group A had reduced postoperative bleeding compared with those in group B (523±202 mL vs 851±605 mL; P<.001) and a lower number of units packed red blood cells (PRBCs) transfused during the postoperative hospital stay (1.2±1.6 units vs 1.9±1.8 units; P=.004). Postoperative bleeding and the number of units of PRBCs transfused were similar in group A and group C. There was no difference in blood-derived products and platelet consumption, mortality, or the need for reoperation among the groups. Patients in group A waited 3.6±1.7 days for surgery. The strategy used for group A saved 280 days of hospital stay in total. The strategy guided by platelet function testing for off-pump CABG offers improved guidance for optimal timing of CABG in patients treated with clopidogrel. This strategy significantly reduces postoperative bleeding and blood consumption, and has a shorter waiting time for surgery than current clinical practice. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Topical anesthesia in strabismus surgery: a review of 101 cases.

PubMed

Seijas, Olga; Gómez de Liaño, Pilar; Merino, Pilar; Roberts, Clare J; Gómez de Liaño, Rosario

2009-01-01

To analyze the results over a 10-year period with a different type of strabismus surgery performed with topical anesthesia, to describe the differences in technique compared with surgery performed with general anesthesia, and to detail current indications and technical changes made according to the experience accrued during these years. A total of 101 patients undergoing strabismus surgery with topical anesthesia in a single hospital were analyzed. These patients were randomly selected from a total of 567 patients who had undergone extra-ocular muscle surgery in the past 10 years. A good result was obtained (squint angle < 10 prism diopters and absence of diplopia) in 95% of patients immediately after surgery and in 85% at final follow-up (mean follow-up: 3.1 years). The mean operating time for each muscle was 29 minutes. Surgery was well tolerated in every patient. Conversion to general anesthesia was not necessary in any case. Atropine was used in three patients (3%) because of induction of the vagal reflex. Topical anesthesia in strabismus surgery is a useful technique in the treatment of extraocular muscle pathology, with few limitations. Appropriate monitoring by an anesthetist is vital to ensure adequate control of pain and possible side effects and to enable conversion to general anesthesia. The oculocardiac reflex is infrequent. For experienced strabismus surgeons, the total surgical time is comparable with topical and general anesthesia. Copyright 2009, SLACK Incorporated.

Comparison of open and laparoscopic pyeloplasty in ureteropelvic junction obstruction surgery: report of 49 cases.

PubMed

Umari, Paolo; Lissiani, Andrea; Trombetta, Carlo; Belgrano, Emanuele

2011-12-01

This study aimed to evaluate laparoscopic dismembered pyeloplasty compared with open surgery and to determine whether the morbidity and outcome rates are different in each of these techniques. We report our 10-year experience with open and laparoscopic pyeloplasty at one istitution. From February 1999 to October 2010, 49 patients with ureteropelvic junction obstruction were assigned into two groups. 25 patients underwent open surgical pyeloplasty (period 1999-2010) and 24 underwent laparoscopic pyeloplasty (period 2004-2010). 25 patients undergoing open pyeloplasty had a retroperitoneal flank approach. Of the 24 laparoscopic cases 18 had a transperitoneal retrocolic access, 1 had a transperitoneal transmesocolic access and 5 had a retroperitoneal access. In all 49 cases an Anderson-Hynes dismembered pyeloplasty was used. We retrospectively compared the operative time, hospital stay, perioperative complications and follow-up of the two groups. Clinical symptoms were assessed before and after surgery, subjectively. Patients dermographic data were similar between the two groups with mean age of 42 years (range 6-78) and with a male/female ratio of 1:1.45. A crossing vessel could be identified in 37.5% (9/24) with laparoscopy vs. 32% (8/25) in open surgery. Compared with open procedures, laparoscopic procedures were associated with a longer mean operating time (274 vs 143 min), a shorter mean hospital stay (9.9 vs 15.8 day) and the perioperative complication rates were 16.7% for laparoscopic pyeloplasties and 20% for open pyeloplasties. The success rates were 90.5% for laparoscopy and 90.9% for open surgery. Average follow-up was 40.9 month for the laparoscopic group and 72.3 month for the open group. Failed procedures showed no improvement in loin pain or obstruction. The efficacy (in term of success rate and perioperative complications) of laparoscopic pyeloplasty is comparable to that of open pyeloplasty, with shorter mean hospital stay and better cosmetic results

Language Mapping in Awake Surgery: Report of Two Cases with Review of Language Networks.

PubMed

Lim, Liang Hooi; Idris, Zamzuri; Reza, Faruque; Wan Hassan, Wan Mohd Nazaruddin; Mukmin, Laila Abd; Abdullah, Jafri Malin

2018-01-01

The role of language in communication plays a crucial role in human development and function. In patients who have a surgical lesion at the functional language areas, surgery should be intricately planned to avoid incurring further morbidity. This normally requires extensive functional and anatomical mappings of the brain to identify regions that are involved in language processing and production. In our case report, regions of the brain that are important for language functions were studied before surgery by employing (a) extraoperative methods such as functional magnetic resonance imaging, transmagnetic stimulation, and magnetoencephalography; (b) during the surgery by utilizing intraoperative awake surgical methods such as an intraoperative electrical stimulation; and (c) a two-stage surgery, in which electrical stimulation and first mapping are made thoroughly in the ward before second remapping during surgery. The extraoperative methods before surgery can guide the neurosurgeon to localize the functional language regions and tracts preoperatively. This will be confirmed using single-stage intraoperative electrical brain stimulation during surgery or a two-stage electrical brain stimulation before and during surgery. Here, we describe two cases in whom one has a superficial lesion and another a deep-seated lesion at language-related regions, in which language mapping was done to preserve its function. Additional review on the neuroanatomy of language regions, language network, and its impairment was also described.

Heminephroureterectomy for duplex kidney: laparoscopy versus open surgery.

PubMed

García-Aparicio, Luis; Krauel, Lucas; Tarrado, Xavier; Olivares, Marta; García-Nuñez, Bernardo; Lerena, Javier; Saura, Laura; Rovira, Jorge; Rodo, Joan

2010-04-01

To report our experience of laparoscopic heminephroureterectomy (Hnu) in pediatric patients with duplex anomalies, in comparison to open surgery. Retrospective review of data from patients who underwent Hnu from 2005 to 2008 was performed. The patients were divided into two groups: laparoscopic (LHnu) and open surgery (OHnu). Laparoscopic surgery was performed by transperitoneal approach in majority of cases. Open surgery was performed by retroperitoneal approach in all cases. Group LHnu: nine patients (8 females, 1 male) with median age of 14 months (range 3-205). Transperitoneal approach was performed in eight patients. Mean operative time was 182 min (CI 95% 146-217). No conversion to open surgery was necessary and there were no complications. Mean hospital stay was 2.44 days (CI 95% 1.37-3.52). Group OHnu: eight patients (3 females, 5 males) underwent nine heminephrectomies at median age of 6.9 months (range 1-12). Mean operating time was 152 min (CI 95% 121-183). There were no complications and mean hospital stay was 4.38 (CI 95% 2.59-6.16) days. Statistical analysis showed no statistically significant difference (P>0.05) in operating time between groups while mean hospital stay was significant (P=0.021). The laparoscopic approach is feasible, safe, reduces hospital stay, does not increase operating time and has better cosmetic results. We believe this should be the first option for heminephrectomy. Copyright © 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Effectiveness of Maxillomandibular advancement (MMA) surgery in sleep apnea treatment: Case report.

PubMed

Ferraz, Otávio; Guimarães, Thais M; Rossi, Rowdley R; Cunali, Paulo A; Fabbro, Cibele Dal; Chaves, Cauby M; Maluly, Milton; Bittencourt, Lia; Tufik, Sergio

2016-01-01

Obstructive sleep apnea (OSA) is characterized by episodes of pharyngeal collapse during sleep. Craniofacial alterations such as retrognathia are often found in OSA patients. Maxillomandibular advancement (MMA) surgeries increase the pharyngeal space and are a treatment option for OSA. The aim of this study was to present a successful case of MMA surgery in the treatment of OSA. A patient with moderate OSA (apnea-hypopnea index (AHI)=25.2) and mandibular retrognathism and Maxillomandibular asymmetry underwent MMA surgery. The apnea-hypopnea index (AHI) were considerably improved after six months (IAH =6.7) and one year of treatment (IAH=0.2).

Accidental ovarian autograft after a laparoscopic surgery: case report.

PubMed

Marconi, G; Quintana, R; Rueda-Leverone, N G; Vighi, S

1997-08-01

To report an autograft of ovarian tissue in the incision of the surgical trocar during laparoscopic surgery and to assess the potentiality of grafting of ovarian parenchyma in nonpelvic tissue in humans. A case report. Instituto de Fertilidad y Ginecología de Buenos Aires (IFER), Buenos Aires, Argentina. Infertile patient undergoing surgery due to an endometriotic cyst of the left ovary. Laparoscopic cystectomy. Accidental retention of a portion of the capsule and adjacent ovarian tissue of the endometrioma in SC cellular tissue. Months after surgery, a SC tumor was formed under the surgical incision. It was subsequently excised. Observation of tumor growth during menstrual cycles and ovulation induction; anatomopathologic study of the tissue after its extirpation. The tumor grew spontaneously in the periovulatory period and during treatments of ovulation induction. The anatomopathologic report of the tumor, removed 15 months after the first surgery, revealed functioning ovarian tissue with vessels of neoformation. This is the first description of autografted ovarian tissue in humans. We describe that the ovary can maintain its ovulatory function even in the absence of its pedicel. Also, we suggest that extirpation of surgical material through the incision of the trocar is not recommended, as the possibility of "sowing" or of autografts may occur.

Association between intraoperative hypotension and 30-day mortality, major adverse cardiac events, and acute kidney injury after non-cardiac surgery: A meta-analysis of cohort studies.

PubMed

Gu, Wan-Jie; Hou, Bai-Ling; Kwong, Joey S W; Tian, Xin; Qian, Yue; Cui, Yin; Hao, Jing; Li, Ju-Chen; Ma, Zheng-Liang; Gu, Xiao-Ping

2018-05-01

The association between intraoperative hypotension (IOH) and postoperative outcomes is not fully understood. We performed a meta-analysis to determine whether IOH is associated with increased risk of 30-day mortality, major adverse cardiac events (MACEs) and acute kidney injury (AKI) after non-cardiac surgery. We searched PubMed and Embase through May 2016 to identify cohort studies that investigated the association between IOH and risk of 30-day mortality, MACEs, or AKI in adult patients after non-cardiac surgery. Ascertainment of IOH and assessment of outcomes were defined by the individual study. Considering the level of clinical heterogeneity, adjusted odds ratios (ORs) with 95% confidence interval (CIs) were pooled using a random-effects model. This meta-analysis is registered on PROSPERO (CRD42016049405). We included 14 cohort studies that were heterogeneous in terms of definition of IOH. IOH alone was associated with increased risk of 30-day mortality (OR 1.29 [95% CI, 1.19-1.41]), MACEs (OR 1.59 [95% CI, 1.23-2.05]), especially myocardial injury (OR 1.67 [95% CI, 1.31-2.13]), and AKI (OR 1.39 [95% CI, 1.09-1.77]). Triple low (IOH coincident with low bispectral index and low minimum alveolar concentration) also predicts increased risk of 30-day mortality (OR 1.32 [95% CI, 1.03-1.68]). IOH alone significantly increases the risk of postoperative 30-day mortality, MACEs, especially myocardial injury, and AKI in adult patients after non-cardiac surgery. Triple low also predicts increased risk of 30-day mortality after non-cardiac surgery. These findings provide evidence that IOH should be recognized as an independent risk factor for postoperative adverse outcomes after non-cardiac surgery. Copyright © 2018 Elsevier B.V. All rights reserved.

Secular trends in acute dialysis after elective major surgery — 1995 to 2009

PubMed Central

Siddiqui, Nausheen F.; Coca, Steven G.; Devereaux, Philip J.; Jain, Arsh K.; Li, Lihua; Luo, Jin; Parikh, Chirag R.; Paterson, Michael; Philbrook, Heather Thiessen; Wald, Ron; Walsh, Michael; Whitlock, Richard; Garg, Amit X.

2012-01-01

Background: Acute kidney injury is a serious complication of elective major surgery. Acute dialysis is used to support life in the most severe cases. We examined whether rates and outcomes of acute dialysis after elective major surgery have changed over time. Methods: We used data from Ontario’s universal health care databases to study all consecutive patients who had elective major surgery at 118 hospitals between 1995 and 2009. Our primary outcomes were acute dialysis within 14 days of surgery, death within 90 days of surgery and chronic dialysis for patients who did not recover kidney function. Results: A total of 552 672 patients underwent elective major surgery during the study period, 2231 of whom received acute dialysis. The incidence of acute dialysis increased steadily from 0.2% in 1995 (95% confidence interval [CI] 0.15–0.2) to 0.6% in 2009 (95% CI 0.6–0.7). This increase was primarily in cardiac and vascular surgeries. Among patients who received acute dialysis, 937 died within 90 days of surgery (42.0%, 95% CI 40.0–44.1), with no change in 90-day survival over time. Among the 1294 patients who received acute dialysis and survived beyond 90 days, 352 required chronic dialysis (27.2%, 95% CI 24.8–29.7), with no change over time. Interpretation: The use of acute dialysis after cardiac and vascular surgery has increased substantially since 1995. Studies focusing on interventions to better prevent and treat perioperative acute kidney injury are needed. PMID:22733671

Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery.

PubMed

Babadjouni, Robin; Wen, Timothy; Donoho, Daniel A; Buchanan, Ian A; Cen, Steven Y; Friedman, Rick A; Amar, Arun; Russin, Jonathan J; Giannotta, Steven L; Mack, William J; Attenello, Frank J

2018-06-08

Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions. To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery. All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year. We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea). After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.

Case review analysis of operating room decisions to cancel surgery.

PubMed

Chang, Ju-Hsin; Chen, Ke-Wei; Chen, Kuen-Bao; Poon, Kin-Shing; Liu, Shih-Kai

2014-07-23

Cancellation of surgery close to scheduled time causes a waste of healthcare resources. The current study analyzes surgery cancellations occurring after the patient has been prepared for the operating room, in order to see whether improvements in the surgery planning process may reduce the number of cancellations. In a retrospective chart review of operating room surgery cancellations during the period from 2006 to 2011, cancellations were divided into the following categories: inadequate NPO; medical; surgical; system; airway; incomplete evaluation. The relative use of these reasons in relation to patient age and surgical department was then evaluated. Forty-one percent of cancellations were for other than medical reasons. Among these, 17.7% were due to incomplete evaluation, and 8.2% were due to family issues. Sixty seven percent of cancelled cases eventually received surgery. The relative use of individual reasons for cancellation varied with patient age and surgical department. The difference between cancellations before and after anesthesia was dependent on the causes of cancellation, but not age, sex, ASA status, or follow-up procedures required. Almost half of the cancellations were not due to medical reasons, and these cancellations could be reduced by better administrative and surgical planning and better communication with the patient and/or his family.

Reoperative surgery: a critical risk factor for complications inadequately captured by operative reporting and coding of lysis of adhesions.

PubMed

Aloia, Thomas A; Cooper, Amanda; Shi, Weiming; Vauthey, Jean-Nicolas; Lee, Jeffrey E

2014-07-01

Reoperative surgery is suspected, but not proven, to increase postoperative complication rates. In the absence of a specific definition for reoperative surgery, the American College of Surgeons NSQIP has proposed using procedural coding for lysis of adhesions (LOA) as a surrogate for reoperative surgery to risk adjust hospitals. We hypothesized that coding of reoperative surgery will be associated with worse 30-day outcomes and, for abdominal procedures, will be more accurate than operative dictation and coding of "lysis of adhesions." Reoperative surgery was categorized at the time of data abstraction from February 2012 to December 2012 for all NSQIP cases collected at a single institution by independent surgical clinical reviewers. Reoperative surgery classification and coding of LOA were compared with each other and with 30-day outcomes. The setting was a tertiary cancer center, multispecialty NSQIP model. During the study period, 1,289 operations were classified as nonreoperative (n = 793), regionally reoperative (n = 39; prior surgery in an adjacent area of current operation), or locally reoperative (n = 457; prior surgery at same site or organ). In the multispecialty cohort, the non-risk-adjusted rates of overall 30-day morbidity, serious morbidity, and mortality were 21.5%, 17.7%, and 0.5%. Compared with nonreoperative surgery (overall 30-day morbidity 16.8%, serious morbidity 13.9%, and mortality .38%), both regionally reoperative surgery (overall 30-day morbidity 30.8%, serious morbidity 28.2%, and mortality 2.5%) and locally reoperative surgery (overall 30-day morbidity 28.9%, serious morbidity 23.4%, and mortality .66%) were associated with worse outcomes (p < 0.001). One hundred ninety-nine of the 327 gastrointestinal/laparotomy cases were recorded as reoperative, but only of 20 of these were CPT coded as LOA (sensitivity = 10%). Reoperative surgery is frequent, increases the risk of complications, and can be captured. Operative LOA coding vastly

Functional results in endoscopic Zenker's diverticulum surgery.

PubMed

Dissard, A; Gilain, L; Pastourel, R; Mom, T; Saroul, N

2017-10-01

The main objective of this retrospective study was to assess functional results in endoscopic Zenker's diverticulum surgery. The secondary objectives were to assess safety, identify recurrence risk factors, and determine optimal management of recurrence. From 2000 to 2014, 50 patients underwent endoscopic surgery for marsupialization of Zenker's diverticulum. Regurgitation and dysphagia were assessed on the FOIS scale, pre- and post-operatively. Recurrences and complications rates were determined retrospectively at a minimum 18 months' follow-up. Regurgitation and dysphagia improved in respectively 96% and 86% of patients. There was a 12% rate of complications, mostly minor. Mean hospital stay and time to return to oral feeding were 2.0 and 1.3 days respectively. Nine patients (18%) showed recurrence of symptoms, requiring revision surgery at a mean 2.7 years, performed endoscopically in the majority of cases. Only one recurrence risk factor was identified: small diverticulum size. Endoscopic Zenker's diverticulum surgery provided functional improvement in most cases. Safe and effective, it is currently the treatment of choice for Zenker's diverticulum. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

The role of ICP monitoring in patients with persistent cerebrospinal fluid leak following spinal surgery: a case series.

PubMed

Craven, Claudia; Toma, Ahmed K; Khan, Akbar A; Watkins, Laurence D

2016-09-01

Cerebrospinal fluid (CSF) leak following spinal surgery is a relatively common surgical complication. A disturbance in the underlying CSF dynamics could be the causative factor in a small group of patients with refractory CSF leaks that require multiple surgical repairs and prolonged hospital admission. A retrospective case series of patients with persistent post spinal surgery CSF leak referred to the hydrocephalus service for continuous intracranial pressure (ICP) monitoring. Patients' notes were reviewed for medical history, ICP data, radiological data, and subsequent management and outcome. Five patients (two males/three females, mean age, 35.4 years) were referred for ICP monitoring over a 12-month period. These patients had prolonged CSF leak despite multiple repair attempts 252 ± 454 days (mean ± SD). On ICP monitoring, all five patients had abnormal results, with the mean ICP 8.95 ± 4.41 mmHg. Four had abnormal pulse amplitudes, mean 6.15 mmHg ± 1.22 mmHg. All five patients underwent an intervention. Three patients underwent insertion of ventriculoperitoneal (VP) shunts. One patient had venous sinus stent insertion and one patient underwent medical management with acetazolamide. All five of the patients' CSF leak resolved post intervention. The mean time to resolution of CSF leak post intervention was 10.8  ± 12.9 days. Abnormal cerebrospinal fluid dynamics could be the underlying factor in patients with a persistent and treatment-refractory CSF leak post spinal surgery. Treatments aimed at lowering ICP may be beneficial in this group of patients. Whether abnormal pressure and dynamics represent a pre-existing abnormality or is induced by spinal surgery should be a subject of further study.

Long-term Follow-up of a Case of Gold Shunt Surgery for Refractory Silicone Oil–induced Glaucoma

PubMed Central

Le, Ryan; Berger, Alan R.

2016-01-01

Purpose: To report the first case of gold shunt surgery for treatment of silicone oil–induced refractory glaucoma in a tertiary care academic center, with 5-year follow-up. Design: The study design is a case report. Participants: The participant was a patient who underwent gold shunt surgery. Methods: Institutional Research Ethics Board approval for the study was obtained. A diabetic patient was referred for refractory glaucoma with a history of proliferative diabetic retinal detachment, and surgery with silicone oil. She was uncontrolled on maximal medical therapy and following informed consent, gold shunt surgery was performed. Ocular outcomes and number of medications were reviewed over a 5-year period. Results: Following uncomplicated surgery, intraocular pressure was reduced from 41 to 14 mm Hg, and the number of medications was reduced from 4 to 1. Glaucomatous optic neuropathy remained stable. Conclusions: Gold shunt surgery in this challenging case of silicone oil refractory glaucoma provided long-term intraocular pressure control and reduced need for medication over a 5-year period. PMID:27253968

Human Erythropoietin Effect in Postoperative Visual Loss Following Spine Surgery: A Case Report

PubMed Central

Hassani, Valiollah; Homaei, Mohammad Mohsen; Shahbazi, Ali; Zamani, Mohammad Mahdi; Safari, Saeid; Nadi, Shermila; Rahimizadeh, Abolfazl; Lashkari, Mohammad Hossein; Alizadeh zendehrood, Siamak

2014-01-01

Introduction: Postoperative visual loss (POVL) has become the focus of attention for anesthesiologists as a hallmark of perioperative management in spine surgery. A number of Intraoperative and postoperative factors has been documented but the exact etiology is still unclear. Nowadays, perioperative management and also complete curing of POLV is a big question of ophthalmologists and anesthesiologists. The purpose of this case report is to present a unique experience of complete curing the POLV. Case Presentation: Our patient was a 61-year-old man, with 75 kg weight and 180 cm height. The patient had no history of visual impairment except mild cataract in his right eye. The patient had a history of diffuse idiopathic skeletal hyperostosis (DISH). The patient had undergone lumbar surgery in prone position. The operation time was about 6 hours. About 30 minutes after transferring to postanesthesia care unit (PACU), patient was awake and complained of losing his eyesight. There was no vision and light perception in his right eye on primary examination. Urgent ophthalmologist consultation was requested. In ophthalmology examinations, the pupil reflex to light was absent in the right eye. After obtaining patients and his family informed consent, four hours after the operation, 40000 I.U. of recombinant human erythropoietin (rhEPO) was administered for patient in PACU (IV infusion, in 30 min). An ophthalmologist visited him every 6 hours after administration of rhEPO. The patient was transferred to intensive care unit (ICU) one hour later with total visual loss in the right eye. Ophthalmologic examination after the second dose of rhEPO, 30 hours after the operation, reported pupil reflex enhancement and light perception in his right eye. Finally the third dose of rhEPO (40000 I.U., IV infusion) was administered on the third day. Ophthalmologic examination after the third dose of rhEPO, 60 hours after the operation, reported normal pupillary light reflex of the right eye

Impact of Accurate 30-Day Status on Operative Mortality: Wanted Dead or Alive, Not Unknown.

PubMed

Ring, W Steves; Edgerton, James R; Herbert, Morley; Prince, Syma; Knoff, Cathy; Jenkins, Kristin M; Jessen, Michael E; Hamman, Baron L

2017-12-01

Risk-adjusted operative mortality is the most important quality metric in cardiac surgery for determining The Society of Thoracic Surgeons (STS) Composite Score for star ratings. Accurate 30-day status is required to determine STS operative mortality. The goal of this study was to determine the effect of unknown or missing 30-day status on risk-adjusted operative mortality in a regional STS Adult Cardiac Surgery Database cooperative and demonstrate the ability to correct these deficiencies by matching with an administrative database. STS Adult Cardiac Surgery Database data were submitted by 27 hospitals from five hospital systems to the Texas Quality Initiative (TQI), a regional quality collaborative. TQI data were matched with a regional hospital claims database to resolve unknown 30-day status. The risk-adjusted operative mortality observed-to-expected (O/E) ratio was determined before and after matching to determine the effect of unknown status on the operative mortality O/E. TQI found an excessive (22%) unknown 30-day status for STS isolated coronary artery bypass grafting cases. Matching the TQI data to the administrative claims database reduced the unknowns to 7%. The STS process of imputing unknown 30-day status as alive underestimates the true operative mortality O/E (1.27 before vs 1.30 after match), while excluding unknowns overestimates the operative mortality O/E (1.57 before vs 1.37 after match) for isolated coronary artery bypass grafting. The current STS algorithm of imputing unknown 30-day status as alive and a strategy of excluding cases with unknown 30-day status both result in erroneous calculation of operative mortality and operative mortality O/E. However, external validation by matching with an administrative database can improve the accuracy of clinical databases such as the STS Adult Cardiac Surgery Database. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Children Coping with Surgery through Drawings: A Case Study from a Parenting Class

ERIC Educational Resources Information Center

Broecher, Joachim

2012-01-01

This case study illustrates how parents can help their children cope with the fear and pain of surgery by engaging them in expressive drawing. As part of a parenting class that utilized art therapy techniques, a father shared his 6-year-old son's spontaneous drawings that had been created directly before and after surgery. Through guidance by the…

[Operative and postoperative management of patients after neck surgery].

PubMed

Szybiak, Bartosz; Golusiński, Wojciech

2012-01-01

Cancer patients after neck surgeries require specific operative and postoperative management, which to some extent determines the final outcome of the surgery. Such procedures require particular attention due to the respiratory and gastrointestinal tracts as well as the presence of functionally and morphologically important anatomical structures on the neck. The majority of patients qualified for surgery have concomitant medical conditions, which increases the probability of certain operative and postoperative complications. Preparation for the procedure requires close cooperation between the laryngologist-head and neck surgeon, general practitioner and anaesthetist. The purpose of the paper was to analyse the factors that influence the normal process of healing in the operative and postoperative periods in patients after neck surgery. The study group consisted of 220 patients who underwent neck surgery in the years 2007-2010. 92.8% of the operations were performed due to a malignant cancer. The following factors were taken into consideration in the evaluation of the healing process: On average, following surgery, patients stayed in the ward for: 5-7 days after selective removal of lymph nodes, 5 days after removal of branchial cleft cyst or persistent thyroglossal duct, 14 days after total laryngectomy, and 12 days after reconstructive laryngeal surgery. All patients after oncological surgery of the oral cavity, oropharynx and larynx stayed in the ICU for the first 24 hours and remained under analgosedation. Laryngeal surgery was performed using a separate surgical incision for tracheotomy. In all cases suction drainage was used for 48 hours. After surgery, patients were mobilised during the first 24 hours in the ward. Appropriate operative and postoperative management, following specific standards, increases the safety of the patient. Providing optimal conditions for healing shortens the patient's stay in the ICU, which reduces the cost of hospitalisation and

[POKING REDUCTION TREATMENT OF DISPLACED SCAPULAR NECK FRACTURE WITH SHOULDER ARTHROSCOPY-ASSISTED SURGERY].

PubMed

Qu, Feng; Yuan, Bangtuo; Qi, Wei; Wang, Junliang; Shen, Xuezhen; Wang, Jiangtao; Zhao, Gang; Liu, Yujie

2014-07-01

To discuss the effectiveness of Poking reduction with shoulder arthroscopy-assisted surgery for displaced scapular neck fracture. Between January 2009 and January 2012, 9 cases of displaced scapular neck fracture underwent shoulder arthroscopy-assisted surgery for Poking reduction treatment. Of 9 cases, 6 were men, and 3 were women, aged 21-54 years (mean, 39 years). The causes were traffic accident injury in 7 cases, falling injury from height in 1 case, and hurt injury in 1 case. The shoulder abduction, flexion, and external rotation were obviously limited. X-ray films showed all cases had obvious displaced scapular neck fracture. Three-dimensional reconstruction of CT showed a grossly displaced of fracture. The time of injury to surgery was 4-27 days (mean, 11 days). Patients obtained healing of incision by first intension, without infection, neurovascular injury, or other surgery-related complications. All patients were followed up 19- 31 months (mean, 23 months). X-ray films showed scapular neck fractures healed from 7 to 11 weeks (mean, 8 weeks). At last follow-up, the shoulder abduction, flexion, and external rotation activity were improved significantly when compared with ones at preoperation (P < 0.05); the shoulder Constant score, American Shoulder and Elbow Surgenos (ASES) score, and Rowe score were significantly better than preoperative scores (P < 0.05). The reduction of displaced scapular neck fracture is necessary, and arthroscopic Poking reduction and fixation for displaced scapular neck fracture can reconstruct the shoulder stability and reduce complications.

Risk Factors and Independent Predictors of 30-Day Readmission for Altered Mental Status After Elective Spine Surgery for Spine Deformity: A Single-Institutional Study of 1090 Patients.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Reddy, Gireesh B; Sergesketter, Amanda; Warwick, Hunter; Jones, Terrell; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2017-05-01

Altered mental status (AMS) has been associated with inferior surgical outcomes. The factors leading to AMS after spine surgery are unknown. The aim of this study is to determine the risk factors and independent predictors of 30-day readmission for AMS in patients with spine deformity after undergoing elective spine surgery. The medical records of 1090 adult (≥18 years old) patients with spine deformity undergoing elective spine surgery at a major academic institution from 2005 to 2015 were reviewed. We identified 18 patients (1.65%) who had AMS as the primary driver for 30-day readmission after surgery. Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. The primary outcome investigated in this study was risk factors associated with 30-day readmission for AMS. Patient demographics and comorbidities were similar between both groups, with the AMS cohort being significantly older than the no-AMS cohort (70.11 vs. 61.93; P = 0.003). There were no significant differences in intraoperative variables and complication rates within the cohorts. The AMS cohort had a significantly higher proportion of patients transferred to the intensive care unit (AMS, 61.11% vs. no-AMS, 19.76%; P = 0.0002) and rate of pulmonary embolism (AMS, 11.11 vs. no-AMS, 0.93; P = 0.02) after surgery. Other postoperative complication rates were similar between the cohorts. In a multivariate stepwise regression analysis, age (P = 0.013) and ICU transfer (P = 0.0002) were independent predictors of 30-day readmission for AMS. Our study suggests that increasing age and intensice care unit transfer are independent predictors of 30-day readmission for AMS after spine surgery in patients with spine deformity. Copyright © 2017 Elsevier Inc. All rights reserved.

[Effect of dexmedetomidine on emergence agitation after general anesthesia in children undergoing odontotherapy in day-surgery operating room].

PubMed

Lin, Luo; Yueming, Zhang; Meisheng, Li; Jiexue, Wang; Yang, Ji

2017-12-01

To study the effectiveness of dexmedetomidine used for general anesthesia maintenance in children undergoing odontotherapy in day-surgery operating room in reducing the incidence of emergence agitation (EA). Eighty children undergoing odontotherapy and under general anesthesia in day-surgery operating room were randomized into two groups, group A (n=40) and group B (n=40). Each patient in group A was administered with a bolus dose of dexmedetomidine (1.0 μg·kg⁻¹, saline diluted to 10 mL) pump-infused after intubation and a maintenance dose of 0.1-0.4 mL·(kg·h)⁻¹ followed-up until 45 min before the end of operation. Each patient in group B was administered with a bolus dose of normal saline 10 mL pump-infused after intubation and maintenance dose of 0.1-0.4 mL·(kg·h)⁻¹ followed-up until 45 min before the end of operation. Gender, age, weight, physical status according to the American Society of Anesthesiologists, perioperative heart rate (HR), mean arterial pressure (MAP), pulse oxygen saturation (SpO₂), sufentanil dosage, duration of surgery, time of extubation, time of regaining consciousness, and time to reach modified Aldrete's score≥12 were recorded. Behavior in postanesthesia care unit was rated on the four-point agitation scale. Compared with group B, decreases were observed in HR and MAP at the beginning of operation, in 10 and 30 min, 1 and 2 h after the beginning of operation, and after extubation of group A (P<0.05). Sufentanil dosage and incidence of EA during recovery of group A were also lower than those of group B (P<0.05). Time to regain consciousness and time to reach modified Aldrete's score≥12 of group A were longer than those of group B (P<0.05). No statistical difference was observed between other indexes of the two groups. As an anesthetic used for general anesthesia maintenance in children undergoing odontotherapy in day-surgery operating room, dexmedetomidine results in low incidence of EA during recovery and more stable

[Case of large sphenoid ridge meningioma treated by 2-stage surgery].

PubMed

Oi, Sachie; Saito, Kiyoshi; Ichikawa, Masahiro; Aimi, Yuri; Okada, Takeshi; Nagatani, Tetsuya; Shimoyama, Yoshie

2008-10-01

Large skull base meningiomas frequently encase the major cerebral vessels and cranial nerves, and receive blood supply from the branches of the internal carotid artery. One-stage resection of these tumors is difficult due to the long time needed for surgery and profuse bleeding from the tumor. We report herein a case of large sphenoid ridge atypical meningioma that was successfully resected using a combination of two-stage surgery and irradiation. A 56-year-old man was referred to us with mild left hemiparesis and visual deterioration. Computed tomography and magnetic resonance imaging showed a large sphenoid ridge meningioma. Angiography showed blood supply from the branches of both external and internal carotid arteries, and pial blood supply from the middle cerebral artery. In the first surgery after embolization of feeder vessels from the external carotid artery, the tumor was still hemorrhagic and was partially resected with 2,374 ml of blood loss. Symptoms were improved after the first surgery. Pathological diagnosis was atypical meningioma. In the second surgery after 40 Gy of irradiation, the remnant tumor was no longer hemorrhagic and was totally resected. Staged surgery with irradiation is one treatment option for large vascular skull base meningiomas, particularly for atypical meningiomas.

Adjustable selective maxillary expansion combined with maxillomandibular surgery: A case report.

PubMed

Leyder, Patrick; Altounian, Gérard; Chardain, Jacques; Quilichini, Julien

2015-09-01

Surgically assisted rapid maxillary expansion (SARME) is usually considered the gold standard for maxillary transverse expansion in adults. However, a second surgical procedure is needed in cases of associated sagittal or vertical discrepancies. We describe the use of two new innovative devices for the correction of discrepancies in all dimensions during a single surgical procedure, thus reducing treatment duration. We report the case of a 21-year-old female patient, referred to our department for skeletal Class III malocclusion associated with right-side laterognathism and transverse maxillary deficiency. The patient underwent one-stage surgery, using sliding osteosynthesis plates and an adjustable bone-borne distractor. Pre-surgical orthodontics consisted in leveling and aligning the mandibular arch; maxillary leveling was initiated 3 months before surgery. Postoperative palatal distraction combined with orthodontic finishing enabled complete correction of dental and bony discrepancies after 3 months. In our experience, treatment of transverse, sagittal and vertical discrepancies has been possible in a single surgical procedure, using two innovative techniques: sliding osteosynthesis and an adjustable bone distractor. Two years post-surgery, the correction is stable in all dimensions. Copyright © 2015. Published by Elsevier Masson SAS.

Cost justification of clinical pharmacy services on a general surgery team: focus on diagnosis-related group cases.

PubMed

Bertch, K E; Hatoum, H T; Willett, M S; Witte, K W

1988-11-01

We used a novel approach to cost-justify clinical pharmacy services on a general surgery team in nine diagnosis-related group cases. The clinical pharmacist monitored nine patients longitudinally on a general surgery team from admission to discharge and intervened in their therapeutic management. Each recommendation was analyzed for rationale, acceptance, perceived impact on quality and/or cost of patient care, whether self-initiated or solicited, and impact on patient outcome. Types of recommendations and outcomes were categorized by process and outcome measurement criteria. Total cost avoidance per patient was calculated using costs of drug therapy, laboratory tests, and length of stay. Accounting for cost of clinical pharmacy services, net cost avoidance per patient was calculated. The clinical pharmacist made 101 recommendations on nine patients. Physicians accepted 82 percent of the recommendations; 77 percent of the recommendations were self-initiated and 23 percent were solicited. Recommendations had a perceived impact on cost, quality, or both at 13, 31, and 56 percent, respectively. Most recommendations (79 percent) brought patient therapy to a level of conformance with current standards of practice as documented in the medical literature. Recommendations that potentially preserved a major organ function by preventing drug-induced toxicity or the exacerbation of existing problems constituted 16 percent of the total. None of the accepted recommendations adversely affected patient outcome and 23 percent directly resulted in a measurable positive outcome in patient care. A total of four hospital days was potentially saved for two cases. Based on objective outcome criteria, a 1.9-day increase in therapeutic control was documented per patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Using length of stay data from a hospital to evaluate whether limiting elective surgery at the hospital is an inappropriate decision.

PubMed

Dexter, Franklin; Lubarsky, David A

2004-09-01

At hospitals without detailed managerial accounting data but with overall longer than average diagnosis-related groups (DRG)-adjusted lengths of stays (LOS), some administrators do not aggressively hire the nurses needed to maintain surgical hospital capacity. The consequence of this (long-term) decision is that day-of-surgery admit cases are delayed or cancelled from a lack of beds. The anesthesiologists suffer financially. In this paper, we show how publicly released national LOS data can be applied specifically to these cases. We applied the method to 1 year of data from two academic hospitals. Each case's LOS was compared to the United States national average LOS for cases with the same DRG. A total of 8,050 and 10,099 hospitalizations, respectively. Among all surgical admissions, mean LOS was 2.5 days longer than the national average for Hospital #1 (95% confidence interval [CI], 2.1 to 2.8) and 3.1 days longer for Hospital #2 (95% CI, 2.8 to 3.4). Among patients undergoing elective, scheduled surgery with day of surgery admission, mean LOS was 0.7 days less than average for Hospital #1 (0.6 to 0.9) and 1.2 days less than average for Hospital #2 (1.1 to 1.4). This method can be used by anesthesiologists to show that LOS are not longer than average among patients whose surgeries may be cancelled or delayed for a lack of hospital ward staff.

[Medical, social, and economic effectiveness of treatment of day-case patients with peptic ulcer].

PubMed

Butorov, I V; Osoianu, Iu P; Maksimov, V V; Butorov, S I

2006-01-01

The purpose of the study was to evaluate medical, social, and economic effectiveness of treatment of day-case patients with peptic ulcer (PU). The subjects of the study were 60 day-case patients with duodenal ulcer aged 18 to 60, who underwent clinical and instrumental examination including esophagogastroduodenoscopy with biopsy and Helicobacter pylori (HP) detection. The patients received 7-day eradication therapy, which included omeprazol in a dose of 20 mg twice a day, clarithromycin--500 mg twice a day, and metronidazole--500 mg twice a day. There was a control group, which included 60 inpatients treated in Gastroenterology Division of the hospital. The use of the three-component medication in the day-case patients and the inpatients led to disappearance of pain syndrome 7.4 +/- 0.3 and 8.6 +/- 0.2 days after the beginning of the treatment, respectively; dyspepsia disappeared in the day-case patients and the inpatients 7.6 +/- 0.2 and 8.8 +/- 0.3 days after the beginning of the treatment, respectively. HP eradication was effective in 86.7% of the day-case patients, and in 88.3% of the inpatients. The course of the disease was recurrence-free during two years in 80% of the day-case patients, and in 76.4% of the inpatients; the cost of the treatment was 2.1 times higher in the group of inpatients. The results show that high effectiveness of the three-component medication, judging by the results of HP eradication, terms of disappearance of pain syndrome and ulcer healing, allows recommending this regimen for wide clinical application in day-case patients with PU.

Comparison of 25 G and 29 G Quincke spinal needles in paediatric day case surgery. A prospective randomized study of the puncture characteristics, success rate and postoperative complaints.

PubMed

Kokki, H; Hendolin, H

1996-01-01

A comparison of a 25 G with a 29 G Quincke needle was performed in paediatric day case surgery. Sixty healthy children aged 1 year to 13 years were randomly allocated to have spinal anaesthesia with either 25 G or 29 G Quincke needle without an introducer needle. There was a failure rate of 10% with the 29 G spinal needle compared with 0% with the 25 G needle. The time needed to perform dural puncture was shorter using 25 G than 29 G needle, 22 (+/- 31)(SD) vs 59 (+/- 63) s. The time taken for cerebrospinal fluid to appear at the needle hub was also longer, 4 (+/- 3) vs 8 (+/- 5) s. The number of puncture attempts was similar, 1.2 (+/- 0.6) vs 1.4 (+/- 0.8), with 25 G and 29 G needle. Low back pain, 5 vs1, and nonpositional headache, 2 vs 4, after 25 G and 29 G needles, respectively, were the most frequent postoperative complaints. Mild postdural puncture headache occurred in one eight year old male patient in the 25 G group. In conclusion, lumbar puncture without introducer needle was possible with both needles. The puncture characteristics favoured the 25 G needle. A shorter needle could partly alleviate the difficulties with the 29 G needle.

CO2 laser surgery for vulvar intraepithelial neoplasia. Excisional, destructive and combined techniques.

PubMed

Penna, Carlo; Fallani, M Grazia; Fambrini, Massimiliano; Zipoli, Elisa; Marchionni, Mauro

2002-11-01

To evaluate CO2 laser excision, vaporization and combined techniques for treatment of vulvar intraepithelial neoplasia (VIN). Thirty-nine cases of VIN 3, 15 cases of VIN 2 and 9 of VIN 1, for a total of 63 patients with histologically proven VIN, underwent laser excision or vaporization under colposcopic guidance, using local anesthesia, in an outpatient setting or after day-surgery admission. Clinical aspects, cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VaIN) association, types of CO2 laser treatment, follow-up, recurrences and second treatments were evaluated. Twenty-seven (41.3%) patients underwent laser vaporization, and 37 (58.7%) with VIN 3, underwent laser excision or the combined technique. Colposcopic and biopsy examinations of patients with VIN revealed three cases of CIN 3 and nine cases of VaIN 3; two patients had concomitant VIN 3, CIN 3 and VaIN 3. Local anesthesia, using 2% carbocaine, and outpatient or day-surgery treatments were possible in all cases. A small incidence of intraoperative complications (4.8%) and absence of postoperative complications were observed. A single session was curative in 76.9% of patients treated with laser vaporization and in 78.4% of those treated with laser excision. Eleven cases of recurrent VIN and two cases of invasive vulvar carcinoma were observed during follow-up. A second laser procedure was carred out in all cases of relapsed VIN, with an overall cure rate of 96.8% after two treatments. Radical vulvectomy associated with inguinal-femoral lymphadenectomy was performed in the two cases of invasive carcinoma. CO2 laser surgery permits treatment of VIN in an outpatient or day-surgery setting under local anesthesia with excellent cosmetic and functional results. The treatment can also be adjusted to the patient's specific needs, with the possibility of calibrating the depth of the vaporized and removed tissues. Excisional treatment is the preferred method because it permits

Factors that influence length of stay for in-patient gynaecology surgery: is the Case Mix Group (CMG) or type of procedure more important?

PubMed

Carey, Mark S; Victory, Rahi; Stitt, Larry; Tsang, Nicole

2006-02-01

To compare the association between the Case Mix Group (CMG) code and length of stay (LOS) with the association between the type of procedure and LOS in patients admitted for gynaecology surgery. We examined the records of women admitted for surgery in CMG 579 (major uterine/adnexal procedure, no malignancy) or 577 (major surgery ovary/adnexa with malignancy) between April 1997 and March 1999. Factors thought to influence LOS included age, weight, American Society of Anesthesiologists (ASA) score, physician, day of the week on which surgery was performed, and procedure type. Procedures were divided into six categories, four for CMG 579 and two for CMG 577. Data were abstracted from the hospital information costing system (T2 system) and by retrospective chart review. Multivariable analysis was performed using linear regression with backwards elimination. There were 606 patients in CMG 579 and 101 patients in CMG 577, and the corresponding median LOS was four days (range 1-19) for CMG 579 and nine days (range 3-30) for CMG 577. Combined analysis of both CMGs 577 and 579 revealed the following factors as highly significant determinants of LOS: procedure, age, physician, and ASA score. Although confounded by procedure type, the CMG did not significantly account for differences in LOS in the model if procedure was considered. Pairwise comparisons of procedure categories were all found to be statistically significant, even when controlled for other important variables. The type of procedure better accounts for differences in LOS by describing six statistically distinct procedure groups rather than the traditional two CMGs. It is reasonable therefore to consider changing the current CMG codes for gynaecology to a classification based on the type of procedure.

[Video-assisted thoracoscopic surgery as an alternative to urgent thoracotomy following open chest trauma in selected cases].

PubMed

Samiatina, Diana; Rubikas, Romaldas

2004-01-01

To prove that video-assisted thoracoscopic surgery in selected cases is an alternative to urgent thoracotomy following open chest trauma. Retrospective analysis of case reports of patients operated for open chest trauma during 1997-2002. Comparison of two methods of surgical treatment: urgent video-assisted thoracoscopy and urgent thoracotomy. Duration of drain presence in the pleural cavity, duration of postoperative treatment, pain intensity and cosmetic effect were evaluated. Data analysis was performed using SPSS statistical software. Statistical evaluation of differences between groups was performed using Mann-Whitney U test. The differences between groups were considered to be statistically significant when the probability of deviation was p<0.05. During 1997-2002, 121 patients with open chest trauma were operated. Thirty three patients underwent urgent video-assisted thoracoscopy, 88 patients were operated through thoracotomy incision: 69 due to isolated open chest trauma, 17 due to thoracoabdominal injury and 2 due to abdominothoracic injury. Almost thirteen percent (12.5%) of patients after urgent thoracotomy underwent urgent laparotomy due to damaged diaphragm and other organs of peritoneal cavity. Duration of drain presence in the pleural cavity after video-assisted thoracoscopy was 4.57 days and after urgent thoracotomy - 6.88 days (p<0.05). Duration of post-operative treatment after video-assisted thoracoscopy was 8.21 days and after urgent thoracotomy - 14.89 days (p<0.05). Amount of consumed non-narcotic analgesics after video-assisted thoracoscopy was 1056.98 mg and after urgent thoracotomy - 1966.70 mg (p<0.05). Video-assisted thoracoscopy is minimally invasive method of thoracic surgery allowing for the evaluation of the pathological changes in the lung, pericardium, diaphragm, mediastinum, thoracic wall and pleura, including the localization of these changes, and the type and severity of the injury. The number of early post

First case report of retroperitoneal metastasis of fascioliasis after surgery

PubMed Central

Wang, Jun-Ke; Ma, Wen-Jie; Lu, Qiang; Zheng, Er-Liang; Yang, Qin; Hu, Hai-Jie; Liu, Fei; Li, Quan-Sheng; Li, Fu-Yu

2017-01-01

Abstract Rationale: Fascioliasis is a rare cause of liver abscesses, and its clinical course consists of hepatic phase and biliary phase. Patient concerns: We describe a 58-year-old female patient who presented with a 2-month history of intermittent fever and abdominal pain. An abdominal computed tomography (CT) revealed confluent low-density lesions in the liver. Complete surgical resection of these abscesses was performed, and postoperative pathological examination and serological tests confirmed a diagnosis of fascioliasis. However, 4 months after the surgery, follow-up CT revealed a lesion in the retroperitoneal area. Meanwhile, ultrasonography-guided percutaneous needle biopsy of the retroperitoneal lesion was performed, and a parasitic infection was suspected. Diagnoses: Retroperitoneal metastasis of hepatic phase fascioliasis. Interventions: The patient received parasitic resistance treatment with triclabendazole at a dose of 10 mg/kg/d for 2 consecutive days. Outcomes: After 2 courses of triclabendazole therapy, the retroperitoneal metastasis regressed to a minor lesion. Lessons: To the best of our knowledge, this is the first case report of retroperitoneal metastasis of fascioliasis, aimed at helping recognize the clinical features and treatment options of this rare disease. PMID:29390366

First case report of retroperitoneal metastasis of fascioliasis after surgery.

PubMed

Wang, Jun-Ke; Ma, Wen-Jie; Lu, Qiang; Zheng, Er-Liang; Yang, Qin; Hu, Hai-Jie; Liu, Fei; Li, Quan-Sheng; Li, Fu-Yu

2017-12-01

Fascioliasis is a rare cause of liver abscesses, and its clinical course consists of hepatic phase and biliary phase. We describe a 58-year-old female patient who presented with a 2-month history of intermittent fever and abdominal pain. An abdominal computed tomography (CT) revealed confluent low-density lesions in the liver. Complete surgical resection of these abscesses was performed, and postoperative pathological examination and serological tests confirmed a diagnosis of fascioliasis. However, 4 months after the surgery, follow-up CT revealed a lesion in the retroperitoneal area. Meanwhile, ultrasonography-guided percutaneous needle biopsy of the retroperitoneal lesion was performed, and a parasitic infection was suspected. Retroperitoneal metastasis of hepatic phase fascioliasis. The patient received parasitic resistance treatment with triclabendazole at a dose of 10 mg/kg/d for 2 consecutive days. After 2 courses of triclabendazole therapy, the retroperitoneal metastasis regressed to a minor lesion. To the best of our knowledge, this is the first case report of retroperitoneal metastasis of fascioliasis, aimed at helping recognize the clinical features and treatment options of this rare disease. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

The case for restraint in spinal surgery: does quality management have a role to play?

PubMed Central

Mirza, Sohail K.

2009-01-01

Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of well-informed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures. PMID:19266220

The case for restraint in spinal surgery: does quality management have a role to play?

PubMed

Deyo, Richard A; Mirza, Sohail K

2009-08-01

Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of well-informed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures.

Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction.

PubMed

Mason, Edward E; Renquist, Kathleen E; Huang, Yu-Hui; Jamal, Mohammad; Samuel, Isaac

2007-01-01

This is a study of the causes of 30-day postoperative death following surgical treatment for obesity and a search for ways to decrease an already low mortality rate. Data were contributed from 1986-2004 to the International Bariatric Surgery Registry by 85 sites, representing 137 surgeons. A spread-sheet was prepared with rows for causes and columns for patients. The 251 causes contributing to 93 deaths were then marked in cells wherever a patient was noted to have one of the causes. Rows and columns were then moved into positions that provided patterns of best fit. 11 patterns were found. 10 had well known initiating causes of death. Overall operative 30-day mortality was 0.24% (93 / 38,501). The most common cause of death was pulmonary embolism (32%, 30/93). 14 deaths were caused by leaks (15%, 14/93), and were equally prevalent after simple (15%, 2/14) or complex (15%, 12/79) operations. Small bowel obstruction caused 8 deaths, exclusively after complex operations. 5 of these involved the bypassed biliopancreatic limb and were defined as "bypass obstruction". A spread-sheet study of cause of 30-day postoperative death revealed a rapidly lethal initiating complication of Roux-en-Y gastric bypass obstruction that requires the earliest possible recognition and treatment. Bypass obstruction needs a name and code to facilitate recognition, study, prevention and early treatment. Spread-sheet pattern analysis of all available data helped identify the initiating cause of death for individual patients when multiple data elements were present.

Managing Drawbacks in Unconventional Successful Glaucoma Surgery: A Case Report of Stent Exposure

PubMed Central

Fea, Antonio; Cannizzo, Paola Maria Loredana; Consolandi, Giulia; Lavia, Carlo Alessandro; Pignata, Giulia; Grignolo, Federico M.

2015-01-01

Traditional options in managing failed trabeculectomy (bleb needling, revision, additional incisional surgery and tube surgery) have a relatively high failure and complication rate. The use of microinvasive glaucoma surgery (MIGS) has generally been reserved to mild to moderate glaucoma cases, proving good safety profiles but significant limitations in terms of efficacy. We describe a patient who underwent MIGS (XEN Aquesys subconjunctival shunt implantation) after a prior failed trabeculectomy. After the surgery, the IOP was well controlled but as the stent was close to an area of scarred conjunctiva of the previous trabeculectomy, it became partially exposed. As a complete success was achieved, we decided to remove the conjunctiva over the exposed area and replace it by an amniotic membrane transplantation and a conjunctiva autograft. Six months after surgery, the unmedicated IOP is still well controlled with complete visual acuity recovery. PMID:26294994

After Surgery

MedlinePlus

... side effects. There is usually some pain with surgery. There may also be swelling and soreness around ... the first few days, weeks, or months after surgery. Some other questions to ask are How long ...

Effectiveness of massage therapy on the mood of patients after open-heart surgery.

PubMed

Babaee, Sima; Shafiei, Zahra; Sadeghi, Mohsen Mir Mohammad; Nik, Ahmadreza Yazdan; Valiani, Mahboobeh

2012-02-01

Cardiovascular diseases have the highest death rates in human society. Coronary artery disease is among the most important of these diseases. No treatment of cardiovascular disease has as much impact on the quality of life of the patients as the heart surgery. The recovery from heart surgery is associated with symptoms of pain and psychological distress. In the early recovery period, the patients will face moderate symptoms of anxiety and depression. In this regard, various measures of nursing, as complementary therapy practices have been performed to help the patients for overcoming the physical and psychological needs. One of these methods, in recent years has been the use of complementary and alternative therapies, particularly massage therapy, after heart surgery. Thus, the aim of this study was to determine the effectiveness of massage therapy on the mood of patients after open-heart surgery in Isfahan Chamran Hospital during 2010-11. In this study 72 patients, who underwent coronary artery bypass surgery, were selected. They were randomly assigned to the two case and control groups. The patients of the case group (n = 36) received Swedish massage for 20 minutes in 4 sessions in 4 consecutive days, 3 to 6 days after the open-heart surgery. The patients in the control group received only the routine care. The mood questionnaire (POMS) which was used in this study has been completed the day before the start of the study and intervention and again after the last day of the intervention. SPSS software version 12 and descriptive and inferential statistical methods were used for data analysis. The comparison of study results showed that massage decreased the overall rating of the patients' mood after the surgery. The use of massage therapy as an effective nursing intervention can improve the patients' mood after open-heart surgery. Due to the low cost and simplicity of this method, it can perhaps be used as a complement to drug therapy and postoperative

Surgery for lung adenocarcinoma with smokers’ polycythemia: a case report

PubMed Central

2013-01-01

Background Smoking is a cause of cancer and polycythemia. Therefore, surgeons who treat patients with cancer may also encounter patients with polycythemia. However, few cases of surgical patients with polycythemia have been reported; in particular, a surgical case involving smokers’ polycythemia has never been reported. We herein report a patient with lung cancer and smokers’ polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period. Case presentation A 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. A ground glass opacity had been identified in the upper lobe of the right lung and was gradually enlarging. In March 2012, bronchoscopic cytology for investigation of the mass revealed non-small cell lung cancer, suggesting primary lung non-small cell carcinoma (T1bN0M0, Stage IA). When he was referred to our hospital for surgery, his complete blood count showed a red blood cell level of 6.50×106/μL, hemoglobin of 21.0 g/dL, and hematocrit of 60.1%. The hematologists’ diagnosis was secondary polycythemia due to heavy smoking (smokers’ polycythemia) because the white blood cell and platelet counts were within normal limits and the erythropoietin was not increased. We calculated the appropriate phlebotomy and infusion volumes based on a formula that we modified. After 550 g of blood was phlebotomized to reduce the hematocrit to approximately 55%, video-assisted right lung upper lobectomy with lymph node dissection was performed in April 2012. The hematocrit was maintained at <50% postoperatively, and the patient was uneventfully discharged on postoperative day 7. The predictive hematocrit and measured hematocrit were very closely approximated in this case. Conclusion We experienced a patient with smokers’ polycythemia who underwent right upper lobectomy for adenocarcinoma. The findings in this case report are meaningful for surgeons treating

Postoperative cerebrovascular accidents in general surgery.

PubMed

Larsen, S F; Zaric, D; Boysen, G

1988-11-01

In a prospective study of postoperative complications, strokes occurred in 6 out of 2463 patients (0.2%) who underwent non-cardiac, non-carotid artery surgery. The patients who experienced cerebrovascular accidents, including three cases of transient ischemic attack, were significantly older than the rest of the group (mean age 79 years versus 65 years) and had manifestations of atherosclerosis in at least one organ preoperatively. Significant predictors of risk for postoperative cerebrovascular accidents were previous cerebrovascular disease, heart disease, peripheral vascular disease, and hypertension. Cerebrovascular accidents occurred late in the postoperative period, 5-26 days after surgery, and were not directly related to surgery and anesthesia. They were more frequent after acute than after elective operations. Precipitating factors for some of the stroke incidents were rapid atrial fibrillation and postoperative dehydration.

Current status of robotic bariatric surgery: a systematic review.

PubMed

Cirocchi, Roberto; Boselli, Carlo; Santoro, Alberto; Guarino, Salvatore; Covarelli, Piero; Renzi, Claudio; Listorti, Chiara; Trastulli, Stefano; Desiderio, Jacopo; Coratti, Andrea; Noya, Giuseppe; Redler, Adriano; Parisi, Amilcare

2013-11-07

Bariatric surgery is an effective treatment to obtain weight loss in severely obese patients. The feasibility and safety of bariatric robotic surgery is the topic of this review. A search was performed on PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science. Twenty-two studies were included. Anastomotic leak rate was 8.51% in biliopancreatic diversion. 30-day reoperation rate was 1.14% in Roux-en-Y gastric bypass and 1.16% in sleeve gastrectomy. Major complication rate in Roux-en-Y gastric bypass resulted higher than in sleeve gastrectomy ( 4,26% vs. 1,2%). The mean hospital stay was longer in Roux-en-Y gastric bypass (range 2.6-7.4 days). The major limitation of our analysis is due to the small number and the low quality of the studies, the small sample size, heterogeneity of the enrolled patients and the lack of data from metabolic and bariatric outcomes. Despite the use of the robot, the majority of these cases are completed with stapled anastomosis. The assumption that robotic surgery is superior in complex cases is not supported by the available present evidence. The major strength of the robotic surgery is strongly facilitating some of the surgical steps (gastro-jejunostomy and jejunojejunostomy anastomosis in the robotic Roux-en-Y gastric bypass or the vertical gastric resection in the robotic sleeve gastrectomy).

Maternal and perinatal outcomes after bariatric surgery: a case control study.

PubMed

de Alencar Costa, Laura Arrais Sydrião; Araujo Júnior, Edward; de Lucena Feitosa, Francisco Edson; Dos Santos, Andréa Cavalcante; Moura Júnior, Luiz Gonzaga; Costa Carvalho, Francisco Herlânio

2016-05-01

To compare the results of maternal and perinatal pregnancies of obese women after bariatric surgery. A retrospective cross-sectional study was carried out on 63 women who had undergone bariatric surgery and 73 obese women (control). Demographic data, the characteristics of the bariatric surgery, and the maternal and perinatal results were evaluated. The Student's t-test and chi-square test (χ2) were used to compare the groups. The gestational complications of the prevalence of gestational diabetes mellitus, anemia, and preeclampsia were analyzed using simple and multivariate logistical regression and odd ratios (OD) with their respective confidence intervals (CI) of 95%. The average body mass index (BMI) at the 1st prenatal appointment of the control group was 34.6±3.3 kg/m2 and that of the post-surgical group was 26.5±4.2 kg/m2. The Roux-en-Y Gastric Bypass was used in 100% of cases; no complications were observed during or after the surgeries. The average weight loss in patients with a prior bariatric surgery was statistically significant (P=0.000). The average weight at birth of the control group was significantly higher than in the post-bariatric surgery group (P=0.017). The women who had a prior bariatric surgery had a higher chance of anemia (OR=3.5; CI 95%: 1.5-8.3) and a reduced chance of macrosomia (OR=0.2; CI 95%:0.1-0.5), and prematurity (OR=0.3; CI 95%:0.1-0.7). Those women who had been submitted to bariatric surgery presented better maternal and perinatal results when compared to obese women.

90-day postoperative mortality is a legitimate measure of hepatopancreatobiliary surgical quality

PubMed Central

Mise, Yoshihiro; Vauthey, Jean-Nicolas; Zimmitti, Giuseppe; Parker, Nathan H.; Conrad, Claudius; Aloia, Thomas A.; Lee, Jeffery E.; Fleming, Jason B.; Katz, Matthew H. G.

2015-01-01

Objective To investigate the legitimacy of 90-day mortality as a measure of hepatopancreatobiliary quality. Summary Background Data The 90-day mortality rate has been increasingly but not universally reported after hepatopancreatobiliary surgery. The legitimacy of this definition as a measure of surgical quality has not been evaluated. Methods We retrospectively reviewed the causes of all deaths that occurred within 365 postoperative days in patients undergoing hepatectomy (n = 2811) and/or pancreatectomy (n = 1092) from January 1997 through December 2012. The rates of surgery-related, disease-related, and overall mortality within 30 days, within 30 days or during the index hospitalization, within 90 days, and within 180 days following surgery were calculated. Results Seventy-nine (3%) surgery-related deaths and 92 (3%) disease-related deaths occurred within 365 days after hepatectomy. Twenty (2%) surgery-related deaths and 112 (10%) disease-related deaths occurred within 365 days after pancreatectomy. The overall mortality rates at 99 day and 118 days optimally reflected surgery-related mortality following hepatobiliary and pancreatic operations, respectively. The 90-day overall mortality rate was a less sensitive but equivalently specific measure of surgery-related death. Conclusions and Relevance The 99-day and 118-day definitions of postoperative mortality optimally reflected surgery-related mortality following hepatobiliary and pancreatic operations, respectively. However, among commonly reported metrics, the 90-day overall mortality rate represents a legitimate measure of surgical quality. PMID:25590497

Varicella-Zoster-Mediated Radiculitis Reactivation following Cervical Spine Surgery: Case Report and Review of the Literature

PubMed Central

Drazin, Doniel; Hanna, George; Shweikeh, Faris; Jeswani, Sunil; Lovely, Leah; Sokolov, Richard; Liu, John C.

2013-01-01

Varicella-zoster virus and herpes simplex virus types 1 and 2 are neurotropic viruses that can be reactivated after a surgical or stressful intervention. Although such cases are uncommon, consequences can be debilitating, and variable treatment responses merit consideration. We describe a 41-year-old male with a history of varicella-mediated skin eruptions, who presented with continuing right arm pain, burning, and numbness in a C6 dermatomal distribution following a C5-6 anterior cervical discectomy and fusion and epidural steroid injections. The operative course was uncomplicated and he was discharged home on postoperative day 1. Approximately ten days after surgery, the patient presented to the emergency department complaining of severe pain in his right upper extremity and a vesicular rash from his elbow to his second digit. He was started on Acyclovir and discharged home. On outpatient follow-up, his rash had resolved though his pain continued. The patient was started on a neuromodulating agent for chronic pain. This case adds to the limited literature regarding this rare complication, brings attention to the symptoms for proper diagnosis and treatment, and emphasizes the importance of prompt antiviral therapy. We suggest adding a neuromodulating agent to prevent long-term sequelae and resolve acute symptoms. PMID:24251050

One-Day Use of Preoperative Topical Nonsteroidal Anti-Inflammatory Drug Prevents Intraoperative Prostaglandin Level Elevation During Femtosecond Laser-Assisted Cataract Surgery.

PubMed

Kiss, Huba J; Takacs, Agnes I; Kranitz, Kinga; Sandor, Gabor L; Toth, Gabor; Gilanyi, Beatrix; Nagy, Zoltan Z

2016-08-01

To determine if pretreatment with topical nonsteroidal anti-inflammatory drug (NSAID) prior to femtosecond laser-assisted cataract surgery (FLACS) prevents intraoperative prostaglandin level elevation as a potential risk factor of postoperative complications. Thirty-six patients with clinically significant cataract and without any concomitant general or ophthalmic disease were enrolled into the three age-matched groups of the study. The mean age of the patients was 62.3 ± 13.1 years. The first group of patients underwent traditional phacoemulsification (Control group), on the second group of patients FLACS was performed, and the third group of patients received topical 0.1% nepafenac pretreatment for 1one day prior to FLACS. Before the phacoemulsification part of the cataract surgery, approximately 110 µL of aqueous humor was collected in all groups. Total prostaglandin concentrations of the collected aqueous humor samples were evaluated by enzyme immunoassay (EIA). The mean of the total prostaglandin concentrations of the aqueous humor samples was 208.8 ± 140.5 pg/mL in patients in the control group, 1449.1 ± 1019.7 pg/mL in the FLACS group (p > 0.001), and 92.2 ± 51.7 pg/mL in the group pretreated with topical NSAID before the FLACS (p > 0.001 compared to FLACS; p > 0.01 compared to control), respectively. FLACS surgery increases intracameral prostaglandin concentration. However, using preoperative 1-day-long nonsteroid anti-inflammatory drops prior to FLACS, this intraoperative increase diminishes. Our study raises the possibility that NSAID pretreatment may be routinely administered before FLACS cataract surgeries to achieve a further decrease in the potential complications of increased total prostaglandin concentration during FLACS surgeries.

The feasibility of short term prophylactic antibiotics in gastric cancer surgery.

PubMed

Lee, Jun Suh; Lee, Han Hong; Song, Kyo Young; Park, Cho Hyun; Jeon, Hae Myung

2010-12-01

Most surgeons administer prophylactic antibiotics for 3 to 5 days postoperatively. However, the Center for Disease Control (CDC) guideline recommends antibiotic therapy for 24 hours or less in clean/uncontaminated surgery. Thus, we prospectively studied the use of short term prophylactic antibiotic therapy after gastric cancer surgery. A total of 103 patients who underwent gastric cancer surgery between October 2007 and June 2008 were prospectively enrolled in a short term prophylactic antibiotics program. One gram of cefoxitin was administered 30 minutes before the incision, and one additional gram was administered intraoperatively for cases with an operation time over 3 hours. Postoperatively, one gram was administered 3 times, every 8 hours. Patients were checked routinely for fever. All cases received open surgery, and the surgical wounds were dressed and checked for Surgical Site Infection (SSI) daily. Of the 103 patients, 15 were dropped based on exclusion criteria (severe organ dysfunction, combined resection of the colon, etc). The remaining 88 patients were included in the short-term program of prophylactic antibiotic use. Of these patients, SSIs were detected in 8 (9.1%) and fever after 2 postoperative days was detected in 11 (12.5%). The incidence of SSIs increased with patient age, and postoperative fever correlated with operation time. Short term prophylactic antibiotic usage is feasible in patients who undergo gastric cancer surgery, and where there are no grave comorbidities or combined resection.

Success of commonly used operating room management tools in reducing tardiness of first case of the day starts: evidence from German hospitals.

PubMed

Ernst, Christian; Szczesny, Andrea; Soderstrom, Naomi; Siegmund, Frank; Schleppers, Alexander

2012-09-01

One of the declared objectives of surgical suite management in Germany is to increase operating room (OR) efficiency by reducing tardiness of first case of the day starts. We analyzed whether the introduction of OR management tools by German hospitals in response to increasing economic pressure was successful in achieving this objective. The OR management tools we considered were the appointment of an OR manager and the development and adoption of a surgical suite governance document (OR charter). We hypothesized that tardiness of first case starts was less in ORs that have adopted one or both of these tools. Using representative 2005 survey data from 107 German anesthesiology departments, we used a Tobit model to estimate the effect of the introduction of an OR manager or OR charter on tardiness of first case starts, while controlling for hospital size and surgical suite complexity. Adoption reduced tardiness of first case starts by at least 7 minutes (mean reduction 15 minutes, 95% confidence interval (CI): 7-22 minutes, P < 0.001). Reductions in tardiness of first case starts figure prominently the objectives of surgical suite management in Germany. Our results suggest that the appointment of an OR manager or the adoption of an OR charter support this objective. For short-term decision making on the day of surgery, this reduction in tardiness may have economic implications, because it reduced overutilized OR time.

42 CFR 412.82 - Payment for extended length-of-stay cases (day outliers).

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Payment for extended length-of-stay cases (day outliers). 412.82 Section 412.82 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Certain Replaced Devices Payment for Outlier Cases § 412.82 Payment for extended length-of-stay cases (day...

42 CFR 412.82 - Payment for extended length-of-stay cases (day outliers).

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Payment for extended length-of-stay cases (day outliers). 412.82 Section 412.82 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Certain Replaced Devices Payment for Outlier Cases § 412.82 Payment for extended length-of-stay cases (day...

42 CFR 412.82 - Payment for extended length-of-stay cases (day outliers).

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Payment for extended length-of-stay cases (day outliers). 412.82 Section 412.82 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Certain Replaced Devices Payment for Outlier Cases § 412.82 Payment for extended length-of-stay cases (day...

42 CFR 412.82 - Payment for extended length-of-stay cases (day outliers).

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Payment for extended length-of-stay cases (day outliers). 412.82 Section 412.82 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF... Certain Replaced Devices Payment for Outlier Cases § 412.82 Payment for extended length-of-stay cases (day...

Gamma knife surgery-induced ependymoma after the treatment of meningioma - a case report.

PubMed

Wang, Ke; Pan, Li; Che, Xiaoming; Lou, Meiqing

2012-01-01

Gamma knife surgery is widely used for a number of neurological disorders. However, little is known about its long-term complications such as carcinogenic risks. Here, we present a case of a radiosurgery-induced ependymoma by gamma knife surgery for the treatment of a spinal meningioma in a 7-year-old patient. In light of reviewing the previous reports, we advocate high caution in making young patients receive this treatment.

Ninety-day Postoperative Mortality Is a Legitimate Measure of Hepatopancreatobiliary Surgical Quality.

PubMed

Mise, Yoshihiro; Vauthey, Jean-Nicolas; Zimmitti, Giuseppe; Parker, Nathan H; Conrad, Claudius; Aloia, Thomas A; Lee, Jeffrey E; Fleming, Jason B; Katz, Matthew Harold G

2015-12-01

To investigate the legitimacy of 90-day mortality as a measure of hepatopancreatobiliary quality. The 90-day mortality rate has been increasingly but not universally reported after hepatopancreatobiliary surgery. The legitimacy of this definition as a measure of surgical quality has not been evaluated. We retrospectively reviewed the causes of all deaths that occurred within 365 postoperative days in patients undergoing hepatectomy (n = 2811) and/or pancreatectomy (n = 1092) from January 1997 to December 2012. The rates of surgery-related, disease-related, and overall mortality within 30 days, within 30 days or during the index hospitalization, within 90 days, and within 180 days after surgery were calculated. Seventy-nine (3%) surgery-related deaths and 92 (3%) disease-related deaths occurred within 365 days after hepatectomy. Twenty (2%) surgery-related deaths and 112 (10%) disease-related deaths occurred within 365 days after pancreatectomy. The overall mortality rates at 99 and 118 days optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. The 90-day overall mortality rate was a less sensitive but equivalently specific measure of surgery-related death. The 99- and 118-day definitions of postoperative mortality optimally reflected surgery-related mortality after hepatobiliary and pancreatic operations, respectively. However, among commonly reported metrics, the 90-day overall mortality rate represents a legitimate measure of surgical quality.

The Relationship between Case-Volume, Care Quality, and Outcomes of Complex Cancer Surgery

PubMed Central

Auerbach, Andrew D; Maselli, Judith; Carter, Jonathan; Pekow, Penelope S; Lindenauer, Peter K

2010-01-01

Background How case volume and quality of care relate to each other and to results of complex cancer surgery is not well understood. Study Design Observational cohort of 14,170 patients 18 or older who underwent pneumonectomy, esophagectomy, pancreatectomy, or pelvic surgery for cancer between 10/1/2003 and 9/1/2005 at a United States hospital participating in a large benchmarking database. Case volumes were estimated within our dataset. Quality was measured by determining whether ideal patients did not receive appropriate perioperative medications (such as antibiotics to prevent surgical site infections) both as individual ‘missed’ measures, as well as the overall number missed. We used hierarchical models to estimate effects of volume and quality on 30-day readmission, in-hospital mortality, length of stay, and costs. Results After adjustment, we noted no consistent associations between higher hospital or surgeon volume and mortality, readmission, length of stay, or costs. Adherence to individual measures was not consistently associated with improvement in readmission, mortality, or other outcomes. For example, continuing antimicrobials past 24 hours was associated with longer length of stay (21.5% higher, 95% CI 19.5% to 23.6%) and higher costs (17% higher, 95% CI 16% to 19%). In contrast, overall adherence, while not not associated with differences in mortality or readmission, was consistently associated with longer length of stay (7.4% longer with one missed measure and 16.4% longer with 2 or more) and higher costs (5% higher with one missed measure, and 11% higher with 2 or more). Conclusions While hospital and surgeon volume were not associated with outcomes, lower overall adherence to quality measures is associated with higher costs, but not improved outcomes. This finding may provide a rationale for improving care systems by maximizing care consistency, even if outcomes are not affected. PMID:20829079

Psychosis following temporal lobe surgery: a report of six cases.

PubMed Central

Mace, C J; Trimble, M R

1991-01-01

Six consecutive patients who had had temporal lobe surgery for epilepsy, and been referred for psychiatric assessment of psychotic symptoms, are reported. Their symptoms (a delusional depression, four schizophrenia-like illnesses, and a case of Capgras' syndrome) are discussed in relation to the possible role of their operations, all of which were on the right hemisphere. PMID:1895129

A behavioral study of daily mean turnover times and first case of the day start tardiness.

PubMed

Wang, Jihan; Dexter, Franklin; Yang, Kai

2013-06-01

Previous research has identified 2 psychological biases in operating room (OR) decisions on the day of surgery: risk attitude of the decision-maker at the OR control desk and decisions made by OR staff to increase clinical work per unit time during the hours they are assigned. Resulting decisions are worse than random chance at reducing overutilized time. To isolate the second bias from decisions at the OR control desk, previous studies of the second bias have analyzed decisions made in non-OR locations and on nights/weekends. Another way to isolate the second bias from decisions at the OR control desk is to study facilities with negligible overutilized OR time. We examined the second bias using data from such a facility. One year of data was collected from a 5-OR hospital. Allocated OR time that minimized the inefficiency of use of OR time was determined first to confirm there was virtually no overutilized OR time. A structural equation model was then built to evaluate the relations among variables while controlling for other correlations. We tested the hypothesis that nonoperative times were no longer on days with little versus relatively large workload. The extra ORs were not cost efficient (i.e., the mean potential improvement varied among days from 21.1% ± 0.2% [SE] to 38.9% ± 0.2%), resulting in very little overutilized OR time. However, conditioned on the preceding tactical decision of running extra ORs, the allocated OR time during the studied period was that which minimized the inefficiency of use of OR time. As the preceding results showed that the facility was suitable for the behavioral study, the behavioral study was performed, and the hypothesized relation confirmed. Each 1-hour decrease in the daily estimated (total) duration of elective cases resulted in a managerially unimportant decrease in the mean turnover times (0.41 ± 0.21 minutes, P = 0.053). Excluding turnovers when there were >2 turnovers occurring simultaneously, there was no

Posterior reversible encephalopathy syndrome with status epilepticus following surgery for lumbar stenosis and spondylolisthesis: case report.

PubMed

Delgado-López, Pedro David; Garcés-Pérez, Gloria; García-Carrasco, Juan; Alonso-García, Esther; Gómez-Menéndez, Ana Isabel; Martín-Alonso, Javier

2018-06-01

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological condition encountered in many different clinical settings, generally occurring in the context of hypertensive crisis, immunosuppressive therapy or autoimmune diseases. It is characterized by headache, stupor, seizures and visual alterations. MRI findings include white matter changes preferentially in the parieto-occipital regions. Although pathogenesis is not fully elucidated, vasoconstriction and brain hypoperfusion seem to be the cause of brain ischemia and vasogenic edema. CSF hypotension is also a reported plausible pathogenic mechanism. We present a unique case of PRES following laminectomy and fixation for L4-5 lumbar stenosis and spondylolisthesis. The patient presented with a 5-day duration status epilepticus immediately after surgery. Brain MRI showed FLAIR and T2 hyperintensities in the bilateral parietal and occipital lobes and external capsules. On the basis of her postoperative lumbar images, we hypothesize that an unnoticed CSF leak might have contributed to develop PRES in this case. The patient developed multiple postoperative complications. Following treatment for severe hypertension and seizures she ultimately recovered. Prompt recognition and treatment of this potentially life-threatening syndrome is necessary in order to increase the likelihood of favorable outcome. Spinal surgeons need to be aware of the possibility of neurological deterioration following spinal surgery and be alert about the occurrence of a dural leak, either recognized or unnoticed, as the plausible mechanism triggering PRES. Copyright © 2018 Elsevier Inc. All rights reserved.

Routine laparoscopic repair of primary unilateral inguinal hernias--a viable alternative in the day surgery unit?

PubMed

Duff, M; Mofidi, R; Nixon, S J

2007-08-01

In September 2004 the NICE institute revised its guidelines on the management of primary inguinal hernias to include laparoscopic repair of unilateral hernias. While published trials have confirmed the equal efficacy of the two approaches, it is not clear what impact a switch to laparoscopic repairs would have on resources and patient throughput in a Day Surgery Unit. All elective hernia repairs performed in a one-year period were considered. Data were obtained from operation notes, discharge summaries and out-patient records. Operating times are routinely documented in theatre. Of the 351 operations studied, 150 were performed laparoscopically predominantly by an extraperitoneal (TEP)approach. Six required conversion to an open procedure. There was no significant difference in operating times, total theatre time or recovery room times between the two groups (51 min, 75 min and 34 min for the laparoscopic group and 53 min, 74 min and 31 min for the open repair group). Among the laparoscopic repair group there were 48 bilateral hernias and 20 recurrent hernias while 190 of the 201 open repairs were for primary unilateral hernias. Rates of overnight stay and immediate complications were similar between the groups though haematoma was more common following open repair (7 vs 2). There is no difference in theatre times, immediate complication rates or rates of overnight stay between open and laparoscopic repair of inguinal hernia. Routine laparoscopic repair of primary unilateral inguinal hernia is a viable alternative within the Day Surgery Unit.

Comparison of Patient Outcomes and Cost of Overlapping Versus Nonoverlapping Spine Surgery.

PubMed

Zygourakis, Corinna C; Sizdahkhani, Saman; Keefe, Malla; Lee, Janelle; Chou, Dean; Mummaneni, Praveen V; Ames, Christopher P

2017-04-01

Overlapping surgery recently has gained significant media attention, but there are limited data on its safety and efficacy. To date, there has been no analysis of overlapping surgery in the field of spine. Our goal was to compare overlapping versus nonoverlapping spine surgery patient outcomes and cost. A retrospective review was undertaken of 2319 spine surgeries (n = 848 overlapping; 1471 nonoverlapping) performed by 3 neurosurgery attendings from 2012 to 2015 at the University of California San Francisco. Collected variables included patient age, sex, insurance, American Society of Anesthesiology score, severity of illness, risk of mortality, procedure type, surgeon, day of surgery, source of transfer, admission type, overlapping versus nonoverlapping surgery (≥1 minute of overlapping procedure time), Medicare-Severity Diagnosis-Related Group, osteotomy, and presence of another attending/fellow/resident. Univariate, then multivariate mixed-effect models were used to evaluate the effect of the collected variables on the following outcomes: procedure time, estimated blood loss, length of stay, discharge status, 30-day mortality, 30-day unplanned readmission, unplanned return to OR, and total hospital cost. Urgent spine cases were more likely to be done in an overlapping fashion (all P < 0.01). After we adjusted for patient demographics, clinical indicators, and procedure characteristics, overlapping surgeries had longer procedure times (estimate = 26.17; P < 0.001) and lower rates of discharge to home (odds ratio 0.65; P < 0.001), but equivalent rates of 30-day mortality, readmission, return to the operating room, estimated blood loss, length of stay, and total hospital cost (all P = ns). Overlapping spine surgery may be performed safely at our institution, although continued monitoring of patient outcomes is necessary. Overlapping surgery does not lead to greater hospital costs. Copyright © 2017 Elsevier Inc. All rights reserved.

Audit of accuracy of clinical coding in oral surgery.

PubMed

Naran, S; Hudovsky, A; Antscherl, J; Howells, S; Nouraei, S A R

2014-10-01

We aimed to study the accuracy of clinical coding within oral surgery and to identify ways in which it can be improved. We undertook did a multidisciplinary audit of a sample of 646 day case patients who had had oral surgery procedures between 2011 and 2012. We compared the codes given with their case notes and amended any discrepancies. The accuracy of coding was assessed for primary and secondary diagnoses and procedures, and for health resource groupings (HRGs). The financial impact of coding Subjectivity, Variability and Error (SVE) was assessed by reference to national tariffs. The audit resulted in 122 (19%) changes to primary diagnoses. The codes for primary procedures changed in 224 (35%) cases; 310 (48%) morbidities and complications had been missed, and 266 (41%) secondary procedures had been missed or were incorrect. This led to at least one change of coding in 496 (77%) patients, and to the HRG changes in 348 (54%) patients. The financial impact of this was £114 in lost revenue per patient. There is a high incidence of coding errors in oral surgery because of the large number of day cases, a lack of awareness by clinicians of coding issues, and because clinical coders are not always familiar with the large number of highly specialised abbreviations used. Accuracy of coding can be improved through the use of a well-designed proforma, and standards can be maintained by the use of an ongoing data quality assurance programme. Copyright © 2014. Published by Elsevier Ltd.

Certification Examination Cases of Candidates for Certification by the American Board of Plastic Surgery: Trends in Practice Profiles Spanning a Decade (2000–2009)

PubMed Central

Chung, Kevin C.; Song, Jae W.; Shauver, Melissa J.; Cullison, Terry M.; Noone, R. Barrett

2011-01-01

Background To evaluate the case mix of plastic surgeons in their early years of practice by examining candidate case-logs submitted for the Oral Examination. Methods De-identified data from 2000–2009 consisting of case-logs submitted by young plastic surgery candidates for the Oral Examination were analyzed. Data consisted of exam year, CPT (Current Procedural Terminology) Codes and the designation of each CPT code as cosmetic or reconstructive by the candidate, and patient age and gender. Subgroup analyses for comprehensive, cosmetic, craniomaxillofacial, and hand surgery modules were performed by using the CPT code list designated by the American Board of Plastic Surgery Maintenance of Certification in Plastic Surgery ( ) module framework. Results We examined case-logs from a yearly average of 261 candidates over 10 years. Wider variations in yearly percent change in median cosmetic surgery case volumes (−62.5% to 30%) were observed when compared to the reconstructive surgery case volumes (−18.0% to 25.7%). Compared to cosmetic surgery cases per candidate, which varied significantly from year-to-year (p<0.0001), reconstructive surgery cases per candidate did not vary significantly (p=0.954). Subgroup analyses of proportions of types of surgical procedures based on CPT code categories, revealed hand surgery to be the least performed procedure relative to comprehensive, craniomaxillofacial, and cosmetic surgery procedures. Conclusions Graduates of plastic surgery training programs are committed to performing a broad spectrum of reconstructive and cosmetic surgical procedures in their first year of practice. However, hand surgery continues to have a small presence in the practice profiles of young plastic surgeons. PMID:21788850

Evaluation of postoperative recovery in day surgery patients using a mobile phone application: a multicentre randomized trial.

PubMed

Jaensson, M; Dahlberg, K; Eriksson, M; Nilsson, U

2017-11-01

Many patients undergoing anaesthesia and surgery experience postoperative complications. Our aim was to investigate whether a systematic follow-up smartphone-based assessment, using recovery assessment by phone points (RAPP) compared with standard care, had a positive effect on day surgery patients' postoperative recovery. We also investigated whether there were differences in women and men's recovery and recovery scores. The study was a single-blind, multicentre randomized controlled trial. A total of 997 patients were randomly allocated to either RAPP or standard care. The Swedish web version of a quality of recovery (SwQoR) questionnaire was used to evaluate the patients' postoperative recovery, either on paper or using an application (RAPP) on postoperative days seven and 14. On postoperative day seven the RAPP group reported significantly better values in seven out of 24 items of the SwQoR: sleeping difficulties; not having a general feeling of wellbeing; having difficulty feeling relaxed/comfortable; and dizziness; headache; pain in the surgical wound; and a swollen surgical wound compared with the control group, implying a good postoperative recovery. Both men and women in the RAPP group reported significantly better values (and, hence good postoperative recovery) compared with the control group in the items sleeping difficulties; not having a general feeling of wellbeing and pain in the surgical wound. Measurement of patient-reported outcomes using a smartphone-based application was associated with decreased discomfort from several postoperative symptoms. Systematic e-assessment can thereby increase patients' quality of recovery and identify key areas for improvement in perioperative care. NCT02492191. © The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

[Revisional radical mastoidectomy surgeries--25 cases'experience].

PubMed

Li, L; Xie, J; Liu, Y; Gong, S S

2017-10-07

Objective: To analyze the risk factors of failure to dry ear after radical mastoidectomy and discuss key points in revisonal surgery. Methods: Clinical data of 25 patients(32 ears) with revisonal mastoidectomy were analyzed. The preoperative temporal bone CT findings, intra-operative findings, surgical procedures, postoperative operating cavities and aural abilities were recorded and analyzed. Results: All patients received preoperative temporal bone CT followed by revisonal radical mastoidectomy under microscope and general anesthesia. Among the revisonal surgeries, 19 ears(59.4%) presented cholesteatoma and 13 ears(40.6%) had no cholesteatoma. In addition, the inadequate opening for mastoid cavity and incompleted removal of the pathological tissues accounted for 90.6%(29/32), the insufficient drainage of surgical cavity for 90.6%(29/32), the lesions in tympanic ostium of eustachian tube for 31.2%(10/32), the improper operation procedures and selection of incision for 15.6%(5/32). As for the re-operation of the modified canal wall down mastoidectomy, tympanoplasty(Ⅱ) plus plastic repairing of cavity of concha were performed in 14 ears(43.8%), the modified canal wall down mastoidectomy, tympanoplasty(Ⅱ) plus reconstruction posterior bony wall of ear canal in 2 ears(6.2%); the modified canal wall down mastoidectomy, tympanoplasty(Ⅲ) plus plastic repairing of cavity of concha in 10 eras(31.3%), the modified canal wall down mastoidectomy, tympanoplasty(Ⅲ) plus reconstruction posterior boney wall of ear canal in 1 ear(3.1%); the radical mastoidectomy plus plastic repairing of cavity of concha in 5 ears(15.6%). Lodoform gauzes were packed in surgical cavity for 2 weeks and the antibiotic was used for 3 days after surgery. All patients had dressing of ears and their ears were dropped with ofloxacin regularly. The dry ear time ranged from 4 to 8 weeks, the average point was the 5th week. During a period of 6-18 months for follow-up, all patients got dried ears

Surgery for lung adenocarcinoma with smokers' polycythemia: a case report.

PubMed

Sugiura, Yasoo; Nemoto, Etsuo; Shinoda, Hiromi; Nakamura, Naoya; Kaseda, Shizuka

2013-02-01

Smoking is a cause of cancer and polycythemia. Therefore, surgeons who treat patients with cancer may also encounter patients with polycythemia. However, few cases of surgical patients with polycythemia have been reported; in particular, a surgical case involving smokers' polycythemia has never been reported. We herein report a patient with lung cancer and smokers' polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period. A 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. A ground glass opacity had been identified in the upper lobe of the right lung and was gradually enlarging. In March 2012, bronchoscopic cytology for investigation of the mass revealed non-small cell lung cancer, suggesting primary lung non-small cell carcinoma (T1bN0M0, Stage IA). When he was referred to our hospital for surgery, his complete blood count showed a red blood cell level of 6.50×106/μL, hemoglobin of 21.0 g/dL, and hematocrit of 60.1%. The hematologists' diagnosis was secondary polycythemia due to heavy smoking (smokers' polycythemia) because the white blood cell and platelet counts were within normal limits and the erythropoietin was not increased. We calculated the appropriate phlebotomy and infusion volumes based on a formula that we modified. After 550 g of blood was phlebotomized to reduce the hematocrit to approximately 55%, video-assisted right lung upper lobectomy with lymph node dissection was performed in April 2012. The hematocrit was maintained at <50% postoperatively, and the patient was uneventfully discharged on postoperative day 7. The predictive hematocrit and measured hematocrit were very closely approximated in this case. We experienced a patient with smokers' polycythemia who underwent right upper lobectomy for adenocarcinoma. The findings in this case report are meaningful for surgeons treating cancer patients because there are few reports

A Surgery-first approach in surgical-orthodontic treatment of mandibular prognathism--a case report.

PubMed

Yu, Chung-Chih; Chen, Po-Hsun; Liou, Eric J W; Huang, Chiung-Shing; Chen, Yu-Ray

2010-01-01

The conventional approach in orthodontic surgery treatment of dentofacial anomalies requires a varied period of pre-surgical orthodontic treatment. This presurgical period is considered to be important for adequate surgical treatment and stable results. This period is usually long bothersome for patients because dental decompensation is required and there is consequent deterioration of aesthetics and function, especially in cases of skeletal Class III occlusion. At Chang Gung Craniofacial Center, a surgery-first approach (SFA), i.e. minimal pre-surgical orthodontics, is one of the treatment choices for Class III patients. In this report, we present a 19-year-old man with mandibular prognathism, an anterior open bite and severe dental crowding treated with SFA. The patient received orthognathic surgery a week after bracing of the teeth. The operation and recovery were uneventful as well as the following orthodontic treatment. The total treatment time was only four months, much shorter than with the conventional approach. The patient benefitted from immediate improvement of the facial profile after surgery, and a much shorter total treatment, and the results were not compromised. We believe in selected cases, SFA is a good and effective treatment alternative.

Current status of robotic bariatric surgery: a systematic review

PubMed Central

2013-01-01

Background Bariatric surgery is an effective treatment to obtain weight loss in severely obese patients. The feasibility and safety of bariatric robotic surgery is the topic of this review. Methods A search was performed on PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science. Results Twenty-two studies were included. Anastomotic leak rate was 8.51% in biliopancreatic diversion. 30-day reoperation rate was 1.14% in Roux-en-Y gastric bypass and 1.16% in sleeve gastrectomy. Major complication rate in Roux-en-Y gastric bypass resulted higher than in sleeve gastrectomy ( 4,26% vs. 1,2%). The mean hospital stay was longer in Roux-en-Y gastric bypass (range 2.6-7.4 days). Conclusions The major limitation of our analysis is due to the small number and the low quality of the studies, the small sample size, heterogeneity of the enrolled patients and the lack of data from metabolic and bariatric outcomes. Despite the use of the robot, the majority of these cases are completed with stapled anastomosis. The assumption that robotic surgery is superior in complex cases is not supported by the available present evidence. The major strength of the robotic surgery is strongly facilitating some of the surgical steps (gastro-jejunostomy and jejunojejunostomy anastomosis in the robotic Roux-en-Y gastric bypass or the vertical gastric resection in the robotic sleeve gastrectomy). PMID:24199869

Mycobacterium chimaera infection following cardiac surgery in the United Kingdom: clinical features and outcome of the first 30 cases.

PubMed

Scriven, James E; Scobie, Antonia; Verlander, Neville Q; Houston, Angela; Collyns, Tim; Cajic, Vjeran; Kon, Onn Min; Mitchell, Tamara; Rahama, Omar; Robinson, Amy; Withama, Shirmila; Wilson, Peter; Maxwell, David; Agranoff, Daniel; Davies, Eleri; Llewelyn, Meirion; Soo, Shiu-Shing; Sahota, Amandip; Cooper, Mike; Hunter, Michael; Tomlins, Jennifer; Tiberi, Simon; Kendall, Simon; Dedicoat, Martin; Alexander, Eliza; Fenech, Teresa; Zambon, Maria; Lamagni, Theresa; Smith, E Grace; Chand, Meera

2018-05-24

Mycobacterium chimaera infection following cardiac surgery, due to contaminated cardiopulmonary bypass heater-cooler units, has been reported worldwide. However, the spectrum of clinical disease remains poorly understood. To address this, we report the clinical and laboratory features, treatment and outcome of the first 30 UK cases. Case note review was performed for cases identified retrospectively through outbreak investigations and prospectively through on-going surveillance. Case definition was Mycobacterium chimaera detected in any clinical specimen, history of cardiothoracic surgery with cardiopulmonary bypass, and compatible clinical presentation. Thirty patients were identified (28 with prosthetic material) exhibiting a spectrum of disease including prosthetic valve endocarditis (14/30), sternal wound infection (2/30), aortic graft infection (4/30), and disseminated (non-cardiac) disease (10/30). Patients presented a median of 14 months post surgery (maximum 5 years) most commonly complaining of fever and weight loss. Investigations frequently revealed lymphopenia, thrombocytopenia, liver cholestasis and non-necrotising granulomatous inflammation. Diagnostic sensitivity for a single mycobacterial blood culture was 68% but increased if multiple samples were sent. 27 patients started macrolide-based combination treatment and 14 had further surgery. To date, 18 patients have died (60%) a median of 30 months (IQR 20-39) after initial surgery. Survival analysis identified younger age, mitral valve surgery, mechanical valve replacement, higher serum sodium concentration and lower CRP as factors associated with better survival. Mycobacterium chimaera infection following cardiac surgery is associated with a wide spectrum of disease. The diagnosis should be considered in all patients who develop an unexplained illness following cardiac surgery. Copyright © 2018. Published by Elsevier Ltd.

Robotic Single-Site and Conventional Laparoscopic Surgery in Gynecology: Clinical Outcomes and Cost Analysis of a Matched Case-Control Study.