Impact of anesthesia technique on post-operative opioid use in open gynecologic surgery in an enhanced recovery after surgery pathway

OBJECTIVE

To examine the effect of anesthesia technique in an enhanced recovery after surgery (ERAS) pathway on post-operative opioid use.

METHODS

Patients undergoing open gynecologic surgery under an ERAS pathway from November 2014 through December 2018 were included retrospectively. All patients received pre-operative analgesia consisting of oral acetaminophen, pregabalin, celecoxib, and tramadol extended release, unless contraindicated. Patients received local wound infiltration with bupivacaine; the post-operative analgesic regimen was standardized. Patients were categorized by anesthesia technique: (1) inhalational, (2) total intravenous anesthesia (TIVA), and (3) combined technique. The primary outcome was post-operative opioid consumption measured as morphine equivalent dose, recorded as the total opioid dose received post-operatively, including doses received through post-operative day 3.

RESULTS

A total of 1184 patients underwent general anesthesia using either inhalational (386, 33%), TIVA (349, 29%), or combined (449, 38%) techniques. Patients who received combined anesthesia had longer surgery times (p=0.005) and surgical complexity was higher among patients who underwent TIVA (moderate/higher in 76 patients, 38%) compared with those who received inhaled anesthesia (intermediate/higher in 41 patients, 23%) or combined anesthesia (intermediate/higher in 72 patients, 30%). Patients who underwent TIVA anesthesia consumed less post-operative opioids than those managed with inhalational technique (0 (0-46.3) vs 10 (0-72.5), p=0.009) or combined anesthesia (0 (0-46.3) vs 10 (0-87.5), p=0.029). Similarly, patients who underwent the combined technique had similar opioid consumption post-operatively compared with those who received inhalational anesthesia (10 (0-87.5) vs 10 (0-72.5), p=0.34).

CONCLUSIONS

TIVA technique is associated with a decrease in post-operative consumption of opioids after open gynecologic surgery in patients on an ERAS pathway.

Can a Low Sperm Concentration without Assessing Motility Confirm Vasectomy Success? A Retrospective Descriptive Study

PURPOSE

A fresh post-vasectomy semen analysis showing 100,000 nonmotile sperm/mL or less confirms sterility. Mailed sample or self-testing at home with SpermCheck® Vasectomy decreases the inconvenience of producing a fresh sample, but without assessing motility. We evaluated if there is a sperm concentration under which no motile sperm are observed that could fortify the use of these alternatives.

MATERIALS AND METHODS

We conducted a study of post-vasectomy semen analyses performed at the andrology laboratory of the Quebec City university hospital, Canada. Sperm concentration and motility were assessed on fresh noncentrifuged 10 µL samples at 400× magnification. We calculated the proportion of post-vasectomy semen analysis showing motile sperm according to sperm concentration for all and first prescribed post-vasectomy semen analysis by the 5 physicians who performed the most vasectomies.

RESULTS

We identified 6,492 post-vasectomy semen analyses prescribed by 169 physicians. The 5 vasectomists prescribed 95.6% (6,204) of the post-vasectomy semen analyses; 96.1% (5,965) were first tests. We observed motility in all sperm concentration strata but it decreased with lower concentrations. At the first post-vasectomy semen analysis, among patients with less than 1 million, 250,000 and 100,000 sperm/mL, 0.5% (27/5,842) and 0.3% (19/5,760 and 17/5,725) had motility, respectively.

CONCLUSIONS

If the first post-vasectomy semen analysis on a mailed sample shows less than 1 million sperm/mL, we recommend requesting an additional mailed sample instead of a fresh sample. SpermCheck Vasectomy could falsely indicate a successful vasectomy in a very small proportion of cases. The optimal post-vasectomy semen analysis strategy must involve shared decision making, balancing the inconvenience of providing a fresh sample with the risk of a false-negative result.

Development and Validation of a Web-Based Prediction Model for AKI after Surgery

BACKGROUND

AKI after surgery is associated with high mortality and morbidity. The purpose of this study is to develop and validate a risk prediction tool for the occurrence of postoperative AKI requiring RRT (AKI-dialysis).

METHODS

This retrospective cohort study had 2,299,502 surgical patients over 2015-2017 from the American College of Surgeons National Surgical Quality Improvement Program Database (ACS NSQIP). Eleven predictors were selected for the predictive model: age, history of congestive heart failure, diabetes, ascites, emergency surgery, hypertension requiring medication, preoperative serum creatinine, hematocrit, sodium, preoperative sepsis, and surgery type. The predictive model was trained using 2015-2016 data (n=1,487,724) and further tested using 2017 data (n=811,778). A risk model was developed using multivariable logistic regression.

RESULTS

AKI-dialysis occurred in 0.3% (n=6853) of patients. The unadjusted 30-day postoperative mortality rate associated with AKI-dialysis was 37.5%. The AKI risk prediction model had high area under the receiver operating characteristic curve (AUC; training cohort: 0.89, test cohort: 0.90) for postoperative AKI-dialysis.

CONCLUSIONS

This model provides a clinically useful bedside predictive tool for postoperative AKI requiring dialysis.

Levels of education and technical skills in registered nurses working in post-anaesthesia care units in Sweden

BACKGROUND

Specialized nursing care should be provided by nurses working in post-anaesthesia care units to ensure safe and successful recovery after surgery and anaesthesia. However, there is no consensus regarding the competence and education needed by nurses working in post-anaesthesia care units.

AIM

The aim of this study is to describe and compare levels of education and technical skills in registered nurses working in post-anaesthesia care units in Sweden, as well as the education that post-anaesthesia care unit nurse managers' desire for registered nurses working in post-anaesthesia care units.

METHODS

This descriptive cross-sectional study was conducted in Sweden between September and December of 2019. A web-based survey was developed that included questions about the levels of education and technical skills possessed by registered nurses working in Swedish post-anaesthesia care units and desired by nurse managers for these nurses. The survey was evaluated for content validity by four experts. The survey was distributed to the nurse manager of each studied post-anaesthesia care unit. All nurse managers received written information and were informed that submitting the survey was considered as consenting to participate in the study.

RESULTS

Most surveyed nurses held a postgraduate diploma in specialist nursing. Registered nurses performed many tasks autonomously; however, there was a significant difference between specialist nurses and registered nurses, with specialist nurses being more autonomous than registered nurses. Most of the nurse managers (n = 31/45) wanted the registered nurses in their units to have education in postoperative care. The relatively low overall response rate of 58% is a study limitation.

CONCLUSIONS

Registered nurses working in post-anaesthesia care units in Sweden must have various technical skills. Some of these skills are only performed by specialist nurses, indicating that postoperative care is an advanced level of nursing care.

Intraoperative dextrose rate during exploratory laparotomies in neonates and the incidence of postoperative hyperglycemia: A retrospective observational study

INTRODUCTION

Compared with the older pediatric population, neonates have greater perioperative morbidity and mortality. Difficulty with glucose regulation may be a contributing modifiable risk factor during perioperative anesthetic management. To mitigate the risk of hyperglycemia in neonates, some providers empirically halve the preoperative rate of dextrose-containing infusions during surgery.

AIM

To assess the association between halving the preoperative maintenance dextrose rate and postoperative euglycemia in neonatal intensive care unit patients undergoing exploratory laparotomies.

METHODS

Neonatal intensive care unit patients who underwent exploratory laparotomy under general anesthesia from 1/1/2014 to 11/21/2019 were included in this analysis. Hyperglycemia and hypoglycemia were defined as >150 mg/dL and <46 mg/dL. A calculated dextrose ratio was utilized to categorize patients into full and half intraoperative dextrose rate cohorts. Univariate analyses were performed with Fisher's exact test, the Wilcoxon rank sum test, or Spearman's correlation. Multivariable analyses with regression models were conducted after graphical evaluation of a predetermined set of independent variables.

RESULTS

107 patients were included in the full dextrose rate cohort and 96 patients in the half dextrose rate cohort with postoperative hyperglycemia occurring in 47 and 28 patients, respectively. On univariate analysis, halving the preoperative dextrose rate was associated with decreased postoperative hyperglycemia (odds ratio: 0.53; 95% CI: 0.28-0.98, P = 0.041). This association continued in the regression model (adjusted odds ratio: 0.49; 95% CI: 0.25-0.80, P = 0.008) after controlling for preoperative dextrose rate, preoperative serum glucose, preoperative pH, surgical duration, postmenstrual age at surgery, and the presence of necrotizing enterocolitis. Only one patient was hypoglycemic postoperatively, and they were in the full dextrose cohort.

CONCLUSION

Halving of preoperative dextrose rates intraoperatively during exploratory laparotomy in neonatal intensive care unit patients was associated with a decreased risk of postoperative hyperglycemia without substantially increasing the occurrence of postoperative hypoglycemia. The practice of halving preoperative dextrose rates may be an effective empirical approach for intraoperative glucose management in the high-risk neonatal population when blood glucose monitoring is challenging.

Revisiting straight-line repair in unilateral complete cleft lip: a comparison with rotation-advancement repair

Rotation-advancement repair (RAR) has been the most widely used technique for unilateral cleft lip repair. We recently used a straight-line repair with medial orbicularis muscle lengthening (SLR-ml) technique, based on the hypothesis that it could minimize the postoperative scar appearance without causing s short-lip deformity when muscle reorientation is performed correctly. A retrospective cohort study was conducted on unilateral complete cleft lip patients who underwent cheiloplasty between 2009 and 2017. Two cheiloplasty techniques were compared: RAR and SLR-ml. Outcomes were evaluated by assessing follow-up photographs using three methods: (1) glance impression on a five-point scale, (2) Manchester Scar Scale, and (3) indirect anthropometry. Seventy-one patients were analysed: 41 in the RAR group (28 male, 13 female) and 30 in the SLR-ml group (15 male, 15 female). The glance impression (P=0.506) and Manchester Scar Scale (P=0.347) scores did not differ between the groups. According to the symmetry ratio (cleft side value/non-cleft side value), vertical lip height (P=0.804), horizontal lip length (P=0.881), and Cupid's bow width (P=0.122) did not differ significantly between the groups. The preoperative lip height discrepancy was not correlated with the postoperative vertical lip height. The SLR-ml method can be regarded as a successful tool for symmetric repair of unilateral cleft lip.

Education, Competence, and Role of the Nurse Working in the PACU: An International Survey

PURPOSE

The aim of this research project was to describe the education, competence, and role of nurses working in the postanesthesia care unit (PACU) in 11 countries having an established perianesthesia specialty nursing organization and membership on the International Collaboration of PeriAnaesthesia Nurses, Inc (ICPAN) Global Advisory Council (GAC).

DESIGN

This is a descriptive international cross-sectional study.

METHODS

A Web-based survey was distributed to members of the ICPAN GAC to be completed by the GAC representative or another expert perianesthesia nurse member from the organization (n = 11). The GAC has one representative from the following 11 ICPAN organizational members: ACPAN, Australian College of PeriAnaesthesia Nurses (Australia); BRV, Beroepsvereniging Recovery Verpleegkundigen (Belgium/The Netherlands); NAPANc, National Association of PeriAnesthesia Nurses of Canada (Canada); FSAIO, The Danish Association of Anaesthesia, Intensive Care and Recovery Nurses (Denmark); FANA, Finnish Association of Nurse Anaesthetists (Finland); Hellenic Perianesthesia Nursing Organization (Greece); IARNA, Irish Anaesthetic and Recovery Nurses Association (Ireland); PNC of NZNO, Perioperative Nurses College of the New Zealand Nurses Organisation (New Zealand); ANIVA, Swedish Association of Nurse Anesthetists and Intensive Care Nurses (Sweden); BARNA, British Anaesthetic and Recovery Nurses Association (United Kingdom); and ASPAN, American Society of PeriAnesthesia Nurses (USA).

FINDINGS

Perianesthesia nursing was recognized as a professional nursing specialty in 6 of 11 countries, and 8 of 11 have established national guidelines or practice standards for perianesthesia nurses. The Netherlands, Ireland, and Australia are the only countries that have a formal education program for perianesthesia nurses. There were variations in nurse-to-patient ratios between the 11 countries, ranging from 2:1 to 1:3 in the Phase I recovery of critically ill patients; in Phase II recovery (day surgery) it was most common to have up to three to four patients per nurse. Perianesthesia nurses were mainly the only profession stationed in the PACU, with professions such as the anesthesiologist and surgeon on call. The nurses performed many job tasks autonomously; however, this differed between countries.

CONCLUSIONS

Perianesthesia nurse education, clinical guidelines, other professions working in the PACU, and job tasks differ between countries. This knowledge can be used in international collaboration to further develop education and training for nurses working in the PACU. Continued international perianesthesia nursing partnership can only bring us closer and strengthen our specialty practice with the focus not on our differences but on our common denominators.

Are radiological measurements reliable methods in the postoperative follow-up of calcaneal fractures?

Background

Böhler's angle (BA) and the crucial angle of Gissane (CAG) are the most frequently used objective measurements for the follow-up of fixation following calcaneus fracture surgery. However, the measurements of these angles by different people can affect the results and cause conflicting interpretations of different results obtained. This has caused confusion in the literature.

Aims

The aim of this study was to investigate the reliability and disagreement of BA and the CAG, and to interrogate the veracity of angular changes in the postoperative period of calcaneal fractures.

Methods

In the first round, a total of 82 postoperative lateral radiographs were investigated to assess the inter-tester reliability and disagreement. Second round; all radiographs were re-evaluated by two testers 15 days after the first measurement. These values were used to assess the intra and inter-tester reliability, disagreement and false negative/positive angular change. All measurements were performed separately by a radiologist and an orthopedic surgeon.

Results

Inter- and intra-tester reliability was found low to high in BA (ICC: 0.465 to 0.837), and moderate to very high in CAG (ICC: 0.661 to 0.926). The mean inter-tester disagreement of BA was 4.19° and 6.07°. These values were 4.76° and 7.22° for CAG. The mean intra-tester disagreement of BA was 4.09° for the orthopedic surgeon and 3.97° for the radiologist. These values were 4.96° and 4.39° for CAG respectively. The false negative angular difference was found for BA in 51 (62.2%) cases for the orthopedic surgeon and 46 (56.1%) cases for the radiologist. The mean values were -3.87° and -4.21°, respectively. For the CAG, the false positive angular difference was found in 43 (52.4%) cases for both the orthopedic surgeon and the radiologist. The mean values were +5.01° and +4.72°, respectively.

Conclusion

These angles alone should not be considered to be of guidance in the postoperative period. If any angular change is determined on the lateral radiographs, this could arise from a disagreement or false angular change.

Physical activity levels among ovarian cancer survivors: a prospective longitudinal cohort study

OBJECTIVE

Physical activity following cancer diagnosis is associated with improved outcomes, including potential survival benefits, yet physical activity levels among common cancer types tend to decrease following diagnosis and remain low. Physical activity levels following diagnosis of less common cancers, such as ovarian cancer, are less known. The objectives of this study were to describe physical activity levels and to explore characteristics associated with physical activity levels in women with ovarian cancer from pre-diagnosis to 2 years post-diagnosis.

METHODS

As part of a prospective longitudinal study, physical activity levels of women with ovarian cancer were assessed at multiple time points between pre-diagnosis and 2 years post-diagnosis. Physical activity levels and change in physical activity were described using metabolic equivalent task hours and minutes per week, and categorically (sedentary, insufficiently, or sufficiently active). Generalized Estimating Equations were used to explore whether participant characteristics were related to physical activity levels.

RESULTS

A total of 110 women with ovarian cancer with a median age of 62 years (range 33-88) at diagnosis were included. 53-57% of the women were sufficiently active post-diagnosis, although average physical activity levels for the cohort were below recommended levels throughout the 2-year follow-up period (120-142.5min/week). A decrease or no change in post-diagnosis physical activity was reported by 44-60% of women compared with pre-diagnosis physical activity levels. Women diagnosed with stage IV disease, those earning a lower income, those receiving chemotherapy, and those currently smoking or working were more likely to report lower physical activity levels and had increased odds of being insufficiently active or sedentary.

CONCLUSIONS

Interventions providing patients with appropriate physical activity advice and support for behavior change could potentially improve physical activity levels and health outcomes.

[The effectiveness of the use of local antibacterial drugs in the postoperative period in a patient with a neoplasm of the external auditory canal]

This article presents clinical case of external auditory canal osteoma and postoperative management of this patients. In this publication the etiology of this pathology, as well as the clinical manifestations that accompany this pathological condition are described. We present a literature review and our own experience of treatment this group of patients.

Preoperative serum biomarkers in the prediction of postoperative delirium following abdominal surgery

AIM

Elderly patients undergoing abdominal surgery have a high risk of developing postoperative delirium. This study aimed to explore risk factors for postoperative delirium by focusing on preoperative hematologic markers, and to develop a model that would be useful in predicting the occurrence of postoperative delirium.

METHODS

This retrospective study included patients aged ≥65 years who underwent elective abdominal surgery under general anesthesia from January 2017 to May 2019. Patients' demographics, hematologic data and intraoperative data were recorded. Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, platelet-to-white blood cell ratio and prognostic nutritional index were calculated. We evaluated risk factors of postoperative delirium assessed using a chart-based method for identification of delirium and developed a predictive model using preoperative and intraoperative data.

RESULTS

Of 931 eligible patients, 833 with a mean age of 73.9 years were included in the analysis. The rate of incidence of postoperative delirium was 7.3%. Age, duration of surgery and preoperative platelet-to-lymphocyte ratio or platelet-to-white blood cell ratio were statistically significant risk factors. The predictive model, which included age, duration of surgery and platelet-to-lymphocyte ratio, had the largest area under the curve of 0.77.

CONCLUSIONS

Age, duration of surgery and preoperative platelet-to-white blood cell ratio or platelet-to-lymphocyte ratio are associated with the development of postoperative delirium. A predictive model, which includes age, duration of surgery and preoperative platelet-to-lymphocyte ratio, is useful in predicting the development of postoperative delirium after elective abdominal surgery. Geriatr Gerontol Int 2020; 20: 1208-1212.

Skin-to-Skin Care Is a Safe and Effective Comfort Measure for Infants Before and After Neonatal Cardiac Surgery

OBJECTIVES

To determine the effect of skin-to-skin care on stress, pain, behavioral organization, and physiologic stability of infants with critical congenital heart disease before and after neonatal cardiac surgery.

DESIGN

A baseline response-paired design was used, with infants acting as their own controls before, during, and after skin-to-skin care at two distinct time points: once in the preoperative period (T1) and once in the postoperative period (T2).

SETTING

Cardiac ICU and step-down unit in a large metropolitan freestanding children's hospital.

SUBJECTS

Convenience sample of 30 infants admitted preoperatively for critical congenital heart disease.

INTERVENTIONS

Eligible infants were placed into skin-to-skin care for 1 hour with their biological mothers once each at T1 and T2.

MEASUREMENTS AND MAIN RESULTS

Measurements of stress (salivary cortisol), pain and behavior state (COMFORT scale), and physiologic stability (vital signs) were assessed immediately before skin-to-skin care, 30 minutes into skin-to-skin care, and 30 minutes after skin-to-skin care ended.At both T1 and T2, infant pain scores were significantly decreased (p < 0.0001) and infants moved into a calmer behavior state (p < 0.0001) during skin-to-skin care as compared to baseline. At T1, infants also had significantly reduced heart rate (p = 0.002) and respiratory rate (p < 0.0001) and increased systolic blood pressure (p = 0.033) during skin-to-skin care. At both T1 and T2, infant cortisol remained stable and unchanged from pre-skin-to-skin care to during skin-to-skin care (p = 0.096 and p = 0.356, respectively), and significantly increased from during skin-to-skin care to post-skin-to-skin care (p = 0.001 and p = 0.023, respectively). Exploratory analysis revealed differences in cortisol reactivity for infants with higher baseline cortisol (> 0.3 μg/dL) versus lower (≤ 0.3 μg/dL) prior to skin-to-skin care. Infants with higher baseline cortisol at T2 experienced significantly reduced cortisol during skin-to-skin care (p = 0.025). No significant differences in demographics or baseline variables were found between infants in either group.

CONCLUSIONS

Skin-to-skin care is a low-cost, low-risk intervention that promotes comfort and supports physiologic stability in infants before and after neonatal cardiac surgery.

Review and synthesis of the experience of patients following total hip or knee arthroplasty in the era of rapidly decreasing hospital length of stay

AIM

The hospital length of stay for orthopedic surgery has been decreasing during the last couple of decades. Therefore, this study was performed to explore the postoperative experiences of adult/older patients (age ≥20 years) with osteoarthritis who underwent total hip or knee arthroplasty, focusing on the first 6 weeks following discharge.

METHODS

A systematic literature search on qualitative studies was conducted using six databases, such as Medline, CINAHL and Mednar. Verbatim interview data and themes or subthemes related to the patients' experience after discharge were extracted. Content analysis was used to code interview data. Codes similar in meaning were grouped, and subcategories were formed. These subcategories were then grouped into categories.

RESULTS

Sixteen qualitative studies with 253 participants were analyzed. In total, 136 codes were generated and formed 29 subcategories. Six categories were generated: (a) postoperative pain and medication; (b) difficulty in performing activities of daily living; (c) appreciation for support and difficulties associated with receiving support; (d) variability in recovery process and information-seeking; (e) lack of patient-centered care; and (f) transportation problems and social isolation.

CONCLUSION

Our review suggests that prospective patients and their caregivers need individually tailored presurgical education and advanced planning for postsurgical reduced mobility.

The impact of COVID-19 pandemic on congenital heart surgery practice: An alarming change in demographics

Background

The aim of this study is to investigate the effect of COVID‐19 outbreak on congenital cardiac surgery practice in a single center.

Methods

The first case of COVID‐19 in our country was seen on March 11th, 2020. The patients operated between March 11th, 2019‐and March 10th, 2020 were taken as the pre‐COVID group, and those operated between March 11th and May 11th, 2020 were taken as the COVID group. The data was retrospectively collected, and the two periods were compared.

Results

Monthly average number of cases which was 52 patients/month (626 patients in 12 months) before COVID decreased to 35 patients/month (70 patients in 2 months) during COVID periods (P < .01). During the pre‐COVID period the median postoperative length of hospital stay was 3 (IQR: 1‐5) days. During the COVID period, this decreased to 1 (IQR: 1‐3) day (P < .01). During the pre‐COVID period, the hospital expenses of 17% (8/47) of the foreign nationals were covered by their homeland. The remaining 83% (39/47) were paid from the asylum seekers’ fund. The proportion of foreign nationals operated significantly decreased during the COVID period ([7%; 47/632 vs 1%; 1/70]; P = .04). No significant difference was observed in terms of STAT mortality scores and categories and postoperative results of the operations performed between the two periods.

Conclusions

Congenital cardiac surgery practice can be safely maintained with restricted case volume during the pandemic period. It is alarming that patients in the deprived areas cannot access pediatric cardiac surgery and possibly other health services because of closure of the borders between countries.

Inhalation sedation for postoperative patients in the intensive care unit: initial sevoflurane concentration and comparison of opioid use with propofol sedation

Background

Although the use of volatile sedatives in the intensive care unit (ICU) is increasing in Europe, it remains infrequent in Asia. Therefore, there are no clinical guidelines available. This study investigates the proper initial concentration of sevoflurane, a volatile sedative that induces a Richmond agitation-sedation scale (RASS) score of –2 to –3, in patients who underwent head and neck surgery with tracheostomy. We also compared the amount of postoperative opioid consumption between volatile and intravenous (IV) sedation.

Methods

We planned a prospective study to determine the proper initial sevoflurane concentration and a retrospective analysis to compare postoperative opioid consumption between volatile sedation and propofol sedation. Patients scheduled for head and neck surgery with tracheostomy and subsequent postoperative sedation in the ICU were enrolled.

Results

In this prospective study, the effective dose 50 (ED50) of initial end-tidal sevoflurane concentration was 0.36% (95% confidence interval [CI], 0.20 to 0.60%), while the ED 95 was 0.69% (95% CI, 0.60 to 0.75%) based on isotonic regression methods. In this retrospective study, remifentanil consumption during postoperative sedation was significantly lower in the sevoflurane group (2.52±1.00 µg/kg/hr, P=0.001) than it was in the IV propofol group (3.66±1.30 µg/kg/hr).

Conclusions

We determined the proper initial end-tidal concentration setting of sevoflurane for patients with tracheostomy who underwent head and neck surgery. Postoperative sedation with sevoflurane appears to be a valid and safe alternative to IV sedation with propofol.

Liver transplant recipients infected with SARS-CoV-2 in the early postoperative period: Lessons from a single center in the epicenter of the pandemic

The impact of coronavirus disease‐19 (COVID‐19) in liver recipients remains largely unknown. Most data derive from small retrospective series of patients transplanted years ago. We aimed to report a single‐center case series of five consecutive patients in the early postoperative period of deceased‐donor liver transplantation who developed nosocomial COVID‐19. Two patients presented important respiratory discomfort and eventually died. One was 69 years old and had severe coronary disease. She rapidly worsened after COVID‐19 diagnosis on 9th postoperative day. The other was 67 years old with non‐alcoholic steatohepatitis, who experienced prolonged postoperative course, complicated with cytomegalovirus infection and kidney failure. He was diagnosed on 36th postoperative day and remained on mechanical ventilation for 20 days, ultimately succumbing of secondary bacterial infection. The third, fourth, and fifth patients were diagnosed on 10th, 11th, and 18th postoperative day, respectively, and presented satisfactory clinical evolution. These last two patients were severely immunosuppressed, since one underwent steroid bolus for acute cellular rejection and another also used anti‐thymocyte globulin for treating steroid‐resistant rejection. Our novel experience highlights that COVID‐19 may negatively impact the postoperative course, especially in elder and obese patients with comorbidities, and draws attention to COVID‐19 nosocomial spread in the early postoperative period.

Physical activity trajectories following gynecological cancer: results from a prospective, longitudinal cohort study

BACKGROUND

Participating in physical activity after a diagnosis of cancer is associated with reduced morbidity and improved outcomes. However, declines in, and low levels of, physical activity are well documented in the broader cancer population, but with limited evidence following gynecological cancer.

OBJECTIVE

To describe physical activity levels from before and up to 2 years after gynecological cancer surgery; to explore the relationship between physical activity patterns and quality of life; and to describe characteristics associated with physical activity trajectories post-gynecological cancer.

METHODS

Women with gynecological cancer (n=408) participated in a prospective study that assessed physical activity and quality of life pre-surgery (baseline), at 6 weeks, and 3, 6, 9, 12, 15, 18 and 24 months post-surgery. Validated questionnaires were used to assess physical activity (Active Australia Survey) and quality of life outcomes (Functional Assessment of Cancer Therapy-General). Generalized estimating equation modeling, group-based trajectory analysis, and analysis of variance were used to identify physical activity levels over time, to categorize women into physical activity trajectory groups, and to assess the relationship between physical activity levels and quality of life, respectively.

RESULTS

Women had a mean±SD age of 60±11.4 years at diagnosis, with the majority diagnosed with endometrial cancer (n=235, 58%) or stage I disease (n=241, 59%). Most women (80%) started with and maintained low levels of physical activity (1-10 metabolic equivalent task hours per week), reported no physical activity throughout the follow-up period, or reduced physical activity levels over time. Only 19% of women maintained or doubled physical activity levels, so that by 24 months post-diagnosis they were engaging in sufficient levels of physical activity. Women with endometrial cancer (58% of the sample) were more likely to be overweight or obese and to report low levels of physical activity or none at all. Higher physical activity levels were associated with higher quality of life (p<0.05).

CONCLUSION

The low baseline and surveillance levels of physical activity show that the vast majority of gynecological cancer survivors have the ability to improve their physical activity levels. Integration of physical activity advice and support into standard care could lead to gains in quality of life during gynecological cancer survivorship.

Meaning of Receiving Artificial Nutritional Support in People in the Postoperative Period of Abdominal Surgery

OBJECTIVES

This work sought to describe the meaning of receiving artificial nutritional support in people in the postoperative period of abdominal surgery.

METHODS

This was a qualitative study of grounded theory, following the guidelines by Corbin and Strauss. The information was collected through 26 in-depth interviews with 21 participants, interned in a tier III health care hospital in the city of Tunja, Colombia.

RESULTS

The study describes four categories, which account for the way in which the person experiences physical, physiological, emotional, and social changes when receiving artificial nutritional support. The categories include stopping eating and becoming artificially fed, decreasing the ability to move to recover movement, experiencing the difficulty of having artificial nutritional support, and reaching the disease to transform life. The data analysis shows that the basic surgical pathology and the artificial nutritional support are sudden events that fragment the daily life of the person. These individuals demand the mobilization of religious, family, and social resources to strengthen the person's internal and external environment and, thus, achieve the health situation.

CONCLUSIONS

The analysis of the meanings shows how the person reflects and interprets the reality of receiving artificial nutritional support, an event that has implicit physical discomfort, emotional changes, and physical appearance, which are determinants in the behavior and practice of artificial nutrition. However, artificial nutritional support becomes for the person an alternative to live and recover the state of health.

EVAN-G score in patients undergoing minimally invasive gynecology oncologic surgery in an Enhanced Recovery After Surgery (ERAS) program

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) has been proven to decrease the length of hospital stay without increasing re-admission rates or complications. There are limited data on the satisfaction of patients undergoing minimally invasive surgery for gynecologic malignancy within ERAS programs. The aim of this study was to evaluate patient satisfaction after minimally invasive surgery for gynecologic malignancy within the ERAS program using the 'Evaluation du Vécu de l'Anésthésie Génerale (EVAN-G)' questionnaire.

METHODS

This observational retrospective study was conducted at the Paoli-Calmettes Institute between June 2016 and December 2018. All the included patients underwent minimally invasive surgery for a gynecologic malignancy. EVAN-G, a validated questionnaire, was used to measure peri-operative patient satisfaction. This questionnaire consists of 26 items assessing six elements: attention, privacy, information, pain, discomfort, and waiting time. Each element is assessed via a 5-step numerical scale and then transformed to a 0-100 scale according to the degree of satisfaction. The EVAN-G questionnaire was given to patients before surgery and collected during the post-operative consultation (2-3 weeks after surgery).

RESULTS

A total of 175 patients underwent minimally invasive surgery for gynecologic malignancy within the ERAS program. Of these, 92 patients were included in the study and 83 patients were excluded. The overall patient compliance rate with our ERAS program was 90%. The analysis of the EVAN-G score of all participants showed an overall high level of satisfaction with a mean score of 81.9 (range 41.6-100). Patients with peri-operative complications or having prolonged hospitalization also showed high levels of satisfaction with a mean score of 80.5 (41.6-100) and 83.2(55-100), respectively.

CONCLUSION

In this study we showed a high patient satisfaction with the ERAS program. When comparing length of stay and complications, neither extended length of stay nor development of complications after minimally invasive surgery impacted patient satisfaction.

Ultrasound appearance of SURGICEL® Absorbable Hemostat (oxidised cellulose) following laparoscopic resection of a splenic cyst - A potential diagnostic peril

We present the case of a 14 year old who underwent laparoscopic marsupialisation of a splenic cyst. Postoperative ultrasound demonstrated an echogenic collection in the surgical bed that was initially misdiagnosed as an infected collection/abscess due to its sonographic appearances but was finally correctly identified as haemostatic material that had been packed into the surgical cavity. We subsequently constructed a tissue phantom containing a compressed ball of SURGICEL (r) Absorbable Hemostat and demonstrated that it showed identical sonographic appearances. Haemostatic agents such as oxidised cellulose are often packed within the operative bed to control microvascular haemorrhage. These agents can be observed on a variety of postoperative imaging modalities, in particular ultrasound and computed tomography, and may cause diagnostic error. The critical importance of understanding the details of the surgical procedure and effective communication between the surgical team and ultrasound practitioner is emphasised to minimise the risk of misdiagnosis and unnecessary further imaging and radiological/surgical intervention.

Patterns in Pain and Opiate Use after Endoscopic Sinus Surgery

OBJECTIVE

To evaluate postoperative opiate use and patients' opinions regarding pain management after endoscopic sinus surgery (ESS).

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary referral medical center.

SUBJECTS AND METHODS

We prospectively evaluated postoperative opiate utilization in adults undergoing ESS over a 2-year period at an academic medical facility. Exclusion criteria included use of nasal packing, intracranial or orbital procedures, tumor surgery, and any use of endoscopic drills. All patients underwent bilateral maxillary antrostomy, total ethmoidectomy, sphenoidotomy, and frontal sinusotomy with or without septoplasty. Patients were discharged with 30 oxycodone-acetaminophen (5-325 mg) and a survey assessing pain and narcotic/nonnarcotic use on postoperative days 0 to 7.

RESULTS

A total of 64 patients completed surveys. Mean ± SD narcotic use over the 7-day postoperative period was 7.7 ± 7.6 pills. Patients with high narcotic use (>6 pills total) had no differences in demographic or surgical factors from those with low use (≤6 pills) but did report a higher level of postoperative day 1 pain (4.8 ± 1.1 vs 2.0 ± 1.4, P < .001). Narcotic use declined during this period, with <30% of patients requiring narcotics by postoperative day 3.

CONCLUSION

Our results support reduced opiate prescription and encouragement of nonnarcotic use after ESS without compromising effective pain management.

Deep vein thrombosis and serum D-dimer after pelvic lymphadenectomy in gynecological cancer

INTRODUCTION

Venous thromboembolism prevention during the perioperative period requires comprehensive risk-level assessment. The aim of this study was to evaluate the incidence of deep vein thrombosis and to assess the cut-off levels of serum D-dimer as a screening strategy for deep vein thrombosis during the perioperative period.

METHODS

A total of 205 patients (ovarian cancer: 68, endometrial cancer: 76, cervical cancer: 61) who underwent gynecological surgery, including retroperitoneal lymph node dissection, were enrolled. We retrospectively analyzed the data on the cut-off value of D-dimer assessed using area under the receiver operating characteristic curve preoperatively, and 2 or 3 months, postoperatively. All patients underwent leg vein ultrasonography regardless of the serum D-dimer level. Furthermore, CT scans were performed to evaluate both disease status and venous thromboembolism, including pulmonary thromboembolism. Statistical analyzes were performed using the Mann-Whitney U-test (D-dimer values of each cancer), Chi-square test, Fisher's exact test (incidence of deep vein thrombosis), and one-way analysis of variance (patient characteristics).

RESULTS

A total of 205 patients (ovarian cancer: 68, endometrial cancer: 76, cervical cancer: 61) who underwent gynecological surgery, including retroperitoneal lymph node dissection, were included in the analysis. Deep vein thrombosis rates were significantly higher in patients with ovarian cancer (P<0.001). The postoperative D-dimer value was significantly higher than the preoperative value. Postoperative D-dimer values were also significantly higher in patients who received adjuvant chemotherapy (P=0.001). The cut-off value of D-dimer was 1.55 µg/mL preoperatively (sensitivity, 48.0%; specificity, 94.1%), and this value was higher postoperatively, at 1.95 µg/mL (sensitivity, 37.0%; specificity, 90.9%).

CONCLUSION

Postoperative D-dimer values are higher not only after surgery but also in patients who received adjuvant chemotherapy. The cut-off value of D-dimer at 2 or 3 months postoperatively was higher than preoperative value.