Defining Major Surgery: A Delphi Consensus Among European Surgical Association (ESA) Members

Goal-directed therapy guided by the FloTrac sensor in major surgery: a systematic review and meta-analysis

OBJECTIVE

To provide insights into the potential benefits of goal-directed therapy guided by FloTrac in reducing postoperative complications and improving outcomes.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials to evaluate goal-directed therapy guided by FloTrac in major surgery, comparing goal-directed therapy with usual care or invasive monitoring in cardiac and noncardiac surgery subgroups. The quality of the articles and evidence were evaluated with a risk of bias tool and GRADE.

RESULTS

We included 29 randomized controlled trials with 3,468 patients. Goal-directed therapy significantly reduced the duration of hospital stay (mean difference -1.43 days; 95%CI 2.07 to -0.79; I2 81%), intensive care unit stay (mean difference -0.77 days; 95%CI -1.18 to -0.36; I2 93%), and mechanical ventilation (mean difference -2.48 hours, 95%CI -4.10 to -0.86, I2 63%). There was no statistically significant difference in mortality, myocardial infarction, acute kidney injury or hypotension, but goal-directed therapy significantly reduced the risk of heart failure or pulmonary edema (RR 0.46; 95%CI 0.23 - 0.92; I2 0%).

CONCLUSION

Goal-directed therapy guided by the FloTrac sensor improved clinical outcomes and shortened the length of stay in the hospital and intensive care unit in patients undergoing major surgery. Further research can validate these results using specific protocols and better understand the potential benefits of FloTrac beyond these outcomes.

Oral hygiene prior to cardiac surgery to prevent infections: Randomized clinical trial

CONTEXT

It is not clear if an oral hygiene protocol to control biofilm applied before cardiac surgery can reduce infection rates.

OBJECTIVE

We aim to verify the effectiveness of an oral hygiene protocol in reducing postoperative infections when compared to usual practices, in patients admitted to a cardiology unit, prior to cardiac surgery.

DESIGN, SETTING AND PARTICIPANTS

Randomized, blind, controlled clinical trial, with 107 participants who expected to undergo cardiac surgery, randomized into two groups: Experimental Group (EG) standardized oral hygiene protocol (54) and Control Group (CG), usual practices performed in patients admitted (53).

INTERVENTION

a standardized oral hygiene protocol, 1 day before surgery: professional prophylaxis with a portable ultrasound device, tooth brushing and flossing plus a 0.12% chlorhexidine gluconate solution (0.12% CHX) mouth rinsing. When applicable, removable prostheses cleaning.

PRIMARY OUTCOME

the presence of infection.

RESULTS

The occurrence of postoperative infection was higher in CG = 7 (13.2%) than in EG = 5 (9.3%); but no statistical difference was found between protocols (p = 0.518). The length of stayed from surgery to discharge presented a statistical difference (p = 0.047; RR = 4.9; CI = 1.01-24.33); the percentage of postoperative infection was almost five times higher in those participants who stayed 11 or more days.

CONCLUSION

The standardized oral hygiene protocol with mechanical and chemical cleaning, 1 day before cardiac surgery, was not more effective than the usual practices performed regarding the reduction of postoperative infections. Other interventions regarding oral hygiene procedures before cardiac surgery must be studied to contribute to the reduction of adverse post-surgical events.

CLINICAL TRIAL REGISTRATION

Site Ensaclinicos.gov.br number U1111-1214-2862.

DESCRIPTORS

Healthcare Associated Infections, Cardiovascular Diseases, Periodontal Diseases, Dental Biofilm, Cardiovascular Surgery.

Abdominal surgery in patients with chronic noncirrhotic extrahepatic portal vein obstruction: A multicenter retrospective study

BACKGROUND AND AIMS

In patients with noncirrhotic chronic extrahepatic portal vein obstruction (EHPVO), data on the morbimortality of abdominal surgery are scarce.

APPROACH AND RESULTS

We retrospectively analyzed the charts of 76 patients (78 interventions) with EHPVO undergoing abdominal surgery within the Vascular Disease Interest Group network. Fourteen percent of the patients had ≥1 major bleeding (unrelated to portal hypertension) and 21% had ≥1 Dindo-Clavien grade ≥3 postoperative complications within 1 month after surgery. Fifteen percent had ≥1 portal hypertension-related complication within 3 months after surgery. Three patients died within 12 months after surgery. An unfavorable outcome (ie, ≥1 abovementioned complication or death) occurred in 37% of the patients and was associated with a history of ascites and with nonwall, noncholecystectomy surgical intervention: 17% of the patients with none of these features had an unfavorable outcome, versus 48% and 100% when one or both features were present, respectively. We then compared 63/76 patients with EHPVO with 126 matched (2:1) control patients without EHPVO but with similar surgical interventions. As compared with control patients, the incidence of major bleeding ( p <0.001) and portal hypertension-related complication ( p <0.001) was significantly higher in patients with EHPVO, but not that of grade ≥3 postoperative complications nor of death. The incidence of unfavorable postoperative outcomes was significantly higher in patients with EHPVO than in those without (33% vs. 18%, p =0.01).

CONCLUSIONS

Patients with EHPVO are at high risk of major perioperative or postoperative bleeding and postoperative complications, especially in those with ascites or undergoing surgery other than wall surgery or cholecystectomy.

Predictive value of a novel digital risk calculator to determine early patient outcomes after major surgery: a proof-of-concept pilot study

BACKGROUND

A structured risk assessment of patients with validated and evidence-based tools can help to identify modifiable factors before major surgeries. The Protego Maxima trial investigated the value of a new digitized risk assessment tool that combines tools which can be easily used and implemented in the clinical workflow by doctors and qualified medical staff. The hypothesis was that the structured assessment and risk-grouping is predictive of short-term surgical quality reflected by complications and overall survival.

METHODS

The Protego Maxima Trial was a prospective cohort analysis of patients undergoing major surgery (visceral, thoracic, urology, vascular and gynecologic surgeries) as key inclusion criterion and the absence of an acute or acute on chronically decompensated pulmo-cardiovascular decompensation. Patients were risk-scored with the software (The Prehab App) that includes a battery of evidence-based risk assessment tools that allow a structured risk assessment. The data were grouped to predefined high and low risk groups and aggregate and individual scores. The primary outcome was to validate the predictive value of the RAI score and the TUG for overall survival in the high and low risk groups. Secondary outcomes were surgical outcomes at 90-days after surgery (overall survival, Clavien-Dindo (CD) 1-5 (all complications), and CD 3-5 (major complications)). The study was carried out in accordance with the DIN ISO 14,155, and the medical device regulation (MDR) at Frankfurt University Hospital between March 2022 and January 2023.

RESULTS

In total 267 patients were included in the intention to treat analysis. The mean age was 62.1 ± 12.4 years. Patients with a RAI score > 25 and/or a timed up and go (TUG) > 8 s had a higher risk for mortality at 90 days after surgery. The low-risk group predicted beneficial outcome and the high-risk group predicted adverse outcome in the ROC analysis (Area Under the Curve Receiver Operator Characteristics: AUROC > 0.800; p = 0.01). Risk groups (high vs. low) showed significant differences for 90-day survival (99.4% vs. 95.5%; p = 0.04) and major complications (16.4% vs. 32.4%; p < 0.001).

CONCLUSION

The proof-of-concept trial showed that a risk assessment with 'The Prehab App' may be viable to estimate the preoperative risk for mortality and major complications before major surgeries. The overall performance in this initial set of data indicated a certain reliability of the scoring and risk grouping, especially of the RAI score and the TUG. A larger data set will be required to proof the generalizability of the risk scoring to every subgroup and may be fostered by artificial intelligence approaches.

TRIAL REGISTRATION

Ethics number: 2021-483-MDR/MPDG-zuständig monocentric; The Federal Institute for Pharmaceuticals and Medical Devices/BfArM, reference number: 94.1.04-5660-13655; Eudamed: CIV-21-07-0307311; German Clinical Trial Registry: DRKS 00026985.

Early dynamic changes to monocytes following major surgery are associated with subsequent infections

Background

Post-operative infections are a common cause of morbidity following major surgery. Little is understood about how major surgery perturbs immune function leading to heightened risk of subsequent infection. Through analysis of paired blood samples obtained immediately before and 24 h following surgery, we evaluated changes in circulating immune cell phenotype and function across the first 24 h, to identify early immune changes associated with subsequent infection.

Methods

We conducted a prospective observational study of adult patients undergoing major elective gastrointestinal, gynecological, or maxillofacial surgery requiring planned admission to the post-anesthetic care unit. Patients were followed up to hospital discharge or death. Outcome data collected included mortality, length of stay, unplanned intensive care unit admission, and post-operative infections (using the standardized endpoints in perioperative medicine-core outcome measures for perioperative and anesthetic care criteria). Peripheral blood mononuclear cells were isolated prior to and 24 h following surgery from which cellular immune traits including activation and functional status were assessed by multi-parameter flow cytometry and serum immune analytes compared by enzyme-linked immunosorbent assay (ELISA).

Results

Forty-eight patients were recruited, 26 (54%) of whom developed a post-operative infection. We observed reduced baseline pre- and post-operative monocyte CXCR4 and CD80 expression (chemokine receptors and co-stimulation markers, respectively) in patients who subsequently developed an infection as well as a profound and selective post-operative increase in CD4+ lymphocyte IL-7 receptor expression in the infection group only. Higher post-operative monocyte count was significantly associated with the development of post-operative infection (false discovery rate < 1%; adjusted p-value = 0.001) with an area under the receiver operating characteristic curve of 0.84 (p < 0.0001).

Conclusion

Lower monocyte chemotaxis markers, higher post-operative circulating monocyte counts, and reduced co-stimulatory signals are associated with subsequent post-operative infections. Identifying the underlying mechanisms and therapeutics to reverse defects in immune cell function requires further exploration.

Postoperative cognitive worsening in seniors with an age above life expectancy: a prospective longitudinal study

BACKGROUND

The growing number of elderly patients in hospitals is a challenge for healthcare systems. The main objective is to measure the postoperative change in the cognitive status at hospital discharge and one year after discharge in elderly patients undergoing planned or deferrable surgery.

METHODS

We planned a prospective longitudinal study, single-center study: secondary care level hospital, enrolment from September 2018 to May 2019. We enroll elderly patients, aged above life expectancy in Italy, who underwent planned or deferrable surgery (men over 80.5 years old, women over 85.0 years old). In six months, we enrolled 76 eligible patients. We collected the scores of the clinical impairment scales Charlson Index, Barthel Index, and Six-Item Cognitive Impairment Test (6CIT). The primary endpoint was the postoperative worsening of the cognitive status at one-year follow-up. Secondary endpoints aimed to describe postoperative disabilities and complications, to investigate possible risk factors for cognitive worsening, and to measure the role of anesthesia in cognitive changes.

RESULTS

We recorded an increased rate of pathological 6CIT values during the hospitalization period, rising from 39.47% to 55.26% (McNemar test, P=0.007), and this rate was still increased at 55.56% (P=0.021) one year after discharge. Anesthesia did not show any significant harmful effect on cognitive status. The preoperative hemoglobin value seems to be a risk factor for cognitive status and one-year mortality.

CONCLUSIONS

Elderly patients had a significantly worse 6CIT value after planned surgery, which may derive in part from age and in part from hospitalization. It is difficult to determine if general anesthesia alone has no harmful effects on cognitive performance in patients at discharge and one year later. Further data are necessary.

[Pre-rehabilitation of oncological patients before extensive abdominal and thoracic surgery: a literature review]

Surgery is one of the leading treatment methods of patients with primary or recurrent malignant neoplasms in the thoracic or abdominal cavity. Extensive abdominal interventions are accompanied by such adverse outcomes as blood loss, hypoxia, inflammation, blood clotting abnormality, emotional and cognitive disorders, that increases the incidence of serious complications and worsens the treatment outcome and life quality in weakened oncological patients. Multimodal pre-rehabilitation before surgery can significantly decrease the incidence and severity of postoperative complications. The rehabilitation complex includes exercise therapy, nutritional and psychological support, smoking cessation and pharmacotherapy. Currently, there are a number of questions facing rehabilitation specialists and oncologists, that are related to the determination of pre-rehabilitation optimal timing and process duration, the choice of specific physical exercises, determining the load intensity. This review presents a current view on understanding of surgical stress in extensive abdominal interventions, its effect on the oncological process course, summarizes the experience of last years in choosing pre-rehabilitation program taking into account pathogenetic mechanisms of surgical stress and individual patient's characteristics. Special attention is paid to the comparison of physical exercises' various types, their action mechanisms at different stages of pathological process, the issues of load dosing during pre-rehabilitation activities.

Preoperative Spirometry in Patients With Known or Suspected Chronic Obstructive Pulmonary Disease Undergoing Major Surgery: The Prospective Observational PREDICT Study

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative pulmonary risk assessment, but the scientific literature is conflicting. The Preoperative Diagnostic Tests for Pulmonary Risk Assessment in Chronic Obstructive Pulmonary Disease (PREDICT) study aimed to determine whether preoperative PFTs improve the prediction of postoperative pulmonary complications (PPCs) in patients with known or suspected chronic obstructive pulmonary disease (COPD) undergoing major surgery. A secondary aim was to determine whether the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) classification of airflow limitation severity (grades I-IV) is associated with PPC.

METHODS

In this prospective, single-center study, patients with GOLD key indicators for COPD scheduled for major surgery received PFTs. Patients with confirmed COPD (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ≤0.7) were included in the COPD cohort and compared with a reference cohort without COPD. We developed 3 multivariable risk prediction models and compared their ability to predict PPC: the "standard model" (medical preconditions, and sociodemographic and surgical data), the "COPD assessment model" (additional GOLD key indicators, pack-years, and poor exercise capacity), and the "PFT model" (additional PFT parameters selected by adaptive least absolute shrinkage and selection operator [LASSO] regression). Multiple LASSO regressions were used for cross-validation.

RESULTS

A total of 31,714 patients were assessed for eligibility; 1271 individuals received PFTs. Three hundred twenty patients (240 with confirmed COPD: 78 GOLD I, 125 GOLD II, 28 GOLD III, 9 GOLD IV, and 80 without COPD) completed follow-up. The diagnostic performance was similar among the standard model (cross-validated area under the curve [cvAUC], 0.723; bias-corrected bootstrapped [bc-b] 95% confidence interval [CI], 0.663-0.775), COPD assessment model (cvAUC, 0.724; bc-b 95% CI, 0.662-0.777), and PFT model (cvAUC, 0.729; bc-b 95% CI, 0.668-0.782). Previously known COPD was an independent predictor in the standard and COPD assessment model. %FEV1 PRED was the only PFT parameter selected by LASSO regression and was an independent predictor in the PFT model (adjusted odds ratios [OR], 0.98; 95% CI, 0.967-.0.998; P = .030). The risk for PPC significantly increased with GOLD grades ( P < .001). COPD was newly diagnosed in 53.8% of the patients with confirmed COPD; however, these individuals were not at increased risk for PPC ( P = .338).

CONCLUSIONS

COPD is underdiagnosed in surgical patients. Patients with newly diagnosed COPD commonly presented with low GOLD severity grades and were not at higher risk for PPC. Neither a structured COPD-specific assessment nor preoperative PFTs added incremental diagnostic value to the standard clinical preassessment in patients with known or suspected COPD. Unnecessary postponement of surgery and undue health care costs can be avoided.

Prevalence and factors associated with surgery anxiety in hospitalized patients: a point-prevalence study

BACKGROUND

Preoperative anxiety is a challenging problem in the preoperative care of patients. Identifying risk factors helps nurses provide psychological support during the pre-operative visit so that stress can be reduced.

AIMS

This study aimed to determine the prevalence of surgical anxiety and related factors in hospitalized surgical patients.

METHODS

This research was designed as a point-prevalence study. The study was completed with 223 patients hospitalized in the surgical clinics of a tertiary hospital in Turkey. Surgical anxiety questionnaire (SAQ) and State-trait anxiety inventory (STAI) were used for the assessment of anxiety.

RESULTS

Preoperative anxiety prevalence was 69.5% according to the SAQ and 49.3% according to STAI. Women, participants with no primary school education, those who were unemployed and had low income, those with no previous surgery, those living in fear of surgery, the participants who underwent major surgery and general anesthesia, and those who did not have knowledge about the surgical procedure and anesthesia had higher anxiety according to the two scales. A highly significant and positive correlation was found between total STAI and total SAQ.

CONCLUSION

The importance of surgical anxiety for the health system, which affects two out of every three hospitalized patients, should not be underestimated. Therefore, national and global plans should be made to prevent and manage surgical anxiety.

Anesthesia in patients with chronic liver disease: An updated review

Anesthesia in chronic liver disease patients can be challenging because of the medications given or interventions performed and their effects on liver physiology. Also, the effects of liver disease on coagulation and metabolism should be considered carefully. This review focuses on anesthesia in patients with different chronic liver disease stages. A literature search was performed for Scopus and PubMed databases for articles discussing different types of anesthesia in patients with chronic liver disease, their safety, usage, and risks. The choice of anesthesia is of crucial importance. Regional anesthesia, especially neuroaxial anesthesia, may benefit some patients with liver disease, but coagulopathy should be considered. Regional anesthesia provides optimum intraoperative relaxation and analgesia that extends to the postoperative period while avoiding the side effects of intravenous anesthetics and opioids. Pharmacodynamics and pharmacokinetics of anesthetic medications must guard against complications related to overdose or decreased metabolism. The choice of anesthesia in chronic liver disease patients is crucial and could be tailored according to the degree of liver compensation and the magnitude of the surgical procedure.

Severity Classification of Laboratory Animal Procedures in Two Belgian Academic Institutions

According to the EU Directive 2010/63, all animal procedures must be classified as non-recovery, mild, moderate or severe. Several examples are included in the Directive to help in severity classification. Since the implementation of the Directive, different publications and guidelines have been disseminated on the topic. However, due to the large variety of disease models and animal procedures carried out in many different animal species, guidance on the severity classification of specific procedures or models is often lacking or not specific enough. The latter is especially the case in disease models where the level of pain, suffering, distress and lasting harm depends on the duration of the study (for progressive disease models) or the dosage given (for infectious or chemically induced disease models). This, in turn, may lead to inconsistencies in severity classification between countries, within countries and even within institutions. To overcome this, two Belgian academic institutions with a focus on biomedical research collaborated to develop a severity classification for all the procedures performed. This work started with listing all in-house procedures and assigning them to 16 (sub)categories. First, we determined which parameters, such as clinical signs, dosage or duration, were crucial for severity classification within a specific (sub)category. Next, a severity classification was assigned to the different procedures, which was based on professional judgment by the designated veterinarians, members of the animal welfare body (AWB) and institutional animal ethics committee (AEC), integrating the available literature and guidelines. During the classification process, the use of vague terminology, such as 'minor impact', was avoided as much as possible. Instead, well-defined cut-offs between severity levels were used. Furthermore, we sought to define common denominators to group procedures and to be able to classify new procedures more easily. Although the primary aim is to address prospective severity, this can also be used to assess actual severity. In summary, we developed a severity classification for all procedures performed in two academic, biomedical institutions. These include many procedures and disease models in a variety of animal species for which a severity classification was not reported so far, or the terms that assign them to a different severity were too vague.

Stair-Climbing Tests or Self-Reported Functional Capacity for Preoperative Pulmonary Risk Assessment in Patients with Known or Suspected COPD-A Prospective Observational Study

BACKGROUND

This prospective study aims to determine whether preoperative stair-climbing tests (SCT) predict postoperative pulmonary complications (PPC) better than self-reported poor functional capacity (SR_PFC) in patients with known or suspected COPD.

METHODS

A total of 320 patients undergoing scheduled for major non-cardiac surgery, 240 with verified COPD and 80 with GOLD key indicators but disproved COPD, underwent preoperative SR_PFC and SCT and were analyzed. Least absolute shrinkage and selection operator (LASSO) regression was used for variable selection. Two multivariable regression models were fitted, the SR_PFC model (baseline variables such as sociodemographic, surgical and procedural characteristics, medical preconditions, and GOLD key indicators plus SR_PFC) and the SCT model (baseline variables plus SCT_PFC).

RESULTS

Within all stair-climbing variables, LASSO exclusively selected self-reported poor functional capacity. The cross-validated area under the receiver operating characteristic curve with bias-corrected bootstrapping 95% confidence interval (95% CI) did not differ between the SR_PFC and SCT models (0.71; 0.65-0.77 for both models). SR_PFC was an independent risk factor (adjusted odds ratio (OR) 5.45; 95% CI 1.04-28.60; p = 0.045 in the SR_PFC model) but SCT_PFC was not (adjusted OR 3.78; 95% CI 0.87-16.34; p = 0.075 in the SCT model).

CONCLUSIONS

Our findings indicate that preoperative SR_PFC adequately predicts PPC while additional preoperative SCTs are dispensable in patients with known or suspected COPD.

Determining the Minimum Dataset for Surgical Patients in Africa: A Delphi Study

BACKGROUND

It is often difficult for clinicians in African low- and middle-income countries middle-income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry.

METHODS

A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds).

RESULTS

Forty-one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk-adjusted perioperative mortality rate was also described.

CONCLUSIONS

The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.

A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology

Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.

Präoperative Physiotherapie vor viszeralen abdominalen Operationen digital umsetzen? – Eine qualitative Machbarkeitsstudie

Hintergrund Große Operationen am Bauchraum stellen die größte Gruppe der Operationen in Deutschland dar. Besonders Patient*innen mit Komorbiditäten zeigen ein hohes Risiko für die Entwicklung postoperativer respiratorischer Komplikationen und damit einhergehend postoperativer Einbußen der körperlichen Funktionsfähigkeit. Obwohl präoperative Physiotherapie positiven Einfluss auf die Komplikationsrate nehmen kann, wird sie in Deutschland nicht regelhaft umgesetzt.

Ziel Untersuchung der Machbarkeit einer digitalen Umsetzung präoperativer Physiotherapie aus der Perspektive von Ärzt*innen, Physiotherapierenden und Patient*innen. Dazu werden Bedarfe an eine digitale Intervention sowie inhaltliche und technische Anforderungen erfragt.

Methode In einer qualitativen Studie wurden 2 Ärzt*innen, 5 Physiotherapierende und 2 Patienten interviewt. Die Daten wurden transkribiert und mittels qualitativer Inhaltsanalyse nach Schreier 35 ausgewertet.

Ergebnisse Die Ergebnisse bestätigten die hohe Relevanz der präoperativen Versorgung. Digitale Interventionen können die in diesem Zusammenhang existierende Versorgungslücke schließen. Die formulierten Anforderungen an eine Individualisierung und einen motivierenden Charakter können insbesondere durch Apps realisiert werden.

Diskussion Die zu entwickelnde App soll darauf abzielen 1.) eine Verhaltensänderung anzubahnen, 2.) Wissen zu vermitteln und 3.) Übungen anzuleiten. Vor dem Hintergrund der Zielsetzungen und dem Kontext, in dem die App Anwendung finden soll, ist von einer hohen Komplexität bei der Entwicklung und besonders der Implementierung auszugehen. Gleichzeitig ermöglicht die vorgelegte Analyse eine direkte Bearbeitung der identifizierten Herausforderungen.

Schlussfolgerung Die Entwicklung einer App als Teil der präoperativen Vorbereitung hat das Potenzial, eine aktuelle Versorgungslücke zu schließen und die möglichen negativen Folgen einer Operation zu adressieren. Die vorgelegte Studie gibt Hinweise für die nächsten Entwicklungsschritte.

Psychological distress among elderly surgical patients who had their surgery postponed during the COVID-19 pandemic

Background

Many institutions withheld elective lists and triaged surgeries during the peak of coronavirus disease 2019 (COVID-19) pandemic. As a result, older surgical patients have had to wait for rescheduled dates in a long waitlist. This study aimed to identify the psychological impact in these patients when they returned for surgery.

Methods

This was a cross-sectional study which included 153 patients aged ≥ 65 years undergoing elective surgery. Trained interviewers recruited and assessed psychological status pre-operatively with two validated questionnaires - Hospital Anxiety and Depression Scale (HADS) and 36-item Short Form Health Survey (SF-36). Specific questions were asked about their postponed surgeries, appetite and fear.

Results

A total of 36 out of 153 (23.5%) patients had their procedures deferred during the first wave of COVID-19 pandemic. Postponed cases were significantly based on the nature of surgery (p = 0.002), cancer diagnosis (p = 0.006) and surgical specialty (p = 0.023). Median HADS scores were higher for patients who were postponed (2.00 versus 4.00 for anxiety, p = 0.180 and 0.00 versus 1.00 for depression, p = 0.424) although no statistical significance was shown. In the whole study population, anxiety was a significant predictor for depression and vice versa (p < 0.001) with other predictive risk factors for anxiety that were age ≥ 85 years old (odds ratio [OR] 6.14, p = 0.018), female (OR 2.41, p = 0.024), cancer (OR 2.19, p = 0.039) and major surgery (OR 2.39, p = 0.023). Similarly, older patients ≥ 85 years old (OR 10.44, p = 0.003) and female (OR 6.07, p = 0.006) had higher risk for depression. Both anxiety and depression were significant risks for loss of appetite (p = 0.005 and 0.001). Lastly, the fear of disease progression due to rescheduling was more frequent in cancer patients (p = 0.035).

Conclusion

The mental health and disease burden of older surgical patients should be taken into careful consideration when cases need to be postponed in our healthcare system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00242-7.

Postoperative cognitive dysfunction in older surgical patients associated with increased healthcare utilization: a prospective study from an upper-middle-income country

Background

Perioperative neurocognitive disorder includes postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). Concerning inconclusive consequences of POCD compared with POD, we explored the association between either POCD or POD and functional decline as well as healthcare utilization.

Methods

Patients aged at least 60 years who underwent a major operation were enrolled. POCD was defined as a decrease in the Montreal Cognitive Assessment (MoCA) score (≥ 2) 1 week after surgery. Postoperative delirium (POD) was defined according to the criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The primary outcome was instrumental activities of daily living (IADLs) 3 months after discharge. Secondary outcomes were the length of stay (LOS), hospital cost, and factors that affected functional decline 3 months after surgery. The multivariate model, including potential confounding factors, namely age, gender, surgery type, and postoperative complications, was used to analyze possible factors that influenced a reduction in function, and the results were expressed by using adjusted relative risk (RR) and 95%CI.

Results

Two hundred eighty-nine patients with a mean age of 72 years were enrolled. The incidence of POCD at 1 week was 28.5%. At their 3-month follow-ups, the patients with POCD were not associated with IADL decline. Nevertheless, patients with POCD were more likely to need a prolonged LOS (11 days [1, 46] vs. 8 days [2, 42]; P = 0.01), and incur higher hospital costs (8973.43 USD [3481.69, 11 763.74] vs. 5913.62 USD [332.43, 19 567.33]; P < 0.001). Additionally, the patients experiencing POD demonstrated increased risks of reducing their IADLs (adjusted RR 2.33; 95% CI, 1.15–4.71; P = 0.02).

Conclusions

POCD at 1 week leaded to increase healthcare utilization in a middle-income country. POD during hospitalization was associated with a decline in function after surgery and increased health care utilization.

Trial registration

Thai Clinical Trials Registry TCTR20190115001.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02873-3.

Polypharmacy in Older Adults Undergoing Major Surgery: Prevalence, Association With Postoperative Cognitive Dysfunction and Potential Associated Anesthetic Agents

BACKGROUND

Polypharmacy, which is defined as the use of 5 or more medications, can exert significant adverse impact on older adult patients. The objective of this study was to determine the prevalence of polypharmacy, and to investigate its association with postoperative cognitive dysfunction (POCD) in older adult patients who underwent elective major surgery at Siriraj Hospital-Thailand's largest national tertiary referral center.

METHODS

This prospective study included older adult patients aged ≥65 years who were scheduled for elective major surgery during December, 2017 to December, 2019 study period. Patient demographic, sociodemographic, anthropometric, clinical, comorbidity, anesthetic, surgical, and medication data were collected and compared between the polypharmacy and non-polypharmacy groups. Postoperative cognitive dysfunction (POCD) was diagnosed in patients with at least a 2-point decrease in their Montreal Cognitive Assessment score after surgery. Multivariate logistic regression analysis was used to identify independent predictors of POCD.

RESULTS

A total of 250 patients (141 males, 109 females) with an average age of 72.88 ± 6.93 years were included. The prevalence of polypharmacy was 74%. Preoperative data showed the polypharmacy group to be more likely to be receiving potentially inappropriate medications, to be scheduled for cardiovascular thoracic surgery, and to have more comorbidities. There was a non-significant trend in the association of polypharmacy and POCD (crude odds ratio (OR): 2.11, 95% confidence interval [CI]: 0.90-4.94; p = 0.08). Benzodiazepine, desflurane, or isoflurane administration during surgery were all significantly associated with POCD in univariate analysis. Multivariate analysis revealed intraoperative benzodiazepine (adjusted OR [aOR]: 2.24, 95% CI: 1.10-4.68; p = 0.026) and isoflurane (aOR: 2.80, 95% CI: 1.35-5.81; p = 0.006) as two independent variables associated with the development of POCD. Desflurane was found to be a protective factor for POCD with a crude OR of 0.17 (95% CI: 0.03-0.74, p = 0.019); however, independent association was not found in multivariate analysis.

CONCLUSION

There was a high prevalence of polypharmacy in this study; however, although close (p = 0.08), significant association was not found between polypharmacy and POCD. Benzodiazepine and isoflurane were both identified as independent predictors of the development of POCD among older adult patients undergoing elective major surgery, especially among those classified as polypharmacy.

Preoperative Anxiety Levels in Surgical Patients: A Comparison of Three Different Scale Scores

PURPOSE

The aim of this study was to compare Anxiety Specific to Surgery Questionnaire (ASSQ) with Spielberger State-Trait Anxiety Inventory (STAI) and Amsterdam Preoperative Anxiety and Information Scale (APAIS) in the assessment of preoperative anxiety level and to evaluate the fears associated with surgery and anesthesia in surgical patients.

DESIGN

This is descriptive, correlational, and cross-sectional study.

METHOD

The study sample included 507 surgical patients in four surgery wards who underwent elective surgery. All the data were collected using The Descriptive Characteristics and Clinical Information Form, STAI, APAIS and ASSQ.

FINDINGS

A majority (70.8%) of the participants had fears associated with surgery and anesthesia and nearly half of them had a moderate level of preoperative anxiety. Anxiety prevalence was 46.4% according to the APAIS, 44.4% according to STAI and 49.3% according to ASSQ. Women, participants with no primary school education, participants undergoing major surgery and general anesthesia who did not have knowledge about the surgical procedure, and surgical complications had higher anxiety according to three scale scores.

CONCLUSION

Nearly half of the participants had moderate/high preoperative anxiety, there were consistent results among the scales and the tools were interchangeable to evaluate the preoperative anxiety level in the surgical patients.

Renal Recovery after the Implementation of an Electronic Alert and Biomarker-Guided Kidney-Protection Strategy following Major Surgery

Background: The facilitation of early recovery of acute kidney injury (AKI) is an important step to improve outcome, particularly because of the limited therapeutic interventions currently available for AKI. The combination of an electronic alert and biomarker-guided kidney-protection strategy implemented in the routine care may have an impact on the incidence of early complete reversal of AKI after major non-cardiac surgery. Methods: We studied 294 patients in two cohorts before (n = 151) and after protocol implementation (n = 143). Data collection required 6 months for each cohort. The kidney-protection protocol included an electronic alert to detect patients who were eligible for urinary biomarker [TIMP2 × IGFBP7]-guided kidney-protection intervention. Intervention was stratified according to three levels of immediate AKI risk: low, moderate, and high. After intervention, postoperative changes in the glomerular filtration rate (eGFR) were identified with a tracking software that included an alert for nephrology consultation if the eGFR had declined by >25% from the preoperative reference value. Primary outcome was early AKI recovery, i.e., the complete reversal of any AKI stage to absence of AKI within the first 7 postoperative days. Results: Protocol implementation significantly increased the recovery of AKI (36/46, 78% compared to control 27/48, 56%, (p = 0.025)) and reduced the length of the ICU stay (p < 0.001). There was no significant difference in the overall incidence of all AKI and moderate and severe AKI in the first 7 postoperative days: 46/143 (32%) and 12/151 (8%) in the protocol implementation group compared to 48/151 (32%) and 18/151 (12%) in the historical control group. Patients with AKI reversal within the first 7 postoperative days had lower in-hospital mortality than patients without AKI reversal. Conclusions: Implementing a combined electronic alert and biomarker-guided kidney-protection strategy in routine care improved early recovery of AKI after major surgery.

Operative Confidence Among U.S General Surgery Residents

BACKGROUND

General surgery residents (GSRs) must develop operative autonomy skills to practice independently after graduation. We aim to investigate perceived confidence and operative autonomy of GSR physicians in order to identify and address influential factors.

METHODS

A 28-question anonymous online survey was distributed to 23 United States general surgery residency programs. Multivariable logistic regression was used for calculating the adjusted odds ratio (aOR) for binary outcomes. Significance was defined as P-values ≤ .05 or 95% confidence intervals (CIs) >1 or <1.

RESULTS

There were 120/558 (21.5%) GSR respondents. General surgery residents with >200 overall operative case volume reported significantly higher confidence with minor cases (P = .05) and major cases (P = .02). General surgery residents that performed both minor and major surgeries reported higher confidence with minor cases at 85.7% compared to GSRs that performed mostly minor surgeries (64.7%) and mostly major surgeries (62.5%). General surgery residents who performed >50 minor surgeries during their PGY 1 and 2 were less confident with major cases than GSRs who performed <50 minor surgeries (aOR: 19.98, 95% CI: 1.26, 318). General surgery residents from community teaching hospitals reported higher confidence with major and minor cases than GSRs from university teaching hospitals and combined programs.

CONCLUSION

Increased case volume, predominant case type, early surgical experience during PGY 1 and 2 years, and training at community teaching hospitals were identified as the most important factors that positively influence perception of operative confidence and autonomy among GSRs. These may have important implications in the development of future surgeons.

The effect of mobilization protocol on mobilization start time and patient care outcomes in patients undergoing abdominal surgery

AIM

To evaluate the effect of mobilization protocol on mobilization start time, maintenance of mobilization and patient care outcomes in patients who underwent major abdominal open surgery.

BACKGROUND

Early mobilization in the first 24 hours postoperatively is recommended. Early mobilization is one of the evidence-based, effective nursing interventions that improve patient care outcomes.

DESIGN

A quasi-experimental non-randomised design was used in the study.

METHODS

In the study, the groups were followed sequentially and the data of the control group (n = 21) were collected before the intervention group (n = 21). The patients in the control group were mobilised postoperatively by the nurses according to the decision of the nurse and physician in the intensive care unit (ICU) on the day of the operation. There was no standard protocol for mobilization in the ICU. Mobilization training was given to the patients in the intervention group by the researcher nurse the evening before the operation, and a mobilization protocol was applied on the 0th postoperative day. Data on patient care outcomes were collected until the day when the patient was discharged from the hospital. The TREND checklist was followed.

RESULTS

According to the postoperative comparison of the patients in the intervention group to those in the control group, patients in the intervention group started mobilization earlier after admission in intensive care unit (6.22 ± 1.95 hours versus 12.21 ± 3.76 hours), had higher postoperative 0^th -day total mobilization time (128 minutes versus 34 minutes), had a shorter passage of flatus time and length of intensive care unit and hospital stay and had higher sleep quality and satisfaction scores.

CONCLUSIONS

The structured mobilization protocol is effective in the management of early mobilization and improvement of patient care outcomes.

RELEVANCE TO CLINICAL PRACTICE

mobilization protocols ensure that the mobilization process is maintained effectively.

The Importance of Iron Administration in Correcting Anaemia After Major Surgery

INTRODUCTION

Postoperative anaemia can affect more than 90% of patients undergoing major surgeries. Patients develop an absolute iron deficiency in the face of significant blood loss or preoperative anaemia and major surgery. Studies have shown the negative impact of these factors on transfusion requirements, infections, increased hospitalisation and long-term morbidities.

AIM OF THE STUDY

The research was performed to determine the correlation between intravenous iron administration in the postoperative period and improved haemoglobin correction trend.

MATERIAL AND METHODS

A prospective study was conducted to screen and treat iron deficiency in patients undergoing major surgery associated with significant bleeding. For iron deficiency anaemia screening, in the postoperative period, the following bioumoral parameters were assessed: haemoglobin, serum iron, transferrin saturation (TSAT), and ferritin, direct serum total iron-binding capacity (dTIBC), mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH). In addition, serum glucose, fibrinogen, urea, creatinine and lactate values were also collected.

RESULTS

Twenty-one patients undergoing major surgeries (52,38% were emergency and 47,61% elective interventions) were included in the study. Iron deficiency, as defined by ferritin 100-300 μg/L along with transferrin saturation (TSAT) < 20 %, mean corpuscular volume (MVC) < 92 fL, mean corpuscular haemoglobin (MCH) < 33 g/dL, serum iron < 10 μmol/L and direct serum total iron-binding capacity (dTIBC) > 36 μmol/L, was identified in all cases. To correct the deficit and optimise the haematological status, all patients received intravenous ferric carboxymaltose (500-1000 mg, single dose). Using Quadratic statistical analysis, the trend of haemoglobin correction was found to be a favourable one.

CONCLUSION

The administration of intravenous ferric carboxymaltose in the postoperative period showed the beneficial effect of this type of intervention on the haemoglobin correction trend in these groups of patients.

Major and minor surgery: Terms used for hundreds of years that have yet to be defined

•

The terms major and minor surgery are commonly used in scientific literature. The lack of an established distinction between the two terms has major implications on the interpretation of research, clinical practices, and outcomes.

•

Researchers should be cautious when using major and minor surgery to describe procedures unless accompanied by a thorough evidence-based explanation of each category.

•

The terminology may be useful for setting the tone of expectations when communicating with patients and their families, but physicians must weigh this utility against the complications caused by unsuitable use in scientific literature and medical education.

Association Between Implementing Comprehensive Learning Collaborative Strategies in a Statewide Collaborative and Changes in Hospital Safety Culture

Importance

Hospital safety culture remains a critical consideration when seeking to reduce medical errors and improve quality of care. Little is known regarding whether participation in a comprehensive, multicomponent, statewide quality collaborative is associated with changes in hospital safety culture.

Objective

To examine whether implementation of a comprehensive, multicomponent, statewide surgical quality improvement collaborative is associated with changes in hospital safety culture.

Design, Setting, and Participants

In this survey study, the Safety Attitudes Questionnaire, a 56-item validated survey covering 6 culture domains (teamwork, safety, operating room safety, working conditions, perceptions of management, and employee engagement), was administered to a random sample of physicians, nurses, operating room staff, administrators, and leaders across Illinois hospitals to assess hospital safety culture prior to launching a new statewide quality collaborative in 2015 and then again in 2017. The final analysis included 1024 respondents from 36 diverse hospitals, including major academic, community, and rural centers, enrolled in ISQIC (Illinois Surgical Quality Improvement Collaborative).

Exposures

Participation in a comprehensive, multicomponent statewide surgical quality improvement collaborative. Key components included enrollment in a common standardized data registry, formal quality and process improvement training, participation in collaborative-wide quality improvement projects, funding support for local projects, and guidance provided by surgeon mentors and process improvement coaches.

Main Outcomes and Measures

Perception of hospital safety culture.

Results

The overall survey response rate was 43.0% (580 of 1350 surveys) in 2015 and 39.0% (444 of 1138 surveys) in 2017 from 36 hospitals. Improvement occurred in all the overall domains, with significant improvement in teamwork climate (change, 3.9%; P = .03) and safety climate (change, 3.2%; P = .02). The largest improvements occurred in individual measures within domains, including physician-nurse collaboration (change, 7.2%; P = .004), reporting of concerns (change, 4.7%; P = .009), and reduction in communication breakdowns (change, 8.4%; P = .005). Hospitals with the lowest baseline safety culture experienced the largest improvements following collaborative implementation (change range, 11.1%-14.9% per domain; P < .05 for all). Although several hospitals experienced improvement in safety culture in 1 domain, most hospitals experienced improvement across several domains.

Conclusions and Relevance

This survey study found that hospital enrollment in a statewide quality improvement collaborative was associated with overall improvement in safety culture after implementing multiple learning collaborative strategies. Hospitals with the poorest baseline culture reported the greatest improvement following implementation of the collaborative.

Treatment of Gastric Cancer Patients During COVID-19 Pandemic: The West is More Vulnerable

The outbreak of the COVID-19 is currently the biggest international concern. Treatment of gastric cancer (GC) patients in the pandemic era with high hospital burden and under severe oncological/surgical resource constraints should implicate a need for resource re-allocation with a new "pandemic" GC treatment algorithm. The neoadjuvant/perioperative (radio-)chemotherapy is applied in the majority of advanced GC cases with poor postoperative therapy compliance. In the East, radical surgery is frequently used in the first instance, with adjuvant chemotherapy reserved for patients with a high risk of recurrence. Moreover, the elderly population might be effectively treated by surgery alone, thus saving oncological resources for younger people who need a more aggressive approach. In this framework, prioritization is a key concept based on the severity of symptoms and the need for urgent (surgical) intervention. High-risk and marginally effective surgery should be replaced with definitive radio- and/or chemotherapy. The pandemic framework to provide optimal care for GC patients must be based on multidisciplinary decision-making and include all anti-cancer treatment options: surgery, systemic therapy, and radiotherapy. The priority and staffing dictate adherence to the new algorithm. We believe that these priorities may improve the delivery of care to all, including elderly GC patients.

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

Background

The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery.

Methods

This was a scoping review of all available literature pertaining to COVID-19 and surgery, using electronic databases, society websites, webinars and preprint repositories.

Results

Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross-cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning.

Conclusion

Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase.