Benefits of the enhanced recovery after surgery pathway for orthognathic surgery

Assessing Use and Familiarity of Enhanced Recovery After Surgery Elements in Pediatric Orthognathic Surgery

Enhanced recovery after surgery (ERAS) protocols have informed perioperative care across multiple surgical specialties, optimizing patient outcomes through surgical stress management and accelerated recovery. This study evaluates the familiarity and adoption of ERAS elements among craniofacial and oral and maxillofacial surgeons in pediatric orthognathic surgery, a field where a formal ERAS protocol has not been established. A closed-ended survey of 102 surgeons was conducted to assess familiarity with and utilization of 14 ERAS elements. The survey garnered a 40.2% response rate, with 41 surgeons participating. The majority of respondents (68.3%) specialized in craniofacial (CF) surgery, and their annual pediatric orthognathic surgery caseload varied widely. Key findings revealed that 7 ERAS elements were widely adopted, including hypothermia prevention, normovolemia maintenance, intraoperative tranexamic acid use, and minimized opioid use for postoperative pain control. However, elements such as liposomal bupivacaine and postoperative goal-directed fluid therapy were less utilized, primarily due to limited availability or knowledge. Surgeons demonstrated high familiarity with elements like jaw immobilization and minimizing opioid use but showed knowledge gaps in areas such as preoperative nutritional screening and goal-directed fluid therapy. These insights underline the need for further education and the development of a standardized ERAS protocol tailored for pediatric orthognathic surgery. The study underscores the importance of multidisciplinary collaboration and comprehensive preoperative education in implementing ERAS protocols. This study serves as a foundation for future research into optimizing perioperative care for pediatric patients undergoing orthognathic surgery.

Comparative analysis of postoperative complications and outcomes in outpatient versus inpatient orthognathic surgery: A retrospective cohort study

The purpose of this study was to assess and compare the complication rates of single-jaw orthognathic surgery between outpatients and inpatients, and to examine their impact on the outcome of care setting. A retrospective cohort study was performed of patients who underwent single-jaw orthognathic procedures. Outpatients between 2008 and 2023 were selected as the study group, while inpatients between 1997 and 2023 were enrolled as the control group. The predictor variable was the patient care setting. The primary outcome variable was the occurrence of overall complications. Secondary outcomes included surgery-, anesthesia-, and patient-related complications. Other study variables included age, sex, surgery, and anesthetic procedures. Descriptive, bivariate, and multiple logistic regression statistics were computed and the significance level was set at p ≤ 0.05. The sample included 307 patients with a mean age of 23.1 years ±9.5 years, of whom 55% were female. The outpatient and inpatient groups consisted of 123 (40.1%) and 184 (59.9%) patients, respectively. Of the 123 outpatients, 104 (85.5%) were discharged on the day of surgery. Age (p = 0.012) and ketamine administration (p = 0.022) were significantly associated with complications among outpatients. Outpatient setting and age were significantly associated with overall complications (OR 2.48; 95% confidence interval [CI] 1.34-4.66, p = 0.003 and OR 0.94, 95% CI 0.88-0.98, p = 0.021, respectively) and anesthetic-related complications (OR 4.43, 95% CI 2.03-10.5, p = 0.0003 and OR 0.92, 95% CI 0.83-0.98, p = 0.041, respectively). The study demonstrated that outpatient orthognathic surgery had a high success rate but also identified a higher rate of anesthetic-related complications among outpatients, particularly in younger patients and in those receiving ketamine.

Quality of plastic surgery Enhanced Recovery After Surgery (ERAS) studies: A systematic review

BACKGROUND

In effort to improve post-operative outcomes, enhanced recovery after surgery (ERAS) protocols have gained popularity. The objective of this systematic review was to assess the reporting and methodological quality of plastic surgery ERAS studies.

METHODS

All plastic surgery ERAS implementation studies, published between January 1, 2020, to November 20, 2023, were included. The primary outcome was reporting quality based on "The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist" (40 points). Secondary outcomes included methodology quality as per ERAS® Society endorsed guidelines (Breast 18 points; Head and Neck (H&N) 24 points).

RESULTS

Fifty ERAS studies were included (breast reconstruction: 29, 58%; head and neck: 7, 14%; craniofacial: 6, 12%; aesthetic: 5, 10%; other: 3, 6%). Average reporting quality was 22.6/40 (56.7%). ERAS protocol elements least adhered to included: patient warming strategy (8/50, 16%), management of post-operative fluids (14/50, 28%), and post-discharge outcome tracking (14/50, 28%). Evaluation of breast methodological quality revealed average compliance of 9.2/18 (51.3%). The least complied with elements included preoperative computed tomography angiography (4/23, 17.4%), intraoperative warming (6/23, 26.1%), and post-operative wound management (2/23, 8.7%). For head and neck studies, average compliance was 9.1/23 (39.6%). The least complied with elements included pre-anesthesia pain medications (1/7, 14.3%), post-operative wound care (0/7, 0%), and urinary catheterization removal (1/7, 14.3%).

CONCLUSIONS

ERAS implementation studies in plastic surgery are highly variable, with overall low reporting and methodology quality. Plastic surgeons should be cautious when adopting published ERAS protocols that do not adhere to the recommended and official ERAS® Society guidelines.

Predicting the Future Focus of Orthognathic Surgery: Outcome-Driven Planning and Treatment With Function, Esthetics, and Occlusion as Key Indicators

As an international group of orthognathic surgeons, we believe the next big thing in orthognathic surgery will be a clinical and research focus on patient-oriented outcomes and improved quality of life. We expect to see advances in diagnosis and treatment planning, materials development, and patient management.

Postoperative nausea and vomiting in orthognathic surgery: systematic review and meta-analysis

PURPOSE

Postoperative nausea and vomiting (PONV) is a frequently reported adverse event following orthognathic surgery. The aim of this work is to conduct a systematic review of the literature on the subject, and to discuss the role of maxillofacial surgeons and the steps that can be taken to prevent or control PONV in orthognathic surgery.

METHODS

A systematic review was conducted according to the PRISMA guidelines, using the search strategy: (orthognathic AND (nausea OR vomiting)). The authors searched PubMed, Embase, Dimensions, Web of Science and Google Scholar databases, without any language restrictions. RevMan 5.4 was used to create a risk of bias graph and a forest plot.

RESULTS

The included articles were classified as having a low risk of bias, despite the limited literature on the subject. Various measures have been reported to be beneficial in preventing or managing PONV, such as the use of dexamethasone, antiemetic drugs, gastric aspiration, and anesthetic blocks. Effective bleeding control and faster surgeries can also be helpful.

CONCLUSIONS

Throat packs have not been found to be effective in preventing PONV. Although no definitive protocol has been established in the literature, the Enhanced Recovery After Surgery (ERAS) protocol could be a useful approach. Overall, a multimodal approach may be taken to prevent PONV, and further research is needed to establish definitive protocols.

Current Orthognathic Surgery Practice Patterns Among Academic OMS

OBJECTIVE

Currently there is variation in perioperative care of orthognathic surgery patients and limited clinical practice guidelines. The current orthognathic surgery practice patterns among US academic OMFS training centers have not been described. The purpose of this study is to describe the practice patterns among US academic OMFS training centers.

DESIGN

The study design is cross-sectional. Data was collected through a survey of the sample.

SETTING

OMFS programs in the US.

PARTICIPANTS

Academic OMFS. 573 surgeons were contacted and 85 responses were received.

MAIN OUTCOME MEASURE

Descriptive and bivariate statistics were reported.

RESULTS

Respondents were 87% male and worked in full-time academic (80%), part-time academic (19%), or military settings (1%). Thirty-one percent have practiced for 30 years or more and then 29% with 11-20 years, 18% with 21-30 years, 12% with 6-10 years and 11% with 1-5 years. Twenty-six percent of respondents perform 20-40 orthognathic surgeries a year, 22% perform less than 20 surgeries a year, 21% perform 40-60 surgeries per year, and 19% perform more than 100 surgeries per year. Intraoperatively, 48% of surgeons request a mean arterial pressure of 60-64 mmHg, 25% utilize tranexamic acid (TXA), 85% report a blood loss of less than 400 milliliters, and 93% report a blood transfusion rate of <1%.

CONCLUSION

There are variations in orthognathic surgery practice patterns with limited clinical practice guidelines. Only 13 of the 32 survey questions had a single response holding a simple majority. This study demonstrates the need for further research and evidence-based protocols and decision making.

An Enhanced Recovery After Surgery (ERAS) Protocol for Orthognathic Surgery Reduces Rates of Postoperative Nausea

For many surgical procedures, enhanced recovery after surgery (ERAS) protocols have improved patient outcomes, particularly postoperative nausea and vomiting. The purpose of this study was to evaluate postoperative nausea following orthognathic surgery after the implementation of an ERAS protocol. This retrospective cohort study included patients between 12 and 35 years old who underwent orthognathic surgery at Boston Children's Hospital from April 2018 to December 2022. Patients with syndromes or a hospital stay greater than 48 hours were excluded from the study. The primary predictor was enrollment in our institutional ERAS protocol. The main outcome variable was postoperative nausea. Intraoperative and postoperative covariates were compared between groups using unpaired t tests and chi squared analysis. Univariate and multivariate regression models with 95% confidence intervals were performed to identify predictors for nausea. A P value<0.05 was considered significant. There were 128 patients (68 non-ERAS, 60 ERAS) included in this study (51.6% female, mean age 19.02±3.25 years). The ERAS group received less intraoperative fluid (937.0±462.3 versus 1583.6±847.6 mL, P ≤0.001) and experienced less postoperative nausea (38.3% versus 63.2%, P =0.005). Enhanced recovery after surgery status ( P =0.005) was a predictor for less postoperative nausea, whereas bilateral sagittal split osteotomy ( P =0.045) and length of stay ( P =0.007) were positive predictors for postoperative nausea in multivariate logistic regression analysis. Implementing an ERAS protocol for orthognathic surgery reduces postoperative nausea. Level of Evidence: Level III-therapeutic.

Does Tranexamic Acid Reduce the Need for Hypotensive Anesthesia Within Orthognathic Surgery? A Retrospective Study

Background

Tranexamic acid (TXA) is utilized frequently in orthognathic surgery to limit blood loss and improve surgical field visualization. This antifibrinolytic has been proven effective with use of concomitant hypotensive anesthesia. Despite proven efficacy, there is a recent push to avoid perioperative hypotensive anesthesia due to risks of organ hypoperfusion, cardiac ischemia and postoperative nausea.

Aims

The aim is to study the efficacy and safety of utilizing TXA without controlled hypotensive anesthesia.

Methods

The authors identified two cohorts of subjects that underwent bimaxillary orthognathic surgery both with and without TXA administration and compared operative and perioperative variables. A retrospective analysis was completed evaluating intraoperative MAP measurements in subjects treated both with and without TXA using descriptive and bivariate analysis.

Results and conclusion

Sixty-three subjects met inclusion criteria. The TXA cohort experienced 11.5% less time under hypotensive anesthesia when compared to the group that did not receive TXA. Additionally, surgical length was decreased by more than 28 min when subjects received TXA. No subjects required a blood transfusion or experienced any TXA-related complications. Given the recommendations to limit hypotensive anesthesia perioperatively, TXA is a useful adjunct in orthognathic surgery to limit controlled hypotensive anesthesia.

Prevention of postoperative nausea and vomiting after orthognathic surgery: a scoping review

INTRODUCTION

Postoperative nausea and vomiting (PONV) is one of the most common adverse events following orthognathic surgery. It's a distressing feeling for patients and continues to be the cause of postoperative complications such as bleeding, delayed healing, and wound infection. This scoping review aims to identify effective PONV prophylaxis strategies during orthognathic surgery that have emerged in the past 15 years.

METHODS

We searched Pubmed, Cochrane Controlled Register of Trials, and Embase from 2008 to May 2023. Studies meeting the following criteria were eligible for inclusion: (1) recruited patients undergo any orthognathic surgery; (2) evaluated any pharmacologic or non-pharmacologic method to prevent PONV. Studies meeting the following criteria were excluded: (1) case series, review papers, or retrospective studies; (2) did not report our prespecified outcomes.

RESULTS

Twenty-one studies were included in this review. Pharmacological methods for PONV prevention include ondansetron and dexamethasone (3 studies), peripheral nerve block technique (4 studies), dexmedetomidine (1 study), pregabalin (2 studies), nefopam (2 studies), remifentanil (1 study), propofol (2 studies), and penehyclidine (1 study). Non-pharmacologic methods include capsicum plaster (1 study), throat packs (2 studies) and gastric aspiration (2 studies).

CONCLUSIONS

Based on current evidence, we conclude that prophylactic antiemetics like dexamethasone, ondansetron, and penehyclidine are the first defense against PONV. Multimodal analgesia with nerve block techniques and non-opioid analgesics should be considered due to their notable opioid-sparing and PONV preventive effect. For the non-pharmacological methods, throat packs are not recommended for routine use because of their poor effect and serious complications. More prospective RCTs are required to confirm whether gastric aspiration can prevent PONV effectively for patients undergoing orthognathic surgery.

Does Anesthesiologist Experience Influence Early Postoperative Outcomes Following Orthognathic Surgery?

BACKGROUND

Anesthesia provider experience impacts nausea and vomiting in other surgical specialties but its influence within orthognathic surgery remains unclear.

PURPOSE

The study purpose was to evaluate whether anesthesiologist experience with orthognathic surgery impacts postoperative outcomes, including nausea, emesis, narcotic use, and perioperative adverse events, for patients undergoing orthognathic surgery.

STUDY DESIGN, SETTING, SAMPLE

This is a retrospective cohort study of subjects aged 12 to 35 years old who underwent orthognathic surgery, including Le Fort 1 osteotomy ± bilateral sagittal split osteotomy, at Boston Children's Hospital from August 2018 to January 2022. Subjects were excluded if they had incomplete medical records, a syndromic diagnosis, or a hospital stay of greater than 2 days.

PREDICTOR VARIABLE

The predictor variable was attending anesthesia provider experience with orthognathic surgery. Providers were classified as experienced or inexperienced, with experienced providers defined as having anesthetized ≥10 orthognathic operations during the study period.

MAIN OUTCOME VARIABLES

The primary outcome variable was postoperative nausea. Secondary outcome variables were emesis, narcotic use in the hospital, and perioperative adverse events within 30 days of their operation.

COVARIATES

Study covariates included age, sex, race, comorbidities (body mass index, history of psychiatric illness, cleft lip and/or palate, chronic pain, postoperative nausea/vomiting, gastrointestinal conditions), enhanced recovery after surgery protocol enrollment, and intraoperative factors (operation performed, anesthesia/procedure times, estimated blood loss, intravenous fluid and narcotic administration, and anesthesiologist's years in practice).

ANALYSES

χ2 and unpaired t-tests were used to compare primary predictor and covariates against outcome variables. A P-value <.05 was considered significant.

RESULTS

There were 118 subjects included in the study after 4 were excluded (51.7% female, mean age 19.1 ± 3.30 years). There were 71 operations performed by 5 experienced anesthesiologists (mean cases/provider 15.4 ± 5.95) and 47 cases by 22 different inexperienced providers (mean cases/provider 1.91 ± 1.16). The nausea rate was 52.1% for experienced providers and 53.2% for inexperienced providers (P = .909). There were no statistically significant associations between anesthesiologist experience and any outcome variable (P > .341).

CONCLUSIONS AND RELEVANCE

Anesthesia providers' experience with orthognathic surgery did not significantly influence postoperative nausea, emesis, narcotic use, or perioperative adverse events.

Post-Procedure Analgesic Management

During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.

Outpatient orthognathic surgery: a prospective study of predictive factors for the length of hospital stays

OBJECTIVES

Transitioning from non-outpatient orthognathic surgery to outpatient surgery is a new challenge, and it is essential to target the eligible population as precisely as possible. Several authors describe series of outpatient orthognathic surgery but do not include the reasons for their success or failure. The main aim of this study was to identify the factors significantly associated with "successful" outpatient orthognathic treatment. The secondary objective was to determine the factors significantly associated with prolonged hospital stays (≥ 2 nights).

MATERIALS AND METHODS

A prospective cohort study including patients undergoing orthognathic surgery was conducted over a period of 1 year. We recorded the prognostic factors that contributed to successful outpatient treatment and prolonged hospital stays. These factors were evaluated by bivariate and multivariate analysis.

RESULTS

A total of 102 patients were included, and the success rate of treatment was 65%. The variables that were isolated by multivariate analysis were: patients over the age of 22, procedures ending before 1 pm, brief operations, the absence of both postoperative vomiting and the administration of morphine.

CONCLUSION

Patient selection, organisation of outpatient facilities and anaesthetic protocols contribute to the development of outpatient orthognathic surgery. These initial considerations provide a framework for our practice, but the considerations that predict the failure of outpatient surgery will need to be clarified.

CLINICAL RELEVANCE

Orthognathic surgery can be performed on outpatient basis in selected cases. Age, the operative time, procedure end time, postoperative vomiting and the administration of morphine are associated with the success of outpatient care.

Latest Evidence on Orthognathic Surgery Techniques and Potential Changes in Oral Microbiota related to Intermaxillary Fixation in Orthodontic Patients: A Systematic Review

Background:

Orthognathic surgery is often applied for the correction of facial dysmorphia, and different findings were highlighted regarding the techniques applied. After surgical treatment, intermaxillary fixation is placed, which compromises oral hygiene and, consequently, can lead to increased plaque accumulation and microbiological changes, promoting the proliferation of periodontopathogenic bacteria. Therefore, the aims of the present review are to describe the main evidence from the last 20 years of clinical studies concerning surgical techniques applied to orthognathic surgery and, finally, to analyze potential changes in the oral microbiota.

Materials and Methods:

An electronic search was conducted in the PubMed (MEDLINE) and Scopus databases; the MeSH (Medical Subject Heading) terms are bacteria, dental plaque, evidence-based practice, maxillomandibular fixation, microbiota, operative procedures, and orthognathic surgery.

Results:

At the end of the search process, 31 relevant articles were finally included and analyzed in this systematic review, which has a low risk of bias. Clinical studies on humans have been considered in this review. Based on the studies included it would be preferable to use piezoelectric technology in osteotomies because of its many advantages, “surgery-first” technique allows for results comparable to the standard technique in Class III malocclusions while improving quality of life more rapidly, the “mandible-first” technique seems to have more advantages than the “maxilla-first” technique, Computer-Aided Design and Manufacturing (CAD/CAM) could provide more accurate and precise results, and finally, Laser can be applied with different advantages. Regarding intermaxillary fixation, no long-term increase in the concentration of periodontal bacteria was recorded.

Conclusion:

Several findings still need to be confirmed with reference to the best suturing technique to reconstitute the nasal wing base, the real effectiveness of “surgery-first,” “maxilla-first,” and “mandible-first” approaches in patients with Class III malocclusion, the use of CAD/CAM and Laser, more studies should be conducted to evaluate quantitative and qualitative changes in other microorganisms following intermaxillary fixation.

Comparative Efficacy of Granisetron and Droperidol After Orthognathic Surgery for Prophylaxis of Postoperative Nausea and Vomiting: A Retrospective Study

BACKGROUND

In the fall of 2021, granisetron was approved for postoperative nausea and vomiting (PONV) management in Japan. However, the comparative efficacy of droperidol and granisetron in the field of orthognathic surgery has not been determined.

PURPOSE

We compare the efficacy of droperidol and granisetron for PONV prophylaxis following orthognathic surgery.

STUDY DESIGN, SETTING, SAMPLE

We performed a retrospective cohort study of patients who underwent orthognathic surgery at a single institution from September 2020 to December 2022. Patients who had undergone Le Fort I osteotomy with sagittal split ramus osteotomy or isolated sagittal split ramus osteotomy were included. Patients were divided into three groups; the isolated droperidol (D), isolated granisetron (G), and droperidol with granisetron (DG) groups. General anesthesia was performed using total intravenous anesthesia for all patients; however, droperidol and granisetron were administered at the anesthesiologist's discretion.

PREDICTOR VARIABLE

PONV prophylactic therapy included isolated droperidol, isolated granisetron, and droperidol with granisetron administration.

OUTCOME VARIABLES

Postoperative nausea (PON) and postoperative vomiting (POV) were determined through medical examination within 48 hours following surgery. Secondary outcomes included complications due to droperidol and/or granisetron administration.

COVARIATES

Age, sex, body mass index, Apfel's score, duration of surgery, duration of anesthesia, intraoperative blood loss, and type of surgery.

ANALYSES

Statistical analysis was conducted using Fisher exact test, Mann-Whitney U test with Bonferroni correction for univariate comparison, and modified Poisson regression for comparison of PON and POV prophylactic efficacy for multivariate analyses. P values <.05 were considered statistically significant.

RESULTS

Our study included 218 participants. There were no significant differences in covariates between groups D (n = 111), G (n = 52), and DG (n = 55). No significant difference in PON incidence was observed between groups. However, POV incidence was significantly lower in group DG than group D (relative risk, 0.21; 95% confidence interval, 0.05 to 0.86; P = .03). No significant difference in complication incidence was observed between groups.

CONCLUSIONS AND RELEVANCE

Granisetron was as effective as droperidol for PONV management, while droperidol combined with granisetron was more effective than isolated droperidol for POV management. As compared to the use of each drug separately, their combination was considered safe, with no increase in complication rates.

Ambulatory sagittal split ramus osteotomy: strategy for enhanced recovery after surgery

The sagittal split ramus osteotomy (SSRO) has been performed mainly on an inpatient basis because of the duration of anaesthesia and the potential risk of postoperative complications, such as bleeding, pain, nausea, and vomiting. However, advances in both surgical and anaesthetic management have enabled the reduction of these risks and shortened the length of hospital stay. Thus, the SSRO may be feasible even in the ambulatory setting in elective cases. The clinical records of all patients who underwent an outpatient SSRO between August 2011 and September 2020 at Lilla Craniofacial Clinic were reviewed retrospectively. Data on age, sex, duration of surgery, operative procedures, intraoperative bleeding, and admission status were investigated. In total, 143 patients underwent a bilateral SSRO. The SSRO was performed as an isolated procedure in 73 patients and concomitantly with other surgical procedures in the remaining 70 patients. Overall, 142 of the 143 patients were discharged on the day of surgery (99.3%); only one (0.7%) required an overnight stay because of a submental haemorrhage after genioplasty. No emergency hospitalizations or readmissions occurred after discharge. Multimodal perioperative management, both surgical and anaesthetic, facilitated enhanced patient recovery after surgery, and SSRO was performed successfully and safely as an ambulatory procedure.

Perioperative therapies to reduce edema after orthognathic surgery: a systematic review and meta-analysis

Objective To systematically review the literature and assess the effectiveness of perioperative systemic and nonsystemic therapies in reducing edema after orthognathic surgery. Study Design Four databases (PubMed, Web of Science, Bireme, and Scopus) were searched. Only randomized clinical trials were included and assessed using the RoB 2.0 software (Cochrane Collaboration, London, UK). Studies were grouped into time of assessment and systemic/nonsystemic therapy. Results Eighteen studies were included in this review (8 in the meta-analysis, n = 349). The qualitative assessment of systemic (enzyme therapy, dexamethasone, betamethasone, and Venoplant) and nonsystemic therapies (thermotherapy and K-Taping) appear to reduce edema. Manual lymphatic drainage (MLD) after 72 hours (CI: -1.03 to 2.31; P = .45), and 30 days (CI: -1.53 to 0.49; P = .49), and laser after 24 hours (CI: -1.36 to 1.48; P = .93), 72 hours (CI: -4.81 to 2.92; P = .63), 30 days (CI: -3.44 to 0.99; P = .28), and 90 days (CI: -1.83 to 0.96; P = .54) showed no significance. Thermotherapy reduced edema after 48 hours (CI: -48.47 to -13.31; P = .0006) and 30 days (CI: -14.73 to -1.98; P = .01). Conclusion The Grading of Recommendations, Assessment, Development and Evaluations tool showed moderate evidence for thermotherapy (significant reduction of edema), whereas the MLD and laser results were rated as high certainty of evidence (no reduction of edema).

Enhanced recovery after orthognathic surgery: a retrospective comparison study of 56 patients

Enhanced Recovery After Surgery (ERAS) protocols have been demonstrated to expedite recovery and decrease hospital stay from multiple surgical specialties. This study sought to determine how an ERAS protocol would improve patient outcomes with regards to inpatient postoperative nausea, vomiting, and pain scores following orthognathic surgeries. This was a retrospective study comparing patients who underwent orthognathic surgery with and without an ERAS protocol. The primary measurables included opioid consumption, antiemetic medical consumption, nausea and vomiting incidences, and pain scores between the two groups during their hospital stays. A total of 56 patients were retrospectively analysed comparing ERAS protocol to non-ERAS protocol. The maximum pain score of the ERAS group was 5.50 out of 10 compared to the control group of 7.50 out of 10 (p<0.001). Morphine equivalent consumption during their time in the ward was statistically significant (51.4 mg control versus 9.4 mg ERAS group). ERAS protocol is safe and effective for decreasing postoperative pain and nausea. The ERAS protocol is not only applicable for orthognathic surgery but should be highly considered for other maxillofacial surgeries.

Is Preoperative Serum Albumin Predictive of Adverse Surgical Outcomes in Maxillofacial Fracture Repair?

PURPOSE

Malnutrition has been recognized as a predictor of postoperative adverse outcomes across many surgical subspecialties. The purpose of this study was to evaluate the relationship between serum albumin and adverse outcomes in patients undergoing operative repair of maxillofacial fractures.

METHODS

The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was preoperative serum albumin level. Outcome variables included complications and other adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between serum albumin and adverse outcomes.

RESULTS

During the study period 1211 subjects underwent operative repair of a facial fracture and had a documented serum albumin level. Of these subjects, 1037 (85.6%) had normal albumin levels and 174 (14.4%) had hypoalbuminemia. A total of 90 subjects experienced a complication (7.43%), although albumin level was not associated with surgical complications or any complication. In bivariate analysis, subjects with hypoalbuminemia were significantly more likely to have an extended length of stay (P ≤ .001), adverse discharge disposition (P ≤ .001), and be readmitted (P = .002). In multivariate analysis, hypoalbuminemia was an independent predictor of an extended length of stay (P ≤ .001, 95% CI 2.50 to 7.62), adverse discharge disposition (P = .048, 95% CI 1.01 to 3.75), and readmission (P = .041, 95% CI 1.03 to 3.47).

CONCLUSIONS

Serum albumin was not an independent predictor of complications after maxillofacial trauma repair. However, it was an independent predictor of other adverse outcomes including extended length of stay, adverse discharge disposition, and readmission. Targeted nutritional optimization may represent an opportunity to improve outcomes in this demographic.