Prolonged operative duration is associated with complications: a systematic review and meta-analysis

Perioperative Airway Management for Midface Surgery in Children With Syndromic Craniosynostosis; a Single Center Experience With Immediate Extubation

BACKGROUND

Midface advancements in children with syndromic craniosynostosis present challenges for anesthesiologists and intensive care teams.

AIMS

This study reviewed the perioperative airway management protocol for immediate tracheal extubation after midface surgery at our tertiary center over the past 10 years.

METHODS

A retrospective cohort study was performed to obtain information on respiratory disorders, surgical and anesthetic management, airway support, and respiratory complications following le Fort III (LF3) and monobloc (MB) with distraction. Patients with a tracheostomy were excluded.

RESULTS

Thirty-two patients (12 LF3, 20 MB) were included. All were immediately extubated with a median of 25 min after surgery. Immediate extubation was performed in young patients (n = 8/32, < 5 years old), in patients with severe OSA (n = 6/32, median oAHI 23/h), with difficult airways (n = 5/32, Cormack-Lehane airway grade ≥ 3), with significant intraoperative blood loss (n = 32, median 46 mL/kg), and with long operative times (n = 32, median 223 min). The majority of patients received no or only oxygen support in the first hours after extubation (n = 29/32) and could be discharged from the pediatric intensive care unit to the surgical ward after 1 day (n = 30/32). A 5-month-old patient with MB required intermittent oxygen and Guedel airway throughout his hospitalization due to airway obstruction at the tongue base combined with supine positioning to allow external traction.

CONCLUSIONS

Despite the pre-existing airway disorder, the extent of the procedure and the effect of anesthesia on airway tone, all patients were extubated immediately after midface advancement, with only one young patient needing prolonged postoperative support. Immediate extubation is feasible following midface advancement in patients with syndromic craniosynostosis. Further prospective randomized trials are needed to demonstrate superiority to delayed extubation.

Delayed ambulation in adult patients after major abdominal surgery in Northwest Ethiopia: a multicenter prospective follow up study

Abdominal surgery is associated with prolonged hospitalization, reduced physical activity levels, and prolonged bed rest. Delayed ambulation is a major problem after abdominal surgery which result in prolonged hospital stay. Ambulation was defined as delayed if the patient could not walk more than 10 m without assistance on postoperative day one within 24 h of surgery. Although abdominal surgery is performed for a variety of surgical procedures in a day to day practice the incidence and factors associated with delayed ambulation after major abdominal surgery have not been well investigated in the study area. Therefore, the aim of this study was to assess the incidence and factors associated with delayed ambulation after major abdominal surgery. A multicenter, prospective follow up study was conducted from March 28, to June 5, 2023, on 422 participants. Patients were taken consecutively, and data were collected by using a semi-structured questionnaire. Data were entered into Epi Data version 4.6 Software and exported to SPSS version 26 for analysis. Both descriptive and analytic statistics were used. Both bivariable and multivariable logistic regression were used. Variables with a p-value less than < 0.2 in the bivariable analysis were fitted into the multivariable analysis. Both the crude odds' ratio (COR) and Adjusted Odds Ratio (AOR) with 95% Confidence Interval were calculated to show the strength of association. Variables with a p-value of < 0.05 were considered as statistically significant. The overall incidence of delayed ambulation after major abdominal surgery was 48.1% (95%CI:43.4-52.6). Having severe pain (AOR:3.23, 95%CI:1.09-9.55), dizziness (AOR:7.21, 95%CI:3.49-14.91), nasogastric tube (AOR:2.36, 95%CI:1.05-5.34), drain (AOR:3.27, 95%CI:1.52-7.04), fatigue (AOR:7.62, 95%CI:3.71-15.66), intraoperative fluid used > 2000 ml (AOR:2.54, 95%CI:1.03-6.24), duration of surgery > 2-hour (AOR:3.96, 95%CI:1.87-8.38) and blood loss > 500 ml (AOR:2.68, 95%CI:1.24-5.79) were significantly associated with delayed ambulation. Nearly half of the patients were unable to ambulate at postoperative day one after major abdominal surgery. Adopting a zero fluid balance approach, minimizing surgical duration and blood loss, timely removal of drains and catheters, and prioritizing postoperative pain management is recommended.

Computer vision-guided rapid and precise automated cranial microsurgeries in mice

A common procedure that allows interfacing with the brain is cranial microsurgery, wherein small to large craniotomies are performed on the overlying skull for insertion of neural interfaces or implantation of optically clear windows for long-term cranial observation. Performing craniotomies requires skill, time, and precision to avoid damaging the brain and dura. Here, we present a computer vision-guided craniotomy robot (CV-Craniobot) that uses machine learning to accurately estimate the dorsal skull anatomy from optical coherence tomography images. Instantaneous information of skull morphology is used by a robotic mill to rapidly and precisely remove the skull from a desired craniotomy location. We show that the CV-Craniobot can perform small (2- to 4-millimeter diameter) craniotomies with near 100% success rates within 2 minutes and large craniotomies encompassing most of the dorsal cortex in less than 10 minutes. Thus, the CV-Craniobot enables rapid and precise craniotomies, reducing surgery time compared to human practitioners and eliminating the need for long training.

Safety of Combined Versus Isolated Cosmetic Breast Surgery and Abdominoplasty: Insights from a Multi-institutional Database

INTRODUCTION

Abdominoplasty and breast surgery are popular cosmetic procedures, often performed as stand-alone or combined procedures. However, the safety of combining these surgeries remains poorly understood.

METHODS

We analyzed data from the ACS-NSQIP database spanning 2008-2021, focusing on patients who underwent isolated cosmetic breast surgery, isolated cosmetic abdominoplasty, or the combination of both. We evaluated four primary outcomes: general complications (reoperation, readmission, mortality), surgical complications, medical complications, and overall complications (general + surgical + medical). Further analysis considered the specific type of cosmetic breast surgery.

RESULTS

A total of 7865 female patients were identified, of whom 20.5% underwent isolated abdominoplasty, 65.3% cosmetic breast surgery, and 14.2% combined abdominoplasty with concurrent cosmetic breast surgery. Combined surgery was associated with a significantly higher risk of reoperations (OR 2.07; p = 0.04) compared to abdominoplasty alone. However, there was no significant difference in overall complications (OR 1.17; p = 0.40), surgical complications (OR 0.72; p = 0.26), or medical complications (OR 0.97; p = 0.91) between these two groups. Comparing combined to isolated cosmetic breast surgery, there was a higher risk of overall complications (OR 1.70; p = 0.04) and medical complications (OR 5.30; p < 0.0001) but no significant difference in general complications (OR 1.40; p = 0.33) or surgical complications (OR 0.85; p = 0.73).

CONCLUSION

Combining breast surgery with abdominoplasty increases the risk of reoperations but does not elevate the risk of surgical or medical complications. However, patients seeking combined surgeries are more likely to experience adverse events than those seeking isolated cosmetic breast surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Robotic-assisted versus laparoscopic surgery for colorectal cancer in high-risk patients: a systematic review and meta-analysis

BACKGROUND

Evidence of superiority of robotic-assisted surgery for colorectal resections remains limited. This systematic review and meta-analysis aims to compare robotic-assisted and laparoscopic surgical techniques in high-risk patients undergoing resections for colorectal cancer.

METHODS

Systematic searches were performed using Pubmed, Embase and Cochrane library databases from inception until December 2024. Randomised and non-randomised studies reporting outcomes of robotic-assisted or laparoscopic resections in the following high-risk categories were included: obesity, male gender, the elderly, low rectal cancer, neoadjuvant chemoradiotherapy and previous abdominal surgery. Comparative meta-analyses for all sufficiently reported outcomes were completed. Risk of bias was assessed using the ROBINS-I and RoB 2 tools for non-randomised and randomised studies, respectively.

RESULTS

48 studies, including a total of 34,846 patients were eligible for inclusion and 32 studies were utilised in the comparative meta-analyses. Conversion to open rates were significantly lower for robotic-assisted surgery in patients with obesity, male patients and patients with low rectal tumours (obese OR 0.41 [CI 0.32-0.51], p < 0.00001); male gender (OR 0.28 [CI 0.22-0.34], p < 0.00001); low tumours OR 0.10 [CI 0.02-0.58], p = 0.01). Length of stay was significantly reduced for robotic-assisted surgery in patients with obesity (SMD 0.25 [CI - 0.41 to - 0.09], p = 0.002). Operative time was significantly longer in all subgroups (obesity SMD 0.57 [CI 0.31-0.83], p < 0.0001; male gender SMD 0.77 [CI 0.17-1.37], p = 0.01; elderly SMD 0.50 [CI 0.18-0.83], p = 0.002; low rectal tumours SMD 0.48 [CI 0.12-0.84], p = 0.008; neoadjuvant chemoradiotherapy SMD 0.72 [CI 0.34-1.09], p = 0.0002; previous surgery SMD 1.55 [CI 0.05-3.06], p = 0.04). When calculable, blood loss, length of stay, complication rate and lymph node yield were comparable in all subgroups.

CONCLUSIONS

This review provides further evidence of non-inferiority of robotic-assisted surgery for colorectal cancer and demonstrates conversion rates are superior in specific, technically challenging operations.

A standardized anesthesiology and surgical protocol leads to zero VTE events: A retrospective study in 502 autologous breast reconstructions

BACKGROUND

Autologous breast reconstruction carries an inherent risk of developing venous thromboembolism (VTE), a complication with potentially severe outcomes. This study evaluated the incidence of VTE events in a large cohort of 502 autologous breast reconstructions, achieved through a standardized surgical, anesthesiologic, and thromboprophylaxis protocol. Our primary aim was to evaluate the effectiveness of this comprehensive approach in preventing VTE events.

METHODS

We conducted a retrospective analysis of 370 patients who underwent autologous breast reconstruction between December 2007 and February 2023, employing a uniform surgical and anesthesiology protocol designed around the enhanced recovery after surgery (ERAS) protocol. The incidence of VTE and flap-related complications was documented, alongside an evaluation of the potential risk factors and Caprini scores.

RESULTS

None of the patients in this cohort developed deep vein thrombosis or pulmonary embolism. Hematomas were noted in 5.4% of the cases. The mean Caprini score observed was 6.67, ranging from 3 to 9. Incidences of total and partial flap necrosis were recorded in 7 (1.4%) and 9 (1.8%) cases, respectively. Analysis revealed no significant disparity in the complication rates between patients categorized as being at low risk (Caprini score ≤6), at 5.4%, and those deemed to have the highest risk and super high risk together (Caprini score ≥7), at 3.8%.

CONCLUSIONS

Our cohort study is the first, to our knowledge, to demonstrate a zero percent incidence of clinical VTE events following autologous breast reconstruction, attributed to the rigorous application of a standardized surgical, anesthesiology, and thromboprophylaxis protocol. This result highlights the potential of a well-implemented pre- and intra-operative management, combined with the ERAS protocol, to significantly reduce the VTE risk in this group of patients.

LEVEL OF EVIDENCE

IV.

Defining Textbook Outcomes for Minimally Invasive Surgical Resection of Small Gastrointestinal Stromal Tumors (GIST) of the Stomach

BACKGROUND

Textbook outcome (TO) has been utilized to assess the quality of surgical care. This study aimed to define TO rates for minimally invasive gastric gastrointestinal stromal tumor (GIST) resections in a bi-institutional cohort.

METHODS

Patients with gastric GIST (≤ 5 cm) who underwent laparoscopic or robotic resection (January 2014 to January 2024) were retrospectively identified from two GIST centers. We excluded patients with concurrent procedures, tumor involvement of adjacent organs, or metastatic disease. To balance perioperative and oncologic outcomes, we defined TO as: R0 resection, no conversion to open surgery, operative time ≤ 120 min, no perioperative transfusions, no intraoperative complications, no Clavien-Dindo ≥ II complications, hospital length of stay (LOS) ≤ 3 days, no 90-day readmission or death, no tumor rupture, and recurrence-free status at 2 years (5% predicted recurrence risk for tumors with a low mitotic index).

RESULTS

A total of 83 patients were included. TO was achieved in 62.7% of cases (N = 52). Mean tumor size was 3.0 ± 1.0 cm and 86.7% of GIST were modified-NIH low or very low risk (i.e., mitotic index ≤5/mm2). Mean operative time was 102.7 ± 49.3 minutes. Mean LOS was 2.3 ± 1.2 days. Among non-TO cases, the most common disqualifying factors were operative time > 120 minutes (N = 20, 24.1%) and LOS > 3 days (N = 15, 18.1%). There were four 90-day readmissions (4.8%) and one case with staple line bleeding requiring endoscopic clipping. During a mean follow-up of 32.6 ± 24.1 months, 3 patients (3.6%) recurred within 2 years. On multivariable regression analysis, no factors were independently associated with non-TO.

CONCLUSIONS

Minimally invasive gastric GIST resection is well-described. Herein, we propose new TO standards to serve as a measure of short- and long-term outcomes for monitoring institutional performance.

Quantifying the Learning Curve in Robotic Peritoneal Flap Vaginoplasty

BACKGROUND

The learning curve (LC) is the process of mastering a new technique. This study assesses the LC for robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV).

METHODS

A retrospective chart review of all consecutive patients undergoing RPGAV between 09/2017 and 02/2023 at a single center was performed. Operative times (OT) were analyzed to describe the LC. A cutoff point was determined after which OT stabilized, and this was used to compare perioperative and postoperative outcomes.

RESULTS

Five hundred RPGAVs were performed. Median OT was 125 (interquartile range 105-181) minutes and decreased significantly over time. The minimum number of cases required to observe a plateau in OT is 300 patients.After adjusting for the LC, 2 variables significantly affected OT: a 1-point increase in body mass index increased OT by 1.4 minutes [95% confidence interval (1.0, 1.9), P < 0.001] and the single port robot decreased OT by 34 minutes [95% CI 1 (-43.1, -25.0), P < 0.001] as compared to the traditional multiport Xi robot.When comparing the first 300 cases (learning phase) to the last 200 (expert phase), length of stay, blood transfusions, and rates of elective revision surgery were lower in the expert phase.

CONCLUSIONS

The LC for RPGAV in this large cohort was 300 cases. Patient body mass index causes a dose-response increase in OT and the single port robot dramatically decreases OT. Although OT is just one facet of overall efficiency, differences between learning and expert phases are evident in decreased length of stay, transfusions, and rates of revision surgery.

Utility of optic nerve sheath ultrasound during laparoscopic colorectal surgery

INTRODUCTION

Abdominal laparoscopic surgery to treat colorectal cancer has been shown to be more effective than open surgery in terms of mobility, hospital stay, tumour recurrence and long-term survival. This surgical approach requires pneumoperitoneum and the Trendelenburg position (35-45º), both of which have a negative effect on the cardiovascular system and can even change the cerebrovascular physiology, leading to an increase in intracranial pressure (ICP). Ultrasound measurement of optic nerve sheath (ONS) diameter has shown excellent correlation with invasive ICP measurement.

OBJECTIVE

To correlate the increase in ONS diameter with surgical time and time to emergence after anaesthesia. The incidence of visual disturbances (visual acuity) and/or neurological complications (agitation, cognitive dysfunction) in the immediate postoperative period was also evaluated.

MATERIAL AND METHODS

30 consecutive patients undergoing laparoscopic surgery for rectal or sigmoid adenocarcinoma were recruited. Pre-, intra- and postoperative ONS measurements were obtained and the Snellen test for visual acuity, Mini Mental Test for cognitive function, and the Richmond Agitation and Sedation Scale (RASS) were administered.

RESULTS

ONS increased intraoperatively in both eyes compared to baseline. However, this was not correlated with total surgical time or time to emergence, and there was no statistically significant correlation between ONS and postoperative neurological or visual alterations.

Cholecystectomy for acute cholecystitis during weekend compared with delayed weekday surgery: A nationwide population cohort study

BACKGROUND

The optimal timing of surgery for acute cholecystitis has been a subject of debate, but the predominant view supports early cholecystectomy. This study investigated the safety of early cholecystectomy during weekends compared with delayed surgery until a weekday.

METHODS

This was a population-based cohort study based on data from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). Data from 2006 to 2020 were analyzed, and patients with acute cholecystitis were included. Patients who underwent surgery during weekends were compared with patients in hospital during weekends and underwent surgery on any subsequent weekday. Statistical analyses were conducted using logistic regression analysis.

RESULTS

15,730 patients were included, and complications were registered in 2,246 patients (14.3%). The proportion of complications was equal in both groups (14.0% vs 14.5%, P = .365). The proportion of open surgery was higher in the weekend surgery group (29.1% vs 26.3%), with an odds ratio of 1.32 in multivariate logistic regression analysis (P < .001). Meanwhile, the duration of surgery exceeding 2 hours was less common when surgery was performed on the weekend (32.7% vs 46.8%, P < .001, odds ratio: 0.69).

CONCLUSION

In this study, procedures performed during weekends had outcomes that did not substantially differ from those performed during weekdays. The results of our study support performing early cholecystectomies during the weekend without increasing the patients' risk of complications.

Peroral endoscopic myotomy for complex achalasia and the POEM difficulty score: An update

Objectives

We present an update on the (peroral endoscopic myotomy (POEM) difficulty score [PDS] by introducing a novel knife with waterjet functionality.

Methods

This is a retrospective review of patients who underwent POEM between May 2018 and July 2023 at the Kingston Health Sciences Center. Demographic and procedural variables were compared using descriptive and inferential statistics.

Results

One hundred thirty-nine consecutive POEMs were included in the study. Seventy-four (56.7% male; aged 56.7 ± 16.5 years) complex achalasia (CA) and 65 (55.4% female; aged 47.3 ± 20.2 years) non-CA POEM procedures were performed. PDS correlates moderately with procedural efficiency with a correlation coefficient of 0.595 (Spearman's p < 0.001). The mean efficiency for non-CA was 3.3 ± 1.2 min/cm compared to CA as follows: type III 3.3 ± 1.3 min/cm; prior myotomy 5.3 ± 2.3 min/cm; ≧4 prior procedures 4.0 ± 1.7 min/cm; sigmoid type 5.2 ± 2.4 min/cm. The median PDS for non-CA was 1 (1-5). In comparison, the median PDS for CA is as follows: type III 3 (2-4); prior myotomy 4 (3-5); ≧4 prior procedures 3 (1.25-4); sigmoid type 3 (2-4). PDS excluding the presence of spastic contractions correlated better with procedural velocity, with a correlation coefficient of 0.645 (Spearman's p < 0.001).

Conclusions

PDS continues to moderately correlate with procedural efficiency using the novel knife. The presence of spastic contractions correlated poorly with procedural efficiency. Thus, it may be omitted in further studies.

Nomogram for prediction of severe postoperative complications in elective hepato-pancreato-biliary surgery after COVID-19 breakthrough infection: A large multicenter study

BACKGROUND

Currently, there is a deficiency in a strong risk prediction framework for precisely evaluating the likelihood of severe postoperative complications in patients undergoing elective hepato-pancreato-biliary surgery subsequent to experiencing breakthrough infection of coronavirus disease 2019 (COVID-19). This study aimed to find factors predicting postoperative complications and construct an innovative nomogram to pinpoint patients who were susceptible to developing severe complications following breakthrough infection of COVID-19 after undergoing elective hepato-pancreato-biliary surgery.

METHODS

This multicenter retrospective cohort study included consecutive patients who underwent elective hepato-pancreato-biliary surgeries between January 3 and April 1, 2023 from four hospitals in China. All of these patients had experienced breakthrough infection of COVID-19 prior to their surgeries. Additionally, two groups of patients without preoperative COVID-19 infection were included as comparative controls. Surgical complications were meticulously documented and evaluated using the comprehensive complication index (CCI), which ranged from 0 (uneventful course) to 100 (death). A CCI value of 20.9 was identified as the threshold for defining severe complications.

RESULTS

Among 2636 patients who were included in this study, 873 were included in the reference group I, 941 in the reference group II, 389 in the internal cohort, and 433 in the external validation cohort. Multivariate logistic regression analysis revealed that completing a full course of COVID-19 vaccination > 6 months before surgery, undergoing surgery within 4 weeks of diagnosis of COVID-19 breakthrough infection, operation duration of 4 h or longer, cancer-related surgery, and major surgical procedures were significantly linked to a CCI > 20.9. A nomogram model was constructed utilizing CCI > 20.9 in the training cohort [area under the curve (AUC): 0.919, 95% confidence interval (CI): 0.881-0.957], the internal validation cohort (AUC: 0.910, 95% CI: 0.847-0.973), and the external validation cohort (AUC: 0.841, 95% CI: 0.799-0.883). The calibration curve for the probability of CCI > 20.9 demonstrated good agreement between the predictions made by the nomogram and the actual observations.

CONCLUSIONS

The developed model holds significant potential in aiding clinicians with clinical decision-making and risk stratification for patients who have experienced breakthrough infection of COVID-19 prior to undergoing elective hepato-pancreato-biliary surgery.

Demographic Factors Associated with Postoperative Complications in Primary Bariatric Surgery: A Rapid Review

BACKGROUND

Bariatric surgery is highly effective for the management of severe obesity, but its safety profile is not completely understood. This review aimed to synthesise evidence linking demographic factors to postoperative complications and mortality following primary bariatric surgery.

METHODS

We searched Medline for observational studies of adult patients linking demographic factors to postoperative complications of primary bariatric surgery published from 2017 to 2022. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated and pooled using random effect meta-analysis. Heterogeneity was quantified using the I2 statistic and tested for statistical significance using the Q-statistic. Sensitivity analyses were used to explore potential sources of heterogeneity.

RESULTS

A total of 71 observational studies (69 cohort, 2 case-control) were reviewed and appraised. Older age was consistently associated with increased risks of postoperative mortality (RR = 2.62, 95% CI 1.63-4.23, I2 = 42.04%), serious complications (RR = 1.76, 95% CI 1.09-2.82, I2 = 93.24%), anastomotic leak (RR = 1.64, 95% CI 1.04-2.58, I2 = 61.09%), and haemorrhage (RR = 1.44, 95% CI 1.07-1.94, I2 = 45.25%). Male sex was associated with increased anastomotic leak (RR = 1.39, 95% CI 1.04-1.87, I2 = 72.36%). Sensitivity analyses did not identify sources of bias. Socioeconomic factors, including Black/African American race, low financial status, and marital status (mixed results), were linked to higher complication risks in some studies.

CONCLUSIONS

Older age and certain demographic factors (male sex, Black/African American race, low financial status, marital status) were associated with increased risks of postoperative complications following primary bariatric surgery.

The impact of specialised orthopaedic surgical nurses on operating room time

OBJECTIVE

Proximal femur fractures (PFF) have been widely recognised as a significant social and health issue due to their costs and their impact on patient mortality, representing one of the most common types of fracture in the elderly population. The most commonly used procedures for this type of fracture are intramedullary nailing or endoprosthesis, depending on the fracture pattern. There is limited research on dedicated surgical teams in the fields of orthopedics surgery. The purpose of this study is to evaluate the importance of having a specialised surgical nurse and the impact this can have on surgical timings.

METHODS

This study was conducted in a level - 2 trauma center. We evaluated all patients who underwent surgery at our hospital from January 1st, 2021, to January 1st, 2022. We divided the patients into two groups, based on the type of treatment performed, then further subdivided based on the presence or absence of a specialised surgical nurse in the operating room.

RESULTS

A total of 167 patients were categorized into two groups: those treated with an intramedullary nail (n = 72) and those receiving an endoprosthesis (n = 95). Each group was further divided based on the presence or absence of a specialised surgical nurse. We noticed significantly shorter operative times in procedures assisted by specialised nurses: 55.37 min (σ 12.97) vs. 81 min (σ 32) for intramedullary nailing (p = 0.0001) and 80.2 min (σ 27) vs. 91.48 min (σ 27) for endoprosthesis (p = 0.04).

CONCLUSIONS

In conclusion, surgical time has a significant impact on elderly patients undergoing surgery for hip fractures. Therefore, a specialised team, including a specialist orthopedic nurse, which helps reduce operative time, is essential.

Factors affecting duration of inability to work after intramedullary stabilization of displaced midshaft clavicular fractures

BACKGROUND

Duration of inability to work (DIW) after displaced midshaft clavicular fractures (DMCF) is an important clinical and socioeconomic treatment outcome. However, evidence on DIW after DMCF intramedullary stabilization (IMS) is still limited. We aimed to examine DIW and to identify medical and socioeconomic predictors with direct or indirect impact on DIW after IMS of DMCF.

HYPOTHESIS

Socioeconomic predictors can explain the unique proportion of the DIW variance after IMS of DMCF above the variance explained by medical predictors.

PATIENTS AND METHODS

Using a retrospective cohort unicentric design we included patients surgically treated with IMS after DMCF from 2009-2022 with employment status subject to compulsory social security contributions, and without major postoperative complications, in one level 2 trauma center in Germany. In total, we tested the impact of 17 different medical (i.e., smoking, body mass index [BMI], operative duration, etc.) and socioeconomic predictors (i.e., health insurance type, physical workload, etc.) on DIW. Statistics included multiple regression and path analyses.

RESULTS

A total of 166 patients met eligibility criteria, with DIW 35.1±31.1days. Operative duration, physical workload, and physical therapy prolonged DIW (p<0.001). In contrast, enrollment in private health insurance reduced DIW (p<0.05). Furthermore, the effect of BMI and fracture complexity on DIW was fully mediated by operative duration. The model explained 43% of the DIW variance.

DISCUSSION

Socioeconomic factors were found to directly predict DIW, even after controlling for medical predictors, which confirmed our research question. This is in line with previous findings and highlights the relevance of socioeconomic predictors in this context. We believe that the proposed model can serve surgeons and patients as an orientation guide to estimate DIW after IMS of DMCF.

LEVEL OF EVIDENCE

IV - retrospective observational cohort study with no control group.

Parastomal Hernia: direct repair versus relocation: is stoma relocation worth the risk? A comparative meta-analysis and systematic review

Parastomal hernia is a prevalent and challenging complication in patients with stomas, frequently necessitating surgical intervention. The two primary approaches to parastomal hernia repair- direct repair without relocation and stoma relocation- offer distinct benefits and drawbacks. This systematic review and meta-analysis aimed to compare the efficacy and safety of stoma relocation versus direct repair in managing parastomal hernia. Following PRISMA guidelines, we conducted a systematic review and meta-analysis of studies involving adult patients (≥ 18 years) with parastomal hernia who underwent either stoma relocation or direct repair, with a focus on clinically relevant outcomes. A comprehensive search of Web of Science, PubMed, Scopus, and Cochrane Library databases was conducted up to September 2024. Key short-term outcomes (operative time, surgical site infection, urinary tract infection, bowel obstruction, length of hospital stay, and overall complications) and long-term outcomes (re-admission, recurrence, re-operation, and mortality) were extracted. Statistical analysis included risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Six studies were included, encompassing both laparoscopic and open-surgical techniques. Direct repair was associated with a significantly shorter operative time (MD: 115 min, 95% CI: 95.71 to 134, P < 0.00001) and a reduced length of hospital stay (MD: 2 days, 95% CI: 0.40 to 3.9, P = 0.02). While reoperation rates were significantly lower in the relocation group (RR: 0.15, 95% CI: 0.03 to 0.62, P = 0.009), other outcomes-including recurrence, re-admission, and overall complication rates-showed comparable results between the two approaches. Notably, there were no significant differences in surgical site infection, urinary tract infection, bowel obstruction, or mortality rates. Direct repair may be advantageous for reducing operative time and hospital stay, whereas stoma relocation appears beneficial in reducing reoperation rates. Future research should focus on developing standardized techniques and incorporating patient-specific factors to inform optimal surgical decision-making in parastomal hernia repair.

Thromboprophylaxis in patients admitted to inpatient rehabilitation and skilled nursing facilities post total joint arthroplasty

PURPOSE

Thromboprophylaxis has significantly reduced the incidence of venous thromboembolic events (VTE) after total joint arthroplasty (TJA). Recent studies have established protocols for VTE prevention using aspirin, given its comparable efficacy to prophylactic anticoagulants and a lower risk of bleeding complications. However, patients admitted to inpatient rehabilitation (IPR) or skilled nursing facilities (SNF) after TJA may require more potent agents due to an increased risk of VTE. This study aims to compare the incidence of symptomatic VTE and postoperative complications in TJA patients receiving aspirin versus anticoagulants in the setting of IPR and SNF.

METHODS

We reviewed an all-payer, national database for patients who had hip and/or knee osteoarthritis who underwent primary TJA between October 1, 2015 and April 30, 2021 (n = 713,548). Patients discharged to IPR or SNF were identified using CPT codes. A propensity score match was performed to limit potential confounders. Patients were stratified into aspirin (n = 2,343) and anticoagulant (n = 2,343) cohorts based on the postoperative VTE prophylaxis they received; anticoagulants included dabigatran, enoxaparin, heparin, rivaroxaban, and warfarin. Complications were identified using ICD-10 codes and included VTE, aseptic revision, cardiac complications, periprosthetic joint infections, surgical site infections, the need for transfusion, and wound complications 90 days after surgery.

RESULTS

The aspirin cohort had a VTE incidence of 4.4% compared to 2.3% in the anticoagulant cohort (p <.001), indicating nearly double the odds of VTE with aspirin use compared to anticoagulant. The odds ratio for VTE was 0.52 (95% CI: 0.37-0.72), with the aspirin cohort as the reference. Incidence rates of other complications were similar between the two cohorts.

CONCLUSION

This study demonstrates a higher risk of VTE with aspirin compared to anticoagulant in patients discharged to IPR or SNF after primary TJA. Surgeons should consider using rivaroxaban, enoxaparin, heparin, dabigatran, or warfarin for VTE prophylaxis instead of aspirin in these high-risk patients.

Clinical predictors associated with prolonged pneumoperitoneum time in laparoscopic living donor nephrectomy

BACKGROUND

Kidney transplantation (KT) is a useful treatment option for patients with end-stage chronic kidney disease to avoid dialysis and achieve a good quality of life. In Japan, approximately 90% of kidneys for KT are obtained from living kidney donors. Laparoscopic renal nephrectomy (LDN) is the most commonly performed KT procedure in Japan. We aimed to determine the clinical variables that influence the prolongation of pneumoperitoneum time (PT) in LDN.

METHOD

This retrospective study was carried out on 218 consecutive patients who underwent LDN at Gifu University Hospital. T The enrolled patients were divided into two groups according to the third quartile of PT in the LDN, with those in the lower third quartile (Q3) as Group 1 and those in the upper Q3 as Group 2. The primary endpoint was identification of predictive factors for prolonged PT.

RESULT

In total, 178 patients were included in the analysis. For all patients, the median PT, estimated blood loss, and warm ischemic time were 170 min, 20 mL, and 4 min, respectively. Significantly longer PT was observed in Group 2 than in Group 1. Multiple regression analysis results showed that male donors, body mass index ≥ 25 kg/m2, and donors with more than two renal arteries were independent predictive factors for PT prolongation.

CONCLUSION

Male sex, BMI ≥ 25 kg/m2, and two or more renal arteries are predictive factors for prolonged PT for donors in LDN.

Validation of a Novel "Windshield Wiper" for Laparoscopes in Cadaver and Live Porcine Models

BackgroundDuring laparoscopic surgeries, laparoscopes are inserted through a trocar port into the body cavity, which is then insufflated with carbon dioxide. Laparoscope lens clarity frequently becomes compromised via condensation or smearing of blood and adipose. This problem is well-known in the field, yet a viable in vivo solution has yet to address the issue and be successfully clinically adopted.Research DesignA structured cadaveric study evaluated the cleaning performance and clinician satisfaction with a novel laparoscope lens cleaning device against 2 gold-standard lens cleaning products. The novel device was also tested in a live animal porcine model to assess cleaning performance in a warm body environment qualitatively. The validation in the porcine model did not have the same evaluation process and comparison with other lens clearing methods as the cadaveric experiment.ResultsCleaning events were timed individually and analyzed post hoc. Average times to clean scopes for the novel device, Clearify™, and Fred™ Anti-Fog solution were 5 ± 5, 16 ± 7, and 14 ± 6 seconds, respectively. In 100 cleaning events with the novel device, the laparoscope was removed from the body zero times, with an average of 2 ± 1.29 cleaning actuations per event. Clearify™ and Fred™ Anti-Fog were removed from the body 102 and 116 times, with an average number of cleaning actuations of 1.07 ± 0.26 and 1.19 ± 0.53 per event, respectively. In the live porcine model, the novel device consistently cleared all debris deposited on the lens, including fog, tissue, blood, and bile fluid.ConclusionThis study demonstrates the novel device's reduction in cleaning duration and scope removals compared to gold-standard technologies, suggesting a potential for improved workflow and reduced intra-operative interruptions.

Prediction of remaining surgery duration based on machine learning methods and laparoscopic annotation data

OBJECTIVES

The operating room is a fast-paced and demanding environment. Among the various factors involved in its optimization, predicting surgery duration is critical for scheduling and resource organization, ultimately resulting in improved quality of surgical care.

METHODS

We design, implement and evaluate a semi-automated machine learning method that takes as input the current phase and tools employed and provides prediction of the Remain Surgery Duration (RSD) in laparoscopic cholecystectomy operations. We use the annotated information of tools and phases provided in the publicly available dataset Cholec80. The method is based on a Random Forest regression model that considers two data streams: the surgical phase and the type of tools employed, at each time-frame of the operation. The data were split into Training-, Validation- and Test-sets. The Mean Absolute Error (MAE) was used as the performance metric for the various models examined.

RESULTS

Our approach managed to achieve a MAE=5.89 min across the overall duration of the surgeries in the test-set and MAE=4.61 min at 20 min before the end of the operation.

CONCLUSIONS

The employment of two separate regression models switched at a specific elapsed time threshold provides significant improvement in RSD prediction compared to other methods that process the video from the endoscope.

Patient-Centered Outcome Assessment of Static and Dynamic Navigation-Aided Endodontic Microsurgery: A Randomized Controlled Trial

INTRODUCTION

This study aimed to evaluate the quality of life (QoL) and analgesic use 1 week after surgery, as well as the surgical duration, associated with static navigation (SN) and dynamic navigation (DN)-aided endodontic microsurgery (EMS).

METHODS

Sixty patients were randomly assigned to the SN group (n = 30) or the DN group (n = 30). Both groups underwent EMS based on a presurgical plan. The primary outcomes were patient-reported QoL and analgesic use during the first week, while the secondary outcome was the duration of guided procedures, including osteotomy and root-end resection. QoL was assessed using a visual analog scale-based questionnaire. The questionnaire evaluated symptoms (pain, swelling, bleeding) and functional impact (mouth opening, chewing, talking, sleeping, daily routine), with average scores for each component calculated daily. The Mann-Whitney U test was used to compare QoL scores and surgery duration between groups, with statistical significance set at P < .05.

RESULTS

Postoperative adverse reactions within the first week after SN- and DN-aided EMS were short-lived, peaking early in the postoperative period and gradually subsiding. No significant differences were observed in QoL or analgesic use between the SN and DN groups. Participants in the SN group had significantly shorter surgery duration compared to DN group.

CONCLUSION

Both SN and DN enable minimally invasive EMS with equivalent patient-centered outcomes, though SN demonstrates a significant advantage in reducing the duration of guided osteotomy and root-end resection. These findings provide patient-centered reference metrics to guide the selection between the 2 guided approaches in clinical practice.

Microtia Reconstruction: 30-Day Outcomes for Autograft Versus Implant Reconstruction in a National Surgical Database

ObjectiveTo compare the use of porous polyethylene implants versus autologous reconstruction for ear reconstruction in patients with microtia or anotia.DesignRetrospective cohort study.SettingHospitals included in the American College of Surgeons National Surgical Quality Improvement Project-Pediatrics, between 2016 and 2022.PatientsChildren with diagnoses of microtia or anotia.InterventionsEar reconstruction utilizing either a porous-polyethylene implant or autologous reconstruction.Main Outcome MeasuresRates of wound complication, hospital readmission, reoperation, and hospital lengths-of-stay within 30 days of index surgery.ResultsThere were 986 patients meeting inclusion criteria, including 893 receiving autograft and 93 receiving synthetic implant. Complication rates, including wound complication, dehiscence, and surgical site infection are similar between the 2 cohorts, though deep surgical site infections are more frequent in patients receiving implant reconstruction.Patients receiving implant reconstruction have a 4-fold higher odds of hospital readmission and a 9-fold higher odds of reoperation within 30 days after controlling for patient characteristics and surgeon specialty. Patients receiving implant reconstruction also have shorter hospital lengths-of-stay.ConclusionsEar reconstruction using autologous cartilage provides better 30-day outcomes compared to implant-based reconstruction with respect to rates of reoperation and readmission. However, these differences may be reflective more of limited surgeon experience with using synthetic implants than of the best possible outcomes achievable with each technique.

Identification of an Operative Time Threshold for Substantially Increased Postoperative Complications After Thoracolumbar Spine Surgery: A Nationwide Retrospective Cohort Analysis

BACKGROUND

The literature extensively describes the influence of operative time (OT) on postoperative outcomes, but the extent of its impact on thoracolumbar fusion outcomes remains unclear. This study aims to identify the threshold beyond which OT increases the risk of surgical adverse events and to quantify the association between increased OT and postoperative complications.

METHODS

A total of 66,904 patients who underwent thoracolumbar fracture surgery between 2010 and 2021 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset. We used the receiver operating characteristic curve to determine an OT threshold that significantly increased 30-day morbidity. Univariate analysis was performed before and after propensity matching for covariates. Multivariate regression was used to further validate the risk of OT on 30-day morbidity.

RESULTS

A total of 66,898 patients met the inclusion criteria, of whom 20% experienced 30-day morbidity and 0.38% 30-day mortality. An OT threshold of 215 minutes best discriminates risk of 30-day morbidity. On univariate analysis, longer OT was significantly associated with all-cause 30-day morbidity (odds ratio, 3.28; 95% confidence interval, 3.12-3.45), including wound infection, increased length of stay, deep vein thrombosis, bleeding requiring transfusion, pneumonia, pulmonary embolism, urinary tract infection, and failure to wean off ventilation. Further analysis with multivariate regression validated that OT was independently associated with an increased risk of overall complications (odds ratio, 3.50; confidence interval, 3.25-3.78; P < 0.0001).

CONCLUSIONS

This study shows that OT ≥215 minutes is strongly associated with increased incidence of postoperative adverse events and longer hospital length of stay after thoracolumbar spine fixation.

Augmented reality for perforator mapping: A systematic review and meta-analysis

BACKGROUND

Augmented reality (AR) is increasingly used to aid perioperative navigation of patient anatomy, improve intraoperative accuracy and reduce operating times. This review compares outcomes relating to AR versus conventional imaging for perforator mapping in flap reconstruction.

METHODS

A systematic search was performed, suitable articles reviewed, and data extracted by 2 independent reviewers, with conflicts resolved by consensus. Meta-analysis was conducted to evaluate AR versus Doppler on outcomes including distance between imaged perforators and intraoperative findings, number of perforators identified, perforator localisation time, total operating time, and postoperative complications.

RESULTS

Of 1005 articles retrieved, 14 were eligible for meta-analysis. Intraoperative use of AR was associated with a significantly shorter distance between identified perforators and intraoperative findings (SMD = -1.88; 95% CI -3.69 to -0.08; P = 0.04) and identification of more perforators than conventional Doppler (SMD = 0.12; 95% CI 0.01 to 0.23; P = 0.04). AR decreased time taken for perforator localisation (SMD = -2.53; 95% CI -5.14 to 0.08; P = 0.06) and significantly reduced total operating time (SMD = -16.34; 95% CI -21.72 to -10.95; P< 0.00001). There was no significant difference between the 2 groups in the number of postoperative complications (SMD = 1.12; 95% CI 0.46 to 2.74; P = 0.80).

CONCLUSIONS

The results suggest that AR technologies offer increased intraoperative accuracy of perforator identification and reduced time to perforator identification and total operating times compared to conventional imaging. Further high-quality studies with larger sample sizes are required to definitively confirm the benefits to support their widespread uptake and use.

Risk factors and clinical impact of prolonged air leak following video-assisted thoracoscopic surgery: a retrospective cohort study

Objective

This study aims to reveal the incidence and risk factors of prolonged air leak (PAL) following video-assisted thoracoscopic surgery (VATS) and to evaluate its impact on postoperative outcomes.

Methods

A retrospective analysis was performed on the clinical data of all pulmonary surgery patients who underwent VATS at the Department of Hospital Surgery No.2 at Sechenov University, from September 2023 to September 2024. Patients were categorized into two groups based on the presence of PAL (defined as prolonged air leak lasting ≥ 5 days): the PAL group and the non-PAL group. Risk factors for PAL and its effects on postoperative recovery were assessed.

Results

A total of 110 patients were included in the study, with an incidence of PAL of 26.3%. Multivariate analysis identified chronic obstructive pulmonary disease (COPD) (OR = 9.023, P = 0.003) and pleural adhesions (OR = 3.404, P = 0.013) as independent risk factors for the development of PAL. Significant differences were found between the PAL and non-PAL groups in terms of length of hospital stay (P < 0.001) and chest tube removal time (P < 0.001). The PAL group had a higher overall complication rate than the non-PAL group, with significantly more postoperative pneumonia (P = 0.003), postoperative empyema (P = 0.023), and postoperative wound infections (P = 0.005).

Conclusion

Chronic obstructive pulmonary disease and pleural adhesions were identified as independent risk factors for PAL after VATS. Patients with PAL experienced more postoperative complications and longer hospital stays.

Does Surgical Approach Impact Wound Complication Rates after Revision Total Hip Arthroplasty?

BACKGROUND

While some literature suggests that wound complications are increased for primary total hip arthroplasty (THA) procedures utilizing the direct anterior (DA) approach, the impact of the surgical approach on wound complications after revision THA cases remains unknown. This study aimed to compare wound complications between different surgical approaches in revision THA.

METHODS

The retrospective study identified 1,749 consecutive patients who underwent revision THA at a single institution between 2017 and 2023. Patients were categorized based on components revised (acetabular only, femur only, both-component, head-liner exchange) during revision THA and by surgical approach (DA, direct lateral (DL), postero-lateral (PL)) for each category. The primary outcome of the study was wound complications within 90 days of surgery.

RESULTS

The wound complication rates for acetabular-only revisions were 0.83 for DA approach, 4.64 for DL approach, and 3.9% for PL approach (P = 0.149). Femoral component revisions had wound complication rates of 9.68 for DA approach, 5.06 for DL approach, and 13.2% for PL approach (P = 0.065). For both component revisions, the wound complication rates were 5.83 for DA approach, 4.49 for DL approach, and 8.47% for PL approach (P = 0.28). Also, head and liner exchange wound complication rates were 6.94 for DA approach, 6.21 for DL approach, and 11.3% for PL approach (P = 0.301). Readmission rates and reoperation rates were similar for all approaches in all revisions except for femoral component revisions performed through the PL approach, which had an increased risk of readmission (12.3%, P = 0.008) and reoperation (10.4%, P = 0.012) compared to DA approach (8.6 and 6.45%, respectively) and DL approach (2.53 and 1.9%, respectively).

CONCLUSIONS

The surgical approach appears to have minimal impact on the likelihood of developing wound complications in revision THAs. The need for readmission and reoperation was also similar across surgical approaches for various revision THA procedures.

Analyzing the impact of surgical technique on intraoperative adverse events in laparoscopic Roux-en-Y gastric bypass surgery by video-based assessment

BACKGROUND

Despite high-level evidence that variations of surgical technique in laparoscopic Roux-en-Y gastric bypass (LRYGB) are correlated with postoperative outcomes and might be linked to intraoperative adverse events (iAEs), there are a paucity of studies analyzing iAEs in depth. The impact of surgical technique on the temporal occurrence of iAEs regarding phases and steps of LRYGB has not been studied so far. The objective of this study was to analyze the impact of variance in surgical technique on temporal occurrence, frequency, and type of iAEs in a multicentric dataset of LRYGB videos.

METHODS

MultiBypass140, a video dataset containing 70 LRYGB surgeries each from Strasbourg University Hospital (StrasBypass70) and Bern University Hospital (BernBypass70) was annotated with surgical phases, iAE type, and grade. The cumulative severity of iAEs per procedure was measured using the SEVERE score and correlated with procedure duration.

RESULTS

Surgical technique significantly differed between StrasBypass70 and BernBypass70 (omentum division: 94% vs. 36%, p < 0.01; closure of mesenteric defects: 100% vs. 21%, p < 0.01). In MultiBypass140, a total of 797 iAEs were analyzed. The most iAE-prone phases were gastric pouch creation, gastrojejunal, and jejunojejunal anastomosis creation containing 77% (616/797) of all iAEs. StrasBypass70 showed significantly more iAEs in the omentum division (23 vs. 5, p < 0.01), Petersen space closure (13 vs. 1, p < 0.01), and mesenteric defect closure phases (34 vs. 1, p < 0.01) compared to BernBypass70. In both centers, SEVERE score was correlated with procedure duration. In BernBypass70, insufficient closure of anastomosis was significantly more frequent in patients with postoperative complications (0.2 ± 0.6 vs. 0.0 ± 0.1, p < 0.01).

CONCLUSION

Variations of the LRYGB technique between centers influence the temporal occurrence and frequency of iAEs. The frequency and severity of iAEs are correlated with procedure duration.

Development of machine learning model for predicting prolonged operation time in lumbar stenosis undergoing posterior lumbar interbody fusion: a multicenter study

BACKGROUND CONTEXT

Longer posterior lumbar interbody fusion (PLIF) surgeries for individuals with lumbar spinal stenosis are linked to more complications and negatively affect recovery after the operation. Therefore, there is a critical need for a method to accurately predict patients who are at risk for prolonged operation times.

PURPOSE

This research aimed to develop a clinical model to predict prolonged operation time for patients undergoing PLIF procedures.

STUDY DESIGN/SETTING

This study employs a machine-learning approach to analyze data retrospectively collected.

PATIENT SAMPLE

About 3,233 patients diagnosed with lumbar spinal stenosis (LSS) had posterior lumbar interbody fusion (PLIF) at 22 hospitals in China from January 2015 to December 2022.

OUTCOME MEASURES

The primary outcome was operation time. Prolonged operation time defined as exceeded 75% of the overall surgical duration, which mean exceeding 240 minutes.

METHODS

A total of 3,233 patients who underwent PLIF surgery with lumbar spinal stenosis (LSS) were divided into one training group and four test groups based on different district areas. The training group included 1,569 patients, while Test1 had 541, Test2 had 403, Test3 had 351, and Test4 had 369 patients. Variables consisted of demographics, perioperative details, preoperative laboratory examinations and other Additional factors. Six algorithms were employed for variable screening, and variables identified by more than two screening methods were incorporated into the final model. In the training cohort, a 10-fold cross-validation (CV) and Bayesian hyperparameter optimization techniques were utilized to construct a model using eleven machine learning algorithms. Following this, the model was evaluated using four separate external test sets, and the mean Area Under the Curve (AUC) was computed to determine the best-performing model. Further performance metrics of the best model were evaluated, and SHapley Additive exPlanations (SHAP) were used for interpretability analysis to enhance decision-making transparency. Ultimately, an online calculator was created.

RESULTS

Among the various machine learning models, the Random Forest achieved the highest performance in the validation set, with AUROC scores of 0.832 in Test1, 0.834 in Test2, 0.816 inTest3, 0.822 in Test4) compared with other machine learning models. The top contributing variables were number of levels fusion, pre-APTT, weight and age. The predictive model was further refined by developing a web-based calculator for clinical application (https://wenle.shinyapps.io/PPOT_LSS/).

CONCLUSIONS

This predictive model can facilitate identification of risk for prolonged operation time following PLIF surgery. Predictive calculators are expected to improve preoperative planning, identify patients with high risk factors, and help clinicians facilitating the improvement of treatment plans and the implementation of clinical intervention.

Operating room times differ for surgical fixation of metacarpal fractures: An analysis of two principally different techniques

Introduction

Time spent in the operating room (OR) has ramifications that impact patient outcomes and the economics of patients, physicians, surgery centers, and insurance industry. For that reason, there is an incentive to seek approaches that allow shorter times to be spent in the OR. To what extent varying routine techniques impact on operating times has not been extensively studied in metacarpal fixation literature, specifically investigating retrograde threaded intramedullary nail fixations (RTNF) and comparing it to open plating fixations (OPF). The present study was designed for the purpose of comparing OR times for different but broadly adopted techniques for internal stabilization of metacarpal shaft fractures.

Methods

A retrospective chart review was conducted for patients aged 18 and above, who over a 41-month period underwent internal fixation with RTNF or OPF for single, extra articular, closed fractures of the index through little finger metacarpals. We examined anesthesia records, which indicated total operating ("skin-to-skin") times.

Results

A total of 81 charts remained for review after exclusions. Statistical analysis of the recorded data showed significantly shorter median OR time values for RTNF (17 minutes, IQR = 14 - 20.75) vs. OPF (36 minutes, IQR = 31.55 - 44; p < 0.001).

Conclusion

Statistical analysis of data shows significantly shorter operating times to achieve satisfactory fracture stabilization using RTNF compared to OPF. Since the differences in OR time significantly differ between the two principally different surgical techniques, it should be considered when choosing which surgical technique to use. However, further review of indications and clinical outcomes is necessary to develop definitive recommendations or guidelines on which technique should be preferred, especially when considering specific patient presentations.

Level of Evidence

Retrospective Comparative Study III.

Association Between Language, Interpreter Use, and Pediatric Surgical Outcomes

BACKGROUND

Inequities exist in pediatric surgical outcomes. Differential outcomes have been identified across racial groups, geography, and socioeconomic standing. However, the association between preferred language, interpreter use, and surgical outcomes is not well-studied in pediatric surgical literature.

METHODS

We performed a retrospective cohort study of surgical patients ages 0-21 years at a quaternary pediatric hospital between 1/1/2016 - 12/31/2020. The 95 languages spoken by our cohort were grouped into English, Spanish, Asian languages, Other Indo-European languages, and Other languages. Study outcomes were 30-day post-operative mortality and serious adverse events (SAE). Logistic regression assessed the relationship between language, interpreter use, and post-operative outcomes. Deviation contrasts avoided centering non-Hispanic white English speakers. All-pairs comparisons (Turkey contrasts) determined differences between language groups.

RESULTS

Among 56,655 patients, 89 % had a documented language of English, 6.7 % Spanish, 1.4 % Other, 1.3 % an Asian language, and 1.3 % an Other Indo-European language. On multivariable regression, English speakers had 54 % decreased odds of mortality (OR 0.46, 95 % CI: 0.31, 0.69), while Other language speakers had 240 % increased odds of mortality (OR 2.4, 95 % CI: 1.31, 4.41). Pairwise comparisons showed that English language speakers had reduced odds of mortality versus Other language speakers (OR 0.18, 95 % CI: 0.07, 0.45). Interpreter use was associated with a significant reduction in the odds of SAE but did not reduce mortality risk.

DISCUSSION

Pediatric surgical patients with a linguistic minority preference experienced statistically significant increased odds of post-operative mortality. Additional inquiry to assess and address disparate pediatric surgical care outcomes associated with language is warranted.

LEVEL OF EVIDENCE

Level III.

ERAS protocol in colorectal surgery is effective in octogenarians: A retrospective cohort study

Purpose

Evaluate the effectiveness of implementing an ERAS protocol in octogenarians.

Methods

This retrospective cohort study analyzed patients undergoing colorectal surgery under the ERAS protocol at Boca Raton Regional Hospital from December 1, 2019 to October 30, 2021. Patients under the age of 18, undergoing emergency surgery, and with incomplete data were excluded. A p < 0.05 was considered statistically significant and analyses were done using EZR and R software.

Results

299 patients met inclusion criteria with 60 (20.1 %) over the age of 80 and 239 (79.9 %) younger than 80. 140 (46.8 %) of the cohort were male. When comparing octogenarians with younger patients there were no differences in compliance with ERAS protocols such as pre-operative medication (p = 1) and oral carbohydrate drink consumption (p = 0.574), oral intake in PACU (p = 0.832), PACU sit and dangle (p = 0.619), or adherence to a narcotic sparing regimen (p = 0.365). Additionally, there were no differences in complications (p = 1), time until bowel function (p = 0.401), or time to first ambulation (p = 0.883). Octogenarians were more likely to have a longer LOS (4.89 v 3.0 days; p = 0.006), disposition requiring either home health care or a skilled nursing facility (SNF) (52.5 % v 28.3 %; p = 0.008), and readmission (42.3 % v 20.8 %; p = 0.042).

Conclusion

The ERAS protocol is safe and effective when used in the octogenarian without decreased compliance or increased complications. Increased LOS, care needed on disposition, and readmission are in-line with other published data of all patients and are likely related to increased frailty among this group and not to the addition of the ERAS protocol.

Cryptorchidism in dogs and cats presented for elective gonadectomy: A descriptive cohort study of 306 animals treated between 2018 and 2023

The objective of this study was to describe the incidence, breed distribution, clinical findings (anatomic location, number of testicles affected, and side), and surgical management of cryptorchidism in dogs and cats presented for elective gonadectomy. Medical record abstracts from a non-profit, high-volume, high-quality, spay-neuter clinic from 2018 to 2023 were reviewed retrospectively for cases of elective surgical gonadectomy of cryptorchid dogs and cats. During the study period, 5,476 dogs and 11,559 cats were presented to the same facility for elective surgical castration, suggesting a cryptorchid incidence of 3.21 % for dogs and 1.12 % for cats. Cryptorchidism affects various breeds and body conformations. Cryptorchid testes were more commonly observed in the inguinal area than in the abdomen, and were more frequently located unilaterally on the right side in both dogs and cats. The mean number of overall incisions required for surgical management was higher for testes located in the abdomen than for those located in the inguinal region in both dogs and cats. Due to differences in anatomy, cryptorchid prevalence, and surgical techniques, cryptorchidism in dogs and cats should be evaluated separately. Careful, preemptive identification and localization of the retained testicle(s) can be beneficial for efficient excision of cryptorchid testes.

Indocyanine green highlights the lymphatic drainage pathways, enhancing the effectiveness of radical surgery for mid-low rectal cancer: A non-randomized controlled prospective study

BACKGROUND

Fluorescence-guided lymphadenectomy (FLND) using indocyanine green (ICG) has emerged as a promising technique to enhance the accuracy of lymphadenectomy in rectal cancer surgery. Effective lymphadenectomy is crucial for improving prognosis in patients with advanced rectal cancer, but it remains technically challenging and controversial.

METHODS

This prospective nonrandomized controlled study was conducted involving 129 patients underwent laparoscopic surgery, and 64 patients assisted by FLND. Patients received submucosal ICG injections before surgery to facilitate FLND. Lymph nodes were categorized as station 251, station 252, or station 253 based on their anatomical locations. The effectiveness of FLND was evaluated by comparing the number of harvested and metastatic lymph nodes between the FLND and control groups.

RESULTS

The FLND group demonstrated a significantly higher median number of harvested station 253 lymph nodes compared to the control group (2.0 vs. 1.0, P = 0.007). The FLND cohort had a shorter postoperative hospital stay (6 days vs. 8 days, P < 0.001) and similar rates of postoperative complications compared to the control cohort. The study found no significant differences in the median number of harvested station 251 (10.0 vs. 11.0, P = 0.872) and station 252 (6.0 vs. 5.0, P = 0.369) lymph nodes between the groups. Univariate and multivariate analyses indicated that FLND significantly increased the harvested lymph node count.

CONCLUSION

Radical surgery assisted by FLND significantly improves the accuracy and yield of lymphadenectomy in mid-low rectal cancer, enhancing surgical outcomes and patient prognosis. Future advancements in fluorescence imaging and related technologies hold promise for further improving the clinical effectiveness of this technique.

Association of surgeon volume and operative factors with early thrombosis of arteriovenous fistulas for hemodialysis

OBJECTIVE

Although arteriovenous fistula (AVF) is the ideal initial option for hemodialysis access, failure can occur due to early thrombosis or lack of maturation. Surgeon volume has previously been associated with higher rates of maturation, but the relationship between volume and early thrombosis remains unknown.

METHODS

All adults undergoing cephalic-based AVF between 2014 and 2019 were identified from five safety net hospitals within the Los Angeles County Department of Health Services system. Surgeons were divided into two groups based on whether their 30-day thrombosis rate was below (Group A) or above (Group B) the mean. The relationship between selected operative characteristics and surgeon volume on surgeon early thrombosis rates was analyzed.

RESULTS

Sixteen surgeons performed 828 cephalic-based AVFs. Group A surgeons had lower rates of early thrombosis overall, 3.8% vs 15.4% (P < .001). There were no differences in age, sex, or comorbidities among the patients operated on by Group A and Group B surgeons. Following adjustment, Group A surgeons were more likely to use intraoperative systemic anticoagulation (odds ratio [OR], 8.745; 95% confidence interval [CI], 5.875-13.019; P < .001), have an AVF volume >40 (OR, 2.847; 95% CI, 1.853-4.374; P < .001), and have an operating time >1.5 hours (OR, 2.031; 95% CI, 1.387-2.974; P < .001). However, Group A surgeons had lower odds of utilizing intraoperative antibiotics (OR, 0.261; 95% CI, 0.130-0.544) and general anesthesia (OR, 0.340; 95% CI, 0.175-0.658; P < .001).

CONCLUSIONS

The present analysis identified variability in 30-day AVF thrombosis. Surgeons with low rates of early thrombosis were likely to have a higher case volume, use intraoperative anticoagulation, and have longer operative times.

Safety and outcome of elective synthetic mesh repair for incisional ventral hernias in immunosuppressed patients - a retrospective propensity-score-matched analysis

INTRODUCTION

Incisional hernia remain an important complication after abdominal surgery. Repair often includes use of synthetic mesh, but certain risk factors for complication after mesh hernia repair have been described. Among these, immunosuppression due to co-existing conditions is hypothesized to increase postoperative complications, but data is scarce and contradicting. Therefore, the aim was to assess outcome after mesh hernia repair in immunosuppressed patients.

MATERIAL & METHODS

Patients with and without immunosuppression undergoing elective incisional hernia repair at our clinic between 2010 and 2019 were analyzed in this retrospective study. Pre-existing conditions, details of immunosuppression, postoperative course and outpatient follow-up for hernia recurrence were collected and impact of clinical variables on outcome was analyzed. Propensity score matching was performed for comparison of cohorts.

RESULTS

Immunosuppression was associated with increased postoperative complications in the overall cohort of 732 patients undergoing incisional ventral hernia repair in univariate but not multivariate analysis (p = 0.036 and p = 0.25, respectively). Overall postoperative complications did not differ between patients with immunosuppression compared to the matched collective. However, use of > 2 immune suppressive agents and immunosuppression history > 48 months showed significant impact on postoperative complications in univariate and multivariate analysis (p = 0.003/p = 0.023 and p = 0.018/p = 0.03, respectively). Age (< 60 years), duration of surgery (> 120 min), midline hernia according to EHS classification and number of immunosuppressive agents administered were identified as important risk factors for recurrence in immunocompromised patients (p = 0.045, p = 0.023, p = 0.012 and 0.049, respectively).

CONCLUSION

In this study, overall safety with desirable outcome of mesh implantation in immunosuppressed patients was documented. Furthermore, data suggested significant impact of number of immunosuppressive agents as a predicator of postoperative complications in this collective, possibly enabling risk stratification within this subgroup.

Risk Factors Involved in the Blood (Leukocyte-Depleted Suspended Red Blood Cells and Plasma) Transfusion During Glioma Operations

Background

The use of blood transfusion in surgery is increasing, and the blood supply is getting tighter. The number of glioma surgeries is increasing year by year, and reports of studies on blood transfusion in glioma surgery are relatively rare.

Purpose

To investigate the risk factors for intraoperative blood (leukocyte-depleted suspended red blood cells and plasma) transfusion in glioma patients.

Patients and Methods

We retrospectively analyzed the data of 200 glioma patients who had been operated on in a general teaching hospital in China from January 1, 2018 to March 31, 2022. In terms of whether blood transfusion (leukocyte-depleted suspended red blood cells and plasma) was used intraoperatively, patients were divided into a transfusion group (n=82) and a non-transfusion group (n=118). Multivariate Logistic regression analysis was conducted to identify the risk factors for intraoperative blood transfusion.

Results

The rate of intraoperative transfusion rate in the 200 glioma patients was 41%. Multivariate Logistic regression analysis showed that operation time, intraoperative blood loss ≥500 mL, vascular involvement, and the extent of tumor resection (total resection) were independent risk factors for intraoperative blood transfusion (P<0.05). Patient height was a protective factor against intraoperative blood transfusion (P<0.05).

Conclusion

The risk of intraoperative blood transfusion was higher in glioma patients with longer operation time, more intraoperative blood loss, vascular involvement, and total tumor resection. Clinically, efforts should be made to avoid these transfusion-related risk factors to minimize the risk of blood transfusion in patients.

Operation time as a prognostic indicator on postoperative complications following percutaneous nephrolithotomy

Objective

We aimed to find an optimal cut-off time for percutaneous nephrolithotomy to prevent complications.

Methods

This study enrolled 165 patients aged 18-80 with renal stones ⩾2 cm or ⩾1 cm in lower pole, confirmed via noncontrast computed tomography. Baseline characteristics, stone features, operation time, and anesthesia time were recorded. Logistic regression models were fitted and the ability of the surgery time to predict complications, major complications, and systemic inflammatory response syndrome was evaluated using receiver-operating characteristic curves. Area under the receiver-operating characteristic curve analysis was used as a general indicator of quality.

Results

Out of 165 enrolled patients, 157 were analyzed (8 excluded due to follow-up and surgery data issues). The cohort consisted of 115 males (73.2%) and 42 females (26.7%), with a mean (SD) age of 47.4 (12.65) years. Multivariate analysis indicated that longer operation times and lower body mass index correlated with higher complication rates. A cut-off of 65 min for operation time showed 96.8% specificity for predicting complications. Additionally, 47.8% of patients were systemic inflammatory response syndrome positive postprocedure, and operation times were not shown to be predictive of systemic inflammatory response syndrome.

Conclusion

Operation time seemed to be a potential risk factor for postpercutaneous nephrolithotomy complications and lowering the operation time could prevent postoperative complications.

Bioprinting-By-Design of Hydrogel-Based Biomaterials for In Situ Skin Tissue Engineering

Burns are one of the most common trauma injuries worldwide and have detrimental effects on the entire body. However, the current standard of care is autologous split thickness skin grafts (STSGs), which induces additional injuries to the patient. Therefore, the development of alternative treatments to replace traditional STSGs is critical, and bioprinting could be the future of burn care. Specifically, in situ bioprinting offers several advantages in clinical applications compared to conventional in vitro bioprinting, primarily due to its ability to deposit bioink directly onto the wound. This review provides an in-depth discussion of the aspects involved in in situ bioprinting for skin regeneration, including crosslinking mechanisms, properties of natural and synthetic hydrogel-based bioinks, various in situ bioprinting methods, and the clinical translation of in situ bioprinting. The current limitations of in situ bioprinting is the ideal combination of bioink and printing mechanism to allow multi-material dispensing or to produce well-orchestrated constructs in a timely manner in clinical settings. However, extensive ongoing research is focused on addressing these challenges, and they do not diminish the significant potential of in situ bioprinting for skin regeneration.

Prehabilitation during neoadjuvant therapy in patients with cancer of the upper gastrointestinal tract and rectum-the study protocol

Aims

The concept of prehabilitation, defined as interventions aimed at enhancing a patient's functional capacity prior to an impending physiological stressor, may contribute to reduced postoperative morbidity and mortality. The study's goal is to verify or refute the feasibility of a prehabilitation programme for two diagnostic patient groups during neoadjuvant chemo(radio)therapy, which is prescribed before the scheduled surgical procedure. This is a single group study design, with all patients enrolled receiving the intervention.

Methods

This is an interventional feasibility study of a prehabilitation programme in the form of physical training conducted at home. The training consists of progressively dosed walking and strength exercises for selected muscle groups. Data will be monitored telemetrically and also through telephone contact with participants. Primary outcomes include: the percentage of patients interested in participating in the study out of all patients indicated for neoadjuvant therapy at University Hospital Ostrava during the observed period, the percentage of patients who complete the prehabilitation programme until the date of surgery and individual patient compliance. Secondary outcomes include physical fitness parameters obtained from cardiopulmonary exercise testing, grip strength measured by a dynamometer, changes in body composition, EORTC QLQ-C30 quality of life questionnaire, and a questionnaire on the subjective perception of the exercise programme. Both primary and secondary outcomes will be compared between study arms (two diagnostic groups). The study is registered at ClinicalTrials.gov, ID: NCT05646043.

Conclusion

The results of this study can serve as a foundation for larger, multicentre, controlled studies in the future.

A low-middle income country experience: conventional hysterectomy vs conservative placenta accreta spectrum management

BACKGROUND

Placenta accreta spectrum is one of the most dangerous complications of pregnancy, and its incidence has been rising in recent years. The standard management approach is an elective cesarean-hysterectomy, but it presents with its own set of risks and complications. Although conservative management options exist, there is a lack of definitive guidelines and must be considered on a case-by-case basis.

OBJECTIVE

This study aimed to describe and compare the outcomes (surgical duration, intraoperative blood loss volume, and maternal mortality) of patients with placenta accreta spectrum who were treated with a hysterectomy and those treated with conservative surgery in the Dr. Cipto Mangunkusumo General Hospital, a tertiary referral hospital in Indonesia.

STUDY DESIGN

Data from 271 patients with placenta accreta spectrum at the Dr. Cipto Mangunkusumo General Hospital that were collected over 3.5 years were taken and analyzed in this retrospective cohort study. Data collected included the patients' age, reproductive history, placenta accreta index score, gestational age, emergency status, management method, type of hysterectomy, surgery duration, intraoperative blood loss volume, histopathologic data, and maternal mortality. The data were analyzed using the Statistical Package for Social Sciences, version 29, with statistical significance set at P<.05. Mann-Whitney U tests, independent t tests, chi-square tests, and correlation tests were used where appropriate.

RESULTS

There were no significant differences in the demographics and reproductive history between the hysterectomy and conservative surgery groups. There was considerable difference in terms of surgical duration, intraoperative blood loss, and placenta accreta index score. The hysterectomy group had longer surgeries (median 180 minutes vs 135 minutes; P<.01), greater blood volume lost (median 1000 mL vs 700 mL; P<.01), and higher placenta accreta index scores (median 6.5 vs 5.5; P<.01). The maternal mortality rate of this study was 1.1%, all of whom were patients from the hysterectomy group, but this finding was not statistically significant.

CONCLUSION

In this study, patients who underwent conservative surgical management for placenta accreta spectrum experienced shorter surgeries with less bleeding and no maternal death. These patients typically had lower placenta accreta index scores, which may have influenced the choice of management methods and affected surgical outcomes. Although conservative surgery is a viable option, patients and surgeons must carefully weigh the risks and benefits before deciding on a treatment approach.

A Novel Checklist Approach to Reduce Time Under Anesthesia in Neurosurgery

BACKGROUND

Neurosurgical procedures require meticulous preparation, including extra measures to ensure patient safety and the appropriate setup of the operating room, which must be fully established before the surgeon can initiate the first incision. Neurosurgical delay encompasses the time from anesthesia induction start to when the neurosurgeon makes the first incision.

METHODS

30 neurosurgery procedures were observed randomly. Data were collected at 4 specific time intervals related to the process of 30 neurosurgery procedures in an operating room.

RESULTS

30 random observations show the bottleneck being anesthesia induction complete to the surgeon's first cut which accounts for 50% of times more than the average time (mean 33 minutes, n = 30). Minimizing the duration of anesthesia from anesthesia induction complete to surgeon first cut reduces risks, improves patient care and patient satisfaction, ensures a seamless flow of activities, and minimizes the variability in neurosurgical operating time.

CONCLUSIONS

Operational neurosurgical delays can be improved using sequential checklists by constraining the variability in each phase. The article provides a conceptual novel checklist that provides a modular approach and completion of all steps in a phase reduces the variability of error to the next phase. This approach eventually reduces the patient's time under anesthesia.

MR imaging for preoperative characterization of pelvic adhesions: role in diagnosis and surgical planning

Pelvic adhesions are nonanatomic connections between organs and normal peritoneal surfaces that develop secondary to a maladaptive inflammatory response to tissue insults. Comprised of fibrous tissue, adhesions can result in the distortion of operative dissection planes, which can complicate the establishment of abdominal access in patients undergoing surgery, prolong the length of surgery, and increase the risk of injury to bowel and other structures if involved by extensive adhesive disease. This can adversely impact patient outcomes by increasing the risk of surgical complications including bleeding, infection, and prolonging postoperative length of stay. Literature on the characterization of adhesions with imaging is limited and a systematic framework for evaluating adhesive disease on cross-sectional imaging of the pelvis does not currently exist. In this review, we discuss the MR imaging features of pelvic adhesions, highlighting unique teaching cases in which surgical exploration was significantly complicated by the presence of adhesive disease. We will also review the correlation between MR imaging and intraoperative findings in these cases. A proposed standardized framework for the detection and characterization of adhesions on pelvic MRI will be reviewed with multiple imaging examples. Identification and characterization of pelvic adhesive disease on preoperative imaging provides radiologists with an opportunity to inform the referring clinician of their presence, potentially improving outcomes and the quality of patient care.

Diaphragmatic stripping versus full-thickness diaphragmatic resection in cytoreductive surgery: a meta-analysis of the current evidence

PURPOSE

The primary objective was to compare the intra- and postoperative outcomes of diaphragmatic stripping versus full-thickness diaphragmatic resection in patients with peritoneal carcinomatosis who underwent cytoreductive surgery.

METHODS

According to the PRSIMA guidelines, a comprehensive literature search was conducted for studies comparing postoperative pulmonary complications as well as intra- and postoperative outcomes of diaphragmatic stripping versus full-thickness diaphragmatic resection in patients with peritoneal carcinomatosis necessitating cytoreductive surgery. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios (ORs) and standardized mean differences (SMDs) with 95 per cent confidence intervals were calculated.

RESULTS

Ten studies with 1325 patients were included in this meta-analysis. Diaphragmatic stripping was associated with lower incidence of pleural effusion (OR 0.47, 95% CI 0.35-0.63, p < 0.00001) and pneumothorax (OR 0.52, 95% CI 0.35-0.78, p = 0.002), less severe postoperative complications (Clavien-Dindo Grade ≥ 3) (OR 0.43, 95% CI 0.30-0.63, p < 0.0001), and shorter duration of surgery (SMD -0.31, 95% CI -0.54 - -0.08, p = 0.007). No significant differences were observed in postoperative subdiaphragmatic abscess occurrence, intraoperative blood loss, hospital- and ICU-stay, and 90-day mortality.

CONCLUSIONS

Diaphragmatic stripping leads to a significantly lower rate of postoperative pulmonary and severe complications compared to diaphragmatic full-thickness resection, while oncological outcomes do not appear to be worse. Larger trials with standardized study protocols and long-term survival data are needed to validate the results presented here.

Single-stage intramedullary nailing for patients with multiple concurrent long-bone fractures in a low-resource setting: what factors contribute to prolonged operative duration?

PURPOSE

To investigate the factors that prolonged the operative duration (OD) in patients who underwent single-stage locked intramedullary nailing of their multiple concurrent long-bone fractures (LBFs) using Surgical Implant Generation Network (SIGN) nails.

METHODS

Forty-nine patients who fulfilled the inclusion criteria were enrolled prospectively over 8½ years. Data collected included age, sex, injury mechanism and severity, fracture characteristics, nail types and diameter, OD, fracture-to-fixation time, length of hospital stay (LOS), functional outcomes and complications. Factors associated with prolonged OD were identified using Pearson's chi-square test.

RESULTS

The mean age was 40.6 years. There were 101 fractures of the humerus (8), femur (41) and tibia (52). The median ISS was 14. The mean OD per fracture was 55.8 min. The average LOS was 11 days. A prolonged OD was significantly associated with fracture-to-fixation time > 5 days, fractures with end-segment involvement, fixation with SIGN standard and thinner nails, open reduction, supplemental plating, and antegrade femoral nailing. Radiographic and functional outcomes were satisfactory. Ten patients developed post-operative breathing difficulty warranting oxygen administration. Four fractures were infected. No mortality within the first post-operative year.

CONCLUSION

The study identified fracture fixation beyond five days, end-segment involvement, open reduction, use of standard and thinner nails, supplemental plating, and antegrade femoral nailing as factors that can prolong the OD during single-stage fixation of multiple concurrent LBFs in settings without modern fracture-care equipment. While some of these factors are unmodifiable on certain occasions, bearing them in mind can improve pre-operative planning and intra-operative efficiency to reduce OD.

Clinical Comparison of CAD/CAM vs. KLS L1® Mandible ReconGuide in Fibula Free Flap Mandible Reconstruction: A Retrospective Clinical Study

Introduction: The fibula free flap (FFF) is regarded as the workhorse for lower jaw reconstruction in maxillofacial surgery. Imitating the preexisting shape of the mandible by an FFF while meeting various clinical and geometric aspects can be challenging, even for an experienced surgeon. To enhance the quality and reproducibility of the reconstruction process, several tools are available, mainly based on CAD/CAM techniques and the KLS L1 Mandible ReconGuide. The objective of this study was to examine the clinical use of the KLS L1® Mandible ReconGuide compared to CAD/CAM templates. Material and Methods: In this study, we compared 25 patients who underwent mandibular reconstruction by a FFF with either the KLS L1® Mandible ReconGuide (G1, n = 17) or personalized CAD/CAM-based cutting guides (G2, n = 8). We performed a pre- and postoperative 3D image reconstruction using standard triangle language (STL) to quantify the anatomical results in terms of volume deviations, intercondylar distance, and gonial angle, as well as clinical criteria such as surgery time, function, and postoperative complications. Results: The analysis of pre- and postoperative clinical outcomes in 25 patients revealed no statistically significant differences between the groups. However, it was observed that longer surgery time was group-independent, associated with a 5.63% increase in the length of hospital stays (p = 0.0002). In terms of geometric criteria, the only significant difference referred to the postoperative length of the symphysis, which measured 34.32 mm in G2 versus 34.78 mm in G1 (p = 0.046). Conclusions: Both the KLS L1® Mandible ReconGuide and CAD/CAM templates seem equivalent, effective devices for standardized mandibular reconstruction, with their suitability depending on the specific indications and the segments involved.

Evaluation of Wound Closure Outcomes Using Barbed Delayed Absorbable Polydioxanone Sutures After Emergency Laparotomy: An Observational Study

BACKGROUND AND OBJECTIVES

There is much debate regarding the ideal suture material for the closure of emergency midline laparotomy wounds. The novel barbed delayed absorbable suture is designed to overcome the shortcomings of conventional suture materials. We conducted a study in 140 patients undergoing emergency laparotomy where barbed delayed absorbable suture was used for rectus sheath closure and observed the time taken for closure and the incidence of postoperative complications like surgical site infection, wound dehiscence, suture sinus formation, and incisional hernia.

METHODS

Barbed delayed absorbable (polydioxanone) suture was used for rectus sheath closure of 140 patients undergoing emergency laparotomy using a 4:1 ratio of suture to wound length. Postoperative complications were observed.

RESULTS

Surgical site infection occurred in 40% (56 out of 140) of patients. By postoperative day 8, 70.7% (99 out of 140) of patients had a healthy suture line, 23.6% (33 out of 140) required skin sutures to be opened, and 5.7% (8 out of 140) had burst abdomen. One patient (0.7%) developed suture sinus formation, and five patients (3.6%) were diagnosed with incisional hernia at six months.

INTERPRETATION AND CONCLUSION

Barbed delayed absorbable suture can be used for emergency laparotomy wound closure with satisfactory outcomes. It allows faster wound closure without the need for an assistant.

Using machine and deep learning to predict short-term complications following trigger digit release surgery

Background

Trigger finger is a common disorder of the hand characterized by pain and locking of the digits during flexion or extension. In cases refractory to nonoperative management, surgical release of the A1 pulley can be performed. This study evaluates the ability of machine learning (ML) techniques to predict short-term complications following trigger digit release surgery.

Methods

A retrospective study was conducted using data for trigger digit release from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) years 2005-2020. Outcomes of interest were 30-day complications and 30-day return to the operating room. Three ML algorithms were evaluated - a Random Forest (RF), Elastic-Net Regression (ENet), and Extreme Gradient Boosted Tree (XGBoost), along with a deep learning Neural Network (NN). Feature importance analysis was performed in the highest performing model for each outcome to identify predictors with the greatest contributions.

Results

We included a total of 1209 cases of trigger digit release. The best algorithm for predicting wound complications was the RF, with an AUC of 0.64 ± 0.04. The XGBoost algorithm was best performing for medical complications (AUC: 0.70 ± 0.06) and reoperations (AUC: 0.60 ± 0.07). All three models had performance significantly above the AUC benchmark of 0.50 ± 0.00. On our feature importance analysis, age was distinctively the highest contributing predictor of wound complications.

Conclusions

Machine learning can be successfully used for risk stratification in surgical patients. Moving forwards, it is imperative for hand surgeons to continue evaluating applications of ML in the field.

Post-operative outcomes of talus fracture open reduction internal fixation in patients with diabetes mellitus

Little is known regarding outcomes of talus fracture management among patients with diabetes mellitus. This study aimed to compare post-operative outcomes after open reduction and internal fixation for talus fracture in patients with complicated diabetes, uncomplicated diabetes, and patients without diabetes. We used the PearlDiver database to identify patients who underwent operative repair of talus fractures from 2009 to 2021. Complications were evaluated at 30-days, 90-days, and 1 year of surgery. As we performed multiple separate analyses, to minimize the risk of type 1 error we employed the Bonferroni correction for statistical significance (p< 0.017). The PearlDiver identified 5,232 patients with talus fracture that underwent open reduction internal fixation. Stratified by diabetes status, the "complicated diabetes," "uncomplicated diabetes," and "no diabetes" groups contained 223, 418, and 4591 patients, respectively. Reoperation, acute kidney injury, and myocardial infarction were increased among diabetes patients compared to non-diabetes patients, irrespective of diabetes severity within 3 months of surgery. Furthermore, patients with complicated diabetes were more likely to develop sepsis and wound disruption compared to their non-diabetes counterparts within 3 months. While not statistically significant, complicated diabetes patients were diagnosed with talar non-union at higher rates compared with non-diabetes patients. Further analysis may reveal a clinically significant discrepancy in non-union between these groups. Complicated diabetes is associated with significantly higher risk of multiple adverse events following talus fracture repair.

Patient-Specific Le Fort I Osteotomy Plates Are More Stable than Stock Plates in Patients with Cleft Lip and Palate

BACKGROUND

There is evidence that patient-specific plate fixation for Le Fort I osteotomies (LFI) is more stable than traditional plate fixation. The purpose of this study was to evaluate stability of LFI in patients with cleft lip and palate and determine stability differences between patient-specific and stock plates.

METHODS

Consecutive patients with cleft lip and palate who underwent isolated LFI by one surgeon (B.L.P.) between 2016 and 2021 were included. The predictor variable was type of plate used for fixation (patient-specific or stock). The outcome variable was magnitude of relapse in the vertical (nasion to A point) and horizontal planes (basion to A point) at 1 year after LFI using 3-dimensional cone beam computed tomography. Statistical analysis included independent samples t , Mann-Whitney U , Fisher exact, and chi-square tests. Values of P < 0.05 were significant.

RESULTS

The sample included 63 subjects; 23 in the patient-specific group (36.5%) and 40 in the stock group (63.5%). Groups were comparable by sex, race, age at surgery, cleft type, presence of pharyngeal flap, and magnitude of horizontal movement ( P > 0.136 for all). Subjects who underwent patient-specific plate fixation were less likely to have greater than or equal to 1-mm change at 1 year in the horizontal (4.3% versus 50.0%; P < 0.001) and vertical planes (4.3% versus 65.0%; P < 0.001) compared with stock plates. For patients who had greater than 10-mm horizontal advancement, the patient-specific plates had significantly less relapse (patient-specific plates, 0.105 ± 0.317 mm; stock plates, 1.888 ± 1.125 mm; P = 0.003).

CONCLUSION

Patient-specific plate fixation of LFI is more stable and demonstrates less relapse after 1 year than stock plates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.