The effect of surgical starting time on elective colorectal cancer surgery: A propensity score matching analysis

The purpose of the current study is to analyze whether surgical starting time affects the short-term outcomes of elective colorectal cancer (CRC) surgery. We retrospectively collected CRC patients who underwent elective surgery from Jan 2008 to Jan 2021 in a single clinical center. The effect of surgical starting time (morning surgery vs afternoon surgery, day surgery vs night surgery) on elective CRC surgery was analyzed using propensity score matching (PSM). A total of 6783 patients were included in the current study. There were 5751 patients in day surgery group and 1032 patients in night surgery group, and there were 2920 patients in morning surgery group and 2831 patients in afternoon surgery group. After 1:1 ratio PSM, there were no significant difference in terms of the baseline information (P > .05). Day surgery group had longer operation time (P = .000) and longer hospital stay (P = .029) than night surgery group after PSM. Morning surgery group had longer operation time than afternoon surgery group before PSM (P = .000) and after PSM (P = .000). Univariate and multivariate analysis of the total of 6783 patients were conducted to find predictors of complications, and found that night surgery was a predictor of major complications (P = .002, OR = 1.763, 95% CI = 1.222-2.543) but not a predictor of overall complications (P = .250, OR = 1.096, 95% CI = 0.938-1.282). Night surgery is a predictor of major complications after elective CRC surgery, therefore, surgeons should be careful when operating at night.

Impact of Nighttime Emergency Surgeries on Patients' Outcome: A Prospective Study

Background and Aim:

The aim of this study was to evaluate the relationship between the time of the day the surgery is conducted and its outcome to provide better protection for patients against fatigue-related errors and reduce the incidence of postoperative morbidity/mortality.

Methods:

All general surgical emergency operations recorded prospectively on the operation theater database of Krishna Hospital and Medical Research Centre, Karad, between April 01, 2018, and March 31, 2019, were included in this study. The operations were categorized according to whether they commenced during the daytime (08:01–20:00 h), or nighttime (20:01–08:00 h). The type of procedure and grade of the participating surgical personnel were also recorded.

Results:

In total, 1128 emergency operations were performed over the study period. The number of emergency procedures performed during the daytime and nighttime was 652 (57.8%) and 476 (42.2%), respectively. Laparotomies and complex vascular procedures collectively accounted for half of all the cases performed after midnight, whereas they represented only 30% of the combined daytime emergency workload. Thirty-two percent (n = 152) of all nighttime operations were supervised or performed by a consultant surgeon.

Conclusion:

When considering a surgical procedure, surgeons must bear in mind that cases that start after the routine hours may face an elevated risk of complications that warrants further evaluation and surgical start times are associated with risk-adjusted patient outcomes.

Same-day surgery may reduce the risk of losing pain perception in dogs with thoracolumbar disc extrusion

OBJECTIVES

To compare the proportions of dogs with thoracolumbar disc extrusion that lose pelvic limb pain perception if surgery is performed on the day of admission or delayed overnight. To describe the outcome of those dogs that deteriorate to lose pain perception.

MATERIALS AND METHODS

Retrospective, single centre study on 273 client-owned dogs with thoracolumbar disc extrusion and intact pain perception, but inability to walk unaided on their pelvic limbs. Dogs were subdivided into two groups: early surgery (spinal decompression between their examination at day of admission and the following morning), and delayed surgery (did not undergo surgery between admission and the following morning). The proportion of dogs that lost pelvic limb pain perception overnight was compared between the early and delayed surgery groups.

RESULTS

Seven of 151 dogs in the early surgery group lost pain perception overnight compared to 15 of 122 in the delayed surgery group (Fisher's exact test, P = 0.025). Number-needed-to-treat analysis suggested that 14 dogs (95% confidence interval: 7-106 dogs) need early surgery to prevent one losing pain perception overnight. Five of the seven dogs that lost pain perception in the early surgery group recovered pain perception by 3 weeks post-operatively, compared to eight of 14 in the delayed group.

CLINICAL SIGNIFICANCE

This study suggests that an overnight delay before spinal decompression increases the risk of clinically meaningful deterioration in dogs unable to walk following thoracolumbar disc extrusion.

Outcomes of an acute care surgery model: a 10-year follow-up study

BACKGROUND

Many hospitals across Australia and New Zealand have implemented acute care surgery (ACS) models over the past decade, often with improved outcomes such as reductions in wait time to surgery, complications and length of stay. The aim of this study was to evaluate the outcomes of patients who underwent non-elective appendicectomy and cholecystectomy and compare these with the results observed shortly after the implementation of an ACS model at our institution 10 years earlier.

METHODS

A retrospective review of contemporary patients who underwent non-elective appendicectomy and cholecystectomy compared with historical data was performed. Primary outcomes were wait time to surgery, surgical complications and length of stay.

RESULTS

In the contemporary cohort, 263 patients underwent non-elective appendicectomy over a 1-year period compared with 226 patients in the historical cohort. The median wait time to surgery had increased (17.7 versus 9.6 h, P < 0.001). There was no significant difference in a composite end-point of complications and readmissions (8.0% versus 9.3%, P = 0.61). The length of stay was unchanged. There was greater use of preoperative imaging and reduced overnight operating. For non-elective cholecystectomies, 132 patients underwent this procedure in the contemporary cohort over a 2-year period compared with 115 patients in the historical cohort. There were no significant differences in wait time to surgery (2 versus 1 day, P = 0.13) or complications (9.8% versus 8.7%, P = 0.75). The length of stay was unchanged.

CONCLUSION

The majority of improvements seen shortly following the implementation of an ACS model have been sustained after 10 years.

Retrospective analysis of postoperative interventions in mandibular fractures: a shift towards outpatient day surgery care

The management of fractured mandibles typically involves admission and operation at the time of presentation. While this should involve only a short stay in hospital these patients are surgically stable, and so priority is often given to more urgent cases. We retrospectively evaluated the postoperative medical requirements of patients who were operated on at Fiona Stanley Hospital, Perth, Western Australia between 1 January 2015 and 31 December 2016. Patients were excluded if they had had multiple facial fractures, multiple injuries, had fractures that were comminuted or in edentulous mandibles, and those who had been in hospital for preoperative medical investigations and care. We also excluded fractures in children aged 16 years and under. The results showed that of a total of 173 patients, 12 had had medical consultations during their hospital stay, and only four had required intervention. The mean (range) preoperative time was 37 (1 - 46) hours and that from operation to discharge 21.5 (2 - 93) hours. While traditional management involves emergency admission and open reduction and internal fixation as soon as possible, delays of up to five days were not associated with appreciably worse outcomes. This, together with the negligible requirements for medical management perioperatively, provides a strong argument for a selected group to be treated as outpatients.

Cambridge Polytrauma Pathway: Are we making appropriately guided decisions?

Addenbrooke's Hospital, the Major Trauma Centre for the East of England Trauma Network, received 1070 major trauma patients between 1st January and 31st December 2014. In order to improve care, an audit was performed of 59 patients meeting our own selection criteria for orthopaedic polytrauma between 1st January 2013 and 31st December 2013. The Cambridge Polytrauma Pathway was devised through NCEPOD guidelines, literature review, internal and external discussion. It facilitates provision of best practice Early Appropriate Care, encompassing - multidisciplinary consultant decisions around the patient in our Neurological and Trauma Critical Care Unit, early full body trauma CT scans, serial measurements of lactate and fibrinogen levels, and out-of-hours orthopaedic theatre reserved for life-and-limb threatening injuries. Re-audit was conducted of 15 patients meeting selection criteria, admitted between 1st October 2014 and 31st March 2015. Significant improvements in recording of lactate and fibrinogen were demonstrated, both on admission (lactate - p<0.000, fibrinogen - p=0.015), and preoperatively (lactate - p=0.003, fibrinogen - p=0.030). Time to trauma CT was unchanged (p=0.536) with a median time to CT of 0.53h at re-audit (IQR 0.48-0.75). The number of patients receiving definitive orthopaedic intervention out-of-hours reduced from 8 to zero (p=0.195). The approach of facilitating management decisions to be made at early daytime MDT meetings has been adopted. It is anticipated that this pathway will improve outcomes in orthopaedic polytrauma patients and it is recommended that either the GOS-E, or the EQ-5D scoring systems be introduced to assess this.

Day and night surgery: is there any influence in the patient postoperative period of urgent colorectal intervention?

BACKGROUND

Medical activity performed outside regular work hours may increase risk for patients and professionals. There is few data with respect to urgent colorectal surgery. The aim of this work was to evaluate the impact of daytime versus nighttime surgery on postoperative period of patients with acute colorectal disease.

METHODS

A retrospective study was conducted in a sample of patients with acute colorectal disease who underwent urgent surgery at the General Surgery Unit of Braga Hospital, between January 2005 and March 2013. Patients were stratified by operative time of day into a daytime group (surgery between 8:00 and 20:59) and the nighttime group (21:00-7:59) and compared for clinical and surgical parameters. A questionnaire was distributed to surgeons, covering aspects related to the practice of urgent colorectal surgery and fatigue.

RESULTS

A total of 330 patients were included, with 214 (64.8%) in the daytime group and 116 (35.2%) in the nighttime group. Colorectal cancer was the most frequent pathology. Waiting time (p < 0.001) and total length of hospital stay (p = 0.008) were significantly longer in the daytime group. There were no significant differences with respect to early or late complications. However, 100% of surgeons reported that they are less proficient during nighttime.

CONCLUSIONS

Among patients with acute colorectal disease subjected to urgent surgery, there was no significant association between nighttime surgery and the presence of postoperative medical and surgical morbidities. Patients who were subjected to daytime surgery had longer length of stay at the hospital.