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Aim: To determine the intraoperative Ramsay sedation score after dexmedetomidine infusion in patients undergoing perineal surgery. Study design: Descriptive study. Place and duration of study: Department of Anaesthesia, JPMC, Karachi from 13th February 2021 to 13th August 2021. Methodology: One hundred and seventy four patients who met the diagnostic criteria were enrolled. Result(s): The mean age was 46.51 years with the standard deviation of +/-10.87. 66 (37.9%) were male and 108 (62.1%) were female. Whereas, mean duration of surgery, Ramsay sedation score at 5 minutes, 15 minutes, 30 minutes, height, weight and BMI in our study was 1.41+/-0.40 hours, 1.72+/-0.44, 3.51+/-0.60, 4.57+/-0.62, 165.62+/-8.23 cm, 68.34+/-8.23 kg and 24.85+/-3.34 kg/m2 respectively. Conclusion(s): Intraoperative dexmedetomidine proved beneficial in perineal surgeries and could be served as a potent sedative drug.Copyright © 2023 Lahore Medical And Dental College. All rights reserved.
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Introduction: Coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) has caused a global health crisis. Initially considered a respiratory tract pathogen, it can cause multiple organ dysfunction. It has also been described to predispose to venous and arterial thromboembolism;however, limited published data is available regarding mesenteric thrombosis COVID-19. Clinicians should be aware of the life-threatening situation in COVID-19 patients. Method(s): A case series analysis of 9 patients admitted and managed under department of operation over a duration of 13 months from September 2020 to September 2021 Results: Out of the total of 9 cases of intestinal ischemia, 3 were COVID-19 positive (rapid antigen, RT PCR or CORADS 4 or higher), overall mortality being 55.5% and patients with COVID- 19 were found to have 100% mortality in the study. Mortality in conservatively managed patients was 100%, Mortality in surgically managed patients was 42.8%. Pre operative acidosis, hypoxia and hypotension were found to be important determinants of outcome of the disease. Conclusion(s): Treatment of COVID - 19 and intestinal Ischemia should go simultaneously and in line with the latest evidence based guidelines of COVID 19, Patients who survive an acute event are likely to die of other complications related to the COVID-19 like ARDS, Disseminated Intravascular Coagulation etc that could have predisposed them to intestinal ischemia. Perioperative acidosis, hypoxia and hypotension are important determinants of the outcome of the course of the disease.
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Aim: While recent evidence describes atypical outcomes of coronavirus disease 2019 (COVID-19) in elderly patients, the frequency of delirium and associated outcomes in elderly patients with COVID-19 (coronavirus disease 2019) infection undergoing emergency surgery are not well defined. This study aims to determine the effect of COVID-19 on postoperative delirium and postoperative death in elderly patients undergoing emergency surgery. Material(s) and Method(s): This descriptive and cross-sectional study was conducted in general surgery, orthopedics, and cardiovascular surgery clinics of a public hospital, including 30 days of follow-up between April 1 and May 1, 2021. All patients who were admitted to these clinics for emergency surgery intervention on these dates constituted the study population, while a total of 140 patients aged >=65 years, who met the study criteria, formed the sample of the study. Descriptive Characteristics Form and Nursing Delirium Screening Scale (Nu-DESC) were used as data collection tools in the study. SPSS 25.0 statistical program was used for data analysis. Result(s): Thirty (42.85%) of the SARS-CoV-2 positive (n=70) patients developed delirium in the study. 12.9% (n=18) of the patients died within 30 days of follow-up after surgery. There were 30 (69.8) of 70 SARS-CoV-2 positive patients who developed delirium, and 12 patients (25.5) died after testing positive for COVID-19, with a mean of 8.08T1.56 days within 30 days of admission. Discussion(s): These findings may lead to a poor clinical prognosis for COVID-19 infection delirium and postoperative death in patients over 65 years of age undergoing emergency surgery.Copyright © 2023, Derman Medical Publishing. All rights reserved.
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Background: Indirect calorimetry (IC) is the gold-standard procedure for measuring resting energy expenditure (REE) in hospitalized patients. Predictive energy equations commonly use static variables and rarely account for changes in REE throughout hospitalization. We hypothesize that predictive equations are typically inaccurate in surgical intensive care unit (ICU) patients. More specifically, we hypothesize that predictive equations often overpredict measured resting energy expenditure (mREE) in early-stage critical illness and underpredict needs later in surgical ICU stay, leading to over-/under-feeding and associated complications. Method(s): This prospective observational trial enrolled surgical ICU patients who underwent emergent or urgent operations for abdominal trauma, perforated viscus, or ischemic bowel within 72 hours of their surgical procedure. Metabolic assessments were performed using the COSMED Q-NRG + Metabolic Monitor ventilator, mask, and canopy at regular intervals during and post ICU admission until hospital discharge. Measurements were categorized by post-surgical intervention ICU admission days 0-3, 4-7, 8-14, 15-21, and 22-28. Patients with multiple measurements taken during the same time interval were averaged. mREE reported in calories (kcal) per kilogram (kg) of admission body weight per day were compared in obese (BMI > 30 kg/m2) and non-obese (BMI < 30 kg/m2) subgroups. Compared to IC, the Mifflin St Jeor (MSJ) equation determined predicted REE using ICU admission anthropometrics. Data are reported as mean+/-standard error of the mean (SEM) and median (interquartile range), and a two-sided p-value of <0.05 was determined significant. Result(s): In total, 18 surgical ICU patients who contributed 47 IC measurements were included in the analysis (Table 1). Most measures were obtained within the first 7 days of post-surgical ICU admission (72%). mREE peaked between days 8-14 in obese and non-obese subgroups (20.6 vs 28.5 kcal/kg;p = 0.02) and was lowest during 0-3 days of post-surgical ICU admission in both groups. Across all 5-time intervals, average kcal/ kg ranged from 14.7-20.6 among obese patients and from 20.1-28.5 in non-obese counterparts (Table 2). Non-obese patients had higher mREE per kg of body weight than obese patients at all time points (Figure 1). MSJ over-predicted mREE during the first 7 days post ICU admission in non-obese patients and within the first 3 days in obese patients and underpredicted mREE in both groups thereafter. Conclusion(s): Equations such as MSJ over- and under-predict mREE in post-operative surgical ICU patients depending on the days elapsed since post-surgical ICU admission. ASPEN's current guideline recommendation of 12-25 kcal/kg may also underfeed post-surgical populations while 25 kcal/kg may not support hypermetabolism among non-obese patients seen in week 2 following post-surgical ICU admission. Alternatively, MSJ multiplied by a 1.2 activity factor may account for hypermetabolism during this time. Notably, non-obese patients experienced greater hypermetabolism than obese patients during week 2 which is consistent with our previously published data in mechanically ventilated COVID- 19 patients. Additionally, the striking dichotomy between the mREE of obese and non-obese patients at all post-surgical time points should be considered in the clinical care of patients. Ultimately, IC remains the gold-standard means of measuring REE and is a critical tool to capture the dynamic nature of energy requirements in post-surgical populations as weight-based and predictive equations continually fall short. (Table Presented).
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INTRODUCTION AND OBJECTIVE: Research demonstrates the benefits of robotic-assisted prostatectomies (RARP) in regard to blood loss and post-operative recovery, there is a paucity in the literature regarding RARP as an outpatient procedure. With minimal operating room capacity during COVID-19, advances in minimally invasive surgical techniques and a relatively healthy patient population, outpatient RARP may be feasible. The aim of our study was to demonstrate the safety and feasibility of RARP as a same day outpatient procedure. METHOD(S): A retrospective cohort study at a single institution was performed by four fellowship trained surgeons who routinely perform RARP. Patients were identified through billing records who underwent RARP between January 2019 and December 2021. Patients were divided into two cohorts, inpatient (one stay past midnight) and outpatient (defined as same day surgery with no stay past midnight). Individual surgeons admission necessity during COVID-19 limitations. We then extracted data using the electronic health record (EHR). The two groups were then compared using standard statistical methods for cohort studies. Statistical significance was defined as p<0.05. RESULT(S): Over a two-year period, a total of 497 RARP were performed with 139 (28%) outpatient cases. There was no difference in baseline demographics between the cohorts. There was a statistically significant difference in estimated blood loss (142 vs 102 mLs, p>=0.001) and operative time (193 vs 180 mins, p=0.004) in the inpatient vs outpatient cohorts, respectively. There was no significant difference in cancer stage, prostate size, or node/margin positivity between cohorts. There was a higher rate of readmissions (5% vs 0%, p=0.007) and number of ED presentations (0.15 vs 0.05, p=0.019) in the inpatient group. There was no difference in complication rates between the groups. Importantly, there was no significant difference in burden on the clinical staff demonstrated by no difference in number of phone calls to clinic, number of EHR messages, or opioid prescriptions on discharge. CONCLUSION(S): Overall, our data suggests that in a well selected patient group, RARP can safely be performed as an outpatient procedure with no significant differences on clinic staff workload or oncologic outcomes. While there was no pre-defined "algorithm" to determine outpatient vs inpatient surgery, the similarity in demographics and pre-operative characteristics between the groups lends support to performing this procedure as an outpatient with inpatient admission being reserved for select patients.
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Introduction: Prior to 2021, impalpable tumours in our unit were localised with Somatex wires. During the COVID pandemic we introduced Magseed due to its logistical advantages in allowing surgery on a site distant from our breast unit. We wanted to ensure our clinical outcomes with this new system were equivalent to those using wire localisation. Method(s): Electronic records for the first 50 consecutive Magseed localised wide local excisions and the preceding 50 consecutive wire localised wide local excisions were compared. Excision biopsies, palpable lesions, bracketed lesions and post neoadjuvant treatment patients were excluded. Patient demographics, tumour size, inadequate radial margin involvement rate, reoperation rate for margins, specimen weight, number of cavity shaves and operative time were recorded. [Formula presented] Results: Results are shown in table 1. There were no preoperative differences in the two groups. There were no significant differences in outcomes between the two groups, with a trend towards lower margin involvement rates but more shaves in the Magseed group. The mean operative time was slightly shorter in the Magseed group despite more axillary procedures being performed in this group. Conclusion(s): The change to the Magseed system led to logistical advantages with patient outcomes at least equivalent to wire guided excision.Copyright © 2023
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Background: Hospitals are one of the primary resources for disease transmission, so many guidelines were published, and neuro-surgeons were advised to postpone elective spine surgeries during the COVID-19 pandemic. Objective(s): To avoid pulmonary complications and reduce the risk of spreading the virus and contracting the disease during the COVID-19 era, we operated a group of our patients under spinal anesthesia rather than general anesthesia. Method(s): We retrospectively analyzed all patients who underwent discectomy surgery for lumbar spinal disc herniation under SA between September 2020 and 2021. Result(s): Sixty-four patients diagnosed with lumbar disc herniation underwent lumbar discectomy with SA. All patients except three were male. The mean age was 44.52 +/- 7.95 years (28 to 64 years). The mean procedure time for SA was 10 minutes. The duration of the surgery was 40 to 90 minutes per each level of disc herniation. The mean blood loss was 350 cc (200 to 600 cc). The most common involved level was L4/L5 intervertebral disc (n = 40 patients;63.5%). The mean recovery time was 20 minutes. Only three patients requested more analgesics for relief of their pain postoperatively. All patients with discectomy were discharged a day after surgery, and in the case of fusion, two days after surgery. All the patients were followed up for six months, showing no recurrence symptoms, good pain relief, satisfaction with the surgery, and no bad memory of the surgery. Conclusion(s): Spinal anesthesia is a good alternative or even the main anesthesia route for patients with lumbar disc herniation. More studies are needed to elucidate the best candidate for SA in patients with lumbar pathology.Copyright © 2023, Author(s).
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INTRODUCTION AND OBJECTIVE: Contemporary rates of burnout amongst urologists are reported to be 60-80%. These rates have significant implications on physician well-being and retention. We investigated predictors of burnout in female surgeons. METHOD(S): An electronic census survey was distributed to residents, fellows and practicing urologists by the Society of Women in Urology in the United States and territories via email and social media between February and May 2022. We assessed participant demographics, personal and professional characteristics, practice environment, compensation, and burnout with chi-square and t-test analyses. RESULT(S): There were 379 survey participants with an average age of 42 years (SD 10). A majority identified as cis-gendered heterosexual females (96%) and were practicing urologists (74%), while 10% were fellows and 15% residents/interns. Average reported time in practice was 9 years (SD 9 years). Most respondents reported burnout (273, 72%), with 87% agreeing COVID worsened burnout in the community. Those reporting burnout worked an average of 58 (SD 15) hours per week versus 49 (SD 18) hours (p<0.00001). Table 1 demonstrates significant personal and professional characteristics for participants who reported burnout. On multivariable logistic regression analysis, increased hours worked per week (OR 1.03, p=0.002), Relative Value Unit based pay versus salary (OR 4.4, p=0.007), correlated to burnout and feeling income is comparable to peers (OR 0.4, p=0.03) was inversely related. Common shared experiences included lack of staffing, reduced operating room time, lack of administrative support, predominance of non-operative referrals, gender and racial inequity or microaggressions, electronic health records with increased documentation demands, increased non-clinical administrative duties, and insufficient compensation or lack of financial advancement. CONCLUSION(S): A majority of women in urology report burnout with work-hours and compensation inequity as leading contributing factors. Concerns raised in this study such as lack of support staff, racial and gender inequity, and poor referral patterns should be further evaluated to determine a comprehensive plan to reduce burnout. (Figure Presented).
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INTRODUCTION AND OBJECTIVE: In 2016 we began offering optional same-day discharge (SDD) to all robotic prostatectomy (RP) patients with increasing acceptance that accelerated during the COVID pandemic. Our resulting 98% SDD rate for RP after COVID facilitated initiation of an ambulatory surgery center (ASC) robotic urology program without overnight capability and planned SDD in all patients. We assessed our outcomes with planned outpatient RP in all patients in both the hospital and ASC settings. METHOD(S): We reviewed one year of consecutive RPs performed by a single surgeon at either a free-standing ASC or one of three hospitals between October 2021-October 2022. Pelvic lymphadenectomy was performed in all patients. Assignment to ASC versus hospital RP was based primarily on insurance eligibility. ASC policy for robotic or non-robotic procedures alike excluded history of severe cardiac disease, difficult airway, malignant hyperthermia, or BMI >45kg/m2 with no additional limitations applied to robotic surgery. All patients were instructed to expect same-day discharge (SDD) directly from the recovery room regardless of ASC or hospital location with overnight stay only for unexpected complications or side effects of anesthesia. RESULT(S): Among 359 RP cases (162 ASC and 197 hospital), 356 (99%) were successfully discharged the same day as surgery with 3 overnight stays in the hospital group and none in the ASC group. Patients in the ASC group were younger (61.4yrs vs 67.1yrs, p<001) with no statistically-significant difference in BMI (29.2 kg/m2 vs 29.3 kg/ m2, p=0.3), preoperative Gleason Score (p=0.1), operative time (131min vs 134min, p=0.2) or blood loss (87.5cc vs 84.8cc, p=0.71). Excluding the three overnight patients in the hospital group, the mean postoperative recovery room stay among SDD patients was shorter in the ASC group (1.7hrs vs 2.3hrs, p<0.0001). The 90-day readmission rate was 2.5% in both groups (4/162 and 5/197, p=0.93). No readmissions occurred within 24 hours of surgery and only one within the first week. CONCLUSION(S): Same day discharge as a routine following robotic prostatectomy is feasible and safe with readmission rates no higher than series with overnight stays. SDD may enable ASC RP when overnight stay capabilities are not available at an ASC with minimal risk of need for hospital transfer.
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Background: There have been numerous techniques used in laparoscopic appendectomy (LA) to divide the mesoappendix, including LigaSure, Harmonic scalpel, clips, endoloop ligatures, Endo GIA staplers, and bipolar coagulation. However, few studies have investigated monopolar diathermy for mesoappendix division. Therefore, this study aimed to assess both its safety and efficacy in LA. Method(s): In this prospective non-randomized study, patients (n = 87) who underwent LA for acute appendicitis were included. The bipolar electrocautery was used for mesoappendix division in the first 33 patients (BC group), while the monopolar electrocautery was used in the next 54 patients (MC group). Result(s): The median operative time was significantly shorter in the MC group (42 min. vs 47 min. in BE group, p = 0.01). One patient converted to open surgery in the MC group due to uncontrollable bleeding. There were no significant differences between both groups regarding postoperative complications and hospital stay (p = 0.91, p = 0.13, respectively). Conclusion(s): Monopolar electrocautery is safe and effective for mesoappendix division in LP in comparison to bipolar electrocautery. However, larger and multicentric studies are required to validate our results.Copyright © 2023 The Authors
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Introduction & Objectives: The frequency of involvement in the oncological process of the ureters in case of pelvis tumors ranges from 15 to 20%. The use of the appendix as a plastic material for the reconstruction of extended ureteral defects (EUD), including left-sided ones, remains debatable. The main goal of this study is evaluating the clinical and functional results after EUD repair using patchy transposition of the appendix. Material(s) and Method(s): Since August 2019 to June 2021, 8 laparoscopic surgeries were performed to replace the EUD using flap transposition of the appendix. Of these, 6 on the left (75%), 2 on the right (25%). 7 women (87.5%) and 1 man (12.5%) were operated on. Mean age 53+/-10.6 years. Average BMI 25.9 kg/m2. Etiology EUD: 25% radiotherapy (n2), 50% iatrogenic surgery (n4), 12.5% (n1) primary ureteral cancer, 12.5% (n1) non-Hodgkin's lymphoma. In all cases, the first stage was a wide mobilization of the ileocecal angle, the appendix was disconnected with a 45 mm hardware suture, in case of left-sided lesion, the appendix was moved isoperistaltically under the mesentery of the sigmoid colon to the left side after preliminary maximum mobilization of the process on the vascular pedicle in the form of a "triangle". All patients received a 7Fr ureteral stent. CT urography was performed on the 3rd, 7th, 11th days. Dynamic nephroscintigraphy was performed on the 90th day. Result(s): The average length of diastasis is 4.6+/-1.7 cm. The average length of the mobilized appendix was 8+/-1.8 cm. Replacement of the ureter with an appendix and a flap of the bladder according to the Demel method was performed in 1 case (12.5%), according to the Boari method in 1 case (12.5%), in 6 (75%) cases an anastomosis was formed according to the "end-to-end" type. the end". The average duration of the operation was 251+/-40.9 min, blood loss was 121+/-56.7 ml. Median removal of the ureteral stent was 36+/-18.28 days. Duration of hospital stay was 14+/-5.2 days. Median follow-up 10+/-5.3 months. Early complications (<30 days): 2 cases of urinary edema (Clavien-Dindo II), 2 cases of ipsilateral hydronephrosis (Clavien-Dindo I-II). Late complications (>30 days): 1 case of partial failure of ureterocystoanastomosis against the background of Sars-Cov-2 infection (Clavien-Dindo IIIa), 1 case of non-functioning left kidney (Clavien-Dindo IVa). Dynamic nephroscintigraphy was performed in 68.4% of patients, the average isotope accumulation time was 4.23+/-0.25 minutes, the duration of the half-life was 14.26+/-0.52 minutes. Conclusion(s): Flap transposition with the appendix is a technically difficult but possible option for extended ureteral strictures. However, various pathological processes that have developed against the background of previous treatment potentially increase the risk of developing repeated strictures or anastomotic leaks. Therefore, given the small sample of patients, further research on this issue is required.Copyright © 2023.
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Male and female sterilisation are important forms of contraception worldwide despite declining popularity in developed countries and limited access during the Covid-19 global pandemic. Vasectomy is the only highly reliable form of male contraception. Appropriate counselling about permanent methods of contraception in both sexes is vital and should include information about irreversibility, failure rates and complications. The alternatives to sterilisation, particularly long-acting reversible contraception (LARC), should be discussed in detail as they are at least as effective and have the advantage of reversibility. Hysteroscopic techniques for female sterilisation are no longer available. In males the no-scalpel technique vasectomy requires minimal operating time and results in less post-operative discomfort than the incisional method. Regret after sterilisation and requests for reversal are more common in patients under 30 years and in men with no children.Copyright © 2023
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Introduction & Objectives: Holmium laser enucleation of the prostate (HoLEP) has the strongest evidence base for bladder outlet surgery, despite its steep learning curve. Rapid enucleation rates can be achieved in established hands with day-case surgery being the norm in service delivery. We have previously shown the validity of such a model. With the post Covid surgical backlog we have developed a tool to support theatre utilization based on established surgeon specific operating room (OR) times for a given prostate volume in our unit based on almost 1100 cases. Material(s) and Method(s): Four HoLEP naive surgeons completed 1096 HoLEPs over 7.5 years using a 50 Watt (W) Holmium laser (Auriga XL, Boston Scientific Inc., Piranha morcellator, Richard Wolf). Pre and post-operative data including TRUS/MRI volume, flow rate, residual volume, international prostate symptom score, quality of life, stop-clock enucleation, morcellation and total operating room (OR) times, hospital stay, histology, haemoglobin, creatinine, sodium and catheter times were prospectively recorded. Mentorship was provided by a senior 100W HoLEP surgeon from an adjoining hospital. Result(s): The data was independently analysed by a bio-statistician (IN). Statistical regression analysis of unit and surgeon specific OR times vs prostate volume were used to produce predictive linear graphs of OR times (mins) for a given prostate volume for individual surgeons and the unit. [Figure presented] Conclusion(s): Use of surgeon-specific and unit specific OR times allows the opportunity to maximize theatre operating schedules to help tackle the post Covid surgical backlog. We encourage this process for index specialist procedures across units.Copyright © 2023 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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Objective: To investigate the clinical evaluation effects of Corona Virus Disease 2019 (COVID-19) risk assessment scale on preoperative and surgical risk of liver transplantation during the COVID-19 outbreak. Method(s): The retrospective and descriptive study was conducted. The clinicopathological data of 6 liver transplant recipients who were admitted to Southern Theater Command General Hospital of PLA between January 20 and March 27, 2020 were collected. There were 5 males and 1 female, aged from 42.0 to 62.0 years, with a median age of 53.0 years. There were 6 donors including 5 males and 1 female, aged from 24.0 to 60.0 years, with a median age of 41.5 years. All the donor livers were obtained through the China Organ Transplant Response System. Liver transplantation was performed in the fixed negative pressure operating room, and secondary protective measures were adopted for low-risk donors. Classic orthotopic liver transplantation or Piggyback liver transplantation was performed according to the specific situations of the recipients. Medical staffs in the ward were exposed to the secondary protective measures, and the three-grade protective measures were adopted for medical staffs when the liver transplant recipients had fever or suspected infection. Observation indicators: (1) risk assessment of COVID-19 on liver transplant recipients;(2) risk assessment of COVID-19 on medical staffs of liver transplantation;(3) treatment situations of liver transplant recipients;(4) postoperative situations of liver transplant recipients;(5) follow-up of liver transplant recipients;(6) infection of medical staffs of liver transplantation. Follow-up was performed using outpatient examination or telephone interview to detect whether liver transplant recipients had suspected or confirmed COVID-19 infection up to March 2020. Medical staffs who were involved in organ acquisition, transplantation surgery and ward management were followed up to detect whether they had suspected or confirmed COVID-19 infection within 14 days. Measurement data with normal distribution were represented as Mean+/-SD, and measurement data with skewed distribution were described as M (range). Count data were expressed as absolute numbers. Result(s): (1) Risk assessment of COVID-19 on liver transplant recipients: all the 6 recipients and their related families were confirmed no contact with suspected COVID-19 patients or travel history in the epidemic area within 14 days. Of the 6 recipients, 1 was diagnosed with fever with body temperature of 38.1 and was tested negative for chest computer tomography (CT) examination and nucleic acid test for COVID-19;1 was diagnosed with fever and hypoxemia with body temperature of 38.5 and was tested negative for nucleic acid test for COVID-19, and the results of chest CT examination showed large amount of pleural effusion in both lungs without invasive pneumonia;other 4 recipients had no clinical symptoms of COVID-19 with negative results of chest CT examination and nucleic acid test for COVID-19. Five of the 6 recipients had no history of contact with COVID-19 patients and 1 recipient had treatment history at hospital of risk level 1. The preoperative risk level of COVID-19 was low in all the 6 liver transplant recipients. (2) Risk assessment of COVID-19 on medical staffs of liver transplantation: of the 6 recipients, 5 had the waiting hospital of risk level 0 and 1 had the waiting hospital of risk level 1. Six recipients had the transplant hospital of risk level 0. (3) Treatment situations of liver transplant recipients: of the 6 recipients, 2 underwent classic orthotopic liver transplantation and 4 underwent piggyback liver transplantation. The cold ischemia time of liver, time of anhepatic phase, volume of intraoperative blood loss, operation time, treatment time at intensive care unit of the 6 recipients were (5.9+/-2.4)hours, (49+/-14)minutes, 1 500 mL(range, 800-1 800 mL), (8.9+/-2.1)hours, 2 days(range, 1-4 days), respectively. Of the 6 recipients, 2 required adjustment of the immunosuppression progr m, and 4 did not change the immunosuppression program. (4) Postoperative situations of liver transplant recipients: of the 6 recipients, 5 had no postoperative serious infection and 1 had postoperative serious infection. The 5 recipients without postoperative serious infection had the range of the highest temperature as 37.8-38.5 , and returned to normal temperature within postoperative 3 days. All of the 5 recipients who had no postoperative serious infection received chest CT examination with no obvious manifestation of viral pneumonia and were tested negative for nucleic acid test for COVID-19 at 1 week postoperatively, and then were discharged from hospital. One recipient who had postoperative serious infection had gastrointestinal fistula and repeated fever at postoperative 7 days with the highest temperature as 39.2 . This recipient had body temperature returned to normal and good function of the graft after treatment in the isolation ward with active drainage, and was transferred back to local hospital for further rehabilitation treatment. The duration of hospital stay of the 6 recipients were 30 days(range, 15-74 days). (5) Follow-up of liver transplant recipients: all the 6 recipients were followed up for 31.5 days(range, 12.0-64.0 days) with the normal body temperature, and they had negative results of viral pneumonia for chest CT examination and nucleic acid test for COVID-19. (6) Infection of medical staffs of liver transplantation: surgeons, nurses, anesthetists, medical staffs at ICU and medical staffs at liver transplantation center who participated in liver transplantation had good health within postoperative 14 days, without suspected or confirmed cases of COVID-19 infection. Conclusion(s): The COVID-19 risk assessment scale has good safety for liver transplant recipients during the COVID-19 outbreak. It is suggested that organ transplantation can be carried out in low-risk recipients and cautiously carried out in recipients of uncertain risk, but organ transplantation should not be carried out in high-risk recipients.Copyright © 2020 by the Chinese Medical Association.
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Objective: To investigate the clinical evaluation effects of Corona Virus Disease 2019 (COVID-19) risk assessment scale on preoperative and surgical risk of liver transplantation during the COVID-19 outbreak. Method(s): The retrospective and descriptive study was conducted. The clinicopathological data of 6 liver transplant recipients who were admitted to Southern Theater Command General Hospital of PLA between January 20 and March 27, 2020 were collected. There were 5 males and 1 female, aged from 42.0 to 62.0 years, with a median age of 53.0 years. There were 6 donors including 5 males and 1 female, aged from 24.0 to 60.0 years, with a median age of 41.5 years. All the donor livers were obtained through the China Organ Transplant Response System. Liver transplantation was performed in the fixed negative pressure operating room, and secondary protective measures were adopted for low-risk donors. Classic orthotopic liver transplantation or Piggyback liver transplantation was performed according to the specific situations of the recipients. Medical staffs in the ward were exposed to the secondary protective measures, and the three-grade protective measures were adopted for medical staffs when the liver transplant recipients had fever or suspected infection. Observation indicators: (1) risk assessment of COVID-19 on liver transplant recipients;(2) risk assessment of COVID-19 on medical staffs of liver transplantation;(3) treatment situations of liver transplant recipients;(4) postoperative situations of liver transplant recipients;(5) follow-up of liver transplant recipients;(6) infection of medical staffs of liver transplantation. Follow-up was performed using outpatient examination or telephone interview to detect whether liver transplant recipients had suspected or confirmed COVID-19 infection up to March 2020. Medical staffs who were involved in organ acquisition, transplantation surgery and ward management were followed up to detect whether they had suspected or confirmed COVID-19 infection within 14 days. Measurement data with normal distribution were represented as Mean+/-SD, and measurement data with skewed distribution were described as M (range). Count data were expressed as absolute numbers. Result(s): (1) Risk assessment of COVID-19 on liver transplant recipients: all the 6 recipients and their related families were confirmed no contact with suspected COVID-19 patients or travel history in the epidemic area within 14 days. Of the 6 recipients, 1 was diagnosed with fever with body temperature of 38.1 and was tested negative for chest computer tomography (CT) examination and nucleic acid test for COVID-19;1 was diagnosed with fever and hypoxemia with body temperature of 38.5 and was tested negative for nucleic acid test for COVID-19, and the results of chest CT examination showed large amount of pleural effusion in both lungs without invasive pneumonia;other 4 recipients had no clinical symptoms of COVID-19 with negative results of chest CT examination and nucleic acid test for COVID-19. Five of the 6 recipients had no history of contact with COVID-19 patients and 1 recipient had treatment history at hospital of risk level 1. The preoperative risk level of COVID-19 was low in all the 6 liver transplant recipients. (2) Risk assessment of COVID-19 on medical staffs of liver transplantation: of the 6 recipients, 5 had the waiting hospital of risk level 0 and 1 had the waiting hospital of risk level 1. Six recipients had the transplant hospital of risk level 0. (3) Treatment situations of liver transplant recipients: of the 6 recipients, 2 underwent classic orthotopic liver transplantation and 4 underwent piggyback liver transplantation. The cold ischemia time of liver, time of anhepatic phase, volume of intraoperative blood loss, operation time, treatment time at intensive care unit of the 6 recipients were (5.9+/-2.4)hours, (49+/-14)minutes, 1 500 mL(range, 800-1 800 mL), (8.9+/-2.1)hours, 2 days(range, 1-4 days), respectively. Of the 6 recipients, 2 required adjustment of the immunosuppression progr m, and 4 did not change the immunosuppression program. (4) Postoperative situations of liver transplant recipients: of the 6 recipients, 5 had no postoperative serious infection and 1 had postoperative serious infection. The 5 recipients without postoperative serious infection had the range of the highest temperature as 37.8-38.5 , and returned to normal temperature within postoperative 3 days. All of the 5 recipients who had no postoperative serious infection received chest CT examination with no obvious manifestation of viral pneumonia and were tested negative for nucleic acid test for COVID-19 at 1 week postoperatively, and then were discharged from hospital. One recipient who had postoperative serious infection had gastrointestinal fistula and repeated fever at postoperative 7 days with the highest temperature as 39.2 . This recipient had body temperature returned to normal and good function of the graft after treatment in the isolation ward with active drainage, and was transferred back to local hospital for further rehabilitation treatment. The duration of hospital stay of the 6 recipients were 30 days(range, 15-74 days). (5) Follow-up of liver transplant recipients: all the 6 recipients were followed up for 31.5 days(range, 12.0-64.0 days) with the normal body temperature, and they had negative results of viral pneumonia for chest CT examination and nucleic acid test for COVID-19. (6) Infection of medical staffs of liver transplantation: surgeons, nurses, anesthetists, medical staffs at ICU and medical staffs at liver transplantation center who participated in liver transplantation had good health within postoperative 14 days, without suspected or confirmed cases of COVID-19 infection. Conclusion(s): The COVID-19 risk assessment scale has good safety for liver transplant recipients during the COVID-19 outbreak. It is suggested that organ transplantation can be carried out in low-risk recipients and cautiously carried out in recipients of uncertain risk, but organ transplantation should not be carried out in high-risk recipients.Copyright © 2020 by the Chinese Medical Association.
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Background: Adolescent pregnancy is a worldwide public health issue, and the intrauterine device (IUD) has been shown to be a safe and highly effective method of long-acting reversible contraception (LARC) in this group. Patient concerns regarding IUDs are common, which should be addressed during routine office visits. Recently, both Pediatric and Gynecologic societies have recommended the IUD as a first line contraceptive for adolescents given their safety and efficacy. We are hoping to understand current IUD practices amongst providers, elucidate barriers to IUD insertion, and explore whether there have been any changes in IUD insertion patterns since the advent of the COVID-19 pandemic, which has increased telehealth and reduced operating room (OR) availability. Method(s): Survey was disseminated to NASPAG (North American Society for Pediatric and Adolescent Gynecologists) members via the listserv on two separate occasions. Consent was obtained upon completion of the survey. Results from the survey are anonymous. Results were tabulated with descriptive statistics. Ethics approval was obtained (REB22-0269). Result(s): There were 55 respondents, with the majority being Pediatric and Adolescent Gynecologists (71%) from North America (93%). As per providers, adolescents most frequently seek out the IUD for contraception (45%) and menstrual management (42%). Providers felt that the most common barrier to the IUD was misconceptions/myths (67%), as well as pain with insertion (64%). Most practitioners had no change in their IUD prescribing patterns since the start of the pandemic (62%), while some performed more office insertions (11%) and some reduced their IUD practice because of less operative time (15%) and less in-person appointments. Although many physicians perform office insertions, many found that a Procedural Sedation Center facilitated wait times (38%) or felt that such a center would be helpful (33%). Cases being done in the OR were often patients with disabilities/developmental delay (95%) or anxiety (75%). Conclusion(s): Our survey demonstrated that there are still some misconceptions surrounding the IUD. Education on contraception, specifically LARCs, is pivotal in decreasing adolescent pregnancy rates, reducing barriers to IUD use, and improving the attitude of adolescents toward the IUD. Pain with insertion is another limiting factor and a Procedural Sedation Center may be helpful in managing pain expectations and increasing acceptance of the IUD. Although there was no significant change in IUD practices during COVID, a decrease in operating room availability and increase in telehealth may impede IUD prescribing, especially in patients with developmental delay or disabilities who may require insertion in the OR.Copyright © 2023
ABSTRACT
Background: Anastomotic leak (AL) after minimally invasive esophagectomy (MIE) is a well-described source of morbidity for patients undergoing surgical treatment of esophageal neoplasm. With improved early recognition and endoscopic management techniques, the long-term impact remains unclear. Method(s): A retrospective review was conducted of patients who underwent MIE for esophageal neoplasm between January 2015 and June 2021 at a single institution. Cohorts were stratified by development of AL and subsequent management. Baseline demographics, perioperative data, and post-operative outcomes were examined. Result(s): During this period, 172 MIEs were performed, with 35 of 172 (20.3%) complicated by an AL. Perioperative factors independently associated with AL were post-operative blood transfusion (leak rate 52.9% versus 16.8%;p = 0.0017), incompleteness of anastomotic rings (75.0% vs 19.1%;p = 0.027), and receiving neoadjuvant therapy (18.5% vs 30.8%;p < 0.0001). Inferior short-term outcomes associated with AL included number of esophageal dilations in the first post-operative year (1.40 vs 0.46, p = 0.0397), discharge disposition to a location other than home (22.9% vs 8.8%, p = 0.012), length of hospital stay (17.7 days vs 9.6 days;p = 0.002), and time until jejunostomy tube removal (134 days vs 79 days;p = 0.0023). There was no significant difference in overall survival between patients with or without an AL at 1 year (79% vs 83%) or 5 years (50% vs 47%) (overall log rank p = 0.758). Conclusion(s): In this large single-center series of MIEs, AL was associated with inferior short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, without an accompanying impact on 1-year or 5-year survival. Key message: In this large, single-center series of minimally invasive esophagectomies, anastomotic leak was associated with worse short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, but was not associated with worse long-term survival. The significant association between neoadjuvant therapy and decreased leak rates is difficult to interpret, given the potential for confounding factors, thus careful attention to modifiable pre- and peri-operative patient factors associated with anastomotic leak is warranted.Copyright © 2022 The Authors
ABSTRACT
INTRODUCTION: Inguinal hernia repair is one of the most common surgical procedures performed by general surgeons. Numerous articles have shown that robotic inguinal hernia repair is safe and effective, but also more costly than other hernia repair techniques. The robotic platform uses high-definition visualization and articulating instruments. A growing number of surgeons are using this technology to refine and obtain a critical view of the myopectineal orifice for hernia repair while lessening the pain associated with the open surgical approach. Lower insufflation pressures and good results without Foley catheterization have been reported. This report presents an update, with a focus on the past 3 years during the SARS COVID-19 pandemic, of a series of robotic, laparoscopic inguinal hernia repairs by a single surgeon with extensive laparoscopic hernia experience at a single institution, along with a review of the recent current literature. METHOD(S): Over 3000 laparoscopic inguinal hernia operations have been performed by the author since 1990. One hundred-fifty-eight were performed from April 2020 to November 2022, in addition to the previously reported 420 robotic TAPP (trans-abdominal pre-peritoneal) procedures performed from April 2012 to March 2020. Hospital records and follow-up care were prospectively reviewed and the patient's age, sex, American Society of Anesthesia (ASA) class and operative time were obtained. Follow-up was done at 2 weeks and 6 weeks following surgery. All patients consented to the use of their data in the study. RESULT(S): Ninety-four percent (94%) of the patients were male. The average age was 64.3 years (range 18-91). Co-morbidities included hypertension, hypercholesterolemia, prostatism and GERD, among others. BMI was between 19 and 37.1 (mean 26.1). In 23 patients (15%), an umbilical hernia repair was performed concomitantly. OR time ranged from 25 to 90 minutes (mean 51.8). Complications were uncommon and urinary retention (2.5%) was an infrequent post-operative occurrence. CONCLUSION(S): 1) Use of a lower insufflation pressure (8-12 mm Hg) was routine. 2) Use of a structural mesh (4x6 inches) gave satisfactory results. 3) While fixation of the mesh was not necessary, fibrin sealant was used routinely. 4) Urinary retention was infrequent, and did not require pre- or intra-op Foley catheterization if the patient voided immediately prior to surgery. Finally, 5) OR time was consistently less than 1 hour. These results support the conclusion that robotic inguinal hernia repair is safe and effective.
ABSTRACT
Objective: The aim of this study was to evaluate the excepted budgetary impact of gradually adopting a magnetic tracer (MT) over a radioisotope tracer in the detection of sentinel lymph nodes (SLN) in operable breast cancer ((BC) from the perspective of one French hospital without a nuclear medicine department. Material(s) and Method(s): This study was conducted in a population of patients with operable breast cancer with SLN dissection. A budget impact model based on a prospective study conducted between April 2020 and March 2021 at Saint Joseph Hospital was developed. The model estimates the costs and revenues associated with an increase in the use of the strategy of SLN detection with a MT versus an isotope over a three-year time horizon. Result(s): Fifty-four patients were included: 20 in the isotope group and 34 in the MT group. The operating time was not statistically different between the two groups (67 minutes for the MT versus 68 minutes for the isotope, p = 0.89). Secretarial time was higher in the isotope group (25 min more than for the TM group). On the basis of 383 patients who underwent surgery the first year and assuming an increase in activity of 10% per year for the standard-of-care strategy and 11.5% for the innovative strategy, the revenues and costs for the hospital are projected to increase for both strategies. However, the increased use of MT would result in an estimated cost to the hospital of 11,639 (9.06 per patient undergoing surgery) over a three-year period. Conclusion(s): The MT detection method provides autonomy to the surgeon in SNL detection. Its cost must be weighed against the simplification of the preoperative patient journey. Its use during the COVID-19 health crisis helped make patient journeys safer by avoiding visits to nuclear medicine departments, thus limiting the risk of infection. No conflict of interest. Copyright © 2022 Elsevier Ltd. All rights reserved
ABSTRACT
Objectives: Reducing operating theatre time can help hospitals to optimise operational efficiency and effectively allocate scarce resources. Holmium Laser Enucleation of the Prostate (HOLEP) is an established procedure for the treatment of symptoms secondary to Benign Prostatic Hyperplasia (BPH). It can be performed with Standard Technology (standard HOLEP) or MOSESTM Technology (MOLEP, Boston Scientific Corp). A recent meta-analysis demonstrated significantly reduced operative time with MOLEP vs. standard HOLEP. Our objective is to understand the potential economic impact of reducing theatre time with MOLEP vs. standard HOLEP and potential increases in operational capacity in hospitals in major European DRG-system countries, England, France, Germany and Italy. Method(s): We developed a health economic model to extrapolate theatre time savings reported in the meta-analysis to annual procedure volumes of a theoretical small (1 HOLEP/week), medium (3 HOLEP/week), and large (15 HOLEP/week) hospital. The model allows individual proportions of the time saved to feed into either theatre time cost savings or increased procedure throughput. We used national DRG tariffs and theatre cost per minute to estimate the economic impact. Result(s): Assigning all time savings to the performance of new procedures, small, medium, and large hospitals could perform up to 14, 44, and 229 additional procedures per year, respectively, increasing their procedure volume by 28-29%. In this example, potential revenue gains ranged from 32.573 (small French hospital) to 653.866 (large German hospital), for MOLEP vs. standard HOLEP. For every four procedures performed with MOLEP vs. standard HOLEP, sufficient time was saved to perform an additional procedure. Conclusion(s): Use of MOLEP saves time vs. standard HOLEP. Depending on the hospital aims, this efficiency gain can result in higher cost savings and generate additional revenue for the hospital. Aspects of operative efficiency and workflow improvements should be considered when evaluating the adoption of state-of-the-art medical technologies, especially in the post-COVID-19 pandemic era. Copyright © 2022