The Case for Improvement in Perioperative Medicine

Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. Although there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. The impact of the COVID-19 pandemic on surgical and procedural practices further highlights the urgency and need for an expanded role of perioperative medicine to impact system improvement. The surgical experience is frequently the first touchpoint to reengage the patient in their own health care. Some of the key interventions that are being effectively instituted by the anesthesiologists include proactive engagement in preoperative optimization of patient's health;personalization and standardization of care delivery by segmenting patients based on their complexity and risk;and implementation of best practices that are data-driven and evidence-based and provide structure that allow patients to return to their optimal state of functional, cognitive, and psychological health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of our patients. © 2023 Elsevier Inc. All rights reserved.

Robotic Morgagni's hernia repair in adults - A single centre experience.

BACKGROUND: This study was aimed at reporting the surgical outcomes and evaluating the safety and feasibility of robotic repair of Morgagni's repair in adults. METHODS: This is a retrospective analysis of seven cases of Morgagni's hernia in adults, managed by robotic method in a tertiary-level thoracic surgery centre over 9 years. A detailed analysis of all perioperative variables including complications was carried out. RESULTS: A total of seven patients underwent Robotic Morgagni's hernia repair during the study period. Males (71.4%) were predominant in the patient cohort. Median age group was 33 years (range: 28-78 years). All patients were pre-obese with median body mass index of 29.4 (range: 27.5-29.9). All patients underwent robotic-assisted hernia repair with no conversions. Omentum was the most common hernial content (100%). In all cases, the defect was reinforced with a composite mesh. Median operative time was 140 min (range: 120-160). Median hospital stay of 3 days (range: 2-4 days). No post-procedural complications. All the patients had complete resolution of presenting symptoms. No recurrence was noted in the median follow-up period of 32 months (range: 6-78 months). CONCLUSION: Robotic-assisted surgical repair of Morgagni's hernia in adults is safe, feasible and effective. However, studies with larger sample size and multi-institutional collaboration are recommended for further conclusions.

Effectiveness of 6 surgical approaches for minimally invasive lumbar interbody fusion: 1-year follow-up results from a global multicentre study

Background: Minimally invasive lumbar interbody fusion (MI-LIF) procedures are an effective treatment for patients with degenerative lumbar disease (DLD). However, consensus does not exist among surgeons for selecting 1 approach over another. The objectives were to collect patientreported, surgical and fusion outcome data at 1 year after surgery for patients receiving either anterior lumbar interbody fusion (ALIF), direct lateral interbody fusion (DLIF), oblique lumbar interbody fusion (OLIF), posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF) or midline lumbar interbody fusion (MIDLF) for DLD. Methods: A total of 340 patients with DLD were consecutively enrolled in a prospective, global, multicentre cohort study (MASTERS-D2;NCT02617563). Patients were treated according to the surgeon's choice with 1 of 6 MI-LIF procedures. Outcome data for disability (Oswestry Disability Index), back and leg pain (Visual Analogue Scale), quality of life (EQ-5D) were collected at baseline, 4 weeks, 3 months and 12 months. Demographic, surgical and safety data were also recorded. Fusion status was assessed by using computed tomography or x-rays at 1 year (plus or minus 6 mo) after surgery. Paired sample t tests were used to test for improvement from baseline. Results: One year after surgery, patients attained clinically significant improvements on all patient-reported outcome measures regardless of approach used. Patients who were selected to receive an ALIF comprised the highest proportion of smokers, were the youngest and had the longest operating time, but low fluoroscopy exposure. Anterolateral (ALIF, DLIF, OLIF) compared with posterior (MIDLF, PLIF, TLIF) approaches had the least amount of blood loss, despite similar or longer surgical times. Within 1 year of follow-up, 7 device-related and 7 surgery-related serious adverse events (SAEs) had been recorded. Assessment of fusion was hindered by the effects of COVID-19. In total, 196 out of 340 (57.6%) patients were assessed. The aggregate fusion rate for anterolateral approaches was 88.1% and for posterior approaches 85.1% at 12 months of follow-up. Conclusion: All 6 approaches for MI-LIF surgery demonstrate favourable patient-reported and surgical outcomes for patients with DLD. Continuing data collection up to 5 years after surgery will yield information on long-term effectiveness, safety, health economics and revision surgery and on the long-term impact of surgeons' choice of approach.

The impact of COVID-19 pandemic on the mortality and morbidity of patients undergoing trauma surgery: a report from the UK Corona TRAUMA Surge (UKCoTS) study.

PURPOSE: To assess the impact of the COVID-19 pandemic on the outcomes of the patients who underwent trauma surgery during the peak of the pandemic. METHODS: The UKCoTS collected the postoperative outcomes of consecutive patients who underwent trauma surgery across 50 centres during the peak of the pandemic (April 2020) and during April 2019. RESULTS: Patients who were operated on during 2020 were less likely to be followed up within a 30-day postoperative period (57.5% versus 75.6% p <0.001). The 30-day mortality rate was significantly higher during 2020 (7.4% versus 3.7%, p <0.001). Likewise, the 60-day mortality rate was significantly higher in 2020 than in 2019 (p <0.001). Patients who were operated on during 2020 had lower rates of 30-day postoperative complications (20.7% versus 26.4%, p <0.001). CONCLUSIONS: Postoperative mortality was higher during the first wave of the COVID-19 pandemic compared to the same period in 2019, but with lower rates of postoperative complications and reoperation.

The Effects of the COVID-19 Pandemic on Mastectomy Outcomes for Breast Cancer.

BACKGROUND: Single center studies have shown that during the Coronavirus Disease 2019 (COVID-19) pandemic, many patients had surgical procedures postponed or modified. We studied how the pandemic affected the clinical outcomes of breast cancer patients who underwent mastectomies in 2020. METHODS: Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we compared clinical variables of 31,123 and 28,680 breast cancer patients who underwent a mastectomy in 2019 and 2020, respectively. Data from 2019 served as the control, and data from 2020 represented the COVID-19 cohort. RESULTS: Fewer surgeries of all kinds were performed in the COVID-19 year than in the control (902,968 vs. 1,076,411). The proportion of mastectomies performed in the COVID-19 cohort was greater than in the control year (3.18% vs. 2.89%, <0.001). More patients presented with ASA level 3 in the COVID-19 year vs. the control (P < .002). Additionally, the proportion of patients with disseminated cancer was lower during the COVID-19 year (P < .001). Average hospital length of stay (P < .001) and time from operation to discharge were shorter in the COVID vs. control cohort (P < .001). Fewer unplanned readmissions were seen in the COVID year (P < .004). CONCLUSION: The ongoing surgical services and mastectomies for breast cancer during the pandemic produced similar clinical outcomes to those seen in 2019. Prioritization of resources for sicker patients and the use of alternative interventions produced similar results for breast cancer patients who underwent a mastectomy in 2020.

COVID-19 infection and ambulatory surgery: Decision making based on known knowns

During the spring of 2020, as Coronavirus Disease 2019 (COVID-19) infections rapidly spread across the globe, all sectors of healthcare, everywhere, would change in ways that were unimaginable. Early on, the ambulatory surgery space, being no exception, would suffer deep and impactful reductions in patient volume and revenue. Though actual care stoppages were short-lived, decreased ambulatory surgical patient volumes continued for a myriad of reasons, though in some cases, ambulatory surgery centers (ASCs) provided surgical care in limited numbers to patients who were "offloaded” from inpatient lists. Released on March 24, 2020, herein, we address the key perioperative issues as they relate to COVID-19 and ambulatory surgery including the many complexities and challenges of a new and rapidly changing virus, the impact of viral infection and vaccine development on perioperative outcomes, key ambulatory surgical approaches to COVID-19-related patient and staff safety, and finally, managing issues related to both supply chain (personal protective equipment (PPE) and other necessary equipment) and facility staffing. © 2022 Elsevier Ltd

Impact of the COVID-19 pandemic on the management and outcomes of emergency surgical patients: A retrospective cohort study.

INTRODUCTION: The COVID-19 pandemic has led to drastic measures being implemented for the management of surgical patients across all health services worldwide, including the National Health Service in the United Kingdom. It is suspected that the virus has had a detrimental effect on perioperative morbidity and mortality. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on these outcomes in emergency general surgical patients. METHODS: Emergency general surgical admissions were included in this retrospective cohort study in one of the COVID-19 hotspots in the South East of England. The primary outcome was the 30-day mortality rate. Secondary outcomes included the length of stay in hospital, complication rate and severity grade and admission rates to the ITU. RESULTS: Of 123 patients, COVID-19 was detected in 12.2%. Testing was not carried out in 26%. When comparing COVID-positive to COVID-negative patients, the mean age was 71.8 + 8.8 vs. 50.7 + 5.7, respectively, and female patients accounted for 40.0 vs. 52.6%. The 30-day mortality rate was 26.7 vs. 3.9 (OR 6.49, p = 0.02), respectively. The length of stay in hospital was 20.5 + 22.2 vs. 7.7 + 9.8 (p < 0.01), the rate of complications was 80.0 vs. 23.7 (OR 12.9, p < 0.01), and the rate of admission to the ITU was 33.3 vs. 7.9% (OR 5.83, p = 0.01). CONCLUSION: This study demonstrates the detrimental effect of COVID-19 on emergency general surgery, with significantly worsened surgical outcomes.

Victoria's surgical response to the COVID-19 pandemic: the first two years.

Victoria suffered three major waves during the first two years of the COVID-19 pandemic. Melbourne became the longest locked down city in the world at 267 days. This narrative review documents the chronological waves of COVID-19 in Victoria and key themes influencing the State-wide surgical response. In 2020, Victoria needed to secure supplies of personal protective equipment (PPE) and later, recognizing the importance of aerosol transmission, introduced a respiratory protection program to protect health care workers (HCWs) with fit-tested N-95 masks. It established routine preoperative PCR testing for periods when community prevalence was high and developed strategies to restrict elective surgery when hospital capacity was limited. In 2021, three short-term outbreaks were contained and eliminated whilst vaccination of HCWs and the vulnerable was taking place. A third major wave (Delta) occurred July to November 2021, succeeded by another involving the Omicron variant from December 2021. Planned surgery waiting list numbers, and waiting times for surgery, doubled between March 2020 and March 2022. In early 2022, almost 300 patients underwent surgery when infected with Omicron, with a low mortality (2.6%), though mortality was significantly higher in the unvaccinated (7.3% versus 1.4%). In conclusion, the Victorian response to COVID-19 involved tight state-wide social restrictions, contact tracing, furlough, escalating PPE guidance and respiratory protection. HCW infections were greatly reduced in 2021 compared with 2020. Pre-operative PCR testing gave confidence for emergency and urgent elective surgery to proceed during pandemic waves. Other elective cases were performed as health system capacity allowed, without compromising outcomes.

Literature Review for Office-Based Anesthesia

The authors observed a decreased heart rate in the dexmedetomidine groups, but none of the patients required treatment for bradycardia. Ann Surg. 2022;276(5):e265–e272 doi:10.1097/SLA.0000000000005597 This study aimed to determine whether COVID-19 vaccination status or mode of anesthesia modified the temporal harms associated with surgery following coronavirus disease-2019 (COVID-19) infection. The authors recommend a thorough consideration of risks and benefits as requests for family presence in the operating environment continue to grow.

The impact of partial and complete lockdown during the COVID-19 pandemic on acute surgical services: a retrospective cohort study.

PURPOSE: The burden of the coronavirus disease of 2019 (COVID-19) pandemic on the healthcare sector has been overwhelming, leading to drastic changes in access to healthcare for the public. We aimed to establish the impact of implemented government partial and complete lockdown policies on the volume of surgical patient admissions at a tertiary referral center during the pandemic. METHODS: A database was retrospectively created from records of patients admitted to the surgical ward through the emergency department. Three 6-week periods were examined: The complete lockdown period (CLP), which included a ban on the use of cars with the exception of health service providers and essential sector workers; A pre-COVID period (PCP) 1 year earlier (no lockdown); and a partial lockdown period (PLP) that involved a comprehensive curfew and implementing social distancing regulations and wear of personal protective equipment (e.g., masks) in public places. RESULTS: The number of patients admitted to the surgery ward was significantly higher in the PCP cohort compared to the CLP and PLP cohorts (p = 0.009), with a 42.1% and 37% decline in patients' admissions, respectively. Admission rates for patients with biliary pathologies and vascular thrombotic events increased. 30-day mortality rates did not differ significantly between the three periods (p = 0.378). CONCLUSIONS: While COVID-19 lockdown regulations had a significant impact on patient admission rates, surgical outcomes were not affected and the standards of care were maintained. Future protocols should strive to improve access to healthcare to avoid complications caused by delayed diagnosis and treatment.

COVID-19 Infection and Ambulatory Surgery: Decision Making based on Known Knowns

During the spring of 2020, as COVID-19 infections rapidly spread across the globe, all sectors of healthcare, everywhere, would change in ways that were unimaginable. Early on, the ambulatory surgery space, being no exception, would suffer deep and impactful reductions in patient volume and revenue. Though actual care stoppages were short lived, decreased ambulatory surgical patient volumes continued for a myriad of reasons, though in some cases, Ambulatory Surgery Centers (ASCs) provided surgical care in limited numbers to patients who were "offloaded” from inpatient lists. Released March 24, 2020, herein, we address key perioperative issues as they relate to COVID-19 and ambulatory surgery including the many complexities and challenges of a new and rapidly changing virus, the impact of viral infection and vaccine development on perioperative outcomes, key ambulatory surgical approaches to COVID-19 related patient and staff safety, and lastly, managing issues related to both supply chain (PPE and other necessary equipment) and facility staffing.

2022 CONFERENCE POSTER COLLECTION: THE OFFICIAL VOICE OF PERIOPERATIVE NURSING

[...]new OR caregivers moved from an observation to an immersion in SPD, allowing them to truly gain an understanding of the importance of the processes and the SPD technician's role. Given this scenario, the implementation of guidelines throughout the perioperative period is of fundamental importance, as they are essential to assist decisions about the most appropriate health care in specific circumstances, guiding and qualifying the practice. The oldest guideline is the Protocol for the Surveillance of Surgical Site Infection, version 6, by Public Health England, which dates to 2013, and the most recent is the Surgical Site Infection Event (SSI), published in 2020 by the Centers for Disease Control and Prevention. Implementing an Ultraviolet Germicidal Irradiation (UVGI) System in Surgical Services, NMRTC, Camp Pendleton, During the COVID-19 Pandemic Annissa Cromer, Regina Leassear, Angela Spruill Within Surgical Services at Navy Medicine Readiness and Training Command, Camp Pendleton, an adjunct method to regular cleaning protocols was implemented to ensure complete disinfection of harmful pathogens.

Highlights from this issue

Economic, clinical and social impact of simple limbal epithelial transplantation for limbal stem cell deficiency (see page 923) A comprehensive literature survey, questionnaire-based survey and economic analysis indicates that simple limbal epithelial transplantation is a better alternative to cultivated limbal epithelial transplantation in terms of anatomical success, cost and accessibility. Association between body mass index and diabetic retinopathy in Asians: the Asian eye epidemiology Consortium (AEEC) study (see page 980) In a pooled analysis including 10 010 Asian adults with diabetes from 12 cross-sectional studies across six Asian countries, obesity was inversely associated with both any diabetic retinopathy and vision-threatening diabetic retinopathy, independent of potential risk factors. Efficacy of a novel personalised aflibercept monotherapy regimen based on polypoidal lesion closure in participants with polypoidal choroidal vasculopathy (see page 987) We report the results of a novel personalised anti-vascular endothelial growth factor monotherapy regimen for the management of polypoidal choroidal vasculopathy which achieves comparable outcomes to a fixed 8-weekly regimen and high polypoidal lesion closure rate.

Pediatric cardiac surgery following severe acute respiratory syndrome coronavirus-2 infection: Early experience and lessons learnt.

Background: We evaluated our early experience of cardiac procedures in children with congenital heart defects (CHD) after asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, to understand whether recent reverse transcription-polymerase chain reaction (RT-PCR) positivity had a negative impact on their postprocedural recovery and outcomes. Materials and Methods: In this retrospective observational study, all patients with CHD who underwent cardiac surgery or transcatheter intervention at our institution between March 2020 and June 2021 who were detected to have asymptomatic SARS-CoV-2 infection on routine RT-PCR were included. Details of the cardiac procedure and postprocedural recovery were reviewed and compared with RT-PCR-negative patients who concurrently underwent similar cardiac surgeries or interventions at our center. Results: Thirteen patients underwent cardiac surgery after recent SARS-CoV-2 positivity after a mean interval of 25.4 ± 12.9 days. One patient expired with multiorgan dysfunction and systemic inflammatory response with elevated D-dimer, serum Ferritin, C-reactive protein, and significant ground-glass opacities on chest radiograph. Another patient developed spontaneous thrombosis of the infrarenal abdominal aorta, bilateral iliac arteries, and bilateral femoral veins, requiring low-molecular weight heparin postoperatively. This patient's postoperative recovery was also prolonged due to lung changes delaying extubation. All other patients had uneventful postprocedural recovery with intensive care unit and hospital stays comparable to non-SARS-CoV-2-infected patients. Conclusions: From our early experience, we can surmise that an interval of 2-3 weeks after asymptomatic SARS-CoV-2 infection is adequate to undertake elective or semi-elective pediatric cardiac surgeries. For patients requiring emergent cardiac surgery prior to this interval, there is potentially increased risk of inflammatory and/or thrombotic complications.

Cohort profile: The Bariatric Experience Long Term (BELONG): a long-term prospective study to understand the psychosocial, environmental, health and behavioural predictors of weight loss and regain in patients who have bariatric surgery

PurposeThe Bariatric Experience Long Term (BELONG) prospective study cohort was created to address limitations in the literature regarding the relationship between surgical weight loss and psychosocial, health, behaviour and environmental factors. The BELONG cohort is unique because it contains 70% gastric sleeve and 64% patients with non-white race/ethnicity and was developed with strong stakeholder engagement including patients and providers.ParticipantsThe BELONG cohort study included 1975 patients preparing to have bariatric surgery who completed a baseline survey in a large integrated health system in Southern California. Patients were primarily women (84%), either black or Hispanic (59%), with a body mass index (BMI) of 45.1±7.4 kg/m2, age 43.3±11.5 years old, and 32% had at least one comorbidity.Findings to dateA total of 5552 patients were approached before surgery between February 2016 and May 2017, and 1975 (42%) completed a baseline survey. A total of 1203 (73%) patients completed the year 1 and 1033 (74%) patients completed the year 3 postoperative survey. Of these survey respondents, 1341 at baseline, 999 at year 1, and 951 at year 3 were included in the analyses of all survey and weight outcome data. A total of 803 (60% of eligible patients) had survey data for all time points. Data collected were self-reported constructs to support the proposed theoretical model. Height, weight and BMI were ed from the electronic medical record to obtain the main outcomes of the study: weight loss and regain.Future plansWe will collect self-reported constructs and obtain height, weight and BMI from the electronic medical record 5 years after bariatric surgery between April 2022 and January 2023. We will also collect patient experiences using focus groups of 8–12 patients each throughout 2022.

Breast Cancer Imaging and Detection

[...]malignant lesions with high water content such as mucinous carcinoma or triple-negative cancer with extensive necrosis might not be picked up by DWI-unenhanced MRI owing to the high apparent diffusion coefficient values within these lesions. The conventional hookwire localisation has been increasingly replaced by newer wireless localisation techniques such as radioactive seeds, magnetic seeds, radar reflectors, and radiofrequency identification tag localisers owing to their increased scheduling flexibility. Abbreviated magnetic resonance imaging (MRI) for breast cancer screening: rationale, concept, and transfer to clinical practice.

Clinical, surgical and histopathological characteristics of liver transplant recipients: An analysis of a large sample from Turkey

Aims: Liver transplantation (LT) is the most effective treatment method for end-stage liver failure and acute liver failure, depending on all causes. This study aimed to examine the clinical, surgical, and histopathological characteristics of LT recipients in a referral center in Turkey. Methods: In this single-center study, demographic, clinical, laboratory, radiological, surgical, and histopathological data of LT recipients aged 18 years or over between December 2017 and February 2021 were retrospectively analyzed. All subjects were transplanted from live donors and cadavers. Results: The sample included 162 subjects [mean age: 50.1 (18-70) years;male: 64.8%. The proportion of live donor transplantation was 86.4% (n=140)]. The mean follow-up time was 20.5 months (1-39 months). The most common primary indication was hepatocellular carcinoma (n=43, 26.5%) and chronic hepatitis B virus infection-related cirrhosis (n=30, 18.5%). The most common postoperative complication was biliary complications (30.9%). One-year survival was 88.9%, two-year survival was 85.8%, and three-year survival was 83.3%. During the 3-year follow-up, the total graft loss rate was observed by 17.9%, and the mortality rate was 15.4%. Conclusions: The main goal in LT is the long-term survival of the graft and the patient. The present study showed that demographic characteristics, etiological characteristics, postoperative complications, and mortality rates among LT recipients were consistent with the results of other centers around the world.

Contemporary Management of Locally Advanced and Recurrent Rectal Cancer: Views from the PelvEx Collaborative.

Pelvic exenteration is a complex operation performed for locally advanced and recurrent pelvic cancers. The goal of surgery is to achieve clear margins, therefore identifying adjacent or involved organs, bone, muscle, nerves and/or vascular structures that may need resection. While these extensive resections are potentially curative, they can be associated with substantial morbidity. Recently, there has been a move to centralize care to specialized units, as this facilitates better multidisciplinary care input. Advancements in pelvic oncology and surgical innovation have redefined the boundaries of pelvic exenterative surgery. Combined with improved neoadjuvant therapies, advances in diagnostics, and better reconstructive techniques have provided quicker recovery and better quality of life outcomes, with improved survival This article provides highlights of the current management of advanced pelvic cancers in terms of surgical strategy and potential future developments.

Physical human–robot interaction for clinical care in infectious environments

The COVID-19 pandemic has highlighted key challenges for patient care and health provider safety. Adaptable robotic systems, with enhanced sensing, manipulation and autonomy capabilities could help address these challenges in future infectious disease outbreaks.