[Comparison of early operative treatment and 48-hour conservative treatment in small bowel obstruction (COTACSO): intermediate results]. / Promezhutochnye rezul'taty otkrytogo prospektivnogo randomizirovannogo mnogotsentrovogo sravnitel'nogo issledovaniya rannei operatsii i 48-chasovogo neoperativnogo lecheniya spaechnoi kishechnoi neprokhodimosti.

Optimal treatment for adhesive small bowel obstruction (SBO) is not defined. Surgery is the only method of treatment for obvious strangulating SBO. Non-operative management (NOM) is widely used among patients with low risk of strangulation, i.e. no clinical, laboratory and CT signs. Randomized controlled trials (RCTs) are recommended to determine the optimal method (early intervention or NOM), but their safety is unclear due to possible delay in surgery for patients needing early intervention. MATERIAL AND METHODS: A RCT is devoted to outcomes of early operative treatment and NOM for adhesive SBO. The estimated trial capacity is 200 patients. Thirty-two patients were included in interim analysis. In 12 hours after admission, patients without apparent signs of strangulation were randomized into two clinical groups after conservative treatment. Group I included 12 patients who underwent immediate surgery, group II - 20 patients after 48-hour NOM. The primary endpoint was success of non-surgical regression of SBO and reduction in mortality. To evaluate patient safety, we analyzed mortality, complication rates and bowel resection in this RCT with previously published studies. RESULTS: In group I, all 12 (100%) patients underwent surgery. Only 4 (20%) patients required surgery in group II. Mortality, complication rates and bowel resection rates were similar in both groups. Strangulating SBO was found in 8 (25%) patients. Overall mortality was 6.3%, bowel resection rate - 6.3%, iatrogenic perforation occurred in 3 (18.8%) patients. These values did not exceed previous findings. CONCLUSION: Non-operative management within 48 hours prevented surgery in 80% of patients with SBO. Interim analysis found no significant between-group differences in mortality, complication rates and bowel resection rate. Patients had not been exposed to greater danger than other patients with adhesive SBO. The study is ongoing.

Clinical Outcomes and Management Strategies for Capitellum and Trochlea Fractures: A Systematic Review.

Purpose: Capitellum and trochlea fractures, also referred to as coronal shear fractures of the distal humerus, are infrequent yet challenging intra-articular fractures of the elbow. There are a variety of surgical approaches and fixation methods with often variable outcomes. This systematic review investigates interventions, outcomes and complications of capitellum and trochlea fractures. Methods: A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the clinical outcomes of capitellum and trochlea fractures managed surgically. Data on patient demographics, surgical approach, implant usage, postoperative outcomes and complications were compiled. Results: Forty-one studies met the inclusion criteria with a total of 700 patients. Surgical interventions primarily utilized either the lateral (79%) or antero-lateral (15%) approaches with headless compression screws as the most common fixation method (68%). Clinical outcomes were measured using the Mayo Elbow Performance Index (MEPI) with a mean score of 89.9 (±2.6) and the DASH score with a mean of 16.9 (±7.3). Elbow range of motion showed a mean flexion of 126.3° (±19.4), extension of 5.71° (±11.8), pronation of 75.23° (±12.2), and supination of 76.6° (±9.8). The mean flexion-extension arc was 113.7° (±16.9), and the mean pronation-supination arc was 165.31° (±9.41). Complications occurred in 19.8% of cases, with re-interventions required in 8.3% of cases, mainly due to symptomatic implants and elbow stiffness requiring surgical release. Other complications included implant removal (10.4%), overall reported stiff elbows (6%), nerve palsies (2%), non-union (1.5%), and infection (1.2%). Conclusion: The treatment of capitellum and trochlea fractures yields satisfactory outcomes but has a considerable rate of complications and reoperations primarily due to symptomatic implants and elbow stiffness. There is noteworthy variability in the achieved range of motion, suggesting unpredictable outcomes. Deficits in functionality and range of motion are common after surgery, especially with more complex injury patterns.

A clinical observation algorithm for anterior abdominal stab wound is safe in an Australian setting.

INTRODUCTION: We previously published the outcomes associated with the use of diagnostic laparoscopy to determine peritoneal breach for AASW patients without an immediate indication for laparotomy. Although this pathway was 100% sensitive there was a 54% non-therapeutic laparotomy rate. Another option that has been extensively reported is the clinical observation algorithm (COA) however, majority of the data originate from high-volume centres. We hypothesized that a COA would also be a safe option in an Australian setting, and reduce the rate of non-therapeutic operative intervention in managing AASW. METHODS: This was a prospective cohort study examining patients with AASW admitted to a level 1 trauma centre in Sydney, Australia, between June 2021 and August 2023. Patient, injury, management and outcome data were collected from electronic medical records and the hospital trauma registry. Data were then analysed to determine the diagnostic accuracy of the COA, complication rates and median hospital length-of-stay (LOS). RESULTS: A total of 48 patients presented with AASW. Of these patients, 11 (22.9%) proceeded to immediate laparotomy. Seven patients had a contraindication to COA and underwent diagnostic laparoscopy. Thirty patients were managed with the COA, with three (10%) patients subsequently requiring a laparotomy. Only one patient (3.3%) underwent a non-therapeutic laparotomy. There were no missed injuries. The COA sensitivity was 100%, specificity 92.7%, PPV 50% and NPV 100%. Patients managed with COA had no complications. Overall median hospital LOS was 1 day (1.0-2.3). CONCLUSION: A COA is a safe approach for evaluating patients with AASW in an Australian setting with adequate resources. It reduces the rate of non-therapeutic operative intervention and has acceptable outcomes compared with a diagnostic laparoscopy pathway.

Comprehensive Treatment of Total Arch Replacement in a Patient With Liver Cirrhosis: A Case Report.

A 78-year-old woman with liver cirrhosis due to chronic hepatitis C visited our department for treatment of a thoracic aortic aneurysm. Her Child-Pugh classification was class A, and her model for end-stage liver (MELD) disease score was 8. As she also had thrombocytopenia associated with splenomegaly and esophageal varices, endoscopic injection sclerotherapy and partial splenic embolization were performed before total arch replacement surgery for treating esophageal varices to reduce the bleeding risk during transesophageal echocardiography and for thrombocytopenia, respectively. After endoscopic injection sclerotherapy and partial splenic embolization, the platelet count increased; hence, total arch replacement surgery was performed. By combining partial splenic embolization and endoscopic injection sclerotherapy, we were able to safely perform transesophageal echocardiography and total arch replacement surgery in the perioperative period.

The Efficacy of Buprenorphine in Preoperative and Postoperative Patients: A Literature Review.

Although research suggests that less than half of individuals who have surgical procedures report effective postoperative pain alleviation, the majority of patients endure acute postoperative discomfort. To lessen and manage postoperative pain, a variety of preoperative, intraoperative, and postoperative treatments and management methods are available. For several years an opioid called buprenorphine has become an effective tool to treat opioid use disorder (OUD) in patients across many different demographics. It has however endured barriers to its usage which can be seen when treating patients with chronic pain or postoperative pain, who also have an OUD. While buprenorphine may be underutilized within the clinical setting, the significantly low rates of chronic abuse when using the drug allow it to be an attractive treatment option for patients. This paper aims to explore a wide range of studies that examine buprenorphine as an analgesic and how it can be used for preoperative pain and postoperative pain. This paper will give an in-depth analysis of buprenorphine and its use in patients with chronic pain as well as OUD. A systematic literature review was performed by identifying studies through the database PubMed. The data from various publications were gathered with preference being given to publications within the last three years. We reviewed studies that examined the pain level of the patients after having buprenorphine. Despite long-available pharmacologic evidence and clinical research, buprenorphine has maintained a mystique as an analgesic. Its usage in the treatment of OUD was further influenced by its well-known safety benefits and relative lack of psychomimetic side effects compared to other opioids. For patients accustomed to long-term, high-dose opioids who may be experiencing hyperalgesia but have not been informed about this phenomenon by their doctors or the potential for buprenorphine to resolve it, buprenorphine's pronounced antihyperalgesic effect is a compelling pharmacologic characteristic that makes it particularly attractive as an option. When used in pre-, peri-, and postoperative circumstances, buprenorphine provides various pain-management benefits and patients can still benefit from effective pain management from mu-opioid agonists while remaining on buprenorphine. Buprenorphine can be continued at a reduced dose as needed to avoid withdrawal symptoms and to improve the analgesic efficiency of mu-opioid agonists used in combination with acute postoperative pain in light of the evidence at hand. Buprenorphine administration needs a patient-centered, multidisciplinary strategy that considers the benefits and drawbacks of the many perioperative therapy options to have the best chance of success.

Interhospital variation in the non-operative management of uncomplicated appendicitis in adults.

Background: Recent randomized trials have suggested non-operative management to be a safe alternative to appendectomy for acute uncomplicated appendicitis. Yet, there remains significant variability in treatment approach. This study sought to characterize center-level variation in non-operative management within a national cohort of adults presenting with appendicitis. Methods: The 2016-2020 Nationwide Readmissions Database was queried to identify all adult (≥18 years) hospitalizations for acute uncomplicated appendicitis. Hierarchical, mixed-effects models were developed to ascertain factors linked with non-operative management. Bayesian methodology was applied to predict random effects, which were then used to rank centers by increasing hospital-attributed rate of non-operative management. Institutions with high center-specific rates of non-operative management (>90th percentile) were considered low-operating hospitals (LOH). Results: Of an estimated 447,500 patients, 52,523 (11.7 %) were managed non-operatively. Compared to those undergoing appendectomy, the non-operative cohort was older, more commonly male, and of a higher comorbidity burden. Approximately 30 % in the variability of non-operative management was attributable to hospital effects, with absolute, risk-adjusted rates ranging from 0.5 to 22.5 %. Centers with non-operative management rates ≥90th percentile were considered LOH.Following risk adjustment, among patients undergoing appendectomy, care at LOH was linked with greater odds of postoperative infection, resource utilization, and non-elective readmission. Conclusions: We identified significant interhospital variation in the utilization of non-operative management for acute uncomplicated appendicitis. Further, we found LOH to be associated with inferior outcomes following surgical management. Future work is needed to assess the care pathways that contribute to increased utilization of non-operative strategies, and disseminate best practices across institutions.

Bilateral Acute Achilles Tendon Rupture Can Be Effectively Treated Non-operatively.

Acute rupture of the Achilles tendon (AT) is a common but debilitating injury that requires immediate diagnosis and effective management. Spontaneous bilateral AT rupture is rare; however, it can lead to severe disability for a significant period. This case report presents a 76-year-old patient who suffered a bilateral AT rupture while engaging in a non-strenuous activity. Upon confirmation of the diagnosis by physical examination and radiologic evaluation, conservative treatment was decided due to the presence of numerous comorbidities. A personalized rehabilitation protocol was implemented, allowing weight-bearing activities using Achilles boots at six weeks. Healing of both ATs was confirmed by an MRI at three months. Our case shows that non-operative treatment of these injuries can result in exceptionally favorable outcomes and should not be disregarded. However, thorough patient compliance and surveillance are prerequisites.

Nonoperative management of acute complicated diverticulitis with pericolic and/or distant extraluminal air: A systematic review.

INTRODUCTION: Colonic Diverticular Disease (CDD) is a multifactorial inflammatory disease. Acute diverticulitis (AD), with extraluminal free air (both pericolic and distant), represents about 15% of radiological scenarios and remains a therapeutic challenge for surgeons. Currently, the WSES guidelines suggest trying a conservative strategy both in the presence of pericolic and distant free extraluminal air, even if both have respectively weak recommendation based on low/very low-quality evidence. METHODS: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. PubMed/MEDLINE, Scopus, Web of Science, and Embase databases were used to identify articles of interest. RESULTS: A total of 2380 patients with AD and extraluminal free air (both pericolic and distant) who underwent nonoperative management (NOM) were analyzed. Of the 2380 patients, 2095(88%) were successfully treated with NOM, while 285 (12%) patients failed. A total of 1574 (93.1%) patients with pericolic extraluminal free air had a successful NOM with 6.9% (117) failure rates, while 135 (71.1%) patients with distant extraluminal free air had a successful NOM with 28.9% (55) failure rates. Regarding distant recurrence, we recorded a rate of 18.3% (261/1430), while a rate of 11.3% (167/1472) was recorded for patients undergoing elective surgery. CONCLUSION: NOM for patients with AD and extraluminal free air (both pericolic and distant) seems to be feasible and safe despite a higher failure rate in the distant subgroup, which remains the most challenging clinical scenario to deal with through conservative treatment.

The Effects of Osteopathic Manipulative Treatment (OMT) on Postoperative Length of Stay: A Meta-Analysis.

Osteopathic manipulative treatment (OMT) is a therapy used by osteopathic physicians in various medical settings. Postoperatively, OMT can be utilized to optimize the body's function and recovery. This meta-analysis examines the efficacy of OMT in reducing the length of postoperative hospital stays. Given the significant implications of prolonged hospitalization for both patients and healthcare resources, research strategies to safely shorten this period are crucial. This meta-analysis examined five select studies that measured the length of hospital stay in postoperative patients who received OMT compared with postoperative patients who did not. A random effects model was applied in our statistical analysis to account for heterogeneity due to variations in surgical procedures, hospitals, and patient populations. Individually, three studies reported statistically significant reductions in hospital stay for OMT patients, while two did not. This meta-analysis, comprising five studies and 519 patients, found a mean difference of -2.37 days in favor of OMT; however, this finding did not reach a statistical significance (P = 0.06). The substantial heterogeneity observed (heterogeneity tau2 = 6.75, chi2 = 34.6, df = 4, P < 0.00001, I2 = 88%) suggests that clinical dissimilarities among the five studies may have resulted in our inconclusive findings. While OMT shows promise in postoperative care, further research with standardized protocols and more homogenous patient populations is needed to assess its true impact.

Peri-Operative Management of Periacetabular Osteotomy: A Report of Current Practices from the Anchor Group, Supporting Literature, and Areas for Future Investigation.

Background: Periacetabular osteotomy (PAO) is a well-established surgical treatment for hip dysplasia, but very few studies report the impact of peri-operative management strategies on early pain and function. The purpose of this study is to describe peri-operative management variability among a group of experienced surgeons and review the literature supporting these practice patterns. Methods: We surveyed 16 surgeons that perform PAO to document various aspects of peri-operative management at four stages: pre-operative, intra-operative, post-operative in the hospital, and at discharge. Our goal was to report current surgical pain management strategies, adjunct medications, type of anesthesia, deep venous thrombosis and heterotopic ossification prophylaxis strategies, initiation of physical therapy, and use of continuous passive motion (CPM). We reviewed current literature to identify studies supporting these perioperative strategies and identify knowledge gaps that would benefit from further investigation. Results: Of the 16 surgeons surveyed, 75% had been in practice greater than 10 years and most had not altered their post-operative protocol for more than 3 years. 15/16 surgeons felt that length of stay could be reduced at their institution with improved peri-operative pain management. 6/16 were considering or had already implemented outpatient PAO as a part of their practice. We found significant variability in the pain medications provided at all peri-operative stages. 14/16 utilized general anesthesia, and many utilized epidural or peripheral nerve blocks. 6/16 surgeons utilized surgical field block (also referred to as periarticular block). These surgeons advocated that surgical field block was an effective intervention with no/minimal complication risk. There is very little literature critically evaluating efficacy of these perioperative management strategies for PAO. Conclusion: There is significant practice variability in peri-operative management of PAO surgery. We report various strategies utilized by a group of experienced surgeons and review supporting literature. There are significant knowledge gaps in best surgical pain management strategies, adjunct medications, surgical field blocks, and use of CPM that need further investigation. Level of Evidence: IV.

Standardizing quality utilization of interventional radiology treatments of blunt splenic injury: SQUIRTS study.

OBJECTIVES: Nonoperative management (NOM) of blunt splenic injury (BSI) is well accepted in appropriate patients. Splenic artery embolization (SAE) in higher-grade injuries likely plays an important role in increasing the success of NOM. We previously implemented a protocol requiring referral of all BSI grades III-V undergoing NOM for SAE. It is unknown the risk of complications as well as longitudinal outcomes. We aimed to examine the splenic salvage rate and safety profile of the protocol. We hypothesized the splenic salvage rate would be high and complications would be low. METHODS: A retrospective study was performed at our Level 1 trauma center over a 9-year period. Injury characteristics and outcomes in patients sustaining BSI grades III-V were collected. Outcomes were compared for NOM on protocol (SAE) and off protocol (no angiography or angiography but no embolization). Complications for angiographies were examined. RESULTS: Between January 2010 and February 2019, 570 patients had grade III-V BSI. NOM was attempted in 359 (63 %) with overall salvage rate of 91 % (328). Of these, 305 were on protocol while 54 were off protocol (41 no angiography and 13 angiography but no SAE). During the study period, for every grade of injury a pattern was seen of a higher salvage rate in the on-protocol group when compared to the off-protocol group (Grade III, 97 %(181/187) vs. 89 %(32/36), Grade IV, 91 %(98/108) vs. 69 %(9/13) and Grade V, 80 %(8/10 vs. 0 %(0/5). The overall salvage rate was 94 %(287) on protocol vs. 76 %(41) off protocol (p < 0.001, Cochran-Mantel-Haenszel test). Complications occurred in only 8 of the 318 who underwent angiography (2 %). These included 5 access complications and 3 abscesses. CONCLUSION: The use of a protocol requiring routine splenic artery embolization for all high-grade spleen injuries slated for non-operative management is safe with a very low complication rate. NOM with splenic angioembolization failure rate is improved as compared to non-SAE patients' at all higher grades of injury. Thus, SAE for all hemodynamically stable patients of all high-grade types should be considered as a primary form of therapy for such injuries.

Outcome of Patients with Locally Advanced Rectal Cancer Pursuing Non-Surgical Strategy in National Cancer Database.

BACKGROUND: Survival data on patients with locally advanced rectal cancer (LARC) undergoing non-operative management (NOM) in a real-world setting are lacking. METHODS: We analyzed LARC patients from the National Cancer Database with the following features: treated between 2010 and 2020, age 18-65 years, Charlson comorbidity index (CCI) ≤ 1, received neoadjuvant multiagent chemotherapy plus radiation ≥ 45 Gray, and underwent surgery or NOM. Patients were stratified into two groups: (A) clinical T1-3 tumors with positive nodes (cT1-3N+) and (B) clinical T4 tumors, N+/- (cT4N+/-). We performed a comparative analysis of overall survival (OS) with NOM versus surgery by the Kaplan-Meier method and propensity score matching. Additionally, a multivariable analysis explored the association between NOM and OS. RESULTS: NOM exhibited significantly lower OS than surgery in both groups. In cT1-3N+ patients, NOM resulted in a 5-year OS of 73.9% (95% confidence interval [CI] = 69.7-77.6%) versus 84.5% (95% CI = 83.6-85.3%) with surgery (p < 0.001). In the cT4N+/- group, NOM yielded a 5-year OS of 44.5% (95% CI = 37.0-51.8%) versus 72.5% (95% CI = 69.9-74.8%) with surgery (p < 0.001). Propensity score matching and multivariable analyses revealed similar conclusions. CONCLUSION: Patients with LARC undergoing NOM versus surgery in real-world settings appear to have inferior survival.

Non-operative management after immune checkpoint inhibitors for early-stage, dMMR/MSI-H gastrointestinal cancers.

Surgery is a standard treatment for early-stage gastrointestinal cancers, often preceded by neoadjuvant chemo(radio)therapy or followed by adjuvant therapy. While leading to cure in a proportion of patients, it has some drawbacks such as intra/post-operative complications, mutilation and life-long functional sequelae. Further to the unprecedented efficacy data from studies of immune checkpoint inhibitors for advanced mismatch repair deficient/microsatellite instable (dMMR/MSI-H) tumours, a strong interest has recently emerged for the investigation of such agents in the neoadjuvant setting. Although limited by the exploratory design and small sample size, trials of neoadjuvant immune checkpoint inhibitors for early-stage dMMR/MSI-H gastrointestinal cancers have consistently reported complete response rates ranging from 70 % to 100 %. As a result, the question has arisen as to whether surgery is still needed or organ-preserving strategies should be offered to this especially immuno-sensitive population. In this article, we discuss the available evidence for neoadjuvant immune checkpoint inhibitors in dMMR/MSI-H gastrointestinal cancers and analyse opportunities and challenges to the implementation of non-operative management approaches in this setting.

Reducing urinary tract infection rates in post-operative surgical patients: A quality improvement intervention.

INTRODUCTION AND OBJECTIVES: The Scarborough Health Network joined the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) in fiscal year 2017-2018 with interest in tracking surgical outcomes in General and Vascular Surgery patients. Results of the ACS NSQIP program revealed poor outcomes in 30-day urinary tract infection (UTI) rates in this population group. Results were in the lowest quartile compared to peer hospitals. To improve patient care, SHN initiated a multi-pronged quality improvement plan (QIP). METHODS: The QIP focused on several improvements: (1) clarify the current state and conduct a root cause analysis, (2) determine a plan to encourage early removal of catheters in post-surgical patients, (3) enhance team communication in the pre-operative, operative and post-operative care environments, and (4) improve education around UTI prevention and treatment. RESULTS: This study demonstrates the success of the quality improvement plan to improve a peri-operative complication in surgical patients. By 2019, SHN saw a significant decrease in UTI rates, and became a top decile performer in ACS NSQIP. CONCLUSIONS: This study demonstrates the feasibility and success of implementing a quality improvement project, and its methods can be adapted at other hospital sites to improve patient care.

National Analysis of Clinical Outcomes Associated With Cirrhotic Blunt Trauma Patients Undergoing Emergency Laparotomy Versus Non-operative Management: A Propensity Case-Matched Analysis.

INTRODUCTION: This study aims to evaluate clinical outcomes among severely injured trauma patients presenting with isolated blunt abdominal solid organ injuries with a pre-diagnosis of liver cirrhosis (LC) undergoing emergency laparotomy vs nonoperative management (NOM). METHODS: This retrospective cohort study utilized the American College of Surgeons Trauma Quality Program Participant Use File (ACS-TQIP-PUF) dataset from 2017 to 2021. Adults (≥18 years) with a pre-existing diagnosis of LC who presented with severe blunt (ISS ≥ 16) isolated solid organ abdominal injuries and underwent laparotomy or NOM were included. Outcomes of interest included in-hospital mortality, intensive care unit length of stay (ICU-LOS), and in-hospital complications such as acute renal failure and deep vein thrombosis. RESULTS: 929 patients were included in this analysis, with 355 undergoing laparotomy and 574 managed nonoperatively. Laparotomy patients suffered greater in-hospital mortality (n = 186, 52.3% vs n = 115, 20.0%; P < .01), required significantly more blood within 4 hours (8.9 units vs 4.3 units, P < .01), and had a significantly longer ICU-LOS (10.2 days vs 6.7 days, P < .01). In the 1:1 propensity score matched analysis of 556 matched patients, in-hospital mortality was greater for laparotomy patients (52.3% vs 20.0%, P < .01). CONCLUSION: Laparotomy was associated with significantly higher in-hospital mortality in propensity-matched trauma patients, longer ICU-LOS, and more blood products given at 4 hours compared to NOM. These findings illustrate that NOM may be a safe approach in managing severely injured trauma patients with isolated blunt abdominal solid organ injuries and a pre-diagnosis of LC.

New Insight into Laryngo-Tracheal Surgery: High-Flow Oxygen Therapy to Prevent Early Complications after Surgery.

BACKGROUND: Early post-operative airway management after laryngo-tracheal surgery is crucial. Acute respiratory failure due to glottis' edema may occur, requiring reintubation. This can prolong ventilatory assistance, jeopardizing anastomosis. To date, only judicious steroid administration and fluid management are available to avoid more invasive procedures. High-flow oxygen therapy (HFOT) is a noninvasive O2 support method providing humidification, warmed air, and Positive End-Expiratory Pressure (AIRVO2). No data about HFOT use to prevent early complications after laryngo-tracheal surgery are reported in the literature. METHODS: Between September 2020 and September 2022, 107 consecutive patients who underwent laryngo-tracheal surgery received HFOT (Group A). Data and long-term results were compared with those of 80 patients operated between September 2018 and August 2020 (Group B), when HFOT was not available. All patients were operated in a single center. No pre- or post-operative settings changed, except for HFOT introduction. We analyzed and compared the risk for "delayed" reintubation (unexpected reintubation within the first 24-48 h after extubating/laryngeal mask removal) in the two groups. RESULTS: No patients reported HFOT-related adverse events. The control group (B) presented "delayed" reintubation in 37% (p = 0.027), intensive care unit admission in 67% (p = 0.005) and longer hospital stay (p = 0.001) compared to the HFOT group (A). The minor complications' rate was 3% in both group and overall mortality was 0%. Re-stenosis was described in 4.6% of the HFOT group, without a statistically significant difference (p = 0.7006). CONCLUSIONS: Our study is the first to investigate HFOT use in patients undergoing laryngo-tracheal surgery, potentially representing a consistent innovation in the peri-operative management of these patients. With the limitation of a retrospective series, we would suggest HFOT use for preventing post-operative reintubation rate, possibly reducing ICU admissions and hospital stays.

Executive Summary of the American Radium Society® (ARS) Appropriate Use Criteria (AUC) for Non-Operative Management (NOM) for Rectal Adenocarcinoma: Systematic Review and Guidelines.

PURPOSE: For rectal cancer patients, the standard approach of chemotherapy, radiation therapy (RT), and surgery (Trimodality Therapy, TMT) is associated with significant long-term toxicity and/or colostomy for most patients. Patient options focused on quality-of-life (QOL) have dramatically improved, but there remains limited guidance regarding comparative effectiveness. This systematic review and associated guidelines evaluate how various treatment strategies compare to each other in terms of oncologic outcomes and QOL. MATERIALS AND METHODS: Cochrane and PRISMA methodology were used to search for prospective and retrospective trials and meta-analyses of adequate quality within the Ovid Medline database between 1/1/2012-6/15/2023. These studies informed the expert panel, which rated the appropriateness of various treatments in 6 clinical scenarios through a well-established consensus methodology (modified Delphi). RESULTS: The search process yielded 197 articles that advised voting. Increasing data show non-operative management (NOM) and primary surgery result in QOL benefits noted over TMT without detriment to oncologic outcomes. For rectal cancer patients for whom TME would result in permanent colostomy or inadequate bowel continence, NOM was strongly recommended as usually appropriate. Restaging with tumor response assessment 8-12 weeks following completion of RT/CRT was deemed a necessary component of NOM. The panel recommended active surveillance in the setting of a near complete or complete response. In the setting of NOM, 54-56 Gy in 27-33 fractions concurrent with chemotherapy and followed by consolidation chemotherapy was recommended. The panel strongly recommends primary surgery as usually appropriate for a T3N0 high rectal tumor for whom LAR and adequate bowel function is possible, with adjuvant chemotherapy considered if N+. CONCLUSIONS: Recent data supports NOM and primary surgery as important options that should be offered to eligible patients. Considering the complexity of multi-disciplinary management, patients should be discussed in a multi-disciplinary setting and therapy should be tailored to individual patient goals/values.

The Operative Management of Capitellum Fractures.

Capitellum fractures represent fewer than 1% of elbow fractures. Most commonly, these fractures occur secondary to either axial loading with the elbow fully extended or direct impact to the lateral aspect of the elbow. Numerous classification systems exist, with many types and subtypes. Since capitellum fractures are uncommon and fracture type varies widely, there is a lack of consensus with regard to treatment recommendations. We present a case series of seven patients with capitellum fractures, who presented between January 2016 and August 2020 to Addenbrooke's Hospital (Cambridge, the United Kingdom). All patients were female, with an average age of 33 years. In each case, the affected elbow joint was immobilised using a backslab before open reduction and internal fixation (ORIF) was performed. Joint mobility was recorded both on the day of the injury and at clinic review postoperatively (first at two weeks and then at between four and eight weeks). The Oxford Elbow Score (OES) was measured retrospectively, relating to (1) before the injury and (2) six months after fracture reduction. ORIF was associated with a near-full return of pronation and supination by eight weeks, with flexion-extension also improving significantly. The Oxford Elbow Score at six months reached 82.0% of pre-injury scores. Overall, our results suggest that ORIF is a well-tolerated and effective treatment strategy for capitellum fractures. Future studies with a greater sample size are required to assess the outcomes across a longer period, to determine whether outcomes are maintained and continue to improve.

The multidisciplinary management of locally advanced rectal cancer.

INTRODUCTION: The classic paradigm for the management of locally advanced rectal cancer (LARC) consists of (chemo)radiotherapy (C)RT), total mesorectal excision, and adjuvant chemotherapy (CHT). At present, due to the high rate of distant metastasis (up to 30%), the total neoadjuvant therapy (TNT) with the administration of systemic CHT in the neoadjuvant setting has gained acceptance as standard of care.Our aim is to critically review the current literature on LARC management and summarize the different approaches recently proposed to improve clinical outcomes. It represents a starting step to develop an effective strategy that ultimately could harmonize the standard of care in daily clinical practice. AREAS COVERED: Studies reporting the impact of TNT approaches were deemed eligible. De-escalation strategies, including non-operative management (NOM) after TNT, as well as RT omission or systemic therapy alone, were also investigated. EXPERT OPINION: The year 2020 has seen promising new data from randomized phase III trials in the field of LARC management. Nowadays, TNT strategy has been accepted as the primary treatment for LARC. The role of de-escalation strategies is still unknown. The goal is to achieve better survival outcomes with improving quality of life. Only selected patients are likely to benefit from NOM or immunotherapy alone.

Opportunity for Reduction of Intensive Care Unit Resource Utilization in Pediatric Blunt Liver and Spleen Injuries: A National Trauma Data Bank Analysis.

INTRODUCTION: Guidelines for blunt liver and spleen injury (BLSI) by the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium (ATOMAC) emphasize hemodynamic stability over injury grade when considering non-operative management (NOM). In this study, we examined rates of intensive care unit (ICU) admission for children with isolated low-risk BLSI among US hospitals. METHODS: The National Trauma Data Bank (NTDB) was queried for patients ages 1-15 admitted between 2017 and 2019 with BLSI. Patients with penetrating injuries and/or concomitant non-abdominal injuries with AIS score ≥3 were excluded. Isolated BLSI was considered low-risk if the patient had normal admission vitals and did not require operative intervention. Primary outcomes measured were ICU admission, ICU length of stay (LOS), and overall LOS. RESULTS: 5777 patients ages 15 and under presented with isolated BLSI during the study period. 2031/5777 (35.2%) were considered low-risk. Low-risk patients had lower rates of ICU admission compared to high-risk patients (30.9% vs. 41.6%, p < 0.001) and had shorter ICU LOS (median 2 days vs. 2, p < 0.001) and shorter overall LOS (median 41 h vs. 54, p < 0.001). Pediatric verified and non-pediatric verified trauma centers had similar rates of ICU admission (36.8% vs. 38.9%, p = 0.11). CONCLUSION: Further work is needed to capture opportunities for reduction in ICU utilization in isolated BLSI. LEVEL OF EVIDENCE: III.