Lack of Routine Postoperative Labs Not Associated With Complications in Pediatric Perforated Appendicitis.

INTRODUCTION: Postoperative (postop) management of pediatric perforated appendicitis varies significantly, and postop intra-abdominal abscesses (IAA) remain a significant issue. Between 2019 and 2020, our standardized protocol included routine postop labs after an appendectomy for perforated appendicitis. However, given the lack of predictive utility of these routine labs, we discontinued this practice in 2021. We hypothesize that discontinuing routine postop labs will not be associated with an increase in complication rates after an appendectomy for pediatric perforated appendicitis. METHODS: A single-institution, retrospective review of all pediatric appendectomies for perforated appendicitis from January 2019 to December 2021 was conducted at University Hospitals Rainbow Babies and Children's Hospital in Cleveland, Ohio. Data were collected on rate of complications (IAA development, re-admissions, bowel obstructions, superficial surgical site infections, intensive care unit transfers, Clostridium difficile infections, allergic reactions, and transfusions), postop imaging, postop interventions, and length of stay. Statistical analysis was completed using Fisher's exact test and Mann-Whitney U-test. RESULTS: A total of 109 patients (2019-2020 n = 61, 2021 n = 48) were included in the study. All 61 patients from 2019 to 2020 had postop labs compared to only eight patients in 2021. There was no statistically significant difference between the two groups in overall complication rates, but there was a decrease in IAAs reported in 2021 (P = 0.03). There were no statistically significant differences in other complications, postop imaging usage, or postop interventions. The median length of stay was 4.5 d in 2021 compared to 6.0 d in 2019-2020 (P = 0.009). CONCLUSIONS: Discontinuing routine postop labs is not associated with an increase in overall complications rates. Further studies are needed to determine whether routine postop labs can be safely removed in pediatric patients with perforated appendicitis, which would reduce patient discomfort and care costs.

Trends and Variations in Drain Use Following Pancreatoduodenectomy: Is Early Drain Removal Becoming More Common?

BACKGROUND: Although previous studies have noted the potential benefit of early drain removal (EDR) after pancreatoduodenectomy (PD), there is a paucity of data on the timing of drain removal utilizing a national database that reflect the "real world" setting. Given the ongoing controversy related to PD drain use and management, we sought to define trends in drain use among a large national cohort, as well as identify factors associated with EDR following PD. METHODS: The ACS NSQIP targeted pancreatectomy database was used to identify patients who underwent PD between 2014 and 2020. The trend in proportion of patients with EDR (removal ≤ POD3) as well as predictors of EDR were assessed. Risk-adjusted postoperative outcomes were evaluated by multivariable regression analysis. RESULTS: Among 14,356 patients, 16.2% of patients (N = 2324) experienced EDR, and the proportion of patients with EDR increased by 68% over the study period (2014: 10.9% vs. 2020: 18.3%, p < 0.001). Higher drain fluid amylase on POD1-3 [LogWorth (LW) = 44.3], operative time (LW = 33.2), and use of minimally invasive surgery (LW = 14.0) were associated with EDR. Additionally, EDR was associated with decreased risk of overall and serious morbidity, PD-related morbidity (e.g., pancreatic fistula), reoperation, prolonged length of stay and readmission (all p < 0.05). CONCLUSIONS: Routine drain placement remains a common practice among most surgeons. EDR following PD increased over time was associated with lower post-operative complications and shorter LOS. Despite evidence that EDR was safe and may even be associated with lower complications, only 1 in 6 patients were managed with EDR.

Drain Placement After Uncomplicated Hepatic Resection Increases Severe Postoperative Complication Rate: A Japanese Multi-institutional Randomized Controlled Trial (ND-trial).

OBJECTIVE: To assess the clinical impact of a no-drain policy after hepatic resection. SUMMARY OF BACKGROUND DATA: Previous randomized controlled trials addressing no-drain policy after hepatic resection seem inconclusive because they did not adopt appropriate study design to validate its true clinical impact. METHODS: This unblinded, randomized controlled trial was done at 7 Japanese institutions. Patients undergoing hepatic resection without biliary reconstruction were randomized to either D group or ND group. When the risk of postoperative bile leakage or hemorrhage were considered high, the patients were excluded during the operation. Primary endpoint was the postoperative complication of C-D grade 3 or higher within 90 postoperative days. A noninferiority of ND group to D group was assessed, and if it was confirmed, a superiority was assessed. RESULTS: Between May 2015 and July 2017, a total of 400 patients were finally included in the per-protocol set analysis: 199 patients in D group and 201 patients in ND group. Intraoperatively, 37 patients were excluded from the final enrollment because of high risk of bile leakage or hemorrhage. Postoperative complication rate of C-D grade 3 or higher was 8.0% (16/199) in the D group and 2.5% (5/201) in the ND group. The risk difference was -5.5% (95% confidence interval: -9.9% to -1.2%) and fulfilled the prescribed noninferiority margin of 4%. No postoperative mortality was experienced in both groups. Bile leakage was diagnosed in 8.0% (16/199) of the D group and none in the ND group (P < 0.001). In none of the subgroups classified based on 8 potentially relevant factors, drain placement was favored in terms of C-D grade 3 or higher complication. CONCLUSIONS: Drains should not be placed after uncomplicated hepatic resections.

A Mixed-Methods Evaluation of Clinician Education Modules on Reducing Surgical Opioid Prescribing.

BACKGROUND: In this study, we developed online interactive clinician education modules highlighting best practices to minimize opioid prescribing at discharge after surgery. The modules were implemented as part of a multicomponent quality improvement initiative across a six-hospital health system. This article describes the development and evaluation of this educational intervention. MATERIALS AND METHODS: Clinician education modules targeting surgical prescribers, nurses, and pharmacists were developed and implemented by an interdisciplinary team. Clinicians were invited to participate in an evaluation survey after completing the modules. Survey items assessed clinicians' rating of the module and intention to change clinical practice because of the module. Quantitative and qualitative survey responses were analyzed by the study team. RESULTS: A total of 2119 clinicians completed the module and 1831 of these clinicians (86.4%) completed the survey. Of clinicians completing the survey, 65.6% reported that they intend to change clinical practice after completing the module. Intended changes were related to increased knowledge and awareness, provider empowerment, opioid prescribing practices, nonopioid prescribing practices, and patient education. Many clinicians who indicated they do not intend to change practice reported that their clinical practices were already in line with module recommendations. Some clinicians did not perceive the module to be relevant to their role. CONCLUSIONS: Module completion was associated with the intention to improve clinical practice in areas related to provider empowerment, opioid prescribing, nonopioid prescribing, and patient education. Evaluation data will inform future module improvements. There is an opportunity to ensure that all clinicians, including those who are not prescribers, recognize their role in opioid stewardship.

A Meta-analysis of Jejunostomy Versus Nasoenteral Tube for Enteral Nutrition Following Esophagectomy.

BACKGROUND: Postoperative nutritional therapy is of paramount importance for patients undergoing esophagectomy. The jejunostomy and nasoenteral tube are the popular routes for nutritional therapy. However, which one is the preferred route is unclear. This study aims to analyze the differences in safety and efficacy of the two routes for nutritional therapy. MATERIALS AND METHODS: PubMed, Web of Science, Cochrane Library, and EMBASE (till September 17, 2020) were searched. The primary outcome was postoperative pneumonia. Secondary outcomes were the length of hospital stays (LOS), bowel obstruction, catheter dislocation, anastomotic leakage, overall postoperative complications, and postoperative albumin. Weighted mean differences (WMD) and odds ratios (OR) were calculated for statistical analysis. RESULTS: Ten studies involving a total of 1,531 patients in the jejunostomy group and 1,375 patients in the nasoenteral tube group were included. Compared with patients in the nasoenteral tube group, those in the jejunostomy group had a lower incidence of postoperative pneumonia (OR = 0.68, P < 0.001), shorter LOS (WMD = -0.85, P < 0.001), and lower risk of catheter dislocation (OR = 0.15, P = 0.001). There were no significant differences in the incidence of anastomotic leakage (OR = 0.84, P = 0.43), overall postoperative complications (OR = 0.87, P = 0.59), and postoperative albumin (WMD = -0.40, P = 0.24). However, patients in the jejunostomy group had a higher risk of bowel obstruction (OR = 8.42, P = 0.002). CONCLUSIONS: Jejunostomy for enteral nutrition showed superior outcomes in terms of postoperative pneumonia, LOS, and catheter dislocation. Jejunostomy may be the preferred enteral nutritional route following esophagectomy.

Rehabilitation following rotator cuff repair: A multi-centre pilot & feasibility randomised controlled trial (RaCeR).

OBJECTIVE: To evaluate the feasibility of a multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of early patient-directed rehabilitation versus standard rehabilitation following surgical repair of the rotator cuff of the shoulder. DESIGN: Two-arm, multi-centre pilot and feasibility randomised controlled trial. SETTING: Five National Health Service hospitals in England. PARTICIPANTS: Adults (n = 73) with non-traumatic rotator cuff tears scheduled for repair were recruited and randomly allocated remotely prior to surgery. INTERVENTIONS: Early patient-directed rehabilitation (n = 37); advised to remove their sling as soon as able and move as symptoms allow. Standard rehabilitation (n = 36); sling immobilisation for four weeks. MEASURES: (1) Randomisation of 20% or more eligible patients. (2) Difference in time out of sling of 40% or more between groups. (3) Follow-up greater than 70%. RESULTS: 73/185 (39%) potentially eligible patients were randomised. Twenty participants were withdrawn, 11 due to not receiving rotator cuff repair. The between-group difference in proportions of participants who exceeded the cut-off of 222.6 hours out of the sling was 50% (80% CI = 29%, 72%), with the early patient-directed rehabilitation group reporting greater time out of sling. 52/73 (71%) and 52/53 (98%) participants were followed-up at 12 weeks when withdrawals were included and excluded respectively. Eighteen full-thickness re-tears were reported (early patient-directed rehabilitation = 7, standard rehabilitation = 11). Five serious adverse events were reported. CONCLUSION: A main randomised controlled trial is feasible but would require allocation of participants following surgery to counter the issue of withdrawal due to not receiving surgery.

Efficiency and safety: comparison between preoperative analgesia and postoperative analgesia using non-steroidal anti-inflammatory drugs in patients receiving arthroscopic knee surgery in a multicenter, randomized, controlled study.

BACKGROUND: This study aimed to compare the efficiency regarding postoperative pain control, consumption of rescue drug, patients' satisfaction and the safety of preoperative analgesia versus postoperative analgesia using non-steroidal anti-inflammatory drugs (NSAIDs) in patients who received arthroscopic knee surgery (AKS). METHODS: Four hundred and sixty-four patients who received AKS were recruited in this multicenter, randomized, controlled study. Subsequently, they were randomized into PRE group (N = 232) and POST group (N = 232). In PRE group, patients received celecoxib, meloxicam or rofecoxib from 2 h pre-operation (Pre (- 2 h)) to 48 h post-operation for analgesia. In POST group, patients received celecoxib, meloxicam or rofecoxib from 4 to 48 h post-operation for analgesia. RESULTS: h and 12 h; pain VAS at passive movement was reduced in PRE group than POST group at 6 h, 12 h and 24 h. Additionally, consumption of rescue drug (pethidine) was decreased, while overall satisfaction was increased in PRE group compared to POST group. As for adverse events, the incidences of nausea, vomiting, constipation, drowsiness and dizziness were similar between PRE group and POST group. In subgroup analysis, the pain VAS score at passive movement at 6 h and nausea and constipation incidences were distinctive among subgroups categorized by meloxicam, celecoxib and rofecoxib administration. However, no difference of other assessments was found among subgroups categorized by meloxicam, celecoxib and rofecoxib administration. CONCLUSION: Preoperative analgesia using NSAIDs is more efficient and equivalently tolerable compared to postoperative analgesia using NSAIDs in patients who receive AKS.

Concomitant Aspirin and Anticoagulation Is Associated With Increased Risk for Major Bleeding in Surgical Patients Requiring Postoperative Intensive Care.

OBJECTIVES: Critically ill surgical patients may receive concomitant aspirin and therapeutic anticoagulation postoperatively, yet the safety of this practice remains unknown. We evaluated the risk of major bleeding with concomitant therapy compared with anticoagulation alone. DESIGN: Observational cohort study. Inverse probability of treatment weighting was used to assess the association between concomitant therapy and a primary outcome of major bleeding. SETTING: Postoperative ICUs at an academic medical center. PATIENTS: Adults (≥ 18 yr old) receiving anticoagulation during postoperative ICU admission between 2007 and 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Nine thousand five hundred eighteen anticoagulated patients were included, including 3,237 (34%) receiving aspirin. A total of 1,874 unique patients (19.7%) experienced a major bleeding event. In inverse probability of treatment weighting analyses, concomitant therapy was associated with increased odds for major bleeding (odds ratio, 1.20; 95% CI, 1.05-1.36; p = 0.006) compared with anticoagulation alone. An interaction test suggested a differential relationship between aspirin use and major bleeding based on aspirin use in the 7 days prior to anticoagulation, such that a strong association between aspirin and major bleeding was observed for recent initiators of aspirin (1.40; 1.13-1.72;p = 0.002) but not for those continuing prior aspirin use. Aspirin use prior to anticoagulation did not modify the relationship between concomitant therapy and new myocardial infarction or stroke (i.e., rates were not increased with aspirin discontinuation prior to anticoagulation). CONCLUSIONS: Concomitant aspirin and anticoagulation in critically ill surgical patients was associated with an increased rate of major bleeding. Future investigations are warranted to further define optimal management of antiplatelet therapy during anticoagulation in surgical patients.

The Role of Postoperative Imaging after Ventral Onlay Buccal Mucosal Graft Bulbar Urethroplasty.

PURPOSE: Our primary objective was to determine the incidence of extravasation on imaging at the time of catheter removal after ventral onlay buccal mucosal graft urethroplasty. MATERIALS AND METHODS: This is a single center retrospective cohort study of patients who underwent ventral onlay buccal mucosal graft bulbar urethroplasty from 2007 to 2017. Patients with imaging at the time of catheter removal were included. Urethroplasty success was defined as the ability to pass a 17Fr cystoscope at the time of followup cystoscopy. RESULTS: A total of 229 patients met the inclusion criteria, including 110 with a ventral onlay buccal mucosal graft and 119 with an augmented anastomotic urethroplasty with a mean stricture length of 4.4 cm. Imaging consisted of a voiding cystourethrogram in 210 and retrograde urethrogram in 19 patients at a median of 21.7 days after surgery. The incidence of extravasation was 3.1% (7/229). Of patients who had a documented followup cystoscopy (60%, 137/229), those with extravasation on imaging had a worse urethroplasty success rate (60%, 3/5) compared to those who did not (94%, 117/130) (p=0.047). On multivariate analysis those who had 5 or more endoscopic interventions were 9.6 times more likely to demonstrate extravasation (OR 9.6, p=0.0080). CONCLUSIONS: The incidence of radiological extravasation after ventral onlay using a single buccal mucosal graft, with or without augmented anastomotic urethroplasty, is 3.1%. Given this low rate it is reasonable to omit routine imaging at the time of Foley removal in this population. It appears that extravasation may be associated with a worse cystoscopic patency rate but does not lead to more complications.

Post-procedure protocol to facilitate next-day discharge: Results of the multidisciplinary, multimodality but minimalist TAVR study.

BACKGROUND: Evidence is lacking to standardize post-procedure care after transcatheter aortic valve replacement (TAVR). OBJECTIVE: We report on the findings of the post-procedure sub-study of the multimodality, multidisciplinary but minimalist TAVR (3M TAVR) study. METHODS: A standardized protocol to guide monitoring, early mobilization, reconditioning, communication, and criteria-driven discharge was implemented in a multicenter, prospective, sequential case series study in 13 North American low, medium, and high-volume centers in 2015-2017. Outcome measures pertaining to post-procedure care included avoidance of invasive lines and delirium, in-hospital bed utilization, patient disposition at the time of discharge, and 30-day use of nonelective medical services. RESULTS: Four hundred eleven participants were enrolled. In the post-procedure phase, 365 (88.8%) participants were admitted without a temporary pacemaker; urinary catheterization was avoided in 402 (97.8%) participants. Of note, 91.7% received care in a single unit (critical care: 72.5%; cardiac telemetry: 19.2%); 99.0% were discharged home. At the time of 30-day follow-up, 6 (1.6%) participants required admission to a rehabilitation or a skilled nursing facility; 30-day emergency department visits were 13.5%. CONCLUSIONS: The implementation of the 3M TAVR standardized accelerated reconditioning protocol is a safe and effective strategy to facilitate next-day discharge home after TAVR in centers of varying size.

Proton Pump Inhibitor Use After Hiatal Hernia Repair: Inhibitor of Recurrent Symptoms and Potential Revisional Surgery.

BACKGROUND: Hiatal hernia recurrence after hiatal hernia repair (HHR) is often underdiagnosed and underreported but may present with recurrent gastroesophageal reflux disease (GERD) symptoms. Because of their availability, proton pump inhibitor (PPI) use is common and may mask patients who would benefit from revisional surgery, which has been shown to improve symptoms and quality of life. METHODS: A retrospective analysis was performed to evaluate recurrence patterns of patients who underwent HHR, specifically for the indication of GERD, from 2007 to 2015 at a single Veterans Administration Medical Center. Clinicopathologic parameters were reviewed for association with hiatal hernia recurrence, including postoperative PPI use. RESULTS: Sixty-four patients were identified with a median follow-up time of 57.8 mo. Thirty-eight patients developed an anatomic recurrence, which did not demonstrate any associated factors on univariate analysis. Seventy percent of patients remained or were restarted on PPI after their initial surgery. For patients with a documented recurrence, the median time to start a PPI was 224 d, but the time to identify recurrence on imaging or endoscopy was 712.5 d. Eleven (39.3%) patients had a reintervention for anatomic recurrence, of which all had developed recurrent symptoms of GERD. CONCLUSIONS: Most patients who developed recurrent hiatal hernia were restarted on PPI without workup for their symptoms. The time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia. The use of PPIs in patients whom have undergone HHR may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms.

Is Routine Postoperative Anticoagulation Necessary in All Patients after First Rib Resection for Paget-Schroetter Syndrome?

BACKGROUND: Definitive treatment of Paget-Schroetter syndrome (PSS) involves first rib resection (FRR), division of the anterior scalene muscle, and resection of the subclavius muscle. This is a single-institution experience with PSS, according to a treatment algorithm of preoperative venogram (accompanied by lysis and percutaneous mechanical thrombectomy as needed) followed by transaxillary FRR. In the later period of this experience, patients have often been discharged on aspirin only, with no plan for anticoagulation postoperatively. We sought to evaluate outcomes in light of this experience and these practice patterns. METHODS: Between 2007 and 2018, 125 transaxillary FRRs were performed in 123 patients. All patients presented with documented venous thrombosis, underwent diagnostic venography and-if indicated-lysis and percutaneous mechanical thrombectomy (VPT) before FRR. The patient was not offered FRR if the vein could not be crossed with a wire and patency was not re-established during percutaneous treatment. The experience was divided into early (before 2012, n = 50) and late (n = 75) periods. RESULTS: Mean patient age was 28.4 (12-64 years) years. Of the cohort, 33 were high-level competitive athletes, 13 presented with documented pulmonary embolism in addition to local symptoms, and 3 had a cervical rib fused to the first rib. Patients underwent FRR a median of 50 (4 days to 18 years) days after their initial symptoms, and a median of 22 (1 day to 9 months) days after their percutaneous intervention. Postoperative VPT was required in 23 patients and performed a median of 5 (1-137 days) days postoperatively; in 19 of these patients, postoperative VPT was required for postoperative re-thrombosis, whereas in 4 patients, postoperative VPT was planned before FRR due to vein stenosis or residual thrombus. All these patients were prescribed postoperative anticoagulation. No operative venous reconstruction or bypass was performed. Median follow-up time after FRR was 242 days; at last follow-up, 98.4% (123/125) of axillosubclavian veins were patent by duplex ultrasound (and all those patients were asymptomatic). Postoperative anticoagulation was less frequently prescribed in the late experience, with no difference in the rate of early re-thrombosis or follow-up patency. CONCLUSIONS: This experience demonstrates 98.4% patency at last follow-up with standard preoperative percutaneous venography and intervention, transaxillary FRR, and postoperative endovascular re-intervention only in cases with persistent symptoms, stenosis, or re-thrombosis. Patients presenting with both acute and chronic PSS did not require surgical venous reconstruction. In the later experience, patients frequently have not been anticoagulated postoperatively. Advantages of this algorithm include the following: (1) the cosmetic benefits of the transaxillary approach, (2) the preoperative assessment of the ability to recanalize the vein to determine which patients will benefit from surgery, (3) the capacity to use thrombolysis preoperatively, and (4) potential elimination of the risk and inconvenience of postoperative anticoagulation.

Patient Injuries in Treatment of Peripheral Arterial Disease in Finland: Review of National Patient Insurance Charts.

BACKGROUND: Patient injury claim data and insurance records constitute detailed sources of information on patient injuries and their contributing or causal factors. This study aimed to identify the unintended incidents that lead to patient injuries in vascular surgery in the treatment of peripheral arterial disease (PAD) in Finland. METHODS: The records of all accepted patient injury claims involving PAD between 2004 and 2017 inclusive were obtained from the nationwide Finnish Patient Insurance Centre registry and were reviewed. Factors contributing to injury were classified by patient careflow. RESULTS: Sixty-nine patient injury incidents were identified in 60 treated patients with PAD. Sixteen injuries (23.2%) were related to outpatient or preoperative care. Twenty-seven injuries (39.1%) were caused by incidents in performing open or endovascular procedures, and 26 injuries (37.7%) were related to postoperative care. Delay in treatment affected 11 (18.3%) patients. Incidents involving surgical technique were identified in the treatment of 13 (21.7%) patients. Retained foreign material caused injuries to four (6.7%) patients. Five (8.3%) patients suffered from postoperative hemorrhage and eleven (18.3%) from infection damage. Delay in treatment resulted in two major amputations. Technical problems in bypass operations led to the loss of the bypass graft and to reoperation. Three nerve injuries led to permanent disability. One (1.7%) patient died because of fatal postoperative bleeding after being discharged from the hospital. CONCLUSIONS: Compensated patient injuries in the treatment of PAD are rare. Injuries occur during all stages of care and are caused by both surgical system procedural failures and common complications.

Allogeneic Leukocyte-Reduced Red Blood Cell Transfusion Is Associated with Postoperative Infectious Complications and Cancer Recurrence after Colon Cancer Resection.

BACKGROUND/AIMS: Transfusion rates in colon cancer surgery are traditionally very high. Allogeneic red blood cell (RBC) transfusions are reported to induce immunomodulation that contributes to infectious morbidity and adverse oncologic outcomes. In an effort to attenuate these effects, the study institution implemented a universal leukocyte reduction protocol. The purpose of this study was to examine the impact of leukocyte-reduced (LR) transfusions on postoperative infectious complications, recurrence-free survival, and overall survival (OS). METHODS: In a retrospective study, patients with stage I-III adenocarcinoma of the colon from 2003 to 2010 who underwent elective resection were studied. The primary outcome measures were postoperative infectious complications and recurrence-free and OS in patients that received a transfusion. Bivariate and multivariable regression analyses were performed for each endpoint. RESULTS: Of 294 patients, 66 (22%) received a LR RBC transfusion. After adjustment, transfusion of LR RBCs was found to be independently associated with increased infectious complications (OR 3.10, 95% CI 1.24-7.73), increased odds of cancer recurrence (hazard ratio [HR] 3.74, 95% CI 1.94-7.21), and reduced OS when ≥3 units were administered (HR 2.24, 95% CI 1.12-4.48). CONCLUSION: Transfusion of LR RBCs is associated with an increased risk of infectious complications and worsened survival after elective surgery for colon cancer, irrespective of leukocyte reduction.

No benefit of early versus late ambulation after incidental durotomy in lumbar spine surgery: a randomized controlled trial.

PURPOSE: Incidental durotomy (ID) is a complication occurring in 4-17% of decompressive spinal surgeries. Persisting CSF leakage can occur even after ID repair and requires revision surgery. Prolonged flat bed rest (BR) to reduce the incidence of persisting CSF leakage is frequently applied but highly debated. A randomized controlled trial comparing prolonged BR versus early ambulation after ID repair is lacking. The aim of this study was to investigate the incidence of revision surgery as a result of persistent cerebro-spinal fluid (CSF) leakage and medical complications after immediate or late post-operative ambulation following ID during decompressive spinal surgery. METHODS: Ninety-four of 1429 consecutive cases undergoing lumbar spine surgery (6.58%) were complicated by an ID. Sixty patients (mean age of 64 ± 13.28 years) were randomized to either early post-operative ambulation (EA, n = 30) or flat BR for 48 h (BR, n = 30). The incidence of CSF leakage resulting in revision surgery, medical complications and duration of hospitalization were compared between groups. RESULTS: Two patients in the BR group and two patients in the EA group underwent revision surgery as a result of persisting CSF leakage. Four patients in the BR group experienced medical complications associated with prolonged immobilization. The duration of hospitalization was 7.25 ± 3.0 days in the BR group versus 6.56 ± 2.64 days in the EA group, p = 0.413. CONCLUSION: The results of this study indicate no benefit of prolonged BR after an adequately repaired ID in lumbar spine surgery. LEVEL OF EVIDENCE: Level 1b (individual randomized controlled trial). These slides can be retrieved under Electronic Supplementary Material.

Prior smoking and nasoseptal flap usage adversely impact quality of life and healing after endoscopic pituitary surgery.

OBJECTIVE: Endoscopic pituitary surgery (EPS) via the endonasal transsphenoidal approach is well established as an effective treatment modality for sellar masses. The objective of this study was to determine the relationship between key patient and operative variables and rhinological outcomes as determined by the 22-item Sino-Nasal Outcome Test (SNOT-22) and endoscopic scores following EPS. METHODS: Prospectively collected SNOT-22 scores and objective endoscopic data were analyzed from a cohort of 109 patients who underwent EPS and had at least 90 days of postoperative follow-up. Trends in postoperative SNOT-22 scores were analyzed using linear mixed-effects models. Time to return to baseline endoscopic score was analyzed using Cox regression. RESULTS: After adjusting for age and sex, the authors found that prior smokers had higher total and rhinological subdomain SNOT-22 scores (p < 0.01, 95% CI 5.82-16.39; p = 0.01, 95% CI 1.38-5.09, respectively) following EPS. Nasoseptal flap use also showed higher total and rhinological subdomain SNOT-22 scores (p = 0.01, 95% CI 1.62-12.60; p = 0.02, 95% CI 0.42-4.30, respectively). Prior sinonasal surgery and concurrent septoplasty did not affect the change in SNOT-22 total scores over time (p = 0.08, 95% CI -0.40 to 0.02; p = 0.33, 95% CI -0.09 to 0.29). CONCLUSIONS: The findings suggest that the evolution of healing and patient-reported quality of life (QOL) measures are multifaceted with contributions from two key variables. Nasoseptal flap usage and prior smoking status may adversely impact postoperative QOL. No variables were found to be associated with objective postoperative endoscopic findings.

Deep venous thrombosis after Achilles tendon rupture is associated with poor patient-reported outcome.

PURPOSE: The aim of this study was to investigate whether patient subjective and functional outcomes after Achilles tendon rupture (ATR) are related to deep venous thrombosis (DVT) during leg immobilization. METHODS: A cohort study with prospectively collected randomized data was conducted between 2010 and 2017. Two-hundred and fifty-one Patients with an Achilles tendon rupture (mean age = 41 ± 8), treated with uniform surgical techniques, were retrospectively analyzed. DVT incidence at 2 and 6 weeks was assessed using compression duplex ultrasound. At 12 months patient-reported outcomes were assessed using the Achilles tendon Total Rupture Score (ATRS), Foot- and Ankle Outcome Score (FAOS), Physical Activity Scale (PAS) and functional outcome with the calf-muscle endurance test. ANOVA analyses were used and adjusted for assumed confounding factors (patient age, sex, BMI and rehabilitation). RESULTS: The total DVT incidence was 122 out of 251 (49%). Patients suffering a DVT exhibited significantly lower ATRS at 1 year compared to patients without DVT (mean 76 vs 83, 95% CI 71-79 vs 80-87; p < 0.01). Sixty-seven percent (95% CI 57-77%) of the patients devoid of DVT reported a good outcome (ATRS > 80) compared to 51% (95% CI 41-61%) of the patients sustaining a DVT (p < 0.05). Quality of life displayed significantly better outcome in the non-DVT versus DVT patients (mean = 75 (95% CI 71-79) vs. mean = 68 (95% CI 64-72); p < 0.05). A significant difference in total concentric work was observed between non-DVT and DVT patients (median = 1.9 kJ (IQR = 0.9 kJ) vs. median = 1.6 kJ (IQR = 1.0 kJ); p < 0.01). CONCLUSION: Sustaining a DVT during leg immobilization significantly impairs patient-reported outcome at 1 year after surgical repair of ATR. LEVEL OF EVIDENCE: III.

The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial.

BACKGROUND: The application of telehealth for surgical follow-up has gained recent exposure in orthopedic care. Although the results following joint arthroplasty are encouraging, the role of telemedicine for postoperative care following arthroscopic rotator cuff repair still needs to be defined. The goal of this study was to evaluate the safety, efficacy, and socioeconomic benefits of telehealth as a platform for postoperative follow-up. METHODS: This was a prospective, randomized controlled trial that enrolled 66 patients who underwent follow-up in the office vs. via telemedicine for postoperative visits at 2, 6, and 12 weeks after surgery. Post-visit surveys were administered to patients and physicians via e-mail, and the Student t test and Fisher exact test were used to compare responses. RESULTS: In total, 58 patients (88%) completed the study (28 telehealth vs. 30 control). Patients in each group demonstrated similar pain scores at each follow-up visit (P = .638, P = .124, and P = .951) and similar overall satisfaction scores (P = .304). Patients in the telehealth group expressed a stronger preference for telehealth than their control counterparts (P < .001). Telehealth visits were less time-consuming from both a patient (P < .001) and physician (P = .002) perspective. Telehealth visits also required less time off work for both patients (P = .001) and caregivers (P < .001). CONCLUSION: Patients undergoing arthroscopic rotator cuff surgery were able to receive safe and effective early postoperative follow-up care using telemedicine. The preference for telehealth increased for both surgeons and patients following first-hand experience. The use of a telehealth platform is a reasonable follow-up model to consider for patients seeking convenient and efficient care following arthroscopic rotator cuff repair.

Preoperative Pneumoperitoneum: Low-Risk Surgical Adjunct to the Surgical Management of Dense Abdominal Adhesions.

Surgical lysis of intra-abdominal adhesions is associated with a high rate of complications. This brief report presents 24 patients with dense intra-abdominal adhesions who underwent preoperative progressive pneumoperitoneum (PPP) prior to surgical lysis of adhesions. PPP was successfully performed in 23 patients, with few adverse events, resulting in subjectively improved ease of intraoperative tissue dissection. One patient withdrew due to intractable pain during insufflation. The results suggest that PPP is a low-risk technique with the potential to improve access to intra-abdominal structures in patients for whom conventional surgical therapy is predicted to carry a high rate of complications.

Immediate versus delayed removal of urinary catheter after laparoscopic hysterectomy: a randomised controlled trial.

OBJECTIVE: To evaluate if immediate catheter removal (ICR) after laparoscopic hysterectomy is associated with similar retention outcomes compared with delayed removal (DCR). STUDY DESIGN: Non-inferiority randomised controlled trial. POPULATION: Women undergoing laparoscopic hysterectomy in six hospitals in the Netherlands. METHODS: Women were randomised to ICR or DCR (between 18 and 24 hours after surgery). PRIMARY OUTCOME: The inability to void within 6 hours after catheter removal. RESULTS: One hundred and fifty-five women were randomised to ICR (n = 74) and DCR (n = 81). The intention-to-treat and per-protocol analysis could not demonstrate the non-inferiority of ICR: ten women with ICR could not urinate spontaneously within 6 hours compared with none in the delayed group (risk difference 13.5%, 5.6-24.8, P = 0.88). However, seven of these women could void spontaneously within 9 hours without additional intervention. Regarding the secondary outcomes, eight women from the delayed group requested earlier catheter removal because of complaints (9.9%). Three women with ICR (4.1%) had a urinary tract infection postoperatively versus eight with DCR (9.9%, risk difference -5.8%, -15.1 to 3.5, P = 0.215). Women with ICR mobilised significantly earlier (5.7 hours, 0.8-23.3 versus 21.0 hours, 1.4-29.9; P ≤ 0.001). CONCLUSION: The non-inferiority of ICR could not be demonstrated in terms of urinary retention 6 hours after procedure. However, 70% of the women with voiding difficulties could void spontaneously within 9 hours after laparoscopic hysterectomy. It is therefore questionable if all observed urinary retention cases were clinically relevant. As a result, the clinical advantages of ICR may still outweigh the risk of bladder retention and it should therefore be considered after uncomplicated laparoscopic hysterectomy. TWEETABLE ABSTRACT: The advantages of immediate catheter removal after laparoscopic hysterectomy seem to outweigh the risk of bladder retention.