Perioperative outcome assessment from the perspectives of different stakeholders: need for reconsideration?

Standardised and universal perioperative endpoint reporting are the cornerstone for outcomes assessment, reliable clinical trials, and health services research. The Outcome4medicine initiative recently reported consensus recommendations on how to assess the quality of surgical interventions, proposing a framework for surgical outcome assessment and quality improvement after medical interventions. In the same field, the Standardised Endpoints in Perioperative Medicine - Core Outcome Measures for Perioperative and Anaesthetic Care (StEP-COMPAC) group recently proposed standardised and valid measures of mortality and morbidity, derived from a three-stage Delphi process. Here a core group of the Outcome4medicine conference discusses how these two initiatives are aligned and emphasises the importance of standardised outcome assessment by integrating the perspectives of different stakeholders.

An Assessment of the Pathological Classification and Postoperative Outcome of Focal Cortical Dysplasia by Simultaneous Hybrid PET/MRI.

OBJECTIVES: The purpose of this research was to investigate whether MRI and Simultaneous Hybrid PET/MRI images were consistent in the histological classification of patients with focal cortical dysplasia. Additionally, this research aimed to evaluate the postoperative outcomes with the MRI and Simultaneous Hybrid PET/MRI images of focal cortical dysplasia. METHODS: A total of 69 cases in this research were evaluated preoperatively for drug-resistant seizures, and then surgical resection procedures of the epileptogenic foci were performed. The postoperative result was histopathologically confirmed as focal cortical dysplasia, and patients then underwent PET and MRI imaging within one month of the seizure. In this study, head MRI was performed using a 3.0 T magnetic resonance scanner (Philips) to obtain 3D T1WI images. The Siemens Biograph 16 scanner was used for a routine scanning of the head to obtain PET images. BrainLAB's iPlan software was used to fuse 3D T1 images with PET images to obtain PET/MRI images. RESULTS: Focal cortical dysplasia was divided into three types according to ILAE: three patients were classified as type I, twenty-five patients as type II, and forty-one patients as type III. Patients age of onset under 18 and age of operation over 18 had a longer duration (p = 0.036, p = 0.021). MRI had a high lesion detection sensitivity of type III focal cortical dysplasia (p = 0.003). Simultaneous Hybrid PET/MRI showed high sensitivity in detecting type II and III focal cortical dysplasia lesions (p = 0.037). The lesions in Simultaneous Hybrid PET/MRI-positive focal cortical dysplasia patients were mostly located in the temporal and multilobar (p = 0.005, 0.040). CONCLUSION: Simultaneous Hybrid PET/MRI has a high accuracy in detecting the classification of focal cortical dysplasia. The results of this study indicate that patients with focal cortical dysplasia with positive Simultaneous Hybrid PET/MRI have better postoperative prognoses.

A Symmetry-Based Superposition Method for Planning and Surgical Outcome Assessment.

Computer-aided surgical planning has been widely used to increase the safety and predictability of surgery. The validation of the target of surgical planning to surgical outcomes on a patient-specific model is an important issue. The aim of this research was to develop a robust superposition method to assess the deviation of planning and outcome by using the symmetrical characteristic of the affected target. The optimal symmetry plane (OSP) of an object is usually used to evaluate the degree of symmetry of an object. We proposed a refined OSP-based contouring method to transfer a complex three-dimensional superposition operation into two dimensions. We compared the typical iterative closest point (ICP) algorithm with the refined OSP-based contouring method and examined the differences between them. The results using the OSP-based method were much better than the traditional method. As for processing time, the OSP-based contouring method was 11 times faster than the ICP method overall. The proposed method was not affected by the metallic artifacts from medical imaging or geometric changes due to surgical intervention. This technique can be applied for post-operative assessment, such as quantifying the differences between surgical targets and outcomes as well as performing long-term medical follow-up.

Assessment of ultrasound features of placenta accreta spectrum in women at high risk: association with outcome and interobserver concordance.

OBJECTIVES: To evaluate the prenatal ultrasound features associated with operative complications and to assess the interobserver agreement of prenatal ultrasound assessment with histopathologic confirmation of placenta accreta spectrum (PAS) in a cohort of high-risk patients with detailed intraoperative and histopathologic data. METHODS: This was a retrospective multicenter cohort study of patients at high risk of PAS referred for specialist perinatal care and management between January 2019 and May 2022. Deidentified ultrasound images were reviewed independently by two experienced operators blinded to clinical details, intraoperative features, outcome and histopathologic findings. The diagnosis of PAS was confirmed by failure of detachment of one or more placental cotyledons from the uterine wall at delivery, and the absence of decidua with distortion of the uteroplacental interface by fibrinoid deposition on histologic examination of the accretic areas obtained by guided sampling of partial myometrial resection or hysterectomy specimens. Patients were categorized as having a low or high likelihood of PAS at birth. Interobserver agreement of prenatal ultrasound assessment with histopathologic confirmation of PAS was assessed using the kappa statistic. Primary outcome was major operative morbidity (blood loss ≥ 2000 mL, unintentional injury to the viscera, admission to intensive care unit or death). RESULTS: A total of 102 women at high risk of PAS were referred, of whom 66 had evidence of PAS at birth and 36 did not. When blinded to other clinical details, the examiners agreed on the low or high probability of PAS, according to ultrasound features, in 75/102 cases (73.5%). The kappa statistic was 0.47 (95% CI, 0.28-0.66), showing moderate agreement. Morbidity was twice as common with concordant prenatal diagnosis of PAS vs concordant diagnosis of not PAS. Concordant assessment of high probability of PAS was associated with the highest morbidity (66.6%) and a very high (97.6%) likelihood of histopathologic confirmation. CONCLUSIONS: The probability of histopathologic confirmation is very high with concordant prenatal assessment suggestive of PAS. The interobserver agreement for preoperative assessment with histopathologic confirmation of PAS is only moderate. Morbidity is associated with both histopathologic diagnosis and concordant antenatal assessment of PAS. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A prospective study of sequential hepatic vein embolization after portal vein embolization in patients scheduled for right-sided major hepatectomy: Results of feasibility and surgical strategy using functional liver assessment.

BACKGROUND: Hepatic vein embolization (HVE) added to portal vein embolization (PVE) can further increase future remnant liver volume (FRLV) compared with PVE alone. This study was aimed to evaluate feasibility of sequential HVE in a prospective trial and to verify surgical strategy using functional FRLV (fFRLV). METHODS: Hepatic vein embolization was prospectively indicated for post-PVE patients scheduled for right-sided major hepatectomy if the resection limit of fFRLV using EOB-magnetic resonance imaging was not satisfied. The resection limit was fFRLV: 615 mL/m2 for predicting post-hepatectomy liver failure. Patients who underwent sequential PVE-HVE (n = 12) were compared with those who underwent PVE alone (n = 31). RESULTS: All patients underwent HVE with no severe complications. Median fFRLV increased from 396 (range: 251-581) to 634 (range: 422-740) mL/m2 by sequential PVE-HVE. From PVE to HVE, both of FRLV (P < .001) and fFRLV (P = .005) significantly increased. The increased width of fFRLV was larger than that of FRLV after performing HVE. Median growth rate was 71.3 (range: 33.3-80.3) %, which was higher than that of PVE alone (27.0%, range: 6.0-78.0). All-cohort resection rate was 88.3%. Strategy of using fFRLV for the resection limit and performing HVE in patients with insufficient functional volume resulted in no liver failure in all patients who underwent hepatectomy. CONCLUSIONS: Sequential HVE after PVE is feasible and safe, and HVE induced possibility of further liver growth and its functional improvement. Our surgical strategy using fFRLV may be justified.

Mastectomy and Immediate Breast Reconstruction with Pre-Pectoral or Sub-Pectoral Implant: Assessing Clinical Practice, Post-Surgical Outcomes, Patient's Satisfaction and Cost.

Immediate breast reconstruction (IBR) rates increase during last years and implant-based reconstruction was the most commonly performed procedure. We examined data collected over 25 months to assess complication rate, duration of surgery, patient's satisfaction and cost, according to pre-pectoral or sub-pectoral implant-IBR. All patients who received an implant-IBR, from January 2020 to January 2022, were included. Results were compared between pre-pectoral and sub-pectoral implant-IBR in univariate and multivariate analysis. We performed 316 implant-IBR, 218 sub-pectoral and 98 (31%) pre-pectoral. Pre-pectoral implant-IBR was significantly associated with the year (2021: OR=12.08 and 2022: OR=76.6), the surgeons and type of mastectomy (SSM vs NSM: OR=0.377). Complications and complications Grade 2-3 rates were 12.9% and 10.1% for sub-pectoral implant-IBR respectively, without significant difference with pre-pectoral implant-IBR: 17.3% and 13.2%. Complications Grade 2-3 were significantly associated with age <50-years (OR=2.27), ASA-2 status (OR=3.63) and cup-size >C (OR=3.08), without difference between pre and sub-pectoral implant-IBR. Durations of surgery were significantly associated with cup-size C and >C (OR=1.72 and 2.80), with sentinel lymph-node biopsy and axillary dissection (OR=3.66 and 9.59) and with sub-pectoral implant-IBR (OR=2.088). Median hospitalization stay was 1 day, without difference between pre and sub-pectoral implant-IBR. Cost of surgery was significantly associated with cup-size > C (OR=2.216) and pre-pectoral implant-IBR (OR=8.02). Bad-medium satisfaction and IBR-failure were significantly associated with local recurrence (OR=8.820), post-mastectomy radiotherapy (OR=1.904) and sub-pectoral implant-IBR (OR=2.098). Conclusion: Complications were not different between pre and sub-pectoral implant-IBR. Pre-pectoral implant-IBR seems a reliable and faster technique with better patient satisfaction but with higher cost.

Assessment of biochemical outcomes in patients with primary aldosteronism after adrenalectomy based on CT scan diagnosis of unilateral adenoma without adrenal vein sampling.

Purpose: The purpose of this study was to assess the surgical outcomes of patients with primary aldosteronism when surgery was based only on CT finding of unilateral adenoma without adrenal vein sampling (AVS). Methods: This is a retrospective review of the records of patients who had undergone retroperitoneal laparoscopic adrenalectomy for primary aldosteronism based on CT scan finding of unilateral adenoma and had a follow-up of at least 6-12 months from January 2012 to December 2020 in a single center; decision for adrenalectomy was based on CT scan, and AVS was not used. The clinical and biochemical outcomes were accessed using the standardized primary aldosteronism surgical outcome (PASO) criteria. Patient's demographics and preoperative factors were analyzed to assess for independent predictor of surgical success. Results: According to the PASO criteria, 172 patients finally enrolled in the training dataset, and 20 patients enrolled in the validation dataset. In the training dataset, complete clinical success was achieved in 71 patients (41.3%), partial success in 87 (50.6%), and absent success in 14 (8.1%). Biochemical outcomes showed that 151 patients (87.8%) were completely cured, 14 patients (8.1%) got a partial biochemical success, and an absent biochemical success was found in seven patients (4.1%). Multivariate logistic regression analysis showed that age, body mass index (BMI), tumor size, mean arterial pressure (MAP), and serum potassium were the most independent factors for incomplete biochemical success. Based on the results of statistical analysis, our study constructed a nomogram prognostic evaluation model for patients after unilateral primary aldosterone surgery. Conclusions: Laparoscopic adrenalectomy for patients with primary aldosteronism base on CT scan finding of a unilateral adenoma without AVS had a high rate of complete biochemical cure at 12 months. Risk factors for incomplete biochemical success include age, BMI, tumor size, MAP, and serum potassium. Our study constructed a nomogram prognostic evaluation model for patients after unilateral primary aldosterone surgery. The nomogram accurately and reliably predicted the incomplete biochemical success.

Computed tomography angiography assessment of the degree of simple coarctation of the aorta and its relationship with surgical outcome: A retrospective analysis.

Objective: To investigate the correlation between the degree of aortic coarctation and surgical prognosis in infants with simple coarctation of the aorta (CoA) using computed tomography angiography (CTA). Methods: This study was a retrospective study. Twenty-seven infants with simple CoA who underwent surgical correction from January 2020 to June 2022 were enrolled. Aortic diameters were measured at five different levels and normalized to Z scores based on the square root of body surface area. The relevant data were collected and analyzed, and the predictors associated with surgical outcome were determined. Results: Patients were divided into the mild CoA group and the severe CoA group according to the severity of coarctation. The mechanical ventilation duration and the length of ICU stay in the mild CoA group were significantly lower than those in the severe CoA group. Multiple linear regression analyses revealed that the degree of aortic coarctation was a significant risk factor for a prolonged postoperative ICU stay. In addition, gestational age and age at operation were risk factors for a prolonged postoperative ICU stay. Correlation analysis showed that the degree of aortic coarctation correlated with the Z scores of the ascending aorta and postcoarctation aorta. Conclusion: The degree of the CoA is an important predictor of surgical outcomes in infants with simple CoA and was significantly correlated with the ascending aorta and postcoarctation aorta Z scores. Therefore, preoperative CTA should be routinely performed to assess the degree of aortic coarctation and better identify risk factors.

Socioeconomic Differences between Sexes in Surgically Treated Carpal Tunnel Syndrome and Ulnar Nerve Entrapment.

We aimed to investigate socioeconomic differences between sexes and the influence on outcome following surgery for carpal tunnel syndrome (CTS) or ulnar nerve entrapment (UNE) at the elbow. Patients with CTS (n = 9000) or UNE (n = 1266) registered in the Swedish National Register for Hand Surgery (HAKIR) 2010-2016 were included and evaluated using QuickDASH 12 months postoperatively. Statistics Sweden (SCB) provided socioeconomic data. In women with CTS, being born outside Sweden, having received social assistance, and more sick leave days predicted worse outcomes. Higher earnings and the highest level of education predicted better outcomes. In men with CTS, more sick leave days and having received social assistance predicted worse outcomes. Higher earnings predicted better outcomes. For women with UNE, higher earnings predicted better outcomes. In men with UNE, only sick leave days predicted worse outcomes. In long-term follow up, socioeconomic status affects outcomes differently in women and men with CTS or UNE.

The association between video-based assessment of intraoperative technical performance and patient outcomes: a systematic review.

BACKGROUND: Efforts to improve surgical safety and outcomes have traditionally placed little emphasis on intraoperative performance, partly due to difficulties in measurement. Video-based assessment (VBA) provides an opportunity for blinded and unbiased appraisal of surgeon performance. Therefore, we aimed to systematically review the existing literature on the association between intraoperative technical performance, measured using VBA, and patient outcomes. METHODS: Major databases (Medline, Embase, Cochrane Database, and Web of Science) were systematically searched for studies assessing the association of intraoperative technical performance measured by tools supported by validity evidence with short-term (≤ 30 days) and/or long-term postoperative outcomes. Study quality was assessed using the Newcastle-Ottawa Scale. Results were appraised descriptively as study heterogeneity precluded meta-analysis. RESULTS: A total of 11 observational studies were identified involving 8 different procedures in foregut/bariatric (n = 4), colorectal (n = 4), urologic (n = 2), and hepatobiliary surgery (n = 1). The number of surgeons assessed ranged from 1 to 34; patient sample size ranged from 47 to 10,242. High risk of bias was present in 5 of 8 studies assessing short-term outcomes and 2 of 6 studies assessing long-term outcomes. Short-term outcomes were reported in 8 studies (i.e., morbidity, mortality, and readmission), while 6 reported long-term outcomes (i.e., cancer outcomes, weight loss, and urinary continence). Better intraoperative performance was associated with fewer postoperative complications (6 of 7 studies), reoperations (3 of 4 studies), and readmissions (1 of 4 studies). Long-term outcomes were less commonly investigated, with mixed results. CONCLUSION: Current evidence supports an association between superior intraoperative technical performance measured using surgical videos and improved short-term postoperative outcomes. Intraoperative performance analysis using video-based assessment represents a promising approach to surgical quality-improvement.

Insulin-Like Growth Factor 1 in the Early Postoperative Assessment of Acromegaly.

OBJECTIVES: Assessment of surgical outcome in acromegaly is typically recommended at 3 to 6 months following surgery. The purpose of this study was to determine if insulin-like growth factor 1 (IGF-1) concentrations at 6 weeks were equally predictive of surgical outcomes compared with IGF-1 concentrations at 3 to 6 months postoperatively applying newer IGF-1 assays. METHODS: Retrospective review of patients with newly diagnosed acromegaly who had surgery between 2013 and 2020 and had postoperative IGF-1 measured by 6 weeks and 3 to 6 months. RESULTS: At 6 weeks, 20 (35%) of the total 57 had normal IGF-1 and became abnormal in 1 at 3 to 6 months, whereas 37 (65%) of 57 had abnormal IGF-1 concentrations at 6 weeks, which normalized in 1 patient by 3 to 6 months. In patients who changed clinical status, IGF-1 at 6 weeks was within ±0.1-fold of normal. Although a difference was seen between median IGF-1 concentrations (286 vs 267 ng/mL, P = .009) at 6 weeks and 3 to 6 months, the mean reduction was small (-19.9 ng/mL). CONCLUSIONS: Compared with 3 to 6 months, use of IGF-1 at 6 weeks was associated with a change in clinical status in 3.5% of patients. Therefore, in most patients, IGF-1 at 6 weeks can be used to assess clinical outcome via newer assays.

Surgical Assessment of Tissue Quality during Pelvic Organ Prolapse Repair in Postmenopausal Women Pre-Treated Either with Locally Applied Estrogen or Placebo: Results of a Double-Masked, Placebo-Controlled, Multicenter Trial.

The aim of this prospective randomized, double-masked, placebo-controlled, multicenter study was to analyze the surgeon's individual assessment of tissue quality during pelvic floor surgery in postmenopausal women pre-treated with local estrogen therapy (LET) or placebo cream. Secondary outcomes included intraoperative and early postoperative course of the two study groups. Surgeons, blinded to patient's preoperative treatment, completed an 8-item questionnaire after each prolapse surgery to assess tissue quality as well as surgical conditions. Our hypothesis was that there is no significant difference in individual surgical assessment of tissue quality between local estrogen or placebo pre-treatment. Multivariate logistic regression analysis was performed to identify independent risk factors for intra- or early postoperative complications. Out of 120 randomized women, 103 (86%) remained for final analysis. Surgeons assessed the tissue quality similarity in cases with or without LET, representing no statistically significant differences concerning tissue perfusion, tissue atrophy, tissue consistency, difficulty of dissection and regular pelvic anatomy. Regarding pre-treatment, the rating of the surgeon correlated significantly with LET (r = 0.043), meaning a correct assumption of the surgeon. Operative time, intraoperative blood loss, occurrence of intraoperative complications, total length of stay, frequent use of analgesics and rate of readmission did not significantly differ between LET and placebo pre-treatment. The rate of defined postoperative complications and use of antibiotics was significantly more frequent in patients without LET (p = 0.045 and p = 0.003). Tissue quality was similarly assessed in cases with or without local estrogen pre-treatment, but it seems that LET prior to prolapse surgery may improve vaginal health as well as tissue-healing processes, protecting these patients from early postoperative complications.

Using Smartphones for Clinical Assessment in Cervical Spondylotic Myelopathy a Feasibility Study.

Degenerative cervical myelopathy (DCM) is characterized by a progressive deterioration in spinal cord function. Its evaluation requires subjective clinical examination with wide interobserver variability. Objective quantification of spinal cord function remains imprecise, even though validated myelopathy-grading scales have emerged and are now widely used. We created a Smartphone Application, the N-Outcome App, with the aim of quantifying accurately and reliably spinal cord dysfunction using a 5-minute Test. A patient suffering from DCM was clinically evaluated before surgery, at 3 and 6 months follow-up after surgical decompression of the cervical spinal cord. Standard scores (Nurick grade, modified Japanese Orthopedic Association (mJOA) score) were documented at these time points. A 5-minute motor and proprioceptive performance test aided by a smartphone with the N-outcome App was also performed. Motor performance in rapid alternating movements and finger tapping improved in correlation with improvements in standard grading scale scores. Clinical improvements were seen in maximum reflex acceleration and in Romberg testing which showed less closed/open eyes variation, suggesting pyramidal and proprioceptive function recovery. We demonstrate that using the N-Outcome App as an adjunct to clinical evaluation of compressive myelopathy is feasible and potentially useful. The results correlate with the results of clinical assessment obtained by standard validated myelopathy scores.

Surgical Outcomes, Health Care Utilization, and Costs Associated with Staple Line Buttressing Among Primary Sleeve Gastrectomy Patients.

PURPOSE: Staple line buttressing is a method of reinforcing surgical staple lines using buttress materials. This study evaluated surgical outcomes, hospital utilization, and hospital costs associated with staple line buttressing among patients who underwent primary laparoscopic sleeve gastrectomy (PLSG) in the United States. METHODS: This was a retrospective cohort study using Premier Healthcare Database data from January 1, 2012 to December 31, 2017. Patients aged ≥ 18 years who underwent PLSG were selected and assigned to buttress or non-buttress cohorts based on the use of buttress material during their hospitalization for PLSG (index). Propensity score matching (PSM) was conducted to balance patient demographic and clinical characteristics between the cohorts. Generalized estimating equation models were used to compare the clinical and economic outcomes of the matched buttress and non-buttress users during the index hospitalization. RESULTS: A total of 38,231 buttress and 27,349 non-buttress patients were included in the study. After PSM, 24,049 patients were retained in each cohort. Compared with non-buttress cohort, the buttress cohort patients had a similar rate of in-hospital leaks (0.28% vs 0.39%; p = 0.160) and a lower rate of bleeding (1.37% vs 1.80%, p = 0.015), transfusion (0.56% vs 0.77%, p = 0.050), and composite bleeding/transfusion (1.57% vs 2.04%, p = 0.019). Total costs ($12,201 vs $10,986, p < 0.001) and supply costs ($5366 vs $4320, p < 0.001) were higher in the buttress cohort compared with the non-buttress cohort. CONCLUSIONS: Staple line buttressing was associated with an improvement in complication rates for bleeding and transfusion. Total and supply costs were higher in the buttress cohort, necessitating further research into cost-effective buttressing materials.

Radiological assessment of Peritoneal Cancer Index on preoperative CT in ovarian cancer is related to surgical outcome and survival.

PURPOSE: To evaluate whether Peritoneal Cancer Index (PCI) assessed on preoperative CT (CT-PCI) can be used as non-invasive preoperative tool to predict surgical outcome, disease-free survival (DFS) and overall survival (OS). MATERIALS AND METHODS: This is a retrospective, observational cohort study performed in a single institution. We considered all patients with diagnosis of ovarian cancer and preoperative CT, who had undergone upfront cytoreductive surgery between 2008 and 2010 and had post-operative clinical follow-up to December 2015. Two radiologists reviewed CT scans and assessed CT-PCI using Sugarbaker's diagram. We assessed the discriminatory capacity of the CT-PCI score on the surgical outcome by ROC curve analysis. DFS and OS were assessed by Kaplan-Meier nonparametric curves and by multivariable Cox-regression analysis. RESULTS: A total of 297 patients were included in the present analysis. CT-PCI was positively correlated with post-operative residual disease [odds ratio (OR) 1.04, 95% CI 1.01-1.07, p = 0.003]. ROC curve analysis returned AUC = 0.64 for the prediction of total macroscopic tumour clearance. In multivariable analysis, patients with no peritoneal disease seen on CT had a significantly longer DFS [Hazard ratio (HR) 2.28, p = 0.007]. Radiological serosal small bowel involvement was an independent predictor for shorter OS (HR 3.01, p = 0.002). CONCLUSION: Radiological PCI assessed on preoperative CT is associated with the probability of residual disease after cytoreductive surgery; however, it has low performance as a triage test to reliably identify patients who are likely to have complete cytoreductive surgery. CT-PCI is positively correlated with both DFS and OS and may be used as an independent prognostic factor, for example in patients with high FIGO stages.

Does pre-operative urodynamics lead to better outcomes in management of urinary incontinence in women? A linked systematic review and meta-analysis.

The use of preoperative urodynamics as a standard investigation for urinary incontinence (UI) has long been a subject of debate, with a lack of robust evidence to demonstrate improved patients' outcomes. We aim to compare the clinical and cost effectiveness of urodynamics versus office clinical evaluation only, prior to the treatment of UI. We conducted three linked systematic reviews and meta-analyses of randomised controlled trials (RCTs) comparing urodynamics assessment versus clinical evaluation only in women prior to 1) non-surgical treatment of UI, 2a) surgical treatment of stress urinary incontinence (SUI) and 2b) invasive treatment for overactive bladder (OAB). Women with severe pelvic organ prolapse, previous continence surgery and neuropathic bladder were excluded. Primary outcomes were patient-reported and objective success post-treatment. Secondary outcomes were adverse events, quality of life, sexual function and health economic measures. We searched MEDLINE, Embase and Cochrane Central Register of Controlled Trials databases for each category, which was last updated on January 2019. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. The random effects model was used to assess risk ratio and mean difference with 95% confidence interval. Statistical heterogeneity was assessed by I2 statistics and the quality of evidence by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Four RCTs compared urodynamics versus clinical evaluation only prior to non-surgical management of UI. Treatment consisted of pelvic floor muscle training, with or without pharmacological therapy. Meta-analysis of 150 women showed no evidence of significant difference in the patient-reported and objective success rates between groups (P = 0.520, RR: 0.91, 95% Cl 0.69-1.21, I2 = 0% and P = 0.470, RR:0.87, 95% Cl 0.59-1.28, I2 = n/a, respectively). Seven RCTs were identified for surgical management of SUI. The majority of women underwent mid-urethral tape procedures (retropubic or transobturator approach). Meta-analysis of 1149 women showed no evidence of significant difference in patient-reported (P = 0.850, RR:1.01, 95% CI 0.88-1.16, I2 = 53%) and objective success between groups (P = 0.630, RR:1.02, 95% CI 0.95-1.08, I2 = 28%). There was no significant difference in incidence of voiding dysfunction, de novo urgency, and urinary tract infection between groups. No RCTs were identified for invasive management of OAB. In conclusion, limited evidence shows that routine urodynamics prior to non-surgical management of UI or surgical management of SUI is not associated with improved treatment outcomes, when compared to clinical evaluation only. Well-designed clinical trials are needed to evaluate the clinical and cost-effectiveness of routine urodynamics prior to surgical management of SUI and OAB.

Unilateral cleft lip: evaluation and comparison of treatment outcome with two surgical techniques based on qualitative (subject/guardian and professional) assessment.

OBJECTIVES: The outcomes of the treatment of unilateral cleft lip can vary considerably due to variations in repair techniques. The aim of this study was to evaluate and compare treatment outcomes of surgical repair of unilateral cleft lip using either the Tennison-Randall or Millard technique based on (qualitative) parent/subject and professional assessments. MATERIALS AND METHODS: This was a prospective, randomized, controlled study conducted at Lagos University Teaching Hospital between January 2013 and July 2014. A total of 56 subjects with unilateral cleft lip presenting for primary surgery who satisfied the inclusion criteria were recruited for the study. Subjects were randomly allocated to surgical groups A or B through balloting. Group A underwent cleft repair with the Tennison-Randall technique, while group B underwent cleft repair with the Millard rotation advancement technique. Surgical outcome was assessed using qualitative evaluation by the guardian/subject and independent assessors based on a modified form of the criteria described by Christofides and colleagues. RESULTS: Of the 56 subjects enrolled in this study, 32 were male, with a male to female ratio of 1.3:1. Fifteen of the guardians/subjects in the Tennison-Randall group were most bothered about the lower part of the residual lip scar, while 12 guardians/subjects in the in the Millard group were most bothered about the upper part of the scar. More noses were judged to be flattened in the Millard group than in the Tennison-Randall group. Assessors observed a striking disparity in scar transgression of the philtral ridges between the two groups. CONCLUSION: Essentially, there were no major difference in the overall results between Millard rotation-advancement and Tennison-Randall repairs. Both Millard and Tennison-Randall's techniques require significant improvements to improve the appearance of the scar on the upper part and lower part of the lip, respectively.

Assessment of the optimal timing for early laparoscopic cholecystectomy in acute cholecystitis: a prospective study of the Club Coelio.

Background: The optimal timing for cholecystectomy in patients with acute cholecystitis remains controversial. The aim of this study is to assess prospectively the impact of the duration of symptoms on outcomes in early laparoscopic cholecystectomy (ELC) for acute cholecystitis. Methods: The series consisted of 276 consecutive patients who underwent ELC for acute cholecystitis in 2016. The patients were divided into three groups according to the timing of surgery: within the first 3 days (group 1), between 4 and 7 days (group 2) and beyond 7 days (group 3) from the onset of symptoms. Results: The percentage of surgical procedure rated as difficult was respectively: 12% in G1, 18% in G2 and 38% in G3 (p < .001). Accordingly, we observed an increased mean operative time within groups but no significant difference in the conversion rate. We noted a different overall postoperative complication rate within groups, respectively: 9% in G1, 14% in G2 and 24% in G3 (p < .04). The median hospital stay was also different within groups, respectively: 3 in G1, 4 in G2 and 6 days in G3 (p < .001). On univariate analysis, age ≥60, male gender, ASA 3, WBC ≥13.000/µL, CRP ≥100 mg/l and delay between onset of symptoms and surgery were factors statistically associated with increased morbidity rate. On multivariate analysis, the delay was the only independent predictive factor of postoperative morbidity (OR: 1,08, 95% CI: 1.01-1.61, p < .031). Conclusion: Our study confirms that it is ideal to perform ELC within 3 days of symptoms onset and reasonable between 4 to 7 days. We do not recommend performing ELC beyond 7 days because of more difficult procedure and significantly increased risk of post-operative complications.

Disparities in Population-Level Socio-Economic Factors Are Associated with Disparities in Preoperative Clinical Risk Factors in Children.

African American children are more than twice as likely as white American children to die after surgery, and have increased risk for longer hospital stays, post-surgical complications, and higher hospital costs. Prior research into disparities in pediatric surgery outcomes has not considered interactions between patient-level Clinical Risk Factors (CRFs) and population-level Social, Economic, and Environmental Factors (SEEFs) primarily due to the lack of integrated data sets. In this study, we analyze correlations between SEEFs and CRFs and correlations between CRFs and surgery outcomes. We used a dataset from a cohort of 460 surgical cases who underwent surgery at a children's hospital in Memphis, Tennessee in the United States. The analysis was conducted on 23 CRFs, 9 surgery outcomes, and 10 SEEFs and demographic variables. Our results show that population-level SEEFs are significantly associated with both patient-level CRFs and surgery outcomes. These findings may be important in the improved understanding of health disparities in pediatric surgery outcomes.