Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review.

Importance: Direct oral anticoagulants (DOACs), comprising apixaban, rivaroxaban, edoxaban, and dabigatran, are commonly used medications to treat patients with atrial fibrillation and venous thromboembolism. Decisions about how to manage DOACs in patients undergoing a surgical or nonsurgical procedure are important to decrease the risks of bleeding and thromboembolism. Observations: For elective surgical or nonsurgical procedures, a standardized approach to perioperative DOAC management involves classifying the risk of procedure-related bleeding as minimal (eg, minor dental or skin procedures), low to moderate (eg, cholecystectomy, inguinal hernia repair), or high risk (eg, major cancer or joint replacement procedures). For patients undergoing minimal bleeding risk procedures, DOACs may be continued, or if there is concern about excessive bleeding, DOACs may be discontinued on the day of the procedure. Patients undergoing a low to moderate bleeding risk procedure should typically discontinue DOACs 1 day before the operation and restart DOACs 1 day after. Patients undergoing a high bleeding risk procedure should stop DOACs 2 days prior to the operation and restart DOACs 2 days after. With this perioperative DOAC management strategy, rates of thromboembolism (0.2%-0.4%) and major bleeding (1%-2%) are low and delays or cancellations of surgical and nonsurgical procedures are infrequent. Patients taking DOACs who need emergent (<6 hours after presentation) or urgent surgical procedures (6-24 hours after presentation) experience bleeding rates up to 23% and thromboembolism as high as 11%. Laboratory testing to measure preoperative DOAC levels may be useful to determine whether patients should receive a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure. Conclusions and Relevance: When patients who are taking a DOAC require an elective surgical or nonsurgical procedure, standardized management protocols can be applied that do not require testing DOAC levels or heparin bridging. When patients taking a DOAC require an emergent, urgent, or semiurgent surgical procedure, anticoagulant reversal agents may be appropriate when DOAC levels are elevated or not available.

Do patients treated with Invisalign have less swelling after orthognathic surgery than those with fixed orthodontic appliances?

INTRODUCTION: Patients treated with perioperative Invisalign for orthognathic surgery may experience less postoperative swelling than those with fixed appliances because of a lack of mucosal irritation from bonded brackets and wires. The aims of this study were to (1) compare facial swelling after orthognathic surgery in subjects with Invisalign to those with fixed appliances using 3-dimensional (3D) subtraction imaging and (2) determine if the type of operation influences differences in swelling. METHODS: This is a retrospective case-control study. To be included in the case group (Invisalign), patients had to have had: (1) LeFort I and/or bilateral sagittal split osteotomies, with or without genioplasty, (2) perioperative orthodontic treatment using Invisalign, and (3) 3D photographs at postoperative timepoints 1 week (T1), 3-4 weeks (T2), and 5-7 weeks. A sex and operation-matched control group with fixed appliances (standard) was also included. The primary outcome variable was the volume of facial swelling, measured by subtraction imposition of the T1 and T2 3D images using reference images (5-7 weeks). RESULTS: Twenty-two subjects (36% female; mean age 20.7 ± 3.15 years) were included: Invisalign (n = 11) and standard (n = 11). For each group, 7 subjects had 1 operation (LeFort I or bilateral sagittal split osteotomies), and 4 had bimaxillary surgery ± genioplasty. At T1, the Invisalign group had significantly less swelling than the standard group (17.52 ± 10.79 cm3 vs 37.53 ± 14.62 cm3; P <0.001). By T2, the differences were no longer significant (6.62 ± 5.19 cm3 for Invisalign; 5.85 ± 4.39 cm3 for standard, P = 0.728). CONCLUSION: Subjects with Invisalign had significantly less facial swelling in the first postoperative week than those with fixed appliances.

[Significance and Points to Note of Perioperative Oral Care].

With the development of minimally invasive surgery for lung cancer, surgical indications for elderly patients have been increasing. However, elderly patients are at risk for aspiration pneumonia, which is accompanied by a decline in swallowing function and results in aspiration pneumonia. More than 700- 1,000 species are present in the oral microbiome, and the progression of the oral microbiome to the lung has been reported to be associated with poor prognosis. Perioperative complications include dental injuries associated with intubation for general anesthesia and postoperative pneumonia. Preoperative tooth extractions and mouth protectors are effective in preventing dental injuries. Perioperative oral care is often reported to be effective in preventing postoperative pneumonia by removing dental calculus and plaque and cleaning the tongue and stimulating saliva production. Oral care should be continued after as well as before surgery to avoid delaying adjuvant therapy. If the hospital performing the surgery has the department of dentistry and oral surgery, oral care can be completed in the hospital. However, if the hospital does not have that department, it is necessary to collaborate with a local dental clinic in various ways.

The preventive effects of perioperative oral care on surgical site infections after pancreatic cancer surgery: a retrospective study.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) is the most malignant cancer of the gastrointestinal system, and is associated with high rates of postoperative complications, including surgical site infections (SSIs). Perioperative oral care is an effective measure for preventing postoperative pneumonia. However, the preventive effects of perioperative oral care on SSIs have not been reported. We investigated the preventive effects of perioperative oral care on SSIs after pancreatic cancer surgery. METHODS: A total of 103 patients with PDAC who underwent radical resection at Hiroshima Prefectural Hospital (2011-2018) were enrolled in this retrospective study. Of the 103 patients, 75 received perioperative oral care by dentists and dental hygienists (oral care group), whereas 28 did not (control group). Univariate and multivariate analyses with propensity score as a covariate were used to investigate the incidence and risk factors of SSIs in the oral care and control groups. RESULTS: The incidence of SSIs was significantly lower in the oral care group than in the control group (12.0% vs. 39.3%, P = 0.004). Logistic regression analysis revealed that a soft pancreas, the surgical procedure (pancreaticoduodenectomy), blood transfusion, diabetes mellitus, and the absence of oral care intervention were risk factors for SSIs. The odds ratio for the absence of oral care intervention was 6.090 (95% confidence interval: 1.750-21.200, P = 0.004). CONCLUSION: Our results suggest that perioperative oral care may reduce the risk of developing SSIs after pancreatic cancer surgery. These findings need to be evaluated in future prospective studies. TRIAL REGISTRATION: UMIN registration number: UMIN000042082; October 15, 2020, retrospectively registered.

Evaluation of effects of perioperative oral care intervention on hospitalization stay and postoperative infection in patients undergoing lung cancer intervention.

PURPOSE: This retrospective study investigated the effect of perioperative oral care intervention on postoperative outcomes in patients undergoing lung cancer resection, in terms of the length of postoperative hospital stay and the incidence of postoperative respiratory infections. METHODS: In total, 585 patients underwent lung resection for lung cancer, 397 received perioperative oral care intervention, whereas the remaining 188 did not. This study retrospectively investigated the demographic and clinical characteristics (including postoperative complications and postoperative hospital stay) of each group. To determine whether perioperative oral care intervention was independently associated with either postoperative hospital stay or postoperative respiratory infections, multivariate analysis, multiple regression analysis, and multivariate logistic regression analysis were conducted. RESULTS: Parameters significantly associated with a prolonged postoperative hospital stay in lung cancer surgery patients were older age, postoperative complications, increased intraoperative bleeding, more invasive operative approach (e.g., open surgery), and lack of perioperative oral care intervention (standard partial regression coefficient (ß) = 0.083, p = 0.027). Furthermore, older age and longer operative time were significant independent risk factors for the occurrence of postoperative respiratory infections. Lack of perioperative oral care intervention was a potential risk factor for the occurrence of postoperative respiratory infections, although not statistically significant (odds ratio = 2.448, 95% confidence interval = 0.966-6.204, p = 0.059). CONCLUSION: These results highlight the importance of perioperative oral care intervention prior to lung cancer surgery, in order to shorten postoperative hospital stay and reduce the risk of postoperative respiratory infections.

Perioperative COVID-19 Defense: An Evidence-Based Approach for Optimization of Infection Control and Operating Room Management.

We describe an evidence-based approach for optimization of infection control and operating room management during the coronavirus disease 2019 (COVID-19) pandemic. Confirmed modes of viral transmission are primarily, but not exclusively, contact with contaminated environmental surfaces and aerosolization. Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C). (1) Place alcohol-based hand rubs on the intravenous (IV) pole to the left of the provider. Double glove during induction. (2) Place a wire basket lined with a zip closure plastic bag on the IV pole to the right of the provider. Place all contaminated instruments in the bag (eg, laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas. After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Use a top-down cleaning sequence adequate to reduce bioburden. Treat operating rooms using UV-C. (3) Decolonize patients using preprocedural chlorhexidine wipes, 2 doses of nasal povidone-iodine within 1 hour of incision, and chlorhexidine mouth rinse. (4) Create a closed lumen IV system and use hub disinfection. (5) Provide data feedback by surveillance of Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas, and Enterobacter spp. (ESKAPE) transmission. (6) To reduce the use of surgical masks and to reduce potential COVID-19 exposure, use relatively long (eg, 12 hours) staff shifts. If there are 8 essential cases to be done (each lasting 1-2 hours), the ideal solution is to have 2 teams complete the 8 cases, not 8 first case starts. (7) Do 1 case in each operating room daily, with terminal cleaning after each case including UV-C or equivalent. (8) Do not have patients go into a large, pooled phase I postanesthesia care unit because of the risk of contaminating facility at large along with many staff. Instead, have most patients recover in the room where they had surgery as is done routinely in Japan. These 8 programmatic recommendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by support from the Anesthesia Patient Safety Foundation (APSF).

Retrospective Comparison of 2 Management Strategies for Perioperative Malaria Episodes in Pediatric Patients in a Limited-Resource Setting.

BACKGROUND: Malaria is a common problem throughout the world, particularly in sub-Saharan Africa, where 90% of all deaths in the world from malaria occur. While many studies on malaria are available in the medical literature, few publications have addressed the problems of managing malaria during surgery and anesthesia. At a newly opened hospital in Niger, we initiated further studies to evaluate our process of managing malaria when we had a number of problems in our first group of pediatric patients having elective cleft lip and palate repairs. Many patients had fevers during and soon after surgery and were found to have clinical malaria, despite recent treatment. METHODS: In our first group of 16 patients (group A), 4 initially tested positive for malaria by light microscopy and were treated before arrival at our hospital. On arrival at our hospital, we retested all the patients for malaria. Three of the original 4 were still positive. Six additional patients also tested positive, for a total of 9 of 16 in group A. Despite treatment, 6 of these 16 patients still had fevers in the operating rooms and postoperative period requiring further treatment for clinical malaria (6/16 or 38% incidence of perioperative malaria; 95% CI, 15%-65%).We then changed our diagnostic and management strategies for subsequent patients: all patients were tested for malaria 3-7 days before surgery at our hospital rather than before arrival. We decided to universally treat all patients coming for surgery for presumed malaria due to the number of problems encountered in the first group and the high prevalence of malaria in our population. We changed the source of the malaria medications used for all subsequent patients. We included rapid diagnostic tests for falciparum and nonfalciparum malaria species. RESULTS: After the change in protocols, no children in the second group of patients (group B, n = 53) developed clinical malaria or fever during or after surgery (P < .0001, comparing 6/16 vs 0/53, using Fisher exact test). During the first 4 months after the implementation of rapid diagnostic tests for malaria testing, we tested 283 patients, of whom 73 were found to be positive for malaria by light microscopy and/or rapid diagnostic test. Of the 73 malarias, 24.6% were nonfalciparum malarias (95% CI, 14.7%-34.5%), much higher than the 1%-5% incidence that international and local health officials told us to expect. CONCLUSIONS: Pediatric patients in many areas of the world often present with a high risk for malaria in the perioperative time frame. Treatment with artemisinin-based therapy 3-7 days before elective surgeries may be an effective method to reduce the risks of febrile episodes and clinical malaria during and after surgery in areas of high transmission. However, these results may be limited by (1) the presence of nonfalciparum malarias, some of which may require prolonged treatment for hepatic cryptogenic malaria; (2) the potential for complications related to counterfeit medications; and (3) international efforts at malaria eradication, especially when considering the use of malaria medications that have the potential to develop drug resistance.

Professional Oral Care Reduces Carcinogenic Acetaldehyde Levels in Mouth Air of Perioperative Esophageal Cancer Patients: A Prospective Comparative Study.

Acetaldehyde is a potential carcinogen for esophageal cancer, and some oral microorganisms produce acetaldehyde from ethanol or glucose. In this prospective study, we examined the influence of professional oral care on acetaldehyde levels in mouth air of esophageal cancer patients. Acetaldehyde concentrations in mouth air and breath were measured by a portable gas chromatograph, and acetaldehyde production from oral microbiota was also evaluated. Samples were taken from 21 esophageal cancer patients (median age 68 years) and 20 age-matched healthy volunteers (control group) before and after oral care. Post-operative samples were also taken from 17 patients who had undergone surgery. All samples (mouth air, breath, and saliva) were collected 2 to 3 hours after lunch. Oral microbial samples were prepared from saliva. Genotype analysis of alcohol dehydrogenase 1B (ADH1B) and aldehyde dehydrogenase-2 (ALDH2) genes revealed no significant differences in the genotypes between the two groups. In the control group, acetaldehyde levels in mouth air showed no significant changes after oral care, while the amount of microbial acetaldehyde production from ethanol was significantly decreased. By contrast, among the patients, acetaldehyde levels in mouth air were significantly decreased after oral care and after operation, while the amount of microbial acetaldehyde production from ethanol showed no significant changes. Moreover, microbial acetaldehyde production from glucose was significantly decreased after operation. Overall, oral health was poorer in the patient group. In conclusion, professional oral care for esophageal cancer patients is effective for reducing acetaldehyde levels in mouth air due to the reduction of microbial count.

Perioperative management of oral anticoagulated patients undergoing an oral, implant, or periodontal procedure: a survey of practices of members of two dental scientific societies, the PRADICO study.

OBJECTIVES: Studies on the perioperative management of patients on direct oral anticoagulants (DOACs) receiving oral invasive procedures are sparse. Moreover, the recommendations of the scientific societies on DOACs are discordant, and the practices are highly variable. We conducted a survey of general and specialized dentists in France to compare their practices concerning the management of patients receiving vitamin K antagonists (VKAs) and DOACs. MATERIALS AND METHODS: Members of two dental surgical societies were invited to participate in the survey. One hundred forty-one practitioners answered an online questionnaire focusing on the periprocedural management of oral anticoagulated patients (participation rate, 17.8%). RESULTS: Practitioners at hospitals or mixed practices and specialists treated significantly more anticoagulated patients and more frequently performed procedures with high hemorrhagic risk than practitioners with private practice and general dentists. Greater than 90% of practitioners did not modify the treatment for patients on VKAs and controlled the International Normalized Ratio (INR) preoperatively. Regarding DOACs, 62.9% of practitioners did not change the treatment, 70.8% did not prescribe any biological tests, and 13.9% prescribed an INR. Practitioners at hospitals and mixed practices and specialists had better training and knowledge about DOACs. CONCLUSIONS: This survey showed that anticoagulated patients were managed mostly by specialists in private or hospital care, notably when requiring oral procedures at high hemorrhagic risk. CLINICAL RELEVANCE: A growing proportion of anticoagulated patients are being treated by dentists in primary care. Consequently, they need training, especially concerning DOACs. Additionally, consensus recommendations are necessary for better coordination of stakeholders and patient safety. Trial registration on ClinicalTrials.gov : NCT03150303.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: prevention of periprosthetic shoulder infection.

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. Over 800 international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form a consensus workgroup. The following proceedings on the prevention of periprosthetic shoulder infection come from 16 questions evaluated by delegates from the shoulder section.

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm.

BACKGROUND: Decision-making related to the care of patients with an abdominal aortic aneurysm (AAA) is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and need to intervene. Careful attention to the choice of operative strategy along with optimal treatment of medical comorbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative surveillance is necessary to minimize subsequent aneurysm-related death or morbidity. METHODS: The committee made specific practice recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. Three systematic reviews were conducted to support this guideline. Two focused on evaluating the best modalities and optimal frequency for surveillance after endovascular aneurysm repair (EVAR). A third focused on identifying the best available evidence on the diagnosis and management of AAA. Specific areas of focus included (1) general approach to the patient, (2) treatment of the patient with an AAA, (3) anesthetic considerations and perioperative management, (4) postoperative and long-term management, and (5) cost and economic considerations. RESULTS: Along with providing guidance regarding the management of patients throughout the continuum of care, we have revised a number of prior recommendations and addressed a number of new areas of significance. New guidelines are provided for the surveillance of patients with an AAA, including recommended surveillance imaging at 12-month intervals for patients with an AAA of 4.0 to 4.9 cm in diameter. We recommend endovascular repair as the preferred method of treatment for ruptured aneurysms. Incorporating knowledge gained through the Vascular Quality Initiative and other regional quality collaboratives, we suggest that the Vascular Quality Initiative mortality risk score be used for mutual decision-making with patients considering aneurysm repair. We also suggest that elective EVAR be limited to hospitals with a documented mortality and conversion rate to open surgical repair of 2% or less and that perform at least 10 EVAR cases each year. We also suggest that elective open aneurysm repair be limited to hospitals with a documented mortality of 5% or less and that perform at least 10 open aortic operations of any type each year. To encourage the development of effective systems of care that would lead to improved outcomes for those patients undergoing emergent repair, we suggest a door-to-intervention time of <90 minutes, based on a framework of 30-30-30 minutes, for the management of the patient with a ruptured aneurysm. We recommend treatment of type I and III endoleaks as well as of type II endoleaks with aneurysm expansion but recommend continued surveillance of type II endoleaks not associated with aneurysm expansion. Whereas antibiotic prophylaxis is recommended for patients with an aortic prosthesis before any dental procedure involving the manipulation of the gingival or periapical region of teeth or perforation of the oral mucosa, antibiotic prophylaxis is not recommended before respiratory tract procedures, gastrointestinal or genitourinary procedures, and dermatologic or musculoskeletal procedures unless the potential for infection exists or the patient is immunocompromised. Increased utilization of color duplex ultrasound is suggested for postoperative surveillance after EVAR in the absence of endoleak or aneurysm expansion. CONCLUSIONS: Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices.

Impact of enhanced recovery after surgery (ERAS) protocol on gastrointestinal function in gynecologic oncology patients undergoing laparotomy.

OBJECTIVE: To evaluate the impact of enhanced recovery after surgery (ERAS) on postoperative gastrointestinal function in gynecologic oncology patients. METHODS: This retrospective cohort study compared gynecology oncology patients undergoing non-emergent laparotomy from 10/2016 to 6/2017 managed on an ERAS protocol to a control cohort from the year prior to ERAS implementation. Major changes to postoperative care after ERAS implementation included multimodal analgesia, early feeding, goal-directed fluid resuscitation, and early ambulation. The primary outcome was rate of postoperative ileus, defined as nausea and vomiting requiring nothing-per-mouth status or nasogastric tube (NGT) placement. Secondary outcomes included length of stay (LOS) and 30-day readmission. RESULTS: 376 patients met inclusion criteria; 197 in the control group and 179 in the ERAS group. Patient demographics were similar between groups. Ileus rate was significantly lower in the ERAS group (2.8% vs. 15.7%; p < 0.001), and fewer patients in the ERAS group required NGT placement (2.2% vs. 7.1%; p = 0.06). ERAS remained independently associated with decreased ileus rates when controlling for other patient and surgical factors (OR 0.2; p = 0.01). Epidural use was correlated with a significant increase in ileus risk (OR 2.6; p = 0.03), as was increased Charlson Comorbidity Index (OR 1.2; p < 0.01). LOS was significantly decreased in the ERAS group (2.9 vs. 4.0 days; p = 0.04), while 30-day readmission rates were similar (10.1% vs. 10.7%; p = 0.62). CONCLUSIONS: Implementation of an ERAS protocol significantly decreases the risk of postoperative ileus in gynecologic oncology patients undergoing laparotomy. ERAS also reduced LOS compared to pre-ERAS controls.

Perioperative thermoregulation and heat balance.

Core body temperature is normally tightly regulated to within a few tenths of a degree. The major thermoregulatory defences in humans are sweating, arteriovenous shunt vasoconstriction, and shivering. The core temperature triggering each response defines its activation threshold. General anaesthetics greatly impair thermoregulation, synchronously reducing the thresholds for vasoconstriction and shivering. Neuraxial anaesthesia also impairs central thermoregulatory control, and prevents vasoconstriction and shivering in blocked areas. Consequently, unwarmed anaesthetised patients become hypothermic, typically by 1-2°C. Hypothermia results initially from an internal redistribution of body heat from the core to the periphery, followed by heat loss exceeding metabolic heat production. Complications of perioperative hypothermia include coagulopathy and increased transfusion requirement, surgical site infection, delayed drug metabolism, prolonged recovery, shivering, and thermal discomfort. Body temperature can be reliably measured in the oesophagus, nasopharynx, mouth, and bladder. The standard-of-care is to monitor core temperature and to maintain normothermia during general and neuraxial anaesthesia.

Perioperative Systemic Corticosteroids in Orthognathic Surgery: A Systematic Review and Meta-Analysis.

PURPOSE: Perioperative systemic corticosteroids are broadly used in orthognathic surgery to prevent postoperative complications, but it is unclear whether this practice is beneficial and concerns about potential side effects have been raised. The purpose of this systematic review and meta-analysis was to assess the effects of perioperative systemic corticosteroids on clinically important outcomes in patients undergoing orthognathic surgery. MATERIALS AND METHODS: The authors conducted a systematic review of randomized controlled trials evaluating the effect of systemic corticosteroids in orthognathic surgery compared with placebo or any other intervention. The authors searched Medline, Embase, Cochrane Central, CINAHL, Lilacs, Scopus, and Web of Science and references of included trials. The primary outcome was the incidence of postoperative reintubation during the index hospitalization. The secondary outcomes were hospital length of stay, decreases in facial edema, and adverse events. Data were summarized using Mantel-Haenszel random-effects models. RESULTS: Of the 1,098 trials retrieved, 8 were included (n = 234). No trial evaluated the risk of postoperative reintubation. One trial evaluated the duration of hospital stay and showed no difference associated with the intervention. There was a decrease in facial edema with the use of systemic corticosteroids (n = 80; standardized mean difference, -1.07; 95% confidence interval, -1.99 to -0.16; I2 = 67%). Three trials reported side effects, such as postoperative surgical site bleeding, hypersensitivity, and stomach discomfort with intake of corticosteroids. The 8 trials had an unclear risk of bias. CONCLUSION: The authors observed no evidence of effect of systemic corticosteroids on the risk of reintubation and hospital length of stay in orthognathic surgery. Although facial edema decrease was observed to be improved with the intervention, adverse effects were inconsistently screened and reported. Thus, the use of systemic steroids in orthognathic surgery is not supported by strong evidence.

Dental management for patients undergoing heart valve surgery.

This study sought to review current guidelines and the most optimal dental management for patients undergoing cardiac valve surgery.

Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty.

BACKGROUND: Alternative techniques have been developed to address pain after shoulder arthroplasty and are well documented. We evaluated the effect of adding intraoperative liposomal bupivacaine and intravenous dexamethasone during shoulder arthroplasty. METHODS: We retrospectively reviewed 2 consecutive cohorts undergoing elective shoulder arthroplasty. The 24 patients in cohort 1 and the 31 patients in cohort 2 received perioperative multimodal management with preoperative and postoperative intravenous and oral narcotics, gabapentin, nonsteroidal anti-inflammatory drugs, acetaminophen, and single-injection interscalene block. Cohort 2 also received 8 to 10 mg of intravenous dexamethasone intraoperatively after the skin incision and liposomal bupivacaine injected at surgery. Patients who did and did not use preoperative narcotics were analyzed together and separately. We evaluated hospitalization length of stay, narcotic use, and visual analog scale pain before and after the change in the perioperative protocol. RESULTS: Cohort 1 was hospitalized longer (2 vs. 1 day; P < .001), required more narcotics on postoperative day 1 (21.0 vs. 10.0 mg; P < .001) and days 0 and 1 cumulatively (30.5 vs. 17.5 mg; P = .001), and had more pain on postoperative days 0 (6.5 vs. 3.5; P < .001) and 1 (7.5 vs. 3.5; P < .001) than cohort 2. In patients using preoperative narcotics, cohort 2 had less pain on postoperative day 1 (3.5 vs. 7.0; P = .006), less cumulative narcotic use (20 vs. 58.5 mg; P = .03), and shorter hospitalization (1 vs. 2 days; P = .052) than cohort 1. CONCLUSION: These changes to the perioperative shoulder arthroplasty protocol decreased hospitalization length of stay, narcotic requirement, and pain.

Influence of Standardized Orientation on Patient Perception of Perioperative Care Following Alveolar Cleft Repair: A Survey Based Study of Patients Treated in a Large Academic Medical Center.

OBJECTIVE: This study aims to better understand patient-reported outcomes for iliac bone grafting surgery for alveolar cleft repair and to determine how standardizing perioperative patient instruction affects patient-reported outcomes. DESIGN: Retrospective survey-based assessment of patients undergoing iliac bone grafting with and without hospital-based systems standardization. SETTING: Academic tertiary care hospital. PATIENTS: Of the 195 identified patients, 127 participated. INTERVENTIONS: Survey on pain and satisfaction regarding iliac bone grafting surgery. MAIN OUTCOME MEASURES: Survey answers measured patient opinions about the surgery. Answers of the pre- and poststandardization patients were compared to determine the effect of standardizing patient instructions. RESULTS: Patients rated their satisfaction with the surgery and recovery a 4.5 and 4.4 out of 5, respectively. They rated their overall pain in the hospital a 5.5 out of 10 (4.9 in the mouth, 5.7 in the hip). Patients were discharged an average of 1.2 days after surgery and could return to normal daily activity in 6.1 days. Poststandardization patients were more likely to adhere to instructions regarding use of an antibacterial mouthrinse and a protective oral splint. CONCLUSIONS: Patients were highly satisfied with the iliac bone grafting procedure and the recovery and reported only moderate levels of postoperative pain. Implementing standardized patient instructions may not affect patient satisfaction or pain severity, but it significantly increased patient adherence to physician instructions.

Long-term efficacy and safety of a nitinol closure clip system for anal fistula treatment.

INTRODUCTION: Treatment failure of anal fistula results in high re-occurrence rate. MATERIAL AND METHODS: Efficacy and safety of a nitinol closure clip system (bear-claw clip) were evaluated for anal fistulae treatment in a 36-month long-term follow-up study. RESULTS: Twenty-two patients were included. No patient had been treated with a bear-claw clip system before. All patients were fully continent before treatment. Follow-up time was 36 months (range 19-48 months). We observed a re-occurrence rate of 41% (nine patients) with presence of an active fistula. Time to recurrence was on average 6.9 months (range 3-11 months). Thirteen patients (59%) showed a complete healing of the fistula. Placed clip was removed in all patients on average after almost 5.8 months (3-12 months), in three cases the clip was left in situ. We did not observe any incontinence; one patient reported recurrent burning after defecation once the clip system was removed. DISCUSSIONS: Clip placement is a minimally invasive sphincter-preserving procedure with minimal complications and with an acceptable recurrence rate in the long term. However, bear-claw clip placement should probably be offered patients as a treatment option before more invasive procedures with higher perioperative morbidity are taken into consideration.

[Perioperative Management Team in Esophageal Cancer Surgery].

Esophagectomy for patients with esophageal cancer is one of the most invasive surgery. Despite advances in surgical techniques and perioperative management, both morbidity and mortality rates after esophagectomy still remains high. Recently, it was suggested that perioperative care bundle is effective for preventing postoperative complications after esophagectomy. Then, we introduced a perioperative multidisciplinary management team, which aimed at systematic perioperative care for patients undergoing esophagectomy. This care bundle mainly included cessation of smoking and drinking, dental cleaning, medication assistance, physical exercise and rehabilitation, respiratory training, and nutritional support. These systematic and cooperative interventions by professionals can decrease the incidence of postoperative complications after esophagectomy.

[Oral management for perioperative patients.]

During perioperative period, several oral-related complications happen to occur, including not only postoperative pneumonia and surgical site infection, but also damage to teeth. Furthermore, in case of surgeries where the materials such as prosthetic valves and artificial joints are installed inside the body, there is a potential risk of developing foreign material infections due to bacteremia from the oral cavity as the periodontitis remains there. There is a possibility that a necessary treatment during perioperative period is not performed with only the oral cleaning which is narrowly defined as oral care, without an assessment of potential problems for oral. The oral-related perioperative complications can be prevented by putting the oral management into practice, which include a necessary dental treatment, rehabilitation for mastication and swallowing, and education of patients and medical staff, based on accurate oral assessment.