18F-fluoro-ethyl-tyrosine PET co-registered with MRI in patients with persisting acromegaly.

OBJECTIVE: To report our experience with 18F-fluoro-ethyl-tyrosine (FET) positron emission tomography-computed tomography (PET-CT) co-registered with magnetic resonance imaging (MRI) (FET-PET/MRICR) in the care trajectory for persistent acromegaly. DESIGN: Prospective case series. PATIENTS: Ten patients with insufficiently controlled acromegaly referred to our team to evaluate surgical options. MEASUREMENTS: FET-PET/MRICR was used to support decision-making if MRI alone and multidisciplinary team evaluation did not provide sufficient clarity to proceed to surgery. RESULTS: FET-PET/MRICR showed suspicious (para)sellar tracer uptake in all patients. In five patients FET-PET/MRICR was fully concordant with conventional MRI, and in one patient partially concordant. FET-PET/MRICR identified suggestive new foci in four other patients. Surgical re-exploration was performed in nine patients (aimed at total resection (6), debulking (2), diagnosis (1)), and one patient underwent radiation therapy. In 7 of 9 (78%) operated patients FET-PET/MRICR findings were confirmed intraoperatively, and in six (67%) also histologically. IGF-1 decreased significantly in eight patients (89%). All patients showed clinical improvement. Complete biochemical remission was achieved in three patients (50% of procedures in which total resection was anticipated feasible). Biochemistry improved in five and was unchanged in one patient. No permanent complications occurred. At six months, optimal outcome (preoperative intended goal achieved without permanent complications) was achieved in six (67%) patients and an intermediate outcome (goal not achieved, but no complications) in the other three patients. CONCLUSIONS: In patients with persisting acromegaly without a clear surgical target on MRI, FET-PET/MRICR is a new tracer to provide additional information to aid decision-making by the multidisciplinary pituitary team.

Development of an Education Material Targeting Patients Undergoing Lower Extremity Amputation due to Severe Limb Ischemia-A Qualitative Study.

INTRODUCTION: Critical limb-threatening ischemia (CLTI) is associated with a high risk of amputation, yet patients undergoing amputation due to CLTI have little knowledge of the amputation process and the rehabilitation that awaits. The aim of the present study was to develop and validate information material for patients undergoing amputation. METHODS: Nine participants were included in the study. Two focus group interviews were performed with seven patients who had undergone lower extremity amputation due to CLTI within the past 2 y. Additionally, two individual interviews were carried out. A semistructured interview guide was used, and the interviews were transcribed verbatim and analysed using qualitative content analysis with a deductive approach. RESULTS: Three themes were identified as essential for the design of the written information: Perspectives on design and formatting, Providing information to enhance participation in care, and Accessibility to information and support. The prototyped information leaflet was perceived as acceptable, useable, relevant, and comprehensible by the participants. CONCLUSIONS: For patients to actively engage in their care, it is vital that their information needs are met and that they are provided with psychosocial support when needed. Written and oral information should be provided by a trusted healthcare professional.

Variation in surgical approach and postoperative complication among older adults undergoing ventral hernia repair.

BACKGROUND: Surgical decision-making for preference-sensitive operations among older adults is understudied. Ventral hernia repair (VHR) is one operation where granular data are limited to guide preoperative decision-making. We aimed to determine risk for VHR in older adults given clinically nuanced data including surgical and hernia characteristics. METHODS: We performed a retrospective analysis of the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry from January 2020 to March 2023. The primary outcome was postoperative complication across age groups: 18-64, 65-74, and ≥ 75 years, with secondary outcome of surgical approach. Mixed-effects logistic regression evaluated association between minimally invasive surgery (MIS) and 30-day complications, controlling for patient and hernia characteristics. RESULTS: Among 8,659 patients, only 7% were 75 or older. MIS rates varied across hospitals [Median = 31.4%, IQR: (14.8-51.6%)]. The overall complication rate was 2.2%. Complication risk for undergoing open versus MIS approach did not vary between age groups; however, patients over age 75 undergoing laparoscopic repair had increased risk (aOR = 4.58, 95% CI 1.13-18.67). Other factors associated with risk included female sex (aOR = 2.10, 95% CI 1.51-2.93), higher BMI (aOR = 1.18, 95% CI 1.03-1.34), hernia width ≥ 6 cm (aOR = 3.15, 95% CI 1.96-5.04), previous repair (aOR = 1.44, 95% CI 1.02-2.05), and component separation (aOR = 1.98, 95% CI 1.28-3.05). Patients most likely to undergo MIS were female (aOR = 1.21, 95% CI 1.09-1.34), black (aOR = 1.30, 95% CI 1.12-1.52), with larger hernias: 2-5.9 cm (aOR = 1.76, 95% CI 1.57-1.97), or intraoperative mesh placement (aOR = 14.4, 95% CI 11.68-17.79). There was no difference in likelihood to receive MIS across ages when accounting for hospital (SD of baseline likelihood = 1.53, 95% CI 1.14-2.05) and surgeon (SD of baseline likelihood = 2.77, 95% CI 2.46-3.11) variation. CONCLUSIONS: Our findings demonstrate that hernia, intraoperative, and patient characteristics other than age increase probability for complication following VHR. These findings can empower surgeons and older patients considering preoperative risk for VHR.

Behaviour, barriers and facilitators of shared decision making in breast cancer surgical treatment: A qualitative systematic review using a 'Best Fit' framework approach.

BACKGROUND: Due to the diversity and high sensitivity of the treatment, there were difficulties and uncertainties in the breast cancer surgical decision-making process. We aimed to describe the patient's decision-making behaviour and shared decision-making (SDM)-related barriers and facilitators in breast cancer surgical treatment. METHODS: We searched eight databases for qualitative studies and mixed-method studies about breast cancer patients' surgical decision-making process from inception to March 2021. The quality of the studies was critically appraised by two researchers independently. We used a 'best fit framework approach' to analyze and synthesize the evidence. RESULTS: Twenty-eight qualitative studies and three mixed-method studies were included in this study. Four themes and 10 subthemes were extracted: (a) struggling with various considerations, (b) actual decision-making behaviours, (c) SDM not routinely implemented and (d) multiple facilitators and barriers to SDM. CONCLUSIONS: Patients had various considerations of breast surgery and SDM was not routinely implemented. There was a discrepancy between information exchange behaviours, value clarification, decision support utilization and SDM due to cognitive and behavioural biases. When individuals made surgical decisions, their behaviours were affected by individual-level and system-level factors. Therefore, healthcare providers and other stakeholders should constantly improve communication skills and collaboration, and emphasize the importance of decision support, so as to embed SDM into routine practice. PATIENT AND PUBLIC CONTRIBUTION: This systematic review was conducted as part of a wider research entitled: Breast cancer patients' actual participation roles in surgical decision making: a mixed method research. The results of this project helped us to better analyze and generalize patients' views.

The ballistic articular structure injury classification (BASIC) system: clarifying ballistic articular injuries.

PURPOSE: This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management. METHODS: We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated. RESULTS: The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews. CONCLUSIONS: Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

Short- and long-term outcomes of laparoscopic or robotic radical gastrectomy based on preoperative perigastric artery CTA surgical decision-making: a high-volume center retrospective study with propensity score matching.

BACKGROUND: Some studies have demonstrated the short-term recovery course for patients who underwent laparoscopic gastrectomy according to preoperative computed tomography angiography (CTA) assessment. However, reports of the long-term oncological outcomes are still limited. METHODS: The data of 988 consecutive patients who underwent laparoscopic or robotic radical gastrectomy between January 2014 and September 2018 were analyzed retrospectively at our center, and propensity score matching was used to eliminate bias. Study cohorts were divided into the CTA group (n = 498) and the non-CTA group (n = 490) depending on whether preoperative CTA was available. The primary and secondary endpoints were the 3-year overall survival (OS) and disease-free survival (DFS) rates and the intraoperative course and short-term outcomes, respectively. RESULTS: 431 patients were included in each group after PSM. Compared with the non-CTA group, the CTA group had more harvested lymph nodes and less operative time, blood loss, intraoperative vascular injury and total cost, especially in the subgroup analysis with BMI ≥ 25 kg/m2 patients. There was no difference in the 3 year OS and DFS between the CTA group and the non-CTA group. When further stratified by BMI < 25 or ≥ 25 kg/m2, the 3-year OS and DFS were significantly higher in the CTA group than in the non-CTA group in terms of BMI ≥ 25 kg/m2. CONCLUSIONS: Laparoscopic or robotic radical gastrectomy based on preoperative perigastric artery CTA surgical decision-making has the possibility of improving short-term outcomes. However, there is no difference in the long-term prognosis, except for a subgroup of patients with BMI ≥ 25 kg/m2.

Surgeons' attitudes during laparoscopic appendectomy: do subjective intraoperative assessments affect the choice of peritoneal irrigation? A spin-off analysis from the REsiDENT-1 multicentre prospective observational trial.

AIMS: Laparoscopic appendectomy (LA) for acute appendicitis (AA) is one of the most performed procedures. The effects of peritoneal lavage (PL) and the reasons to perform it have not been cleared and all meta-analyses didn't show a statistical advantage to prevent infectious complications. This study aims to investigate surgeons' perceptions during LA, comparing intraoperative findings with histological results, and exploring how surgeons' subjectivity influences the decision-making process on PL. METHODS: Data were extracted from the two-year data lock from REsiDENT-1 registry, a prospective resident-led multicentre observational trial. This study investigates the relationships between PL and postoperative intraabdominal abscesses (pIAA) introducing a classification for AA to standardize the intraoperative grading. We included pre, intra, and postoperative variables. We applied our classification proposal, used a five-point Likert scale (Ls) to assess subjective LA difficulty and ran a concordance analysis between the assessment of AA and histology. Subsequently, a multivariate logistic regression model was built to find factors influencing PL. RESULTS: 561 patients were enrolled from twenty-one hospitals and 51 residents. 542 procedures were included in the logistic regression analysis and 441 in the concordance analysis, due to missing data. PL was used in 222 LA (39, 6%). We discovered a moderate positive monotonic relationship between surgical evaluation and histology, p < 0.001. Despite this, the reliability of the surgeon's assessment of appendicitis is progressively lower for gangrenous and perforated forms. The increasing grade of contamination, the increasing grade of subjective difficulty and the intraoperative finding of a gangrenous or perforated appendicitis were independent predictors of PL. CONCLUSION: This study shows how surgeons' evaluation of AA severity overestimated more than half of gangrenous or perforated appendices with the perception of a challenging procedure. These perceptions influenced the choice of PL. We proved that the evaluation during LA could be affected by subjectivity with a non-negligible impact on the decision-making process.

Decision-making tree for surgical treatment in meningioma: a geriatric cohort study.

Controversies persist regarding the benefits of surgery in elderly patients with meningiomas. The objective of this study was to develop decision-making scale to clarify the necessity for surgical intervention and provide clinical consultation for this special population. This retrospective cohort study was conducted at a single center and included 478 elderly patients (≥ 65 years) who underwent meningioma resection. Follow-up was recorded to determine recurrence and mortality rates. Univariate and multivariate analyses were performed to identify significantly preoperative factors, and prognostic prediction models were developed with determined cutoff values for the prognostic index (PI). Model discrimination was evaluated using Kaplan-Meier curves based on the PI stratification, which categorized patients into low- and high-risk groups. A decision-making tree was then established based on the risk stratification from both models. Among all patients analyzed (n = 478), 62 (13.0%) experience recurrence and 47 (10.0%) died during the follow-up period. Significantly preoperative parameters from both models included advanced age, aCCI, recurrent tumor, motor cortex involvement, male sex, peritumoral edema, and tumor located in skull base (all P < 0.05). According to the classification of PI from the two models, the decision-making tree provided four recommendations that can be used for clinical consultation. Surgery is not recommended for patients assigned to the high-risk group in both models. Patients who meet the low-risk criteria in any model may undergo surgical intervention, but the final decision should depend on the surgeon's expertise.

Acute limb ischaemia due to thrombosed persistent sciatic artery aneurysm presents a surgical challenge in a frail octogenarian.

OBJECTIVES: Persistent sciatic artery (PSA) is a rare congenital anomaly, whereby the embryonic sciatic artery remains patent with associated degrees of femoral axis hypoplasia. Aneurysmal degeneration and distal ischaemia from thromboembolic complications are common. Revascularisation strategies include embolectomy, bypass or interposition grafting and catheter-directed thrombolysis. METHODS: We describe a sedentary 88-year-old woman with right acute limb ischaemia secondary to a thrombosed PSA aneurysm and concurrent occlusive thrombus at the femoral bifurcation. RESULTS: The patient presented with a 3-day history of a cold, painful right foot. Examination revealed Rutherford IIb ischaemia. CT-angiography demonstrated no continuity between the hypoplastic superficial femoral and popliteal arteries, complete occlusion of the right PSA distal to the thrombosed aneurysm and occlusive thrombus in the right profunda. As she was too frail for femoral-distal bypass, we restored femoral axis inflow via profunda embolectomy. Her prognosis remained guarded as we deliberately did not reconstruct the PSA. However, she was discharged pain-free and mobilising with aids 2 weeks later. CONCLUSION: Limb ischaemia in frail, high-risk patients is an ever-increasing challenge for vascular surgeons and requires complex decision-making, balancing comorbidities against desired outcomes. This case illustrates that a selective approach can be sufficient to maintain function despite complex anatomy.

A surgical Decision-making scoring model for spontaneous ventilation- and mechanical ventilation-video-assisted thoracoscopic surgery in non-small-cell lung cancer patients.

BACKGROUNDS: Spontaneous ventilation-video-assisted thoracoscopic surgery (SV-VATS) has been applied to non-small cell lung cancer (NSCLC) patients in many centers. Since it remains a new and challenging surgical technique, only selected patients can be performed SV-VATS. We aim to conduct a retrospective single-center study to develop a clinical decision-making model to make surgery decision between SV-VATS and MV (mechanical ventilation) -VATS in NSCLC patients more objectively and individually. METHODS: Four thousand three hundred sixty-eight NSCLC patients undergoing SV-VATS or MV-VATS in the department of thoracic surgery between 2011 and 2018 were included. Univariate and multivariate regression analysis were used to identify potential factors influencing the surgical decisions. Factors with statistical significance were selected for constructing the Surgical Decision-making Scoring (SDS) model. The performance of the model was validated by area under the receiver operating characteristic curve (AUC), calibration curves and decision curve analysis (DCA). RESULTS: The Surgical Decision-making Scoring (SDS) model was built guided by the clinical judgment and statistically significant results of univariate and multivariate regression analyses of potential predictors, including smoking status (p = 0.03), BMI (p < 0.001), ACCI (p = 0.04), T stage (p < 0.001), N stage (p < 0.001), ASA grade (p < 0.001) and surgical technique (p < 0.001). The AUC of the training group and the testing group were 0.72 and 0.70, respectively. The calibration curves and the DCA curve revealed that the SDS model has a desired performance in predicting the surgical decision. CONCLUSIONS: This SDS model is the first clinical decision-making model developed for an individual NSCLC patient to make decision between SV-VATS and MV-VATS.

Modified classifications and surgical decision-making process for chronic anterior talofibular ligament injuries based on the correlation of imaging studies and arthroscopic findings.

PURPOSE: Surgical treatment of chronic ankle instability (CAI) typically includes ligament repair or reconstruction. Using preoperative ultrasonography or magnetic resonance imaging (MRI) to choose an appropriate arthroscopic procedure is still difficult. The aim of this study was to evaluate the correlation of imaging studies with arthroscopic findings and support the arthroscopic surgical decision-making process. METHODS: One hundred twelve patients with chronic anterior talofibular ligament (ATFL) injuries were treated using the arthroscopic surgical decision-making process from November 2018 to August 2020. Preoperative imaging assessments using dynamic ultrasonography, MRI, and combined methods were applied to categorize the ATFL remnants into three quality grades ("good," "fair," and "poor"). Arthroscopic findings were classified into 6 major types (7 subtypes) and used to select an appropriate surgical procedure. Correlations between imaging studies, arthroscopic findings, and surgical methods were evaluated. Diagnostic parameters, clinical outcomes, and complications were also assessed. RESULTS: There was a significant interobserver agreement in the evaluation of dynamic ultrasonography (0.954, P < 0.001), MRI (0.958, P < 0.001), and arthroscopy diagnosis (0.978, P < 0.001). There was a significant correlation between the modified imaging classifications, arthroscopic diagnostic types, and surgical procedures. The mean follow-up period was 33.58 ± 8.85 months. Significant improvements were documented in postoperative ankle functions when assessed with Karlson-Peterson scores and Cumberland Ankle Instability Tool scores. The risk of complications is also very low. CONCLUSION: The modified classifications and surgical decision-making process based on dynamic ultrasonography, MRI, and arthroscopic findings, as proposed in this study, might help in selecting an appropriate arthroscopic surgical procedure for chronic ATFL injuries.

A systematic review of patient-reported outcome measures patients with chronic limb-threatening ischemia.

Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and important measures for clinical evaluation in both clinical care and research. PROMs are important for the measurement of clinical effectiveness and cost effectiveness and for shared decision-making on treatment options. However, the PROMs used to describe the experience of patients with CLTI are heterogeneous, incomplete, and lack specific applicability to the underlying disease processes and diverse populations. For example, certain PROMs exist for patients with extremity wounds, and other PROMs exist for patients with pain, and still others exist for patients with vascular disease. Despite this multiplicity of tools, no single PROM encompasses all of the components necessary to describe the experiences of patients with CLTI. This significant unmet need is evident from both published reports and contemporary large-scale clinical trials in the field. In this systematic review, we review the current use of PROMs for patients with CLTI in clinical practice and in research trials and highlight the gaps that need to be addressed to develop a unifying PROM instrument for CLTI.

The relationship between perceptions of shared decision-making and patient-reported outcomes in a cross-sectional cohort of haemorrhoidectomy patients.

AIM: Shared decision-making between patients and clinicians is important to surgical practice and patients' perceptions of their healthcare experience. This study aims to measure associations between patients' perceptions of their shared decision-making (SDM) process and health-related quality of life among a cohort of patients choosing surgical management of an elective surgical procedure, haemorrhoidectomy. METHODS: This study is a single-site study based in Vancouver, Canada. Consecutive patients of five colorectal surgeons registered for elective haemorrhoidectomy between September 2016 and June 2020 were eligible to participate. Participants completed the CollaboRATE instrument which measures patients' perceptions of their SDM after the surgical consultation, along with a number of other patient-reported outcomes. RESULTS: The participation rate was 45.3%, with 157 patients scheduled for haemorrhoidectomy providing complete information. Unadjusted results found that participants having the most comorbidities reported better communication with their surgeon. The adjusted results show that socioeconomic status and depression were associated with lower CollaboRATE scores. There was no effect of sex, pain interference, anxiety or perceived health status on participants' CollaboRATE scores. CONCLUSION: This study found evidence that participants with lower economic status or those reporting depressive symptoms had worse perceptions of their SDM process with their surgeon. These findings suggest that special attention should be paid to the surgical decision-making process for these patient populations.

Implementation of functional imaging using 11C-methionine PET-CT co-registered with MRI for advanced surgical planning and decision making in prolactinoma surgery.

PURPOSE: To report the first experience of our multidisciplinary team with functional imaging using 11C-methionine positron emission tomography-computed tomography (11C-methionine PET-CT) co-registered with MRI (Met-PET/MRICR) in clinical decision making and surgical planning of patients with difficult to treat prolactinoma. METHODS: In eighteen patients with prolactinoma, referred to our tertiary referral centre because of intolerance or resistance for dopamine agonists (DA), Met-PET/MRICR was used to aid decision-making regarding therapy. RESULTS: Met-PET/MRICR was positive in 94% of the patients. MRI and Met-PET/MRICR findings were completely concordant in five patients, partially concordant in nine patients, and non-concordant in four patients. In five patients Met-PET/MRICR identified lesion(s) that were retrospectively also visible on MRI. Met-PET/MRICR was false negative in one patient, with a cystic adenoma on conventional MRI. Thirteen patients underwent transsphenoidal surgery, with nine achieving full biochemical remission, two clinical improvement and near normalized prolactin levels, and one patient clinical improvement with significant tumour reduction. Hence, nearly all patients (94%) were considered to have a positive outcome. Permanent complication rate was low. Three patients continued DA, two patients have a wait and scan policy. CONCLUSION: Met-PET/MRICR can provide additional information to guide multidisciplinary preoperative and intraoperative decision making in selected cases of prolactinoma. This approach resulted in a high remission rate with a low rate of complications in our expert centre.

Substratification of patients with highest-risk non-muscle invasive bladder cancer helps to identify the candidates for immediate radical cystectomy: A two-center study.

OBJECTIVES: Performing immediate radical cystectomy in all patients with the highest-risk non-muscle invasive bladder cancer results in overtreatment. We confirm whether the substratification of highest-risk patients can more effectively select suitable patients for radical cystectomy. METHODS: Patients with primary T1 high grade bladder cancer from two centers were included and roughly stratified into high-risk or highest-risk. The highest-risk patients were further substratified according to the number of risk factors. Endpoints were tumor recurrence and progression. The predictive accuracy was assessed with internal validation that consists of time-dependent receiver operating characteristic curve and calibration curves. RESULTS: A total of 262 patients were included. Although highest-risk patient had a poor prognosis, after further substratification, we found that those with only one factor showed the same prognosis with high-risk patients (recurrence: hazard ratio 1.79, P = 0.105; progression: hazard ratio 1.38, P = 0.532), while those with ≥2 factors had worst prognosis than high-risk patients. The 3-year area under the curve showed that the predictive accuracy of substratification in terms of recurrence and progression were superior to that of non-substratification (0.685 vs 0.622 and 0.666 vs 0.599, respectively). Additionally, calibration curves showed perfect agreement between the predicted and the actual recurrence and progression. CONCLUSIONS: Substratification of highest-risk enables us to further optimize the surgical decisions-making. Highest-risk patients with one factor show the similar outcomes as high-risk patients and deserve to try bladder-sparing treatment, whereas those with ≥2 risk factors were strongly recommended to undergo radical cystectomy.

Documenting surgical triage in rural surgical networks: Formalising existing structures.

OBJECTIVE: It is essential that the embedded process of rural case selection be highlighted and documented to provide reassurance of rigour across rural surgical services supported by generalist surgeons, general practitioners with enhanced surgical skills and general practitioner anaesthetists. This enables feedback and improves the triage and case selection process to ensure the highest quality outcomes. Therefore, this research aims to explore participants' rational criteria for decision making around rural case selection. DESIGN: Participants participated in a series of semi-structured in-depth interviews which were coded and underwent thematic analysis. SETTING: Six community hospitals in British Columbia, Canada. PARTICIPANTS: General practitioners with enhanced surgical skills, general practitioner anaesthetists, local maternity care providers, and specialists. RESULTS: Based on participant accounts, rural surgical and obstetrical decision-making processes for local patient selection or regional referral had five major components: (1) Clinical Factors, (2) Physician Factors, (3) Patient Factors, (4) Consensus Between Providers and (5) the Availability of Local Resources. CONCLUSION: Decision-making processes around rural surgical and obstetrical patient selection are complex and require comprehensive understanding of local capacity and resources. Current policies and guidelines fail to consider the varying capacities of each rural site and should be hospital specific.

A Practical Guideline for the Implementation of Shared Decision-making in Complex Ventral Incisional Hernia Repair.

BACKGROUND: Although obtaining preoperative procedural consent is required to meet legal and ethical obligations, consent is often relegated to a unidirectional conversation between surgeons and patients. In contrast, shared decision-making (SDM) is a collaborative dialog that elicits patient preferences. Despite emerging interest in SDM, there is a paucity of literature on its application to ventral incisional hernia repair (VIHR). The various surgical techniques and mesh types available, the potential impact on functional outcomes and quality of life, the largely elective nature of the operation, and the significant risk of perioperative patient complications render VIHR an ideal field for SDM implementation. METHODS: The authors reviewed the current literature and drew on their own practice experience to describe evidence-based practical guidelines for implementing the SDM into VIHR care. RESULTS: We summarized the evidence basis for SDM in surgery and discussed how this model can be applied to VIHR given the multiple, complex factors that influence surgical decision-making. We outlined an example of using an SDM framework, "SHARE," with a patient with a large, recurrent ventral hernia. CONCLUSIONS: SDM has the potential to improve patient-centered and preference-concordant care among individuals being considered for VIHR to ensure that treatment interventions meet a patient's goals, rather than solely treating the underlying disease process.

Current use of the pelvic organ prolapse quantification system in clinical practice among Korean obstetrician-gynecologists.

BACKGROUND: To assess current use of the Pelvic Organ Prolapse Quantification (POP-Q) system in clinical practice among Korean obstetrician-gynecologists. METHODS: A web-based questionnaire was sent to 780 Korean Society of Obstetrics and Gynecology members. The items evaluated in the questionnaire were demographic characteristics and current use of the POP-Q system in the evaluation of pelvic organ prolapse (POP) and surgical decision-making. Differences between POP-Q users and nonusers were analyzed by using the two-sample t-test and chi-squared test. RESULTS: One hundred twenty-six members (16%) responded to the survey. Of the respondents, 48% reported using the POP-Q system in the evaluation of POP. Members who were female, urogynecologists, or performed a high volume of prolapse surgery were more likely to use the POP-Q system (p < 0.05). All but one of the POP-Q users reported using the specific criteria to determine whether each compartmental prolapse should be corrected during prolapse surgery. Most respondents used stage 2 or the hymen as a threshold for prolapse to be corrected for all compartments. CONCLUSIONS: Less than half of Korean obstetrician-gynecologists use the POP-Q system in the evaluation of POP. Almost all of POP-Q users make a surgical decision based on the results of the POP-Q examination.

Coronary Artery Bypass Grafting in Cardiogenic Shock: Decision-Making, Management Options, and Outcomes.

Coronary artery bypass grafting is a highly efficacious mode of myocardial revascularization that reduces mortality from ischemic heart disease. The patient presenting after acute myocardial infarction in cardiogenic shock presents a unique challenge. Early revascularization is proven to reduce mortality, but many questions remain, including the optimal mode and extent of revascularization, the role of mechanical circulatory support, and which patients are candidates for surgical intervention. Unprecedented attention to the outcomes of cardiac surgery means decisions about the management of the acute myocardial infarction in cardiogenic shock patients are influenced by risk aversion. The authors here review this topic to arm the reader with a comprehensive understanding of the literature to better guide surgical decision-making and perioperative management.

The Year in Perioperative Echocardiography: Selected Highlights from 2020.

This article is the fifth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank Editor-in-Chief Dr. Kaplan and the editorial board for the opportunity to continue this series. In most cases, these will be research articles that are targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles will target the use of perioperative echocardiography in general.