Cancellation of Surgeries: Integrative Review.

PURPOSE: To analyze cancellations of surgeries and identify evidence-based interventions to address this issue. DESIGN: Integrative literature review. METHODS: An integrative literature search was conducted in four databases: CINAHL, PubMed, Embase, and Cochrane and included literature sources dated January 2011 to January 2016. The complete list of search terms consisted of the following: ambulatory surgery, day surgery center, elective surgical procedure, elective operation, elective surgery, schedule, access to care, surgery cancellation, operation cancellation, and surgery delay. FINDINGS: Twenty-three literature sources were identified. Evidence included one randomized controlled trial and multiple studies. Causes of cancellations were classified into three categories: hospital-related reasons, patient-related reasons, and surgeon-related reasons. Evidence confirmed most cancellations were avoidable. CONCLUSIONS: Cancellation of scheduled surgeries has a significant impact on patients' health, resources, cost, and quality of care. It is difficult to devise a solution without understanding the cause of cancellations.

Elective Surgical Cancellations in a Tertiary Hospital in the Middle East: Quality Improvement Process.

PURPOSE: Cancellation of elective surgery negatively affects patient outcomes and the efficiency of the work environment. The purpose of this project was to analyze the cancellation of elective surgeries and identify the best evidence-based interventions to address cancellations in a tertiary hospital in the Middle East. DESIGN: A quality improvement study design. METHODS: A retrospective review of cancellations conducted over two 3-month periods in 2016 and 2017. FINDINGS: In both phases of the audit, patient-related reasons were the leading cause of cancellations. Conducting a preoperative call 2 days before surgery and doing a weekly review of the surgery schedule reduced cancellations from 3.8% to 3.5%. Cancellations because of patient-related reasons reduced from 81% to 79.7% whereas cancellations because of hospital-related reasons reduced from 17.5% to 15.9%. CONCLUSIONS: Cancellation of surgeries is a worldwide health care issue and without understanding the causes of cancellations, it is difficult to devise an effective intervention to address this issue.

Contemporary management of recurrent pectus excavatum.

BACKGROUND: Optimal management of recurrent pectus excavatum (PE) has not been established. Here, we review our institutional experience in managing recurrent PE to evaluate long-term outcomes and propose an anatomic classification of recurrences, and a decision-making algorithm. METHODS: Clinical records of patients undergoing repair of recurrent PE (1996-2011) were reviewed. Univariate and multivariate logistic regression analyses were employed to examine patient characteristics as potential predictors for re-recurrence. RESULTS: Eighty-five patients with recurrent PE were identified during the study period. The initial operation was a Ravitch procedure in 85% of cases. Revision procedures were most frequently Nuss repairs (N=73, 86%), with remaining cases managed via open approach. Overall cosmetic and functional results were satisfactory in 67 patients (91.8%) managed with Nuss and in 7 (58%) patients managed with other techniques. Seven (8%) patients required additional surgical revision. Multivariate analysis identified no statistically significant patient or procedural factors predictive of re-recurrence. CONCLUSION: This study demonstrates that the Nuss procedure can be an effective intervention for recurrent pectus excavatum, regardless of the initial repair technique. However, open repair remains valuable when managing severe cases with abnormalities of the sternocostal junction and cartilage regrowth under the sternum.

Z-type pattern pectus excavatum/carinatum in a case of Noonan syndrome.

Noonan syndrome is a genetic condition that can present with complex thoracic defects, the management of which often presents a surgical challenge. We present the surgical approach applied to a severe combined excavatum/carinatum deformity that had resulted in a Z-type configuration of the chest in a 9-year-old girl with Noonan syndrome.

Perioperative strategies and technical modifications to the Nuss repair for pectus excavatum in pediatric patients: a large volume, single institution experience.

BACKGROUND: The safety and efficacy of minimally invasive pectus excavatum repair have been demonstrated over the last twenty years. However, technical details and perioperative management strategies continue to be debated. The aim of the present study is to review a large single-institution experience with the modified Nuss procedure. METHODS: A retrospective review was performed of patients who underwent primary pectus excavatum repair at a single tertiary hospital via a modified Nuss procedure that included: no thoracoscopy, retrosternal dissection achieved via a left-to-right thoracic approach, four-point stabilization of the bar, and no routine epidural analgesia. Data collected included demographics, preoperative symptoms, operative characteristics, hospital charges and postoperative outcomes. RESULTS: A total of 336 pediatric patients were identified. No cardiac perforations occurred and the rate of pericarditis was 0.6%. Contemporary rates of bar displacement have fallen to 1.2%. Routine use of chlorhexidine scrub reduced superficial site infections to 0.7%. Two patients (0.6%) with severe recurrence required reoperation. Bars were removed after an average period of 31.7(SD 13.2) months, with satisfactory cosmetic and functional results in 94.9% of cases. CONCLUSIONS: We report here a single-institution large volume experience, including modifications to the Nuss procedure that make the technique simpler and safer, improve results, and minimize hospital charges.

Operative management of acquired Jeune's syndrome.

BACKGROUND: Acquired Jeune's syndrome is a severe iatrogenic deformity of the thoracic wall following a premature and aggressive open pectus excavatum repair. We report herein our technique and experience with this rare condition. METHODS: From 1996 to 2011, nineteen patients with acquired Jeune's syndrome were retrospectively identified in a tertiary referral center. The technique used to expand and reconstruct the thoracic wall consisted of 1) release of the sternum from fibrous scar tissue, 2) multiple osteotomies along the lateral aspect of the ribs with anterior advancement of costal-cartilages to protect the heart, 3) stabilization of the thorax by placing a curved bar for retrosternal support and, 4) restoration of the sterno-costal junction by wiring the lower cartilages to the edge of the sternum. RESULTS: Major complications observed in this series were: bar displacement (seven cases), postoperative death from cardiac arrest following bronchoscopy (one case), late cardiac tamponade from migration of wire suture fragment (one case), and need for multiple reoperations (one case). Long-term cosmetic results and improvement in daily quality of life were reported as positive in the majority of cases. CONCLUSIONS: Anterior chest wall reconstruction successfully treated our series of patients with acquired Jeune's syndrome. This multifaceted technique is an effective procedure that allows expansion of the thoracic cavity and improvement of aerobic activity.

Pectus bar repair of pectus excavatum in patients with connective tissue disease.

PURPOSE: Few studies address the surgical correction of pectus excavatum (PE) in patients with connective tissue disease (CTD). We have identified the preoperative characteristics, postoperative complications, and outcomes of patients with CTD undergoing bar repair of PE and compared these outcomes to a control group without CTD. METHODS: A retrospective review of patients undergoing primary repair of PE with a bar procedure from 1997 to 2006 identified 22 patients with CTD. Of those, 20 (90.9%) had their bars removed. We identified 223 patients of similar age without CTD whose bars were removed. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. RESULTS: Among those with CTD, the median age at repair was 15.5 years, with a mean pectus index of 4.0 +/- 1.4. Three patients (13.6%) experienced bar displacement or upper sternal depression requiring surgical revision. Only 1 patient recurred after bar removal. Rates of bar displacement, upper sternal depression, and recurrence were not statistically different than those in the comparison group. CONCLUSIONS: Patients with CTD benefit from primary bar repair of PE and experience excellent operative outcomes after repair, with complication rates being no different than those found in similarly aged control patients.

Lorenz bar repair of pectus excavatum in the adult population: should it be done?

BACKGROUND: Although extensive literature exists on the Lorenz bar repair of pectus excavatum (PE) in pediatric patients, few data examine this repair in adults or compare long-term outcomes in adults with the pediatric population. We identified the preoperative characteristics, postoperative complications, and outcomes of adult patients undergoing Lorenz bar repair of PE who had bar removal and compared these outcomes with a pediatric population undergoing the same procedure. METHODS: A retrospective review (1997 to 2006) of patients undergoing primary repair of PE with a Lorenz bar identified 107 individuals aged older than 18 and 137 patients aged 6 to 14, of whom 52 and 80 had their bar(s) removed, respectively. These latter patients were the focus of analysis. Data collected included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. RESULTS: The median (interquartile range, IQR) age and pectus index of adult patients (81% men) at the time of repair was 23 (18 to 30) years and 3.8 (3.5 to 4.3), respectively. In 2 adults (3.9%), PE recurred after bar removal, and 6 (11.6%) required surgical revision for bar displacement or upper sternal depression. These rates of complications were similar to those found in children undergoing Lorenz bar repair of PE at our institution. CONCLUSIONS: Lorenz bar placement to correct PE in adults can be performed safely and effectively, with rates of bar displacement, sternal depression, recurrence, and reoperation that are not statistically different than those found in a younger pediatric population.

Upper sternal depression following Lorenz bar repair of pectus excavatum.

An upper sternal depression following Lorenz bar repair of pectus excavatum (PE) represents a partial recurrence and poses a difficult problem for the surgeon. There is no published experience detailing the management options or best course of therapy for this complication. This study presents our institutional experience in treating eight patients with this specific subtype of recurrence and we discuss intraoperative considerations which aid in the identification and better management of this deformity. A retrospective review (1997-2006) of patients undergoing primary repair of PE with a Lorenz bar procedure identified eight patients who experienced upper sternal depression with the bar still in place following initial repair of PE. All patients were revised with the insertion of a second bar to elevate the upper sternal depression. Data collected for each patient included demographics, preoperative symptoms, operative characteristics, and postoperative outcomes. The mean age at the time of Lorenz bar repair and surgical revision was 20.8 +/- 9.5 and 21.5 +/- 10.1 years, respectively. A majority of patients (87.5%) were male. The mean time to reoperation was 23.8 +/- 11.8 months. Following this second procedure, no patient has experienced bar displacement, recurrence of the upper sternal depression, or has required a third procedure. Our limited experience supports the use of a second Lorenz bar in the treatment of upper sternal depression after bar correction of a PE deformity. Appropriate recognition and treatment of this entity will advance patient outcomes and satisfaction after surgery for PE deformities.