Drapes in Routine Aseptic Procedures for Environmental Sustainability (project DRAPES): a protocol for a multi-centre randomised controlled trial comparing post-operative wound complication rates following routine neutering of dogs and cats using reusable or disposable surgical drapes.

BACKGROUND: Reusable surgical drapes have a lower lifetime environmental impact than disposable drapes in most cases. There is limited evidence regarding whether drape choice impacts patient outcomes including post-operative wound complications. The aim of this study is to compare wound complication rates following routine neutering surgeries in cats and dogs when reusable drapes are used as compared with disposable drapes. METHODS: The trial will be conducted as a pragmatic, multi-centre, parallel group randomised controlled trial in the UK. Dogs and cats undergoing routine neutering will be randomised to disposable or reusable drapes with all other aspects of care occurring as they usually would at the practice. The required sample size is 2,850, with 4750 animals to be recruited from up to ten practices to allow for a 40% loss to follow-up. Demographic data and details on peri-operative care will be collected at the time of surgery. Post-operative wound complications will be assessed and recorded as usual at each practice using clinical codes. The post-operative wound clinical codes and any antibiotic use within 30 days of surgery will be retrieved from the practice management software. The primary outcome that will be compared between the two groups is the rate of post-operative wound complications within 30 days of surgery which will be analysed by multivariable logistic regression with a binary outcome of wound complication (yes/no). Secondary outcomes are the prevalence of different types of complications and antibiotic use within 30 days of surgery which will be compared between the two groups by chi square analysis. DISCUSSION: Our hypothesis is that there will be no difference in post-operative wound complication rates between disposable and reusable drapes. If the likely rate of post-surgical wound complications with reusable drapes is similar to that with disposable drapes, then veterinary clinical teams can choose the more sustainable option, confident that their patients will not be impacted by this choice. TRIAL REGISTRATION: We have retrospectively registered the protocol on the Open Science Framework on 14 Nov 2023 (Trial registration entry: https://doi.org/10.17605/OSF.IO/72HMA ).

Development of Advanced FEM Simulation Technology for Pre-Operative Surgical Planning.

Intracorporeal needle-based therapeutic ultrasound (NBTU) offers a minimally invasive approach for the thermal ablation of malignant brain tumors, including both primary and metastatic cancers. NBTU utilizes a high-frequency alternating electric field to excite a piezoelectric transducer, generating acoustic waves that cause localized heating and tumor cell ablation, and it provides a more precise ablation by delivering lower acoustic power doses directly to targeted tumors while sparing surrounding healthy tissue. Building on our previous work, this study introduces a database for optimizing pre-operative surgical planning by simulating ablation effects in varied tissue environments and develops an extended simulation model incorporating various tumor types and sizes to evaluate thermal damage under trans-tissue conditions. A comprehensive database is created from these simulations, detailing critical parameters such as CEM43 isodose maps, temperature changes, thermal dose areas, and maximum ablation distances for four directional probes. This database serves as a valuable resource for future studies, aiding in complex trajectory planning and parameter optimization for NBTU procedures. Moreover, a novel probe selection method is proposed to enhance pre-surgical planning, providing a strategic approach to selecting probes that maximize therapeutic efficiency and minimize ablation time. By avoiding unnecessary thermal propagation and optimizing probe angles, this method has the potential to improve patient outcomes and streamline surgical procedures. Overall, the findings of this study contribute significantly to the field of NBTU, offering a robust framework for enhancing treatment precision and efficacy in clinical settings.

A systematic review of the outcomes of partial ulnar collateral ligament tears of the elbow in athletes treated non-operatively with platelet-rich plasma injection.

Background: This study aimed to analyze the effects of platelet-rich plasma (PRP) for partial ulnar collateral ligament (UCL) tears in athletes and predicted positive outcomes. Methods: The researchers systematically reviewed the PubMed, Cochrane CENTRAL, MEDLINE, Scopus, and Google Scholar databases to identify studies with clinical outcomes of PRP for partial UCL tears. They excluded studies that did not stratify data by tear type or included surgical management. Results: Five studies with 156 patients were included. The timing, amount, platelet concentration, type, and number of PRP injections were highly variable among the studies. However, 75% (n = 97/127) of athletes returned to sport (RTS) at a weighted average of 82.1 days (37-84) after PRP injection. One study showed significant improvements in patient-reported outcomes. Two studies showed positive outcomes in the modified Conway scale, complete reconstitution of the UCL in 87% of patients on MRI, and significant improvement in the humeral-ulnar joint space after PRP injection via ultrasound. The Coleman methodology score (CMS) averaged 48/100, indicating an overall poor quality of evidence. Conclusion: This review demonstrates favorable RTS, clinical, and radiographic outcomes in patients receiving PRP for partial UCL tears, but the literature remains heterogeneous and of low quality. Level of Evidence: III.

Comparison of outcome of early tangential excision with autografting versus interactive antimicrobial dressing in deep-partial thickness burn patients: A retrospective analysis.

BACKGROUND: The relative effectiveness of early excision and autografting (EG) for deep-partial thickness burns needs to be updated through comparison to initial non-operative (INO) treatment using modern interactive antimicrobial (IA) dressings in a South-Asian burn patient population. OBJECTIVE: To compare the outcome of early tangential excision and autografting (EG) to initial non-operative (INO) treatment using interactive antimicrobial dressing. METHODS: Records of 106 adult burn survivors with predominantly deep-partial thickness thermal burns of TBSA ≤ 30 % were retrospectively reviewed (53 patients each in EG-arm and INO-arm). EG-arm patients underwent excision and autografting within 7 days. INO-arm patients, who had opted against surgical excision, received interactive antimicrobial dressing (hydrofiber with ionic silver). Outcomes measured include percentage of wound healed on days 14 and 21, days to complete wound healing, duration of hospital stay, complications (on 12 months' follow-up) and patient satisfaction scores. Patients were analyzed as treated. RESULT: Patients in each arm had similar TBSA and demographic profiles. In EG-arm patients, 15-20 % of TBSA were grafted on 5.02 ± 0.71 post-burn day. Thirty percent of EG-arm patients required a second session of grafting for the remaining burn wound, which occurred on 6.873 ± 0.34 post-burn day. On the 21st post-burn day the EG-arm, compared to the INO-arm, had a higher percentage of wound epithelization (98.60 ± 4.03, versus 76.16 ± 7.02, P < 0.01), less days to complete healing (17.60 ± 5.83, versus 40.16 ± 9.09, P < 0.01), and shorter hospital stays (19.62 ± 6.85 days, versus 35.56 ± 7.77 days, P < 0.01). Twenty-five (47 %) INO-arm patients underwent delayed grafting on post-burn day 25.42 ± 0.49. The INO-arm suffered significantly more complications, such as hypertrophic scar, dyspigmentation and functional disability (P < 0.05). EG-arm patients were more satisfied than INO-arm patients (P < 0.01). CONCLUSION: We report superior outcomes in the early tangential excision and autografting-arm as compared to the initial non-operative treatment arm. The dogma of early excision and autografting remains valid despite significant advances in wound dressing materials.

Identification and stratification of placenta percreta with gynecologic oncologist management.

OBJECTIVE: Gynecologic oncologist involvement in the surgical team of patients with placenta percreta has shown improved patient outcomes. Yet, stratification of cases is dependent on identification of placenta percreta by ultrasonography which has a poor detection rate. To allow patients to receive optimal team management by pre-operative stratification our objective was to identify the pre-operative characteristics of patients with previously underdiagnosed placenta percreta. METHODS: A retrospective single institution case-control study was performed from January 2010 to December 2022 of singleton, non-anomalous pregnancies with suspicion for placenta accreta spectrum (PAS). Ultrasonography was used as the primary method of detection. Final inclusion was dependent on histology confirmation of PAS and degree of invasion. We explored the role of concurrent antenatal magnetic resonance imaging (MRI) on patients with previously unrecognized placenta percreta. RESULTS: During the 13 year study period, 140 cases of histologically confirmed PAS were managed by our team and met inclusion criteria. A total of 72 (51.4%) cases were for placenta percreta and 27 (37.5%) of these were diagnosed pre-operatively while 45 (62.5%) were only diagnosed post-operatively. Comparison between these two groups revealed patient body mass index (BMI) >30 kg/m2 was independently associated with unrecognized placenta percreta (p=0.006). No findings by MRI were associated with mischaracterization of placenta percreta. Yet, concurrent MRI assessment of patients with BMI >30 kg/m2 (n=18), increased placenta percreta detection by 11 cases (61%). CONCLUSION: The ability to determine pre-operatively which patients are more likely to have placenta percreta allows for gynecologic oncologists to be involved in the most complex cases in a planned manner. This study shows that women at risk for placenta accreta spectrum, who are obese (BMI >30 kg/m2), may benefit from further assessment with pre-operative MRI to facilitate appropriate staffing and team availability for cases of placenta percreta.

The Safety and Outcomes of Elective Endovascular Aneurysm Repair in the Elderly: A Systemic Review and Meta-Analysis.

PURPOSE: Prevalence of abdominal aortic aneurysms (AAAs) increases with age. Previous trials confirm that elective endovascular aneurysm repair (EVAR) is an effective intervention for AAA. However, few elderly patients were recruited into randomized trials, whereas in contemporary clinical practice, elective repair is commonly performed on octogenarians. We evaluated the safety and outcome of elective EVAR in elderly patients to inform clinical practice and vascular service provision. METHODS: A systematic review and meta-analysis of studies reporting risk of complications and death in patients undergoing elective EVAR was performed (PROSPERO CRD: 42022308423). Observational studies and interventional arms of randomized trials were included if the outcome rates or raw data were provided. Primary outcome was 30-day mortality. Secondary outcomes were longer-term mortality, 30-day major adverse events, and aneurysm-related mortality. Primary and secondary outcomes were compared between octogenarians and non-octogenarians. Exclusion criteria were emergency procedures, non-infrarenal aneurysms, and lack of octogenarian data. RESULTS: A total of 41 studies were eligible from 10 099 citations, including 10 national and 5 international registries, 26 retrospective studies, and our own prospective cohort. The analysis included 208 997 non-octogenarians (mean age=70.19 [SD=0.62]) and 106 188 octogenarians (mean age=83.75 [SD=0.35]). The 30-day mortality post-elective EVAR was higher in octogenarians (1.08% in non-octogenarians, 2.31% in octogenarians, odds ratio [OR]=2.27 [2.08-2.47], p<0.0001). Linear regression demonstrated a 0.83% increase in 30-day mortality for every 10-year age increase above 60 years old. Mortality for octogenarians increased significantly during follow-up: 11.35% (OR=1.87 [1.65-2.13], p<0.001), 22.80% (OR=1.89 [1.52-2.35], p<0.001), 32.00% (OR=1.98 [1.66-2.37], p<0.001), 47.53%, and 51.08% (OR=2.40 [1.90-3.03], p<0.001) at 1-through-5-year follow-up, respectively. The 30-day major adverse events after elective EVAR were higher in octogenarians (OR=1.75-2.83, p<0.001). CONCLUSIONS: Octogenarians experience higher but acceptable peri-operative morbidity and mortality compared with younger patients. However, 3-year to 5-year survival is very low among octogenarians. Our findings challenge the notion of routine intervention in elderly patients and support very careful selection for elective EVAR. Many octogenarians with peri-threshold (<6 cm) AAAs may derive no benefit from EVAR due to limited 3-year to 5-year overall survival and low risk of aneurysm rupture with conservative management. An adjusted threshold for intervention in octogenarians may be warranted. CLINICAL IMPACT: Octogenarians with infra-renal AAA are increasingly managed with elective EVAR. Previous studies have demonstrated that EVAR is safer than open repair for octogenarians, with lower peri-operative mortality and major adverse events. However, randomised trials, on which much of contemporary evidence is based, recruited a relatively younger population of participants. This systematic review and meta-analysis provides a contemporary synthesis of the literature comparing outcomes in octogenarians to younger patients. The results of this analysis, together with low rupture rates amongst octogenarians in existing literature, question the benefit of routine elective intervention for peri-threshold aneurysms and an adjusted threshold for intervention in octogenarians may be warranted.

Utilisation of a post-Fontan management pathway reduces chest tube drainage and hospital readmission rates.

BACKGROUND: Complications following the Fontan procedure include prolonged pleural drainage and readmission for effusions. To address these complications, a post-Fontan management pathway was implemented with primary goals of reducing chest tube duration/reinsertion rates and decreasing hospital length of stay and readmissions. METHODS: Fontan patients were identified by retrospective chart review (2017-2019) to obtain baseline data for chest tube duration/reinsertion rates, hospital length of stay, and readmission rates for effusion. A post-Fontan management pathway was implemented (2020-2021) utilising post-operative vasopressin, nasal cannula oxygen until chest tube removal, and discharge regimen of three times daily diuretics, sildenafil, and afterload reducing medications. Patients were followed to evaluate primary outcomes. RESULTS: The pre- and post-pathway groups were similar in single ventricle morphology, demographics, and pre-operative haemodynamics. Forty-three and 36 patients were included in the pre- and post-pathway cohorts, respectively. There were statistically significant reductions in chest tube duration (8 vs. 5 days, p ≤ 0.001), chest tube output on post-operative day 4 (20.4 vs. 9.9 mL/kg/day, p = 0.003), and hospital readmission rates for effusion (13[30%] vs. 3[8%], p = 0.02) compared to baseline. There was an absolute reduction in hospital length of stay (11 vs. 9.5 days, p = 0.052). When combining average cost savings for the Fontan hospitalisations, readmissions for effusion, and cardiac catheterisations within 6 months of Fontan completion, there was a $325,144 total cost savings for 36 patients following pathway implementation. CONCLUSION: Implementation of a post-Fontan management pathway resulted in significant reductions in chest tube duration and output, and readmission rates for effusion in the perioperative period.

[Surgical or non-operative treatment of acute Achilles tendon rupture : What does the current literature say?] / Operative oder konservative Behandlung der akuten Achillessehnenruptur : Was sagt die aktuelle Literatur?

BACKGROUND: The Achilles tendon is the strongest tendon in humans and is frequently injured, especially in the physically active young to middle-aged population. An increasing frequency of Achilles tendon ruptures (ATR) has been reported in several studies. However, there is no international consensus regarding possible non-operative (N-OP) or operative (surgical) treatment (OP). OBJECTIVES: The aim of this article is to semi-quantitatively compare both treatment options for ATR by analyzing the results reported in the literature. MATERIAL AND METHODS: For this purpose, relevant categories were identified, and the literature was then evaluated in a PubMed analysis. Ten meta-analyses and two cost analyses were included. The data was extracted according to the categories and evaluated comparatively. RESULTS: OP and N­OP for acute ATR can lead to equally good restitution of clinical function if early functional rehabilitation is applied. The lower re-rupture rate is an advantage of OP, whereas the lower general complications speak in favor of N­OP. The minimally invasive or percutaneous surgical technique (M-OP) appears to be advantageous over the open surgical technique (O-OP), although studies show an increased rate of lesions of the sural nerve. CONCLUSION: There is no consensus regarding the superiority of OP or N­OP for acute ATR, as several studies conducted since the introduction of early mobilization protocols have shown similar results for these two interventions. Results and complications of M­OP and O­OP are also comparable. Considering the available data on the various surgical procedures, the authors prefer the M­OP technique with adequate sural nerve protection for repair of acute ATR, combined with an early mobilization protocol.

Operative Management of Charcot Neuropathy of the Foot and Ankle: A Retrospective Cohort Study of Long-Term Outcomes.

Treatment of Charcot neuroarthropathy (CN) of the foot and ankle remains challenging for both patients and surgeons. Nonoperative treatment with cast/orthosis immobilization has long been the main treatment, but surgical intervention has gained interest to improve poor long-term outcomes. Few long-term outcome studies exist on operative management of CN. A retrospective chart review was performed to analyze demographics, comorbidities, complications, and outcomes of operative management of CN. Patients were divided into two cohorts for analysis: limited surgical intervention (LSI) and reconstructive surgery (RS). Fifty-eight patients with CN treated surgically over 11 years were identified. Average follow-up was 46 months (range, 1 to 173 months). The mean age was 60.2 (range, 29 to 81) years, and the average body mass index was 34.3. Diabetes caused CN in 72.4% (42/58) of patients. The LSI cohort (n = 32) had significantly higher rates of presenting infection (59.4%; 19/32) and ulceration (87.5%; 28/32) compared with the RS cohort (n = 26; 23.1% [6/26] and 50% [13/26], respectively). Rates of postoperative infection and ulceration were lower in the LSI group (25% [8/32] and 34.4% [11/32], respectively) than the RS group (42.3% [11/26] and 42.3% [11/26], respectively). The amputation rate for the LSI cohort was 21.9% (7/32) compared with 23.1% (6/26) for RS. This large, single-center study of operatively treated CN patients showed no significant difference between LSI and RS. This study provides data to help surgeons counsel patients on expected outcomes.

Identifying key predictors for uterine manipulator use in robotic simple hysterectomy: a retrospective cohort analysis.

Background: Robotic simple hysterectomy (RSH) is the most common robotic gynecologic surgery in the United States. Uterine manipulators are commonly used to handle the uterus during laparoscopic surgery, but few studies have examined their necessity in RSH. This study retrospectively compares RSH cases with and without the use of manipulators, and identifies predictors for their intraoperative use. Materials and methods: This retrospective cohort study included patients undergoing RSH for benign pathologies at Kawasaki Medical School from October 2020 to December 2022. Patients with malignancies were excluded. The robotic surgeries were performed by three skilled surgeons using the four-arm da Vinci Xi surgical system. Data on perioperative and operative parameters were collected, including age, body mass index (BMI), history of abdominal surgery, disease type, presence of ovarian cysts, and operative time. Statistical analyses were performed using EZR software, with multivariate logistic regression to identify predictive factors for uterine manipulator use. Results: The study included 113 patients who underwent RSH without a uterine manipulator and 58 with one. Patients without a manipulator were older, while those with a manipulator had higher BMIs and a higher prevalence of ovarian chocolate cysts and Douglas obliteration. Operating time was shorter without a manipulator. Independent predictors for manipulator use were higher BMI, presence of ovarian endometrioid cysts, and Douglas obliteration. Conclusion: RSH without a uterine manipulator is feasible and can reduce the need for surgical assistants. Predictors for manipulator use include higher BMI, ovarian cysts, and Douglas obliteration. The use of a fourth robotic arm can enhance surgical independence and resource efficiency. Further research is needed to assess the long-term cost-effectiveness and outcomes of this approach.

Navigating Post-operative Challenges: A Comprehensive Review of Complications Following Anterior Cruciate Ligament (ACL) Tear Surgery.

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating sports-related injuries, often necessitating surgical intervention to restore knee stability and function. ACL reconstruction surgery, which has evolved significantly over the years, aims to enable patients, particularly those who are young and physically active, to return to their pre-injury activity levels. However, despite advancements in surgical techniques and rehabilitation protocols, post-operative complications remain a significant concern that can adversely affect patient outcomes. This comprehensive review explores the spectrum of complications that can arise following ACL tear surgery, ranging from common issues such as infection, graft failure, and knee stiffness to less frequent but clinically significant complications like osteoarthritis and neurological injuries. The review also delves into the various factors influencing the likelihood of these complications, including patient-related variables, surgical techniques, and the effectiveness of rehabilitation protocols. By providing an in-depth analysis of these post-operative challenges, this review aims to enhance the understanding of ACL reconstruction outcomes and guide healthcare professionals in implementing preventive strategies and optimizing patient care. Through a multidisciplinary approach, the goal is to minimize the risk of complications, improve surgical outcomes, and ultimately enhance the quality of life for patients undergoing ACL reconstruction.

Total ankle replacement: Implant Manufacturer's guidelines for post-operative rehabilitation: A review of literature.

Introduction: Total ankle replacements (TARs) is emerging as a successful alternate treatment option to arthrodesis for surgical treatment of end stage ankle arthritis. This has led to manufacturers producing a selection of implants. There is wide variations in post-operative rehab protocols being adopted for treatment following TAR surgery. This depends on choice of implants and manufacturer recommendations too. Following the author's investigation, a lack of standardisation between manufacturer post-operative protocols was identified. The aim of this project was to analyse similarities and differences in guidelines for: choice of immobilisation, weight-bearing (WB) status, of range of movement (ROM) exercises and Physiotherapy. Method: Current commonly used TAR implants in the UK were identified using National Joint Registry's 2020 Annual Report. Additional implants were included after accessing data regarding the TAR market. Individual company websites were researched for information available on public domain for post op management guidelines and the results were summarised. Results: Only 7 implants were reviewed as 6 companies either did not provide post-operative protocols or recommended a surgeon guided rehabilitation process. Different manufacturers allow partial WB by week 2, week 3 and week 7. One protocol suggested full WB from week 4 whereas two others suggested it from week 6. Choices of immobilisation varied as one company suggested casting alone for 6 weeks, two suggest casting followed by a period in a boot, one suggests splinting and a boot and one uses all 3 types of immobilisations. ROM exercises were mentioned by three manufacturers and were encouraged from week 2 and 3. Physiotherapy was mentioned in four protocols, two of which suggest intervention from week 6, one from week 7 and the other mentions the importance of therapy rather than specific timelines. Conclusion: There are differences between post op TAR guidelines from the implant manufacturers regarding the categories analysed. The variation in the data collected makes it challenging to suggest a singular protocol to be followed after TAR surgery.

Critical care unit bed availability and postoperative outcomes: a multinational cohort study.

BACKGROUND: Critical care beds are a limited resource, yet research indicates that recommendations for postoperative critical care admission based on patient-level risk stratification are not followed. It is unclear how prioritisation decisions are made in real-world settings and the effect of this prioritisation on outcomes. METHODS: This was a prespecified analysis of an observational cohort study of adult patients undergoing inpatient surgery, conducted in 274 hospitals across the UK and Australasia during 2017. The primary outcome was postoperative morbidity at day 7. Logistic regression models were used to evaluate the relationship between critical care admission and patient and health system factors. The causal effect of critical care admission on outcome was estimated using variation in critical care occupancy as a natural experiment in an instrumental variable analysis. RESULTS: A total of 19,491 patients from 248 hospitals were eligible for analysis, of whom 2107 were directly admitted to critical care postoperatively. Postoperative morbidity occurred in 2829/19,491 (15%) patients. Increasing surgical risk was associated with critical care admission, as was increased availability of critical care beds (odds ratio (95%CI) 1.04 (1.01-1.06), p = 0.002) per available bed; however, the probability of admission varied significantly between hospitals (median odds ratio 3.05). There was no evidence of a difference in postoperative morbidity with critical care admission (odds ratio (95%CI) 0.91 (0.57-1.45), p = 0.710). DISCUSSION: Postoperative critical care admission is variable and related to bed availability. Statistical methods that adjust for unobserved confounding lowered the estimates of harm previously reported to have been associated with postoperative critical care admission. Our findings provide a rationale for a clinical trial which would evaluate any potential benefits for postoperative critical care admission for patients in whom there is no absolute indication for admission.

The Intra-Aortic Balloon Pump as a Rescue Device: Do we need to shift our strategy for cardiogenic shock rescue after cardiac surgery?

OBJECTIVE: The intra-aortic balloon pump (IABP) is widely used to rescue patients from complications following cardiac surgery. With improvements in rescue strategies over the past decade, the appropriateness of IABP must be reexamined. This study assesses the risk factors, outcomes, and predictors of survival of rescue IABP. METHODS: Patients receiving isolated, rescue IABP during or after cardiac surgery from 2012 to 2020 were studied. All adult patients undergoing cardiac surgery except transplantation and primary mechanical circulatory support (MCS) procedures were included. RESULTS: Of 10,591 patients, 397 (3.7%) patients received peri-operative IABP with rescue IABP instituted in 182 (45.8%). The indications for rescue IABP were post-cardiotomy shock (66, 36.3%), failure to wean cardiopulmonary bypass (58, 31.9%), myocardial ischemia (30, 16.5%), cardiac arrest (25, 13.7%), and ventricular arrhythmia (3, 1.6%). The in-hospital failure to rescue rate was 17.6% (32/182) with a 90-day and one-year survival of 80.8% and 76.9%, respectively. The most common etiology of mortality was ongoing cardiogenic shock (26/42, 61.9%). IABP > 4 days and cardiac arrest as an indication for IABP were risk factors for one-year mortality (adjusted hazards ratio [aHR]: 2.68, 95% confidence interval [CI]: 1.31-5.50; aHR: 2.69, 95% CI 1.11-6.54, respectively). CONCLUSION: Rescue IABP following cardiac surgery is associated with increased early and one-year mortality. Prolonged IABP beyond 4 days or cardiac arrest as an indication portended a significantly worse prognosis. Rescue IABP may not be the optimal first-line temporary MCS for all patients, as the level of support provided might not match the severity of cardiogenic shock. Alternative MCS strategies should be considered early.

Predictors of appendicectomy one year after antibiotic treatment for acute appendicitis: Insights from a prospective, multicentre, observational study.

BACKGROUND: Surgeons are sometimes reluctant to manage uncomplicated appendicitis non-operatively. Reasons cited include the risk of recurrent appendicitis and the risk of missed appendiceal malignancy. The aim of this study was to address these uncertainties and determine the long-term efficacy of antibiotic versus operative management of appendicitis. METHOD: One-year follow-up of patients enrolled in the multicentre, COVID:HAREM cohort study during March-June 2020 was performed. Initial operative or non-operative management was determined on a case-by-case basis by the responsible surgeon. Outcomes were appendicectomy rate at 1-year, histology of removed appendix and predictors of unsuccessful antibiotic treatment. RESULTS: A total of 625 patients who had non-operative management were included. Emergency appendicectomy had been performed by 1-year in 24% (149/625), with a median time to appendicectomy of 12 days [IQR 1-77] from presentation. Thirty-one patients had elective appendicectomy. Normal histology was reported in 6% of emergency procedures and 58% of elective ones. There were 7 malignancies and 3 neuroendocrine tumors identified at histology. All patients with malignant histology had ≥1 risk factors for malignancy at initial presentation. Faecolithiasis (hazard ratios (HR) 2.3, 95% confidence intervals (CI) 1.51-3.49) and a high Adult Appendicitis Score (AAS >16; HR 2.44, 95% CI 1.52-3.92) were independent risk factors for unsuccessful non-operative management. CONCLUSION: At 1 year, 71% of patients managed non-operatively did not undergo an appendicectomy. Recurrence of appendicitis was associated with faecolithiasis and a high AAS. Patients at higher risk for appendiceal malignancy should have targeted follow-up. These factors should be considered when counseling patients on non-operative management.

Establishing Benchmarks for Airway Replacement: Long-Term Outcomes of Tracheal Autografts in a Large Animal Model.

OBJECTIVE: Airway replacement is a challenging surgical intervention and remains an unmet clinical need. Due to the risk of airway stenosis, anastomotic separation, poor vascularization, and necrosis, it is necessary to establish the gold-standard outcomes of tracheal replacement. In this study, we use a large animal autograft model to assess long-term outcomes following tracheal replacement. METHODS: Four New Zealand White rabbits underwent tracheal autograft surgery and were observed for 6 months. Clinical and radiographic surveillance were recorded, and grafts were analyzed histologically and radiographically at endpoint. RESULTS: All animals survived to the endpoint with minimal respiratory symptoms and normal growth rates. No complications were observed. Computed tomography scans of the post-surgical airway demonstrated graft patency at all time points. Histological sections showed no sign of stenosis or necrosis with preservation of the native structure of the trachea. CONCLUSION: We established benchmarks for airway replacement. Our findings suggest that a rabbit model of tracheal autograft with direct reimplantation is feasible and does not result in graft stenosis or airway collapse.

Thoracolumbar injuries: non operative treatment: indications, management.

INTRODUCTION: Thoracolumbar spine injuries can result from various traumatic events such as falls, motor vehicle accidents, and sports injuries. While surgical intervention is often indicated for complex fractures and in case of neurological deficits, non-operative treatment remains a viable option for certain types of injuries. AIMS: This manuscript aims to provide a comprehensive overview of the specific indications and treatment options of non-operative thoracolumbar spine injuries. It seeks to provide evidence-based recommendations for selecting patients suitable for conservative management based on fracture type and stability, absence of neurological deficits, spine deformity, integrity of the posterior ligament complex and patient specific factors.

Microwave vs radiofrequency ablation for small renal masses: perioperative and oncological outcomes.

OBJECTIVE: To conduct a comprehensive comparison of microwave ablation (MWA) vs radiofrequency ablation (RFA) outcomes in the treatment of small renal masses (SRMs), specifically: TRIFECTA ([i] complete ablation, [ii] absence of Clavien-Dindo Grade ≥III complications, and [iii] absence of ≥30% decrease in estimated glomerular filtration rate) achievement, operative time (OT), and local recurrence rate (LRR). PATIENTS AND METHODS: We retrospectively analysed 531 patients with SRMs (clinical T1a-b) treated with MWA or RFA at a single centre (2008-2022). First, multivariable logistic regression models were used for testing TRIFECTA achievement. Second, multivariable Poisson regression models were used to evaluate variables associated with longer OT. Finally, Kaplan-Meier plots depicted LRR over time. All analyses were repeated after 1:1 propensity score matching (PSM). RESULTS: Of 531 patients with SRMs, 373/531 (70.2%) underwent MWA and 158/531 (29.8%) RFA. MWA demonstrated superior TRIFECTA achievement (314/373 [84.2%]) compared to RFA (114/158 [72.2%], P = 0.001). These differences were driven by higher rates of complete ablation in MWA- vs RFA-treated patients (348/373 [93.3%] vs 137/158 [86.7%], P < 0.001). In multivariable logistic regression models, MWA was associated with higher TRIFECTA achievement, compared to RFA, before (odds ratio [OR] 1.92, P = 0.008) and after PSM (OR 1.99, P = 0.023). Finally, the median OT was shorter for MWA vs RFA (105 vs 115 min; P = 0.002). At Poisson regression analyses, MWA predicted shorter OT before (incidence rate ratio [IRR] 0.86, P < 0.001) and after PSM (IRR 0.85, P < 0.001). Local recurrence occurred in 17/373 (4.6%) MWA-treated patients and 21/158 (13.3%) RFA-treated patients (P = 0.29) after a median (interquartile range) follow-up of 24 (8-46) months. There were no differences in the LRR in Kaplan-Meier plots before (P = 0.29) and after PSM (P = 0.42). CONCLUSION: Microwave ablation provides higher TRIFECTA achievement, and shorter OT than RFA. No significant differences were found regarding the LRR.

Outcomes of nonemergency cardiac surgery after overnight operative workload: A statewide experience.

Objective: Cardiac surgeons experience unpredictable overnight operative responsibilities, with variable rest before same-day, first-start scheduled cases. This study evaluated the frequency and associated impact of a surgeon's overnight operative workload on the outcomes of their same-day, first-start operations. Methods: A statewide cardiac surgery quality database was queried for adult cardiac surgical operations between July 1, 2011, and March 1, 2021. Nonemergency, first-start, Society of Thoracic Surgeons predicted risk of mortality operations were stratified by whether or not the surgeon performed an overnight operation that ended after midnight. A generalized mixed effect model was used to evaluate the effect of overnight operations on a Society of Thoracic Surgeons composite outcome (5 major morbidities or operative mortality) of the first-start operation. Results: Of all first-start operations, 0.4% (239/56,272) had a preceding operation ending after midnight. The Society of Thoracic Surgeons predicted risk of morbidity and mortality was similar for first-start operations whether preceded by an overnight operation or not (overnight operation: 11.3%; no overnight operation: 11.7%, P = .42). Unadjusted rates of the primary outcome were not significantly different after an overnight operation (overnight operation: 13.4%; no overnight operation: 12.3%, P = .59). After adjustment, overnight operations did not significantly impact the risk of major morbidity or mortality for first-start operations (adjusted odds ratio, 1.1, P = .70). Conclusions: First-start cardiac operations performed after an overnight operation represent a small subset of all first-start Society of Thoracic Surgeons predicted risk operations. Overnight operations do not significantly influence the risk of major morbidity or mortality of first-start operations, which suggests that surgeons exercise proper judgment in determining appropriate workloads.