Impact of frailty on complications and length of stay after minimally invasive adrenalectomy surgery.

BACKGROUND: Adrenal disease requiring surgery incidence increases with age, and minimally invasive adrenalectomy procedures have improved the safety of adrenal surgery. This study evaluates the perioperative outcomes of elective adrenalectomies when performed in older patients and how frailty affects such outcomes. METHODS: Patients undergoing elective minimally invasive adrenalectomy were identified using the American College of Surgeon's National Surgical Quality Improvement Program Participant Use Targeted File years 2005 to 2020. The surgical indication was categorized as a benign disease, an endocrine disorder, or a malignant disease. Frailty was defined using the 5-item modified frailty index. Multivariable regressions were used to model the relationship of age and frailty with surgical outcomes. RESULTS: In 8,693 minimally invasive adrenalectomy patients, 5,281 (61%) were female, 5,026 (58%) were White, and 1,924 (22%) were aged 65 years or older. Surgical indications were benign disease 5,487 (63%), endocrinopathy 2,850 (33%), and malignancy 356 (4%). Patients aged <65 years (compared to those aged ≥65) were more likely to have a 5-item modified frailty index = 0 (26% vs 14%, respectively) and less likely to have a 5-item modified frailty index = ≥3 (2% vs 4%, respectively; P < .001). OUTCOMES: 30-day mortality 20 (0.2%), complications 459 (5%), return to operating room 73 (0.8%), and median length of stay 2 days. Thirty-day mortality was associated with a 5-item modified frailty index ≥3 (P = .009) and endocrine disease (P = .005) but not with age. Complications were associated with a 5-item modified frailty index ≥2 (≤P < .001) and malignant disease (P = .002), but not with age. CONCLUSION: Minimally invasive adrenalectomy has low 30-day mortality and complication rates that increase with frailty and not age. Frailty is a better predictor than the age of most adverse outcomes after elective minimally invasive adrenalectomy.

Racial disparities in complications following elective colon cancer resection: Impact of laparoscopic versus robotic approaches.

BACKGROUND: We sought to examine differences in outcomes for Black and White patients undergoing robotic or laparoscopic colectomy to assess the potential impact of technological advancement. METHODS: We queried the ACS-NSQIP database for elective robotic (RC) and laparoscopic (LC) colectomy for cancer from 2012 to 2020. Outcomes included 30-day mortality and complications. We analyzed the association between outcomes, operative approach, and race using multivariable logistic regression. RESULTS: We identified 64,460 patients, 80.9% laparoscopic and 19.1% robotic. RC patients were most frequently younger, male, and White, with fewer comorbidities (P â€‹< â€‹0.001). After adjustment, there was no difference in mortality by approach or race. Black patients who underwent LC had higher complications (OR 1.10, 95% CI 1.03-1.08, P â€‹= â€‹0.005) than their White LC counterparts and RC patients. CONCLUSIONS: Robotic colectomy was associated with lower rates of complications in minority patients. Further investigation is required to identify the causal pathway that leads to our finding.

Emergent Applications of Machine Learning for Diagnosing and Managing Appendicitis: A State-of-the-Art Review.

Background: Appendicitis is an inflammatory condition that requires timely and effective intervention. Despite being one of the most common surgically treated diseases, the condition is difficult to diagnose because of atypical presentations. Ultrasound and computed tomography (CT) imaging improve the sensitivity and specificity of diagnoses, yet these tools bear the drawbacks of high operator dependency and radiation exposure, respectively. However, new artificial intelligence tools (such as machine learning) may be able to address these shortcomings. Methods: We conducted a state-of-the-art review to delineate the various use cases of emerging machine learning algorithms for diagnosing and managing appendicitis in recent literature. The query ("Appendectomy" OR "Appendicitis") AND ("Machine Learning" OR "Artificial Intelligence") was searched across three databases for publications ranging from 2012 to 2022. Upon filtering for duplicates and based on our predefined inclusion criteria, 39 relevant studies were identified. Results: The algorithms used in these studies performed with an average accuracy of 86% (18/39), a sensitivity of 81% (16/39), a specificity of 75% (16/39), and area under the receiver operating characteristic curves (AUROCs) of 0.82 (15/39) where reported. Based on accuracy alone, the optimal model was logistic regression in 18% of studies, an artificial neural network in 15%, a random forest in 13%, and a support vector machine in 10%. Conclusions: The identified studies suggest that machine learning may provide a novel solution for diagnosing appendicitis and preparing for patient-specific post-operative complications. However, further studies are warranted to assess the feasibility and advisability of implementing machine learning-based tools in clinical practice.

Video-based Coaching: Current Status and Role in Surgical Practice, Part II- Practical Implementation and Risk Mitigation from the Society for Surgery of the Alimentary Tract, Health Care Quality and Outcomes Committee.

INTRODUCTION: Video-based surgical coaching is gaining traction within the surgical community. It has an increasing adoption rate and growing recognition of its utility, especially an advanced continuous professional growth tool, for continued educational purposes. This method offers instructional flexibility in real-time remote settings and asynchronous feedback scenarios. In our first paper, we delineated fundamental principles for video-based coaching, emphasizing the customization of feedback to suit individual surgeon's needs. METHOD: In this second part of the series, we review into practical applications of video-based coaching, focusing on quality improvements in a team-based setting, such as the trauma bay. Additionally, we address the potential risks associated with surgical video recording, storage, and distribution, particularly regarding medicolegal aspects. We propose a comprehensive framework to facilitate the implementation of video coaching within individual healthcare institutions. RESULTS: Our paper examines the legal and ethical framework and explores the potential benefits and challenges, offering insights into the real-world implications of this educational approach. CONCLUSION: This paper contributes to the discourse on integrating video-based coaching into continuous professional development. It aims to facilitate informed decision-making in healthcare institutions, considering the adoption of this innovative educational quality tool.

A Pathway for Increased Diversity, Equity, and Inclusion in the Surgical Infection Society.

Background: With the rise of diversity, equity, and inclusion (DEI) efforts across medicine, the Surgical Infection Society (SIS) leadership undertook a several-year mission to evaluate DEI issues within the SIS, through the formation of a DEI Ad Hoc Committee to guide the application of best practices. The purpose of this article is to describe the work of the DEI committee since its inception, as well as report on advances made during that time. Methods: Beginning in September 2020, 26 volunteer committee members met monthly to explore the current state of science and best practices around DEI, identify opportunities for the SIS, and translate opportunities into recommendations. As part of this initiative, a survey of the SIS membership was conducted. Survey results, published best practices from business and medicine, and experiences of committee members were utilized collaboratively to outline specific opportunities and recommendations. These findings were presented to the SIS Executive Council and to the membership at the SIS Annual Business Meeting. Results: Committee-identified opportunities and recommendations fell into broad categories of Membership, Leadership and Society Structure, the Annual Meeting, and Research Priorities. Several recommendations were immediately enacted, and a standing DEI committee was established to continue this work. Conclusions: Beyond the main mission of the SIS to advance the science of surgical infections, the SIS can also have a major impact on DEI within society and academic surgery at large.

Clinical outcomes of elective robotic vs laparoscopic surgery for colon cancer utilizing a large national database.

BACKGROUND: Prior studies have shown comparable outcomes between laparoscopic and robotic approaches across a range of surgeries; however, these have been limited in size. This study investigates differences in outcomes following robotic (RC) vs laparoscopic (LC) colectomy across several years utilizing a large national database. METHODS: We analyzed data from ACS NSQIP for patients who underwent elective minimally invasive colectomies for colon cancer from 2012 to 2020. Inverse probability weighting with regression adjustment (IPWRA) incorporating demographics, operative factors, and comorbidities was used. Outcomes included mortality, complications, return to the operating room (OR), post-operative length of stay (LOS), operative time, readmission, and anastomotic leak. Secondary analysis was performed to further assess anastomotic leak rate following right and left colectomies. RESULTS: We identified 83,841 patients who underwent elective minimally invasive colectomies: 14,122 (16.8%) RC and 69,719 (83.2%) LC. Patients who underwent RC were younger, more likely to be male, non-Hispanic White, with higher body mass index (BMI) and fewer comorbidities (for all, P < 0.05). After adjustment, there were no differences between RC and LC for 30-day mortality (0.8% vs 0.9% respectively, P = 0.457) or overall complications (16.9% vs 17.2%, P = 0.432). RC was associated with higher return to OR (5.1% vs 3.6%, P < 0.001), lower LOS (4.9 vs 5.1 days, P < 0.001), longer operative time (247 vs 184 min, P < 0.001), and higher rates of readmission (8.8% vs 7.2%, P < 0.001). Anastomotic leak rates were comparable for right-sided RC vs LC (2.1% vs 2.2%, P = 0.713), higher for left-sided LC (2.7%, P < 0.001), and highest for left-sided RC (3.4%, P < 0.001). CONCLUSIONS: Robotic approach for elective colon cancer resection has similar outcomes to its laparoscopic counterpart. There were no differences in mortality or overall complications, however anastomotic leaks were highest after left RC. Further investigation is imperative to better understand the potential impact of technological advancement such as robotic surgery on patient outcomes.

An Evaluation of Sex-Based Differences in Surrogate Consent for Older Adults Undergoing Surgical Intervention.

INTRODUCTION: Differences between female and male patients have been identified in many facets of medicine. We sought to understand whether differences in frequency of surrogate consent for operation exist between older female and male patients. MATERIALS AND METHODS: A descriptive study was designed using data from the hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients age 65 y and older who underwent operation between 2014 and 2018 were included. RESULTS: Of 51,618 patients identified, 3405 (6.6%) had surrogate consent for surgery. Overall, 7.7% of females had surrogate consent compared to 5.3% of males (P < 0.001). Stratified analysis based on age categories showed no difference in surrogate consent between female and male patients aged 65-74 yy (2.3% versus 2.6%, P = 0.16), but higher rates of surrogate consent in females than males among patients aged 75-84 y old (7.3% versus 5.6%, P < 0.001) and age ≥85 y (29.7% versus 20.8%, P < 0.001). A similar relationship was seen between sex and preoperative cognitive status. There was no difference in preoperative cognitive impairment in female and male patients age 65-74 y (4.4% versus 4.6%, P = 0.58), but higher rates of preoperative cognitive impairment were seen in females than males for those age 75-84 (9.5% versus 7.4%, P < 0.001) and aged ≥85 y (29.4% versus 21.3%, P < 0.001). Matching for age and cognitive impairment, there was no significant difference between rate of surrogate consent in males and females. CONCLUSIONS: Female patients are more likely than males to undergo surgery with surrogate consent. This difference is not based on patient sex alone - females undergoing operation are older than their male counterparts and more likely to be cognitively impaired.

Recent advances in anaesthesia for intrauterine and foetal surgery.

Advances in prenatal diagnostic techniques have enabled early detection of potentially correctable foetal anomalies. Here, we summarise recent developments in anaesthesia for foetal surgery. Types of foetal surgery include minimally invasive, open mid-gestational and ex-utero intrapartum treatment (EXIT) procedures. Foetoscopic surgery avoids hysterotomy, with risk of uterine dehiscence, preserving the possibility of subsequent vaginal delivery. Minimally invasive procedures are performed under local or regional anaesthesia; open or EXIT procedures are usually done under general anaesthesia. Requirements include maintenance of uteroplacental blood flow, and uterine relaxation to prevent placental separation and premature labour. Foetal requirements include monitoring of well-being, providing analgesia and immobility. EXIT procedures require maintenance of placental circulation till the airway is secured, requiring multidisciplinary involvement. Here, the uterine tone must return after baby delivery to prevent major maternal haemorrhage. The anaesthesiologist plays a crucial role in maintaining maternal and foetal homeostasis and optimising surgical conditions.

Palliative Care in a Pandemic: A Multicenter Cohort of Critically Ill Patients with Coronavirus Disease 2019.

Background: Trends in mortality, palliative care, and end-of-life care among critically ill patients with coronavirus disease 2019 (COVID-19) remain underreported. We hypothesized that use of palliative care and end-of-life care would increase over time, because improved understanding of the disease course and prognosis would potentially lead to more frequent use of these services. Patients and Methods: Adult patients with severe acute respiratory syndrome coronavirus 2 infection (SARS-CoV-2) during pandemic wave one (W1: March 2020 to September 2020) or wave two (W2: October 2020 to June 2021) admitted to an intensive care unit (ICU) in one of six northeastern U.S. hospitals were identified and clinical characteristics obtained. Vaccination data were unavailable. Outcomes of interest included mortality, palliative care consultation, and any end-of-life care (including hospice and comfort care). Results: There were 1,904 critically ill patients with COVID-19: 817 (42.9%) in W1 and 1,087 (57.1%) in W2. Patients received mechanical ventilation more often during W1 than W2 (52.9% vs. 46.3%; p = 0.004), with no difference in ICU or hospital length of stay between waves. Mortality between W1 and W2 was similar (31.2% vs. 30.9%; p = 0.888). There was no difference in use of palliative care or any end-of-life care between waves. Patients who died during W2 versus W1 were more likely to have received both mechanical ventilation (77.1% vs. 67.1%; p = 0.007) and palliative care services (52.1% vs. 41.2%; p = 0.009). However, logistic regression adjusted for demographics, baseline comorbid disease, and clinical characteristics showed no difference in mortality (odds ratio [OR], 1.15; 95% confidence interval [CI], 0.89-1.48), palliative care (OR, 1.08; 95% CI, 0.84-1.40), or any end-of-life care (OR, 1.05; 95% CI, 0.82-1.34) in W2 versus W1. Conclusions: Mortality among critically ill patients with COVID-19 has remained constant across two pandemic waves with no change in use of palliative or end-of-life care.

Assessing the Prevalence of Medical Optimization Therapy in Vascular Surgery Clinics.

This cross-sectional study uses checklist data to assess optimal medical therapy prescribed for veterans with atherosclerotic cardiovascular disease.

Indoor Versus Outdoor: Does Occupational Sunlight Exposure Increase Melanoma Risk? A Systematic Review.

INTRODUCTION: Melanoma is the fifth most common cancer diagnosed in the United States, representing 5.6% of all new cancer cases. There are conflicting reports correlating a relationship between primarily outdoor occupations, associated with increased exposure to direct sunlight, and the incidence of cutaneous melanoma. Our objective was to outline and critically evaluate the relevant literature related to chronic occupational exposure to sunlight and risk of developing cutaneous melanoma. METHODS: The study protocol for this systematic review was submitted to the International Prospective Register of Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. For each relevant study included, the following information was extracted: author names, publication year, study name, study design, age, exposure assessment, outcome, comparison, number of cases, case ascertainment, and descriptive and adjusted statistics. Study quality and evidence certainty was assessed using the Grading of Recommendations, Assessment, Development and Evaluations model. RESULTS: The initial database search yielded 1629 articles for review and following full-text screening, a total of 14 articles were included for final analysis. Of the studies included, seven articles were retrospective case control and seven were cohort studies. The studies did not report any differences in the likelihood of cutaneous melanoma development based upon membership in the outdoor versus indoor occupation groups included in each study. CONCLUSIONS: Overall, the articles included in this systematic review did not report an increased risk of developing cutaneous melanoma among individuals with outdoor occupations. Further investigation is required to determine if other occupational or life-style-related risk factors exist, to help support the development of individualized skin screening recommendations and improve the early detection of melanoma in all populations.

Pregabalin Versus Duloxetine on Postoperative Analgesic Requirement Following Lower Extremity Trauma Surgeries: A randomised, Clinical Trial.

OBJECTIVE: The use of pregabalin versus duloxetine in postoperative lower limb traumatic pain has not been compared. The aim of this study was to evaluate the response rate of rescue analgesic requirement with perioperative pregabalin versus duloxetine in lower limb trauma surgeries. METHODS: In this randomised, clinical trial, 60 patients of American Society of Anesthesiologists physical status I-II undergoing lower limb trauma surgery were randomised to receive oral pregabalin 150 mg day-1 or duloxetine 60 mg day-1, 2 hours prior to surgery and then once daily for next 2 days postoperatively. The surgery was performed under standardised spinal anaesthesia technique. The investigator was blinded to the study drug, oral paracetamol 1 g every 6 hours and intravenous diclofenac 75 mg was a rescue analgesic. The primary outcome of the study was response rate in terms of rescue analgesia requirement. Secondary outcomes included total rescue analgesia, visual analogue scale at rest and on movement, haemodynamics, anxiety depression score, and patient satisfaction score and adverse effects. RESULTS: In group pregabalin, 60% of patients required the first dose of rescue analgesia versus 50% in group duloxetine for 72 hours postoperatively. In group pregabalin, 6.6% of patients required the second dose of rescue analgesia after a mean duration of 24 hours, and 10% of patients in group duloxetine required the second dose after a mean duration of 40 hours. The visual analogue scale scores, time to first rescue, and cumulative rescue analgesic were comparable in both the groups. CONCLUSION: Equivalent rate-responsive rescue analgesia was required in patients receiving pregabalin or duloxetine following lower limb trauma surgery.

Look in the Mirror, Not Out the Window: In Favor of Internal Benchmarking.

Over the past few decades, institutions have developed complex systems to compare themselves to others with the goal of improving healthcare quality. This process of comparison to others, called external benchmarking, has become the standard approach for quality improvement. However, external benchmarking is resource intensive, may not be flexible enough to focus on problems unique to individual institutions, and may lead to complacency for institutions ranking near the top of the quality bell curve for the measured metrics. Our singular focus on external benchmarking could also divert resources from other approaches. Here, we describe how the use of internal benchmarking, in which an institution focuses on improving their own processes over time, can offer unique advantages as well as offset the limitations of external benchmarking. We advocate for investment in both internal and external benchmarking as complimentary tools to improve healthcare quality.

Surrogate consent for surgery among older adult patients.

BACKGROUND: Surrogate consent for surgery is sought when a patient lacks capacity to consent for their own operation. The purpose of this study is to describe older adults who underwent surgical interventions with surrogate consent. METHODS: A descriptive analysis was performed using data from the American College of Surgeons National Surgical Quality Improvement Program Geriatric Surgery Pilot collected from 2014 to 2018. All patients included were ≥65 years old and underwent a surgical procedure. Demographic and preoperative health characteristics were evaluated to examine differences between those with and without surrogate consent. RESULTS: In total, 51,618 patients were included in this study, and 6.6% underwent an operation with surrogate consent. Surrogate consent was more common among older patients (median age 83 vs 73, P < .001), female patients (7.7% vs 5.3%, P < .001), patients undergoing emergency as opposed to elective procedures (21.9% vs 1.6%, P < .001), patients with cognitive impairment (50.5% vs 2.4%, P < .001), and patients who were dependent on others for activities of daily living (41.9% vs 4.1%, P < .001). Nearly half of patients with a diagnosis of cognitive impairment signed their own consent. CONCLUSION: Surrogate consent was more common among patients who were older, female, had a higher comorbidity burden, and had preoperative disability. Nearly half of patients with documented cognitive impairment signed their own consent. These results indicate that further research is needed to understand how surgeons determine which patients require surrogate consent.